Health inspection·March 7, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure drugs, biologicals and medical supplies used in the facility were stored and labeled in accordance with currently accepted professional principles, for 3 of 3 medication storage areas (medication room, Short Hall Cart, and Long Hall Cart ) reviewed for medication storage. The facility failed to ensure that all medications and supplies stored in the medication room the short hall Medication Cart were properly labeled and not past their expiration date. The Change-of-Shift Record of Control Substance Log for the Short Hall Medication Cart, and the Long Hall medication carts were missing signatures. These failures could place resident's at risk of ineffective therapeutic response to medications and a decline in health. The findings included: Record review of Resident #12's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: diabetes (high blood sugar). Record review of Resident 12's active physician orders revealed she had an order for Novolog Flex Pen 5 u subcutaneously (inject into the fatty layer of the skin) before meals. Observation of the Short Hall medication cart on 03/072024 at 10:52 AM revealed the top drawer of the cart contained one vial of Novolog flex pen with Novolog Insulin Flex Pen. The pen was not labeled by the pharmacy with directions for use and dose, it was dated opened on 02/28/24 and had the last name of Resident #12 written on the pen in black permanent marker . Record review of Resident 11's face sheet revealed he was an 89 - year old male, admitted to the facility on [DATE] with a diagnoses of diabetes (high blood sugar) Record review of Resident # 11's active e orders dated 03/07/24 revealed the resident had Lispro Insulin 8 Units ordered subcutaneously ( in the fatty tissue) before meals. Observation of the Short Hall medication cart at 10:00 AM on 03/07/2024 revealed a vial labeled Lispro Insulin Inject 9 units subcutaneously before meals. Page 1 of 9 676148 676148 03/07/2024 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with LVN C at 10:52 AM on 03/07/24 revealed the insulin pen for Resident #12 came from the Emergency Box and that was why it was not properly labeled. She stated she would order the medication for Resident #12. She stated The Insulin for Resident #11 was not labeled correctly because the order had been changed and the nurse did not request a label change from the pharmacy and notify them of the order change. She stated it was the nurses responsibility to order medications when they were out and to monitor to see if the medications were labeled properly with the resident's name, dose, medication name and expiration date. She stated failure to do could result in the resident receiving the wrong medication or dosage. Interview with the Director of Nurses (DON) on 03/07/24 at 02:27 PM the DON's response was the nurses were responsible for checking the medication carts and medication rooms for expired medications on a routine basis. She stated they should check for medications needing label changes daily. She stated it was the nurse that took a new orders responsibility to notify the pharmacy of the medication change and a label change. She stated failure to do so could result in a med error. Record review of the facility policy Recommended Medication storage, undated, stated If the physicians directions for use change or the pharmacy types an error on the label and it is impractical to return the medication to the pharmacy for re-labeling, the nurses place a signal label on the container indicating there is a change in directions for use. When such a label appears on the container, the medication nurse checks the resident's current medication administration record or the physicians order for up-to-date information. If the directions for use change the provider pharmacy should be informed prior to the next refill. Record review of the Control Drug Card Count Sheets revealed the sheets were missing signatures on the following dates and shifts: December 2023 Cart All Signatures missing: 12/01/2023 2 PM - 10 PM on coming and off going nurse signatures missing. 12/04/2023 6 AM - 2 PM off going nurse and 2 - 10 on coming and off going signatures missing. 2/06/2024 6 AM - 2 PM off [NAME] nurse signature and 2 PM - 10 PM off going shift nurse signature. 12/07/2023 6 AM - 2 PM off [NAME] nurse signature and 2 PM - 10 PM off going shift nurse signature; 12/08/2023 2 PM - 10 PM off going nurse signature and 10 PM - 6 AM on coming nurse signature. 12/11/2024 6 AM - 2 PM nurse on signature, 2 PM - 10 PM nurse off signature and nurse on signatures, and 10 PM - 6 AM nurse off signature. 12/12/2023 2PM - 10 PM nurse on signature and 10 PM - 6 AM nurse off signature. 12/13/2024 6 AM - 2 PM nurse on signature, and 2PM - 10 PM nurse off signature. 676148 Page 2 of 9 676148 03/07/2024 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0755 2/14/2023 2PM - 10 PM nurse off signature 10 PM - 6 AM nurse on signature. Level of Harm - Minimal harm or potential for actual harm 12/15/2023, 2PM - 10PM nurse off, 2PM - 10PM nurse on, 10PM - 6AM nurse off. 12/16/2023 6AM - 2PM nurse on, 10PM - 6AM nurse off. Residents Affected - Some 12/17/23 10PM - 6AM nurse off; 12/18/23 2PM -10PM nurse on, 10PM -6AM nurse off. 12/19/23 6AM - 2PM nurse on, 2PM - 10 PM nurse off. 12/20/23 2PM- 10PM nurse on, 2PM- 10 PM nurse off; 12/22/23 2PM- 10PM nurse on, 2PM- 10 PM nurse off, 12/22/23 10 PM -6AM nurse on: 12/23/23 6AM- 2PM nurse on. 12/25/23 6AM- 2PM nurse on, 2PM- 10 PM nurse on, 2pm - 10 PM nurse off 12/25/23 10PM - 6AM nurse off. 12/26/23 2PM- 10PM nurse on, 2PM- 10 PM nurse off. 12/27/23 6AM- 2PM nurse on, 2PM- 10 PM nurse off, 2PM - 10PM nurse on; 10PM - 6AM nurse off. 12/28/23 2PM- 10PM nurse on, 10PM- 6 AM nurse off. 12/29/23 6AM - 2PM nurse on, 2PM- 10PM nurse on, 2PM- 10 PM nurse off, 10PM -6AM nurse off. Cart All January 2024 Signatures Missing 01/05/2024 6 AM - 2PM nurse on, 2 PM - 10 PM nurse on, 2 PM- 10 PM nurse off, 10PM - 6 AM nurse off. 01/06/2024 10 PM - 6 AM nurse off. 01/09/2024 6 AM - 2 PM nurse on, 2 PM - 10 PM nurse off. 01/10/2024 6 AM - 2 PM nurse on, 2 PM - 10 PM nurse off. 01/09/2024 - 2 PM nurse on, 2 PM - 10 PM nurse off; 01/16/2024 6 AM - 2P M nurse on, 2 PM - 10 PM nurse off; 2 PM - 10 PM nurse on, 10 PM - 6 AM nurse off. 01/17/2024, 2 PM - 10 PM nurse on, 2 PM - 10 PM nurse off. 01/18/2024 6 AM - 2 PM nurse on, 2 PM - 10 PM nurse off, 2 PM -10 PM nurse off, 10 PM -6 AM nurse off. 676148 Page 3 of 9 676148 03/07/2024 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0755 01/19/2024 6 AM - 2 PM nurse on, 2 PM - 10 PM nurse off, 2 PM -10 PM nurse off, 10 PM -6 AM nurse off. Level of Harm - Minimal harm or potential for actual harm 01/22/2024 6 AM - 2 PM nurse on, 2 PM - 10 PM nurse off, 2 PM -10 PM nurse off, 10 PM -6 AM nurse off. Residents Affected - Some 01/24/2024 6 AM - 2 PM nurse on, 2 PM - 10 PM nurse off, 2PM -10PM nurse off, 10PM -6AM nurse off. 01/25/2024 6AM - 2 PM nurse on, 2 PM - 10 PM nurse off; 01/26/2024 2 PM - 10 PM nurse on, 10 PM -6 AM nurse on, 10 PM -6 AM nurse off. 01/27/2024 6 AM - 2 PM nurse off, 10 PM -6 AM nurse on. 01/28/2024 6 AM - 2 PM nurse off. 01/29/2024 6 AM - 2 PM nurse on, 2 PM - 10 PM nurse on, 2 PM -10 PM nurse off, 10 PM - 6 AM nurse off. 01/30/2024 6 AM - 2 PM nurse on, 2 PM - 10 PM nurse on, 2 PM -10 PM nurse off, 10 PM -6 AM nurse off. 01/31/2024 2 PM - 10 PM nurse on, 10 PM -6 AM nurse off. February 2024 Cart All Signatures missing: 02/01/2024 2 PM - 10 PM nurse on . 02/02/2024 6 AM - 2 PM nurse off signature missing, 2 PM - 10 PM nurse off, 2 PM - 10 PM nurse on. 02/16/2024 6 AM - 2 PM nurse on, 2 PM - 10 PM nurse off, 10 PM - 6 AM nurse off. 02/25/2024 6 AM - 2 PM nurse on, 6 AM - 2 PM nurse off, 2 PM - 10 PM nurse off, 2 PM - 10 PM nurse on, 10 PM -6AM nurse off. 02/28/2024 6AM - 2 PM nurse on, 2 PM - 10 PM nurse off. During an interview on 03/07/24 at 11:01 AM LVN B, stated staff should be signing in and out on the Control Drug Card Count Sheets when taking possession of the medication cart to indicate that the count was correct and has been counted by the oncoming and off going nurses at the change of each shift. She said it was the responsibility of the charge nurse to monitor the sign in sheets as well as review they are being completed. During an interview with LVN C on 03/07/24 at 11: 05 AM, she stated nurses were to count drugs at the beginning and end of their shift with the oncoming nurse, and both shifts should sign the log 676148 Page 4 of 9 676148 03/07/2024 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some signifying that they accepted the count of the narcotics as correct, and they are accepting responsibility for the contents of the cart. She stated failure to do so could result in a drug diversion. During an interview with the DON on 03/07/2024 at 12:30 PM, verified that the signatures were missing for the Control Drug Card Count Sheets for December 2023, January 2024, and February 2024 She stated she was a new DON that had been employed at the facility since 09/2023 and she did not know that the narcotics should be counted and signed for on the facility form titled Controlled Drugs Audit Record until she was told this needed to be documented by her pharmacy consultant. She stated she had instructed all nursing staff regarding counting and signing the count sheets stating that all narcotics were counted and reconciled at the beginning and end of the shift by the nurse coming on duty and the off going nurse. She said that staff should be signing the sign in and out narcotic log (Control Card Count) when they take possession of the cart. She stated the DON and ADON should be monitoring to see that it was done. She stated failure to count narcotics, could result in a drug diversion. During an interview with the ADON on 03/07/24 at 12:41 PM she stated she had not been aware of the procedure for counting narcotics at the end of each shift. She stated she was new to long term care nursing and this facility, and the failure had occurred due to lack of familiarity with state, local and federal laws, and regulations. She stated she was not aware of the facilities policy and procedure. Review of facilities Policy titled: Controlled Drug Audit and Accountability revealed the following in part: The change of shift audit sheets is where nursing staff will sign to indicate that the controlled drugs were audited and that the responsibility of accountability of the controlled drugs is being changed to a different nursing staff. This form has columns to indicate the total number of controlled drug audit sheets present at each shift change. 676148 Page 5 of 9 676148 03/07/2024 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed kitchen sanitization. 1. The facility failed to ensure the floors were not soiled with food particles beneath the appliances and stainless-steel shelf units throughout the kitchen and dry storage area. 2. The facility failed to ensure two of two refrigerators did not have what appeared to be dried liquids, and food crumbs on the bottom floor of the refrigerator. These failures could place residents at risk for foodborne illness and a decline in health status. The findings included: Observations on 03/05/2024 at 9:40 AM, during the initial tour of the facility kitchen, revealed the following: - the floor was soiled with food debris and grease beneath shelves and appliances throughout the kitchen. - 2 of 2 refrigerators had what appeared to be spilled milk, dried liquids, and food crumbs on the bottom shelf. Observations on 03/05/2024 at 9:50 AM revealed daily cleaning logs, dated March 2024, used for all the kitchen cleaning duties revealed all cleaning duties for the morning had been completed and initialed by the kitchen staff who completed the cleaning. In an interview on 03/05/2024 at 10:40 a.m. with the Dietary Manager stated, her kitchen staff followed a cleaning schedule, but someone must have opened a box, and it spilled in the freezer and was not cleaned. She further stated, it's important that the kitchen counters, refrigerators, freezers, and equipment be clean to prevent foodborne illness. In an interview on 03/05/2024 at 3:35 p.m. the DON stated, her expectation was for the dietary department to follow the dietary department cleaning policy. In an interview on 03/06/2024 at 3:40 p.m. the Facility Administrator stated, her expectation was for the dietary department to follow their cleaning schedule per dietary department policy. Record review of the facility's Policy titled Refrigerators, Coolers and Freezers dated, October 1, 2018, revealed [in-part]: The facility will maintain refrigerators, coolers and freezers in a clean and sanitary manner to minimize the risk of food hazards. Refrigerators, coolers, and freezers will be kept clean on a daily basis and will be thoroughly cleaned every month or more often as needed . 676148 Page 6 of 9 676148 03/07/2024 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4(Resident #16, Resident #19, Resident #24 and Resident #20) of 19 residents in dining room reviewed for infection control techniques in that: Residents Affected - Some 1. The facility failed to ensure CNA washed or sanitized her hands in between feeding resident #20 and resident #24. 2. The facility failed to ensure the Hospitality Aide-A washed or sanitized her hands between feeding resident #16 and resident #19. These failures could place residents at risk of infections. The findings included: 1. Record review of Resident #16's face sheet, dated 3/6/2024, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included other Alzheimer's disease (impaired ability to remember, think or make decisions) and moderate protein-calorie malnutrition (lack of enough protein and calorie in food intake). Record review of Resident #16's MDS assessment dated [DATE] revealed the following: Section GG revealed the resident dependent with meals (helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity). 2. Record review of Resident #19's face sheet, dated 3/6/2024, revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of which included dementia (impaired ability to remember, think or make decisions) and hypertension (high blood pressure). Record review of Resident #19's MDS annual assessment dated [DATE] revealed the following: Section GG revealed the resident dependent with meals (helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity). 3 Record review of Resident #20's face sheet, dated 3/6/2024, revealed he was a [AGE] year old male who was admitted to the facility on [DATE] with diagnoses which included unspecified dementia (impaired ability to remember, think or make decisions) and dysphagia (difficulty swallowing). Record review of Resident #20's MDS dated [DATE] revealed the following: Section GG Supervision or touching assistance with meals (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently). 4. Record review of Resident #24's face sheet, dated 3/6/2024, revealed she was a [AGE] year-old 676148 Page 7 of 9 676148 03/07/2024 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some female who was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease (impaired ability to remember, think or make decisions) and generalized muscle weakness. Record review of Resident #24's MDS assessment, dated 2/22/2024, revealed the following: Section C revealed a staff assessment of the BIMS score of 01, which indicated severe cognitive impairment. Section GG revealed the resident required supervision or touching assistance with meals (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as residents completes activity. Assistance may be provided throughout the activity or intermittently). Observation on 03/05/24 12:11 PM of CNA-A and Hospitality aide-A revealed both at a table with four residents (Residents #16, #19, #20, #24). CNA A and Hospitality Aide were each feeding two residents at same time, touching top of their glasses, using utensils to feed, not sanitizing hands between alternating residents. Hospitality aide cleaned spoon of Resident #16 then picked up Resident #24 cup and gave drink, then fed Resident #24, then picked up glass & spoon of Resident #16 and fed her. CNA A was feeding Residents #19 and Resident #20, using utensils and beverage containers alternating between the two residents, feeding each resident, and giving them hydration without using hand sanitizer between each instance. Observation on 03/05/24 12:22 PM revealed the Administrator entered dining room, instructed CNA A and hospitality to feed one resident at a time or to sanitize between each resident. Both CNA A and the hospitality aide at table then got hand sanitizer out of scrubs to begin using it. Observation on 03/05/24 12:26 PM revealed Resident #19 digging in pants, CNA A touched and redirected his arm, then held his hand to move it back to table, then picked up glass of Resident #20 for hydration, then picked up fork of Resident #20 and fed him without sanitizing hands. Interview on 3/5/2024 at 12:48 PM with CNA A revealed that she has been a CNA for 14 years and employed with this company 12 years. She stated that she usually always feeds two residents at the same times and to use hand sanitizer between the two. She stated the possible effect of lack of hand hygiene while feeding she stated, it could cause infection, spread disease or if one resident is sick and we don't know it then the other resident could get sick too. Interview on 3/5/2024 at 12:53 PM with the Hospitality Aide revealed that she has been employed with this facility since December 2023 and was previously certified in another stated, her certification just hasn't transferred yet. Hospitality aide -A stated she always works with another CNA, mostly CNA -A. She stated hand hygiene was performed after I mess with any resident, after feeding we normally wash hands, after picking up trays or after picking up things from the floor. She stated, I just forgot earlier. when I was feeding the residents in the dining room. She stated not performing proper hand hygiene she stated that cross contamination could happen. Interview on 3/6/2024 at 3:45 PM with DON revealed that her expectation was use of gel sanitizer when feeding two residents. Interview on 3/7/2024 at 1:30 PM, the Administrator stated proper hand hygiene is my expectation. When I noticed I immediately reminded them to use hand sanitizer. 676148 Page 8 of 9 676148 03/07/2024 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review on 3/7/24 @ 9:30 AM of Infection Control Policy and Procedure Manual updated 3/2023, was found to state the following: Preventing Spread of Infection: The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. Intent: Implement hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination. 676148 Page 9 of 9