Health inspection·March 30, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 2 of 15 residents (Residents #14 and #25) reviewed for care plans. The facility failed to ensure Resident #14 and Resident #25's care plans accurately reflected residents' PASRR positive status. This deficient practice could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings include: Record review of facility face sheet dated 03/28/2023 indicated Resident #14 was a [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses iron deficiency anemia (low iron levels in the blood), intellectual disabilities (a condition characterized by significant limitations in both intellectual functioning and adaptive behavior that originates before the age of 22), and hypertension (elevated blood pressure). Record review of annual MDS dated [DATE] for Resident #14 revealed that the answer to question A1500 was yes indicating that resident had been evaluated by PASSR. Record review of PASSR Level I evaluation dated 9/9/21 for Resident #14 revealed that she was positive for Mental Illness (MI), Intellectual Disability (ID), and Developmental Disability (DD). Record review of a PASSR Comprehensive Service Plan (PSCP) Form dated 7/26/2021 for Resident #14 indicated the meeting was for an update and the Local Authority added a new service of Speech Therapy. Resident #14 and guardian wanted to add Speech Therapy and all things were discussed and agreed upon. Record review of Resident # 14's medical record revealed the comprehensive care plan dated 3/28/23 did not address resident's PASRR positive status nor address if PASRR services were being received. Record review of Resident #25s face sheet, dated 3/28/23 revealed that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: cerebral palsy (a group of disorders that affect movement and muscle tone or posture), severe intellectual disabilities (noticeable motor Page 1 of 21 676183 676183 03/30/2023 Huntington Health Care & Rehabilitation Center 220 E Ash Street Huntington, TX 75949

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few impairment, severe damage to, or abnormal development of, their central nervous system, and generally having an IQ range of 20 to 34), and quadriplegia (condition in which both the arms and legs are paralyzed and lose normal motor function). Record review of an admission MDS dated [DATE] for Resident #25 revealed that the answer to question A1500 was yes indicating that resident had been evaluated by PASSR. Record review of PASSR Level I evaluation dated 6/2/22 for Resident #25 revealed that he was positive for Developmental Disability (DD). Record review of a PASSR Comprehensive Service Plan (PCSP) form dated 8/18/2011 for Resident #25 indicated it was an initial meeting with the Local Authority and Habilitation Coordination and Independent Living Skills Training was added. Comments indicated Resident #25 did not need therapy as he was on Part A for Occupation Therapy and Physical Therapy. Record review of Resident #25s medical record revealed the comprehensive care plan dated 3/28/23 did not address resident's PASRR positive status nor address if PASRR services were being received. During an interview on 3/29/23 at 10:30am SW said that she did complete and sign her portion of the care plan which included social needs, but the ADON completed the rest, including PASSR. She was unable to answer why PASRR positive status was not addressed on Resident #14 and Resident #25's comprehensive care plans. She said that this could put residents at risk of not receiving needed services based on their needs. During an interview on 3/29/23 at 10:35am, Admin said that ADON was responsible for ensuring care plans accurately reflected the current needs of the residents, and the DON oversaw the ADON, but that ultimately, he was responsible for overseeing that it was done. He stated that it could put residents at risk for not receiving the care they needed if care plans were not accurate. During an interview on 3/29/23 at 10:45am, DON stated that she was responsible for overseeing that the ADON correctly addressed residents' needs on the care plans, and she did sign behind her on the comprehensive care plans but was unable to answer why PASRR positive status was not addressed on Resident #14 and Resident #25's care plans. She said that this could cause residents to not receive the level of care that they needed. ADON was unavailable for interview. Record review of facility policy titled Care Plans, Comprehensive Person-Centered revised December 2016 stated .d. Describe any specialized services to be provided as a result of PASRR recommendations . 676183 Page 2 of 21 676183 03/30/2023 Huntington Health Care & Rehabilitation Center 220 E Ash Street Huntington, TX 75949

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 1 of 15 residents (Resident #43) reviewed for accident hazards. The facility failed to ensure an aerosol can of air freshener was not sitting on the bedside table of Resident #43's room. Label contained the phrase .KEEP OUT OF REACH OF CHILDREN AND PETS . This failure could place residents with dementia that may wander at risk of injury by ingestion or inhalation. Findings include: Record review of facility face sheet dated 3/29/23 for Resident #43 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Parkinson's disease (body tremors), psychotic disorder with hallucinations, generalized anxiety disorder, and osteoporosis (decrease in bone density causing fragile bones). Record review of a quarterly MDS dated [DATE] for Resident #43 revealed that resident should not be interviewed for BIMS score due to rarely or never being understood. Observation on 03/27/23 at 09:16 AM of Resident #43's room revealed an aerosol spray can ofair freshener located on bedside table with label stating .KEEP OUT OF REACH OF CHILDREN AND PETS . During an interview on 3/29/23 at 10:35am, Admin said that the air freshener was not allowed in residents room due to being a safety hazard. He said that the resident's husband had brought it in a few days earlier and he had since talked to husband explaining why that was not allowed. He said that this could pose a risk to residents with dementia that may wander and ingest it or try to use it to harm other residents. During an interview on 3/29/23 at 10:45am, DON said that she was unsure how the air freshener got in the resident's room, but it is not allowed as it could pose a hazard to residents possibly with ingestion. Record review of resident admission paperwork titled List of Items not allowed in resident room that is given to residents upon admission states .any products labeled Keep out of reach of children or carries any type of caution label is merchandise that contains ingredients which are harmful if taken without supervision or used in a way not designated. Many of our residents, due to mental impairments or poor eyesight might inadvertently drink or eat some of the above items causing irreparable harm . and .Safety Hazard .Aerosol cans . and .Room deodorizers .Not allowed . 676183 Page 3 of 21 676183 03/30/2023 Huntington Health Care & Rehabilitation Center 220 E Ash Street Huntington, TX 75949

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 13 residents (Residents #16 and #28) reviewed for respiratory care. Residents Affected - Few The facility failed to ensure Residents #16 and #28's nasal cannula tubing on the wheelchair was changed every 7 days and labeled. This deficient practice could place residents at risk of developing respiratory infections and complications. Findings include: 1. Record review of Resident #16's face sheet, dated 03/29/2023, indicated Resident # 16 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included major depressive disorder, cough, and rash. Record review of the admission MDS assessment, dated 03/29/2023, indicated Resident # 16 required oxygen therapy and was cognitively intact with a BIMS of 14. Record review of Resident #16's care plan, dated 11/22/2022, indicated Resident # 16 had chronic obstructive pulmonary disease and required oxygen and oxygen setup per facility protocol. Record review of Resident #16's physician orders, dated 03/29/2023, indicated oxygen at 2 liters per through the nasal cannula with start date of 02/25/2023 and change oxygen tubing every week on Sunday with start date of 11/23/2022. An observation on 03/29/2023 at 11:00 AM revealed Resident #16 was receiving oxygen at 2 liters per nasal cannula via cylinder attached to his wheelchair and the oxygen tubing was not dated. During an observation and interview on 03/29/2023 at 4:00 PM revealed Resident #16 was back in his room receiving oxygen at 2 liters per nasal cannula concentrator. He said that he used his oxygen most all of the time and wears it when he is in his wheelchair. Record review of Resident #28's facility face sheet, dated 03/29/2023, indicated Resident #16 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia, cough, and obstructive sleep apnea. Record review of annual MDS, dated [DATE], indicated Resident # 28 required oxygen therapy. Record review of Resident #28's care plan, dated 12/19/2022, indicated Resident # 28 had shortness of breath and required oxygen therapy. Record review of Resident #28's physician orders, dated 03/29/2023, indicated oxygen 3 liters per nasal cannula with a start date of 02/25/2023 and change oxygen tubing weekly on Sunday start date 10/30/2022. 676183 Page 4 of 21 676183 03/30/2023 Huntington Health Care & Rehabilitation Center 220 E Ash Street Huntington, TX 75949

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 3/29/23 at 4:10 PM, Resident #28 had a portable oxygen cylinder attached to his wheelchair that was unbagged and undated. An observation and interview on 03/30/23 at 10:00 AM revealed Resident # 28 was in bed, had oxygen in place at 3 liters per nasal cannula connected to a prefilled humidifier bottle (bubbler). The nasal cannula tubing was dated 03/29/2023 and the prefilled humidifier was dated 03/29/23. He said he used his oxygen when up in his wheelchair. During an interview and observation on 03/30/23 at 1:20 PM, LVN C said oxygen tubing and supplies were changed on the night shift each week, but each nurse was responsible for their patients on each shift. She stated she was not aware any oxygen tubing was not dated. LVN C looked at the wheelchairs in the 100 hallway and said the two wheelchairs belonged to Residents #16 and #28. She acknowledged both oxygen cannulas and tubing were not dated. She said the risk if not dated and changed weekly, could be respiratory infections. During an interview on 03/29/2023 at 1:45 PM, the DON stated the nurses on the night shift were responsible for changing out the oxygen tubing and nebulizer setups each Sunday night or as needed. She stated she and the ADON were responsible for hall checks and ensuring tasks were completed. She stated the risk could be infection and improper distribution of oxygen. She stated she had been in her position as the DON for two weeks. She said the staff would be in serviced on the facility policy and expected that all respiratory supplies were changed out weekly and dated. During an interview on 03/29/2023 at 2:00 PM, the Administrator stated the DON and ADON were responsible for oversight in the nursing department. He stated he would assist with overseeing the DON and ADON were retraining nursing staff on policy and procedures and his expectation was that the policy and nursing standards of care were followed. Record review of the facility policy and procedure titled Respiratory Therapy- Prevention of Infection, revised 11/2011 indicated .change the oxygen cannula and tubing every 7 days and label with date. Supplies should be bagged while not in use. 676183 Page 5 of 21 676183 03/30/2023 Huntington Health Care & Rehabilitation Center 220 E Ash Street Huntington, TX 75949

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 3 medication carts (nurse cart 100 hall) and the medication storage room reviewed for labeling and storage. 1. The facility failed to remove expired insulin and glucose control solutions (high and low solutions) from the nurse medication cart on hall 100. 2. The facility failed to label and remove expired Tuberculin (TB) testing solution from the medication room refrigerator. These deficient practices could place residents at risk for improper glucose monitoring and could result in residents not receiving the intended therapeutic effects of their medications causing a health decline. Findings include: Record Review of physician order summary dated 3/27/23 reflected Resident #6 was an [AGE] year-old admitted [DATE] with a diagnosis of diabetes (high blood sugar). Review of physician orders reflected: insulin lispro 100 unit per milliliter inject per sliding scale before meals and at bedtime: 0-140= 0 units141-200= 2 units 201-250= 4 units 251-300= 6 units 301-350= 8 units 351-400= 10 units >401= 10 units and call MD dated 2/16/23. Record review of a treatment administration record for Resident #6 dated March 2023 indicated a dosage of 10 units was given on 3/17/23 for a glucose level of 380. During observation and interview on 03/27/23 at 8:45 AM of the nurse cart on 100 hall revealed a expired vial of Lilly Lispro Insulin for Resident #6 was dated as opened on 2/16/2023 and the package insert indicated to discard 28 days after opening, (discard date 03/16/23) and a box of expired glucose control solutions. Assure Prism Glucose control level 1 Lot #CSTM04AN expiration date 10/03/2022 and Level 2 Lot #CSTA13AM expiration date 11/12/2022. Box was marked opened date of 01/18/23, (both vials were expired before opening). Box had the same expiration date and lot numbers as on vial. LVN C said that the glucose controls are only good for so many days depending on the manufacturer. She said that the vials had been opened and put in use after they had already expired. LVN C said insulins are good for so many days, depending on the manufacturer. She removed the expired insulin and glucose controls. LVN C said she would get a new vial from the medication room. She said the risks to the resident was possible site infection from a contaminated vial or decrease efficacy of the insulin. LVN C said the nurses were responsible for checking that insulin was within administration dates before administration. LVN C said she was not aware of exactly how long the insulin was good for, usually 30 days. LVN C said the night staff performed the Glucose monitor checks and logged them in the control log at the nurse's station. 676183 Page 6 of 21 676183 03/30/2023 Huntington Health Care & Rehabilitation Center 220 E Ash Street Huntington, TX 75949

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview and record review on 3/27/23 at 10:24 AM of Glucose Monitoring system daily quality Control Record for the month of March 2023 with the DON revealed the log had a check for 3/1/23 and 3/2/23 omissions for 3/3/23 to 3/9/23. Check completed 3/10/23, then omissions from 3/11/23 to 3/21/23. A check was completed 3/22/23. Omissions for 3/23/23 until that day 3/27/23; no check completed. The DON said oh, they are not logging the glucometer control checks. The DON said she would conduct in service and provide training. The DON said she had been in her position for two weeks. During an interview and observation on 03/27/23 02:56 PM of the medication room refrigerated medications with the DON revealed Tubersol TB tests 0.1 ml 10 test vial with no date opened, date filled 12/07/22, and expiration date 12/31/23. Lot #52070 package insert indicates an expiration date of 30 days after opening. The DON said had not completed any cart checks or checked the medication room. She said she and the ADON were responsible for ensuring all medications were stored within use date. She said she would complete an in-service with the staff nurses on using and dating multi use vials. During an interview on 03/29/23 09:05 AM, the Administrator stated the DON and ADON were responsible for oversight in the nursing department. He stated he would assist with overseeing the DON and ADON retrained nursing staff on policy and procedures and those policies were followed. He said that the negative outcome of not removing expired medications could be that residents are given medications that have lost their effectiveness. Record review of the facility policy and procedure titled Preparation and General guidelines, revised August 2014, indicated, for Vials and ampules of injectable medications .Policy: Vials and ampules of ampules dispensed by the pharmacy are maintained in the box or container, with the pharmacy label, in which they are dispensed. Procedures: A. Vials and ampules dispensed by the pharmacy by the pharmacy are maintained in the box or container, with the pharmacy label, in which they are dispensed. B. Expiration dates: Unopened vials expire on the manufacturer's expiration date. Opening a vial triggers a shortened expiration date that is unique for that product. The date opened and this triggered expiration date that is unique for that product. The date opened and this triggered expiration date are both important to be recorded on multi-dose vials. At a minimum, the date opened must be recorded. These labels are not required on single doe vials or ampules. Triggered expiration dates may be found in the manufacturer's package insert, on the package, provided, or on a reference chart by the pharmacy, or by containing the pharmacist. Review of Policy dated October 2022: Obtaining a fingerstick a fingerstick glucose level Purpose: The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level .14. Follow the instructions provided by the manufacturer of the glucose monitoring system to obtain a blood glucose reading. 676183 Page 7 of 21 676183 03/30/2023 Huntington Health Care & Rehabilitation Center 220 E Ash Street Huntington, TX 75949

F 0805 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for the lunch meal on 03/28/23 reviewed for food form and preparation. Residents Affected - Few The facility failed to ensure the pureed turkey, prepared on 03/28/22 for the noon meal, was pureed to a smooth consistency without grainy, fibrous particles in it. This failure could place residents who received pureed or mechanically chopped meat at risk of consuming foods that could cause choking, decrease meal intake, and not having nutritional needs met. Findings included: During an observation and interview on 03/28/23 at 11:45 a.m., [NAME] E was preparing the pureed meat for the lunch meal. She said she had worked at the facility, this time, for a year and a half. She said the previous DM taught her how to puree. [NAME] E said she had two residents in the facility on a pureed diet, but she pureed extra just in case. She placed the turkey slices in the Robot Coupe and added ¼ cup of chicken broth and processed. She then poured the turkey into a serving pan to place on the steamtable. The surveyor requested to sample the puree for consistency, and it was not pureed in a form designed to meet individual needs. During an interview on 03/28/23 at 12:00 p.m., the DM said the turkey had to be a pudding like consistency and requested [NAME] E place it back into the Robot Coupe and continue to process to a pudding consistency. During an interview on 03/29/23 02:51 PM with the DM, she said if the puree was not pudding like consistency a resident could choke. During an interview on 03/29/23 at 4:04 p.m. with the Administrator, he said he expected the puree to be of appropriate consistency and for the staff to follow the recipe and use proper size scoops for serving. He said not pureeing to pudding consistency could cause the resident to choke. Record review of the Progressive Dysphagia Diet, indicates - It is a nutritionally adequate diet that can be swallowed easily . The diet uses slurred, blenderized or pureed food that has a pudding-like consistency without pulp or small food particles .3. Blenderized foods do not require chewing. They should have a pudding like consistency without lumps (i.e., sour cream or mayonnaise thickness/moistness). All foods are appropriate if the consistency is pureed smooth without fibrous particles. Definitions of puree: Prepared by straining or blending to form a cohesive and homogenous bolus . 676183 Page 8 of 21 676183 03/30/2023 Huntington Health Care & Rehabilitation Center 220 E Ash Street Huntington, TX 75949

F 0812 Level of Harm - Minimal harm or potential for actual harm 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 ensure food was stored, prepared, and distributed under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation. Residents Affected - Some Cook D had hair hanging out of the back of her hair net while washing dishes. The inside bin of the ice maker was dirty. Cook E laid the spoon used for stirring the pureed meat, on the three-compartment sink drainboard, then picked it up and continued to use it. These failures could place the residents at risk of foodborne illnesses. Findings include: During an observation and interview on 03/27/23 at 08:50 a.m., [NAME] D was washing dishes at the dish machine and her hair was hanging out of the back of her hair net. [NAME] D said she had worked at the facility since August 2022 and the previous Dietary Manager had taught her how to wear a hairnet. She said she was not aware her hair was hanging out of her hairnet in the back. She said not keeping her hair in the hairnet could cause hair to fall out into the food. During an observation and interview on 03/27/23 at 9:10 a.m., a paper napkin wiped across the inside of the ice machine bin, had black sludge on it. The DM said the ice machine was last cleaned about two weeks ago. She said she did not think her staff knew to clean the inside bin; nobody had taught them how to clean the machine. She said her staff went in from the top of the machine to clean it. During an observation and interview on 03/28/23 at 11:45 a.m., [NAME] E was pureeing the meat for the noon meal and laid the spoon used for stirring the pureed meat on the drainboard of the three-compartment sink. She then picked it up to continue to stir the meat. During an interview with [NAME] E she said she was very nervous. During an interview on 03/29/23 at 12:00 p.m., the DM said she was responsible for ensuring the hairnet covered all the hair. She said she would try and order a different kind of hairnet, that would better cover their hair to prevent hair from falling out in the food. She said not covering their hair completely could cause hair to fall into the food. During an interview on 03/29/23 at 03:55 p.m. the Administrator said he expected staff to wear hairnets and for the hairnets and to cover hair completely. He said not wearing a hairnet correctly could cause hair to get in the food. During an interview on 03/29/23 at 3:57 p.m., the Administrator said he had the maintenance man put a reminder in TEL to clean the ice machine weekly and change the water filters bi-monthly. He said he expects the ice machine to be kept clean to prevent bacteria from growing in the machine. Review of a policy titled, Preventing Food Borne Illnesses, revised November 2010, indicated, 676183 Page 9 of 21 676183 03/30/2023 Huntington Health Care & Rehabilitation Center 220 E Ash Street Huntington, TX 75949

F 0812 12. Hair nets or caps, and or beard restraints must be worn to keep hair from contacting the food. Level of Harm - Minimal harm or potential for actual harm Review of a policy titled, Dietary Policies and Procedures, Subject: Hair Nets, effective 8-2022, indicated, Residents Affected - Some 4. Hair restraints will cover all parts of hair to ensure no hair comes in contact with food or food preparation surfaces. Review of a policy titled, Dietary Policy and Procedure, Subject: Ice Machine, effective 8-2022, indicated, 3. Ice machines will be cleaned on a weekly basis by dietary staff. 676183 Page 10 of 21 676183 03/30/2023 Huntington Health Care & Rehabilitation Center 220 E Ash Street Huntington, TX 75949

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 3 resident personal refrigerators reviewed for food safety (Resident #25). Residents Affected - Few The facility failed to ensure the refrigerator for Resident #25 did not contain expired diced peaches and box of coffee creamer singles. This failure could place resident at risk for food borne illnesses. Findings include: Record review of Resident #25's face sheet, dated 3/28/23 revealed that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: cerebral palsy (a group of disorders that affect movement and muscle tone or posture), severe intellectual disabilities (noticeable motor impairment, severe damage to, or abnormal development of, their central nervous system, and generally having an IQ range of 20 to 34), and quadriplegia (condition in which both the arms and legs are paralyzed and lose normal motor function). During an observation and interview on 03/28/23 at 09:31 AM, Resident #25 said he drank coffee with his mom, and she would put the creamer in it for him. His personal refrigerator had a container of coffee creamer singles, French Vanilla flavor, open and almost full, with best if used by October 2022 on outside of box, and one single size serving of diced peaches, with best by date December 29, 2022. When asked if staff checked his refrigerator, he said his mom took care of it for him. During an interview on 3/28/23 at 9:40 am, LVN H said that housekeeping cleaned out the resident refrigerators. During an interview on 3/29/23 at 08:00 am, CNA B said that housekeepers cleaned out resident refrigerators but that if she happened to notice anything expired in the refrigerators, she would throw it out. She said that residents could get sick if they ate or drank expired food items. During an interview on 3/29/23 at 10:00 am with HSK A, she said they checked the refrigerators daily. She said she normally worked in laundry and only worked housekeeping about twice a month. She said that she had been doing laundry Monday, which was where she normally worked, when informed that expired foods were found in Resident #25's refrigerator. She said that it was the housekeeper's responsibility to check the personal refrigerators daily. During an interview on 3/29/23 at 10:35 am, Admin said that Resident #25 liked to drink coffee with his mother, and she would always put the creamer in it for him. He said that was really the only times that Resident #25 would drink coffee. He also said that Resident #25's mother would often bring items and keep residents' refrigerator clean, but that ultimately the facility was responsible for ensuring items were safe to consume. He was unsure whether items were placed in refrigerator recently or if they had been there since December. He said that eating or drinking expired food items could cause residents to get food poisoning or increase problems with their current illnesses. During an interview on 3/29/23 at 10:40 am, HSK sup said that housekeeping staff was responsible 676183 Page 11 of 21 676183 03/30/2023 Huntington Health Care & Rehabilitation Center 220 E Ash Street Huntington, TX 75949

F 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for checking residents' personal refrigerators daily and that ultimately it was her responsibility to ensure that her staff was doing this. She said that Resident #25's mother normally took care of his refrigerator, but that she should have ultimately still checked to ensure so that resident did not ingest any expired foods which could lead to him getting sick. During an interview on 3/29/23 at 10:45 am, DON said that housekeeping was responsible for cleaning out residents' personal refrigerators. She said that residents would be at risk for food poisoning if they ate expired food items. Record review of facility policy titled Refrigerator - Personal dated 8/2022 indicated .The housekeeping supervisor/designee will monitor resident's refrigerator weekly . and .Clean and remove expired food as needed . 676183 Page 12 of 21 676183 03/30/2023 Huntington Health Care & Rehabilitation Center 220 E Ash Street Huntington, TX 75949

F 0839 Employ staff that are licensed, certified, or registered in accordance with state laws. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure services provided met professional standards of quality for 1 of 18 licensed staff (ADON) reviewed for valid nursing licenses. Residents Affected - Few The facility failed to ensure the ADON's nurse license did not expire as of [DATE]. This failure could place residents at risk for not receiving nursing services by a licensed nurse. The findings include: Record review of a personnel file review for the facility indicated the ADON had been employed at the facility since [DATE] with a LVN nursing license. A copy of the Texas Board of Nursing license verification for ADON indicated her nursing license expired on [DATE]. Record review of a license search on the national licensure and disciplinary database with a report date of [DATE] at 10:34 AM indicated a search of the nursing license for the ADON. The report indicated the ADON's license was delinquent with an expiration date of [DATE]. Record review of the Texas Board of Nursing license verification dated [DATE] indicated the ADON was issued a LVN license on [DATE] with the current expiration date of [DATE]. The license status was delinquent with compact status N/A. Record review of an Employee Review Report dated [DATE] by the BOM/HR indicated that it was discovered on [DATE] that the ADON let her nursing license expire on 10/2022. The ADON was called and told she must provide proof she submitted for her renewal then she could be rehired. If employee had submitted to state and it is an error on processing, termination will be reversed. Otherwise, employee will have to apply for new position. Employee on cruise termed verbally. Record review of an email by the BOM/HR dated [DATE] at 11:58 AM indicated an email was sent to the Texas Board of Nursing mailbox to report the ADON nursing license was expired on [DATE]. BOM/HR indicated the ADON failed to maintain her license requirements for the job as laid out in the employee handbook and was terminated upon discovery on [DATE]. An email notification response was received on [DATE] at 12:31 PM that indicated the complaint had been received and forwarded to the enforcement department. During an interview on [DATE] at 3:28 PM, the BOM/HR said she did not know that the ADON's nurse license had been expired since [DATE]. She said she has had 2 Administrative assistants in the past 6 months that were responsible for checking the nursing licenses. She said it was the facility policy that the nurses and CNA's were to be responsible for keeping up with their expiration dates. She said the ADON was on paid vacation. She said it was the policy to terminate effective that day [DATE] for her expired license. She said it just slipped through the cracks and was not checked. She said the ADON had many responsibilities in the facility which included being on call, was the MDS nurse and the Infection Preventionist. She said having unlicensed staff treating the residents could be a risk. Attempted a phone interview on [DATE] at 4:54 PM with the ADON, phone rang one time and went to voicemail to leave a message. 676183 Page 13 of 21 676183 03/30/2023 Huntington Health Care & Rehabilitation Center 220 E Ash Street Huntington, TX 75949

F 0839 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on [DATE] at 3:50 PM, the Administrative Assistant said she had been employed at the facility since [DATE]. She said she was responsible for filing papers, completing Medicaid applications and renewals, assisting with new hire packets, and making sure they were filed correctly. She said she was also responsible for checking EMR's (Employee misconduct registry), OIG (Office of Inspector General) and criminal history checks. She said she did not know the ADON license was expired, because she did not check nursing licenses, the BOM/HR did. During an interview on [DATE] at 4:15 PM, the BOM/HR said she had been employed at the facility full time since [DATE]. She said she was responsible for delegating the Administrative Assistants to conduct monthly checks of annuals for EMR's, criminal histories and license verifications along with new hire paperwork. She said the Administrative Assistants would bring everything to her and she would check to make sure it was done. She said the ADON was also responsible for infection control and was certified through the CDC (Centers for Disease Control) as an Infection Preventionist, she was on an on call rotation, worked as a charge nurse sometimes, was the MDS nurse and completed resident assessments. She said in the past 6 months she had two Administrative Assistants and was currently on the 3rd one who was still employed at the facility. She said on [DATE] an Administrative Assistant was hired and terminated on [DATE]. She said another Administrative Assistant was hired on [DATE] and on [DATE] that one quit. She said the current Administrative Assistant had been employed at the facility since [DATE]. She said no one at the facility was aware that the ADON's nursing license was inactive. She said one of the previous Administrative Assistants checked the ADON's nurse license on [DATE] but did not notify her or anyone else that the ADON's nurse license was expired. She said she talked to the ADON on [DATE] through Facebook Messenger because she was on a cruise. She said the ADON told her that she submitted the information to the board of nursing for renewal and called her back later that night on [DATE] and told her she could not find any emails or information that would support that she submitted for renewal of her nurse license. She said the ADON was terminated as of [DATE] and would not be rehired. She said she notified the Texas Board of Nursing that the ADON's license was delinquent. She said going forward the Administrator would provide oversight to ensure nurse licenses were current and up to date. She said the HR department failed in catching the nurse license of the ADON had expired. During an interview on [DATE] at 10:02 AM, the Administrator said he was not aware the ADON's nurse license was expired. He said going forward all licenses would be checked monthly. He said the ADON was responsible for MDS assessments, she scheduled staff for work, and was a part of everything nursing. He said the biggest risk to the residents in the facility would be for a staff member to work without an active license in the facility was the potential for an incident to occur with someone not having a license. Record review of a facility policy titled Annual Screening of Staff undated indicated, .Our facility conducted employment background screening checks, reference checks and criminal conviction investigation checks on all applicants. 1. License verification via the appropriate board pertaining to the license shall be conducted prior to hire and annually on the employee's anniversary date. 4. Per our employee handbook it is the responsibility of the employee to maintain their own license . 676183 Page 14 of 21 676183 03/30/2023 Huntington Health Care & Rehabilitation Center 220 E Ash Street Huntington, TX 75949

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to maintain medical records on each resident that were complete and accurate, in accordance with accepted professional standards and practices for 3 of 6 residents (Resident #17, Resident #28 and Resident #38) reviewed for accurate records. The facility failed to ensure Resident #17, Resident #28 and Resident #38's executed (signed by MD and resident representative) Consent for Antipsychotic or Neuroleptic Medication Treatment (Form 3713) was placed in the medical record per facility policy. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and risk to safety. The findings included: Record review of Resident #17's order summary dated 3/27/23 revealed Resident #17 was [AGE] years old, was admitted to the facility on [DATE] with diagnosis of psychotic disorder (mental illness), anxiety and depression and received the services of Psychiatry. Resident #17 was prescribed Abilify 5mg at bedtime. Record review of Resident #28's order summary dated 3/27/23 revealed Resident #28 was [AGE] years old, was admitted to the facility on [DATE] with diagnosis of schizoaffective disorder bipolar type (mental illness) and received the services of Psychiatry. Resident #28 was prescribed fluoxetine 50mg at bedtime. Record review of Resident #38's order summary dated 3/27/23 revealed Resident #38 was [AGE] years old, was admitted to the facility on [DATE] with diagnosis of schizoaffective disorder (mental illness) and received the services of Psychiatry. Resident #38 was prescribed Zyprexa 15mg at bedtime. During a record review on 03/29/23 at 4:19 PM of Resident #17, Resident #28 and Resident #38's electronic records, there were no Consent for Antipsychotic or Neuroleptic Medication Treatment (forms HHSC 3713) in the electronic record. Record review of a binder containing drug destruction, pharmacy reviews, and executed Consent for Antipsychotic or Neuroleptic Medication-HHSC form 3713 Treatment for all residents in the facility indicated the HHSC3713 forms for all residents were not housed in the medical record. During an Interview on 03/30/23 at 08:30 AM, the Medical Records LVN said that she has worked at the facility for 15 years. She said she been working on getting all records into the new electronic system since December 2022 and all records should be housed in the individual paper chart or in the electronic chart. She said most old assessments and documents had been scanned already but some of the consents had been missed. There should be no records kept outside those locations. She said all of the 3713 forms must be scanned into the into the electronic medical record. During an Interview on 3/30/23 at 08:45 AM, the DON said that all assessments and consents should 676183 Page 15 of 21 676183 03/30/2023 Huntington Health Care & Rehabilitation Center 220 E Ash Street Huntington, TX 75949

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few be scanned into the electronic medical record. She said that failure to place all documents could cause inaccurate assessments and care planning. The DON said there should be no resident records kept outside the electronic record. She said all of the 3713 forms must be scanned into the into the electronic medical record and not kept in a binder. During an interview on 3/30/23 at 08:50 AM, the Administrator said all assessments and consents should be scanned into the electronic medical record. He said that failure to place all documents could cause inaccurate assessments and care planning. He said that he was responsible for ensuring the medical records department was keeping all record up to date. Review of Policy for Charting and Documentation dated 2017, policy statement: All services provided to the resident, progress toward the care goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .3. Documentation in the medical record may be electronic, manual or a combination. 676183 Page 16 of 21 676183 03/30/2023 Huntington Health Care & Rehabilitation Center 220 E Ash Street Huntington, TX 75949

F 0851 Level of Harm - Potential for minimal harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS reviewed for administration (Fiscal year 2023 for the first quarter October 1, 2022 to December 31, 2022) The facility failed to submit PBJ staffing information to CMS for the 4th quarter of the fiscal year 2022. The facility's failure could place residents at risk for personal needs not being identified and met. The findings included: Review of the facility's undated staff roster indicated the following: 1 Administrator 2 RN's (included DON) 14 LVN's (included 1 ADON/MDS Coordinator and 1 Treatment nurse) 22 CNA/MA's 1 Maintenance Person 8 Housekeeping/Laundry Personnel 6 Dietary Personnel (included 1 Dietary Manager) 14 Therapy Personnel (Included 1 Director of Rehab) 1 Social Worker 1 Activity Director 1 Administrative Assistant 1 BOM/HR 1 Transportation Person Record review of the facility's CMS for 672 (Resident Census and Conditions of Residents) dated and signed by the DON on 3/27/2023 that was provided by the Administrator indicated a total of 50 residents in the facility. 676183 Page 17 of 21 676183 03/30/2023 Huntington Health Care & Rehabilitation Center 220 E Ash Street Huntington, TX 75949

F 0851 Level of Harm - Potential for minimal harm Residents Affected - Many Record of the CMS PBJ Staffing Data Report, CASPER Report 1705 D FY Quarter 1 2023 (October 1December 31), dated 3/22/2023, indicated the following entry: Failed to Submit Data for the Quarter .Triggered .Triggered=No Data Submitted for the Quarter. Record review of a PBJ Transmission Activity report from SIMPLE LTC dated 3/29/2023 indicated the facility's last submission for Quarter 4 2022 was submitted on 11/14/2022 at 4:20 PM. It was uploaded, transmitted, and finalized. There was no record of a submission for Quarter 1 2023. During an interview on 3/29/2023 at 4:05 PM, the BOM/HR said she had been employed at the facility since January 2022. She said she was responsible for all things in the business office, HR, and accounts payable. She said she was responsible for submitting the PBJ submissions to CMS. She said the last PBJ submission for 4th quarter of year 2022 was submitted on 11/14/2022. She said she tried to submit 1st quarter of 2023 for dates of October 1 to December 31, 2022, on 1/9/2023. She said on 1/17/2023 she attempted again because it showed pay code errors, job title and excluded hours that was showing up. She said the facility was in the process of changing time keeping and payroll system to an all-in-one system. She said when SIMPLE pulled the information there was a data corruption somewhere and it had to do with the job codes. She said quarter 1 of 2023 was still not submitted because of the same issue. She said with the implementation of the new system, the PBJ submission would be submitted. During an interview on 3/30/2023 at 10:02 AM, the Administrator said the BOM/HR was responsible for submitting the PBJ quarterly. He said he was not aware the 1st quarter of 2023 was not submitted. He said he knew there was some issues, and he did not think the numbers were accurate for staffing in SIMPLE as he checked the quality measures often. He said the BOM/HR had an upcoming training that would hopefully resolve the issues with submission. He said going forward, he would add it to their monthly QAPI meetings and PBJ would be included in the monthly check offs. He said the biggest risk to the facility for not submitting the information would be staffing the facility inappropriately. Record review of a facility's policy titled Staffing with a revised date of October 2017 indicated, .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. 4. Direct care staffing information per day (including agency and contract staff) is submitted to the CMS payroll-based journal system on the schedule specified by CMS, but no less than once a quarter . Record review of a facility policy titled Reporting Direct-Care Staffing Information (Payroll-Based Journal) with a revised date of October 2017 indicated, .Staffing and census information will be reported electronically to CMS through the Pay-roll Based Journal system in compliance with 6106 of the Affordable Care Act. 6. The PBJ system is accessed through the QIES at https://www.qtso.com\. 9. Staffing information is collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. Dates are as follows: Fiscal Quarter 1 date range October 1-December 31, submission deadline February 14 . 676183 Page 18 of 21 676183 03/30/2023 Huntington Health Care & Rehabilitation Center 220 E Ash Street Huntington, TX 75949

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment, in safe operating condition, for 1 of 1 stove in the kitchen reviewed for food service. Residents Affected - Few The facility did not ensure the gas stove was in working order. One of six gas stove burners did not light automatically, when the knob was turned. This failure could place residents who eat out of the kitchen at risk for injury and under cooked food. Findings include: During an observation and interview on 03/27/23 at 9:00 a.m. when the DM, turned the knobs on the gas stove, the front right burner did not light from the pilot. The DM then had to use a striker to light the burner. She said they had a work order out on the stove, that it had been that way for a while. She said the owner was trying to get them a new one. During an interview on 03/28/23 at 2:15 PM, the Maintenance Director said he did not have a work order on the stove prior to 03/27/23 when the DM told him the stove burner didn't light when the knob was turned. He said when the DM told him he put in a work order and on the morning of 03/28/23 the repairman came and fixed the stove. During a record review an invoice dated 03/28/23 indicated, Commercial Kitchen replaced two pilot tubes on the stove. During an interview on 03/29/23 03:53 PM with the Administrator, he said the pilot light not lighting could cause a gas leak and possible injury to the staff and residents if a fire was to break out. During an interview on 03/28/23 at 2:30 p.m., the DM said the burners not lighting could cause carbon monoxide to build up, or a fire. During the survey multiple requests were made for a policy on essential equipment, but the facility was unable to provide a policy before exit. 676183 Page 19 of 21 676183 03/30/2023 Huntington Health Care & Rehabilitation Center 220 E Ash Street Huntington, TX 75949

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relays the call directly to a centralized staff work area for 2 of 12 residents reviewed for call lights. (Resident # 30 and Resident #48) Residents Affected - Few The facility failed to ensure Resident #30 and #48's emergency call light in the bathroom would reach the floor. The call light cord was coiled up in a bundle above the support bar. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life. Findings include: 1. Record review of a face sheet for Resident # 20 dated 3/29/2023 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of major depressive disorder (persistent feeling of sadness and loss of interest), dementia (not able to remember, think or make decisions in everyday activities), essential hypertension, and Alzheimer's disease (a disease that destroys memory and thinking skills). Record review of a Quarterly MDS assessment for Resident #20 dated 3/14/2023 indicated she did not have any impairment in thinking with a BIMS score of 15. She required set up help only with toilet use with supervision and was always continent of bowel/bladder. Record review of a care plan dated 3/29/2023 for Resident #20 indicated she was at risk for fall/injury with intervention to place call light within reach. 2. Record review of a face sheet for Resident #48 dated 3/29/2023 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia (not able to remember, think or make decisions in everyday activities), major depressive disorder (persistent feeling of sadness and loss of interest), COPD (a chronic lung disease that causes blocked airflow and breathing problems), and heart failure (heart is not able to pump effectively). Record review of a MDS for Resident #48 dated 3/13/2023 indicated she did not have any impairment in thinking with a BIMS score of 14. She required supervision in toileting hygiene and was always continent of bowel/bladder. Record review of a care plan for Resident #48 dated 31/5/2023 indicated she had poor safety awareness related to falls with intervention to remind to ask staff for assistance with ambulation. She is at risk for fall/injury with intervention to place call light within reach. During an observation and interview on 3/27/2023 at 2:41 PM in Resident #20 and #48's room, both residents were observed sitting on their beds. Observation in the restroom revealed a call light cord tied up against the wall above the support bar. Resident #48 walked to the restroom to look at the call light and said she had never noticed the string was tied up. She said she remembered when the facility installed the new system, but never paid any attention to the call light in the restroom. Resident #48 pulled on the string and the call light was activated and she immediately deactivated it. Both Resident #20 and #48 said if either of them fell in the restroom they would not be able to 676183 Page 20 of 21 676183 03/30/2023 Huntington Health Care & Rehabilitation Center 220 E Ash Street Huntington, TX 75949

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reach the call light. They both said they never thought about the cord being tied up and were able to go the bathroom on their own without any assistance. During an interview on 3/29/2023 at 7:55 AM, CNA B said she had been employed for 3 years at the facility. She said about a month to 2 months ago the facility installed a new call light system in the rooms and the bathrooms. She said when the Maintenance Supervisor installed the call lights, he left them tied up in a bundle and the staff had to go in each bathroom and untie them so they would reach the floor. She said both Resident #20 and #48 were independent with toileting and if they were to fall in the bathroom and the call light was tied up, they would not be able to reach it to call for help. She said she had never gone in their bathroom because they were independent. During an interview on 3/29/2023 at 11:45 AM, the Maintenance Supervisor said he had been employed at the facility for 3 years. He said in mid-January 2023, he installed a new call light system in the resident rooms and bathrooms. He said he just installed the lights in the bathrooms, and he did not think about uncoiling the strings. He said if someone were to fall in a bathroom with the call light coiled up, they could potentially stay on the floor for a long time before help arrived. He said all the call lights have been checked to make sure they were long enough for a resident to reach it if they fell. During an interview on 3/30/2023 at 10:02 AM, the Administrator said the facility recently installed a new call light system in January 2023. He said the Maintenance supervisor installed the in the rooms and bathrooms in the facility. He said he had spoken to the CNA's about uncoiling the call lights in the bathrooms when they were installed. He said if a resident fell in the bathrooms and the call light cords were coiled up, they would be on the floor up to 2 hours until the CNA made their rounds. He said going forward the CNA's would be required to check the call lights daily in rooms and the bathrooms and it was a basic task for them as they should be checked daily. He said he would provide oversight along with nursing staff to ensure they were checked daily. Record review of a facility policy titled Call Light-Use of with an effective date of 8/2022 indicated, .It is the policy of this home to ensure residents have a call light within reach that they are physically able to access and that they have been instructed on its use . 676183 Page 21 of 21