Health inspection·February 29, 2024

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident # 4's Medication administration record 2/29/24 at 11:50 am dated 2/29/24 for the month of February shows the resident is receiving Duloxetine HCL Capsule delayed release Particles 60 mg and 30 mg daily. Review of Resident # 4's consents for psychotropic medications on 2/29/24 at 10:30 am revealed no written consent for the Duloxetine in the Electronic record. Interview with DON on 2/29/24 at 12:30 stated that she was unable to locate consent for Duloxetine in the paper chart or in medical records. Review of Resident #7's face sheet printed 02/29/24 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included unspecified dementia(A group of thinking and social symptoms that interferes with daily function of unknown cause) , major depressive disorder( A mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with you daily life) , bipolar disorder ( a disorder associated with episode of mood swings ranging from depressive lows to manic highs), schizoaffective disorder ( a disorder that affects a person's ability to think, feel and behave clearly with and additional mood disorder), and repeated falls ( older adults who fall more than once per year) . Review of Resident #7's annual MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 12 indication moderately impaired cognition. Section E (Behavior) reflected no hallucinations, delusions, or behavioral symptoms. Section N (Medications) reflected she received antipsychotic and antidepressant medications. Review of Resident # 7's care plan revised on 2/14/2024 revealed Resident # 7 uses psychotropic medications, Ability, related to Bipolar disease and Resident # 7 uses antidepressant medication, Sertraline ,related to history of depression Review of Resident #7's physician order dated 09/27/23 reflected, Aripiprazole Tablet 5mg give 1 tablet by mouth one time a day for bipolar disorder. Review or Resident #7's discontinued orders reflected orders for Aripiprazole 2mg by mouth in the morning initiated on 08/09/22 and discontinued on 08/30/23. The discontinued orders also reflected Aripiprazole 5mg one time a day initiated 08/31/23 and discontinued 09/27/23. Review of Resident #7's consents for psychotropic medications revealed no written consent for the Aripiprazole. Review of Resident # 7's psychiatric progress note written 08/17/22 reflected in part, .a switch to Abilify was recommended out of an abundance of caution. Initial dose of Abilify (Aripiprazole) was given on 08/11/22 per e-MAR. Writer spoke with patient's [family member] about POC and received consent. Interview on 2/29/24 at 12:30 pm the DON stated that her expectation was that a new anti-psychotic or anti-depressive is not started until the consent was signed. She stated that the potential harm maybe the resident was not aware of the reason for the medications and the side effects. She also stated she was unable to locate Resident# 7's consent for Aripiprazole either in the paper chart or in the medical records office. She stated she is unsure how the consent got missed and the charge nurse on the floor is responsible to obtain consent prior to the first dose, which they administer. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676280 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676280 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Georgetown Nursing and Transitional Care 4011 Williams Dr Georgetown, TX 78628 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DON stated that consents are monitored monthly by nursing leadership ( don or assistant director of nurses) and the pharmacy consultant. Interview on 2/29/24 at 1:00 pm the ADM stated her expectation was all residents had the right to know the treatment they were receiving and that consents for anti-psychotic and anti-depressive medication be obtained prior to starting treatment. She stated that she did not see the harm, but agreed it was a resident rights issue. Record Review of Policy Resident Rights undated revealed to be informed of, and participate in, his or her treatment, including the right to: . De informed, in advance, by the physician of the risks and benefits of proposed care, of the treatment and alternatives and the right to choose the alternative option they prefer.' FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676280 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676280 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Georgetown Nursing and Transitional Care 4011 Williams Dr Georgetown, TX 78628 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 5 of 16 residents (Resident #4, Resident #7, Resident #8, Resident #14, and Resident #35), reviewed for care plans. -The facility failed to ensure Resident #4's care plan accurately reflected her antidepressant medication. -The facility failed to ensure Resident #7's care plan reflected her code status. -The facility failed to ensure Resident #8's care plan accurately reflected his antidepressant medication. -The facility failed to ensure Resident #14's care plan accurately reflected the current g-tube status. -The facility failed to ensure Resident #35's care plan accurately reflected the current diet, cognitive status, and pressure ulcer status. These failures could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Review of Resident #4's face sheet printed 02/29/24 revealed a [AGE] year-old female, admitted to the facility 10/22/19. Her diagnoses included paraplegia, complete (when the damage to the spinal cord is severe enough to completely cut off all connections between the brain and areas below the level of injury), major depressive disorder, recurrent severe without psychotic features (an episode of depression in which symptoms are marked and distressing, typically loss of self-esteem and ideas of worthlessness or guilt), post-traumatic stress disorder, chronic (a common and often disabling anxiety disorder). Review of Resident #4's quarterly MDS dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 13 indicating intact cognition. Section N (Medications) reflected the resident was taking antipsychotic, antianxiety and antidepressant medications. Record review of Resident #4 current physician's orders revealed Duloxetine HCL Oral Capsule delayed release particles 30 mg daily written 08/30/23 and Duloxetine HCL oral capsule delayed release particles 60 mg daily written 07/12/23. Review of Resident #4's discontinued medications reflected an order for Sertraline written 10/27/21 had been discontinued. Review of Resident #4's care plan, initiated on 02/12/20 and revised 09/09/20, reflected the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676280 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676280 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Georgetown Nursing and Transitional Care 4011 Williams Dr Georgetown, TX 78628 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident used the antidepressant medication Sertraline related to a history of depression and anxiety. The goal of decreased signs and symptoms of depression was revised on 01/11/24. Approaches included, Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of Sertraline initiated 02/12/20 and revised on 09/09/20. Review of Resident #7's face sheet printed 02/29/24 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, major depressive disorder, bipolar disorder (a mental illness that causes extreme mood swings), schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), and repeated falls. Review of Resident #7's annual MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 12 indication moderately impaired cognition. Section E (Behavior) reflected no hallucinations, delusions, or behavioral symptoms. Section N (Medications) reflected she received antipsychotic and antidepressant medications. Review of Resident #7's physician order dated 12/03/19 reflected, FULL CODE. Review of Resident #7's comprehensive care plan initiated 12/27/19 and last revised on 01/19/24, reflected no entry regarding the code status. Review of Resident #8's face sheet printed 02/29/24 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease with late onset, dysphagia (difficulty swallowing, diabetes insipidus (an uncommon problem that causes the fluids in the body to become out of balance), major depressive disorder, and anxiety disorder (intense and excessive worry and fear). Review of Resident #8's annual MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 1 indicating severely impaired cognition. Section N (Medications) reflected the resident was not taking an antidepressant medication. Review of Resident #8's active physician orders printed 02/28/24, reflected no orders for antidepressant medications. Review of Resident #8's discontinued physician orders reflected an order for Sertraline (an antidepressant medication) that was discontinued 07/14/22. Review of Resident #8's comprehensive care plan revised on 12/02/20 reflected, Need Resident #8 uses antidepressant medication, Sertraline, related to history of depression. The Goal of showing decreased signs and symptoms of depression was revised on 01/19/24. Approaches included administer antidepressant medications as ordered by physician and educate the resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms of Sertraline. Review of Resident #14's face sheet printed 02/29/24, reflected an [AGE] year-old female admitted to the facility 07/15/20. Her diagnoses included unspecified dementia, dysphagia (difficulty swallowing), major depressive disorder, Bell's palsy (A condition that causes temporary weakness or paralysis of the muscles in the face), and hemiplegia and hemiparesis following a cerebral infarction (paralysis that affects one side of the body after a stroke). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676280 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676280 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Georgetown Nursing and Transitional Care 4011 Williams Dr Georgetown, TX 78628 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #14's quarterly MDS assessment dated [DATE] Section C (Cognitive Patterns) reflected resident was unable to participate in the BIMS assessment but had both long- and short-term memory impairment. Section K (Swallowing/Nutritional Status) reflected the resident did not have a feeding tube but had a mechanically altered diet. Review of Resident #14's Discharge summary from the acute care hospital, dated 10/17/23, reflected in part, 81F h/o RA, .multiple strokes, dysphagia s/p PEG placement, removal in 2022, and subsequent persistent gastrocutaneous fistula (a hole or tract connecting the stomach and the skin) so was take to OR for fistula closure. Review of Resident #14's comprehensive care plan, revised 01/29/24 reflected in part, Need Resident #14 has a G-tube related to history of refusing to eat . Goal Resident #14 will have decreased risk for potential side effects or complications related to G-tube placement .Approaches Head of bed elevated 45 degrees, check for tube placement and gastric contents/residual volume per facility protocol and record. Hold medications if greater than 100cc aspirate .Discuss with resident/family/caregivers any concerns about tube feeding . Review of Resident #35's face sheet printed 02/29/24, reflected a [AGE] year-old male admitted to the facility 07/01/20. His diagnoses included Alzheimer's disease, type 2 diabetes (a condition that affects the way the body processes blood sugar), cognitive communication deficit (difficulty communicating after a stroke), dysphagia (difficulty swallowing), and cerebral infarction, (stroke). Review of Resident #35's quarterly MDS assessment dated [DATE] Section B (Hearing, Speech, and Vision) reflected his speech was unclear, he sometimes makes himself understood, and he sometimes understood others. Section C (Cognitive Patterns) reflected a BIMS score of 1 indicating severely impaired cognition. Section K (Swallowing/Nutritional Status) reflected a mechanically altered diet. Section M (Skin Conditions) reflected the resident had two pressure ulcers. Review of Resident #35's physician order dated 03/08/23 reflected, Regular diet pureed texture, nectar consistency liquids. Review of Resident #35's physician orders dated 08/01/23 reflected wound care orders for both the coccyx and right ischial tuberosity that reflected, cleanse with normal saline, pat dry. Apply moisture barrier cream to area cover with hydrocolloid dressing three times a week and PRN. Review of Resident #35's comprehensive care plan revised 01/19/24 reflected in part, Resident #35 has impaired cognitive function with approaches including ask yes/no questions. The care plan also reflected, Resident #35 has a diagnosis of diabetes with approaches including educate regarding medications and importance of compliance. Have resident verbally state understanding. The care plan reflected a potential for impairment to skin integrity, revised 12/13/23 .Stage 2 to coccyx/right ischial tuberosity healed 12/12/23 . Review of Resident #35's weekly skin assessment completed 02/22/24 reflected stage II pressure ulcers on the right ischial tuberosity and coccyx. During an observation and interview on 02/28/24 at 8:42 AM, LVN A performed wound care on Resident #14's abdominal stoma. There was no g-tube present. LVN A stated the tube had been removed a while back, but it often leaked so the resident had a procedure a few months ago to close up the wound on the inside. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676280 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676280 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Georgetown Nursing and Transitional Care 4011 Williams Dr Georgetown, TX 78628 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An observation on 02/29/24 at 8:07 AM revealed Resident #14 in bed, with the head of the bed elevated, drinking from a cup with a straw. During an interview on 02/29/24 at 11:36 AM, the CPC stated he was responsible for completing the MDS assessments for the long-term care residents. He stated as the care plan coordinator, he was responsible for inputting the nursing care plans. He stated each department, such as social services, activities, or dietary, was responsible for inputting their section of the care plan. He stated the wound care nurse was responsible for updating care plans regarding wounds. He stated if a resident no longer had a g-tube, he would expect that would have been removed from the care plan. He stated the care plans were revised after an MDS assessment was completed. He stated he had a program on his computer that alerted him when updates were due. He stated the updates and alerts were based on the assessment reference date. He stated if a resident was no longer taking a medication, he would expect the medication would have been removed from the care plan. He stated he compared the MDS with the care plan to see if anything needed to be updated. He stated he did not attend care plan meetings but learned of changes to medications and diets, falls and behaviors in the morning meetings. He stated he used information from the morning meeting to update care plans. He stated as the care plan coordinator, he was technically responsible for ensuring the MDS assessments and care plans were accurate. He stated, If the care plan isn't right, they aren't getting the care they need. During an interview on 02/29/24 at 12:19 PM, the DON stated, she expected the MDS assessments and care plans to be accurate as she was the one who signed off on them. She stated she looked through the meds and section GG. She stated she was familiar with the residents, and they talked about changes in the morning meetings. She stated if a resident had a diagnosis of CVA, it should have been reflected on the MDS. She stated having an inaccurate MDS or care plan would not cause an adverse outcome for a resident. She stated the physician orders contained the information needed and that was found on the medication administration records, the treatment records, and the FYI box in the medical records. She stated the care plan was a reference. She stated staff performed report at shift change and any changes were passed on at that time. When asked about psychotropic medications on care plans, she stated the care plan should focus more on the behaviors than the medication. She stated the FYI box was updated when there was a change. She stated the care plan and the MDS should match. During an interview on 02/29/24 at 1:05 PM, the ADM stated care plans should be accurate. She stated each department was responsible for adding and updating as appropriate. She stated overall, the MDS/Care plan coordinators were responsible for the MDS and care plans and for accuracy. She stated she and the DON were responsible to oversee the process. She stated if the resident was up for a care plan meeting, that was where the MDS and care plan were reviewed. She stated the policy and procedure should say that the MDS and care plans were kept up to date. She stated she did not think the resident would experience any negative impact because of inaccurate care plans because they were getting the care they needed. She stated the staff completed shift to shift report and passed on pertinent information during that time. Review of the undated facility policy titled Comprehensive Care Plans reflected the following: 1. The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 2. The comprehensive care plan will describe the following: the services that are to be furnished (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676280 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676280 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Georgetown Nursing and Transitional Care 4011 Williams Dr Georgetown, TX 78628 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm to attain the resident's highest practicable, physical, mental, and psychosocial well-being. Any services that would otherwise be required but are not provided due to a resident exercising the right to refuse treatment and services . 3. The comprehensive care plan will be Residents Affected - Some a. developed within seven days after completion of the comprehensive assessment unless the comprehensive care plan will be used as the baseline care plan which requires completion within 48 hours of admission to the facility. b. Prepared by an interdisciplinary team IDT that includes but is not limited to: i. Attending physician. ii. Assigned nurse with responsibility for the resident. iii. Food and nutrition services staff member. iv. Activity Director staff member. v. The resident and their representative, where practicable and/or requested, and documentation in the medical record, explaining why their participation isn't practicable for the development of the residence care plan. vi. Other appropriate staff, or disciplines, as determined by need or requested by the resident. c. Reviewed and revised (including discharge plans) by the interdisciplinary team after each assessment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676280 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676280 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Georgetown Nursing and Transitional Care 4011 Williams Dr Georgetown, TX 78628 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safely for 1 of 1 kitchen reviewed for food storage and sanitation. 1. The facility failed to ensure food and beverages in refrigerator unit #2 and 3 and the walk-in freezer, were covered, labeled, and dated. This failure could place residents at risk of foodborne illness. Findings included: Observation of the kitchen 02/27/24 08:45 am during initial tour revealed , refrigerator # 2 had a rack of covered drinks not labeled with a use by date, refrigerator # 3 with a 7 shelf rack with brown squares in white container with no cover or labeled, ,3rd shelf with clear bowl containers of green and brown substance not covered and dated or identified 4th, 5, and 6th racks with clear small container with green, purple, white and red pieces in them. The walk in freezer with rack with light brown oblong objects uncovered, not dated, or identified. A tray of red oblong shaped objects with light brown covering. On the bottom shelf was an open bag of red substance undated and not identified. Interview with the DM on 2/27/24 at 08:50 am, he stated that he was responsible for the kitchen and was aware that the food was not covered, and they had run out of saran wrap and they were working on getting some. He stated that he was unaware that each item had to be individually covered. He thought the rack could be covered and a date applied to the rack, not each item. He stated he didn't think about the food getting contaminated. The DM stated that they had a policy in English but there was no copy in Spanish and that he has several staff that English was not their first language and since he also in a Spanish speaker he goes over the policies with them during orientation Interview with the DON at 2/29/24 at 12:00 pm, she stated her expectation was that the kitchen follows CMS and State of Texas guidelines for food storage and covering. She stated not following those guidelines could result in potential illness. Interview with the ADM at 2/29/24 at 1:30 pm, she stated her expectation was that the kitchen staff follow food safety guidelines when preparing meals for the residents. She stated that not following guidelines for food handling could lead to an outbreak of food borne illness. Review of the Policy entitled Food and supply storage, revised 1/24 revealed: Cover, label and date unused portions and open packages. Complete all sections on a [NAME] orange label or use the Medvantage/Freshdate labeling system. Products are good through the close of business on the date noted on the label. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676280 If continuation sheet Page 9 of 9