Health inspection·January 20, 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 observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two of four residents (Resident #34 and Resident #166) reviewed for care plans. The facility failed to ensure Resident #34 and Resident #166 had a comprehensive person-centered care plan that included care for respiratory services. This failure could place residents at risk for their needs not being met and not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being. Finding included: 1. Record review of Resident #34's face sheet, dated 01/19/23, revealed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #34 had diagnoses which included leg fracture, dementia, heart disease, kidney disease, anxiety, and falls. Record review of Resident #34's MDS, dated [DATE], revealed she was moderately cognitively impaired with a BIMS score of 9. She required extensive assistance of two staff members with bed mobility, extensive assistance of one staff member for toileting, and the supervision of one staff member for personal hygiene. Record review of Resident #34's physician orders revealed: Continuous oxygen at 2-5L per min via NC every shift dated to start 05/11/22. Record review of Resident #34's Comprehensive Care Plan, dated 01/18/23, revealed no documentation of care interventions for oxygen delivery care provided. In observation of Resident #34 on 01/18/23 at 10:58 AM revealed the resident was in her wheelchair in her room. Resident #34's nasal cannula was in her nostrils and concentrator turned on. In observation of Resident #34 on 01/19/23 at 10:29 AM revealed the resident in her bed. The resident's nasal cannula was in her nostrils and the concentrator was turned on. 2. Record review of Resident #166's face sheet, dated 01/20/22, revealed an [AGE] year-old female Page 1 of 7 676351 676351 01/20/2023 Discovery Village at Southlake 201 Watermere Drive Southlake, TX 76092

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few who was admitted to the facility on [DATE]. Resident #166 had diagnoses which included respiratory failure, hypertension (high blood pressure), inflammation of the lower extremity blood vessels, obstruction of lung disease, kidney disease, and mobility abnormalities. Record review of Resident #166's MDS, dated [DATE], revealed she was cognitively intact with a BIMS score of 15. She was totally dependent on staff with bed mobility, extensive assistance with toileting and personal hygiene. Record review of Resident #166's physician orders revealed: oxygen at 2l/nc continually every shift dated to start 01/08/23. Record review of Resident #166's Comprehensive Care Plan, dated 01/08/23, revealed no documentation of care interventions for oxygen delivery care provided. In observation of Resident #166 on 01/19/23 at 1:51 PM revealed the resident was in her recliner resting. The nasal cannula was positioned in the resident's nostrils and the concentrator was turned on. In interview with the DON on 01/20/23 at 11:51 AM, she stated Comprehensive Care Plans were initiated by the Social Worker and organized by the leadership team. She stated the MDS Coordinator updated care plans and ensured accuracy. She stated respiratory services should have been captured on the care plans for Resident #34 and Resident #166. She stated it was not a harm to the resident if the care plan is being carried out but she stated it was the facility's policy to ensure any type of treatment, intervention, and care to meet the patient's needs, especially oxygen therapy, to be reflected on the care plan. An attempt was made to interview MDS Coordinator on 01/20/23 at 12:00 PM, but the MDS Coordinator was not available for interview. Record review of the facility policy, Care Planning - Interdisciplinary Team, revised September 2013, reflected: Policy Statement, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. Record review of the facility policy, Care Plans, Comprehensive Person-Centered, revised December 2016, reflected: Policy Statement, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implements for each resident. Policy Interpretation and Implementation, 1. The Interdisciplinary Team (IDT) .develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . 8. The comprehensive, person-centered care plan will .l. Identify the professional services that are responsible for each element of care .o. Reflect currently recognized standards of practice for problem areas and conditions. 676351 Page 2 of 7 676351 01/20/2023 Discovery Village at Southlake 201 Watermere Drive Southlake, TX 76092

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 ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 4 of 4 residents (Resident #25, Resident #34, Resident #166 and Resident #170) reviewed for respiratory care. Residents Affected - Some 1. The facility failed to ensure Resident #34 and Resident #166 had oxygen concentrator filters free of sediment and debris. 2. The facility failed to ensure Resident #25, Resident #34, Resident #166, and Resident #170 had oxygen tubing that was not on the floor. These failures could place residents at risk of not receiving proper delivery of oxygen, cross contamination, respiratory compromise and/or infection and residents not having their respiratory needs met. Finding included: 1. Record review of Resident #25's face sheet, dated 01/20/23, revealed an [AGE] year-old female who was re-admitted to the facility on [DATE] on hospice. Resident #25 had diagnoses which included fracture of the back, back pain, brain hemorrhage, mobility abnormalities, falls, and cognitive deficits. Record review of Resident #25's MDS, dated [DATE], stated she was moderately cognitively impaired with a BIMS score of 10. She required extensive assistance of one staff with bed mobility, toileting, and limited assistance of one staff with personal hygiene. Record review of Resident #25's physician orders revealed: Continuous oxygen at 2L per NC prn every 8 hours as needed dated to start 10/22/2022. Record review of Resident #25's Comprehensive Care Plan, dated 01/18/22, revealed Resident #25 had an altered cardiovascular status with an intervention as give oxygen as ordered by the physician. In observation of Resident #25 on 01/18/23 at 10:50 AM revealed the resident was resting in her bed in her room. Resident #25's nasal cannula was in her nostrils and the concentrator was on. The resident's nasal cannula tubing was observed on the floor to the right side of her bed. 2. Record review of Resident #34's face sheet, dated 01/19/23, revealed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #34 had diagnoses which included leg fracture, dementia, heart disease, kidney disease, anxiety, and falls. Record review of Resident #34's MDS, dated [DATE], revealed she was moderately cognitively impaired with a BIMS score of 9. She required extensive assistance of two staff members with bed mobility, extensive assistance of one staff member for toileting, and the supervision of one staff member for personal hygiene. Record review of Resident #34's physician orders revealed: Continuous oxygen at 2-5L per min via NC 676351 Page 3 of 7 676351 01/20/2023 Discovery Village at Southlake 201 Watermere Drive Southlake, TX 76092

F 0695 every shift dated to start 05/11/22. Level of Harm - Minimal harm or potential for actual harm In observation of Resident #34 on 01/18/23 at 10:58 AM revealed the resident was in her wheelchair in her room. Resident #34's nasal cannula was in her nostrils and the concentrator was turned on. The resident's nasal cannula tubing was on the floor to the left side of her bed. Resident #34's oxygen concentrator filter was observed to have significant brown, black, and grey debris sediment accumulation present. Residents Affected - Some In observation of Resident #34 on 01/19/23 at 10:29 AM revealed the resident in her bed. Resident #34's nasal cannula was in her nostrils and the concentrator was turned on. The resident's nasal cannula tubing was on the floor to the left side of her bed. Resident #34's oxygen concentrator filter was observed to have significant brown, black, and grey debris sediment accumulation present. 3. Record review of Resident #166's face sheet, dated 01/20/22, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #166 had diagnoses which included respiratory failure, hypertension, inflammation of the lower extremity blood vessels, obstruction of lung disease, kidney disease, and mobility abnormalities. Record review of Resident #166's MDS, dated [DATE], revealed she was cognitively intact with a BIMS score of 15. She was totally dependent on staff with bed mobility, extensive assistance with toileting and personal hygiene. Record review of Resident #166's physician orders revealed: oxygen at 2l/nc continually every shift dated to start 01/08/23. In observation of Resident #166 on 01/19/23 at 1:51 PM revealed resident in her recliner resting. Nasal cannula positioned in resident's nostrils and concentrator turned on. Resident's nasal cannula tubing on the floor to the right side of her bed. Resident #166's oxygen concentrator filter was observed to have significant brown, black, and grey debris sediment accumulation present. 4. Record review of Resident #170's face sheet, dated 01/20/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #170 had diagnoses which included respiratory failure, depression, heart failure, obstruction of lung disease, mobility abnormalities, and Type 2 diabetes. Record review of Resident #170's MDS, dated [DATE], revealed she was moderately cognitively impaired with a BIMS score of 8. She required extensive assistance of 2 staff for bed mobility and assistance of one staff for transfers. Record review of Resident #170's physician orders revealed: Continuous oxygen at 2L per NC every shift dated to start 01/06/23. In observation of Resident #170 on 01/19/23 at 2:04 PM, the resident was in her bed resting. The nasal cannula was positioned in the resident's nostrils and the concentrator was turned on. The resident's nasal cannula tubing was observed on the floor. In interview on 01/19/23 at 1:40 PM with LVN M, she stated Resident #34's filter was dirty. She stated she was not sure when the oxygen concentrator's filter was cleaned. She stated the nasal cannula tubing was on the floor for Resident #25, Resident #34, Resident #166, and Resident #170 was not a 676351 Page 4 of 7 676351 01/20/2023 Discovery Village at Southlake 201 Watermere Drive Southlake, TX 76092

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some concern. She stated it was ultimately the nurse's responsibility to ensure the oxygen concentrator and tubing was functioning and kept clean, but she never received instructions to keep the nasal cannula tubing off the floor nor how or when to clean the oxygen concentrator filter. She stated if the oxygen concentrator filter was dirty, it could cause respiratory compromise, as the resident could inhale foreign particulates. In observation and interview with LVN J on 01/19/23 at 1:51 PM, she stated Resident #166's filter was dirty. She stated nasal cannula tubing should not be on the floor for Resident #25, Resident #34, Resident #166, and Resident #170. She stated she should roll up any excess nasal cannula tubing up to prevent it from being on the floor. She stated she was not sure when the oxygen concentrator filter was cleaned for Resident #166. She stated it was ultimately the nurse's responsibility to ensure the oxygen tubing was off the ground and the filter was clean. She stated there was currently no system in place to inspect and/or clean the oxygen concentrator filter. She stated if the oxygen concentrator filter was dirty, it could cause the concentrator to not work properly causing respiratory compromise. She stated if the tubing was on the floor, it could be an infection control risk. In interview with DON on 01/20/23 at 11:51 AM, she stated there was not a policy, protocol, or procedure on oxygen concentrator filter inspection and/or cleaning. She stated it was best practice to clean the filter weekly and she was in the process of implementing interventions to ensure this was completed by the nursing staff. She stated if the oxygen concentrator filter was dirty, it could result in possible respiratory issues from the accumulation of particles and infection control concerns. She stated she did not consider the nasal cannula tubing on the floor for Resident #25, Resident #34, Resident #166, and Resident #170 as a concern. She stated there was not a policy for the facility to ensure the nasal cannula tubing remained off the floor. An attempt was made to interview MDS Coordinator on 01/20/23 at 12:00 PM, but the MDS Coordinator was not available for interview. Record review of the facility policy, Oxygen Administration, revised October 2010, reflected: Purpose, The purpose of this procedure is to provide guidelines for safe oxygen administration .Preparation .2. Review the resident's care plan .Steps in Procedure .12. Check the .tank . to be sure they are in good working order 676351 Page 5 of 7 676351 01/20/2023 Discovery Village at Southlake 201 Watermere Drive Southlake, TX 76092

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. Residents Affected - Some 1. The facility failed to ensure all foods stored in the refrigerator, freezer, and dry food storage areas were dated with a use by or expiration date. 2. The facility failed to ensure expired foods were discarded upon the use by or expiration date. This failure could place residents at risk of food-borne illnesses. Findings included: Observation on 01/18/23 at 8:45 AM of the kitchen revealed the following: • Four 6-pound cans of Tapioca Pudding revelaed no date of when the products were received and stored by the facility • Twenty-seven Loaves of wheat bread revelaed no date of when the products were received and stored by the facility • Twelve 12 loaves of hamburger buns revelaed no date of when the products were received and stored by the facility. • Observation of the facility's walk-in refrigerator revealed one gallon container of opened cocktail sauce with a use by date of 07/08/22. • One whole strawberry cream pie revelaed no date of when the products were received and stored by the facility Interview with [NAME] A on 01/18/23 at 8:50 AM revealed she was one of the cooks at the facility and had been there for 2 years. She stated everyone was supposed to know how to date and label products that were delivered. She stated they did have a Dietary Aide, not at work today, putting away delivered products, and label and date them accordingly. She stated they had a shipment that came in the morning of 01/17/23, and the dietary aide failed to label and date some products. She stated the loaves of bread and cans of pudding had arrived in that shipment. She stated the risks to residents if 676351 Page 6 of 7 676351 01/20/2023 Discovery Village at Southlake 201 Watermere Drive Southlake, TX 76092

F 0812 food items were not properly labeled and dated was they could be served expired food and become sick. Level of Harm - Minimal harm or potential for actual harm Interview with the Dietary Manager (DM) on 01/19/23 at 09:40 AM revealed she had been the DM for 2 years. She stated she was advised by the [NAME] of the concerns identified and had corrected them. She stated food items were to be dated and labeled prior to being stored. She stated her dietary aide, who was not at work that day, and was assigned to date and label items that were delivered, prior to it being stored. She stated the food had arrived this past Tuesday, 01/17/23. She stated dietary aides were assigned to checking for expired foods in the pantry, refrigerator, and freezer. She stated the risk to residents if food was not properly dated and labeled was that residents could get ill from eating expired foods. Residents Affected - Some Interview with the Administrator on 01/20/2023 at 12:30 PM revealed he was the Executive Director of the entire facility and has been at the facility over two years. He stated he was advised by his Dietary Manager of the findings, and he knew the Dietary Manager had completed In-service on storing food items. The Administrator stated they had just received a shipment the morning of 01/17/23 and the dietary aide that was working, failed to properly date and label all of the inventory that came in because he had gotten distracted attempting to assist a resident. The Administrator stated the requirements for labeling and dating inventory was that it must be done immediately before storing the items. He stated the risk to not properly dating and labeling food was the resident was at risk of eating expired food and could get ill. Record review of the facility's policy on Food Receiving and Storage, dated July 2014, revealed all foods should be labeled and dated use by date. 676351 Page 7 of 7