Health inspection·August 18, 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 that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 of 24 residents (Resident #62) reviewed for care plans in that: Resident #62's comprehensive person-centered care plan did not reflect the resident receiving respiratory care. This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs. The findings were: Record review of Resident #62's face sheet, dated 8/18/23 reflected a [AGE] year-old female admitted on [DATE] with diagnoses that included Chronic obstructive pulmonary disease with (acute) lower respiratory infection. Record review of Resident #62's most recent quarterly MDS assessment, dated 8/18/23 reflected the resident was moderately impaired for daily decision-making skills, and additionally identified as receiving oxygen. Record review of Resident #62's physician's order referring to oxygen, dated 4/26/23 reflected Oxygen (O2) at 2 L/min per nasal cannula. Record review of Resident #62's comprehensive person-centered care plan, dated 8/16/23, reflected only areas related to: pressure ulcer development, current skin conditions, and advanced directive code status without any indication of oxygen therapy or any other area of care. Interview and observation on 8/16/23 at 4:59 PM revealed Resident #62 was receiving oxygen via nasal cannula at three liters per minute. Resident #62 stated, I don't change my oxygen, I feel okay, but I can't get out of bed or change it even if I wanted to Interview and observation on 8/18/23 at 9:21 AM revealed Resident #62 receiving oxygen via three liters per minute via nasal cannula. Resident #62 stated she did not change the oxygen level and the nurses were the only ones who do it. Page 1 of 14 676402 676402 08/18/2023 Windemere at Westover Hills 11106 Christus Hills San Antonio, TX 78251

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 8/18/23 at 9:27 AM, RN C stated resident's physician orders were followed exactly however when related to respiratory care, a resident assessment by nursing would trigger for the order to be requested to be updated to change the oxygen volume. RN D stated she observed Resident #62's oxygen to be currently at three liters per minute and stated Resident #62 to be normally needing this amount of oxygen. RN D stated the expected protocol when this occurred was to communicate with the physician to be the correct volume and to have had the physician update the order. Interview on 8/18/23 at 3:36 PM, MDS Coordinator D stated a resident receiving oxygen or respiratory care ought to have it indicated in the comprehensive care plan. MDS Coordinator D stated Resident #62 was a resident not receiving skilled services and was serviced by MDS Coordinator E. Interview on 8/18/23 at 3:52 PM, the DON stated resident care plans were to reflect the actual care plan of the resident to include the respiratory care utilized. The DON stated the nursing staff were expected to contact the physician to update the physician order and thus to update the care plan. Interview on 8/18/23 at 4:49 PM, the ADM stated it was her expectation that comprehensive care plans represent the resident's current care requirements. The ADM stated she was not aware of the current care plan for Resident #62 and expected respiratory care to be reflected in the care plan. Record review of the facility policy and procedure titled, Comprehensive Person-Centered Care Planning, undated, revealed in part, .It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment .5. The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment and as needed. Interventions put in place are to (be) followed as the plan of care for the resident. These interventions may be adjusted or resolved as needed to facilitate resident needs . 676402 Page 2 of 14 676402 08/18/2023 Windemere at Westover Hills 11106 Christus Hills San Antonio, TX 78251

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, interviews, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals, and preferences for 2 of 3 residents (Resident #50 and #62) reviewed for oxygen therapy in that: Residents Affected - Some 1. Resident #50's oxygen concentrator filter was covered in a thick white substance. 2. Resident #62's oxygen was provided oxygen inconsistent with the physician's order. These failures could affect residents who received respiratory therapy and put them at risk for inadequate or inappropriate amounts of oxygen delivery. The findings included: 1. Record review of Resident #50's face sheet, dated 8/16/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included cerebral infarct (a stroke, a disrupted blood flow to the brain due to problems with the blood vessels that supply it), acute and chronic respiratory failure with hypoxia (not enough oxygen in your blood, but your levels of carbon dioxide are close to normal, mild intermittent asthma (a respiratory condition marked by spasms in the lungs causing difficulty in breathing), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people), wheezing (breathing with a whistling or rattling sound in the chest caused by partially blocked airway), need for assistance with personal care, tracheostomy status (incision in the windpipe made to relieve an obstruction to breathing and may be used to deliver oxygen to the lung) and respiratory disorders. Record review of Resident #50's most recent quarterly MDS assessment, dated 6/13/23 revealed the resident was moderately cognitively impaired for daily decision-making skills and required oxygen therapy. Record review of Resident #50's comprehensive care plan, effective date 2/23/23 revealed the resident had a tracheostomy and was at risk for increased secretions/congestion and infections with interventions that included to provide oxygen per orders. Further review of Resident #50's comprehensive care plan revealed the resident was unable to maintain oxygen saturation and received oxygen at 8 liters per minute via a trach collar. Record review of Resident #50's Physician Order Sheet, dated 8/17/23 revealed the following: -Oxygen at 8 liters per minute, oxygen administered via trach collar by shift, with order date 4/14/23 and no end date. Observation on 8/15/23 at 9:19 a.m. revealed Resident #50 in bed with the oxygen concentrator operating via trach collar at 8 liters per minute. Further observation revealed Resident #50 had two oxygen filters, one on the left of the concentrator and one on the right, both covered in a thick white substance. 676402 Page 3 of 14 676402 08/18/2023 Windemere at Westover Hills 11106 Christus Hills San Antonio, TX 78251

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 8/16/23 at 10:14 a.m. revealed Resident #50 in bed with the oxygen concentrator operating via trach collar at 8 liters per minute. The filters on the left and right side of the oxygen concentrator were covered in a thick white substance. Observation on 8/17/23 at 10:37 a.m. revealed Resident #50 in bed with the oxygen concentrator operating via trach collar at 8 liters per minute. The filter on the left of the oxygen concentrator was black and no longer covered in a thick white substance. The filter on the right of the concentrator was covered in a thick white substance. During an observation and interview on 8/17/23 at 10:38 a.m., LVN B revealed Resident #50 required continuous oxygen therapy and further revealed the facility nursing staff were responsible for ensuring the filters on the oxygen concentrator were cleaned as needed. LVN B revealed Resident #50's oxygen concentrator had only one filter and had cleaned the oxygen filter on the left of the concentrator. LVN B revealed, after observing the oxygen concentrator filter on the right, he was not aware the oxygen concentrator had two filters. LVN B removed the filter on the right of the oxygen concentrator and stated, it's dirty, it looks like dust. LVN B revealed the oxygen concentrator filters needed to be cleaned by nursing staff because it could cause the resident to have respiratory problems. During an observation and interview on 8/17/23 at 4:18 p.m., the DON stated, when the (oxygen) concentrator has 10 or more liters, it has two filters, but most staff didn't know that, and I learned that through trial and error. The DON stated all facility nurses were responsible for checking the filters, but mostly the nurse managers when doing their daily rounds. The DON, after observing a photo of the oxygen concentrator filter used by Resident #50 stated, it looks like bad, cheap carpet. The DON revealed, a dirty oxygen concentrator filter could impede the resident's breathing or cause a respiratory issue. 2. Record review of Resident #62's face sheet, dated 8/18/23 reflected a [AGE] year-old female admitted on [DATE] with diagnoses that included Chronic obstructive pulmonary disease with (acute) lower respiratory infection. Record review of Resident #62's most recent quarterly MDS assessment, dated 8/18/23 reflected the resident was moderately impaired for daily decision-making skills. Record review of Resident #62's physician order referring to oxygen, dated 4/26/23 reflected Oxygen (O2) at 2 L/min per nasal cannula. Record review of Resident #62's comprehensive person-centered care plan, dated 8/16/23, reflected only areas related to: pressure ulcer development, current skin conditions, and advanced directive code status without any indication of oxygen therapy or any other area of care. Interview and observation on 8/16/23 at 4:59 p.m., Resident #62 was revealed to be receiving oxygen via nasal cannula at three liters per minute. Resident #62 stated, I don't change my oxygen, I feel okay but I can't get out of bed or change it even if I wanted to Interview and observation on 8/18/23 at 9:21 AM revealed Resident #62 to be receiving oxygen via three liters per minute via nasal cannula. Resident #62 stated she did not change the oxygen level and the nurses are the only ones who do it. Interview on 8/18/23 at 9:27 AM, RN D stated resident's physician orders are followed exactly 676402 Page 4 of 14 676402 08/18/2023 Windemere at Westover Hills 11106 Christus Hills San Antonio, TX 78251

F 0695 Level of Harm - Minimal harm or potential for actual harm however when related to respiratory care, a resident assessment by nursing would trigger for the order to be requested to be updated to change the oxygen volume. RN D stated she observed Resident #62's oxygen to be currently at three liters per minute and stated Resident #62 to be normally needing this amount of oxygen. RN D stated the expected protocol when this occurred was to communicate with the physician to be the correct volume and to have had the physician update the order. Residents Affected - Some Interview on 8/18/23 at 3:52 PM, the DON stated the nursing staff were expected to contact the physician to update the physician order based on the assessment of respiratory needs. Interview on 8/18/23 at 4:49 PM, the ADM stated it is her expectation that nursing staff communicate and inform the physician if respiratory care requirements for residents change and thus submit an order change. Record review of the facility policy and procedure titled, Protocol for Oxygen Administration, updated March 2019 revealed in part, .Oxygen concentrator filters will be assessed for cleanliness . 676402 Page 5 of 14 676402 08/18/2023 Windemere at Westover Hills 11106 Christus Hills San Antonio, TX 78251

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was fed by enteral means received appropriate treatment and services to prevent complications for 1 of 1 resident (Resident #18) reviewed for feeding tubes. The facility failed to ensure LVN A properly administered crushed medications into Resident #18's feeding tube. This failure could place residents who received medications via a feeding tube at risk for medical complications or a decline in health. The findings included: Record review of Resident #18's face sheet, dated 8/16/23 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, need for assistance with personal care, enterocolitis (inflammation that occurs throughout the intestines) due to clostridium difficile (bacterial infection) and dysphagia (difficulty or discomfort in swallowing). Record review of Resident #18's most recent quarterly MDS assessment, dated 5/6/23 revealed the resident was severely cognitively impaired for daily decision-making skills and required a feeding tube. Record review of Resident #18's comprehensive care plan, effective date 2/22/23 revealed the resident received tube feedings with the goal to receive adequate nutrition without side effects associated with tube feedings. Record review of Resident #18's Physician Order Sheet, dated 8/17/23 revealed the following: 1. Crush Medications before administering through G-tube (feeding tube) by shift, with order date 2/24/23 and no end date 2. Flush G-Tube (feeding tube) with 50 cc water before and after medication administration by shift, with order date 4/25/23 and no end date 3. Pramipexole 0.5 mg tablet g-tube one time daily for Parkinson's disease with order date 3/1/23 and no end date 4. Ropinirole 0.25 mg tablet enteral tube three times daily for Parkinson's disease with order date 3/1/23 and no end date 5. Carbidopa 25 mg-levodopa 250 mg tablet g-tube three times daily for Parkinson's disease with order date 3/1/23 and no end date 6. Cranberry extract 425 mg capsule, 2 capsules g-tube one time daily for disorders of urinary system with order date 3/1/23 and no end date 676402 Page 6 of 14 676402 08/18/2023 Windemere at Westover Hills 11106 Christus Hills San Antonio, TX 78251

F 0755 Level of Harm - Minimal harm or potential for actual harm 7. Multivitamin with minerals tablet, 1 tablet enteral tube one time daily for nutritional deficiency with order date 3/1/23 and no end date 8. Vitamin C 500 mg tablet enteral tube two times daily for nutritional deficiency with order date 3/1/23 and no end date Residents Affected - Some 9. Levetiracetam 100 mg/ml oral solution for seizures, 10 ml g-tube two times daily with order date 3/1/23 and no end date 10. Lorazepam 0.5 mg tablet (0.25 ml = 0.5 mg) g-tube for seizures every 8 hours with order date 7/30/23 and no end date Observation on 8/16/23 at 7:28 a.m., during the medication pass, LVN A removed 7 pills/capsules from the blister packs and from stock bottles for Resident #18 and placed them into one medication cup. LVN poured a liquid medication into a separate medication cup. LVN A then took the pills/capsules from the cup and crushed each pill individually but poured multiple medications into the same cup. LVN A had 3 medication cups that contained 1 liquid medication and 2 cups with the remainder 7 crushed pills/capsules mixed together. LVN A then administered 30 cc of water to Resident #18's feeding tube before administering the first cup of medication and then flushed each medication with 10 to 15 cc of water between the remaining cups of medication. LVN A then administered approximately 30 cc of water to Resident #18's feeding tube after medication administration. During an interview on 8/16/23 at 1:48 p.m., LVN A revealed she was nervous and stated, I don't know why I mixed the medications together, I don't know why I did that. LVN A revealed the medications administered to Resident #18 had to be administered through the feeding tube one medication at a time but did not know the actual reason why other than it was facility protocol. LVN A then stated, I'm gonna say that mixing the medications while administering during peg (feeding tube) is probably not safe for the resident. During an interview on 8/16/23 at 4:52 p.m., the DON revealed she believed it was ok to cocktail the medications, but best practice was to put each medication in a separate cup. The DON revealed, separating and flushing each medication separately won't plug the feeding tube and maybe because the medications would not dissolve well or medications could interactive with other medications. Record review of LVN A's competency training titled, Medication Administration Through a Feeding Tube, dated 7/27/23 revealed LVN A had satisfied the requirements for administering medications through a feeding tube. Further review of the competency training revealed in part: -3. Dilute liquid medication and crush/dilute tablets .Never mix different liquid medications together -Prepare medications individually for administration -4. Dilute liquid medications with 10-30 cc of water and dissolve or suspend crushed medications in 5-10 cc of water -9. Administer medications, flushing with 5-10 cc (or per physician's orders) of warm water between each medication 676402 Page 7 of 14 676402 08/18/2023 Windemere at Westover Hills 11106 Christus Hills San Antonio, TX 78251

F 0755 Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy and procedure, titled Medication Administration Through a Feeding Tube, updated March 2019 revealed in part, .Purpose .To provide a route for accurate and timely medication administration for a Patient who cannot or should not take medications orally .If tablets are crushed, crush to a fine powder and dissolve in water .Prepare medications individually for administration . Residents Affected - Some 676402 Page 8 of 14 676402 08/18/2023 Windemere at Westover Hills 11106 Christus Hills San Antonio, TX 78251

F 0759 Ensure medication error rates are not 5 percent or greater. 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 it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 28%, based on 7 errors out of 28 opportunities, which involved 1 of 6 residents (Resident #18) reviewed for medication administration in that: Residents Affected - Some The facility failed to ensure LVN A properly administered crushed medications into Resident #18's feeding tube. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. The findings included: Record review of Resident #18's face sheet, dated 8/16/23 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, need for assistance with personal care, enterocolitis (inflammation that occurs throughout the intestines) due to clostridium difficile (bacterial infection) and dysphagia (difficulty or discomfort in swallowing). Record review of Resident #18's most recent quarterly MDS assessment, dated 5/6/23 revealed the resident was severely cognitively impaired for daily decision-making skills and required a feeding tube. Record review of Resident #18's comprehensive care plan, effective date 2/22/23 revealed the resident received tube feedings with the goal to receive adequate nutrition without side effects associated with tube feedings. Record review of Resident #18's Physician Order Sheet, dated 8/17/23 revealed the following: 1. Crush Medications before administering through G-tube (feeding tube) by shift, with order date 2/24/23 and no end date 2. Flush G-Tube (feeding tube) with 50 cc water before and after medication administration by shift, with order date 4/25/23 and no end date 3. Pramipexole 0.5 mg tablet g-tube one time daily for Parkinson's disease with order date 3/1/23 and no end date 4. Ropinirole 0.25 mg tablet enteral tube three times daily for Parkinson's disease with order date 3/1/23 and no end date 5. Carbidopa 25 mg-levodopa 250 mg tablet g-tube three times daily for Parkinson's disease with order date 3/1/23 and no end date 6. Cranberry extract 425 mg capsule, 2 capsules g-tube one time daily for disorders of urinary system with order date 3/1/23 and no end date 676402 Page 9 of 14 676402 08/18/2023 Windemere at Westover Hills 11106 Christus Hills San Antonio, TX 78251

F 0759 Level of Harm - Minimal harm or potential for actual harm 7. Multivitamin with minerals tablet, 1 tablet enteral tube one time daily for nutritional deficiency with order date 3/1/23 and no end date 8. Vitamin C 500 mg tablet enteral tube two times daily for nutritional deficiency with order date 3/1/23 and no end date Residents Affected - Some 9. Levetiracetam 100 mg/ml oral solution for seizures, 10 ml g-tube two times daily with order date 3/1/23 and no end date 10. Lorazepam 0.5 mg tablet (0.25 ml = 0.5 mg) g-tube for seizures every 8 hours with order date 7/30/23 and no end date Observation on 8/16/23 at 7:28 a.m., during the medication pass, LVN A removed 7 pills/capsules from the blister packs and from stock bottles for Resident #18 and placed them into one medication cup. LVN poured a liquid medication into a separate medication cup. LVN A then took the pills/capsules from the cup and crushed each pill individually but poured multiple medications into the same cup. LVN A had 3 medication cups that contained 1 liquid medication and 2 cups with the remainder 7 crushed pills/capsules mixed together. LVN A then administered 30 cc of water to Resident #18's feeding tube before administering the first cup of medication and then flushed each medication with 10 to 15 cc of water between the remaining cups of medication. LVN A then administered approximately 30 cc of water to Resident #18's feeding tube after medication administration. During an interview on 8/16/23 at 1:48 p.m., LVN A revealed she was nervous and stated, I don't know why I mixed the medications together, I don't know why I did that. LVN A revealed the medications administered to Resident #18 had to be administered through the feeding tube one medication at a time but did not know the actual reason why other than it was facility protocol. LVN A then stated, I'm gonna say that mixing the medications while administering during peg (feeding tube) is probably not safe for the resident. During an interview on 8/16/23 at 4:52 p.m., the DON revealed she believed it was ok to cocktail the medications, but best practice was to put each medication in a separate cup. The DON revealed, separating and flushing each medication separately won't plug the feeding tube and maybe because the medications would not dissolve well or medications could interactive with other medications. Record review of LVN A's competency training titled, Medication Administration Through a Feeding Tube, dated 7/27/23 revealed LVN A had satisfied the requirements for administering medications through a feeding tube. Further review of the competency training revealed in part: -3. Dilute liquid medication and crush/dilute tablets .Never mix different liquid medications together -Prepare medications individually for administration -4. Dilute liquid medications with 10-30 cc of water and dissolve or suspend crushed medications in 5-10 cc of water -9. Administer medications, flushing with 5-10 cc (or per physician's orders) of warm water between each medication 676402 Page 10 of 14 676402 08/18/2023 Windemere at Westover Hills 11106 Christus Hills San Antonio, TX 78251

F 0759 Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy and procedure, titled Medication Administration Through a Feeding Tube, updated March 2019 revealed in part, .Purpose .To provide a route for accurate and timely medication administration for a Patient who cannot or should not take medications orally .If tablets are crushed, crush to a fine powder and dissolve in water .Prepare medications individually for administration . Residents Affected - Some 676402 Page 11 of 14 676402 08/18/2023 Windemere at Westover Hills 11106 Christus Hills San Antonio, TX 78251

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 observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1. The facility failed to maintain the cleanliness of the ice maker found within the kitchen. 2. The facility failed to maintain the cleanliness of the juice dispensers found within the kitchen. 3. The facility failed to remove expired and past dated items from the dry food storage. 4. The facility failed to complete daily temperature logs of reach-in refrigerators and freezers found within the kitchen and nourishment room. 5. The facility failed to ensure the chemical dishwasher operated at or above 120 degrees Fahrenheit. These failures could place residents at risk for cross-contamination and foodborne illnesses. The findings included: Observation on 8/15/23 beginning at 9:02 AM revealed the following: The walk-in refrigerator to have recorded temperatures ranging from 39 degrees to 46 degrees for the month of August. The ice maker within the kitchen was revealed to have a black substance built up inside the unit. The juice dispenser to have encrusted red and orange mass build up on and adjacent to the dispensing spout. The chemical dishwasher to have recorded temperatures ranging from 107 - 122 during the wash cycle and 115 - 123 during the rinse cycle. Interview on 8/15/23 at 9:34 AM, the DM stated the kitchen staff was responsible for emptying and cleaning out the ice maker every 3 months by draining and emptying the ice maker and cleaning it from the inside. She stated the MS had just cleaned the ice maker within the last few weeks. The DM stated he did not notice the black substance build-up and could not identify what it was. The DM stated the ice maker should be cleaned and would contact his MS to have it partially disassembled to remove the black substance build up as the substance could cause foodborne illness in residents who consume ice from the ice maker. The DM stated the staff who enter the kitchen in the morning are responsible for completing the temperature logs for all fridges and freezers, in addition to reporting to herself and the MS if the fridges or freezers are reaching high temperatures. The DM stated the expected protocol when staff are recording temperatures out of expected scope for any major appliance are to report them to himself and the maintenance supervisor. The DM stated the risks associated with 676402 Page 12 of 14 676402 08/18/2023 Windemere at Westover Hills 11106 Christus Hills San Antonio, TX 78251

F 0812 these failures was a potential for foodborne illness in residents. The DM stated the nourishment rooms are not the responsibility of the dietary department. Level of Harm - Minimal harm or potential for actual harm Observation on 8/16/23 at 11:02 AM revealed the following items within the dry food storage: Residents Affected - Many (1) Unit of crackers best by dated 6/3/23 (2) Units of key lime flavoring sauce best by dated 6/24/23 & 7/6/23 (1) Unit of white chocolate sauce best by dated 7/10/23 (1) Unit of chocolate sauce best by dated 6/16/23 (3) Units of thickened cranberry juice use by dated 8/3/23 Interview on 8/16/23 at 11:14 AM, the DM stated he was unaware of the past dated items within the dry food storage and expects all of his staff who enter the dry food storage to remove any items past dated. He stated he does not complete a routine audit of the dry food storage. The DM stated his policy for best by dated items is to treat them the same as use by items and to dispose of them upon reaching the listed date. The DM stated the risk associated with failing to remove expired items would be a potential for foodborne illness. Observation on 8/17/23 at 1:48 PM, Nourishment Room A was revealed to have a temperature log with temperatures ranging from 32 to 46 degrees Fahrenheit. The ice maker within Nourishment Room A was revealed to also contain a black substance build up within the unit. Observation on 8/17/23 at 4:07 PM, Nourishment Room B was revealed to have a temperature recording of 44 degrees Fahrenheit on 8/9/23 and 8/17/24 with a current internal temperature of 50 degrees Fahrenheit. Interview on 8/17/23 at 4:43 PM, the MS stated he was not aware of the black substance build up of the ice makers within the kitchen or the nourishment rooms and had planned to have a vendor come to service the units as they had never received a service [NAME] to this before. The MS stated the refrigerators and respective logbooks detailing high temperatures have never been reported to him historically. The MS stated the low temperatures of the chemical dishwasher within the kitchen have never been reported to him. Interview on 8/17/23 at 4:57 PM, the ADM stated she was unaware of the concerns identified within the kitchen and nourishment rooms and stated it is her expectation that the dietary department report 676402 Page 13 of 14 676402 08/18/2023 Windemere at Westover Hills 11106 Christus Hills San Antonio, TX 78251

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many concerns and temperatures outside of expected ranges to the MS. The ADM stated the responsibility of the nourishment rooms to be the nursing department however she believes there was a confusion of this distinction to the nursing department as there had been administration changes recently and new staff. Record review of the facility nutritional policy titled Refrigerator/Freezer Temperature log, undated, reflected Person assigned or DSM must record temperature for each refrigerator and freezer and sign in column provided . take temperatures at same time every morning (AM) and evening (PM). The morning reaching should preferably be taken upon opening the department. Record review of the facility nutritional policy titled Cleaning of the Ice Machine, undated, reflected The ice machine shall be cleaned and sanitized according to manufacturer's instructions to maintain sanitary conditions in order to prevent food contamination and the growth of disease producing organisms and toxins. Record review of the facility nutritional policy titled Food Storage and Supplies, undated, reflected All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry, and protected from vermin and insects . Record review of US FDA Food Code, dated 2022, revealed Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as . ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. Some equipment manufacturers and industry associations, e.g., within the tea industry, develop guidelines for regular cleaning and sanitizing of equipment . and 3-304.11 Food Contact with Equipment and Utensils. FOOD shall only contact surfaces of: (A) EQUIPMENT and UTENSILS that are cleaned as specified under Part 4-6 of this Code and SANITIZED as specified under Part 4-7 of this Code; P (B) Single-service and single-use articles. 676402 Page 14 of 14