Health inspection·July 13, 2023

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care, for 2 of 8 Residents (Residents #236 and #238) reviewed for base line care plans, in that: 1. The facility failed to develop and implement a baseline care plan to support Resident #236's needs for hypotension, low blood pressure, with prescribed medications meant to raise blood pressure, oxygen use, prescribed opioid use for pain, and support interventions for a fractured hip. 2. The facility failed to develop and implement a baseline care plan to support Resident #238's needs for communication in Arabic. These failures could place residents at risk of not having their needs identified within the required timeframe, to provide person centered care. The findings included: 1. A record review of Resident #236's admission record, dated 07/11/2023, revealed an admission date of 07/04/2023, with diagnoses which included hypotension [low blood pressure], displaced intertrochanteric fracture of right femur [broken right hip], and hemiplegia and hemiparesis following non traumatic intracerebral hemorrhage affecting right dominant side [a right side of the body paralysis a stroke], and dependence on supplemental oxygen. A record review of Resident #236's admission MDS, dated [DATE], revealed Resident #236 was an [AGE] year-old female admitted from the hospital and assessed with a BIMS of 15 out of 15 score indicating no mental cognition impairment. A record review of Resident #236's physician orders, dated 07/11/2023, revealed the physician ordered for Resident #236 to receive the following: Page 1 of 14 676447 676447 07/13/2023 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

F 0655 1. Level of Harm - Minimal harm or potential for actual harm Oxygen at 2 to 3 liters per minute to maintain oxygen levels greater than 92%. 2. Residents Affected - Some Floor nurse to monitor right trochanter [hip] closed surgical site every shift and report as needed three times a day. 3. Midodrine [a drug which raises blood pressure] tablet 5 milligram give one tablet by mouth three times a day for hypotension [low blood pressure]. 4. Tramadol [an opioid] oral tablet 50 milligrams give half a tablet by mouth every 24 hours as needed for breakthrough pain. 5. Tramadol [an opioid] oral tablet 50 milligrams give one tablet by mouth every six hours as needed for moderate pain. A record review on 07/10/2023, of Resident #236's Initial Nursing Care Plan, dated 07/04/2023, revealed no focuses, goals, and / or interventions for Resident #236's needs for support for her broken hip, potential complications from her opioid use to control pain, oxygen use, and need for midodrine a drug which raises blood pressure [can be dangerous if given when the blood pressure is high]. During an observation and interview on 07/11/2023 at 11:12 AM, Resident #236 was in bed awake, alert, receiving oxygen at 2 liters a minute via a nasal cannula [a thin tube]. Resident #236 stated she was recovering from a broken hip surgery and needed oxygen to breathe and used pain medications. Resident #236 stated she was not aware she was to receive a blood pressure medication. Resident #236 stated she was not aware she was prescribed a medication to raise her blood pressure but did state she has had episodes of dizziness, light head feelings, to include shortness of breath. During an interview on 07/11/2023 at 02:30 PM, ADON J stated he assessed Resident #236 upon admission on the afternoon of 07/04/2023 and reviewed Resident #236's hospital discharge paperwork and received orders for Resident #236 to include: 1. Oxygen at 2 to 3 liters per minute to maintain oxygen levels greater than 92%. 2. Floor nurse to monitor right trochanter [hip] closed surgical site every shift and report as needed three times a day. 676447 Page 2 of 14 676447 07/13/2023 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

F 0655 3. Level of Harm - Minimal harm or potential for actual harm Midodrine [a drug which raises blood pressure] tablet 5 milligram give one tablet by mouth three times a day for hypotension [low blood pressure]. Residents Affected - Some 4. Tramadol [an opioid] oral tablet 50 milligrams give half a tablet by mouth every 24 hours as needed for breakthrough pain. 5. Tramadol [an opioid] oral tablet 50 milligrams give one tablet by mouth every six hours as needed for moderate pain. During an interview on 07/12/2023 at 04:10 PM, ADON I stated nursing and interdisciplinary staff all contributed to a resident's care plan. ADON I stated she was not aware who initiated Resident #236's care plan and further stated the care plan should have care details for Resident #236's needs. ADON I stated she and the DON were responsible for quality reviews of all care plans and could not account for the failure. 2. A record review of Resident #238's admission record, dated 07/10/2023, revealed an admission date of 07/05/2023, with diagnoses which included pneumonia [an infection of the lungs]. A record review of Resident #238's admission MDS, dated [DATE], revealed Resident #238 was a 77-yr-old male admitted from the hospital. A record review of Resident #238's Nursing Evaluation notes, dated 07/05/2023, authored by the ADON I, revealed Resident #238 was assessed as speaking Arabic and unable to speak or read English, does not speak English. a translator / interpreter is not needed. A record review of Resident #238's Initial Nursing Care Plan, dated 07/06/2023, revealed no supports for Resident #238's need for communication and / or translation services due to his only speaking the Arabic Language. During an observation and interview on 07/10/2023 at 09:27 AM Resident #238 presented in bed in his room with his family member visiting. Resident #238 could not interview with the surveyor. Resident #238's family member stated they spoke and understood both English and Arabic. Resident #238's family member stated Resident #238 only spoke Arabic. The surveyor asked Resident #238's family member to ask for permission from Resident #238 for his family to interpret for Resident #238's, Resident #238 made eye contact with the surveyor and nodded his head in an affirmative and Resident #238's family member stated Resident #238 gave permission. Resident #238 stated he was not able to understand English and could not communicate with staff if his family was not present. Resident #238 stated the stay at the facility has been frustrating. When asked what needs were not being met, Resident #238 stated many but for now he would like his communication needs improved. During an interview on 07/11/2023 at 10:02 AM RN H stated Resident #238 only spoke Arabic and staff 676447 Page 3 of 14 676447 07/13/2023 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some would utilize family to interpret. RN H stated Resident #238 spoke some and understood some English. RN H stated she and other staff used various methods to communicate to include internet-based translators when family was not available to translate. During an interview on 07/12/2023 at 04:20 PM, ADON I stated nursing and interdisciplinary staff all contributed to a resident's care plan. ADON I stated she was the RN who initiated Resident #238's care plan and did not recognize she failed to develop a care plan for Resident #238's need for Arabic Language communication. ADON I stated she and the DON were responsible for care plan reviews to ensure accuracy and quality. ADON I stated she could not account for why she missed Resident #238's need for Arabic communication. ADON I stated the lack of a care plan for communication could make the interaction between staff and residents difficult. During an interview on 07/13/2023 at 05:20 PM the Administrator stated all residents should have a care plan in place, developed and implemented to support resident's needs. The Administrator stated Resident #238's care plan has been revised and updated to include Arabic communication supports instructions for all staff who care for Resident #238. A record review of the facility's policy Care Plan, dated April 2023, revealed, General: Each resident will have a care plan that is current, individualized, and consistent with their medical regimen . Policy: A baseline care plan is developed for each resident upon admission, but no later than 48 hours of admission to the facility. This care plan includes minimum health care information necessary to properly care for the Resident. Required components of the baseline care plan: Initial goals based on admission orders. Services planned to attain or maintain residence higher practicable physical, mental, and psychosocial well-being, including, but not limited to: activities of daily life, nutrition, fall risk, skin integrity, and pain management . 676447 Page 4 of 14 676447 07/13/2023 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

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 observations, interviews, and record reviews the facility failed to ensure a medication error rate below 5%. The facility error rate was 10.7% based on 3 errors out of 28 opportunities for 2 of 5 residents (Resident #256 and #257) reviewed for medication administration: Residents Affected - Some 1. LVN M administered a late medication for Resident #256. The medication was scheduled for 07:30 AM administration, the medication was administered at 08:44 AM. 2. MA N administered late medications for Resident #257. The medications were scheduled for administration any time between 07:00 AM and 10:00 AM. The medications were administered at 11:54 AM. These deficient practices could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: 1. Resident #256 A record review of Resident #256's admission record, dated 07/12/2023, revealed an admission date of 06/28/2023 with diagnoses which included diabetes mellitus type II [a deadly disease where the body cannot process sugar]. A record review of Resident #256's admission MDS, dated [DATE], revealed Resident #256 was an [AGE] year-old female admitted from the hospital. A record review of Resident #256's physician's orders, dated 07/13/2023, revealed Resident #256 was prescribed to receive Insulin (Isophane & Regular) Subcutaneous Suspension (70%-30%) 100 UNIT/ML [a mix of regular quick acting insulin and man-made long-acting insulin], Inject 7 units subcutaneously [under the skin] two times a day for DM at 07:30 AM and again at 05:00 PM. During an observation and interview on 07/12/2023 at 08:44 AM revealed LVN M preparing an insulin injection for Resident #256. LVN M prepared 7 units of Insulin (Isophane & Regular) Subcutaneous Suspension (70%-30%) and administered the injection to Resident #256. LVN M stated he was late in the administration due to the breakfast was late for Resident #256. LVN M stated he was concerned if he gave Resident #256 her insulin too early before she was able to eat, she would have a blood sugar that would be too low. The breakfast meal was not served to Resident #256 until 08:45 AM. LVN M stated the meal is usually served after 08:00 AM and he would usually administer the insulin injection right before the breakfast meal. LVN M stated he had not brought the schedule issue to anyone's attention. During an interview on 07/12/2023 at 08:50 AM, Resident #256 stated she received her insulin right before breakfast and the practice was routine since her admission in June 2023. Resident #256 stated she usually received breakfast at 08:30 AM although sometimes the breakfast was served later. 2. 676447 Page 5 of 14 676447 07/13/2023 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

F 0759 Resident #257 Level of Harm - Minimal harm or potential for actual harm A record review of Resident #257's admission record, dated 07/12/2023, revealed an admission date of 06/30/2023 with diagnoses which included hypertension [high blood pressure] and polyneuropathy [painful nerves]. Residents Affected - Some A record review of Resident #257's admission MDS, dated [DATE], revealed Resident #257 was a [AGE] year-old woman admitted into the facility on [DATE] from the hospital. A record review of Resident #257's physician orders, dated 07/13/2023, revealed Resident #257 was prescribed to receive: 1. Gabapentin Oral Capsule 300 MG; Give 1 capsule by mouth two times a day for Nerve Pain, anytime between 07:00 AM - 10:00 AM and again anytime between 04:00 PM and 07:00 PM. 2. Metoprolol Tartrate Oral Tablet 50 MG (Metoprolol Tartrate), Give 1 tablet by mouth two times a day for HTN, anytime between 07:00 AM - 10:00 AM and again anytime between 04:00 PM and 07:00 PM. During an observation and record review on 07/12/2023 at 11:54 AM, revealed MA N prepared and administered to Resident #257: 1. Gabapentin Oral Capsule 300 MG. 2. Metoprolol Tartrate Oral Tablet 50 MG. MA N stated the medications were late due to her workload assigned was overwhelming. MA N stated she was scheduled to work from 06:00 AM to 02:00 PM and assigned to administer medications to half of the facility's residents [the census was 91]. MA N stated she started on the 3rd floor [the facility has 3 floors] and by the time she arrived on the 1st floor to administer medications to 1st floor residents [Resident #257 was a 1st floor Resident] it was 11:54 almost noon. MA N stated she had not reported the late medication administration to anyone but her leadership was aware since March 2023 when she had raised concerns about the fluctuating census and increased workload. During an interview on 07/12/2023 at 04:33 PM ADON I stated LVN M and MA N did not alert her to the potential and actual late medication administrations for residents. ADON I stated she believed MA N could have administered the medications on time and referenced other staff were able to do so. ADON I stated MA N should have reported the potentially late medication administration to allow the ADON's to intervene for a on time safe medication administration. A record review of the facility's Medication Administration policy, dated 05/2023, revealed, Policy: It is the policy of the facility to ensure that medications are passed following the procedures 676447 Page 6 of 14 676447 07/13/2023 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

F 0759 outlined below: Procedure; . verify medication is being provided at the right time per physician orders and the medication administration record . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 676447 Page 7 of 14 676447 07/13/2023 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents are free of any significant medication errors, for 2 of 5 residents (Resident #236 and Resident #256) reviewed for medication administration, in that: Residents Affected - Some 1. MA N administered midodrine (a drug prescribed to raise blood pressure) while Resident #236 was experiencing high blood pressure. 2. LVN M administered Resident #256's insulin late. These failures could place residents at risk for not receiving therapeutic effects of their medications to include a diminished health status. The findings included: 1. Resident #236 A record review of Resident #236's admission record, dated 07/11/2023, revealed an admission date of 07/04/2023, with diagnoses which included hypotension [low blood pressure]. A record review of Resident #236's admission MDS, dated [DATE], revealed Resident #236 was an [AGE] year-old female admitted from the hospital and assessed with a BIMS of 15 out of 15 score indicating no mental cognition impairment. A record review of Resident #236's physician orders, dated 07/11/2023, revealed the physician ordered for Resident #236 to receive Midodrine [a drug which raises blood pressure] tablet 5 milligram give one tablet by mouth three times a day for hypotension [low blood pressure]. A record review of the federal governments National Heart, Lung, and Blood Institute's website, https://www.nhlbi.nih.gov/health/high-blood-pressure , accessed 07/20/2023, revealed definitions of high blood pressure, High blood pressure develops when blood flows through your arteries at higher-than-normal pressures. Your blood pressure is made up of two numbers: systolic and diastolic. Systolic pressure is the pressure when the ventricles pump blood out of the heart. Diastolic pressure is the pressure between heartbeats when the heart is filling with blood. Your blood pressure changes throughout the day based on your activities. For most adults, a normal blood pressure is less than 120 over 80 millimeters of mercury (mm Hg), which is written as your systolic pressure reading over your diastolic pressure reading - 120/80 mm Hg. Your blood pressure is considered high when you have consistent systolic readings of 130 mm Hg or higher or diastolic readings of 80 mm Hg or higher. A record review of Resident #236's July 2023 Medication Administration Record revealed Resident #236 was administered midodrine 5mg by MA L on 07/11/2023 in the morning while Resident #236's blood 676447 Page 8 of 14 676447 07/13/2023 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

F 0760 pressure was 142/68. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 07/11/2023 at 11:12 AM, Resident #236 was in bed awake, alert, receiving oxygen at 2 liters a minute via a nasal cannula [a thin tube]. Resident #236 stated she was recovering from a broken hip surgery and needed oxygen to breathe. Resident #236 was not aware she was to receive a blood pressure medication which would raise her blood pressure but did state she has had episodes of dizziness, light head feelings, to include shortness of breath. Residents Affected - Some During an interview on 07/11/2023 at 02:30 PM, ADON J stated he assessed Resident #236 upon admission on the afternoon of 07/04/2023 and reviewed Resident #236's hospital discharge paperwork and received orders for Resident #236 to include Midodrine tablet 5 milligram give one tablet by mouth three times a day for hypotension. ADON J stated the order for the midodrine was not given with parameters to give and/or hold the medication. ADON J stated the medication raises a person's blood pressure. ADON J stated Resident #236 was prescribed the midodrine for low blood pressure. ADON J stated a blood pressure of 142 systolic and 68 diastolic would be considered high blood pressure for most residents. ADON J stated Resident #236's midodrine medication was stored on the medication aide cart and was assigned to medication aides to administer, although from time-to-time LVN's are assigned the medication aide cart. ADON J stated MA L had not reported Resident #236 had high blood pressure this morning, on 07/11/2023, and should have reported to Resident #236's nurse. ADON J stated the doctor did not provide any parameters and therefore had no guidance other than to call the doctor for clarification of the order. During an interview on 07/13/2023 at 04:00 PM, the Medical Director stated he prescribed Resident #236 the medication midodrine for her episodes of low blood pressure. The Medical Director received a report from the facility that Resident #236 had received the midodrine while she was experiencing an episode of high blood pressure. On 07/13/2023, The Medical Director discontinued the order for the midodrine without parameters and prescribed a new order for midodrine to include parameters. The Medical Director stated he wished for Resident #236 to receive the midodrine if her systolic blood pressure was not above 160. The Medical Director stated, a question should have been asked regarding the report of MA L administered the medication when Resident #236's blood pressure was high. The Medical Director stated midodrine raises blood pressure and Resident #236 has episodes of hypotension and needs the medication. 2. Resident #256 A record review of Resident #256's admission record, dated 07/12/2023, revealed an admission date of 06/28/2023 with diagnoses which included diabetes mellitus type II [a deadly disease where the body cannot process sugar]. A record review of Resident #256's admission MDS, dated [DATE], revealed Resident #256 was an [AGE] year-old female admitted from the hospital. A record review of Resident #256's physician's orders, dated 07/13/2023, revealed Resident #256 was prescribed to receive Insulin (Isophane & Regular) Subcutaneous Suspension (70%-30%) 100 UNIT/ML [a mix of regular quick acting insulin and man-made long-acting insulin], Inject 7 units subcutaneously [under the skin] two times a day for DM at 07:30 AM and again at 05:00 PM. 676447 Page 9 of 14 676447 07/13/2023 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation and interview on 07/12/2023 at 08:44 AM revealed LVN M preparing an insulin injection for Resident #256. LVN M prepared 7 units of Insulin (Isophane & Regular) Subcutaneous Suspension (70%-30%) and administered the injection to Resident #256. LVN M stated he was late in the administration due to the breakfast was late for Resident #256. LVN M stated he was concerned if he gave Resident #256 her insulin too early before she was able to eat, she would have a blood sugar that would be too low. The breakfast meal was not served to Resident #256 until 08:45 AM. LVN M stated the meal is usually served after 08:00 AM and he would usually administer the insulin injection right before the breakfast meal. LVN M stated he had not brought the schedule issue to anyone's attention. During an interview on 07/12/2023 at 08:50 AM, Resident #256 stated she received her insulin right before breakfast and the practice was routine since her admission in June 2023. Resident #256 stated she usually received breakfast at 08:30 AM although sometimes the breakfast was served later. During an interview on 07/12/2023 at 04:33 PM ADON I stated LVN M and MA L did not alert her to the potential and actual late medication administrations for residents. ADON I stated she believed MA N could have administered the medications on time and referenced other staff were able to do so. ADON I stated MA L should have reported the high blood pressure for Resident #236 to allow the ADON's to intervene for a safe medication administration. A record review of the federal governments National Institutes of Health website, https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=8c7038f4-60d4-4604-814d-74921cdc1ad8&type=display# , accessed 07/20/2023, revealed, INDICATIONS AND USAGE for Insulin (Isophane & Regular) Subcutaneous Suspension (70%-30%), Read the instructions for use that come with your Novolin 70/30 product .Take Novolin 70/30 exactly as prescribed. Novolin 70/30 is an intermediate-acting insulin. The effects of Novolin 70/30 start working ½ hour after injection. The greatest blood sugar lowering effect is between 2 and 12 hours after the injection. This blood sugar lowering may last up to 24 hours. 676447 Page 10 of 14 676447 07/13/2023 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 1 of 8 Residents (Resident #47) reviewed for storage of medications. Resident #47's triamcinolone cream [a cream used to treat the itching, redness, dryness, crusting, scaling, inflammation, and discomfort of various skin conditions], was stored in his room at his bedside. This deficient practice could place residents at risk for harm due to improper storage. The findings are: A record review of Resident #47's admission record, dated 07/13/2023, revealed an admission date of 06/28/2023, with diagnoses which included a rash. A record review of Resident #47's admission MDS, dated [DATE], revealed Resident #47 was a [AGE] year-old male, admitted from the hospital. A record review of Resident #47's physician's orders dated 07/10/2023 revealed Resident #47 was prescribed triamcinolone cream 0.1% topical apply to bilateral lower extremities topically three times a day for rash. During an observation and interview on 07/10/2023 at 03:33 PM, Resident #47 was in his room seated at his bedside. Further observation revealed a 454-gram container of the medicated cream triamcinolone kept atop of Resident #47's bedside nightstand. Resident #47 stated the morning nurse applied the cream and left the cream at the bedside. During an interview and observation on 07/10/2023 at 03:40 PM, LVN K stated the medication atop of the nightstand was the medicated cream triamcinolone. LVN K stated the medication should be stored in the medication / treatment cart and removed the medication to store it in the medication cart . During an interview on 07/12/2023 at 04:33 PM ADON I stated all medications are to be stored in the medication carts. A record review of the facilities medication labeling, and storage policy dated January 2020, revealed, policy: medications are labeled in accordance with facility requirement and state and federal law. all drug containers will be labeled, and drug labels must be clear, consistent, legible and in compliance with state and federal requirement. there will be a standard method for appropriately and safely labeling medications dispensed to all residents. 676447 Page 11 of 14 676447 07/13/2023 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents were provide the therapeutic diets as prescribed by the attending physician for 1 of 8 residents (#71) reviewed in that: Resident # 71 did not receive his sugar free health shake lunch meal as ordered by physician. This failure could affect residents with diet needs and could result in a decrease in calories and potential weight loss. The Findings were: Record review of Resident #71's admission Record dated 7/13/2023 revealed he was admitted on [DATE] with acute kidney failure, diabetes II and chronic kidney disease Record review of Resident #71's consolidated physician orders for July 2023 documented House Shake-Sugar Free three times a day with meals. Record review of Resident #71's admission MDS dated [DATE] revealed Section C: Cognitive Patterns BIMS score was 11/15 (moderately impaired). Record review of Resident #71's Care plan dated 6/13/2023 revealed Resident #71 for diet, controlled carbohydrate, regular texture, thin liquids., The resident has the potential for nutritional deficit related to diabetic foot ulcer, diet restrictions. The interventions were diabetic diet as ordered and RD (regional dietician) to evaluate and make diet change recommendations as needed. Record review of Resident #71's MAR (medications administration record) dated 7/2023 revealed House Shake -Sugar Free three times a day with meals was provided as ordered. MAR was not completed at time, nurse's work 12-hour shifts. Record review of Resident #71's Diet Type Report dated 7/10/2023 revealed he had a diet supplement of House Shake-Sugar Free with meals. Observation on 7/11/2023 at 1:05 PM in Resident #71's room revealed he received lunch tray for today, with no House Shake-Sugar Free. Interview on 7/11/2023 at 1:06 PM with Resident #71 revealed he often did not get the House Shake-Sugar Free during meals. Resident #71 stated the kitchen runs out to food in the kitchen at times. Interview on 7/13/2023 at 11:33 AM with RD she was not aware the kitchen was out of sugar free shake and the DM (dietary manager) orders food from food company. Observation on 7/12/2023 at 2:42 PM with the DM in the kitchen pantry, observed 3 rows of sugar free shakes. Interview on 7/12/2023 at 2:42 PM the DM stated there were sugar free shakes in the panty and they order them from the food company. They were not sure who told the resident there was not more sugar 676447 Page 12 of 14 676447 07/13/2023 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

F 0808 free shakes. Level of Harm - Minimal harm or potential for actual harm Record review of policy Supplements dated 2021 revealed Nutritional supplements will be provided as ordered to clients whose nutrients needs may be increased. Residents Affected - Few 676447 Page 13 of 14 676447 07/13/2023 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

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 observations, interview and record review revealed the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens in that: Residents Affected - Some The DM used a white towel from the sanitizer bucket under the holding food cart as a sanitizer thermometer testing in between food items. This failure could place residents at risk of cross contamination and food borne illness. The Findings were: Observation on 7/13/2023 at 4:08 PM in kitchen for food temperature, testing with the DM, he used a white towel from a small red bucket. This was labeled sanitizer bucket and was under the holding food cart, to wipe the food thermometer in between food items. Interview on 7/13/2023 at 4:09 PM the DM stated he always had used a towel from the sanitizer bucket to take the food temperature of food items. Interview on 7/13/23 at 4:10 PM [NAME] O stated he had just put a new bucket that was sanitizer and had not used, before the DM used it to take food item temperatures. [NAME] O stated he had not used the sanitizer towel for anything else at the time . Interview on 7/13/2023 at 4:11 PM the Administrator discussed the DM using a towel from the sanitizer bucket to take food item temperatures. She stated she would take care of it and would talk to the DM. The surveyor asked for the policy on food temperature testing in between food items at that time and it was not provided at the exit. 676447 Page 14 of 14