Health inspection·February 13, 2024

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 implement a comprehensive 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 and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #188) of 18 Residents reviewed for comprehensive care plans. -The facility failed to include care plans for Resident #188's use of oxygen therapy. This failure could affect residents receiving care per comprehensive person-centered care plans resulting in resident not being able to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Finding include: Record review of Resident #188's face sheet dated 2-12-2024 revealed she was a [AGE] year-old female resident admitted to the facility originally on 3-27-2019 and readmitted on [DATE] with diagnoses to include acute respiratory failure with hypoxia (sudden failure of lungs to deliver oxygen to the body), Influenza ) a common, sometimes deadly viral infection of the nose, throat, and lungs, also called the flu), major depression (mental illness causing sadness due to lack of chemicals in the brain that cause happiness), falls, anemia (low red blood cell count), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), hypertension (a condition in which the force of the blood against the artery walls is too high), and Rheumatoid Arthritis (autoimmune inflammation of the joints). Record review of Resident #188's clinical record revealed her last MDS assessment was a quarterly completed 1-10-2024 listing her with a BIMS of 15 indicating she was cognitively intact, and she required the use of a walker and partial/moderate assist with her activities of daily living. Record review of Resident #188's Orders form with active orders as of 2-12-2024 revealed the following orders: May use oxygen @ 2 l/m via nasal cannula every day and night shift- Active 1-11-2024. Record review of Resident #188's Oxygen saturation log from 2-1-2024 to 2-11-2024 revealed that Resident #188 was wearing her Oxygen 26 of the 32 times that her oxygen saturation was checked. Page 1 of 6 676455 676455 02/13/2024 Five Points Nursing and Rehabilitation 1625 Point West Parkway Amarillo, TX 79124

F 0656 Record review of Resident #188's care plan with admission date of 1-3-2024 revealed the following: Level of Harm - Minimal harm or potential for actual harm There was no care plan for oxygen therapy. Residents Affected - Few During an observation and interview on 02-12-2024 at 11:15 AM Resident #188 was noted to be wearing her O2 via NC with hydration set at 3L/min. Resident #188 reported that at one time she was down to needing only 1L/min of oxygen therapy but due to her recent hospitalization she was back to needing 3L/min. Resident #188 stated that she hopes that she can get stronger and wean herself from needing oxygen in the future. During an interview on 02-13-2024 at 09:19 AM with MDS B, MDS C, and MDS D all 3 MDS Nurses were asked that since Resident #188 had orders for oxygen therapy, had documentation for monitoring O2 saturations/oxygen therapy, and Resident #188's MDS was marked for O2 therapy why wasn't Resident #188 care planned for oxygen therapy. MDS C stated that if the oxygen therapy is acute the floor nurses will update the care plan and if the oxygen therapy comes across the MDS when the MDS assessment is due then the MDS nurses would update the care plan. All 3 MDS nurses were asked since it was in the MDS then why wasn't Resident #188's care plan updated, none of the MDS nurses responded. When asked what a negative outcome would be for not updating the care plan, MDS C stated that the residents wouldn't receive the care they are planned for. Record review of facility provided policy titled Comprehensive Care Planning, undated, revealed the following: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that include measurable objectives and timeframes to meet a resident medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following-The services that are to be furnished to attain or maintain the resident highest practicable physical, mental, and psychosocial well-being . Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the residents medical, physical, and psychosocial needs. When developing a comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) . 676455 Page 2 of 6 676455 02/13/2024 Five Points Nursing and Rehabilitation 1625 Point West Parkway Amarillo, TX 79124

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to post the following information on a daily basis: facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift--registered nurses, licensed practical nurses, or licensed vocational nurses (as defined under state law), certified nurse aides-and resident census for one of one facility reviewed for posted nurse staffing information. Residents Affected - Few The facility failed to post nurse staffing data as required in that it did not include the current date on posting, posting was dated 01/30/2024. This failure could place residents and visitors at risk of not being informed regarding the current day's nurse staffing levels. Findings included: During an observation on 02/11/2024 at 08:23 AM the nurse staffing posting hanging on the wall hanging next to Nurses station in the center of the facility was dated 01/30/2024. Observation on 02/13/2024 at 08:03 AM revealed the nurse staff posting hanging on the wall next to Nurses station in the center of the facility was dated 12/12/2024. Observation on 02/13/2024 at 10:11AM revealed nursing staff posting hanging on the wall next to the Nurses station in the center of the facility was dated 12/13/2024. Interview on 02/13/2024 at 10:02 AM with ADON, stated that the schedule should be updated on a daily basis. ADON stated, My template that I use the date was not updated to show the correct date. I fixed it the day you guys came in. ADON stated there could be a negative outcome. Interview on 02/13/2024 at 10:07 AM with DON, stated that a negative outcome for not having an updated schedule could lead to staffing ratios not being correct. Interview on 02/13/2024 at 11:14 AM with ADM, stated We do not have a policy regarding schedule posting and that the facility will follow regulations. Record review of the code of Federal Regulations revealed the following guidelines: § 483.35(g) Nurse Staffing Information. § 483.35(g)(1) Data requirements. The facility must post the following information on a daily basis: (i) Facility name. 676455 Page 3 of 6 676455 02/13/2024 Five Points Nursing and Rehabilitation 1625 Point West Parkway Amarillo, TX 79124

F 0732 (ii) Level of Harm - Minimal harm or potential for actual harm The current date. (iii) Residents Affected - Few The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census. 676455 Page 4 of 6 676455 02/13/2024 Five Points Nursing and Rehabilitation 1625 Point West Parkway Amarillo, TX 79124

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. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure foods were properly stored, labeled, and dated. 2. The facility failed to ensure personal items were properly stored. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings include: Observation of the freezer on 2/11/24 at 8:05 AM revealed the following: 1. 2 bags of spinach, no label or date, not in the original box. 2. 1 bag of frozen hash brown patties, no label or date, not in the original box. 3. 2 bags of okra, no label or date, not in the original box. 4. 1 plastic baggie of frozen strawberries, no label or date, not in the original box. 5. 1 plastic baggie of eggrolls with frost inside the bag and on the eggrolls. In an observation and interview of the kitchen food preparation area on 2/11/24 at 8:10 am, a personal drink cup was noted on the kitchen prep table. [NAME] A picked up the personal drink cup and stated the cup was hers. [NAME] A stated she knew she was not supposed to have personal drinks in the kitchen preparation area and the drink should have been kept in the office and not on the prep table. She stated this could contaminate the resident foods that were prepared in the kitchen. Observation of the freezer on 2/12/24 @ 10:05 AM revealed the following: 1. 2 bags of spinach, no label or date, not in the original box. 2. 1 bag of frozen hash brown patties, no label or date, not in the original box. 3. 2 bags of okra, no label or date, not in the original box. 4. 1 plastic baggie of frozen strawberries, no label or date, not in the original box. 5. 1 plastic baggie of eggrolls with frost inside the bag and on the eggrolls. In an interview and a walk through with the DM on 2/12/24 at 2:15 pm, the DM stated of the issues with the food not being labeled and dated in the freezer was that it was just missed. The DM stated she trained staff and did in-services frequently on labeling and dating and keeping personal items 676455 Page 5 of 6 676455 02/13/2024 Five Points Nursing and Rehabilitation 1625 Point West Parkway Amarillo, TX 79124

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many out of the kitchen prep areas. The DM stated she expected all staff to label and date all food items after they use the package. The DM stated the consequences of not labeling and dating foods could cause residents to have food borne illnesses. The DM stated [NAME] A was just nervous when she left the personal cup on the kitchen preparation table. The DM stated [NAME] A knew she was supposed to keep personal items out of the kitchen preparation area. The DM stated she has a place in her office where staff are to store the personal items. Record Review of the policy titled, Work Conduct, in the Dietary Services Policies and Procedures Manual updated 10/23/23, documented all personal belongings must be kept out of the food preparation area. Record Review of the policy titled, Sanitation and Food Handling, in the Dietary Services Policies and Procedures Manual updated 10/23/23, documented all food items were to be labeled and dated as to their content. Store items in their original container unless otherwise directed to do so. 676455 Page 6 of 6