Health inspection·September 22, 2022

F 0695 dated [DATE]. The concentrator was running at four liters per minute. Level of Harm - Minimal harm or potential for actual harm Observation on [DATE] at 1:50 p.m. revealed Resident #14 lying asleep in her bed with her nasal cannula applied and oxygen concentrator in the same condition as the day before: dusty with an empty humidifier bottle and running at four liters per minute. Skin around the resident's nose was not visibly irritated or broken down. Residents Affected - Few Review of the face sheet for Resident #90 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of cerebral infarction (dead tissue in the brain as a result of the loss of blood supply), atrial fibrillation, heart failure, and anxiety disorder. Review of the significant change MDS for Resident #90 dated [DATE] reflected she was receiving oxygen therapy. Review of the care plan for Resident #90 dated [DATE] reflected the following: The resident has Shortness of Breath requiring O2 via NC. The resident will have no complications related to SOB though the review date. Assist resident/family/ caregiver in learning signs of respiratory compromise. Refer significant other/caregiver to participate in basic life support class for CPR, as appropriate. Encourage sustained deep breaths by: Using demonstration (emphasizing slow inhalation, holding end inspiration for a few seconds, and passive exhalation), Using incentive spirometer (place close for convenient resident use), Asking resident to yawn. Maintain a clear airway by encouraging resident to clear own secretions with effective coughing. If secretions cannot be cleared, suction as needed to clear secretions. Monitor /document changes in orientation, increased restlessness, anxiety, and air hunger. Monitor/document breathing patterns. Report abnormalities to MD: Nasal flaring, Respiratory depth changes, Altered chest excursion, Use of accessory muscles, Pursed-lip breathing or prolonged expiratory phase, Increased anteroposterior chest diameter. Monitor/document/Report breathing abnormalities to MD. Review of physician orders for Resident #90 reflected the following, dated [DATE] May use oxygen @2-5 L via nc for SOB to maintain greater than 90% and the following, dated [DATE]: Change oxygen/neb tubing weekly. Time and date. Observation on [DATE] at 8:51 a.m. revealed Resident #90 lying in bed asleep with a nasal cannula applied to both nostrils and connected to an oxygen concentrator. The humidifier bottle was almost empty with less than an eighth of an inch of water inside. Observation on [DATE] at 3:25 p.m. revealed the humidifier bottle on Resident #90's oxygen concentrator was empty. The concentrator was running at four liters per minute. During an interview on [DATE] at 12:28 p.m., LVN B stated she was the charge nurse for Resident #14 that day. She stated she was from a staffing agency and did not know everything about the residents, but she knew the oxygen tubing and humidifier bottle should have been changed every Sunday night by the overnight charge nurse or as needed by the halls' charge nurse. She stated that, if the humidifier bottle was empty during the week, the charge nurse should have changed it. She stated sometimes the CNAs would notice the bottle was empty and let the charge nurses know. She stated it was important to change out the humidifier bottle to keep the resident's nose and throat moist and comfortable. She stated she had not received any specific training or in-servicing on oxygen concentrator and tubing maintenance since she had been working at the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676462 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Anthony's Care Center 7501 Bagby Ave. Waco, TX 76712 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on [DATE] at 12:35 p.m., LVN C stated he was the charge nurse for Resident #90. He stated it was the charge nurse's responsibility to monitor and maintain the oxygen concentrator and tubing. He stated they had an overnight shift charge nurse who changed the tubing every week on a certain night but was not sure which night that was. He stated, if they saw a humidifier bottle empty, they were to replace it. He stated they monitor by using their own observations and relying on reports from CNAs, the resident, and the resident's family. He stated the humidifier kept the nose and throat from drying out during continuous oxygen therapy. He stated they received training off and on and discuss issues such as oxygen therapy at meetings. He stated he could not remember a specific training about oxygen therapy. During an interview on [DATE] at 12:39 p.m., the MDSN stated the humidifier bottle should have always been replaced when it was empty, because they did not want the nostrils to be dry and bleeding. She stated they needed to have the humidity there to keep the nostrils and throat moist so the resident would not be uncomfortable. During an interview on [DATE] at 1:10 p.m., the DON stated humidifier bottles on the oxygen concentrator should have contained water at all times, and they should be a part of the orders to change the tubing each week. She stated the bottles were pre-filled and sterile, so they were easy to replace. She stated the charge nurses should have changed the tubing and bottle out each Sunday night, wipe down the concentrator, and make sure the filter was clean. She stated when she learned the humidifier bottles had sat empty for a couple of days, she updated the orders to include the bottle. She stated that should have been in the orders all along. She stated the charge nurses were responsible for entering orders into the EMR. She stated the humidifier bottle was necessary and did affect the oxygen delivery. She stated the ambient air was probably humid enough to hydrate a resident's nostrils. She stated continuous oxygen therapy could dry out sinuses and cause discomfort and skin breakdown. She stated she thought there had been in-servicing on oxygen therapy. She stated it was her responsibility and that of the ADONs to monitor for compliance. During an interview on [DATE] at 2:31 p.m., the ADM stated there had not been one person responsible for monitoring that oxygen concentrators were properly cleaned and stocked. She stated each charge nurse should have been responsible for their hall's oxygen concentrators, but the Sunday night charge nurses on the 10 p.m. to 6 a.m. shift were responsible for changing out the tubing and humidifier bottles. She stated the humidifier bottle should have contained water on the concentrator and been dated, and the filters should have been cleaned. She stated the DON maintained accountability for ensuring the procedure was upheld. She stated she had assumed the DON was following up, but they would put more accountability in place. She stated she did not know exactly why they used the humidifiers on the oxygen concentrators, but she thought it might be to keep the nose moist so that it was more comfortable for the residents. She stated she did not know the potential consequence for not having water in the humidifier bottle. Review of in-services from [DATE] to [DATE] reflected no in-servicing related to oxygen therapy or respiratory care. Review of undated guidance from the American Lung Association found at Oxygen Delivery Devices and Accessories | American Lung Association reflected the following: A humidifier is required for oxygen flows at over 4 liters per minutes (continuous). The type of humidifier you use will depend on your type of home oxygen and how much oxygen you need. A humidifier can help ease the nose and sinus dryness that can come with oxygen use. The humidifier should always remain level so water does not spill into the tubing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676462 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Anthony's Care Center 7501 Bagby Ave. Waco, TX 76712 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Review of undated facility policy titled Respiratory Care reflected that oxygen should be administered according to physician orders and clinical standards of practice. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676462 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Anthony's Care Center 7501 Bagby Ave. Waco, TX 76712 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm 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** Tag 761-D Residents Affected - Few Based on observation, interview and record review the facility failed to ensure all drugs and biological medications were not past their expiration dates and/or discontinued for 2 (two) of 2 (two) Nurses Medication Carts (Hall 100/600 Cart and Hall 200/400 cart) reviewed. The facility failed to ensure expired and/or discontinued medications were removed from the carts. This failure could place residents at risk of not receiving the intended therapeutic benefits of their medications or of receiving medications not prescribed for them. Findings include: Observation and interview on [DATE] at 10:15 a.m. of Hall 200/400 nurse's medication cart revealed Prednisone (a steroid medication) 20mg tablet bottle with no expiration date indicated on the bottle. LVN A stated, I don't see a date written on it. During an interview on [DATE] at 10:31 a.m., the DON stated she was not able to find the expiration date on the Prednisone (a steroid medication) bottle. After checking the computer records, DON stated, This medication has been exhausted or discontinued and should have been pulled out. The medication has been exhausted referring to resident has completed taking the medication for the given time. Observation on [DATE] at 10:40 a.m., on Hall 100/600 nurse's medication cart revealed a bottle of Hibiclens (used for cleaning the wounds) with expiration date 05/2022. During an interview on [DATE] at 1:30 p.m., LVN A stated the nurses are mainly responsible for removing medication that are discontinued as soon as the medication are discontinued. The discontinued medications get put into the discontinued box inside the medication room. LVN A stated it's important to removed discontinued medications so the medication would not be administered to residents. LVN Astated adverse effect of administering expired medication could possibly cause some kind of reaction to the residents. During an interview on [DATE] at 1:39 a.m., the DON stated when medications are discontinued or exhausted the medications should be removed from the med cart. Either the nurse or medication aide are responsible to remove the discontinued medication from the cart. The DON stated it is important to remove the discontinued medication from the cart to prevent medication error or to prevent from being administered to residents and could prevent misappropriation depending on what the medication are. The DON stated pharmacist from the pharmacy audits medication carts on their visits. The DON stated, pharmacy did not do a medication cart audit in [DATE] and last time the audit was done was in August of 2022. During an interview on [DATE] at 2:30 p.m., the ADM stated all staff are in-served by ADON regarding discontinued medications to be removed from the medication carts. Admin stated DON and ADON are responsible to ensure the medication carts does not have discontinued medications and Pharmacy is also responsible to ensure medication audits are conducted at the time of the visit. The Admin stated it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676462 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Anthony's Care Center 7501 Bagby Ave. Waco, TX 76712 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete is important to removed discontinued medication from the medication cart so that wrong dosage will not be administered and to leave no room for error. Record review of facility's policy of Discontinued Medication reflected: 2. Medications are removed from the medication cart immediately upon receipt of an order to discontinue avoiding inadvertent administration. Event ID: Facility ID: 676462 If continuation sheet Page 6 of 6