Health inspection·October 26, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and protect and promote the rights of the Resident, for 3 of 25 (Resident #215, Resident #42, Resident #214) residents reviewed for dignity, in that; 1. The facility failed to ask Resident #215 and Resident #42 if they wanted to wear a clothing protector around their neck to protect their clothes from getting dirty, while they had their meal. Resident #215 did not want to wear the clothing protector on 10/23/2023 and 10/25/2023 lunch. Resident #42 did not want to wear a clothing protector around her neck for 10/25/2023 lunch. 2. The facility failed to give Resident #214 an egg roll that she ordered and was looking forward to, for 10/25/2023 lunch. This failure placed residents at risk for diminished quality of life, loss of dignity, and self-worth. The findings included: 1. A record review of Resident #215's admission record on 10/23/2023 revealed an admission date of 09/25/2023 with diagnoses which included cerebral infarction (stroke), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), major depressive disorder, and cognitive communication deficit. A record review of Resident #215's MDS assessment dated [DATE] revealed Resident #215 had a BIMS score of 05/15 indicating severe mental cognition impairment. A record review of Resident #215's care plan dated 10/23/2023, revealed, focus of My resident rights will be respected and maintained through the review date. With an Intervention/Task of Dignity and respect: *be treated with dignity, courtesy, consideration, and respect . Freedom of choice: I have the right to: make my own choices regarding personal affairs, care, benefits, and services . A record review of Resident #42's admission record revealed an admission date of 10/26/2023 with diagnoses which included major depressive disorder, cognitive communication deficit, and generalized anxiety disorder (mental health condition that causes fear, worry and a constant feeling of being overwhelmed). Page 1 of 18 745001 745001 10/26/2023 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A record review of Resident #42's MDS assessment dated [DATE] revealed Resident #42 had a BIMS score of 13/15 indicating intact cognition. A record review of Resident #42's care plan dated 10/26/2023, revealed focus of My resident rights will be respected and maintained through the review date. With an Intervention/task of Dignity and respect: *be treated with dignity, courtesy, consideration, and respect . Freedom of choice: I have the right to: make my own choices regarding personal affairs, care, benefits, and services . Observation on 10/23/2023 at 12:16 PM, out of 22 residents in the dining room for lunch, Resident #214 was observed with no maroon-colored clothing protector around her neck. Resident #214 reported on 10/23/2023 at 12:19 PM that she did not need the clothing protector. Resident #215 was wearing a clothing protector and was later interviewed. Observation on 10/25/23 at 12:23 PM revealed 23 residents in the dining room for lunch meal. 5 out of 23 residents were observed with no maroon-colored clothing protectors around their neck. Staff were observed asking if residents wanted a clothing protector or not. During an interview on 10/23/2023 at 12:32 PM with Resident #215, he revealed that he did not like the clothing protector around his neck. He reported that he doesn't want enemies and sometimes it's better not to say anything. He reported that staff put it on him without asking. During an interview on 10/25/2023 at 12:18 PM, Resident #42 blew a raspberry (made a sputtering noise by pressing the tongue and lips together) when asked if she liked the maroon-colored clothing protector around her neck. Resident #42 then revealed that she did not like the clothing protector because food still fell through it and she forgot to take it off sometimes. During an interview on 10/26/2023 starting at 5:35 PM, the DON revealed that staff are supposed to ask if the resident would like to wear a clothing protector. This would cause a resident to be embarrassed. The DON revealed that they do not want the residents to be treated differently by putting the clothing protector if they did not want it on. 2. A record review of Resident #214's admission record on 10/25/2023 revealed an initial admission date of 06/12/2023 and was re-admitted [DATE] with diagnoses which included generalized muscle weakness, abnormalities of gait and mobility, and other lack of coordination. A record review of Resident #214's MDS assessment dated [DATE] revealed Resident #214 had a BIMS score of 14/15 indicating intact cognition. A record review of Resident #214's care plan dated 10/25/2023, revealed, focus of My resident rights will be respected and maintained through the review date. With an Intervention/task of Dignity and respect: *be treated with dignity, courtesy, consideration, and respect . Freedom of choice: I have the right to: make my own choices regarding personal affairs, care, benefits, and services . During an observation and an interview on 10/25/2023 at 1:08 PM, Resident #214 revealed that she did not receive an egg roll when her meal ticket revealed that she had an egg roll selected to receive for 10/25/2023 lunch. Resident reported that she was disappointed that she did not get her egg roll because she was looking forward to having it for lunch. During an interview on 10/25/2023 at 1:08 PM the RD confirmed that Resident #214's lunch meal tray 745001 Page 2 of 18 745001 10/26/2023 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ticket had an egg roll on her ticket and there was no egg roll on the plate. Resident #214 then confirmed with the RD that she did not receive an egg roll. During an interview on 10/25/2023 starting at 1:18 PM, the RD revealed that there were no more egg rolls available in the kitchen. The RD reported that he did not like it when there was not enough food for all of the trays. The RD further revealed that residents who did not receive their food requests was an issue because a lot of times residents looked forward to their meals. During an interview on 10/26/2023 starting at 5:35 PM, the DON revealed that she would feel upset and disappointed if she did not receive what she wanted at mealtime. During an interview on 10/26/23 at 6:40 PM, the ADMN revealed that he wanted to have the residents happy and fulfilled, so residents needed to get what they wanted to eat, when it was revealed that a resident did not receive an egg roll that she ordered. He further revealed that food was one of the pleasures that they provided for their residents as things get taken away from them as a part of life. A record review of the Resident Rights policy, reviewed December 2022, states Employees shall treat all residents with kindness, respect and dignity. And 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; h. be supported by the facility in exercising his or her rights; 745001 Page 3 of 18 745001 10/26/2023 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement their written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents for 15 of 26 staff (ADMN, ADON, DM, AD, RN J, RN K, LVN D, LVN L, CNA M, CNA N, CNA O, RA P, Hskg Q, Recept R, MR S) reviewed for abuse and neglect, in that: Residents Affected - Some The facility failed to implement their abuse policy when the ADMN, ADON, DM, AD, RN J, RN K, LVN D, LVN L, CNA M, CNA N, CNA O, RA P, Hskg Q, Recept R, MR S's annual EMR was not completed in the past year. This failure could place residents at risk for abuse and neglect. The findings were: Record review of facility policy titled Abuse, Neglect, Exploitation, Mistreatment of Resident, or Misappropriation of Resident Property, reviewed 08/2017 which read 5. [ .] Screening: Potential employees will be screened, per federal &/or state regulation, [ .] Screening will consist of: [a] Inquiries into the State licensing authorities [b] Inquires into State nurse aide registry [ .]. 1. Record review of the Staff Roster, undated, revealed the ADMN was hired on 06/18/2021. Record review of the ADMN's staff records revealed the ADMN's last searched EMR, provided by the facility, was dated 10/24/2023. 2. Record review of the Staff Roster, undated, revealed the ADON was hired on 08/15/2022. Record review of the ADON's staff records revealed the ADON's last searched EMR, provided by the facility, was dated 07/28/2022. 3. Record review of the Staff Roster, undated, revealed the DM was hired on 09/09/2015. Record review of the DM's staff records revealed the DM's last searched EMR, provided by the facility, was dated 05/17/2022. 4. Record review of the Staff Roster, undated, revealed the AD was hired on 05/19/2021. Record review of the AD's staff records revealed the AD's last searched EMR, provided by the facility, was dated 05/24/2022. 5. Record review of the Staff Roster, undated, revealed the RN J was hired on 08/23/2022. Record review of the RN J's staff records revealed the RN J's last searched EMR, provided by the facility, was dated 08/18/2022. 6. Record review of the Staff Roster, undated, revealed the RN K was hired on 06/01/2021. Record review of the RN K's staff records revealed the RN K's last searched EMR, provided by the facility, was dated 05/24/2022. 745001 Page 4 of 18 745001 10/26/2023 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

F 0607 7. Record review of the Staff Roster, undated, revealed the LVN D was hired on 10/28/2022. Level of Harm - Minimal harm or potential for actual harm Record review of the LVN D's staff records revealed the LVN D's last searched EMR, provided by the facility, was dated 10/24/2022. Residents Affected - Some 8. Record review of the Staff Roster, undated, revealed the LVN L was hired on 10/28/2022. Record review of the LVN L's staff records revealed the LVN L's last searched EMR, provided by the facility, was dated 10/24/2022. 9. Record review of the Staff Roster, undated, revealed the CNA M was hired on 02/09/2022. Record review of the CNA M 's staff records revealed the CNA M's last searched EMR, provided by the facility, was dated 02/04/2022. 10. Record review of the Staff Roster, undated, revealed the CNA N was hired on 05/18/2022. Record review of the CNA N 's staff records revealed the CNA N's last searched EMR, provided by the facility, was dated 05/11/2022. 11. Record review of the Staff Roster, undated, revealed the CNA O was hired on 11/24/2021. Record review of the CNA O 's staff records revealed the CNA O's last searched EMR, provided by the facility, was dated 05/04/2022. 12. Record review of the Staff Roster, undated, revealed the RA P was hired on 12/12/2017. Record review of the RA P's staff records revealed the RA P's last searched EMR, provided by the facility, was dated 05/17/2022. 13. Record review of the Staff Roster, undated, revealed the Hskg Q was hired on 05/24/2021. Record review of the Hskg Q 's staff records revealed the Hskg Q's last searched EMR, provided by the facility, was dated 05/24/2022. 14. Record review of the Staff Roster, undated, revealed the Recept R was hired on 06/03/2022. Record review of the Recept R's staff records revealed the Recept R's last searched EMR, provided by the facility, was dated 06/02/2022. 15. Record review of the Staff Roster, undated, revealed the MR S was hired on 07/14/2021. Record review of the MR S 's staff records revealed the MR S's last searched EMR, provided by the facility, was dated 10/24/2023. During an interview and record review, of EMR's still needed by several staff, on 10/26/2023 at 3:44 p.m., HR stated he was aware of the required annual EMR's but he was not aware that he needed to print them for the staff member's file. He stated the potential harm to residents depended on the staff member's background for abuse. 745001 Page 5 of 18 745001 10/26/2023 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview and record review, of EMR's still needed by several staff, on 10/26/2023 at 6:34 p.m., the DON stated she was aware of the required annual EMR. She stated HR was who ran and looked up the information but the IDT staff were who ensured it was completed. The DON stated the potential harm to resident depended on what the EMR showed for that staff member's background. During an interview and record review, of training still needed by several staff, on 10/26/2023 at 7:14 p.m., the ADMN stated he was aware of the required EMR. He stated the Administration staff was who ensured it was completed. The ADMN stated the potential harm to a resident was if the staff member's records showed they should not be working in a nursing home because of a criminal history. 745001 Page 6 of 18 745001 10/26/2023 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that the assessments accurately reflected the resident's status for 1 of 29 residents (Resident #57) reviewed for resident assessments, in that: Residents Affected - Few The facility failed to ensure Resident #57's discharge MDS, dated [DATE], was coded as a hospital discharge instead of a community discharge. This deficient practice could place residents at risk of not having their individually assessed needs met. The findings were: Record review of Resident #57's face sheet, dated 10/26/2023, revealed the resident was admitted to the facility on [DATE] with the diagnoses that included: end stage renal disease, vascular dementia without behavioral disturbance, and major depressive disorder. Record review of Resident #57's Quarterly MDS, 09/12/2023, revealed on A2100. Discharge status entered as 01. Community instead of 03. Acute Hospital. Record review of Resident #57's Progress Notes, dated 10/26/2023, note entered 09/12/2023 at 2:18 p.m., revealed As per family request resident to be sent to University [name of hospital] due to altered mental status. Further review of progress notes did not reveal resident returned from the hospital. During an interview and record review of Resident #57's discharge MDS on 10/26/2023 at 4:21 p.m., the MDS Coordinator confirmed discharge MDS was coded as community and needed to be acute hospital. The MDS Coordinator was unable to recall why it was coded incorrectly. She stated the potential harm to resident was mental harm because the record was not accurate. During an interview on 10/26/2023 at 6:39 p.m., the DON stated the MDS Coordinator was responsible for coding the MDS' but that she, as the DON, looked over the information and signed off on it. The DON stated she believed there was no potential harm to the resident because he was already in a higher level of care than a nursing home. During an interview on 10/26/2023 at 7:16 p.m., the Administrator stated the MDS Coordinator and BOM were ultimately responsible to ensure MDS' were coded correctly. The Administrator stated there was always a potential harm to the resident but none noted at this time. Record review of the facility's policy titled, MDS Correction, revised 12/2022, revealed, The Assessment Coordinator and/or the Interdisciplinary Assessment Team will follow the established processes for making corrections to the MDS. 745001 Page 7 of 18 745001 10/26/2023 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 3 of 25 residents (Resident #28, #29, and #37) for care plan revisions, in that: 1. The facility failed to ensure Resident #28's care plan was revised to indicate the residents change in code status. 2. The facility failed to ensure Resident #29's and Resident #37's care plan was revised to include tube feedings. These failures could place residents at risk of receiving inappropriate care. The findings include: 1. Record review of Resident #28's face sheet dated 10/24/2023 revealed an initial admission date of 09/11/2023 with a most recent admission of 10/03/2023 and diagnoses which included: acute posthemorrhagic anemia (acute blood loss anemia), gastrointestinal hemorrhage (bleeding from the gastrointestinal tract) and adult failure to thrive (insufficient weight gain, loss of appetite). Further review of Resident #28's face sheet, revealed under the section DNR. Record review of Resident #28's Quarterly MDS assessment, dated 10/09/2023, revealed the resident's BIMS score was 04, which indicated severe cognitive impairment. Record review of Resident #28's care plan, last review date 10/10/2023, revealed I am a Full Code and If found absent of vital signs initiate CPR. Record review of Resident #28's electronic medical record Order Summary Report, Active Orders as of 10/24/2023, revealed an order dated 10/12/2023 for DNR. Record review of Resident #28's electronic clinical record revealed an OOH-DNR signed by Resident #28, dated 10/12/2023. 2. Record review of Resident #29's face sheet dated 10/23/2023 revealed an initial admission date of 08/08/2022 and diagnoses which included: senile degeneration of brain (cognitive decline, particularly memory loss), muscle wasting and atrophy (thinning or lose of muscle tissue), and dysphagia (difficulty in swallowing food or liquid) following cerebrovascular disease (conditions that impact the blood vessels in your brain). Record review of Resident #29's MDS assessment, dated 10/15/2022, revealed the resident's BIMS score was 13/15, which indicated intact cognition. Further review of the MDS assessment indicated Resident #29 had received tube feedings prior to and while being a resident, receiving 51% or more of total calories and 501 cc/day or more through tube feedings. Record review of Resident #29's care plan, dated 10/23/2023, revealed a Focus of (Resident #29) require tube feeding and also has Regular diet, 4)texture, 0) liquids when family request or therapy (has waiver), revised on 11/17/2022 with an Intervention/Task of FiberSource HN 60 mL/hour x22=1320mL 745001 Page 8 of 18 745001 10/26/2023 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

F 0657 formula/1584kcals/71gr. Protein/1063mL free water. 150ml flushes q6 hours via g-tube. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #29's electronic medical record Order Summary Report, Active Orders as of 10/23/2023, revealed an order dated 07/31/2023 for FiberSource HN 70mL/hour x 22=1540mL formula/1848kcals/81 gr. Protein/1212mL free water. 150ml flushes q6 hours via g-tube. Residents Affected - Some Record review of Resident #37's face sheet dated 10/26/2023 revealed an initial admission date of 09/09/2023 and diagnoses which included: adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, gastrostomy status (artificial opening to the stomach), and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Record review of Resident #37's MDS assessment, dated 10/02/2023, revealed the resident could not have a BIMS conducted. The Staff Assessment for Mental Status revealed resident had both short- and long-term memory problems. It was further revealed that resident had severely impaired cognitive skills for decision making. Further review of the MDS assessment indicated Resident #37 had received tube feedings during the entire last 7 days, receiving 51% or more of total calories and 501 cc/day or more through tube feedings. Record review of Resident #37's care plan, dated 10/23/2023, revealed a Focus of I require tube feeding r/t dementia and AFTT with pocketing food behavior, initiated 09/11/2023, with no specific tube feeding orders. Record review of Resident #37's electronic medical record Order Summary Report, Active Orders as of 10/23/2023, revealed an order dated 10/10/2023 for Jevity 1.5 @65cc/hr for 22hrs/day. Record Review of HPSI (acronym not found) Policy & Procedure Manual, Guidelines for the Food and Nutrition Services Department, Copyright 2017 revised, revealed Section H. Nutrition Care IV. Nutrition Support and Interventions .B. Total Enteral Feeding (TEN) Procedure: 7. The Registered Dietitian Nutritionist (RDN) reviews residents on TEN monthly unless otherwise indicated by a resident's condition All progress notes are placed in the medical record and the care plan is updated to current condition of resident. During an interview on 10/26/23 starting at 4:24 PM, the MDS coordinator revealed that Resident #28 is DNR but confirmed that Resident #28's care plan stated that resident was a Full Code. The MDS Coordinator reported that if the care plan was not updated to a code status of Full Code, that consequences could be catastrophic. The MDS coordinator revealed that she looked over care plans to make sure they are updated. Other staff, like the DON and ADON, helped update care plans too. During an interview on 10/26/23 at 5:35 PM, the DON revealed that Resident #28 is coded DNR but the care plan revealed that the resident's code status is Full Code. During an interview on 10/26/2023 starting at 5:35 PM, the DON confirmed that the Order Summary Report printed on 10/23/2023 for Resident #29 did not have the updated tube feeding order, which could cause the resident to not get enough calories and protein which could affect their wound healing and weight. During an interview on 10/26/23 at 7:00 PM, the ADMN revealed that care plans existed to know how to take care of residents and meet their needs. 745001 Page 9 of 18 745001 10/26/2023 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

F 0657 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, reviewed December 2022, revealed, 13. Assessments of residents are on-going and care plans are revised as information about the residents and residents' condition change. Residents Affected - Some 745001 Page 10 of 18 745001 10/26/2023 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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, interviews and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one resident (Residents #43) out of 5 residents reviewed for medication administration, in that: The facility failed to ensure Resident #43 received Acetylcysteine [a medication to help thin and loosen mucus in the airways due to certain lung diseases], and Baclofen [a medication for the treatment of muscle spasms] on 10/25/2023 as ordered. This failure could place residents at risk for not receiving the intended therapeutic effects of their medications and result in a diminished quality of life. The findings include: Record review of the admission Record revealed Resident #43 was a [AGE] year-old male originally admitted on [DATE]. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #43's primary reason for admission was for stroke [disruption of blood flow to the brain that causes brain cell death]. Other active diagnoses included hemiplegia/hemiparesis [slight weakness to paralysis on one side of the body], muscle weakness, abnormalities of gait and mobility, lack of coordination, and asthma. Resident #43 had a BIMS summary score of 14 indicative of intact cognition. Resident #43 received pain medication in the previous 5 days of the assessment. Record review of the Order Summary Report printed 10/25/2023 revealed Resident #43 had active physician orders for: physical therapy skilled services three times per week with an order date of 9/20/2023; skilled occupational therapy services three times per week with an order date of 9/21/2023; acetylcysteine oral capsule 500 milligram 1 capsule via PEG tube [percutaneous endoscopic gastrostomy tube allowing nutrition, fluids or medications into the stomach] one time a day with a start date of 9/11/2023; baclofen oral tablet 5 milligram 1 tablet by mouth two times a day with a start date of 10/11/2023. Record review of the Care Plan revealed Resident #43 had a focus area of altered respiratory status, with the associated intervention of administer medications as ordered with a start date of 5/12/2023. Resident #43 had a focus area of hemiplegia/hemiparesis with the associated intervention of give medications as ordered with a start date of 5/12/2023. Resident #43 had a focus area of pain related to impaired mobility with the associated intervention of administer analgesia as per orders; give before treatments or care with a start date of 5/12/2023. Record review of Medication Administration Record, printed 10/26/2023, revealed Resident #43's acetylcysteine and baclofen administrations for the 9:00 AM doses on 10/25/23 were coded as not administered 9 = Other/See Nurses Notes by LVN A. In an observation and interview on 10/25/2023 at 9:19 AM, LVN A prepared medications for Resident #43 that did not include the scheduled dose of acetylcysteine or baclofen. LVN A stated the 745001 Page 11 of 18 745001 10/26/2023 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medications were, currently, not available. LVN A stated acetylcysteine was ordered on 10/17/2023, which was before it ran out. LVN A stated baclofen was ordered on 10/22/2023 and was before it ran out. Resident #43 stated that the baclofen made therapy easier, and he (Resident #42) expressed he was glad that at least had the tramadol on board. LVN A stated she would order the medications again and hope they will be here soon. LVN A stated when there is only a few days left of the medication, that is when you send an electronic message from the MAR to the pharmacy to send a new card of medication. Record review of Medication Administration Record, printed 10/26/2023 at 3:56 PM, revealed Resident #43's acetylcysteine and baclofen administrations for the 9:00 PM dose on 10/25/23 and for the 9:00 AM dose on 10/26/2023 were coded as administered by scheduled nursing staff. In an interview on 10/26/2023 at 6:48 PM, the DON stated, everyone was made aware of the medications needing to be refiled. The DON stated Resident #43 received the medication as soon as it was received in the building. The DON stated the expectation is medications were ordered in a timely manner in order to manage the resident's pain. The DON stated she was not sure why the medication was not received sooner. The DON stated she would investigate further into the issue. The DON stated there could be potential harm to the resident because of his pain level not being managed either by him not being comfortable or in discomfort. Record review of Medication Administration General Guidelines dated 12/2022, revealed under the subheading Medication Administration, step 1.) Medications are administered in accordance with written orders of the prescriber. Record review of the topic Pain Management of the Clinical Programs Manual, undated, revealed, under step 6e.) Maintain prescribed levels; ensure medications are taken on time even if asymptomatic unless ordered PRN. Under step 9.) Utilize adjuvant medications for pain control, when appropriate, including but not limited to: .muscle relaxants for treatment of skeletal muscle pain. 745001 Page 12 of 18 745001 10/26/2023 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

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. Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys in 1 medication carts of 6 medication carts (Treatment Cart 300-hallway) reviewed for medication storage, in that; The facility failed to ensure the Treatment Cart 300-hallway was locked when left unattended in the hallway. This deficient practice could place residents at risk of medication misuse or drug diversion. The findings were: In an observation on 10/25/2023 at 8:50 AM, the Treatment Cart on the 300-hallway was unlocked and unattended. The Treatment Cart contained prescription and over the counter medications related to skin and wound care. There were ambulatory residents and visitors in the immediate vicinity. Staff were seated at the 300-hallway nurses' station but could not see the Treatment Cart from their position. In an interview on 10/25/2023 at 8:54 AM, LVN D stated the Treatment Cart was her responsibility. LVN D stated she had been at the cart until just a few minutes prior preparing for the wound care practitioner to provide care to residents but had been called away by a co-worker for another, urgent task. LVN D stated she knew the Treatment Cart should not have been left unlocked and unattended before she left the area. LVN D stated the Treatment Cart had been left unlocked and unattended less than 5 minutes. LVN D ended the interview stating the wound care practitioner was waiting for her and she needed to attend to that task now. In an interview on 10/26/2023 at 6:46 PM, the DON stated she had been made aware the Treatment Cart was left unlocked and unattended. The DON explained that nurses would work on tasks together that required access to the Treatment Cart. The DON stated the primary nurse responsible for the Treatment Cart had stepped away while the wound care practitioner was still obtaining supplies from that Treatment Cart. The DON stated that the nurse with the keys is responsible for the security of the Treatment Cart. The DON stated the Treatment Cart contained items needed for the cleaning or treatment of skin issues, and if a resident had an allergy, or slipped and fell, or ingested something from the cart, there could be potential for harm to a resident. Record review of Storage of Medications dated 12/2022, revealed a policy statement of, store all drugs and biologicals in a safe, secure and orderly manner. Under the heading, Policy Interpretation and Implementation, step 7.) Compartments containing drugs and biologicals shall be locked when not in use .or otherwise potentially available to others. 745001 Page 13 of 18 745001 10/26/2023 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observations, interviews, and record reviews, failed to provide a therapeutic diet which was prescribed by the attending physician for two residents (Resident #4 and Resident #7) out of 8 residents reviewed for therapeutic diets, in that: 1. The facility did not serve Resident #4 a minced & moist diet and a magic cup for lunch as prescribed by the attending physician. 2. The facility did not serve Resident #7 soft & bite sized potatoes & onions as was reflected in his 10/24/2023 lunch meal tray ticket and the recipe. The facility did not change Resident #7's diet on for 10/24/2023 lunch from a soft & bite sized diet to a minced & moist diet as was revealed as a doctor's order on 10/23/2023. These failures could place residents who received food from the kitchen at risk for decreased meal satisfaction, potential weight loss due to poor meal intake, not having their nutritional needs met, and a decline in health status. The findings were: 1. A record review of Resident #4's face sheet on 10/25/2023 revealed an initial admission date of 05/10/2022 and was readmitted [DATE] with diagnoses which included aphasia (loss or impairment of the power to use or comprehend words usually resulting from brain damage) and dysphagia (difficulty in swallowing food or liquid) following cerebral infarction (stroke), muscle wasting and atrophy, altered mental status. A record review of Resident #4's MDS assessment dated [DATE] revealed BIMS should not be conducted for Resident #4 due to cognitive skills for daily decision-making being severely impaired and there are short-term and long-term memory problems present. A record review of Resident #4's care plan dated 10/25/2023, revealed, focus of I have a nutritional problem or potential for nutritional problem r/t dysphagia with Interventions/Tasks of Monitor/document/report to MD PRN for s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. A record review of Resident #4's Doctor's order revealed resident had an Regular diet Minced &Moist texture, Thin . Ice cream and soup with lunch and dinner with an order date of 06/14/2023. Record review of HPSI (unable to find acronym meaning but it's defined as an Avendra Group Company) Diet manual, copyright 2023 revised HPSI provides five levels of mechanically altered foods: Mechanical Soft/Ground (mastication issues), Dysphagia Diets (difficulty in swallowing): Puree (Level 4); Minced & Moist (Level 5 - MM5); Soft & Bite Sized (Level 6 - SB6), EC7 (Level 7). The HPSI Dysphagia Diets and Easy to Chew EC7 are following the guidelines of the International Dysphagia Diet Standardization Initiative (IDDSI framework). The facility used pureed, minced & moist, soft & bite sized, and regular diets. Record review of HPSI Diet manual, copyright 2023 revised, revealed Minced & Moist diet is defined 745001 Page 14 of 18 745001 10/26/2023 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some as: A diet used in the management of dysphagia with the food texture prepared as minced and moist. The food can be scooped and shaped into a ball shape and the size of the lump must be no greater than 4 mm x 15 mm (approximately 1/8-inch x 1/2-inch pieces) for adults. Biting is not required with this diet and only minimal chewing is needed. The foods are easily mashed with a fork and have no separate thin liquids. Record review of HPSI Diet manual, copyright 2023 revised, revealed, Soft & Bite Sized diet is defined as: A diet used in the dietary management of dysphagia with the food texture to be prepared as soft, tender, and moist with no separate thin liquid. The particle size of the food should be no greater than 15 mm x 15 mm (approximately 1/2 x 1/2 pieces) for adults. Biting is not required, but chewing is required. The diet does require the resident to have adequate tongue force to move the bolus to prevent aspiration. And All prepared food should be tested for texture and piece size before service. During an observation and a combined interview on 10/25/2023 with the RD and Resident #4's significant other, starting at 12:58 PM, Resident #4 received a soft and bite sized meal instead of a minced and moist meal even though her 10/25/23 lunch meal tray ticket reflected a minced and moist diet. Meats were long and rectangular (with a length greater than ½-inch) instead of small and cubed as was reflected in the recipe. This observation was confirmed with the RD. Resident #4 also did not receive a magic cup that was reflected on her lunch meal tray ticket. This observation was also confirmed with the RD. Resident #4's significant other verified the lunch meal tray did not have a magic cup. The RD did try to take the meal from Resident #4 to give her the correct textured diet. However, Resident #4's significant other stopped the RD because the significant other did not want Resident #4 to receive the minced and moist meal. The RD identified that this can be a choking hazard. During an interview on 10/26/2023 at 06:40 PM, the ADMN revealed that if a resident did not receive a magic cup, they could lose extra calories and be at risk for weight loss. 2. A record review of Resident #7's admission record on 10/24/2023 revealed an admission date of 10/05/2023 with diagnoses which included altered mental status, cognitive communication deficit, dysphagia (difficulty in swallowing food or liquid), and lack of coordination. A record review of Resident #7's MDS assessment dated [DATE] showed no BIMS being performed. A record review of Resident #7's care plan dated 10/24/2023, revealed, focus of I have a nutritional problem or potential for nutritional problem r/t MECHANICAL DIET with Interventions/Tasks that include Provide and serve diet as ordered. A record review of Resident #7's Doctor's order revealed resident had an NAS/CC diet Minced &Moist texture, Nectar consistency, level 5/no puree items please with an order date of 10/23/2023. A record review of Resident #7's 10/25/2023 lunch meal tray ticket revealed Diet was Soft & Bite Sized CC NAS. Record review of Week 2 menu revealed a side of potatoes & onions for Tuesday lunch. Record review for recipe of potatoes & onions revealed Soft & Bite sized should be chop cooked regular portions. Make sure all particles are no more than 15 millimeters x 15 millimeters (approx ½ in. x ½ in.) in size. During an interview on 10/24/2023 at 1:15 PM, CNA J reported that the potatoes & onions side dish for Resident #7's lunch meal looked like pureed mashed potatoes. 745001 Page 15 of 18 745001 10/26/2023 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview and observation on 10/24/2023 at 1:17 PM, the DM reported the potatoes & onions side dish were mashed potatoes for Resident #7's meal. Upon review of the 10/24/2023 lunch meal tray ticket, an updated lunch meal tray ticket should have been printed; the DM revealed that Resident #7's diet should have been NAS/CC Minced & Moist. The DM further revealed that the ST T had probably given her a pink communication slip and the system to print tray tickets was not updated. The DM further revealed that after the ST T updated a diet, this should be updated in between meal services. During an interview on 10/24/2023 at 4:44 PM, the ST T reported that the lunch tray ticket for Resident #7 appeared to not be updated in time for 10/24/2023 lunch. The ST T revealed that if the tray tickets were already printed out that the update would need to be handwritten on the ticket that was printed out. The ST T further revealed that if a downgraded diet was not updated in time, a resident is at risk for choking. Also, if an upgraded diet was not updated in time, the resident could possibly not be satisfied with the meal. During an interview on 10/26/23 at 5:35 PM, the DON revealed that a resident should not receive the wrong textured diet because the nurse should check and correct it before passing it to the resident. If a resident received an upgraded diet, like a regular diet, and they were supposed to receive a doctor prescribed downgraded diet, like a pureed diet, resident could aspirate, may not be able to chew, and decrease nutrient intake. If a resident received a downgraded diet instead of their doctor prescribed upgraded diet, a resident could not want to eat their meal. The DON also revealed that adding a magic cup to meals would be needed for wound healing and to prevent weight loss. Record review of the HPSI diet manual and Record Review of HPSI Policy and Procedures, copyright 2017 revised, defines therapeutic diets as, Therapeutic Diets as well as texture modifications for diets must be prescribed by the attending physician . Fortified foods are considered a therapeutic diet. Record Review of HPSI Policies and Procedures revealed Section D: Food Production . IV. Food Service Temperature Control .N. Textures . 1. All foods will be prepared in the texture/viscosity modification-as needed by each resident's individual requirement 2. Standard texture modifications include chopped, ground, pureed 5. Standards of preparation must follow the most current guidelines for the preparation of textured modified foods for those with swallowing disorders. And, Section E: Dining Service III. Tray Cards . Policy: A tray card will be issued for each resident . Procedure: 1. Upon receipt of a diet communication slip from nursing containing a new or changed diet order, the Nutrition Services staff will prepare a tray card for the resident 4. If computer generated tray cards are used, a new set will be printed for each meal. And, XI. Accurate Diet Service . Policy: Each resident will receive the proper diet as prescribed by their physician. Procedure: 1. Before each meal service, a Food & Nutrition Services Department employee will check the tray cards with a master list to assure the correct diet order, consistency order and liquid consistency order are on the card. 2. Prior to serving the tray, the nurse aide must check the tray card to assure that the correct tray is being served to the resident. If there is doubt, the charge nurse should be notified and the chart checked for the current physician's order. 745001 Page 16 of 18 745001 10/26/2023 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: Residents Affected - Some 1. There were 3 storage containers of prepared food in two separate refrigerators that were not properly sealed. 2. DA K wore jewelry with dangling charms on her wrist while engaged in food preparation in the kitchen. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 10/23/2023 at 9:52 AM in one of the refrigerators revealed an opened clear bag (the manufacturer's bag that would be inside of the product's box) of French fries. In the next refrigerator there was an opened clear, plastic bag of sausage patties. This exposed the contents of the bags to the ambient air in the cooler and potential contamination by pathogens and bacteria. The DM then went to get a Ziploc bag to put the French fries in, to seal it. Observation on 10/25/2023 at 11:31 AM, revealed an opened Ziploc bag of waffles for 10/25/2023 breakfast, which was confirmed by the DM. Interview on 10/23/2023, after above observation, the DM revealed the [NAME] E forgot to keep the fries sealed while preparing them as the lunch alternative for 10/23/2023. This was confirmed by [NAME] E, during this interview. The opened package of sausages was for 10/23/2023 breakfast. The DM further revealed all dietary employees were trained to make sure that there were not any open bags in the fridge/freezer. Interview on 10/25/2023 at 11:31 AM, the RD revealed that the Ziploc bags do open and it is a problem. The RD revealed that the products could possibly be put in storage containers or have zip ties on them. In a combined interview on 10/25/2023 at 11:36 AM, the DM and the RD agreed that exposed food products could cause contamination and even freezer burn. They agreed that they strived for minimal error. 2. Observation on 10/25/2023 at 11:41 AM revealed DA K wearing a bracelet with dangling charms while preparing for 10/25/2023 lunch. Interview with the DM on 10/25/2023 at 11:42 AM revealed that DA K is trained on not wearing the bracelet, but DA K is new and still being trained. DA K confirmed the DM's statement and revealed that she understood the risk of contamination. Record review of facility policy Preventing Foodborne Illness-Employee Hygiene and Sanitary 745001 Page 17 of 18 745001 10/26/2023 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Practices reflected Policy Interpretation and Implementation 1. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illnesses . 13. Jewelry will be kept to a minimum and hand jewelry (e.g., rings) will be kept covered with gloves during food handling. Record Review of HPSI Policy and Procedures, Copyright revised 2017, revealed Section C: Cost Containment . IV. Food Storage All opened and partially used foods shall be dated, labeled and sealed before being returned to the storage area. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, 3-305.11, revealed: Preventing Contamination from the Premises - Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed, 2-303.11 Jewelry Prohibition. Except for a plain ring such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. 745001 Page 18 of 18