Coldwater Manor

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen reviewed for food and nutritional services, when they failed to:
A.
The facility failed to ensure kitchen staff used proper hand washing and sanitation procedures when handling food.
This failure could cause decreased meal satisfaction and decreased meal consumption due to using unsanitary practices in the facility's only kitchen and could affect all residents in the facility that receive meals from the facility kitchen.
Findings include:
In an observation and interview on 6/16/25 at 12:00 pm, [NAME] A was observed in the kitchen with gloved hands serving the noon meal. [NAME] A changed her gloves, touched various kitchen surfaces, picked up a plate and the serving utensils. [NAME] A plated the food then used her gloved hand and picked up a roll. [NAME] A set the plate on the counter then picked up another plate. [NAME] A did not make any attempts to change her gloves or wash her hands. [NAME] A was asked if she realized she had touched the bread without changing her gloves. [NAME] A did not speak English well and just looked at this writer. The DM explained to [NAME] A what had happened. [NAME] A nodded.
In an observation and interview on 6/16/25 at 12:05 pm, [NAME] B touched various kitchen surfaces, walked to the tray cart, picked up a tray with both gloved hands, set the tray on the counter, touched the tray ticket, picked up a plate, picked up the serving utensils and plated the food. [NAME] B then used her gloved hands to pick up a roll from the muffin tin. [NAME] B picked up a knife to loosen the rolls from the pan and touched the rolls and the pan with her gloved hands. [NAME] B then went to the window and placed the tray of food in the window. [NAME] B picked up a new tray and took the tray to the serving table. [NAME] B did not make any attempts to change her gloves or wash her hands. [NAME] B stated the roll was stuck to the pan. The DM stated tongs should be used to serve bread.
In an interview on 6/18/25 at 8:50 am, the DM stated she expected staff to use tongs when touching food and she expected gloves to be changed as the tasks change and she expected hands to be washed when changing tasks. The DM stated both [NAME] A and [NAME] B were not supposed to touch the food and should have used utensils and should have washed hands and changed gloves between tasks. The DM stated the consequences of not washing hands and changing gloves would be risk of food borne illness. The DM stated she trained the staff in hand washing and glove use and expected all staff to wash hands and change gloves between tasks. The DM stated there was no policy on using tongs for serving food.
Record Review of the facility policy dated November 2022, titled Preventing Food Borne Illness-Employee Hygiene and Sanitary Practices documented: Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single use items and are discarded after each use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 1 of 16 residents (Resident #18) reviewed for accuracy of MDS assessments.
-The facility failed to accurately assess Resident #18 for the use of oxygen on her 06/04/25 quarterly MDS.
This failure to accurately assess a resident could place residents at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services.
Finding include:
Record review of Resident #18's face sheet printed 06/16/25 revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include unspecified chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure) and dementia (a group of thinking and social symptoms that interferes with daily functioning).
Record review of Resident #18's last MDS was a quarterly assessment completed 06/04/25 listing her with a BIMS of 06 indicating she was severely cognitively impaired, and she had a functionality of being dependent for most of her activities of daily living. Section O - Special Treatments, Procedures, and Programs: Resident #18 was not listed for Oxygen Therapy while a resident.
Record review of Resident #18's care plan with admission date of 03/03/25 revealed the following:
Focus:
-The resident has oxygen therapy. - Date initiated 03/25/25.
Record review of the clinical record for Resident #18 revealed an Order Summary Report with active orders as of 06/17/25 with the following order:
- Continuous Oxygen @ 2LPM via NC to keep sats greater than 90%, humidify PRN every day and night shift. Start Date: 03/03/25.
During an observation on 06/16/25 at 10:14 AM Resident #18 was in her bed sleeping restlessly with her oxygen on set a 2L/min via NC. Resident #18 awoke to knocking. Resident #18 reported no issues with her oxygen and that staff provided all care related to her oxygen.
During an interview on 06/18/25 at 08:59 AM the DON reported that she was responsible for completing all resident MDS's. The DON reviewed Resident #18's chart and verified that Resident #18 was on oxygen per her orders and care plans. The DON reviewed Resident #18's 6/04/25 quarterly MDS and reported that the MDS did not address Resident #18's use of oxygen. The DON reported that she just missed it. and it would have to be corrected. The DON reported that a MDS not accurately reflecting the resident's condition and care could result in the resident not receiving the care that they were required to have. The DON reported that the facility followed the RAI manual for all MDS related issues.
Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, dated October 2023 revealed the following:
SECTION O: SPECIAL TREATMENTS, PROCEDURES, AND
PROGRAMS
Coding Instructions for Column b. While a Resident
Check all treatments, procedures, and programs that the resident received or performed after
admission/entry or reentry to the facility and within the last 14 days. If no treatments,
procedures or programs were received by, performed on, or participated in by the resident
within the last 14 days or since admission/entry or reentry, check Z, None of the above.
o O0110C1, Oxygen therapy
Code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a
resident to relieve hypoxia in this item. Code oxygen used in Bi-level Positive Airway
Pressure/Continuous Positive Airway Pressure (BiPAP/CPAP) here. Do not code hyperbaric
oxygen for wound therapy in this item. This item may be coded if the resident places or removes
their own oxygen mask, cannula.

Based on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.
The facility did not have an RN in the facility on 4/5/25, in the 5 past months.
This deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for coordination of events such as emergency care.
Findings include:
Record review of the facility's last 5 months of time sheets for RN coverage revealed that the facility did not have an RN in the facility on 4/5/25.
During an interview on 6/17/25 at 10:15 am, the ADM stated she had only been at the facility for 3 weeks and was not aware of the RN coverage until now. She stated it was one day and the DON had surgery. The ADM stated the consequences of not having RN coverage were that it was against federal guidelines and that the facility needed to have an RN on duty every day. She stated she could not see any grave consequences or impact to residents by not having RN coverage for I day.
During an interview on 6/17/25 at 11:15 am, the DON stated there was probably no RN coverage that day. She stated she had been out for surgery during that time period and had not been able to monitor the schedule. She stated if she was not there to monitor the schedule, it got missed. She stated the consequences of not having RN coverage would have been possible poor care for residents.
Record review of facility presented Time Clock- In and Out information revealed the facility had no RN coverage for 4/5/25.
Record review of facility policy dated August 2022, titled, Departmental Supervision revealed a registered nurse provides services at least eight consecutive hours every 24 hours, seven days a week.

Based on observation, interview, and record review; the facility failed to ensure medications were stored in accordance with currently accepted professional principles for 1 (the medication room) of 2 medication storage areas reviewed for medication storage.
The medication room refrigerator had medications that had been stored outside of the recommended storage temperatures.
The facility's failure could result in a resident receiving a medication that would be ineffective for their treatment resulting in exacerbation of the resident's condition and disease processes.
Findings included:
Record review of the medication room's only refrigerator log for May 1, 2025, to June 17, 2025, revealed the following documented temperatures:
(-per merriam-webster.com: freezing point of water is 32 degrees Fahrenheit.)
05/08/25 - 35 degrees Fahrenheit
05/09/25 - 32 degrees Fahrenheit
05/11/25 - 32 degrees Fahrenheit
05/16/25 - 34 degrees Fahrenheit
05/17/25 - 34 degrees Fahrenheit
05/18/25 - 32 degrees Fahrenheit
05/19/25 - 32 degrees Fahrenheit
05/20/25 - 32 degrees Fahrenheit
05/21/25 - 32 degrees Fahrenheit
05/22/25 - 34 degrees Fahrenheit
05/23/25 - 34 degrees Fahrenheit
05/24/25 - 34 degrees Fahrenheit
05/25/25 - 34 degrees Fahrenheit
05/26/25 - 32 degrees Fahrenheit
05/27/25 - 34 degrees Fahrenheit
05/28/25 - no temperature check completed.
05/29/25 - 34 degrees Fahrenheit
05/30/25 - 32 degrees Fahrenheit
05/31/25 - 30 degrees Fahrenheit
06/01/25 - 34 degrees Fahrenheit
06/02/25 - 34 degrees Fahrenheit
06/04/25 - 32 degrees Fahrenheit
06/05/25 - 32 degrees Fahrenheit
06/06/25 - 34 degrees Fahrenheit
06/08/25 - no temperature check completed.
06/09/25 - no temperature check completed.
06/10/25 - no temperature check completed.
During an observation on 06/17/25 at 09:33 AM of the medication room completed with LVN C the following was noted in the medication room refrigerator:
1. 1 - Timolol eye drop solution filled 6-5-2025. Manufacturer recommended storage temperature was between 59 degrees Fahrenheit to 77 degrees Fahrenheit.
2. 1 - Novolog Insulin Vial filled 6-3-202. Manufacturer recommended storage temperature for unopened Novolog insulin vials was between 36 degrees Fahrenheit to 46 degrees Fahrenheit.
3. 2 - Lantus Insulin Pens filled 5-5-2025. Manufacturer recommended storage temperature for unopened Lantus insulin pens was between 36 degrees Fahrenheit to 46 degrees Fahrenheit.
4. 4 - Humalog Insulin Pens filled 5-8-2025. Manufacturer recommended storage temperature for unopened Humalog insulin pens was between 36 degrees Fahrenheit to 46 degrees Fahrenheit.
5. 3 - Lantus Pens filled 6-16-2025. Manufacturer recommended storage temperature for unopened Lantus insulin pens was between 36 degrees Fahrenheit to 46 degrees Fahrenheit.
6. 1 - Humalog insulin Pen filled 10-4-2024.
During an interview on 06/17/25 at 09:40 AM LVN C verified each medication stored in the medication room refrigerator and the dates each medication was filled. LVN C reported that a medication stored at 32 degrees or less would be considered freezing. LVN C reviewed the temperature log for the medication room refrigerator from 5-1-2025 to 6-17-2025 and noted several temperatures documented at 32 degrees of less and several missing temperature checks. When asked if this was an issue, LVN C stated, Oh yes, definitely. It will freeze the liquid solution. LVN C reported that if a resident received a medication that was not stored properly then they could have a reaction to the medication, or the medication would not be effective for their treatment such as if they have a high blood sugar then the medication would not do anything for their condition.
During an interview on 06/18/25 at 08:50 AM the DON reported that the staff had made her aware of the issue with the medications being stored improperly in the medication room refrigerator and that she did not think it was an issue because she was in and out of that refrigerator often and she had never seen any of the medications frozen. The DON reported that 32 degrees was considered a freezing temperature. The DON reported that if a medication was stored outside of recommended storage temperature ranges, then that could affect the medications efficiency and it may not have the desired effect on the resident's care.
Record review of the facility provided policy titled Medication Labeling and Storage undated, revealed the following:
Policy Statement:
The facility stores all medications and biologicals in locked compartment under proper temperatures .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 3 (Resident #8, #17, and #18) of 15 residents reviewed for advanced directives.
Residents #8, #17, and #18 had a DNR in their records that was missing the date when the notary signed the form.
The facility's failure could place residents a risk for not receiving healthcare as per their or their legal representatives wishes.
Findings included:
Resident #8:
Record review of Resident #8's face sheet printed [DATE] revealed she was an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning). Resident #8 was listed as a DNR.
Record review of Resident #8's last MDS was a quarterly assessment completed [DATE] listing her with a BIMS score of 09 indicating she was moderately cognitively impaired, and she had a functionality of being dependent on staff for most of her activities of daily living.
Record review of Resident #8's care plan with admission date of [DATE] revealed the following:
Focus:
-Resident had a DNR in her chart.
Goal:
-Resident and family wishes will be honored over the next 90 days.
Intervention/Tasks:
-If resident found not breathing, do not perform CPR, notify nurse, physician, and family. -Revision [DATE].
Record review of the clinical record for Resident #8 revealed an Order Summary Report with active orders as of [DATE] with the following order:
-DNR - Active [DATE].
Record review completed on [DATE] at 12:09 PM of the clinical record for Resident #8 revealed a DNR dated [DATE] (signed by the physician) with the following:
Section - Two Witnesses - Notary in the State of Texas and County of Sherman - there was a signature for the notary, a printed name for the notary, but no date of when the notary completed the DNR form.
Resident #17:
Record review of Resident #17's face sheet printed [DATE] revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include Alzheimer's (a progressive disease that destroys memory and other important mental functions). Resident #17 was listed as a DNR.
Record review of Resident #17's last MDS was a quarterly assessment completed [DATE] listing her with a BIMS that could not be evaluated due to short- and long-term memory problems, and she had a functionality of being dependent for most of her activities of daily living.
Record review of Resident #17's care plan with admission date of [DATE] revealed the following:
Focus:
-Resident had a DNR in her chart.
Goal:
-Resident and family wishes will be honored over the next 90 days.
Intervention/Tasks:
-If resident found not breathing, do not perform CPR, notify nurse, physician, and family. -Revision [DATE].
Record review of the clinical record for Resident #17 revealed an Order Summary Report with active orders as of [DATE] with the following order:
-DNR - Active [DATE].
Record review completed on [DATE] at 12:12 PM of the clinical record for Resident #17 revealed a DNR dated [DATE] (signed by the physician) with the following:
Section - Two Witnesses - Notary in the State of Texas and County of Sherman - there was a signature for the notary, a printed name for the notary, but no date of when the notary completed the DNR form.
Resident #18:
Record review of Resident #18's face sheet printed [DATE] revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), and chronic kidney disease (longstanding disease of the kidneys leading to kidney failure). Resident #18 was listed as a DNR.
Record review of Resident #18's last MDS was a quarterly assessment completed [DATE] listing her with a BIMS of 06 indicating she was severely cognitively impaired, and she had a functionality of being dependent for most of her activities of daily living.
Record review of Resident #18's care plan with admission date of [DATE] revealed the following:
Focus:
-Resident had a DNR in her chart.
Goal:
-Resident and family wishes will be honored over the next 90 days.
Intervention/Tasks:
-If resident found without spontaneous respirations, do not initiate CPR, notify nurse, physician, and family. -Revision [DATE].
Record review of the clinical record for Resident #18 revealed an Order Summary Report with active orders as of [DATE] with the following order:
-DNR - Active [DATE].
Record review completed on [DATE] at 12:02 PM of the clinical record for Resident #18 revealed a DNR dated [DATE] (signed by the physician) with the following:
Section - Two Witnesses - Notary in the State of Texas and County of Sherman - there was a signature for the notary, a printed name for the notary, but no date of when the notary completed the DNR form.
During an interview on [DATE] at 12:47 PM LVN C (the nurse responsible for Resident #8, #17, and #18 this shift) and LVN D both reported if a staff member reported to them that a resident was not breathing or had no heart beat they would verify the residents condition and if they that resident was in the process of coding (no heart beat or respirations) they would review the resident chart to verify if the resident was a DNR code status. LVN C and LVN D both reported that if the resident was a DNR they would not start CPR then contact the physician, DON, and Administrator. They reviewed Resident #17's chart, found her DNR, and reported that Resident #17 was a DNR and therefor they would not start CPR. When asked to review Resident #17's DNR to see if the form was complete, both LVN C and LVN D reviewed Resident #17's DNR form and verified that the notary did not date their signature and therefore the DNR was not valid. LVN C and LVN D reported that they would get the code status corrected immediately and complete a new DNR form for Resident #17. LVN C and LVN D reviewed Resident #8 and Resident 18's DNR forms, verified both forms did not have a date of when the notary signed the form and both DNR forms were invalid also. LVN C and LVN D reported that they would have to treat all three residents as if they were a full code which would mean that the resident wishes would not be carried through. LVN C and LVN D verified that N E (who was the notary that signed for Resident #8 and #17's DNR forms) was the former Business Office Manager and no longer worked for the facility.
During an interview on [DATE] at 08:45 AM the DON reported that she had been made aware of Resident #8, #17, and #18 DNR's that the notary did not date their signatures. The DON reported that she was not sure if this made the form invalid or not but if the form was invalid then staff could possibly perform CPR on a resident that may or may not have wanted it which would affect that residents care. The DON reported that she personally checked the residents DNR's at least every 3 months and that she just missed these.
During an interview on [DATE] at 09:23 AM the BOM (the notary for the facility) verified that she was a notary and that she was the notary for Resident #18's DNR. The BOM reported that she did forget to date Resident #18's DNR and that if a notary forgot to date a DNR then that DNR was invalid until it was properly completed. BOM reported that if the DNR was not valid then staff would not follow the order/DNR as it should be. She verified that the notary did not date Resident #8's and Resident #17's DNR and reported that the notary for both Resident #8 and #17 no longer worked for the facility, that she (the current BOM) had taken the previous notary's place when she resigned.
Record review of the facility provided policy titled Advanced Directives undated, revealed the following:
Policy Statement: The resident has the right to formulate and advance directive . Advance directives are honored in accordance with state law and facility policy.
Determining Existence of Advance Directives:
4. Written information includes a description of the facility's policies to implement advance directives and applicable state law.
-there was no information provided in the Advanced Directives policy about ensuring the Advanced Directive was fully and properly completed. A copy of the OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES form was provided with the policy.
Record review of the OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES undated, revealed the following:
-The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professional

Based on interview and record review, the facility failed to respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service of 2 of 3 confidential residents interviewed.
The facility did not deliver unopened mail for 2 of 3 resident interviewed during a confidential group interview.
This failure could affect residents personal privacy and could result in decreased quality of life.
Findings included:
During a confidential group interview on 06/17/2025 at 2:00 PM two of three residents identified by the facility as being alert, oriented, and interview able, revealed that their mail was delivered open by the activity director. One confidential resident stated he had his mail opened twice and one confidential resident stated she had a card from her church opened once. Two of the three residents stated they would like their mail to be unopened when it was delivered.
In an Iinterview on 06/17/2025 at 2:47 PM, the AD stated that she did not like carrying the big letter opener throughout the facility because of safety issues so at times she would open the mail before delivering it. The AD said a possible negative outcome for not opening mail in the presence of the resident would be if something in the mail comes up missing, she could be blamed.
In an interview on 06/17/2025 at 2:54 PM, the DON stated the BOM and AD were the staff responsible for getting the mail and delivering it to the residents. The DON stated the ADM was the one responsible for ensuring the BOM and AD and all staff were responsible for ensuring privacy for residents and a negative outcome for opening mail without permission from the resident would be invasion of the resident's privacy.
In an interview on 06/18/2025 at 8:55 AM, the BOM stated that she had worked at the facility for about six months, and she was responsible for picking up the mail from the post office, bringing it back to the facility, and putting it in the AD's office area. The BOM stated she had not seen the AD open the mail prior to delivering it, but the AD was the one responsible for delivering the mail to each resident. The BOM stated that a possible negative outcome for opening mail outside the presence of a resident would be a violation of privacy. The BOM stated the ADM was responsible for ensuring her staff was aware of resident rights.
In an interview on 06/18/2025 at 10:39 AM , the ADM stated that she was notified of his violation and that she was working on educating the AD. The ADM stated this was a resident rights issues and an invasion of privacy. The ADM stated she was working with the AD and stated that it did not matter what cognition level the resident had, it was their right to open their own mail, and if they needed or wanted her help, then it needed to be in their presence and requested each time mail was received.
Record Review of the facility's Residents' Rights Policy located in the admission Packet dated November 2021 revealed the following:
Privacy and Confidentiality:
You have the right to:
Send and receive unopened mail and to receive help in reading or writing correspondence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 1 (Resident #13) of 9 residents reviewed for advanced directives in that:
Resident #13 had a DNR in her record with no physician information.
This failure could place residents a risk for not receiving healthcare as per their or their legal representatives wishes.
Findings included:
Record review of Resident #13's face sheet printed 5-13-2024 revealed she was an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), dementia (a group of thinking and social symptoms that interferes with daily functioning), aortic valve deficiency (condition in which the heart's aortic valve does not work properly), cardiac arrythmias (improper beating of the heart, whether irregular, too fast, or too slow), and atherosclerosis (a buildup of fat, cholesterol, and other substances in the artery walls). Section Advance Directives listed Resident #13 as a DNR (Do Not Resuscitate).
Record review of Resident #13's last MDS was a quarterly assessment completed 2-7-2024 listing her with a BIMS score of 8 indicating she was moderately cognitively impaired, and she had a functionality of requiring set-up to touch assistance with activities of daily living.
Record review of Resident #13's care plan with admission date of 10-27-2022 revealed the following:
Focus: Resident has a DNR on chart. Date initiated 11-11-2022.
Goal: Resident and family wishes will be honored for the next 90 days and ongoing. Date initiated 11-11-2022. Target date 5-12-2024
Interventions: If resident is found no breathing, do not do CPR . Date initiated 11-11-2022. Revision on 2-12-2024.
Record review of the clinical record for Resident #13 revealed an Order Summary with active orders as of 5-1-2024 with the following order:
DNR (with an order date of 10-27-2022)
Record review of the clinical record for Resident #13 revealed a DNR dated 10-24-2022 (signed by Declaration of the adult person) with the following:
Section: Physician's Statement-there is no physician signature, no date for the physician's signature, no printed signature, and no license number.
Section: All persons who have signed above must sign below, acknowledging that this document has been completed-there is no attending physician signature.
During an interview on 05-13-2024 at 02:50 PM RN A and LVN B both reported all residents in the facility were currently DNR's except for one resident which was not Resident #13 so Resident #13 was currently a DNR. RN A reported that Resident #13 was a DNR which meant that if Resident #13 was to be found not breathing or without a heartbeat they would not perform resuscitative measures and keep her comfortable. LVN C agreed with RN A. Both reported that they would notify the residents family member and the physician. RN A then checked Resident #13's DNR and was unable to find the physicians information. Then RN A asked LVN C to check Resident #13's DNR form. LVN C was also unable to find any physician information on Resident #13's DNR form. RN A and LVN C reported that due to the physician not signing the DNR form for Resident #13 the DNR was invalid and since the resident was currently stable, they would get the form corrected immediately and hope that Resident #13 did not have a decline in her condition but if Resident #13 did have a change in her condition Resident #13 would be considered a full code.
During an interview on 05-14-2024 at 12:56 PM AC C reported that the DNR part of resident care was not her department, that nursing takes care of the DNR process. AC C reported that the DNR was not her responsibility.
During an interview on 05-15-2024 at 08:51 AM the DON reported that when a resident code's all staff were to verify the code status on the front of the residents MAR and then handle the situation properly. The DON reported that AC C was to verify all paperwork to include the DNR when a resident was admitted and that she (the DON) verifies the DNR's accuracy. The DON reported that with Resident #13's DNR form, it had so many signatures with both witnesses and the notary that the physician section was just missed, it fell through the cracks. The DON reported that the social worker verifies the DNR with each care plan meeting each quarter and that the social worker recently resigned, and their new social worker has not had time to learn the new process. The DON reported that if a DNR was not correctly completed it would be invalid and it would mean the resident would need to be resuscitated (have CPR started) and would be revived. The DON reported that there would be a potential for the resident to be harmed.
Record review of the facility provided policy titled Advanced Directives Policy and Procedures undated, revealed the following:
It is the policy of the facility to include elements and component that have an impact on the resident's health care in accordance with state law.
.the facility will comply with the requirement of state law governing Advance Directives.
Record review of the OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES, undated revealed the following:
-The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professional

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food service safety.
The facility failed to ensure stored food was properly labelled and dated.
The facility failed to discard leftover food by use by date on the label.
These failures could place residents at risk of food borne illness.
Findings included:
An observation on 05/13/24 at 09:30 AM of shelving in the kitchen revealed the following:
A plastic lidded tub of what appeared to be heart-shaped cereal with no label and no date.
A plastic lidded container of whipped vanilla frosting with an open date of 05/03/24. The lid was ballooning up as if pressure was inside the container. The manufacturer's instructions read to cover and refrigerate for up to 30 days after opening.
A resealable plastic bag containing 12-15 bread-like objects in roundish asymmetrical shapes approximately 2-3 inches in diameter with no label or date.
An observation on 05/13/24 at 09:33 AM of the walk-in refrigerator revealed the following:
An open bottle of yellow electrolyte drink ¾ full with no open date.
A pitcher approximately 1/10th full of cloudy, yellowish liquid labelled pineapple juice and dated 05/07/24.
3 whole heads of lettuce no date.
1 partial head of what appeared to be lettuce wrapped in plastic wrap no date.
1 partial head of lettuce in original packaging open to air with brown slimy substance on packaging and a cut edge of lettuce.
Cardboard box of tomatoes with no date. One tomato of several visible in the box had a brownish caved in area the size of a $.50 piece.
Round plastic lidded container labelled as whole tomatoes half full of red liquid open to air as the lid was warped and not sealed.
Round plastic lidded container labelled as cherry pie filling with the following dates 04/22/24 and 04/28/24.
Non-dairy whipped topped in original plastic bag packaging, half full. The end of the bag was not secured, open to air.
Cheese slices with the following dates 04/22/24 and 04/28/24.
An observation on 05/13/24 at 09:48 AM of freezers revealed the following:
Box of pork sausage with no date.
Box of tilapia with no date.
6 pies with no date
1 bag of round cream-colored objects approximately 2 inches in diameter with no label or date.
Box of individual ice cream cups no date.
Bag of round white disks approximately ½ inch thick and 3-4 inches across with no label or date.
Box of pizza with no date.
Box of waffles with no date.
Box of meat with no date.
During an interview on 05/14/24 at 09:34 AM ADM stated they do not have any kitchen policies regarding food labelling, storage, and leftovers.
During an interview on 05/14/24 at 12:36 PM DM stated she did not have food policies. She said she followed the Texas Food Establishment Rules regarding food storage. She stated she had verbal trainings with her staff almost every day but did not have any written copies of the trainings or sign in sheets for trainings. DM stated she had trouble with her staff remembering to label and date food appropriately. She stated leftover food was to be thrown away in 3 days to keep residents from getting sick. DM stated she has trained her staff to label food and date it the day it was made and the day it needed to be thrown out. She stated food in the freezers should be labelled with the date received on the case and on any individual packages taken out of the case.
During an interview on 05/15/24 at 08:44 AM DM stated residents could get sick if food was stored without correct labels, dates, refrigeration or if food is not thrown out when scheduled. She said, They (residents) can get sick if we serve it to them and don't know when we put it in there (refrigerator).
During an interview on 05/15/24 at 08:46 AM DS stated leftover food was to be labelled and dated with the day it was made and three days after. She stated the food should be thrown out 3 days after it was made. She stated residents could get sick if food was not labelled and dated correctly. DS stated she had been trained to label food with the date cooked and the date it needed to be taken out of the freezer or refrigerator. She stated she was trained to date cases of food on the day they were received from the truck.
Record review of facility policy titled Foods Brought by Family/Visitors and dated December 2008 revealed the following:
. 6. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator.
Record review of facility policy titled Refrigerators and Freezers and dated December 2008 revealed the following:
. 7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates.
Record review of the undated pages of the Texas Food Establishment Rules provided by DM revealed the following:
. A date marking system . may include: . marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises . or discarded . Food packaged in a food establishment, shall be labeled . Label information shall include: (A) the common name of the food, or absent a common name, an adequately descriptive identity statement; .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchens when they failed to:
A.
Ensure stored food were properly labeled and dated.
B.
Ensure that frozen foods were properly labeled and dated
C.
Ensure that expired foods were not in the pantry, refrigerator, and freezer.
These failures could place residents who ate the food at risk for food-borne illness.
Findings include:
Observation of the refrigerator on 3/15/23 at 10:00AM revealed the following:
1.
Thousand Island dressing opened 9/14/2022 with expiration date 11/3/22.
2.
1 gallon of vanilla extract with expiration date 6/22/2022.
3.
1 gallon of BBQ Sauce with expiration date 1/21/2023.
4.
1 open 8oz Boost nutritional drink which was not dated.
5.
½ bell pepper in a clear plastic bag which was not dated.
6.
1 2-pound bag of carrots which was not dated.
7.
1 clear bag of cilantro which was not dated.
8.
2 large bags of celery which were not dated.
9.
1 open 12oz. bottle of orange Gatorade, ½ full, which was not dated.
Observation of the walk-in pantry on 3/15/2023 at 10:30am revealed the following:
1.
1 Food Service box curly lasagna noodles, which was open to the air and not dated.
2.
1 Food Service bag of Navy Beans opened 2/21/23 with a best by date of 2/1/23.
3.
2 12oz. bottles Balsamic vinaigrette with best by date of 12/28/22.
4.
1 Food Service bottle [NAME] food coloring with expiration date of 7/11/2010.
5.
1 Food Service bottle light corn syrup, open and sitting on pantry shelf, with label which states, Refrigerate After
Opening.
6.
1 open Food Service bottle Worchester Sauce, not dated.
7.
1 Food Service bottle red wine vinegar with expiration date of 7/1/22 and open date of 8/27/22.
8.
1 Food Service container unsweetened baking cocoa opened 8/25/22 with expiration date of 3/11/22.
Observation of the freezer on 3/15/23 at 2:00PM revealed the following:
1.
One large food service bag of hushpuppies, open to air, not dated.
2.
One large food service bag of bread sticks, open to air, not dated.
3.
One large food service bag of frozen spinach, open, not dated.
4.
One food service bag of frozen cheddar cheese shreds, open, not dated
5.
One food service bag of frozen hashbrowns, open, not dated
6.
On food service bag of Mozzarella cheese shreds with expiration date of 12/6/22
7.
One food service box of crinkle cut French Fries with expiration date of 9/1/22
In an interview on 3/15/2023 at 2:30PM, the Dietary Manager states that all kitchen staff are responsible for keeping the pantry area clean. Staff are trained in making sure expired food is thrown away and in keeping the pantry clean. Dietary manager states the negative outcome of having expired food in pantry is that it can attract bugs or ants. DM states that they do not have a policy and procedure book but follow the Texas Food Establishment Rules dated March 15, 2006.
In an interview on 3/16/2023 at 9:00 am, the Administrator states that they do not have a policy and procedure book but uses the Texas Food Establishment book that the DM has in her office. Administrator states that in the last six months of QAPI meetings they have not discussed any kitchen issues and that no residents have gotten sick due to expired foods.