Health inspection·August 15, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few monitor the effect of medication and for dosage adjustment. [Resident #1's] psychotropic medication is beneficial in this case to control their psychiatric symptoms and to manage the [Resident #1's] condition and to prevent relapse or hospitalization. [Resident #1] reports to I'm okay. Staff report [Resident #1's] behavior has improved.[Resident #1] is seen in the secure memory care unit. [Resident #1] does not appear to be feeling sad, nervous, angry, or elated today. [Resident #1] presents no delusions and does not appear to be responding to internal stimuli. [Resident #1] has been sleeping well, with adequate daytime energy. [Resident #1] has a good appetite. [Resident #1] participates in some of the available activities.Current Medication:Other MD:1 Benztropine Mes 0.5 Mg Tab SIG: Take 1 twice daily (used to treat Parkinson's Disease)2 Melatonin 3 Mg Odt SIG: 1 po q 24h (a natural hormone that regulates sleep)3 Oxcarbazepine 150 Mg Tablet SIG: Take 1 twice daily (used to treat seizure and mood disorder)4 Risperdal 1 Mg Tablet SIG: 1 at night (anti-psychotic medication)5 Sertraline Hcl 100 Mg Tablet SIG: 2 po qd (used to treat mood disorder)6 Trazodone 50 Mg Tablet SIG: 1 po qhs (used to regulate sleep and stabilize mood) Assessment/Plan:Schizophrenia: Sertraline, RisperidoneSleep: Trazodone, MelatoninSz and mood stabilization: Oxcarbazepine. Record review of Resident #1's progress notes, dated 7/1/25 at 7:08 AM by LVN Q, reflected the following: CNA removed razors from [Resident #1's] room and [Resident #1] became upset, knocking carts over in hallway and attempting to grab and hit CNA. CNA went into nursing station and [Resident #1] sttempted [sic] to reach over door to hit and grab CNA. [Resident #1] made threats that he was going to come after CNA and ‘get him.' [LVN Q] explained that razors are not allowed to be left in the room and that staff has to follow the regulations. [Resident #1] yelled at [LVN Q] that he can have them and that he had a lot of razors in his room. Record review of Resident #1's progress notes, dated 8/12/25 at 1:28 PM by LVN A, reflected the following: [Resident #1] was informed that the money is available but [Resident #1] continued to want the money immediately, the business lady informed resident that she will bring [Resident #1] his money as soon as she cashes [Resident #1's] check but [Resident #1] did not want to wait., [Resident #1] continued to kick the door and asking for his money. Record review of Resident #1's progress notes, dated 8/12/25 at 1:33 PM by LVN A, reflected the following:[LVN A] was called to come to the entrance door of the unit by [Activity Director], on arrival [LVN A] noticed [Resident #1] bleeding from his wrist and that [Resident #1] had cut his wrist with a razor and was bleeding heavily. [LVN A] collected towel and applied pressure to stop the bleeding. [LVN A] asked for other employees to come help stop the bleeding by applying pressure. [LVN A] called 911 and asked for paramedics and police to come and transport [Resident #1] to [local hospital] for eval and treatment. Record review of Resident #1's progress notes, dated 8/12/25 at 1:43 PM by LVN A, reflected the following: [NP] notified of [Resident #1] cutting his wrist and [Resident #1] was being sent to [local hospital] for treatment and eval. Paramedics arrived and transported [Resident #1] to ER. Record review of Resident #1's hospital records, dated 8/12/25, reflected in part the following: HPI: [Resident #1] is a 70 y.o male who presents with 4cm left wrist laceration after [Resident #1] became angry at his group home for not giving him the cash from his social security checks fast enough. [Resident #1] States he was not trying to kill himself, he was just trying to make a point. [Resident #1] denies any decreased sensation distal (farther from) to the laceration. [Resident #1] with difficulty of wrist flexion (action of bending). [Resident #1] has no issue with MCP (knuckle), PIP (middle joint of each finger), or DIP (fingertips) flexion.Physical Exam:Laceration: Volar laceration (involves multiple structures) of the proximal forearm. Exposed tendon within the laceration most likely FCR (tendons that help bend wrist). Tendon appears partially intact. FDS and FDP (tendons that help bend fingers) intact. [Resident #1] with severe difficulty in wrist flexion. FPL (tendons that help bend (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455416 If continuation sheet Page 2 of 7 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 455416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Ridge Wellness & Rehabilitation 8001 Western Hills Blvd Fort Worth, TX 76108 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few thumb) intact. [Resident #1] denies decreased sensation distal to the laceration. Strong ulnar artery (major blood vessel in forearm) pulse using Doppler. Weak radial pulse (pulse in wrist) using Doppler.Flexlon Cascade (natural resting posture of hand): No scissoringTendons: FDS and FDP intact in the index, middle, ring, small finger. FPL intact in thumb. No extensor lag (inability to extend) present. Able to fully extend all digits.Sensation: Sensation intact to light touch on the radial and ulnar border aspect of all digits. Sensation intact to light touch in the radial, ulnar and median nerve (major nerve that runs from arm to hand) distribution.Vascular: Less than 2 sec capillary refill present in all digits.Motor: Positive [NAME], PIN (nerves responsible for motor function), ulnar nerve function.Imaging: XR left hand: There is a soft tissue laceration but no acute fracture.Assessment:-Left wrist laceration-Suicidal ideation-Admit [Resident #1] to intermediate care-Bedside sitter-Psychiatric consultation-Bedside repair (closed laceration). Record review of Resident #1's EHR reflected the resident was discharged from the facility and at a local hospital; therefore, Resident #1 was unable to be interviewed. In an interview on 8/15/25 at 9:25 AM with the Administrator and DON, the Administrator stated Residen#1 resided on the secured unit due to diagnosis of dementia and was receiving psychiatric services for management of medication and behaviors. She stated on 8/12/25 it was reported that Resident #1 became frustrated about not receiving his money and pulled out a sharp object and cut his wrist. The Administrator stated the Activity Director was on the unit and attempted to stop Resident #1 however, it happened so fast he was unable to. The DON stated she was called onto the unit and assisted with stopping the bleeding until EMS arrived. She stated she was occupied with tending to the wound and never saw the sharp object that Resident #1 used. The Administrator also denied seeing the sharp object and stated she did not know how Resident #1 could have obtained a sharp object to cut himself as all sharp objects were locked up. The DON stated it had not been reported that Resident #1 expressed any thoughts of suicide or behaviors just prior to the incident; however, he was diagnosed with schizophrenia and had a history of aggression when things did not happen right when he wanted them to. The Administrator stated staff did a full sweep of the entire facility immediately after the incident to check for and remove any unsafe objects. The DON stated Resident #1 had a parole officer; however, the facility did not have any information about why he was on parole and the resident's parole officer had not visited the facility. The DON stated Resident #1 was his own responsible party and did not have any family involvement. In an interview on 8/15/25 at 9:42 AM, the Activity Director stated he was on the unit preparing to take residents out for a smoke break when he heard Resident #1 upset and kicking on the door. The Activity Director stated he went to talk to Resident #1 to calm him down and the resident stated he was upset because he did not have his money. The Activity Director stated Resident #1 said he was going to cut his wrist, then pulled out a sharp object and proceeded to do cut himself. The Activity Director stated he tried to stop Resident #1 but was unable to. The AD stated he did not know what object Resident #1 used to cut himself and he never saw the object afterwards. He stated he walked away and let the nurse take over. He stated he immediately called for LVN A and CNA B to help, and they came to take over. The Activity Director stated he interacted with Resident #1 all the time because the resident was a smoker, and he often supervised the smoke breaks. The Activity Director stated Resident #1 was normally calm especially if he could smoke, and he had never seen him agitated or aggressive. The Activity Director stated he always made sure the residents who smoked had cigarettes and went to break on time because that made them happy. He denied having concerns for any residents being abused or neglected at the facility. The Activity Director stated staff were often trained on abuse and neglect and had in-services regarding resident safety, rights, and suicidal behaviors after the incident this week. In an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455416 If continuation sheet Page 3 of 7 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 455416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Ridge Wellness & Rehabilitation 8001 Western Hills Blvd Fort Worth, TX 76108 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few interview on 8/15/25 at 10:17 AM, the BOM stated Resident #1's funds were in the facility's trust fund, and he would get $45 a month. The BOM stated initially there were some issues with the facility becoming payee over Resident #1's money, but she was finally able to get it worked out and the resident had 2 checks for $45 available. The BOM stated she was just waiting for the Administrator to go to the bank and cash the checks. The BOM stated Resident #1 became a little agitated after she explained that the checks were available but needed to be cashed. In an interview on 8/15/25 at 10:44 AM, LVN A stated he worked at the facility for 10 years and worked with Resident #1 on the male secured unit. LVN A stated he worked on 8/12/25 when the incident occurred. LVN A stated he was assisting other residents in the dining area on the unit when the Activity Director called for his assistance because Resident #1 was agitated. LVN A stated by the time he made it down the hallway, Resident #1 had cut himself and he saw a lot of blood. LVN A stated he grabbed towels and wrapped them on Resident #1's arm to stop the bleeding while calling 911. LVN A stated he did not see the object that Resident #1 used and could not state what happened to it after the incident. LVN A stated Resident #1 had a history of being aggressive towards other residents but was normally calm until something triggered him. LVN A stated Resident #1 had been involved in physical altercations with other residents for them getting in his space. He stated Resident #1 never showed any signs of being suicidal. LVN A stated Resident #1 was independent with most ADL's; however, the CNAs were still expected to monitor him while shaving and to immediately dispose of the razors in a sharps container. LVN A stated the residents were not allowed to keep disposable razors in their rooms, and he denied ever seeing any razors left in resident rooms. He stated new razors were always locked in a supply closet that was on the unit. In an interview on 8/15/25 at 10:58 AM, Resident #4 stated he felt safe at the facility. He stated staff assisted him with ADL's as needed; however, he was able to do some things on his own and it made him feel good about himself. Resident #4 stated he used to keep a disposable razor in his room because he liked to shave himself daily without bothering staff, but all razors were removed a couple of days ago after an incident happened at the facility. Resident #4 stated he understood it was for safety, but it also felt like they were taking some of his independence. Resident #4 stated staff told him that he could still shave himself every day, they just had to bring in the razor and monitor him. In an interview on 8/15/25 at 11:08 AM, the Floor Technician stated he cleaned the floors at the facility, including in resident rooms. He stated when cleaning in the resident rooms, there were times he saw disposable razors in the bathrooms prior to the incident. The Floor Technician stated he did not remove the razors because he had not been told to do so and he did not report it to nursing because he thought the residents were allowed to have the disposable razors to shave. In an interview on 8/15/25 at 11:15 AM, CNA B stated she worked at the facility since 1988. She stated she worked on the male secured unit with Resident #1 and worked on 8/12/25 when the incident occurred. CNA B stated Resident #1 had been asking about his money all morning but did not seem agitated at first. CNA B stated the BOM came to the unit to speak to Resident #1 about his money around lunch time and shortly after, the resident started kicking the door and repeating that he wanted his money. CNA B stated she began directing all other residents to the dining area for safety and the Activity Director was with Resident #1 trying to calm him down. CNA B stated she suddenly heard more yelling and when she turned around, she saw blood coming from Resident #1. She stated LVN A went to help Resident #1 while she remained with the other residents. She stated she was not sure how Resident #1 was able to get anything sharp to cut himself with. CNA B stated they kept razors for shaving locked in the closet. CNA B stated when she showered residents, she would assist them with shaving if needed then immediately put the razors in a sharps container. She denied ever leaving a razor out and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455416 If continuation sheet Page 4 of 7 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 455416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Ridge Wellness & Rehabilitation 8001 Western Hills Blvd Fort Worth, TX 76108 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few in a resident's possession, not even the residents who were able to shave themselves. The CNA stated she could not speak for all staff and there were times they would come on shift and find razors left out prior to the incident. CNA B stated she would always remove any razors she found. In an interview on 8/15/25 at 12:01 PM, CNA C stated she worked on the male secured unit and was familiar with Resident #1; however, she did not work on 8/12/25 when the incident occurred. CNA C described Resident #1 as pleasant and denied ever seeing him agitated or exhibiting signs of being suicidal. CNA C stated the aides were responsible for assisting and monitoring residents with shaving and had to remove the razors immediately. She stated she would always place the razors in a sharps container outside of the resident rooms. CNA C stated staff were expected to check drawers, sinks, and bathrooms in resident rooms daily for things like silverware, razors, electric shavers, or other items that could be unsafe before and after the incident. CNA C stated sometimes during her checks she would find disposable razors left in the bathrooms and she would remove them and report it to the nurse. She denied seeing any razors since the incident occurred. CNA C stated the disposable razors were locked in the supply closet; however, the residents were smart and would sometimes figure out the code by watching staff. CNA C stated she found Resident #1 inside of the supply closet one day and after she reported it the code was changed. CNA C stated although she was off on 8/12/25, the DON called and in-serviced her by phone regarding resident safety, rights, behaviors and abuse and neglect. She stated prior to the incident, staff received those trainings periodically. Further interview on 8/15/25 at 5:31 PM, the Administrator stated the expectation was for staff to check resident rooms with a fine-tooth comb for unsafe items and monitor residents closely for any changes in mood or behavior. She stated management would also complete ambassador rounds to check rooms and visit with residents. The Administrator stated reports would be shared every morning during stand-up to discuss any incidents or changes in residents. The Administrator stated they would continue to educate residents and RPs on what items are allowed in rooms. She stated staff would also continue to be educated on maintaining a safe environment, which would include being aware of packages received at the facility. The Administrator stated staff were aware of resident rights and that permission was needed to check personal belongings; however, safety was first. The Administrator stated not adequately supervising residents and ensuring a safe environment could place the residents at risk of harm. Review of the facility's policy titled Safety of Residents, revised August 2020, revealed in part the following:Purpose: To provide a safe environment for residents and Facility Staff. Policy: Residents who display combative behaviors receive prompt and appropriate intervention. Procedure:I. ScreeningA. Prior to admission, all inquiries are evaluated by the Director of Nursing (DON) for potential combative behavior based on historical data, diagnoses, and medication regimen. II. PreventionA. Upon admission, residents will be monitored for behavioral triggers including, but not limited to:i. Tension in body language or facial expression;ii. Increased pacing or wandering;iii. Elevated voice volume;iv. Rapid mood changes; andv. Increased anger or frustration. III. Response to Unsafe BehaviorA. If a resident's behavior becomes abusive, hostile, or unmanageable in a way that compromises his or her safety or the safety of others, the Charge Nurse and the DON are notified immediately.B. B. The Charge Nurse will:i. Identify and remove the source of the problem, if known;ii. Calmly reassure the resident and direct him/her to a more relaxing area; andiii. Maintain one-on-one supervision of the resident until the behavior has subsided or other arrangements have been secured. C. The DON will:i. Notify the resident's Attending Physician and obtain orders, if necessary;ii. Notify the resident's representative;iii. Notify the Administrator; andiv. Task an available CNA to ensure all other residents are safe and provide calm reassurance on the unit. Record review of a document provided by the Administrator, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455416 If continuation sheet Page 5 of 7 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 455416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Ridge Wellness & Rehabilitation 8001 Western Hills Blvd Fort Worth, TX 76108 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few untitled and undated, revealed in part the following: .Safety ConcernsThe following is a list of items that are not allowed in resident rooms due to potential for harm/fire/or other dangerous situations:. Sharp objects, scissors, knives, razors, unsecured glass objects, crochet needles. The non-compliance was identified as past non-compliance (PNC). The facility had corrected the non-compliance before the state's investigation began. The facility took the following actions to correct the non-compliance prior to the survey: Record review on 8/15/25 of a document provided by the Administrator titled AD HOC Quality Assurance and Performance Improvement Plan, dated 8/13/25, reflected a QAPI meeting was held to discuss the incident and interventions put in place, which included: Resident #1 being sent to an acute care hospital for evaluation and/or treatment, daily ambassador rounding to check for unsafe items in resident rooms, the facility providing extra cigarettes as needed to prevent related agitation/behaviors, inventory sheets completed at admission and updated for all current residents, staff educated on unsafe items not allowed in resident rooms, behavior identification and suicidal thoughts and de-escalation, notification and documentation of incidents, off-cycle resident council meeting to review items not allowed in rooms and inventory sheets with residents. Record review on 8/15/25 of Resident #1's EHR reflected the resident was discharged from the facility to the local hospital on 8/12/25. Record review on 8/15/25 of documents provided by the DON titled Inventory of Personal Belongings,, dated 8/12/25, reflected all current residents' personal inventory was updated. Record review on 8/15/25 of an in-service document, dated 8/12/25, reflected all staff received education regarding checking for unsafe items in resident rooms during rounds, updating resident inventory sheets, and policy and procedures for abuse and neglect and resident rights. Record review on 8/15/25 of an in-service document, dated 8/12/25, reflected all staff received education regarding identifying behaviors and suicidal prevention. Record review on 8/15/25 of a check-off resident census provided by the Administrator, dated 8/12/25-8/15/25, reflected safety checks of all resident rooms began and was on-going to ensure a safe environment. Observations on 8/15/25 from 9:45 AM-11:00 AM, of the facility's environment including resident rooms and bathrooms, shower rooms, and supply closets reflected the environment was free of potential hazardous and unsafe items. All razors were locked in the supply closet and requires a code to enter. Record review on 8/15/25 of Residents #1, #2, #3, #4, and #5 EHRs, who were all at risk for accidents, revealed their care plans included interventions to address ADL and behavioral needs as appropriate to ensure adequate supervision/assistance and safety. Resident #1's care plan was revised on 8/12/25 to reflect his behavior and harm to self with appropriate interventions. Interviews on 8/15/25 from 10:15 AM-11:00 AM with Resident #4's RP and Residents #1, #2, #3, #4, and #5, who were all at risk of accidents, revealed no concerns for inadequate supervision or safety. Interview on 8/15/25 at 4:43 PM with the MD revealed she was made aware of Resident #1's incident on 8/12/25. The MD stated she was also a part of the QAPI meeting on 8/13/25 and agreed with interventions put in place to ensure the safety of all residents. The MD stated the IDT would have to review the final evaluation from the hospital to determine if Resident #1 would be a good fit for the facility and appropriate protocol would be followed. Interviews on 8/15/25 from 9:25 AM-5:31 PM conducted with the Administrator, DON, nurses and CNAs: LVN A (1st shift/weekdays), CNA B (1st shift/rotating days), CNA C (1st shift/rotating days), RN D (1st shift/rotating days), CNA E (1st shift/rotating days), RN F (1st shift/weekdays), CNA G (1st shift/rotating days), CNA H (2nd shift/ rotating days), CNA I (2nd shift/ rotating days), RN J (2nd shift//weekdays), RN K (1st/2nd shift/double weekends), CNA L (2nd shift/rotating days), RN M (PRN), LVN N (3rd shift/weekdays), CNA O (3rd shift/ rotating days), CNA P (3rd shift/ rotating days), indicated they all participated in in-services 8/12/25-8/14/25, and prior to the start their shifts. All staff were able (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455416 If continuation sheet Page 6 of 7 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 455416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Ridge Wellness & Rehabilitation 8001 Western Hills Blvd Fort Worth, TX 76108 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete to state that they were responsible for ensuring the safety of all residents by checking all resident rooms and common areas for unsafe items, removing the items and reporting it to the Administrator. All staff were able to state how to identify s/sx of suicidal ideations and changes in residents' mental and physical conditions, who to report it to, and to documents all incidents. The Administrator stated it was management's responsibility to ensure that staff were educated on identifying and reporting changes in residents' mental and physical conditions, behaviors, and ensuring the safety of residents, and ongoing trainings to ensure retention of education. The Administrator stated management would be updated on any changes or updates daily during stand-up meetings. The DON stated resident behaviors were monitored, the medical director involved, and psychiatric services were put in place as needed. All staff were able to state in their own words the facility's policy and procedures regarding resident rights and abuse and neglect. All staff were able to describe abuse, neglect, and exploitation, when to report it, and who to report it to. All staff were able to state that residents have the right to have personal items and must give permission for staff to go through their personal items; however, any unsafe items observed would be removed and reported to the Administrator. Event ID: Facility ID: 455416 If continuation sheet Page 7 of 7