Health inspection·April 12, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview and record review the facility failed to provide housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior in 1 of 2 showers (Shower A) used for resident care. Nursing staff left dirty linens (towels and gowns) on the floor, briefs with fecal matter in the trash can, fecal matter on the wall by the trash can containing the dirty briefs, a used wash towel on the floor in Shower A's stall and debris on the floor. In addition, the drainage covers were not placed back to secure drainage openings in both stalls. These findings could affect residents who used the shower and could contribute to feelings of dissatisfaction. The findings were: 1. Observation on 4/6/23 at 4:40 PM during tour of Shower A revealed dirty linens (towels and gowns) on the floor, briefs with fecal matter in the trash can, fecal matter on the wall by the trash can containing the dirty briefs, a used wash towel on the floor in the shower stall and debris on the floor. In addition, the drainage covers were not placed back to secure drainage openings in both stalls. Interview on 4/6/23 at 4:45 PM with CNA A revealed there were dirty linens (towels and gowns) on the floor, briefs with fecal matter in the trash can, fecal matter on the wall by the trash can containing the dirty briefs, a used wash towel on the floor in one of Shower A's stall and debris on the floor. In addition, the drainage covers were not placed back to secure the drainage opening in each stall. CNA A stated Shower A was dirty and the draining opening left uncovered created a safety hazard. She stated residents could step into the opening and hurt their toes. CNA A stated she would not want to shower or have one of her family members shower in Shower A. CNA A stated all trash should be placed inside the plastic liner and disposed of in the dirty barrel. The drainage openings should be covered with the hair catchers, the brown stains on the wall which looked like feces should be cleaned and sanitized. All dirty lines should be removed and placed in the dirty linen barrel. The floor should be swept and mopped. CNA A stated any aide using the shower should clean it after each use and get it ready for the next resident. She stated there were two showers for resident use and she would not think any resident would be happy or comfortable about showering in Shower A in its condition. Interview on 4/6/23 at 4:55 PM with CNA B revealed she was walking out of the shower located on the far right hall. Further observation revealed all linens had been removed and she had a plastic bag. Page 1 of 9 455676 455676 04/12/2023 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few CNA B stated she showered a resident about 2:55 PM. She stated she meant to go back and clean the shower but lost track of time. CNA B confirmed she removed the dirty linens and towel left on the floor and put them in the dirty barrel. She stated she was on her way to dispose of the dirty briefs that she left in the trash can. CNA B confirmed it was her responsibility to clean the shower after each use and she would not expect any resident to want to use the shower in the condition she left it in. CNA B also confirmed the residents could hurt their toes on the drainage openings. Interview on 04/12/2023 at 4:49 PM with the ADON revealed CNA's were responsible for cleaning up the shower after each resident shower they gave. She further stated the DON was ultimately responsible for ensuring it was done to ensure a clean and comfortable environment for the residents. Review of facility policy, Resident Rights, dated October 2016, read in part: 2. Residents' Rights for People in Long Term Care Facilities a. Your rights to safety and good care. ii. Your facility must be clean. 455676 Page 2 of 9 455676 04/12/2023 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review revealed the facility failed to make prompt efforts to resolve grievances the resident had for 1 of 5 Residents (Resident #1) whose records were reviewed for resident rights. Resident #1 complained to different staff about her missing gray/brownish recliner for over 1 month and staff failed to reach a resolution. This deficient practice could affect any resident and could contribute to resident's dissatisfaction and feelings of worthlessness. The findings were: Review of Resident #1's face sheet, dated 4/6/23, revealed she was admitted to the facility on [DATE] with diagnoses to include hemiplegia affecting right dominant side and Depression. Further review revealed Resident #1 had a family representative. Review of Resident #1's annual MDS, dated [DATE], her BIMS score was 9 reflecting moderate cognitive impairment. Review of grievances from January to April 2023 revealed on 1/31/23 Resident #1 complained about existing bed was broken. The resolution reflected rental bed provided. Further review revealed no other grievances filed by or on Resident #1's behalf. Observation and interview on 4/5/23 at 11 AM revealed Resident #1 lying in bed. Resident #1 stated she purchased a recliner. She stated she had moved rooms several times and did not know where it was located. Resident #1 stated she had talked to different staff and no one had told her what happened to her recliner. She stated she wanted her recliner in her room. Interview on 4/5/23 at 12 PM with the Complainant revealed he was concerned about Resident #1's personal belongings. He stated Resident #1 moved 4 times in a course of 3 weeks. He stated Resident #1's blue recliner was stored somewhere in the facility but staff could not tell him exactly where it was stored. The Complainant stated Resident #1 told him she did not know what happened to it. He stated the recliner was too small for the Resident but she wanted to know what happened to it. The Complainant stated at the time he met with Resident #1 she was distraught about the situation. He stated he was concerned the room changes along with her missing items could exacerbate her depression. Interview at 4/5/23 at 2 PM with CNA C revealed she had worked at the facility for 32 years. She stated she knew Resident #1 very well and Resident #1 would often ask for her to discuss express concerns. CNA C stated Resident #1 had asked her several times about what happened to her recliner. CNA C stated there were a couple of recliners stored in empty resident rooms. She presented an electric beige/light brown recliner in room A 6 and another electric recliner about the same color in the room across the hallway from A 6. CNA C stated the recliner in room A 6 belonged to Resident #1. It did not have cup holders. CNA C demonstrated it did not work; stated Resident #1 was 311 lbs and did not fit in the recliner. CNA C stated she told Resident #1 the recliner was stored in the facility but stated the Resident was forgetful and she often had to repeat information to Resident #1. CNA C stated she did tell the ADM or DON because they already knew. 455676 Page 3 of 9 455676 04/12/2023 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 4/6/23 at 9:05 AM with the DOR revealed she filed 2 grievances on Resident #1's behalf. One of them was related to Resident #1's recliner. Resident #1 wanted to know what happened to her recliner and wanted her recliner back in her room. The DOR stated she had provided the grievances to the previous ADM and was not sure who addressed the residents' concerns. The DOR stated Resident #1's recliner was in the last room down hall A on the left-hand side of the hall. It was an electric beige/brownish recliner with two cup holders. The DOR stated she had not talked to Resident #1 further about her recliner. Interview on 4/6/23 at 11 AM with the ADM revealed he did not know what happened with Resident #1's recliner. He stated no one had said anything to him about it and he had provided all grievances for the investigation process. The ADM further stated he or the department heads were responsible for addressing grievances related to their department. He stated he reviewed all grievances to ensure they were addressed and a resolution had been reached. Interview on 4/6/23 at 2:52 PM with Resident #1 revealed the previous AD purchased an electric recliner for her some months back. She stated the recliner was gray/brownish and it had two cup holders. Resident #1 confirmed it was small, but it was not broken. She stated she wanted it back or would like to know where it was stored. She stated staff had not provided her with answers. Interview on 4/6/23 at 3:45 PM with Resident #1's Resident Representative confirmed Resident #1 had bought a recliner. He stated he did not know that it was missing. He stated staff had not called him to talk with him about any of Resident #1's concerns. Interview on 4/6/23 at 5:06 PM with the previous ADM revealed she was aware the AD had purchased Resident #1 a recliner. She stated Resident #1 had moved rooms a couple of times and did not know what happened to her recliner. The previous ADM stated she did not remember if a grievance was filed on Resident #1's behalf regarding her recliner. Review of facility policy, Resident Right dated October 2016 read in part: f. Grievances. A Resident has the right to: i. voice grievances without discrimination or reprisal and. ii. prompt efforts by the facility to resolve grievances the Resident may have. Your personal property rights ii. You may keep and use your own property, including some furniture if there is enough space, unless this interferes with the heath and safety of other Residents. iv. Your facility must try to keep your property from being lost or stolen. If your property is missing, the home must try to find it. 455676 Page 4 of 9 455676 04/12/2023 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review revealed the facility failed to ensure residents were free from misappropriation of resident property and exploitation for 1 of 6 Residents (Resident #1) whose records were reviewed for misappropriation. Residents Affected - Few Facility staff used Resident #1's personal trapeze (an assistive device used for repositioning while in bed) for Resident #3 without her consent for over one month. This deficient practice could affect any resident and could contribute to continued misappropriation of resident's property. The findings were: Review of Resident #1's face sheet, dated 4/6/23, revealed she was admitted on [DATE] with diagnoses to include hemiplegia affecting right dominant side and Depression. Further review revealed Resident #1 had a family member as her responsible party. Review of Resident #1's annual MDS, dated [DATE], her BIMS score was 9 reflecting moderate cognitive impairment; she required extensive assistance by two people with bed mobility related to limited range of motion on upper and lower right extremities. Review of grievances from January to April 2023 revealed on 1/31/23 Resident #1 complained her existing bed was broken. The resolution reflected rental bed provided. Further review revealed no other grievances filed by or on Resident #1's behalf. Review of delivery ticket, dated 2/3/23, from a contracting supply company, revealed a bariatric bed and pressure reduction foam mattress was delivered to the facility for Resident #1. Observation and interview on 4/5/23 at 11 AM revealed Resident #1 lying in bed. Resident #1 stated she purchased a trapeze which she used on her previous bed to assist her in sitting up while in bed. She stated staff reported they could not transfer her in the mechanical lift with the trapeze on her current bed because it interfered with the transfer. She stated they gave it away and did not know who had the trapeze. Interview on 4/5/23 at 12 PM with the Complainant revealed he was concerned about Resident #1's personal belongings. He stated the facility was allowing Resident #3 to use Resident #1's personal trapeze but Resident #1 told him she did not give the facility permission to do so. The Complainant stated he made a report to the HHSC because Resident #1 was distraught during their visit about the situation. Interview at 4/5/23 at 2 PM with CNA C revealed she had worked at the facility for 32 years. She stated she knew Resident #1 very well and Resident #1 would often ask for her to discuss her concerns. CNA C stated Resident #1 was forgetful and she had to often repeat information to her over and over. CNA C stated Resident #1 had asked her several times about what happened to her trapeze. She stated she explained to Resident #1 each time the trapeze interfered with staff's ability to safely transfer her with a mechanical lift since she received the bariatric bed. CNA C stated she never told Resident #1 another resident was using her trapeze even though she knew Resident #3 was using the 455676 Page 5 of 9 455676 04/12/2023 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few trapeze. She stated she did not know what agreement the previous ADM and Resident #1 had reached about the trapeze. Interview on 4/5/23 at 3:06 PM with the ADM revealed he did not know what happened with Resident #1's trapeze and was not aware that Resident #3 was using her trapeze. He stated no one had said anything to him about it and he had provided all grievances for the investigation process. The ADM further stated he or the department heads were responsible for addressing grievances related to their department. He stated he reviewed all grievances to ensure they were addressed and a resolution had been reached. Interview on 4/6/23 at 9:05 AM with the DOR revealed she filed 2 grievances on Resident #1's behalf. One of them was related to Resident #1 trapeze. Resident #1 wanted to know what happened to her trapeze. The DOR also reported staff was not able to safely use the mechanical lift since swapping out Resident #1's bed with a bariatric bed. The DOR stated the trapeze was a standalone piece of equipment and the frame enclosed Resident #1's previous bed. She stated the bariatric bed was wider than her previous bed, the trapeze did not go around it and staff would not roll the base of the mechanical lift under the bed and widened the base for stability with the trapeze in place. Observation on 4/6/23 at 9:15 AM revealed a standalone trapeze enclosing Resident #3's bed. Interview on 4/6/23 at 9:23 AM with the MS revealed the previous MS told him Resident #3 was using Resident #1's trapeze. He stated he did not know any of the details because it happened before he took over the position. The MS stated he was going to remove Resident #1's trapeze from Resident #3's room per the ADM. Interview on 4/6/23 at 2:52 PM with Resident #1 revealed she had told different staff she would be ok with someone else using the trapeze since she was not able to use it. She stated she would have preferred a bed that would have allowed her to use the trapeze. Resident #1 stated staff kept moving her from room to room; she had expressed concerns about other missing personal items and nothing had been done so she did not believe she had a choice about anything. Resident #1 stated staff never approached her directly to tell her another resident was using her trapeze. Observation and interview on 4/6/23 at 3:21 PM revealed a trapeze attached to Resident #3's headboard. Interview with Resident #3 revealed the MS removed the one he was using last night and he installed the one he was using now this morning (4/6/23). Resident #3 stated the one he using was different and it went around his bed. Every time staff moved the bed it made a noise. Resident #3 stated he liked the new one better. Interview on 4/6/23 at 3:45 PM with Resident #1's Resident Representative confirmed Resident #1 had bought a trapeze and was using it on her bed. He stated he did not know it had been removed because her bed was swapped out. Resident #1's Resident Representative stated staff did not notify him or ask for his consent allowing another resident to use the trapeze. He also stated like Resident #1 that if someone else could use it then it would be ok with him but he expected staff to talk with him about it first. Interview on 4/6/23 at 4:10 PM with the ADM revealed he presented a grievance dated 3/21/23 reflecting Resident #1 wanted her personal trapeze reinstalled in her room. It was noted the ADM had a discussion with her about the trapeze impeding with safe transfers. It further noted Resident #1 agreed to allow another resident to use it as needed. The ADM stated he found the grievance on his desk and 455676 Page 6 of 9 455676 04/12/2023 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few remembered staff told him that Resident #1 was asking about her trapeze. The ADM stated he talked with Resident #1 but did not obtain a written consent for the use of her personal trapeze. The ADM stated it was not common practice for residents to use each other belongings because it could be perceived as misappropriation of resident property. Interview on 4/6/23 at 5:06 PM with the previous ADM revealed she was aware that Resident #1 bought a trapeze but did not know what happened to it. She stated she did not authorize that another resident use it. Review of facility policy, Abuse, Neglect and Misappropriation of Property Policy, undated, read in part: Community Care Center is committed to ensuring residents are free from neglect, mental or physical abuse, involuntary seclusion, and misappropriation of property of patients/residents entrusted to our care. 455676 Page 7 of 9 455676 04/12/2023 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to report the results of all investigations to officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 2 of 4 self reports (394902 and 362466) reviewed for compliance. Residents Affected - Few 1. The facility failed to provide a 5- day provider investigation report for intake 394902 involving facility staff related to an allegation of infection control. 2. The facility failed to provide a 5- day provider investigation report for intake 362466 involving Resident #3 related to an allegation of Resident Neglect. This deficient practice could affect any resident and could result in allegations not being investigated timely. The findings were: 1. Review of HHSC intake 394902 revealed on 12/16/22 a staff member tested positive for COVID. Review of an email from the previous ADM to HHSC, dated 12/16/23, revealed a staff member tested positive for COVID. The staff member's last day worked was 12/14/23. Interview on 4/6/23 at 4:10 PM with the ADM revealed he was unable to locate the PIR for intake #394902. He stated they had reached out to the previous ADM and she had not returned any calls. He stated he also reached out to Corporate and was waiting on a response. Interview on 4/6/23 at 5:06 PM with the previous ADM revealed she filed all PIR reports and filed them with HHSC. She stated she left the facility at least 1 month ago and could not say where it would be at the facility but it should be available. Interview on 4/12/23 at 4:49 PM with the ADM revealed he stated he was not able to provide documentation the 5-day report #394902 was submitted within the appropriate time frame. 2. Review of HHSC intake #362466 revealed on 7/6/22 Resident #3 made a blanket allegation of staff currently in house abused him. Review of facility PIR's revealed there was a PIR for intake #362466. Further review revealed there was no confirmation that it was transmitted to HHSC. Interview on 4/6/23 at 4:10 PM with the ADM revealed he was unable to locate the confirmation fax transmittal for PIR #362466. Interview on 4/6/23 at 5:06 PM with the previous ADM revealed she filed all PIR reports and filed them with HHSC. She stated she left the facility at least 1 month ago and could not say where it would be at the facility but it should be available. Interview on 4/12/23 at 4:49 PM with the ADM revealed he stated he was not able to provide documentation the 5-day report #362466 was submitted within the appropriate time period. 455676 Page 8 of 9 455676 04/12/2023 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0610 Level of Harm - Minimal harm or potential for actual harm Review of facility policy, Abuse Prohibition Policy-Investigation, dated 12/1/08, read in part: Procedures-1. The facility conducts an internal investigation and reports results of all investigations to the enforcement agency in accordance with state law including the State Survey and Certification Agency within five working days of the incident or according to state applicable law. Residents Affected - Few 455676 Page 9 of 9