Health inspection·January 22, 2024

F 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide comfortable and safe temperature levels maintained within a range of 71 to 81 degrees Fahrenheit for 7 of 7 residents (Resident #s 1, 2, 3, 5 on Hall 100 Male Secured Unit) and (Resident #s 4, 6, 7 - Hall 200) reviewed for environment. The facility presented with 2 non-functioning Heating Ventilation and Air Conditioning [HVAC] systems, which resulted in cold resident room interior temperatures (low 50s - 60s Fahrenheit) for residents living in 100 Hall (Male Secured Unit) and 200 Hall. Facility leadership was aware the HVAC systems were not adequately functioning since October 2023. An Immediate Jeopardy (IJ) situation was identified on 01/17/24. While the IJ was removed on 01/22/24, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for harm by a diminished quality of life, specifically, sleep deprivation and cold-related injuries (hypothermia). The findings were: Observation on 01/17/24 at 2:15 PM, when entering the facility, revealed it was noticeably cold and residents/staff were still wearing winter clothing (jackets/gloves/scarfs/ski caps) while in the building. Record review of website: Past Weather in [city] Texas, USA - Yesterday or Further Back (timeanddate.com) of the air temperatures for [city], Texas revealed the following air temperatures and corresponding dates for the city this facility was located: Date: Low High 1/12/2024 29 F 59 F 1/13/2024 24 F 61 F 1/14/2024 16 F 28 F 1/15/2024 14 F 30 F Page 1 of 16 455724 455724 01/22/2024 Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028

F 0584 1/16/2024 15 F 34 F Level of Harm - Immediate jeopardy to resident health or safety 1/17/2024 13 F 52 F Residents Affected - Some Interview on 01/16/2024 at 2:34 PM, the administrator stated the facility's heating units for 100 Hall (Male Secured Unit) and 200 Hall were not functioning and pending replacement. The administrator stated 2 portable heating units had been placed at both ends of the 100 Hall (Male Secured Unit) and one large space heater was placed at the end of 200 Hall until the facility's permanent heating units could be replaced. The administrator also said portable heaters were purchased and offered to residents who wanted one in their room in response to staff and residents complaining of cold temperatures within the building on the night of 1/13/2024. Observation on 01/16/2024 at 3:06 PM of 100 Hall (Secured Men's) revealed 2 temporary heating units (THU) located at both ends of the hall. Further observation revealed the THU at the beginning of 100 Hall was running at a setting of 80 F and indicated room temperature (Hallway) of 69 F. Observation of the THU at the end of 100 Hall revealed the THU was not running. Observation and interview on 01/16/2024 at 3:09 PM, Resident #1 was observed walking 100 Hall (Male Secured Unit) and lead this investigator his room. Resident #1 indicated his room was cold and would get colder at night. Resident #1 proceeded to show this investigator 4 blankets on his bed he was utilizing in an attempt to stay warm. The room temperature in this location felt uncomfortably cold while wearing a jacket. Observation and interview on 01/16/2024 at 3:14 PM, Resident #2 (100 Hall - Male Secured Unit) was observed lying in his bed. Resident #2 was observed wearing gloves and when asked why, Resident #2 responded, because I like them! When asked if the resident was cold at night, he responded, Yes! When asked how the resident was doing in an attempt to stay warm, he responded, The blankets. The room temperature in this location felt uncomfortably cold while wearing a jacket. Observation and interview on 01/16/2024 at 3:16 PM, Resident #3 (100 Hall - Male Secured Unit) was observed sitting in the secured dining area in his wheelchair. During the interview, Resident #3 said that this week had been, really cold. The room temperature in this location felt uncomfortably cold while wearing a jacket. Observation on 01/16/2024 at 3:38 PM revealed a space heater at the end of Hall 200.The space heater was on and glowing. The room temperature in this hall felt uncomfortably cold while wearing a jacket. Observation and interview on 01/16/2024 at 3:40 PM, Resident #4 (200 Hall) was asked about the temperature of her room and indicated she had been, Very cold, and said she had been using multiple blankets in an attempt to stay warm. The room temperature in this location felt uncomfortably cold while wearing a jacket. Observation and interview on 01/17/2024 at 7:38 AM, facility staff were observed wearing winter-clothing in the building which consisted of extra layers and ski hats. At this time, an unknown staff shouted, It's cold in there, 50 degrees. Observation and interview on 01/17/2024 at 7:44 AM, Resident #1 was observed lying in his bed with a blanket over his head. A reading of the room's temperature revealed a temperature of 56 F. During 455724 Page 2 of 16 455724 01/22/2024 Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028

F 0584 Level of Harm - Immediate jeopardy to resident health or safety an interview at this time, Resident #1 was asked if he was cold and responded, Yes The resident stated he did not sleep well because his room was cold. Observation and interview on 01/17/2024 at 7:57 AM with LVN B, this investigator pointed a thermal thermometer laser at the wall closest to Resident #1's bed which revealed a temperature reading of 56 F. LVN B confirmed the temperature in Resident #1's room was 56 F and responded, Oh wow, that's cold. Residents Affected - Some Observation and interview on 01/17/2024 at 7:44 AM, Resident #5 was observed lying in bed with a navy blue blanket over his head (photo taken). A reading of the room's temperature revealed a temperature of 51 F. During an interview at this time, Resident #5 was asked how he was doing and responded, Cold. When asked if the Resident #5 felt tired, he responded, Yeah, I can't sleep. Observation and interview on 01/17/2024 at 7:58 AM with LVN B, this investigator pointed a thermal thermometer laser at the wall closest to Resident #5's bed which revealed a temperature reading of 51 F. During an interview at this time, LVN B was asked what the temperature should be to be considered comfortable to which she responded, Around 70 F. Observation and interview on 01/17/2024 at 8:07 AM with Staff C, this investigator pointed a thermal thermometer laser at the wall closest to Resident #4's bed which revealed a temperature reading of 51 F. Staff C confirmed the temperature for Resident #4's room was 51 F. During an interview at this time, Staff C said Resident #4 had requested to be moved to a new location due to feeling cold in her room. Staff C mentioned another resident, Resident #7 - Hall 200, had also requested to be moved because she was cold in her room. Interview and observation on 01/17/2024 at 9:50 PM, the Maintenance Supervisor and this investigator compared thermal temperature guns and confirmed their readings matched within +/-.3 degrees F. The Maintenance Supervisor's thermal temperature gun was orange and black (IR1 Infrared Thermometer), The Maintenance Director was asked what the room temperatures should be and responded, Around 75 F in the winter and around 70 F in the summer. Interview and observation on 01/17/2024 at 10:00 AM, the Maintenance Supervisor measured Resident #1's room (100 Hall - Male Secured Unit) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #1's which revealed a temperature of 61 F. During an interview at this time, the Maintenance Supervisor said, It feels chili in here, I would need more blankets and double socks. Interview and observation on 01/17/2024 at 10:04 AM, the Maintenance Supervisor measured Resident #5's room (100 Hall - Male Secured Unit) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #5's which revealed a temperature of 61 F. Resident #5 was observed still lying in bed with blankets over his head. A space heater was observed in this resident's room and was emitting heat but the room still felt cold. During an interview at this time, Resident #5 was asked if he was still cold to which he responded, Ya. At this time, the Maintenance Director said, Even with a space heater the room still feels cold. I don't see why the main heating unit (for 100 Hall) wasn't fixed before the cold weather. Interview on 01/17/2024 at 10:15 AM, the administrator stated she had moved all but 1 resident on 200 Hall from the second half of 200 Hall to other locations including the first half of 200 Hall. The Administrator also stated she had closed the smoke barrier doors located in the middle of 200 Hall 455724 Page 3 of 16 455724 01/22/2024 Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028

F 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some in an effort to prevent cold air coming down the first half of the 200 hall. Additionally, the Administrator said all residents on the 100 Hall (Male Secured Unit) were moved to the 100 Hall (Female Secured Unit) and indicated that section of 100 Hall had a HVAC. Interview and observation on 01/17/2024 at 10:29 AM, the Maintenance Supervisor measured Resident #7's room (200 Hall) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #1's which revealed a temperature of 57.7 F. Resident #6 was observed lying in her bed under layers of blankets. During an interview at this time, Resident #6 was asked how she was doing to which she responded, I'm cold. The Maintenance Director then said, Ya, it's cold, I wouldn't want to be in there. The Maintenance Director then confirmed Resident #7's room was on the first half of 200 Hall that was supposed to be the side residents were moved to because it was warmer than the second half of 200 Hall. The Maintenance Supervisor agreed it felt much colder in the resident's room than in the hall. Interview on 01/17/2024 at 4:45 pm with the Chief Operations Officer (COO) and the administrator revealed the facility discovered in October 2023 the HVAC for 100 Hall Male Secured Unit and 200 Hall were not adequately functioning. The administrator indicated the facility had been in the process of replacing the units since then but there had been delays. The administrator further stated she anticipated the heating units for 200 Hall and 100 Hall (Male Secured Unit) would be replaced by 01/19/2024. Record review of facility policy, Quality of Life - Homelike Environment, (Revised May 2017), stated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible . 2. The facility and staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: .h. Comfortable and safe temperatures (71 F - 81 F) . Record review of website, https://www.nia.nih.gov/health/safety/cold-weather-safety-older-adults , dated, 01/03/2024 , stated: Older adults have a higher chance of being affected by cold weather. Changes that come with aging can make it harder for older adults to be aware of their body becoming too cold, which can turn into a dangerous health issue quickly. Hazards of cold weather include falls on wintry surfaces; injury caused by freezing (frostbite); and hypothermia, a medical emergency that occurs when your body temperature gets too low. Being informed and taking certain actions can help lessen risks during the colder months . Staying warm indoors. About 20% of injuries related to exposure to cold occur in the home. Here are some tips to help keep warm: Even mildly cool homes with temperatures from 60 to 65°F can lead to hypothermia in older adults. This was determined to be an Immediate Jeopardy on 01/17/24 at 5:50 PM. The administrator and COO were notified. The administrator was provided the Immediate Jeopardy template on 01/17/24 at 6:00 PM . The following Plan of Removal submitted by the facility was accepted on 01/19/24 at 2:00 PM: Plan for REMOVAL The facility failed to provide a safe, clean, comfortable, and homelike environment, to include maintenance services necessary to maintain comfortable and safe temperature 455724 Page 4 of 16 455724 01/22/2024 Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028

F 0584 levels, for 1 of 1 facility reviewed for a safe, clean, comfortable, and homelike Level of Harm - Immediate jeopardy to resident health or safety environment. Residents Affected - Some 1- On 1/17/2024 Residents on 100 unit (men's secure unit) were moved to warm secure

F584 unit. Residents on 200 hallway cold areas were moved to warm side of the unit by IDT. Units that are not holding temperature of 71 degrees Fahrenheit were temporarily closed by Maintenance Director. 2- On 1/17/2024 Maintenance Director ordered and paid for heating units repairs which are scheduled for 1/22/204 to be installed due to a delay in the crane delivery. Per the contractor all work on the HVAC units will be repaired on the same day as arrival. 3- On 1/17/2024 Social Worker/Designee notified RPs of the room changes. 4- On 1/17/2024 Director of Nursing/Designee assessed residents for s/s of hypothermia or sleep deprivation due to feeling cold - no negative findings noted. The Medical Director updated on findings by Administrator on 1/17/2024. 5- On 1/17/2024 COO (Chief Operating Officer) completed 1:1 in-service with Administrator and Maintenance Director on emergency readiness, inclement weather preparedness, and s/s of hypothermia. 6- On 1/17/2024 Director of Nursing/Designee initiated in-services with staff of identifying s/s of hypothermia, timely notification of Administrator/Supervisor when noting patients room/residents' areas feel cold or residents/staff/visitors complaints of feeling cold, residents' sleep deprivation, and cold-related injuries (hypothermia) due to cold temperatures in the facility. Staff will not be allowed to work until they receive training, including agency staff and PRN. Anyone who is not able to receive training will not be allowed to work until the in servicing is completed. 7- Ad-Hoc QAPI meeting was held on 1/17/2024, with the Medical Director, NHA (Nursing Home Administrator), DON, and Maintenance Director to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. The policies pertaining to Emergency readiness were reviewed on 1/17/2024 by the NHA (Nursing Home Administrator), DON, and Medical Director. 8- Starting on 1/17/2024, IDT (Interdisciplinary team), including Administrator, Activity 455724 Page 5 of 16 455724 01/22/2024 Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028

F 0584 Director, DON, Social Worker, admission manager, MDS, and Maintenance Director will Level of Harm - Immediate jeopardy to resident health or safety meet with residents daily to identify if any residents have sleep deprivation and s/s of Residents Affected - Some on Saturday, Sunday, until heating units are repaired. Any issues or concerns will be hypothermia due to cold temperatures Monday through Friday, and Manager on Duty brought up to the Administrator immediately and IDT team members for any follow-up needed. Residents' room temps will be taken daily to ensure compliance by Maintenance Director or designee until HVAC units are installed. If any room temperatures are below 71 degrees; the Administrator will be contacted and the resident will be offered another room that is above 71 degrees. Temperatures of the rooms will be taken 2xs a day and temps recorded in the temperature spreadsheet in maintenance book until HVAC units are installed. Residents' temperature will be taken daily to ensure no signs or symptoms of hypothermia. 9-The Administrator/designee will monitor compliance by completing an audit of five (5) residents per week for four (4) weeks until heating units are repaired. This was initiated on 1/17/2024. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance. 10- The COO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed.[sic] The facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: -Observations on 01/19/2024 of 200 Hall, between 3:15 PM and 3:17 PM revealed room temperatures between 71.4 F to 74.4 F. Further observation reviewed smoke barrier doors were closed in the middle of 200 Hall to prevent the escape of warm air. Observations on 01/19/2024 of 100 Hall, between 3:18 PM and 3:19 PM revealed room temperatures between 71.4 F to 74.4 F. Observations on 01/19/2024 at 3:20 PM revealed 100 Hall (Male Secured Unit) had been completely vacated by all residents. 455724 Page 6 of 16 455724 01/22/2024 Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028

F 0584 Level of Harm - Immediate jeopardy to resident health or safety Interview on 01/19/2024 at 4:08 PM, the Maintenance Director stated 3 HVAC three units had been ordered and paid for and had heard they would be installed on Monday 01/22/2024. Record review at this time supported the information provided specific to this interview. Observation on 01/22/2024 at 2:00 PM, HVAC staff were observed over 200 Hall working on the HVAC Unit on the roof. Residents Affected - Some Interview on 01/22/2024 at 2:05 PM, the administrator stated the new HVAC unit was being in-stalled over 200 Hall and said HVAC installers were in the process of custom fitting the plenum and anticipated both units would be completely installed by cob. Record review of the facility's Electronic Resident Database under section, Progress Notes. Revealed documentation inputted by the facility's social worker indicating RP and/or attempted RP notifications for residents that had been moved to a different room. Interview and record review on 01/19/2024 at 3:42 PM, the DON stated she assessed all residents impacted by the cold weather to ensure they did not have s/s of hypothermia. Record review of facility documentation supported this statement. Interview on 01/19/2024 at 3:53 PM, the administrator stated the emergency preparedness in-service covered inclement weather and other items specific to disasters. This included checking the generator, making sure an evacuation plan was in place, extra blankets were available, and a phone roster for staff in-case of an emergency. Regarding hypothermia, the administrator said this can be determined by body temperature, vital signs, and alert/oriented status. Interview on 01/19/2024 at 4:00 PM, the Maintenance Director stated he would look for drowsiness, confusion, shivering, memory loss et specific to hypothermia. Regarding emergency preparedness, the Maintenance Director said he was instructed to make sure there were adequate blankets, an addendum to have heaters, check room temps periodically throughout the day. He said he was also in-serviced regarding inclement weather, specifically ensuring thermostats were set properly, windows were to be shut, the generator was adequately working, et. He further stated the generator was tested on [DATE] and added a solution to prevent gelling of the gasoline. Interview with the administrator on 01/22/2024 at 5:44 PM, the administrator said that if conditions were extreme, heaters would be used as needed. The Administrator stated they would be placed in the hallways within the line of sight of nurses/aides). The administrator said this was indicated in her emergency preparedness manual. Record review of sign in sheets on 01/22/2024 provided by the administrator revealed information that supported this interview. Interview on 01/19/2024, the Corporate Nurse stated staff that have been in-serviced by person or via telephone were documented on a list and said that staff who have not yet received the in servicing will not be able to work. Record review of a 3 page document titled, Employee Roster, generated on 01/17/2024, revealed a list of all facility staff. Further review of this document revealed signatures next to staff who had completed the trainings. This list also showed attempts to contact 6 staff but had been unsuccessful. 455724 Page 7 of 16 455724 01/22/2024 Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028

F 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Observations and interviews on 01/18/2024 thru 01/22/2024 of resident rooms where residents were temporarily transferred 100 Hall (Women's Secured Unit) and the first half of 200 Hall (before smoke barrier doors) measured above 71 degrees F and it was noticeably a comfortable temperature in those resident rooms. Interviews with a sample of staff (CNAs, LVNs, RNs, DON - from all 3 facility shifts), the Maintenance Director, and administrative staff 01/19/2024 thru 01/22/2024 revealed staff had been in-serviced specific to the Plan of Removal and knew to immediately notify the administrator if they noticed an unusual occurrence, which included if the heat went out in the building. Staff were also able to explain their familiarity with signs and symptoms of hypothermia and indicated they would provide blankets, warm liquids, and ensure all doors and windows were closed to keep the heat inside. Record review of sign in sheets on 01/22/2024 provided by the administrator revealed information that supported this interview. Interview on 01/19/2024 at 4:06 PM, the Maintenance Director stated he had been checking room temps 4 times daily to ensure compliance and said the nurses were also checking room temps in the evening utilizing his thermal temperature gun (the same thermal temperature gun utilized during previous temperature observations with this investigator). Record review facility documentation revealed monitoring was occurring in accordance to this plan. Interview on 01/18/2024 at 4:42 PM, the administrator said she would be monitoring 5 residents a week for 4 weeks and would be monitoring residents daily to ensure there were not signs or symptoms of hypothermia or other potential adverse reactions related to cold weather or new interventions. She said they would be utilizing a resident roster daily to document this information. Record review of documentation on 01/22/2024 provided by the administrator revealed information that supported this interview. Interview on 01/18/2024 at 4:29 PM, the COO stated she would be frequenting the facility once per month to provide oversite to the Administrator to ensure items on the plan of removal are reviewed and completed. The administrator was informed the Immediate Jeopardy was removed on 01/22/2024. The facility remained out of compliance at a severity of potential for more than minimal harm that was not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place . 455724 Page 8 of 16 455724 01/22/2024 Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures for 7 of 7 residents (Resident #'s 1-7) reviewed for neglect, in that: Resident #'s 1-7 were occupying rooms in 100 Hall (Male Secured Unit) and 200 Hall without functioning HVAC/Heating Systems which resulted in these residents being subjected to enduring cold temperatures during cold winter weather. The facility did not report this to the state agency. This deficiency placed residents at risk for harm by a diminished quality of life, specifically, sleep deprivation and cold-related injuries (hypothermia) for residents. The findings included: Observation on 01/17/24 at 2:15 PM, when entering the facility, revealed it was noticeably cold and residents/staff were still wearing winter clothing (jackets/gloves/scarfs/ski caps) while in the building. Record review of website: Past Weather in [city] Texas, USA - Yesterday or Further Back (timeanddate.com) of the air temperatures for [city], Texas revealed the following air temperatures and corresponding dates for the city this facility was located: Date: Low High 1/12/2024 29 F 59 F 1/13/2024 24 F 61 F 1/14/2024 16 F 28 F 1/15/2024 14 F 30 F 1/16/2024 15 F 34 F 1/17/2024 13 F 52 F Interview on 1/16/2024 at 2:34 PM, the administrator stated the facility's heating units for 100 Hall (Male Secured Unit) and 200 Hall were not functioning and pending replacement. The administrator stated 2 portable heating units had been placed at both ends of the 100 Hall (Male Secured Unit) and one large space heater was placed at the end of 200 Hall until the facility's permanent heating units could be replaced. The Administrator also said portable heaters were purchased and offered to residents who wanted one in their room in response to staff and residents complaining of cold 455724 Page 9 of 16 455724 01/22/2024 Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028

F 0609 temperatures within the building on the night of 1/13/2024. Level of Harm - Minimal harm or potential for actual harm Observation on 1/16/2024 at 3:06 PM of 100 Hall (Secured Men's) revealed 2 temporary heating units (THU) located at both ends of the hall. Further observation revealed the THU at the beginning of 100 Hall was running at a setting of 80 F and indicated room temperature (Hallway) of 69 F. Observation of the THU at the end of 100 Hall revealed the THU was not running. Residents Affected - Some Observation and interview on 1/16/2024 at 3:09 PM, Resident #1 was observed walking 100 Hall (Secured Men's) and lead this investigator his room. Resident #1 indicated his room was cold and would get colder at night. Resident #1 proceeded to show this investigator 4 blankets on his bed he was utilizing in an attempt to stay warm. The room temperature in this location felt uncomfortably cold while wearing a jacket. Observation and interview on 1/16/2024 at 3:14 PM, Resident #2 (100 Hall Secured Men's) was observed lying in his bed. Resident #2 was observed wearing gloves and when asked why, Resident #2 responded, because I like them! When asked if the resident was cold at night, he responded, Yes! When asked how the resident was doing in an attempt to stay warm, he responded, The blankets. The room temperature in this location felt uncomfortably cold while wearing a jacket. Observation and interview on 1/16/2024 at 3:16 PM, Resident #3 (100 Hall Secured Men's) was observed sitting in the secured dining area in his wheelchair. During the interview, Resident #3 said that this week had been, really cold. The room temperature in this location felt uncomfortably cold while wearing a jacket. Observation on 1/16/2024 at 3:38 PM revealed a space heater at the end of Hall 200.The space heater was on and glowing. The room temperature in this hall felt uncomfortably cold while wearing a jacket. Observation and interview on 1/16/2024 at 3:40 PM, Resident #4 (200 Hall). Resident #4 was asked about the temperature of her room and indicated she had been, Very cold, and said she had been using multiple blankets in an attempt to stay warm. The room temperature in this location felt uncomfortably cold while wearing a jacket. Observation and interview on 1/17/2024 at 7:38 AM, facility staff were observed wearing winter-clothing in the building which consisted of extra layers and ski hats. At this time, an unknown staff shouted, It's cold in there, 50 degrees. Observation and interview on 1/17/2024 at 7:44 AM, Resident, Resident #1 was observed lying in his bed with a blanket over his head. A reading of the room's temperature revealed a temperature of 56 F. During an interview that this time, Resident #1 was asked if he was cold and responded, Yes The resident stated he did not sleep well because his room was cold. Observation and interview on 1/17/2024 at 7:57 AM with LVN B, this investigator pointed a thermal thermometer laser at the wall closest to Resident #1's bed which revealed a temperature reading of 56 F. LVN B confirmed the temperature in Resident #1's room was 56 F and responded, Oh wow, that's cold. Observation and interview on 1/17/2024 at 7:44 AM, Resident #5 was observed lying in bed with a navy blue blanket over his head (photo taken). A reading of the room's temperature revealed a 455724 Page 10 of 16 455724 01/22/2024 Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some temperature of 51 F. During an interview at this time, Resident #5 was asked how he was doing and responded, Cold. When asked if the Resident #5 felt tired, he responded, Yeah, I can't sleep. Observation and interview on 1/17/2024 at 7:58 AM with LVN B, this investigator pointed a thermal thermometer laser at the wall closest to Resident #5's bed which revealed a temperature reading of 51 F. During an interview at this time, LVN B was asked what the temperature should be to be considered comfortable to which she responded, Around 70 F. Observation and interview on 1/17/2024 at 8:07 AM with Staff C, this investigator pointed a thermal thermometer laser at the wall closest to Resident #4's bed which revealed a temperature reading of 51 F. Staff C confirmed the temperature for Resident #4's room was 51 F. During an interview at this time, Staff C said Resident #4 had requested to be moved to a new location due to feeling cold in her room. Staff C mentioned another Resident, Resident #7 (Hall 200) had also requested to be moved because she was cold in her room. Interview and observation on 1/17/2024 at 9:50 PM, the Maintenance Supervisor and this investigator compared thermal temperature guns and confirmed their readings matched within +/-.3 degrees F. The Maintenance Supervisor's thermal temperature gun was orange and black ([NAME] Tools IR1 Infrared Thermometer), The Maintenance Director was asked what the room temperatures should be and responded, Around 75 F in the winter and around 70 F in the summer. Interview and observation on 1/17/2024 at 10:00 AM, the Maintenance Supervisor measured Resident #1's room (100 Hall - Secured Men's Unit) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #1's which revealed a temperature of 61 F. During an interview at this time, the Maintenance Supervisor said, It feels chili in here, I would need more blankets and double socks. Interview and observation on 1/17/2024 at 10:04 AM, the Maintenance Supervisor measured Resident #5's room (100 Hall - Secured Men's Unit) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #5's which revealed a temperature of 61 F. Resident #5 was observed still lying in bed with blankets over his head. A space heater was observed in this resident's room and was emitting heat but the room still felt cold. During an interview at this time, Resident #5 was asked if he was still cold to which he responded, Ya. At this time, the Maintenance Director said, Even with a space heater the room still feels cold. I don't see why the main heating unit (for 100 Hall) wasn't fixed before the cold weather. Interview on 1/17/2024 at 10:15 AM, the administrator stated she had moved all but 1 resident on 200 Hall from the second half of 200 Hall to other locations including the first half of 200 Hall. The Administrator also stated she had closed the smoke barrier doors located in the middle of 200 Hall in an effort to prevent cold air coming down the first half of the 200 hall. Additionally, the Administrator said all residents on the 100 Hall (Male Secured unit) were moved to the 100 Hall (Female Secured unit) and indicated that section of 100 Hall had a HVAC. Interview and observation on 1/17/2024 at 10:29 AM, the Maintenance Supervisor measured Resident #7's room (200 Hall) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #1's which revealed a temperature of 57.7 F. Resident #6 was observed lying in her bed under layers of blankets. During an interview at this time, Resident #6 was asked how she was doing to which she responded, I'm cold. The Maintenance Director then said, Ya, it's cold, I wouldn't want 455724 Page 11 of 16 455724 01/22/2024 Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to be in there. The Maintenance Director then confirmed Resident #7's room was on the first half of 200 Hall that was supposed to be the side residents were moved to because it was warmer than the second half of 200 Hall. The Maintenance Supervisor agreed it felt much colder in the resident's room than in the hall. A record review of the facility's Abuse/Neglect - Clinical Protocol revised 12/2016, stated, Assessment and Recognition - 2. Neglect is defined as the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional destress . 4. If there is concern related to possible abuse and/or neglect of a resident, a nurse will assess the individual and document findings. Further review stated, The facility management and staff will comply with applicable laws and regulations pertaining to the documentation and management of abuse and neglect. 455724 Page 12 of 16 455724 01/22/2024 Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews, the facility failed to maintain essential equipment in safe operating condition for 2 of 2 HVAC Heating Units reviewed for safe operating equipment: Residents Affected - Some 1. The HVAC Heating Unit for Hall 100 (Male Secured Unit) was not functioning during cold winter weather 2. The HVAC Heating Unit for Hall 200 was not functioning during cold winter weather This failure placed residents at risk for harm by a diminished quality of life, specifically, sleep deprivation and cold-related injuries (hypothermia). The findings included: Observation on 01/17/24 at 2:15 PM, when entering the facility, revealed it was noticeably cold and residents/staff were still wearing winter clothing (jackets/gloves/scarfs/ski caps) while in the building. Record review of website: Past Weather in [city] Texas, USA - Yesterday or Further Back (timeanddate.com) of the air temperatures for [city], Texas revealed the following air temperatures and corresponding dates for the city this facility was located: Date: Low High 1/12/2024 29 F 59 F 1/13/2024 24 F 61 F 1/14/2024 16 F 28 F 1/15/2024 14 F 30 F 1/16/2024 15 F 34 F 1/17/2024 13 F 52 F Interview on 1/16/2024 at 2:34 PM, the administrator stated the facility's heating units for 100 Hall (Male Secured Unit) and 200 Hall were not functioning and pending replacement. The administrator stated 2 portable heating units had been placed at both ends of the 100 Hall (Male Secured Unit) and one large space heater was placed at the end of 200 Hall until the facility's permanent heating units could be replaced. The Administrator also said portable heaters were purchased and offered to residents who wanted one in their room in response to staff and residents complaining of cold temperatures within the building on the night of 1/13/2024. Observation on 1/16/2024 at 3:06 PM of 100 Hall (Secured Men's) revealed 2 temporary heating units (THU) located at both ends of the hall. Further observation revealed the THU at the beginning of 100 Hall was running at a setting of 80 F and indicated room temperature (Hallway) of 69 F. Observation 455724 Page 13 of 16 455724 01/22/2024 Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028

F 0908 of the THU at the end of 100 Hall revealed the THU was not running. Level of Harm - Minimal harm or potential for actual harm Observation and interview on 1/16/2024 at 3:09 PM, Resident #1 was observed walking 100 Hall (Secured Men's) and lead this investigator his room. Resident #1 indicated his room was cold and would get colder at night. Resident #1 proceeded to show this investigator 4 blankets on his bed he was utilizing in an attempt to stay warm. The room temperature in this location felt uncomfortably cold while wearing a jacket. Residents Affected - Some Observation and interview on 1/16/2024 at 3:14 PM, Resident #2 (100 Hall Secured Men's) was observed lying in his bed. Resident #2 was observed wearing gloves and when asked why, Resident #2 responded, because I like them! When asked if the resident was cold at night, he responded, Yes! When asked how the resident was doing in an attempt to stay warm, he responded, The blankets. The room temperature in this location felt uncomfortably cold while wearing a jacket. Observation and interview on 1/16/2024 at 3:16 PM, Resident #3 (100 Hall Secured Men's) was observed sitting in the secured dining area in his wheelchair. During the interview, Resident #3 said that this week had been, really cold. The room temperature in this location felt uncomfortably cold while wearing a jacket. Observation on 1/16/2024 at 3:38 PM revealed a space heater at the end of Hall 200.The space heater was on and glowing. The room temperature in this hall felt uncomfortably cold while wearing a jacket. Observation and interview on 1/16/2024 at 3:40 PM, Resident #4 (200 Hall). Resident #4 was asked about the temperature of her room and indicated she had been, Very cold, and said she had been using multiple blankets in an attempt to stay warm. The room temperature in this location felt uncomfortably cold while wearing a jacket. Observation and interview on 1/17/2024 at 7:38 AM, facility staff were observed wearing winter-clothing in the building which consisted of extra layers and ski hats. At this time, an unknown staff shouted, It's cold in there, 50 degrees. Observation and interview on 1/17/2024 at 7:44 AM, Resident, Resident #1 was observed lying in his bed with a blanket over his head. A reading of the room's temperature revealed a temperature of 56 F. During an interview that this time, Resident #1 was asked if he was cold and responded, Yes The resident stated he did not sleep well because his room was cold. Observation and interview on 1/17/2024 at 7:57 AM with LVN B, this investigator pointed a thermal thermometer laser at the wall closest to Resident #1's bed which revealed a temperature reading of 56 F. LVN B confirmed the temperature in Resident #1's room was 56 F and responded, Oh wow, that's cold. Observation and interview on 1/17/2024 at 7:44 AM, Resident #5 was observed lying in bed with a navy blue blanket over his head (photo taken). A reading of the room's temperature revealed a temperature of 51 F. During an interview at this time, Resident #5 was asked how he was doing and responded, Cold. When asked if the Resident #5 felt tired, he responded, Yeah, I can't sleep. Observation and interview on 1/17/2024 at 7:58 AM with LVN B, this investigator pointed a thermal thermometer laser at the wall closest to Resident #5's bed which revealed a temperature reading of 51 455724 Page 14 of 16 455724 01/22/2024 Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some F. During an interview at this time, LVN B was asked what the temperature should be to be considered comfortable to which she responded, Around 70 F. Observation and interview on 1/17/2024 at 8:07 AM with Staff C, this investigator pointed a thermal thermometer laser at the wall closest to Resident #4's bed which revealed a temperature reading of 51 F. Staff C confirmed the temperature for Resident #4's room was 51 F. During an interview at this time, Staff C said Resident #4 had requested to be moved to a new location due to feeling cold in her room. Staff C mentioned another Resident, Resident #7 (Hall 200) had also requested to be moved because she was cold in her room. Interview and observation on 1/17/2024 at 9:50 PM, the Maintenance Supervisor and this investigator compared thermal temperature guns and confirmed their readings matched within +/-.3 degrees F. The Maintenance Supervisor's thermal temperature gun was orange and black ([NAME] Tools IR1 Infrared Thermometer), The Maintenance Director was asked what the room temperatures should be and responded, Around 75 F in the winter and around 70 F in the summer. Interview and observation on 1/17/2024 at 10:00 AM, the Maintenance Supervisor measured Resident #1's room (100 Hall - Secured Men's Unit) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #1's which revealed a temperature of 61 F. During an interview at this time, the Maintenance Supervisor said, It feels chili in here, I would need more blankets and double socks. Interview and observation on 1/17/2024 at 10:04 AM, the Maintenance Supervisor measured Resident #5's room (100 Hall - Secured Men's Unit) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #5's which revealed a temperature of 61 F. Resident #5 was observed still lying in bed with blankets over his head. A space heater was observed in this resident's room and was emitting heat but the room still felt cold. During an interview at this time, Resident #5 was asked if he was still cold to which he responded, Ya. At this time, the Maintenance Director said, Even with a space heater the room still feels cold. I don't see why the main heating unit (for 100 Hall) wasn't fixed before the cold weather. Interview on 1/17/2024 at 10:15 AM, the administrator stated she had moved all but 1 resident on 200 Hall from the second half of 200 Hall to other locations including the first half of 200 Hall. The Administrator also stated she had closed the smoke barrier doors located in the middle of 200 Hall in an effort to prevent cold air coming down the first half of the 200 hall. Additionally, the Administrator said all residents on the 100 Hall (Male Secured unit) were moved to the 100 Hall (Female Secured unit) and indicated that section of 100 Hall had a HVAC. Interview and observation on 1/17/2024 at 10:29 AM, the Maintenance Supervisor measured Resident #7's room (200 Hall) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #1's which revealed a temperature of 57.7 F. Resident #6 was observed lying in her bed under layers of blankets. During an interview at this time, Resident #6 was asked how she was doing to which she responded, I'm cold. The Maintenance Director then said, Ya, it's cold, I wouldn't want to be in there. The Maintenance Director then confirmed Resident #7's room was on the first half of 200 Hall that was supposed to be the side residents were moved to because it was warmer than the second half of 200 Hall. The Maintenance Supervisor agreed it felt much colder in the resident's room than in the hall. 455724 Page 15 of 16 455724 01/22/2024 Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of website, https://www.nia.nih.gov/health/safety/cold-weather-safety-older-adults , dated, 1/3/2024 , stated: Older adults have a higher chance of being affected by cold weather. Changes that come with aging can make it harder for older adults to be aware of their body becoming too cold, which can turn into a dangerous health issue quickly. Hazards of cold weather include falls on wintry surfaces; injury caused by freezing (frostbite); and hypothermia, a medical emergency that occurs when your body temperature gets too low. Being informed and taking certain actions can help lessen risks during the colder months . Staying warm indoors. About 20% of injuries related to exposure to cold occur in the home. Here are some tips to help keep warm: Even mildly cool homes with temperatures from 60 to 65°F can lead to hypothermia in older adults. 455724 Page 16 of 16