Health inspection·June 16, 2023

F 0550 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 7 of 13 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) reviewed for resident rights. The facility failed to ensure Resident #1 did not experience humiliation when LVN A threw his nebulizer treatments (medication used to help breathe better) at him. The facility failed to ensure Resident #2 did not feel scared of retaliation and intimidated by staff. The facility failed to ensure Resident #2 did not feel humiliated when CNA D rudely refused to get her out of bed. The facility failed to ensure Resident #3 did not feel humiliated and disrespected when LVN A stated, I can't stomach this wound, and NA B told him not to be needy. The facility failed to ensure Resident #4 did not feel humiliated and scared of retaliation when LVN A told him, I'm done with you. The facility failed to ensure Resident #5 was not scared to report when the CNAs yelled at her because she was scared, she would be yelled at again. The facility failed to ensure Resident #6 was not scared to report LVN A after she told him he acted like a three-year-old and he was sorry. The facility failed to ensure Resident #7 did not feel intimidated and belittled when CNA C yelled and cursed at her. This failure resulted in an Immediate Jeopardy (IJ) identified on [DATE] at 3:47PM. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Page 1 of 40 455831 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0550 Findings included: Level of Harm - Immediate jeopardy to resident health or safety 1. Record review of a face sheet dated [DATE] indicated Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, with agitation (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and panic disorder episodic paroxysmal anxiety (intense feeling of fear and discomfort that begins abruptly and rises to a maximum within minutes). Residents Affected - Some Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #1 was understood and was able to understand others. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #1 had no delusions or hallucinations. The MDS assessment indicated Resident #1 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #1 required supervision for bed mobility, transfers, eating, toilet use, and limited assistance for dressing and personal hygiene. Record review of the Physician Order Report dated [DATE] - [DATE] indicated Resident #1 had an order for Ipratropium Bromide and Albuterol (medication used to help breathe better) 0.5mg/3ml liquid; 0.5mg/3ml, 1 vial every 4 hours at 12:00 AM, 04:00 AM, 08:00 AM, 12:00 PM, 04:00 PM, 08:00 PM. Record review of a care plan last revised [DATE] indicated a problem that Resident #1 exhibited verbally abusive behavioral symptoms such as others were threatened, calling 911, screamed at and cursed at staff related to wanting a breathing treatment due to anxiety and shortness of breath with interventions which included convey an attitude of acceptance toward the resident, maintain a calm environment and reassure the resident by checking his oxygen saturations to assure within normal limits and observe for anxiety and attempt to have resident purse breath. During an interview on [DATE] at 9:44 AM, Resident #1 said LVN A was rude to everybody. Resident #1 said he had asked her for a breathing treatment because he felt like he could not breathe. Resident #1 said LVN A grabbed 5-6 of the nebulizer treatments (medication used to help breathe better) and threw them at him. Resident #1 said he could not remember the date that it happened. Resident #1 said he had gotten used to her being rude that way. Resident #1 said LVN A made him feel humiliated, and he was scared of her retaliating. Resident #1 said he was scared LVN A would get back at him by making him wait until the end for his medicine even if he was the first one in line. Resident #1 said in the past LVN A had made him wait for his medication because she was mad at him. Resident #1 was unable to provide exact dates. Resident #1 said he had told the office staff he was scared LVN A would retaliate against him when he was questioned about the incident with LVN A. Record review of the Provider's Investigation Report dated [DATE] indicated the incident with Resident #1 and LVN A occurred on [DATE]. The Provider's Investigation Report indicated the facility took the following actions post investigation: completed a Head-to-Toe Assessment, Resident Interviews, Staff Interviews, Safe Surveys and Culture sensitivity/Abuse and Neglect Inservice dated [DATE]. The Culture sensitivity/Abuse and Neglect Inservice was not signed by LVN A which indicated she was not in-serviced. Record review of a Performance Improvement Plan implemented on [DATE] indicated LVN A had a 30-day timeline for performance improvement or termination would occur. 455831 Page 2 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0550 Level of Harm - Immediate jeopardy to resident health or safety 2. Record review of a face sheet dated [DATE] indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right sided weakness and paralysis after a stroke), and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). Residents Affected - Some Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. The MDS assessment indicated Resident #2 had a BIMS score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #2 had no delusions or hallucinations. The MDS assessment indicated Resident #2 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #2 did not exhibit rejection of care. The MDS assessment indicated Resident #2 required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, and supervision for eating. Resident #2 was totally dependent for transfers and bathing. Record review of Resident #2's care plan last revised [DATE] indicated she had a problem of resident must be lifted mechanically and interventions included staff to get resident up out of bed daily 5-7 times a week and required 2 staff members at all times to use the mechanical lift. Resident #2's care plan indicated she had a history of anxiety and interventions included to allow resident to voice thoughts. Resident #2's care plan indicated that she required 2 staff assistance depending on type of bath or shower, required, 1-2 staff for dressing/grooming, and 1-2 staff to provide incontinent care, and her preferred time for bath/shower was once a day on Tuesday, Thursday, and Saturday 2:00 PM- 10:00 PM. Resident #2's care plan indicated to allow her to express her feelings, allow her to participate in daily care and decision/goal making, and to listen carefully and be non-judgmental. Resident #2's care plan did not indicate she refused care. Record review of the electronic health record indicated Resident #2 was discharged to another facility on [DATE]. During an interview on [DATE] at 09:56 AM, the ombudsman said on [DATE] while in the facility she heard screaming and walked into Resident #2's room. The Ombudsman said CNA D yelled at Resident #2, What do you want? Resident #2 said she wanted to get out of bed. CNA D said to Resident #2, you know it ain't your day to get out of bed. Resident #2 said, I know it is not my shower day, but I want to get out of bed to play bingo. CNA D replied to Resident #2 and said, I don't know what to tell you. The Ombudsman said she went and reported this incident to the ADON the same day she witnessed it. During an interview on [DATE] at 3:06 PM, Resident #2 said she moved to a different nursing home approximately 5 days ago. Resident #2 said if she would have stayed at the other facility she would have died. Resident #2 said she had gone without a shower for 10 days, and she told the staff everyday she wanted a shower. Resident #2 said she was told there were not enough CNAs. Resident #2 said CNA C was horrible, cursed and screamed at her, and it broke her heart because she could hear her scream and curse at the resident across the hall from her. Resident #2 said she told him she would jerk him out of his bed, and she could not understand why she talked to everyone like that. Resident #2 said that there were plenty of other residents at the facility that had heard CNA C say the same things to other residents. Resident #2 said when CNA C and another CNA had scrubbed her leg and left a bruise while giving her a shower. Resident #2 said she reported CNA C to the DON, and that did nothing but make CNA C retaliate against her. Resident #2 said when CNA C would go into her room to leave a meal she would not speak to her or make eye contact with her. Resident #2 said the CNAs always told 455831 Page 3 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0550 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some her she could not get up and she could not get showers because they did not have enough staff. Resident #2 said the CNAs told her not to use the call light. Resident # 2 said her family member was very upset and reported this to the DON. Resident #2 said she had to lay in her feces from 11 AM to 7 PM. Resident #2 said she told NA B three times and he kept saying he would be right with her. Resident #2 said that was the most degraded and awful feeling she ever had. Resident #2 was teary eyed. Resident #2 said her family members came to visit her and she was laying in shit. Resident #2 said this messed with her emotions and she would never forget it. Resident #2 said the facility never had the right briefs and her husband would try to supply them so she could get out of bed more. Resident #2 said if her husband did not provide the appropriate size briefs the facility would apply a smaller size and it was causing her belly area to break down. Resident #2 said the CNAs were intimidating, and CNA D was always short and rude. Resident #2 said it was a yucky situation and she felt when she reported the CNAs they retaliated. 3. Record review of a face sheet dated [DATE] indicated Resident #3 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), non-pressure chronic ulcer of skin of other sites with unspecified severity (long-time open sore on the skin), and post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #3 was understood and understood others. The MDS assessment indicated Resident #3 had a BIMS score of 15, which indicated he was cognitively intact. The MDS assessment indicated Resident #3 had no delusions or hallucinations. The MDS assessment indicated Resident #3 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #3 exhibited rejection 1 to 3 days in the 7-day lookback period. The MDS assessment indicated Resident #3 required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene, supervision for eating, and total dependence for bathing. The MDS assessment indicated Resident #3 had an open lesion other than ulcers, rashes, and cuts. Record review of Resident #3's care plan last revised [DATE] indicated he exhibited signs and symptoms of anxiety and agitation and was receiving clonazepam (medication used to treat anxiety), interventions included to allow the resident to voice his thoughts and feelings and to explore with resident the reason for anxiety. Resident #3's care plan indicated to allow him to participate in daily care and decision/goal making and to listen carefully and be non-judgmental. Resident #3's care plan indicated he had open lesions related to a history of chronic abdominal wounds and had interventions which included to cleanse area to left abdomen with normal saline, pat dry, apply calcium alginate with silver (absorbent dressing applied to wounds), cover with pads twice a day and cleanse area to left inguinal area with normal saline, pat dry and apply calcium alginate silver twice daily. During an interview and observation on [DATE] at 1:28 PM, Resident #3 said NA B told him not to be needy, referring to Resident #3 using his call light to request assistance, between 7 AM and 9 AM because these were the busiest times of the day. Resident #3 was unable to provide the exact dates. Resident #3 said LVN A did not perform wound care on him when she worked at night. Resident #3 said he had complained to the Administrator and all the other nurses that LVN A was not performing wound care on him. Resident #3 said after he complained to the Administrator, the ADON accompanied LVN A to watch her perform the wound care. While the ADON was observing the wound care, LVN A told the ADON, I cannot stomach this wound. Resident #3 said the incidents with NA B and LVN A made him feel 455831 Page 4 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0550 humiliated and disrespected. Resident #3 was teary during the interview. Level of Harm - Immediate jeopardy to resident health or safety 4. Record review of Face Sheet dated [DATE] indicated Resident #4 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Chronic obstructive pulmonary disease (a lack of adequate blood supply to brain cells), other seizures (burst of uncontrolled electrical activity between brain cells), unsteadiness on feet, weakness, pain, dementia (brain impairment of memory loss and judgement), schizoaffective disorder (combination of mood disorder such as depression and bipolar disorder), hypertension, (increased blood pressure), chronic kidney disease stage 3 (mild to moderate kidney damage - less likely to filter). Residents Affected - Some Record review of quarterly MDS dated [DATE] indicated Resident #4 understood others and made himself understood. The MDS indicated Resident #4 was moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #4 did not reject evaluation or care. The MDS indicated Resident #4 required supervision and setup with transferring, dressing and limited assistance with personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #4 was care planned for psychosocial well-being. The care plan indicated interventions included Resident #4 was allowed to express feelings, allowed to participate in daily care and decision/goal making, adhere to customary routines, keep topics of conversation light and cheerful, listen carefully and non-judgmental. Resident #4 was care planned for cognitive loss related to dementia. The care plan indicated interventions included Resident #4 was approached in a calm manner, anticipate needs and observe for non-verbal cues. During an interview and observation on [DATE] at 10:49 AM, Resident #4 said LVN A told him she was done with him in a very hateful way. Resident #4 said LVN A was very bully over the residents. Resident #4 said LVN A hurt his feelings and it made him cry. Resident #4 said LVN A was bullying other patients that night and the rest of the patients came forward after him and wrote their statements. Resident #4 did not remember when the incident occurred. Resident #4 said he was very much intimated by LVN A. Resident #4 was teary when recounting the incident. 5. Record review of the Face Sheet dated [DATE] indicated Resident #5 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Transient cerebral ischemic attack (a lack of adequate blood supply to brain cells), infections of the skin and subcutaneous tissue, Chronic Obstructive pulmonary disease (a lack of adequate blood supply to brain cells), Hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the boy that can affect the arms, legs, facial muscles) affecting left dominant side. Record review of the quarterly MDS dated [DATE] indicated Resident #5 had moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #5 did not reject evaluation or care. The MDS indicated Resident #5 required limited assistance with transferring, dressing and personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #5 had episodes of anxiety and had Ativan (medication used to decrease anxiety). The care plan indicated interventions included Resident #5 was allowed to voice thoughts and feelings and to explore with resident the reason for anxiety. During an interview on [DATE] at 2:40 PM, Resident #5 said the CNAs screamed at her, but she was 455831 Page 5 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0550 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some not able to recall who the CNAs were or the date the incident happened. Resident #5 said she was scared to report the CNAs because she did not want them to yell at her again. 6. Record review of Face Sheet dated [DATE] indicated Resident #6 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Diffuse traumatic brain injury, Excoriation (skin picking) disorder, Paraplegic (paralysis of the lower body), Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury, Nausea (urge to vomit), Bipolar Disorder (changes in mood and energy levels), Pain, reduced mobility. Record review of quarterly MDS dated [DATE] indicated Resident #6 understood others and made himself understood. The MDS indicated Resident #6 was cognitively intact with a BIMS score of 15. The MDS indicated Resident #6 did not reject evaluation or care. The MDS indicated Resident #6 required extensive care with transferring, dressing and personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #6 had an activities of daily living (ADL) self-care performance deficit related to paraplegia. The care plan indicated interventions included Resident #6 required assistance x2 for bath/shower 3 times weekly. During an interview and observation on [DATE] at 5:05 PM, Resident #6 said LVN A told him he acted like a 3-year-old. Resident #6 said after LVN A told him he acted like a 3-year-old he said, I'm sorry, and LVN A responded, Yes, you are sorry. Resident #6 said this made him feel intimidated. Resident #6 said he had not reported this to the facility staff because he was scared LVN A would retaliate against him. Resident #6 could not recall when the incident occurred. Resident #6 was tearful during the interview. 7. Record review of the Face Sheet dated [DATE] indicated Resident #7 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Chronic Obstructive Pulmonary Disease (a lack of adequate blood supply to brain cells), Pain, Muscle Weakness, Pressure ulcer of other site - stage 4, Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury), Partial traumatic amputation at knee level - left lower leg, Dementia (brain impairment of memory loss and judgement), DM Type 2 (a chronic condition that affects the way the body processes blood sugar), Personal history of transient ischemic attack (TIA) (a temporary condition that mimics a stroke), cerebral infarction (a lack of adequate blood supply to brain cells) without residual deficits. Record review of the quarterly MDS dated [DATE] indicated Resident #7 understood others and made herself understood. The MDS indicated Resident #7 was cognitively intact with a BIMS score of 13. The MDS indicated Resident #7 did not reject evaluation or care. The MDS indicated Resident #7 required extensive care with transferring, dressing and personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #7 had an activities of daily living (ADL) self-care performance deficit related to amputation at knee level. The care plan indicated interventions included Resident #7 required assistance x2 for bath/shower 3 times weekly. During an interview on [DATE] at 11:19 AM, Resident #7 said CNA C yelled and cursed at her. Resident #7 said CNA C told her, I don't care who you tell, I have been working here for 20 years. Resident # 7 said when the CNAs yelled or cursed at her it made her feel intimidated and belittled. Resident #7 did not give exact dates of when this happened. Resident #7 said she had told the DON Resident 455831 Page 6 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0550 #7 yelled and cursed at her, but nothing had been done. Level of Harm - Immediate jeopardy to resident health or safety During an interview on [DATE] at 12:57 PM, CNA D said she worked the 6AM - 2PM shift since December of 2022. CNA D said she had never had any problems with any of the residents, had not been complained on, or accused of any allegations. CNA D said she had never told a resident they needed to stay in the bed. CNA D said no residents had been upset on my hall to my knowledge. CNA D said if a resident was upset with her, she would deescalate by finding out why and go get the DON. CNA D said she did not know the abuse coordinator's name because they switch positions often. CNA D said she had not been rude to residents or told the residents not to use their call lights. CNA D said she had not witnessed any of the staff members being rude to anyone. CNA D said she had never been rude or yelled at Resident #2. Residents Affected - Some During an interview on [DATE] at 2:15 PM, CNA F said no residents reported abuse to her and she had not had any problems with any of the residents. CNA F said, I have not witnessed any type of abuse to the residents by any staff member. During an interview on [DATE] at 02:04 PM, CNA E said she had worked at the facility for one year and worked the 6AM - 2PM shift. CNA E said she had never been suspended or accused of yelling at a resident. CNA E said she never yelled at Resident #2 for staying on the call light. CNA E said she never told a resident they could not get out of bed. CNA E said when Resident #2 asked to get up, we would get her up. CNA E said if Resident #2 asked to get up, I got her up even if it was not her get up day. During an interview on [DATE] at 08:59 AM, Anonymous Staff Member #1 said sometimes the facility was short staffed and it fueled the fire on tolerance with the CNAs. Anonymous Staff Member #1 said the CNAs voices did get raised. Anonymous Staff Member #1 said CNA F raised her voice at the residents. Anonymous Staff Member #1 said the CNAs raising their voices at the residents made her feel uncomfortable. Anonymous Staff Member #1 said she reported these incidents to the ADON on multiple occasions. Anonymous Staff Member #1 said the ADON's response was she was doing in-services with the CNAs. Anonymous Staff Member #1 said, If I was the resident and the CNAs talked to me that way, I would feel intimidated by them and I would be scared to ask them for things. Anonymous Staff Member #1 said she did not feel like she had the authority to effectively delegate tasks or reprimand the CNAs for their actions because she felt like she had no authority. Anonymous Staff Member #1 said there were no consequences for the CNAs actions. Anonymous Staff Member #1 said the CNAs did not answer the call lights. Anonymous Staff Member #1 said the residents should have autonomy and be able to make decisions and the staff should accommodate their requests. During an interview on [DATE] at 2:41 PM, NA B said he had worked at the facility for 3 months on all shifts. NA B said, I have never told a resident not to use their call light between 7 AM and 9 AM because it was busy. NA B said, I never witnessed another CNA be rude or yell. NA B said, In some situations you have to treat people different, they cannot all be treated the same. NA B said LVN A had been a police officer. NA B said LVN A was [NAME] so when she spoke it was a loud voice. NA B said I did not make the comment you need to lose weight to any of the residents. NA B said he always got Resident #2 up and never made her stay in the bed. NA B said it was important to respect their right because this was their home if they want to do something we should do it for them. During an interview on [DATE] at 3:56 PM, Anonymous Staff Member #2 said, she had heard the CNAs yelling and cursing at the residents. 455831 Page 7 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0550 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Anonymous Staff Member #2 said in the past she had witnessed CNA D, CNA E, CNA F, and CNA C yell and curse at any resident that could express themselves or express their needs. In particular Resident #2, Resident #7 and Resident #6. Anonymous Staff Member said they were very mean to Resident #2. Anonymous Staff Member #2 said she witnessed the incident on [DATE] when CNA D and CNA E yelled and cursed at Resident #7 and Resident #2. Anonymous Staff Member #2 said it was CNA D that told Resident #2 that she could not get up. Anonymous Staff Member #2 said she called the Ombudsman to the nurse's station to hear the incident. Anonymous Staff Member #2 said the facility was the residents' home and the residents should be able to get up when they wanted to do so. Anonymous Staff Member #2 said the residents could become depressed because of isolating them. Anonymous Staff Member #2 said verbal abuse would make the residents feel withdrawn and scared to be at the facility. Anonymous Staff Member #2 said she did not feel like she could report abuse to the Administrator at any time. Anonymous Staff Member #2 said when she reported abuse to the Administrator, the Administrator would throw her under the bus, and tell the CNAs she reported them. The CNAs would then tell her to do things herself. During an interview on [DATE] at 8:20 AM, Anonymous staff member #3 said she no longer employed at the facility, and it had been 4-6 weeks since the last time she worked. Anonymous staff member #3 said CNA E and CNA F yelled and cursed at the residents. Anonymous staff member #3 said CNA E and CNA F would tell the residents they were not getting them out of bed. Anonymous staff member #3 said CNA E and CNA F would tell Resident #2 and Resident #7 not to ask to get out of bed because they were not going to do it. Anonymous staff member #3 said CNA E and CNA F made Resident #2 and Resident #7 cry many times. Anonymous staff member #3 said it was like an act of congress to get anyone to help him, referring to the CNAs assisting Resident #3 with his ADLs. Anonymous staff member #3 said Resident #3 was scared to ask the CNAs for assistance. Anonymous staff member #3 said she reported the CNAs yelling, cursing, and not assisting the residents to the DON and Administrator over and over again and there were no consequences for the CNAs. During an attempted phone interview with LVN A on [DATE] at 4:40 PM, LVN A did not respond to phone call. During an interview on [DATE] at 06:19 PM, the ADON said she had been the ADON for 6 - 7 weeks. The ADON said she and the DON were responsible for the oversight and monitoring of clinical staff. The ADON said she was not in Resident #3's room when LVN A said she couldn't stomach the wound. The ADON said Resident #3 reported this incident to her and she did the grievance form, and it was signed by the Administrator and DON. The ADON said she had not witnessed nor had any reports of any of the CNA's yelling or cursing at the residents. During an interview on [DATE] at 06:33 PM, the DON said she was not present during the incident with Resident #1. The DON said Resident #1 did not tell her LVN A threw the nebulizer treatments at him. The DON said Resident #1 said the box fell in his lap and was not a big deal. The DON said Resident #1 was scared of LVN A because he asked her for something and instead of giving it, she belittled him. The DON said that she did not recall the incident with Resident #5 other than provided in-services regarding abuse and educate the staff that this is the resident's home, and they have the right to feel safe and secure in the home. The DON said Resident #2 had reported to her that the CNAs did not want to get her out of bed. The DON said there were multiple times Resident #2 would say she did not get a shower. The DON said I am not saying she never missed a shower because there were problems. The DON said I tried to coordinate that people were getting their showers. The DON said she was aware of the incident with Resident #4. The DON said she took his witness statement because he could not write. The DON said Resident #4 was shaking, scared, upset, and crying. The DON said she was not 455831 Page 8 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0550 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some aware of the incidents with Resident # 3, Resident #7. The DON said she had no complaints about NA B, CNA C, CNA D, CNA E, CNA F. During an interview on [DATE] at 08:18 PM, The Administrator said Resident #5's family member talked to her and confirmed that the incident with the CNAs yelling at Resident #5 did not happen. The Administrator did not specify how this was confirmed. The Administrator said she protected the residents by educating the staff on abuse and neglect and completing safe surveys on the residents. The Administrator said a family member complained to her that the CNAs would not get Resident #2 out of bed. The Administrator said Resident #2 got out of bed every time she wanted. The Administrator said Resident #1 said the nurse dropped the nebulizer treatments in his lap. The Administrator said that Resident #1 did not want to report the incident because it was not a big deal. The Administrator said a Performance Improvement Plan was started on LVN A at this time ([DATE]). The Administrator said LVN A was terminated after the incident with Resident #4. The Administrator said LVN A was terminated on [DATE]. The Administrator said she was not notified of any abuse allegations involving NA B, CNA C, and CNA D. The Administrator said she was the abuse coordinator. The Administrator said she was not aware that the staff or residents were scared to report abuse allegations to her. The Administrator said it was important to protect the residents from abuse for their safety and to prevent emotional harm. The Administrator said it was important to treat the residents with dignity and respect because it was their right. The Administrator said not treating a resident with dignity and respect could affect their well-being and make them feel bad. During an interview on [DATE] at 5:15 PM, LVN A said she had not received notification she was terminated by the facility. LVN A said she quit by not returning to work. LVN A said the last day she worked was [DATE]. LVN A said she quit after she was told she would have to pass out cigarettes during her medication pass time. LVN A said she was not going to stop passing out medications to give the residents their cigarettes. LVN A said she told several of the residents that smoked, including, Resident #4, that she was not going to stop pas[TRUNCATED] 455831 Page 9 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0584 Level of Harm - Minimal harm or potential for actual harm 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 a safe, clean, and comfortable environment for 3 of 3 halls (East, South, and [NAME] halls), 1 of 1 dining rooms, 1 of 1 lobby area, and 2 of 13 residents (Resident #9 and Resident #11) reviewed for a homelike environment. The facility failed to ensure the East, South and [NAME] halls, lobby, and dining room were free of offensive odors. The facility failed to ensure Resident #9 and Resident #11's bed linens were changed. This failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life. Findings included: 1. Record review of a face sheet dated 06/16/2023 indicated, Resident #9 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke), hyperlipidemia (high levels of fats in the blood), and anxiety disorder. Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #9 was understood and was able to understand others. The MDS assessment indicated Resident #9 had a BIMS score of 14, which indicated her cognition was intact. The MDS assessment indicated Resident #9 required supervision for bed mobility, transfers, dressing, and extensive assistance for toilet use, personal hygiene, and two- person assist for bathing. Record review of the care plan with a target date of 07/16/2023 indicated, Resident #9 was independent for transfers, required standby assistance of one person for bathing/hygiene, was independent for dressing/grooming, and required occasional assistance of 1 person for toileting. 2. Record review of a face sheet dated 06/16/2023 indicated, Resident #11 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side (right sided weakness and paralysis after a stroke), essential primary hypertension (high blood pressure), and depression (mental disorder with persistent sadness and a lack of interest or pleasure in previously enjoyable activities). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #11 was understood and was able to understand others. The MDS assessment indicated Resident #11 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #11 required supervision for bed mobility, transfers, dressing, toilet use and personal hygiene and supervision for eating, and total dependence for bathing. Record review of the care plan with a target date of 07/06/2023 indicated, Resident #11 required two-person assistance or total assistance for dressing and grooming needs, and total assistance for toileting. During an observation upon entrance of the facility on 06/13/2023 at 09:03 AM a strong odor of 455831 Page 10 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0584 urine was detected in the lobby area and East Hall. Level of Harm - Minimal harm or potential for actual harm During an observation on 06/13/2023 at 11:45 AM, a strong odor of urine was detected in the South Hall and in the dining room. Residents Affected - Some During an observation and interview starting on 06/13/2023 1:05 PM, the [NAME] and South Hall had a strong, pungent urine odor. While walking down the South Hall the Administrator said she thought it was because one of the residents had incontinent episode in the hallway or maybe it was somebody that had walked by. During an observation and interview on 06/13/2023 at 1:49 PM, Resident #11 said the sheets on his bed had not been changed in a long time. The sheets had dirty yellow and orange stains on them, and the pillow was light brownish tinged. Resident #11 said he should not have to ask the CNAs to change his sheets they should be doing this. During an observation and interview on 06/13/2023 at 2:06 PM, Resident #9 had light brownish tinged sheets on her bed, the blue pad on the bed had smears of feces on them. There was a musty, pungent, feces odor. Resident #9 said the CNAs told her they could not change her sheets because they did not have enough staff to do it. Resident #9 said the CNAs told her they want her to do those things herself. Resident #9 said she was not able to change her own sheets and she cannot wipe herself good enough after she had a bowel movement. During an observation and interview starting on 06/14/2023 5:07 AM, the [NAME] Hall and South Hall had a strong urine odor. There were trash barrels in the [NAME] and South Hall with no lids and flies around them. CNA G said she had left them uncovered because she was changing people. During an observation and interview starting on 06/14/2023 at 9:14 AM, a strong odor of urine was detected in the South Hall. Resident #10 said she kept the door to her room closed because it smells like pee out there. Resident #10 said the urine odor made her feel sick and disgusting. During an observation on 06/15/2023 at 3:11 PM, there was an odor of urine on the [NAME] and South Halls. During an observation and interview on 06/16/2023 at 11:10 AM, there was an odor of urine on the [NAME] and South Halls. During an observation and interview on 06/16/2023 at 5:18 PM, Resident #11 said his sheets had not been changed. Resident #11's sheets had dirty yellow and orange stains on them, and the pillow had a light browning tinge to it. During an observation and interview on 06/16/2023 at 5:20 PM, Resident #9 said her blue pad had been changed but not the sheets on her bed. Resident #9's sheets were light brownish tinged, and there was a musty odor. During an interview on 06/16/2023 at 5:35 PM, CNA C said she changed Resident #9's sheets last night, but she had not changed Resident #11's. CNA C said Resident #11 does his own thing when he wants to. CNA C said it was important to change the residents' sheets because it was their home, and it was their right. 455831 Page 11 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 06/16/2023 at 6:24 PM, the ADON said she had noticed a urine odor on East Hall. The ADON said the residents had not complained to her about a urine odor. The ADON said all the staff were responsible for making sure the facility did not have offensive odors. The ADON said the offensive odors could make the residents not want to leave their room, and it could affect their mental health. During an interview on 06/16/2023 at 8:01 PM, the DON said she had noticed the offensive odors in the facility, and she had reported it to the Administrator and the housekeepers. The DON did not provide specific dates. The DON said she expected the CNAs to change the residents' sheets and she was not aware that any of the residents' sheets had not been changed. The DON said all the staff should be making sure the facility did not have offensive odors. The DON said it was important to keep the facility free of offensive odors because I don't like to smell bad odors. The DON said it was important for the residents to have clean sheets because she wanted to provide a clean and safe environment for the residents. During an interview on 06/16/2023 at 8:27 PM, the Administrator said she had noticed the urine odor in the facility. The Administrator said urine odor was not a normal thing at the facility, and she did not know what was happening this week that there was a urine odor in the facility. The Administrator said all the staff were responsible for making sure there were no offensive odors in the facility. The Administrator said she expected for the staff to provide a homelike environment for the residents. Record review of the facility's policy titled, Homelike Environment, last revised February of 2021, indicated, Policy Statement Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .clean bed and bath linens that are in good condition .The facility staff and management minimizes, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include: . institutional odors . 455831 Page 12 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the right of the residents to be free from abuse for 7 of 13 residents reviewed for abuse. (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7) The facility failed to ensure Resident #1 did not experience humiliation when LVN A threw his nebulizer treatments (medication used to help breathe better) at him. The facility failed to ensure Resident #2 did not feel scared of retaliation and intimidated by staff. The facility failed to ensure Resident #2 did not feel humiliated when CNA D rudely refused to get her out of bed. The facility failed to ensure Resident #3 did not feel humiliated and disrespected when LVN A stated, I can't stomach this wound, and NA B told him not to be needy. The facility failed to ensure Resident #4 did not feel humiliated and scared of retaliation when LVN A told him, I'm done with you. The facility failed to ensure Resident #5 was not scared to report when the CNAs yelled at her because she was scared, she would be yelled at again. The facility failed to ensure Resident #6 was not scared to report LVN A after she told him he acted like a three-year-old and he was sorry. The facility failed to ensure Resident #7 did not feel intimidated and belittled when CNA C yelled and cursed at her. This failure resulted in an Immediate Jeopardy (IJ) identified on [DATE] at 3:47PM. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: 1. Record review of a face sheet dated [DATE] indicated Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, with agitation (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and panic disorder episodic paroxysmal anxiety (intense feeling of fear and discomfort that begins abruptly and rises to a maximum within minutes). 455831 Page 13 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #1 was understood and was able to understand others. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #1 had no delusions or hallucinations. The MDS assessment indicated Resident #1 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #1 required supervision for bed mobility, transfers, eating, toilet use, and limited assistance for dressing and personal hygiene. Record review of the Physician Order Report dated [DATE] - [DATE] indicated Resident #1 had an order for Ipratropium Bromide and Albuterol (medication used to help breathe better) 0.5mg/3ml liquid; 0.5mg/3ml, 1 vial every 4 hours at 12:00 AM, 04:00 AM, 08:00 AM, 12:00 PM, 04:00 PM, 08:00 PM. Record review of a care plan last revised [DATE] indicated a problem that Resident #1 exhibited verbally abusive behavioral symptoms such as others were threatened, calling 911, screamed at and cursed at staff related to wanting a breathing treatment due to anxiety and shortness of breath with interventions which included convey an attitude of acceptance toward the resident, maintain a calm environment and reassure the resident by checking his oxygen saturations to assure within normal limits and observe for anxiety and attempt to have resident purse breath. During an interview on [DATE] at 9:44 AM, Resident #1 said LVN A was rude to everybody. Resident #1 said he had asked her for a breathing treatment because he felt like he could not breathe. Resident #1 said LVN A grabbed 5-6 of the nebulizer treatments (medication used to help breathe better) and threw them at him. Resident #1 said he could not remember the date that it happened. Resident #1 said he had gotten used to her being rude that way. Resident #1 said LVN A made him feel humiliated, and he was scared of her retaliating. Resident #1 said he was scared LVN A would get back at him by making him wait until the end for his medicine even if he was the first one in line. Resident #1 said in the past LVN A had made him wait for his medication because she was mad at him. Resident #1 was unable to provide exact dates. Resident #1 said he had told the office staff he was scared LVN A would retaliate against him when he was questioned about the incident with LVN A. Record review of the Provider's Investigation Report dated [DATE] indicated the incident with Resident #1 and LVN A occurred on [DATE]. The Provider's Investigation Report indicated the facility took the following actions post investigation: completed a Head-to-Toe Assessment, Resident Interviews, Staff Interviews, Safe Surveys and Culture sensitivity/Abuse and Neglect Inservice dated [DATE]. The Culture sensitivity/Abuse and Neglect Inservice was not signed by LVN A which indicated she was not in-serviced. Record review of a Performance Improvement Plan implemented on [DATE] indicated LVN A had a 30-day timeline for performance improvement or termination would occur. 2. Record review of a face sheet dated [DATE] indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right sided weakness and paralysis after a stroke), and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. The MDS assessment indicated Resident #2 had a BIMS score of 10, which indicated 455831 Page 14 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0600 Level of Harm - Immediate jeopardy to resident health or safety her cognition was moderately impaired. The MDS assessment indicated Resident #2 had no delusions or hallucinations. The MDS assessment indicated Resident #2 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #2 did not exhibit rejection of care. The MDS assessment indicated Resident #2 required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, and supervision for eating. Resident #2 was totally dependent for transfers and bathing. Residents Affected - Some Record review of Resident #2's care plan last revised [DATE] indicated she had a problem of resident must be lifted mechanically and interventions included staff to get resident up out of bed daily 5-7 times a week and required 2 staff members at all times to use the mechanical lift. Resident #2's care plan indicated she had a history of anxiety and interventions included to allow resident to voice thoughts. Resident #2's care plan indicated that she required 2 staff assistance depending on type of bath or shower, required, 1-2 staff for dressing/grooming, and 1-2 staff to provide incontinent care, and her preferred time for bath/shower was once a day on Tuesday, Thursday, and Saturday 2:00 PM- 10:00 PM. Resident #2's care plan indicated to allow her to express her feelings, allow her to participate in daily care and decision/goal making, and to listen carefully and be non-judgmental. Resident #2's care plan did not indicate she refused care. Record review of the electronic health record indicated Resident #2 was discharged to another facility on [DATE]. During an interview on [DATE] at 09:56 AM, the ombudsman said on [DATE] while in the facility she heard screaming and walked into Resident #2's room. The Ombudsman said CNA D yelled at Resident #2, What do you want? Resident #2 said she wanted to get out of bed. CNA D said to Resident #2, you know it ain't your day to get out of bed. Resident #2 said, I know it is not my shower day, but I want to get out of bed to play bingo. CNA D replied to Resident #2 and said, I don't know what to tell you. The Ombudsman said she went and reported this incident to the ADON the same day she witnessed it. During an interview on [DATE] at 3:06 PM, Resident #2 said she moved to a different nursing home approximately 5 days ago. Resident #2 said if she would have stayed at the other facility she would have died. Resident #2 said she had gone without a shower for 10 days, and she told the staff everyday she wanted a shower. Resident #2 said she was told there were not enough CNAs. Resident #2 said CNA C was horrible, cursed and screamed at her, and it broke her heart because she could hear her scream and curse at the resident across the hall from her. Resident #2 said she told him she would jerk him out of his bed, and she could not understand why she talked to everyone like that. Resident #2 said that there were plenty of other residents at the facility that had heard CNA C say the same things to other residents. Resident #2 said when CNA C and another CNA had scrubbed her leg and left a bruise while giving her a shower. Resident #2 said she reported CNA C to the DON, and that did nothing but make CNA C retaliate against her. Resident #2 said when CNA C would go into her room to leave a meal she would not speak to her or make eye contact with her. Resident #2 said the CNAs always told her she could not get up and she could not get showers because they did not have enough staff. Resident #2 said the CNAs told her not to use the call light. Resident # 2 said her family member was very upset and reported this to the DON. Resident #2 said she had to lay in her feces from 11 AM to 7 PM. Resident #2 said she told NA B three times and he kept saying he would be right with her. Resident #2 said that was the most degraded and awful feeling she ever had. Resident #2 was teary eyed. Resident #2 said her family members came to visit her and she was laying in shit. Resident #2 said this messed with her emotions and she would never forget it. Resident #2 said the facility never had the right briefs and her husband would try to supply them so she could get out of bed more. Resident #2 said if her husband did not provide the appropriate size briefs the facility would apply a smaller 455831 Page 15 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some size and it was causing her belly area to break down. Resident #2 said the CNAs were intimidating, and CNA D was always short and rude. Resident #2 said it was a yucky situation and she felt when she reported the CNAs they retaliated. 3. Record review of a face sheet dated [DATE] indicated Resident #3 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), non-pressure chronic ulcer of skin of other sites with unspecified severity (long-time open sore on the skin), and post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #3 was understood and understood others. The MDS assessment indicated Resident #3 had a BIMS score of 15, which indicated he was cognitively intact. The MDS assessment indicated Resident #3 had no delusions or hallucinations. The MDS assessment indicated Resident #3 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #3 exhibited rejection 1 to 3 days in the 7-day lookback period. The MDS assessment indicated Resident #3 required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene, supervision for eating, and total dependence for bathing. The MDS assessment indicated Resident #3 had an open lesion other than ulcers, rashes, and cuts. Record review of Resident #3's care plan last revised [DATE] indicated he exhibited signs and symptoms of anxiety and agitation and was receiving clonazepam (medication used to treat anxiety), interventions included to allow the resident to voice his thoughts and feelings and to explore with resident the reason for anxiety. Resident #3's care plan indicated to allow him to participate in daily care and decision/goal making and to listen carefully and be non-judgmental. Resident #3's care plan indicated he had open lesions related to a history of chronic abdominal wounds and had interventions which included to cleanse area to left abdomen with normal saline, pat dry, apply calcium alginate with silver (absorbent dressing applied to wounds), cover with pads twice a day and cleanse area to left inguinal area with normal saline, pat dry and apply calcium alginate silver twice daily. During an interview and observation on [DATE] at 1:28 PM, Resident #3 said NA B told him not to be needy, referring to Resident #3 using his call light to request assistance, between 7 AM and 9 AM because these were the busiest times of the day. Resident #3 was unable to provide the exact dates. Resident #3 said LVN A did not perform wound care on him when she worked at night. Resident #3 said he had complained to the Administrator and all the other nurses that LVN A was not performing wound care on him. Resident #3 said after he complained to the Administrator, the ADON accompanied LVN A to watch her perform the wound care. While the ADON was observing the wound care, LVN A told the ADON, I cannot stomach this wound. Resident #3 said the incidents with NA B and LVN A made him feel humiliated and disrespected. Resident #3 was teary during the interview. 4. Record review of Face Sheet dated [DATE] indicated Resident #4 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Chronic obstructive pulmonary disease (a lack of adequate blood supply to brain cells), other seizures (burst of uncontrolled electrical activity between brain cells), unsteadiness on feet, weakness, pain, dementia (brain impairment of memory loss and judgement), schizoaffective disorder (combination of mood disorder such as depression and bipolar disorder), hypertension, (increased blood pressure), chronic kidney disease stage 3 (mild to moderate kidney damage - less likely to filter). 455831 Page 16 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of quarterly MDS dated [DATE] indicated Resident #4 understood others and made himself understood. The MDS indicated Resident #4 was moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #4 did not reject evaluation or care. The MDS indicated Resident #4 required supervision and setup with transferring, dressing and limited assistance with personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #4 was care planned for psychosocial well-being. The care plan indicated interventions included Resident #4 was allowed to express feelings, allowed to participate in daily care and decision/goal making, adhere to customary routines, keep topics of conversation light and cheerful, listen carefully and non-judgmental. Resident #4 was care planned for cognitive loss related to dementia. The care plan indicated interventions included Resident #4 was approached in a calm manner, anticipate needs and observe for non-verbal cues. During an interview and observation on [DATE] at 10:49 AM, Resident #4 said LVN A told him she was done with him in a very hateful way. Resident #4 said LVN A was very bully over the residents. Resident #4 said LVN A hurt his feelings and it made him cry. Resident #4 said LVN A was bullying other patients that night and the rest of the patients came forward after him and wrote their statements. Resident #4 did not remember when the incident occurred. Resident #4 said he was very much intimated by LVN A. Resident #4 was teary when recounting the incident. 5. Record review of the Face Sheet dated [DATE] indicated Resident #5 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Transient cerebral ischemic attack (a lack of adequate blood supply to brain cells), infections of the skin and subcutaneous tissue, Chronic Obstructive pulmonary disease (a lack of adequate blood supply to brain cells), Hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the boy that can affect the arms, legs, facial muscles) affecting left dominant side. Record review of the quarterly MDS dated [DATE] indicated Resident #5 had moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #5 did not reject evaluation or care. The MDS indicated Resident #5 required limited assistance with transferring, dressing and personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #5 had episodes of anxiety and had Ativan (medication used to decrease anxiety). The care plan indicated interventions included Resident #5 was allowed to voice thoughts and feelings and to explore with resident the reason for anxiety. During an interview on [DATE] at 2:40 PM, Resident #5 said the CNAs screamed at her, but she was not able to recall who the CNAs were or the date the incident happened. Resident #5 said she was scared to report the CNAs because she did not want them to yell at her again. 6. Record review of Face Sheet dated [DATE] indicated Resident #6 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Diffuse traumatic brain injury, Excoriation (skin picking) disorder, Paraplegic (paralysis of the lower body), Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury, Nausea (urge to vomit), Bipolar Disorder (changes in mood and energy levels), Pain, reduced mobility. Record review of quarterly MDS dated [DATE] indicated Resident #6 understood others and made 455831 Page 17 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some himself understood. The MDS indicated Resident #6 was cognitively intact with a BIMS score of 15. The MDS indicated Resident #6 did not reject evaluation or care. The MDS indicated Resident #6 required extensive care with transferring, dressing and personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #6 had an activities of daily living (ADL) self-care performance deficit related to paraplegia. The care plan indicated interventions included Resident #6 required assistance x2 for bath/shower 3 times weekly. During an interview and observation on [DATE] at 5:05 PM, Resident #6 said LVN A told him he acted like a 3-year-old. Resident #6 said after LVN A told him he acted like a 3-year-old he said, I'm sorry, and LVN A responded, Yes, you are sorry. Resident #6 said this made him feel intimidated. Resident #6 said he had not reported this to the facility staff because he was scared LVN A would retaliate against him. Resident #6 could not recall when the incident occurred. Resident #6 was tearful during the interview. 7. Record review of the Face Sheet dated [DATE] indicated Resident #7 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Chronic Obstructive Pulmonary Disease (a lack of adequate blood supply to brain cells), Pain, Muscle Weakness, Pressure ulcer of other site - stage 4, Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury), Partial traumatic amputation at knee level - left lower leg, Dementia (brain impairment of memory loss and judgement), DM Type 2 (a chronic condition that affects the way the body processes blood sugar), Personal history of transient ischemic attack (TIA) (a temporary condition that mimics a stroke), cerebral infarction (a lack of adequate blood supply to brain cells) without residual deficits. Record review of the quarterly MDS dated [DATE] indicated Resident #7 understood others and made herself understood. The MDS indicated Resident #7 was cognitively intact with a BIMS score of 13. The MDS indicated Resident #7 did not reject evaluation or care. The MDS indicated Resident #7 required extensive care with transferring, dressing and personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #7 had an activities of daily living (ADL) self-care performance deficit related to amputation at knee level. The care plan indicated interventions included Resident #7 required assistance x2 for bath/shower 3 times weekly. During an interview on [DATE] at 11:19 AM, Resident #7 said CNA C yelled and cursed at her. Resident #7 said CNA C told her, I don't care who you tell, I have been working here for 20 years. Resident # 7 said when the CNAs yelled or cursed at her it made her feel intimidated and belittled. Resident #7 did not give exact dates of when this happened. Resident #7 said she had told the DON Resident #7 yelled and cursed at her, but nothing had been done. During an interview on [DATE] at 12:57 PM, CNA D said she worked the 6AM - 2PM shift since December of 2022. CNA D said she had never had any problems with any of the residents, had not been complained on, or accused of any allegations. CNA D said she had never told a resident they needed to stay in the bed. CNA D said no residents had been upset on my hall to my knowledge. CNA D said if a resident was upset with her, she would deescalate by finding out why and go get the DON. CNA D said she did not know the abuse coordinator's name because they switch positions often. CNA D said she had not been rude to residents or told the residents not to use their call lights. CNA D said she had not witnessed any of the staff members being rude to anyone. CNA D said she had never been rude or yelled 455831 Page 18 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0600 at Resident #2. Level of Harm - Immediate jeopardy to resident health or safety During an interview on [DATE] at 2:15 PM, CNA F said no residents reported abuse to her and she had not had any problems with any of the residents. CNA F said, I have not witnessed any type of abuse to the residents by any staff member. Residents Affected - Some During an interview on [DATE] at 02:04 PM, CNA E said she had worked at the facility for one year and worked the 6AM - 2PM shift. CNA E said she had never been suspended or accused of yelling at a resident. CNA E said she never yelled at Resident #2 for staying on the call light. CNA E said she never told a resident they could not get out of bed. CNA E said when Resident #2 asked to get up, we would get her up. CNA E said if Resident #2 asked to get up, I got her up even if it was not her get up day. During an interview on [DATE] at 08:59 AM, Anonymous Staff Member #1 said sometimes the facility was short staffed and it fueled the fire on tolerance with the CNAs. Anonymous Staff Member #1 said the CNAs voices did get raised. Anonymous Staff Member #1 said CNA F raised her voice at the residents. Anonymous Staff Member #1 said the CNAs raising their voices at the residents made her feel uncomfortable. Anonymous Staff Member #1 said she reported these incidents to the ADON on multiple occasions. Anonymous Staff Member #1 said the ADON's response was she was doing in-services with the CNAs. Anonymous Staff Member #1 said, If I was the resident and the CNAs talked to me that way, I would feel intimidated by them and I would be scared to ask them for things. Anonymous Staff Member #1 said she did not feel like she had the authority to effectively delegate tasks or reprimand the CNAs for their actions because she felt like she had no authority. Anonymous Staff Member #1 said there were no consequences for the CNAs actions. Anonymous Staff Member #1 said the CNAs did not answer the call lights. Anonymous Staff Member #1 said the residents should have autonomy and be able to make decisions and the staff should accommodate their requests. During an interview on [DATE] at 2:41 PM, NA B said he had worked at the facility for 3 months on all shifts. NA B said, I have never told a resident not to use their call light between 7 AM and 9 AM because it was busy. NA B said, I never witnessed another CNA be rude or yell. NA B said, In some situations you have to treat people different, they cannot all be treated the same. NA B said LVN A had been a police officer. NA B said LVN A was [NAME] so when she spoke it was a loud voice. NA B said I did not make the comment you need to lose weight to any of the residents. NA B said he always got Resident #2 up and never made her stay in the bed. NA B said it was important to respect their right because this was their home if they want to do something we should do it for them. During an interview on [DATE] at 3:56 PM, Anonymous Staff Member #2 said, she had heard the CNAs yelling and cursing at the residents. Anonymous Staff Member #2 said in the past she had witnessed CNA D, CNA E, CNA F, and CNA C yell and curse at any resident that could express themselves or express their needs. In particular Resident #2, Resident #7 and Resident #6. Anonymous Staff Member said they were very mean to Resident #2. Anonymous Staff Member #2 said she witnessed the incident on [DATE] when CNA D and CNA E yelled and cursed at Resident #7 and Resident #2. Anonymous Staff Member #2 said it was CNA D that told Resident #2 that she could not get up. Anonymous Staff Member #2 said she called the Ombudsman to the nurse's station to hear the incident. Anonymous Staff Member #2 said the facility was the residents' home and the residents should be able to get up when they wanted to do so. Anonymous Staff Member #2 said the residents could become depressed because of isolating them. Anonymous Staff Member #2 said verbal abuse would make the residents feel withdrawn and scared to be at the facility. Anonymous Staff 455831 Page 19 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Member #2 said she did not feel like she could report abuse to the Administrator at any time. Anonymous Staff Member #2 said when she reported abuse to the Administrator, the Administrator would throw her under the bus, and tell the CNAs she reported them. The CNAs would then tell her to do things herself. During an interview on [DATE] at 8:20 AM, Anonymous staff member #3 said she no longer employed at the facility, and it had been 4-6 weeks since the last time she worked. Anonymous staff member #3 said CNA E and CNA F yelled and cursed at the residents. Anonymous staff member #3 said CNA E and CNA F would tell the residents they were not getting them out of bed. Anonymous staff member #3 said CNA E and CNA F would tell Resident #2 and Resident #7 not to ask to get out of bed because they were not going to do it. Anonymous staff member #3 said CNA E and CNA F made Resident #2 and Resident #7 cry many times. Anonymous staff member #3 said it was like an act of congress to get anyone to help him, referring to the CNAs assisting Resident #3 with his ADLs. Anonymous staff member #3 said Resident #3 was scared to ask the CNAs for assistance. Anonymous staff member #3 said she reported the CNAs yelling, cursing, and not assisting the residents to the DON and Administrator over and over again and there were no consequences for the CNAs. During an attempted phone interview with LVN A on [DATE] at 4:40 PM, LVN A did not respond to phone call. During an interview on [DATE] at 06:19 PM, the ADON said she had been the ADON for 6 - 7 weeks. The ADON said she and the DON were responsible for the oversight and monitoring of clinical staff. The ADON said she was not in Resident #3's room when LVN A said she couldn't stomach the wound. The ADON said Resident #3 reported this incident to her and she did the grievance form, and it was signed by the Administrator and DON. The ADON said she had not witnessed nor had any reports of any of the CNA's yelling or cursing at the residents. During an interview on [DATE] at 06:33 PM, the DON said she was not present during the incident with Resident #1. The DON said Resident #1 did not tell her LVN A threw the nebulizer treatments at him. The DON said Resident #1 said the box fell in his lap and was not a big deal. The DON said Resident #1 was scared of LVN A because he asked her for something and instead of giving it, she belittled him. The DON said that she did not recall the incident with Resident #5 other than provided in-services regarding abuse and educate the staff that this is the resident's home, and they have the right to feel safe and secure in the home. The DON said Resident #2 had reported to her that the CNAs did not want to get her out of bed. The DON said there were multiple times Resident #2 would say she did not get a shower. The DON said, I am not saying she never missed a shower because there were problems. The DON said she tried to coordinate that people were getting their showers. The DON said she was aware of the incident with Resident #4. The DON said she took his witness statement because he could not write. The DON said Resident #4 was shaking, scared, upset, and crying. The DON said she was not aware of the incidents with Resident # 3, Resident #7. The DON said she had no complaints about NA B, CNA C, CNA D, CNA E, CNA F. During an interview on [DATE] at 08:18 PM, The Administrator said Resident #5's family member talked to her and confirmed that the incident with the CNAs yelling at Resident #5 did not happen. The Administrator did not specify how this was confirmed. The Administrator said she protected the residents by educating the staff on abuse and neglect and completing safe surveys on the residents. The Administrator said a family member complained to her that the CNAs would not get Resident #2 out of bed. The Administrator said Resident #2 got out of bed every time she wanted. The Administrator said Resident #1 said the nurse dropped the nebulizer treatments in his lap. The Administrator said that 455831 Page 20 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Resident #1 did not want to report the incident because it was not a big deal. The Administrator said a Performance Improvement Plan was started on LVN A at this time ([DATE]). The Administrator said LVN A was terminated after the incident with Resident #4. The Administrator said LVN A was terminated on [DATE]. The Administrator said she was not notified of any abuse allegations involving NA B, CNA C, and CNA D. The Administrator said she was the abuse coordinator. The Administrator said she was not aware that the staff or residents were scared to report abuse allegations to her. The Administrator said it was important to protect the residents from abuse for their safety and to prevent emotional harm. Record review of LVN A's personnel file did not indicate any previous disciplinary actions. LVN A's personnel file did not indicate a termination date. During an interview on [DATE] at 5:15 PM (LVN A returned phone call after facility exit), LVN A said she had not received notification she was terminated by the facility. LVN A said she quit by not returning to work. LVN A said the last day she worked was [DATE]. LVN A said she quit after she was told she would have to pass out cigarettes during her medication pass time. LVN A said she was not going to stop passing out medications to give the residents their cigarettes. LVN A said she told several of the residents that smoked, including, Resident #4, that she was not going to stop passing out medications to give them their cigarettes. LVN A said after she told them this Resident #4 got really pissed of[TRUNCATED] 455831 Page 21 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement their written policies and procedures to prohibit neglect and abuse for 7 of 13 residents reviewed for abuse. (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7). Residents Affected - Some The facility failed to ensure Resident #1 did not experience humiliation when LVN A threw his nebulizer treatments (medication used to help breathe better) at him. The facility failed to ensure Resident #2 did not feel scared of retaliation and intimidated by staff. The facility failed to ensure Resident #2 did not feel humiliated when CNA D rudely refused to get her out of bed. The facility failed to ensure Resident #3 did not feel humiliated and disrespected when LVN A stated, I can't stomach this wound, and NA B told him not to be needy. The facility failed to ensure Resident #4 did not feel humiliated and scared of retaliation when LVN A told him, I'm done with you. The facility failed to ensure Resident #5 was not scared to report when the CNAs yelled at her because she was scared, she would be yelled at again. The facility failed to ensure Resident #6 was not scared to report LVN A after she told him he acted like a three-year-old and he was sorry. The facility failed to ensure Resident #7 did not feel intimidated and belittled when CNA C yelled and cursed at her. The facility abuse coordinator failed to ensure staff were able to report allegations of abuse without fear of reprisal. This failure resulted in an Immediate Jeopardy (IJ) identified on [DATE] at 3:47PM. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. This failure could place residents at risk of unreported abuse, neglect, exploitation and a decreased quality of life. Findings included: 1. Record review of a face sheet dated [DATE] indicated Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, with agitation (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and panic disorder episodic 455831 Page 22 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some paroxysmal anxiety (intense feeling of fear and discomfort that begins abruptly and rises to a maximum within minutes). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #1 was understood and was able to understand others. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #1 had no delusions or hallucinations. The MDS assessment indicated Resident #1 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #1 required supervision for bed mobility, transfers, eating, toilet use, and limited assistance for dressing and personal hygiene. Record review of the Physician Order Report dated [DATE] - [DATE] indicated Resident #1 had an order for Ipratropium Bromide and Albuterol (medication used to help breathe better) 0.5mg/3ml liquid; 0.5mg/3ml, 1 vial every 4 hours at 12:00 AM, 04:00 AM, 08:00 AM, 12:00 PM, 04:00 PM, 08:00 PM. Record review of a care plan last revised [DATE] indicated a problem that Resident #1 exhibited verbally abusive behavioral symptoms such as others were threatened, calling 911, screamed at and cursed at staff related to wanting a breathing treatment due to anxiety and shortness of breath with interventions which included convey an attitude of acceptance toward the resident, maintain a calm environment and reassure the resident by checking his oxygen saturations to assure within normal limits and observe for anxiety and attempt to have resident purse breath. During an interview on [DATE] at 9:44 AM, Resident #1 said LVN A was rude to everybody. Resident #1 said he had asked her for a breathing treatment because he felt like he could not breathe. Resident #1 said LVN A grabbed 5-6 of the nebulizer treatments (medication used to help breathe better) and threw them at him. Resident #1 said he could not remember the date that it happened. Resident #1 said he had gotten used to her being rude that way. Resident #1 said LVN A made him feel humiliated, and he was scared of her retaliating. Resident #1 said he was scared LVN A would get back at him by making him wait until the end for his medicine even if he was the first one in line. Resident #1 said in the past LVN A had made him wait for his medication because she was mad at him. Resident #1 was unable to provide exact dates. Resident #1 said he had told the office staff he was scared LVN A would retaliate against him when he was questioned about the incident with LVN A. Record review of the Provider's Investigation Report dated [DATE] indicated the incident with Resident #1 and LVN A occurred on [DATE]. The Provider's Investigation Report indicated the facility took the following actions post investigation: completed a Head-to-Toe Assessment, Resident Interviews, Staff Interviews, Safe Surveys and Culture sensitivity/Abuse and Neglect Inservice dated [DATE]. The Culture sensitivity/Abuse and Neglect Inservice was not signed by LVN A which indicated she was not in-serviced. Record review of a Performance Improvement Plan implemented on [DATE] indicated LVN A had a 30-day timeline for performance improvement or termination would occur. 2. Record review of a face sheet dated [DATE] indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right sided weakness and paralysis after a stroke), and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). 455831 Page 23 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. The MDS assessment indicated Resident #2 had a BIMS score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #2 had no delusions or hallucinations. The MDS assessment indicated Resident #2 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #2 did not exhibit rejection of care. The MDS assessment indicated Resident #2 required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, and supervision for eating. Resident #2 was totally dependent for transfers and bathing. Record review of Resident #2's care plan last revised [DATE] indicated she had a problem of resident must be lifted mechanically and interventions included staff to get resident up out of bed daily 5-7 times a week and required 2 staff members at all times to use the mechanical lift. Resident #2's care plan indicated she had a history of anxiety and interventions included to allow resident to voice thoughts. Resident #2's care plan indicated that she required 2 staff assistance depending on type of bath or shower, required, 1-2 staff for dressing/grooming, and 1-2 staff to provide incontinent care, and her preferred time for bath/shower was once a day on Tuesday, Thursday, and Saturday 2:00 PM- 10:00 PM. Resident #2's care plan indicated to allow her to express her feelings, allow her to participate in daily care and decision/goal making, and to listen carefully and be non-judgmental. Resident #2's care plan did not indicate she refused care. Record review of the electronic health record indicated Resident #2 was discharged to another facility on [DATE]. During an interview on [DATE] at 09:56 AM, the ombudsman said on [DATE] while in the facility she heard screaming and walked into Resident #2's room. The Ombudsman said CNA D yelled at Resident #2, What do you want? Resident #2 said she wanted to get out of bed. CNA D said to Resident #2, you know it ain't your day to get out of bed. Resident #2 said, I know it is not my shower day, but I want to get out of bed to play bingo. CNA D replied to Resident #2 and said, I don't know what to tell you. The Ombudsman said she went and reported this incident to the ADON the same day she witnessed it. During an interview on [DATE] at 3:06 PM, Resident #2 said she moved to a different nursing home approximately 5 days ago. Resident #2 said if she would have stayed at the other facility she would have died. Resident #2 said she had gone without a shower for 10 days, and she told the staff everyday she wanted a shower. Resident #2 said she was told there were not enough CNAs. Resident #2 said CNA C was horrible, cursed and screamed at her, and it broke her heart because she could hear her scream and curse at the resident across the hall from her. Resident #2 said she told him she would jerk him out of his bed, and she could not understand why she talked to everyone like that. Resident #2 said that there were plenty of other residents at the facility that had heard CNA C say the same things to other residents. Resident #2 said when CNA C and another CNA had scrubbed her leg and left a bruise while giving her a shower. Resident #2 said she reported CNA C to the DON, and that did nothing but make CNA C retaliate against her. Resident #2 said when CNA C would go into her room to leave a meal she would not speak to her or make eye contact with her. Resident #2 said the CNAs always told her she could not get up and she could not get showers because they did not have enough staff. Resident #2 said the CNAs told her not to use the call light. Resident # 2 said her family member was very upset and reported this to the DON. Resident #2 said she had to lay in her feces from 11 AM to 7 PM. Resident #2 said she told NA B three times and he kept saying he would be right with her. Resident #2 said that was the most degraded and awful feeling she ever had. Resident #2 was teary eyed. Resident #2 said her family members came to visit her and she was laying in shit. Resident #2 said this messed with her emotions and she would never forget it. Resident #2 said the facility never had 455831 Page 24 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the right briefs and her husband would try to supply them so she could get out of bed more. Resident #2 said if her husband did not provide the appropriate size briefs the facility would apply a smaller size and it was causing her belly area to break down. Resident #2 said the CNAs were intimidating, and CNA D was always short and rude. Resident #2 said it was a yucky situation and she felt when she reported the CNAs they retaliated. 3. Record review of a face sheet dated [DATE] indicated Resident #3 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), non-pressure chronic ulcer of skin of other sites with unspecified severity (long-time open sore on the skin), and post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #3 was understood and understood others. The MDS assessment indicated Resident #3 had a BIMS score of 15, which indicated he was cognitively intact. The MDS assessment indicated Resident #3 had no delusions or hallucinations. The MDS assessment indicated Resident #3 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #3 exhibited rejection 1 to 3 days in the 7-day lookback period. The MDS assessment indicated Resident #3 required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene, supervision for eating, and total dependence for bathing. The MDS assessment indicated Resident #3 had an open lesion other than ulcers, rashes, and cuts. Record review of Resident #3's care plan last revised [DATE] indicated he exhibited signs and symptoms of anxiety and agitation and was receiving clonazepam (medication used to treat anxiety), interventions included to allow the resident to voice his thoughts and feelings and to explore with resident the reason for anxiety. Resident #3's care plan indicated to allow him to participate in daily care and decision/goal making and to listen carefully and be non-judgmental. Resident #3's care plan indicated he had open lesions related to a history of chronic abdominal wounds and had interventions which included to cleanse area to left abdomen with normal saline, pat dry, apply calcium alginate with silver (absorbent dressing applied to wounds), cover with pads twice a day and cleanse area to left inguinal area with normal saline, pat dry and apply calcium alginate silver twice daily. During an interview and observation on [DATE] at 1:28 PM, Resident #3 said NA B told him not to be needy, referring to Resident #3 using his call light to request assistance, between 7 AM and 9 AM because these were the busiest times of the day. Resident #3 was unable to provide the exact dates. Resident #3 said LVN A did not perform wound care on him when she worked at night. Resident #3 said he had complained to the Administrator and all the other nurses that LVN A was not performing wound care on him. Resident #3 said after he complained to the Administrator, the ADON accompanied LVN A to watch her perform the wound care. While the ADON was observing the wound care, LVN A told the ADON, I cannot stomach this wound. Resident #3 said the incidents with NA B and LVN A made him feel humiliated and disrespected. Resident #3 was teary during the interview. 4. Record review of Face Sheet dated [DATE] indicated Resident #4 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Chronic obstructive pulmonary disease (a lack of adequate blood supply to brain cells), other seizures (burst of uncontrolled electrical activity between brain cells), unsteadiness on feet, weakness, pain, dementia (brain impairment of memory loss and judgement), schizoaffective disorder (combination of mood disorder such as depression and 455831 Page 25 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some bipolar disorder), hypertension, (increased blood pressure), chronic kidney disease stage 3 (mild to moderate kidney damage - less likely to filter). Record review of quarterly MDS dated [DATE] indicated Resident #4 understood others and made himself understood. The MDS indicated Resident #4 was moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #4 did not reject evaluation or care. The MDS indicated Resident #4 required supervision and setup with transferring, dressing and limited assistance with personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #4 was care planned for psychosocial well-being. The care plan indicated interventions included Resident #4 was allowed to express feelings, allowed to participate in daily care and decision/goal making, adhere to customary routines, keep topics of conversation light and cheerful, listen carefully and non-judgmental. Resident #4 was care planned for cognitive loss related to dementia. The care plan indicated interventions included Resident #4 was approached in a calm manner, anticipate needs and observe for non-verbal cues. During an interview and observation on [DATE] at 10:49 AM, Resident #4 said LVN A told him she was done with him in a very hateful way. Resident #4 said LVN A was very bully over the residents. Resident #4 said LVN A hurt his feelings and it made him cry. Resident #4 said LVN A was bullying other patients that night and the rest of the patients came forward after him and wrote their statements. Resident #4 did not remember when the incident occurred. Resident #4 said he was very much intimated by LVN A. Resident #4 was teary when recounting the incident. 5. Record review of the Face Sheet dated [DATE] indicated Resident #5 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Transient cerebral ischemic attack (a lack of adequate blood supply to brain cells), infections of the skin and subcutaneous tissue, Chronic Obstructive pulmonary disease (a lack of adequate blood supply to brain cells), Hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the boy that can affect the arms, legs, facial muscles) affecting left dominant side. Record review of the quarterly MDS dated [DATE] indicated Resident #5 had moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #5 did not reject evaluation or care. The MDS indicated Resident #5 required limited assistance with transferring, dressing and personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #5 had episodes of anxiety and had Ativan (medication used to decrease anxiety). The care plan indicated interventions included Resident #5 was allowed to voice thoughts and feelings and to explore with resident the reason for anxiety. During an interview on [DATE] at 2:40 PM, Resident #5 said the CNAs screamed at her, but she was not able to recall who the CNAs were or the date the incident happened. Resident #5 said she was scared to report the CNAs because she did not want them to yell at her again. 6. Record review of Face Sheet dated [DATE] indicated Resident #6 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Diffuse traumatic brain injury, Excoriation (skin picking) disorder, Paraplegic (paralysis of the lower body), Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury, Nausea (urge to vomit), Bipolar 455831 Page 26 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0607 Disorder (changes in mood and energy levels), Pain, reduced mobility. Level of Harm - Immediate jeopardy to resident health or safety Record review of quarterly MDS dated [DATE] indicated Resident #6 understood others and made himself understood. The MDS indicated Resident #6 was cognitively intact with a BIMS score of 15. The MDS indicated Resident #6 did not reject evaluation or care. The MDS indicated Resident #6 required extensive care with transferring, dressing and personal hygiene. Residents Affected - Some Record review of the comprehensive care plan updated [DATE] indicated Resident #6 had an activities of daily living (ADL) self-care performance deficit related to paraplegia. The care plan indicated interventions included Resident #6 required assistance x2 for bath/shower 3 times weekly. During an interview and observation on [DATE] at 5:05 PM, Resident #6 said LVN A told him he acted like a 3-year-old. Resident #6 said after LVN A told him he acted like a 3-year-old he said, I'm sorry, and LVN A responded, Yes, you are sorry. Resident #6 said this made him feel intimidated. Resident #6 said he had not reported this to the facility staff because he was scared LVN A would retaliate against him. Resident #6 could not recall when the incident occurred. Resident #6 was tearful during the interview. 7. Record review of the Face Sheet dated [DATE] indicated Resident #7 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Chronic Obstructive Pulmonary Disease (a lack of adequate blood supply to brain cells), Pain, Muscle Weakness, Pressure ulcer of other site - stage 4, Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury), Partial traumatic amputation at knee level - left lower leg, Dementia (brain impairment of memory loss and judgement), DM Type 2 (a chronic condition that affects the way the body processes blood sugar), Personal history of transient ischemic attack (TIA) (a temporary condition that mimics a stroke), cerebral infarction (a lack of adequate blood supply to brain cells) without residual deficits. Record review of the quarterly MDS dated [DATE] indicated Resident #7 understood others and made herself understood. The MDS indicated Resident #7 was cognitively intact with a BIMS score of 13. The MDS indicated Resident #7 did not reject evaluation or care. The MDS indicated Resident #7 required extensive care with transferring, dressing and personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #7 had an activities of daily living (ADL) self-care performance deficit related to amputation at knee level. The care plan indicated interventions included Resident #7 required assistance x2 for bath/shower 3 times weekly. During an interview on [DATE] at 11:19 AM, Resident #7 said CNA C yelled and cursed at her. Resident #7 said CNA C told her, I don't care who you tell, I have been working here for 20 years. Resident # 7 said when the CNAs yelled or cursed at her it made her feel intimidated and belittled. Resident #7 did not give exact dates of when this happened. Resident #7 said she had told the DON Resident #7 yelled and cursed at her, but nothing had been done. During an interview on [DATE] at 12:57 PM, CNA D said she worked the 6AM - 2PM shift since December of 2022. CNA D said she had never had any problems with any of the residents, had not been complained on, or accused of any allegations. CNA D said she had never told a resident they needed to stay in the bed. CNA D said no residents had been upset on my hall to my knowledge. CNA D said if a resident was upset with her, she would deescalate by finding out why and go get the DON. CNA D said she 455831 Page 27 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some did not know the abuse coordinator's name because they switch positions often. CNA D said she had not been rude to residents or told the residents not to use their call lights. CNA D said she had not witnessed any of the staff members being rude to anyone. CNA D said she had never been rude or yelled at Resident #2. During an interview on [DATE] at 2:15 PM, CNA F said no residents reported abuse to her and she had not had any problems with any of the residents. CNA F said, I have not witnessed any type of abuse to the residents by any staff member. During an interview on [DATE] at 02:04 PM, CNA E said she had worked at the facility for one year and worked the 6AM - 2PM shift. CNA E said she had never been suspended or accused of yelling at a resident. CNA E said she never yelled at Resident #2 for staying on the call light. CNA E said she never told a resident they could not get out of bed. CNA E said when Resident #2 asked to get up, we would get her up. CNA E said if Resident #2 asked to get up, I got her up even if it was not her get up day. During an interview on [DATE] at 08:59 AM, Anonymous Staff Member #1 said sometimes the facility was short staffed and it fueled the fire on tolerance with the CNAs. Anonymous Staff Member #1 said the CNAs voices did get raised. Anonymous Staff Member #1 said CNA F raised her voice at the residents. Anonymous Staff Member #1 said the CNAs raising their voices at the residents made her feel uncomfortable. Anonymous Staff Member #1 said she reported these incidents to the ADON on multiple occasions. Anonymous Staff Member #1 said the ADON's response was she was doing in-services with the CNAs. Anonymous Staff Member #1 said, If I was the resident and the CNAs talked to me that way, I would feel intimidated by them and I would be scared to ask them for things. Anonymous Staff Member #1 said she did not feel like she had the authority to effectively delegate tasks or reprimand the CNAs for their actions because she felt like she had no authority. Anonymous Staff Member #1 said there were no consequences for the CNAs actions. Anonymous Staff Member #1 said the CNAs did not answer the call lights. Anonymous Staff Member #1 said the residents should have autonomy and be able to make decisions and the staff should accommodate their requests. During an interview on [DATE] at 2:41 PM, NA B said he had worked at the facility for 3 months on all shifts. NA B said, I have never told a resident not to use their call light between 7 AM and 9 AM because it was busy. NA B said, I never witnessed another CNA be rude or yell. NA B said, In some situations you have to treat people different, they cannot all be treated the same. NA B said LVN A had been a police officer. NA B said LVN A was [NAME] so when she spoke it was a loud voice. NA B said I did not make the comment you need to lose weight to any of the residents. NA B said he always got Resident #2 up and never made her stay in the bed. NA B said it was important to respect their right because this was their home if they want to do something we should do it for them. During an interview on [DATE] at 3:56 PM, Anonymous Staff Member #2 said, she had heard the CNAs yelling and cursing at the residents. Anonymous Staff Member #2 said in the past she had witnessed CNA D, CNA E, CNA F, and CNA C yell and curse at any resident that could express themselves or express their needs. In particular Resident #2, Resident #7 and Resident #6. Anonymous Staff Member said they were very mean to Resident #2. Anonymous Staff Member #2 said she witnessed the incident on [DATE] when CNA D and CNA E yelled and cursed at Resident #7 and Resident #2. Anonymous Staff Member #2 said it was CNA D that told Resident #2 that she could not get up. Anonymous Staff Member #2 said she called the Ombudsman to the nurse's station to hear the incident. Anonymous Staff Member #2 said the facility was the residents' home 455831 Page 28 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0607 Level of Harm - Immediate jeopardy to resident health or safety and the residents should be able to get up when they wanted to do so. Anonymous Staff Member #2 said the residents could become depressed because of isolating them. Anonymous Staff Member #2 said verbal abuse would make the residents feel withdrawn and scared to be at the facility. Anonymous Staff Member #2 said she did not feel like she could report abuse to the Administrator at any time. Anonymous Staff Member #2 said when she reported abuse to the Administrator, the Administrator would throw her under the bus, and tell the CNAs she reported them. The CNAs would then tell her to do things herself. Residents Affected - Some During an interview on [DATE] at 8:20 AM, Anonymous staff member #3 said she no longer employed at the facility, and it had been 4-6 weeks since the last time she worked. Anonymous staff member #3 said CNA E and CNA F yelled and cursed at the residents. Anonymous staff member #3 said CNA E and CNA F would tell the residents they were not getting them out of bed. Anonymous staff member #3 said CNA E and CNA F would tell Resident #2 and Resident #7 not to ask to get out of bed because they were not going to do it. Anonymous staff member #3 said CNA E and CNA F made Resident #2 and Resident #7 cry many times. Anonymous staff member #3 said it was like an act of congress to get anyone to help him, referring to the CNAs assisting Resident #3 with his ADLs. Anonymous staff member #3 said Resident #3 was scared to ask the CNAs for assistance. Anonymous staff member #3 said she reported the CNAs yelling, cursing, and not assisting the residents to the DON and Administrator over and over again and there were no consequences for the CNAs. During an attempted phone interview with LVN A on [DATE] at 4:40 PM, LVN A did not respond to phone call. During an interview on [DATE] at 06:19 PM, the ADON said she had been the ADON for 6 - 7 weeks. The ADON said she and the DON were responsible for the oversight and monitoring of clinical staff. The ADON said she was not in Resident #3's room when LVN A said she couldn't stomach the wound. The ADON said Resident #3 reported this incident to her and she did the grievance form, and it was signed by the Administrator and DON. The ADON said she had not witnessed nor had any reports of any of the CNA's yelling or cursing at the residents. During an interview on [DATE] at 06:33 PM, the DON said she was not present during the incident with Resident #1. The DON said Resident #1 did not tell her LVN A threw the nebulizer treatments at him. The DON said Resident #1 said the box fell in his lap and was not a big deal. The DON said Resident #1 was scared of LVN A because he asked her for something and instead of giving it, she belittled him. The DON said that she did not recall the incident with Resident #5 other than provided in-services regarding abuse and educate the staff that this is the resident's home, and they have the right to feel safe and secure in the home. The DON said Resident #2 had reported to her that the CNAs did not want to get her out of bed. The DON said there were multiple times Resident #2 would say she did not get a shower. The DON said I am not saying she never missed a shower because there were problems. The DON said I tried to coordinate that people were getting their showers. The DON said she was aware of the incident with Resident #4. The DON said she took his witness statement because he could not write. The DON said Resident #4 was shaking, scared, upset, and crying. The DON said she was not aware of the incidents with Resident # 3, Resident #7. The DON said she had no complaints about NA B, CNA C, CNA D, CNA E, CNA F. The DON said it was important to follow the abuse policy because it was the residents' right not to be abused. The DON said the abuse policy needed to be followed so that people understood they could not abuse the residents. The DON said the abuse policy protected the residents from abuse and gave the facility a guideline to follow so abuse could be identified and reported. The DON said if the residents experienced verbal abuse it could result in them being scared, withdrawn and cause failure to thrive. 455831 Page 29 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During an interview on [DATE] at 08:18 PM, The Administrator said Resident #5's family member talked to her and confirmed that the incident with the CNAs yelling at Resident #5 did not happen. The Administrator did not specify how this was confirmed. The Administrator said she protected the residents by educating the staff on abuse and neglect and completing safe surveys on the residents. The Administrator said a family member complained to her that the CNAs would not get Resident #2 out of bed. The Administrator said Resident #2 got out of bed every time she wanted. The Administrator said Resident #1 said the nurse dropped the nebulizer treatments in his lap. The Administrator said that Resident #1 did not want to report the incident because it was not a big deal. The Administrator said a Performance Improvement Plan was started on LVN A at this time ([DATE]). The Administrator said LVN A was terminated after the incident with Resident #4. The Administrator said LVN A was terminated on [DATE]. The Administrator said she was not notified of any abuse allegations involving NA B, CNA C, and CNA D. The Administrator said she was the abuse coordinator. The Administrator said she was not aware that the staff or residents were scared to report abuse allegations to her. The Administrator said it was important to protect the residents from abuse for their safety and to prevent emotional harm. The Administrator said in-services were provided to the staff. The Administrator said she expected all of the staff to follow the abuse policy. The Administrator said it was important to follow the abuse policy to ensure the safety of the residents. The Administrator said not follow[TRUNCATED] 455831 Page 30 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 2 of 13 residents reviewed for ADLs (Residents #9, Resident #11) Residents Affected - Some The facility did not provide scheduled showers for Resident #9 and Resident #11. These failures could place residents at risk of not receiving services/care and decreased quality of life. 1. Record review of a face sheet dated 06/16/2023 indicated, Resident #9 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke), hyperlipidemia (high levels of fats in the blood), and anxiety disorder. Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #9 was understood and was able to understand others. The MDS assessment indicated Resident #9 had a BIMS score of 14, which indicated her cognition was intact. The MDS assessment indicated Resident #9 required supervision for bed mobility, transfers, dressing, and extensive assistance for toilet use, personal hygiene, and two-person assist for bathing. Record review of the care plan last revised 05/24/2023 indicated, Resident #9 was independent for transfers, required standby assistance of one person for bathing/hygiene, was independent for dressing/grooming, and required occasional assistance of 1 person for toileting. During an interview and observation on 06/13/2023 at 02:06 PM, Resident #9 said she had not had a bath/shower since last Tuesday, June 6, 2023. Resident #9 said she was supposed to receive a shower three times weekly on Tuesday, Thursday, and Saturday on the 2 - 10 shifts. Resident #9 said she had not been offered a shower since last Tuesday, June 6th, 2023. Resident #9 said she would really like to get her hair washed and a good shower because she can smell herself. Resident #9 said she had asked the CNA on Thursday for the shower, but the CNA told Resident #9 maybe around 4PM that she could help her bath, but they never come back and offered the shower. Resident #9 said she asked over the weekend, for a shower but the CNA told her she was the only CNA and no time to perform the requested shower. Resident #9 said she would have liked to go play bingo, but she was always waiting on her shower. Resident #9 was observed with uncombed oily hair, and a strong musty odor lingered in the room. The odor was stronger with Resident #9's body movements. During an interview and observation on 06/14/2023 at 12:00 PM, Resident #9 said she had not received a shower. Resident #9 was observed with uncombed oily hair, and a strong musty odor lingered in the room. During an observation on 06/15/2023 at 04:00 PM, Resident #9 was lying in bed her hair was oily and disheveled, and a strong musty odor lingered in the room. Record Review of the Resident Showers Log indicated Resident #9 received showers on the following dates: 06/06/2023 - Tuesday, 06/08/2023 - Thursday, 06/10/2023 - Saturday, 06/13/2023 - Tuesday 455831 Page 31 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During interview and observation on 06/16/2023 at 05:20 PM, Resident #9 said she received a shower yesterday evening on 06/15/2023. Resident #9 said she felt better after the shower. Resident's #9 was observed with clean and combed hair. During interview on 06/16/2023 at 05:35 PM, CNA C said Resident #9 had asked for a shower on Wednesday, 06/14/2023, because she had not had one. CNA C said she told Resident #9 she would give her a shower tomorrow (Thursday 06/15/2023). CNA C said Resident #9 refused a lot of showers. CNA C said the CNAs had to chart the resident refusals. CNA C said the CNAs are responsible for giving the showers to the residents. CNA C said it was important to give the residents their showers because it made the residents feel better. CNA C said not giving the residents their showers could affect the residents emotionally. 2. Record review of a face sheet dated 06/16/2023 indicated, Resident #11 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side (right sided weakness and paralysis after a stroke), essential primary hypertension (high blood pressure), and depression (mental disorder with persistent sadness and a lack of interest or pleasure in previously enjoyable activities). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #11 was understood and was able to understand others. The MDS assessment indicated Resident #11 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #11 required supervision for bed mobility, transfers, dressing, toilet use and personal hygiene and supervision for eating, and total dependence for bathing. The MDS indicated Resident #11 did not reject care. The MDS indicated Resident #11 did not exhibit any behavioral symptoms. Record review of the care plan with a start date of 12/08/2021 indicated, Resident #11 required physical assistance of one person for bathing. The care plan indicated Resident #11 was to receive showers on Monday, Wednesday, and Fridays. During an interview on 06/13/2023 at 01:49 PM, Resident #11 said he had not received a shower/bath for as long as he could remember probably around the time COVID hit. Resident #11 said he was not able to stand on his own. Resident #11 said the CNAs had not offered a shower. Resident #11 said he used the sink to bathe himself the best he could. Resident #11 said, you can only keep some of the odor away using a sink as a shower. Resident #11 said he had not requested a bath because he should not have had to ask. Resident #11 said he needed his toenails clipped but staff was never available to offer the services that are care planned. Resident #11 said his toenails got caught on the sheets and on his socks. Resident #11 said his feet hurt when he wore his shoes because his toenails are too long. Resident #11 said he had purchased clippers so he could cut his own hair. Resident #11 said he had not refused to have a shower, or his toenails clipped because the staff had never tried. Residents #11's toenails were thick, yellow, and approximately ½ inch long. During an interview on 06/14/2023 at 11:42 AM, Resident #11 said he had not received a shower. During an interview on 06/15/2023 at 03:50 PM, Resident #11 said he had not received a shower. Record Review of the Resident Showers Log indicated Resident #11 received showers on the following dates: 06/02/2023, 06/05/2023, 06/07/2023, 06/09/2023, 06/12/2023, 06/14/2023 455831 Page 32 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview and observation on 06/16/2023 at 05:18 PM, Resident #11 said he had not received a shower and no staff had offered a shower this week. Resident #11 said my toenails had not been trimmed. Resident #11 said he had never told staff not to clip his toenails. Residents #11's toenails on both feet were thick, yellow, and approximately ½ inch long. During interview on 06/16/2023 at 05:35 PM, CNA C said Resident #11 does everything by his own self. CNA C said she had never offered to clip Resident # 11 nails. CNA C said the nurses were responsible for clipping the resident's toenails. CNA C said the CNAs had to chart the resident refusals. CNA C said the CNAs are responsible for giving the showers to the residents. CNA C said it was important to give the residents their showers because it made the residents feel better. CNA C said it was important to clip the resident's nails to prevent hangnails. CNA C said not giving the residents their showers could affect the residents emotionally. During an interview on 06/16/2023 at 06:33 PM, the ADON said the CNAs are responsible to give the residents showers/baths. The ADON said the nurses are responsible to review the shower sheets daily. The ADON said nobody had reported to her any refusals this week. The ADON said that Resident # 9 received a shower on Wednesday. The ADON said that Resident #11 frequently refuses showers. The ADON said that CNAs could clip Resident #11's toenails. During an interview on 06/16/2023 at 06:22 PM, the DON said the CNAs are responsible for baths/showers. The DON said the nurse could give baths/showers if needed also. The DON said the CNAs and nurses should fill out the shower sheets daily. The DON said Resident #9 did not like to get showers. The DON said Resident #9 is random. The DON said Resident #9 had not refused baths/shower this week. The DON said Resident #11 wouldn't let anybody give him a shower that he refused MWF on the 2 -10 shift. The DON said the residents should be able to get a bath/shower if they asked for one. The DON said it was important for the residents to get their baths/showers to help them feel good about themselves and keep the skin clear. The DON said if the residents had not received baths/showers they would feel dirty and be at a risk for wounds and infection. The DON said if the resident is a diabetic the facility podiatrist or the nurse could clip toenails. The DON said if the resident did not have the diabetic diagnosis the CNA could trim the resident's toenails. The DON said it was important for toenails to get trimmed, so the residents didn't experience ingrown toenail/infection control. The DON said she had never offered to trim Resident #11's toenails. During an interview 06/16/2023 at 08:18 PM, the administrator said she expected baths/showers as scheduled or as requested by the resident. The Administrator said clinical management is responsible for making sure the baths/showers were provided. The Administrator said if the residents refused ADL care, the staff educated the residents. The Administrator said it was important for the residents to receive baths/showers for hygiene purposes and to make the residents feel good. Record review of facility policy and procedure titled, Activities of Daily Living (ADLs), Supporting revised March 2018, indicated . Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); . 455831 Page 33 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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, the facility failed to provide food that was palatable for 2 of 13 residents (Resident #5 and Resident #11) reviewed for dietary services. Residents Affected - Few The facility failed to provide palatable food to Resident #5 and Resident #11. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: 1. Record review of the face sheet dated 06/16/2023 indicated Resident #5 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Transient cerebral ischemic attack (a lack of adequate blood supply to brain cells), infections of the skin and subcutaneous tissue, Chronic Obstructive pulmonary disease (a lack of adequate blood supply to brain cells), Hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the boy that can affect the arms, legs, facial muscles) affecting left dominant side. Record review of the quarterly MDS dated [DATE] indicated Resident #5 had moderate cognitive impairment with a BIMS score of 12. The MDS assessment indicated Resident #5 was understood and understood others. The MDS assessment indicated Resident #5 required supervision for eating. Record review of the Physician Order Report dated 05/16/2023-06/16/2023 indicated, Resident #5 had a regular diet with low concentrated sweets and regular texture with a start date of 01/21/2023. During an interview on 06/13/2023 at 2:40 PM, Resident #5 said the food tasted bad, looked bad, and smelled bad. 2. Record review of a face sheet dated 06/16/2023 indicated, Resident #11 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side (right sided weakness and paralysis after a stroke), essential primary hypertension (high blood pressure), and depression (mental disorder with persistent sadness and a lack of interest or pleasure in previously enjoyable activities). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #11 was understood and was able to understand others. The MDS assessment indicated Resident #11 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #11 required supervision for eating. Record review of the Physician Order Report dated 05/16/2023-06/16/2023 indicated, Resident #11 had a regular diet, regular texture with a start date of 04/25/2023. During an interview on 06/13/2023 at 1:49 PM Resident #11 said the food did not taste good. During an observation and interview on 06/14/2023 starting at 12:11 PM, a lunch tray was sampled by the Dietary Manager and 2 surveyors. The sample tray consisted of spaghetti and meatballs, Italian vegetables, a garlic biscuit, and white cake. The spaghetti and meatballs were bland. The Dietary 455831 Page 34 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Manager said the spaghetti and meatballs were okay. The Italian vegetables were mushy and bland. The Dietary Manager said the Italian vegetables were mushy and bland. The garlic biscuit was soggy and bland. The Dietary Manager said the biscuit was soggy and it should not be that way. During an interview on 06/16/2023 at 12:10 PM, the Dietary Manager said she was responsible for making sure the food tasted good. The Dietary Manager said she only sampled some food prior to it being served. The Dietary Manager said she walked around the dining room at mealtimes and asked the residents if they liked the food. The Dietary Manager said she had received complaints about how the food tastes, and she would offer the resident an alternative. The Dietary Manager said it was important for the meals to be palatable because the facility was the residents' home, and if they did not like the food they would stop eating and have weight loss. During an interview on 6/16/2023 at 6:55 PM, the DON said in the past she had received complaints from different residents about the food. The DON said the dietary staff should make sure the food was palatable. The DON said in the past she had a test tray and noticed the vegetables were mushy. The DON said it was important for the food to taste good for the residents' quality of life. The DON said if the food was not good the residents would not eat, and they would have weight loss. During an interview on 06/16/2023 at 8:21 PM, the Administrator said all the staff were responsible for making sure the food was palatable. The Administrator said she expected all the residents to receive food that was palatable. The Administrator said it was important for the residents to receive food that was palatable so they would not have weight loss. Record review of the facility's policy titled, Food and Nutrition Services Staff, last revised October 2017, indicated, . Food will be palatable, attractive, and served in a timely manner at proper temperatures . 455831 Page 35 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 staff (CNA D and CNA F) reviewed for infection control. Residents Affected - Few The facility failed to ensure CNA D and CNA F changed their gloves and performed hand hygiene while providing incontinent care to Resident #8. These failures could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: During an observation on 06/13/2023 starting at 1:39 PM, CNA D and CNA F provided incontinent care to Resident #8. CNA D and CNA F put on gloves. CNA D removed the dirty sheets and placed them on the floor. CNA D and CNA F unfastened Resident #8's brief. CNA D tucked the dirty brief under Resident #8's side and both CNAs turned him on his side. Resident #8 had a yellow-brownish ring on his sheets and his bed pad that extended up to his shoulders and down to his knees. CNA F wiped Resident #8's back peri area and removed the dirty brief. CNA F threw the dirty brief in the trashcan. CNA D and CNA F did not remove their dirty gloves and they did not perform hand hygiene. CNA D and CNA F applied the clean brief with dirty gloves. CNA F proceeded to apply zinc barrier cream to Resident #8's buttocks due to slight redness to his buttocks. The CNAs fastened the brief, and CNA F went to Resident #8's drawers to look for clean clothes. CNA D removed Resident #8's hospital gown and then helped CNA F dress Resident #8. CNA D and CNA F did not remove their gloves and they did not perform hand hygiene prior to applying Resident #8's clean clothes. CNA F went out of the room to get the Hoyer lift still wearing the same gloves. CNA D and CNA F transferred Resident #8 to his wheelchair. After transferring him to his wheelchair CNA D removed her gloves and did not perform hand hygiene, and CNA F wheeled Resident #8 to the lobby area still wearing the same gloves. CNA F removed her gloves after leaving Resident #8 in the lobby area. CNA F did not perform hand hygiene. During an interview on 06/13/2023 at 2:09 PM, CNA D said she had not been to check on Resident #8 today because she was working in a team with CNA F. CNA D said she would not have done anything differently when providing incontinent care. CNA D said hand hygiene should be performed before starting and when you leave the room. CNA D said she should have performed hand hygiene when she finished providing incontinent care to Resident #8. CNA D said hand hygiene should be performed after glove removal. CNA D said she changed her gloves when she should have changed them when she left the room. CNA D said she did not remember when her last check off or training on incontinent care had been. CNA D said it was important to provide prompt incontinent care to prevent skin breakdown. CNA D said it was important to perform glove changes and hand hygiene while providing incontinent care because of cross contamination and germs. During an interview on 06/13/2023 at 2:20 PM, CNA F said the last time she checked on Resident #8 was at 11:30 AM that morning. CNA F said she was supposed to check on the residents every 2 hours. CNA F said she was not able to do this due to being short. CNA F said she should have changed gloves and washed her hands after removing the dirty brief. CNA F said she should not have placed the dirty linens on the floor, but she did not have a trash bag to put them in. CNA F said she did not wash her hands because there was no soap or paper towels in Resident #8's room. CNA F said this had been 455831 Page 36 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0880 Level of Harm - Minimal harm or potential for actual harm happening a lot and she had notified the Housekeeping Supervisor and the Maintenance Supervisor. CNA F said her last training on providing incontinent care was 3 months ago. CNA F said it was important to provide prompt incontinent care to prevent skin breakdown, redness, and rashes. CNA F said it was important to perform hand hygiene and change gloves while providing incontinent care for cross contamination. Residents Affected - Few During an interview on 06/14/2023 at 6:17 AM, LVN G said there was no soap or paper towels that this happened randomly. LVN G said sometimes they had them and sometimes they did not. LVN G said had notified the DON, ADON, and the maintenance man. LVN G said he was told it was on back order. During an interview on 06/14/2023 at 5:48 PM, the Housekeeping Supervisor said she did not know how the facility had come up short on paper towels and soap that this had been going on for about a week. The Housekeeping Supervisor said they were short because she forgot to order earlier in the month and she usually had a stash, but she guessed people used it up. The Housekeeping Supervisor said it was important to have soap and paper towels available to the staff to keep clean and for the staff to be able to wash their hands. During an interview on 06/16/2023 at 6:15 PM, the ADON said nurse management was responsible for making sure the CNAs provided proper incontinent care. The ADON said nurse management monitored the CNAs to ensure they were providing proper incontinent care by performing the yearly competencies. The ADON said the CNAs should be checking on the residents every 2 hours. The ADON said while providing incontinent care gloves should be changed after removing the dirty brief and after providing perineal care. The ADON said gloves should be changed and hand hygiene performed anytime you moved from dirty to clean. The ADON said the CNAs should not leave the room with the dirty gloves. The ADON said it was important to provide prompt incontinent are to prevent skin breakdown. The ADON said not performing hand hygiene and not changing gloves adequately while providing incontinent care placed the residents at risk for infection. During an interview on 6/16/23 at 7:08 PM, the DON said while providing incontinent care the CNAs should perform hand hygiene when they enter the room and prior to applying gloves. The DON said the CNAs should change gloves when moving from dirty to clean. The DON said while providing incontinent care the CNAs should change gloves and perform hand hygiene several times. The DON said proficiencies for the CNAs on incontinent care were performed yearly by her or the ADON. The DON said she randomly went into rooms to observe the CNAs provide incontinent care. The DON said there was a time when she observed CNA D and CNA F provide incontinent care and she had to tell them to change their gloves. The DON said she could not remember when this occurred. The DON said it was important to provide prompt and proper incontinent care so the residents would not get a UTI, skin breakdown, and to make sure their skin was clean. During an interview on 06/16/2023 at 8:26 PM, the Administrator said she expected the CNAs to provide proper incontinent care and perform hand hygiene. The Administrator said clinical management should make sure the CNAs are providing proper incontinent care. The Administrator said it was important to provide proper incontinent care and to perform hand hygiene to reduce infection. Record review of the facility's policy titled, Perineal Care, last revised, 01/20/2023, indicated Steps in the Procedure .3. Perform hand hygiene and don gloves. 4. Arrange the supplies so they can be easily reached . 6. Remove clothing enough to perform peri-care. Avoid unnecessary exposure of the resident's body. 7. Remove the soiled clothing, linens, and brief. Place items in the proper receptacle . B. For a Male Resident: (1) Use a cleansing wipe. (2) Clean perineal area starting with 455831 Page 37 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few urethra and working outward . (5) Clean urethral area with a cleansing wipe using a circular motion. Use a clean section of the cleansing wipe for each stroke by folding each used section inward. Use a new cleansing wipe, as needed. (6) Continue to clean the perineal area including the penis, scrotum, inner thighs. (7) Thoroughly clean perineal area in same order, using a new cleansing wipe as needed . (12) Clean the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks, change the cleansing wipe, as needed. Use a clean section of the cleansing wipe for each stroke by folding each used section inward. 10. Dry area thoroughly. 11. Discard disposable items into designated containers. 12. Remove gloves and discard into designated container. 13. Perform Hand Hygiene. 14. Reposition the bed covers. Make the resident comfortable. 15. Place the call light within easy reach of the resident. 16. Perform Hand Hygiene . Record review of the facility's policy titled, Handwashing/Hand Hygiene , last revised 01/20/2023, indicated, Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 5. Hand hygiene must be performed prior to donning and after doffing gloves . 455831 Page 38 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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, the facility failed to maintain an effective pest control program to keep the facility free from pests in 3 of 3 halls, 1 of 1 dining room, and 2 of 13 (Resident #6 and Resident #8) residents reviewed for pest control. Residents Affected - Some The facility did not maintain an effective pest control program to ensure the facility was free of flies. This failure could place residents at risk for an unsanitary environment and a decreased quality of life. Findings included: 1. Record review of a face sheet dated 06/16/2023 indicated Resident #6 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including diffuse traumatic brain injury (head injury causing damage to the brain), paraplegic (paralysis of the lower body), neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury), bipolar disorder (changes in mood and energy levels). Record review of Quarterly MDS assessment dated [DATE] indicated Resident #6 understood others and made himself understood. The MDS assessment indicated Resident #6 was cognitively intact with a BIMS score of 15. The MDS assessment indicated Resident #6 required extensive care with transferring, dressing and personal hygiene. Record review of Resident #6's care plan last revised 06/11/2023 did not indicate to provide an environment free of pests. 2. Record review of a face sheet dated 06/16/2023 indicated, Resident #8 was a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cerebral palsy (a group of disorders that affect movement and muscle tone or posture caused by damage to the brain before birth), essential primary hypertension (high blood pressure), and epilepsy unspecified, not intractable, with status epilepticus (seizures that occur back to back with no time in between). Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #8 was sometimes understood and was usually understood. The MDS assessment indicated Resident #8 had a BIMS score of 3, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #8 was totally dependent on staff for bed mobility, transfers, dressing, personal hygiene, and bathing. Record review of Resident #8's care plan last revised 06/11/2023 did not indicate to provide an environment free of pests. During an observation of the facility's only dining room on 06/13/2023 at 12:04 PM, numerous amounts of flies were present while the residents were eating their lunch meal. During an observation on 06/13/2023 starting at 1:32 PM, multiple flies observed flying around and on Resident #8 while he was in bed. Resident #8 was non-interviewable. 455831 Page 39 of 40 455831 06/16/2023 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 06/14/2023 starting at 5:07 AM, numerous flies were observed in the east, west, and south hall. During an observation and interview on 06/14/2023 at 5:05 PM, Resident #6 said there were flies and gnats in his room all the time. Resident #6 said it bothered him because they kept landing on him, and he did not like that. Resident #6 said the staff were aware of the flies and the gnats in his room and in the facility. Multiple flies observed in his room. During an interview on 06/16/2023 9:49 AM, the Maintenance Director said the exterminator went to the facility once a month to spray for ants, spiders, and roaches for pest control. The Maintenance Director said he was aware the facility had gnats and flies, and the residents had complained to him about the gnats and flies. The Maintenance Director said the exterminator said he could not spray for the gnats that the facility needed to pour hot water down the drain. The Maintenance Director said he had not asked the exterminator if he could spray for the flies. The Maintenance Director said he would not like to live in an environment with flies because they would aggravate him. The Maintenance Director said it was important to provide the residents an environment free of gnats and flies because he would not want a living environment with flies or gnats in it. During an interview on 06/16/23 at 2:48 PM, the exterminator said he went once a month to the facility, unless the facility needed him to go more often. The exterminator said he was at the facility 2 or 3 days ago and he sprayed for spiders. The exterminator said he noticed the gnats and spoke with housekeeping and the kitchen and gave them instructions to pour boiling water down the drains. The exterminator said the facility had not reported to him that there were flies in the facility. The exterminator said there was an aerosol he could use for the flies. During an interview on 06/16/2023 at 8:01 PM, the DON said she had noticed the flies in the halls, dining area, and in the rooms. The DON said all the staff should be making sure there were no flies in the facility. The DON said it was important to keep an environment free of flies for the residents because it was an infection control issue. The DON said she personally would not want to have flies in her food or around her. The DON said she wanted to provide a clean and safe environment for the residents, During an interview on 06/16/2023 at 8:27 PM, the Administrator said none of the resident had complained to her about the gnats or flies in the facility. The Administrator said all the staff were responsible for making sure the residents had an environment free of gnats/flies, and she expected them to provide this for the residents. The Administrator said it was important to keep an environment free of gnats and flies to provide a homelike environment to the residents. Record review of the facility's Pest Control Chemical & Log Sheets dated 01/12/2023, 02/04/2023, 03/10/2023, 04/11/2023 04/19/2023, 05/18/2023 did not indicate the facility was treated for flies. Record review of the facility's policy, titled, Pest Control, last reviewed May 2008, indicated, Policy Statement Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents .6. Maintenance services assist, when appropriate and necessary, in providing pest control services . 455831 Page 40 of 40