Health inspection·December 7, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to implement their written policies and procedures to prohibit abuse, neglect, exploitation, and misappropriation of resident property for 1 of 8 employee files (Employee C) reviewed for abuse protocol. Residents Affected - Few The facility did not complete reference checks on Employee C, with a hire date of 11/27/2023, prior to employment at the facility. This failure could place residents at risk for abuse, neglect, and exploitation. Findings included: In a record review of Employee C's personnel file revealed the facility did not complete reference checks with a hire date of 11/27/2023 prior to employment. In an interview on 12/07/23 at 11:30 AM, the Human Resource Specialist said the reference checks for Employee C were not completed. He said it was the responsibility of the Human Resource Coordinator to ensure reference checks are completed and documented prior to hire. He said reference checks helps prevent abuse. In an interview on 12/07/23 at 1:54 PM, the Administrator said Human Resources should be completing employee reference checks prior to employment. She said Employee C's references were not checked or documented. She said a potential negative outcome of not checking employee references would be the employee would not be a satisfactory hire. Review of the facility's policy Criminal Background Checks, dated as revised 11/17/2017, revealed the following [in part]: Policy: It is the policy of the company to conduct criminal background checks of all applicants within 72 hours of employment . Procedure: 6. The Criminal History Coordinator will be responsible for obtaining reference checks and licensure verification/registries prior to employment. Written documentation of reference checks and licensure/verification will be maintained in the personnel file. Review of the facility's policy Abuse/Neglect, dated as revised 03/29/2018, revealed the following [in part]: Page 1 of 10 455968 455968 12/07/2023 Graham Oaks Care Center 1325 First St Graham, TX 76450

F 0607 The resident has a right to be free from abuse, neglect, misappropriation of resident property, and exploitation . Level of Harm - Minimal harm or potential for actual harm Procedure: Residents Affected - Few 4. The facility will attempt to obtain at least one reference check on all new hires. 455968 Page 2 of 10 455968 12/07/2023 Graham Oaks Care Center 1325 First St Graham, TX 76450

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours for 2 of 5 residents (Residents #39 and #56) whose record were reviewed for recent admission to the facility, in that: 1. Resident #39 was admitted to the facility on [DATE] and a baseline care plan had not been developed within 48 hours of his admission. 2. Resident #56 was admitted to the facility on [DATE] and a baseline care plan had not been developed within 48 hours of her admission. This failure placed the residents at risk for not receiving care and services to meet their needs and to promote their physical and mental health and well-being within their new living environment. The findings included: 1. Resident #39 Review of Resident #39's admission Record, dated 12/07/2023, revealed an [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included: Type 2 diabetes mellitus with foot ulcer; hyperlipidemia (high cholesterol); hypertension (high blood pressure); heart failure; end stage renal disease (kidney failure); dependence on renal dialysis; and dysphagia (difficulty swallowing). Review of Resident #39's Baseline Care Plan Acknowledgement form, dated 09/30/2023, revealed a copy of the baseline care plan was provided to the resident's representative. Review of Resident #39's Baseline Care Plan revealed it was dated as developed on 10/03/2023, later than 48 hours after admission. During an interview and record review on 12/07/2023 at 10:37 AM, the DON reviewed the Baseline Care Plan Acknowledgement form and the Baseline Care Plan for Resident #39. She stated the Baseline Care Plan dated 10/03/2023 was done late. She stated the Baseline Care Plan Acknowledgement had been done by the LVN charge nurse and she probably did the form as part of the nursing admission packet. The DON stated she was the one who initiated the baseline care plan within 48 hours and the LVN should not have completed the acknowledgement form. The DON stated the LVN would not have given the resident's representative a copy of a baseline care plan. 2. Resident #56 Review of Resident #56's admission Record, dated 12/07/2023, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included: iron deficiency anemia; depression; Alzheimer's disease; hypertension (high blood pressure); and cardiac arrhythmia (abnormal heartbeat). Review of Resident #56's Baseline Care Plan Acknowledgement form, dated 04/17/2023, revealed a copy 455968 Page 3 of 10 455968 12/07/2023 Graham Oaks Care Center 1325 First St Graham, TX 76450

F 0655 of the baseline care plan was provided to the resident's representative. Level of Harm - Minimal harm or potential for actual harm Review of Resident #56's Baseline Care Plan revealed it was dated as developed on 04/25/2023, later than 48 hours after admission. Residents Affected - Some Review of the facility's policy and procedure for Base Line Care Plans, not dated, revealed the following [in part]: Completion and implementation of the baseline care plan withing 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan . 455968 Page 4 of 10 455968 12/07/2023 Graham Oaks Care Center 1325 First St Graham, TX 76450

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to update the comprehensive care plan after the assessment for 1 of 6 residents (Resident #'s 53) reviewed for plan of care revision. The facility failed to include in the care plan, nutritional interventions for a significant weight loss for Resident #53 after the 11/26/2023 Comprehensive MDS . This failure could place the residents at risk of staff and providers not having the most current information for the Resident's plan of care. Findings included: Record review of Resident #53's electronic health record revealed a [AGE] year-old male with a, re-admission date 11/21/2023, Diagnoses: dysphagia (difficulty swallowing), essential (primary) hypertension (high blood pressure), Alzheimer's disease (progressive memory loss), atrial fibrillation (the hearts upper chambers beat out of sequence with the lower chambers which can lead to poor blood flow, blood clots and stroke), anxiety disorder (feelings of worry and fear that interfere with daily activities), muscle weakness and muscle wasting and atrophy (decreased muscle mass resulting in weakness due to decreased physical activity, and nutritional deficiencies). Record review of Resident 53's electronic health record revealed the most recent Care Plan dated 3/21/23 listed a focus area for potential risk for malnutrition dated 3/1/23. The goal was for Resident #53 to maintain a stable weight and nutritional parameters. The Care Plan further revealed the interventions were last updated 5/16/23, the interventions were not reviewed or revised after the 31-pound weight loss in November 2023. Record review of Resident #53's electronic health record revealed he had a weight of 131.6 on 11/21/23 and a weight of 164.6 on 11/8/23 (a 31-pound weight loss loss). The weight documented on 11/21/23 was the last recorded weight for the resident. Record review of Resident #53's admission MDS with an assessment reference date of 11/26/23, section K 0200 documented a weight of 132 pounds and a height of 72 inches. Section K0300 documented that Resident #53 had a weight loss of 5 percent or more in the last month and was not on a prescribed weight loss program. Section K0520 he had not received intravenous feeding, a feeding tube, mechanically altered diet, or a therapeutic diet while not a resident, or while a resident. Record review of the electronic health record revealed the physician orders, dated 12/6/23, for Resident #53 reflected that he was on a Regular diet with Regular consistency and thin fluids. In an interview on 12/06/23 at 10:52 AM Resident #53's wife stated that he did not eat as much due to his dementia. She stated she did not know that he had a significant weight loss . She stated she was here for every meal, and she cuts his meat. She stated he has dentures and has no trouble chewing. Interview on 12/07/23 at 3:32 pm with the DON revealed it would be her expectation that re-weight 455968 Page 5 of 10 455968 12/07/2023 Graham Oaks Care Center 1325 First St Graham, TX 76450

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few would happen if a large discrepancy in weight was discovered, and she would also expect the family and physician to be notified. She stated the care plan should be updated by the MDS nurse after the MDS was completed. She stated failure to update the care plan could result in the resident not receiving the care he needs. Interview on 12/07/23 at 4:03 pm with MDS Coordinator revealed she was responsible for updating the care plan with the MDS but if it is an acute problem then it was nursing that was to update the care plan. She stated failure to update the care plan and communicato the te the weight loss to the interdisciplinary team could result in the resident not receiving the care he needs. Review of the facilities undated policy titled: Comprehensive Care Planning revealed the following: The facility will establish, document, and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives interventions are the specific services that will be implemented. 455968 Page 6 of 10 455968 12/07/2023 Graham Oaks Care Center 1325 First St Graham, TX 76450

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 3 (Resident # 55) residents reviewed for quality of care. Residents Affected - Few The facility failed to ensure Resident #55's pain was managed at a level that did not interfere with the resident's sleep or day to day activities This deficient practice could place residents at risk of pain, discomfort, and a diminished quality of life. Findings included: A review of Resident #55's Electronic Health Record (EHR) indicated her admission date was 05/31/2023 with relevant diagnoses of pain in left ankle and joints of left foot, abnormal gait, and mobility (difficulty walking and moving from place to place), muscle atrophy (decrease in size of the muscle tissue from not using the muscle). Review of Resident #55's routine medications indicated : Tylenol 500 mg 2 tablets every 6 hours for fever with a start date of 8/8/23, and Tylenol 500 mg 2 po every 6 hours as needed for pain/inflammation with a start date of 12/7/23. Review of Resident #55's quarterly MDS assessment dated [DATE] revealed Resident #55 experienced pain o at a level of an 8 constantly during the 5-day lookback period. Review of the MDS assessment dated [DATE] showed a Quarterly Assessment which revealed in the pain assessment the following: interview; Section J0300Have you had pain or hurting at any time in the last 5 days? - Yes How much of the time have you experienced pain or hurting over the last 5 days? - Almost Constantly Please rate your pain over the last 5 days on a zero to ten pain scale, with zero being no pain and ten as the worst pain you can imagine. 08. Record Review of Resident #52's MAR revealed the resident had recieved Tylenol 500 mg caps 2 by mouth on 11/5/23 for a pain level of 5, on 11/9/23 for a pain level of 4, and on 11/27/23 and 11/28/23 for pa pain level of 5, and not again until 12/5/23 for a pain level of 3. In an interview with Resident #55 on 12/06/23 at 10:25 AM she said that she normally, constantly had pain since her admission in May 2023. She said that she had told someone that she needed a pain medication, the pain medication that had been given did not help and they were supposed to get her something else ordered for pain. She stated she did not remember who she told about her pain, or if it was a nurse. She stated that the pain limits her day-to-day activity and was constant. 455968 Page 7 of 10 455968 12/07/2023 Graham Oaks Care Center 1325 First St Graham, TX 76450

F 0697 Level of Harm - Actual harm Residents Affected - Few In an interview with the DON (Director of Nursing) on 12/07/23 at 2:28 PM She stated said she did not know the resident was having so much pain. She stated it was her expectation that the pain assessment information gathered on the 11/10/23 MDS would have resulted in the nurse communicating with the physician and getting her an order for pain medication She said that the RN MDS Coordinator signed the MDS, and the social worker did the actual interview for pain on the 11/10/23 quarterly MDS and it should have been addressed by nursing. The social worker did the MDS and did not notify her with her pain score. She said stated she would be contacting the physician to get a new order for pain. She stated it would be her expectation that a nurse completes the pain interview in section J of the MDS.A facility policy on pain management was not reviewed. 455968 Page 8 of 10 455968 12/07/2023 Graham Oaks Care Center 1325 First St Graham, TX 76450

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents who have not used psychotropic drugs are not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record and gradual dose reductions were attempted for 1 of 5 residents (Resident #56) whose records were reviewed for unnecessary medications. Resident #56 was admitted to the facility on [DATE]. Her admission orders included an order for the antipsychotic medication Zyprexa 5 mg for a diagnosis of depression, with a start date on 04/18/2023. She did not have a diagnosis or indication of use for antipsychotic medication. The facility's failure placed the resident at risk for adverse side effects from receiving antipsychotic medication that was not indicated for use. The findings included: Review of Resident #56's admission Record, dated 12/07/2023, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included: iron deficiency anemia; depression; Alzheimer's disease; hypertension (high blood pressure); and cardiac arrhythmia (abnormal heartbeat). Review of Resident #56's Physician Order Summary revealed an order dated 04/17/2023 for Zyprexa 5 mg by mouth one time daily related to depression, with a start date on 04/18/2023. Review of the Consent for Antipsychotic Medication Treatment for Resident #56 revealed the physician documented the resident had been receiving Zyprexa since 04/17/2023 and the benefit was to help psychosis and agitation. The form was signed by the physician on 05/25/2023 and was signed by the resident's family member on 07/06/2023. The documented indication for use had not been clarified and added to the resident's list of diagnoses. Review of Resident #56's comprehensive care plan, dated as initiated on 07/06/2023 and last reviewed on 10/28/2023, revealed the care plan The resident requires anti-psychotic medications. Review of Resident #56's Quarterly MDS Assessment, dated 10/24/2023, revealed a BIMS score of 00 out of 15 (severe cognitive impairment); verbal behavioral symptoms on 1-3 days; other behavioral symptoms 4-6 days; wandering daily; selected Psychiatric/Mood disorder diagnosis of depression; and antipsychotic, antidepressant and anticoagulant medications received. There was no GDR attempted for antipsychotic medication. Review of the Pharmacist Consultant Medication Regimen Review Recommendation, dated 10/31/2023, revealed it was recommended a GDR be attempted for Zyprexa 5 mg by mouth daily. There was no documented physician follow-up to the Pharmacist Consultant's recommendation. During an interview and record review on 12/07/2023 at 6:31 PM, the DON reviewed Resident #56's physician order Zyprexa 5 mg daily for depression dated 04/17/2023 and the Consent for Antipsychotic Medication Treatment form. She stated the physician did document psychosis on the consent form. The 455968 Page 9 of 10 455968 12/07/2023 Graham Oaks Care Center 1325 First St Graham, TX 76450

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DON stated there were several residents with antipsychotic medication orders that did not have the correct diagnosis for indication for use. The DON stated she would look for a policy and procedure for pharmacy services and psychotropic medications. A policy and procedure for pharmacy services and psychotropic medications was not provided at the time of the completion of the survey and exit from the facility on 12/07/2023. 455968 Page 10 of 10