Health inspection·September 27, 2023

F 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to assure residents who have authorized the facility in writing to manage any personal funds have ready and reasonable access to those funds for 3 of 5 (Resident #10, Resident #16, and Resident #21) residents reviewed for trust funds. Residents Affected - Some The facility failed to ensure Resident #'s 10, 16, and 21 personal use funds were disbursed monthly. This failure could place residents whose funds are managed by the facility at risk of not having money needed to purchase personal items. Findings Included: Record review of Resident #10's face sheet revealed an [AGE] year-old female admitted on [DATE] with medical diagnoses of high blood pressure, depression, chronic pain, heart disease, and dementia. Record review of Resident #10's quarterly MDS dated [DATE] revealed at BIMS score of 13 out of 15 indicating intact cognition. Record review of Resident #16's face sheet revealed a [AGE] year-old male admitted on [DATE] with medical diagnoses of cerebral palsy (abnormal brain development or damage to the developing brain that affects a person's ability to control his or her muscles) and epilepsy. Record review of Resident #16's quarterly MDS dated [DATE] revealed a BIMS score of 15 out of 15 indicating intact cognition. Record review of Resident #21's face sheet revealed a [AGE] year-old female admitted on [DATE] with medical diagnosis of liver failure, heart failure, kidney failure, curvature of the spine and seizures. Record review of Resident #21's quarterly MDS dated [DATE] revealed a BIMS score of 15 out of 15 indicating intact cognition. During an interview on 09/25/2023 at 12:22 PM, Resident #21 stated she had no complaints about the facility except the fact that she had not received her monthly allowance of $60 in at least 3 months. Resident #21 explained she had asked the BOM on several occasions when the funds would be available and was told the BOM was working with the social security office to resolve the problem, but the resident believed this to be untrue because she didn't do anything. Resident #21 also stated she had Page 1 of 10 675009 675009 09/27/2023 Coleman Healthcare Center 2713 S Commercial Ave Coleman, TX 76834

F 0567 not received a statement from the facility in a long time. Level of Harm - Minimal harm or potential for actual harm During an interview on 09/25/2023 at 02:25 PM, the Regional BOM stated residents had not received their monthly allowance since July 7, 2023, due to a change in ownership. She stated she emailed the former owner on 09/25/23 for a status update on the disbursements and was waiting for a reply. Residents Affected - Some During an interview on 09/26/2023 at 11:34 AM, the Regional BOM stated she had received a reply from the corporate BOM of the former owners on 09/25/23. The Regional BOM stated she was told by the corporate BOM the resident trust fund account should have been closed months ago when the new administration took over. The corporate BOM explained she called the bank and found out the account had not been closed. The corporate BOM provided names to the Regional BOM of residents with funds available for transfer. The Regional BOM was waiting on a routing number and account numbers to make transfers into the resident trust account. She stated the transfers should be complete by 2 PM tomorrow. The Regional BOM explained that trust fund statements were generated quarterly. Residents responsible for their own finances received hand delivered statements and a copy was placed in their file. For residents with representatives, the representative received the statements, and a copy was placed in the resident's file. She stated the next statement cycle was at the end of September 2023. During an interview on 09/27/2023 at 10:15 AM, Resident #16 stated he was not aware disbursements had not been made into his account since July 2023. He stated he was glad someone was working on fixing the problem so that he had money for his snacks and drinks. During an interview on 09/27/2023 at 11:08 AM, Resident #10 stated she did not know the last time she received a monthly allowance. She stated she did not need much and hardly ever asked for money. During an interview on 09/27/2023 at 12:52 PM, the Regional BOM stated the new trust fund account for residents who authorized the facility to manage their funds was opened 06/23/2023. The Social Security Administration was still processing the paperwork to change the payee account. The Regional BOM stated the failure occurred because the former BOM left without notice last week. The Regional BOM was working on paperwork that either was not done or done properly. She stated the facility did not have a policy on disbursing resident funds. She stated the effect on the residents not receiving their money may be depression if they do not have the money to purchase wanted or needed items or go out to eat. During an interview on 09/27/2023 at 02:54 PM, the Administrator stated the BOM was responsible for reconciling the resident trust fund account and transferring funds to resident trusts. She stated the reason the failure occurred was the issues with the Social Security Administration during the leadership change. She stated the representative payee paperwork had to be refiled with the Social Security Administration. The Administrator stated the potential effects on residents was a lack of money could keep them from getting things they want. She stated the residents should not have any needs not met by the facility, so this issue pertains to personal wants. The Administrator stated her expectation was for residents to receive their money timely. When asked for a policy pertaining to resident funds the administrator stated there was not a policy. Record review of Resident Fund Management Service Authorization and Agreement to Handle Resident Funds, Resident #10 signed agreement, no date on the agreement. Record review of Resident Fund Management Service Authorization and Agreement to Handle Resident Funds, Resident #16 signed agreement, no date on the agreement. 675009 Page 2 of 10 675009 09/27/2023 Coleman Healthcare Center 2713 S Commercial Ave Coleman, TX 76834

F 0567 Record review of Resident Fund Management Service Authorization and Agreement to Handle Resident Funds, Resident #21 signed agreement on 05/15/2023. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 675009 Page 3 of 10 675009 09/27/2023 Coleman Healthcare Center 2713 S Commercial Ave Coleman, TX 76834

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 interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property by failing to conduct a criminal history/EMR/NAR verification on employees prior to employment and/or annually for 3 of 18 (RN-A, RN-B, and SW-C) employees reviewed for abuse and neglect. Residents Affected - Few Facility staff did not have criminal history verification and/or an EMR/NAR verification prior to offering employment to the facility and/or annually for employees. These findings could place residents at risk of receiving care by someone that was unemployable. The findings included: Record review on 09/27/2023 of the CMS-807 Employee files review revealed: RN-A was hired on 05/10/2023, the facility verified his CH on 09/26/2023. RN-A's EMR was dated 05/02/2023 and was verified on 09/26/2023. RN-B was hired on 08/05/2023, her EMR verification was dated 09/27/2023 and SW-C was hired on 04/12/2023, her CH verification was dated 09/26/2023. SW-C's EMR verification was dated 09/26/2023. During an interview on 09/27/2023 at 2:14: PM, the ADM stated the RSADM and RSHR from a sister facility had filled out the personnel file review form provided and did not know where they received the dates from. The ADM stated the RSHR had told her they might have gotten the dates wrong on the form. The ADM stated the RSHR had told her the CH and EMR's were most likely ran at different times. During a follow-up interview on 09/27/2023 at 2:44 PM, the ADM stated the facility no longer had an HR staff member to conduct CH and EMR verifications. The ADM stated she spoke to (corporate) CHR, and stated If they are not there, we don't have them. The ADM stated she did not believe the previous HR staff member did not do the CH and EMR's as she was trained. She stated there was no reason for these not to have been completed. The ADM stated the CH and EMR checks were to be completed prior to being hired due to maybe having a history of having an offense. She stated the negative impact to residents could be possible abuse or exploitation. She stated HR was responsible for running the background checks with the ADM monitoring. The ADM stated she did not realize HR was having the issues of not running those reports. The ADM stated the failure was with HR as she was not doing her job, with her expectations being for all of the pre-hire paperwork to be completed before their first day of working with residents. Record Review of facility policy Abuse Prohibition Policy with the revised dated of 09/14/2023 revealed: INTENT: This protocol was intended to assist in the prevention of abuse, neglect and misappropriation of property. 675009 Page 4 of 10 675009 09/27/2023 Coleman Healthcare Center 2713 S Commercial Ave Coleman, TX 76834

F 0607 Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse . Level of Harm - Minimal harm or potential for actual harm .Abuse Prohibition Program: Residents Affected - Few The facilities abuse prevention program includes the following comment: o Screening o Training o Prevention o Identification o Investigation o Protection o Reporting/Response Screening: 1. Free employment screening will be completed on all employees, to include: o Criminal History Check o Reference Check 675009 Page 5 of 10 675009 09/27/2023 Coleman Healthcare Center 2713 S Commercial Ave Coleman, TX 76834

F 0607 o Level of Harm - Minimal harm or potential for actual harm Professional licensure, certification, or registry check as applicable Residents Affected - Few .3. Leave the facility cannot employ individuals who have had a disciplinary action taken against their professional license start a state licensure body as a result of a finding of abuse, neglect, mistreatment of residents or misappropriation of their property. Prevention: . .6. The Screening and training policies will be adhered to as outlined above . Record Review of facility policy Criminal History Record, undated revealed: Purpose: In order to conduct normal nursing facility business, the facility is required by the Texas Department of Aging and Disability Services to perform criminal history verifications on all potential employees and. In order to perform these criminal history verifications, the facility will access the Texas Department of Public Safety Secure Website to access the individual's criminal history data as authorized in Texas 411; Subchapter F. Purpose of Search: The purpose of the search is to comply with chapter 242 and 250, Health and Safety Codes. These codes require a licensed nursing facility to ensure that background checks are conducted on potential employees, volunteers etc, in order to assure that no one be allowed to work in the facility with a conviction that prohibits employment under the Chapter 250, Health and Safety Code . 675009 Page 6 of 10 675009 09/27/2023 Coleman Healthcare Center 2713 S Commercial Ave Coleman, TX 76834

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen. Residents Affected - Many The facility failed to: A. dispose of food items after the use by or expiration date. B. Store, seal and date food items. These failures could place residents receiving oral nutritional intake at risk for foodborne illness and a decline in health status. The findings included: During observation on 09/25/2023 from 9:47am to 10:30am of the kitchen Dry Storage: o One unsealed open 10 pounds plastic bag containing graham cracker crust with open date 04/05/2023, o Four 32-ounce bottles of lemon juice with manufactures expire date of 09/05/2023, and o Box with approximately eight individual cheese crackers with arrive date of 08/09/2023 no open date. Refrigerator o One 10 ponds box containing individual 1.5 sausage patties in unsealed plastic bag open date 09/17/2023 and o One unsealed plastic bag containing 5 pounds of raw hamburger meat from an original 10 pound 675009 Page 7 of 10 675009 09/27/2023 Coleman Healthcare Center 2713 S Commercial Ave Coleman, TX 76834

F 0812 package dated open 09/24/2023 and use date 09/27/2023. Level of Harm - Minimal harm or potential for actual harm Freezer o Residents Affected - Many One half full unsealed open bag containing frozen biscuits arrive date of 08/09/2023 and open date of 08/22/2023 in 29.7-pound box. During an interview on 09/26/23 at 07:58 AM, the Dietary Manager stated that she was responsible to ensure foods were stored, labeled and dated properly. The Dietary Manger stated that if foods were not stored, labeled and dated properly that it could cause cross contamination, food Boerne illness' and make residents sick. The Dietary Manager stated that she had several new employees when she was asked what led to the failure of not properly storing, labeling and dating of foods. She went on to say that she will need to retrain her staff. The Dietary Manage stated that her expectation of her kitchen staff was that all employees would seal, label, date all foods properly. after opening. She stated that she was the primary person to trained staff to seal, label and the dating of foods. She stated she had physically showed them where, how to label and date with expirations, stated that I liked her staff to put their initials on the labels to know who had labeled foods. During an interview on 09/26/2023 at 8:18 AM, the [NAME] stated that her supervisor the Dietary Manager had trained her how to properly store, label and date foods. She stated the negative effects of not storing, labeling and dating foods properly would make residents sick or kill them. She also stated that it could've even give them salmonella or E. coli which are all connected with improperly storage and cooking of foods or expired food. The [NAME] stated you must be very careful/mindful of storage and dates. She went on to say that need to make sure that you wash your hands and used gloves. During interview on 09/26/2023 at 8:29 AM, the Dietary aide/Dishwasher stated that the Dietary Manager did the training to properly store, date and label foods. She stated that the negative effects of foods not being stored labeled and dated properly was that it could cause someone to get sick. She stated that is was everyone's job in the kitchen to make sure foods are stored properly. She stated that someone didn't do their job the right way that caused the failure of foods not being labeled, dated and stored properly. Review of facility policy titled Food Receiving and Storage of Food in dry food storage and Refrigerated/freezers, revised November 2022, revealed: All foods must be labeled with the contents and date food item was placed in storage. 675009 Page 8 of 10 675009 09/27/2023 Coleman Healthcare Center 2713 S Commercial Ave Coleman, TX 76834

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain complete and accurate clinical records for 1 of 4 (Resident #2) residents reviewed for weights. The facility failed to weigh Resident #2 since 07/10/2023. These findings place residents at risk for quick interventions for weight loss. Findings included: Record review of Resident #2's Facesheet dated 09/25/23 revealed: An [AGE] year-old male admitted to the facility on [DATE]. He had a diagnosis list that included: COPD(Primary), Cognitive communication deficit, Amnesia, Dysphagia, Dementia with psychotic disturbance, Chronic pain, GERD, Vitamin B12 deficiency anemia, Vitamin D deficiency, Constipation. Record review of Resident #2's Significant Change MDS dated [DATE] revealed a BIMS of 2 meaning severe cognitive impairment. No chewing or swallowing difficulties. A weight of 137 lbs. No or unknown weight loss of 5 percent in last 6 months. Resident had a mechanically altered diet . Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS of 2 meaning severe cognitive impairment. He had no chewing or swallowing difficulties. The recorded weight was 137 lbs with no or unknown weight loss of 5 percent in the last 6 months. Resident #2 had a mechanically altered diet. Record review of Resident #2's Weight Records dated 09/26/23 revealed a weight of 136.5 pounds on 07/10/23, no other weights documented. Record review of Resident #2's Care Plan dated 09/27/23 revealed that Resident refuses monthly weights. As a part of the Focus problem of The resident is resistive to care (ADLs) at times. His goal for the problem included, The resident will cooperate with care through next review date. Interventions for the problem included, Allow the resident to make decisions about treatment regime, to provide sense of control . If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again. During an observation on 09/25/23 at 10:48 AM, Resident #2, he was a thin male laying in a low bed with a fall mat at his bedside. He did not respond to verbal or physical stimuli. During an interview on 09/27/23 at 08:36 AM with DON, she said Resident #2 had a refusal for weights on careplan in the dietary area. She said she knew he needed a weight obtained. DON said Resident #2 frequently refused to allow staff to weigh him. She said he was not losing weight but that it was hard to tell because he was just a small man. The DON said the facility did monthly weights by the 7th of each month and weekly weights on Thursdays for new residents or residents that had significant weight loss or gain. She said if the numbers were different from the last weight, then the facility would recalibrate the scale, and reweigh those residents. She said she would do a progress note to explain the weight loss or gain. The DON said the Dietician would look at the weights, but the previous dietician did not discuss anything about the weights. She said the facility had talked with 675009 Page 9 of 10 675009 09/27/2023 Coleman Healthcare Center 2713 S Commercial Ave Coleman, TX 76834

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #2's doctor and he said, do the best you can. The DON said that not obtaining weights in 2 months and only 1 progress note at the end of august was simply a lack of documentation by the nurses. She said the point to obtain weights monthly was to catch issues early. Record review of Facility Policy labeled Weight Management last reviewed 01/17/23 revealed: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents . Residents will routinely be weighed by facility staff monthly. 675009 Page 10 of 10