Health inspection·January 10, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality for 1 of 15 residents reviewed for dignity. (Resident #19) The facility failed to provide Resident #19 with a type of clothing protector (designed to protect clothing from mealtime mishaps) to ensure she did not have food on gown after eating. The facility failed to ensure Resident #19 was cleaned up promptly after meals. These failures placed residents at risk for diminished quality of life, loss of dignity and self-worth. Findings included: Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and admitted on [DATE] with diagnoses including abnormal posture, dysphagia (difficulty swallowing), hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction (stroke) affecting left no-dominant side, and muscle weakness. Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 required partial/moderate assistance for eating. Record review of Resident #19's care plan dated 04/10/23 indicated Resident #19 had psychosocial well-being problem related to disease process. Intervention included encourage participation from resident who depends on others to make own decisions. Record review of Resident #19's care plan dated 04/10/23 indicated resident [Resident #19] is at risk for nutritional impairment related to above ideal body weight, received regular diet. Intervention OT to screen and provide adaptive equipment for feeding as needed. During an observation and interview on 01/08/24 at 1:04 p.m., revealed Resident #19 was in her bed and was wearing a hospital gown on. On Resident #19's hospital gown and right hand were small amounts of food particles. Resident #19 said she fed herself and did not use a towel or clothing protector. Page 1 of 51 675293 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview on 01/09/24 at 1:15 p.m., revealed Resident #19 was in her bed and was wearing a hospital gown. On Resident #19's hospital gown and face were moderate amounts of food particles. Resident #19 said she fed herself and was not offered a towel or clothing protector. Resident #19 said she did not want food on herself. During an interview on 01/10/24 at 12:22 p.m., RCP O said Resident #19 sometimes made a mess when she ate. She said when she worked with Resident #19, she offered her a towel to cover herself. She said it was the RCP's and LVN's responsibility to make sure the resident had a clothing protector or was cleaned up after a resident ate. She said Resident #19 having food particles on their body, and unable to clean it probably did not make her feel good. She said it could also make the resident feel like they were bothering staff. During an interview on 01/10/24 at 12:47 p.m., LVN P said Resident #19 was able to feed herself finger food better than other types of food. She said staff were supposed to encourage and assist her if needed during mealtimes. She said Resident #19 spilled food when she ate. She said it was the RCP's and LVN's responsibility to offer a clothing protector with meals or clean her up afterwards. She said it was important for Resident #19's dignity and appearance. During an interview on 01/10/24 at 2:29 p.m., the DCO said Resident #19 could feed herself. She said it was the RCP's responsibility to provide and offer a resident a clothing protector and clean a resident up, who was unable to do it themselves. She said she expected the staff to clean the residents up right away and change into dry clothes. She said Resident #19 having food particle on herself was a dignity issue. During an interview on 01/10/24 at 3:57 p.m., the ADM said she expected the staff to offer all residents a clothing protector. She said she expected the staff to clean the food from a resident. A resident's rights policy was requested at this time and was not received before or after exit. 675293 Page 2 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure the residents has the right to be informed of the risks and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or options he or she preferred, for 2 of 15 residents (Resident #19 and Resident #242) reviewed for resident rights. Residents Affected - Few 1. The facility failed to ensure Resident #19's psychoactive (substances that, when taken in or administered into one's system, affect mental processes) medication therapy consents were completed properly upon admission and prior to the administration of Zyprexa ( antipsychotic medication that can treat several mental health conditions like schizophrenia and bipolar disorder), Venlafaxine ( used to treat major depressive disorder, anxiety, and panic disorder), Trazodone ( used to treat depression), and Carbamazepine ( used to treat certain types of seizures and bipolar disorder). 2.The facility failed to obtain informed consent based on information of the benefits, risks, and options available for Resident #242 prior to administering Risperdal (is an antipsychotic medication that can treat several mental health conditions like schizophrenia and bipolar disorder), Depakote (used to treat seizures and stabilize mood), and Buspirone (used to treat anxiety). These failures could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party. Findings included: 1. Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and was admitted on [DATE] with diagnoses including Schizoaffective Disorder (is a mental illness that can affect your thoughts, mood and behavior), Bipolar type, Bipolar disorder (is a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), mild depressed, recurrent depressive disorder, generalized anxiety (you are worrying constantly and can't control the worrying), insomnia (is a common sleep disorder), and conversion disorder with seizures or convulsions (is a condition in which a person experiences physical and sensory problems, such as paralysis, numbness, blindness, deafness or seizures, with no underlying neurologic pathology). Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 required substantial/maximal assistance for personal and oral hygiene, shower/bath self, and dependent for toilet hygiene. The MDS indicated Resident #19 received antipsychotic, antianxiety, and antidepressant during the last 7 days of the assessment period. Record review of Resident #19's care plan dated 03/21/23, revised 04/10/23 indicated Resident #19 was at risk for adverse consequence related to receiving psychotropic medications. Intervention included administer psychotropic medications as ordered. Record review of Resident #19's order summary dated 01/09/24 indicated: 675293 Page 3 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0552 *Carbamazepine 200 mg, give 2 tablets by mouth at bedtime for bipolar disorder, start date 03/18/23. Level of Harm - Minimal harm or potential for actual harm *Trazodone 100 mg, give 1 tablet by mouth at bedtime for insomnia, start date 03/18/23. *Venlafaxine, give 225 mg by mouth one time a day for depression, start date 03/19/23. Residents Affected - Few *Carbamazepine 200 mg, give 1 tablet by mouth one time a day for bipolar disorder, start date 03/19/23. * Zyprexa, give 20 mg by mouth at bedtime for increased mood, decreased anxiety, and agitation, start date 08/11/23. * Zyprexa, give 50 mg by mouth in the morning for increased mood, decreased anxiety, and agitation, start date 08/12/23. Record review of Resident #19's MAR dated 01/01/24-01/31/24 indicated: *Carbamazepine 200 mg, give 2 tablets by mouth at bedtime for bipolar disorder, start date 03/18/23. *Trazodone 100 mg, give 1 tablet by mouth at bedtime for insomnia, start date 03/18/23. *Venlafaxine, give 225 mg by mouth one time a day for depression, start date 03/19/23. *Carbamazepine 200 mg, give 1 tablet by mouth one time a day for bipolar disorder, start date 03/19/23. * Zyprexa, give 20 mg by mouth at bedtime for increased mood, decreased anxiety, and agitation, start date 08/11/23. * Zyprexa, give 50 mg by mouth in the morning for increased mood, decreased anxiety, and agitation, start date 08/12/23. Record review of Resident #19's Psychoactive Medication Therapy Consent dated 08/25/23 revealed verbal consent was obtained from Resident #19's RP on 03/18/23 and signature/signatures of the persons (DCO and CRS), who obtained the verbal consent was dated 08/25/23, which was approximately five months after admission and start of Zyprexa. The consent indicated Zyprexa .Schiz-affective .improved function ability .antipsychotic .the probable clinically significant side effects or risks associated with the medication included: stiffness of neck, confusion, muscle rigidity .black box warning . Record review of Resident #19's Psychoactive Medication Therapy Consent dated 08/25/23 revealed verbal consent was obtained from Resident #19's RP on 03/18/23 and signature/signatures of the persons (DCO and CRS), who obtained the verbal consent was dated 08/25/23, which was approximately five months after admission and start of Trazodone. The consent indicated Trazodone .Schizo-Affective .Sleep disorder . antidepressant . the probable clinically significant side effects or risks associated with the medication included: dry mouth, blurred vision . black box warning . Record review of Resident #19's Psychoactive Medication Therapy Consent dated 08/25/23 revealed 675293 Page 4 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few verbal consent was obtained from Resident #19's RP on 03/18/23 and signature/signatures of the persons (DCO and CRS), who obtained the verbal consent was dated 08/25/23, which was approximately five months after admission and start of Carbamazepine. The consent indicated Carbamazepine .bipolar disorder .improved function ability .antimanic (are medications used as mood stabilizers in psychiatric conditions such as bipolar disorder and schizophrenia) . the probable clinically significant side effects or risks associated with the medication included: confusion, drowsiness, hypotension (low blood pressure) . black box warning . Record review of Resident #19's Psychoactive Medication Therapy Consent dated 08/25/23 revealed verbal consent was obtained from Resident #19's RP on 03/18/23 and signature/signatures of the persons (DCO and CRS), who obtained the verbal consent was dated 08/25/23, which was approximately five months after admission and start of Venlafaxine. The consent indicated Venlafaxine .Depression .improved function ability .antidepressant . the probable clinically significant side effects or risks associated with the medication included: dry mouth, blurred vision . black box warning . During an interview on 01/10/24 at 12:47 p.m., LVN P said the LVNs, or upper nursing management were responsible for medication consents. She said when a verbal consent was done, the nurse who received the verbal consent signed and the ADCO or DCO signed behind them. She said she believed a medication could be given with one nurse signature for verbal consent. She said if the family visited, staff were supposed to try to get a hand signature. She said consents done correctly were important so family aware of current treatment. During an interview on 01/10/24 at 2:25 p.m., the responsible party for Resident #19 said she did not recall giving verbal consent for Resident #19's medication immediately after admission. She said she remembered when her family member was transferred to the facility and was not called. She said the facility only told her when Resident #19 started medications but did not go over the consent form. During an interview on 01/10/24 at 2:29 a.m., the DCO said nurses were responsible to get consent for medication when they were ordered. She said consent should also be obtained upon admission. She said consent for medication was important to make sure family was aware of risks and benefits of treatment. She said she expected staff to go over the consent form and explain risks and benefits with family before consent was received. During an interview on 01/10/24 at 3:57 p.m., the ADM said she expected staff to get consent before giving medications. She said staff should go over risks and benefits before consent was received. She said it was important to give informed consent, so the resident or family understood what the resident was taking. 2. Record review of Resident #242's face sheet dated 1/08/24 indicated she was a [AGE] year-old female and admitted to the facility on [DATE] with diagnoses including heart failure, Bipolar disorder (associated with episodes of mood swings ranging from depressive or sad lows to manic or excited highs), schizoaffective disorder (combination of symptoms of schizophrenia (affects ability to think, feel and behave clearly) and mood disorder, such as depression or bipolar disorder), major depressive disorder (persistent depressed mood or loss of interest in activities, causing impairment in daily life), and dementia (progressive loss of intellectual functioning, impairment of memory and thinking, often with personality changes caused by disease of the brain). Record review of Resident #242's admission MDS assessment revealed it had not been completed. 675293 Page 5 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #242's Baseline Care plan dated 1/03/24 revealed she used psychotropic medications. Record review of Resident #242's Order summary report dated 1/08/24 revealed an order for: Risperdal 2 mg 1 tablet by mouth at bedtime for bipolar disorder with a start date of 1/03/24; Buspirone 5 mg 2 tablets three times daily for anxiety with a start date of 1/03/24, and Depakote 125 mg 4 tablets three times a day for behaviors with a start date of 1/04/24. Record review of Resident #242's MAR dated 1/01/24-1/31/24 indicated Resident #242 had received: Risperdal 2 mg at bedtime since 1/03/24, Buspirone 5 mg 2 tablets three times daily since 1/03/24, Depakote 125 mg 4 tablets two times a day on 1/03/24 to 1/04/24, and Depakote 125 mg 4 tablets three times a day since 1/04/24. Record review of a Behavioral Management-psychoactive medication therapy consent dated 1/04/24 indicated a verbal consent for the use of Risperdal was obtained from Resident #242's RP on 1/09/24. This verbal consent was obtained 6 days after admission and after administration of Risperdal to Resident #242. Record review of a Behavioral Management-psychoactive medication therapy consent dated 1/04/24 indicated a verbal consent for the use of Buspirone was obtained from Resident #242's RP on 1/09/24. This verbal consent was obtained 6 days after admission and after administration of Buspirone to Resident #242. Record review of a Behavioral Management-psychoactive medication therapy consent dated 1/04/24 indicated a verbal consent for the use of Depakote was obtained from Resident #242's RP on 1/09/24. This verbal consent was obtained 6 days after admission and after administration of Depakote to Resident #242. On 1/08/24 at 2:27 PM and 1/10/23 at 12:36 PM, attempted to interview Resident #242's RP via phone. There was no answer, and a voicemail was left. Resident #242's RP did not return call prior to the exit of the facility. During an interview on 1/09/24 at 11:30 AM, RN N said the admitting nurses were responsible for obtaining the consents for antipsychotics and psychotropic medications. RN N said the admitting nurse obtained consent by calling the RP for verbal consent or obtaining written consent from the RP if they were in the facility. RN N said the DCO was responsible for ensuring the antipsychotic and psychotropic medication consents were completed. During an interview on 1/10/24 at 1:02 PM, the DCO said antipsychotic and psychotropic medication consents should be obtained upon admission and the medications should not be administered without obtaining proper informed consent. The DCO said she did not know what happened or why Resident #242's consents were not obtained upon admission. The DCO said she was the initial admitting nurse for Resident #242 and started the admission, but she did not complete it and turned it over to the next nurse. The DCO said it was a group effort to ensure proper informed consent was obtained for antipsychotic and psychotropic medications from the resident or their RP prior to administering the medications. During an interview on 1/10/24 at 1:28 PM, the ADM said she would expect proper informed consent to be obtained prior to administering antipsychotic or psychotropic medications from the resident or their RP. 675293 Page 6 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0552 Level of Harm - Minimal harm or potential for actual harm Requested a policy on antipsychotic and psychotropic medication consents from the DCO on 1/10/24 at 1:02 PM. Requested a policy on antipsychotic and psychotropic medication consents from the ADM on 1/10/24 at 3:28 PM. Residents Affected - Few On 1/10/24 at 4:00 PM, the ADM said they did not have a policy on antipsychotic or psychotropic medication consents. 675293 Page 7 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 15 residents (Resident #19) reviewed for reasonable accommodations. Residents Affected - Few The facility failed to ensure Resident #19's call light was placed on her dominant side and hand without a contracture (is a fixed tightening of muscle, tendons, ligaments, or skin). This failure could place residents at risk for unmet needs. Findings included: Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and admitted on [DATE] with diagnoses including contracture, left hand and ankle, abnormal posture, hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction (stroke) affecting left no-dominant side, and muscle weakness. Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 had limited range of motion to both sides of her lower extremities. The MDS indicated Resident #19 required substantial/maximal assistance for personal and oral hygiene, shower/bath self, and dependent for toilet hygiene. The MDS indicated Resident #19 was frequently incontinent of urine and always incontinent of bowel. Record review of Resident #19's care plan dated 03/21/23, revised on 04/10/23 indicated Resident #19 had history of falls and at risk for increased falls and fracture evidence by history of falls and physical impairment/immobility. Intervention included ensure call light is in reach and answer promptly. During an observation and interview on 01/08/24 at 1:04 p.m., Resident #19 said she could not reach the call light sometimes and could not use her left hand. Resident #19 was lying in bed and her left arm appeared flaccid with no voluntary movement of her hand. Resident #19's call light was on her left side near her hand. During an observation on 01/09/24 at 1:15 p.m., revealed Resident #19 was lying in her bed, asleep, with her call light placed in the middle of the bed, not near her right hand. During an interview on 01/10/24 at 12:22 p.m., RCP O said the RCP, LVN or anyone who walked in the room should make sure the resident's call light was within reach or placed on the resident's non affected side. She said Resident #19's call light should be placed on her right side, which was not affect by her stroke. She said she liked to place her left hand on a pillow because she could not control it. She said if Resident #19's call light was placed on the wrong side of her body or not within reach, she could not get help. She said call lights not being within reach could cause residents to fall or not get their needs met. During an interview on 01/10/24 at 12:47 p.m., LVN P said the RCP and LVN were responsible for making sure resident's call light were within reach. She said it would not be appropriate to place 675293 Page 8 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #19's call light on her left side. She said when call lights were not within reach or on the resident's stroke affected side, they could fall, not get help, or staff attention. During an interview on 01/10/24 at 2:29 p.m., the DCO said everyone was responsible for ensuring resident's call light were within reach. She said Resident #19's call light should be placed on her unaffected side. She said call lights being placed within reach was important to get the help they needed. During an interview on 01/10/24 at 3:57 p.m., the ADM said she expected call lights to be within reach. She said call lights should be placed on the resident's dominant side. She said all staff should ensure it happened. She said staff should check call light placement every 2 hours and as needed during rounds. She said when call lights were not within reach, residents were not able to call for assistance. A call light policy was requested at this time, a policy was not received before or after exit. 675293 Page 9 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility did not immediately notify the physician and resident representative of a significant change in in the resident's mental or psychosocial status for 1 of 15 residents (Resident #5) reviewed for resident rights. The facility failed to inform the attending Physician and the residents representative for Resident #5 when she barricaded herself in her room on 10/22/2023. This failure could place residents at risk for not receiving appropriate care and interventions. Findings included : Record Review of Resident #5 Face Sheet dated 1/8/2024 indicated Resident #5 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #5's diagnosis included Alzheimer's disease with late onset (progressive decline in episodic memory that begins after the age of 64), Dementia in other diseases classified elsewhere (general term for loss of memory, language, and problem-solving abilities), unspecified severity, without behavioral disturbances and other abnormalities of gait and mobility. Record review of Resident #5's Quarterly MDS assessment dated [DATE] indicated resident was understood and usually able to understand others. The MDS indicated a BIMS score of 3 indicating Resident #5 was severely cognitive impaired. Resident #5's MDS indicated physical behaviors, verbal behaviors and other behavior symptoms not directed toward others for 1-3 days during the look back period. Record Review of Resident #5's care plan revised date 10/23/2023 indicated Resident #5's focus of care on Alzheimer's with late onset with fluctuations between stages with interventions initiated on 6/28/2023 of resident can move around room or facility with use if a walker but requires assist for long distances with occasional use of wheelchair. Resident #5's Care plan revised on 8/4/2023 indicating the resident's mobility will be improved/restored by use of adaptive equipment such as crutches, cane, walker, or wheelchair. Resident #5's care plan revised on 7/31/2023 indicated to monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, except course, declines in function. Resident #5's Care plan revised on 8/4/2023 indicating the resident's mobility will be improved/restored by use of adaptive equipment such as crutches, cane, walker, or wheelchair. Resident #5's care plan revised on 7/31/2023 indicated to monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, except course, declines in function. Resident #5's care plan indicated impaired cognitive function and thought processes but did not address behavioral issues. Record Review of the facility investigation summary provided by the Administrator on 1/8/2024, not dated or signed by the author, indicated an incident involving Resident #5 occurred on 10/22/2023, on the night shift. The report indicated Resident #5 refused care during the entire night shift on 10/22/2023, where Resident #5 barricaded herself in her room. The night shift reported they were able to check on Resident #5 through a small opening in the door. Resident #5's representative made an allegation of neglect to the facility's DCO on 10/23/2023 at 1:30 pm. He reportedly made the statement that he did not believe that the staff adequately checked on/monitored Resident #5 during the previous night. The investigation summary indicated that a thorough review of all statements by residents 675293 Page 10 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and staff did not support the allegations of neglect. Actions taken post-investigation reflected: all community staff were provided with in-service education on resident abuse and neglect, education on notifying the DCO and/or ADCO immediately if a resident barricaded themselves in their room. The DCO completed 1:1 education with the charge nurse on duty during time of investigation. Record Review of a witness statement, dated/signed by CNA M on 10/25/2023, indicated CNA M made first rounds at an unknown time. Resident #5 refused care x 2 attempts and then was reported to the charge nurse. At 12 am the resident was still sitting in her chair with the door open and continued to refuse care and was reported to charge nurse. The next round started at 2 am and the door was closed. The CNA attempted to open the door but could not and notified the charge nurse. Multiple attempts between rounds were made according to the statement. During med pass rounds starting at 4 am, CNA M still could not get in the door and reported to the charge nurse. CNA M went to the room before leaving their shift and reported to 6 a.m.-2 p.m. shift aide about not being able to gain access to room. Record Review of Resident #5 Progress note dated 10/23/2023 at 11:52 p.m. revealed LVN G noted that Resident #5 was sitting in front of the restroom door falling asleep in her chair. LVN G offered to assist Resident #5 to bed, and the resident refused. Resident #5 told LVN G that she did not want to be bothered. LVN G gave Resident #5 a moment to calm down, then returned to her room and Resident #5 had the door open slightly with her wheel to her wheelchair blocking the door and refused care. LVN G noted he would attempt contact later. Record Review of Resident #5 Progress Note dated 10/23/2023 12:22 am revealed LVN G noted Resident #5 refused assistance and slammed the door and parked the wheelchair behind the closed door and would not open the door. Resident #5 refused to move from behind the door. Record review of Resident #5 Progress note dated 10/23/2023 at 2:25 am revealed LVN G documented that Resident #5 was still behind door in her wheelchair. Record review of Resident #5 Progress note dated 10/23/2023 at 4:45 am revealed LVN G documented he received report from the RCP who attempted to speak with Resident #5 through the door but could not make out what Resident #5 was saying. LVN G attempted to push on the door while turning the doorknob and was able to get the door open enough just to see Resident #5. Resident #5 was still seated in wheelchair behind the door holding the curtain. Resident #5 yelled Don't do that, I'm putting my socks on. LVN G said ok and advised Resident #5 he would be back to give her time to calm down. At 5:15 am after passing morning medications, LVN G returned to room to see if Resident #5 had moved. Resident #5 remained seated right behind the door in her wheelchair. Resident #5 stated Leave me alone. LVN G reported during the morning shift change that the resident blocked the door and did not want to be bothered. LVN G noted that Resident #5 was still awake and alert sitting in wheelchair at the end of shift. Record review of Resident #5 Progress note dated 10/23/2023 at 8:30 am revealed LVN H noted that LVN G reported at 6:15 am during the morning shift change that Resident #5 was sitting in wheelchair against the door throughout the night and would not let anyone in room. After the report was received at 6:15 am, LVN H went to Resident #5 room and was able to push the door open about 2 inches, enough to see her feet stretched out in front of her and could see her striped shirt. LVN H noted it appeared Resident #5 was sitting on the floor with her right shoulder against the door. LVN H asked Resident #5 to move away from the door so she could come in. Resident #5 yelled Give me a minute, don't do that. LVN H notified the DCO and ADCO at 6:19 am and explained the situation. LVN H returned to 675293 Page 11 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the room and where Resident #5 continued to refuse to move. LVN H notified the resident's hospice provider at 6:47 am. LVN H called the DCO again at 6:54 am and LVN H called Resident #5'srepresentative to notify him of the situation. Representative arrived at facility at approximately at 7:30 am and Plant Operation Manager J was able to the open window from the outside to get into room and open the door. LVN H documented she observed Resident #5 sitting on her bottom on the floor with her right shoulder toward door and feet stretched out in front of her. Resident #5 was observed to have multiple red markings on back of right shoulder and she c/o pain but was able to move her arm. Vital signs documented at 8:30 am reflected blood pressure 136/85 , HR 92, RR 18 Temperature 97.6 degrees Fahrenheit, and Oxygen 94% Room Air. LVN H noted that Resident #5 appeared more confused than normal. Resident #5 was assisted into her wheelchair and onto the bed. The RCP and ADCO noted to have washed Resident #5 up and changed her clothes. Resident #5 was served breakfast and given her morning medications. Record review of In-service dated 10/23/2023 RE: Notification. Description- Nurses and RCP's: Anytime a resident is in a room barricaded please notify the DCO and ADCO immediately. Record Review of Resident #5's Hospice Comprehensive Assessment and Plan of Care Updated report dated 6/30/2023 revealed Resident #5 had become more forgetful, delusional, and confused resulting in more combative behaviors toward staff providing ADL care. Record Review of progress notes from 10/9/2023 to 1/10/2024 revealed resident had behaviors of refusing care, medications, and increased episodes of crying. Resident #5 did not have any previous reports of barricading herself in her room. Observation of Resident #5 on 1/9/2024 at 8:00 am revealed the resident was observed sitting up in bed eating breakfast. Resident #5 said she had a good night and smiled during the conversation. Observation of Resident #5's room on 1/9/2024 at 10:25 am with Plant Operations Manager J revealed the bathroom door swung open toward the hinges of entrance of Resident #5's room door which blocked the opening of the entrance door. Observed the entrance door opening approximately 2 inches when the bathroom door was fully opened. Attempted Interview with CNA M on 1/9/2024 at 1:09 PM but was unable to leave a message and did not receive a return call by exit date 1/10/2024. During an interview on 1/8/2024 at 1:28 PM, Resident #5 said she did not have any concerns about facility other than she has lots of falls. Resident #5 said she was not interested in talking. During an interview on 1/8/2024 at 2: 04 PM, Resident #5's RP said the facility reported to him on 10/23/2023 Resident #5 had barricaded herself in her room the previous night. Resident #5's RP said a male nurse was taking care of her that night. Resident #5 was lying down on the other side of the door. Resident #5's RP said that the maintenance man walked by while he was there, and they decided to walk around to window and determined it was open. Resident #5's RP said that his mother was on the floor against the door and was wet of urine. Resident #5's RP said the nurse did not notify him that his mother was barricaded in her room, refused access to staff, and refused to take her medications throughout the night. Resident #5's RP said if he had been notified, earlier in the situation, he could have come to facility and intervened preventing his mother from lying in the floor for extended period of time in her own urine. 675293 Page 12 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 1/9/2024 at 11:53 AM, LVN H said it was reported by the night shift nurse that the resident had barricaded self in her room and Resident # 5 was in her wheelchair. LVN H went down to check on the situation and was only able to open the door about an inch. She stated that the night shift nurse had already left. LVN G reported to her that he was able to see the resident in her wheelchair 20 minutes prior. LVN H said she felt like Resident #5 was on the floor when she attempted to visualize Resident #5 inside her room. LVN H immediately notified the DCO, Physician or representative. LVN H said Resident #5's RP arrived at facility and the Plant Operations Manager and Resident #5's RP went to the window and was able to gain access through the outside window. LVN H reported Resident #5 was wet from incontinence. LVN H said Resident #5 was confused and said Resident #5 had been experiencing hallucinations, talking about people trying to hurt her all night. LVN H said not being able to access the resident could result in fall with injury such as hitting head or worse injury. During an interview on 1/9/2024 at 1:09 PM, LVN G said he arrived at facility on 10/22/2023 at 9:30 p.m . and the resident was sitting in her wheelchair. LVN G said he made his rounds to first check vital signs. LVN G said that he did not observe weakness with Resident #5. LVN G said the aide came in at 10 p.m. and made rounds and filled ice. LVN G said Resident #5 was agitated and upset the whole night. LVN G said the resident's bedroom door was wide open all night. LVN G said Resident #5 has an attitude and did not want to be bothered. LVN G said he noticed between 3:30 a.m. - 4 am that her door was closed, and Resident #5 was up all night. LVN G said after Resident #5's door was observed closed, he attempted to open the door and Resident #5 told him Stop, I am back here. LVN G said he was able to open the door enough to stick his head in and visualize her sitting up in her wheelchair. LVN G said he was not able to pass morning medications to the resident due to her barricading herself in room and only reported to the oncoming nurse. During an interview on 1/10/2024 at 1:30 PM, LVN G said he relayed information to the nurse the next morning concerning Resident #5 being barricaded behind the door and refusing care. LVN G said CNA M did report Resident #5 was refusing care and she refused care all night. LVN G said he made 3 attempts to provide care. LVN G was unable to determine how many times a resident refuses care before contacting the family, physician, or administrator per the facility policy. LVN G said he received advice from staff that was on duty at the time on what to do. LVN G said he spoke with another nurse on another unit. LVN G said that he did have access to an on-call nurse after-hours. LVN G said that he was hoping to coach Resident #5 down to a better mood and did not call the on-call nurse. LVN G said he felt it was appropriate care at the time, so he sent CNA M to check and coach Resident #5. LVN G said he does not feel Resident #5 wants a male nurse. LVN G said he was concerned Resident #5 may have some sundowners . (Increased confusion with Alzheimer's and dementia may experience from dusk through night) During an interview on 1/9/2024 at 3:12 PM, the DCO said she expected the staff to call and report to the DCN/ADCO/Admin for help and guidance on a barricaded resident. The DCO said she was unsure of any policy on barricaded residents. The DCO said she expected staff to notify family of a barricaded resident. The DCO said she expected staff to notify the family if the resident refused care 3 times and that included monitoring the resident. The DCO said if a resident was barricaded behind a door and not monitored appropriately, she could have adverse symptoms such as shortness of breath , elimination issues, cardiovascular issues, depending on disease process, including death. DCO said she was updated on Resident #5's condition once she was able to be assessed. During an interview on 1/9/2024 at 3:33 PM, the ADCO said the morning shift nurse reported to her that Resident #5 was barricaded behind the closed door throughout the night. The ADCO said she 675293 Page 13 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few expected the night shift nurse to report any issues after-hours to the on-call nurse or administration. The ADCO said LVN G reported that he could see part of her such as her legs. The ADCO said after 3 attempts, LVN G should have contacted the ADCO/DCO/ADM. The ADCO said with Resident #5 barricaded behind a closed door could result in adverse events such as stop breathing, injury or death. During an interview on 1/10/2024 at 12:20 PM, the Administrator said she expected the nurse and staff to report changes in condition to the family, MD, and administration. Administrator said Resident #5 had the right to refuse care but she expected in this situation, that after a couple of hours, the family, MD and ADM or nurse on-call to be notified. The Administrator said LVN G was able to see the resident through a crack in the door and was able to visualize her. Administrator said their ability to monitor Resident #5 was limited. Record review of a policy titled Incident and Accidents, dated 3/1/2017 revealed Accidents or incidents involving residents shall be investigated and reported to the Executive Director of Operations . 675293 Page 14 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

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, functional, sanitary, and comfortable environment to those residents who eat their meals in one of one dinning rooms. The facility failed to identify and rectify foul smells in the dining room. This failure could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth. Findings included: During an observation on 01/08/2024 at 10:30 a.m., it was observed that the dining room had a foul smell similar to the smell of sewage. During an interview and observation on 01/08/2024 at 11:00 a.m., Director of Plant Operations J stated that there were no drains that were backing up sewage in the facility. He said in the kitchen there was a drain cleaning solution that was pumped into a pipe while dishes were being washed. He said that was to ensure that the drainage pipe was cleaned and to prevent a smell from occurring. He said at the end of November 2023 and early December 2023 they ran out of the cleaning solution, but it was back in stock by mid December 2023. He said that there were no sewage backups in the facility, and he did not know where the smell in the dining room was coming from. It was observed that the smell identified in the dining room was not coming from the kitchen. The kitchen was clean and had no offensive odors. During an interview on 01/08/2024 at 11:05 a.m., Dietary Manager K said that there was no overflow of sewage in the kitchen nor were there any foul smells as a result of any pipes or other sources from the kitchen. She said the kitchen was very clean and there were no sewage backups visible. During an interview on 01/08/2024 11:14 a.m., the Administrator said there was no sewage backup that she is aware of in the facility. She said sometimes there was an off smell in the building, but it isn't identified. She said there have not been any plumbers that have come to the facility to resolve an overflow sewage issue. She said there were some issues with pipes that were corrected but it was due to flushable wipes being flushed into the toilets. Record review of requested plumbing invoices for the last year (2023) revealed no indication of sewage backups. Record review of statements reflected that the facility contacted plumbing services on 01/08/2024 to request an appointment, Focused care at [NAME] is scheduled for an appointment January 17, 2024 to check sewage smell. During an interview on 01/09/2024 at 08:21 a.m., Resident #16 stated that the smell in the dining room was like sewage. Resident #16 said that the smell in the dining room bothered her. She said she did not know where the smell came from, but it was only in the dining room. She said that the Director of Plant Operations J was going to spray into the ceiling vents when it smelled really bad to help reduce how bad it could smell. During an interview on 01/09/2024 at 08:45 a.m., a Community Member said there was a very strong 675293 Page 15 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some smell in the dining room the Sunday they went to have church services on 12/03/2023. She said they were told the sewer leak was in the kitchen or maybe the dining area. She said she was unable to remember who said this. She said the smell was bad enough for them to not want to provide church services that weekend. She said they were there this past Sunday, 01/07/2024, and the smell was not nearly as bad as on 12/03/2023 but it was still noticeable. She said she didn't hear anyone mention about the smell, but they didn't ask either. During an interview on 01/10/2024 at 10:54 a.m., with the Administrator she said she didn't have an answer on why there was a smell inside the dining room. She said they called plumbers to come and investigate. She said she didn't remember when the smell started. She said she had smelled it intermittently. She said they used a chemical in the kitchen to try and keep the pipes clean in an effort to reduce the smell. She said residents have the right to have a homelike environment. She said that a resident could be dissuaded from eating in the dining room due to the foul smell. Record review of the Maintenance Work Request Log dated from June 2023 to December 2023 did not reveal an issue reported regarding the smell in the dining room. Maintenance requests for clogged toilets in residents' rooms were logged however none of them were in proximity of the dining area. Review of a Quality of Life - Homelike Environment facility policy dated May 2017 indicated, Residents are provided with a safe, clean, comfortable, homelike environment .staff shall provide person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences .the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting. These characteristics include clean, sanitary, and orderly environment . pleasant neutral scents. 675293 Page 16 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0641 Ensure each resident receives an accurate assessment. 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 ensure assessments accurately reflected the status for 1 of 15 resident reviewed for assessments. (Resident #25) Residents Affected - Few The facility failed to code Resident #25's fall on his MDS. This failure could place residents at risk of not having individual needs met. Findings included: Record review of Resident#25's face sheet printed on 01/09/24 indicated Resident #25 was an [AGE] year-old male and was admitted on [DATE] with diagnoses including Parkinson's, Dementia, moderate, with other behavioral disturbance and fall on same level from slipping, tripping, and stumbling with subsequent striking against other objects. Record review of Resident #25's quarterly MDS assessment dated [DATE] indicated Resident #25 was usually understood and usually had the ability to understand others. The MDS indicated Resident #25 had a BIMS score of 03 which indicated severe cognitive impairment. The MDS indicated Resident #25 was dependent for walking and substantial/maximal assistance for toilet transfer, chair/bed to chair transfer, and sit to stand. The MDS did not indicate Resident #25 had any falls in the last month, since admission, or prior assessment. Record review of Resident #25's care plan dated 12/08/23, revised on 12/29/23 indicated Resident #25 had an actual fall with serious injury, poor balance, fall on same level from slipping, tripping, and stumbling with subsequent striking against other object, and periprosthetic fracture (are fractures that occur in association with an orthopedic implant) around internal prosthetic left knee joint (is a surgery to replace a knee joint with a man-made artificial joint. The artificial joint is called a prosthesis). Fall: 12/12/23, 12/13/23, 12/18/23, and 12/28/23. Interventions included 12/12/23: incontinent care frequently, 12/13/23: staff to assist to bathroom, and 12/18/23: encourage resident to use call light. Record review of the facility's incident report date range 07/08/23-01/08/24 indicated Resident #25 had unwitnessed falls on 12/13/23, 12/18/23, and 12/28/23. During an interview on 01/10/24 at 1:20 p.m., the CRS said she was responsible for MDSs and care plans. She said she only worked part time at the facility. She said Resident #25's fall should have been coded on his MDS. She said it was important to have an accurate MDS to notify the state, and it affected the facility's quality measures and statistics. She said the corporate MDS performed audits every 3 months to check the accuracy of the MDSs completed. During an interview on 01/10/24 at 2:29 p.m., the DCO said the CRS was responsible for MDSs. She said she knew MDSs needed to be accurate for the resident information to be correct and billing purposes. She said Resident #25's MDS should be correct and show his falls. During an interview on 01/10/24 at 3:57 p.m., the ADM said the CRS was responsible for accuracy of the resident's MDS. She said the MDS should be correct because it reflected the condition of each resident. 675293 Page 17 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0641 Record review of a facility's MDS Completion Accuracy and Timeliness policy revised 11/15/23 indicated .the purpose of this policy is to ensure accuracy . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675293 Page 18 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 5 resident's (Resident #34) reviewed for PASRR. The facility failed to submit NFSS forms timely for Resident #34. This failure could place residents identified at a level II for PASRR evaluation at risk for their specialized services not being provided in a timely manner. Findings included: Record review of face sheet dated 01/08/24 indicated Resident #34 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses of myotonic muscular dystrophy (a genetic condition that causes progressive muscle weakness and wasting), dysphagia (difficulty swallowing), and lack of coordination. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #34 was usually understood and understood others. The MDS indicated a BIMS of 08 which indicated moderate cognitive impairment. The MDS indicated Resident #34 required partial/moderate assistance with rolling left to right, sit to lying, and lying to sitting on side of bed. Resident #34 required partial/moderate assistance with upper body dressing and substantial/maximal assistance with bathing. Distinct Calendar Days of Therapy, was marked 5, meaning Resident #34 did receive occupational, speech, or physical therapy during the 7 days of the assessment. In section G0400, the MDS indicated Resident #34 received 0 individual minutes, concurrent minutes, and group minutes for Speech-Language Pathology and Audiology Services and 0 individual minutes, concurrent minutes, and group minutes for occupational therapy. Both had a therapy start date of 11/09/23. Record review of physician's orders dated 01/08/24 for Resident #34 indicated an order with a start date of 07/10/23 indicated: An order dated 07/10/23, OT (occupational therapy) to eval and treat as indicated. An order dated 07/10/23, OT clarification: Patient to receive skilled OT services 3x week x 30 days (3 times a week for 30 days) for treatment .to include therapeutic activity, therapeutic exercise, neuro re-ed (neurological re-education), group activity and self-care training. An order dated 08/09/23, OT clarification: Recertification completed; PT (patient) to continue to receive OT services 3x/week (3 times a week) to include ther ex (therapeutic exercise), group therapy, neuro re-ed, self-care training, and ther act (therapeutic activity). An order dated 04/05/23, ST (speech therapy) order clarification: Skilled speech therapy to address speech production and clarity with diet evaluation and changes as needed. An order dated 11/16/23, ST eval and treat effective 11/09/23. 675293 Page 19 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of a care plan last revised on 12/28/23 indicated Resident #34 had an ADL self-care performance deficit related to disease processes. There was an intervention for PT/OT to evaluate and treat as per physician's orders. The care plan did not address PASRR. Record review of a PASRR Comprehensive Service Plan form dated 07/06/23 indicated a quarterly meeting was held. The meeting was attended by Resident #34, a PASSR Health Coordinator, the Social Worker, the DON, and the Director of the Rehabilitation department. The Nursing Facility Specialized Services section indicated specialized occupational therapy and specialized speech therapy were recommended. Record review of Simple LTC portal (portal used to submit PASRR service requests) for Resident #34 indicated notes dated 07/24/23: * .NFSS Form for Occupational Therapy was not submitted within 30 calendar days of the IDT meeting. * .NFSS Form for Physical Therapy was not submitted within 30 calendar days of the IDT meeting. * .NFSS Form for Speech Therapy was not submitted within 30 calendar days of the IDT meeting. * Form submitted. There was no indication if this form was for physical therapy, occupation therapy, or speech therapy. Record review of the Simple LTC portal for Resident #34 dated 7/25/23 indicated a note from the PASSR Unit, Each request must have its own, unique and original signatures and signature pages. You may not use typed or digitally written signatures, stamps, or copied signatures. Please complete the following steps. Q. Upload a valid completed signature page that is original,, ensure signatures are legible and the signature dates match the portal, and resubmit. 2. Set all appropriate tabs that are in Pending Denial status to Pending State Review before 07/31/23 to avoid a system -generated denial. Record review of a letter dated 07/27/23 from the PASRR Unit to Resident #34 indicated, .We have received a request for PASRR nursing facility specialized services The following service or items have been denied .Occupational Therapy. Reason for Denial: We needed more information to review your request. We didn't receive the information by the deadline .Speech Therapy .Denied .We needed more information to review your request. We didn't receive the information by the deadline . Record review of a letter dated 07/28/23 from the PASRR Unit to Resident #34 indicated, .The following services or items have been approved .Physical Therapy . Record review of an email correspondence from the PASSR Unit to the MDS coordinator dated 06/26/23 indicated, .Provides must complete a Nursing Facility Specialized Services (NFSS) for to request PASRR nursing facility specialized services . A training link was included in the email. During an interview on 01/09/24 at 1:12 p.m., the Director of Rehabilitation department/Certified Occupational Therapist said Resident #34 had always received physical therapy, occupation therapy, and speech therapy. She said the services were covered by his Medicare. She said Medicare would not approve further services. She said they started the process to have the services approved through PASSR specialized services. 675293 Page 20 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 01/09/24 at 2:15 p.m., the MDS Coordinator said the process to obtain PASSR services for a PASSR positive resident would be to hold a meeting with local health authority to determine if services were needed. She said then a care plan meeting would be held. She said therapy then picked them up and filled out the NFSS form to get it approved. She said Resident #34 had been in the hospital and when he came back to the facility, they used his Part B services until those services were up and there was a new meeting to determine the services needed. She said she had not received any correspondence or letter concerning denial. During an interview 01/10/24 at 8:15 a.m., the Director of Rehabilitation department/Certified Occupational Therapist said Resident #34 received therapy from April - June 27, 2023 She said it was funded through his Part B . She said Resident #34 received occupational therapy 7/10/23 - 8/10/23 and speech therapy 7/11/23 - 8/10/23. She said on 8/10/23 Resident #34 was admitted to the hospital. When he was readmitted to the facility, he received all therapies through Part B until the benefits were exhausted. She said at this time they were working on getting him recertified through PASSR services. She said she was unaware that she had to fill at a NFSS for each service. During an interview on 01/10/24 at 10:58 a.m., the MDS Coordinator said the Director of Rehabilitation department/Certified Occupational Therapist was responsible for submitting the NFSS forms for residents. She said she was only in the facility 2 days a week and she was not sure why the occupational therapy NFSS or the speech therapy NFSS forms were not submitted. She said the appropriate forms not being submitted could cause a resident to not receive needed services. During an interview on 01/10/24 at 11:57 a.m., the DON said the MDS Coordinator, and the Social Worker were responsible for submitting the NFSS forms to the PASSR Unit. She said she would have expected the requested forms to have been submitted. She said the forms not being submitted could cause a resident to receive specialized services. During an interview on 01/10/24 at 12:38 p.m., the Administrator said Director of Rehabilitation department/Certified Occupational Therapist was responsible for submitting NFSS forms. She said she would have expected for the forms to have been summited if they were requested from the PASSR unit. She said the NFSS form not being summitted could cause a resident to not receive therapy services. Review of a facility PASSR facility policy dated 11/2023 indicated, .Follow Texas PASSR Policy for all mandatory meetings and care coordination including any changes that may require a change in resident's PASSR status . 675293 Page 21 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 ensure individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 of 5 residents, (Resident #16) reviewed for PASRR Level 1 screenings. Residents Affected - Few The facility failed to complete a PASRR Level 1 screening for Resident #16 following a discharge from a mental health hospital with a new diagnosis of mental illness. This failure could place residents at risk of not being evaluated for PASRR services and receiving needed services. The findings were: Record review of face sheet dated 01/09/24 revealed Resident #16 was [AGE] years old and was initially admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), Bipolar type (episodes of mania and sometimes depression) with an onset of 08/19/22, Major Depressive Disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and anxiety disorder. Record review of a quarterly MDS dated [DATE] revealed Resident #16 had a BIMS of 15, which indicated the resident was cognitively intact. Resident #16 required supervision to set up assistance with most ADLs. Record review of a care plan last revised on 09/18/23 indicated Resident #16 was at risk for adverse consequences related to receiving psychotropic medications due to diagnoses of anxiety, depression, paranoia, and psychotic/psychosis. Record review of PASRR Level One Screening forms dated 03/02/17 did not indicate Resident #16 had a mental illness. Resident #16's electronic medical record did not indicate any further PASRR Level One Screening forms or a PASRR Evaluation. Record review of a Discharge Summary from a behavioral hospital with an admission date of 08/04/22 and a discharge date [DATE] indicated Resident #16 had a diagnosis of bipolar disorder type 1 (Bipolar I disorder is defined by manic episodes that last for at least 7 days (nearly every day for most of the day) or by manic symptoms that are so severe that the person needs immediate medical care), recurrent, severe, with psychotic features. During an interview on 01/09/24 at 2:15 p.m., the MDS Coordinator said the previous DON had entered the diagnosis into the electronic medical record for Resident #16. The MDS Coordinator said she was unaware of the diagnosis of schizoaffective disorder, bipolar type for the resident and there had not been a PASSR Level One Screening resubmission. She said there was not a PASSR evaluation for Resident #16. During an interview on 01/10/24 at 11:57 a.m., the DON said after Resident #16's medical record was updated to reflect the resident had a diagnosis of schizoaffective disorder, bipolar type 1 and 675293 Page 22 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few after the resident returned from the behavioral hospital with a diagnosis of bipolar disorder, she would have expected the resident to have been received a new PASRR Level One Screening and a PASSR Evaluation. She said a resident with a new diagnosis of mental illness not being re-evaluated appropriately could cause them to not receive needed PASSR services. During an interview on 01/10/24 at 12:38 p.m., the Administrator said after a resident received a new mental illness diagnosis, she would have expected a new PASRR Level One Screening and a PASSR Evaluation to have been done for the resident. She said a resident with a mental illness not having a PASSR Evaluation could cause them to not get support and services they need. Review of a PASSR facility policy dated 11/2023 indicated, .The purpose of this policy is to ensure PASRRs are being obtained and completed timely and accurately .Follow Texas PASRR Policy for all mandatory meetings and care coordination including any changes that may require a change in resident's PASRR status. 675293 Page 23 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 a baseline care plan within 48 hours of a resident's admission for one (Resident #192) of six residents reviewed for care plan completion. The facility failed to complete Resident #192's baseline care plan within the required 48-hour timeframe of admission. This failure could place residents who were admitted within the last 30 days at risk for not receiving necessary care and services or having important care needs identified. Findings included : Review of Resident #192's face sheet dated 12/29/2023 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including Senile Degeneration of the Brain (the mental deterioration or loss of intellectual ability), Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing-related problems), and Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Review of Resident #192's Baseline Care Plan revealed a date of admission of 12/29/23 and an implementation date of 12/31/23. The Baseline Care Plan reflected Ten days overdue . on 01/08/2023. No baseline care plan was available to use as it was marked incomplete. During an interview on 01/09/2024 at 1:50 p.m., the DON said it was nursing services who were responsible to ensure that baseline care plans are completed. She said Resident #192's baseline care plan was not completed. She said staff were unable to view the baseline care plan as a section were not marked complete until 01/09/2024 (after the survey began). She said residents' baseline care plans could not be accessed by staff to view during this time. During an interview on 01/10/2024 at 10:54 a.m., the Administrator said the nurse that admits the resident was responsible for developing a resident's baseline care plan. She said multiple people develop the care plan including nurses and social services. She said they are required to enter a baseline care plan within 48 hours. She said the purpose of a baseline care plan was so that staff can understand the care and needs of a resident within the first 48 hours after admission. She said residents can be placed at risk for staff not knowing the care needs of the resident if the baseline care plan was not completed. She said it could lead to a resident not receiving the care that they require. Review of facility's policy Baseline Care Plan dated November 1st, 2019, reflected, . A baseline care plan is required to be completed within 48 hours of admission . 675293 Page 24 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 2 of 15 residents reviewed for care plans. (Resident# 19, Resident #29) The facility failed to implement Resident #19's care plan intervention to off-load (is described as lifting or pushing an area of high pressure away from the cause of the pressure) her heels when in bed. The facility failed to care plan Resident # 19's diagnosis of Type 2 diabetes (is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) and use of insulin (therapy often is an important part of diabetes treatment), diuretic (are medicines that help reduce fluid buildup in the body), opioid (sometimes called narcotics, are a type of drug), and antiplatelet (are medications that prevent blood clots from forming) coded of her MDS. The facility failed to care plan Resident #19's use of an anticonvulsant (are prescription medications that help treat and prevent seizures). The facility failed to care plan Resident #29's use of an antiplatelet. These failures could place residents at risk of not having individual needs met and cause residents not to receive needed services. Findings included: 1. Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and admitted on [DATE] with diagnoses including Type 2 diabetes, edema (is swelling caused by too much fluid trapped in the body's tissues), cerebrovascular disease (is a term for conditions that affect blood flow to your brain), bipolar (causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)), and conversion disorder (is a condition where a mental health issue causes physical symptoms) with seizures (is a sudden, uncontrolled burst of electrical activity in the brain) or convulsion (are rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement). Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 required substantial/maximal assistance for personal and oral hygiene, shower/bath self, and dependent for toilet hygiene. The MDS indicated Resident #19 had diagnoses including diabetes mellitus and seizure disorder or epilepsy (is a brain condition that causes recurring seizures). The MDS indicated Resident #19 received scheduled pain medication regimen and experienced presence of pain in the last 5 days. The MDS indicated Resident #19 received diuretic, opioid, and antiplatelet medications during the last 7 days of the assessment period. Record review of Resident #19's order summary dated 01/09/24 indicated Clopidogrel (It is an antiplatelet drug. It helps keep blood flowing smoothly in your body) 75 mg, give 1 tablet by mouth one 675293 Page 25 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0656 time a day for anticoagulation, start date 03/18/23. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #19's order summary dated 01/09/24 indicated Carbamazepine (is in a class of medications called anticonvulsants. It works by reducing abnormal electrical activity in the brain) 200 mg, give 2 tablets by mouth at bedtime for bipolar disorder, start date 03/18/23. Residents Affected - Few Record review of Resident #19's order summary dated 01/09/24 indicated Carbamazepine 200 mg, give 1 tablet by mouth one time a day for bipolar disorder, start date 03/19/23. Record review of Resident #19's order summary dated 01/09/24 indicated Lasix (is a strong diuretic (water pill') and may cause dehydration and electrolyte imbalance) 20 mg, give 2 tablets by mouth one time a day for cerebrovascular disease, start date 03/19/23. Record review of Resident #19's order summary dated 01/09/24 indicated Gabapentin (is an anticonvulsant medication primarily used to treat partial seizures and neuropathic pain) 600 mg, give 1 tablet by mouth one time a day for neuropathy (happens when the nerves that are located outside of the brain and spinal cord (peripheral nerves) are damaged), start date 03/19/23. Record review of Resident #19's order summary dated 01/09/24 indicated Novolin (is a type of insulin used to control blood sugar) 100 units/ML (Insulin Regular (Human)), inject as per sliding scale, subcutaneously two times a day for diabetes type 2, start date 04/19/23. Record review of Resident #19's order summary dated 01/09/24 indicated Tramadol (is in a class of medications called opiate (narcotic) analgesics and used to treat moderate to severe pain that is not being relieved by other types of pain medicines) 50 mg, give 1 tablet by mouth three times a day for pain, start date 08/14/23. Record review of Resident #19's order summary dated 01/09/24 indicated Lantus (is a long-acting form of insulin), inject 30 unit subcutaneously at bedtime for diabetes type 2, start date 11/08/23. Record review of Resident #19's order summary dated 01/09/24 indicated Lantus, inject 40 unit subcutaneously in the morning for diabetes type 2, start date 11/08/23. Record review of Resident #19's care plan dated 07/19/23 indicated Resident #19 had a DTI (is a form of pressure ulcer or pressure sore) to left heel. Intervention off-load heels while in bed. The care plan did not address Resident #19's diagnosis of Type 2 diabetes and use of an anticonvulsant and use of insulin, diuretic, opioid, and antiplatelet coded of her MDS. During an observation and interview on 01/08/24 at 1:04 p.m., Resident #19 was lying in the bed on her back. Resident #19's feet were not off-loaded. She said the staff did not put anything underneath her heels but sometimes put heel protectors on after therapy. The heel protectors were on the bed next to Resident #19. Resident #19 said she had not had them on in a while. During an observation and interview on 01/09/24 at 1:15 p.m., Resident #19 was lying in the bed on her back. Resident #19's feet were not off-loaded. During an interview on 01/10/24 at 12:22 p.m., RCP O said the RCPs and LVNs were responsible for ensuring Resident #19's heels were floated. She said Resident #19 also had heel protectors she would wear. She said Resident #19 had sores on her feet and they were floating them to heal. She said 675293 Page 26 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0656 floating a resident's heels kept the pressure off the area damaged. Level of Harm - Minimal harm or potential for actual harm During an interview on 01/10/24 at 12:47 p.m., LVN P said the nurse was responsible for floating Resident #19's heels or placing her heel protectors on. She said Resident #19 would sometimes refuse the heel protectors or would not float her heels for long periods of time. She said Resident #19 had a DTI and was paralyzed on her left side so floating her heels was important for prevention of skin breakdown. She said she did not know if nurses had access or could see care plans interventions. She said nursing staff knew resident care from morning meeting updates. She said implementing Resident #19 care plan intervention was important to prevent wounds or injuries. Residents Affected - Few 2. Record review of Resident #29's face sheet printed 01/09/24 indicated Resident #29 was an [AGE] year-old male and was admitted on [DATE] and 05/31/22 with diagnosis including atherosclerotic heart disease of native coronary artery (is caused by plaque buildup in the wall of the arteries that supply blood to the heart (called coronary arteries)). Record review of Resident #29's quarterly MDS assessment dated [DATE] indicated Resident #29 was understood and sometimes had the ability to understand others. The MDS indicated Resident #29 had a BIMS score of 03 which indicated severe cognitive impairment. The MDS indicated Resident #29 required partial/moderate assistance for toilet hygiene and shower/bath self, supervision for personal hygiene, and independent for oral hygiene and eating. The MDS indicated Resident #29 received an antiplatelet during the last 7 days of the assessment period. Record review of Resident #29's order summary dated 01/09/24 indicated Aspirin (is used to treat pain and reduce fever or inflammation. It is sometimes used to treat or prevent heart attacks, strokes, and chest pain) 81 mg, give 1 tablet by mouth one time a day for preventative, start date 12/18/20. Record review of Resident #29's care plan printed 01/09/24 did not indicate use of an antiplatelet. During an interview on 01/10/24 at 1:20 p.m., the CRS said she was responsible for MDSs and care plans. She said she only worked part time at the facility. She said she developed the comprehensive care plan from the CAAs on the MDS, medical diagnoses, physician's orders, activities, reviewed progress and social notes, and anything special in the resident's history. She said Resident #19's diagnoses and medications should be included on her care plan. She said comprehensive care plans were important to make sure residents received services and any special needs the staff needed to be aware of. She said Resident #29's use of an antiplatelet should have been added to his care plan. She said new nurses could look at a care plan and may not know the appropriate care for the resident if problem areas were not added to the care plan. During an interview on 01/10/24 at 2:29 p.m., the DCO said the MDS Coordinator (CRS) and the DCO were responsible for comprehensive care plans. She said Resident #19's diagnoses and medications and Resident #29 use of an antiplatelet should be care planned. She said comprehensive care plans were important, so nurses were aware of the resident's issues. She said the nurses were responsible for care plan interventions to be implemented. She said sometimes Resident #19 refused to off-load her heels. She said staff were supposed to chart if Resident #19 refused. The DCO said LVNs were able to view residents' care plans on the facility's charting system but not RCPs. She said LVNs should inform RCPs of care plan interventions such as off-loading heels, so they knew to monitor. 675293 Page 27 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0656 Level of Harm - Minimal harm or potential for actual harm During an interview on 01/10/24 at 3:57 p.m., the ADM said if an intervention was on a care plan, she expected it to be followed or done. She said if the information was on the MDS and was triggered (coded), she expected it to be on the care plan. She said nurses and nurse management was responsible for ensuring comprehensive care were complete and interventions are followed or done. She said diagnoses and medications had risked that had to be monitored and intervention developed. Residents Affected - Few Record review of a facility's Comprehensive Care Plan revised on 04/21 indicated .the interdisciplinary team will continue to develop the plan in conjunction with RAI (MDS 3.0) and CAAS .the IDT will review the healthcare practitioner's notes and orders and implement a comprehensive care plan to meet the residents' immediate needs including but not limited to .physician orders .pain management .specific care plan on the main reason for admission . Record review of a facility's Skin Management: Prevention and Treatment of Wounds policy revised 10/06/22 indicated .is for prevention and treatment of skin breakdown such as pressure injuries .prevention .dependent residents will have heels floated while in bed . 675293 Page 28 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

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 observation, interview and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 15 residents (Residents #34), reviewed for care plans. The facility failed to revise and update Resident #34's comprehensive care plan for an anticoagulant medication (a medication that helps prevent blood clots). This failure could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Record review of face sheet dated 01/08/24 indicated Resident #34 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses of myotonic muscular dystrophy (a genetic condition that causes progressive muscle weakness and wasting), dysphagia (difficulty swallowing), and atrial flutter (a type of abnormal heart rhythm). Record review of physician's orders dated 01/08/24 indicated an order for Eliquis Oral Tablet 5 milligrams give 1 tablet by mouth two times a day with an order date and start date of 08/21/23. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #34 was usually understood and understood others. The MDS indicated a BIMS of 08 which indicated moderate cognitive impairment. The MDS indicated the resident was taking an anticoagulant, which is a high-risk drug. Record review of a care plan last revised on 12/28/23 for Resident #34 did not indicate the use of an anticoagulant. During an interview on 01/10/24 at 10:58 a.m., the MDS Coordinator said she was responsible for updating care plans. She said she may have overlooked the fact that Resident #34 was on an anticoagulant and failed to add it to the care plan. She said she was not sure when the Eliquis had been prescribed. She said she reviewed the 24-hour reports for the residents for any new problems that need to be added to each residents' care plan. She said new nurses could look at a care plan and may not know the appropriate care for the resident if problem areas were not added to the care plan. She said a nurse may not know to monitor for bruising for someone taking anticoagulants. During an interview on 01/10/24 at 11:57 a.m., the DON said a care plan was used to plan the necessary care for each resident. She said she would have expected the anticoagulant for Resident #34 to have been added to his care plan. During an interview on 01/10/24 at 12:38 p.m., the Administrator said she would have expected for an anticoagulant to have been care planned. She said it was the responsibility of the nurse manager to update care plans. She said Eliquis had risks that have to be monitored. Review of a Comprehensive Care Plan facility policy dated 1/20/21 indicated, .The Care Plan is 675293 Page 29 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0657 Level of Harm - Minimal harm or potential for actual harm revised every quarter, significant change of condition, Annual or as the resident condition changes on an individualized basis .The Interdisciplinary Team will review the healthcare practitioner's notes and orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a Comprehensive Care Plan to meet the residents' immediate care needs . Residents Affected - Few 675293 Page 30 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

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 provide the necessary services to maintain personal hygiene for 1 of 15 resident reviewed for ADLs. (Resident #19) Residents Affected - Few The facility failed remove Resident #19's unwanted facial hair. The facility failed to provide Resident #19 her schedule bath/showers. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. Findings included: Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and admitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction (stroke) affecting left no-dominant side and muscle weakness. Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 required substantial/maximal assistance for personal and oral hygiene, shower/bath self, and dependent for toilet hygiene. Record review of Resident #19's care plan dated 04/10/23 indicated Resident #19 had limited physical mobility related to stroke and weakness. Intervention included Resident #19 was non-weight bearing. The care plan did not address ADL care and intervention. Record review of Resident #19's ADL bathing report dated 12/11/23-01/08/24 indicated no documentation for Resident #19 for 6 out of 13 scheduled bath/showers. The ADL bathing report indicated Resident #19's shower days were Mondays, Wednesdays, and Fridays. Record review of Resident #19's shower sheets from 12/11/23-01/08/24 indicated 12/11/23 (bed bath), 12/13/23 (refused shower, received bed bath, shaved), 12/18/23, 12/22/23 (bed bath), 12/28/23 (bed bath), 01/03/24 (showered, shampoo), 01/05/24, 01/08/24 (bed bath). During an interview and observation on 01/08/24 at 1:04 p.m., Resident #19 was lying in her bed in a hospital gown with food on her hand and the bed. Resident #19 said she did not get enough baths. She said her baths were on Mondays, Wednesdays, and Fridays but she only got them once or twice a week. Resident #19 had small amount of black, curly hair on both side of her mouth. Resident #19 said she wanted it (facial hair) off. During an observation on 01/09/24 at 11:30 a.m., Resident #19 was lying in her bed in a hospital gown with a small amount of black, curly hair on both side of her mouth. During an observation on 01/09/24 at 1:15 p.m., Resident #19 was lying in her bed in a hospital gown with a small amount of black, curly hair on both side of her mouth. 675293 Page 31 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 01/10/24 at 12:22 p.m., RCP O said RCPs were responsible for giving residents bath or showers and removing facial hair. She said Resident #19 refused showers at least once a shift when she worked. She said Resident #19 let the RCPs remove her facial hair. She said ADL care was charted on the facility's charting system. She said the ADCO and DCO decided the shower scheduled. She said the shower schedule was posted at the nurse's station with the resident's day and which shift. She said the facility just started using shower sheets also to document resident's showers. She said ADL care was important for hygiene. She said sometimes if the facility only had 2 RCPs on the floor, things did not get done like resident's shower and baths. During an interview on 01/10/24 at 12:47 p.m., LVN P said RCPs were responsible for ADL care of residents. She said if the resident refused, the RCP was supposed to notify the nurse and the nurse was supposed to also ask then document if the resident still refused. She said Resident #19 refused to get up for showers but would get a bed bath instead. She said Resident #19 rarely refused to have her facial hair removed. She said refusals were documented on shower sheets. She said ADL care was important for the resident's dignity and to smell good. During an interview on 01/10/24 at 2:29 p.m., the DCO said the RCP was responsible for ADL care. She said residents should get bed bath daily and showers three times a week. She said she was not sure when women were shaved. She said ADL care was documented in the facility's charting system. She said she was not sure if Resident #19 refused to have her facial hair removed but she refused showers but would do bed baths. She said bed baths and showers were supposed to be charted in the facility's charting system. She said shower sheets were supposed to be done for all bath and showers. She said shower/baths were important to promote cleanliness. During an interview on 01/10/24 at 3:57 p.m., the ADM said RCP was responsible for ADL care. She said she expected the staff to follow the shower schedule unless the resident refused. She said facial hair should be removed as needed. She said nurses and nursing management should make rounds to ensure resident were be provided ADL care. A policy regarding ADL for shower/bath and facial hair was requested at this time, the policy was not received before or after exit. 675293 Page 32 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 4 residents (Resident #19) reviewed for range of motion and mobility The facility failed to ensure Resident #19 had on a hand device. This failure had the potential to affect resident with limited ROM by placing them at risk for a decline in their functional abilities. Findings included: Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and admitted on [DATE] with diagnoses including contracture, left hand and ankle, abnormal posture, hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction (stroke) affecting left no-dominant side, and muscle weakness. Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 had limited range of motion to both sides of her lower extremities. The MDS indicated Resident #19 required substantial/maximal assistance for personal and oral hygiene, shower/bath self, and dependent for toilet hygiene. Record review of Resident #19's care plan dated 04/10/23 indicated Resident #19 had limited physical mobility related to stroke and weakness. Interventions included provide gentle range of motion as tolerated with daily care and monitor/document/report as needed any signs/symptoms of immobility. Record review of Resident #19's order summary date 01/09/24 indicated remove hand device at bedtime, start date 03/18/23. During an interview and observation on 01/08/24 at 1:04 p.m., Resident #19 was lying in bed with no hand device on her left hand. A hand device was noticed on the empty bed next to the resident. Resident #19 said the CNAs (RCPs) normally put the brace on her hand. She said she normally wore it for 2 hours and took it off for 2 hours. She said she had not had the brace on since yesterday. During an interview and observation on 01/09/24 at 1:15 p.m., Resident #19 was lying in bed with no hand device on her left hand. A hand device was not visualized in the room. Resident #19 said she did not know where her hand device was and had not had it on today. During an interview on 01/09/24 at 4:04 p.m., the Director of Rehabilitation Department/Certified Occupational Therapist said the CNAs (RCPs) were responsible for putting on Resident #19's hand device. She said the hand brace was supposed to be on as long as Resident #19 tolerated it. During an interview on 01/10/24 at 12:22 p.m., RCP O said Resident #19 and staff were the ones who asked for a hand brace for her left hand. She said the RCP and LVN were responsible for putting the device on and off. She said only the LVN could see the order of the length of time the device was 675293 Page 33 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few supposed to be on. She said Resident #19 was supposed to have on her hand brace every day and all day until she asked for it to be removed. She said sometimes they did alternate it off and on by a couple hours if she was in pain. She said the brace was important because her hand was contracted. During an interview on 01/10/24 at 12:47 p.m., LVN P said the nurses were primarily responsible for placement of the hand device. She said the RCP should let the nurse know if it got dirty or something so it could get changed. She said she placed a rolled towel in Resident #19's hand and did not know about a hand device. She said the hand device should be put on every shift and given a break when Resident #19 complained of discomfort or pain but then reapplied. She said the hand device was important to prevent further contractures. During an interview on 01/10/24 at 2:29 p.m., the DCO said the LVN was responsible for the hand device. She said sometimes Resident #19 refused the hand device. She said if Resident #19 refused the hand device, it should be documented in the facility's charting system. She said the hand device was important to prevent breakdown and increased contracture. During an interview on 01/10/24 at 3:57 p.m., the ADM said the RCP was responsible for applying Resident #19's hand device and the nurse should monitor when its off and on. She said the hand device was important, so the contracture did not get worse. A policy for contracture management was requested at the time, a policy was not received before or after exit. 675293 Page 34 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 2 residents (Resident #23) who were reviewed for indwelling urinary catheter care. The facility failed to ensure CNA F followed appropriate procedures and infection control during foley catheter care for Resident #23. This failure could place residents at risk for urinary tract infections. Findings included: Record review of Resident #23's face sheet dated 1/09/23 indicated Resident #23 was a [AGE] year-old female and admitted on [DATE] with diagnoses including paralytic syndrome (unable to move) following a cerebrovascular disease (problem with blood flow to the brain causing damage to the brain), paraplegia (complete or partial loss of muscle function to all or part of the trunk, legs, or pelvic organs), reduced mobility, and hypertension (high blood pressure). Record review of Resident #23's quarterly MDS assessment dated [DATE] indicated Resident #23 was usually understood and usually understood others. The MDS indicated Resident #23 had a BIMS score of 13 which indicated she was cognitively intact. The MDS indicated Resident #23 required maximal assistance with toileting and bathing. The MDS indicated Resident #23 required total assistance dressing her lower body. The MDS indicated Resident #23 had an indwelling catheter, was always incontinent of urine, and was frequently incontinent of bowel. Record review of Resident #23's care plan revised 11/17/23 indicated Resident #23 was incontinent and at risk for skin breakdown with intervention to monitor for signs and symptoms of infection and notify physician promptly. The care plan revealed Resident #23 was on an antibiotic for a urinary tract infection. Resident #23's care plan revealed there were no focused area or interventions for her foley catheter. Record review of Resident #23's order summary report dated 1/09/24 did not reveal an order for a foley catheter. Record review of Resident #23's progress notes dated 11/14/23 revealed the nurse had received an order from Resident #23's urologist to place a foley catheter and change it monthly and to start on Macrobid (antibiotic) 100 mg twice a day for seven days for a urinary tract infection. During an observation and interview on 1/08/24 at 10:39 AM, Resident #23 was sitting up in her bed and a foley catheter drainage bag was hanging from the side of her bed with a privacy bag. Resident #23 said she had the foley catheter because she was unable to control her bladder or move her lower body. During an observation on 01/09/24 at 10:30 AM, CNA F performed foley catheter care on Resident #23 with ADCO C in the room also. CNA F washed her hands, applied gloves, and placed opened trash bags on the BST. CNA F then with her same gloved hands grabbed and moved the BST closer, then pulled back 675293 Page 35 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #23's covers, grabbed a package of incontinent wipes off of Resident #23's nightstand and pulled out 4 wipes and then laid the wipes on the resident's incontinent pad. CNA F using the same gloves, then held the bedsheet over the resident's pelvic area with her left hand and used her right hand to pick up a wipe off the incontinent pad and wiped the foley catheter starting at the point closest to Resident and slid the wipe down the foley catheter away from the resident and then placed it in the trash bag on the BST and repeated this process three times. CNA F using the same gloves, then pulled Resident #23's adult brief up between her legs and fastened the sticky tabs and then pulled up the bedsheet over the resident. CNA F then removed her gloves and pulled the rest of the covers up over the resident. During an interview on 1/09/24 at 10:48 AM, CNA F said she usually changed her gloves at least twice when performing foley catheter care, but only changed gloves once because she was nervous. CNA F said she laid the incontinent wipes on Resident #23's incontinent pad because she had changed the resident's incontinent pad after Resident #23 had a bowel movement not long prior to going to provide foley catheter care, so she knew it was clean. CNA F said by not changing her gloves prior to starting foley care she could have transferred bacteria to the foley catheter, and the resident could get sick. CNA F said the purpose of cleaning the foley catheter was to prevent infections. During an interview on 1/10/24 at 10:55 AM, LVN B said staff should change gloves after touching other surfaces in a resident's room, such as a BST or bedding, prior to performing foley catheter care. LVN B said it would not be appropriate to place incontinent wipes to be used to perform foley catheter care on the resident's incontinent pad. LVN B said it would be cross-contamination and could give the resident a UTI. During an interview on 1/10/24 at 1:02 PM, the DCO said CNA F did not perform appropriate foley catheter care and should have changed her gloves prior to starting the foley catheter care after touching multiple surfaces. The DCO said CNA F should not have laid the incontinent wipes on the incontinent pad or handled Resident #23's sheet without removing or changing her gloves. The DCO said improper foley catheter care could cause infections, such as a UTI. During an interview on 1/10/24 at 1:28 PM, the ADM said CNA F should have changed her gloves after touching multiple surfaces in Resident #23's room prior to and after performing foley catheter care. The ADM said once you touch multiple things, the gloves were no longer clean. The ADM said by not performing proper foley catheter care, it could pose an increased risk of infection to the resident. During an interview on 1/10/24 at 3:45 PM, ADCO C said she had saw enough during the foley catheter care provided by CNA F for Resident #23 to know she needed to do an in-service with her staff on foley catheter care. ADCO C said CNA F did not change her gloves after touching multiple other surfaces prior to performing foley catheter care. ADCO C said CNA F should not have placed the incontinent wipes on the resident's incontinent pad or used the wipes off the incontinent pad. ADCO C said CNA F should not have touched Resident #23's sheet with the same gloves used to clean the foley catheter. ADCO C said the trash bags should have not been placed on the resident's BST either. ADCO C said the foley catheter care that was provided by CNA F for Resident #23 was an infection control issue and could increase the resident's risk of developing a UTI. Requested competency or skills check list for CNA F for foley catheter care from the DCO on 1/10/24 at 1:02 PM. Requested competency or skills check list for CNA F for foley catheter care from the ADM on 1/10/24 675293 Page 36 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few at 3:28 PM and at 4:00 PM the ADM said they did not have competency or skills check list for CNA F for foley catheter care. Record review of the facility's policy titled Catheters-Insertion and Care: Indwelling, Straight, Supra-Pubic, and External dated 4/2021 revealed . it was the policy of the community that the resident with a urinary catheter be provided services in a safe and appropriate manner to minimize the risks of urinary tract complications . physician order was required for all catheters . order should include type of catheter, size of catheter and size of bulb, frequency to change catheter and drainage bag . 675293 Page 37 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 that respiratory care was provided consistent with professional standards of practice for 2 of 15 residents reviewed for respiratory care. (Resident #13 and Resident #19) Residents Affected - Few 1.The facility failed to ensure Resident #13's yankauer suction catheter (hard-plastic tip with handle used to suction secretions from the mouth) was properly stored. 2. The facility failed to ensure Resident #19 had a filter (the air passes through a series of filters that remove impurities, ensuring that the oxygen delivered to the patient is of high quality) in the oxygen concentrator (take air from your surroundings, extract oxygen and filter it into purified oxygen for you to breathe). 3. The facility failed to ensure Resident #19's compartment that held the oxygen concentrator filter did not have white, fuzzy material. These failures could place residents at risk of respiratory complications or respiratory infection. Findings included: 1. Record review of Resident #13's face sheet dated 1/08/24 revealed he was an [AGE] year-old male, who admitted to the facility on [DATE]. Resident #13 had diagnoses of COPD (chronic obstructive pulmonary disease -constriction of the airways and difficulty or discomfort in breathing), hypertension (high blood pressure), history of cerebral infarction (disruption or lack of blood supply to the brain causing parts of the brain to die, also called a stroke), right sided hemiplegia (unable to move right side of body), and weakness. Record review of Resident #13's quarterly MDS dated [DATE] revealed he was understood and understood others. Resident #13 had a BIMS of 11 which indicated he had moderate cognitive impairment. Resident #13 was dependent on someone to perform most ADLs. Resident #13 was receiving hospice care (end of life care). Record review of Resident #13's undated care plan revealed he had shortness of breath with an intervention to maintain a clear airway and to suction as needed to clear secretions. Record review of Resident #13's Order Summary Report dated 1/09/24 revealed an order to admit to hospice dated 8/22/22. During an observation on 1/09/24 at 8:48 AM revealed Resident #13's lying in bed, unable to communicate. There was a yankauer suction catheter laid directly on top of his BST (not bagged) with tubing attached to a suction machine with approximately 3 inches of yellow tinged fluid in the collection canister. During an observation on 1/09/24 at 9:25 AM revealed Resident #13 lying in bed, unable to communicate, and his yankauer suction catheter continued to be laid directly on top of his BST (not bagged) with tubing attached to a suction machine with approximately 3 inches of yellow tinged fluid in the 675293 Page 38 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0695 collection canister. Level of Harm - Minimal harm or potential for actual harm During an observation on 1/09/24 at 10:54 AM revealed Resident #13 sitting up in bed, unable to communicate and his yankauer suction catheter continued to be laid directly on top of his BST (not bagged) with tubing attached to a suction machine with approximately 3 inches of yellow tinged fluid in the collection canister. Residents Affected - Few During an interview on 1/10/24 at 10:55 AM, LVN B said she had worked at the facility for three months and normally worked the 6 AM-2 PM. LVN B said Resident #13 was on hospice services and she was performing frequent checks on him because he was nearing end of life. LVN B said Resident #13 already had the suction machine in his room prior to her 6 AM-2 PM shift on 1/09/24 and the yankauer suction catheter was already lying directly on the BST. LVN B said she had not used the yankauer suction catheter to suction his mouth during her shift. She said the yankauer suction catheter should be stored in a plastic bag with the resident's name on it to prevent the growth and/or spread of infection. LVN B said it would not be appropriate for a yankauer suction catheter to be laid directly on the BST because it was equipment used in the resident's mouth. LVN B said the yankauer suction catheter should have been thrown in the trash when she saw it lying directly on the BST to ensure it was not used on Resident #13 by other staff. During an interview on 1/10/24 at 11:22 AM, RN E said she had worked at the facility about a year and normally worked the 6 AM-2 PM shift. RN E said the yankauer suction catheter should be stored in packaging or a plastic bag to prevent the growth of bacteria. RN E said it would not be proper procedure to lay a used uncovered yankauer suction catheter on a BST. RN E said you would be contaminating the BST and the yankauer suction catheter. RN E said the yankauer suction catheter should be properly stored to keep it clean due to it was used to suction the resident's mouth. RN E said using a contaminated yankauer suction catheter in a resident's mouth would increase the risk of infection to the resident. During an interview on 1/10/24 at 1:02 PM, the DCO said Resident #13's yankauer suction catheter should have been replaced after being found lying directly on the BST and not properly stored due to it was then contaminated. The DON said the yankauer suction catheter should be stored in a plastic bag or something, not directly on top of the BST due to possible infection control issues and increased risk of infection to the resident. During an interview on 1/10/24 at 1:28 PM, the ADM said she would expect Resident #13's yankauer suction catheter to have been stored properly in something and not laid directly on the BST. The ADM said not storing the yankauer suction catheter properly posed an increased risk of infection to the resident. During an interview on 1/10/24 at 3:04 PM, LVN D said she had worked at the facility for 5-6 years PRN and normally worked the 10 PM-6 AM shift. LVN D said she had worked the 10 PM-6 AM on 1/8/24 and provided care to Resident #13. LVN D said the suction machine with the yankauer suction catheter was already in his room when she came in on her shift and the suction canister had about two inches of yellow secretions in it. LVN D said she used the yankauer suction catheter a little on him, kept his head of bed elevated, and kept him comfortable on her shift. LVN D said the yankauer suction catheter was already lying on the BST when she went into Resident #13's room, but she used the yankauer suction catheter in his mouth but was not able to suction any secretions back from his mouth. LVN D asked surveyor was I not supposed to use it after it sat on his BST? LVN D said she was not sure what the policy said but she probably should have thrown it in the trash and obtained a new one before 675293 Page 39 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few putting it in his mouth. LVN D said by placing the yankauer suction catheter in his mouth after it had laid directly on the BST, it placed the resident at an increased risk of infection from cross-contamination. 2.Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and admitted on [DATE] with diagnoses cerebrovascular disease (is a term for conditions that affect blood flow to your brain), morbid (severe) obesity due to excess calories, hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction (stroke) affecting left no-dominant side. Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 required substantial/maximal assistance for personal and oral hygiene, shower/bath self, and dependent for toilet hygiene. The MDS indicated Resident #19 experienced shortness of breath or troubled breathing with exertion. The MDS indicated Resident #19 had oxygen therapy within the last 14 days while a resident in the facility. Record review of Resident #19's care plan dated 04/10/23 indicated Resident #19 had oxygen therapy related to cerebral vascular accident (stroke) and obesity. Intervention included give medications as ordered by physician. Record review of Resident #19's order summary dated 01/09/24 indicated clean/change oxygen concentrator filters every night shift every Sunday, start date 03/19/23. Record review of Resident #19's TAR dated 01/01/24-01/31/24 indicated clean/change oxygen concentrator filters every night every Sun (01/07/24 LVN Q). During an observation on 01/08/24 at 1:04 p.m., Resident #19 was lying in her bed with a nasal cannula on which was connected to an oxygen concentrator. The oxygen concentrator did not have a filter and the compartment that held the filter, had a small amount of white, fuzzy material. During an observation on 01/09/24 at 11:30 a.m., Resident #19 was lying in her bed with a nasal cannula on which was connected to an oxygen concentrator. The oxygen concentrator did not have a filter and the compartment that held the filter, had a small amount of white, fuzzy material. During an observation on 01/09/24 at 1:15 p.m., Resident #19 was lying in her bed with a nasal cannula on which was connected to an oxygen concentrator. The oxygen concentrator did not have a filter and the compartment that held the filter, had a small amount of white, fuzzy material. On 01/10/24 at 12:05 p.m., attempted to contact LVN Q by phone, left message with no return call before or after exit. During an interview on 01/10/24 at 12:47 p.m., LVN P said she mostly worked the 2pm-10pm shift but had worked all the shifts. She said the filters on concentrators were supposed to be cleaned by the Sunday night shift nurse. She said the nurse who cleaned the filter should make sure the resident had a filter also. She said a resident while no filter or filter area with fuzzy, white material placed them at risk for upper respiratory infection like pneumonia. 675293 Page 40 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 01/10/24 at 2:29 p.m., the DCO said the oxygen concentrator filters were cleaned on Sunday nights by the nursing staff and as needed. She said the nurses should ensure the resident had a filter in their oxygen concentrator. She said the RCPs could also notify the charge nurse if they noticed the filter missing or dirty. She said the filter was important to filter the good and bad things in the air. During an interview on 01/10/24 at 3:57 p.m., the ADM said staff members who changed the oxygen tubing should also check the filter. She said there was no potential harm to the resident if the oxygen concentrator did not have a filter, but it could eventually affect how the machine worked. Review of the facility's Respiratory policy titled Suctioning dated 04/2021 indicated . policy of this community that oral suctioning of a resident's mouth . would be provided to remove mucus, drainage or saliva away from the resident's airway . connect tubing to suction machine . put on glove and attach catheter to connecting tubing, taking care not to contaminate suction catheter . Record review of a facility's Oxygen Therapy policy dated 04/21 indicated .wash filters from oxygen concentrators every 7 days in warm soapy water . 675293 Page 41 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 3 of 5 residents (Resident #19, Resident #25, and Resident #29) reviewed for unnecessary psychotropic medications (are medications that affect the mind, emotions, and behavior). The facility failed to ensure Resident #19 had behavior monitoring for her prescribed antianxiety (treats anxiety disorders), anticonvulsant (are prescription medications that help treat and prevent seizures), and antipsychotic (are the main class of drugs used to treat people with schizophrenia) medications. The facility failed to ensure Resident #19 had side effect monitoring for her prescribed antianxiety, anticonvulsant, and antipsychotic medications. The facility failed to ensure Resident #25 had an appropriate diagnosis for his prescribed Quetiapine (Seroquel; is an atypical antipsychotic used to treat schizophrenia, bipolar disorder, and depression) 50 mg. The facility failed to ensure Resident #25 had an anxiety diagnosis for his prescribed antianxiety medication. The facility failed to ensure Resident #25's prn Lorazepam (is used to treat anxiety) was ordered for 14 days. The facility failed to ensure Resident #25 had behavior monitoring for his prescribed psychotropic medications. The facility failed to ensure Resident #25 had side effect monitoring for his prescribed psychotropic medications. The facility failed to ensure Resident #29 had a documented diagnosis for the use of his prescribed Seroquel (Quetiapine) 25 mg. These failures could put residents at risk of receiving unnecessary psychotropic medications. Findings included: 1. Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and was admitted on [DATE] with diagnoses including Schizoaffective Disorder (is a mental illness that can affect your thoughts, mood and behavior), Bipolar type, Bipolar disorder (is a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), mild depressed, recurrent depressive disorder (a depressed mood or loss of pleasure or interest in activities for long periods of time), generalized anxiety (you are worrying constantly and can't control the worrying), insomnia (is a common sleep disorder), and conversion disorder with 675293 Page 42 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some seizures or convulsions (is a condition in which a person experiences physical and sensory problems, such as paralysis, numbness, blindness, deafness or seizures, with no underlying neurologic pathology). The face sheet did not indicate a diagnosis of anxiety. Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #19 had verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others). The MDS indicated Resident #19 required substantial/maximal assistance for personal and oral hygiene, shower/bath self, and dependent for toilet hygiene. The MDS indicated Resident #19 received antipsychotic, antianxiety, and antidepressant during the last 7 days of the assessment period. Record review of Resident #19's care plan dated 03/21/23, revised 04/10/23 indicated Resident #19 was at risk for adverse consequence related to receiving psychotropic medications. Interventions included monitor side effects of anti-depressant (a type of medicine used to treat clinical depression) and antipsychotic. Monitor/document/report prn adverse reactions to antidepressant and psychotropic, monitor/record occurrence for target behavior symptoms (pacing, wandering, disrobing, inappropriate response to verbal communication, verbal/aggression towards staff/others, etc.,) and document per facility protocol. Record review of Resident #19's order summary dated 01/09/24 indicated Carbamazepine (is used to treat certain types of seizures and bipolar disorder) 200 mg, give 2 tablets by mouth at bedtime for bipolar disorder, start date 03/18/23. Record review of Resident #19's order summary dated 01/09/24 indicated Carbamazepine 200 mg, give 1 tablet by mouth one time a day for bipolar disorder, start date 03/19/23. Record review of Resident #19's order summary dated 01/09/24 indicated Gabapentin (works in the brain to prevent seizures and relieve pain for certain conditions in the nervous system) 600 mg, give 1 tablet by mouth one time a day for neuropathy (happens when the nerves that are located outside of the brain and spinal cord (peripheral nerves) are damaged). Record review of Resident #19's order summary dated 01/09/24 indicated Zyprexa (is an antipsychotic medication that can treat several mental health conditions like schizophrenia and bipolar disorder), give 20 mg by mouth at bedtime for increased mood, decreased anxiety, and agitation, start date 08/11/23. Record review of Resident #19's order summary dated 01/09/24 indicated Buspirone (is used to treat anxiety disorders or in the short-term treatment of symptoms of anxiety) 10 mg, give 1 tablet by mouth three times a day for antianxiety, start date 08/19/23. Record review of Resident #19's order summary dated 01/09/24 indicated monitor resident for side effect of muscle rigidity, change in appetite, sleep disturbance, tardive dyskinesia (is an uncommon side effect of certain medicines), seizures, cardiac changes every shift, start date 03/18/23. Record review of Resident #19's order summary dated 01/09/24 indicated monitor resident for behaviors including but not limited to crying, withdrawn, and unrealistic fears every shift for depression, start date 03/19/23. 675293 Page 43 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #19's order summary dated 01/09/24 indicated monitor resident for behavior of unrealistic fears, yelling/screaming, hallucinations every shift: see diagnosis, start date 08/28/23. Record review of Resident #19's order summary dated 01/09/24 did not indicate behavioral monitoring for Buspirone (antianxiety), Carbamazepine (anticonvulsant), Gabapentin (anticonvulsant), Zyprexa (antipsychotic). Record review of Resident #19's order summary dated 01/09/24 did not indicate side effect monitoring for Buspirone (antianxiety), Carbamazepine (anticonvulsant), Gabapentin (anticonvulsant), Zyprexa (antipsychotic). 2. Record review of Resident#25's face sheet printed on 01/09/24 indicated Resident #25 was an [AGE] year-old male and was admitted on [DATE] with diagnoses including Parkinson's disease (is a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) with dyskinesia, Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), moderate, with other behavioral disturbance, and Alzheimer's disease (is a type of dementia that affects memory, thinking and behavior). Record review of Resident #25's quarterly MDS assessment dated [DATE] indicated Resident #25 was usually understood and usually had the ability to understand others. The MDS indicated Resident #25 had a BIMS score of 03 which indicated severe cognitive impairment. The MDS indicated Resident #25 did not have display behaviors. The MDS indicated Resident #25 was dependent for walking and substantial/maximal assistance for toilet transfer, chair/bed to chair transfer, and sit to stand. The MDS indicated Resident #25 received an antipsychotic during the last 7 days of the assessment period. Record review of Resident #25's care plan dated 12/27/23 indicated Resident #25 was at risk for adverse consequence related to receiving psychotropic medication. I [Resident #25] am currently taking psychotropic medication with diagnosis of anxiety and dementia with behaviors. Intervention administers psychotropic medications as ordered by physician, monitor for side effects and effectiveness every shift. Record review of Resident #25's order summary dated 01/09/24 indicated Lorazepam 0.5 mg, give 1 tablet by mouth every 8 hours as needed for anxiety/sundowners, start date 12/13/23. Record review of Resident #25 order summary dated 01/09/24 indicated Quetiapine 50mg, give 1 tablet by mouth at bedtime for behaviors, start date 12/27/23. Record review of Resident #25 order summary dated 01/09/24 did not indicate behavior monitoring for psychotropic medications. Record review of Resident #25 order summary dated 01/09/24 did not indicate side effect monitoring for psychotropic medications. Record review of Resident #25's MAR dated 01/01/24-01/31/24 indicated Lorazepam 0.5 mg, give 1 tablet by mouth every 8 hours as needed for anxiety/sundowners. Dose given 01/01/24, 01/02/24, 01/04/24, 01/05/24, 01/06/24, 01/07/24, 01/09/24, 01/10/24. 3. Record review of Resident #29's face sheet dated printed 01/09/24 indicated Resident #29 was an 675293 Page 44 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some [AGE] year-old male and admitted on [DATE] with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), mild, with agitation, delusional disorder (is a type of psychotic disorder), and psychosis (is when people lose some contact with reality). The face sheet did not indicate schizoaffective disorder (is a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). The face sheet indicated MD S was Resident #29's primary physician. Record review of Resident #29's quarterly MDS assessment dated [DATE] indicated Resident #29 was understood and sometimes had the ability to understand others. The MDS indicated Resident #29 had a BIMS score of 03 which indicated severe cognitive impairment. The MDS did not indicate Resident #29 had psychosis or behavioral symptoms. The MDS indicated Resident #29 required partial/moderate assistance for toilet hygiene and shower/bath self, supervision for personal hygiene, and independent for oral hygiene and eating. The MDS indicated Resident #29 received an antipsychotic during the last 7 days of the assessment period. Record review of Resident #29's care plan dated 01/09/23 indicated Resident #29 was at risk for adverse consequence related to receiving psychotropic medication. I [Resident #29] am currently taking psychotropic medication with diagnosis of depression and psychotic/psychosis. Intervention administers psychotropic medications as ordered by physician, monitor for side effects and effectiveness every shift. Record review of Resident #29's order summary dated 01/09/24 indicated Seroquel 25 mg, give 1 tablet by mouth at bedtime for schizoaffective, start date 09/30/23. During an interview on 01/10/24 at 12:47 p.m., LVN P said she used diagnoses list in the chart to add to orders she received. She said sometimes MD and NP sent order with diagnoses already added. She said nurses were responsible for ordering and doing behavior and side effect monitoring. She said the behavior and side effect monitoring should be done by drug classification. She said it was important to do behavior and side effect monitoring for each drug class because each classification had different side effects monitor and behaviors it treated. She said prn psychotropic meds could be ordered for 14 days for hospice residents. She said she was not sure about other residents. She said she did not know why prn psychotropic meds needed 14 days stop dates. She said the MDS coordinator (CRS), NP, and MD made sure residents had appropriate diagnosis for antipsychotic meds and would let the staff know if it was not appropriate. She said antipsychotic meds should have appropriate diagnoses to make sure the resident gets the right medication and know if the black box warnings applied to the resident. During an interview on 01/10/24 at 1:20 p.m., the CRS said if she found an inappropriate diagnoses while reviewing the chart, she notified staff of the issue. She said Resident #25 diagnosis of dementia with behaviors was not an appropriate diagnosis for Seroquel. She said the Resident #29 did not have Schizoaffective as a listed diagnosis on his chart. On 01/10/24 at 2:23 p.m., attempted to contact MD S by phone, no return call before or after exit. During an interview on 01/10/24 at 2:29 p.m., the DCO said nurse were responsible for doing behavior and side effect monitoring. She said the nurse who received the order should make sure to add behavior and side effect monitoring. She said behavioral and side effect monitoring should be for each drug classification. She said it was important to have side effect monitoring to have information to 675293 Page 45 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some relay to the doctor. She said it was important to have behavioral monitoring to know if a medication worked or needed. She said an antianxiety prn medication should have 14 days stop date. She said the nurse who received the prn order and before administration of the antianxiety med should make sure it had a stop day. She said she monitored prn orders and 14 days stop dates. She said she must have missed Resident #25's Lorazepam order. She said 14 days stop date were important to reassess the need of the medication. She said it could risk the resident getting a medication they did not need. She said the CRS looked at orders for appropriate diagnoses. She said appropriate diagnoses and medications were important to treat the actual diagnosis. During an interview on 01/10/24 at 3:57 p.m., the ADM said if the resident was care planned for side effect and behavior monitoring, it should be done. She said monitoring should be documented in notes and followed up on. She said monitoring should be done by drug class. She said it was the nurse responsibility for monitoring of psychotropic medications. She said nursing management should be ensuring nurses were doing the monitoring. She said nursing management should be doing chart audits and if issues found, do in-services with the staff. She said prn meds should be 14 days so they could be reassessed for the need of it. She said diagnosis added to the resident chart should come from the physician. Record review of a facility's Psychotropic Medication Review policy dated 04/20 indicated .careful assessment as to whether the medication is necessary and pharmacologically appropriate .comply with state and federal regulations related to the use .to include regular review for continued need, appropriate dosage, side effects, risk and/or benefits .monitors psychotropic drug use noting and adverse effects .reviews of the use of the medication with IDT on monthly basis . 675293 Page 46 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 15 residents (Resident #14) and 1 of 1 treatment carts reviewed for drug storage. The facility failed to securely store over the counter medication Neosporin for Resident #14. LVN D failed to securely lock the wound treatment cart. These failures could place residents at risk for adverse reactions. Findings included: 1. Record review of the face sheet 1/8/2024 indicated Resident #14 was [AGE] years old and was admitted on [DATE] with diagnoses including Ataxia (poor muscle control), Functional urinary incontinence (involuntary leakage of urine due to environment or physical barriers to toileting), History of falling, lack of coordination, and diabetes. Record review of the MDS dated [DATE] indicated Resident # 14 was usually understood and understood by others. Resident #14 indicated a BIMS score of 5 indicating Resident #14 was cognitively impaired. Resident #14 MDS indicated moderate hearing loss that required hearing appliance and for the speaker to increase volume and speak distinctly. Record review of Order Summary Report dated 1/10/2024 for Resident #14 did not indicate an order for Neosporin. Record review of a Medication Administration Record (MAR) for January 2024 indicated Resident #14 did not indicate an intervention or order for Neosporin. During an observation and interview on 1/10/2024 at 10:23 a.m., Resident #14 was sitting in recliner. There were 2 - tubes of Neosporin on bedside table. The Neosporin tubes was yellow and white. There was no label identifying orders or resident identifying information. The Neosporin did not have a resident identifying label. The resident said she kept the two ointments at her bedside table, so she uses the ointment on her arms and face as needed for an itch. The resident did not have a roommate at time of interview or observation. Resident #14 said she had the ointment since she was admitted on [DATE]. During Interview on 1/10/2024 at 11:18 a.m. LVN B said she was not aware Resident #14 had Neosporin on her bedside table. She said the Neosporin should be stored in the medication cart and would require an order. LVN said if medication is identified in a resident's room, staff should remove the medication and explain to resident the importance of notifying staff of any medication brought in facility. During an interview on 1/10/2024 at 11:27 a.m. CNA A who has worked Resident #14's hall said she never seen ointment sitting on Resident #14's bedside table. She said that residents are not supposed to have medications in their room and if identified by staff, it should be removed and given to the charge nurse or her boss. During Interview on 1/10/2024 at 11:39 a.m. the DON said normally residents are not supposed to have medications in room unless they have order for self-administering medication. The DON said 675293 Page 47 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medication is supposed to be stored on the wound care cart and expects aids to report to nurse, then the nurse is to go in the room and identify if the resident is supposed to have the medication. The DON said she expects the nurses to check the orders, call the family to identify where the medication came from or if ordered. The DON said the resident can have medications in room if determined they are able to self-administer. DON said the physician is the one who makes the determination if a resident can self-administer. The DON said having medications in room without staff knowledge could cause harm such as an adverse reaction or allergic breakout. During Interview on 1/10/2024 at 12:30 pm Administrator _ SP said she expects the nurse to notify charge nurse if a resident has medication that is not prescribed in room. She said normally the medications are stored on treatment cart or medication cart unless the resident has an order to have the medication in the room. She said the physician is the one who makes the determination if a resident can self-medicate, and we would need to know about it to provide the best care. 2. During an observation on 01/09/24 at 11:20 a.m., the wound treatment cart was sitting in the hall outside of room [ROOM NUMBER]. The cart was unlocked with a ring of keys laying on top of the cart. There were no staff members present. The door to room [ROOM NUMBER] was closed. There were no residents in the hall. There were rooms across the hall and near 309 that were occupied by residents. In drawer # 1 there was a tube of Santyl 250 units (a medication used to remove damaged tissue from chronic skin ulcers and severely burned areas), Nystatin cream (a medicated cream or ointment that treats fungal or yeast infections in your skin), 1 tube of Triamcinolone Acetonide Cream 0.1 % (medication used to help relieve redness, itching, swelling, or other discomfort caused by skin condition), 2 bottles Nyamyc 100,000 units per gram (a medicated cream or ointment that treats fungal or yeast infections in your skin), 6 boxes of BPCO Ointment (a medication used as a wound dressing for topical use used to manage chronic and acute wounds, and dermal ulcers), 1 box of Hydrocortisone Cream (a topical medication skin conditions that cause swelling, redness, itching and rashes), Therahoney gel (a medication used to treat wounds and other skin conditions), 2 boxes of hemorrhoidal cream (a cream used to treat swollen veins in your lower rectum) . Drawer 2 had 2 boxes Nyamyc 100,000 usp units per gram, 2 bottles of Betadine (a topical antiseptic that provides infection protection against a variety of germs for minor cuts, scrapes, and burns), Drawer 3 contained various supplies and wound dressings, the 4th drawer had one spray bottle of wound cleanser, 1 bottle of Dakin's solution (a dilute sodium hypochlorite (NaClO) solution commonly known as bleach), and various wound care supplies, and the 5th drawer contained H-chlor 0.125 solution (the same as Dakin's solution) along with various dressing and wound care supplies. During an interview on 01/09/24 at 11:25 a.m., RN L said she had been in room [ROOM NUMBER] providing wound care. She said during wound care she found another place on the resident that required a bandage. She said she had to come out of the room during care to get the supplies from the cart. She said she was just in a hurry. She said leaving the cart unlocked could cause problems if a resident got a hold of something in the cart. During an interview on 01/10/24 at 11:57 a.m., the DON said all carts should be locked when the nurses were not present, and the nurse should take the keys with them. She said the cart should be locked any time a nurse walks away from the cart. She said any cart being left unlocked could make it to where anyone could take or misplace anything that was in the cart. During an interview on 01/10/24 at 12:38 p.m., the Administrator said if a nurse was not using a medication cart or treatment cart then the cart should be locked. She said a resident could get something out of an unlocked cart they should not have. 675293 Page 48 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of a Bedside Medication Storage facility policy # 4.3 Effective date 09-2018 and revised date 08-2020 indicated, .Bedside medication storage is permitted for residents who wish to self-administer medications, upon written order of the prescriber and once self-administration skills have been assessed and deemed . Review of a Storage of Medications facility policy dated 09/2018 indicated, .Medications and biologicals are stored safely, securely and properly .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access . 675293 Page 49 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0880 Provide and implement an infection prevention and control program. 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 ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents reviewed for transmission-based precautions. (Resident #6 and Resident #9) Residents Affected - Few The facility failed to isolate Resident #6 and Resident #9 after urine cultures (test checks urine for germs (microorganisms) that cause infections) revealed ESBL (enzymes break down and destroy some commonly used antibiotics) in their urine. This failure could place residents at risk for being exposed to health complications and infectious diseases. Findings included: 1. Record review of Resident #6's face sheet printed on 01/10/24 indicated Resident #6 was an [AGE] year-old female and admitted on [DATE] with diagnoses including senile degeneration of brain (a progressive decline in a person's ability to think and remember can be due to a wide range of brain conditions) and need for assistance with personal care. Record review of Resident #6's annual MDS assessment dated [DATE] indicated Resident #6 was understood and understood others. The MDS indicated Resident #6 had a BIMS score of 06 which indicated severe cognitive impairment. The MDS indicated Resident #6 was dependent for toilet hygiene and was always incontinent of urine and bowel. Record review of Resident #6's care plan dated 10/30/21 indicated Resident #6 was frequently incontinent and at risk for skin breakdown. Intervention labs as ordered. Record review of Resident #6's order summary dated 12/01/23-01/10/24 indicated urinalysis (s a test that examines the visual, chemical and microscopic aspects of your urine)with culture (is a test to find germs (such as bacteria or a fungus) that can cause an infection) and sensitivity (checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection), ordered date 12/18/23. The order summary did not indicate isolation for ESBL in the urine. Record review of Resident #6's culture and sensitivity results dated 12/19/23 indicated .high pathogens detected .Escherichia coli .antibiotic notes .ESBL (Extended Spectrum Beta-lactamase detected .are usually multi-drug resistant . 2. Record review of Resident #9's face sheet printed 01/16/24 indicated Resident #9 was a [AGE] year-old male and admitted on [DATE] with diagnoses including schizoaffective disorder (is a mental health condition with symptoms of both schizophrenia and mood disorders), acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), and overactive bladder (is a collection of symptoms that may affect how often you pee and your urgency). Record review of Resident #9's quarterly MDS assessment dated [DATE] indicated Resident #9 was understood and understood others. The MDS indicated Resident #9 had a BIMS score of 10 which indicated moderately impaired cognition. The MDS indicated Resident #9 required partial/moderate assistance for 675293 Page 50 of 51 675293 01/10/2024 Focused Care at Linden 1201 W Houston St Linden, TX 75563

F 0880 toileting hygiene and was occasionally incontinent of urine and bowel. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #9's care plan dated 01/17/23 indicated Resident #9 had occasional bladder incontinence and was at risk for skin breakdown. Intervention included monitor/document for signs and symptoms of urinary tract infection. Residents Affected - Few Record review of Resident #9's order summary dated 01/10/24 did not indicate isolation for ESBL in the urine. Record review of Resident #9's culture and sensitivity results dated 11/14/23 indicated .high pathogens detected .Escherichia coli .antibiotic notes .ESBL (Extended Spectrum Beta-lactamase detected .are usually multi-drug resistant . During an interview on 01/10/24 at 9:45 a.m., the DCO said the ADCO was the ICP, but she was unavailable due to being out sick today. She said the facility did not notice Resident #6 or Resident #9's lab results that said they had ESBL in their urine. She said the ICP was responsible for reviewing lab results. She said the ICP and LVNs were responsible for developing and implementing interventions to address the results. She said so neither Resident #6 nor Resident #9 were placed on contact isolation. She said it was the facility's policy to place residents with ESBL on contact isolation. She said she was not sure of the duration of the contact isolation period. She said Resident #6 and Resident #9 should have been placed on contact isolation to prevent the spread of ESBL. During an interview on 01/10/24 at 3:57 p.m., the ADM said after reviewing the lab results of Resident #6 and Resident #9, she said she felt the lab needed a better way to relay information like ESBL. She said the ICP was responsible for reviewing lab results and coordinating the treatment. She said not placing the resident on contact isolation could have allowed ESBL to spread and other resident to spread it. Record review of a facility's Transmission-Based Precaution for Infections policy revised on 10/24/22 indicated .contact .in addition to standard precaution, use Contact precautions (gown, gloves, mask, or face shield if splashing could occur) for resident known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact .the above included epidemiologically important organisms (Multidrug-resistant organisms) .physician order is required to begin transmission-based precaution and to end .add transmission-based precaution to care plan with all interventions based on type . 675293 Page 51 of 51