Health inspection·November 24, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress and to protect the resident's right to be free from neglect for 5 of 9 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for neglect. The facility failed to ensure that one or more residents were free from neglect when LVN A and CNA C did not provide services that were necessary to avoid physical harm, pain, mental anguish, or emotional distress to one or more residents. Cumulative effects from LVN A and CNA C individual failures to provide oversight of care delivery to Resident #1 for 8 hours on [DATE] 10:00 PM - 6:00 AM ([DATE]). During the 8-hour span, Resident #1 committed suicide. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 2:30 PM. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of isolated and severity level of actual harm that is not IJ due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. Resident #2 did not receive incontinence care [DATE] between 10:00 PM and 3:00 AM. An open area to Resident #2's right upper coccyx area was discovered on [DATE] during incontinence care observation. LVN A failed to perform adequate supervision or monitoring of residents throughout her scheduled shift on [DATE] 10:00 PM -6:00 AM ([DATE]) to oversee if resident care was provided by CNA C based on one or more resident's needs. Resident #4 and Resident #5 did not receive incontinence care [DATE] between 10:00 PM and 3:00 AM. These deficient practices placed residents at considerable risk of serious injury, harm, impairment, developing complications, or death by not receiving services necessary, and a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Findings included: Record review of the facility's Abuse: Prevention of and Prohibition Against policy, Effective Date: [DATE], Revision/Review Date(s): [DATE]; [DATE]; [DATE]; [DATE], revealed: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, Page 1 of 20 675305 675305 11/24/2023 Pleasant Valley Healthcare and Rehabilitation Cent 1525 Pleasant Valley Rd Garland, TX 75040

F 0600 and exploitation. Level of Harm - Immediate jeopardy to resident health or safety Definitions: To assist the Facility's staff members in recognizing incidents of possible abuse, neglect, misappropriation of resident property, or exploitation, the following definitions are provided: Neglect is the failure of the Facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Residents Affected - Few Prevention . The Facility will act to protect and prevent abuse and neglect from occurring within the Facility by: Supervising staff to identify and correct any inappropriate or unprofessional behaviors. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur, to include validating that the Facility has deployed the correct number of competent staff on each shift to meet the needs of the residents. Assuring that residents are free from neglect by having the structures and processes to provide needed care and services to all residents, which includes, but is not limited to, the completion of a Facility Assessment to determine what resources are necessary to care for its residents competently. Identifying, assessing, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect . Identification, Investigation, Protection, Reporting / Response Record review of the nursing schedule dated [DATE] revealed LVN A [Hall 100 even rooms and Hall 300] and CNA C [Rooms 309, 310, 312-317] were scheduled and worked on [DATE] 10:00 PM - 6:00 AM. Record review of Police Department Incident Report dated [DATE] 7:28 AM, revealed Incident Related Property collected [by Officer #1] as evidence (found in [Resident #1's assigned room/bed near Resident #1's body]): Blue bucket/plastic container with apparent blood on it Camouflage pocketknife with apparent blood on it Kitchen knife with apparent blood from inside [Blue bucket/plastic container] Plastic bag and paper towel with apparent blood on it DNA swab of apparent blood from west side of bathroom door frame Scissors with orange handle/finger holes Record review of Police Department Narratives (OFFICER NARRATIVE) for Incident Report, Detective field notes, dated [DATE] 9:53 AM, reflected: On [DATE] at approximately 6:58 AM Officer #1 and Officer #2 were dispatched to the [SNF]. 675305 Page 2 of 20 675305 11/24/2023 Pleasant Valley Healthcare and Rehabilitation Cent 1525 Pleasant Valley Rd Garland, TX 75040

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Officer #1 spoke with LVN B, who advised that at approximately 7:00 AM he discovered [Resident #1] in his bed, not breathing, with blood on his face and body. Officer #1 then spoke with LVN A, who advised that she last saw [Resident #1] alive at approximately 3:00 AM in his bed, moving his legs as if he were peddling a bicycle. Officer #1 entered [Resident #1's assigned room/bed] and observed [Resident #1] to be in his bed, laying on his right side, with his right hand toward his head and his left hand down near his left leg and crotch. A large laceration was visible on the left side of [Resident #1's] neck. [Resident #1's] neck and clothing (blue jeans and a green sweatshirt) were covered in blood. Between [Resident #1's] legs Officer #1 observed an orange handled scissors. RESIDENT #1 Record review of Resident #1's admission Record, revealed an [AGE] year-old male, who admitted to the facility on [DATE] with the following diagnoses: Cerebral Infarction, Uns; Unspecified Dementia, Uns Severity, with Agitation; Insomnia, Uns; Presence of Cardiac Pacemaker; MDD, Single Episode, Uns; Orthostatic Hypotension (lightheadedness or dizziness when standing after sitting or lying down); and Other Abnormalities of Gait and Mobility. Record review of Resident #1's modified Quarterly MDS review assessment, dated [DATE], revealed Resident #1 had a BIMS of 11 which suggested moderately impaired cognition. Resident #1's Mood Interview ([PHQ-9] objectifies and assesses degree of depression severity via questionnaire) reflected a total severity score of 10 which suggested moderate level of depression that required a treatment plan, counseling, follow-up and/or pharmacotherapy (treatment of conditions by using pharmaceutical products (drugs) as medication). The Mood Interview revealed Resident #1 presented symptoms several days (2-6 days) to nearly every day (12-14 days) over a 14-day look back. Resident #1's functional status required one-person physical assist with ADLs. Resident #1 was occasionally incontinent of bladder and frequently incontinent of bowel. Resident #1 admitted to Hospice on [DATE] with active diagnoses of Malignant neoplasm, uns (cancerous tumor); uns CHF (a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs); COPD (a group of diseases that cause airflow blockage and breathing-related problems); CKD (kidneys have mild to moderate damage); and BPH (frequent need to urinate [during the day and night], a weak urine stream, and leaking or dribbling of urine) without lower urinary tract symptoms. Record review of Resident #1's progress notes indicated: Nurse's Note Effective Date: [DATE] at 10:08 PM [Entered: [DATE] at 8:30 AM], written by LVN A, reflected, During shift round resident observe lying in bed open eyes watching tv. s/v taken with normal limited. denied for pain or discomfort at this time. 675305 Page 3 of 20 675305 11/24/2023 Pleasant Valley Healthcare and Rehabilitation Cent 1525 Pleasant Valley Rd Garland, TX 75040

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Nurse's Note Effective Date: [DATE] at 12:30 AM [Entered: [DATE] at 8:33 AM], written by LVN A, reflected, During round resident in bed sleeping comfortable with eyes closed breathing even and unlabored with no distress Nurse's Note Effective Date: [DATE] at 3:00 AM [Entered: [DATE] at 8:42 AM], written by LVN A, reflected, During round shift resident observed lying on the bed with eyes closed with no complaint of pain or discomfort. remain stable with no acute distress noted. Nurse's Note Effective Date: [DATE] at 6:50 AM [Entered: [DATE] at 11:48 AM], written by LVN B, reflected, nurse making rounds, noted resident in bed, wound to left side of neck with blood on it, blood on hand, resident did not respond. touched forehead, resident warm, still did not respond. summoned night nurse and verified DNR. upon other nurse in room, noted scissors in left hand and blood on resident neck and left hand and on the floor between the bed and window.911 called. Responsible party and hospice notified. EMS at facility at approximately 0700 [7:00 AM]. Nurse gave report to EMS and Police also at facility. ADON was at the facility and notified of the situation. Resident #1's clinical physician orders reflected: o [DATE] Monitor level of pain every shift o [DATE] Refer to Senior Psych Care and/or Senior Psychological Care for Evaluation and Treatment o [DATE] Admit to hospice services with DX of malignant Neoplasm of unknown origin. o [DATE] Mirtazapine Tablet 7.5 MG (an atypical antidepressant used primarily for the treatment of MDD) Give 1 tablet by mouth at bedtime for Weight loss o [DATE] Norco Tablet 5-325 MG (HYDROcodone-Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for pain o [DATE] Anti-depressant targeted behavior monitoring o 675305 Page 4 of 20 675305 11/24/2023 Pleasant Valley Healthcare and Rehabilitation Cent 1525 Pleasant Valley Rd Garland, TX 75040

F 0600 [DATE] Melatonin Oral Capsule 3 MG Give 1 capsule by mouth at bedtime for insomnia Level of Harm - Immediate jeopardy to resident health or safety o [DATE] Morphine Sulfate Oral Solution 20 MG/5ML (Morphine Sulfate) Give 0.25 ml by mouth every 4 hours as needed for moderate pain/ dyspnea Residents Affected - Few o [DATE] Lidocaine External Patch 4 % (Lidocaine) Apply to lower back topically one time a day for pain Record review of Resident #1's November MAR reflected MA M entered a chart/follow up code, '1' = Drug Refused, and his user initials in the time row (HS [7:00 PM]) under the date column for [DATE], [DATE], [DATE], and [DATE] (bedtime medications were not refused other nights in [DATE]) for Resident #1's scheduled medications at bedtime included: o Gabapentin 300 mg Capsule Give 1 capsule by mouth at bedtime for restless legs syndrome o Melatonin Oral Capsule 3 MG Give 1 capsule by mouth at bedtime for insomnia. o Mirtazapine Tablet 7.5 MG Give 1 tablet by mouth at bedtime for Weight loss Resident #1 MAR reflected Lidocaine patch last applied [DATE] at 6:00 AM. Morphine (Order date: [DATE] never administered. Norco 5-325 mg tablet PRN last given [DATE] at 7:13 AM. MAR reflected: Monitor level of pain every shift. All responses reflected 0, even on days PRN pain medications were administered. Record review of Resident #1's Comprehensive Care Plan, dated [DATE], did not reveal Resident #1 had suicidal ideations, homicidal ideations, or a history of suicidal attempt(s). The care plan did not reflect that Resident #1's assistance was different between the day or night. Resident #1's Comprehensive Care Plan, dated [DATE], focused on Resident #1: Pacemaker status; Altered respiratory status; Bowel/bladder incontinence; Potential for mood problem r/t depression; and Fall Risk. Interventions reflected: Provide oxygen as ordered; Staff will provide the level of physical assist as needed with ADL's due to resident's self-performance may fluctuate; INCONTINENCE: Check as required for incontinence. The goal was to maintain safety, for Resident #1 to remain free of complications [pacemaker malfunction or failure], and provide quality care. Record review of Police Department Narratives (CID Follow-up) for Incident Report, Det. #3 field notes, dated [DATE] 1:12 PM, reflected: [Det. #3] spoke with Officer #1 who told [Det. #3] the deceased , [Resident #1], appeared to have slit his throat sometime overnight. 675305 Page 5 of 20 675305 11/24/2023 Pleasant Valley Healthcare and Rehabilitation Cent 1525 Pleasant Valley Rd Garland, TX 75040

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few [Det. #3] entered [Resident #1's assigned room/bed] and observed Resident #1 to be laying on his right side with his right hand near his face. Resident #1's left hand was by his waist. [Det. #3] also observed a pair of orange handled scissors to be near Resident #1's left hand. [Det. #3] observed Resident #1 to have a deep wound in the left side of his neck. There was a large pool of blood on the floor between the bed and the wall, along with blood splatter on the air conditioning unit and wall, as well as on Resident #1's person. [Det. #3] observed the temperature of the room to be 73 degrees based on the thermostat on the air conditioning unit. [Det. #3] spoke with Resident #1's roommate [Resident #10] and he stated the following in summary. [Resident #10] last saw Resident #1 yesterday [[DATE]] around dinner time (between 5:00 PM - 6:00 PM). Resident #10 stated he never heard Resident #1 talk about suicide or wanting to harm himself. Resident #10 stated Resident #1 usually kept to himself, and as far as Resident #10 knew, Resident #1 didn't have problems with anyone at the facility. Resident #1's RP arrived at the location. RP stated Resident #1 had told the pastor how he was looking forward to RP coming on Friday ([DATE]), however within the last few days, Resident #1 had been complaining to the pastor about stomach pains. [Det. #3] spoke with PNFA. PNFA was able to pull up camera footage from a surveillance camera that is located close to Resident #1's and Resident #10's room. PNFA reviewed the video from approximately 3:00 AM to approximately 6:50 AM. PNFA stated no one entered the room in that time frame except Resident #10 and the nurse who found Resident #1 deceased . County ME MDI arrived on scene. MDI removed the scissors from near Resident #1's left hand and waist. MDI noted that the scissors appeared to be clear and had very little to no blood on them. Underneath the scissors, MDI located a metal file that can be used to sharpen a blade. MDI noted the file also had little to no blood on it. MDI rolled Resident #1 onto his back, exposing another large and deep laceration to the right side of Resident #1's neck as well as the large and deep laceration that was already visible on the left side of Resident #1's neck. The cut was not all the way across the neck as there was a small piece of flesh still intact in the front, center pat of Resident #1's neck. MDI then located a folding knife with blood on it in a blue tub which was located on a shelf next to Resident #1's bed. MDI also located several tissues inside the tub with blood on them. During an interview on [DATE] at 2:24 PM, the PNFA indicated that he was notified by the ADON about Resident #1. The PNFA said that the cluster DON from the sister facility assisted with reporting the incident to state agency. The PNFA said that he was not familiar with Resident #1, that he was still learning resident's names and living arrangements in the SNF. The PNFA said that he notified the medical director by phone around 10:00 AM. The PNFA said that he participated in an interview and cooperated with the police. The PNFA said that mental health service providers for contacted and arrived to the SNF to provide consultation with staff and residents, management conducted suicide and suicide prevention in-services (still on-going). The PNFA indicated he was a new hire as of a month ago and was still learning the specific policies and procedures of the SNF. The PNFA stated the ADON would be the staff to speak with because she was present around the time Resident #1 was discovered. Observation on [DATE] at 3:06 PM of [Resident #1's assigned room] revealed red tape across the door to block entry. Upon entry to room, there were two beds - Bed A was closest to the entry door, parallel to the common wall that is shared between the bathroom and room; [Resident #1's] bed was parallel to Bed A and a wall with a window and wall-mounted AC unit. The bed was made, and two personal fleece blankets were placed on the bed, folded back that formed a diagonal line. A brief overview of 675305 Page 6 of 20 675305 11/24/2023 Pleasant Valley Healthcare and Rehabilitation Cent 1525 Pleasant Valley Rd Garland, TX 75040

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the area revealed two blood stains (the size of a saucer, an overall diameter of approx. 5 - 6 [inches]) on the right side of bed - one near the mid-upper edge of bed and one near the mid-lower edge of bed. On the right side of bed, blood drops and a thick blood puddle (approx. 11 - 12 [inches]) by visual estimation, was observed on the floor. Blood spatter was observed on the AC unit. Record review of Police Department Narratives (CID Follow-up) for Incident Report, Det. #3 field notes, dated [DATE] 8:53 AM, reflected: On [DATE], . the pathologist who performed Resident #1's autopsy informed that Resident #1 had no defensive wounds on his person. Resident #1 had several hesitation type wounds on his neck, and the main deep cuts were parallel cuts which would be consistent with them being self-inflicted. The pathologist stated no major arteries were cut, but numerous veins were cut which would have caused a slower time to bleed out and allow time for Resident #1 to put the knife back in the blue bin by his bed. She also stated it was unlikely someone besides Resident #1 could have cut Resident #1's neck based on the wounds and the fact that the other individual would have gotten a large amount of blood on themselves due to the amount of blood loss from Resident #1. She also told that Resident #1 had a gastric rupture. She stated this would have been very painful for Resident #1 and may explain why he took the actions that he did. During an interview on [DATE] at 10:13 AM, the ADON indicated she worked at the SNF for less than one year as the ADON and the treatment nurse. The ADON said that her primary responsibility as the ADON and treatment nurse was to perform wound care, coordinate care with the wound doctor, and to oversee that care was provided by nursing staff (nurses and CNAs). The ADON said that she expected staff to perform standard practice withing their scope of work, to check on residents at least every two hours and as needed, for both on-coming and off-going nurse to conduct walking rounds together during shift change. The ADON said the purpose of resident rounds during shift change and at least every two hours was to know where the residents were and that they were safe. The ADON said in addition to verbal report, there was a written 24-hr report the nurses were expected to complete. The ADON said on [DATE], she arrived to work before 7:00 AM. The ADON said that LVN A and LVN B approached the nurses' station and informed her that Resident #1 was found dead. The ADON said while LVN B called 911, she called the PNFA and headed to Resident #1's room. The ADON said another day shift nurse accompanied her to the room. The ADON said that she observed Resident #1 in bed, lying on his right side and she left back out the room. The ADON said that she called the NP after she tried to contact the MD, called hospice and left a message with the on-call nurse. During an interview on [DATE] at 11:17 AM, the ULSW said that she worked at the SNF for less than one week and was not familiar with Resident #1. The ULSW said that she learned about Resident #1 on [DATE] when she arrived to work shortly after 7:00 AM. The ULSW said that she prioritized psych consultations were ordered and follow ups were conducted as needed. During an interview on [DATE] at 11:49 AM, the LCSW with psych consultation services stated during her last visit with Resident #1 (on [DATE]), he would not engage in conversation about his family or accomplishments. The LCSW said that Resident #1 was pre-occupied with the problems of the world at large, deeply religious, and looked forward to the day God comes down and destroys all the people not living a godly life . but he probably would not be alive to see it happen. The LCSW said that she would assist Resident #1 with processing feelings by providing supportive counseling and listening because it would decrease symptoms of depression and anxiety. The LCSW said that Resident #1 displayed symptoms such as agitation, adjustment difficulty, anxiety, and depression. The LCSW said the goal for therapy included symptoms of depression reduction. The LCSW said that Resident #1 had a diagnosis of MDD but scored less than 5 on the PHQ-9; therefore, Resident #1 did not require follow up. 675305 Page 7 of 20 675305 11/24/2023 Pleasant Valley Healthcare and Rehabilitation Cent 1525 Pleasant Valley Rd Garland, TX 75040

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview on [DATE] at 12:20 PM, the hospice CM indicated she admitted Resident #1 to hospice on [DATE] at the RP's home. The hospice CM stated she received clinical information from hospital records. The hospice CM said that at the time of admission, Resident #1 was seeing an Oncologist for stomach cancer but stopped treatments. The hospice CM said that she received a text on [DATE] at 7:22 AM from the DON that indicated the ADON needed to speak with [hospice CM] and provided a call back number. The hospice CM said that she received an email around the same time from the hospice on-call that notified to contact the SNF regarding Resident #1. The hospice CM said she placed a call to the ADON on [DATE] around 7:30 AM. The hospice CM said that she was shocked when she heard about Resident #1 and informed the ADON that she would be there as soon as possible. The hospice CM said that she arrived to the SNF around 9:45 AM and officers and the ME were on-site. The hospice CM said that she was not allowed to see Resident #1 but stayed with Resident #1's RP because she was alone. The hospice CM said that she communicated with the RP to inform on Resident #1's clinical status and of any changes. The hospice CM said that she conducted a hospice recertification visit on [DATE]. The hospice CM said that Resident #1 was more cooperative and in a good mood. The hospice CM said that she often received notifications from the hospice skilled nurse (LVN) and aide that Resident #1 was uncooperative, refused care, was grouchy, and/or refused visits. The hospice CM said that she received a picture via text from the RP of Resident #1 during a visit with the RP at her home. Resident #1 had been shaved and was making his own pizza. The hospice CM said that Resident #1 had chronic pain issues, N/V and diarrhea related to the stomach cancer. Resident #1 was last seen by the hospice skilled nurse (LVN) on [DATE]. Record review of hospice documentation revealed: [DATE] [Hospice Admission] - [Resident #1] is alert/oriented x 2 [to self and surroundings/time of day] with forgetfulness. [RP] states [Resident #1] is beginning to decline cognitively with intermittent confusion. [Resident #1] has chronic pain in left shoulder, back & abdomen. [Resident #1] ambulates with a walker, and gait is unsteady with muscle wasting to BLE (bilateral lower extremities). [Resident #1] was continent of bladder and bowel prior to illness & now has intermittent incontinence requiring pull ups. [DATE] - [Resident #1] has dyspnea (shortness of breath) with moderate exertion requiring oxygen PRN. [Resident #1] reports pain in back not always controlled with scheduled hydrocodone. [DATE] - [Resident #1] was lying in bed upon arrival. Chaplain got facility RN to help [Resident #1] put oxygen on which helped with confusion. [Resident #1] said back hurt but pain med had been given. [DATE] - [RP] present & reports [Resident #1] just had diarrhea . he was too weak to get to the bathroom. 02 sat is 75% on room air & pt feeling weak/fatigued. [hospice LVN] started [Resident #1] on continuous oxygen at 2 lpm . [Resident #1] now eating less than 30% of meals and continues to skip meals at times. is thin & frail in appearance with muscle wasting. ambulates with a walker, and gait is unsteady d/t generalized weakness. [Resident #1] requires assist with ADLS d/t pain . has intermittent incontinence of b&b. [DATE] - [Resident #1] reports chronic back pain & takes Hydrocodone (Norco 3/325 mg) as well as uses Fentanyl patch with fair relief. BP 98/59 . [DATE] - now takes hydrocodone, fentanyl patch as well as newly added morphine & lidocaine patches prn. 675305 Page 8 of 20 675305 11/24/2023 Pleasant Valley Healthcare and Rehabilitation Cent 1525 Pleasant Valley Rd Garland, TX 75040

F 0600 Level of Harm - Immediate jeopardy to resident health or safety [DATE] - [Resident #1] has chronic pain in left shoulder, back & abdomen. [Resident #1] was only taking hydrocodone at admission to hospice, but now also requires fentanyl patch & morphine prn to control pain. [Resident #1] continues having N/V 1-2x week & requires scheduled promethazine to control. [Resident #1] continues to have diarrhea 1-2 x week & is now incontinent of B&B d/t increased weakness/fatigue. [DATE] - was lying in bed upon arrival. Patient complained that tummy hurt . facility staff aware. Residents Affected - Few On [DATE] at 1:48 PM, observation of video surveillance on [DATE] 10:00 PM - [DATE] 7:00 AM was conducted with the PNFA. The following time stamps from the SNF video surveillance (right center downwards angle toward Resident #1's room) revealed: [DATE] at 10:44 PM: LVN A and off-going nurse entered Resident #1's room during change of shift walking rounds. The door was slightly ajar when the nurses exited the room. [DATE] at 12:16 AM: The door to Resident #1's room was pushed closed from the inside of the room. [DATE] at 6:18 AM: Resident #10 entered the room and exited at 6:22 AM. [DATE] at 6:24 AM: Resident #10 re-entered the room and exited at 6:25 AM. [DATE] at 6:39 AM: Resident #10 re-entered the room and exited at 6:41 AM. [DATE] at 6:50 AM: LVN B entered Resident #1's room. During an interview on [DATE] with the PNFA after video surveillance was observed, the PNFA indicated that he understood that staff only needed to check on residents based on their level of care. The PNFA said that he was informed that Resident #1 could use the call light when needed, did not need assistance to the restroom, was ambulatory; therefore, staff did not need to check on him every two hours. The PNFA said that he would need to review Resident #1's care plan to determine how often staff should check on him overnight. The PNFA stated that leadership informed him that staff were required to only check on residents who required incontinence care, turning and repositioning. The PNFA stated that best practice would be to following the facility protocol on resident rounds and he was not currently familiar with the actual written policy on resident rounds. An outbound call to CNA C on [DATE] at 3:20 PM was answered by an unidentified male. The unidentified male stated that CNA C had left her phone at home and did not know when she would return. The unidentified male said that he would have CNA C return the call to the number that showed up on the caller ID. Additional outbound calls were placed to CNA C on [DATE], [DATE], and [DATE] that were unanswered and unable to leave a message. No return call from CNA C before facility exit. During an interview on [DATE] at 4:36 PM, LVN A indicated she worked on [DATE] from 10:00 PM to 6:00 AM. LVN A said that she arrived to work on [DATE] around 9:50 PM. LVN A said that she was assigned to half of Hall 100 and all of Hall 300. LVN A said that she received report, counted narcotics, and conducted walking rounds with the off-going nurse. LVN A said that she conducted rounds on Resident #1's hall first. LVN A said after she conducted walking rounds, she administered medications and provided direct care to three G-tube residents, performed colostomy care and indwelling catheter care to residents on both halls. LVN A said that [CNA C] sat on the hall and would notify if something happened. LVN A said that she tried to do resident rounds every three hours. LVN A said that some 675305 Page 9 of 20 675305 11/24/2023 Pleasant Valley Healthcare and Rehabilitation Cent 1525 Pleasant Valley Rd Garland, TX 75040

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few residents did not like for staff to come back in their rooms after change of shift rounds were completed. LVN A said that she had a new admission that needed a PICC line, and she needed to assist the PICC line placement nurse because the resident was aggressive. LVN A said that she spent a long time on Hall 100. LVN A said that she had to assist a resident on Hall 300 for an IV line and had to collect a urine specimen. LVN A could not state what time she checked on Resident #1 again after change of shift rounds with off-going nurse. LVN A said that she usually checked on residents based on the resident preference. LVN A said that if the video surveillance was reviewed, she would be seen pushing a resident in a wheelchair down the hall around 1:00 AM. LVN A said that at the same time she peeked through the door to check on Resident #1. LVN A said that she could see Resident #1 lying on his bed, he was fine, no problem. LVN A said that there was enough light from the over the bed and TV light to see Resident #1. LVN A said that Resident #1 would use his call light if he needed assistance, he would always talk about the bible, and could go to the restroom without assistance. In a continued interview on [DATE] at 4:36 PM, LVN A said that on the morning of [DATE], she was waiting for LVN B to relieve her from her shift (at 6:00 AM). LVN A said that she needed to take her kids to school and was about to leave the medication cart keys with another nurse because LVN B was always late. LVN A said that she saw LVN B come in around 6:15 AM. LVN A said that she gave LVN B verbal report and performed narcotic count. LVN A said that LVN B told her that he would do walking rounds and would come back to the nurses' station to let her know if something happened. LVN A said LVN B returned to the nurses' station and told her that he thought that Resident #1 killed himself. LVN A said that she was shocked and did not know how that could happen, that she did not understand. LVN A said that she went to Resident #1's room with LVN B, donned gloves on the way to the room, and saw Resident #1 lying on his back with his left hand between his legs, his shirt raised enough to see his stomach. LVN A said she touched his stomach, to feel for movement (if Resident #1 was breathing). LVN A said Resident #1's stomach was warm, but it did not move (to indicate breathing). LVN A said that the blood looked fresh and since [Resident #1's] skin was still warm, he could not have been dead too long. LVN A said that she saw a pair of orange scissors under Resident #1's left hand between his legs. LVN A said that there was a cut on the left side of Resident #1's neck, there was no dripping blood. LVN A said that there was blood like a puddle of water on the floor on the right bedside. LVN A said that she checked for pulse on wrists but did not listen for a heartbeat because she did not have a stethoscope. LVN A said she returned to the nurses' st[TRUNCATED] 675305 Page 10 of 20 675305 11/24/2023 Pleasant Valley Healthcare and Rehabilitation Cent 1525 Pleasant Valley Rd Garland, TX 75040

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and records review, the facility failed to implement written policies and procedures that prohibit and prevent neglect for 5 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5) of 28 residents reviewed for provision of care and services by staff. Residents Affected - Few The facility failed to ensure staff implemented abuse and neglect policies and procedures during the provision of care and services to residents. The facility failed to implement abuse and neglect policies and procedures by immediately removing or suspending LVN A and CNA C from the care of any resident during the investigation of potential abuse or neglect to protect other residents from harm. LVN A and CNA C worked [DATE] 10:00 PM - 6:00 AM. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 2:30 PM. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of isolated and severity level of actual harm that is not IJ due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. This deficient practice placed a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Residents are at high risk of serious injury, harm, impairment, or death by not protecting from harm by staff identified in an abuse or neglect investigation. Findings included: Record review of the facility's Abuse: Prevention of and Prohibition Against policy, Effective Date: [DATE], Revision/Review Date(s): [DATE]; [DATE]; [DATE]; [DATE], revealed: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, and exploitation. Definitions: To assist the Facility's staff members in recognizing incidents of possible abuse, neglect, misappropriation of resident property, or exploitation, the following definitions are provided: Neglect is the failure of the Facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Prevention . The Facility will act to protect and prevent abuse and neglect from occurring within the Facility by: Supervising staff to identify and correct any inappropriate or unprofessional behaviors. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur, to include validating that the Facility has deployed the correct number of competent staff on each shift to meet the needs of the residents. Assuring that residents are free from neglect by having the structures and processes to 675305 Page 11 of 20 675305 11/24/2023 Pleasant Valley Healthcare and Rehabilitation Cent 1525 Pleasant Valley Rd Garland, TX 75040

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few provide needed care and services to all residents, which includes, but is not limited to, the completion of a Facility Assessment to determine what resources are necessary to care for its residents competently. Identifying, assessing, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect . Protection . if the allegation of abuse, neglect . involves an employee, the Facility will: Immediately remove the employee from the care of any resident. Suspend the employee during the pendency of the investigation. Record review of the nursing schedule dated [DATE] revealed LVN A [Hall 100 even rooms and Hall 300] and CNA C [Rooms 309, 310, 312-317] were scheduled and worked on [DATE] 10:00 PM - 6:00 AM. Record review of Police Department Incident Report dated [DATE] 7:28 AM, revealed Incident Related Property collected [by Officer #1] as evidence (found in [Resident #1's assigned room/bed near Resident #1's body]): Blue bucket/plastic container with apparent blood on it Camouflage pocketknife with apparent blood on it Kitchen knife with apparent blood from inside [Blue bucket/plastic container] Plastic bag and paper towel with apparent blood on it DNA swab of apparent blood from west side of bathroom door frame Scissors with orange handle/finger holes Record review of Police Department Narratives (OFFICER NARRATIVE) for Incident Report, Detective field notes, dated [DATE] 9:53 AM, reflected: On [DATE] at approximately 6:58 AM Officer #1 and Officer #2 were dispatched to the [SNF]. Officer #1 spoke with LVN B, who advised that at approximately 7:00 AM he discovered [Resident #1] in his bed, not breathing, with blood on his face and body. Officer #1 then spoke with LVN A, who advised that she last saw [Resident #1] alive at approximately 3:00 AM in his bed, moving his legs as if he were peddling a bicycle. Officer #1 entered [Resident #1's assigned room/bed] and observed [Resident #1] to be in his bed, laying on his right side, with his right hand toward his head and his left hand down near his left leg and crotch. A large laceration was visible on the left side of [Resident #1's] neck. [Resident #1's] neck and clothing (blue jeans and a green sweatshirt) were covered in blood. 675305 Page 12 of 20 675305 11/24/2023 Pleasant Valley Healthcare and Rehabilitation Cent 1525 Pleasant Valley Rd Garland, TX 75040

F 0607 Between [Resident #1's] legs Officer #1 observed an orange handled scissors. Level of Harm - Immediate jeopardy to resident health or safety RESIDENT #1 Residents Affected - Few Record review of Resident #1's admission Record, revealed an [AGE] year-old male, who admitted to the facility on [DATE] with the following diagnoses: Cerebral Infarction, Uns; Unspecified Dementia, Uns Severity, with Agitation; Insomnia, Uns; Presence of Cardiac Pacemaker; MDD, Single Episode, Uns; Orthostatic Hypotension (lightheadedness or dizziness when standing after sitting or lying down); and Other Abnormalities of Gait and Mobility. Record review of Resident #1's modified Quarterly MDS review assessment, dated [DATE], revealed Resident #1 had a BIMS of 11 which suggested moderately impaired cognition. Resident #1's Mood Interview ([PHQ-9] objectifies and assesses degree of depression severity via questionnaire) reflected a total severity score of 10 which suggested moderate level of depression that required a treatment plan, counseling, follow-up and/or pharmacotherapy (treatment of conditions by using pharmaceutical products (drugs) as medication). The Mood Interview revealed Resident #1 presented symptoms several days (2-6 days) to nearly every day (12-14 days) over a 14-day look back. Resident #1's functional status required one-person physical assist with ADLs. Resident #1 was occasionally incontinent of bladder and frequently incontinent of bowel. Resident #1 admitted to Hospice on [DATE] with active diagnoses of Malignant neoplasm, uns (cancerous tumor); uns CHF (a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs); COPD (a group of diseases that cause airflow blockage and breathing-related problems); CKD (kidneys have mild to moderate damage); and BPH (frequent need to urinate [during the day and night], a weak urine stream, and leaking or dribbling of urine) without lower urinary tract symptoms. Record review of Resident #1's progress notes indicated: Nurse's Note Effective Date: [DATE] at 10:08 PM [Entered: [DATE] at 8:30 AM], written by LVN A, reflected, During shift round resident observe lying in bed open eyes watching tv. s/v taken with normal limited. denied for pain or discomfort at this time. Nurse's Note Effective Date: [DATE] at 12:30 AM [Entered: [DATE] at 8:33 AM], written by LVN A, reflected, During round resident in bed sleeping comfortable with eyes closed breathing even and unlabored with no distress Nurse's Note Effective Date: [DATE] at 3:00 AM [Entered: [DATE] at 8:42 AM], written by LVN A, reflected, During round shift resident observed lying on the bed with eyes closed with no complaint of pain or discomfort. remain stable with no acute distress noted. Nurse's Note Effective Date: [DATE] at 6:50 AM [Entered: [DATE] at 11:48 AM], written by LVN B, reflected, nurse making rounds, noted resident in bed, wound to left side of neck with blood on it, blood on hand, resident did not respond. touched forehead, resident warm, still did not respond. summoned night nurse and verified DNR. upon other nurse in room, noted scissors in left hand and blood on resident neck and left hand and on the floor between the bed and window.911 called. Responsible party and hospice notified. EMS at facility at approximately 0700 [7:00 AM]. Nurse gave report to EMS and Police also at facility. ADON was at the facility and notified of the situation. Resident #1's clinical physician orders reflected: 675305 Page 13 of 20 675305 11/24/2023 Pleasant Valley Healthcare and Rehabilitation Cent 1525 Pleasant Valley Rd Garland, TX 75040

F 0607 o Level of Harm - Immediate jeopardy to resident health or safety [DATE] Monitor level of pain every shift Residents Affected - Few [DATE] Admit to hospice services with DX of malignant Neoplasm of unknown origin. [DATE] Refer to Senior Psych Care and/or Senior Psychological Care for Evaluation and Treatment [DATE] Mirtazapine Tablet 7.5 MG (an atypical antidepressant used primarily for the treatment of MDD) Give 1 tablet by mouth at bedtime for Weight loss [DATE] Norco Tablet 5-325 MG (HYDROcodone-Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for pain [DATE] Anti-depressant targeted behavior monitoring [DATE] Melatonin Oral Capsule 3 MG Give 1 capsule by mouth at bedtime for insomnia [DATE] Morphine Sulfate Oral Solution 20 MG/5ML (Morphine Sulfate) Give 0.25 ml by mouth every 4 hours as needed for moderate pain/ dyspnea [DATE] Lidocaine External Patch 4 % (Lidocaine) Apply to lower back topically one time a day for pain Record review of Resident #1's November MAR reflected MA M entered a chart/follow up code, '1' = Drug Refused, and his user initials in the time row (HS [7:00 PM]) under the date column for [DATE], [DATE], [DATE], and [DATE] (bedtime medications were not refused other nights in [DATE]) for Resident #1's scheduled medications at bedtime included: o Gabapentin 300 mg Capsule Give 1 capsule by mouth at bedtime for restless legs syndrome o Melatonin Oral Capsule 3 MG Give 1 capsule by mouth at bedtime for insomnia. o Mirtazapine Tablet 7.5 MG Give 1 tablet by mouth at bedtime for Weight loss Resident #1 MAR reflected Lidocaine patch last applied [DATE] at 6:00 AM. Morphine (Order date: [DATE] never administered. Norco 5-325 mg tablet PRN last given [DATE] at 7:13 AM. MAR reflected: Monitor level of pain every shift. All responses reflected 0, even on days PRN pain medications were administered. Record review of Resident #1's Comprehensive Care Plan, dated [DATE], did not reveal Resident #1 had suicidal ideations, homicidal ideations, or a history of suicidal attempt(s). The care plan did not reflect that Resident #1's assistance was different between the day or night. Resident #1's 675305 Page 14 of 20 675305 11/24/2023 Pleasant Valley Healthcare and Rehabilitation Cent 1525 Pleasant Valley Rd Garland, TX 75040

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Comprehensive Care Plan, dated [DATE], focused on Resident #1: Pacemaker status; Altered respiratory status; Bowel/bladder incontinence; Potential for mood problem r/t depression; and Fall Risk. Interventions reflected: Provide oxygen as ordered; Staff will provide the level of physical assist as needed with ADL's due to resident's self-performance may fluctuate; INCONTINENCE: Check as required for incontinence. The goal was to maintain safety, for Resident #1 to remain free of complications [pacemaker malfunction or failure] and provide quality care. Residents Affected - Few Record review of Police Department Narratives (CID Follow-up) for Incident Report, Det. #3 field notes, dated [DATE] 1:12 PM, reflected: [Det. #3] spoke with Officer #1 who told [Det. #3] the deceased , [Resident #1], appeared to have slit his throat sometime overnight. [Det. #3] entered [Resident #1's assigned room/bed] and observed Resident #1 to be laying on his right side with his right hand near his face. Resident #1's left hand was by his waist. [Det. #3] also observed a pair of orange handled scissors to be near Resident #1's left hand. [Det. #3] observed Resident #1 to have a deep wound in the left side of his neck. There was a large pool of blood on the floor between the bed and the wall, along with blood splatter on the air conditioning unit and wall, as well as on Resident #1's person. [Det. #3] observed the temperature of the room to be 73 degrees based on the thermostat on the air conditioning unit. [Det. #3] spoke with Resident #1's roommate [Resident #10] and he stated the following in summary. [Resident #10] last saw Resident #1 yesterday [[DATE]] around dinner time (between 5:00 PM - 6:00 PM). Resident #10 stated he never heard Resident #1 talk about suicide or wanting to harm himself. Resident #10 stated Resident #1 usually kept to himself, and as far as Resident #10 knew, Resident #1 didn't have problems with anyone at the facility. Resident #1's RP arrived at the location. RP stated Resident #1 had told the pastor how he was looking forward to RP coming on Friday ([DATE]), however within the last few days, Resident #1 had been complaining to the pastor about stomach pains. [Det. #3] spoke with PNFA. PNFA was able to pull up camera footage from a surveillance camera that is located close to Resident #1's and Resident #10's room. PNFA reviewed the video from approximately 3:00 AM to approximately 6:50 AM. PNFA stated no one entered the room in that time frame except Resident #10 and the nurse who found Resident #1 deceased . County ME MDI arrived on scene. MDI removed the scissors from near Resident #1's left hand and waist. MDI noted that the scissors appeared to be clear and had very little to no blood on them. Underneath the scissors, MDI located a metal file that can be used to sharpen a blade. MDI noted the file also had little to no blood on it. MDI rolled Resident #1 onto his back, exposing another large and deep laceration to the right side of Resident #1's neck as well as the large and deep laceration that was already visible on the left side of Resident #1's neck. The cut was not all the way across the neck as there was a small piece of flesh still intact in the front, center pat of Resident #1's neck. MDI then located a folding knife with blood on it in a blue tub which was located on a shelf next to Resident #1's bed. MDI also located several tissues inside the tub with blood on them. During an interview on [DATE] at 2:24 PM, the PNFA indicated that he was notified by the ADON that Resident #1 was deceased when found by LVN B during change of shift walking rounds. The PNFA said that the cluster DON from the sister facility assisted with reporting the incident to state agency. 675305 Page 15 of 20 675305 11/24/2023 Pleasant Valley Healthcare and Rehabilitation Cent 1525 Pleasant Valley Rd Garland, TX 75040

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The PNFA said that he was not familiar with Resident #1, that he was still learning resident's names and living arrangements in the SNF. The PNFA said that he notified the medical director by phone around 10:00 AM. The PNFA said that he participated in an interview and cooperated with the police. The PNFA said that mental health service providers for contacted and arrived to the SNF to provide consultation with staff and residents, management conducted suicide and suicide prevention in-services (still on-going). The PNFA indicated he was a new hire as of a month ago and was still learning the specific policies and procedures of the SNF. The PNFA stated the ADON would be the staff to speak with because she was present around the time Resident #1 was discovered. During an interview on [DATE] at 10:13 AM, the ADON indicated she worked at the SNF for less than one year as the ADON and the treatment nurse. The ADON said that her primary responsibility as the ADON and treatment nurse was to perform wound care, coordinate care with the wound doctor, and to oversee that care was provided by nursing staff (nurses and CNAs). The ADON said that she expected staff to perform standard practice withing their scope of work, to check on residents at least every two hours and as needed, for both on-coming and off-going nurse to conduct walking rounds together during shift change. The ADON said the purpose of resident rounds during shift change and at least every two hours was to know where the residents were and that they were safe. The ADON said in addition to verbal report, there was a written 24-hr report the nurses were expected to complete. The ADON said on [DATE], she arrived to work before 7:00 AM. The ADON said that LVN A and LVN B approached the nurses' station and informed her that Resident #1 was found dead. The ADON said while LVN B called 911, she called the PNFA and headed to Resident #1's room. The ADON said another day shift nurse accompanied her to the room. The ADON said that she observed Resident #1 in bed, lying on his right side and she left back out the room. The ADON said that she called the NP after she tried to contact the MD, called hospice, and left a message with the on-call nurse. On [DATE] at 1:48 PM, observation of video surveillance on [DATE] 10:00 PM - [DATE] 7:00 AM was conducted with the PNFA. The following time stamps from the SNF video surveillance (right center downwards angle toward Resident #1's room) revealed: [DATE] at 10:44 PM: LVN A and off-going nurse entered Resident #1's room during change of shift walking rounds. The door was slightly ajar when the nurses exited the room. [DATE] at 12:16 AM: The door to Resident #1's room was pushed closed from the inside of the room. [DATE] at 6:18 AM: Resident #10 entered the room and exited at 6:22 AM. [DATE] at 6:24 AM: Resident #10 re-entered the room and exited at 6:25 AM. [DATE] at 6:39 AM: Resident #10 re-entered the room and exited at 6:41 AM. [DATE] at 6:50 AM: LVN B entered Resident #1's room. During observation of video surveillance on [DATE] at 1:48 PM revealed LVN A worked on [DATE] 10:00 PM - 6:00 AM. LVN A was assigned to the same residents as the night before ([DATE]). During an interview on [DATE] with the PNFA after video surveillance was observed, the PNFA indicated that LVN A was suspended during the pendency of the investigation. The PNFA said that staff are required to check on residents every shift for safety and as needed for repositioning or incontinence care. The PNFA said that he would have to review a resident's care plan to determine their care 675305 Page 16 of 20 675305 11/24/2023 Pleasant Valley Healthcare and Rehabilitation Cent 1525 Pleasant Valley Rd Garland, TX 75040

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few needs. The PNFA stated that best practice for resident safety would be to schedule staff based on acuity when individual staff assignments are coordinated for continuity of care. The PNFA said that he expected staff to follow the facility protocol on patient care and resident rounds. The PNFA was not able to speak to the policies and procedures for provision of care. The PNFA stated that written P&P should be reviewed with staff and ensured staff understood. The PNFA stated he has been in the role as Operations Manager pending his Administrator licensure for a month and is learning the process(es) to determine if new or updated policies were needed, and how they were develop or updated. Record review of LVN A's clock in/out history from [DATE] to [DATE] revealed LVA worked 10:12 AM - 7:51 AM. During an interview on [DATE] at 4:36 PM, LVN A indicated she worked on [DATE] from 10:00 PM to 6:00 AM. LVN A said that she arrived to work on [DATE] around 9:50 PM. LVN A said that she was assigned to half of Hall 100 and all of Hall 300. LVN A said that she received report, counted narcotics, and conducted walking rounds with the off-going nurse. LVN A said that she conducted rounds on Resident #1's hall first. LVN A could not state what time she checked on Resident #1 again after change of shift rounds ([DATE] at 10:45 PM) with off-going nurse. LVN A said that she tried to do resident rounds every three hours. LVN A said that some residents did not like for staff to come back in their rooms after change of shift rounds were completed. LVN A said that [CNA C] sat on the hall ([DATE]) and would notify if something happened. LVN A said that she usually checked on residents based on the resident preference. LVN A said that if the video surveillance was reviewed, she would be seen pushing a resident in a wheelchair down the hall around 1:00 AM. LVN A said that at the same time she peeked through the door to check on Resident #1. LVN A said that she could see Resident #1 lying on his bed, he was fine, no problem. LVN A said that there was enough light from the over the bed and TV light to see Resident #1. LVN A said that Resident #1 would use his call light if he needed assistance, he would always talk about the bible, and could go to the restroom without assistance. LVN A stated that Resident #1 was ambulatory with a rolling walker but was still considered a fall risk. LVN A stated that she worked [DATE] 10:00 PM - 6:00 AM shift. During an interview on [DATE] at 12:23 PM, the DON stated that ([DATE]) was her first day back to work after vacation. The DON said that she was contacted by the ADON on [DATE] (around 7:00 AM CST, could not state for sure because she was out of the country). The DON said that the ADON informed about Resident #1, needed to speak with the hospice CM, and did not know what to do. The DON said that she texted the hospice CM because she had her direct number and asked if she would contact the ADON as soon as possible to discuss Resident #1. The DON said that she was familiar with Resident #1 and his care needs. The DON said that Resident #1 was independent, private, was ambulatory with a rolling walker, could verbally make needs known, and voice concerns. The DON said that her expectations were for nursing staff to check on residents if they were not within the staff line of sight to be aware of their whereabouts and to meet the resident needs. The DON said that the capacity of needs was different based on the resident level of care - incontinence, feeding assistance, turning, and repositioning, etc. The DON said for staff to meet the basic needs of the resident, the staff would need to lay eyes on the resident to determine their clinical status. The DON said that some residents prefer that their doors remained closed, but staff should still check on the resident to ensure their safety. The DON said that the facility processes in place to prevent ANE was in-services, surveillance, random direct care observations, on-hire training. The DON said that LTC residents did not require daily skilled assessment notes; however, nurses should document any change in condition, new medications, any communication with the MD/NP or RP. The DON said that the SNF utilized PCC to electronically manage resident records and for care continuity. The DON said that nurses were not required to document every time they 675305 Page 17 of 20 675305 11/24/2023 Pleasant Valley Healthcare and Rehabilitation Cent 1525 Pleasant Valley Rd Garland, TX 75040

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few checked on a resident but should chart at least document once during their shift to reflect the resident status even if there were no concerns. Record Review of the facility's Rounds policy revised 02/2019 reflected: It is the policy of this facility to account for the whereabouts of each resident; Facility staff will round on all residents every shift for whereabouts and safety; Staff will check trash from room at a minimum of once a shift; Staff will check for the whereabouts and safety of each resident at that time; If resident is not in his/her room, staff will round the facility and grounds to locate the resident; and Staff will document each shift in Point of Care. Record Review of the facility's Incontinent Care policy revised 05/2007, reflected: It is the policy of this facility to remove urine or feces from skin; cleanse and lubricate skin; provide dry, odor free perineal care system. Record Review of the facility's Skin and Wound Monitoring and Management policy initiated 03/2015, revised 01/2022, reflected: It is the policy of this facility that: 1) A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable; and 2) A resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. The purpose of this policy is that the facility provides care and services to 1. Promote interventions that prevent pressure injury development; 2. Promote the healing of pressure injuries that are present (including prevention of infection to the extent possible); and 3. Prevent the development of additional, avoidable pressure injury. Procedure: Resident Assessment; Skin and wound assessment on admission and readmission; Ongoing skin and wound assessments Prevention: Reposition the resident; If the resident is incontinent, make sure that his/her skin remains clean and dry with regular pericare and toileting when appropriate. Documentation: Pressure Ulcer, Non-pressure Ulcer, and PRN/Weekly skin assessment/evaluation forms; Weekly Skin Check Treatment: Continue preventive measures as appropriate, including but not limited to pressure reduction; continence care; mobility; nutrition and hydration management. Monitoring The NFA was notified of an Immediate Jeopardy (IJ) on [DATE] at 2:30 PM, due to the above failures and the IJ template was provided. The facility's Plan of Removal (POR) was accepted on [DATE] at 2:45 PM and included: 1. The Medical Director was notified of IJs on [DATE] at 3:15 PM. 2. Education/in-servicing, (training with use of facility policy and procedures based on best practice), was initiated by DON, Clinical Resource, ADON, OPS Manager and cluster partners with all 675305 Page 18 of 20 675305 11/24/2023 Pleasant Valley Healthcare and Rehabilitation Cent 1525 Pleasant Valley Rd Garland, TX 75040

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few nursing staff on resident rounds on [DATE] and is ongoing with staff prior to the start of their next shift. Education/in-servicing, (training with use of facility policy and procedures based on best practice), was initiated with all staff on abuse and neglect on [DATE] and is ongoing with staff prior to the start of their next shift. 3. The facility's policies on abuse and neglect prevention and reporting were reviewed by the Ops Manager, DON, and Clinical Resources. There were no concerns and facility will continue with current policy. The facility's policy on resident rounds was reviewed by the Ops Manager, DON and Clinical Resources and updated to include resident rounds completed every 2 hours or as needed, based on the resident's needs. 4. Education/in-servicing was initiated on [DATE] with all staff on abuse and neglect and education initiated on [DATE] with nursing staff for rounds. Education/in-servicing to be completed by the DON/ADON/Clinical Resource/Cluster DONs. Education/in-servicing on abuse and neglect included identification, prevention, reporting and what could happen should the staff member fail to follow facility policy including potential injury to a resident. Staff were instructed on examples of resident abuse/neglect and to report any and all allegations of abuse and neglect to the Abuse Coordinator. Knowledge check forms are completed with all staff on abuse and neglect training that was received. Education on rounds included purposeful rounds, checking residents every 2 hours, or as needed, based on the resident's needs. Knowledge checks were completed with all nursing staff to ascertain their understanding of purposeful rounds. Education was given in person or via phone in written form and verbally to accommodate different learning styles of the staff for abuse/neglect and resident rounds. This education/in-servicing was given using developed policy and procedures based on best practice, establishing clear guidelines on frequency and purpose of resident rounds every 2 hours and as needed to provide adequate supervision and monitoring as well as facility policy on abuse/neglect. With this education/in-servicing, staff will have definitions of the purposes and procedures and will decrease the likelihood of resident abuse or neglect occurrences. 5. All staff to receive education prior to working their next shift. All regular staff will receive the education by [DATE] or prior to their next shift at the facility. PRN staff received the mandatory training notice and will receive education prior to their next shift. 6. This education/in-servicing and the knowledge check forms will be completed with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. The facility does not use agency/registry staff. 7. An ad hoc QA meeting regarding items in the IJ template was completed on [DATE]. Attendees will include the Medical Director, Clinical Resource, DON, ADON, Operations Manager, and will include the plan of removal items and interventions. 8. The DON, ADON, Cluster DONs or Clinical Resource will verify staff competency via knowledge checks / knowledge check forms with 10 nursing staff weekly on resident rounds. The DON, ADON, Cluster DONs or Clinical Resource will complete knowledge checks with 10 staff weekly on abuse and neglect. These forms will be completed with staff randomly, sampling from each shift, weekend and weekday 675305 Page 19 of 20 675305 11/24/2023 Pleasant Valley Healthcare and Rehabilitation Cent 1525 Pleasant Valley Rd Garland, TX 75040

F 0607 Level of Harm - Immediate jeopardy to resident health or safety staff, and PRN staff. The facility does not use agency / registry staff. Any concerns with staff competency will be addressed immediately through re-education and/or staff counseling. 9. The PNFA and DON will investigate and report any and all allegations of neglect or abuse through staff reporting, observations, incident/accident reporting and review of the 24-hour report. Any concerns with staff knowledge or conduct will be addressed including reeducation and/or counseling. Residents Affected - Few 10. Summary of IJ, corrective actions and allegations of abuse/neglect to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Resident #2 Record review of Resident #2's admission Record revealed the resident was a 65 y.o. female, who admitted to the facility on [DATE] with the primary diagnosis: Non-Alzheimer's Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Other diagnoses on admission included: Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination); Acute and chronic respiratory failure with hypercapnia (high levels of carbon dioxide in your blood); Morbid (severe) obesity due to excess calories; schizoaffective disorder, bipolar type (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms such as mania and depression); COPD, unspecified; Pain; Anxiety; and Depression. Record review of Resident #2's Quarterly MDS review assessment, dated [DATE], revealed Resident #2's latest re-entry to SNF was [DATE]. Resident #2 had a BIMS of 10 which suggested moderately impaired cognition. Resident #2's functional status required two-person physical assist with ADLs. Resident #1 was always incontinent of bladder and bowel. Record review of Resident #2's weekly skin evaluations, revealed: On [DATE], completed by ADON, Skin clean dry and intact. Continue with bar[TRUNCATED] 675305 Page 20 of 20