Health inspection·December 5, 2023

F 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS, in that: The facility failed to submit staffing information to CMS for the 3rd quarter (April, May, June) of the fiscal year 2023. This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings included: Review of the facility's staff roster, 12/03/2023 indicated the following: 1 Administrator 1 Nurse manager 1 MDS 5 RNs 3 LVNs 6 MAs 5 CNAs Record review of the facility state form 3761 Civil Rights (Civil Rights Survey Report Titles VI and VII of the Civil Rights Act of 1964)) dated12/03/2023 provided by Administrator indicated a total of 84 residents in the facility. Record review of the PBJ Staffing Data Report, FY Quarter 3 2023 (April 1 - June 30) (), dated Page 1 of 3 675424 675424 12/05/2023 Advanced Rehabilitation and Healthcare of Athens 121 Commons Drive Athens, TX 75751

F 0851 11/30/2023, revealed the facility had failed to submit data for the quarter. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/03/2023 at 3:45 PM, the Administrator said the PBJ reports she thinks are submitted by the HR Director who is not here today. The ADON who does the staffing had no idea who submits the PBJ report. were submitted by the accounting department at the corporate office and all hours were not accurately captured and reported due to an error with the payroll system. It failed to include agency staffing or salaried employees in the reported hours. She said they were not familiar with the requirement for reporting staffing to CMS, because she was not responsible for reporting for the facility. She said the facility did not have a Payroll Based Journal for submission to CMS policy. Residents Affected - Many During a Record review of the PBJ labeled ([NAME] 04/01/2023 - 06/30/2023 exported on 08/03/2023 10:22 AM. The Administrator said this information was only exported from the facility and had not been submitted information to CMS. During an interview on 12/05/2023 at 2:50 PM, the Regional RN Consultant and Facility Administrator both stated that the corporate office had failed to submit the PBJ by the deadline for the 3rd quarter. They both said that they do not have anything to do with PBJ reporting. Record review of the CMS, Electronic Staffing Data Submission Payroll-Based Journal, Long-Term Care Facility Policy Manual, Version 2.6, June 2022, section 1.2 Submission Timeliness and Accuracy, revealed Direct care staffing and census data will be collected quarterly, and is required to be timely and accurate. Further review revealed Report Quarter 3 date range as April 1- June 30,2023. Policy manual revealed, Deadline: Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Time) after the last day in each fiscal quarter in order to be considered timely. 675424 Page 2 of 3 675424 12/05/2023 Advanced Rehabilitation and Healthcare of Athens 121 Commons Drive Athens, TX 75751

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on an interview and record review, the facility failed to ensure that the facility's medical director or his/her designee attended the Quality Assessment and Assurance/Quality Assurance and Performance Improvement Committee meetings, for 1 of 1 facility, reviewed for QAA/QAPI. Residents Affected - Some The facility failed to ensure the medical director attended their QAA and QAPI meetings for the months of December 2022, February 2023, July, August, September and October 2023. This failure could place residents at risk for quality deficiencies being unidentified and no appropriate plans of actions developed or implemented. Findings included: Review of the facility's QAA/QAPI meeting signature logs for the months of December 2022, February 2023, July, August, September, and October 2023 revealed, meetings were conducted each month during that period. Neither the Medical Director nor his/her designee signed the sign-in sheets, nor was it indicated on the sign-in sheet that the Medical Director or his designee attended the QAA/QAPI meetings for December 2022, February 2023 and July, August, September, and October 2023, via zoom or by phone. The signature sign-in log also indicated, the Medical Director only attended 5 of 12 monthly QAA/QAPI meetings. During an interview on 12/05/2023 at 3:07 PM, the Administrator said the Medical Director receives notification of the QAA/QAPI meeting from the DON. She said some of the meetings were held before she became administrator. During an interview on 12/05/2023 at 4;15 PM, the DON said she notifies the Medical Director of the QAA/QAPI meetings by phone or text. She said sometimes the Medical Director was in the facility and she would notify him of the meeting verbally. The DON did not say why the Medical Director had missed several meetings. Review of the facility's policy Quality Assessment and Assurance Committee, dated 10/24/2022, revealed, Policy Explanation Compliance Guideline: 1. the QAA committee will be composed of, at a minimum: a. The Director of Nursing, b. The Medical Director or his/her designee .5 the QAA committee .a. Meet at least quarterly as needed. 675424 Page 3 of 3