Health inspection·April 2, 2024

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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 implement their written policies and procedures to prohibit abuse and neglect for 1 of 15 residents reviewed for abuse. (Residents #1) Residents Affected - Few The facility failed to report\per policy to the state agency within 2 hours of Resident #1's allegations of abuse. This failure could place residents at risk of unreported abuse, neglect, and exploitation. Findings included: Record review of facility's Policy for Abuse and Neglect with a revised date of 03/29/2018 indicated: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in the subpart e. Reporting Any person having reasonable cause to believe, and elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services . Record review of Resident #1's face sheet dated 04/01/2024 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of Parkinson disease (a disorder of the central nervous system that affects movements, often including tremors), Type 2 Diabetes Mellitus (a long term condition in which the body has trouble controlling blood sugar and using it for energy), Cognitive communication, and Schizoaffective Disorder, Bipolar Type (feelings of euphoria, racing thoughts, increased risky behavior and symptoms of mania). The face sheet also indicated Resident #1 was his own responsible party. Record review of Resident #1's Discharge MDS assessment dated [DATE] indicated Resident #1 was usually able to be understood by others, usually able to understand others, had a BIMS of 15 which indicated Resident #1 was cognitively intact. The MDS also indicated Resident #1 required extensive assistance for dressing and personal hygiene, bed mobility and physical help to transfer with bathing. Record review of a witness statement dated 08/01/2023 signed by the ADON indicated Resident #1 made repeated allegations of abuse stating, she's abusing me, don't tell [the ADON] anything - she's Page 1 of 10 675439 675439 04/02/2024 Mullican Care Center 105 N Main St Savoy, TX 75479

F 0607 abusing me and stop yelling at me [ADON]. Level of Harm - Minimal harm or potential for actual harm During an interview on 03/27/2024 at 3:08 PM, Resident #1 said the DON and ADON were mean to him. Resident #1 said the DON and ADON would get mad at him when he felt weak from Parkinson's and needed extra help. Residents Affected - Few During an interview on 04/01/2024 at 10:35 AM, the ADON said the incident involving the witness statement dated 08/01/2023 was not reported to state because it was not abuse. The ADON said the Administrator at the time told her to document the incident. The ADON said she did not know why the Administrator wanted her to write the statement. The ADON stated all allegation of abuse should be reported to the Abuse Coordinator and the DON if the abuse coordinator is not available to prevent harm to residents. During an interview on 04/02/2024 at 11:15 AM, the DON said she had not seen the written witness statement dated 08/01/2023 before. The DON said she was not present when the situation occurred but later had heard about it and did not feel it was reportable. The DON said the importance of reporting allegations is for proper investigations to be conducted to protect the residents. During an interview on 04/02/2024 at 01:10 PM, LVN A said he was the Administrator for the facility from April - September 2023. LVN A said he could not recall if he asked the ADON to write the witness statement dated 08/01/2023. LVN A said Resident #1 had not reported any history of abuse in the past with the ADON. LVN A said he was not able to answer if the incident should have been reported as an allegation of abuse because to many variables and he could not remember what was happening at that exact time. LVN A stated any allegations of abuse should be reported to the Administrator (Abuse Coordinator). When the Abuse Coordinator is not available, the staff should report to the DON. LVN A stated all abuse allegation should be reported to the state no later than 24 hours. LVN A said investigation should be completed to protect the residents. 675439 Page 2 of 10 675439 04/02/2024 Mullican Care Center 105 N Main St Savoy, TX 75479

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 15 (Resident #1) residents reviewed for abuse and neglect. The facility failed to report to the state agency within 2 hours of Resident #1's allegations of abuse. This failure could place the residents at risk for abuse. Findings included: Record review of Resident #1's face sheet dated 04/01/2024 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of Parkinson disease (a disorder of the central nervous system that affects movements, often including tremors), Type 2 Diabetes Mellitus (a long term condition in which the body has trouble controlling blood sugar and using it for energy), Cognitive communication, and Schizoaffective Disorder, Bipolar Type (feelings of euphoria, racing thoughts, increased risky behavior and symptoms of mania). The face sheet also indicated Resident #1 was his own responsible party. Record review of Resident #1's Discharge MDS assessment dated [DATE] indicated Resident #1 was usually able to be understood by others, usually able to understand others, had a BIMS of 15 which indicated Resident #1 was cognitively intact. The MDS also indicated Resident #1 required extensive assistance for dressing and personal hygiene, bed mobility and physical help to transfer with bathing. Record review of a witness statement dated 08/01/2023 signed by the ADON indicated Resident #1 made repeated allegations of abuse stating, she's abusing me, don't tell the ADON anything - she's abusing me and stop yelling at me ADON. During an interview on 04/01/2024 at 10:35 AM, the ADON said the incident involving the witness statement dated 08/01/2023 was not reported to state because it was not abuse. The ADON said the Administrator at the time told her to document the incident. The ADON said she did not know why the Administrator wanted her to write the statement. The ADON stated all allegation of abuse should be reported to the Abuse Coordinator and the DON if the abuse coordinator was not available to prevent harm to residents. During an interview on 03/27/2024 at 3:08 PM, Resident #1 said the DON and ADON were mean to him. Resident #1 said the DON and ADON would get mad at him when he felt weak from Parkinson's and needed extra help. During an interview on 04/02/2024 at 11:15 AM, the DON said she had not seen the written witness 675439 Page 3 of 10 675439 04/02/2024 Mullican Care Center 105 N Main St Savoy, TX 75479

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few statement dated 08/01/2023 before. The DON said she was not present when the situation occurred but later had heard about it and did not feel it was reportable. The DON said the importance of reporting allegations is was for proper investigations to be conducted to protect the residents. During an interview on 04/02/2024 at 01:10 PM, LVN A said he was the Administrator for the facility from April - September 2023. LVN A said he could not recall if he asked the ADON to write the witness statement dated 08/01/2023. LVN A said Resident #1 had not reported any history of abuse in the past with the ADON. LVN A said he was not able to answer if the incident should have been reported as an allegation of abuse because to many variables and he could not remember what was happening at that exact time. LVN A stated any allegations of abuse should be reported to the Administrator (Abuse Coordinator). When the Abuse Coordinator is was not available, the staff should report to the DON. LVN A stated all abuse allegation should be reported to the state no later than 24 hours. LVN A said investigation should be completed to protect the residents. Record review of facility's Policy for Abuse and Neglect with a revised date of 03/29/2018 indicated: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in the subpart d. Identification The facility will identify and investigate events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination of events. e. Reporting Any person having reasonable cause to believe, and elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services . 675439 Page 4 of 10 675439 04/02/2024 Mullican Care Center 105 N Main St Savoy, TX 75479

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman of the transfer or discharge and the reasons for the transfer or discharge in writing for 1 of 3 residents (Residents #1) reviewed for transfer and discharge. The facility initiated a discharge for Resident #1 due to a change of condition and did not notify the State Long-Term Care Ombudsman by phone or in writing. This failure could place residents at risk of improper discharge planning and diminished quality of life. Findings included: Record review of Resident #1's face sheet dated 04/01/2024 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of Parkinson disease (a disorder of the central nervous system that affects movements, often including tremors), Type 2 Diabetes Mellitus (a long term condition in which the body has trouble controlling blood sugar and using it for energy), Cognitive communication, and Schizoaffective Disorder, Bipolar Type (feelings of euphoria, racing thoughts, increased risky behavior and symptoms of mania). The face sheet also indicated Resident #1 was his own responsible party. Record review of Resident #1's Discharge MDS assessment dated [DATE] indicated Resident #1 was usually able to be understood by others, usually able to understand others, had a BIMS of 15 which indicated Resident #1 was cognitively intact. The MDS also indicated Resident #1 required extensive assistance for dressing and personal hygiene, bed mobility and physical help to transfer with bathing. Record review of Resident #1's Discharge summary dated [DATE] signed by the physician indicated Resident #1 was discharged from the facility and sent to behavioral psychological hospital with Resident #1 to return to facility after evaluation and treatment. Record review of Resident #1's order summary report dated as of 08/04/2023 indicated: May send to inpatient psychiatric hospital per physicians dated 08/04/2023. Further review revealed there was no discharge order noted. Record review of Resident #1's Discharge summary dated [DATE] signed by the physician indicated Resident #1 was discharged from the facility and sent to behavioral psychiatric hospital with Resident #1 to return to facility after evaluation and treatment. During an interview on 03/25/2024 at 2:59 PM the Social Worker said she was responsible for issuing 30-day notices and assisting with discharges when residents were discharged home. She said Resident #1 was sent out on 08/04/2023 at his request to a psychiatric unit and never returned to the facility and she could not recall anything more regarding Resident #1. The Social Worker said clinical nursing followed up when residents were sent out to another facility and the Administrator managed those types of discharges. 675439 Page 5 of 10 675439 04/02/2024 Mullican Care Center 105 N Main St Savoy, TX 75479

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 03/26/2024 at 1:30 PM LVN A (Administrator from April - September 2023. ) said Resident #1 was not allowed to return to the facility after the psychiatric hospital evaluation and treatment. LVN said the psychological hospital tried to send him back, but he told the hospital that the facility would not accept Resident #1 back because the facility could no longer meet Resident #1's needs. LVN A said Resident #1 should have received a 30-day discharge notice, but he was unsure of the policy and procedure. LVN A said the failure would make it difficult for Resident #1 to find placement elsewhere. During an interview on 03/27/2024 at 2:30 PM the Ombudsman said the facility did not notify her of the discharge of Resident #1. During an interview on 03/27/2024 at 4:45 PM, LVN A (Administrator from April - September 2023) said he could not recall the proper procedure or policy regarding a discharged resident. LVN A said all the paperwork was placed in a folder and he was no longer the administrator and does not know where the paperwork was located. LVN A said the failure to notify the Ombudsman placed Resident #1 at risk of not having other options, the Ombudsman would have been capable of assisting in placement. Record review of facility's undated Policy for Discharge or Transfer to another Facility indicated: It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances . Policy Explanation and Compliance Guidelines: The facility will evaluate and determine the level of care needed for the resident prior to admission to the facility's ability to meet resident's needs. Once admitted , the resident has the right to remain in the facility unless their transfer or discharge meets one of the following specified exemptions: The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility . Emergency Transfer/Discharges- initiated by the facility for medical reasons to an acute care setting such as a hospital, for immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified). Obtain a physicians' orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis . The Social Services Director, or designee, will provide copies of emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as list meets all requirements for content if such notices. The resident will be permitted to return to the facility upon discharge from the acute care setting . Documentation - Notification of Discharges 675439 Page 6 of 10 675439 04/02/2024 Mullican Care Center 105 N Main St Savoy, TX 75479

F 0623 Level of Harm - Minimal harm or potential for actual harm For Facility-initiated transfer or discharge of a resident, the facility will notify the resident and the residents' representative(s) of the transfer or discharge and the reasons for of the move in writing and in a language and manner they understand. Additionally, the facility will send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term (LTC) Ombudsman. Residents Affected - Few 675439 Page 7 of 10 675439 04/02/2024 Mullican Care Center 105 N Main St Savoy, TX 75479

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish and follow written policy on permitting residents to return to the facility after they were hospitalized for one (Resident #1) of 3 residents reviewed for transfer/discharge. 1. The facility failed to admit Resident #1 back to facility after he was sent to the psychiatric hospital on [DATE]. 2.The facility failed to give Resident #1 a 30-day discharge notice. This failure could place residents at risk of not receiving the care and services to meet their needs and could affect their mental and emotional well-being. Findings included: Record review of Resident #1's face sheet dated 04/01/2024 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of Parkinson disease (a disorder of the central nervous system that affects movements, often including tremors), Type 2 Diabetes Mellitus (a long term condition in which the body has trouble controlling blood sugar and using it for energy), Cognitive communication, and Schizoaffective Disorder, Bipolar Type (feelings of euphoria, racing thoughts, increased risky behavior and symptoms of mania). The face sheet also indicated Resident #1 was his own responsible party. Record review of Resident #1's Discharge MDS assessment dated [DATE] indicated Resident #1 was usually able to be understood by others, usually able to understand others, had a BIMS of 15 which indicated Resident #1 had was cognitively intact. The MDS also indicated Resident #1 required extensive assistance for dressing and personal hygiene, bed mobility and physical help to transfer with bathing. Record review of Resident #1's Discharge summary dated [DATE] signed by the physician indicated Resident #1 was discharged from the facility and sent to behavioral psychiatric hospital with Resident #1 to return to facility after evaluation and treatment. Record review of Resident #1's order summary report dated as of 08/04/2023 indicated he had orders as followed: 1. May send to inpatient psychiatric hospital per physicians dated 08/04/2023. There was no discharge order noted. During an interview on 03/25/2024 at 2:59 PM the Social Worker said she was responsible for issuing 30-day notices and assisting with discharges when residents were discharged home. She said Resident #1 was sent out on 08/04/2023 at his request to a psychiatric unit and never returned to the facility. The Social Worker said the Administrator and clinical nursing followed up when residents were 675439 Page 8 of 10 675439 04/02/2024 Mullican Care Center 105 N Main St Savoy, TX 75479

F 0626 sent out to another facility. Level of Harm - Minimal harm or potential for actual harm During an interview on 03/26/2024 at 1:30 PM LVN A said he was the Administrator for the facility from April - September 2023. LVN A said Resident #1 was not allowed to return to the facility after the psychological hospital evaluation and treatment. LVN said the psychiatric hospital tried to send him back, but he told the hospital that the facility would not accept Resident #1 back because the facility could no longer meet Resident #1's needs. LVN A said he could not recall the reasons the facility could no longer meet the resident's needs exactly. LVN A said Resident #1 should have received a 30-day discharge notice, but he was unsure of the policy and procedure. LVN A said the failure would make it difficult for Resident #1 to find placement elsewhere. Residents Affected - Few During an interview on 03/27/2024 at 3:08 PM, Resident #1 said he did not receive a discharge notice from the facility. Resident #1 said the LVN A had told him he could return to the facility after evaluation and treatment from the psychiatric hospital. Resident #1 said he felt emotionally drained during this time because he felt homeless. Record review of facility's undated Policy for Discharge or Transfer to another Facility indicated: It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances . Policy Explanation and Compliance Guidelines: The facility will evaluate and determine the level of care needed for the resident prior to admission to the facility's ability to meet resident's needs. Once admitted , the resident has the right to remain in the facility unless their transfer or discharge meets one of the following specified exemptions: The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility . Emergency Transfer/Discharges- initiated by the facility for medical reasons to an acute care setting such as a hospital, for immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified). Obtain a physicians' orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis . The Social Services Director, or designee, will provide copies of emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as list meets all requirements for content if such notices. The resident will be permitted to return to the facility upon discharge from the acute care setting . Documentation - Notification of Discharges For Facility-initiated transfer or discharge of a resident, the facility will notify the resident 675439 Page 9 of 10 675439 04/02/2024 Mullican Care Center 105 N Main St Savoy, TX 75479

F 0626 Level of Harm - Minimal harm or potential for actual harm and the residents' representative(s) of the transfer or discharge and the reasons for of the move in writing and in a language and manner they understand. Additionally, the facility will send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term (LTC) Ombudsman. Residents Affected - Few 675439 Page 10 of 10