Health inspection·July 12, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an assessment accurately reflected a resident's status for three of 13 residents (Resident #3, Resident #6, Resident #12) reviewed for accuracy of MDS assessments. Residents Affected - Some The facility failed to ensure residents were accurately reflected for ADL functions on the MDS. This failure could place residents at risk for not receiving the correct care to meet their physical, mental, and psychosocial needs. Findings include: 1. Record review of Resident #3's admission record, dated 07/11/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE], to the male secure unit. Resident #3 had diagnoses which included: chronic atrial fibrillation (irregular heart beat), anxiety disorder, dementia, intermittent explosive disorder (sudden episodes of impulsive aggressive, violent behavior or angry verbal outburst), cognitive communication deficit, and chronic venous hypertension (idiopathic) with other complications unspecific lower extremities (where there is increased pressure inside your veins and the veins in the legs are damaged). Record review of Resident #3's Quarterly MDS, dated [DATE], revealed Section C a BIMS of 10, indicated moderately impaired cognition. Section G, Functional Status for walking in room as self-performance was 1, indicated supervision and support as 3 indicated two plus person physical assistance. Walking in corridor as self-performance as 1, indicated supervision and support as 3 indicated two plus person assistance. Locomotion off unit as self-performance as 1 indicated supervision and support as 2 indicated one-person physical assistance. Dressing self-performance as 1 indicated supervision and support as 3 indicated two plus person physical assistance. Eating as self-performance as 1 indicated supervision and support as 3 indicated two plus person physical assistance. Personal hygiene self-performance as 2 indicated limited assistance and support as 2 indicated one-person physical assistance. Observation and interview on 07/11/2023 at 10:30 AM revealed Resident #3who resided in the men's secure unit, was walking around with no assistance. Resident #3, stated he showered himself; he fed himself; he dressed himself; and he went to the bathroom by himself. He stated he needed no assistance in taking care of himself. During an interview on 07/11/2023 at 11:50 AM, NA C stated Resident #3 was able to shower himself with only setup assistance. She stated Resident #3 was more independent than most of the residents in Page 1 of 13 675527 675527 07/12/2023 Whisperwood Nursing & Rehabilitation Center 5502 W 4th St Lubbock, TX 79416

F 0641 the secure unit. Level of Harm - Minimal harm or potential for actual harm 2. Record review of Resident #6's admission record, dated 07/11/2023, revealed an [AGE] year-old male originally admitted to the facility on [DATE] and readmitted [DATE] to the male secure unit. Resident #6 had diagnoses which included the following: Alzheimer's Disease with late onset (memory loss), Type 2 diabetes with diabetic neuropathy (nerve damage caused by long term high blood sugar levels), depressive disorder (feeling of sadness & loss of interest), anxiety disorder (persistent and excessive worry that interferes with daily activity), emphysema (lung condition causes shortness of breath), chronic obstructive pulmonary disease (lung disease), osteoarthritis (swelling & tenderness of joints), cognitive communication deficit, and personal history of prostate cancer. Residents Affected - Some Record review of Resident #6's Acute hospital MDS, dated [DATE], revealed Section G Functional Status bed mobility, transfer and dressing self-performance as 3 indicated extensive assistance and support as 2 indicated one-person physical assistance. walking in room, walking in corridor, locomotion on and off the unit, and personal hygiene as self-performance 2 indicated limited assistance and support as 2 indicated one-person physical assistance. Observation on 07/11/2023 at 10:35 AM, revealed Resident #6 was sitting in a wheelchair in the dining area. He propelled himself with his feet to the hallway. 3. Record review of Resident #12's admission record, dated 07/11/2023, revealed a 70-year- old male who was admitted to the facility on [DATE] to the male secure unit. Resident #12 had diagnoses which included: neurocognitive disorder with Lewy Bodies (progressive dementia which leads to decline in thinking, reasoning and independent function), benign prostatic hyperplasia with lower urinary tract symptoms (frequent urination with weak stream and leaking or dribbling of urine), psychosis, psychotic disorder with hallucinations, anxiety disorder, wandering in disease, and chronic pain syndrome. Record review of Resident #12's Acute Hospital MDS, dated [DATE], revealed in Section G Functional Status transfer, walking in room, walking in corridor, dressing, and eating self-performance as one indicated supervision and support as three indicated two plus person physical assistance. In an observation on 07/11/2023 at 10:20 AM, Resident #12 was standing in the doorway of his room. He proceeded to walk down the hall towards the dining area. In an observation on 07/11/2023 at 10:40 AM, Resident #12 was sitting in the dining room eating breakfast by feeding himself. During an interview on 07/11/2023 at 10:41 AM, NA C stated Resident #12 did not talk he just looked at you when you spoke to him although he could understand some things. He could feed himself; he ambulated with no assistance and toileted himself with cueing. During an interview on 07/11/2023 at 11:05 AM, LVN I stated information on the MDS would self-populate when she went and clicked on refresh to update the MDS. She stated she did not go back and check to ensure the information on Section G Functional Status was accurate. She stated she probably didn't check on the support part of the MDS. LVN I was asked about Resident #3, Resident #6 and Resident #12 and inconsistencies of self-performance and support on section G of their MDS's and she stated, that information is probably inaccurate just a carryover from previous MDS's that were completed. LVN I stated she got the information for the MDS, from the POC, when she updated the MDS the 675527 Page 2 of 13 675527 07/12/2023 Whisperwood Nursing & Rehabilitation Center 5502 W 4th St Lubbock, TX 79416

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some electronic system would pull over information the CNA's documented in the POC for the MDS, She stated she should have gone to the CNA's and asked if the information was accurate, and then she should have gone and looked at the residents to see if that type of care was requires. During an interview on 07/11/2023 at 2:00 PM, the DON stated Resident #3 would be able to shower himself with setup assistance only. She stated Resident #6 would need assistance with a shower. During an interview on 07/11/2023 at 4:17 PM, LVN E stated she was at the facility as the MDS Corporate Nurse and had planned on doing an in-service for the MDS nurses and CNAs on coding ADLs properly. She stated residents in the unit were coded for supervision and if staff had not seen a resident in the unit in at least 10 minutes they needed to go look for the resident and put eyes on them. She stated she verified with CNA H who worked nights he had been coding the residents in the men's secure unit as two persons assist because there had been two CNAs in the unit at nights working, not providing assistance at the same time to each resident just two staff in the unit working. She stated she started an in-service with staff on what a two-person assist was and when to code that way not just because two people were in the unit working. During an interview on 07/11/2023 approximately 4:45 PM, the Corporate RN stated there was not a policy regarding MDS, the MDS RAI Manual was followed in conducting MDS assessments. 675527 Page 3 of 13 675527 07/12/2023 Whisperwood Nursing & Rehabilitation Center 5502 W 4th St Lubbock, TX 79416

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for eight of 13 residents (Residents #3, #4, #5, #6, #7, #8, #10, and #12) reviewed for activities. Residents Affected - Some The facility failed to offer engaging activities in the secure units. This failure could place residents at risk by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings include: 1. Record review of Resident #3 (BIMS 10) activity assessment, dated 05/08/2023, revealed the resident preferred doing things with groups of people, participating in favorite activities, spending time away from the nursing home. During an interview on 07/11/2023 at 10:30 AM, Resident #3 stated they did not do any activities in the unit. He stated they were bored. 2. Record review of Resident # 4's (BIMS 00) activity assessment, dated 05/2/2023, revealed the resident was interviewed and not the family, the activity assessment was incomplete. 3. Record review of Resident #5's (BIMS 08) clinical record revealed no documentation of an activity assessment for Resident #5. 4. Record review of Resident #6's (BIMS 00) activity assessment, dated 05/22/2023, revealed the resident was interviewed and not the family; the activity assessment was incomplete. 5. Record review of Resident #7's (BIMS 01) clinical record revealed no documentation of an activity assessment for Resident #7. 6. Record review of Resident #8's (BIMS 05) activity assessment, dated 04/21/2023, revealed it was incomplete. 7. Record review of Resident #10's (BIMS 03) clinical record revealed no documentation of an activity assessment for Resident #10. 8. Record review of Resident #12's (BIMS 02) activity assessment, dated 05/22/2023, revealed the resident was interviewed, and the family was not. The resident preferences were choosing clothes to wear and caring for personal belongings. During an observation on 07/11/2023 at 10:20 AM, revealed residents in the men's secure unit were walking up and down the hall, watching TV and/or laying down in their bedrooms. 675527 Page 4 of 13 675527 07/12/2023 Whisperwood Nursing & Rehabilitation Center 5502 W 4th St Lubbock, TX 79416

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation made on 07/11/2023 at 11:40 AM in Unit D, the secure men's unit of one staff in the unit at the end of the hall with two residents. One resident was sitting in his wheelchair in the dining room, A wooden box was observed with different puzzle pieces all different sizes of puzzle pieces were in the box, along with crayons, and markers and one coloring book. There was a large ball observed in the corner of the dining room. Observation of a closet revealed a radio in the closet, plastic bowling pins in the closet. There was a large activity calendar posted on the wall. During an interview on 07/11/2023 at 11:25AM, the Activity Director stated when she first started to work at the facility, she had an activity assistant, but the facility took away the assistant job position. She stated she did not document any activities that were done with any of the residents. She stated, no one ever told her she needed to document any activities. She stated the facility provided materials for activities for the secure units and the materials were in the closets in the units. She stated she was unaware if the staff in the secure units provided the activities to the residents. She stated when the beauty shop was on the activity calendar, she was busy taking the residents one at a time out of the unit to the beauty shop and sitting with the resident while in the beauty shop, so she was not sure what staff was doing with the other residents during that time in the units for an activity. She stated the beauty shop was on the activity calendar but not all residents participate, depending on if they had money or not. She stated there were different people that went to the facility to sing or play music and she would bring a few residents out of the secure units to participate in those activities. She stated not all the residents in the secure unit could go out of the unit and go to the activity. She stated she could not be in two places at one time, so if she had an activity in the dining room around lunch time, she could not be in the secure unit to do the same activity during lunch time. She stated she didn't know if the staff working in the secure units provided the activities to the residents in the units. During an interview on 07/11/2023 at 2:00 PM, the Administrator stated the residents in the secure unit should be participating in activities because the Activity Director had reported to her and the DON the activities, she had provided for the residents in the secure unit. During an interview on 07/12/2023 at 11:45 AM, CNA F stated she worked in the men's secure unit and the Activity Director did not go to the secure unit and do activities with the residents. She stated she would try to do activities with the residents in the unit when she could, but she didn't have time being busy providing resident care. She stated the male residents did not like to color or put puzzles together and they usually put the puzzle pieces in their mouth. She stated she did not know why they had the large activity calendar on the wall in the secure unit because the men did not participate in activities. She stated she did not have time to do activities because she was busy doing her job providing resident care and monitoring the residents. Record review of Activity Programming policy dated 2011 revealed: STANDARD: The activity Director and staff will provide for ongoing Activity programs. PRACTICE GUIDELINES: 1. Recreation programs are based on the interest and needs of the residents expressed through the Activity assessment. 675527 Page 5 of 13 675527 07/12/2023 Whisperwood Nursing & Rehabilitation Center 5502 W 4th St Lubbock, TX 79416

F 0679 Level of Harm - Minimal harm or potential for actual harm 2. Resident's or family's expressed needs and interests are included in the development of programs. Input from residents may be done on a n individual basis or may be discussed at Resident Council/Group. 3. Activity programs are be designed based on resident's leisure interests and implemented to meet the needs (physical, cognitive, creative, social, spiritual, independent, and sensory) of the residents. Residents Affected - Some 4. Programs will be geared to maintain functional ADL's, provide social interactions and, at the same time, protect residents from environmental over stimulation. 5. Those who cannot participate in group settings are provided individuals programming. Inability to participate could include those who refuse to participate in activities, those who are in isolation, or physician ordered bed rest. 6. Programming includes large groups, small groups, individual and independent opportunities. 7. Programs may take place in mornings, afternoons and/or evenings that span throughout the entire week. 8. Programs use various areas available in and out of the health care center. 9. The resident population is cognitively assessed routinely to determine the number of functional level programs needed. 10. The opportunity is provided for regular community outings/trips. Programs are developed to include community resources and involvement within, as well as outside the health care center. 675527 Page 6 of 13 675527 07/12/2023 Whisperwood Nursing & Rehabilitation Center 5502 W 4th St Lubbock, TX 79416

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the residents environment remained as free from accidents and hazards as possible, and the facility failed to ensure each resident received adequate supervision to prevent accidents for five of eight residents (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #7) reviewed for accidents and supervision. The facility failed to provide adequate supervision to the women's and men's secure units to help defuse aggressive behaviors. This failure could place residents at risk for incidents of aggression that could lead to injuries such as bruising, skin tears, fractures, suffocation, and subdural hematomas. Findings include: 1. Record review of Resident #1's, undated face sheet, indicated she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: dementia unspecified severity (memory loss), with agitation (nervous), lack of coordination (unable to control muscle movement), cognitive communication deficit (difficulty with thinking), dementia in other diseases classified elsewhere with behavioral disturbance, psychotic disorder with delusions due to known physiological condition (mental illness), mood disorder due to known physiological condition with major depressive-like episode (mood swings), anxiety disorder, Alzheimer's disease with late onset (destroys memory and mental functions), restlessness, and agitation. Record review of Resident #1's Annual MDS, dated [DATE], indicated on Section C, BIMS Summary Score of a 03, indicated severe cognitive impairment. Section E, Behavior indicated none; behaviors did not exist. Section G, Functional Status indicated she required supervision oversight, encouragement or cueing with bed mobility and transfers, and when walking in her room/corridors and locomotion on and off her unit. Record review of Resident #1's Care Plan, dated 05/02/2023, indicated she was a potential to demonstrate verbally and abusive behaviors to staff and other residents. The interventions included resident was very territorial of her belongings and her room when she got a roommate, she would yell at them and continue to put her stuff on their side of the room. Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document, assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Record review of the facility Provider Investigation Report, dated 06/01/2023, indicated on 05/29/2023 Resident #1 was observed by staff to have her hands on Resident #2's shirt collar near her neck. Resident #1 had a history of having difficulty with all roommates. Resident #1 thought her roommates were in her house and did not belong. No injuries noted and notifications were made to physician, and family. 2. Record review of Resident #2's, undated, face sheet indicated she was a 66 -year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: unspecified dementia (memory loss), unspecified severity, without behavioral disturbance, psychotic disturbance (mental health issue), mood disturbance (mood swings), anxiety (fear about everyday situations), 675527 Page 7 of 13 675527 07/12/2023 Whisperwood Nursing & Rehabilitation Center 5502 W 4th St Lubbock, TX 79416

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some difficulty in walking, schizoaffective disorder, depressive type, intermittent explosive disorder(mental health and mood disorder), muscle weakness (decreased strength in muscles), lack of coordination, schizophrenia (disorder that affect's a person's ability to think, feel and behave clearly), and cognitive communication disorder (difficulty communicating). Record review of Resident #2's Quarterly MDS, dated [DATE], indicated on Section C, BIMS Summary Score of a 03, indicated severe cognitive impairment. Section E, Behavior indicated none, behaviors did not exist. Section G, Functional Status indicated she required supervision oversight, encouragement or cueing with bed mobility and transfers, and when walking in her room/corridors and locomotion on and off her unit. Record review of Resident #2's Care Plan, dated 07/03/2023, indicated she was a potential to have behavior problems due to dementia and psychological issues. Resident #2 had behaviors of making allegations against staff and family. Will shake her head back and forth while chanting lets go lets go. Resident will sit down anywhere and then refuse to get up when angry or attention seeking. Interventions included assist resident to develop more appropriate methods of coping and interacting. Encourage resident to express feelings appropriately. Minimize potential for the resident's disruptive behaviors by offering tasks that divert attention. Record review of Resident #2's Incident Report, dated 05/29/2023 at 7:15PM, written by LVN A, indicated Med Aide B reported to LVN A that Resident #1 was choking Resident #2 for approximately two seconds and then Resident #1 let go of Resident #2. Resident #2 stated she choked me. The residents were separated, and one resident went to another room. No injuries noted, notification was made to family, administrator, physician, and DON. During an observation and interview on 07/11/2023 at 10:23 AM, NA C was the only staff person in Unit D, men's secure unit. NA C stated she just completed her CNA classes at the facility; she had been employed about two and half months. NA C stated she came in for the 6AM to 6PM shift and there was another NA at the beginning of the shift, around 7:00 AM, that staff member was called to another hall due to a staff member calling in. She stated this was not the first time she worked on the secure unit by herself. NA C stated the training in the CNA class was the training she received. During an observation on 07/11/2023 at 11:40 AM there was one staff member, NA C, observed working in the secure men's unit. The census was 14 in Unit D. During an observation on 07/11/2023 at 1:46 PM, NA C was the only staff member in the men's secure unit. During an interview on 07/11/2023 at 10:30 AM, Resident #3 stated there is not enough staff back here, most of the time it is just one staff person because they will pull the other staff person off to another hall. 3. Record review of Resident #3's admission record, dated 07/11/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE], to the male secure unit. Resident #3 had diagnoses which included: chronic atrial fibrillation (irregular heartbeat), anxiety disorder (feeling nervous), dementia (memory loss), intermittent explosive disorder (sudden episodes of impulsive aggressive, violent behavior or angry verbal outburst), cognitive communication deficit, and chronic venous hypertension (idiopathic) with other complications unspecific lower extremities (where there is increased pressure inside your veins and the veins in the legs are damaged). 675527 Page 8 of 13 675527 07/12/2023 Whisperwood Nursing & Rehabilitation Center 5502 W 4th St Lubbock, TX 79416

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #3's Quarterly MDS, dated [DATE], revealed Section C a BIMS of 10, indicated moderately impaired cognition. Section G, Functional Status for walking in room as self-performance was 1, indicated supervision and support as 3 indicated two plus person physical assistance. Walking in corridor as self-performance as 1, indicated supervision and support as 3 indicated two plus person assistance. Locomotion off unit as self-performance as 1 indicated supervision and support as 2 indicated one-person physical assistance. Dressing self-performance as 1 indicated supervision and support as 3 indicated two plus person physical assistance. Eating as self-performance as 1 indicated supervision and support as 3 indicated two plus person physical assistance. Personal hygiene self-performance as 2 indicated limited assistance and support as 2 indicated one-person physical assistance. During an interview on 07/11/2023 at 11:50 AM, NA C stated she was the only staff assigned to work in The men's unit. She stated when staff called in sick to work on the floor the facility would pull one of the staff working in the secure men's unit to work on the floor. She stated that left only one staff to work in the secure unit with 14 or 15 residents. She stated she could not monitor the residents when she had to go in a room to provide care for another resident. She stated she could open the door and call out for a staff to come help her; however, it took time to get a staff to come and she would have residents who needed their brief changed. She stated she could not make the residents wait to have their brief changed so if help didn't come, she would have to go in the resident's room and change the brief by herself. She stated during that time residents were left alone without a second staff to monitor them. She stated she had four residents in the secure men's unit that needed briefs changed. She stated she had one resident who needed assistance with his meal to ensure he didn't choke. She stated she was not able to give showers to residents if she worked by herself because she would have to leave the shower room door propped open in order to hear if any of the other residents needed assistance. She stated there was one resident that was ambulatory, and he received tube feeding. She stated if he was walking around, he went in other residents' rooms and he would eat their food or drink their drinks. She stated he was Resident #4 and when he was awake walking around the unit, he required constant supervision. She stated Resident # 4 would go in other resident's rooms and then an altercation would happen because the other residents did not want him in their rooms. She stated Resident #4 had been involved in resident-to-resident altercations because of going in other residents' rooms and those residents wanted him to leave their room. She stated when she needed help, she would get out her cell phone and text or call another CNA from one of the other halls to come help her. Record review of Facility Provider Investigation Report dated 06/16/2023 indicated Resident #4 was involved in a resident-to-resident altercation on 06/16/2023 with Resident #7. Resident #4 was found in the bathroom with Resident #7, by DON. Resident #4 was pulling down on Resident #7's arm trying to pull him to the ground with his teeth clinched. No injuries and no bruising or redness noted. Both residents reside in Unit D. Resident #4 was referred to a behavioral facility however was not cooperative with the assessment. Continue to monitor. Record review of Resident #4's undated Face Sheet indicated he was a [AGE] year-old male who was admitted to the facility on [DATE]. The face sheet included the following diagnosis: unspecified dementia, unspecified severity, with anxiety, psychotic disorder with delusions due to know physiological condition, dysphagia, gastrostomy status, encephalopathy, dementia in other diseases classified elsewhere with behavioral disturbances, mood disorder, unspecified lack of coordination, unspecified dementia with behavioral disturbance, alcohol dependence uncomplicated, anxiety disorder due to known physiological condition. 675527 Page 9 of 13 675527 07/12/2023 Whisperwood Nursing & Rehabilitation Center 5502 W 4th St Lubbock, TX 79416

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #4's Quarterly MDS dated [DATE] indicated on Section C BIMS Summary Score 00, as Resident #4 was unable to complete Brief Interview for Mental Status. Section E, for behaviors indicated physical behavioral symptoms directed towards others as 1 indicating behavior of this type occurred 1 to 3 days. Verbal behavioral symptoms directed towards other indicated 1 indicating behavior of this type occurred 1 to 3 days. Other behavioral symptoms not directed towards others as 1 indicating behavior of this type occurred 1 to 3 days. Rejection of care as 1 indicating behavior of this type occurred 1 to 3 days. Wandering as 3 indicating behavior of this type occurred daily. Section G Functional Status indicated he required extensive assistance and 2 plus persons physical assistance with bed mobility positioning in bed, transfer from bed to chair, or standing position, walk in room, walk in corridor, dressing, and eating, toilet use as extensive assistance with one-person physical assistance and personal hygiene as limited assistance and one plus person assistance. Record review of Resident #4's Care Plan dated 07/10/2023 indicated behaviors as Resident #4 has potential to demonstrate physical/verbal behaviors towards staff and other residents. Resident #4 does not stick to NPO status grabs whatever food is near him-family aware that resident does this situation. Resident has a habit of scratching his skin to the point of making sores. Interventions as give the resident as many choices as possible about care and activities and allow him within reason to make his decisions. If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately. Labs obtained per physician order for physical hitting another resident. Monitor resident during meals, he has been noted to place silverware in his pocket. When resident becomes agitated, intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive staff to walk calmly away, and approach later. Nutrition as NPO - Tube Feeding Resident #4 will grab food from other residents' plates and eat food causing potential for aspiration. Resident #4 has a communication problem not always understanding direct conversation or responding accordingly. Interventions as monitor/document for physical nonverbal indicators of discomfort or distress and follow up as needed. Monitor/document frustration level, wait 30 seconds before providing resident #4 with word. Nutrition as NPO - Tube Feeding Resident #4 will grab food from other residents' plates and eat food causing potential for aspiration. Record review of Resident #7's undated Face Sheet indicated he was a [AGE] year-old male admitted to the facility on 01/202023. The face sheet following diagnosis: mild cognitive impairment of uncertain or unknown etiology, personal history of traumatic brain injury, cognitive communication deficit, psychotic disorder with delusions due to known physiological condition, vascular dementia, unspecified severity, with other behavioral disturbance, major depressive disorder, recurrent sever without psychotic features. Record Review of Resident #7's quarterly MDS dated [DATE] indicated on Section C BIMS Summary Score 01 indicating sever impairment. Section E Behaviors scored 0 indicating none. Section G Functional Status for bed mobility, transfer, walking in room and corridor, dressing, eating, toilet use indicated supervision and setup help only. Locomotion on unit and off unit indicated limited assistance and one-person physical assistance, personal hygiene indicated extensive assistance with one-person physical assistance. Record Review of Resident #7's Care Plan dated 05/08/2023 Men's Secure Unit, elopement/wandering risk, history of vascular dementia, disoriented to place, history of attempts facility unattended, impaired safety awareness, resident wanders aimlessly and resides in the men's secure unit. Interventions, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, if the resident is exit seeking, stay with the resident, and notify 675527 Page 10 of 13 675527 07/12/2023 Whisperwood Nursing & Rehabilitation Center 5502 W 4th St Lubbock, TX 79416

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the charge nurse by calling out, sending another staff member, call system. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. During an interview on 07/11/2023 at 2:00 PM, the Administrator stated the residents in the men's secure unit wonder off if they were not behind a secured door. The Administrator stated the residents required supervision to a point. During an interview on 07/11/2023 at 3:54 PM, MA B stated on 05/29/2023 she went in the woman's secured unit to pass medications and did not realized staff working in the woman's secured unit left when she entered the unit. She stated she heard yelling coming from the end of the hall and ran to the end and found Resident #1 and Resident #2 in their room and Resident #1 had Resident #2 by the shirt collar. She stated she told Resident #1 to let go of Resident #2 and she did and then she had Resident #1 leave the room with her and go to the dining room. MA B stated she continued to pass medications and then heard yelling again and went back to the room and found Resident #1 had returned to the room and had Resident #2 by the shirt. She stated she told Resident #1 to let go of Resident #2. She stated Resident #1 let go of Resident #2. She stated the night shift CNA entered the woman's secured unit and she asked for them to go get the nurse. MA B stated there were times where she would cover the women's secure unit because they would have one CNA J working in the unit. She stated the facility tried to have two CNAs in the woman's secured unit however that didn't always happen. During an interview on 07/11/2023 at 3:15 PM, LVN D stated he worked as the charge nurse for the woman's secured unit, and two other halls. He stated he would make rounds in men's secured unit, just to help out and check on the residents since that was the secure men's unit. He stated the facility did try to have two CNA's working in the secured woman's unit but the secured men's unit at times would have one CNA. He stated, he did not believe the secure units had enough staff, both secure units should have at least two CNAs at all times. He stated, CNA's will go to the doors of the unit and open them and call for help or use the phone. During an interview on 07/11/2023 at 4:17 PM, LVN E stated all residents in the men's and women's secure unit were coded as 1, which meant they all required supervision. She stated if staff had not seen a resident in the secure unit for at least 10 minutes the staff were to go find the resident and put their eyes on the resident. During an interview on 07/11/2023 at 5:15 PM, LVN A stated on 05/29/2023 he was getting report when staff notified him of a resident-to-resident altercation in the woman's secured unit. He stated he entered the woman's secured unit and MA B told him Resident #1 and Resident #2 had an altercation. He stated he completed assessments on both residents and made notifications to physicians, and family. He stated the two residents were roommates and neither resident wanted to change rooms, however Resident #2 did agree and changed rooms. During an interview on 07/12/2023 at 8:30 AM, the Administrator stated staff who worked in either secure unit received training on residents with behaviors and residents with dementia in orientation. She stated staff who worked in the unit also received special training before working with residents in the secure unit with behaviors and memory concerns. During an interview on 07/12/2023 at 11:45 AM, CNA E stated she was the CNA for the men's secured unit and at times she worked by herself as the only CNA in the unit. She stated usually what happened was someone would call in sick in the main area and so they would pull a CNA from the men's secured 675527 Page 11 of 13 675527 07/12/2023 Whisperwood Nursing & Rehabilitation Center 5502 W 4th St Lubbock, TX 79416

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some unit, which left only one CNA in the unit. She stated when she worked by herself in the men's secured unit, she was not able to shower resident's until she was able to have an additional staff come to the unit. She stated there were times when she came in for her shift, 6AM-6PM, and one of the night CNAs had already left, leaving only one CNA in the unit. She stated at times the facility would place a NA in the unit to work with her but they are new staff and don't know the residents, so it is like working by yourself. She stated the residents in the male secure unit needed supervision and there were times they could use three CNAs in the unit. She stated the only way to get help when working in the unit was to open the door and call out for help or go get her cell phone and call the facility. She stated they did have a facility phone in the men's secured unit; however, she stated the phone was no longer in the unit and she was unsure what had happened to the phone. She stated she spends a lot of time redirecting the male residents and providing care to them. She stated when she was the only staff working in the men's secured unit and had to provide care for a resident there was not any other staff to monitor the other residents. She stated she was not able to always chart the care provided to each resident until later in her shift when she was by herself due to not having time since she was the only staff in the unit. During an interview on 07/12/2023 at 2:35 PM, NA G stated she worked at the facility for a few months and worked in both the woman's and men's secured units. She stated at times she had to work by herself in both units because staff called in sick and they pulled staff from the units to the main floor. She stated when she worked by herself in the men's unit, she was not able to shower residents because she didn't have anyone to watch the other residents while giving one a shower. She stated when she would change a resident's brief in the men's secure unit the other residents were left unattended because there wasn't another staff in the unit. During an interview on 07/12/2023 at 2:40 PM, the Physician Assistant for the medical director stated, if the resident is in the secure unit, they require a higher level of monitoring. Record review of the facility in-services, dated 04/12/2023, titled Secure Unit documented: Staff cannot leave the secure unit unattended for any reason. If you are the only aide on the hall, you must call your nurse or med aid to relieve you while you go out. You can't go get coffee or just run out to grab a bag of briefs. This is not allowed. Someone must remain on the unit at all times. You must make rounds every 2 hours on the unit. More frequent on some residents depending on their actions/behaviors on that day. If there are two staff assigned for your shift. One must have eyes on the hallway, and one must have eyes on the dining area. You must complete the secure care training on SNF clinic by 4/30/23. If you have questions about it or can't find it, please see Administrator. Never for any reason-can you allow a resident off of the hallway unless you are accompanying them. They cannot go to activities in the dining room unless the AD or you are sitting with them the entire time. Never for any reason-can you send a secure care resident out for coffee or snacks etc. Charge nurses for secure care unit---must make walking rounds upon arrival with off going nurse on the unit you are assigned to. You must round at least every 2 hours on the unit. Record review of the facility's, undated, Resident Rights policy revealed, The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. Safe Environment- The resident has a right to safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and support for daily living safely. The facility must provide(continued on next page) 675527 Page 12 of 13 675527 07/12/2023 Whisperwood Nursing & Rehabilitation Center 5502 W 4th St Lubbock, TX 79416

F 0689 Level of Harm - Minimal harm or potential for actual harm 1. A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent as possible. a. This includes ensuring that the resident can receive care and services safety and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Residents Affected - Some 675527 Page 13 of 13