Health inspection·June 14, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 22 residents reviewed for resident rights. (Resident #19) The facility failed to close the blinds to the outside window while providing incontinent care to Resident #19. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increase anxiety. Findings included: Record review of the face sheet dated 06/13/23 indicated Resident #19 was [AGE] years old and admitted on [DATE] with diagnoses including heart failure, anxiety disorder, and reduced mobility. Record review of the MDS dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated a BIMS score of 13 which indicated Resident #19 was cognitively intact. The MDS indicated Resident #19 required limited to extensive assistance from staff for activities of daily living. Record review of a care plan revised on 02/22/23 indicated Resident #19 had been observed to make statements regarding feeling down, depressed, or hopeless. The care plan indicated Resident #19 ineffective individual coping skills related to the inability to manage internal and external stressors. There was an intervention to redirect away from source of increased stimuli. During an observation on 06/12/23 at 11:05 a.m., CNA D provided incontinent care for Resident #19. CNA D did not close the blinds to a window leading out into the outside yard. The resident was fully exposed at times during the incontinent care. The blinds remained open the entire time care was provided. During an interview on 06/12/23 at 11:15 a.m., CNA D said she was a new CNA, and she was nervous for having to provide care in front of a state surveyor. She said she forgot to close the blinds. She said the blinds would need to be closed so other people could not see in the window and look at the resident's privates. During an interview on 06/12/23 at 11:20 a.m., Resident #19 said CNA D never closed the blinds Page 1 of 30 675539 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0550 while providing care. She said it made her feel indecent for the blinds to be left open to the outside. Level of Harm - Minimal harm or potential for actual harm During an interview on 06/14/23 at 12:35 p.m., RN F said all residents deserve the ultimate privacy during incontinent care. She said staff should always respect the resident's dignity. She not closing the blinds to an outside window could cause someone to see the resident privates. She said this could cause depression. Residents Affected - Few During an interview on 06/14/23 at 01:42 p.m., the DON said while staff are providing care, curtains should be pulled, and blinds should be closed . She said the body should be exposed as little as possible. She said this could be a privacy thing or dignity thing. No one wants to be exposed. During an interview on 06/14/23 at 2:40 p.m., the Administrator said when an employee goes in to provide incontinent care, they should make sure the resident's dignity is respected. She said curtains should be pulled, blinds closed, and doors closed. She said leaving the blinds open during incontinent care is not acceptable. Review of facility Resident Rights policy dated November 2016 indicated, .The resident has a right to a dignified existence .A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident . The resident has a right to personal privacy .Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care . 675539 Page 2 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0553 Allow resident to participate in the development and implementation of his or her person-centered plan of care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #51 Residents Affected - Some FTag Initiation Based on interview and record review, the facility failed to ensure that the residents and/or representatives had the right to participate in the development and implementation of his or her person-centered plan of care, and to ensure that the planning process facilitated the inclusion of the residents and/or representatives for 5 (Resident #23, #28, #38, #42 and #51) of 16 residents reviewed for care planning. The facility failed to ensure the IDT, Resident #23, Resident #28, and Resident #38 and RP of Resident #38, Resident #42 and the RP of Resident #42, Resident #51 and RP of Resident #51 were involved in the review of the comprehensive assessment and were able to discuss their individualized care needs for services to include their need for medical and nursing care, medications, therapy, psychological and dietary needs. The failure could affect residents by placing them at risk for not receiving adequate or individualized care. Findings included: 1. Record review of Resident 23's undated face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dementia (group of thinking and social symptoms that interferes with daily functioning), and osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down). Record review of Resident #23's quarterly MDS assessment, dated 03/17/2023, reflected she had a BIMS score of 08, which indicated a moderate impaired cognitive status. Her functional status reflected she required extensive assistance with bed mobility, toilet use and personal hygiene. She required set up only for eating. Record review of Resident #23's comprehensive care plan showed the last review was done on 02/23/2023. Record review of Resident #23's EHR showed the last care conference was held on 10/03/2022. An interview with Resident #23 on 06/14/2023 at 11:15 a.m., revealed she had not been to her own care plan meeting in six months or greater. Resident #23 stated it was important to her to be a part of her plan of care and she did not want strangers to decide her care. Resident #23 stated that she used to get a letter from the social worker that said when the care plan meetings would be held but she had not gotten one in more than 6 months. 2 Record review of Resident 28's undated face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: anemia (condition in which the blood doesn't have 675539 Page 3 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some enough healthy red blood cells), bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs (mania) to lows (depression), and schizophrenia (a serious mental disorder in which people interpret reality abnormally). Record review of Resident # 28's quarterly MDS, dated [DATE], reflected she had a BIMS score of 09, which indicated a moderate impaired cognitive status. Her functional status reflected he required limited assistance with bed mobility, toilet use and personal hygiene. He required set up only for eating. Record review of the care plan reflected the last update to the comprehensive care plan for Resident #28 was on 02/23/2023. Record review of last recorded care plan meeting was dated 10/12/2022. The care plan meeting was recorded as a quarterly care plan meeting. An interview with Resident #28 on 06/13/2023 at 2:12 p.m., revealed Resident #28 had not had a care plan meeting in over six months. Resident #28 stated she had a family member that would attend if they were invited. Resident #28 wanted to have a care plan meeting to discuss her need for mental health services related to her bipolar and schizophrenia diagnoses. 3. Record review of Resident 38's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs), dementia (group of thinking and social symptoms that interferes with daily functioning), and depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). Record review of Resident # 38's annual MDS, dated [DATE], reflected she had a BIMS score of 04, which indicated severe impaired cognitive status. Her functional status reflected she required supervision assistance with bed mobility, toilet use and personal hygiene. She required set up only for eating. Review of Resident #38's face sheet reflected she had a responsible party who was also listed as her primary contact. An interview with Resident #38's responsible party on 06/14/2023 at 11:30 a.m., revealed the RP had not been invited to a care plan meeting since 2022 and was not aware that of any care plan meetings since that time. 4. Record review of Resident 42's face sheet reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: dysphagia (swallowing difficulties), dementia (group of thinking and social symptoms that interferes with daily functioning), and Raynaud's syndrome (causes some areas of the body - such as fingers and toes - to feel numb and cold in response to cold temperatures or stress). Record review of Resident # 42's quarterly MDS, dated [DATE], reflected she had a BIMS score of 03, which indicated severe impaired cognitive status. Her functional status reflected she required extensive assistance with bed mobility, toilet use and personal hygiene. She required set up only for eating. 675539 Page 4 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #42's face sheet reflected she had a responsible party who was also listed as her primary contact. An interview with Resident #42's responsible party on 06/14/2023 at 12:30 p.m., revealed the RP had not attended a care plan meeting since October 2022 for Resident #42 because she had not received notice one was occurring. Record review of Resident #42's EHR revealed no care plan letter invitations and no documentation of a care plan being held since October 2022. 5. Record review of Resident 51's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: Unspecified Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), adjustment disorder with anxiety (nervousness, worry, difficulty concentrating or remembering things, and feeling overwhelmed), muscle weakness (commonly due to lack of exercise, ageing, muscle injury or pregnancy.), unspecified psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), lack of coordination (uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements), rheumatoid arthritis (a chronic inflammatory disorder affecting many joints, including those in the hands and feet), hyperlipidemia (too many lipids (fats) in your blood), depression (is a common and serious medical illness that negatively affects how you feel, the way you think and how you act.) Record review of Resident #51's quarterly undated MDS, reflected he had a BIMS score of 7, which indicated a severe impairment of cognitive status. His functional status reflected he required supervision and limited assistance. Review of Resident #51's face sheet reflected she had a resident representative who was also listed as his primary contact. During an interview on 06/14/2023 at 9:20 a.m. with Resident #51's Representative. she stated that she has not been to a care plan meeting since October of 2022. She stated she did not know the exact date. She stated that she has not been to a care plan meeting or has been invited to a care plan meeting for at least 8 months She stated that she would prefer to be a part of Resident #51's care planning. She said that it was important to her to be a part of the planning for Resident #51 so his voice could be heard. An interview was attempted with Resident #51 on 06/14/2023 at 09:40 am. Surveyor attempted to ask Resident #51 whether he had been a part of his care plan meeting. Resident #51 was unable to answer any questions regarding care plan meetings. An interview with the Social worker on 06/14/2023 at 1:15 p.m., revealed she was the one in charge of coordinating the care plan meetings. She stated care plan meetings were supposed to occur each quarter following the completion of the MDS. The social worker stated generally she sent out a care plan letter to inform the primary contacts of the care plan meetings and gave a copy to the residents to invite them. Then she scanned the letter into the EHR. The social worker stated that she recorded each meeting in the care plan section of the EHR. The social worker stated that each care plan meeting the social worker, dietary manager, activities, rehab coordinator, resident and resident representative were invited. The social worker stated the team had gotten behind on doing care plan meetings over the past several months. The social worker did not know specifically why Resident #23, 675539 Page 5 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #28, #39, #42 and Resident #51 did not have recorded care plan meetings . The social worker stated not having a care plan meeting with the family and resident present could make the resident feel like they are not part of important decisions about their care and life. An interview with the DON on 06/14/2023 at 3:30 pm revealed the care plan meetings were important to be held quarterly and as needed so they family and resident could be a part of their plan of care. The DON stated it was the MDS nurse that gave the schedule of who was due for a care plan meeting and the social worker was to schedule and hold the care plan meetings. The DON stated she was aware several months had passed and the change of staff affected the completion of care plan meetings. The DON stated it was the responsibility of the Social Worker and MDS nurse to ensure the care plan meetings were happening and everyone attended. An interview with the Administrator on 06/14/2023 at 4:30 pm revealed the care plan meetings were to be attended by all members of the IDT team and were to be done quarterly and as needed. The Administrator stated the social worker was responsible for coordinating the care plan meetings and it had not been brought to her attention that care plan meetings were being missed. The Administrator stated it was important for the residents and family to have a say it the resident's care. The Administrator stated if the residents and family did not get as say in the care of the resident, they could feel their autonomy was not being honored. Review of an undated policy titled Care Planning/Interdisciplinary Team on 06/14/2023 at 4:45 p.m., revealed The care planning team shall be composed of but not necessarily limited to the following personnel: a. RN assessment coordinator, b. Director of nursing, c. Medical director, d. attending physician, e. Therapist, f. Activity director, g. Social service director, h. Dietician/food service manager, i. Pharmacist, j. other individuals as the resident's need dictates and meet quarterly.the secretary to the team shall be responsible for notifying team members when a meeting is scheduled, providing reports, ect., to be reviewed, and maintaining written reports of all meetings. 675539 Page 6 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 22 residents (Resident #225) reviewed for reasonable accommodations. Residents Affected - Few The facility failed to provide an appropriately sized bedside commode for Resident #225. This failure could place residents at risk for unmet needs. Findings included: Record review of a face sheet dated 06/13/23 revealed Resident #225 was a [AGE] year-old female admitted on [DATE] with diagnosis including presence of right artificial ankle joint (is where your shin bone (tibia), calf bone (fibula) and talus bone meet). Record review of the MDS revealed Resident #225 was admitted to the facility less than 21 days ago. No MDS for Resident #225 was completed prior to exit. Record review of an undated baseline care plan revealed Resident #225 was alert/cognitively intact, and continent of urine and bowel. The baseline care plan revealed Resident #225 voiding method was bedside commode and toilet/bathroom. The baseline care plan revealed Resident #225 transfer status was stand pivot (indicates that the person bears at least some weight on one or both legs and spins to move their bottom from one surface to another) with assist x 1 person. During an observation and interview on 06/12/23 at 10:35 a.m., Resident #225 was sitting up in her bed with her right ankle propped on a pillow. Next, to Resident #225 bed and in the bathroom over the toilet seat, was non-bariatric (equipment that can hold up to 600 lbs.) bedside commodes. Resident #225 said she was admitted on Saturday (06/10/23) around 4am from the hospital. She said initially she had a female external catheter (works outside the body to draw urine away) for voiding but she felt like the suction was not strong enough. Resident #225 said she requested a bedside commode and initially was told bedside commodes were locked on the weekend and physical therapy had to hand them out. She said she could not use the toilet in the restroom because it was too low. Resident #225 said LVN C eventually brought her a bedside commode, but she realized it was too small. She said she could barely squeeze on the bedside commode then when she stood up, the bedside commode was stuck on her hips. Resident #225 said because her legs were so close together when she urinated, the urine got trapped between her legs then leaked everywhere when she stood up. During an observation and interview on 06/13/23 at 10:23 a.m., Resident #225 was sitting up in her bed with her right ankle propped on a pillow. Next to Resident #225 bed, was a bariatric bedside commode. Resident #225 said yesterday (06/12/23) afternoon, the Director of Rehab, found a bariatric bedside commode for her to use. During an interview on 06/14/23 at 1:37 p.m., the Director of Rehab said on Monday (06/12/23), he easily found Resident #225 a bariatric bedside commode in one of the shower rooms. He said the facility did prefer the therapy department to assess the residents to determine if the resident was safe to use equipment such as bedside commodes. The Director of Rehab said therapy staff did not work the weekends and were not available to do assessments. 675539 Page 7 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 06/14/23 at 2:10 p.m., LVN C said he took care of Resident #225 last weekend (06/10/23, 06/11/23). He said Resident #225 was supposed to admit to the facility Friday afternoon but did not arrive until Saturday (06/10/23) around 5am. LVN C said Resident #225 felt the external catheter was not working correctly and requested a bedside commode. He said he called management to get permission for Resident #225 to get one without a therapy assessment. LVN C said he looked in the clean and dirty utility rooms but did not recall if he looked in the shower rooms for a larger bedside commode. He said he did not call management to ask where to locate a larger bedside commode. LVN C said, I tried everything to please her [Resident #225]. During an interview on 06/14/23 at 3:45 p.m., the DON said she did not know if the facility had bariatric equipment such as a bedside commode on site. She said the facility did not normally store bariatric equipment but ordered or rented according to the resident's insurance. The DON said the facility did prefer therapy to assess the resident for safety, but it was not possible on the weekends. She said she did not feel the facility should have bariatric equipment on site because it could be ordered and arrived in 24 hours. The DON said the facility was aware of Resident #225 admission and had enough time to prepare for it. She said Resident #225's baseline care plan did specify bedside commode as voiding preference. The DON said if Resident #225 did not want to use the bathroom toilet, she had the option to use a bariatric bed pan (is a container used to collect urine or feces, and it is shaped to fit under a person lying or sitting in bed). She said she did not know if Resident #225's toilet seat height was appropriate for someone over 6 feet tall. The DON said the facility was responsible for providing accommodation of needs to maintain or increase the level of a resident activity of daily living. During an interview on 06/14/23 at 4:00 p.m., the Administrator said it was important to have appropriately sized bedside commodes for residents. She said the incident involving Resident #225 was a lack of communication amongst the staff. The administrator said phone calls to upper management could have prevented the incident. She said using an inappropriately sized bedside commode for the weekend was probably frustrated Resident #225. The administrator said not accommodating a resident's needs, affected their activities of daily living and for Resident #225, affected her dignity. She said she expected all staff to accommodate resident's needs. Record review of a facility Quality of life-Accommodation of Needs policy dated 08/09 revealed .our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity, and well-being .the resident's individual needs and preferences shall be accommodated to the extent possible .the residents' individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission . 675539 Page 8 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to promote resident self-determination through support of resident choice for 1 of 22 residents reviewed for resident rights. (Resident #19) The facility did not assist Resident #19 out of bed when he requested. This failure could place dependent residents at risk for feelings of depression, lack self-determination and decreased quality of life. Findings included: Record review of the face sheet dated 06/13/23 indicated Resident #19 was [AGE] years old and admitted on [DATE] with diagnoses including heart failure, anxiety disorder, and reduced mobility. Record review of the MDS dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated a BIMS score of 13 which indicated Resident #19 was cognitively intact. The MDS indicated Resident #19 required extensive assistance with bed mobility and was totally dependent on staff for transfers. Record review of a care plan revised on 02/22/23 indicated Resident #19 had been observed to make statements regarding feeling down, depressed, or hopeless. The care plan indicated Resident #19 ineffective individual coping skills related to the inability to manage internal and external stressors. There was an intervention to encourage the resident to get out of bed. The care plan indicated Resident #19 required extensive assistance with transfers. There were interventions for Resident #19 to be out of bed in chair and to transfer Resident #19 with a board or lift device. During an observation and interview on 06/12/23 at 11:00 a.m., Resident #19 was in bed. Resident #19 said she requested to be gotten out of bed at 9:00 a.m. and had not been gotten up. She said staff did not always get her up. She said she wanted to get up right after breakfast and be up for lunch. During an observation on 06/12/23 at 11:37 a.m., CNA D was at the bedside of Resident #19. She told Resident #19 the mechanical lift was being used for showers and she would check again after lunch to see if it was available. She said if she could not get Resident #19 up, the next shift would. During an observation and interview on 06/12/23 at 1:51 p.m., Resident #19 was in the bed. She said she had not been gotten up all day. She said CNA D was the staff member she had asked to get her out of bed. She said she had asked CNA D at 9:00 a.m. During an observation and interview on 06/12/23 at 3:30 p.m., Resident #19 was in the bed. She said staff did come in to clean her up. She said at this time it was too late in the day for her to be gotten up. During an observation and interview on 06/13/23 08:45 a.m., Resident #19 said she had told a nurse that came in the room with a white coat on that she wanted to get out of bed after breakfast. 675539 Page 9 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0561 Resident #19 was in bed. She said she had just finished her breakfast. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 06/13/23 at 10:33 a.m., Resident #19 was in bed. She said she did tell the nurse and the aide she wanted to get up. She said now it was too late and she had to get up after lunch for her shower. Residents Affected - Some During an observation and interview on 06/13/23 11:50 a.m., Resident #19 was in bed. She said she would be getting up after lunch for her shower. During an observation and interview on 06/13/23 at 2:32 p.m., Resident #19 was in bed. She said no one came back to get her up and take her to the shower. During an interview on 06/14/23 at 11:09 a.m., Resident #19's roommate said for a good while Resident #19 did refuse to get out of bed. She said for the last week she had heard her ask staff to get out of bed on multiple occasions. She said staff always had an excuse not to get her up and they had not gotten her up when she had requested to be gotten up. During an observation and interview on 06/14/23 at 11:10 a.m., Resident #19 said she recently had two friends die and had been sad. She said she had refused to get up for a while, but over the last week had requested to be gotten up out of bed every day and had not been gotten up. During an interview on 06/14/23 at 11:40 a.m., CNA D said on the morning of 6/12/2023 Resident #19 did ask to be gotten out of bed. She said she did not get her up because the hall was very busy, and the mechanical lift was being used for showers. She said she was only aware of the facility having 1 mechanical lift. During an interview on 06/14/23 at 11:40 a.m., RN F said residents should be gotten up out of bed if they request to get up. She said residents get angry and depressed if they want to get out of bed but are not assisted getting out of bed. During an interview on 06/14/23 at 1:42 p.m., the DON said she when a resident ask to be gotten out of bed they should be gotten up. She said there are three mechanical lifts available in the facility . She said a resident not being gotten out of bed could cause a resident to be even more sad or depressed and lose functional abilities. During an interview on 06/14/23 at 2:40 p.m., the Administrator said if a resident request to get out of bed. They should be gotten out of bed. She said there is no limit to how often a resident is to be gotten out of bed. She said physically it is not good for them to lay in bed and it is depressing to stay in the same place all of the time. Review of facility Resident Rights policy dated November 2016 indicated, .The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice . The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident . 675539 Page 10 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an accurate MDS assessment was completed for 1 of 14 residents reviewed for MDS accuracy. (Resident # 51 and #43) Residents Affected - Few 1. The facility failed to accurately document Resident #51's and Resident #43's wander/elopement alarm usage. These failures could place residents at risk for not receiving needed care and services. Findings included: 1. Record review of Resident# 51's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: Unspecified Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), adjustment disorder with anxiety (nervousness, worry, difficulty concentrating or remembering things, and feeling overwhelmed), muscle weakness (commonly due to lack of exercise, ageing, muscle injury or pregnancy.), unspecified psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), lack of coordination (uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements), rheumatoid arthritis (a chronic inflammatory disorder affecting many joints, including those in the hands and feet), hyperlipidemia (too many lipids (fats) in your blood), depression (is a common and serious medical illness that negatively affects how you feel, the way you think and how you act.) Record review of Resident #51's quarterly MDS dated [DATE], reflected he had a BIMS score of 7, which indicated a severe impairment of cognitive status. His functional status reflected he required supervision and limited assistance. The MDS revealed no usage of Wanderguard (A device that alerts facility staff if a resident leaves the building and prevents wandering) alarm device. Record review of order dated 2/21/2023 by resident #51 primary care physician revealed that a Wanderguard was ordered. Record review of care plan for Resident #51 dated 02/23/2023 revealed that Resident #51 was at risk for wandering and that Resident #51 should be free of risk while wandering. The care plan indicated that Resident #51 is to wear a Wanderguard bracelet and to monitor for attempts to leave the facility. 2. Record review of Resident #43's undated face sheet reflected an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: Unspecified Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), diabetes mellitus (a group of diseases that result in too much sugar in the blood), coronary artery disease (coronary arteries struggle to supply the heart with enough blood, oxygen, and nutrients). Record review of Resident #43's quarterly MDS dated [DATE], reflected he had a BIMS score of 03, which indicated a severe impairment of cognitive status. His functional status reflected he required limited assistance. The MDS revealed no usage of wander/elopement alarm device. Record review of order dated 3/24/2023 by resident #43's primary care physician revealed that a 675539 Page 11 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0641 Level of Harm - Minimal harm or potential for actual harm wander/elopement alarm device was ordered for Resident #43 and function and placement were to be monitored every shift. Record review of TAR for Resident #43 dated March 2023, April 2023, May 2023, and June 2023 revealed the wander/elopement device was checked for placement and function each shift . Residents Affected - Few Record review of care plan for Resident #43 dated 02/23/2023 revealed that Resident #43 was at risk for wandering and that Resident #43 should be free of risk while wandering. During an interview on 6/14/2023 at 10:20 a.m. the ADM stated that the Patient Care Coordinator is the MDS nurse. She stated that the MDS nurse is responsible for completing and the accuracy of the patient MDSs. She stated that inaccurate MDSs will fail to represent the patient. She said that incorrect MDSs affected the information transmitted to regulatory agencies. She stated that the MDS nurse and all other nursing staff are responsible for accurate MDSs. During an interview on 6/14/23 at 10:43 a.m. the MDS Nurse stated that she was responsible for completing MDSs in the facility. She stated that she was aware that Residents #51 and #43 wore the wander/elopement alarm device system as it is in their care plan. She stated that rResident #51's and #43's MDS indicated that they were not using a wander/elopement alarm system. She stated that this was a data entry error by her. She stated that the DON signs the MDSs for completion but not for verification of its accuracy. She stated that it is important that assessments are accurate so that facility staff can take care of the resident's needs. During an interview on 6/14/23 at 2:25 p.m. the DON said she expected that MDSs to be accurately coded. She stated that the MDS Nurse was responsible for the accuracy of the MDS. She stated that her signature on the MDS paperwork only signified the MDS was completed and not for its accuracy. She stated that residents could be placed at risk of not receiving the services they require with an inaccurate MDS. Record review of CMS Manual provided by the facility as their guidance to MDS updated in October 2019. Chapter 1: Resident Assessment Instrument sows that, Care Area Triggers are specific resident responses for one or a combination of MDS elements. The triggers identify residents who have or at risk for developing specific functional problems and require further assistance. Care Area Assessment is the further investigation of triggered areas, to determine if the care area triggers require interventions and care planning. The key to successfully using the resident assessment instrument is to understand that its structure is designed to enhance resident care, increase a resident's active participation in care, and promote the quality of a resident's life. The resident assessment has multiple regulatory requirements The assessment accurately reflects the resident's status. Resident #51 FTag Initiation 675539 Page 12 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 1 of 3 residents reviewed for new admissions (Resident #225). The facility failed to ensure Resident #225 completed her baseline care plan within 48 hours of admission and was provided a written summary. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of a face sheet dated 06/13/23 revealed Resident #225 was a [AGE] year-old female admitted on [DATE] with diagnoses including presence of right artificial ankle joint (is where your shin bone (tibia), calf bone (fibula) and talus bone meet), Type 2 diabetes (is a disease that occurs when your blood glucose, also called blood sugar, is too high), depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest), and pain. Record review of the MDS revealed Resident #225 was admitted to the facility less than 21 days ago. No MDS for Resident #225 was completed prior to exit. Record review of #225's undated baseline care plan reflected unknown initial goals. The baseline care plan reflected the facility had not printed a copy of the medication orders for Resident #225 and reviewed the orders. The baseline care reflected the Resident #225 had not signed care plan which indicated .I have participated in the completion and review of the baseline care plan .I have reviewed all current medication and treatment orders with the nursing staff . The baseline care reflected a copy of the baseline care plan had not been provided to Resident #225. During an interview on 06/13/23 at 10:23 a.m., Resident #225 said she was admitted on Saturday (06/10/23) around 4am from the hospital. She said she had not reviewed or received a copy of her medication or treatment orders. Resident #225 said maybe if the staff over the weekend had reviewed her medications with her, she would not have had a difficult adjustment. She said she had not received a copy of a baseline care plan either. Resident #225 said she was supposed to have a care plan meeting yesterday (06/12/23) but it did not happen. During an interview on 06/14/23 at 9:15 a.m., LVN B said the charge nurse on the admission started the baseline care plans and it was completed within 72 hours of admission. She said resident signed, if possible, the baseline care plan when it was reviewed and completed. During an interview on 06/14/23 at 3:45 p.m., the DON said baseline care plans had to be completed within 72 hours of admission. She said she did not know state regulations required baseline care plans had to be completed within 48 hours of admission. The DON said the admission charge nurse was responsible for the completion of the baseline care plan. She said the unit managers were responsible for ensuring baseline care plans were completed by admission nurses. The DON said unit managers performed audits after each admission. She said the resident's signature on the baseline care indicated 675539 Page 13 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0655 the resident understood and agreed with the plan of care. Level of Harm - Minimal harm or potential for actual harm Record review of a facility Patient Care Management System policy dated 11/17 revealed .the baseline care plan must be initiated within 48 hours of admission .the care must include initials goals .the facility must provide the patient and their representative with a summary of the baseline care plan that includes the initial goals of the patient, a summary of the patient's medications . Residents Affected - Few 675539 Page 14 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 3 of 22 residents reviewed for ADLs (Resident #17, Resident #19, and Resident #219). Residents Affected - Some The facility failed to provide scheduled baths/showers for Resident #17 and Resident #19. The facility failed to trim and clean Resident #219 nails. These failures could place residents who required assistance from staff for personal hygiene at risk of not receiving care and services to meet their needs. Findings included: 1. Record review of the face sheet dated 06/13/23 indicated Resident #17 was [AGE] years old and admitted on [DATE] with diagnoses including heart failure, history of colon cancer, and anxiety disorder. Record review of the MDS dated [DATE] indicated Resident #17 was understood and understood others. The MDS indicated a BIMS score of 15 which indicated Resident #17 was cognitively intact. The MDS indicated Resident #17 required supervision with one-person physical assist from staff for activities of daily living. Record review of a care plan revised on 02/22/23 indicated Resident #17 required setup with setup with occasional assist from 1 staff member with ADLs. There was an intervention to set-up, assist, give shower as scheduled and as needed. Record review of an ADL Verification Worksheet dated 06/01/23 - 06/13/2023 indicated Resident #17 received showers on 06/02/23, 06/05/23, and 06/12/23 . The worksheet indicated Resident #17 did not receive scheduled showers on 06/07/23 and 06/09/23. Resident #17 did not have a shower for a 7-day period. Record review of Clinical Notes from 06/01/23 - 06/12/23 did not indicate any refusals by Resident #17. During an interview on 06/12/23 at 1:55 p.m., Resident #17 said she did not receive her scheduled showers. During an interview on 06/13/23 at 11:57 a.m., Resident #17 said the only time she had ever refused a shower was when she was sick but had not recently refused. She said she was scheduled for her showers on Mondays, Wednesdays, and Fridays. During an interview on 06/14/23 at 11:09 a.m., Resident #17 said she had gone up to 11 days without getting a bath or shower. She said on 6/12/2023 she went to the desk and asked staff how long they were going to go without giving her a shower. 2. Record review of the face sheet dated 06/13/23 indicated Resident #19 was [AGE] years old and admitted on [DATE] with diagnoses including heart failure, anxiety disorder, and reduced mobility. 675539 Page 15 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the MDS dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated a BIMS score of 13 which indicated Resident #19 was cognitively intact. The MDS indicated Resident #19 required limited to extensive assistance from staff for activities of daily living. Resident #19 was totally dependent for baths. Record review of a care plan revised on 02/22/23 indicated Resident #19 had been observed to make statements regarding feeling down, depressed, or hopeless. The care plan indicated Resident #19 required extensive assistance with bathing. There was an intervention to bath Resident #19. Record review of an ADL Verification Worksheet dated 06/01/23 - 06/13/2023 indicated Resident #19 received showers on 06/06/23, and 06/13/23. The worksheet indicated Resident #19 did not receive scheduled showers on 06/01/23, 06/03/23, 06/08/23 and 06/10/23. Resident #17 did not have a shower for a 5 & 7-day period. Record review of Clinical Notes from 06/01/23 - 06/12/23 did not indicate any refusals by Resident #19. During an interview on 06/12/23 at 1:51 p.m., Resident #19 said she did not always get her showers. She said she asked to be showered at times and had been told no. She said her showers were scheduled for Tuesdays, Thursdays, and Saturdays. During an interview on 06/14/23 at 10:47 a.m., LVN B said shower schedules were documented in the Daily Care Guide. She said this is an electronic medical record assessable by the CNAs. She said Resident #19 was scheduled on Tuesdays, Thursdays, and Saturdays. She said Resident #19 was scheduled on Mondays, Wednesdays, and Friday. During an interview on 06/14/23 at 11:40 a.m., CNA D said residents were to be showered 3 days a week. She said she did not know why Resident #17 or Resident #19 went 7 days without a bath. She said neither resident had ever refused care for her. She said if a resident did refuse it would have been charted in the ADL documentation. During an interview on 06/14/23 at 12:35 p.m., RN F said all residents should be bathed at least 3 days a week. She said Resident #17 and Resident #19 refuse frequently. She said the aides were supposed to report any refusals to the nurse and then the refusals are charted in the resident's documentation. During an interview on 06/14/23 at 1:42 p.m., the DON said residents should receive showers when they request them and/or on scheduled days. She said she would not expect a resident to go 7 days without a bath or shower. She said the aides should report refusals to the nurses. Then the nurses should call the family and document the refusal on the chart. During an interview on 06/14/23 at 2:40 p.m., the Administrator said residents should be showered or bathed 3 times a week as scheduled. She said a resident should not go 7 days without a shower/bath. She said refusals should be charted and they should get another staff member to go in and offer the shower even if it is at a different time. 3. Record review of a face sheet dated 06/14/23 revealed Resident #219 was a [AGE] year-old female admitted on [DATE] with a diagnosis including transient cerebral ischemic attack (stroke). 675539 Page 16 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0677 Level of Harm - Minimal harm or potential for actual harm Record review of the MDS revealed Resident #219 was admitted to the facility less than 21 days ago. No MDS for Resident #219 was completed prior to exit. Record review of Resident #219's baseline care plan dated 06/09/23 revealed alert/cognitively intact. The baseline care plan revealed Resident #219 required assist x1 for bathing, dressing, and grooming. Residents Affected - Some During an interview and observation on 06/12/23 at 11:33 p.m., Resident #219 was in her bed watching television. Resident #219 had 3-4 long nails and 2 nails on her right hand had moderate amount of black material underneath. Resident #219 said staff had not offered to clean or cut her nails. She said she liked her nails shorter and clean. During an interview on 06/14/23 at 9:01 a.m., CNA A said shower aides were responsible for resident's nail care and if there were no shower aides, then aides. She said the facility had scheduled shower aides 2-3 times a week. CNA A said on Monday night (06/12/23), Resident #219 had dirty nails. She said dirty nails were not good because of germs and scratches could get infected. During an interview on 06/14/23 at 9:15 a.m., LVN B said she was a unit manager for the facility. She said shower aides if available were responsible for nail care but if not available then the aides. LVN B said staff should inspect nails daily to three times a week. She said nail care was important to ensure resident did not hurt or scratch themselves. LVN B said dirty nails could cause infections. During an interview on 06/14/23 at 3:45 p.m., the DON said CNAs and LVNs were responsible for nail care. She said it was primarily CNAs responsibility but if a LVN noticed a resident with dirty, long nails, they should provide nail care. The DON said most resident did not want dirty nails and it was the facility's responsibility to assist them with nail care. She said it was an infection control risk for residents to have long, dirty nails. Record review of a facility A.M. CARE-EARLY MORNING CARE policy dated 03/13 revealed .responsibility .licensed nurse and nursing assistant .to refresh the patient .cleanliness, comfort and neatness . Review of a facility Bath/Shower policy dated March 2013 indicated, .Responsibility: Licensed Nurse and Nursing Assistant .Purpose: To cleanse and refresh the patient; and to observe skin . The policy did not indicate the frequency of baths/showers. Review of a facility Activities of Daily Living policy dated May 2016 did not indicate the frequency baths/showers. 675539 Page 17 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder and entered the facility with an indwelling catheter was assessed for removal of the catheter as soon as possible for 1 of 2 residents (Resident #226) reviewed for catheter use. The facility failed to remove Resident #226's indwelling catheter after admission due to no appropriate diagnosis of use. This failure placed resident at risk for urinary tract infection (is an infection in any part of your urinary system, which includes your kidneys, bladder, ureters, and urethra) and inappropriate treatment and services. Findings included: Record review of a face sheet dated 06/13/23 revealed Resident #226 was a [AGE] year-old female admitted on [DATE] with diagnoses including hemiplegia (is paralysis that affects one side of your body) following cerebral infarction (stroke) and gastrostomy (is a tube inserted through the belly that brings nutrition directly to the stomach). The face sheet did not reveal an appropriate diagnosis for an indwelling catheter. Record review of Resident #226's consolidated physician orders dated 06/23 did not reveal an order for indwelling catheter. Record review of the MDS revealed Resident #226 was admitted to the facility less than 21 days ago. No MDS for Resident #226 was completed prior to exit. Record review of a care plan dated 06/12/23 revealed Resident #226 had urinary continence and always incontinent. Intervention included check for incontinence; change if wet/soiled. During an observation on 06/12/23 at 3:00 p.m., Resident #226 was in the bed with a family member at the bedside. The family member of Resident #226 spoke to Resident #226 with no verbal reply or physical acknowledgement of voice. On the right side of Resident #226's bed was indwelling catheter bag with urine. During an interview on 06/13/23 at 9:15 a.m., a family member of Resident #226 said he did not know why his family member had catheter. He said Resident #226 had a catheter in the hospital and at this facility probably because of her bad stroke. During an observation on 06/13/23 at 2:20 a.m., Resident #226 was in bed turned on her right side. No indwelling catheter visualized. During an interview on 06/14/23 at 9:01 a.m., CNA A said Resident #226 had an indwelling catheter since admission and on 06/12/23. She said she did not why she had the catheter. CNA A said she only provided incontinence care and emptied the urine out. She said Resident #226 currently did not have the indwelling catheter. 675539 Page 18 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 06/14/23 at 9:15 a.m., LVN B said Resident #226 admitted to the facility on [DATE]. She said she arrived from the hospital with a catheter. LVN B said when a resident arrived with an indwelling catheter, the admission nurse should call the doctor for an order to keep or remove the catheter. She said Resident #226 did not have a diagnosis to support the use of an indwelling catheter. LVN B said the admission nurse should have called the doctor to get an order for removal, then removed it as soon as possible. She said unit managers did daily rounds, but unit managers were not assigned specific rooms or residents. LVN said resident needed a supporting diagnosis for indwelling catheters to decrease the risk of infection. During an interview on 06/14/23 at 3:45 p.m., the DON said she was not aware if Resident #226 had appropriate diagnoses for the indwelling catheter she had on Monday (06/12/23). She said inappropriately placed indwelling catheters placed residents at risk for infections. The DON said she expected the admission nurse to call the physician for an order to keep or removal of the catheter. A policy regarding indwelling catheter usage was requested prior to exit, the policy received only address care of an indwelling catheter. Review of Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009), www.cdc.gov was accessed on 06/20/2023 indicated .insert catheters only for appropriate indications .and leave in place only as long as needed .avoid use of urinary catheters in patients and nursing home residents for management of incontinence .Table 2 .examples of Appropriate indications for Indwelling Urethral Catheter Use .acute urinary retention or bladder outlet obstruction . 675539 Page 19 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 22 residents reviewed for respiratory care. (Resident #22, Resident #60). Residents Affected - Few The facility failed to ensure Resident #22's nebulizer mask and tubing was properly stored and dated per the facility's policy. The facility failed to assist Resident #60 with putting on and taking off her Bipap machine (a form of non-invasive ventilation that providers might use if you can breathe on your own but are not getting enough oxygen or cannot get rid of carbon dioxide). These failures could place residents at risk of respiratory complications or respiratory infection. Findings included: 1. Record review of an undated face sheet revealed Resident #22 was a [AGE] year-old, male, and admitted on [DATE] with diagnoses including respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body), acute and chronic respiratory failure with hypercapnia (result of mechanical defects, central nervous system depression, imbalance of energy demands and supplies and/or adaptation of central controllers), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), hypertensive heart disease (a long-term condition that develops over many years in people who have high blood pressure), morbid obesity with aveleoar hypoventilation (Obesity hypoventilation syndrome, or Pickwickian syndrome, is a breathing disorder that affects some people who have obesity), encephalopathy (a broad term for any brain disease that alters brain function or structure), and sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts.) Record review of the admission MDS dated [DATE] revealed Resident #22 had a BIMS of 14, which indicated he was cognitively intact. Shows that Resident #22 receives oxygen therapy. Shows that resident #22 requires extensive assistance with ADLs. Record review of the Resident #22s order summary report dated 5/13/23 revealed an order for oxygen at 4 liters per nasal cannula and formoterol fumarate 20 micrograms/2 milliliters solution for nebulization, 1 Inhalation. During an observation and interview on 06/12/2023 at 9:44 a.m. Resident # 22's nasal cannula was laying on a towel in the seat of his wheelchair not in use, not bagged, and the tubing was not labeled or dated. He stated that his nasal cannula is never labeled and dated, and it is never in a bag. He stated that he uses his nasal cannula in his wheelchair every day. He stated that he uses his oxygen everyday as well. During an observation on 6/13/2023 at 8:11 a.m. Resident # 22's nasal cannula was laying in his wheelchair seat not in use, not in a bag, and without a label or date on the tubing. During an observation on 06/14/23 08:20 AM Resident #22's nasal cannula was laying on Resident's 675539 Page 20 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wheelchair towel that was laying in the seat of the chair. Resident's nebulizer mask was laying on the floor next to his bed. Resident was eating breakfast, food was on the floor next to the nebulizer mask, and a plastic lid to a soda bottle was lying next to the nebulizer mask. During an interview on 6/14/2023 at 10:20 a.m. with the ADM she stated that she expects that her staff will store nasal cannula in a bag with their name and the date on the bag. She stated that includes nasal cannula and nebulizer masks. She stated that if staff fail to do follow these precautions residents could be placed at a higher risk for infections. During an interview on 6/14/2023 at 1:45 p.m. with the DON she stated that a resident could be placed at risk if their nebulizer or nasal canula was not stored in a bag. She stated that there was risk of contaminating the mask. She stated that oxygen tubing should be labeled and dated so that staff know when the last time the tubing had been replaced. She stated that the nurses on the night shift are responsible to replace them. She stated that the nurses change the tubing out weekly. She stated that each time a nurse enters the room they should ensure that respiratory equipment is stored in a bag. 2. Record review of the face sheet dated 06/13/23 revealed Resident #60 was [AGE] years old and admitted on [DATE] with diagnoses including pneumonia (infection that inflames air sacs in one or both lungs), obstructive sleep apnea (intermittent air flow blockage during sleep), and sleep disorder. Record review of Resident #60's physician's orders dated 06/14/23 revealed an open order dated 05/30/23 for the Bipap to be placed on Resident #60 daily at 8:00 p.m. There was an open order dated 05/30/23 for the Bipap to be removed daily at 7:00 a.m. Record review of a MDS dated [DATE] revealed Resident #60 was understood and understood other. The MDS indicated Resident #50 had a BIMS of 1 4, which indicated Resident #60 was cognitively intact. The MDS did not indicate non-invasive mechanical ventilation. Record review of a care plan dated 03/31/23 for Resident #60 did not indicate use of oxygen or the Bipap machine. Record review of a June 2023 Treatment record indicated on 06/13/23 LVN E placed the Bipap on Resident #60 at 8:00 p.m. Record review of Clinical Notes dated 06/13/23 did not indicate Resident #60 refused to wear her Bipap machine. During an observation and interview on 06/12/23 at 10:40 a.m., a family member of Resident #60 said staff had not been assisting Resident #60 with her Bipap machine. The family member said they had brought the Bipap machine and supplies to the facility. She said Resident #60 had moved to her current room approximately one week ago. She said the Bipap machine had been sitting on the dresser in the same position. She said Resident #60 told her she was not wearing her Bipap machine at night. The family member said Resident #60 had recently not been feeling well and she was afraid this was because she had not been wearing her Bipap at night . She said she had attended a meeting on 05/25/23 with the Social Worker, ADON, DON and Physical Therapy. She said the Bipap was one of the topics discussed during this meeting. During an observation on 06/13/23 at 10:41 a.m., Resident #60 asleep in bed. Bipap machine and 675539 Page 21 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0695 supplies were sitting on the dresser across the room in the exact position as 06/12/23. Level of Harm - Minimal harm or potential for actual harm During an interview on 06/13/23 at 3:40 p.m., Resident #60 said staff were not putting her bi-pap machine on her at night. She said she had been sleeping at night without the Bipap machine on. Residents Affected - Few During an observation on 06/14/23 at 5:51 a.m., Resident #60 was in her bed asleep with the lights off. She was not wearing the Bipap machine. The Bipap machine and supplies were sitting on the dresser across the room in the exact position as 06/12/23 and 06/13/23 . During an interview on 06/14/23 at 5:54 a.m., LVN E said she was the nurse for Resident #60. She said she did click off on the treatment record that Resident #60 was wearing her BiPap. She said Resident #60 was not wearing her BiPap and she had not attempted to assist her with the BiPap. She said since there was a doctor's order, nursing staff should be assisting Resident #60 with her BiPap machine. During an interview on 06/14/23 at 1:42 p.m., the DON said nursing staff should have been assisting Resident #60 with her Bipap machine. She said Resident #60 told her on the morning of 06/14/23 that she did not want to wear the Bipap. She said if the resident had refused to wear the Bipap, the refusal should have been documented and reported to the family member. During an interview on 06/14/23 at 2:40 p.m., the Administrator said if Resident #60 refused to use the Bipap machine, it should have been documented and reported to the doctor. She said then a care plan meeting should have been held to resolve the issue. She said she would have expected the resident to be assisted with the Bipap or refusals to have been documented and reported to family and the physician. Record review of facility policy titled Oxygen Storage and Protocol for Oxygen Administration revised in March of 2019 revealed that, When not in use, Oxygen cannulas and facemasks will be stored in plastic bags attached to oxygen concentrators or tank. The policy did not indicate the use of a Bipap machine. Resident #22 Respiratory Care 675539 Page 22 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation the facility failed to ensure 1 of 22 residents reviewed for psychotropic medications were given the meds to treat a specific condition. The facility failed to have an appropriate diagnosis or indication of use for Resident #38's Risperdal (antipsychotic). This failure could put residents at risk of receiving unnecessary psychotropic medications. Findings included: Record review of Resident 38's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs), dementia (group of thinking and social symptoms that interferes with daily functioning), and depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). Record review of Resident # 38's annual MDS, dated [DATE], reflected she had a BIMS score of 04, which indicated severe impaired cognitive status. Her functional status reflected she required supervision assistance with bed mobility, toilet use and personal hygiene. She required set up only for eating. The MDS revealed Resident #38 took antipsychotic and antidepressant medication routinely. No behaviors were recorded on the MDS. No signs and symptoms of depression were recorded on the MDS. Record of review of the consolidated MD orders for Resident #38 for June 2023 revealed an open order started 03/01/2023 for Risperdal (antipsychotic) 0.5 milligrams once daily for depression . Prior to 03/01/2023 Resident #38 was on Seroquel 25 mg once a day for depression. During an observation on 06/12/2023 at 10:02 a.m., Resident #38 was asleep in her bed facing the door. During an observation on 06/12/2023 at 12:30 p.m., Resident #38 was asleep in her bed facing the wall with her meal tray uneaten in front of her. During an observation on 06/12/2023 at 3:30 p.m., Resident #38 was asleep in her bed facing the door. During an observation on 06/13/2023 at 9:10 a.m., Resident #38 was asleep in her bed facing the door. During an observation on 06/13/2023 at 12:15 p.m., Resident #38 was asleep in her bed facing the door. Record review of a care plan dated 04/07/2023 revealed a care plan for the use of psychotropic medication Risperdal for Resident #38. The goal was for the resident to be free of psychotropic drug related complications, that included movement disorder, discomfort, hypotension, and gait disturbance 675539 Page 23 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0758 to include falls. Level of Harm - Minimal harm or potential for actual harm During an interview on 06/14/2023 at 3:45 p.m., the DON said she was aware Risperdal was a black box drug in the elderly dementia resident. The DON said Risperdal was not an appropriate drug to treat depression and Resident #38 was no longer having the behaviors that prompted the use of antipsychotic medications. The DON said Resident #38 did not currently have a diagnosis to support the use of an antipsychotic medication. Residents Affected - Few Review of the policy titled Texas Administrative Code dated January 15, 2021, indicated the facility would: Unnecessary Drugs. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: (A) in excessive dose (including duplicate drug therapy); (B) for excessive duration; (C) without adequate monitoring; (D) without adequate indications for its use; (E) in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (F) in any combination of the reasons stated in subparagraphs (A) - (E) of the paragraph. 675539 Page 24 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to provide specialized rehabilitative services for 1 of 22 residents reviewed for specialized rehabilitative services. (Resident #62) Residents Affected - Few The facility failed to ensure Resident #62 received occupational therapy and as per physician orders after being readmitted to the facility. This failure could place residents with orders for therapy at risk of not meeting their highest practicable well-being. Findings include: Record review of the face sheet dated 06/13/23 indicated Resident #62 was [AGE] years old and admitted on [DATE] with diagnoses including cerebral infarction (stroke), muscle weakness, and history of falling. Record review of Physician's Orders for Resident #62 dated June 2023 indicated an order dated 05/30/23 that indicated, Therapy - OT Clarification Order. Skill OT (occupational therapy) 3x/wk x 4 weeks (3 times a week for 4 weeks) .including therapeutic exercise, therapeutic activities, neuromuscular re-education, balance/safety training, ADL/self-care management, and ADL training . Record review of the MDS dated [DATE] indicated Resident #62 was understood and understood others. The MDS indicated a BIMS score of 12 which indicated moderate cognitive impairment. The MDS indicated Resident #62 required extensive assistance from staff for activities of daily living. Record review of a care plan revised on 05/09/23 indicated Resident #62 had a history of a stroke with left sided hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscle). There was an intervention for therapy referral as needed. Record review of an Occupational Therapy, OT Evaluation & Plan of Treatment with a start of care date of 05/30/23 indicated a certification period of 05/30/2023 - 06/28/2023. The Plan of Treatment indicated, Treatment approaches may include therapeutic exercises, neuromuscular re-education, occupational therapy evaluation .therapeutic activities, self-management training, Frequency: 3 times/week, 4 weeks daily . There were no further evaluations. Record review of Occupational Therapy Treatment Encounter Notes indicated Resident #62 received therapy treatment on 05/30/23 and 06/01/23. Resident #62's electronic medical record was reviewed on 06/13/23 and there were no further Occupational Therapy Treatment Notes. Record review of Clinical Notes dated 06/01/23 - 06/13/23 indicated on 6/5/23 at 2:29 p.m. Resident #62 was experiencing complete loss of movement to left extremities along with L (left) sided facial droop. Resident #62 was sent to the hospital for assessment. A note on 06/06/23 at 5:51 p.m. indicated Resident #62 had returned to the facility from the hospital. During an observation and interview on 06/12/23 at 1:48 p.m., Resident #62 was in bed watching television. Resident #62 said she wanted to receive therapy. She said she had received therapy, but it had stopped. She said she did not know why she is not on therapy. She said she really wanted to get 675539 Page 25 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few out of bed. She said when she asked the aides they tell her no. She said they told her they were scared to get her up because she would fall. She said she would at least like to get up and sit up in a chair. During an observation on 06/12/23 at 3:39 p.m., Resident #62 in the bed watching television. During an observation and interview on 06/13/23 at 8:41 a.m., Resident #62 was in bed watching television. Resident #62 said she was not gotten up out of bed on 06/12/23. She said she had not asked to get up the morning of 06/13/23. She said, I cannot tell the girls because they will not get me up if I do not have therapy. She said she received therapy in the hospital and cannot understand why she is not receiving therapy in the facility. During an observation and interview on 06/13/23 at 10:29 a.m., Resident #62 was in bed. She said she had not been up all morning. During an observation and interview on 06/13/23 at 2:28 p.m., Resident #62 was in bed. Resident #62 said she was gotten up out of bed earlier. She said she just stayed in her room. She said it felt good to sit up. She said she still had not received any therapy. During an interview on at 06/14/23 at 9:10 a.m., the Rehabilitation Department Director said if a resident was on Medicaid once the resident was discharged from the facility they had to be re-evaluated when they returned to the facility. He said Resident #62 was Medicaid only. He said the order was put into the system by an occupational therapist. He said they had evaluated the resident and were giving her 5 Pro bono therapy sessions while trying to get authorization from Medicaid . He said the resident had completed two sessions. He said in the two years he had worked at the facility he had only one resident be approved for therapy through Medicaid. He said Resident #62 had a new stroke. He said they are waiting on the doctor to write an order saying she needed to be in a facility setting and not an outpatient setting. He said the facility was out of network for Medicaid Skilled Therapy. He said since she was out of the facility overnight she would have to be discharged from therapy and then re-evaluated. He said since her stroke was a new stroke, timely therapy would be beneficial to regain her function that was lost. He said without therapy she would not progress as quickly as she would with therapy. He said if an authorization was not approved the resident could still receive restorative therapy, but she would still need to be re-evaluated to put her on the restorative plan. During an interview on 06/14/23 at 12:00 p.m., CNA A said she was very familiar with Resident #62. She said when Resident #62 was first admitted she was able to walk and go to the bathroom on her own. She said she was not sure if Resident #62 ever received therapy. She said when Resident #62 was sent to hospital on 6/5/2023 she had a stroke and when she returned on 6/6/2023 she could no longer walk, and she was weak on her left side. She said she was now requiring more help. She said Resident #62 had been sad because she wanted to get up and take care of herself and one day go home. During an interview on 06/14/23 at 1:42 p.m., the DON said Resident #62 was originally admitted to the facility after having a stroke. She was then sent to the hospital on 6/5/2023 for weakness to her face and not acting normal. She was admitted to the hospital overnight for observation and returned to the facility the next day, 6/6/2023. She said she would not have expected the therapy department to re-start her therapy sessions when she returned to the facility because her payor source was Medicaid. She said she would have expected for Resident #62 to have been screened by the therapy department after returning to the facility. She said Resident #62 would have qualified for restorative 675539 Page 26 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few therapy but would still need to be re-evaluated by the therapy department . She said the therapy department would then create a plan of care for the restorative aides to follow. She said she did feel Resident #62 should have been re-evaluated before 6/14/2023. She said the resident not receiving therapy could cause her to lose abilities she had prior to her hospitalization. During an interview on 06/14/23 at 2:40 p.m., the Administrator said Resident #62 should have been re-evaluated by therapy when she returned to the facility on 6/6/2023. She said a doctor's order should have been obtained and an authorization requested through Medicaid. She said all residents qualify for restorative therapy. She said she would have expected the resident to have been re-evaluated between 6/6/2023 - 6/14/2023 and the resident should have received some form of therapy. She said the resident was not going to improve and could have a decline without therapy. On 06/20/23 an email was sent to the Administrator requesting a policy concerning therapy. The policy was not received prior to survey exit. Review of Rehab Therapy after a Stroke by the American Stroke Association dated 05/30/23 and was accessed on 06/21/23 at https://www.stroke.org/en/life-after-stroke/stroke-rehab/rehab-therapy-after-a-stroke indicated, .The long-term goal of rehabilitation is to help the stroke survivor become as independent as possible. Ideally this is done in a way that preserves dignity and motivates the survivor to relearn basic skills like bathing, eating, dressing and walking. Rehabilitation typically starts in the hospital after a stroke. If your condition is stable, rehabilitation can begin within two days of the stroke and continue after your release from the hospital . 675539 Page 27 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #19 FTag Initiation Residents Affected - Few Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 22 residents (Residents #19 and Resident #223) reviewed for infection control practices. The facility to ensure the WCN performed a sterile dressing change on Resident #223. The facility failed to ensure CNA D changed gloves and practiced good hand hygiene during incontinent care provided to Resident #19. These failures placed residents at risk for cross contamination and infection. Findings include: 1. Record review of a face sheet dated 06/13/23 revealed Resident #223 was an [AGE] year-old male admitted on [DATE] with diagnoses including cerebral infarction (stroke) due to thrombosis (blood clot) and pain. Record review of Resident #223's consolidated physician order dated 06/01/23 revealed wound treatmentcalcium alginate (are designed to absorb wound exudate, form a gel that keeps the wound moist and protect the wound from contamination), cleanse wound to sacrum with normal saline or skin cleanser. Pat dry. Apply calcium alginate to wound bed. Cover with dry dressing. Record review of an admission MDS dated [DATE] revealed Resident #223 was sometimes understood and sometimes understood others. The MDS revealed Resident #223 had a BIMS (cognitive/mental status) of 00 which indicated severe cognitive impact and required extensive assistance for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene but total dependence for bathing. The MDS revealed Resident #223 had 1 unstageable (is a term that refers to an ulcer that has full thickness tissue loss) with slough (yellow dead tissue) and/or eschar (black dead tissue) pressure ulcer and 1 unstageable with deep tissue injury (is an injury to the soft tissue under the skin due to pressure). Record review of a care plan dated 06/01/23 revealed Resident #223 had a pressure ulcer stage 3 (injuries extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) located on sacrum. Intervention included treatment to pressure ulcer per physician's order and assess pressure ulcer during treatment. During an observation on 06/14/23 at 2:30 p.m., the WCN provided wound care to Resident #223 sacrum pressure ulcer. During the dressing change, the WCN tucked Resident #223's dirty brief underneath his side then placed a piece of calcium alginate to the wound bed. The WCN grabbed another piece of calcium alginate, it dropped on Resident #223's bed sheet, she picked up the piece and placed the dressing in the wound bed. The WCN covered the sacrum wound with a dry dressing. 675539 Page 28 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 06/14/23 at 3:00 p.m., the WCN said she recalled during the wound dressing change touching Resident #223's used brief then grabbed the calcium alginate and placed it in the wound bed. She said she also dropped a piece of calcium alginate of Resident #223's bed and placed it in the wound. The WCN said both incidents were not appropriate and sterile. She said she should have changed gloves after she touched Resident #223's brief and got a new piece of calcium alginate to place in his wound. The WCN said she placed Resident #223 at risk for developing a wound infection and continually deterioration of his wound. would During an interview on 06/14/23 at 3:45 p.m., the DON said she expected the nursing staff to maintain good, clean technique during dressing changes. She said good, clean technique prevented infections. The DON said infections placed residents at a lot of risks. She said the facility would start weekly dressing change check offs, but skills check offs were done yearly. During an interview on 06/14/23 at 4:00 p.m., the administrator said she expected nurses to do dressing changes correctly. She said the WCN should be highly skilled and performed wound care properly. Review of Techniques for aseptic dressing and procedures (2015) by [NAME] Puckering and [NAME], www.ncbi.nlm.nih.gov was accessed on 06/20/2023 indicated .when applying or changing dressings, an aseptic technique is used in order to avoid introducing infections into a wound .never re-introduce them to a clean area once they have been contaminated . 2. Record review of the face sheet dated 06/13/23 indicated Resident #19 was [AGE] years old and admitted on [DATE] with diagnoses including heart failure, anxiety disorder, and reduced mobility. Record review of the MDS dated [DATE] indicated Resident #19 was understood and understood others. The MDS indicated a BIMS score of 13 which indicated Resident #19 was cognitively intact. The MDS indicated Resident #19 required limited to extensive assistance from staff for activities of daily living. Record review of a care plan revised on 02/22/23 indicated Resident #19 had been observed to make statements regarding feeling down, depressed, or hopeless. The care plan indicated Resident #19 required extensive assistance with personal hygiene and toileting. During an observation on 06/12/23 at 11:05 a.m., CNA D provided incontinent care to Resident #19. CNA G cleaned up fecal matter during the incontinent care. After cleaning the fecal matter, CNA D did not change her gloves before touching the clean brief, clean sheet and blanket, and clean pads. After touching the clean items, CNA D did change her gloves but did not wash or sanitize her hands before applying the clean gloves and continuing care. During an interview on 06/12/23 at 11:15 a.m., CNA D said she was a new CNA, and she was nervous for having to provide care in front of the state surveyor. She said while providing care, she realized she had on dirty gloves after she touched the clean brief, bed covers, and pads. She said she changed her gloves once she realized it. She said you would want to change your gloves after cleaning a bowel movement to prevent cross contaminations. During an interview on 06/14/23 at 12:35 p.m., RN F said not changing your gloves or washing your hands is an infection control issue. She said any time your gloves might be soiled, they should be changed, and you should wash your hands. 675539 Page 29 of 30 675539 06/14/2023 The Bradford at Brookside 301 West Park Drive Livingston, TX 77351

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 06/14/23 at 1:42 p.m., the DON said staff should always change their gloves between anything that was soiled an anything that was clean. She said should wash or sanitize their hand appropriately. She said possible infection was the biggest issue . During an interview on 06/14/23 at 2:40 p.m., the Administrator said an aide should have put everything in a dirty bag. Then her gloves should have been removed. She said the aide should have washed or sanitized her hands before continuing care. She said the aide contaminated everything by not changing her gloves or washing her hands. Review of a facility Handwashing/Hand Hygiene policy dated 08/2019 indicated, .This facility considers hand hygiene the primary means to prevent the spread of infection .wash hands with soap and water .use an alcohol-based rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .before moving from a contaminated body site to a clean body site during patient care . 675539 Page 30 of 30