Health inspection·September 12, 2024

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, interview, and record review, the facility failed to ensure each resident was treated with respect and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #1) of 4 residents reviewed for resident rights. The facility failed to honor Resident #1's request of being assisted out of bed between 8:30 and 9:00 AM on 09/12/2024. This failure could place resident at risk for depression, diminished quality of life and isolation. Findings included: Record review of Resident #1's face sheet, dated 09/12/2024, reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a condition that occurs when the right side of the brain is damaged, resulting in physical disabilities on the left side of the body), depression, unspecified (disorder than can impact your mood, thoughts and feelings, weight, sleeping habits, etc.), tobacco use (a plant with leaves that have high levels of the addictive chemical nicotine), age-related physical debility (a symptom of frailty, a syndrome that occurs as people age and their bodies decline). Resident #1 was her own responsible party. Record review of Resident #1's MDS admission Assessment, dated 07/22/2024, reflected Resident #1 had a BIMS score of a 10, which indicated her cognition was moderately impaired. Resident #1 required mechanical lift with transfers. Record review of Resident #1's Comprehensive Care Plan , revised on 07/27/2024, reflected Resident #1 had a diagnosis of depression (disorder than can impact your mood, thoughts and feelings, weight, sleeping habits, etc.), had a history of depression and was at risk for episodes of depression and adverse reactions ( fatigue, digestive issues, weight gain or loss, and/or dry mouth). Interventions: Encourage Resident #1 to be an active participant in decision making. Encourage Resident #1 to be involved in activities of choice and preferences. Monitor for impending episodes of depression and document in the clinical record. Resident #1 had pressure wound. Intervention: Assist with turn and re-positioning during rounds and as needed. Keep family/ RP/MD informed of resident's progress. Provide pressure reducing device for bed and wheelchair. Resident #1 had potential for pain. Intervention: Encourage socialization and activity attendance as tolerated. Resident #1's comprehensive care plan did not reflect any documentation of her smoking. Page 1 of 8 675564 675564 09/12/2024 Harmony Care at Giddings 1181 N Williamson Giddings, TX 78942

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's electronic medical record on 09/12/2024 reflected there were no records/ documentation indicating Resident #1 may not be out of bed or how much time she may be allowed to be out of bed. There was no documentation of any restrictions of resident smoking from the attending physician or the Director of Nurses. Record review of Resident #1's admission file reflected she did not have an admission file of any signed documents. Resident #1 was her own responsible party. admission documents including resident rights was not reviewed with resident upon day of admission. There were not any facility admission records reviewed with Resident #1. The facility did not have any admission records on Resident #1. Record review of Resident #1's 15 minute round checklist, dated 9/11/2024 reflected the staff completed 15 minute checks on Resident #1 until she was transferred to hospital. Observation on 09/12/2024 at 7:30 until 9:00 AM revealed there were residents being assisted out of bed into wheelchairs and residents sitting in the dining room, lobby, and common areas. Resident #1 was not in the smoking area at 9:00 AM smoke break. Resident #1 was in her room in bed at 9:00 AM Interview on 09/12/2024 at 8:30 AM Resident #1 was in her room lying in bed. She stated she told one of the staff she wanted to get out of bed by 9:00 AM for smoke break. She stated she preferred to get up in the morning for the first smoke break. Resident #1 stated this was when she wanted out of bed in the morning and she liked to take naps in the afternoon. She stated she did have a wound on her bottom but she was able to be out of bed and it does not hurt when she is up in her chair approximately two hours. She stated she becomes depressed sometimes and feels lonely in her room when she remains in bed most of the day. She stated she has asked staff to help her out of bed and the staff will say they will need to get someone to help them to get her out of bed and no one comes back to her room and assists her out of bed. Resident #1 stated no one had discussed with her about not being able to get out of bed. She stated the nurses had not mentioned to her she was not able to get out of bed for any reason. Resident #1 stated she will ask to get out of bed not only to go smoke but she would want to do artwork in her room to help her from becoming depressed and the staff will not assist her out of bed. She stated she was very depressed yesterday and asked to be assisted out of bed and the staff refused. Resident #1 stated she made a statement she would hurt herself and within few minutes the staff assisted her out of bed and assisted her to the dining room for a meal. She stated she was out of bed over an hour and the staff did not have an issue to assist her out of bed when she made this statement. Resident #1 stated she does become anxious and depressed. She stated when she does not get a cigarette this makes her anxiety increase and she does feel more depressed because what she enjoys doing the most is smoking and it gives her some enjoyment in life. She also stated she preferred to socialize with residents during smoking times. During smoking times was when she preferred to meet new friends instead of activity programs. Smoking was her activity and socialization time. She stated she was not informed of the facility's rules on smoking when she was admitted to the facility and she was not presented any form about smoking. Resident #1 stated she only said that she was going to hurt herself due to the staff would not assist her out of bed. Observation on 09/12/2024 from 9:00 AM to 9:30 AM revealed Resident #1 remained in bed. Interview on 09/12/2024 at 9:30 AM Resident #1 stated she requested two times to be assisted out of bed and the staff stated they may help her at a later time. She stated she wanted to go to smoke at 9:00 AM and was not able to go because no one would assist her out of bed. Observation on 09/12/2024 at 11:45 AM revealed Resident #1 was up in her wheelchair and stated she 675564 Page 2 of 8 675564 09/12/2024 Harmony Care at Giddings 1181 N Williamson Giddings, TX 78942

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few did go to the 11:00 smoke break but she wanted to be assisted out of bed before 9:00 but they did not give her a reason why they could not get her up at that time and she had to wait about 2 hours. In an interview on 09/12/2024 at 1:20 PM Anonymous Staff A stated Resident #1 required two staff members to assist her out of bed and sometimes it was easier to assist her out of bed later in the day. Anonymous Staff A did not answer any other questions about the reason it was easier to assist Resident #1 out of bed later in the day. Anonymous Staff A stated Resident #1 would sit up for hours when she was out of bed and it did not affect her wound and Resident #1 did not complain of pain when she was out of bed. Anonymous Staff A stated no one had informed nursing staff Resident #1 was not to be out of bed and sitting her wheelchair and was not informed Resident #1 was only to be out of bed a certain amount of time. Anonymous staff A stated the facility staff did not have residents except for Resident #1 which required more care and it was easier to give care to other residents than Resident #1. Anonymous Staff A stated if a resident wanted to get out of bed they had a right to get out of bed and not have to wait for few hours before receiving assistance. Anonymous Staff A stated there was time to assist Resident #1 out of bed when she requested before 9:00 AM today (09/12/2024). Anonymous Staff A stated any nurse could assist with resident care even assisting resident out of bed. Anonymous Staff A stated there were no meetings or instructions of any restrictions with Resident #1's smoking. In an interview on 09/12/2024 at 2:00 PM Director of Nurses B stated Resident #1 was out of bed during the day. She stated Resident #1 did have a wound on her buttocks. Director of Nurses B stated there was not any record that indicated Resident #1 was not to be out of bed and no record indicated the amount of time she was to be out of bed or in bed. Director of Nurses B stated if a resident asks to be assisted out of bed the staff was to assist the resident out of bed. Director of Nurses B stated she could not answer if it was a resident right to be assisted out of bed when they requested and the staff was available when the resident requested to be assisted out of bed. She stated this was a privilege and not a right. She stated Resident #1 would want to be assisted out of bed to go smoke and if this is the only reason she wants to be out of bed it is a privilege and not a right. She stated Resident #1 was being referred to psych services. In an interview on 09/12/2024 at 2:40 PM Director of Nurses B stated if a resident wanted to be assisted out of bed and they had a wound they did not need to be out of bed but maybe less than 10 minutes. She stated Resident #1 did enjoy doing crafts in her room and she did sit up and do crafts. Director of Nurses B stated if Resident #1 requested to be out of bed to do crafts she could not answer if this was a right or privilege. In an interview on 09/12/2024 at 3:05 PM CNA C stated she had not always assisted Resident #1 out of bed so she can go smoke. She stated there had been times she would want to be assisted out of bed to do some crafts in her room and sometimes it may be 3 or 4 hour later and Resident #1 would not want to get out of bed at that time due to being around 9:00 PM. She stated if she wants to be assisted out of bed to go smoke the staff was not required to assist her out of bed due to it is a privilege to go smoke and they do not have to assist her out of bed. CNA C stated it was difficult to assist her out of bed if she wants to do crafts and then she would want to go back to bed. CNA C said they would assist her back to bed around 4:00 PM and she would want to be assisted out of bed for the 8:00 PM smoke break and it was too difficult to assist her to bed at 4:00 PM and assist her out of bed again at 8:00 PM. She stated there were other residents they would assist to bed and then assist out of bed but these residents only required one person assist and not two person assist. She stated there were enough staff to assist her in and out of bed but it was too difficult sometimes and especially if she only wanted to go smoke. 675564 Page 3 of 8 675564 09/12/2024 Harmony Care at Giddings 1181 N Williamson Giddings, TX 78942

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 09/12/2024 at 3:40 PM the Administrator stated if a resident wanted to get out of bed and the staff had time to assist the resident out of bed it was their right to be out of bed. She stated if a resident wanted out of bed to go smoke that was a privilege and not a resident right to assist her out of bed to go smoke. The Administrator stated if a resident wanted to be assisted out of bed to do crafts in their room or to be up to do something else that would be their right to be assisted out of bed to do those things but not to go smoke. She stated a resident did have a right to get out of bed when they requested. She stated the facility had a smoking form to explain the facility smoking protocol was a privilege and the smoking privilege can be taken away from a resident The Administrator said Resident #1 did not sign this form and she did not have any admission paperwork including resident rights signed by Resident #1. She stated Resident #1 was her own responsible party. She stated Resident #1 did not sign any of the facility's admission paperwork. The administrator stated they did not have an admission file on Resident #1. In an interview with Resident #1 at 4:15 PM Resident #1 stated she was her own responsible party and she did not sign any forms when she was admitted to this facility. She stated no one discussed facility rules, resident rights, smoking form, or anything about what to expect in this facility. In an attempted interview on 09/12/2024 at 3:45 PM with the MD on the MD did not return the phone call. Record review of the Facility Policy of Resident Rights , not dated, reflected the resident , do not give up any rights when you enter a nursing facility. The facility must assist you to fully exercise your rights. Any violation of these rights is against the law. You have a right to : all care necessary for you to have the highest possible level of health. Be treated with courtesy, consideration , and respect. Participate in activities inside and outside the facility. Record review of the Residents Smoking policy, not dated, reflected the following: This facility shall establish and maintain safe resident smoking practices. 1. Prior to, or upon admission, residents shall be informed about any limitations on smoking, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences; for example, in making room assignments. 2. The staff shall consult with the Attending Physician and the Director of Nursing Services to determine any restrictions on a resident's smoking privileges. 3. Any smoking-related privileges, restrictions, and concerns shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 675564 Page 4 of 8 675564 09/12/2024 Harmony Care at Giddings 1181 N Williamson Giddings, TX 78942

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to ensure the comprehensive care plans for Resident #1 included ADLs, behaviors, and diagnosis of mental illness on 07/25/2024. This failure could affect residents by placing them at risk of not receiving appropriate physical and psychosocial care. Findings included: Record review of Resident #1's face sheet , dated 09/12/2024, reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a condition that occurs when the right side of the brain is damaged, resulting in physical disabilities on the left side of the body), depression, unspecified (disorder than can impact your mood, thoughts and feelings, weight, sleeping habits, etc.) age-related physical debility ( a symptom of frailty, a syndrome that occurs as people age and their bodies decline), schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, and emotional responsiveness), bi-polar disorder (a mental illness that causes extreme shifts in mood and energy) and, tobacco use (a plant with leaves that have high levels of the addictive chemical nicotine). Record review of Resident #1's MDS admission Assessment, dated 07/22/2024, reflected Resident #1 had a BIMS score of a 10, which indicated her cognition was moderately impaired. Resident #1 required mechanical lift with transfers. Resident #1 had verbal behavior symptoms. She had impairment with lower extremity. Resident #1 required maximal assistance (helper does more than half the effort) with eating and rolling left and right. Resident #1 was dependent on staff for oral hygiene, toileting, showers, lower body dressing, putting on/taking off footwear, personal hygiene, sit to lying position, lying to sitting on side of bed, and wheeling in manual wheelchair. Resident #1 was frequently incontinent of bladder and always incontinent of bowels. Record review of Resident #1's Comprehensive Care Plan, dated, 07/25/2024 reflected no care planning for ADLs such as: require mechanical transfers, eating, hygiene, toileting, showers, dressing, positioning in bed, type of ambulation and if resident able to propel self. Resident #1's behaviors, diagnosis of schizophrenia , bi-polar disorder, and tobacco use were not documented on Resident #1's care plan. In an interview on 09/12/2024 at 2:40 PM the Director of Nurses stated Resident #1's ADLs including the following: Hygiene, transfers with mechanical lift, toileting, showers, eating abilities, dressing, repositioning in bed and type of ambulation was required to be on the comprehensive care plan. She stated if a resident had a mental illness such as schizophrenia and bi-polar and any type of behaviors it was to be also care planned. The Director of Nurses stated the staff would not know the 675564 Page 5 of 8 675564 09/12/2024 Harmony Care at Giddings 1181 N Williamson Giddings, TX 78942

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few type of care a resident needed if it was not care planned. She stated all staff was to follow the care plan to know what type of care each resident needed. She stated the MDS Coordinator was not in the facility. In an interview on 09/12/2024 at 3:05 PM CNA C stated she knew about care plans and what is documented on the care plan is what type of care a resident needed and if it was not documented it would be difficult to know the care every resident needed. She stated she thought she knew what type of care Resident #1 needed and she knew she needed all of her care to be completed by the staff. CNA C did not respond to any specific questions about Resident #1's care. In an interview on 09/12/2024 at 3:40 PM the Administrator stated anything documented on the MDS was to be care planned. She stated all residents' psychosocial and physical needs were to be care planned. She stated if Resident #1's care plan did not have behaviors, ADLs, and psychiatric diagnosis on the care plan it would be difficult to know the correct care to give to Resident #1. The Administrator stated it was the MDS/ Care plan coordinator's responsibility to ensure all care plans were completed according to the MDS and each residents' specific needs. She stated a resident may have a decline in quality of life or quality of care if their care plan was not completed accurately and was not person centered. In an interview with Resident #1 at 4:15 PM she stated she did not feel her ADLs needs were being met by the staff. Resident #1 stated she did not believe the staff knew how to turn and position her in bed or how to give her personal hygiene care. She stated she believed they needed more training on how to care for residents who was overweight like her. Record review of the Facility's Comprehensive Assessments and the Care Delivery Process, not dated, reflected the following: Comprehensive assessments will be conducted to assist in developing person-centered care plans. Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing, and initiating interventions, and then monitoring results and adjusting interventions. Assessment and information collection includes (what, where and when?). The objective of the information collection (assessment) phase is to obtain, organize, and subsequently analyze information about a patient. Assess the individual. Gather relevant information from multiple sources, including: 1. Observation. 2. Physical assessment. 3. Symptom or condition-related assessments (Braden (tool to predict the risk of pressure ulcers, AIMs Abnormal Involuntary Movement Scale, a rating scale used to assess the severity of involuntary movements in patients taking neuroleptic medications, falls, etc.); 4.Resident and family interview. 675564 Page 6 of 8 675564 09/12/2024 Harmony Care at Giddings 1181 N Williamson Giddings, TX 78942

F 0656 5.Hospital discharge summaries. Level of Harm - Minimal harm or potential for actual harm 6. Consultant reports. 7. Lab and diagnostic test results; and Residents Affected - Few 8. Evaluations from other disciplines (for example, dietary, respiratory, social services, etc.). 9. Complete the Minimum Data Set within 14 days after admission, within 14 days after it is determined that the resident has had a significant change in physical or mental condition, and annually. Information analysis steps include (How and Why?). Define issues, including problems, risk factors, and other concerns (to which all disciplines can relate). Define conditions and problems that are causing, or could cause, other problems. 1. Identify potential causes or contributing factors of problems and symptoms, including: a. Medical. b. Psychosocial. c. Environmental; and Functional. d. Arrange conditions, problems and outcomes in their proper order based on the information gathered in steps I and 2. e. Try to determine the interrelationship between existing problems. f. Determine the most plausible relationships between conditions. g. Define current treatments and services; link with problems/diagnoses. h. Identify the current interventions and treatments; and i. Link these to problems and diagnoses they are supposed to be treating. j. Identify overall care goals and specific objectives of individual treatments. k. Evaluate whether or not these treatments are accomplishing the anticipated results. l. Make decisions about care and treatment. m. Apply clinical reasoning to assessment information and determine the most appropriate interventions. n. Decision making leading to a person-centered plan of care includes: 675564 Page 7 of 8 675564 09/12/2024 Harmony Care at Giddings 1181 N Williamson Giddings, TX 78942

F 0656 o. Selecting and implementing interventions, based on the results of the above. Level of Harm - Minimal harm or potential for actual harm Monitoring results and adjusting interventions includes: a. Periodically reviewing progress and adjusting treatments. Residents Affected - Few b. Continue to define or refine the objectives of specific treatments as well as overall care and services. 675564 Page 8 of 8