Health inspection·March 31, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 5 (Resident #1) residents reviewed for grievances. The facility did not thoroughly investigate or take prompt action to resolve grievances voiced by Resident #1 that she did not want CNA A or CNA B enter her room or provide care. This failure could place residents at risk of unresolved grievances and decreased quality of life. Findings included: Record review of Resident #1's face sheet indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included dementia (loss of cognitive functioning), anxiety (intense, excessive and persistent worry and fear about everyday situations), schizophrenia (serious mental health condition that affects how people think, feel and behave), unspecified mood disorder (complex mental health condition), paranoid personality disorder (mental health condition marked by a long-term pattern of distrust and suspicion of others without adequate reason to be suspicious (paranoia). People with PPD often believe that others are trying to demean, harm or threaten them.), major depressive disorder (persistent feeling of sadness and loss of interest), and bipolar disorder (mental health condition that causes extreme mood swings). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated she was able to make herself understood and understood others and she was cognitively intact (BIMS-15). Record review of Resident #1's care plan dated 08/25/23 indicated she had a history of confabulation (a memory error consisting of the production of fabricated, distorted, or misinterpreted memories about oneself or the world. It is generally associated with certain types of brain damage (especially aneurysm in the anterior communicating artery) or a specific subset of dementia) presented false information she believed to be true, and indicated aides did not provide the right care. Interventions included allow resident to verbalize feelings, redirect resident during episodes of confabulation, psych consult as ordered, and report to MD as needed and document episodes of confabulation in the clinical record. Record review of Resident #1's care plan dated 04/06/2021 indicated Resident #1 had a behavior problem related to confabulation, schizophrenia, major depressive disorder, and bipolar disorder. Interventions included administer medications as ordered, anticipate and meet her needs, and assist her to develop more appropriate methods of coping and interacting without confabulation. Page 1 of 4 675595 675595 03/31/2025 Harmony Care at Beaumont 2660 Brickyard Rd Beaumont, TX 77703

F 0585 Level of Harm - Minimal harm or potential for actual harm Record review of a grievance dated 02/05/25 and written by previous Administrator K indicated Resident #1 did not want CNA A or CNA B. Resident #1 could not tell me why she did not want the employee in her room. The DON indicated there was no CNA B employed with the facility (this was an error due to the name documented and it was not recognized by the DON). The DON informed CNA A not to go in Resident #1's room. Grievance was noted as resolved and Resident #1 said thank you and had no other concerns. Residents Affected - Few Record review of a grievance dated 02/12/25 and written by Resident #1 indicated she wanted CNA A and CNA B banned from her room related to putting on her diaper wrong and provoking her by not doing things as she asked. ADON E noted Resident #1 refused care from certain aides because she liked certain aides better and was used to them. Resident #1 was informed the facility could not assign specific aides to Resident #1. The grievance was not completed as resolved or if Resident #1 was satisfied with the resolution. Record review of an undated grievance completed by the SW indicated Resident #1 did not like how CNA A set her meal tray down, the tray was not set up right and she did not want CNA in her room. The SW asked Resident #1 how she wanted her tray and Resident #1 directed the SW to set the tray up. The grievance was noted as resolved and Resident #1 was satisfied. There was no indication which aide was not wanted in her room or how it was addressed or resolved. Record review of the facility staffing sheets indicated CNA A was assigned to provide care for Resident #1 on 03/05/25, 03/12/25, 03/24/25, and 03/30/25. Record review of facility staffing sheets indicated CNA B was assigned to provide care for Resident #1 on 02/07/25, 02/10/25, 02/12/25, 02/18/25, 03/08/25, 03/13/25, 03/14/25, and 03/22/25. During an interview on 03/30/25 at 9:10 a.m., MA G said Resident #1 complained about CNAs if she did not like how they did something. She said she was aware there were certain staff that Resident #1 did not want in her room. She said CNA A was assigned to provide Resident #1's care. During an interview on 03/30/25 at 9:20 a.m., CNA A said she was assigned to provide Resident #1's care. She said she was not informed she was not supposed to go in to Resident #1's room or provide care. She said she was aware there was some staff Resident #1 did not like and those staff did not go in her room. During an interview on 03/30/25 at 10:00 a.m., Resident #1 said she did not want CNA A or CNA B in her room or providing care. She said she felt they were not nice. She said she felt unsafe and afraid. She said told ADON E and other staff but could not recall who else she told. She could not recall the date she told ADON E. She did not tell the Administrator but she did tell other staff. She did not want to identify the other staff. She said the staff caused her anxiety because they did not do things right or how she wanted. She said it was abusive because the staff did not provide her care how she wanted. During an interview on 03/30/25 at 11:06 a.m., LVN H said Resident #1 said she does not want certain staff in her room. She said when she was made aware of it, she would switch the assigned aide or do the care herself. She said she was not aware of a list of staff who were not supposed to go in Resident #1's room or provide care. During an interview on 03/30/25 at 1:00 p.m., Resident #1 said CNA C came in her room on 03/30/31 675595 Page 2 of 4 675595 03/31/2025 Harmony Care at Beaumont 2660 Brickyard Rd Beaumont, TX 77703

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and told her CNA A was assigned to her and would complete her care. She said she did not want CNA A and CNA C said she was too busy. During an interview on 03/30/25 at 1:34 p.m., the SW said the previous administrator was the grievance official until the new administrator (Administrator J) took over and made her (the SW) the grievance official. She said she was the grievance official for approximately 1 month. She said she could not recall the exact date of the grievance she completed for Resident #1 related to CNA A not setting up Resident #1's tray as she wanted. She said she did not address which aide Resident #1 did not want in her room. During an interview on 03/31/25 at 9:08 a.m., Administrator J said she was in the position for one month. She said the SW was the grievance official. She said the facility would try to best to accommodate Resident #1's request but sometimes there would not be enough staff or the staff she wanted so she would agree to care with a staff she did not want and a witness. She said she was not aware of any complaints or grievances related to CNA A but was aware she did not want CNA B in her room. She said if she were aware Resident #1 did not want a particular staff in her room, she would get someone else to go to the room. She said a few times there was no staff she wanted so Resident #1 agreed to a staff and a witness. During an interview on 03/31/25 at 9:20 a.m., ADON E said Resident #1 told her she did not want CNA D and CNA I in her room but agree to let CNA D provide care after she was retrained. She said there was no allegations of abuse. She said Resident #1 indicated the staff were rushing and leaving. She said the facility was running out of options because Resident #1 only wanted certain staff to provide care for her. She said Resident #1 did not say she did not want CNA A or CNA B in her room or providing care. During an interview on 03/31/25 at 10:56 a.m., the DON said she was not aware Resident #1 did not want CNA A or CNA B in her room to provide care. She said she was not aware of the grievance dated 02/05/25. She said ADON F did not write any grievances related to Resident #1 saying she did not want CNA A or CNA B. During an interview on 03/31/25 at 11:57 a.m., Administrator J if aides were assigned to provide care to Resident #1 and it was aides she did not want then they should have been re-assigned and another staff would have to provide her care. She said Resident #1 was at risk of feeling a certain way, like she was not being heard if aides continued to provide care that she did not want providing her care. During an interview on 03/31/25 at 12:04 p.m., previous Administrator K said he was made aware Resident #1 did not want CNA A and CNA B in her room or providing care but could not recall the date of the grievance. He said he informed the DON and he believed the staff were verbally told not to go in Resident #1's room. He said Resident #1 did not like how certain staff provided care. During an interview on 03/31/25 at 12:24 p.m., ADON F said she gave Resident #1's grievance related to staff she did not want to the DON. She said she did not recall exactly what Resident #1 said or which staff she did not want in her room. Record review of the facility's Complaints/Grievance policy revised 06/19 indicated It is the policy of this facility to adopt a process to support the resident's right to voice complaints/grievances to facility management and have those grievances/complaints investigated and resolved in a 675595 Page 3 of 4 675595 03/31/2025 Harmony Care at Beaumont 2660 Brickyard Rd Beaumont, TX 77703

F 0585 Level of Harm - Minimal harm or potential for actual harm reasonable timeframe. 9. Grievances/complaints can be taken by any staff member and documented on a Concern Form. The concern form is then forwarded to the Grievance Official. 10. Immediately upon receiving a grievance/complaint, facility Leadership will seek a resolution and will keep the resident informed of the progress of the investigation/resolution. 11. The Facility will take immediate action to prevent further potential violation of any resident right while the alleged violation is being investigated Residents Affected - Few 675595 Page 4 of 4