Health inspection·April 4, 2023

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** The facility failed to ensure that all written grievance decisions included date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusion regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued for 1 of 8 residents (Resident # 10) reviewed for grievances. The facility failed to provide rationale or response to the residents on their concerns or requests. This failure could place residents who file grievances at risk of frustration, a decreased confidence in administration and a decrease in resident rights. Findings include: Record review of a face sheet dated 4/4/23 for Resident #10 revealed that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Schizophrenia (mental disorder in which people interpret reality abnormally), osteoarthritis (joint pain), and peripheral vascular disease (poor circulation). Record review of a quarterly MDS dated [DATE] for Resident #10 revealed that she had a BIMS score of 15, indicating that she was cognitively intact with no impaired thinking. During an interview on 4/02/2023 at 2:00 P.M. Resident #10 voiced concerns that administration did not listen to or follow up on her grievances. During an interview on 4/03/2023 at 3:45 p.m. the SW said she was the grievance officer and had been in this position since January of 2023. She said she would always file a grievance form anytime a resident or family member came to her with a concern. She said it was their policy to have grievances resolved and followed up on within 5 days of it being filed. She said the resident or family member filing grievances would be notified of the resolution within those 5 days. During an interview on 4/03/2023 at 3:50 p.m. the ADON said she would always file a grievance when a resident or family member came to her with any issues. She said if there were any concern with abuse or neglect issues, she would immediately report to Administrator due to being a short window to get those issues reported to the State Agency. Page 1 of 7 675691 675691 04/04/2023 Huntsville Health Care Center 2628 Milam Huntsville, TX 77340

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 4/3/23 at 4:00 p.m. the DON and ADM both stated they always filed formal grievances when a resident or family member came to them with a grievance. Both said they always followed up with residents when investigations were completed and resolved. The ADM said she was not responsible for grievances, that it was the SW who was responsible for grievances and follow up. The DON said there could be a risk of psychosocial issues to residents who felt like they were not listened to and it could discourage them from coming forward with concerns. During an interview with Resident #10 on 04/04/23 at 10:40 AM she said she had filed multiple grievances regarding the food and nurse aide's being rude to her and she had not been given a written copy or been followed up with verbally on any of her grievances. During an interview on 4/4/23 at 10:58 a.m., the SW said she did not provide a written copy of the investigation and resolution for grievances unless the resident or family member requested one. She said she normally did not ask them if they wanted a copy, but she would just check no in that spot of the form if they did not specifically ask for one. She was unsure as to why there were blanks in the grievance form for 2/1/23 for Resident #10. She said that she must have overlooked them. She said she would ask going forward if the resident would like a copy provided to them. The SW clarified verbally that the blank in their facility policy should read 5 working days (please see below). She said she could not think of any harm that could come to the residents by not following up on grievances. Record review of grievance log for January 1, 2023 through March 31, 2023 revealed the following: Grievance dated 2/1/23 for Resident #10, with .date written opportunity presented to grievance official . left blank; .date of response . left blank; and .written decision of grievance requested . checked no. Record review of facility policy titled Grievances/Complaints, Recording and Investigating dated 2001, revised April 2017 revealed: .The Administrator has assigned the responsibility of investigating grievances and complaints to the Grievance Officer .a written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office 675691 Page 2 of 7 675691 04/04/2023 Huntsville Health Care Center 2628 Milam Huntsville, TX 77340

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 a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 7 residents (Resident #4) reviewed for respiratory care. Residents Affected - Few The facility failed to ensure Resident #4's nasal cannula tubing, on their wheelchair, was changed every 7 days, labeled and bagged to prevent contaimination when not in use. The deficient practice could place residents at risk of developing respiratory infections and complications. Findings include: Record review of Resident #4's facility face sheet, dated 04/03/2023, indicated Resident #4 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, cough and chronic respiratory failure. Record review of quarterly MDS, dated [DATE], indicated Resident # 4 required oxygen therapy and was cognitively intact. Record review of Resident #4's care plan, review date 12/19/22 indicated Resident # 4 had shortness of breath and required oxygen therapy. Record review of Resident #4's physician's order summary, dated 04/03/2023, indicated oxygen 2-4 liters per nasal cannula with a start date of 01/22/2022. During an observation and interview on 04/02/23 at 12:11 PM revealed Resident # 4 's, O2 tubing and nasal cannula was not bagged or dated and was connected to the O2 cylinder on the wheelchair. The cannula and tubing was coiled up on the wheelchair handle, not bagged and not dated. Resident # 4 said she got up in her wheelchair every day and used the oxygen on her wheelchair when she would leave her room. During an observation on 04/03/23 11:32 AM revealed the O2 cannula and tubing on Resident #4's wheelchair was not in use. The tubing was not dated, not bagged and was wound up around the right-side handle of the wheelchair. During an observation on 4/03/23 at 2:00 PM revealed Resident #4 had a portable oxygen cylinder attached to her wheelchair with oxygen in use at 3 liters per nasal cannula. The cannula and tubing were undated. During an observation and interview on 04/03/23 at 2:45 PM revealed Resident #4 was sitting in her wheelchair and had oxygen in place at 3 liters per nasal cannula connected to the cylinder on the wheelchair. The nasal cannula tubing was undated. She said she used her oxygen when up in her wheelchair to attend the resident council meeting held at 2:00 PM today. During an interview and observation on 04/03/23 at 3:00 PM, LVN A said oxygen tubing and supplies 675691 Page 3 of 7 675691 04/04/2023 Huntsville Health Care Center 2628 Milam Huntsville, TX 77340

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few were changed on the night shift each week but each nurse was responsible for their residents on each shift. She stated she was not aware any oxygen tubing on Resident #4's wheelchair was not dated or bagged. LVN A looked at the wheelchair in the resident's room, and said it belonged to Resident #4. She acknowledged the oxygen cannula and tubing were not dated or bagged and the tubing was coiled around the right-side handle of the wheelchair. She said the risk of not dating, changing tubing weekly and contaminating the tubing by wrapping it around the handle of the wheelchair could be respiratory infections. During an interview on 04/03/2023 at 3:15 PM, the DON stated the nurses on the night shift were responsible for changing out the oxygen tubing and nebulizer setups each Sunday night or as needed. She stated she and the ADON was responsible for hall checks and ensuring tasks were completed. She stated the risk could be infection and improper distribution of oxygen. She stated she had been in her position as the DON for two years. She said the staff would be in-serviced on the facility policy and expected that all respiratory supplies were changed out weekly, dated and bagged when not in use. During an interview on 04/03/2023 at 4:00 PM, the Administrator stated the DON and ADON were responsible for oversight in the nursing department. She stated she would assist with overseeing the DON and ADON were retraining nursing staff on policy and procedures and her expectation was that the policy and nursing standards of care were followed. Record review of the facility policy and procedure titled Respiratory Therapy- Prevention of Infection, dated November 2022 revealed, Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff .7. Change the oxygen cannula and tubing every 7days or as needed .8. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use. 675691 Page 4 of 7 675691 04/04/2023 Huntsville Health Care Center 2628 Milam Huntsville, TX 77340

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to maintain and ensure safe and sanitary storage of resident's food items for 1 of 5 resident's personal refrigerators reviewed for food safety (Resident #9). Residents Affected - Few The refrigerator for Resident #9 had: One small cup of strawberry applesauce with a best by date of March 9, 2023 One small cup of applesauce with a best by date of March 10, 2023 These failures could place residents at risk for food borne illnesses. The findings included: During an observation and interview on 4/02/2023 at 10:47 AM, revealed the personal refrigerator of Resident #9 had one small cup of strawberry applesauce with a best by date of March 9, 2023, and one small cup of applesauce with a best by date of March 10, 2023. Resident #9 said she was not able to get anything out of her personal refrigerator and had to rely on staff to get items for her. During an observation on 4/03/2023 at 9:50 AM, revealed Resident #9's personal refrigerator still had both cups of applesauce present with best by dates of March 9, 2023, and March 10, 2023. During an observation on 4/04/2023 at 9:10 AM, revealed Resident #9's personal refrigerator still had both cups of applesauce present with best by dates of March 9, 2023, and March 10, 2023. During an observation and interview on 4/04/2023 at 9:18 AM, the HSK Supervisor said he had been employed at the facility since November 2021 and was responsible for checking the personal refrigerators daily and had housekeeping staff check them on the weekends. He said he checked for cleanliness and temperatures, so the food did not spoil or freeze. He stated he also checked for expired foods. He said he checked the personal refrigerator of Resident #9 a couple of hours ago. He said the cups of applesauce were good until September of this year. This surveyor had him to look at the cups of applesauce again and he said he was reading it by the day, month, then year. He said they both expired March 2023 and placed them in the trash. He said if a resident ate foods that were past their best by dates, they could get sick. During an interview on 4/04/2023 at 9:35 AM, the Administrator said the department heads conducted Angel rounds and every resident was assigned a person who they could voice concerns to and checked their rooms daily for any issues. She said she was not aware that Resident #9 had foods in her personal refrigerator that were past the best by date. She said the HSK supervisor was responsible for checking the personal refrigerators in the facility. She said going forward they would train the HSK Supervisor to read the dates on food items to ensure they were not past the best by or expiration date. She said they would have more than one person assigned to check the personal refrigerators daily and would add them to the department heads during their Angel rounds. She said if a resident ate foods that were past the best by date or expired it could make them sick. Record review of a facility policy titled Foods Brought by Family/Visitors with a revised date of October 2017 indicated, .Food brought to the facility by visitors and family is permitted. Facility 675691 Page 5 of 7 675691 04/04/2023 Huntsville Health Care Center 2628 Milam Huntsville, TX 77340

F 0813 staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. 8. The nursing staff will discard perishable foods on or before the use by date . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675691 Page 6 of 7 675691 04/04/2023 Huntsville Health Care Center 2628 Milam Huntsville, TX 77340

F 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow their own established smoking policy for 1 of 2 smoking areas (outside of dining room). Residents Affected - Few The facility failed to keep trash out of a red can designated for cigarette butts and ashes. This failure could place residents at risk for injury, burns, and an unsafe smoking environment. Findings include: During an observation on 4/02/2023 at 3:24 PM outside of the dining room area, revealed a red metal can was present filled to the top with cigarette butts, ashes and had trash present that consisted of multiple empty cigarette boxes, a plastic cup a soda bottle. During an interview on 4/03/2023 at 9:03 AM, the Maintenance Supervisor said on yesterday 4/2/2023 he emptied the red can and saw it had a lot of empty cigarette packs. He said he checked the cans daily. He said there was risk of a fire with putting trash in the red cans instead of cigarette butts and ashes. He said going forward he would place a sign on the cans to not place trash inside and would in-service staff starting today about not placing trash in the metal cans. During an interview on 4/04/2023 at 9:55 AM, the Administrator said she was aware of the trash that was present in the red can outside of the dining room because the Maintenance Supervisor told her on 4/2/2023 that it just had cigarette boxes inside. She said they in-serviced staff on 4/2/2023 and a sign was placed on the cans to not put trash in them. She said staff was always present with the residents when they were smoking. She said going forward the Maintenance Supervisor would make sure the cans were checked daily and she would provide oversight to ensure it was done. She said the only items that should be in the cans were cigarette butts and ashes. She said there was potentially a risk for something to be flammable in the can if trash was placed there. Record review of a facility policy titled Fire Safety and Prevention with a revised date of May 2011 indicated, .All personnel must learn methods of fire prevention and must report condition(s) that could result in a potential fire hazard. 1. Fire prevention is the responsibility of all personnel, residents, visitors, and the general public . 675691 Page 7 of 7