Health inspection·November 20, 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, interview, and record review the facility failed to ensure residents had the right to a dignified existence and were treated with respect and dignity that promoted or enhanced their quality of life for 1 of 5 residents reviewed for resident rights.(Resident #1) Resident #1 was not assisted with her meal or allowed to finish eating. The staff took Resident #1's Breakfast tray on 10/23/23 while she was still chewing without asking if she was finished. This negative finding caused resident to not have the right to a dignified existence. Findings included: Record review of Resident #1's face sheet dated 11/13/23 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses were abnormal poster, high blood pressure, diabetes, and dementia without behavioral disturbances. Record review of Resident#1's Annual MDS dated [DATE] indicated she had severely impaired cognition. She required extensive assistance with one person for bed mobility, transfer, and locomotion off the unit. She was totally dependent for dressing, toilet use, and personal hygiene, and required the assistance of one person. The resident required extensive assistance with eating with one person assistance. Record review of Resident #1's care plan dated 11/18/21 indicated a Focus area of required assistant with ADLS and was at risk for deterioration in ADLS such as bed mobility, bathing, transfer, walking in room, walking in corridor, locomotion on the unit, locomotion off the unit, dressing, eating, toilet use, personal hygiene related to cognitive impairment. The resident would often lay her head down on the dining room table during activities and meal services. Some of the interventions were to assist with ADLs as needed with the assistance of one staff member. The staff would feed the resident if she was unable to complete the meal with the assistance of one staff member. A Focused area dated 10/23/23 indicated Resident #1 was part of the red napkin program to alert staff there was weight loss, and assistance was needed, and encouragement to eat. Some of the interventions where staff would assist and encourage resident as needed. Staff would offer alternative foods if less than 25 percent was eaten. Record review of Resident #1's weights indicated on 4/11/23 she weighed 130 pounds. Her last weight on 10/31/23 indicated she weighed 138.2 pounds. Page 1 of 10 675814 675814 11/20/2023 Arbor Grace Guest Care Center 2700 S Henderson Blvd Kilgore, TX 75662

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation of a video dated 10/23/23 at 12:53 p.m. Resident#1 was sitting up in bed, with the bedside table over her lap and a tray of food sitting on the table. Resident #1was seen chewing. An unidentified aide came in the room and asked Resident #1 if she was finished eating. Resident #1 mumbled something, and the aide left. She did not ask her if she need assistance or encourage her to eat. Observation of the video at 12:58 p.m. Resident #1 was sitting in bed still chewing when CNA E came into the room. The CNA did not say a word, she picked up the plate cover from the foot of the bed, put the cover over the tray, and took the tray out of the room. Resident#1 did not say anything, she watched the aide leave the room, and leaned back in the bed. Record review of Resident #1's ADL sheets dated 10/23/23 indicated for lunch and 1 ( supervision oversight, encouragement or cueing) 1- setup help only. The ADL nutrition indicated Resident #1 ate 51 percent to 75 percent. The ADL documentation for that day was completed by CNA E. Record review of a family concern written by the administrator dated 10/26/23 indicated Resident #1's family member stated the other day she came into the dining room and Resident #1 had her head down on the table and no food was around. She asked the aide where the food was and was told Resident #1 had already eaten. The family member found the tray on the cart and noticed only a small amount was eaten. The family member asked Resident #1 if she was hungry and she said she was hungry. The family member said after the aide was questioned, she did feed Resident #1 and said Resident #1 ate every bite. The Administrator wrote, I did seek further clarification and possible different thought, that with the assistance of the family, could it have been possible the family brought some encouragement to finish the meal. The family had some concerns about weight loss and was informed according to the facility records the resident had gained about 8 pounds form April 2023 to October. During an interview on 11/13/23 at 11:11 a.m. LVN A said Resident #1 required total care when she transferred to his hall on or about 11/1/23. He said at that time she did not eat much, required assistance with eating, and was placed on Hospice. During an interview on 11/13/23 at 11:24 a.m. LVN B said she worked with Resident #1 before she was moved to the other hall. LVN B said Resident #1 would normally feed herself, but sometimes she required assistance. During an interview on 11/13/23 at 11:34 a.m. CNA C said worked with NA C said Resident #1 would eat by herself, however sometimes they would need to feed her a little more because she would not eat well on her own. During an interview on 11/13/23 at 12: 14 p.m. the Administrator said Resident #1's family had some care and concerns that Resident #1 had a big decline. The Administrator said the family had concerned that she was lost weight because she felt the facility was not making sure she ate. The family member had seen her in the dining room with her [NAME] down and no tray was in front of her. They looked on the rack and saw her tray was on there with only a little food missing, and the family felt Resident #1 had lost weight. The Administrator said review of Resident #1's weight logs indicted she had gained 8. 2 pounds from April 2023 to October 24, 2023. During an interview on 11/13/23 at 12:33 p.m. the DON said Resident #1 was on the red napkin program. That program was to identify to staff that resident was identified as someone that was high risk for weight loss or needed extra encouragement to eat. The DON said those residents were brought to the dining room to eat and were always gotten up for their meals. 675814 Page 2 of 10 675814 11/20/2023 Arbor Grace Guest Care Center 2700 S Henderson Blvd Kilgore, TX 75662

F 0550 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/13/23 at 12:49 p.m. the ADON said the family member did mention some time ago Resident #1 did not get to eat. The ADON said it was a random thing not a current issue, she said it was in the past could not give a date. The ADON said a dietary review indicated Resident #1 was on red napkin program and had no significant weight loss. The ADON said Resident #1 ate in the dining room, but the family member requested she eat in her room so she could watch her eat on the camera. Residents Affected - Few During a telephone interview on 11/16/23 at 3:15 p.m. CNA E said she did not remember taking Resident #1's tray on 10/23/23. She said they pick up the trays around 1:00 p.m. and if she took the tray the resident hadthe tray a long time. She said Resident #1 did not require assistance with eating, and sometimes she did require encouragement. CNA E said if the ADL sheet said she filled it out she likely did. She said she would have been upset if someone took her food and she was not done eating. She also said if she had done so it was wrong. During an interview on 11/20/23 at 9:05 a.m. LVN B said Resident #1 was a slow eater and would have likely not finished her tray in 30 minutes. She said she needed encouragement to eat and would often put her head down while eating. She said if you woke her up, she would eat her food fine, but she required some encouragement to eat. Record review of the facility Resident Rights Guidelines for All Nursing Procedures dated October 2010. Indicated the purpose of the general guidelines was to provide resident rights while care for residents. Prior to having direct care responsibilities for resident's staff use have appropriate training on residents' rights including resident dignity and respect. Some of the general guidelines were to knock and gain permission before entering the resident room. Introduce self and ask permission before implementing the procedure. 675814 Page 3 of 10 675814 11/20/2023 Arbor Grace Guest Care Center 2700 S Henderson Blvd Kilgore, TX 75662

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 received care, consistent with professional standards of practice to prevent pressure ulcers for 1 of 2 residents reviewed for pressure ulcers. (Resident #1) Residents Affected - Few Resident #1 was noted with an area on her hip on [DATE]. However, skin assessment for the same date did not note the area. Resident #1 had staff reported areas of concern on her right hip prior to being notified by the family on [DATE] that she has a pressure ulcer. Resident #1 was identified by the family on [DATE] to have a stage 3 pressure ulcer to the right hip. These failures could cause residents to develop pressure ulcers. Findings included. Record review of Resident #1's face sheet dated [DATE] indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses were abnormal poster, high blood pressure, diabetes, and dementia without behavioral disturbances. Record review of Resident#1's Annual MDS dated [DATE] indicated she had severely impaired cognition. She required extensive assistance with one person for bed mobility, transfer, locomotion off the unit. She was totally dependent for dressing, toilet use and personal hygiene, and required the assistance of one person. Record review of Resident #1's care plan dated [DATE] indicated a Focus area of required assistant with ADLS and was at risk for deterioration in ADLS such as bed mobility, bathing, transfer, walking in room, walking in corridor, locomotion on the unit, locomotion off the unit, dressing, eating, toilet use, personal hygiene related to cognitive impairment. A Focused area initiated on [DATE] indicated Resident #1 was at risk for frequent infections, pressure/venous/status ulcers, vision impairment hyper/hypoglycemia, renal failure, cognitive/physical impairment/skin desensitized to pain and pressure, slow healing process related to a diagnosis of diabetes. Some of the interventions were monitor skin for changes; redness, circulatory problems, breakdown, and report to the MD/RP. (After area identified) A Focused area dated [DATE] indicated Resident #1 had alteration in skin integrity as evidenced by at risk for recurrence related to abrasions to the right hip due to constant scratching and picking at this are. Apply skin barrier cream to scabbed areas to the right hip and cover with border gauze daily. On [DATE] now Right thigh had a stage 3 measuring 0.8 x 0.5 x0.1 cm. some of the interventions were keep MD and RP informed of resident's progress, keep skin clean, dry and sheets wrinkle free, monitor area for increased breakdown, treatment as ordered if no improvement notify the MD. Observation of a video on [DATE] at 2:11 p.m. Resident #1 had an area noted to her right hip, the area was red with about a dime sized raised area that was dark on top. Record review of Resident #1's a Skin assessment dated [DATE] indicated no new skin areas and the 675814 Page 4 of 10 675814 11/20/2023 Arbor Grace Guest Care Center 2700 S Henderson Blvd Kilgore, TX 75662

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few comments indicated blanchable redness to the perineal, barrier cream used with brief changes to prevent break down. Record review of Resident #1's Braden Scale for Predicting Pressure Sore Risk dated [DATE] indicated she was a low risk. The form indicated she had slightly limited sensory perception, she was rarely moist, chair fast, she had slightly limited mobility, her nutritional intake was adequate, and there was a potential problem for friction and shearing. Record review of Resident #1's wound assessment dated [DATE] at 11:52 p.m. indicated a skin assessment was completed at this time. The skin is warm and dry; color is normal for race. There was redness noted to the right hip, barrier cream applied. Observation of a video dated [DATE] at 11:15 a.m. showed Resident #1 in the bed, CNA E, an unidentified CNA, and a family member in the room. Resident #1 received incontinent care. During the care the family member asked if there was a wound on Resident #1's right hip. The aide said it was not a wound it was an area where a wound had healed. Record review of Resident #1's wound assessment dated [DATE] at 9:58 p.m. indicated a skink assessment was completed at this time. The skin is warm and dry, color is normal for race. There was redness noted to the right hip, barrier cream applied. Observation of a video dated [DATE] at 2:40 p.m. Resident #1 in bed on her left side with her right hip showing. A view of Resident #1's right lower thigh showed several deep cut-like areas that looked healed, but the skin was not closed. On her right hip was an old area that looked to have healed with discolored skin. There were two small areas that had scrabs and one of those areas was partially opened. There was one area to the lower hip that looked to be about the size of a dime, with the top layer of skin missing. Record review of Resident #1's nurses notes dated [DATE] at 5:28 p.m. indicated red areas noted to the resident's right hip. Order to monitor and offload. Record review of Resident #1's physician note dated [DATE] at 8:13 a.m. indicated the resident was seen today due to recent decline in her verbal communication and fluctuating glucose levels. She had a 10-pound weight gain. The patient had been primarily responding with Yeah,: indicated a decline in her verbal communications. Despite this her appetite remains fair, and she gained weight over the past year. She had episodes of recorded low glucose readings 74 on [DATE] and recent readings at heights of 456 and 496. He dementia symptoms appeared to be worsening. Family reported a possible wound. Spoke to the family member by phone and recommended considering hospice due to recent decline. Review of Resident #1's nursing notes date[DATE] at 11:46 a.m. indicated the Treatment Nurse was notified of open areas to Resident #1's right hip. Upon assessment treatment nurse noted 3 areas to right hip (1) upper right hip scab noted, no drainage noted, surrounding skin intact, measured 0.5 x 0.5(2) Lateral right thigh, scab noted, no drainage noted, surrounding skin intact measured 1.) x 0.5 cm (3) Medial right thigh abrasion noted, no drainage, surrounding skin intact 1.5 x1.0cm. MD notified of areas and wound care doctor to see tomorrow when making rounds. Wound care orders received: Cleanse with Normal saline, pat dry, apply skin barrier cream and cover with border gauze. The treatment nurse noted the resident scratching at right hip during wound care. Record Review of Resident #1's computerized physician order dated [DATE] indicated to monitor 3 675814 Page 5 of 10 675814 11/20/2023 Arbor Grace Guest Care Center 2700 S Henderson Blvd Kilgore, TX 75662

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few areas to the right hip by offloading every day. An order dated [DATE] indicated apply skin barrier cream to scabbed areas to the right hip and cover with border gauze daily for wound healing and discontinued [DATE]. Record Review of Resident #1's Physician's Wound Summary report dated [DATE] indicated (site 1) Stage 3 pressure wound of the right hip full thickness, duration 1 day, size 0.8 x0.5cm x 0.1 cm. the surface area was 0.40 cm with light serous drainage and 50 percent slough, and 50 percent granulation tissue. (Site 2) non pressure wound of the right thigh partial thickness, the origin indicated trauma injury, duration 1 day, size of wound 1 x 0.5 dept was unmeasurable due to scab. (Site 3) non pressure wound of the right hip partial thickness. The origin indicated it was trauma, injury duration one day measured 0/4 x 0.4 cm, depth was unmeasurable due to scab. Record review of Resident #1's nurses note dated [DATE] indicated an order was placed on Hospice services. Record review of Resident #1's Record of Death dated [DATE] indicated the resident died on Hospice services with the family at the bedside. During an interview on [DATE] at 11:11 a.m. LVN A said Resident #1 was full care when she transferred to his hall on or about [DATE]. He said at that time she did not eat much, required assistance with eating, and was placed on Hospice. He said Resident #1 had wound on the inside of the mouth and that was the only wound he was aware of. During an interview on [DATE] at 11:24 a.m. LVN B said she worked with Resident #1 before got moved to the other hall. Resident #1 was a diabetic, blood sugar would fluctuate a lot. LVN B said Resident #1 had some breakdown on the right hip. She would lay on right side, would try to turn her but turn self to the right. LVN B said Resident #1 was declining. LVN B said she did not usually complete treatments they were completed by the wound care nurse. During an interview on [DATE] at 11:34 a.m. CNA C said worked with Resident #1 sometimes. She said Resident#1 had something on her hip, but it covered when she saw it. CNA C said Resident #1 had a rash on her buttock and she out ointment on it. During an interview on [DATE] at 12: 14 p.m. the Administrator said Resident #1's family had some care and concerns about that the resident had a big decline. He said the family notified staff on [DATE] Resident #1 had wounds on her hip. He said the facility had care planned Resident #1 for scratching and picking at her wounds. The Administrator said the family had concerned that she was lost weight because she felt the facility was not making sure she ate. We moved Resident #1 on [DATE]. He said the resident had a rapid decline and they had completed labs on her, her blood sugars were going up and up. He said when the labs were received, they were not good. The MD spoke to the family member on [DATE] regarding hospice care. He said the wound care physician looked at her wounds on [DATE] and said they were tiny. He said if the resident had anything on her hip on [DATE] the family would have notified them immediately. During a telephone interview on [DATE] at 4:40 p.m. the Treatment Nurse/ LVN said the procedure was the nursing staff were supposed to notify treatment nurse and the physician if any new areas were identified. She said once she completed her assessment, she would notify physician and make the wound care physician aware to determine what the orders for wound care would be. The Treatment nurse said she had put treatments in place when notified on [DATE] of Resident #1's wounds. She conducted her 675814 Page 6 of 10 675814 11/20/2023 Arbor Grace Guest Care Center 2700 S Henderson Blvd Kilgore, TX 75662

F 0686 skin assessment with the wound care doctor on [DATE]. Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 4:59 p.m. the DON said they had conducted a skin assessment all residents in the building, and completed new skin assessments where necessary. She said they looked at changing their policy on how they conduced skin assessments. The nursing staff were doing the skin assessments weekly if the resident had no pressure areas. Residents Affected - Few During an interview on [DATE] at 12:58 p.m. the family member said they had a camera in Resident #1's room. They were reviewing the videos due to concerns with Resident #1's care. She said Resident #1 had an area on her right hip they saw on the camera on [DATE]. The family said another day CNA E told them Resident #1 had an old wound in a spot the family member asked about on the right hip. The family said no one ever told them Resident #1 had an area on her hip. The family member said on [DATE] the family identified a wound on Resident #1's right hip and notified the facility. The facility was not aware of the wound and had no treatments in place. Family member sent videos and pictures. During a telephone interview on [DATE] at 3:15 p.m. CNA E said the family had asked her about an area on Resident #1's right hip and it was an old area that looked like it was going to reopen. CNA E said she had seen an area on Resident #1's right hip about a week before she was transferred on [DATE]. CNA E said she had reported the area to LVN B. She said the place was red, but it was not opened when she reported it the LVN B. During an interview on [DATE] at 9:05 a.m. LVN B said CNA E had informed her of the wounds before the family identified the areas. She said she reported the concerns to the treatment nurse. LVN B said her observation of Resident #1's right hip had 3 small areas. She said there was no open wounds. LVN said she was not sure of what the date was, but she did not see the wound after it was opened. She said the area on her hip was about 3 x 2 cm about the size of a dime, but she did not measure it. During an interview on [DATE] at 10:00 a.m. the DON said the Treatment Nurse did [NAME] assessment [DATE] that identified the area on the right hip as red. She said the area opened on [DATE] and they put treatments in place for the wound. During an interview on [DATE] at 10:15 a.m. LVN F said she worked at the facility approximately 2 months. She said when Resident #1 came her hall on about [DATE]. She said when Resident #1 came she had an open wound that was about the size of a dime. She said Resident #1 had two scabbed areas. She said when she arrived on her hall she was not eating. The physician was in the facility on [DATE] and he spoke to the family on the phone about putting Resident #1 on hospice. She said the resident declined rapidly and died a few days after she was placed on hospice. Record review of the facility Prevention of Pressure Injuries policy revised [DATE] indicated the purpose of the procedure was to provide information regarding identification of pressure injury risk factors and intervention for specific factors. Review the resident's care plan and identify risk factors as well as intervention designed to reduce or eliminate those considered modifiable. Assess the resident on admission, weekly and upon any change in condition, skin assessment should be comprehensive, during the skin assessment inspect presence of erythema, temperature of skin, soft tissue and edema, inspect the skin on a daily basis when performing or assisting with personal care or ADLs. 675814 Page 7 of 10 675814 11/20/2023 Arbor Grace Guest Care Center 2700 S Henderson Blvd Kilgore, TX 75662

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. **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 provided at least three meals daily for 1 of 5 residents reviewed for frequency of meals. (Resident #1) The facility neglected to provide a resident with a breakfast tray on 10/23/23. This negative finding could cause the resident to suffer physical harm and or emotional abuse. Findings included: Record review of Resident #1's face sheet dated 11/13/23 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses were abnormal poster, high blood pressure, diabetes, and dementia without behavioral disturbances. Record review of Resident#1's Annual MDS dated [DATE] indicated she had severely impaired cognition. She required extensive assistance with one person for bed mobility, transfer, locomotion off the unit. She was totally dependent for dressing, toilet use and personal hygiene, and required the assistance of one person. The resident required extensive assistance with eating with one person assistance. Record review of Resident #1's care plan dated 11/18/21 indicated a Focus area of required assistant with ADLS and at risk for deterioration in ADLS such as bed mobility, bathing, transfer, walking in room, walking in corridor, locomotion on the unit, locomotion off the unit, dressing, eating, toilet use, personal hygiene related to cognitive impairment. The resident would often lay her head down on the dining room table during activities and meal services. Some of the interventions were assist with ADLs as needed with the assistance of one staff member. The staff would feed the resident if she was unable to complete the meal with the assistance of one staff member. A Focused area dated 10/23/23 indicated Resident #1 was part of the red napkin program to alert staff that there was weight loss, and assistance was needed, and encouragement to eat. Some of the interventions where staff would assist and encourage the resident as needed. Staff would offer alternative foods if less than 25 percent was eaten. A Focused area was the resident would often lay her head down on the dining room table during activities and meal services. Some of the interventions were assist with ADLs as needed with the assistance of one staff member. The staff would feed the resident if she was unable to complete the meal with the assistance of one staff member. A Focused area noted as at risk for nutritional impairment related to below ideal body weight, currently receiving regular diet, mechanical soft texture, nectar thick liquids consistency. Self-care performance fluctuates related to diagnosis of dementia. Some of the interventions were assist with eating, staff to feed the resident if she was unable to feed herself. Ensure staff were aware of ADL functional level and report any increase or decline. Observation of a video dated 10/28/23 and timed 7:30 a.m. LVN B was seen wheeling Resident #1 into the room. LVN B was heard to say your family member wanted you to eat in your room. LVN B told Resident #1 here are some crackers to eat until they bring your tray. The video showed Resident #1 eating the crackers. Observation of the video at 8:06 am., 8:41 a.m. , 9:00 a.m. and at 9:31 a.m. showed the Resident #1 sitting in the chair at the bedside table with her head down. The video showed at 675814 Page 8 of 10 675814 11/20/2023 Arbor Grace Guest Care Center 2700 S Henderson Blvd Kilgore, TX 75662

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 10:00 a.m. Resident #1 wheeled herself away from the table towards the bed. During these observations there was no food tray noted. Record review of Resident #1's ADL sheets dated 10/28/23 indicated for breakfast and 1 ( supervision oversight, encouragement or cueing) 1- setup help only. The ADL nutrition indicated Resident #1 ate 51 percent to 75 percent. The ADL documentation for that day was completed by CNA E. During an interview on 11/13/23 at 11:11 a.m. LVN A said Resident #1 was full care when she transferred to his hall on or about 11/1/23. He said at that time she did not eat much, required assistance with eating, and was placed on Hospice. During an interview on 11/13/23 at 11:24 a.m. LVN B said she worked with Resident #1 before was moved to the other hall. Resident #1 was a diabetic, blood sugar would fluctuate a lot. LVN B said Resident #1 would normally feed herself, but sometimes she required assistance. During an interview on 11/13/23 at 11:34 a.m. CNA C said worked with Resident #1 said Resident #1 would eat by herself, however sometimes they would need to feed her a little more because she would not eat well on her own. During an interview on 11/13/23 at 12: 14 p.m. the Administrator said Resident #1's family had some care and concerns about that the resident had a big decline. The Administrator said the family had concerned that she was lost weight because she felt the facility was not making sure she ate. The family member had seen her in the dining room with her [NAME] down and no tray was in front of her. They looked on the rack and saw her tray was on there and the family felt Resident #1 had lost weight. The Administrator said review of Resident #1's weight logs indicted she had gained 8. 2 pounds from April 2023 to October 24, 2023. During an interview on 11/16/23 at 12:58 p.m. the complainant said they had a ring camera in Resident #1's room. She said they had concerns that on 10/23/23 someone was seen bringing Resident back to the room and telling Resident her breakfast tray would arrive soon at 7:30 a.m. they checked the camera every 30 minutes after that and at 10:00 a.m. Resident #1 did not have a breakfast tray at all that morning. The facility staff did not bring her a tray and never fed her breakfast that day. During a telephone interview on 11/16/23 at 3:15 p.m. CNA E said she always made sure all my residents got a tray. She said Resident #1 did not require assistance with eating. CNA E said on the morning of 10/28/23 she was not sure if Resident #1 got her tray or not. CNA E said at that time she may have been reassigned and not working with Resident #1. She said she may have charted on the ADL sheet for someone else. During an interview on 11/20/23 at 9:05 a.m. LVN B said she remembered the day she took Resident #1 back to her room and she gave her crackers. She said Resident #1 was in the dining room and she took her back to her room because the family member had said she wanted her to eat in her room. LVN B said she could not say for sure if Resident #1 got a tray that day or not. She said resident was a slow eater and would have likely not finished her tray in 30 minutes. She said she needed encouragement to eat and would often put her head down while eating. She said if you woke her up, she would eat her food fine, but she required some encouragement to eat. Record review of the facility Abuse policy revised September 2022 indicated preventing resident neglect is a priority throughout all levels of the organizations. Neglect is defied as failure of the 675814 Page 9 of 10 675814 11/20/2023 Arbor Grace Guest Care Center 2700 S Henderson Blvd Kilgore, TX 75662

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical pain, mental anguish, or emotional distress. Neglect occurs when the facility was aware of, or should have been aware of , goods or services a resident required but the facility failed to provide them, and this had a result or may have resulted in physical harm, pain, mental anguish, or emotional distress. Neglect included cases where the facility's indifference to or disregard for resident care, comfort or safety resulted in or could have resulted in physical harm, mental anguish, or emotional distress. Neglect may be a patter of failures or may be the result of one or more failures involving one resident and one staff. 675814 Page 10 of 10