Health inspection·February 23, 2024

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 observation interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 4 residents reviewed for grievances. (Resident #1) The facility Administrator and DON failed to document, resolve, and follow up on grievances related to quality of care on behalf of Resident #1 on 01/26/2024 and 02/09/2024. These failures could place residents at risk for grievances not being addressed or resolved promptly. Findings included: Record review of Resident #1's face sheet dated 2/16/24 indicated Resident #1 was a [AGE] year-old female who admitted on [DATE] and readmitted to facility on 9/15/23 with diagnoses including, atherosclerotic heart disease of native coronary artery without angina pectoris (is caused by plaque buildup in the wall of the arteries that supply blood to the heart (called coronary arteries). Plaque is made up of cholesterol deposits. Plaque buildup causes the inside of the arteries to narrow over time. This process is called atherosclerosis), type 2 diabetes (a chronic condition that happens when you have persistently high blood sugar levels), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), hallucinations (involve seeing, hearing, feeling, tasting, or smelling things that aren't really there), Parkinson's disease (A disorder of the central nervous system that affects movement, often including tremors), hypertension (also known as high blood pressure, is a long-term medical condition in which the blood pressure in the arteries is persistently elevated), and gastro-esophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach). Record review of Resident #1's revised care plan dated 10/10/23 indicated the following: Focus - Self-Care deficit: bathing, dressing, feeding due to terminal illness. Goal - staff will anticipate all needs. Interventions Evaluate Resident #1s ability to perform ADLs, maintain consistent schedule with daily routine, provide assistance with ADLs, and Provide meal support per Resident #1's need. Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 had difficulty communicating some words or finishing thoughts but was able if prompted or given time. Also, Resident #1 misses some part/intent of message but comprehends most conversation. She had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. Section GG: Resident #1 requires partial/moderate assistance with rolling left and right. Resident #1 was Page 1 of 5 675814 675814 02/23/2024 Arbor Grace Guest Care Center 2700 S Henderson Blvd Kilgore, TX 75662

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dependent, and helper did all of the effort for eating (assistance with utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident). Section GG also indicated Resident #1 was dependent for most ADLs. Record review of grievance/complaint report dated 12/11/23 indicated the following: Received by: The facility SW; Resident Representative - Relationship: Resident #1's family member; Grievance/complaint reported to: The facility SW; Describe grievance/complaint using factual terms: Staff at times not checking on Resident #1, not giving ice and water, not feeding Resident #1, not putting trapeze bar in her reach; Documentation of facility follow - up section: Individual(s) designated to take action on this concern; Date assigned; Time; Date to be resolved by; Was a group meeting held; Identify all individuals in attendance; Plan of care reviewed and updated date; questions were all BLANK and Not completed; What other action(s) were taken to resolve grievance/complaint (be specific)? Care plan scheduled for Friday 12/15/24 with department heads, Hospice, Ombudsman; and family rescheduled to 12/19/23 to accommodate all schedule. Resolution of Grievance/Complaint Section - Was grievance/complaint resolved: Yes, describe resolution; Care plan meeting held with family, ombudsman, and department leads on 12/19/23 to address issues/concerns. Report was signed at the bottom by both the Administrator and the SW and dated 12/19/23. Record review care plan meeting typed notes dated 12/19/23, attached to Resident #1's family member grievance report date 12/11/23 revealed the following: .The ombudsman asked Resident #1's family what the facility could do to fix the issues. Resident #1 stated she had brought the concerns to SW and ADON. She stated that the concerns were addressed at the time but feels they are patched and not fixed for good. Resident #1's family member stated she wanted the problems fixed. The Administrator explained that those current concerns were discussed during department head meeting after it was brought to their attention and that he was personally going in to check in on Resident #1. Resident #1's family members stated they had brought their concerns to CNAs and the nurses and they in turn stated they have reported the concerns to administration. The Ombudsman explained to Resident #1's family members to contact the Administration immediately upon any concerns. The DON and the Administrator let Resident #1's family know their information was posted in the facility for contacting them and that they can do so at any time. Resident #1's family member stated she knew everyone was busy and she hated to bother them. The Administrator and DON both stated to call them at any time. The DON explained their goal was to better care for Resident #1 and to build on the communication between the family and administration. She also asked Resident #1's family member to let administration know immediately of concerns. Resident #1's family member stated she that meeting had helped open up that communication and she felt better about her concerns and that they would be addressed. Resident #1's family member stated she would contact administration on concerns from then on. Record review of facility's grievance log revealed that grievances were not documented/filed on 01/26/2024 and 02/09/2024 on behalf of Resident #1. Record review of text messages dated 1/16/24 between Resident #1's family member to the Administrator and the DON stated we have another incident of Resident #1 not being properly fed. Family member is sending photos of the unknown staff bringing Resident #1 her food that evening. Then of that unknown staff sitting down to feed Resident #1 and a third picture of same unknown staff getting up and walking out and leaving Resident #1 food plate sitting open. The unknown staff left and never came back to feed Resident #1. A nightshift CNA said there were three residents on the same hall who were not fed. Y'all need more help on that hall. There were too many residents needing hands on care for one person. Who is the unknown staff in the pictures? Lastly, family member will send a picture of how Resident #1 was whenever another family member got there. Family member sent a second text 675814 Page 2 of 5 675814 02/23/2024 Arbor Grace Guest Care Center 2700 S Henderson Blvd Kilgore, TX 75662

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few message that stated Things seems to be headed right back down the wrong path again. What actions will you take to correct these issues? The DON responded She is a new aid that just started this week. Today was her first day out of orientation. I will get with her tomorrow as she is already gone tonight. Thank you for letting us know. Record review of text messages dated 2/09/24 between Resident #1's family member to the Administrator and the DON stated Question, what is the procedure for training these new aides for facility? Staff put Resident #1 in the recliner at 10am and no one had been in to put her back in her bed. Did not see an aide in Resident #1's room until 1pm for lunch. Charge nurse came in and sat up Resident #1 because she was slumped all the way over that evening, but no one had changed her pad since. That was part of the reason Resident #1 bottom kept getting open sores. A CNA came in and fed Resident #1 her dinner and came back to move Resident #1 back to bed whenever she finished feeding Resident #1. The night CNA needed help to tend to all the residents. Resident #1 had been in the same spot in her recliner since 10am, 9 hours. Unacceptable, Also the CNA who fed Resident #1 her lunch was talking on the phone to someone on her phone while feeding Resident #1. What happened to the no cell phone usage in residents' room? Things seemed to be headed backwards again. Resident #1 was completely soiled in poop, so much that it soiled the blanket she was sitting on in the chair. Completely unacceptable. The Administrator replied Unfortunately they could not be everywhere and see everything. Thank you for bringing it to their attention. All personnel go through the same orientation and appropriate on the job process. They will revisit and will keep working until they find the correct staff. The DON will follow up with her team. Resident #1's family member replied stating It was not about being everywhere, it was about the staff being trained appropriately and that you can trust that the CNAs were doing what they're supposed to. Again, this may come back to the chain of command, if the CNAs were not doing their jobs then someone should be checking on them throughout the day to make sure that the resident was not the one suffering. How would you like to sit in your own feces for no telling how long to the point that it bled through the blanket she was sitting on into the chair, that was a long time. Resident #1 has open sores on her bottom and the pad that was on her open sores was soiled all the way through to her skin. If anyone had taken the time to look, they would have seen she was soiled so badly you could tell from the front. The Administrator replied stating Thank you for bringing it to our attention. The DON will follow up with her team immediately. Record review of handwritten note dated 02/14/2024 revealed Resident #1's family member visited Resident #1 and asked the Administrator what was being done to correct the problems from last week, and the Administrator replied the DON was working on that. Resident #1's family member asked what the DON was working on, and the Administrator just repeated that the DON was working on it. During observation on 2/16/24 at 3:18 p.m., Resident #1 was lying in bed resting, she did not appear to be in pain at that time and was not able to answer questions asked. During an interview on 2/16/24 at 5:245 p.m., and via phone on 3/1/24 at 11:15 a.m., Resident #1's family member said a lot had changed since the facility hired the new Administrator and DON for the worse nearly a year ago. Resident #1's family member said she had voiced several complaints to the CNAs, but nothing was getting better, so she complained to the SW who scheduled a care plan meeting with all the department heads back in December 2023. Resident #1's family member said during the December 2023 care plan meeting the ombudsman, the Administrator and the DON told her to start notifying the Administrator and/or the DON personally regarding any issues/concerns and they would address it. Resident #1's family member said back on 1/26/24 and on 2/9/24 she had group texted the Administrator and the DON regarding issues/concerns and as of 3/1/24 the Administrator nor the DON had gotten back to her regarding her complaints to let her know what had been done. Resident #1's family member 675814 Page 3 of 5 675814 02/23/2024 Arbor Grace Guest Care Center 2700 S Henderson Blvd Kilgore, TX 75662

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few said on 2/14/24 she tried asking the Administrator what was being done about her complaint she made via text message to him on 2/9/24 and the Administrator would say the same response the DON was handling it; she said she questioned what the DON was doing, and the Administrator repeated DON was working on it. Resident #1's family member said she would love to know from Administration what was going on and what was being done because she was still having issues, and she felt like the facility did not care because she was not getting any answers from anyone. During an interview on 3/1/24 at 11:06 a.m., The Ombudsman said Resident #1's family has had numerous complaints about the care of Resident #1 that happened prior to the December 2023 big care plan meeting and was still going on. The Ombudsman said whenever Resident #1's family make a complaint, the first couple of days they attempted to improve care, but then thereafter it would go downhill. The Ombudsman said the Administrator mentioned that if Resident #1's family was not satisfied then they can move Resident #1. During an interview on 2/23/24 at 2:58 p.m., The DON said they had a care plan meeting in December 2023 with Resident #1`s family regarding several issues and concerns the family had. The DON said they were able to address Resident #1's family concerns and since the meeting Resident #1's family have voiced issues to other staff about having issues with staff not feeding Resident #1 and not turning Resident #1 every two hours. The DON was asked if she addressed the issues or concerns the other staff had brought to her and she said she felt Resident #1's family did not like her and that was why she did not follow up with the family regarding any of the issues, and she did not know if the Administrator had followed up with the family regarding their concerns/issues. During an interview on 2/23/24 at 3:23 p.m., The Social Worker said she was the grievance official who maintained the grievances. She said back on December 11, 2023 Resident #1's family member voiced several concerns to her and SW scheduled a care plan meeting for 12/13/24 to addressed the concerns with department heads and ombudsman. The SW said during the care plan meeting it was arranged/suggested for Resident #1's family to reach out directly to the DON and/or the Administrator moving forward with all concerns/issues. The SW said Resident #1's family had not come to her in 2024 regarding issues or concerns and she was not aware if Resident #1's family had reached out to the DON and/or the Administrator if they had then the DON nor the Administrator had told her. During an interview on 2/23/24 at 4:20 p.m., The Administrator said back in December 2023 all the department heads, the ombudsman and Resident #1's family members had a care plan meeting regarding all the concerns the family was having, and they were able to address most of the issues. During the meeting the Administrator said he told the Resident 1's family to personally let him and/or the DON know of any issues or concerns going forward and they would address it. The Administrator said Resident #1's family member had texted him and the DON a few times regarding concerns. The Administrator read off his phone the text messages from February 9, 2024 from Resident #1's family member to him and the DON; when the Administrator was asked if he notified or followed up with Resident #1's family about the status or the outcome from the concerns that were texted to him and he said he did not follow up with Resident #1's family and said the DON pretty much addressed everything. The administrator was asked how the DON addressed the issues Resident #1's family texted to them, and he could not answer what the DON did, and stated that he was sure the DON did something but did not know nor did he ask the DON what she did. The Administrator said Resident #1's family would normally reach out to him on a Friday evening, and he had five children at home, so he was not also able to immediately get back with the family, but he personally did not follow up with Resident #1's family with the outcomes. The Administrator said on 2/14/24 Resident #1's family member stopped him in the hall and asked what happened to the staff she complained about on 2/9/24 via text message, and he said he told her 675814 Page 4 of 5 675814 02/23/2024 Arbor Grace Guest Care Center 2700 S Henderson Blvd Kilgore, TX 75662

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that it was confidential and could not disclose to her what happened to the staff. The Administrator was asked what happened to the staff he was referring to and he did not answer the question. The Administrator said he felt Resident #1's family had unrealistic expectations and said he told Resident #1's family if they were unhappy or had so many issues, they could take Resident #1 somewhere else. During an interview on 2/23/24 at 6:15 p.m., The DON said during the exit conference that she was not aware text messages needed to be followed up or was considered a complaint. Record review of revised Grievance policy dated December 2004 revealed facility will assist residents, their representatives (sponsors), other interested family members, or resident advocates in filing grievances or complaints when such requests are made. Policy Interpretation and Implementation: 1) Any resident, his or her representative (sponsor), family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, staff members, theft of property, etc., without fear of threat or reprisal in any form. 2) Grievances and/or complaints may be submitted orally or in writing. Written complaints or grievances must be signed by the resident or the person filing the grievance or complaint on behalf of the resident. 3) The Social Worker has been delegated as the Grievance Official for the facility. Upon receipt of a written grievance and/or complaint, Designee will investigate the allegations and submit a written report of such findings to the QA committee. 4) The administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any, need to be taken. 5) Should the resident not be satisfied with the result of the investigation, or the recommended actions, he or she may file a written complaint to the local ombudsman office or to the state survey and certification agency. Record review of the Rights of the Elderly included in the facility's revised new admission packet dated February 2023 revealed An elderly individual has all the rights, benefits, responsibilities, and privileges granted by the constitution and laws of this State and the United States, except where lawfully restricted. The elderly individual has the right to be free of interference, coercion, discrimination, and reprisal in exercising these civil rights. An elderly individual has the right to be treated with dignity and respect for the personal integrity of the individual, without regard to race, religion, national origin, sex, age, disability, marital status, or source of payment. This means that the elderly individual: . An elderly individual may complain about the individual's care or treatment. The complaint may be made anonymously or communicated by a person designated by the elderly individual. The person providing service shall promptly respond to resolve the complaint. The person providing services may not discriminate or take other punitive action against an elderly individual who makes a complaint. 675814 Page 5 of 5