Health inspection·March 20, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that all alleged violations involving hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury for 1 of 5 (Resident #8) residents reviewed for abuse and neglect. The facility did not report an allegation of abuse that occurred between 3/8/24-3/10/24 when Resident #8 reported to LVN A that CNA B had been rough while providing care and had caused a bruise on her right thigh. This failure could place residents at risk of injuries, abuse, and/or neglect. Findings included: Record review of a facility face sheet dated 3/19/24 for Resident #8 indicated that she was a [AGE] year-old female that admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease (causes airflow blockage and breathing related problems), schizophrenia (affects a person's ability to think, feel, and behave clearly), and muscle weakness. Record review of a Quarterly MDS assessment dated [DATE] for Resident #8 indicated that he had a BIMS score of 11 indicating that she had a mildly impaired cognitive deficit. Record review of a comprehensive care plan for Resident #8 revised on 11/14/23 indicated that she was PASRR positive due to a severe mental illness. Resident #8 refused all PASRR services and had signed refusal of PASRR MI specialized services form 1041. During an interview on 3/18/24 at 10:42 AM, Resident #8 said on Thursday 3/14/24 or sometime last week (could not remember exact day) CNA B had come into her room to put on her nighttime brief, and CNA B jerked the right side of the brief up causing a tear in the skin at the crease of her thigh and groin area. Resident #8 said she yelled out that it hurt, and CNA B jerked up the right side of the brief again causing a bruise to her right upper thigh. Resident #8 said she reported the incident to LVN A the night it happened. Resident #8 said LVN A went and filled out a report about the incident and brought it back for her to sign. Resident #8 said after she signed the report LVN A told her she was going to place it under the door of Robbie (no known staff by that name). Resident #8 said after she reported the incident to LVN A she had not heard anything else about the incident. Page 1 of 12 675814 675814 03/20/2024 Arbor Grace Guest Care Center 2700 S Henderson Blvd Kilgore, TX 75662

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview by phone on 3/18/24 at 6:52 PM, LVN A said Resident #8 did report to her that CNA B had pulled Resident #8's brief up to rough while putting on her nighttime brief. LVN A said she told Resident #8 to talk to the Administrator. LVN A said she did not fill out any kind of report or have Resident #8 sign anything. LVN A said she did not report the incident to the Administrator or DON because Resident #8 said she was going to report the incident to administration on Monday. LVN A said she did not feel like CNA B had intentionally hurt Resident #8 and felt like Resident #8 had a personal issue with CNA B. LVN A said she did not remember what specific day the incident took place but thought it happened over the weekend of 3/8/24-3/10/24. LVN A said she had been trained on reporting abuse and neglect but did not think Resident #8 had been abused so she did not report it. LVN A said the facility policy was to report all allegations of abuse to the Administrator. On 03/19/24 8:41 AM, Attempted phone interview with CNA B, she did not answer or return call by the time of exit. During an interview on 3/19/24 at 9:30 AM Resident #8 said the Administrator had come to her room earlier that morning and talked to her regarding the incident with CNA B. Resident #8 said she did not get to tell the Administrator the whole story of what happened during the incident because the Administrator did all the talking and would not let her finish telling him what had happened. During an observation and interview on 03/19/24 at 09:33 AM with the ADON C present observed Resident #8's groin area with red raw irritated with no obvious skin tear in the crease of the groin, no bruises observed to the right thigh area. Resident #8 said the bruises are healing up now because it happened last week. While skin was being observed Resident #8 told ADON C that CNA B had come in to put on her nighttime brief and jerked the right side of her brief up and caused a tear in the crease of her right leg. Resident #8 said she yelled out ouch that hurt and CNA B jerked the brief up again causing a bruise to her right leg. During an interview on 3/19/24 at 9:37 AM, the ADON C said she worked at the facility for about 1 year. She said LVN A called her on 3/18/24 around 7:30pm after speaking to the surveyor and asked her if she was going to lose her job because she did not report that Resident #8 had said CNA B was being rough with her. The ADON C said she returned to the facility and the ADON C and LVN A went to Resident #8's room and Resident #8 described her interaction with CNA B as rough. Stating that CNA B pulled her brief up too tight causing bruising. The ADON C said Resident #8 also stated that she had told someone about the situation a week ago on a Monday. The ADON C said she felt like the incident was more of a personality conflict between Resident #8 and CNA B. The ADON C said CNA B normally dotes on Resident #8 and she thought CNA B told Resident #8 that she could be more independent and do some of her own tasks and it would make her stronger and Resident #8 got mad at CNA B for that. The ADON C said CNA B was on vacation out of state and had not spoken with her. The ADON C said she started staff education on: Skin Assessments/Reporting Skin Changes, Safe Handling, Skin Integrity on 3/18/24. The ADON C said she had not started abuse education training. During an interview on 3/19/24 at 9:58 AM the Administrator said he was notified that a surveyor was asking questions about Resident #8 and a possible allegation of abuse at approximately 9:00pm on 3/18/24. He said he did not report the incident to HHSC because he did not feel like the incident was abuse. The Administrator said he and the SW spoke with Resident #8 and she told him CNA B was hateful and talking to her in a way she did not like and did not like CNA B's approach. The Administrator said Resident #8 told him CNA B put a brief on her and that she had a bruise on her leg but did not say what the bruise was from. He said he did not speak with LVN A that the complaint was originally reported to because the DON was handling the investigation on 3/18/24 due to him being in the ER 675814 Page 2 of 12 675814 03/20/2024 Arbor Grace Guest Care Center 2700 S Henderson Blvd Kilgore, TX 75662

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with his 1 ½ year old child. He said he had not reported the incident as of 3/19/24 at 9:58am because Resident #8 did not make the allegation of abuse to him. During an interview on 3/19/24 at 10:30 AM, the SW she said she went to speak with Resident #8 with the administrator the morning of 3/19/24. She said Resident #8 said CNA B has an attitude and said to her what do you want but did not say anything about the CNA B being physical. The SW said Resident #8 said CNA B told Resident #8 to not push her call light. The SW said Resident #8 did not mention anything about the brief or bruise. The SW said she had not received any complaints about CNA B before. During an interview on 3/20/24 at 9:16 AM, the DON said she had worked at the facility for about 1 year. The DON said she received a text message from the ADON C and was notified of the alleged abuse by Resident #8 on 3/18/24 at 7:40pm and said she notified the administrator on 3/18/24 at 7:55pm. The DON said she was notified that Resident #8 complained to a the surveyor that CNA B was too rough putting a brief on her and had bruised her. The DON said the ADON C and LVN A did a skin assessment on 3/18/24 and did not find a bruise. She said the ADON C started in-servicing staff on Skin Assessments/Reporting Skin Changes, Safe Handling, Skin Integrity. The DON said she identified who the CNA was and made sure she was not working. The DON said the ADON C made sure Resident #8 was safe. The DON said she had not spoken with CNA B due to her being out of state on vacation. The DON said whether or not the abuse occurred, CNA B will not care for Resident #8 anymore. The DON said on 3/18/24 was the first time she had heard of the incident and LVN A had not reported the incident to her. The DON said that LVN A felt like Resident #8 was a constant complainer and took it as being another issue verses something she should report. The DON said the investigation was still pending and the SW had been doing safe surveys. The DON said her expectation was for staff to report all allegations of abuse to the administrator or if it was reported to a nurse manager, they would get that information to the administrator. The DON said the potential negative outcome for staff not reporting alleged abuse was the potential for further abuse to the resident. On 03/20/24 11:28 AM Attempted phone interview with CNA B, she did not answer or return call by the time of exit. During an interview on 3/20/24 at 1:08 PM the Administrator said his expectation was that staff were to report all allegations of abuse to him or their supervisor immediately. The Administrator said the resident could potentially continue to be subjected to abuse if staff did not follow the facility abuse policy. Record Review of the ADON C statement dated 3/18/24. The statement revealed: On the evening of March 18, 2024, I returned to the facility after receiving a call from the charge nurse, LVN A, in regard to Resident #8. After arriving I had LVN A to go with me to resident room. I was able to visit with Resident #8 in regard to her concern with night CNA B. Resident #8 described her interaction with CNA B as Rough. Stating that CNA B pulled her brief up too tight causing bruising . Record review of a facility incident log for March 2024 indicated that no incident report was filed for an incident regarding Resident #8. Review of website for state complaints and incidents on 3/18/24 revealed there was no self-report to HHSC for incident on Resident #8 from facility. Record review of in-service dated 1/2/24 titled Abuse/Neglect Reporting/Identifying revealed CNA 675814 Page 3 of 12 675814 03/20/2024 Arbor Grace Guest Care Center 2700 S Henderson Blvd Kilgore, TX 75662

F 0609 had been educated prior to the incident. Level of Harm - Minimal harm or potential for actual harm Record review of in-service dated 2/29/24 titled Abuse/Neglect Reporting/Identifying revealed LVN had been educated prior to the incident. Residents Affected - Few Review of website for state complaints and incidents on 3/19/24 revealed the incident with Resident #8 had been reported to HHSC on 3/19/24 at 10:39am. Record review of facility titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating with a revised date of September 2022 revealed: 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The Administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility;. 675814 Page 4 of 12 675814 03/20/2024 Arbor Grace Guest Care Center 2700 S Henderson Blvd Kilgore, TX 75662

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 provide the necessary services to maintain personal hygiene for 1 of 12 residents reviewed for ADLs (Residents #48.) Residents Affected - Few The facility did not clean or trim Resident #48's fingernails on 03/18/2023, 03/19/2024 and 03/20/2024. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. The findings included: Review of Resident #48's electronic face sheet dated 09/22/22 revealed a [AGE] year old male who was admitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure (shortness of breath or feeling like you can't get enough air, extreme tiredness, an inability to exercise as you did before, and sleepiness), Muscle Weakness (commonly due to lack of exercise, ageing, muscle injury or pregnancy), Cardiac Pacemaker (a small, battery-powered device that prevents the heart from beating too slowly). Record review of Resident #48's annual MDS dated [DATE] revealed a BIMS with a score of 09, which indicated Resident #48 had moderately impaired cognition. The MDS also revealed, Resident #48, required total assistance with ADLs. Record review of Resident #48's care plan dated 1/24/24 revealed a problem initiated on 4/14/20. Resident #48 requires assistance with ADLs including personal hygiene. Care plan reflected that Resident # 48 will maintain a sense of dignity by being clean, odor free, and well groomed. During an interview and observation on 3/18/24 at 9:51 a.m., Resident #48 said he wanted his fingernails cut. He said he did not know when his nails were cut last. He said he was unable to cut his own nails. He said a staff had cut them in the past. Resident #48's nails were long and there was a black unknown substance under his nails. During an observation on 3/19/24 at 3:20 p.m., Resident #48 nails were long and there was a black unknown substance under his nails. During an observation on 3/20/24 at 8:55 a.m., Resident #48 nails were long and there was a black unknown substance under his nails. During an interview on 03/20/24 at 9:20 a.m., with the DON she said residents could be placed at risk for infection if their fingernails were not cut and maintained. She said that it was the responsibility of the CNAs to ensure that residents who were dependent for ADLs were cared for and their nails were kept cut and clean. Review of the facility policy and procedure titles Activities of Daily Living (ADL), Supporting revised March 2018 revealed that Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) .Residents 675814 Page 5 of 12 675814 03/20/2024 Arbor Grace Guest Care Center 2700 S Henderson Blvd Kilgore, TX 75662

F 0677 who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675814 Page 6 of 12 675814 03/20/2024 Arbor Grace Guest Care Center 2700 S Henderson Blvd Kilgore, TX 75662

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 residents who need respiratory care are provided with such care, consistent with professional standards of practices for 2 of 12 residents (Resident #35 and Resident #37) reviewed for respiratory care. Residents Affected - Few The facility failed to change the filters on oxygen concentrator machines that were in use for Resident #35 and Resident #37. These failures could place residents at risk for of respiratory infections. Findings included: 1.Record review of an undated face sheet revealed Resident #35 was an [AGE] year-old, female, and admitted on [DATE] with diagnoses including Autonomic Neuropathy (the damage to nerves that control your internal organs), Muscle Weakness (commonly due to lack of exercise, ageing, muscle injury or pregnancy), Anxiety Disorder (persistent and excessive worry that interferes with daily activities). Record review of the MDS dated [DATE] revealed Resident #35 had a BIMS of 13, which indicated she was cognitively intact. MDS reflects Resident #35 received oxygen therapy. MDS reflected resident #35 required assistance with ADLs. Record review of the Resident # 35's care plan dated 2/17/24 revealed Resident #35 was on oxygen therapy. Care plan revealed that Resident #35 will have no signs or symptoms of poor oxygen absorption. During an observation and interview on 3/18/24 at 9:37 a.m., Resident # 35 said she used the oxygen concentrator every day. She said she did not know if the staff cleaned the machine or not. The concentrator was observed and the oxygen filter on Resident # 35's oxygen concentrator had a dirty filter. The filter had white and grey substances covering the filter. During an observation on 3/20/24 at 9:15 a.m., Resident #35's air concentrator filter was dirty. The filter had unknown white and gray particles covering the air filter. 2. Record review of an undated face sheet revealed Resident #37 was an [AGE] year-old, female, and admitted on [DATE] with diagnoses including Chronic Obtrusive Pulmonary Disease (a common lung disease causing restricted airflow and breathing problems), Acute Respiratory Failure with Hypoxia (a condition where you don't have enough oxygen in the tissues in your body), Lack of Coordination (Impaired balance or coordination, can be due to damage to brain, nerves, or muscles). Record review of the MDS dated [DATE] revealed Resident #37 had a BIMS of 11, which indicated she had mildly impaired cognition. MDS reflected Resident #37 received oxygen therapy. MDS reflected Resident #37 required assistance with ADLs. Record review of the Resident # 37's care plan dated 1/24/24 revealed Resident #37 was on oxygen therapy related to Chronic Obtrusive Pulmonary Disease. The care plan revealed that Resident #37 will have no signs or symptoms of poor oxygen absorption. 675814 Page 7 of 12 675814 03/20/2024 Arbor Grace Guest Care Center 2700 S Henderson Blvd Kilgore, TX 75662

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview on 3/18/24 at 9:32 a.m., Resident #37 said she was not sure if anyone cleaned the air filter on the oxygen concentrator she used. She said she used the oxygen concentrator every day. It was observed that the oxygen concentrator machine had a dirty filter. The filter had unknown white and gray particles covering the air filter. During an observation on 3/20/24 at 9:13 a.m., Resident #37's air concentrator filter was dirty. The filter had unknown white and gray particles covering the air filter. During an interview on 03/20/24 at 9:20 a.m., the DON said nursing staff were responsible to ensure all oxygen tubing and filters were changed on the oxygen concentrators. She said there could be a risk for infection or the equipment malfunctioning when the oxygen concentrator did not have a clean filter. During an interview on 3/20/24 at 1:08 p.m., the ADM said nursing staff were responsible to clean the filters on oxygen concentrators. He said he could not state the risks of oxygen concentrators with dirty filters as he was not a medical professional. A record review of an oxygen concentrator policy was not completed as the facility was unable to provide a policy that addresses oxygen concentrators prior to exit. 675814 Page 8 of 12 675814 03/20/2024 Arbor Grace Guest Care Center 2700 S Henderson Blvd Kilgore, TX 75662

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen (Main Kitchen), in that: On 3/18/24 the facility failed to ensure food was discarded by the expiration date. This deficient practice could place residents who ate food from the kitchen at risk for foodborne illness. The findings included: During an observation, in the dry storage area inside of the kitchen, on 03/18/2024 at 09:00 a.m., revealed one box of Swiss Miss hot chocolate mix containing twenty 0.73 ounce packets with expiration date of July 2023, three 13 ounces packets of Morrisons brown gravy mix with expiration date of 02/09/2024. During an observation, of emergency food supply, on 03/18/2024 at 09:25 a.m., revealed six 8lb cans of Carriage House grape jelly with the expiration date of 06/22/2022, 2 cases of twenty-four 4 ounce cups of Sysco diced pears with the expiration date of 03/01/2024, one case of sixteen 14 ounce packets of Folgers coffee with the expiration date of 12/13/2023, 4 cases of ninety-six 1.25 ounce packs of Malt O'Meal raisin bran cereal with the expiration date of 11/11/2023, 2 cases of ninety-six 1.25 ounce packs of Malt O'Meal crispy rice cereal with the expiration date of 12/23/2023, 1 case of ninety-six 1.25 ounce packs of Malt O'Meal crispy corn flakes with the expiration date of 09/05/2023, 140 cups Snack Pack vanilla pudding 3.25 ounce cups with the expiration date of 12/11/2023. During an observation and interview on 03/18/2024 at 09:25 a.m. the DM confirmed, by observations, that items in the dry storage area, and emergency food supply were not discarded by the expiration dates. During an interview on 03/19/24 at 02:18 p.m., the DM said she had worked at the facility for about 28 years. She said it was her responsibility to check the expiration dates on all food in the kitchen. She said the last time she checked the food in the pantry in the kitchen was 3/19/24. She said she was supposed to check the food expiration dates on the day's groceries were delivered. She said she last checked the emergency food supply about 3-4 weeks ago but did not get to finish. She said consuming expired foods could put the residents at risk of food borne illnesses. She said the facility policy was all expired food was to be discarded by the expiration dates. During an interview on 03/20/2024 at 03:00 p.m. the Administrator said he had worked at the facility for about 1 year. He said his expectations was for all expired food to be thrown away or sent back to the food company. The Administrator said, I've eaten expired food before, and it did not hurt me but maybe it could cause food borne illnesses. Record review of facility policy titled Dry Storage and Supplies dated 2012, revealed All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. The facility policy did not address expiration dates. 675814 Page 9 of 12 675814 03/20/2024 Arbor Grace Guest Care Center 2700 S Henderson Blvd Kilgore, TX 75662

F 0812 Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy titled Use by Date Guide undated revealed: The following guide should be used to determine a use by date when labeling opened or unopened food that must be used within a certain timeframe. An exception to this would be if the manufacturer use by date comes before the date determined using the labeling guide. Residents Affected - Many 675814 Page 10 of 12 675814 03/20/2024 Arbor Grace Guest Care Center 2700 S Henderson Blvd Kilgore, TX 75662

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to maintain all essential equipment in safe operating condition, for 1 of 1 stove in the kitchen reviewed for food service in that: Residents Affected - Many The facility did not ensure the gas stove was in working order. Three of six gas stove burners (front middle, right front, and right back) did not light automatically on 03/18/2024, when the knob was turned, the pilot light on the burners would not stay lit and both burners had carbon buildup. This failure could place residents who eat out of the kitchen at risk for injury and under cooked food. Findings included: During an observation on 03/18/24 at 9:00 AM, the gas stove had six burners and three burners located in the front middle, right front, and right back had excess carbon buildup. The burners would not light automatically and the pilot light would not stay lit. During an interview on 03/18/24 at 10:30 AM, the [NAME] stated she notified the Maintenance Director on 03/11/24 that the burners were not working. She said the Maintenance Director came and worked on the stove and the burners worked that day but the next day they were not working again. She said she notified the Maintenance Director again the next day and he came and tested the burners, but he had not been back since and burners continued to not work. She said the dietary manager was aware the burners did not work. She stated that the burners not working correctly could be a fire hazard. During an interview on 03/19/24 at 10:28 AM the Maintenance Director said the ovens were deep cleaned this past weekend 3/15/24-3/17/24. He said he was called by the kitchen and told that a few of the stove burners were not working properly. He said he had checked on it first thing Monday morning 3/11/24 and noticed that the pilot light has a flame but took forever to light. He said the stove had a 1-year warranty, so he was working on getting someone to come out and repair the burners that are not working. He said even if it was not covered by warranty, he would still have the burners repaired . He said he was going to call and check on the status of the repair person coming out. During an interview on 03/19/24 at 02:18 PM the DM stated that she and the other kitchen staff were responsible for maintaining the stove and keeping it clean. She stated if the burners were not working, or the carbon build up was excessive then she would tell the Maintenance Director. She stated she was aware of the burners not working and had notified the Maintenance Director. She said the Maintenance Director told her the burners may be stopped up. She said the Maintenance Director told her on 3/19/24 that he was going to call the manufacturer to check on the warranty. She stated if the stove was not working correctly, it could be a fire hazard. During an interview on 03/20/24 at 3:00 PM the administrator stated it is news to me the stove in the kitchen was not in working order. The Administrator said that a deep clean was done on Friday 3/15/24 and no one mentioned to him there was a problem with the stove, or he would have taken care of it. The Administrator said the stove may still be under warranty. He said the Maintenance Director had asked him on 3/18/24 who the stove was purchased from. He said there was an open service call on the stove. The Administrator said the stove not working properly would not interfere with resident meals. 675814 Page 11 of 12 675814 03/20/2024 Arbor Grace Guest Care Center 2700 S Henderson Blvd Kilgore, TX 75662

F 0908 On 3/18/24 the Surveyor requested a facility policy regarding essential equipment, and none was provided by the time of exit. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 675814 Page 12 of 12