Health inspection·November 2, 2022

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through the means other than a postal service for 3 of 20 confidential residents reviewed for weekend mail delivery. Residents Affected - Some The facility failed to ensure residents received their mail on Saturdays. This failure could place residents at risk for not receiving mail in a timely manner that could result in a decline in a resident's psychosocial well-being and quality of life. Findings included: During a confidential interview 3 residents indicated they did not receive mail on Saturdays. The residents indicated they had to wait until Monday when the facility allowed the Activity Director to pass it out. During an interview on 11/02/22 at 9:05 a.m., Receptionist N indicated when the mail was received on Saturdays, the mail was not passed out to the residents until Monday. The Receptionist N indicated the mail was not delivered to the residents to prevent the residents from receiving the checks for their payments, medications ordered from places like Amazon, or supplements. During an interview on 11/02/22 at 10:30 a.m., Receptionist O indicated she obtains the mail on Saturdays. The Receptionist O indicated she was told by the Receptionist N not to deliver any mail . The Receptionist O indicated the weekend supervisor would be the person to release the mail. During an interview on 11/02/22 at 11:07 a.m., RN P indicated she worked every other Saturday. RN P indicated she had never been told to deliver mail on Saturday's. During an interview on 11/02/22 at 1:49 p.m., the Administrator indicated he was just made aware the residents had not been receiving their mail on Saturdays. The Administrator indicated the activity department staff should deliver the weekend mail. The Administrator indicated residents not receiving their mail could make them wait longer for expected items. Record review of a Resident Rights policy dated October 2022 revealed the purpose of the Resident Rights policy was to ensure the facility would inform the residents both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing residents conduct and responsibilities during the stay in the facility. 7.i. The resident has the right to send and receive unopened mail, and to receive letters, packages, and other materials Page 1 of 18 675873 675873 11/02/2022 Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418

F 0583 Level of Harm - Minimal harm or potential for actual harm delivered to the facility for the resident through a means other than a postal service, including the right to: privacy of such communications consistent with this section. The policy did not address getting resident mail on the weekends. Residents Affected - Some 675873 Page 2 of 18 675873 11/02/2022 Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure an accurate MDS was completed for 2 of 25 residents reviewed for MDS assessment accuracy. (Resident #28 and Resident #31). Residents Affected - Some The facility failed to accurately document Resident #28's insulin injections on the 7 day look back section of the MDS by charting Resident #28 received insulin over the last 7 days and Resident #28 did not have an order for insulin. The facility failed to accurately reflect Resident #31's positive Preadmission Screening and Resident Review (PASRR) status on the comprehensive MDS. These failures could place residents at risk for not receiving care and services to meet their needs. Findings included: Record Review of Resident #28's consolidated face sheet (no date) indicated he was a [AGE] year-old male that was admitted to the facility on [DATE]. Resident #28 had a diagnosis of bipolar (episodes of mood swings), type 2 diabetes (blood sugar disorder) and PTSD (being afraid and having triggering events). Record Review of Resident #28's physician order summary report did not indicate Resident #28 was taking insulin. Record Review of Resident #28's MARS dated 08/01/2022-08/31/22 did not indicate Resident #28 was taking insulin. Record Review of Resident #28's care plan dated 08/31/2022 did not indicate insulin was given. Record Review of Resident #28's MDS dated [DATE] indicated he had a BIMS score of 15 for cognitively intact. Section 1 of the MDS under active diagnosis indicated Resident #28 had diabetes mellitus. Section

N0350 of the MDS under Medications was marked 7 days of insulin was received. During an interview on 10/31/22 at 11:24 AM with Resident #28, Resident #28 stated he did not take insulin and had not taken insulin in the past. During an interview on 11-1-22 at 10:40 am with MDS nurse A. MDS nurse A stated she had made a mistake on the MDS, and Resident #28 should not have been marked that he took insulin. MDS nurse A stated the facility had a Scrubber report they used to check the MDS for mistakes and it was put in place around 08/2022. MDS nurse A stated she was responsible for making sure the MDS was correct and just missed it. MDS nurse A stated the MDS should have been correct because it impacted quality measures and informed staff of how many diabetics were in the building. During an interview on 11/2/2022 at 11:00 a.m. with the DON, the DON stated the MDS nurse was responsible for completing the MDS's and she expected them to be accurate. The DON stated MDS nurse A had 20+ years of experience and she was unaware of what trainings had been put in place for the MDS coordinator. The DON stated the facility had just started using the MDS scrubber program in the last 675873 Page 3 of 18 675873 11/02/2022 Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some month to check the MDS's for accuracy. The DON stated, Care plans were still reviewed and accurate and marking insulin on the MDS should have only impacted payment. The DON stated there was not a policy on MDS's, they just followed CMS guidelines. During an interview on 11/2/22 at 1:20 pm with the Admin, the Admin stated the MDS coordinator was responsible for completing the MDS's and he expected them to be accurate. The Admin stated he was unsure of the training provided to the MDS nurse. The Admin stated they had different reviews, checks and balances that were completed, so Resident #28 was not impacted by marking the MDS wrong. 2. Record review of the face sheet (undated) and consolidated physician orders dated 11/2/22 indicated Resident #31 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of paranoid schizophrenia (kind of psychosis, which means your mind doesn't agree with reality), bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression), and unspecified psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). Record review of the comprehensive MDS dated [DATE] indicated Resident #31 was not considered by the state level II PASSR process to have serious mental illness or intellectually disability. The MDS indicated Resident #31 had diagnoses of bipolar disorder, psychotic disorder (other than schizophrenia), and Schizophrenia. Record review of the comprehensive care plan, last revised on 10/7/22, indicated Resident #31 had been identified as having PASRR positive status related to an intellectual disability and has refused services offered by the local authority. During an interview on 11/2/22 at 1:38 PM, the MDS nurse A indicated both MDS nurses were responsible for ensuring the MDS's were accurate. MDS nurse A indicated the PASSR positive status on Resident #31 was not coded because Resident #31 refused PASSR services. MDS Nurse A indicated she should have coded the MDS to indicate positive PASSR status. MDS Nurse A indicated that the MDS's were reviewed by the DON and corporate MDS Coordinator to ensure the accuracy. MDS nurse A indicated the failure for not accurately coding PASSR positive status on Resident #31's MDS would be failure to receive services. During an interview on 11/2/22 at 2:37 PM, the DON indicated the MDS nurses were responsible for ensuring the MDSs were accurate and correct. The DON indicated she performed random checks on the MDSs and care plans completed by the MDS nurses to ensure accuracy. The DON indicated ultimately; she was responsible for monitoring the accuracy of the MDSs. The DON indicated the failure for not correctly coding the PASSR positive status on Resident #31's MDS could be she would not receive services she was entitled to. During an interview on 11/2/2022 at 11:00 a.m. the DON indicated there was not a policy on MDSs, they just followed CMS guidelines. 675873 Page 4 of 18 675873 11/02/2022 Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program to the maximum extent practicable to avoid duplicative testing and effort for 7 of 25 residents reviewed for PASARR. (Resident #'s 31, 35, 37, 75, 77, 80, and 84) The facility failed to ensure the correct PASRR Screening was submitted to the local authority for Resident #'s 75, 77, 80, and 84) who had Mental Illness (MI) diagnosis upon admission. The facility failed to refer Resident #37 for a PASRR level II assessment when he was diagnosed with a mental illness. The facility failed to coordinate the annual IDT meetings for Resident #31 with the local authority. The facility failed to coordinate IDT (interdisciplinary) meetings to discuss specialized services with the Local Mental Health Authorities/Local Behavioral Health Authorities for Resident #35. These failures could place residents with positive PASRR at risk of not receiving specialized services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being. The findings included: 1. A record review of the undated face sheet indicated Resident #77 admitted on [DATE] and was [AGE] years old. A record review of the physician's orders dated November of 2022 indicated Resident #77 had diagnoses that included: bipolar disorder, current episode depressed, severe with psychotic features, (a mental disorder characterized by periods of depression and periods of abnormally elevated mood, each lasting from days to weeks. Psychotic features indicate a disconnection with reality.), Recurrent Depressive Disorders (mood disorder causing persistent feelings of sadness or loss of interest-leading to a variety of emotional and physical problems), and PTSD (Post Traumatic Stress Disorder is a mental and behavioral disorder that can develop because of exposure to a traumatic event including symptoms of disturbing thoughts, mental or physical distress, and alterations in the way a person thinks or feels. The physician's orders indicated Resident #77 was ordered: 9/6/22 Depakote Sprinkles Capsule Delayed Release, 125 mg, 4 capsules by mouth one time a day related to other recurrent depressive disorders. 9/7/22 Paroxetine, HCI Tablet, 10 mg, give 1 tablet by mouth one time a day related to other recurrent depressive disorders. A record review of the undated care plan indicated Resident #77 was at risk for adverse side effects related to psychoactive medication, Paroxetine related to diagnosis of Depression and Bipolar Disorder. The care plan indicated he was exhibiting adverse behaviors as evidenced by a history of behaviors according to his son, such as striking out, yelling, and resisting care due to bipolar 675873 Page 5 of 18 675873 11/02/2022 Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some disorder. The care plan indicated he was at risk for side effects of Depakote but did not indicate what the Depakote was taken for. The care plan indicated Resident #77 was at risk of complications related to PTSD and exhibited anxiety/agitation caused by PTSD by trying to evade/escape when remembering war experience. This was evidenced by striking, hitting, and kicking staff and other residents. A record review of the most recent MDS dated [DATE] indicated Resident #77 had clear speech, usually understood others, was usually understood by others, and had severe cognitive impairment. The MDS indicated he had inattention and disorganized thinking that fluctuated in severity. The MDS indicated he had received an antianxiety for 4 of the last 7 days and an antidepressant for 7 of the last 7 days of the lookback period. A record review of the PASRR Level 1 Screening (PL1) dated 11/2/21 indicated Resident #77 was negative for mental illness, intellectual disability, and developmental disability. During an interview on 11/01/22 at 10:24 AM, MDS A said Resident #77 came from another facility and was a negative PASRR. She said the LIDDA told her that if Resident #77 had PTSD or Bipolar he would not qualify if he had not had a psychiatric stay in a hospital, so she did not redo the PL1. She said she did not know when she talked to the LIDDA, and she did not document it. She said if a resident had admitted from home, she would redo the PL1 to be sure it was correct. She said it was not appropriate for the MDS A and the LIDDA to decide over the phone if a person qualified for PASRR services or not. She said she did not redo the negative PL1 for Resident #77 even though he had diagnoses including: PTSD, depression, and bipolar disorder. When asked if bipolar disorder, depression, or PTSD should have made Resident #77 a PASRR positive for mental illness she answered Well, every resident is different. During an interview on 11/01/22 at 11:00 AM, MDS A said she did not change PL1's when they came to her from another facility. She said she could have called the LIDDA and asked them to evaluate a resident, but she did not do that with Resident #77. When asked if a resident was at risk of not receiving service's they could possibly get through PASRR she said, I do not have an answer for that. She said she would certainly want any resident to get any services they needed and qualified for, including PASRR. She said they used HHSC regulations regarding PASRR. She said she did not have any other paperwork or communications regarding PASRR for Resident #77. During an interview on 11/01/22 at 11:15 AM, the DON said they do not typically change the PL1 when they receive them. She said if Resident #77 had behaviors from the diagnoses of PTSD and Bipolar disorder they would address it with psychiatric services. She said she was not really involved in the PASRR process. She said Resident #77 had mental illness based on his diagnoses of PTSD, depression, and bipolar disorder. When asked if there was a risk regarding the negative PASRR, she said due to his dementia he would more than likely not benefit from PASRR services, but she was not 100% sure. During a phone interview on 11/02/22 at 9:49 AM, LIDDA B said because Resident #77 had mental health diagnoses the facility should have changed his PL1 to positive for mental illness. She said if they had done that it would have alerted them in the computer to go and evaluate him. She said she did not know if there was a risk to Resident #77 not being positive because the other facility could have had him positive and changed later to negative so without knowing what happened at the other facility, she could not say what the risk was to the resident. 2. Record Review of Resident #37's PASRR indicated he was diagnosed with delusions on 12/24/20020 675873 Page 6 of 18 675873 11/02/2022 Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and a PASRR level 1 screening was not completed. Resident #37's last PASRR was completed on 12/13/2017 and section C0100 of the PASRR indicated no mental illness. Record Review of Resident #37's consolidated face sheet (no date) indicated he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #37 had a diagnosis of hemiplegia (one sided weakness) with an onset date of 12/22/2017, delusional disorders (mental disorder) with an onset date of 12/24/2020 and other depressive disorders (decreased mood) with an onset date of 12/22/2017. Record review of Resident #37's MDS dated [DATE] indicated he had a BIMS score of 12 for mildly impaired. Section I of the MDS for active diagnosis indicated he had a diagnosis of psychotic disorder. Record Review of Resident #37's care plan dated 08/23/2022 indicated resident #37 exhibits delusional ideations, as evidenced by false reasoning of actual circumstances. The interventions included using simple, clear language when speaking to residents and notifying the physician as needed. 3. Record Review of Resident #80's PASRR level 1 screening section C0100 dated 03/24/2022 indicated Resident #80 did not have a mental illness. Record Review of Resident #80s consolidated face sheet (no date) indicated Resident #80 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #80 had a diagnosis of dementia (confusion), bipolar (episodes of mood swings), PTSD (being afraid and having triggering events), visual hallucinations (seeing things that are not there) and psychotic disorder with delusions (disconnection from reality). Record Review of Resident #80's active orders dated 11/02/2022 indicated he was taking buspirone 15mg for PTSD and Zyprexa 5mg for bipolar disorder and psychosis. Record Review of Resident #80's care plan dated 10/12/2022 indicated he was at risk for adverse side effects from psychoactive medications. Resident #80 was at risk for exhibiting sad mood or tearfulness r/t bipolar and depression. Resident #80 was at risk for complications r/t PTSD d/t visual hallucinations and adverse side effects r/t antipsychotic medications r/t hallucinations. Record Review of Resident #80's MDS dated [DATE] indicated he had a BIMS score of 15 indicating moderately impaired. Section I of the MDS indicated Resident #80 had a diagnosis of non-Alzheimer's dementia, anxiety, depression, bipolar disorder, psychotic disorder, and PTSD. Section N (medications) of the MDS indicated Resident #80 had psychotic medications over the last 7 days. Section N0450 of the MDS indicated antipsychotics were received on a routine basis. During an interview on 11/01/22 at 10:24 AM with MDS nurse A, MDS nurse A stated, if residents came from another facility and had a negative PASRR they did not redo them. MDS nurse A stated she did not complete another P1 on Resident #37 when he was diagnosed with delusions, and she should have. MDS nurse A was asked how not completing the P1 could impact Resident #37 negatively and no response. MDS nurse A stated that Resident #80 had a diagnosis of dementia and that was why she listed no under the mental illness section, because she knew that Resident #80 would not quality for services. During an interview on 11/2/2022 at 11:00 a.m. with the DON, the DON stated the MDS coordinator was responsible for completing the PASSR and she expected the PASSR's to be competed accurately. The DON stated she was not really involved in the PASRR process and unsure of the training's that were provided to the MDS nurse. The DON stated, care plans are always reviewed and accurate to make sure 675873 Page 7 of 18 675873 11/02/2022 Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some residents are taken care of, but the PASRR could result in residents not receiving services or impact facility payment. The DON denied having a process in place for making sure the PASRR's were completed correctly. During an interview on 11/2/22 at 1:20 pm with the Admin, the Admin stated the MDS coordinator was responsible for completing the PASSR's and he expected them to be completed accurately. The Admin was unsure of the training's provided on PASSR's and stated, No harm could have been done because of different reviews, checks and balances that are completed by staff. 4. Record review of Resident #75's order summary report, dated 11/2/2022, indicated Resident #75 was a [AGE] year-old-male, admitted to the facility on [DATE] with a diagnosis which included post-traumatic stress disorder. Record review of Resident #75's significant change in status MDS, dated [DATE], revealed Section A1500 asked Is the resident currently considered by the state level II PASRR process to have serious mental ill ness and/pr intellectual disability or a related condition? This section was marked 0 which meant No. Section A.1510 Level II Preadmission Screening and Resident Review (PASRR) Conditions did not have A. Serious mental illness, B. Intellectual Disability, or C. Other related conditions checked. The assessment indicated Resident #75 usually understood others and usually made himself understood. The assessment indicated Resident #75 was unable to complete the interview to address his cognitive status. Record review of Resident #75's care plan, dated 10/3/2022, did not address Resident #75's mental illness. Record review of Resident #75's PASRR Level 1 Screening, completed on 04/04/2021, indicated, in section C0100, no evidence of this individual having mental illness. 5. Record review of Resident #84's order summary report, dated 11/2/2022, indicated Resident #84 was a [AGE] year-old-male, admitted to the facility on [DATE] with a diagnosis which included post-traumatic stress disorder. Record review of Resident #84's admission MDS, dated [DATE], revealed Section A1500 asked Is the resident currently considered by the state level II PASRR process to have serious mental ill ness and/pr intellectual disability or a related condition? This section was marked 0 which meant No. Section A.1510 Level II Preadmission Screening and Resident Review (PASRR) Conditions did not have A. Serious mental illness, B. Intellectual Disability, or C. Other related conditions checked. The assessment indicated Resident #84 understood others and made himself understood. The assessment indicated Resident #84 was cognitively intact with a BIMS of 15. Record review of Resident #84's care plan, dated 10/12/2022, indicated Resident #84 was at risk for complications related to PTSD. The care plan interventions included, allow resident time to express feelings, do not argue with resident, and speak calmly to resident. Record review of Resident #84's PASRR Level 1 Screening, completed on 07/08/2022, indicated, in section C0100, no evidence of this individual having mental illness. During an interview on 11/02/2022 at 10:02 a.m., MDS Nurse A stated she was responsible for ensuring the PASRR Level 1 was completed accurately for Residents #75 and #84. MDS Nurse A stated she was 675873 Page 8 of 18 675873 11/02/2022 Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418

F 0644 Level of Harm - Minimal harm or potential for actual harm unaware she should submit a PL1 correction, if the referring entity incorrectly completed the PL1, so the resident could be evaluated for PASRR services. MDS Nurse A stated after reviewing Residents #75 and #84 records and saw they had a diagnosis which included PTSD a new PASRR Level 1 Screening should have been submitted. MDS Nurse A stated not completing the PASRR accurately could result in residents not been evaluated for eligibility and services. Residents Affected - Some During an interview on 11/02/2022 at 1:07 p.m., the DON stated her expectation was for all PL1's to be completed accurately and timely on all residents. The DON stated PTSD could be considerate a mental illness. The DON acknowledged Residents #75 and #84 PL 1 did not indicated a diagnosis of mental illness and should have. The DON stated the MDS nurses were responsible for completing the PL 1 correctly. The DON stated MDS Nurse A had been trained in this area, a portion of the training may have not been interpreted correctly or fully. The DON stated she was responsible for monitoring to ensure the mental illness diagnosis were captured on the PL1's that was received from the referring entity. The DON stated there was not an effective system in place to ensure accuracy of the PASRR process. The DON stated not completing the PASRR accurately could result in residents not receiving services they were entitled too. During an interview on 11/02/2022 at 2:11 p.m., the Administrator stated his expectation was for all PL1's to be completed accurately and a failure to do so could prevent the residents from receiving services their eligible for. 6. Record review of the face sheet (undated) and consolidated physician orders dated 11/2/22 indicated Resident #31 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of paranoid schizophrenia (kind of psychosis, which means your mind doesn't agree with reality), bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)), and unspecified psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). Record review of the comprehensive MDS dated [DATE] indicated Resident #31 was not considered by the state level II PASSR process to have serious mental illness or intellectually disability. The MDS indicated Resident #31 had diagnoses of bipolar disorder, psychotic disorder (other than schizophrenia), and Schizophrenia. Record review of the comprehensive care plan, last revised on 10/7/22, indicated Resident #31 had been identified as having PASRR positive status related to an intellectual disability and has refused services offered by the local authority. The interventions included were Invite the LIDDA representative annually to care plan meetings and as needed to discuss Resident #31''s status and any changes, provide service coordination with a representative from the LIDDA. Record review of the PASSR Level 1 Screening, dated 4/11/2018, indicated Resident #31 had evidence or an indicator for mental illness. No PASSR Level II or PASSR evaluation provided by the facility. No PASRR Comprehensive Service Plan (PCSP) Forms provided for 2018 or 2019. Record review of the PASSR Level 1 Screening, dated 12/14/2020, indicated Resident #31 had evidence or an indicator for mental illness. Record review of the PASRR Level II or PASSR evaluation, dated 12/17/2020, indicated Resident #31 met the PASRR definition of mental illness. 675873 Page 9 of 18 675873 11/02/2022 Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the PASRR Comprehensive Service Plan (PCSP) Form, dated 12/31/2020, indicated Resident #31 requested Skills Training and Development and Counseling Services. During an interview on 11/1/22 at 1:15 PM MDS coordinator A stated Resident #31 had requested services in December 2020. MDS Coordinator A stated Resident #31 refused to go to the services provided when they came to the facility. Record review of the quarterly PASRR Comprehensive Service Plan (PCSP) Form, dated 4/29/2021, indicated Resident #31 refused services. Record review of the PASRR Comprehensive Service Plan (PCSP) Form, dated 2/24/22, indicated Resident #31 refused to attend the meeting and refused any PASSR services. During an interview on 11/2/22 at 1:38 PM, the MDS Coordinator A indicated both MDS coordinators were responsible for ensuring coordination with the local authority for annual IDT meetings for PASSR positive residents. MDS Coordinator A revealed the reason Annual IDT meetings were not completed by local authority or the facility was because they were not aware they needed to be completed if the resident refused PASSR services. MDS Coordinator A indicated the failure for not completing annual IDT meetings for PASSR positive residents would be failure to receive services. During an interview on 11/2/22 at 2:37 PM, the DON indicated the MDS Coordinators were responsible for coordinating the annual PASSR IDT meetings for PASSR positive residents. The DON stated that ultimately, she was responsible for monitoring to ensure that PASSR positive resident's received annual IDT meetings. The DON indicated the failure for not performing the annual IDT meetings for PASSR positive residents could be failure to receive services she was entitled to. 7. Record review of the face sheet dated 11/02/22 revealed Resident #35 was an [AGE] year old male admitted on [DATE] with diagnoses including schizoaffective disorder (a condition that can make you feel detached from reality and affects mood), psychotic disorder with hallucinations due to know physiological condition (mental illness results in losing touch with reality and involves seeing or hearing thinks that other people cannot see or hear), chronic atrial fibrillation (irregular, often rapid heart rate), and insomnia (difficulty falling and staying asleep). Record review of the MDS dated [DATE] revealed Resident #35 was understood and understood others. The MDS revealed Resident #35 had a Brief Interview for Mental Status (BIMS) of 14, this indicated Resident #35 was cognitively intact. The MDS section, Preadmission Screening and Resident Review indicated Resident #35 did not have a serious mental illness. The section named Level II Preadmission Screening and Resident Review Conditions did not reflect a mental illness. The MDS section of Psychiatric/mood disorder indicated diagnoses of depression, psychotic disorder, and schizophrenia. Record review of an undated care plan indicated Resident #35 was at risk for adverse side effects related to psychoactive medication doxepin related to diagnosis of depression, Resident #35 was at risk for adverse side effects related to antipsychotic medications related to schizoaffective disorder, target behavior auditory hallucinations, Resident #35 was at risk for alteration in sleep pattern related to diagnosis of insomnia target behavior is sleeplessness. Record review of Resident #35's PASRR Level 1 Screening completed on 11/05/18 indicated in section C0100 that there was evidence or an indicator that this individual had mental illness. 675873 Page 10 of 18 675873 11/02/2022 Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418

F 0644 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #35's PASRR Evaluation dated 11/08/2018 revealed he had mood disorder (bipolar disorder, major depression or other mood disorder), other psychotic disorder, and schizoaffective disorder. For Resident #35 the PASRR evaluation question based on the QMHP (qualified mental health professional) assessment, does this individual meet the PASRR definition of mental illness was answered yes. Residents Affected - Some During an interview on 11/01/22 at 2:28 PM, records were requested from MDS coordinator A for IDT meetings with the Local Mental Health Authorities/Local Behavioral Health Authorities and none were provided. During an interview on 11/02/22 at 2:40 PM, MDS coordinator A indicated she was responsible for ensuring the PASRRs were completed accurately and ensuring meetings were done with the QMHP for residents with mental illness. MDS coordinator A indicated she did not know how often the meetings should take place she would have to look it up and that she did not know she was supposed to be conducting these on a regular basis. MDS coordinator A indicated not having these meetings could prevent the residents from receiving additional services they may qualify for. During an interview on 11/02/22 at 3:23 PM, the DON indicated MDS coordinator A was responsible for correlating all services with PASRR. The DON indicated she was not familiar with PASRR due to MDS coordinator A is responsible for this. The DON indicated she did not think there would be a significant impact on residents if they did not receive PASRR services. During an interview on 11/2/22 at 3:10 PM the ADMIN indicated that annual IDT meetings should be completed on residents with positive PASSR status. The ADMIN stated the DON was responsible for monitoring to ensure positive PASSR resident's received annual IDT meetings. The ADMIN stated the impact for resident's not receiving annual IDT meetings would be not getting services they are qualified for. Record review of an undated Preadmission Screening and Resident Review (PASRR) policy indicated . to ensure each resident in a nursing facility are screened for a mental disorder or intellectual disability prior to admission and that the individuals identified with the MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs . Record review of the facilities undated policy for Preadmission Screening and Resident Review (PASRR) did not address the correlation of PASRR meetings for individuals identified with mental illness. 675873 Page 11 of 18 675873 11/02/2022 Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents reviewed for transfers. (Resident #8) The facility failed to ensure LVN G transferred Resident #8 appropriately with use of gait belt. This failure could place residents who required assistance with transfers at risk for pain or injury. The findings included: Record review of the face sheet (undated) and consolidated physician orders dated 11/2/22 indicated Resident #8 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of COPD chronic obstructive pulmonary disease with (acute) exacerbation (chronic inflammatory lung disease that causes obstructed airflow from the lungs) and type I diabetes mellitus without complications (a chronic condition in which the pancreas produces little or no insulin). Record review of the MDS, dated [DATE], indicated Resident #8 was able to understand others and was easily understood by others. The MDS revealed Resident #8 had a BIMS score of 15 which indicated no cognitive impairment. The MDS indicated Resident #8 required extensive assistance and the use of 2 person-physical assist with bed mobility, transfers, and toilet use. Record review of the comprehensive care plan, last revised on 9/8/22, indicated Resident #8 required assistance from staff related to weakness with daily personal care. Interventions revealed Res requires extensive assistance on ADL's due to weakness. Staff to assist. During an observation on 11/01/22 at 11:25 AM, LVN G transferred Resident #8 from a sitting position to a standing position bearing weight under his left arm. No gait belt was observed around Resident #8. During an interview on 11/02/22 at 1:12 PM, CNA L stated Resident #8 required assistance with transfers. CNA L stated staff was required to use a gait belt on Resident #8 and all residents who required the use of one or two staff assistance with transfers. CNA L stated you should not grab residents under the arms during transfers. CNA L stated she grabs the gait belts from therapy when she needed to transfer residents. CNA L stated grabbing residents under the arm and not using a gait belt during transfers could cause injury to the resident or staff. An attempted telephone interview on 11/2/22 at 1:56 PM with LVN G was unsuccessful. During an interview on 11/2/22 at 1:56 PM with COTA M stated therapy staff were responsible for training new employees on transfers with use of gait belt and mechanical lifts. COTA M stated nursing staff should transfer with use of the gait belt and should not hook a resident underneath the arm to lift them. COTA M stated the nursing unit managers were responsible for ensuring transfers are done correctly after the training is completed by therapy during orientation. COTA M stated the potential harm to Resident #8 could be a shoulder injury or pain. 675873 Page 12 of 18 675873 11/02/2022 Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418

F 0689 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/02/22 2:03 PM, LVN H stated she was the unit manager for 200 Hall. LVN H stated anyone that sees an incorrect transfer is responsible for correcting that person. LVN H stated nursing management is responsible for ensuring staff is educated and checked off for transfers. LVN H stated all nursing staff were trained how to transfer including: not transferring under the arms and without a gait belt. LVN H stated the potential harm to Resident #8 could be pain or injury. Residents Affected - Few Record review of facility education regarding transfers revealed step-by-step instructions for Transfers from Bed to Wheelchair Using Transfer Belt. Step 10 revealed Before assistance to stand, applies transfer belt securely at the waist over clothing/gown. 675873 Page 13 of 18 675873 11/02/2022 Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to in accordance with accepted professional standards and practices, maintain medical records on each resident that was accurately documented for 1 of 25 residents (Resident #38) reviewed for accuracy of medical records. The facility failed to transcribe a physician order for contact precautions for Resident #38. The facility failed to care plan Resident #38's need for contact precautions. These failures could place the residents at risk of not having their individualized needs met, a decline in their quality of care and life and a risk for spread of infection due to lack of implementation of orders. Findings included: 1. A record review of an undated face sheet indicated Resident #38 was a [AGE] year-old male with an initial admission date of 6/7/17 and a readmission date of 11/4/20 and diagnoses of non-ST elevation myocardial infarction (heart attack), atrial fibrillation (irregular heart rate), stage 4 pressure ulcer of sacrum (deep pressure wound reaching the muscles, ligaments, or bones), and high blood pressure. Record review of the most recent quarterly MDS dated [DATE] indicated Resident #38 was understood and understood others. Resident #38's BIMs (Brief Interview for Mental Status) score was 13 indicating intact cognition. The MDS indicated Resident #38 required extensive assistance with bed mobility, dressing and personal hygiene. Resident #38 required total care with toileting and bathing. During an observation and interview on 10/31/22 at 2:31 p.m., Resident #38 had signage on his room door indicating he was on contact precautions. LVN G indicated Resident #38 was on contact precautions due to a wound infection. Record review of a progress note dated 10/24/22 at 1: 54 p.m. signed by RN Q indicated .per wound care nurse new orders received from MD for resident to start .Contact precautions initiated at this time . Record review of Resident #38's electronic medical records on 10/31/22 did not reveal an order for contact precautions. During an interview on 11/1/22 at 9:48 a.m., LVN G indicated she was unable to find Resident #38's wound culture results and would try to obtain. Record review of Resident #38's wound culture results dated 10/22/22 indicated multi-drug resistant bacteria markers for ESBL (extended spectrum beta-lactamase), MRSA (methicillin-resistant staphylococcus aureus), and VRE (vancomycin-resistant enterococci). During an interview on 11/1/22 at 11:24 a.m., RN E, indicated Resident #38 was on contact precautions due to VRE and staph infections in wound. 675873 Page 14 of 18 675873 11/02/2022 Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418

F 0842 Level of Harm - Minimal harm or potential for actual harm Record review of a physician order for contact isolation related to wound infection indicated order was created on 11/1/22 at 09:24am. Record Review of Resident #38's comprehensive care plan indicated contact isolation care plan related to Resident #38 wound infection was created on 11/1/22. Residents Affected - Few During an interview on 11/1/22 at 2:44 p.m. CNA F indicated Resident #38 was on contact precautions due to infection in his urine and has been on isolation since last week. CNA F indicated the charge nurse communicated when someone was placed on isolation and why. CNA F indicated she wore gloves and gown when entering Resident #38's room and when providing care. She indicated there was an isolation box in Resident #38 bathroom where trash was disposed of. During an interview on 11/1/22 at 2:50 p.m., LVN G indicated Resident #38 was on contact isolation due to multiple infections. LVN G indicated Resident #38 had been on isolation since she returned to work on Thursday of last week. LVN G indicated the nurse receiving the order was responsible of placing sign on the door, placing PPE outside of room, and notifying staff when a resident was placed on isolation. During an interview on 11/1/22 at 2:57 p.m., the ADON indicated she was the infection preventionist and Resident #38 was on contact precautions due to ESBL and MRSA infection to his wound. The ADON indicated RN Q was responsible for putting the physician order in, placing the isolation signage on the door, and communicating with staff. During an interview on 11/1/22 at 3:09 p.m., the DON indicated Resident #38 was on contact isolation due to possible VRE or VRSA but was unable to recall which infection for Resident #38's wound. The DON indicated the ADON was responsible for reviewing all infections and then they are communicated with management. The DON indicated she expected staff to use appropriate PPE when caring for residents on isolation. The DON indicated LVN H, was responsible for auditing the chart. The DON indicated she was unaware the order for contact precautions was not transcribed in the electronic medical record. During an interview on 11/1/22 at 3:42 p.m., the MDS Coordinator K, indicated she was responsible for updating residents care plans. The MDS Coordinator K indicated she updated care plans as she received the physician's order. The MDS Coordinator K indicated she updated Resident #38's care plan on 11/1/22 when she received the order regarding contact isolation. During an interview on 11/1/22 at 3:36 p.m., LVN H indicated Resident #38 was on contact isolation for wound infection. LVN H indicated the charge nurse who obtained the order was responsible for ensuring order was put in the system and implemented. LVN H indicated she was responsible for a weekly chart audit. LVN H indicated she had not noticed Resident #38 did not have an order for contact isolation until 11/ and she then implemented it. LVN H indicated the Infection Preventionist was responsible for providing the in-services. During an interview on 11/2/22 at 10:58 a.m., RN E indicated the order for contact precautions was overlooked. She indicated Resident #38 was on contact precautions on 10/24/22. She indicated she could have transcribed the order herself but did not. During an interview on 11/2/22 at 1:52 p.m., the Administrator indicated he expected the nurses to put in the order as it was received. He indicated the infection preventionist nurse was responsible 675873 Page 15 of 18 675873 11/02/2022 Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for keeping up with the infections in the facility and ensuring orders are placed in the resident's chart. The Administrator indicated he expected the order for contact precautions be care planned and the MDS coordinator was responsible for ensuring that was done. During an interview on 11/2/22 at 1:58 p.m., the DON indicated she expected the order to be put in the resident's chart by the nurse receiving the order. She indicated the charge nurse was responsible for notifying the supervisor so appropriate PPE and signage was placed. The DON indicated the order should have been care planned and it was the responsibility of the MDS coordinator to ensure that was done. Record review of Telephone Order policy dated October 2012, indicated to follow acceptable nursing standards of practice with documentation of physician's telephone orders. Record review of Care Plan (Comprehensive) policy dated June 2019, indicated to develop an interdisciplinary resident centered comprehensive care plan to meet the individual needs of each resident .an interdisciplinary team develops and maintains a comprehensive care plan for each resident .care plans are revised as changes as indicated. 675873 Page 16 of 18 675873 11/02/2022 Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418

F 0880 Provide and implement an infection prevention and control program. 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents reviewed for infection control (Resident #351). Residents Affected - Few The facility failed to ensure Resident #351 had a contact precautions sign posted at his door. This failure could place residents at risk for cross contamination and the spread of infection due to lack of implementation of orders. Findings included: Record review of the face sheet dated 11/2/22 indicated Resident #351 was a [AGE] year-old male, admitted on [DATE], with diagnoses of hypo-osmolality and hyponatremia (volume depletion related to low sodium), interstitial pulmonary disease (progressive scarring of lung tissue), candidal stomatitis (fungal infection of the mouth), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the MDS dated [DATE] revealed Resident #351 makes self-understood and understands others. Resident #351 had a Brief Interview for Mental Status (BIMS) of 15, which indicated he was cognitively intact. The MDS indicated Resident #351 required limited assistance and one-person physical assist for bed mobility, transfers, dressing, and toilet use. The MDS indicated resident #351 had Moisture Associated Skin Damage (MASD). The MDS did not indicate Resident #351 had any other wounds. The MDS indicated Resident #351 received antibiotics. Record review of an undated care plan indicated Resident #351 was at risk for complications related to wound infection, and an intervention indicated Resident #351 was on contact isolation for ESBL (extended-spectrum beta-lactamases) perianal wound. Record review of Resident #351 physician orders dated 11/02/22 revealed an order for contact isolation related to ESBL perianal wound with start date of 10/24/22 and no end date. During an observation and interview on 11/01/22 at 11:30 AM no sign for contact precautions posted on Resident #351 door. A cart with isolation gear was noted in hallway but not outside of Resident #351 door. Surveyor entered Resident #351 room for initial screening and resident did not mention being on contact isolation precautions. Resident #351 family member at bedside with no PPE. During an observation on 11/01/22 at 3:08 PM no sign for contact precautions posted on Resident #351 door. During an observation on 11/02/22 at 10:17 AM no sign for contact precautions posted on Resident #351 door. During an observation on 11/02/22 at 4:05 PM no sign for contact precautions posted on Resident #351 door. 675873 Page 17 of 18 675873 11/02/2022 Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/01/22 at 4:14 PM, MA D indicated she thought Resident #351 was on isolation, but she did not know what type of isolation. MA D indicated she would just put on what the sign at the door told her to put on. MA D indicated it was important to have a sign at the door to ensure everybody knew Resident #351 was on contact precautions and people would now what PPE to don to prevent spread of infection. Surveyor pointed out no sign was currently posted and asked MA D what PPE she was donning, and MA D shrugged and stated, I see what you mean and did not answer any further. During an interview on 11/01/22 at 4:15 PM, CNA C indicated Resident #351 was on contact precautions but not sure for what possibly his bottom. CNA C indicated Resident #351 indicated she would don a gown and gloves when she went in the room, but she did not know if this was all she was supposed to use. CNA C indicated there was no sign on the door, but one was necessary because it would help her understand exactly what she needed to do and what PPE to don. CNA C indicated now knowing what PPE to don could cause her to get infected and take the infection home to her kids. During an interview on 11/02/22 at 3:23 PM the DON indicated Resident #351 was on contact precautions for ESBL to wound, and that it was important to have a sign on the door so staff and visitors would not go in unprotected. The DON indicated it would depend on who received the order for the contact precautions on who put into place applying the sign to the door and placing an isolation care outside of the resident's room. The DON indicated she did not know why Resident #351 did not have a sign on the door. The DON indicated not having the sign on the door could cause the infection to spread to other residents and to their families. Record review of the facilities policy titled Contact Precautions last revised September 2012 revealed . The orange Contact Precautions sign will be placed on the door. 675873 Page 18 of 18