Health inspection·September 28, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for three (Residents #34, #9, and #11) of four residents reviewed for resident rights. The facility did not ensure CNA Y treated residents with dignity and respect by referring to them as feeders. This failure could place residents at an increased risk of embarrassment, isolation, and diminished quality of life. Findings included: During a dining observation on 09/26/23 at 12:14 PM, CNA Y stated to multiple unknown staff that those residents over at that table were feeders. CNA Y was in the middle of the dining room where 21 residents were currently seated at different tables. In an interview on 09/26/23 at 12:34 PM with PTA V, she revealed she was not sure who said the word feeder but did hear someone refer to a table in the dining room as the feeders' table. PTA V said she had been trained not to say that word because it could be offensive to residents. In an interview on 09/26/23 at 12:36 PM with CNA Y, she revealed she did say the word feeders and did not see anything wrong with it because that was what the residents were since the residents needed help with feeding or being fed. CNA Y said she was trying to communicate to the other staff in the dining room that there was another table that would be considered feeders and would need that help. CNA Y said she had never been told to say something different or use a different phrase. CNA Y said she did not see anything wrong with what she said or how she said it in front of the residents in the dining room. In an interview on 09/26/23 at 1:11 PM with ST U, she revealed she was in the dining room and did hear that CNA Y had referred to residents as feeders. ST U said she tried to correct CNA Y in the moment by saying assisted diners, but she was not sure if CNA Y heard or not. ST U said the term feeders was not ensuring residents were dignified and using the term assisted diners sounded more appropriate and professional for staff to say. In an interview on 09/26/23 at 1:14 PM with Medical Records, she revealed she was in the dining room and did hear CNA Y calling residents feeders when discussing how to arrange the residents at the Page 1 of 25 675877 675877 09/28/2023 Greenbrier Health Care Center 301 W Randol Mill Rd Arlington, TX 76011

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some tables. Medical Records said she did not normally use that terminology or call residents that, instead she called them residents who needed assistance. Medical Records said all staff had been educated on what terms to use regarding residents. In an interview on 09/26/23 at 2:02 PM with the DON, she revealed she was not in the dining room during meal service earlier; however, she had heard from staff that CNA Y referred to residents as feeders in front of everyone. The DON said staff should not use that term anymore and instead should use a phrase such as residents who need assistance with dining or eating because it was derogatory and not dignified. The DON said she had never heard staff using that word, so she never addressed it with them before today. In an interview on 09/26/23 at 2:50 PM with the Administrator, she revealed she was not in the dining room during meal service earlier, however she had heard from staff that CNA Y referred to residents as feeders in the dining room. The Administrator said CNA Y should have used a different term because they needed to keep resident's dignity in mind and be respectful of their needs. The Administrator said instead CNA Y could have used phrases such as residents who need assistance with eating. The Administrator said staff do not want residents to feel bad about being labeled as something such as feeders. Review of the facility's Protecting Resident Rights policy, dated 12/01/18, reflected: Rights of Residents .These include the right to .privacy 675877 Page 2 of 25 675877 09/28/2023 Greenbrier Health Care Center 301 W Randol Mill Rd Arlington, TX 76011

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 observation, interview, and record review, the facility failed to provide an MDS assessment that accurately reflected the resident's status for one resident (Resident #23) of five residents reviewed for accurate assessments in that: Residents Affected - Few Resident #23's depression was not listed as an active diagnosis on his MDS assessment. This deficient practice could affect residents who receive MDS assessments and could result in missed care. Findings included: Review of Resident #23's face sheet, dated 09/27/23, reflected the resident was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included paranoid schizophrenia (altered perception of reality), schizoaffective disorder (a mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), bipolar type, and major depressive disorder (clinical depression). Review of Resident #23's continuity of care document, dated 09/27/23, reflected he was diagnosed with paranoid schizophrenia, schizoaffective disorder, bipolar type, and major depressive disorder, recurrent with psychotic symptoms on 04/17/23; which were all being medically managed. Review of Resident #23's quarterly MDS Assessment, dated 08/16/23, revealed he had active diagnoses of schizophrenia and anxiety. The MDS did not reflect the resident had a diagnosis of depression. Review of Resident #23's care plan, dated 03/09/23, reflected he was currently taking psychotropic drugs for the treatment of: anxiety, depression, and bipolar. In an interview on 09/28/23 at 10:28 AM with the MDS Coordinator, she revealed she was responsible for ensuring any diagnoses a resident had were documented on the MDS if they were receiving treatment for it. The MDS Coordinator said she reviewed Resident #23's most recent MDS on 08/16/23 and saw that depression was not triggered under active diagnoses even though he had an active diagnosis. The MDS Coordinator said the purpose of ensuring the active diagnoses on the MDS were correct was to ensure the facility was care planning and providing the maximum care that benefits the resident for the diagnoses. The MDS Coordinator said there was not a concern with a diagnosis not being triggered on the MDS assessment for a resident. In an interview on 09/28/23 at 10:44 AM with the DON, she revealed the MDS Coordinator was responsible for ensuring all accurate diagnoses for a resident were included on the MDS. The DON said the purpose of this was to develop a comprehensive care plan for the resident. The DON said the concern with a diagnosis being left off the MDS was that staff needed to make sure they were monitoring the resident's mood and behavior and to see if they were adjusting well to any medications prescribed. In an interview on 09/28/23 at 11:00 AM with the Administrator, she revealed the MDS Coordinator was responsible for verifying if a resident had a diagnosis and reflecting it on the MDS. In an email from the Administrator, dated 09/28/23, revealed the facility did not have policy 675877 Page 3 of 25 675877 09/28/2023 Greenbrier Health Care Center 301 W Randol Mill Rd Arlington, TX 76011

F 0641 addressing MDS Assessments but followed the RAI guidelines. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675877 Page 4 of 25 675877 09/28/2023 Greenbrier Health Care Center 301 W Randol Mill Rd Arlington, TX 76011

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interview and record review, the facility failed to coordinate the assessment with the PASRR program for two (Residents #23 and #29) of five resident assessments reviewed for PASRR evaluations. 1. The facility did not refer Resident #23 to the appropriate state-designated mental health authority for review when he received new diagnoses of schizoaffective disorder, bipolar type; paranoid schizophrenia, bipolar type; and major depressive disorder. 2. The facility did not refer Resident #29 to the appropriate state-designated mental health authority for review when he received new diagnoses of schizophrenia and bipolar disorder. These failures could affect residents with psychiatric diagnoses who may not be evaluated and receive needed PASRR services. Findings included: 1. Review of Resident #23's face sheet, dated 09/27/23, reflected the resident was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included paranoid schizophrenia (altered perception of reality), schizoaffective disorder (a mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), bipolar type, and major depressive disorder (clinical depression). Review of Resident #23's care plan, dated 03/09/23, reflected he was currently taking psychotropic drugs for the treatment of: anxiety, depression, and bipolar disorder. Review of Resident #23's PASRR Level 1 Screening, dated 03/23/23, reflected he did not have a mental illness. Review of Resident #23's quarterly MDS Assessment, dated 08/16/23, revealed he had active diagnoses of schizophrenia and anxiety. The MDS did not reflect the resident had a diagnosis of depression. Review of Resident #23's continuity of care document, dated 09/27/23, reflected he was diagnosed with paranoid schizophrenia and major depressive disorder, recurrent with psychotic symptoms on 04/17/23; which were all being medically managed. Further review revealed Resident #23 was diagnosed with schizoaffective disorder, bipolar type, on 08/31/23 which was being medically managed. In an interview on 09/28/23 at 10:28 AM with the MDS Coordinator, she revealed she started working at the facility in May 2023. The MDS Coordinator said if a resident received a new diagnosis of mental illness, she would have to submit a new PASRR Level 1 Screening form reflecting that information. The MDS Coordinator said a resident with a diagnosis of major depressive disorder, schizoaffective disorder, paranoid schizophrenia, undifferentiated schizophrenia were all considered mental illnesses and should have been reflected as such on their PASRR Level 1 Screening forms. The MDS Coordinator said she was not aware that Resident #23 had diagnoses of mental illness. The MDS Coordinator said she was not at the facility when the March 2023 PASRR Level 1 Screening forms were submitted and had not been notified that Resident #23 had a new qualifying diagnosis as of 08/31/23. The MDS Coordinator said she was responsible for ensuring the PASRR Level 1 Screening form was submitted accurately. 675877 Page 5 of 25 675877 09/28/2023 Greenbrier Health Care Center 301 W Randol Mill Rd Arlington, TX 76011

F 0644 Level of Harm - Minimal harm or potential for actual harm The MDS Coordinator said the purpose of the PASRR Level 1 Screening form being accurate was to ensure the resident was receiving the appropriate services within the facility as well as anything appropriate outside of the facility. The MDS Coordinator said the concern with residents not having a correctly submitted Level 1 Screening form was that they might be eligible for certain services that are not provided to them due to the missed diagnoses. Residents Affected - Few In an interview on 09/28/23 at 10:44 AM with the DON, she revealed she was not fully aware of everything to do with PASRR since she was from a different state and just arrived at the facility at the end of July 2023. The DON said a resident with a diagnosis of major depressive disorder, schizoaffective disorder, paranoid schizophrenia, undifferentiated schizophrenia were all considered mental illnesses and that information should be reflected on the resident's PASRR Level 1 Screening form. The DON said she was not made aware from the psychiatrist that Resident #23 had a new diagnosis of schizoaffective disorder, bipolar type from 08/31/23. 2. Review of Resident #29's face sheet, dated 09/28/23, reflected the resident was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included Parkinson's disease (disorder of central nervous system), muscle weakness, bipolar disorder (mood disorder), and schizophrenia (extremely disordered thinking and behavior). Review of Resident #29's EHR revealed he was diagnosed with bipolar disorder on 08/24/22 and diagnosed with schizophrenia on 08/24/22. Review of Resident #29's PASRR Level 1 Screening, dated 03/22/23, reflected resident was PASRR positive for mental illness. Review of Resident #29's care plan, dated 06/21/23, reflected he was diagnosed with bipolar disorder, anxiety, and schizophrenia with interventions that included administering psychotropic medications and monitoring/recording occurrences of target behavior symptoms. Further review revealed Resident #29 was PASRR positive related to mental illness and had refused all PASRR services, with an intervention of social services consultation as indicated. Review of Resident #29's quarterly MDS Assessment, dated 08/15/23, revealed he had active diagnoses of schizophrenia and bipolar disorder. In an interview on 09/28/23 at 01:32 PM with the DON, she revealed Resident #29's diagnoses of bipolar disorder and schizophrenia were considered mental illnesses that should have triggered a PASRR Level I screening being done at the time resident was diagnosed. The DON stated she was unaware that Resident #29's PASSR Level I was done 7 months after he was diagnosed with mental illness because she was not working at the facility then. She stated the risk to the resident was that he was not offered additional services that he qualified for, although he had since refused the services. In an interview on 09/28/23 at 2:15 PM with the MDS Coordinator, revealed it was her responsibility to ensure that PASSR Level I screenings were completed on residents upon admission and when there was a change in mental status. She stated she was not at the facility during the time Resident #29 was diagnosed with bipolar disorder and schizophrenia on 08/24/22. The MDS Coordinator stated a PASSR Level I screening should have been completed for Resident #29 when he was diagnosed with mental illness. She could not explain why the PASRR Level I screening was completed 7 months later; however, she stated this placed Resident #29 at risk of not receiving services he could have benefitted from. 675877 Page 6 of 25 675877 09/28/2023 Greenbrier Health Care Center 301 W Randol Mill Rd Arlington, TX 76011

F 0644 Level of Harm - Minimal harm or potential for actual harm In an interview on 09/28/23 at 11:00 AM with the Administrator, she revealed she did not have a lot of information about PASRR. The Administrator said a resident with a diagnosis of major depressive disorder, schizoaffective disorder, paranoid schizophrenia, undifferentiated schizophrenia were all considered mental illnesses. The Administrator said the MDS Coordinator was responsible for ensuring the PASRR was submitted accurately. Residents Affected - Few In an email from the Administrator, dated 09/28/23, revealed the facility did not have policy addressing PASSR but that they followed HHSC guidelines. 675877 Page 7 of 25 675877 09/28/2023 Greenbrier Health Care Center 301 W Randol Mill Rd Arlington, TX 76011

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 individuals with mental disorders were evaluated and received care and services for two (Residents #22 and #30) of five residents reviewed for PASRR Level 1 screenings. Residents Affected - Few 1. The facility failed to follow up on Resident #22, who was PASARR Level I negative on admission with a diagnosis of mental illness and submit another PASARR Level I to the local authority for further evaluation to determine need for specialized services. 2. The facility did not correctly identify Resident #30 as having a mental illness and did not complete a new PASRR Level One Screening. These failures could place residents at risk of not being evaluated for PASRR services. Findings included: 1. Review of Resident #22's admission Record revealed the resident was a [AGE] year-old female admitted to the facility on 08 /06/23 with diagnoses that included osteomyelitis (a serious infection of the bone), anxiety, and bipolar disorder (is a mental illness that causes unusual shifts in a person's mood). Review of Resident #22's PASRR Level I completed on 08/03/23 indicated she had no mental illness. Review of Resident #22's admission MDS, dated [DATE], revealed a BIMS score of 12 indicating she had moderate cognitive impairment. Review of Resident #22's care plan, dated 09/28/23, revealed her bipolar disorder was not addressed. Review of Resident #22's physician orders, dated 09/13/23, revealed she was not prescribed antipsychotic medication, but she was on Remeron 15 mg, 1 tablet at night for sleep. Review of Resident #22's second PASRR Level was not completed after Resident # 22 was admitted to the facility with a diagnosis of bipolar disorder. 2. Review of Resident #30's face sheet, dated 09/27/23, reflected the resident was a [AGE] year-old male who originally admitted to the facility on [DATE]. His diagnoses included major depressive disorder, anxiety disorder, and undifferentiated schizophrenia. Review of Resident #30's PASRR Level 1 Screening, dated 03/23/23, reflected he did not have a mental illness. Review of Resident #30's quarterly MDS Assessment, dated 08/04/23, reflected he had active diagnoses of anxiety disorder, depression, and schizophrenia. Review of Resident #30's continuity of care document, dated 09/27/23, reflected he was diagnosed with major depressive disorder, recurrent, unspecified, anxiety disorder, unspecified, and 675877 Page 8 of 25 675877 09/28/2023 Greenbrier Health Care Center 301 W Randol Mill Rd Arlington, TX 76011

F 0645 undifferentiated schizophrenia on 08/24/22; which were all being medically managed. Level of Harm - Minimal harm or potential for actual harm Review of Resident #30's care plan, dated 11/23/23, reflected he had a diagnosis of depression and was currently taking antidepressants. Residents Affected - Few In an interview on 09/28/23 at 10:28 AM with the MDS Coordinator, she revealed she started working at the facility in May 2023. The MDS Coordinator said if a resident had a diagnosis of mental illness, she would have to submit a new PASRR Level 1 Screening form reflecting that information if it was previously submitted incorrectly. The MDS Coordinator said a resident with a diagnosis of major depressive disorder, schizoaffective disorder, paranoid schizophrenia, undifferentiated schizophrenia were all considered mental illnesses and should have been reflected as such on their PASRR Level 1 Screening forms. The MDS Coordinator said she was not aware that Resident #30 had diagnoses of mental illness. The MDS Coordinator said she was not at the facility when the March 2023 PASRR Level 1 Screening form was submitted and had not been notified that Resident #30 had qualifying diagnosis as of 08/24/22. The MDS Coordinator said she was responsible for ensuring the PASRR Level 1 Screening form was submitted accurately. The MDS Coordinator said the purpose of the PASRR Level 1 Screening form being accurate was to ensure the resident was receiving the appropriate services within the facility as well as anything appropriate outside of the facility. The MDS Coordinator said the concern with residents not having a correctly submitted Level 1 Screening form was that they might be eligible for certain services that are not provided to them due to the missed diagnoses. Interview on 09/28/23 at 12:04 PM with the MDS nurse revealed, entrance PASRR level 1 indicated Resident #22 was negative for mental illness. MDS nurse revealed it was her responsibility to go through the diagnosis when new residents are admitted at the facility. MDS nurse revealed Resident # 22 bipolar disorder diagnosis was missed and a new PASRR level 1 form was not filled. MDS nurse stated it was her responsibility to a have sent a new PASRR level 1 to authority for evaluation. M D S nurse stated failure to identify the mental illness diagnosis and filling a new PASSR level 1form could lead to Resident #22 standing a chance of missing supporting services while still being a resident in this facility and, she can be inappropriately placed. MDS nurse stated she was trained on PASSR by corporate on various forms to fill if resident have new diagnosis, a diagnosis was missed and confirming the diagnosis on admission. In an interview on 09/28/23 at 10:44 AM with the DON revealed she was not fully aware of everything to do with PASRR since she was from a different state and just arrived at the facility at the end of July 2023. The DON said a resident with a diagnosis of major depressive disorder, schizoaffective disorder, paranoid schizophrenia, undifferentiated schizophrenia were all considered mental illnesses and that information should be reflected on the resident's PASRR Level 1 Screening form. The DON said she was not at that facility when Resident #30 admitted to the facility. In an interview on 09/28/23 at 11:00 AM with the Administrator revealed she did not have a lot of information about PASRR. The Administrator said a resident with a diagnosis of major depressive disorder, schizoaffective disorder, paranoid schizophrenia, undifferentiated schizophrenia were all considered mental illnesses. The Administrator said the MDS Coordinator was responsible for ensuring the PASRR was submitted accurately. In an email from the Administrator, dated 09/28/23, revealed the facility did not have policy addressing PASSR but that they followed HHSC guidelines. 675877 Page 9 of 25 675877 09/28/2023 Greenbrier Health Care Center 301 W Randol Mill Rd Arlington, TX 76011

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for two (Resident #32 and Resident #41) of six residents reviewed for care plans. The facility failed to develop and implement a comprehensive person-centered care plan to address Residents #32 and #41's use of TED compression hose. This failure could place residents at risk of not having their individual care needs met, which could cause a decline in physical health, psychosocial health, and quality of care. Findings included: 1. Record Review of Resident #32's face sheet, downloaded on 09/28/23, revealed the resident was a [AGE] year-old female who re-admitted to the facility on [DATE]. Resident #32 admitted to the facility with diagnoses of unspecified sequelae of cerebral infarction (residual effects or conditions produced after the acute phase of an illness), muscles weakness, contracted left knee, and muscle wasting and atrophy (the decrease in size and wasting of muscle tissue). Record review of Resident #32's quarterly MDS assessment, dated 09/13/23, revealed Resident #32's cognition was intact with a BIMS score of 13, and she required two-person physical assistance with bed mobility. Record review of the physician orders tab in Resident #32's EHR revealed the following order: TED hose to bilateral lower extremity ON in the morning off in the NIGHT. Special Instructions: [NAME] hose to bilateral lower extremity on in the morning off in the NIGHT. Once A Day 08:00 11/18/2022 Open Ended Treatments Record review of Resident #32's Care Plan, dated 08/22/23, revealed the care plan did not address the resident's physician orders to wear TED hose. Observation and interview on 09/26/23 at 11:27 AM revealed Resident #32's TED hose were on top of a dresser. Resident #32 stated the staff put the TED hose on her when they remembered, but today 09/26/23 staff did not put them on her. Resident #32 stated the TED hose were supposed to be worn in the morning and off at night. Observation and interview on 09/27/23 at 12:27 PM revealed Resident #32's TED hose were observed on top of a dresser. Resident #32 stated the TED hose were where she left them yesterday. 2. Record review of Resident #41's face sheet, downloaded on 09/28/23, revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #41 admitted to the facility with diagnoses of acute kidney failure (when kidneys suddenly become unable to filter waste products 675877 Page 10 of 25 675877 09/28/2023 Greenbrier Health Care Center 301 W Randol Mill Rd Arlington, TX 76011

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few from the blood), following aftercare joint replacement surgery, and morbid (severe) obesity due to excess calories. Record review of Resident #41's MDS admission assessment, dated 08/18/23, revealed Resident #41 had moderate cognitive impairment with a BIMS score of 11, and she required two-person physical assistance with bed mobility and transfers. Record review of the physician orders tab in Resident #41's EHR revealed the following order: Apply TED HOSE in the A.M. and off in the PM Twice A Day 08:00, 20:00 08/18/2023 Open Ended Treatments Record review of Resident #41's Care Plan, dated 08/11/23, revealed the care plan did not address the resident's use of TED hose. Observation and interview on 09/26/23 at 10:33 AM revealed Resident #41's TED hose were observed by the window. Resident #41 stated the staff put the TED hose on depending on who was working. She stated when she was newly admitted there were two nurses one worked morning and afternoon nurse that were putting on and removing at night and since she did not see them anymore, she got them on depending on who are on duty. Resident #41 stated they were supposed to be on in the morning and off at night. Observation and interview on 09/27/23 at 12:44 PM, Resident #41 was observed seated in her wheelchair. The resident's TED hose were observed by the window. Resident #41 stated no staff had offered to put the TED hose on 09/26/23 and 09/27/23. Interview on 09/28/23 at 9:10 AM with the DON revealed Resident #32 and Resident #41 were supposed to be care planned and the MDS Coordinator was responsible. She stated it was the best practice to care plan why TED hose were being used. Interview on 09/28/23 at 12:13 PM with the MDS Coordinator revealed she was responsible for care plan initiation and updating. The MDS Coordinator stated she was supposed to update care plans within 24 hours of receiving the order. She stated Resident #32 orders for TED hose was 11/18/22 and for Resident #41 the were ordered on 08/18/23. The MDS Coordinator stated she got emails from the nursing department or updates from the morning meetings, then she would care plan it, but she did not know how she missed both residents. The MDS Coordinator stated failure to care plan for Resident #32 and Resident #41's TED hose was that they were both at risk not receiving the most practical care, and they could miss out on treatment that maximized their care and independence. The MDS Coordinator stated TED hose helped in circulation and prevent blood clots and edema. Record review of the facility's Comprehensive Resident Centered Care Plans policy, dated September 2022, reflected: It is the policy of this home that staff must develop a comprehensive care plan to meet the needs of the resident. 1. Long-Term Goal 675877 Page 11 of 25 675877 09/28/2023 Greenbrier Health Care Center 301 W Randol Mill Rd Arlington, TX 76011

F 0656 a. Level of Harm - Minimal harm or potential for actual harm Must be measurable and must relate to the discharge plan objective (goal). Example: long term goal independent ambulation; discharge plan goal - return to home. Residents Affected - Few b. Must be time limited. List a target date for the resident to achieve the long-term goal. Review in weeks/months is not recommended since sometimes the date the goal was established is not clear. .12. Resident Care Plan Documentation and Use of The Plan a. The resident care plan is used to plan and assign care for all disciplines. b. The resident care plan must be started the day the resident is admitted and completed within seven days after the comprehensive assessment is completed. c. The resident care plan must be kept current at all times. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident .It Is our purpose to ensure that each resident is provided with individualized, goal-directed care, which is reasonable, measurable, and based on resident needs. A resident's care should have the appropriate intervention and provide a means of interdisciplinary communication to ensure continuity on resident care . 675877 Page 12 of 25 675877 09/28/2023 Greenbrier Health Care Center 301 W Randol Mill Rd Arlington, TX 76011

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 residents who were unable to carry out activities of daily living the necessary services to maintain good personal hygiene to dependent residents for 1 resident (Resident #29) of 5 reviewed for ADL care: Residents Affected - Few -The facility failed to ensure that Resident #29 was accommodated with all bathing needs to receive a proper bath/shower on a routine basis. This failure could place all residents who are dependent on staff for showers/baths at risk of a decreased quality of life, poor hygiene, and skin breakdown. Findings included: Review of Resident #29's face sheet, dated 09/28/23, reflected he was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included Parkinson's disease (disorder of central nervous system), muscle weakness, bipolar disorder (mood disorder), and schizophrenia (extremely disordered thinking and behavior). Review of Resident #29's care plan, dated 06/21/23, reflected he was at risk for a problem with his psychosocial well-being due to resisting assistance with ADL care and a fear of people touching him. Interventions included staff intervening if the behavior endangered the resident or others, encourage resident to express concerns, monitor symptoms, and reiterate the purpose of treatment. Review of Resident #29's quarterly MDS Assessment, dated 08/15/23, revealed he was independent with bathing and personal hygiene. The MDS Assessment also revealed Resident #29 had a BIMS score of 13, which indicated his cognition was intact. Record review of Resident 29's bathing task documented electronically in the facility's point of care from 09/01/23-09/27/23 revealed there were no documented refusals and Resident #29 showered or wiped off independently every day, with the exceptions of being assisted by staff on the following dates: 09/07/23, 09/15/23, and 09/20/23. Interview and observation on 09/26/23 at 01:22 PM with Resident #29 revealed he could not recall the last time he received shower. He stated he liked to wash himself with wipes because his skin was sensitive to the soap at the facility. Resident #29 stated he needed to see a dermatologist about his skin. He stated his sensitive skin was obvious and that staff should have been aware of it. He could not state if he had informed staff that he wanted to see a dermatologist but they knew he did not like the soap and only wanted to use wet wipes. Resident #29 stated he was able to shower or wipe off anytime he wanted to. Resident #29 became frustrated and stated he would not allow staff to touch him with their soap. Observation of Resident #29 revealed he was disheveled with a strong body odor and his hair was oily. There was no visible skin breakdown, marks, or bruises. Interview on 07/06/23 at 01:15 PM with CNA D revealed she had worked at the facility for about 5 months. She stated she worked on the hall with Resident #29 and assisted him with showers when he allowed her to. CNA D stated Resident #29 often refused his showers and preferred to clean himself with wipes. She stated she did not know why Resident #29 preferred to use wipes. She stated Resident #29 never informed her that he had sensitive skin and when she assisted him with showers, using the 675877 Page 13 of 25 675877 09/28/2023 Greenbrier Health Care Center 301 W Randol Mill Rd Arlington, TX 76011

F 0677 Level of Harm - Minimal harm or potential for actual harm facility's soap, she never saw any rashes or irritation on his skin. CNA D stated the resident was independent with most ADLs, but staff would assist him when needed. She stated Resident #29 allowed her to assist him with shower about once a month. CNA D stated Resident #29 sometimes had an odor. She stated that all residents had scheduled shower days, but independent residents could shower as they preferred. She denied that any residents complained to her about not receiving showers. Residents Affected - Few Interview on 09/28/23 at 2:30 PM with LVN B revealed he worked with Resident #29. He stated he had done skin assessments on the resident and had not seen any signs of sensitive or irritated skin. LVN B stated Resident #29 would often refuse for staff to assist him with showers and preferred to clean himself with wipes. He stated Resident #29 had a scent like everyone but did not necessarily have an odor to him. He stated Resident #29's room smelled stale due to the building being old. LVN B stated he was no aware that Resident #29 was sensitive to the facility's soap and wanted to see a dermatologist for his skin. Interview on 09/28/23 at 03:50 PM with the DON revealed she had been employed at the facility since 07/2023. She stated it was her expectation for all residents to receive baths or showers as scheduled unless refused. DON stated that all showers should be documented under the shower task in the electronic medical records. She stated being informed that Resident #29 often refused showers and could sometimes be encouraged to shower with incentives such as fast food. The DON stated she was unaware that Resident #29 had sensitive skin and did not like using the soap provided by the facility; however, after speaking with the resident on this date he revealed to her that he wanted to see a dermatologist. She denied staff ever reporting concerns about Resident #29's skin after a shower or skin assessment. DON stated not receiving showers as scheduled could place residents at risk of developing odors and skin breakdowns. Review of the facility's policy titled Bath, Bed, Tub or Shower, dated 08/2022, revealed the following: Policy: It is the policy of this home that residents will be assisted with their bathing needs and will be bathed on a routine basis. Information provided by the Administrator on the CMS form 672, Resident Census and Conditions of Residents, dated 09/26/23, reflected 38 residents were dependent on staff for bathing. 675877 Page 14 of 25 675877 09/28/2023 Greenbrier Health Care Center 301 W Randol Mill Rd Arlington, TX 76011

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (Residents #32 and #41) of six residents reviewed for quality of care. Residents Affected - Few The facility failed to ensure Resident#32 and Resident #41 were wearing TED compression hose as ordered by the physician. This failure placed residents at risk of not receiving appropriate care and worsening of their conditions. Findings included: Record review of Resident #32's face sheet, downloaded on 09/28/23, revealed the resident was a [AGE] year-old female who re-admitted to the facility on [DATE]. Resident #32 admitted to the facility with diagnoses of unspecified sequelae of cerebral infarction (residual effects or conditions produced after the acute phase of an illness), muscles weakness, contracted left knee, and muscle wasting and atrophy (the decrease in size and wasting of muscle tissue). Record review of Resident #32's MDS quarterly assessment, dated 09/13/23, revealed Resident #32 was cognitively intact cognitive with a BIMS score of 13, and she required two-person physical assistance with bed mobility. Record review of the physician orders tab in Resident #32's EHR revealed the following orders with an order and start date of 11/18/22 and it was open ended. TED hose to bilateral lower extremity ON in the morning off in the night. Special Instructions: [NAME] hose to bilateral lower extremity on in the morning off in the night. Once A Day 08:00 11/18/2022 Open Ended Treatments Record review of Resident #32's Care Plan, dated 08/22/23, revealed no indication the resident had orders to wear TED hose. Record review of Resident #41's face sheet, downloaded on 09/28/23, revealed the resident was sa [AGE] year-old female who admitted to the facility on [DATE]. Resident #41 admitted to the facility with diagnoses of acute kidney failure (when kidneys suddenly become unable to filter waste products from the blood), following aftercare joint replacement surgery, and morbid (severe) obesity due to excess calories. Record review of Resident #41's MDS admission assessment, dated 08/18/23, revealed Resident #41 had moderate cognitive impairment with a BIMS score of 11, and she required two-person physical assistance with bed mobility and transfers. Record review of the physician orders tab in Resident #41's EHR revealed the following orders with an order and start date of 08/18/23 and it was open ended. 675877 Page 15 of 25 675877 09/28/2023 Greenbrier Health Care Center 301 W Randol Mill Rd Arlington, TX 76011

F 0684 Level of Harm - Minimal harm or potential for actual harm Apply TED HOSE in the A.M. and off in the PM. Twice A Day 08:00, 20:00 08/18/2023 Open Ended Treatments. Record review of Resident #41's Care Plan, dated 08/11/23, revealed no indication the resident was on TED hose. Residents Affected - Few Record review of the September 2023 TAR revealed the nurses were documenting the TED hose were applied for Resident #32 on 09/26/23 and 09/27/23. Record review of the September 2023 TAR revealed the nurses were documenting the TED hose were applied for Resident #41 on 09/26/23 and 09/27/23. Observation and interview on 09/26/23 at 10:33 AM revealed Resident #41's TED hose were observed by the window. Resident #41 stated the staff put the TED hose on depending on who was working. She stated when she was newly admitted there were two nurses, one worked morning and the other in the afternoon, were putting the TED hose on her and removing them at night. Since she did not see those nurses anymore, she got the TED hose put on depending on which nurse was on duty. Resident #41 stated they were supposed to be on in the morning and off at night. Observation and interview on 09/26/23 at 11:27 AM revealed Resident #32's TED hose were observed on top of a dresser. Resident #32 stated the staff put the TED hose on her when they remembered and today (09/26/23) staff did not put them on her. She stated the TED hose were supposed to be on in the morning and off at night. Observation and interview on 09/27/23 at 12:27 PM revealed Resident #32's TED hose were observed on top of a drawer. Resident #32 stated the TED hose were where she had left them yesterday. Observation and interview on 09/27/23 at 12:44 PM revealed Resident #41 was observed seated in her wheelchair. The TED hose were observed by the window. Resident # 41 stated no staff had offered to put the TED hose on 09/26/23 and 09/27/23. Interview on 09/27/23 at 1:22 PM with LVN T revealed it was his responsibility to monitor Resident #32 and Resident #41 to ensure they had their TED hose on every morning and off at night unless there was a specific order. LVN T stated he had not put the TED hose on Resident #32 and Resident #41, and he had not delegated this task to CNAs to put the TED hose on the residents. LVN T stated he did not know how he documented on the TAR as administered at 8:00 AM. LVN T stated he did not know whether Resident #32 and Resident #41 had orders for TED hose because he only worked on the weekend, but he would check and notify the surveyor which he did not. When LVN T was shown Resident #32 and Resident #41's TARs where he had documented he had applied the TED hose, he stepped out of the conference room, and then he stated he was a weekend nurse, so he was not familiar with those residents. LVN T stated it was facility policy to follow doctor orders. LVN T stated nursing staff were responsible for ensuring the socks (TED hose) were on daily. LVN T stated failure to put the socks (TED hose) on Resident #32 and Resident #41 predisposed them to embolism, blood clots, and oozing due to an increase of edema. Interview on 09/28/23 at 9:10 AM with the DON revealed her expectation was that the nurses and CNAs followed the physician's orders. The DON revealed the TED hose should be put on by any nursing staff. The DON stated since the TED hose orders were on the nurses' TAR the charge nurse was responsible for initiating and administering the compression hose daily for Resident #32 and Resident #41. The 675877 Page 16 of 25 675877 09/28/2023 Greenbrier Health Care Center 301 W Randol Mill Rd Arlington, TX 76011

F 0684 Level of Harm - Minimal harm or potential for actual harm DON stated she was not sure the nurse had put the compression hose on Resident #32 and Resident #41. The DON stated not using the compression hose could place Resident #32 and Resident #41 at risk of complications of edema, developing deep vein thrombosis, since both residents were not ambulatory. Record review of the facility's Antihemolytic Stockings (Elastic Stockings), dated August 2020, reflected: Residents Affected - Few POLICY It is the policy of this home to assist or apply antihemolytic stockings in a safe manner. A Physician order is required 675877 Page 17 of 25 675877 09/28/2023 Greenbrier Health Care Center 301 W Randol Mill Rd Arlington, TX 76011

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who are fed by enteral means receive the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, and metabolic abnormalities in that they failed to ensure physician orders were followed for one resident (Resident #40) of five residents reviewed for enteral nutrition. The facility failed to provide Resident #40 his tube feeding as ordered by the physician. This failure could affect all residents who receive enteral feeding and place them at risk for metabolic abnormalities, medical complications, or a decline in health due to not following appropriate procedures. Findings included: Review of Resident #40's face sheet, dated 09/28/23, reflected the resident was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included encephalopathy (brain disease or damage), congestive heart failure, dysphasia (speech disorder), mild protein-calorie malnutrition, and disturbances of salivary secretion (blocked salivary glands). Review of Resident #40's care plan, dated 08/24/23, reflected he received hospice services as evidenced by terminal illness. Further review revealed Resident #40 received enteral feedings and medications through a gastrostomy tube, with interventions that including administering feedings and medication as ordered. Review of Resident #40's quarterly MDS Assessment, dated 06/13/23, revealed he required extensive assistance or total dependence with all ADLs. The MDS Assessment also revealed Resident #40 had a BIMS score of 14, which indicated his cognition was intact. Further review only revealed Resident #40 was on a therapeutic diet and did not specify enteral feedings. Record review of Resident #40's physician orders, dated 08/28/23-09/28/23, revealed the following orders: Isosource 1.5 Cal. Special instructions: continuous feeding with Isosource 1.5 at 50ml/hr water flushes at 300ml every 5 hours and 300ml on at 8 PM and off at 6 AM start date of 08/31/23-open ended. Enteral feeding: change bag and syringe QD start date of 05/21/23-open ended. Observation and interview on 09/26/23 at 10:30 AM revealed a bag of Isosource 1.5 formula hanging and dated 09/24/23, with pump off and 100 ml of formula remaining. Resident #40 was lying in bed with no visible marks, bruises, or signs of distress. Resident #40 stated he felt well and did not have any discomfort or pain. He only stated he wanted to get out of the bed. Interview on 09/26/23 at 09:30 AM with LVN A revealed she had worked at the facility for five months, and she worked with Resident #40 on the 6:00 AM-2:00 PM shift Monday-Friday. LVN A stated Resident #40 received enteral feedings overnight from 8:00 PM-6:00 AM. She stated by the time her shift 675877 Page 18 of 25 675877 09/28/2023 Greenbrier Health Care Center 301 W Randol Mill Rd Arlington, TX 76011

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few started at 6:00 AM the feeding would be stopped, and the bag would usually be removed. She stated sometimes it would still be hanging. She stated Resident #40's enteral feeding was not started during her shift, so she could not state if a new bag was hung daily. However, if she found the formula bag still hanging, she would check, and the date would be accurate. She could not state why the bag was dated 09/24/23. LVN A stated she was only responsible for giving Resident #40 his medications and flushes through bolus. Interview on 09/26/23 at 3:00 PM with LVN B revealed he worked at the facility since May 2023. He stated he worked with Resident #40 on the 2:00 PM-10:00 PM shift Monday-Friday. LVN B stated he was responsible for starting Resident #40's enteral feeding at 8:00 PM. He stated that Resident #40's enteral feeding supplies were normally provided by hospice, and he received his formula in cans that staff could pour into empty bags. However, when the resident would run out of the cans, staff would use the facility's supply of bags pre-filled with 1000 ml of Isosource formula. LVN B stated Resident #40's enteral feeding ran at a rate of 50ml/hr for 10 hours, which was 500 ml of formula a day. LVN B stated he would hang a new bag every day, even if there was formula remaining in the bag. He stated at the rate Resident #40 was fed, there would be approximately 500 ml of formula remaining when they used the pre-filled bags. When asked about the bag that was observed on 09/26/23 being dated for 09/24/23, LVN B stated he hung that bag and likely misdated it. He could not state why there was only 100 ml of formula remaining if a new pre-filled bag with 1000 ml formula was hung on 09/25/23. Observation on 09/27/23 at 9:25 AM revealed Resident #40 did not have a bag of formula hanging on the pole. Interview on 09/27/23 at 2:15 PM with the DON revealed she had been at the facility since July 2023. She stated her expectation was for staff to follow all physician orders. The DON stated Resident #40 received enteral feedings with orders to change the bag daily. She stated all of Resident #40's enteral feeding supplies were provided by hospice, and he used cans of Isosource 1.5 Cal that could be poured into fillable bags with the exact amount of formula needed. The DON stated she was unsure why staff were using the facility's pre-filled formula bags, which contained 1000 ml of formula, because Resident #40 had his own supply. The DON stated even if Resident #40 was out of formula, the facility had an extra supply of Isosource 1.5 Cal cans that could have been used to pour the proper amount of formula for Resident #40 instead of using the pre-filled bags with 1000 ml of formula. The DON could not state why there was a bag of formula hanging in the resident's room on 09/26/23, dated for 09/24/23 with 100 ml of formula remaining. She stated the bag should have been changed every day even if there was half of the formula remaining, and it had to be wasted. The DON stated she had not provided any in-services on enteral feedings because there had not been any issues. She stated if the bag was not changed and the formula was used over the two days, there was a risk of the formula not being viable and stable. Interview on 09/27/23 at 5:35 PM with LVN C revealed he had worked at the facility for 18 years. He stated he worked with Resident #40 from 10:00 PM-6:00 AM, Monday-Friday. He stated when he arrived on his shift, Resident #40's feeding pump would already be running. LVN C stated Resident #40 used bags that could be filled from cans of formula with the appropriate amount for each feeding; however, sometimes he would run out of the cans and staff would use pre-filled bags of formula that contained 1000 ml of formula. He stated it was his responsibility to check the bag and tubing to ensure there were no issues, and this included checking the dates. He stated the bags were supposed to be changed daily and normally there was a new bag hanging when he checked. LVN C stated he would normally remove the bag at the end of his shift at 6:00 AM, but if there was a pre-filled bag being used and there was a lot of formula remaining, he would leave the bag hanging for staff to use throughout the 675877 Page 19 of 25 675877 09/28/2023 Greenbrier Health Care Center 301 W Randol Mill Rd Arlington, TX 76011

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few day for any additional feedings that might be needed. He stated Resident #40 was at risk for malnutrition and sometimes needed extra feedings. However, he stated the expectation would be for a new bag to be placed at time of next scheduled feeding. LVN C stated there were times he would come back on shift at 10:00 PM and find the same bag that he left hanging from the morning still being used for the next feeding. LVN C stated when that happened, he would pause the feeding and change the bag himself. LVN C stated feeding the resident formula that had been out for over 24 hours could increase the risk of bacteria and infection. He stated all nurses received annual special focused trainings on enteral feedings and in-services as needed. Review of the facility's Enteral and Parenteral Feeding-Documentation, Orders and Nutrition, dated December 2018, revealed in part the following: Policy: It is the policy of this home that enteral or parenteral nutrition will not be utilized unless clinically unavoidable. The resident, who utilizes enteral or parenteral nutrition, will be free, to the extent possible, from complications related to enteral and parenteral nutrition. It is the policy of this home that nutritional support is provided to residents when the oral intake/diet cannot support 100% of the residents estimated nutritional needs. Procedure: .4. Instructions for TF residuals checks, hold orders, vital signs, and aspiration precautions, bed positioning instructions, routine monitoring and treatment orders are specified in the physician orders 12. Standard precautions, clean techniques, applicable nursing polices, and manufacturer's recommendations are followed by the nursing personnel when dealing with nutrition support residents. Review of the Resident Census and Conditions of Residents Form CMS-672, dated 09/26/23, reflected four residents had tube feedings. 675877 Page 20 of 25 675877 09/28/2023 Greenbrier Health Care Center 301 W Randol Mill Rd Arlington, TX 76011

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals, to meet the needs of each resident for one (Station 1 medication cart ) of two medication carts reviewed for medication storage. The facility failed to dispose of two expired vials of insulin and four pieces nicotine gum. This failure could place the residents at risk of not receiving the required therapy or receiving gums that were expired. Findings included: Observation of the Station 1 medication cart on 09/27/23 at 10:21 AM revealed two vials of Lantus insulin with an open date of 08/25/23, Humulin R with an opening date on the bottle of 08/10/23 placed in a box dated 08/29/23, and four pieces of nicotine gums with an expiry date of July 2023. Interview on 09/27/23 at 10:32 AM with LVN T revealed it was his responsibility to check the cart every shift for expired medications, but it was all nurses' responsibility to check and remove expired medications from the carts. LVN T stated he did not check the cart when he reported on shift. LVN T stated insulins were good for 28 days since they were short acting, and he was supposed to have discarded them together with the expired Nicotine gums. LVN T revealed the failure to remove the expired medication, if administered they would cause reactions, and the resident would not get the required therapy. LVN T stated he had done training on when to discard the insulins once they expired and other medications. Interview on 09/27/23 11:08 AM with the DON revealed her expectation was for the nurses to check the medication carts for the expired medications every shift and when passing the medication. She stated the DON was responsible of auditing the carts every week. The DON stated the last time she checked the carts was on the weekend, and she only checked one cart for Station 2. She stated she was not able to check for Station 1 since she was working on the floor. The DON stated she had not done training with staff on removing expired medications because she was also new and started working at the facility on 07/31/23. The DON also stated if the staff were not checking the carts for expired medications the risk would be the resident will be receiving expired medications and will not receive the expected therapy. The last destruction of expired medication was done by the Pharmacist on 08/23/23, and it was documented. Review of the facility's Medication Administration, Injectables Vials and Ampules policy, revised May 2016, reflected the following: .Vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use and disposal. .9.Disvcard multi-dose vials when empty ,when suspected or visible contamination occurs or when the manufacturer's stated expiration date is reached ,provided the manufacturer's storage conditions have been maintained. Expiration dating not specifically referenced in the manufacturer's package insert should not exceed 28 days once the vials has been opened. 675877 Page 21 of 25 675877 09/28/2023 Greenbrier Health Care Center 301 W Randol Mill Rd Arlington, TX 76011

F 0755 Level of Harm - Minimal harm or potential for actual harm .11. The nursing staff is responsible for reviewing the dates on opened vials and removal of expired items.8.All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining. Residents Affected - Few 675877 Page 22 of 25 675877 09/28/2023 Greenbrier Health Care Center 301 W Randol Mill Rd Arlington, TX 76011

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 each resident's drug regimen was free of unnecessary medication for one (Resident #36) of five residents reviewed for adequate monitoring of unnecessary medication. Residents Affected - Few The facility did not monitor Resident #36 for side-effects related to the use of the anti-anxiety medication Buspirone. This failure could place the residents at risk for adverse consequences of medication. Findings included: Review of Resident #36's face sheet, dated 09/27/23, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included major depressive disorder (clinical depression), anxiety disorder (a group of mental illnesses that cause constant fear and worry), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident #36's quarterly MDS Assessment, dated 08/18/23, reflected a BIMS score of 13, indicating she was cognitively intact. Further review revealed active diagnoses of anxiety disorder and that she was being administered anti-anxiety medication. Review of Resident #36's physician's orders from 08/27/23 to 09/27/23 reflected an order for buspirone tablet; 5 mg; amt: 1 tab; oral [DX: Anxiety disorder, unspecified] Three Times A Day; 08:00, 16:00, 20:00 [sic]. The orders did not address monitoring the anti-anxiety medication. Review of Resident #36's care plan, dated 09/12/23, reflected she required psychotropic drugs for the treatment of anxiety with an approach to monitor/record occurrence of target behavior symptoms and document per facility protocol. Review of Resident #36's September 2023 MAR/TAR revealed she had been receiving the buspirone three times a day as ordered. The MAR/TAR did not include documented evidence the facility was monitoring for side-effects related to the use of the buspirone. In an interview on 09/27/23 at 10:05 AM with LVN T, she revealed he was not familiar with Resident #36 or her medications since this was his first day working with her but would check her orders to see if she was ordered an anti-anxiety medication. LVN T said he saw that Resident #36 was ordered to take Buspar (buspirone) three times a day. LVN T said staff were supposed to monitor every resident for every medication and since Buspar was used to treat anxiety it should have an additional order for monitoring the side effects. LVN T said it was standard to have the additional monitoring order, but he did not see one in the system and was not sure why it was not there. LVN T said that meant staff were not monitoring or documenting the monitoring for the side effects of the anti-anxiety medication. LVN T said whoever put the order in for the medication should have also added the monitoring order. In an interview on 09/27/23 at 10:23 AM with the DON, she revealed residents on certain medications should have orders for monitoring the side effects for every shift documented on their MAR/TAR. The DON said it should pre-populate in the system for what adverse effects to monitor for each 675877 Page 23 of 25 675877 09/28/2023 Greenbrier Health Care Center 301 W Randol Mill Rd Arlington, TX 76011

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication a resident was ordered. The DON said if a resident was on an anti-anxiety medication there should have been a monitoring order put in place as well and whoever admitted the resident was responsible for ensuring it was also added. The DON said the concern with not having a monitoring order in place was that staff were supposed to be monitoring that resident for that specific medication. Review of the facility's Behavior Management- Psychoactive Medication- Antipsychotic Drug Therapy policy, dated December 2018, reflected a chart with the following information: .The Following is a Summary of Psychoactive Guidelines .Drug and DX, Anti-anxiety with dx of anxiety disorder .Side effect monitoring Yes (general) 675877 Page 24 of 25 675877 09/28/2023 Greenbrier Health Care Center 301 W Randol Mill Rd Arlington, TX 76011

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 one of one kitchen reviewed for kitchen sanitation. Cook Z and [NAME] X failed to properly wear a beard restraint while in the food preparation area. This failure could place residents at risk for food contamination and foodborne illness. Findings included: Observation on 09/26/23 at 8:45 AM of [NAME] Z and [NAME] X revealed they both had facial hair. [NAME] Z was observed near the dishwashing machine loading dishes into the machine. [NAME] X was observed near the steamtable wiping surfaces down to clean them. In an interview on 09/26/23 at 10:31 AM with [NAME] Z and [NAME] X, they revealed they had run out of beard restraints yesterday (09/25/23) and did not have access to them since they were locked up in the Dietary Manager's office. [NAME] Z and [NAME] X said they knew they were supposed to wear beard restraints since they both had facial hair but since the Dietary Manager had not arrived to open her office before breakfast service they had to go without. [NAME] Z and [NAME] X said that once the Dietary Manager arrived at the facility, she was able to provide them with beard restraints. In an interview on 09/26/23 at 10:35 AM with the Dietary Manager, she revealed she arrived after the breakfast service and did have the beard restraints locked up in her office. The Dietary Manager said both [NAME] Z and [NAME] X had facial hair and should have been wearing beard restraints but did not have access to them until she arrived. The Dietary Manager said she did not realize the staff had run out of the ones available to them outside her office, so she did not replenish them until she arrived after breakfast. The Dietary Manager said the purpose of wearing a beard restraint was to keep hair from getting into the resident's food. Record review of the facility's Employee Sanitation policy, dated 10/01/18, reflected: .3. Employee Cleanliness Requirements .b. Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces Record review of the Federal Food Code 2022 reflected: .2-402.11 Effectiveness. (Hair Restraints) 1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel (b) (1) Wearing outer garments suitable to the operation (4) Removing all unsecured jewelry (6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other effective hair restraints (8) Confining .eating food, chewing gum, drinking beverages or using tobacco and (9) Taking other necessary precautions . 675877 Page 25 of 25