Health inspection·December 18, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to develop and implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, and Establish policies and procedures to investigate any such allegations, for 1 of 30 residents (Resident #1) reviewed for investigating injuries of unknown origin, in that. Residents Affected - Few Resident #1 was discovered on 6/16/2023 by LVN A with an injury of unknown origin and did not report the injury to the Administrator or the DON. This deficiency could have placed resident at risk for harm by abuse, neglect, and or mistreatment. The findings included: A record review of Resident #1's admission record dated 11/07/2023, revealed an admission date of 04/18/2022, a discharge date of 06/19/2023, with diagnoses which included downs syndrome and osteoporosis. A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old mentally disabled female admitted for long term care and assessed with a BIMS score of 04 out of a possible 15, which indicated severe cognitive impairment. A record review of Resident #1's care plan dated 11/7/2023 revealed, I am at risk for falls r/t but not limited to HX [history] of Falls, cognitive impairment and FX [fractures] of Left Hip with surgical intervention. Date Initiated: 05/03/2022, [Resident #1] will be free of falls through the review date . Interventions; Anticipate and meet resident's needs. Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed. Pt evaluate and treat as ordered or PRN .Review information on past falls and attempt to determine cause of falls. Record possible root causes A record review of Resident #1's Incident Report dated 06/16/2023 revealed, person preparing report: [ LVN A] .Nursing description: Resident was in bed and evidently tried to get up and fell to the floor hitting her head. The bed was down to the floor. She was noticed on the floor sitting on her bottom .Resident description: Resident unable to give description .description: this nurse assessed patient for injuries and took a set of vital signs. No lacerations noted. Only a knot to her forehead above the eyebrow on the right .witnesses: no witness found. During an interview on 11/08/2023 at 12:44 PM the previous DON stated she was the interim DON Page 1 of 6 675929 675929 12/18/2023 Cedar Creek Nursing and Rehabilitation Center 159 Montague Ave Bandera, TX 78003

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few during June, July, and August 2023. The previous DON stated LVN A had not reported Resident #1 had an unwitnessed fall which resulted in an injury. The previous DON stated if she was unaware of resident #1's head injury and had she known she would have begun an investigation and reported the injury of unknown origin to the state agency. During an interview on 11/08/2023 at 01:02 PM the DON stated she was on staff since September 2023. The DON stated the expectation was for all staff to report injuries of unknown origin to leadership to which included the abuse, neglect, and exploitation prevention coordinator which was the Administrator. During an interview on 11/8/2023 at 4:30 PM the Administrator stated he was not the Administrator in June 2023 when the fall for Resident #1 occurred. The Administrator stated an unwitnessed fall which resulted in an injury and could not be explained by the resident was an injury of unknown origin and needed to be investigated and reported to the state agency. The Administrator stated failure to investigate and report could place residents at risk for harm. A record review of the facility's Abuse/Neglect policy dated 03/29/2018, revealed, .Reporting . facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property, or injury of unknown source to the facility Administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of provider letter 19-17 dated 07/10/2019. If the allegations involve abuse or result in serious bodily injury the report is to be made within two hours of the allegation. 675929 Page 2 of 6 675929 12/18/2023 Cedar Creek Nursing and Rehabilitation Center 159 Montague Ave Bandera, TX 78003

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures for 1 of 30 residents (Resident #1) reviewed for reporting injuries of unknown origin, in that. Resident #1 was discovered on 6/16/2023 by LVN A with an injury of unknown origin and did not report the injury to the Administrator or the DON. This deficiency could have placed resident at risk for harm by abuse, neglect, and or mistreatment. The findings included: A record review of Resident #1's admission record dated 11/07/2023, revealed an admission date of 04/18/2022, a discharge date of 06/19/2023, with diagnoses which included downs syndrome and osteoporosis. A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old mentally disabled female admitted for long term care and assessed with a BIMS score of 04 out of a possible 15, which indicated severe cognitive impairment. A record review of Resident #1's care plan dated 11/7/2023 revealed, I am at risk for falls r/t but not limited to HX [history] of Falls, cognitive impairment and FX [fractures] of Left Hip with surgical intervention. Date Initiated: 05/03/2022, [Resident #1] will be free of falls through the review date . Interventions; Anticipate and meet resident's needs. Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed. Pt evaluate and treat as ordered or PRN .Review information on past falls and attempt to determine cause of falls. Record possible root causes A record review of Resident #1's Incident Report dated 06/16/2023 revealed, person preparing report: [ LVN A] .Nursing description: Resident was in bed and evidently tried to get up and fell to the floor hitting her head. The bed was down to the floor. She was noticed on the floor sitting on her bottom .Resident description: Resident unable to give description .description: this nurse assessed patient for injuries and took a set of vital signs. No lacerations noted. Only a knot to her forehead above the eyebrow on the right .witnesses: no witness found. During an interview on 11/08/2023 at 12:44 PM the previous DON stated she was the interim DON during June, July, and August 2023. The previous DON stated LVN A had not reported Resident #1 had an unwitnessed fall which resulted in an injury. The previous DON stated if she was unaware of resident #1's head injury and had she known she would have begun an investigation and reported the injury of unknown origin to the state agency. 675929 Page 3 of 6 675929 12/18/2023 Cedar Creek Nursing and Rehabilitation Center 159 Montague Ave Bandera, TX 78003

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/08/2023 at 01:02 PM the DON stated she was on staff since September 2023. The DON stated the expectation was for all staff to report injuries of unknown origin to leadership to which included the abuse, neglect, and exploitation prevention coordinator which was the Administrator. During an interview on 11/8/2023 at 4:30 PM the Administrator stated he was not the Administrator in June 2023 when the fall for Resident #1 occurred. The Administrator stated an unwitnessed fall which resulted in an injury and could not be explained by the resident was an injury of unknown origin and needed to be investigated and reported to the state agency. The Administrator stated failure to investigate and report could place residents at risk for harm. A record review of the facility's Abuse/Neglect policy dated 03/29/2018, revealed, .Reporting . facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property, or injury of unknown source to the facility Administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of provider letter 19-17 dated 07/10/2019. If the allegations involve abuse or result in serious bodily injury the report is to be made within two hours of the allegation. 675929 Page 4 of 6 675929 12/18/2023 Cedar Creek Nursing and Rehabilitation Center 159 Montague Ave Bandera, TX 78003

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for professional standards for food service safety, in that: The facility failed to keep personal items and keys out of the food preparation areas. This failure could place residents at risk for food borne illness. The findings included: During an observation and interview on 11/8/2023 at 11:00 AM of the kitchen revealed a food preparation table with 2 pills, one oval blue capsule and 1 oval white pill, in a small clear zip top bag, next to a half full clear 500ml water bottle, which was next to a similar sized multicolored drink tumbler. Further observation revealed a set of keys on a nylon fob atop of another food preparation table. The facility's [NAME] stated the counter where the pills were and the drinks were had a food puree machine, a bread toaster, a blender, and a coffee dispenser. The cook stated the pills and drinks were hers. The [NAME] stated the keys on the other food prep table were used to unlock the food pantry. The [NAME] was asked what her expectations were for the keys, pills, and drinks to which the [NAME] did not verbally respond and used body language and appeared to be thinking. During an interview on 11/08/2023 at 11:08 AM the FSM stated the food pantry keys, the personal pills, and drinks should not have been on the food prep counters. The FSM stated the keys had a hook where they were supposed to be kept, and the personal pills and drinks should not be in the food prep areas and could have been better stored in the employee lockers. The FSM stated the practice could have placed residents at risk for food borne illness due to cross contamination from personal items and improperly placed keys. The FSM stated the staff had received training for cross contamination in the kitchen and the responsibility was with each staff member and the FSM's responsibility for oversight. During an interview on 11/08/2023 at 11:50 AM the DON stated the food pantry keys, the personal pills, and the personal drinks which were on the food prep areas in the kitchen could have placed residents at risk for food borne illnesses. The DON stated personal items should not be around residents' food preparation areas. A record request was made to the DON and the Administrator on 11/07/2023 at 02:50 PM for a policy regarding the personal items on the food preparation areas and as of exit on 11/09/2023 at 10:00 AM no policies were provided. A record review of the Federal Government Food and Drug Administrations Food Code 2022 revealed, Epidemiological outbreak data repeatedly identify five major risk factors related to employee behaviors and preparation practices in retail and food service establishments as contributing to foodborne illness: .Contaminated equipment, .Poor personal hygiene. The Food Code addresses controls for risk factors and further establishes 5 key public health interventions to protect consumer health .these interventions are: demonstration of knowledge, employee health controls, controlling hands as a vehicle of contamination . 675929 Page 5 of 6 675929 12/18/2023 Cedar Creek Nursing and Rehabilitation Center 159 Montague Ave Bandera, TX 78003

F 0812 Level of Harm - Minimal harm or potential for actual harm Public Health and Consumer Expectations It is a shared responsibility of the food industry and the government to ensure that food provided to the consumer is safe and does not become a vehicle in a disease outbreak or in the transmission of communicable disease. This shared responsibility extends to ensuring that consumer expectations are met and that food is .prepared in a clean environment, and honestly presented. Residents Affected - Few 2-401 Food Contamination Prevention 2-401.11 Eating, Drinking, or Using TOBACCO PRODUCTS. (A) Except as specified in (B) of this section, an EMPLOYEE shall eat, drink, or use any form of TOBACCO PRODUCTS only in designated areas where the contamination of exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES; or other items needing protection can not result. 675929 Page 6 of 6