Health inspection·December 17, 2023

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to allow residents to organize without a staff member present, approve a staff member to aide, and demonstrate responses and rationales for changes made for 7 (#1, #4, #5, #7, #8, #9, #10, #11) of 7 residents who attended Resident Council meetings. Residents Affected - Some The facility failed to include the approval of the Resident Council for decisions involving family members, approved staff, and frequency of meeting time. This failure restricted the privacy of these 8 residents and placed the residents at risk of not having the right to voice their concerns without staff being present or overhearing their concerns, conduct resident council meetings without interference, and approve changes made for the council meetings. Findings include: An observation on 12/15/23 at 12:42 PM, revealed a sign was located on each door to each hall stating: Resident Counsel Meeting- Will be moved to the 4th Thursday of the month from here on out. Thank you for your cooperation. Next meeting is December 28, 2023. An interview on 12/15/23 at 11:32 AM, Resident #1 revealed she is the resident council president. Resident #1 stated that the resident council meets every second Thursday of the month, and it was changed to the third Thursday of every month. Resident #1 stated the council was not made aware of this, the council did not approve for the meeting to move, and the AD did not know the proper protocol. Resident #1 stated the meeting held 11/9/23, the staff made family members aware they would not be allowed in council meetings and a family council will be formed. Resident #1 indicated the council did not have a voice in this decision. In an interview on 12/15/23 at 3:11 PM, Resident #2 stated they did not invite anyone, including staff, to the meeting because she had never heard of that the resident council had to. In an interview on 12/15/23 at 6:14 PM, ADM stated the council invited all the staff, but AD. ADM stated AD belongs to group who stated they run their own respected meetings and there has been no discussion with the council members. ADM stated the AD was told to move the meetings to the end of the month because they were being held in the middle of the month. ADM stated the AD told council that the meeting was moved. In an interview on 12/16/23 at 2:46 PM, Resident #4's FM reported that nobody said anything, but AD reported some residents did not want them there. Page 1 of 21 675970 675970 12/17/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident Advisory Council Minutes, dated 9/13/23, revealed family members were not approved to be in this month's meeting but AD was approved. Resident Council Minutes, dated 10/12/23, revealed the resident council did not want to have a private meeting and approved activity director and family members. Resident Council Minutes, dated 11/9/23, revealed activity director was approved for the meeting. Under heading ACTIVITIES: Me (regarding the Activities Director)- was noted on the top line by compliments/concerns and third line stated Resident Counsel- don't like new changes. States next month's meeting will be held on 12/14/23. Record review of Resident Rights dated 11/28/2016, line 5 stated: The resident has a right to organize and participate in resident groups in the facility. B- Staff, visitors, or other guests may attend resident group or family group meetings on at the respective group's invitation. Record review of policy titled, revised 12/13/16, revealed objectives were to help residents organize to represent their own best interest, contribute to the management of the facility, and to enhance the residents' sense of self-worth and effectiveness. Procedures were the residents will develop a self-administered residents' council with its own officers, agenda, and regular meeting times. Staff, visitors, or other guest may attend resident council meetings only at the respective group's invitation. The facility will provide a designated staff person who is approved by the resident council who is responsible for providing assistance and responding to written requests that result from group meetings. The facility will consider the views of the resident council and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. 675970 Page 2 of 21 675970 12/17/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews, the facility failed to protect residents of verbal abuse and neglect for 1 (Resident #1) of 6 residents reviewed for abuse and neglect. Residents Affected - Some 1) AD verbally abused Resident #1 by yelling at her in front of residents and family members during an activity. 2) ADM failed to protect Resident #1 from verbal abuse from AD when it was reported to her by other staff members An Immediate Jeopardy (IJ) was identified on 12/16/2023 at 2:30 PM. While the immediate jeopardy was removed on 12/17/2023 at 4:00 PM, the facility remained out of compliance at actual harm that is not immediate jeopardy and scope of isolated, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. This failure could affect all residents at the facility by placing them at risk for physical, mental, and emotional decline, psychosocial harm, and can lead to isolation and withdrawal from activities of enjoyment. Findings Included: Record review of Resident #1's medical record revealed that Resident #1 was an [AGE] year-old female. Resident #1 was admitted to the facility on [DATE]. Resident #1 had the following diagnosis of major depressive disorder, recurrent, unspecified, cerebral infarction, muscle weakness, unspecified abnormalities of gait and mobility, unspecified lack of coordination, hemiplegia and hemiparesis following cerebral infarction, difficulty in walking, not elsewhere classified, unsteadiness on feet. Record review of Resident #1's MDS assessment revealed that resident is independent an 87-yeaar-old female who was admitted to the facility on [DATE]. Resident #1 does have touch assist with bathing. Resident #1 had a BIMs of 15 with no cognitive impairment. Record review of Resident #1's care plan revealed that Resident #1 needs out of room social, spiritual, and stimulus activities and mental stimulation. Resident #1 enjoys participating in exercises and reading daily chronicle. Resident #1 likes listening to music, bingo, cards, games, parties/socials, attending religious services, watching T.V./movies, watching football, and shopping. Resident #1 love spending time with grandkids and family when they come to visit. In an interview on 12/15/23 at 10:19 AM, DM reported a negative outcome of abuse or neglect is the continuation of abuse or neglect. In an interview on 12/15/23 at 11:02am with Resident #1 revealed that Resident #1 stated that the AD was verbally abusive when the resident mentioned that another resident's family could assist her with picking up pizzas for the facility that are provided by a business owner in town. The AD however did not appreciate the verbal assistance from the resident and started hollering at Resident #1. Resident #1 stated that she let AD know that she was just offering help and nothing more. Resident #1 stated that the AD was sent home, for what was supposed to be a week, but AD went home on Friday 675970 Page 3 of 21 675970 12/17/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0600 afternoon and returned the following Thursday. Level of Harm - Immediate jeopardy to resident health or safety In an interview on 12/15/23 at 11:32 AM with Resident #1 revealed AD screamed at her. Resident #1 stated that BOM heard AD scream in the activity room where an activity was being held. Resident #1 stated that BOM reported the screaming heard to ADM. Resident #1 stated AD was in a Resident Council meeting on 11/09/23 where AD was mad when item line of the Resident Council meeting was on activities. AD was upset at a comment regarding the discussion and told Resident #1 they need to discuss this in the ADM's office. Resident #1 went to ADM's office where AD interrupted the meeting. Residents Affected - Some In an interview on 12/15/23 at 2:01pm with BOM revealed that she heard arguing between a resident and the AD's voice kept getting louder and louder. BOM stated that she went to go and get her abuse coordinator who is the ADM of the building. BOM stated that the ADM went down to the activity room, BOM stated that it got quiet and cannot recall what was being said when voices were raised. BOM stated that the AD was suspended for a couple of days for a completely different altercation. BOM stated that the other altercation was due to another resident's family member stating that the AD was rude to the residents. In an interview on 12/15/23 at 2:20pm with Resident #4's family member regarding any issues or altercations with the AD. Family member stated that she (AD) has never done anything to mother (Resident #4) but was just as hateful as could be to another resident, Resident #1, but since she (AD) got in trouble a couple weeks ago, she has been just as sweet as can be. Family member stated that when she pointed out to the AD that she was being hateful to the resident the AD put her hand in Family members face and said, I'm done! and walked away. Family member stated that she walked after the AD and went into the ADM's office and discussed the issue with the ADM present. The AD stated that she did not even realize what she was doing at the time of the altercation. In an interview on 12/15/23 at 3:11 PM with Resident #2 revealed that AD yelled at Resident #1 during a Resident Council meeting. In an interview on 12/15/23 at 3:32 PM with Resident #3 revealed Resident #1 had stopped going to activities and there were only three to four residents attending activities. In an interview on 12/15/23 at 4:13 PM with ADON revealed AD put in her 2 weeks' notice to resign from her position and had an argumentative attitude when doing so. In an interview on 12/15/23 at 4:23 PM with Resident #1 revealed she has attended activities one or two times. Resident #1 stated that she would rather stay in her room than be around AD. Resident #1 reported that AD told her she was going through menopause. In an interview on 12/15/23 at 6:14 PM with ADM and BOM, ADM stated that BOM reported raised voices. BOM was asked if she reported raised voices or yelling. BOM stated yelling. ADM agreed with BOM that she reported yelling. AD was suspended for five days and was allowed to return to the facility on [DATE] where she continued regular duties. In an interview on 12/16/23 at 6:33am with Resident #3 stated that she just doesn't think the AD knows what she is doing. Resident #3 stated that the AD, doesn't show herself very well at times. Resident #3 stated that some residents will not come back to resident council due to the AD. In an interview on 12/16/23 at 7:59am with Resident #4 FM revealed FM, Resident #1, and AD were in 675970 Page 4 of 21 675970 12/17/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some a room, date unknown, and AD began yelling at Resident #1 regarding a monthly donation made to the facility. Resident #4's family member stated that the AD stated that family member does not need to be involved in getting the donation set up. AD became agitated and started yelling. AD raised her voice and stated, I will take care of it!. Resident #4's family member stated that the AD has NEVER been pleasant or nice to her (family member or Resident #1). In an interview on 12/16/23 at 8:40 AM with BOM confirmed heard yelling in the activity room. BOM reported AD does not know how to handle residents correctly and AD has not been nice or friendly. In an interview on 12/16/23 at 9:10am with ADM, ADM stated that she (ADM) meant to say loud voices. ADM was asked why she confirmed yesterday (12/15/2023) that BOM reported yelling? ADM repeated she meant to say loud voices. ADM did not answer why she agreed with the BOM previous day. ADM stated that when she went to go and investigate the altercation, she did not visualize any signs of abuse and the yelling had stopped. Record review of Resident #3's progress note, dated 11/9/23 at 11:42 AM by RN A, stated Resident #3 was crying because that activity director was arguing with another resident during resident council meeting. Record review of policy title, Abuse and Neglect, dated 3/29/18, states residents should not be subjected to abuse by anyone including facility staff. Under heading Definition: 3. Verbal Abuse- any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance. 6. Mental abuse- includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. 10. Mistreatment- means inappropriate treatment .of a resident. Under heading C. Prevention: 1. The facility will provide the residents, families, and staff an environment free from abuse and neglect. 3. All reports of abuse or suspicion of abuse/neglect .will be investigated as per facility protocol. The facility has in place a method to identify events such as suspicious bruising of residents. 4.The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. E: 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 7/10/19: A. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. B. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. Record review of Long-Term Care Regulatory Provider Letter, dated 7/10/19, stated: A NF must report to HHSC the following types of incidents, in accordance with the applicable state and federal requirements: a). Abuse A table located below the Policy Details and Provider Responsibilities indicated the type of incident as abuse (with or without serious bodily injury) is to be reported immediately, but no later than two hours after the incident occurs or is suspected. On 12/16/23 at 2:30 PM, the ADM was notified that an Immediate Jeopardy had been identified, IJ templates were provided, and a 675970 Page 5 of 21 675970 12/17/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0600 Plan of Removal was requested. Level of Harm - Immediate jeopardy to resident health or safety The Facility's Plan of Removal (as follows) was accepted on 12/17/23 at 7:08 AM. Residents Affected - Some The IJ documentation provided to the facility on [DATE] states: Facility failed to protect residents from verbal abuse. Multiple incidents occurred between Resident #1 and Activity Director. All incidents investigated revealed witnessed verbal abuse from residents and family members. AD was suspended for five days and was allowed to return to the facility on [DATE] where she continued regular duties. Need for Immediate Action: Facility Plan of Removal states: One on One in-service on Abuse Investigation with the Administrator/DON by Area Director of Operations on 12/16/2023 3:52 pm. o Staff working with alleged perpetrator have been interviewed. o The alleged perpetrator was suspended on 12/16/2023 pending the outcome of investigation. o Resident safe surveys have been initiated by Administrator/ADON/MDS Nurse. on 12/16/2023 for all interview able residents. Those who cannot be interviewed will have a head-to-toe assessment completed. No abuse incidents have been reported. o The employees will protect the potential victims of A/N/E by stopping alleged behavior and removing the resident from harm. Then they will report the incident to the Abuse Coordinator immediately. o A complete investigation will be done following our Protocol/Ad Hoc QAPI - Actual/Alleged Abuse o The investigation will be evaluated by the Area Director of Operations &/or the Corporate Compliance nurse to ensure complete interviews of all possible witnesses prior to determining a conclusion. o The following in-services were initiated on 12/16/2023 by Administrator/DON/ADON/MDS Nurse: Any staff member not present or in-serviced on 12/16/2023, will not be allowed to assume their duties until in-serviced by Admin/DON/ADON/MDS Nurse. O All Staff o Abuse/Neglect o Abuse/Neglect Reporting o Who to Report Abuse/Neglect to o All staff will need to be able to articulate back on reporting any type of abuse allegation and to whom to report. The in-service includes if they believe the report was not acted upon to contact the [Abuse hotline for company] [###-###-####], the ADO [Area Director of Operations] at [###-###-####] or call HHSC at [###-###-####]. o Any employees that are reported of any abuse will be suspended pending investigation. 675970 Page 6 of 21 675970 12/17/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0600 o The medical director was notified of the immediate jeopardy situation on 12/16/2023 at 4:30 pm. Level of Harm - Immediate jeopardy to resident health or safety Monitoring of the Plan of Removal Included: Record review of assessments, dated 12/16/23, revealed 23 Safe Surveys and 6 skin assessments completed. Residents Affected - Some Record review of in-service for Abuse and Neglect, dated 12/17/23, revealed ADM and DON received education over policy Abuse and Neglect. Record review of Employee Disciplinary Report, dated 12/16/23, revealed AD had been suspended via text message from ADM. An interview on 12/17/23 at 4:00 PM, ADO revealed company accepted AD letter of resignation effective immediately and did not return to the facility. An observation on 12/17/23 at 11:25 AM revealed a photo taken from ADM phone with a text message to AD that stated AD was placed on suspension again and AD confirmed she had received it. On 12/17/23 from 11:41 PM to 2:22 PM, 23 residents were interviewed regarding safe surveys that were conducted by staff. 18 residents confirmed speaking with staff regarding safe surveys and abuse and neglect. 6 residents were unable to recall the surveys. Residents confirmed or denied knowing who to report abuse and neglect to. If they denied, safe surveys show they were educated on who the abuse coordinator is. On 12/17/23 from 12:22pm to 3:15pm, 40 employees (1 PT, 2 OT, 4 RN, 8 LVN, 11 CNA, 1 HA, 1 MDSN, 1 BOM, 7 DS, 4 HK, 2 LS, and 2 MS, 1 ADON, 1 DON, and 1 ADM) were interviewed and confirmed obtained training via phone or in person. Training attached to in-services that identified the seven areas of the Abuse/Neglect/Exploitation policy along with the types of abuse and how/who to report to. Employees that were contacted were able to state they received abuse and neglect training, knows who to report to and feels comfortable with reporting. Record review of AD-HOC QAPI, dated 12/16/23, revealed ADM, DON, ADON, MD, and ADO attended AD Hoc QAPI meeting. An interview on 12/17/23 at 3:07 pm with MD revealed he was contacted on 12/16/23 regarding outcomes and plan of removal that was conducted. MD stated he was aware of in-services and additional training that would be provided prior to employee's next working shift. An Immediate Jeopardy (IJ) was identified on 12/16/2023 at 2:30 PM. While the immediate jeopardy was removed on 12/17/2023 at 4:00 PM, the facility remained out of compliance at actual harm that is not immediate jeopardy and scope of isolated, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. 675970 Page 7 of 21 675970 12/17/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to implement its' written policies and procedures that prohibit and prevent abuse and neglect for 1 of 6 residents (Resident #1) reviewed for abuse and neglect when: Residents Affected - Some -The ADM was made aware of an allegation that AD was yelling during an activity and failed to follow policy and procedures of abuse and neglect. The facility's failure to ensure suspicions of abuse/neglect were investigated and reported to State could place all residents at risk for injuries, physical and mental decline, decrease in social gatherings, and delay of care. An Immediate Jeopardy (IJ) was identified on 12/16/2023 at 2:30 PM. While the immediate jeopardy was removed on 12/17/2023 at 4:00 PM, the facility remained out of compliance at actual harm that is not immediate jeopardy and scope of isolated, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. Findings Included: Record review of Resident #1's medical record revealed that Resident #1 was an [AGE] year-old female. Resident #1 was admitted to the facility on [DATE]. Resident #1 had diagnosis of major depressive disorder, recurrent, unspecified, cerebral infarction, muscle weakness, unspecified abnormalities of gait and mobility, unspecified lack of coordination, hemiplegia and hemiparesis following cerebral infarction, difficulty in walking, not elsewhere classified, unsteadiness on feet. Record review of Resident #1's MDS assessment revealed that resident is and [AGE] year-old female who was independent with touch assist with bathing. Resident #1 had a BIMs of 15 with no cognitive impairment. Record review of Resident #1's care plan revealed that Resident #1 needs out of room social, spiritual, and stimulus activities and mental stimulation. Resident #1 enjoys participating in exercises and reading daily chronicle. Resident #1 likes listening to music, bingo, cards, games, parties/socials, attending religious services, watching T.V./movies, watching football, and shopping. Resident #1 love spending time with grandkids and family when they come to visit. In an interview on 12/15/23 at 11:32 AM, Resident #1 stated BOM heard yelling and reported the incident to ADM. In an interview on 12/15/23 at 2:03 PM with BOM revealed she reported to ADM of AD yelling at someone in the activity room. No date provided. In an interview on 12/15/23 at 3:59 PM with BOM revealed 2 additional incidents at Resident Council on 11/9/23 and an encounter with a family member on 11/10/2023. In an interview on 12/15/23 at 6:14 PM with ADM revealed BOM reported an incident of AD yelling in the activity room. ADM stated by the time she reached the room, there was no yelling, and the residents were reading. 675970 Page 8 of 21 675970 12/17/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some In an interview on 12/16/23 at 9:10am, ADM stated a staff member or a family member who reported abuse would be no different. State Surveyor asked ADM if BOM felt it was bad enough to report it to ADM, why was it not investigated. ADM stated she went to the room and there was no sign of abuse or distress. ADM stated a negative outcome of not reporting abuse or neglect is the facility will run into trouble with state and propagate many more abuses to occur. On 12/17/23 at 12:59 PM, ADM stated as soon as I hear about abuse, will report and suspend employee to do an investigation, complete investigation and report to the state. Record review of policy title, Abuse and Neglect, dated 3/29/18, states residents should not be subjected to abuse by anyone including facility staff. Under heading Definition: 3. Verbal Abuse- any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance. 6. Mental abuse- includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. 10. Mistreatment- means inappropriate treatment .of a resident. Under heading C. Prevention: 1. The facility will provide the residents, families, and staff an environment free from abuse and neglect. 3. All reports of abuse or suspicion of abuse/neglect .will be investigated as per facility protocol. The facility has in place a method to identify events such as suspicious bruising of residents. 4.The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. E: 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 7/10/19: A. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. B. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. Record review of Long-Term Care Regulatory Provider Letter, dated 7/10/19, stated: A NF must report to HHSC the following types of incidents, in accordance with the applicable state and federal requirements: a). Abuse A table located below the Policy Details and Provider Responsibilities indicated the type of incident as abuse (with or without serious bodily injury) is to be reported immediately, but no later than two hours after the incident occurs or is suspected. On 12/16/23 at 2:30 PM, the ADM was notified that an Immediate Jeopardy had been identified, IJ templates were provided, and a Plan of Removal was requested. The Facility's Plan of Removal (as follows) was accepted on 12/17/23 at 7:08 AM. Need for Immediate Action: The IJ documentation provided to the facility on [DATE] states: Facility failed to protect residents from verbal abuse. Multiple incidents occurred between Resident #1 and Activity Director. All incidents investigated revealed witnessed verbal abuse from residents and family members. AD was suspended for five days and was allowed to return to the facility on [DATE] where she continued regular duties. 675970 Page 9 of 21 675970 12/17/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0607 Level of Harm - Immediate jeopardy to resident health or safety o Facility Plan of Removal states: One on One in-service on Abuse Investigation with the Administrator/DON by Area Director of Operation [ADO] on 12/16/2023 3:52 pm. o Staff working with alleged perpetrator have been interviewed. o The alleged perpetrator was suspended on 12/16/2023 pending the outcome of investigation. Residents Affected - Some o Resident safe surveys have been initiated by Administrator/ADON/MOS Nurse. on 12/16/2023 for all interview able residents. Those who cannot be interviewed will have a head-to-toe assessment completed. No abuse incidents have been reported. o The following in-services were initiated on 12/16/2023 by Administrator/DON/ADON/MDS Nurse: Any staff member not present or in-serviced on 12/16/2023, will not be allowed to assume their duties until in-serviced by Admin/DON/ADON/MDS Nurse. O All Staff o Abuse/Neglect o Abuse/Neglect Reporting o Who to Report Abuse/Neglect to o All staff will need to be able to articulate back on reporting any type of abuse allegation and to whom to report. The in-service includes if they believe the report was not acted upon to contact the [abuse hotline] [###-###-####], the ADO [Area Director of Operations] at [###-###-####], or call HHSC at [###-###-####]. o Any employees that are reported of any abuse will be suspended pending investigation. o The medical director was notified of the immediate jeopardy situation on 12/16/2023 at 4:30 pm. Monitoring of the Plan of Removal Included: An observation on 12/17/23 at 11:25 AM revealed a photo taken from ADM phone with a text message to AD that stated AD was placed on suspension again and AD confirmed she had received it. An interview on 12/17/23 at 4:00 PM, ADO revealed company accepted AD letter of resignation effective immediately and AD did not return to the facility. On 12/17/23 from 11:41 PM to 2:22 PM, 23 residents were interviewed regarding safe surveys that were conducted by staff. 18 residents confirmed speaking with staff regarding safe surveys and abuse and neglect. 6 residents were unable to recall the surveys. Residents confirmed or denied knowing who to report abuse and neglect to. If they denied, safe surveys show they were educated on who the abuse coordinator is. On 12/17/23 from 12:22pm to 3:15pm, 40 employees (1 PT, 2 OT, 4 RN, 8 LVN, 11 CNA, 1 HA, 1 MDSN, 1 BOM, 7 DS, 4 HK, 2 LS, and 2 MS, 1 ADON, 1 DON, and 1 ADM) were interviewed and confirmed obtained training via phone or in person. Training attached to in-services that identified the seven areas of 675970 Page 10 of 21 675970 12/17/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the Abuse/Neglect/Exploitation policy along with the types of abuse and how/who to report to. Employees that were contacted were able to state they received abuse and neglect training, knows who to report to and feels comfortable with reporting. An interview on 12/17/23 at 3:07 pm with MD revealed he was contacted on 12/16/23 regarding outcomes and plan of removal that was conducted. MD stated he was aware of in-services and additional training that would be provided prior to employee's next working shift. Record review of assessments, dated 12/16/23, revealed 23 Safe Surveys and 6 skin assessments completed. Record review of AD-HOC QAPI, dated 12/16/23, revealed ADM, DON, ADON, MD, and ADO attended AD Hoc QAPI meeting. Record review of Employee Disciplinary Report, dated 12/16/23, revealed AD had been suspended via text message from ADM. Record review of in-service for Abuse and Neglect, dated 12/17/23, revealed ADM and DON received education over policy Abuse and Neglect. Immediate Jeopardy (IJ) was identified on 12/16/23 at 2:30 PM. While the IJ was removed on 12/17/23 at 4:00 PM, the facility remained out of compliance at actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. 675970 Page 11 of 21 675970 12/17/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to report an alleged violation of abuse or neglect immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse or neglect or result in serious bodily injury, to officials in accordance with State law, including to the State Survey Agency for 2 (Resident #1 and Resident #6) of 6 residents reviewed for abuse/neglect. 1. The facility failed to report that Resident #1 had a laceration to the lower left leg which required 9 stitches. 2. The facility failed to report that Resident #1 was verbally abused by Activity Director. 3. The facility failed to report bruises to Resident #6's upper right arm, origin of injury could not be determined. This failure could place residents at risk of in a delay in care, continuous abuse or neglect, physical or psychosocial harm, including death. Findings include: Record review of Resident #1's medical record revealed that Resident #1 was an [AGE] year-old female. Resident #1 was admitted to the facility on [DATE]. Resident #1 had the following diagnosis of major depressive disorder, recurrent, unspecified, cerebral infarction, muscle weakness, unspecified abnormalities of gait and mobility, unspecified lack of coordination, hemiplegia and hemiparesis following cerebral infarction, difficulty in walking, not elsewhere classified, unsteadiness on feet. Record review of Resident #1's MDS assessment revealed that resident is independent an 87-yeaar-old female who was admitted to the facility on [DATE]. Resident #1 does have touch assist with bathing. Resident #1 had a BIMs of 15 with no cognitive impairment. Record review of Resident #1's care plan revealed that Resident #1 needs out of room social, spiritual, and stimulus activities and mental stimulation. Resident #1 enjoys participating in exercises and reading daily chronicle. Resident #1 likes listening to music, bingo, cards, games, parties/socials, attending religious services, watching T.V./movies, watching football, and shopping. Resident #1 love spending time with grandkids and family when they come to visit. An interview on 12/15/2023 At 11:02am with Resident #1 revealed that Resident #1 received a laceration on her lower left leg that required 9 stitches. Resident #1 stated CNA C did not move a bar that Resident #1 hit her leg on. Resident #1 stated that the laceration would not stop bleeding and that stiches were placed. Resident #1 also mentioned that the AD was verbally abusive towards her during a conversation regarding the monthly donation of pizza to the facility. The AD however did not appreciate the verbal assistance from Resident #1 and started hollering at Resident #1,. sShe stated that she let AD know that she was just offering help and nothing more. Record review of Resident #1's face sheet revealed that Resident #1 was an [AGE] year-old female. Resident #1 was admitted to the facility on [DATE]. Resident #1 had diagnoses of major depressive 675970 Page 12 of 21 675970 12/17/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some disorder, cerebral infarction, muscle weakness, unspecified abnormalities of gait and mobility, unspecified lack of coordination, paralysis on one side of the body following a stroke, difficulty in walking, and unsteadiness on feet. Record review of Resident #1's MDS assessment revealed that resident is independent with touch assist with bathing. Resident #1 had a BIMs of 15 with no cognitive impairment. Record review of Resident #1's care plan revealed that Resident #1 needs out of room social, spiritual, and stimulus activities and mental stimulation. Resident #1 enjoys participating in exercises and reading daily chronicle. Resident #1 likes listening to music, bingo, cards, games, parties/socials, attending religious services, watching T.V./movies, watching football, and shopping. Resident #1 love spending time with grandkids and family when they come to visit. An interview on 12/15/2023 at 11:43am with CNA D revealed that Resident #1 was trying to get up and turned towards the side of the chair in the transport van by the time CNA D was getting to the back of the transport van. CNA D stated that Resident #1 did not move her feet so that she could turn around completely to sit down in the wheelchair, and that she (CNA D) had to move the wheelchair or Resident #1 would have fallen. CNA D stated that a surgery center placed the stitches in Resident #1's leg. CNA D stated that she reported the injury to her ADON. An interview on 12/15/23 at 2:01pm with BOM revealed that she heard arguing between a resident and the AD's voice kept getting louder and louder. BOM stated that she went to go and get her abuse coordinator who is the ADM of the building. BOM stated that the ADM went down to the activity room, BOM stated that it got quiet and cannot recall what was being said when voices were raised. An interview on 12/15/23 at 6:14 PM with ADM revealed BOM reported an incident of AD yelling in the activity room. ADM stated by the time she reached the room, there was no yelling, and the residents were reading, and that there was no need to make a report . In an interview on 12/16/23 at 9:10am, ADM stated a staff member or a family member who reported abuse would be no different. State Surveyor asked ADM if BOM felt it was bad enough to report it to ADM, why was it not investigated. ADM stated she went to the room and there was no sign of abuse or distress and BOM was a concerned employee. ADM stated that reportable incidents would be abuse, neglect, and exploitation as well as falls with injury and injury of unknown origin. ADM stated a negative outcome of not reporting abuse or neglect is the facility will run into trouble with state and many more abuses will occur . Record review of skin assessment dated [DATE], of Resident #6 revealed 2-3 x 3 bruising to upper inner arms. Record review of Resident #6's face sheet, dated 12/17/2023 revealed that Resident #6 is an [AGE] year-old female who was admitted to facility on 01/04/2021. Resident #6 has diagnoses of dementia, with agitation, difficulty swallowing, cognitive communication deficit, dysphagia, muscle wasting and atrophy, other reduced mobility, need for assistance with personal care, other lack of coordination, major depressive disorder, recurrent, moderate, bipolar disorder, current episode manic severe with psychotic features. Record Review of Resident #6's MDS assessment, dated 09/28/2023, revealed that Resident #6 has a BIMs of 02 indicating severe cognitive impairment and is totally dependent on staff for care. 675970 Page 13 of 21 675970 12/17/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #6's care plan, dated 10/04/2023, revealed that Resident #6 will receive daily skin assessments secondary to being on anticoagulant therapy. Observation on 12/17/2023 at 11:43am ADON wheeled Resident #6 to her room so that visualization of bruising could be seen. Visualization of 2 small bruises were visualized on Resident #6's right upper arm. Resident #6 could not verbalize where these bruises came from. DON was also present at time of visualization. Bruising appears to be 2 small circles well below where a vaccine would be administered. The bruising is not on the deltoid muscle of the arm. Bruising is in the healing stages of light green and faded purple. Interview on 12/17/2023 at 11:45am revealed during visualization of bruising DON stated that Resident #6 recently had a vaccine in that arm. Neither the DON nor ADON could say where the bruising came from. DON stated that education was given on sling use as Regional nurse and DON expressed the bruising could possibly come from the mechanical lift straps. ADON stated the bruising could have taken place from Resident #6's shirt rubbing on resident's arm. Neither DON or ADON could confirm or deny where bruising came from. Record review of Resident #6's skin assessment dated [DATE] did not reveal any bruising on Resident #6. Event nurses note, dated 12/17/23, documented 2 small bruises identified on resident's right upper arm. Record review of Resident #6's vaccine record does show that a vaccine was administered on 12/05/2023 to the Right Deltoid. Interview on 12/17/23 at 12:59 PM, ADM stated as soon as I hear about abuse, will report and suspend employee to do an investigation, complete investigation and report to the state. Interview on 12/17/2023 at 3:15pm with ADM was asked what a reportable injury would be, ADM stated that an injury of unknown origin and or an injury that caused harm to the resident. Interview on 12/17/2023 at 3:28pm with ADON, DON, and Regional RN were asked about bruises on Resident #6. Staff responded with an injury of unknown origin or an injury that caused harm to a resident as a reportable injury. Staff were asked how they could prove without a doubt, that the bruising on Resident #6 was from the mechanical lift sling straps, since the previous interviews were inconsistent, and a definitive answer could not be given. Staff stated that the facility would perform an investigation to determine where if the injury of unknown origin should be reported. Staff was unable to provide policy regarding this process. Staff stated bruising would be reported since a definitive origin of the injury could not be determined. It was acknowledged by staff that bruising would be reported to State agency. Staff stated the injury that Resident #1 received on the transport van was not reportable. Staff stated that the injury was addressed by the surgery center, making the injury non-reportable. Staff stated that an injury that caused harm to a resident would be reportable. ADM joined meeting at this time, and stated she was unaware of injury to Resident #1. Record review of facility provided policy titled Abuse/Neglect, revised date 03/29/2018 stated the following: 675970 Page 14 of 21 675970 12/17/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0609 .E. Reporting . Level of Harm - Minimal harm or potential for actual harm .3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of resident, 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. Residents Affected - Some a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. b. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. F. Investigation 2. After receipt of the allegation the Abuse Preventionist and administrator in conjunction with Risk Management will immediately evaluate the resident's situation using the criteria as stated in this policy. Determination will be made for the required reporting to HHSC per reporting guidelines found in Provider Letter 19-17. 675970 Page 15 of 21 675970 12/17/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0610 Respond appropriately to all alleged violations. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to conduct a thorough investigation of all allegations of abuse and neglect for 1 of 6 residents (Resident #1) reviewed for abuse and neglect when: Residents Affected - Few -the facility reported an allegation of abuse reported by a family member and did not conduct a thorough investigation. The facility's failure to ensure allegations of abuse and neglect were thoroughly investigated could lead to continuous abuse, mental and physical decline, psychosocial harm. An Immediate Jeopardy (IJ) was identified on 12/16/2023 at 2:30 PM. While the immediate jeopardy was removed on 12/17/2023 at 4:00 PM, the facility remained out of compliance at actual harm that is not immediate jeopardy and scope of isolated, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. The facility's failure to ensure allegations of abuse and neglect were thoroughly investigated could lead to continuous abuse, mental and physical decline, psychosocial harm. Findings Included: Record review of Resident #1's medical record revealed that Resident #1 was an [AGE] year-old female. Resident #1 was admitted to the facility on [DATE]. Resident #1 had the following diagnosis of major depressive disorder, recurrent, unspecified, cerebral infarction, muscle weakness, unspecified abnormalities of gait and mobility, unspecified lack of coordination, hemiplegia and hemiparesis following cerebral infarction, difficulty in walking, not elsewhere classified, unsteadiness on feet. Record review of Resident #1's MDS assessment revealed that resident is independent an 87-yeaar-old female who was admitted to the facility on [DATE]. Resident #1 does have touch assist with bathing. Resident #1 had a BIMs of 15 with no cognitive impairment. Record review of Resident #1's care plan revealed that Resident #1 needs out of room social, spiritual, and stimulus activities and mental stimulation. Resident #1 enjoys participating in exercises and reading daily chronicle. Resident #1 likes listening to music, bingo, cards, games, parties/socials, attending religious services, watching T.V./movies, watching football, and shopping. Resident #1 love spending time with grandkids and family when they come to visit. An interview on 12/15/23 at 6:14 PM with ADM revealed after BOM reported yelling in activity room, ADM went to activity room and by the time she arrived in the room, there was no yelling. In an interview on 12/16/23 at 9:10am ADM stated a staff member or a family member who reported abuse would be no different . State Surveyor asked ADM if BOM felt it was bad enough to report it to ADM, why was it not investigated. ADM stated she went to the room and there was no sign of abuse or distress and BOM was a concerned employee. ADM stated that reportable incidents were abuse, neglect, and exploitation as well as fall with injury and injury of unknown origin. On 12/17/23 at 12:59 PM, ADM stated as soon as I hear about abuse, I will report and suspend the employee to do an investigation, complete investigation and report to the state. 675970 Page 16 of 21 675970 12/17/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of Provider Investigation Report (PIR), dated 11/13/23, was provided by ADM. Under section of assessment, dated 11/10/23, no time or name of person who completed the assessment was written in the designated spaces. Injury or adverse effect answered no. Note of psychosocial assessment completedno adverse s/s. Treatment provided no, treatment location: In-House? No. Was the incident reported to the police? Yes. Under investigation summary, After asking Resident #1 and other resident's present, it was determined the said FM was not from this family and did not have firsthand knowledge of incident. States investigation findings were inconclusive. Provider action taken post-investigation, finish in-services, do 1:1 in-service with AD on handling difficult situations and customer service. Interviews conducted during PIR reported two negative responses from Resident #1 and Resident #4. Record review did not provide any written witness statements, staff statements, or statements by complainant. No documentation of in-services or one-on-ones provided to AD after returning to the facility from suspension. One in-service, dated 11/10/23, was signed by AD prior to her suspension from the facility. Record review of staff interviews conducted by ADO, dated 12/16/23, revealed ADO spoke with administrator, MDSC, and ADON. Stated did not interview BOM due to being placed on an action plan on 12/15/23 as ADO felt answers could be retaliation. ADO had written, I did not interview ADM or other non dept heads. This was done right after the IJ was called. The document was signed by ADO on 12/17/23. Record review of policy title, Abuse and Neglect, dated 3/29/18, section F. Investigation stated comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source. 2. After receipt of the allegation, the Abuse Preventionist and administrator in conjunction with Risk Management will immediately evaluate the resident's situation using the criteria stated in Provider Letter 19-17. 6. The Abuse Preventionist and/or administrator will conduct a thorough investigation of the incident(s). On 12/16/23 at 2:30 PM, the ADM was notified that an Immediate Jeopardy had been identified, IJ templates were provided, and a Plan of Removal was requested. The Facility's Plan of Removal (as follows) was accepted on 12/17/23 at 7:08 AM. It is alleged that the facility failed to establish and implement. Need for Immediate Action: The IJ documentation provided to the facility on [DATE] states: Facility failed to protect residents from verbal abuse. Multiple incidents occurred between Resident #1 and Activity Director. All incidents investigated revealed witnessed verbal abuse from residents and family members. AD was suspended for five days and was allowed to return to the facility on [DATE] where she continued regular duties. o Facility Plan of Removal states: One on One in-service on Abuse Investigation with the Administrator/DON by Area Director of Operations [ADON] on 12/16/2023 3:52 pm. o Staff working with alleged perpetrator have been interviewed. 675970 Page 17 of 21 675970 12/17/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0610 o The alleged perpetrator was suspended on 12/16/2023 pending the outcome of investigation. Level of Harm - Immediate jeopardy to resident health or safety o Resident safe surveys have been initiated by Administrator/ADON/MOS Nurse. on 12/16/2023 for all interview able residents. Those who cannot be interviewed will have a head-to-toe assessment completed. No abuse incidents have been reported. Residents Affected - Few o The employees will protect the potential victims of A/N/E by stopping alleged behavior and removing the resident from harm. Then they will report the incident to the Abuse Coordinator immediately. o A complete investigation will be done following our Protocol/AD Hoc QAPI- Actual/Allege Abuse o The investigation will be evaluated by the Area Director of Operations &/or the Corporate Compliance nurse to ensure complete interviews of all possible witnesses prior to determining a conclusion. o The following in-services were initiated on 12/16/2023 by Administrator/DON/ADON/MDS Nurse: Any staff member not present or in-serviced on 12/16/2023, will not be allowed to assume their duties until in-serviced by Admin/DON/ADON/MDS Nurse. O All Staff o Abuse/Neglect o Abuse/Neglect Reporting o Who to Report Abuse/Neglect to o All staff will need to be able to articulate back on reporting any type of abuse allegation and to whom to report. The in-service includes if they believe the report was not acted upon to contact the [company name#########] , the ADO [Area Director of Operations][#########], or call HHSC [#########] o Any employees that are reported of any abuse will be suspended pending investigation. o The medical director was notified of the immediate jeopardy situation on 12/16/2023 at 4:30 pm. Monitoring of the Plan of Removal Included: An observation on 12/17/23 at 11:25 AM revealed a photo taken from ADM phone with a text message to AD that stated AD was placed on suspension again and AD confirmed she had received it. An interview on 12/17/23 at 4:00 PM, ADO revealed company accepted AD letter of resignation effective immediately and did not return to the facility. On 12/17/23 from 11:41 PM to 2:22 PM, 23 residents were interviewed regarding safe surveys that were conducted by staff. 18 residents confirmed speaking with staff regarding safe surveys and abuse and neglect. 6 residents were unable to recall the surveys. Residents confirmed or denied knowing who to report abuse and neglect to. If they denied, safe surveys show they were educated on who the abuse coordinator is. 675970 Page 18 of 21 675970 12/17/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0610 Level of Harm - Immediate jeopardy to resident health or safety On 12/17/23 from 12:22pm to 3:15pm, 40 employees (1 PT, 2 OT, 4 RN, 8 LVN, 11 CNA, 1 HA, 1 MDSN, 1 BOM, 7 DS, 4 HK, 2 LS, and 2 MS, 1 ADON, 1 DON, and 1 ADM) were interviewed and confirmed obtained training via phone or in person. Training attached to in-services that identified the seven areas of the Abuse/Neglect/Exploitation policy along with the types of abuse and how/who to report to. Employees that were contacted were able to state they received abuse and neglect training, knows who to report to and feels comfortable with reporting. Residents Affected - Few An interview on 12/17/23 at 3:07 pm with MD revealed he was contacted on 12/16/23 regarding outcomes and plan of removal that was conducted. MD stated he was aware of in-services and additional training that would be provided prior to employee's next working shift. Record review of assessments, dated 12/16/23, revealed 23 Safe Surveys and 6 skin assessments completed. Record review of AD-HOC QAPI, dated 12/16/23, revealed ADM, DON, ADON, MD, and ADO attended AD Hoc QAPI meeting. Record review of Employee Disciplinary Report, dated 12/16/23, revealed AD had been suspended via text message from ADM. Record review of in-service for Abuse and Neglect, dated 12/17/23, revealed ADM and DON received education over policy Abuse and Neglect. Immediate Jeopardy (IJ) was identified on 12/16/23 at 2:30 PM. While the IJ was removed on 12/17/23 at 4:00 PM, the facility remained out of compliance at actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. 675970 Page 19 of 21 675970 12/17/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services in that: The staff did not complete hand hygiene while handling or distributing food or wear proper head coverings in the kitchen. This failure can place residents at risk of cross contamination, physical decline, and weight loss. Findings Included: An observation on 12/15/23 at 10:19 AM revealed DM not wearing a hair net in the kitchen. An observation on 12/15/23 at 12:07 PM showed DS I touched her face and not practicing hand hygiene before touching the hydration cart. An observation on 12/15/23 at 12:19 PM revealed RN A handing trays to staff without practicing hand hygiene. An observation on 12/15/23 at 12:35 PM revealed DM and DS F not wearing hair nets while serving in the kitchen. In an interview on 12/15/23 at 2:29 PM, DM revealed DS F had left for the day. DM was unaware that DS F was not donning a hairnet or beard net while in the kitchen. DM stated a negative outcome could be contamination of food. An observation on 12/15/23 at 5:27 PM revealed DS H making small single size serving cups with sauerkraut and did not practice hand hygiene or wear gloves. An observation on 12/15/23 at 5:28 PM revealed DS G wearing gloves, touched faced, and continued to make food. An observation on 12/15/23 at 5:31 PM revealed DS H throwing away a box of thickener in a blue and pink container in the trash can, lifted lid with bare hand, grabbed another box and continued to make thickened tea. No hand hygiene was practiced. An observation on 12/15/23 at 5:33 PM revealed DS H grab a grey plate cover, ice cream, and silver ware with no hand hygiene practiced. An observation on 12/15/23 at 5:34 PM revealed DS G wipe nose on arm and continue serving meals. An observation on 12/15/23 at 5:35 PM revealed DS H deliver a tray after touching hair and face with no hand hygiene practiced. An observation on 12/15/23 at 5:36 PM revealed ADM walking in the kitchen with a hair net that did not cover all hair and began going through refrigerator without practicing hand hygiene. 675970 Page 20 of 21 675970 12/17/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0812 Level of Harm - Minimal harm or potential for actual harm An observation on 12/15/23 at 5:37 PM revealed DS G continue making plates with no hand hygiene observed. ADM grabbed a pitcher without practicing hand hygiene. An observation on 12/15/23 at 5:37 PM revealed DS G making mechanical soft plate and did not practice hand hygiene after touching box of thickener. Residents Affected - Many In an interview on 12/15/23 at 6:03 PM with DS H revealed she had just started 5 days ago. DS H revealed she has not had training in hand hygiene or official training from tenured kitchen staff. DS H stated a negative outcome could be spreading germs. In an interview on 12/15/23 at 6:06 PM with DS G revealed she had been here for two weeks, and she was trained by someone in corporate. She stated they had to wash their hands after touching anything in the kitchen and anytime handling food. DS G stated that a negative outcome of not practicing hand hygiene could be residents may get sick and it could cause harm to the resident. Record review of CDC guidelines of Handwashing: A Healthy Habit in the Kitchen, dated 7/18/22, under heading Why, When, and How to Wash Hands, stated handwashing is important when germs can easily spread. Situations include before and after preparing any food, before and after using gloves, after touching garbage, and after coughing, sneezing, or blowing your nose. 675970 Page 21 of 21