Health inspection·August 2, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 16 residents (Residents # 4 & # 44) reviewed for resident rights. The facility failed to ensure Residents # 4 & # 44 were assisted with eating in a dignified manner. This failure could place residents at risk for decreased quality of life, quality of care, and self-esteem. Findings: Resident #4 Record review of a facility face sheet for Resident #4 dated 8/2/23 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: multiple sclerosis (a disabling disease of the brain and spinal cord), metabolic encephalopathy (occurs when problems with your metabolism cause brain dysfunction), and muscular dystrophy (a group of genetic diseases that cause progressive weakness and degeneration of skeletal muscles). Record review of a comprehensive MDS for Resident #4 dated 6/18/23 indicated a BIMS score of 14 indicating she was cognitively intact. Record review of a comprehensive care plan for Resident #4 revised 6/23/23 indicated that resident was dependent on 1 person for eating. Resident #44 Record review of a facility face sheet for Resident #44 dated 8/2/23 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: metabolic encephalopathy (occurs when problems with your metabolism cause brain dysfunction), hypertension (high blood pressure), and dementia (a loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). Record review of a quarterly MDS for Resident #44 dated 5/26/23 indicated a BIMS score of 6, indicating severe cognitive impairment. Page 1 of 20 675976 675976 08/02/2023 Winfield Rehab & Nursing 1108 E Loop 304 Crockett, TX 75835

F 0550 Level of Harm - Minimal harm or potential for actual harm Record review of a comprehensive care plan for Resident #44 revised on 1/24/22 indicated that resident was dependent on 1 person for eating. During an observation on 7/31/23 at 12:30 pm LVN F and NA E were observed standing and conversing with each other while feeding Resident's # 4 and #44. Residents Affected - Few During an interview with NA E on 8/1/23 at 3:05 pm she said she knew she was not supposed to stand over residents while feeding them because it was a dignity issue. She said she was supposed to pay attention to residents while feeding and she was not thinking about it. During an interview with LVN F on 8/2/23 at 10:00 am, she said she has been employed at this facility for a couple of years and she normally does not stand over residents to feed them. She said it could make the resident feel intimated and it was a dignity issue. During an interview with the DON on 8/2/23 at 10:05 am, she said she had already in-serviced involved staff members and was working on an in-service for the remaining staff on dignity and respect. She said going forward, she would expect her staff to understand that dignity was a resident right and not to stand over residents to feed them. During an interview with Administrator on 8/2/23 at 10:45 am, she said standing over residents to feed them was a resident right and dignity issue and she expected her staff to know that as well. She said that she was preparing an in-service for all staff. Record review of a facility policy titled Promoting/Maintaining Resident Dignity dated 2/12/2017, indicated .all staff members are involved in providing care to residents to promote and maintain resident dignity . and .when interacting with a resident, pay attention to the resident as an individual . and .It is the practice of the facility to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect . 675976 Page 2 of 20 675976 08/02/2023 Winfield Rehab & Nursing 1108 E Loop 304 Crockett, TX 75835

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 3 of 16 staff (Licensed Social Worker, Activity Director, and Food Service Supervisor) reviewed for develop and implement abuse policies. Residents Affected - Some The facility failed to ensure the Human Resource (HR) Coordinator implemented the facility's abuse/neglect policy and procedure when she failed to complete training to prevent abuse, neglect, and exploitation upon hire and annually for the Licensed Social Worker, Activity Director, and annually for the Food Service Supervisor. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. Findings included: Record review of the facility's Abuse/Neglect policy revised on 02/01/2021, indicated . The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart .The facility will provide and ensure the promotion and protection of resident rights . Procedure II. Training on freedom of abuse will occur on hire and annually .to include: 1.Activities to constitute abuse, neglect, and misappropriation. 2. Procedures for reporting abuse. 3.Dementia Management and Resident Abuse Prevention. .6. Discuss behavioral interventions that can be used for inappropriate resident behaviors. Record review of Licensed Social Worker's personnel file on 08/02/23, indicated she was hired on 04/15/23 and had no documentation of abuse training on hire. Record review of the Activity Director's personnel file on 08/02/23, indicated she was hired on 03/20/23 and had no documentation of abuse training on hire. Record review of the Food Service Supervisor's personnel file on 08/02/23, indicated she was hired on 11/08/21 and had no documentation of abuse training annually. During an interview on 08/02/23 at 9:22 AM, the Human Resource Coordinator said she was responsible for ensuring the employees abuse training was completed annually and upon hire. The Human Resource Coordinator the corporate training program had recently changed, and the trainings were missed. The HR Coordinator said the abuse training should be completed on hire and annually to ensure that all employees were knowledgeable on abuse, neglect, and exploitation and how to report it. The HR coordinator said the Activity Director's and Licensed Social Worker's training were not completed on hire as required by policy. The HR Coordinator said the Food Service Supervisor's abuse annual training should have been completed by 11/08/22 and that the FSS had transferred from a sister facility, and she had no documentation of any abuse training in her file. 675976 Page 3 of 20 675976 08/02/2023 Winfield Rehab & Nursing 1108 E Loop 304 Crockett, TX 75835

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 08/02/23 at 1:01 PM, the Administrator said the abuse training was required at the time of hire with the background check before any staff started employment. The Administrator said they were assigned annually. The Administrator said the risk for not completing abuse training could cause the employee to not know what constitutes abuse, procedures to report abuse and the risk for resident abuse. The Administrator said the HR Coordinator was responsible for ensuring the abuse training was completed upon hire and annually. 675976 Page 4 of 20 675976 08/02/2023 Winfield Rehab & Nursing 1108 E Loop 304 Crockett, TX 75835

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 1 medication storage room and 1 of 2 medication carts (100/400 medication aide cart) reviewed for pharmacy services. The facility failed to remove expired influenza vaccines, hepatitis B vaccine, and Tuberculin PPD (purified protein derivative) from the refrigerator located inside the medication storage room. The facility failed to remove expired Latanoprost eye drops from the medication cart 100/400 for Resident #3. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications Findings: 1. During an observation of the medication storage room on 08/01/23 at 10:35 am, the medication refrigerator had 8 vials of Influenza vaccine with an expiration date of 6/29/2023, 1 vial of Hepatitis B vaccine with an expiration date of 11/08/2022, and 1 vial of Tuberculin PPD with an open date of 6/24/2023 and should have been discarded on 7/24/2023. 2. Record review of facility face sheet dated 8/02/23 indicated that Resident #3 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including type 2 diabetes (high blood sugar), glaucoma (a disease that damages your eye's optic nerve), and hypertension (high blood pressure). During an observation of medication carts on 08/01/2023 at 2:00 PM, latanoprost eye drops for Resident #3 were labeled with an opened date of 6/18/23. Package insert indicated that once opened, medication should be discarded after 6 weeks. Medication should have been discarded on 7/30/23. During an interview on 08/01/23 at 10:45 am LVN A stated she had been employed at the facility a few weeks and she was not sure who was responsible checking the medication storage room for expired medications, but she would check the expiration date of any medicine before she gave it. She stated if a resident was to receive expired medication it could cause an adverse effect. During an interview on 08/01/2023 at 10:50 am LVN B stated she went through the OTC medications weekly with the medication aide but did not check the refrigerator medications. She stated the charge nurses checked the refrigerator but not sure on any schedule. She stated the charge nurses administer injectable medications and if a resident were to receive expired medicine it could make them sick, have an adverse reaction or be ineffective. During an interview on 08/01/2023 at 10:55 am RN C stated she had worked at the facility for 16 months as a charge nurse and the charge nurses and night nurses were responsible for ensuring all expired medications were removed and disposed of properly. She stated the nurses gave vaccinations to the residents as needed and the expiration date should be checked before administering any medicine. 675976 Page 5 of 20 675976 08/02/2023 Winfield Rehab & Nursing 1108 E Loop 304 Crockett, TX 75835

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some She stated multi-dose vials should be dated when opened and discarded after 30 days or when the manufacturer specifies. She stated the risk could be ineffective medicine or an adverse reaction. During an interview on 08/01/2023 at 11:00 am the DON stated all nurses and medication aides were responsible for checking for expired medications in the storage room and medication carts. She stated she randomly checks the storage room and medication carts but overlooked the expired vaccinations in the refrigerator. She stated there was no system or audit tool she used but would put in place a new system for removing expired medications. She stated she thought the pharmacist checked for expired medications when she came once a month and would check that report. She stated she expected all nurses to check the expiration date of all medications before administering them in order to avoid an adverse reaction. During an interview on 08/01/23 at 2:10 pm MA G stated that she worked at the facility prn (as needed) and had been at the facility for several years. She stated that she was unaware of how long the eye drops were good for once opened and that she had not been told to discard them after any length of time. She stated residents receiving outdated medications could be at risk of adverse reactions. During an interview on 08/01/2023 at 3:58 pm the consultant pharmacist stated she visited the facility monthly, and she audited the medication room and medication carts for expired medications. She stated she did an audit at her July visit on 07/25/2023 but missed the expired vaccinations in the refrigerator. She stated when she found expired medications, she would remove them and then have an informal one on one with the nurse or medication aide about removing expired medications. She stated the risk to the resident receiving expired medications could be ineffective medication action. During an interview on 08/02/2023 at 10:45 am the administrator stated that the medication storage room and medication carts were the responsibility of the charge nurses, medication aides, and the consultant pharmacist. She stated she expected all expired medications to be removed from carts and the storage room and for the DON or ADON to ensure that the task was done. She stated the risk to residents receiving expired medications could be the medication not working as it should. Record review of vial labels for 8 vials of Influenza vaccine had an expiration date of 6/29/2023, 1 vial of Hepatitis B vaccine had an expiration date of 11/08/2022, and 1 vial of Tuberculin PPD had an open date of 6/24/2023 and should have been discarded on 7/24/2023. Record review of a prescription label for Latanoprost Eye Drops on 08/01/2023 at 2:00 PM for Resident #3 showed an opened date of 6/18/23. Package insert indicated that once opened, medication should be discarded after 6 weeks. Medication should have been discarded on 7/30/23. Record review of Med Cart/Room Check report by consultant pharmacist dated 7/25/2023 indicated no expired medications were in the medication room refrigerator or on any medication carts. Record review of facility policy titled Medication Storage dated 1/20/2021 indicated, .8. medication carts are routinely inspected for outdated medications, 9. unused medications: the pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated . Record review of facility policy titled Injection safety dated 5/2/2019 indicated' .multi-dose medications are discarded within 28 days of opening unless the manufacturer specifies a different date . Record review of manufacturer insert for Tuberculin PPD indicated .A vial of Tuberculin PPD which 675976 Page 6 of 20 675976 08/02/2023 Winfield Rehab & Nursing 1108 E Loop 304 Crockett, TX 75835

F 0755 has been entered and in use for 30 days should be discarded. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 675976 Page 7 of 20 675976 08/02/2023 Winfield Rehab & Nursing 1108 E Loop 304 Crockett, TX 75835

F 0812 Level of Harm - Minimal harm or potential for actual harm 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 ensure food was stored, prepared, and distributed under sanitary conditions in 1of 1 kitchen reviewed for kitchen sanitation. Residents Affected - Some The floor underneath the dish machine was dirty with a slimy, black mold looking substance. There was a pink sticky substance spilled in the bottom of the three-door refrigerator. These failures could place the residents at risk of foodborne illnesses. Findings include: During an observation 07/31/23 at 9:40 AM the floor underneath the dish machine in the kitchen had a black, slimy mold looking substance on it. During an observation 07/31/23 at 9:50 AM a pink sticky substance was spilled in the bottom of the three-door refrigerator. During an interview on 07/31/23 at 9:22 AM [NAME] D said she had worked at the facility since 2009. She said they had not figured out how to get behind the pipe on the floor to clean under the dish machine. During an interview 08/02/23 at 9:30 AM the Dietary Manager said she had worked at the facility since November of 2021, she said they had fell behind on doing their deep cleaning the last month. She said the refrigerator was not on a cleaning schedule. She said she thought the pink substance spilled in the bottom of the refrigerator was juice. She said it was everyone's responsibility to keep the refrigerator clean. She said not keeping the kitchen clean and sanitized could make the residents sick. During an interview 08/02/23 at 12:59 PM the Administrator said her expectations for the kitchen was for the floor under the dish machine and the refrigerator to be placed on the cleaning schedule. She said the cleaning schedule would be monitored by the Dietary Manager and the Administrator for compliance. She said not keeping the kitchen clean and sanitized could make the residents sick. Record review of a daily cleaning schedule dated 07/30/23 for AM and PM shifts indicated: This checklist is to be completed by AM and PM cooks. At shift change, AM cook needs to do a walkthrough of all the kitchen. If manager is on site, inform manager when you are doing a walk through. PM cook must turn checklist in to a designated location for manager review. Further review of AM and PM checklist indicated: Entire dishwashing area wiped down and cleaned after dinner ware washing. Under the dishwasher is swept and mopped. Record Review of a facility policy, Titled Equipment Cleaning Procedures revised 2/2015 indicated: . 5. Daily cleaning assignments will be given to the dietary staff. For example, cleaning assignments may be listed on a cleaning assignment form, an index cared dry erase board etc., include 675976 Page 8 of 20 675976 08/02/2023 Winfield Rehab & Nursing 1108 E Loop 304 Crockett, TX 75835

F 0812 Level of Harm - Minimal harm or potential for actual harm equipment or environment to be cleaned, the responsible person, and completion deadline. The equipment assignment system needs to include the following through the staff completing an assignment need to inform the manager of completion and the manager needs to check for accuracy and completeness. Residents Affected - Some 675976 Page 9 of 20 675976 08/02/2023 Winfield Rehab & Nursing 1108 E Loop 304 Crockett, TX 75835

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to maintain medical records on each resident that were complete and accurate, in accordance with accepted professional standards and practices for 4 of 10 residents (Residents #10, #13, #26, and #217) reviewed for accurate records. The facility failed to ensure Resident #10, Resident #13, Resident #26, and Resident #217's progress notes in the medical record were updated accordingly when physician notifications were made per facility policy. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and risk to safety. Findings: Resident #10 Record review of a facility face sheet for Resident #10 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: intellectual disabilities (a term for when a person has limited mental abilities and skills for daily life), down syndrome (genetic disorder associated with physical growth delays, characteristic facial features and mild to moderate developmental and intellectual disability), type 2 diabetes, and end stage renal disease (kidneys no longer work as they should to meet the body's needs). Record review of a comprehensive care plan for Resident #10 revised 5/17/23 indicated that .for any blood sugars not within the acceptable parameters as dictated by the physician, document and notify the physician . Record review of Resident #10's blood sugar readings under the weights and vitals tab in the electronic record indicated that resident had a blood sugar reading of 53 on 7/18/23 and did not reflect any progress notes documenting physician notification of an abnormal blood sugar reading on 7/18/23. Resident #13 Record review of a facility face sheet for Resident #13 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: type 2 diabetes, tachycardia (fast heart rate), and epilepsy (seizures). Record review of comprehensive care plan for Resident #13 revised 7/10/23 indicated that .for any blood sugars not within the acceptable parameters as dictated by the physician, document and notify the physician . Record review of Resident #13's blood sugar readings under the weights and vitals tab in the electronic record indicated that he had the following blood sugar readings: 7/29/23 - 414, 7/29/23 - 455, 7/26/23 - 420, 7/25/23 - 418, 7/17/23 - 406 and 7/16/23 - 402, but did not reflect any progress notes documenting physician notification of abnormal blood sugar readings on 7/16/23, 7/17/23, 7/25/23, 7/26/23, or 7/29/23. 675976 Page 10 of 20 675976 08/02/2023 Winfield Rehab & Nursing 1108 E Loop 304 Crockett, TX 75835

F 0842 Resident #26 Level of Harm - Minimal harm or potential for actual harm Record review of a facility face sheet for Resident #26 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: type 2 diabetes, dementia, and hypertension. Residents Affected - Some Record review of comprehensive care plan for Resident #26 revised 9/20/22 indicated that .for any blood sugars not within the acceptable parameters as dictated by the physician, document and notify the physician . Record review of Resident #26's blood sugar readings under the weights and vitals tab in the electronic record indicated the following abnormal blood sugar readings: 7/28/23 - 401, 7/22/23 - 425, and 7/17/23 404, but did not reflect any progress notes documenting physician notification of abnormal blood sugar readings on 7/17/23, 7/22/23, or 7/28/23. Resident #217 Record review of a facility face sheet for Resident #217 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: type 2 diabetes, asthma, and hypertension. Record review of a comprehensive care plan for Resident #217 revised on 7/31/23 indicated that .for any blood sugars not within the acceptable parameters as dictated by the physician, document and notify the physician . Record review of Resident #217's blood sugar readings under the weights and vitals tab in the electronic record indicated the following abnormal blood sugars: 7/6/23 - 59 and 7/5/23 - 57, but did not reflect any progress notes documenting physician notification of abnormal blood sugar readings on 7/5/23 or 7/6/23. During an interview with RN C on 8/1/23 at 7:45 am, she said she had been a long-time hospital nurse and has been in this facility for 2 years. She said that if she were to check a resident's blood sugar and it was too low, she would immediately treat for the low blood sugar and then notify the physician. She said in the case of a high blood sugar she would immediately notify the physician. She said there were parameters in the computer for physician notification because each resident is different, and each doctor likes their own parameters. She said anytime she notified a physician regarding a resident, she documented it in a progress note. During a phone interview with the MD on 8/1/23 at 8:22 am, who was the physician for all 4 residents, he said he would expect to be notified for any blood sugar less than 70 or higher than 401. He said the facility had been good at communicating with him and had been notifying him of any resident's blood sugars that were out of parameters. During an interview with DON on 8/2/23 at 10:10 am, she said they are working out some new systems since they have a new medical director but she would expect her nurses to always document physician notification in a progress note when the MD was notified. She said she understood the medical record should be a complete picture of a resident and easily accessible for any healthcare providers that may need to access it. 675976 Page 11 of 20 675976 08/02/2023 Winfield Rehab & Nursing 1108 E Loop 304 Crockett, TX 75835

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with Administrator on 8/2/23 at 10:45 am she said that going forward that she expected her nurses to document every notification to the physician so that their documentation will be complete. Record review of a facility policy titled Clinical Document Guideline dated 3/14/2014 with a revision date of 3/25/2014 indicated that .The patient's clinical record provides a record of the health status, including observations, history and prognosis and serves as the primary document describing healthcare services provided to the patient . Facility policy requested for Electronic Medical Records from Administrator on 8/2/23 at 10:50 am, none provided. 675976 Page 12 of 20 675976 08/02/2023 Winfield Rehab & Nursing 1108 E Loop 304 Crockett, TX 75835

F 0941 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Based on interview and record review, the facility failed to provide effective communications mandatory training for 3 of 16 direct care staff (LVN M, Activity Director, and Licensed Social Worker) reviewed for training. The facility failed to ensure effective communication training was provided to LVN M, Activity Director, and Licensed Social Worker. This failure could affect residents and place them at risk of miscommunication and social isolation due to lack of staff training. Findings included: Record review of the personnel file for LVN M revealed a hire date of 02/05/2020 and no evidence of annual training on effective communication. Record review of the personnel file for Activity Director revealed a hire date of 03/06/2023 and no evidence of new hire training on effective communication. Record review of the personnel file for Licensed Social Worker revealed a hire date of 04/15/2023 and no evidence of new hire training on effective communication. During an interview on 08/02/23 at 9:22 AM, the Human Resource Coordinator said she was responsible for ensuring the employees effective communication training was completed annually and upon hire. The Human Resource Coordinator the corporate training program had recently changed, and the trainings were missed. The HR Coordinator said the effective communication training should be completed on hire and annually to ensure that all employees were knowledgeable. The HR coordinator said the Activity Director's and Licensed Social Worker's training were not completed on hire as required by policy. The HR Coordinator said LVN M's effective communication should have been completed on or before 02/02/23. During an interview on 08/02/23 at 1:01 PM, the Administrator said effective communication training was required at the time of hire before any staff started employment. The Administrator said they were assigned annually. The Administrator said the risk for not completing effective communication training could cause the employee to not know what other means of communication were available i.e., tablets or communication boards and methods for the hearing impaired or cognitively impaired residents. The Administrator said the HR Coordinator was responsible for ensuring all required training was completed upon hire and annually. During an interview on 08/02/23 at 1:15 PM, the DON stated she was responsible for monitoring for incomplete training modules of the nursing staff. The DON stated one reason for staff failing to complete training was a breakdown in communication. She stated the consequences to residents was they may not receive the care expected. Review of the facility's policy titled I Training Program, Training requirements, dated 11/29/2022 675976 Page 13 of 20 675976 08/02/2023 Winfield Rehab & Nursing 1108 E Loop 304 Crockett, TX 75835

F 0941 revealed item #6. Training content includes, at a minimum: Level of Harm - Minimal harm or potential for actual harm A. Effective communication for direct staff. Residents Affected - Some 675976 Page 14 of 20 675976 08/02/2023 Winfield Rehab & Nursing 1108 E Loop 304 Crockett, TX 75835

F 0942 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Based on interview and record review, the facility failed to provide the required education on the rights of the resident and the responsibilities of a facility to properly care for its residents for 5 of 17 employees (Activity Director, ADON N, DON, Food Service Supervisor, and LVN M) reviewed for training, in that: The facility failed to ensure required education was provided on the rights of the resident and responsibilities of a facility to properly care for its residents was conducted with the Activity Director, ADON N, DON, Food Service Supervisor and LVN M This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings were: Record review of the personnel file for the Activity Director revealed a hire date of 03/06/2023 and no evidence of new hire training on resident rights and the responsibilities of a facility to properly care for its residents. Record review of the personnel file for ADON N revealed a hire date of 03/01/2021 and no evidence of annual training on resident rights and the responsibilities of a facility to properly care for its residents. Record review of the personnel file for the DON revealed a hire date of 03/01/2021 and no evidence of annual training on resident rights and the responsibilities of a facility to properly care for its residents. Record review of the personnel file for the Food Service Supervisor revealed a hire date of 11/08/2021 and no evidence of annual training on resident rights and the responsibilities of a facility to properly care for its residents. Record review of the personnel file for LVN M revealed a hire date of 02/05/2020 and no evidence of annual training on resident rights and the responsibilities of a facility to properly care for its residents. During an interview on 08/02/23 at 9:22 AM, the Human Resource Coordinator said she was responsible for ensuring the employees resident Rights training was completed annually and upon hire. The Human Resource Coordinator stated the corporate training program had recently changed, and the trainings were missed. The HR Coordinator said the effective mandatory training should be completed on hire and annually to ensure that all employees were knowledgeable. The HR coordinator said the Activity Director's and Licensed Social Worker's training were not completed on hire as required by policy. During an interview on 08/02/23 at 1:01 PM, the Administrator said all mandatory training was required at the time of hire before any staff started employment. The Administrator said they were assigned annually. The Administrator said the risk for not completing resident rights training could cause the employee to not know what the rights were and could lead to violations. The Administrator said the HR Coordinator was responsible for ensuring all required training was completed upon hire and 675976 Page 15 of 20 675976 08/02/2023 Winfield Rehab & Nursing 1108 E Loop 304 Crockett, TX 75835

F 0942 annually. Level of Harm - Minimal harm or potential for actual harm During an interview on 08/02/23 at 1:15 PM, the DON stated she was responsible for monitoring for incomplete training modules of the nursing staff. The DON stated one reason for staff failing to complete training was a breakdown in communication. She stated the consequences to residents was they may not receive the care expected. Residents Affected - Some Review of the facility's policy titled I Training Program, Training requirements, dated 11/29/2022 revealed item #6. Training content includes, at a minimum: . B. Resident Rights and facility responsibilities for caring of residents. 675976 Page 16 of 20 675976 08/02/2023 Winfield Rehab & Nursing 1108 E Loop 304 Crockett, TX 75835

F 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on interview and record review, the facility failed to provide the required annual or new hire Abuse training including all activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, dementia management and resident abuse prevention. for 3 of 16 employees (Licensed Social Worker, Activity Director, and Food Service Supervisor) reviewed for training. The facility failed to ensure abuse training including activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, Dementia management and resident abuse prevention was provided to the Licensed Social Worker, Activity Director, and Food Service Supervisor. This failure could affect residents and place them at risk Abuse due to lack of staff training. Findings included: Record review of Licensed Social Worker's personnel file indicated she was hired on 04/15/23 and had no documentation of new hire abuse training including all activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, dementia management and resident abuse preventionon hire. Record review of the Activity Director's personnel file indicated she was hired on 03/20/23 and had no documentation of new hire abuse training including all activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, dementia management and resident abuse preventionon hire. Record review of the Food Service Supervisor's personnel file indicated she was hired on 11/08/21 and had no documentation of annual abuse training including all activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, dementia management and resident abuse prevention annually. During an interview on 08/02/23 at 11:26 AM, the Human Resource Coordinator said she was responsible for ensuring the employees abuse training was completed annually and upon hire. The Human Resource Coordinator the corporate training program had recently changed, and the trainings were missed. The HR Coordinator said the abuse training including all activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, dementia management and resident abuse prevention should be completed on hire and annually to ensure that all employees were knowledgeable on abuse, neglect, and exploitation and how to report it. The HR coordinator said the Activity Director's and Licensed Social Worker's training were not completed on hire as required by policy. The HR Coordinator said the Food Service Supervisor's abuse annual training should have been 675976 Page 17 of 20 675976 08/02/2023 Winfield Rehab & Nursing 1108 E Loop 304 Crockett, TX 75835

F 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some completed by 11/08/22 and that the FSS had transferred from a sister facility, and she had no documentation of any abuse training in her file. During an interview on 08/02/23 at 1:36 PM, the Administrator said the abuse training was required at the time of hire with the background check before any staff started employment. The Administrator said they were assigned annually. The Administrator said the risk for not completing abuse training could cause the employee to not know what constitutes abuse, procedures to report abuse and the risk for resident abuse. The Administrator said the HR Coordinator was responsible for ensuring the abuse training was completed upon hire and annually. Review of the facility's policy titled I Training Program, Training requirements, dated 11/29/2022 revealed item #6. Training content includes, at a minimum: J Abuse, Neglect and Exploitation prevention. Record review of the facility's Abuse/Neglect policy revised on 02/01/2021, indicated . II. Training on freedom of abuse will occur on hire and annually .to include: 1.Activities to constitute abuse, neglect, and misappropriation. 2. Procedures for reporting abuse. 3.Dementia Management and Resident Abuse Prevention. .6. Discuss behavioral interventions that can be used for inappropriate resident behaviors 675976 Page 18 of 20 675976 08/02/2023 Winfield Rehab & Nursing 1108 E Loop 304 Crockett, TX 75835

F 0949 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide behavior health training consistent with the requirements and as determined by a facility assessment. Based on interview and record review, the facility failed to provide mandatory effective behavioral health training for 8 of 17 employees (Activity Director, ADON N, ADON O, the DON, CNA L, Licensed Social Worker, LVN B, and LVN M) reviewed for training, in that: The facility failed to ensure effective behavioral health training was provided to the Activity Director, ADON N, ADON O, the DON, CNA L, Licensed Social Worker, LVN B, and LVN M. This failure could place residents with behaviors at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. The findings were: Record review of the personnel file for the Activity Director revealed a hire date of 03/06/23 and no evidence of new hire training on effective behavioral health. Record review of the personnel file for ADON N revealed a hire date of 03/01/23 and no evidence of new hire training on effective behavioral health. Record review of the personnel file for ADON O revealed a hire date of 03/11/16 and no evidence of annual training on effective behavioral health. Record review of the personnel file for the DON revealed a hire date of 03/01/21 and no evidence of annual training on effective behavioral health. Record review of the personnel file for CNA L revealed a hire date of 03/20/23 and no evidence of annual training on effective behavioral health. Record review of the personnel file for LVN B revealed a hire date of 03/01/2020 and no evidence of annual training on effective behavioral health. Record review of the personnel file for LVN M revealed a hire date of 02/05/2020 and no evidence of annual training on effective behavioral health Record review of the personnel file for the Licensed Social Worker revealed a hire date of 04/15/2023 and no evidence of new hire training on effective behavioral health. During an interview on 08/02/23 at 9:22 AM, the Human Resource Coordinator said she was responsible for ensuring the employees training was completed annually and upon hire. The Human Resource Coordinator the corporate training program had recently changed, and the trainings were missed. The HR Coordinator said the mandatory training should be completed on hire and annually to ensure that all employees were knowledgeable. The HR coordinator said the Activity Director's and Licensed Social Worker's training were not completed on hire as required by policy since there was no new hire packet signed in the employee files. The HR Coordinator said annual behavioral health trainings were not completed by ADON N, ADON O, DON, CNA L, LVN B, and LVN M. 675976 Page 19 of 20 675976 08/02/2023 Winfield Rehab & Nursing 1108 E Loop 304 Crockett, TX 75835

F 0949 Level of Harm - Minimal harm or potential for actual harm During an interview on 08/02/23 at 1:01 PM, the Administrator said mandatory training was required at the time of hire before any staff started employment. The Administrator said they were then assigned annually. The Administrator said the risk for not completing effective behavioral training could put the residents at risk for injuries or staff not being able to recognize and report negative behaviors. The Administrator said the HR Coordinator was responsible for ensuring all required training was completed upon hire and annually. Residents Affected - Some During an interview on 08/02/23 at 1:15 PM, the DON stated she was responsible for monitoring for incomplete training modules of the nursing staff. The DON stated one reason for staff failing to complete training was a breakdown in communication. She stated the consequences to residents was they may not receive the care expected. Review of the facility's policy titled I Training Program, Training requirements, dated 11/29/2022 revealed item #6. Training content includes, at a minimum: Behavioral health including informed trauma care. G. Restraints H. HIV I. Dementia Management and care of the cognitively impaired. 675976 Page 20 of 20