Health inspection·February 9, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency for 1 of 10 residents (Resident #35) reviewed for abuse and neglect. The facility did not report to the State Survey Agency (HHSC) an incident in which Resident #36 was inappropriately touching Resident #35. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. The findings included: 1. Record review of Resident #35's face sheet, dated 2/7/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia, intellectual disabilities, need for assistance with personal care, anxiety disorder (a normal reaction to stress in an intense, excessive, and persistent worry and fear about everyday situations), impulse disorder (characterized by urges and behaviors that are excessive and/or harmful to oneself or others and cause significant impairment in social and occupational functioning) and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Record review of Resident #35's most recent quarterly MDS assessment, dated 11/4/23 revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #35's comprehensive care plan, dated 1/28/24 revealed the resident was touched inappropriately by another elder (Resident) with interventions that included, Nursing is attempting to keep elder separated from male elder at this time and Elder is not able to give description of incident as she has IDD (Intellectual and Developmental Disabilities). Elder does not demonstrate any distress over incident. 2. Record review of Resident #36's face sheet, dated 2/7/24 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included attention and concentration deficit, and Alzheimer's disease with late onset. Record review of Resident #36's most recent quarterly MDS assessment, dated 1/5/24 revealed the resident was severely cognitively impaired for daily decision-making skills. Page 1 of 31 676026 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #36's comprehensive care plan, dated 1/28/24 revealed the resident had a behavior problem of touching another elder (resident) inappropriately, with interventions that included, elder remains separated from other female residents at this time. Elder denies touching any other elders. Care Partners (staff) in-serviced on what to do and who to inform when an incident occurs. Record review of the late entry incident note dated 1/28/24 at 1:35 p.m. and authored by RN E revealed, Summoned to room [ROOM NUMBER]B by housekeeping (Housekeeper F). Resident #36 sitting in wheelchair patting Resident #35 on the lower portion of her breast as she held her blouse out of the way. Resident #36 stated doing nothing [sic]. I am sorry. Elders separated. Elders educated on unacceptable behavior; Resident #36 is not to be on hall 4, not in the lady's [sic] rooms and not in the living room with Resident #35 .Inservice given on new procedures regarding incident . Record review of the incident note dated 1/28/24 at 10:09 p.m. and authored by LVN G for Resident #36 revealed, Follow up note for incident that occurred .regarding inappropriate behavior from another resident (Resident #35) on Hall 2. All parties notified .No other incidents have occurred since initial encounter. No signs or symptoms of distress or discomfort. Elder (Resident #36) is resting in bed at this time with call light in reach . Record review of the In-Service Training Reports, dated 1/28/24 revealed the following: - Resident #36 and Resident #35 are no to be in living room together. Resident #36 is not to follow staff down Hall 4. The In-Service Training Report did not have the staff name or signature of who conducted the in-service. - Men should not be in women room and women should not be in men room without approval. The In-Service Training Report for the in-service was conducted by the DON. - Any sexual behavior between two demented or not cognitively intact elders is not ok, please separate if you witness this. The In-Service Training Report for the in-service was conducted by the DON. Observation on 2/7/24 at 5:24 p.m. revealed Resident #35 sitting in the living room holding a doll to her chest. During a telephone interview on 2/8/24 at 2:35 p.m., Housekeeper F stated she had observed Resident #36 self-propelling in the wheelchair up and down the hallway and when she passed Resident #35's room she observed Resident #36 touching Resident #35's waist down her legs. Housekeeper F stated she reported the incident to RN E, who was at the nurse's station and stated RN E took Resident #36 out of the room. Housekeeper F stated shortly thereafter she signed an in-service regarding the incident which included to ensure to report to the nurse if Resident #36 was seen entering Resident #35's room. An attempt at a telephone interview on 2/8/24 at 2:45 p.m. with RN E was unsuccessful. During an interview on 2/8/24 at 2:46 p.m., Hydration Aide H stated she had been in-serviced by RN E about not allowing Resident #36 to enter Resident #35's room and for these residents not to be sitting in the tv room together. Hydration Aide H stated she considered the incident between Resident #35 and Resident #36 as inappropriate. 676026 Page 2 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview on 2/8/24 at 3:07 p.m., Resident #35 was seen in her room, laying in bed. This surveyor knocked on Resident #35's bedroom door and asked if I could enter. Resident #35 stated, no, get out. During an observation and interview on 2/8/24 at 3:11 p.m., Resident #36 was seen laying in bed, awake and alert. Resident #35 was asked how long he had lived in the facility and answered, que?, meaning what? in Spanish. Resident #36 was then asked in Spanish how long he had been living in the facility and answered, what?. During an interview on 2/9/24 at 8:09 a.m., CNA A revealed he had signed an in-service given by RN E regarding an incident in which Resident #36 had been caught in Resident #35's room and touching her inappropriately. CNA A further revealed the in-service highlighted keeping Resident #36 from entering Resident #35's room and to keep an extra eye on these two residents because they both liked to hang out in the tv room. CNA A stated Resident #36 had been known to be verbally inappropriate, such as making derogatory comments to other residents in Spanish but otherwise was hospitable. During an interview on 2/9/24 at 8:46 a.m., Med Aide I revealed he had been in-serviced approximately 2 to 3 weeks ago by the DON and the Administrator that highlighted abuse/neglect and ensuring Resident #35 and Resident #36 could not be in each other's room. Med Aide I stated he believed the incident between Resident #35 and Resident #36 was reported to the state (HHSC) because what if Resident #35 had a bruise or Resident #36 actually touched Resident #35 inappropriately?. During an interview on 2/9/24 at 10:03 a.m., LVN J revealed she had been in-serviced by the DON, maybe last week regarding an incident that occurred between Resident #35 and Resident #36. LVN J stated, Resident #36 was found in Resident #35's room and Resident #36 was touching Resident #35's breast or something. LVN J stated the in-service provided highlighted keeping Resident #35 and Resident #36 apart and abuse/neglect. LVN J revealed she was not certain if the facility reported the incident to the state (HHSC). LVN J stated, Resident #35 was demented and did not have the intellectual ability to say she would not want to be touched in a certain way. LVN J stated, Resident #36 was alert and oriented but probably unable to tell the time of day or year but could express what he wanted. During an interview on 2/9/24 at 10:18 a.m., the Administrator revealed Resident #35 had IDD and could not make decisions. The Administrator further revealed she believed Resident #36 did not have mental capacity either and believed the resident had dementia. The Administrator stated, both Resident #35 and Resident #36 lacked mental capacity and could not give consent. The Administrator stated, the facility followed the diagram from the HHSC Provider Letter 19-17 and believed the incident did not fall under the criteria highlighted on the Provider Letter and therefore the incident was not reportable to HHSC. The Administrator revealed she had been notified by phone by RN E that Resident #35 was holding her top up and Resident #36 was touching Resident #35's breast. The Administrator stated she instructed RN E to interview both residents, notify the family and educate. The Administrator further stated mental status and care planning were also discussed. After reviewing the HHSC Provider Letter 19-17 with the state surveyor, the Administrator stated, It makes sense now. Should have been reported only because the residents involved could not consent. Record review of the facility's policy and procedure titled, Abuse Investigations, revision date December 2009 revealed in part, .All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management .The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may 676026 Page 3 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0609 be required by state or local laws, within five (5) working days of the reported incident . Level of Harm - Minimal harm or potential for actual harm Record review of the HHSC Long-Term Care Regulatory Provider Letter, Number PL 19-17, date issued 7/10/19 and titled Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents in part, .This letter provides guidance for reporting incidents to HHSC .A NF must report to HHSC the following types of incidents, in accordance with applicable state and federal requirements .Abuse .Neglect .The following table describes required reporting timeframes for each incident type .abuse (with or without serious bodily injury); or neglect, exploitation or mistreatment .that result in serious bodily injury .Immediately, but not later than two hours after the incident occurs or is suspected .An incident that does not result in serious bodily injury and involves .neglect .exploitation .Immediately, but not later than 24 hours after the incident occurs or is suspected .Attachment 2: How to Report Abuse, Neglect, Exploitation (ANE), other incidents, and Sexual Activity .The facility becomes aware of, or receives an allegation of suspected abuse, neglect, exploitation or another reportable accident .Can all residents involved in the sexual activity consent to participation .No .Report the incident within two hours . Residents Affected - Few 676026 Page 4 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 3 of 5 residents (Resident #7, #46, and #13) reviewed for indwelling urinary catheter care, in that: 1. Resident #7's indwelling urinary catheter drainage bag was on the floor. 2. Resident #46's indwelling urinary catheter drainage bag was on the floor. 3. Resident #13's indwelling urinary catheter drainage bag was on the floor. These failures could place the residents with indwelling urinary catheter devices at risk for the development of new or worsening urinary tract infections. The findings included: 1. Record review of Resident #7's face sheet, dated 2/9/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included urinary tract infection, abnormalities of gait and mobility, hydronephrosis (condition characterized by excess fluid in a kidney due to a backup of urine), and retention of urine. Record review of Resident #7's most recent quarterly MDS assessment, dated 1/1/24 revealed the resident was moderately cognitively impaired for daily decision-making skills and required an indwelling urinary catheter. Record review of Resident #7's comprehensive care plan, revision date 8/30/23 revealed the resident had an indwelling urinary catheter related to urinary retention with a goal for the resident to remain free from catheter-related trauma and interventions that included to provide catheter care as ordered. Record review of Resident #7's Order Summary Report, dated 2/9/24 revealed the following orders: -replace foley (indwelling urinary) bag every night shift every Sunday for infection control with order date 7/22/21 and no end date. -foley care every shift for foley catheter with order date 7/4/21 and no end date. -Insert 16 French foley catheter, 10 cc balloon by aseptic technique into urethral meatus as needed related to retention of urine with order date 7/22/21 and no end date. Observation on 2/9/24 at 8:00 a.m. revealed Resident #7's indwelling urinary catheter drainage bag was on the floor on the left side of the bed in full view of the hallway. 2. Record review of Resident #46's face sheet, dated 2/9/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (an alteration in 676026 Page 5 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some consciousness caused by diffuse or global brain dysfunction), gastrointestinal hemorrhage (bleeding of the digestive tract), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Record review of Resident #46's most recent quarterly MDS assessment, dated 1/21/24 revealed the resident was severely cognitively impaired for daily decision-making skills and required an indwelling urinary catheter. Record review of Resident #46's comprehensive care plan, revision date 3/6/23 revealed the resident had an indwelling urinary catheter related to urinary retention with a goal the resident would be free from catheter related trauma and interventions that included to monitor and document for pain/discomfort due to catheter and provide catheter care as ordered. Record review of Resident #46's Order Summary Report, dated 2/9/24 revealed the following order: -Change foley bag every Sunday for infection control every night shift with order date 2/27/23 and no end date. -Change foley catheter, 16 French every month, every day shift for urinary retention with order date 2/27/23 and no end date. Observation on 2/9/24 at 8:00 a.m. revealed Resident #46 in bed and the indwelling urinary catheter drainage bag was on the floor on the right side of the bed in full view of the hallway. 3. Record review of Resident #13's face sheet, dated 02/09/24 revealed a [AGE] year old female admitted to the facility 03/20/23 with diagnoses that included urinary tract infection, acute cystitis with hematuria (bladder inflammation with bleeding), neuromuscular dysfunction of bladder (lack of bladder control due to brain, spinal cord or nerve problem), major depressive disorder (mood disorder), Type 2 Diabetes Mellitus (chronic health condition that affects how body turns food into energy) without complications and multiple sclerosis (a disease that impacts the brain, spinal cord and optic nerves, which make up the central nervous system and controls everything). Record review of Resident #13's Care Plan with date initiated on 03/28/23, revealed resident has a suprapubic catheter due to neurogenic bladder. The interventions included change suprapubic catheter as ordered, measure output q (every) shift, and monitor for s/sx (signs/symptoms) of discomfort on urination and frequency. Record review of Resident #13's MDS assessment dated [DATE] revealed a BIMS score of 9 indicating moderate cognitive impairment. On 02/06/24 at 11:22 am, Resident #13 was observed from the hallway asleep in her bed. Her catheter bag was observed to be hooked on her low bed and touching the floor. The catheter bag was not in a privacy bag. An observation and interview on 02/07/24 at 11:30 AM revealed Resident #13's catheter bag on the floor with a privacy bag. LVN D, who was working just outside Resident #13's room, was asked to observe the catheter on the floor and was interviewed. LVN D said the catheter should not be touching the floor due to the potential for an infection control issue. LVN D was asked what could be done to 676026 Page 6 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some prevent the catheter bag from touching the floor since the bed needed to be in the low position. LVN D then obtained a small plastic basin and placed the catheter bag in it to prevent it from coming in contact with the floor. During an observation an interview on 2/9/24 at 8:02 a.m., CNA A stated Resident #7 and Resident #46's indwelling urinary catheter drainage bag should not have been on the floor due to a sanitary issue. CNA A further stated the indwelling urinary catheter drainage bag could result in the bag being snagged on something or leak and again stated it was just not sanitary. CNA A revealed the CNA staff were responsible for ensuring the indwelling urinary catheter drainage bag was placed in a dignity bag, off the floor and draining by gravity. During an interview on 2/9/24 at 8:34 a.m., the DON revealed it was the expectation of the facility to ensure the indwelling urinary catheter drainage bags should not be on the floor, even when placed in a dignity bag, because the resident could get a urinary tract infection and if the indwelling urinary catheter drainage bag was on the floor it was also an infection control issue. The DON stated it was everybody's responsibility to ensure the indwelling urinary catheter drainage bags were kept off the floor. Record review of the facility policy and procedure titled, Catheter Care, Urinary, revision date August 2022 revealed in part, .The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections .Be sure the catheter tubing and drainage bag are kept off the floor . 676026 Page 7 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals, and preferences for 1 of 3 residents (Resident #17) reviewed for oxygen therapy in that: Residents Affected - Few Resident #17's oxygen concentrator filter was covered in a thick white substance. This failure could affect residents who received respiratory therapy and put them at risk for inadequate or inappropriate amounts of oxygen delivery. The findings included: Record review of Resident #17's face sheet, dated 2/8/24 revealed a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hypertension (high blood pressure), presence of cardiac pacemaker, heart failure, history of pulmonary embolism (condition in which one or more arteries in the lungs become blocked by a blood clot) and pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest). Record review of Resident #17's most recent quarterly MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills. Record review of Resident #17's comprehensive care plan, with revision date 9/28/23 revealed the resident used oxygen therapy related to shortness of breath and congestive heart failure with a goal for the resident not to have signs or symptoms of poor oxygen absorption with interventions that included to administer oxygen and breathing treatments as ordered. Record review of Resident #17's Order Summary Report, dated 2/8/24 revealed the following orders: -Oxygen at 2 liters per minute by nasal canula for shortness of breath related to acute chronic diastolic (congestive) heart failure and acute and chronic respiratory failure with hypoxia (lack of oxygen in the tissues to sustain bodily functions) with order date 8/15/23 and no end date. Observation and interview on 2/6/24 at 10:53 a.m., during initial rounds revealed Resident #17 sitting up in a recliner and the resident was wearing the nasal canula. Resident #17 had the oxygen concentrator behind the recliner but was not turned on. Resident #17 stated they put that on me today, referring to the oxygen concentrator. Further observation revealed the oxygen concentrator had a filter at the back of the unit and it was covered in a thick white substance. Observation on 2/7/24 at 5:26 p.m. revealed Resident #17 sitting up in the recliner wearing the nasal canula and the oxygen concentrator was operating. Resident #17's oxygen concentrator was observed with the filter on the back of the unit covered in a thick white substance. During an observation and interview on 2/7/24 at 5:53 p.m., LVN B revealed Resident #17 used the oxygen concentrator with the nasal canula as needed. LVN B revealed Resident #17 was able to remove the canula at will but was not able to reach the concentrator that was behind the resident's recliner. LVN B revealed his shift started at 2:00 p.m. and Resident #17's concentrator was already 676026 Page 8 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few operating. LVN B stated, the night shift nursing staff took care of changing out the oxygen concentrator tubing/canula and labeling the tube with a date. LVN B revealed he would check the oxygen concentrator periodically during the shift to ensure it was operating properly and at the right oxygen setting. LVN B pulled the oxygen concentrator filter from behind Resident #17's oxygen concentrator and stated, it's nasty. LVN B revealed the oxygen concentrator filter appeared to be covered in lint and dust. LVN B stated the oxygen concentrator filter was not supposed to be covered in lint and dust because it could keep the machine from working properly and could alter the amount of oxygen Resident #17 was supposed to receive. LVN B stated, I would not want to breath it. During an interview on 2/8/24 at 11:56 a.m., the DON stated it was the nursing staff's responsibility for maintaining the oxygen concentrators including changing out the oxygen tubing/canula and making sure the oxygen concentrator filters were clean. The DON stated LVN B had shown her Resident #17's oxygen concentrator filter and stated, it looked like it (the filter) had never been cleaned. The DON stated the oxygen concentrator filter appeared to be covered in dust and lint. The DON revealed, the dirty oxygen concentrator filter could affect proper oxygen therapy and could result in the resident developing a respiratory infection or result in lower oxygen levels. Record review of the facility policy and procedure titled, Oxygen Administration, revision date October 2010 revealed in part, .The purpose of this procedure is to provide guidelines for safe oxygen administration .Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened .Observe the resident set up and periodically thereafter . 676026 Page 9 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **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 assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 2 of 2 Residents (Resident #3 and #31) reviewed for medication administration in that: LVN D administered insulin to Residents #3 and #31 without priming the insulin pen prior to injection. These deficient practices could affect residents who received medication and place them at risk of not receiving the appropriate amount of medication and could result in an adverse reaction or a decline in health. The findings included: 1. Record review of Resident #3's face sheet, dated 2/8/24 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), chronic kidney disease state 3 (kidneys are damaged and can't filter blood the way they should), peripheral vascular disease (a slow and progressive circulation disorder. Narrowing, blockage, or spasms in a blood vessel), and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Record review of Resident #3's most recent annual MDS assessment, dated 12/15/23 revealed the resident was severely cognitively impaired for daily decision-making skills and received insulin injections. Record review of Resident #3's comprehensive care plan, revision date 1/8/24 revealed the resident had diabetes with interventions that included to administer diabetes medication as ordered by the doctor and to monitor and document for side effects and effectiveness. Record review of Resident #3's Order Summary Report, dated 2/8/24 revealed the following order: -Novolog PenFill Solution Cartridge 100 unit/ML, inject 3 units subcutaneously before meals for type 2 diabetes, with order date 1/5/23 and no end date Observation on 2/7/24 at 11:05 a.m., during the medication pass revealed LVN D took Resident #3's Novolog PenFill Solution Cartridge insulin pen and set the insulin pen dial to 3 units but did not prime the pen prior to injecting Resident #3 with the insulin. 2. Record review of Resident #31's face sheet, dated 2/8/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included disorder of kidney and ureter, impaired fasting glucose, morbid (severe) obesity, long term care of oral hypoglycemic (low blood sugar) drugs, type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), and hyperlipidemia (high cholesterol). 676026 Page 10 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #31's most recent quarterly MDS assessment, dated 1/8/24 revealed the resident was moderately cognitively impaired for daily decision-making skills and received insulin injections. Record review of Resident #31's comprehensive care plan, revision date 7/17/23 revealed the resident had type 2 diabetes with interventions that included to administer diabetes medication as ordered by the doctor and to monitor and document for side effects and effectiveness. Record review of Resident #31's Order Summary Report, dated 2/8/24 revealed the following order: -Novolog PenFill Subcutaneous Solution Cartridge 100 UNIT/ML, inject as per sliding scale subcutaneously four times a day related to type 2 diabetes, with order date 12/8/23 and no end date. Observation on 2/7/24 at 11:17 a.m., during the medication pass revealed LVN D took Resident #31's Novolog PenFill Subcutaneous Solution Cartridge insulin pen and set the insulin pen dial to 10 units but did not prime the pen prior to injecting Resident #31 with the insulin. During an interview on 2/7/24 at 11:27 a.m., LVN D revealed, prior to injecting a resident with insulin from an insulin pen, the rubber stopper had to be disinfected with an alcohol wipe and then the dial should be set to the dosage prescribed by the doctor and administered to the resident. LVN D revealed he was not aware about priming the insulin pen to Resident #3 and Resident #31. LVN D stated he was not aware what it meant to prime the insulin pen. LVN D revealed, after it was explained what the concept was behind priming the insulin pen and stated, he understood it was to ensure the resident receiving the insulin was getting the intended amount of insulin as prescribed by the physician. LVN D stated, if a resident did not get enough insulin it would result in the resident's sugar continuing to increase and if the resident received too much insulin it could results in the resident's sugar dropping too much. During an interview on 2/8/24 at 11:37 a.m., the DON stated, insulin pens must be primed prior to injection to ensure there was no air in the pen and the resident received the correct dose. The DON further stated, if the insulin pen was not primed, the resident could get the wrong dose and if too much insulin was received it could result in the blood sugar dropping too low and if not enough insulin was given, the resident's sugar could continue to elevate. Record review of the facility policy and procedure titled, How to Use an Insulin Pen in 15 Easy Steps, dated 11/1/23 revealed in part, .Prepare your insulin pen .dial up 1 to 2 units .Press the injection button to let out any air bubbles (called priming) .if you see a small drop of insulin come out the tip of the pen, it's ready to use . 676026 Page 11 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the drugs and biologicals used in the facility must be labeled and stored in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions and the expiration date when applicable for 1 of 5 medication carts, (Treatment Cart), and in 1 of 6 resident rooms ( Resident #27's room) in that: 1. The facility failed to ensure the Treatment Cart was not left unattended and unlocked. 2. The facility failed to ensure a container of refresh eyedrops and an albuterol inhaler were stored properly in the facility. This deficient practice could affect residents who receive medications for treatments and could result in less potent or an adverse effects and drug diversion. The findings included: 1. Observation on 2/8/24 at 9:34 p.m. revealed the Treatment Cart was left unattended and unlocked on the 100 Hall next to room [ROOM NUMBER] and facing the hallway. During an interview on 2/8/24 at 9:37 a.m., LVN C confirmed the Treatment Cart on the 100 Hall next to room [ROOM NUMBER] and facing the hallway had been left unattended and unlocked. LVN C stated the Treatment Cart should have been locked when unattended because a resident could get into the cart and take a topical medication and it could make them sick. LVN C revealed the Treatment Cart belonged to the Treatment Nurse and asked this surveyor if the Treatment Nurse was on the 100 Hall. The Treatment Nurse was not seen on the 100 Hall at the time of the observation. During an interview on 2/8/24 at 11:52 a.m., the DON revealed it was her expectation that all medication carts, including the Treatment Cart were to be locked when left unattended. The DON stated, the medication carts, including the Treatment Cart, if left unlocked could result in a resident using a medication incorrectly or ingesting a medication that was supposed to be used topically. The DON revealed, all medication carts including the Treatment Cart were supposed to be locked at all times. 2. Observation on 02/07/24 09:41 a.m., Resident #27 with a container of eye drops and an albuterol inhaler in front of the resident on the bedside table. During an interview on 02/07/24 at 9:44 a.m. Resident #27 stated the eye drops were left by staff in the room when they used them yesterday, the resident went on to explain the feeling of not being sure the albuterol inhaler should be in the room and did not elaborate further about where it came from. During an interview on 02/07/2024 at 10:08 a.m. with LVN ZZ , while reviewing Resident #27's electronic health record, stated, I did not know Resident #27 had those medications by the bedside, they should not be there, the resident has not been assessed to self administer those medications; the resident and the staff both know that, I will call the doctor know and take care of the issue. 676026 Page 12 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0761 Level of Harm - Minimal harm or potential for actual harm During an interview on 02/08/24 at 3:32 p.m. the DON stated, I was told about Resident #27 having the eye drops and the inhaler at bedside, those medications should not have been there because we are supposed to know about all medications in the facility; when and how they are administered to ensure the residents needs are met as they should be. DON went on to say, I think the Resident brought the medications from home as she does go on pass in the community. Residents Affected - Few Record review of the facility policy and procedure titled, Security of Medication Cart, revision date April 2007 revealed in part, .The medication cart shall be secured during medication passes .The nurse must secure the medication cart during the medication pass to prevent unauthorized entry .The cart doors and drawers should be facing the resident's room .Medication carts must be securely locked at all times when out of the nurse's view .When the medication cart is not being used, it must be locked and parked at the nurse's station or inside the medication room . 676026 Page 13 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 4 of 5 of the food and nutrition service staff reviewed for competency training in that: The facility did not ensure the DM, [NAME] W, [NAME] X, DA Y or DA Z had current food handlers training. The DM's food handler's certificate had an expiration date of 10/12/2023 with a start date of 05/21/2007. Cook W's food handler's certificate had an expiration date of 10/13/2023 with at start date of 06/17/2013. Cook X's food handler's certificate had an expiration date of 10/14/2023 with a start date of 08/17/2007. DA Z's food handler's certificate had an expiration date of 10/15/2023 with a date of 10/27/2008. The deficient practice could place residents who consumed food prepared from the kitchen at-risk of foodborne illness or nutritional deficiencies. The finding included: Interview on 02/08/2024 at 12:05 p.m. with the DM, the DM stated all of the kitchen's staff training was expired, their training should have already been completed but it was not and mine is expired too. No other state inspector looks at the stuff you look at, I have been here for years and no one has ever asked me for these certificates. DM also stated there are other staff in the kitchen that only wash dishes and are not required to have the food handlers course, I only gave you the ones that should have the training. Interview on 02/08/24 at 4:27 p.m. the ADMN stated, I am aware of all but one of the kitchen staff's food handler's certificate was expired. The ADMN went on to say the expectation was for all kitchen staff to have the required trainings and it should have been up to date, each individual should keep up with when their training was due and make sure it was done. Then the ADMN explained there should be a system, the individual should first make sure their training was current, the DM should be checking, HR should be reviewing that and the facility pays a dietician and consultant that was supposed to be monitoring that as well. Interview with HR on 02/08/2024 at 6:02 p.m. said, I was not taking care of making sure that the Dietary Department was up to date with their training, the DM usually does those, but I will probably be keeping up with that from now on after all of this happened. We do not have a policy and procedure for how to monitor dietary staff training. Record review of USDA Food Code 2022, Chapter 8 Compliance and enforcement reflected the following: By the time of the preoperational inspection, operating procedures for training should include definitive practices and expectations of how the management of the proposed food establishment plans to 676026 Page 14 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0802 comply with paragraph 2-103.11(N) of this Code which requires the person in charge to assure that food employees are properly trained in food safety as it relates to their assigned duties. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 676026 Page 15 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen areas in that: Residents Affected - Some There were items in the kitchen that were not dated, not labeled with a date, not labeled with a name, ingredients or contents of packaging, and damaged kitchen spatulas. In addition there were only unpasteurized eggs in the kitchen that had been reportedly served with runny middles to residents. A cook failed to ensure eggs served soft fried with runny middle were pasteurized for 2 residents. These failures could place residents at risk for foodborne illness. The findings included: Observation in the kitchen on 02/06/2024 at 9:26 a.m. revealed: One large bag of cheese cubes opened exposing the contents of the bag to other odors in the refrigerator. One large approximately 5-gallon container of a white substance identified by [NAME] X as thickener with no label or date and opened, in the kitchen under a preparation table. One large bag of a substance later identified as processed chicken in the freezer with no label or date of any type anywhere on the clear manufacture's bag. During an interview with [NAME] X on 02/06/2024 at approximately 10:00 a.m, [NAME] X said she should not have served unpasteurized eggs with runny middles to any of the residents and she knew this, but she did not want the residents to get upset and wanted them to have the eggs the way they wanted them. [NAME] X said she did know if eggs were going to be served with runny middles she was supposed to use pasteurized eggs, but the facility didn't have any and it would probably be several days before they got anymore. [NAME] X said all the items observed should have been labeled and dated, she did not know why they were not and explained the training says they are supposed to be labeled. [NAME] X said the rubber spatulas should not be used because they could get bad stuff in the cracks and make someone sick, and then took them down from the hanging area. During a follow up interview with the DM on 02/06/2024 at 11:15 a.m., the DM said all items in the kitchen should be labeled and dated in some way and damaged tools (the rubber spatulas) shouldn't be used if they have cracks in them because stuff can get stuck in the cracks or bacteria can grow in them and that would not be good. When asked about the use of unpasteurized versus pasteurized eggs when serving eggs not cooked until solid, the DM stated Cook X knows better and she said she told you that, I have no idea why she did that we can go to the store and get some if we need them, there is just no excuse for that at all. Policy provided prior to facility exit titled, Food Storage chapter 3 not dated revealed the following: 676026 Page 16 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Sufficient storage facilities will be provided to keep foods safe, wholesome and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. 8. Plastic containers with tight -fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables and broken lots of bulk food or opened packages. All containers or storage bags must be legible and accurately labeled and dated. 676026 Page 17 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 8 residents (Resident #3, #30 and #57) reviewed for infection control practices, in that: Residents Affected - Some 1. LVN D did not utilize appropriate hand hygiene during the medication pass to Resident #3 2. Med Aide T did not sanitize the blood pressure cuff used between Resident #30 and Resident #57 These failures could place residents at risk of infection, transmission of communicable diseases and a decline in health. The findings included: 1. Record review of Resident #3's face sheet, dated 2/8/24 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), chronic kidney disease state 3 (kidneys are damaged and can't filter blood the way they should), peripheral vascular disease (a slow and progressive circulation disorder. Narrowing, blockage, or spasms in a blood vessel), and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Record review of Resident #3's most recent annual MDS assessment, dated 12/15/23 revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #3's comprehensive care plan, revision date 1/8/24 revealed the resident had diabetes with interventions that included to monitor for hyperglycemia (increased blood sugar levels) and hypoglycemia (low blood sugar levels). Observation on 2/7/24 at 11:05 a.m., during the medication pass, revealed LVN D grabbed Resident #3's wheelchair and assisted the resident from the dining room to the resident's bedroom. LVN D then returned to the medication cart and obtained the glucometer (a test device used to obtain a rapid assessment of blood glucose concentration results) to prepare to take a blood sample. LVN D took a sanitizing wipe and cleaned the glucometer. LVN D then put on a pair of gloves, did not utilize appropriate hand hygiene and obtained a small blood sample from Resident #3's second finger with a small lancet. LVN D was not successful in obtaining a blood sample from Resident #3 and returned to the medication cart for another test strip. LVN D continued to wear the same gloves, returned to the bedside and obtained a second blood sample from Resident #3. During an interview on 2/7/24 at 11:27 a.m., LVN D revealed he was nervous and realized he did not utilize appropriate hand hygiene prior to obtaining the small blood sample from Resident #3. LVN D stated he should have been washing or sanitizing his hands before putting on gloves because it was considered cross contamination and the resident could get sick. During an interview on 2/8/24 at 11:37 a.m., the DON stated, after Resident #3 was assisted to her room, LVN D should have been sanitizing his hands prior to getting the supplies and should have been 676026 Page 18 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some sanitizing his hands prior to putting on gloves. The DON stated the reason for washing or sanitizing the hands before putting on gloves was to stop the spread of infection and was considered an infection control issue. The DON stated, not utilizing proper hand hygiene could result in the resident getting an infection. 2.a. Record review of Resident #30's face sheet, dated 2/8/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included respiratory failure, heart failure, shortness of breath and hyperlipidemia (high cholesterol). Record review of Resident #30's most recent quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making skills. Record review of Resident #30's comprehensive care plan, revision date 9/16/23 revealed the resident had coronary artery disease with interventions that included to monitor blood pressure and notify the physician of any abnormal readings. b. Record review of Resident #57's face sheet, dated 2/8/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), hypertension (high blood pressure) and hyperlipidemia (high cholesterol). Record review of Resident #57's most recent quarterly MDS assessment, dated 1/12/24 revealed the resident was moderately cognitively intact for daily decision-making skills. Record review of Resident #57's comprehensive care plan, revision date 4/25/23 revealed the resident had coronary artery disease with interventions that included to give medications for hypertension and document response to medication and any side effects. Observation on 2/8/24 at 8:49 a.m., during the medication pass revealed Med Aide T took the wrist blood pressure cuff from the medication cart and obtained Resident #30's blood pressure but did not sanitize the blood pressure cuff prior to use. Med Aide T, after obtaining Resident #30's blood pressure, returned to the medication cart and placed the wrist blood pressure cuff on the medication counter without sanitizing it. Med Aide T then used the same wrist blood pressure cuff used on Resident #30 and obtained Resident #57's blood pressure. During an interview on 2/8/24 at 9:15 a.m., Med Aide T revealed the wrist blood pressure cuff used on Resident #30 and Resident #57 was not provided by the facility and was her own personal equipment. Med Aide T confirmed she had not sanitized the wrist blood pressure cuff prior to using it on Resident #30 or before using it on Resident #57. Med Aide T stated the wrist blood pressure cuff should have been sanitized/disinfected prior to use on a resident because it would mean potentially spreading germs from one resident to the other and was cross contamination. Med Aide T further stated an example of cross contamination would be using the wrist blood pressure cuff on a resident with COVID-19 and if not sanitized could spread COVID-19 (a severe acute respiratory syndrome also known as SARS-COV-2) to another resident. During an interview on 2/8/24 at 11:37 a.m., the DON revealed it was her expectation when a blood pressure cuff was used on a resident it should be sanitized prior to use to prevent the spread of infection. The DON further revealed, cross contamination could result in a resident getting sick or getting an infection. 676026 Page 19 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0880 Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy and procedure titled, Handwashing/Hand Hygiene, revision date April 2012 revealed in part, .This facility considers hand hygiene the primary means to prevent the spread of infection .When to use Alcohol-Based Hand Rub .before donning sterile gloves .before preparing or handling medications .after contact with objects in the immediate vicinity of the resident and after removing gloves . Residents Affected - Some Record review of the facility policy and procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revision date September 2022 revealed in part, .Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard .Non-critical items are those that come in contact with intact skin but not mucous membranes .include .blood pressure cuffs .Reusable resident care equipment is decontaminated and/or sterilized between residents . 676026 Page 20 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for 2 of 4 Halls (Hall #2 and Hall #3) reviewed for environment in that: 1. The bedroom door to Resident room [ROOM NUMBER] on Hall #2 had splintered edges and had several pieces of wood missing and the bedroom door to Resident room [ROOM NUMBER] on Hall #2 had splintered edges and was partially covered in black duct tape. 2. The bedroom door to Resident room [ROOM NUMBER] on Hall #3 had splintered edges and had several pieces of wood missing. The bedroom door to Resident room [ROOM NUMBER] on Hall #3 had splintered edges and had several pieces of wood missing. The bedroom door to Resident room [ROOM NUMBER] on Hall #3 had splintered edges and was partially covered in black duct tape. The bedroom door to Resident room [ROOM NUMBER] on Hall #3 had splintered edges and was partially covered in black duct tape. This deficient practice could place residents at risk of a diminished quality of life due to an unsafe environment. The findings included: During a joint observation and interview on 2/9/24 at 4:07 p.m. with the MD (Maintenance Director) and the Administrator revealed Resident room [ROOM NUMBER] on Hall #2 could have resulted in the bedroom door having splintered edges and several pieces of wood missing from the resident's bed having been moved a couple of weeks ago. The MD stated the facility was built in 1963 and the bedroom door seen in Resident room [ROOM NUMBER] was the same door. The MD and the Administrator acknowledged the splinters could cause injury to a resident if their body came in contact with the splinters. The MD stated the purpose of the duct tape seen on Resident room [ROOM NUMBER]'s door on Hall #2, Resident room [ROOM NUMBER] and Resident room [ROOM NUMBER] on Hall #3 was to keep splinters from sticking out and if the splinters were sticking out they could poke a resident. The door on room [ROOM NUMBER] had been repaired with a metal strip along the side of the door where it had been frayed. The MD further stated, the doors needed to be fixed and had been addressed but then we got COVID, and it went on the wayside. The Administrator stated, I feel we need to do something, it's not a decent environment. The Administrator further stated the facility used an electronic notification maintenance system, but staff were not reporting the situation anymore because the doors had been that way for a while. The Administrator acknowledged the doors were not conducive to a homelike environment. 676026 Page 21 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0941 Level of Harm - Minimal harm or potential for actual harm 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 include effective communications as mandatory training for Residents Affected - Some 14 of 14 employees (CNA A, LVN B, LVN D, CNA K, CNA L, CNA M, MA N, CNA O, CNA P, CNA Q, LVN R, LVN S, FSS, and AD). The facility failed to provide CNA A, LVN B, LVN D, CNA K, CNA L, CNA M, MA N, CNA O, CNA P, CNA Q, LVN R, LVN S, FSS, and AD with effective communications as mandatory training. This failure could place residents at risk of being cared for by untrained staff. The findings included: Review of CNA A's personnel record had a hire date of 09/27/23, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of LVN B's personnel record had a hire date of 08/24/22, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of LVN D's personnel record had a hire date of 09/29/22, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of CNA K's personnel record had a hire date of 04/24/14, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of CNA L's personnel record had a hire date of 03/14/19, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of CNA M's personnel record had a hire date of 07/15/22, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of MA N's personnel record had a hire date of 02/07/23, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of CNA O's personnel record had a hire date of 11/30/20, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of CNA P's personnel record had a hire date of 01/01/22, with annual training in-services 676026 Page 22 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0941 provided by the facility that did not include evidence of effective communications as mandatory training. Level of Harm - Minimal harm or potential for actual harm Review of CNA Q's personnel record had a hire date of 04/08/22, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Residents Affected - Some Review of LVN R's personnel record had a hire date of 20/20/23, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of LVN S's personnel record had a hire date of 08/22/22, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of FSS's personnel record had a hire date of 05/21/07, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of AD's personnel record had a hire date of 04/28/23, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. During the record review and interview with HR personnel on 02/09/24 at 4:30 pm, HR presented a spreadsheet with 22 inservices conducted over the past year forming columns at the top and a list of employees, forming the rows, listed on the first column. An X mark was placed in the column underneath each inservice that an employee attended. HR stated the ADM and DON presented various topics they felt were needed for the facility. HR stated she was not aware of all the required inservice topics but the facility would ensure these were completed in the future. 676026 Page 23 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

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 required education on the rights of the resident and the responsibilities of a facility to properly care for its residents for 7 of 14 employees (CNA A, LVN B, CNA L, CNA O, CNA Q, LVN R and AD). The facility failed to ensure education on the rights of the resident and the responsibilities of a facility to properly care for its residents was provided to CNA A, LVN B, CNA L, CNA O, CNA Q, LVN R and AD. This failure could place residents at risk of being cared for by untrained staff. The findings included: Review of CNA A's personnel record had a hire date of 09/27/23, with annual training in-services provided by the facility that did not include evidence of resident rights training. Review of LVN B's personnel record had a hire date of 08/24/22, with annual training in-services provided by the facility that did not include evidence of resident rights training. Review of CNA L's personnel record had a hire date of 03/14/19, with annual training in-services provided by the facility that did not include evidence of resident rights training. Review of CNA O's personnel record had a hire date of 11/30/20, with annual training in-services provided by the facility that did not include evidence of resident rights training. Review of CNA Q's personnel record had a hire date of 04/08/22, with annual training in-services provided by the facility that did not include evidence of resident rights training. Review of LVN R's personnel record had a hire date of 20/20/23, with annual training in-services provided by the facility that did not include evidence of resident rights training. Review of AD's personnel record had a hire date of 04/28/23, with annual training in-services provided by the facility that did not include evidence of resident rights training. During the record review and interview with HR personnel on 02/09/24 at 4:30 pm, HR presented a spreadsheet with 22 inservices conducted over the past year forming columns at the top and a list of employees, forming the rows, listed on the first column. An X mark was placed in the column underneath each inservice that an employee attended. HR stated the ADM and DON presented various topics they felt were needed for the facility. HR stated she was not aware of all the required inservice topics but the facility would ensure these were completed in the future. 676026 Page 24 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0943 Level of Harm - Minimal harm or potential for actual harm 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 resident abuse prevention training to 4 of 18 staff reviewed including CNA K, CNA L, CNA O, and CNA Q. Residents Affected - Some The facility failed to ensure that 4 of 18 staff reviewed had completed their mandatory abuse annual training. This failure could place residents at risk of being cared for by untrained staff. The findings included: Review of CNA K's personnel record had a hire date of 04/24/14, with annual training in-services provided by the facility that did not include evidence of abuse prevention mandatory training. Review of CNA L's personnel record had a hire date of 03/14/19, with annual training in-services provided by the facility that did not include evidence of abuse prevention mandatory training. Review of CNA O's personnel record had a hire date of 11/30/20, with annual training in-services provided by the facility that did not include evidence of abuse prevention mandatory training. Review of CNA Q's personnel record had a hire date of 04/08/22, with annual training in-services provided by the facility that did not include evidence of abuse prevention mandatory training. During the record review and interview with HR personnel on 02/09/24 at 4:30 pm, HR presented a spreadsheet with 22 inservices conducted over the past year forming columns at the top and a list of employees, forming the rows, listed on the first column. An X mark was placed in the column underneath each inservice that an employee attended. HR stated the ADM and DON presented various topics they felt were needed for the facility. HR stated that abuse prevention training was included in the initial orientation training for new staff as well as during the year. 676026 Page 25 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 14 of 14 employees (CNA A, LVN B, LVN D, CNA K, CNA L, CNA M, MA N, CNA O, CNA P, CNA Q, LVN R, LVN S, FSS, and AD). The facility failed to ensure that quality assurance and performance improvement training was provided to CNA A, LVN B, LVN D, CNA K, CNA L, CNA M, MA N, CNA O, CNA P, CNA Q, LVN R, LVN S, FSS, and AD. This deficient practice could place residents at risk for not receiving safe and appropriate care by adequately informed staff regarding goals for care as identified by the QAPI committee and could result in a decline in health and well-being. The findings included: Review of CNA A's personnel record had a hire date of 09/27/23, with annual training in-services provided by the facility that did not include evidence of QAPI training. Review of LVN B's personnel record had a hire date of 08/24/22, with annual training in-services provided by the facility that did not include evidence of QAPI training. Review of LVN D's personnel record had a hire date of 09/29/22, with annual training in-services provided by the facility that did not include evidence of QAPI training. Review of CNA K's personnel record had a hire date of 04/24/14, with annual training in-services provided by the facility that did not include evidence of QAPI training. Review of CNA L's personnel record had a hire date of 03/14/19, with annual training in-services provided by the facility that did not include evidence of QAPI training. Review of CNA M's personnel record had a hire date of 07/15/22, with annual training in-services provided by the facility that did not include evidence of QAPI training. Review of MA N's personnel record had a hire date of 02/07/23, with annual training in-services provided by the facility that did not include evidence of QAPI training. Review of CNA O's personnel record had a hire date of 11/30/20, with annual training in-services provided by the facility that did not include evidence of QAPI training. Review of CNA P's personnel record had a hire date of 01/01/22, with annual training in-services provided by the facility that did not include evidence of QAPI training. Review of CNA Q's personnel record had a hire date of 04/08/22, with annual training in-services provided by the facility that did not include evidence of QAPI training. Review of LVN R's personnel record had a hire date of 20/20/23, with annual training in-services 676026 Page 26 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0944 provided by the facility that did not include evidence of QAPI training. Level of Harm - Minimal harm or potential for actual harm Review of LVN S's personnel record had a hire date of 08/22/22, with annual training in-services provided by the facility that did not include evidence of QAPI training. Residents Affected - Some Review of FSS's personnel record had a hire date of 05/21/07, with annual training in-services provided by the facility that did not include evidence of QAPI training. Review of AD's personnel record had a hire date of 04/28/23, with annual training in-services provided by the facility that did not include evidence of QAPI training. During the record review and interview with HR personnel on 02/09/24 at 4:30 pm, HR presented a spreadsheet with 22 inservices conducted over the past year forming columns at the top and a list of employees, forming the rows, listed on the first column. An X mark was placed in the column underneath each inservice that an employee attended. HR stated the ADM and DON presented various topics they felt were needed for the facility. The list did not include QAPI training. 676026 Page 27 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0945 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Based on interview and record review, the facility failed to provide the mandatory training on standards, policies, and procedures for an infection prevention and control program for 9 of 14 staff (CNA A, LVN B, LVN D, CNA K, CNA L, MA N, CNA O, LVN S and AD) reviewed for training, in that: The facility failed to ensure infection prevention and control training was provided to CNA A, LVN B, LVN D, CNA K, CNA L, MA N, CNA O, LVN S and AD. This failure could place residents at risk of illness due to lack of staff training. The findings included: Review of CNA A's personnel record had a hire date of 09/27/23, with annual training in-services provided by the facility that did not include evidence of infection prevention and control training. Review of LVN B's personnel record had a hire date of 08/24/22, with annual training in-services provided by the facility that did not include evidence of infection prevention and control training. Review of LVN D's personnel record had a hire date of 09/29/22, with annual training in-services provided by the facility that did not include evidence of infection prevention and control training. Review of CNA K's personnel record had a hire date of 04/24/14, with annual training in-services provided by the facility that did not include evidence of infection prevention and control training. Review of CNA L's personnel record had a hire date of 03/14/19, with annual training in-services provided by the facility that did not include evidence of infection prevention and control training. Review of MA N's personnel record had a hire date of 02/07/23, with annual training in-services provided by the facility that did not include evidence of infection prevention and control training. Review of CNA O's personnel record had a hire date of 11/30/20, with annual training in-services provided by the facility that did not include evidence of infection prevention and control training. Review of LVN S's personnel record had a hire date of 08/22/22, with annual training in-services provided by the facility that did not include evidence of infection prevention and control training. Review of AD's personnel record had a hire date of 04/28/23, with annual training in-services provided by the facility that did not include evidence of infection prevention and control training. During the record review and interview with HR personnel on 02/09/24 at 4:30 pm, HR presented a spreadsheet with 22 inservices conducted over the past year forming columns at the top and a list of employees, forming the rows, listed on the first column. An X mark was placed in the column underneath each inservice that an employee attended. HR stated the ADM and DON presented various topics they felt were needed for the facility. The list included 2 opportunities for training for infection prevention and control but the staff listed above did not attend either one. 676026 Page 28 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0946 Provide training in compliance and ethics. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to communicate the compliance and ethics program's standards, policies and procedures through a training program or other practical manner which explains the requirements for 8 of 14 employees (CNA A, LVN B, CNA L, CNA O, CNA Q, LVN R, LVN S and AD) reviewed for training, in that: Residents Affected - Some The facility failed to ensure that compliance and ethics training was provided to CNA A, LVN B, CNA L, CNA O, CNA Q, LVN R, LVN S and AD. This failure could place residents at risk for improper care due to a lack of training. The findings included: Review of LVN B's personnel record had a hire date of 08/24/22, with annual training in-services provided by the facility that did not include evidence of compliance and ethics training. Review of CNA L's personnel record had a hire date of 03/14/19, with annual training in-services provided by the facility that did not include evidence of compliance and ethics training. Review of CNA O's personnel record had a hire date of 11/30/20, with annual training in-services provided by the facility that did not include evidence of compliance and ethics training. Review of CNA Q's personnel record had a hire date of 04/08/22, with annual training in-services provided by the facility that did not include evidence of compliance and ethics training. Review of LVN R's personnel record had a hire date of 02/20/23, with annual training in-services provided by the facility that did not include evidence of compliance and ethics training. Review of LVN S's personnel record had a hire date of 08/22/22, with annual training in-services provided by the facility that did not include evidence of compliance and ethics training. Review of AD's personnel record had a hire date of 04/28/23, with annual training in-services provided by the facility that did not include evidence of compliance and ethics training. During the record review and interview with HR personnel on 02/09/24 at 4:30 pm, HR presented a spreadsheet with 22 inservices conducted over the past year forming columns at the top and a list of employees, forming the rows, listed on the first column. An X mark was placed in the column underneath each inservice that an employee attended. HR stated the ADM and DON presented various topics they felt were needed for the facility. Ethics was offered during 2 inservices but the staff listed above did not attend either one. 676026 Page 29 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on interview and record review, the facility failed to maintain the required minimum of 12 hours annual in-service records for 6 out of 7 CNAs employed for longer than one year reviewed for training (CNA K, CNA L, MA N, CNA O, CNA P and CNA Q). The facility failed to provide CNA K, CNA L, CNA M, MA N, CNA O, CNA P and CNA Q with 12 hours of in-service training per year. This failure could place residents at risk of being care for by untrained staff. The findings included: During the record review and interview with HR personnel on 02/09/24 at 4:30 pm, HR presented a spreadsheet with 22 inservices conducted over the past year forming columns at the top and a list of employees, forming the rows, listed on the first column. An X mark was placed in the column underneath each inservice that an employee attended. HR stated the ADM and DON presented various topics they felt were needed for the facility. HR stated that none of the CNAs had attended the required 12 hours of inservices and that many of the required training topics were not provided to staff. The training that was offered did not indicate the length of the inservice so that hours attended could be calculated for each staff member. Record review of training for CNA K, CNA L, CNA M, MA N, CNA O, CNA P and CNA Q revealed: Review of CNA K's personnel record revealed a hire date of 04/24/14 and showed she only attended one in-service training on ethics and HIPAA. There was no evidence of attendance for any other required training including communication, abuse, infection control, resident rights, QAPI, HIV, falls, restraints, or dementia Review of CNA L's personnel record revealed a hire date of 03/14/19 and indicated she had only attended in-services for hand washing, phone use, oral care and emergency preparedness/fire safety. There was no evidence of attendance for any other required training including communication, abuse, infection control, ethics, resident rights, QAPI, HIV, falls, restraints, or dementia. Review of CNA M's personnel record revealed a hire date of 07/15/22 and that she had attended 16 out of the 22 in-services offered but did not receive training for communication, resident rights, QAPI, HIV, falls and restraints. Review of MA N's personnel record revealed a hire date of 02/07/23 and that she had attended 11 out of the 22 in-services offered but did not receive training for communication, resident rights, QAPI, HIV, falls and restraints. Review of CNA O's personnel record revealed a hire date of 11/30/20 and that she had only attended in-services for hand washing, infection control, abuse and mental disorders. There was no evidence of attendance for any other required training including resident rights, QAPI, HIV, falls, restraints, or dementia. Review of CNA P's personnel record revealed a hire date of 01/01/22 with no evidence of training 676026 Page 30 of 31 676026 02/09/2024 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0947 for resident rights, QAPI, HIV, falls, restraints, or dementia. Level of Harm - Minimal harm or potential for actual harm Review of CNA Q's personnel record revealed a hire date of 04/08/22 with no evidence of training for communication, resident rights, dementia, QAPI, ethics, HIV, falls, or restraints. Residents Affected - Some 676026 Page 31 of 31