Health inspection·October 26, 2022

F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Level of Harm - Minimal harm or potential for actual harm Resident #62 Residents Affected - Some FTag Initiation Based on observation and interview, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 13 of 68 residents reviewed for resident rights. (Anonymous Residents # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and Resident #62.) The facility failed to treat Anonymous Residents # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and Resident #62 with respect or dignity by feeding some residents on ceramic plates with metal flat wear and others on foam plates with plastic utensils daily. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increase anxiety. Findings included: 1.During an interview on 10/24/2022 at 10:40 a.m., Resident #62 said meals were being served frequently on paper plates. During an observation of the lunch meal and interview on 10/24/2022 at 12:30 p.m. 7 out of 10 residents on the dementia unit were served on foam plates with plastic utensils. CNA C revealed the kitchen ran out of regular plates and silverware and every meal the dementia unit gets most of their meal served on foam plates with plastic utensils. CNA C stated they even serve things like chili and food that belongs in bowls on foam plates. CNA C stated it was very hard to cut a piece of meat on a foam plate with a plastic fork. CNA C stated most older adults do not like eating off foam because they came from a time of ceramic plates and heavy-duty silverware. CNA C stated she had worked at the facility for nearly 7 years and the residents on the dementia unit had been receiving meals on foam for nearly a year. During an interview on 10/25/2022 at 9:10 a.m., Resident #62 said more and more often meals were being served on plastic ware. She said sometimes it is hard to cut food with and on plastic ware. She said one day she was served a meal on a glass plate with a pretty trim and a matching bowl. She said, I thought I had moved up in the world. She said staff told her they were using plastic ware because residents were keeping the dishes and silverware. She said she did not understand this because they picked up her tray every day. She said when she was served on plastic ware, the plastic ware was Page 1 of 36 676051 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0550 thrown in her trash, and she had to smell it all day. Level of Harm - Minimal harm or potential for actual harm During a resident group meeting on 10/25/2022 at 3:00p.m., AR1-AR11 said they attended the meeting regularly. All residents said for the past eight months they had meals served on foam plates with plastic utensils. All residents said not having real plates and silverware made them feel undignified and like less important people than the residents being served off regular plates and using silverware. They stated they did not like to see that most people on the dementia unit got foam plates and plastic wear because small things like real plates and silverware were the last bits of dignity those residents had. All residents stated the concern of having foam plates and plastic utensils had been voiced each council meeting for the last 8 months. Residents Affected - Some During a record review of the resident council meeting minutes for February 2022 through September 2022, each month the concern of why the facility was using foam plates and plastic utensils was listed under current concerns for dietary services. During an observation on 10/26/2022 at 8:15 a.m., breakfast dishes were being cleaned off tables in the main dining room. There were 2 of 7 tables with used disposable plastic plates. The remaining tables had glass plates. During an interview on 10/26/22 at 9:48 a.m., the Registered Dietician said she noticed the kitchen using disposable utensils and plates on Tuesday (10/25/22). She said she thought the facility was only using disposal ware because there was no electricity. She said the facility should be using non-disposal ware flatware and silverware. She said some residents may be so upset about being served on disposal ware, they may not eat. During an interview on 10/26/22 at 10:43 a.m., [NAME] O said the dietary manager was responsible for ordering silverware and plates. She said recently their supply kept getting low. She said resident probably felt plastic ware was hard to use and do not care to eat off it. She said the facility should not serve the residents their meals on disposable ware because this was their home, and most of the resident would not use it at home. During an interview on 10/26/22 at 11:02 a.m., Dishwasher P said the dishes recently had not been coming back to the kitchen after meal service. She said the DM asked staff to look for missing dishes in resident's rooms. She said the issue with missing dishes has been going on since June 2022 when she started. She said the residents probably did not like eating from disposable ware because dining service was set up like a restaurant and the restaurants do not use plastics. During an interview on 10/26/2022 at 10:00 a.m. the DON stated that she had noticed the residents were getting served on foam plates at times. The DON stated it was discussed in the morning meeting and it was the responsibility of the kitchen manager to order new plates and silverware to ensure all residents were served on and with the same or similar plates and flat wear. The DON stated she understood that the residents could feel that eating off foam plates and with plastic utensils was less dignified than eating off of ceramic plates with regular flat wear During an interview on 10/26/2022 at 1:59 p.m., CNA L said she had seen residents being served food off disposable plates and with plastic ware. She said she knew they were last Friday, October 21, 2022, because there was a football game, and the staff was wanting to get home to their kids. She said the morning of 10/26/2022 she had passed out trays with disposable plates and plastic ware and she was told it was because they had run out of plates and silverware. She said a resident told her 676051 Page 2 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0550 next time she comes in with her food she better have real silverware. Level of Harm - Minimal harm or potential for actual harm During an interview and record review on 10/26/2022 at 2:00p.m., the Dietary Manager stated the residents are hoarding the silverware and had broken the plates and the kitchen did not have enough to serve everyone with. The Dietary Manager stated the kitchen was on a budget and she ordered new plates and utensils when the budget allowed. The Dietary Manager did not think serving elderly residents from foam plates and using plastic utensils was a dignity issue. The Dietary Manager stated everyone ate off paper plates at home and this was the resident's home. The last time silverware was ordered was August 2022 and plates were ordered 10/25/2022 per the Dietary Manager and the receipts shown as proof. Residents Affected - Some During an interview on 10/26/2022 at 2:03 p.m., LVN K said she had witnessed food being served to the residents on disposable plates and with plastic ware. She said it was usually a little more towards the weekend when staff was a little lazier. During an interview on 10/26/2022 at 3:00 p.m., the Administrator revealed he was aware of the shortage of regular plates and silver wear. The Administrator stated the Dietary Manager purchased new forks, spoons, and knives several times since he began in August of 2022. The Administrator stated the Dietary Manager had ordered plates recently to make up for the missing plates. The Administrator stated the Dietary Manager believed the residents were hoarding plates and silver wear in their rooms. The Administrator stated he agreed with the residents that the preference of eating on real plates and having real forks and knives provide more dignity. Record review of a Resident Rights facility policy dated 7/13/2021 indicated, .the resident has a right to a dignified existence .be treated with courtesy, consideration, and respect. 676051 Page 3 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to promptly resolve grievances and failed to demonstrate their response and rationale for the response, for 12 of 12 residents in a group meeting (09/14/21, 10/12/21,11/09/21,12/14/21, 01/11/22, 2/22/22, 3/29/22, 4/26/22, 5/31/22, 7/26/22, 8/25/22, and 9/27/22) reviewed for grievance response. Residents Affected - Some The facility failed to ensure resident council grievances were promptly resolved, followed up on timely, and provided a response and rationale to the residents to ensure the issue was resolved. This deficient practice could place the residents at risk for decreased quality of life and feelings of neglect. Findings included: 1. Record review of the Resident Council Meeting Form dated 09/14/2021 revealed: A. Old business -Housekeeping: Issues with sweeping have gotten worse. -Nursing: Cell phone usage is still a problem at this time. B. Current business- Nursing-night medications are being given out way too late. Call light answering by CNA staff is taking too long. - Dietary- Too many meal substitutions and the kitchen keeps running out of food. Food is cold/has sat out in open air much too long for all meals. -Housekeeping- The floor cleaning is not effective. Bathrooms in rooms are not cleaned well enough and main bath/shower room on C hall not cleaned well. Record review of the Resident Council Response Sheet dated 09/14/2021 revealed: The minutes of each department should be reviewed, responses should be completed noting any follow up completed and answers to questions as needed. Sign and date and return to the Wellness Department Within 72 hours. -The written response signed on 09/21/2022 by RN F revealed Nursing Department -An in-service is in progress in hallways, nurse management will monitor late medication administration. Call light response to be addressed at next full staff in-service. -The undated written response signed by the Dietary Manager revealed, {Food distributor} is out of stock so I have to substitute some of the food. The temperature of the food is where it supposed to be. The aides let the trays set out. Trying to get staff so we can be able to run steam cart down the hall. -The response signed on 09/23/2021 by HK T revealed, Manager will be re-in-service all staff on the daily 5 and 7 step cleaning process and refresh the training in following routines to assure that all areas are completed daily as assigned. 676051 Page 4 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0565 2. Record review of the Resident Council Meeting Form dated 10/12/2021 revealed: Level of Harm - Minimal harm or potential for actual harm A. Old business -Nursing: Cell phone usage is better but still a problem at nighttime. Residents Affected - Some B. Current business, - Nursing- The night medication times are hit or miss, still a bit slow on call light response, emphasis on nighttime call light response. -Dietary: Still too many meals substitutions. Food is cold. Meal portions are ridiculously small, ex: one chicken strip at dinner. Poor quality fresh produce and dairy. [NAME] slimy lettuce in salads, tomatoes are rotten in spots. Milk was soured one evening. Record review of the Resident Council Response Sheet dated 10/12/2021 revealed: The minutes of each department should be reviewed, responses should be completed noting any follow up completed and answers to questions as needed. Sign and date and return to the Wellness Department Within 72 hours. -No response from nursing was given. -The undated written response signed by the Dietary Manager revealed, {Food distributor} is out of stock so I have to substitute some of the food. The temperature of the food is where it supposed to be. The aides let the trays set out. Trying to get staff so we can be able to run steam cart down the hall. Talked with staff about serving size to make sure the correct scoop is being used. Will refrigerate dairy until serving time. 3. Record review of the Resident Council Meeting Form dated 11/09/2021 revealed: A. Old business -Nursing: Cell phone usage is still a problem at this time. B. Current business- Dietary- too many meal substitutions and running out of food. Please cut back on fruit cocktail. -Housekeeping- floors not getting clean. Housekeepers using too much bleach. Record review of the Resident Council Response Sheet dated 11/09/2021 revealed: The minutes of each department should be reviewed, responses should be completed noting any follow up completed and answers to questions as needed. Sign and date and return to the Wellness Department Within 72 hours. -The undated written response signed by the Dietary Manager revealed, {Food distributor} is out of stock so I have to substitute some of the food. Staff in serviced on portion sizes. -The undated response signed by HK T revealed, Manager will be re-in-service all staff on what chemicals to use when cleaning. 676051 Page 5 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0565 4. Record review of the Resident Council Meeting Form dated 12/14/2021 revealed: Level of Harm - Minimal harm or potential for actual harm A. Old business -Nursing: Cell phone usage is still a problem at this time. And CNAs are having conversations on cell phones while giving care to residents. Residents Affected - Some B. Current business- Nursing-C Hall is not getting their sheets changed. - Dietary- Still too many meal substitutions and running out of food. Please cut back on fruit cocktail. Why do we not get real silverware? Dietary is not following resident meal choices on cards. -Housekeeping- The floors are sticky. Record review of the Resident Council Response Sheet dated 12/14/2021 revealed: The minutes of each department should be reviewed, responses should be completed noting any follow up completed and answers to questions as needed. Sign and date and return to the Wellness Department Within 72 hours. -The undated written response signed by the Dietary Manager revealed, {Food distributor} is out of stock so I have to substitute some of the food. -The undated response signed by HK T revealed, The staff will be instructed on delusion of chemicals for the floors. 5. Record review of the Resident Council Meeting Form dated 01/11/2022 revealed: A. Old business -Nursing: C Hall not getting sheets changed and the staffing shortage is becoming more apparent. B. Current business- Nursing- C Hall is not getting their sheets changed. - Dietary- Still too many meal substitutions and running out of food. Please cut back on fruit cocktail. Why do we not get real silverware? Dietary is not following resident meal choices on cards. -Housekeeping- Housekeepers not getting to accidental spills for hours. Residents feel 40% of things that need to be cleaned are being cleaned. Record review of the Resident Council Response Sheet dated 01/11/2022 revealed: The minutes of each department should be reviewed, responses should be completed noting any follow up completed and answers to questions as needed. Sign and date and return to the Wellness Department Within 72 hours. -The undated written response signed by the Dietary Manager revealed, {Food distributor} is out of stock so I have to substitute some of the food. -The undated response signed by HK T revealed, Housekeeping is having a staffing shortage. 6. Record review of the Resident Council Meeting Form dated 02/22/2022 revealed: 676051 Page 6 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0565 A. Old business -Nursing: C hall is still not getting their sheets changed. Level of Harm - Minimal harm or potential for actual harm B. Current business- Residents Affected - Some -Nursing- Call light response times are 45 minutes to 1 hour on night shift. CNAs phone usage in the hall and having loud conversations while on their phone during patient care and it is not acceptable. - Dietary-Still too many meal substitutions and running out of food. They run out of the meal the residents are choosing and are giving alternates because they do not cook enough food. Please cut back on fruit cocktail. Where is the fresh fruit? Why do we not get real silverware? Dietary is not following resident meal choices on cards. It has been several months since meal of the month was served. Has this program ended? -Housekeeping- The floors are sticky. No rooms cleaned from 02/17/2022 to 02/22/2022. Cell phone usage started with housekeepers while cleaning. Requesting Housekeeping supervisor join the next meeting to answer questions. Record review of the Resident Council Response Sheet dated 02/17/2022 revealed: The minutes of each department should be reviewed, responses should be completed noting any follow up completed and answers to questions as needed. Sign and date and return to the Wellness Department Within 72 hours. -Nursing- Undated response signed by the DON: Inservice completed related to cell phone usage, call light response time, having sheets changed and staff meeting scheduled. -Dietary had no response -Housekeeping had no response 7. Record review of the Resident Council Meeting Form dated 03/29/2022 revealed: A. Old business -Nursing: C hall is still not getting their sheets changed. B. Current business- -Nursing- CNAs phone usage in the hall and having loud conversations while on their phone during patient care and it is not acceptable. - Dietary-Please cut back on fruit cocktail. Where is the fresh fruit? Why do we not get real silverware? Dietary is not following resident meal choices on cards. Finally had a meal of the month. Record review of the Resident Council Response Sheet dated 03/29/2022 revealed: The minutes of each department should be reviewed, responses should be completed noting any follow up completed and answers to questions as needed. Sign and date and return to the Wellness Department Within 72 hours. -Nursing- Undated response signed by DON Inservice completed related to cell phone usage, call light response time, having sheets changed and staff meeting scheduled. 676051 Page 7 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0565 -Dietary had no response Level of Harm - Minimal harm or potential for actual harm -Nursing- no response 8. Record review of the Resident Council Meeting Form dated 04/26/2022 revealed: Residents Affected - Some A. Old business -Nursing: C hall is still not getting their sheets changed. Call light response time is awful. B. Current business -Nursing Can we get confirmation on who the aide is for D hall before the unit? - Dietary- Please cut back on fruit cocktail. Where is the fresh fruit? Why do we not get real silverware? And a few days we got no dinnerware at all. Record review of the Resident Council Response Sheet dated 04/26/2022 revealed: The minutes of each department should be reviewed, responses should be completed noting any follow up completed and answers to questions as needed. Sign and date and return to the Wellness Department Within 72 hours. -Nursing-An undated response signed by the DON, CNAs are assigned to D hall. -No response from dietary 9. Record review of the Resident Council Meeting Form dated 05/31/2022 revealed: A. Old business -Nursing: C hall is still not getting their sheets changed. Call light response time is still awful. B. Current business- Dietary- Please cut back on fruit cocktail. Can we get more meat choices/ different types of meat/ less processed meat? -Housekeeping- Trash left in bathroom due to dispute between housekeeping and CNAs on responsibility. Record review of the Resident Council Response Sheet dated 05/31/2022 revealed: The minutes of each department should be reviewed, responses should be completed noting any follow up completed and answers to questions as needed. Sign and date and return to the Wellness Department Within 72 hours. -Nursing- An undated response signed by the DON revealed, Inservice completed 06/09/2022 by DON. -No response from dietary - The undated response from HK T revealed-If the trash has a brief in it, it is the responsibility of the CNA to take it out. 10. Record review of the Resident Council Meeting Form dated 06/28/2022 revealed: 676051 Page 8 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0565 A. Old business -None Level of Harm - Minimal harm or potential for actual harm B. Current business- Residents Affected - Some - Dietary-Can dietary leave the window open when done serving while people are eating so they can ask for seconds and ask questions? Record review of the Resident Council Response Sheet dated 06/28/2022 revealed: The minutes of each department should be reviewed, responses should be completed noting any follow up completed and answers to questions as needed. Sign and date and return to the Wellness Department Within 72 hours. No response from dietary 11. Record review of the Resident Council Meeting Form dated 07/26/2022 revealed: A. Old business -None B. Current business- Dietary- Can we get a spice rack in the dining room so we can season our food to taste? -Housekeeping- Can we keep the back patio cleaner? Record review of the Resident Council Response Sheet dated 07/26/2022 revealed: The minutes of each department should be reviewed, responses should be completed noting any follow up completed and answers to questions as needed. Sign and date and return to the Wellness Department Within 72 hours. -No response from dietary -Housekeeping- An undated response signed by HK T revealed Taking care of it. 12. Record review of the Resident Council Meeting Form dated 08/25/2022 revealed: A. Old business -None B. Current business-Administration- Could we please meet the new administrator? He has not been around to meet us yet. - Dietary- Meals are disjointed. The combinations served don't make sense. We have plain white cake a lot and it is dry or overcooked. 676051 Page 9 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0565 -Housekeeping- Can we keep the back patio cleaner? Level of Harm - Minimal harm or potential for actual harm Record review of the Resident Council Response Sheet dated 08/25/2022 revealed: Residents Affected - Some The minutes of each department should be reviewed, responses should be completed noting any follow up completed and answers to questions as needed. Sign and date and return to the Wellness Department Within 72 hours. -No response from dietary -No response from administration 13. Record review of the Resident Council Meeting Form dated 09/27/2022 revealed: A. Old business -None B. Current business- Dietary-Please, please no more fruit cocktail and we are requesting fried chicken from Brookshires for meal of the month. -Housekeeping- C hall shower is mildewing. Record review of the Resident Council Response Sheet dated 09/27/2022 revealed: The minutes of each department should be reviewed, responses should be completed noting any follow up completed and answers to questions as needed. Sign and date and return to the Wellness Department Within 72 hours. -No response from dietary -No response from housekeeping. During a resident group meeting on 10/25/2022 from 3:00p.m. through 3:30p.m., the residents wished to remain anonymous and said they attended the meeting regularly. All residents said for the past year they have not had the response to their concerns delivered to them. The entire group agreed that each council meeting they had concerns and they would like the departments to address the concerns with the council, so they feel heard. The chief concerns the resident council members were worried about were having to eat off foam plates with plastic utensils, not having fresh fruit served when the menu says it was available, call light response times and the dirty sticky floors. The resident council stated they have been making the same complaints for a year and would like a resolution given to them with explanation by the department head responsible. At 3:15 p.m., AR-1 stated the facility has been feeding the residents on foam plates and using plastic utensils for nearly eight months. AR-1 stated it made her feel poor and unimportant because some residents get glass plates and real utensils. She stated she felt the sorriest for the ladies that lived on the dementia unit because they all got foam plates and plastic utensils. AR-1 stated it made her feel like the facility did not care if the dementia residents did not have their dignity respected. At 3:20 p.m. AR-7 stated that the group had requested for the last 6 months to have fresh fruit and please quit serving fruit cocktail as a substitute. AR-7 stated they could not get a straight answer why they could not have fresh 676051 Page 10 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some oranges, apples and bananas when the menu clearly stated fresh fruit. At 3:25 p.m. AR-8 stated the call light response time on the night shift was 45 minutes to 1 hour because the staff are on their cell phones or outside smoking. AR-8 stated often they had to put themselves in bed despite therapy telling them not to do it alone for safety reasons. AR-8 stated there was no one around to help assist them to bed from 8p.m. to 10p.m. and night shift only had three aides staffed most nights from 6 p.m. to 6 a.m. At 3:30 p.m., AR-11 stated the lack of housekeeping, especially the dirty floors had been talked about for a year or more and the resident council cannot get a clear answer to why it has not been fixed. AR-11 stated it may be the chemicals, the type of mop they are using or lack of education on the housekeeper's part that keeps the floors dirty and sticky. AR-11 stated it was not very sanitary to roll around on sticky floors and your hands become sticky from touching your wheelchair wheels. At3:30 p.m., AR-11 stated the lack of housekeeping, especially the dirty floors had been talked about for a year or more and the resident council cannot get a clear answer to why it has not been fixed. AR-11 stated it may be the chemicals, the type of mop they are using or lack of education on the housekeeper's part that keeps the floors dirty and sticky. AR-11 stated it was not very sanitary to roll around on sticky floors and your hands become sticky from touching your wheelchair wheels. During an interview on 10/25/2022 at 4:00 pm the LEC (Life Enrichment Coordinator) stated that after each resident council meeting the minutes are sent to the department heads and they have 72 hours to respond to their portion with a resolution or explanation. Most of the time the explanations are short with little to no detail and not always what the residents wanted to hear when read to them at the next council meeting. The residents have stated they would like the department heads to come and speak to them so they can ask questions and they would like the response sooner than 30 days later. The LEC stated she had discussed that in the morning meetings with the department heads several times. The LEC stated the SW decided what concerns became grievances, but it was her understanding that anything that could not be resolved immediately was a grievance. The LEC stated no concerns from the resident council were ever treated as a grievance from her knowledge. No grievances were found for concerns from resident council. During an interview on 10/26/2022 at 10:00 a.m. the DON stated when resident council concluded the LEC would email each department head the concerns list for the meeting. A written response of what was done to correct or manage the issue was then recorded and sent back to the LEC. This correspondence was supposed to take place within 72 hours of receiving the concerns. The DON stated she did talk to some of the council members individually about the resolution to their nursing concerns such as call lights being answered on time and cell phone usage but did not address the entire group. The DON stated several in-services had been held since she took the position on cell phone usage, answering the call lights in a timely manner, and changing the sheets for each resident on bath days. The DON stated she could see how addressing the entire group on the concerns would allow them to agree or disagree with their decisions and feel like they had a say in how the building was ran. During an interview on 10/26/2022 at 2:00 p.m. the Dietary Manager stated she wrote on the response forms after each resident council meeting. The Dietary Manager stated she only came to the resident council meetings if she was invited to them and had never gone to a meeting to present the resolution from the grievances in resident council. The Dietary Manager stated the residents are hoarding the silverware and had broken the plates and the kitchen did not have enough to serve everyone. The Dietary Manager stated the supply company was out of several of the foods on the menu and they must substitute the items when they cannot get them. The Dietary Manager stated she was not allowed to order from outside vendors to get out of stock items. The last time silverware was ordered was August 2022 and plates were ordered 10/25/2022 per the Dietary Manager. 676051 Page 11 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0565 Level of Harm - Minimal harm or potential for actual harm During an interview on 10/26/2022 at 2:20 p.m. HK S stated in services were done regularly with the staff to ensure they are aware of their assignments, how to clean properly, and not to use cell phones in care areas. HK S stated the only time she told the residents the resolution to their complaints was when the resident council asked her to come to the meeting to answer questions about 4 or 5 months back. HK S stated she thought it was the responsibility of the LEC to tell the residents the resolutions to their issues. Residents Affected - Some During an interview on 10/26/2022 at 3:00 p.m. the Administrator stated he had been to one resident council meeting to introduce himself since he was hired in August 2022. The Administrator stated all issues that cannot be resolved immediately were considered grievances and were written as a grievance by himself or the social worker. The Administrator further explained the process was to meet with the complainant, apologize, resolve the matter, and go back to the complainant to explain the resolution. The Administrator stated he was unsure if the resident council concerns were treated as grievances or just as concerns. The Administrator stated either way a resolution should be presented to them within 72 hours of the concern. The Administrator stated he was unaware the department heads were not following up with the resident council meetings to ensure the residents knew the resolutions to their concerns. The Administrator stated he knew they were concerned about food substitutions but the supplier the facility was required to use was out of a lot of items. The Administrator stated dietary had ordered silverware several times and it all kept disappearing. The Administrator stated not knowing the resolution to the concerns could make the residents feel neglected and unimportant. Record review of the grievance book from 01/2022-09/2022 did not reveal any complaints related to resident council concerns of foam plates, plastic utensils, food concerns, call light response time, and housekeeping concerns. Record review of the facility's grievance policy dated 01/12/20 revealed .the facility will ensure prompt resolution to all grievance .keeping resident .informed throughout investigation and resolution process .the facility grievance process will be overseen by a designated Grievance who will be responsible for receiving and tracking grievance through their conclusion .communicate with resident throughout process to resolution and coordinate with other staff .systematic mechanism for receiving and promptly acting upon issues .monitoring and trending grievances and complaints .all grievance identified during the resident council meeting will be submitted to administrator and/or designee for investigation and resolution .reporting of resolution outcome will be given to the resident council per protocol . 676051 Page 12 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #7 Residents Affected - Some FTag Initiation Resident #65 Urinary Catheter or UTI 10/24/22 12:39PM catheter because he's not stable enough to walk to bathroom; staff do not provide foley care 10/26/22 05:08 PM Did not follow order to make urologist appointment Based on interview and record review, the facility failed to implement a person-centered plan of care and provide services that were furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 19 residents reviewed for plans of care. (Resident #7, Resident #65, and Resident # 13) 1. The facility failed to develop and implement a care plan regarding Resident #7's need for diabetic shoes. 2. The facility failed to follow Resident #65's care plan intervention to consult urology. 3. The facility failed to develop and implement a care plan regarding Resident #13's lap strap used for positioning and safety. These failures could place residents at risk of not having their individualized needs met, falls and a decline in their quality of care and life. Findings included: 1. Record review of the consolidated physician order dated 10/26/22 revealed Resident #7 was [AGE] years old male and admitted on [DATE] with diagnoses including drug induced hypoglycemia (low blood sugar) without coma, type 2 diabetes and abnormalities of gait and mobility. Record review of Resident #7's consolidated physician order dated 09/06/22 revealed diabetic shoes. Record review of the quarterly MDS dated [DATE] revealed Resident #7 was usually understood and usually understood others. The MDS revealed Resident #7 had adequate hearing, clear speech, and highly impaired vision without corrective lenses. The MDS revealed Resident #7 had a BIMS score of 14 which indicated intact cognition. The MDS revealed Resident #7 required supervision for bed mobility, transfer, dressing, toilet use, and personal hygiene but extensive assistance for bathing. Record review of Resident #7's care plan dated 02/21/22 revealed at risk for/actual skin breakdown as evidence by mild pressure ulcer risk, wound (pressure, diabetic or stasis), bruises/discolored, 676051 Page 13 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0656 Level of Harm - Minimal harm or potential for actual harm and dry/flaky. Intervention included inspect skin daily with care and bathing, keep skin clean, dry, and free of irritants, and position resident properly. Further review revealed the resident had a diagnosis of diabetes mellitus with intervention of administer insulin and/or oral hypoglycemics as ordered, labs as ordered, and therapeutic diet as ordered. The care plan did not address order for diabetic shoes related to diabetes mellitus. Residents Affected - Some During an observation and interview on 10/24/22 at 3:08 p.m., Resident #7 was outside on the facility back porch patio. He said he was taken care of his plants. Resident #7 was in a wheelchair with non-skid socks with holes in them. He said he did not have shoes and needed diabetic shoes. He said his insurance used to cover the cost but does not anymore. He said the facility had not assisted him in obtaining a pair of diabetic shoes. He said he wore non-skid socks the facility provided all the time. During an interview on 10/26/22 at 7:43 a.m., the Social Worker said she had been employed at the facility for 3 months. She said Resident #7 did not have shoes or diabetic shoes since she started and did not know how long he had been without shoes. She said she obtained an order for diabetic shoes in September 2022. She said the insurance would not cover the cost for shoes and the facility had tried different resources, but no one could help. She said she contacted a certain resource in September 2022 then was denied the same month. She said in October 2022 the family said they would help. She said the facility tried to buy regular shoes and none fit. She said the family said they would cover half the cost but had not provided the funds yet. She said the facility had to cover the cost of the diabetic shoes if the family would not help. She said he was currently wearing socks as footwear the facility was providing. She said the Administrator of the facility in September 2022 was an interim and told her the next Administrator would address the issue. 2. Record review of the consolidated physician orders dated 10/26/22 revealed Resident #65 was [AGE] years old, male, and admitted on [DATE] with diagnoses including acute kidney failure, obstructive and reflux uropathy (a condition in which the flow of urine is blocked), and laceration (a deep cut or tear in skin or flesh) without foreign body of penis. Record review of Resident #65's consolidated physician order dated 08/15/22 revealed Consult: a doctor (urologist). Record review of the quarterly MDS dated [DATE] revealed Resident #65 was usually understood and usually understood others. The MDS revealed Resident #65 had a BIMS score of 12 which indicated moderately impaired cognition. The MDS revealed Resident #65 required limited assistance for transfer and dressing but extensive assistance with bed mobility, toilet use, personally hygiene, and bathing. The MDS revealed Resident #65 had an indwelling catheter. Record review of Resident #65's care plan dated 08/24/22 revealed urinary catheter related to laceration to penis. Interventions included clotrimazole 1% topical cream BID and consult urology. Record review of Resident #65's nurses note written by LVN K dated 08/15/22 revealed CNA came .SN noticed a laceration to the pts penis .pt. sent to ER and treatment . Record review of Resident #65's nurses note written by RN Q dated 08/15/22 revealed notified Dr. office of need for resident to have urology appt .referral sent to office . Record review of Resident #65's nurses note written by LVN K dated 08/15/22 revealed .pt. is to 676051 Page 14 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0656 follow up with a urologist as soon as possible . Level of Harm - Minimal harm or potential for actual harm Record review of Resident #65's nurses note written by RN Q dated 08/16/22 revealed referral was sent to Dr. on 08/15 .waiting on Dr. office to contact facility about referral . Residents Affected - Some During an interview on 10/24/22 at 12:39 p.m., Resident #65 said he had a foley catheter and a couple months ago something happened to his penis. He said he was sent to the hospital, but they did not figure out what happened. He said he was supposed to go to a urologist about the issue but never did. During an interview on 10/26/22 at 2:05 p.m., a representative from the urologist office said Resident #65 was supposed to be seen by the doctor. She said they received a referral on 08/15/22 and the new patient scheduler reached out to the facility, but no one called back to make an appointment. She said she did not know the specific on when the called the facility or who the office spoke to because the new patient scheduler was not available. During an interview on 10/26/22 at 3:53 p.m., the DON said Resident #7 requested diabetic shoes, so the facility got an order for them. She said there had been issues with insurance covering the cost. She said the facility contacted the family to provide the cost of the shoes because the facility did not normally supply residents diabetic shoes. She said Resident #7 was a diabetic and wore socks around the facility and outside. She said she felt Resident #7 was financial stable enough to pay for his own diabetic shoes. She said the facility's responsibility was to assist in the process. She said obtaining Resident #7's diabetic shoes were a process and three months was not a long time. She said Resident #7 was a diabetic which could cause him to not feel his feet, so shoes were important. She said but anything could happen to his feet with or without shoes. The DON said she called the urologist office about Resident #65's appointment and she believed they called the wrong number. She said RN Q did send two referrals to the office, but she did not know what happened. She said normally the nurse gets the order and puts it the system. She said then the nurse prints out the order and face sheet then give it to the DON. She said the DON gives the information to the van driver who makes the appointments and lets the nurse and DON know when the appointment was scheduled. She said it was the van driver's responsibility to follow up on appointments. She said they have not had a set van driver the last few months. She said the nurses did have some responsibility to ensure Resident #65 had his urologist appointment because it was a doctor's order. She said the inability to make Resident #65's appointment should have been placed on the 24-hour report so the referral would not have been missed. She said the appointment was for his lesion on his penis, but it had resolved on 10/20/22. She said it was important for Resident #65 to go to the urologist for continuity of care and follow doctor's orders. She said she was not sure what could have happened since Resident #65 did not go to the urologist. During an interview on 10/26/22 at 4:35 p.m., RN Q said she did not normally care for Resident #65 but recalled helping make his urologist appointment. She said she thought the urologist office said they would not schedule Resident #65's appointment until he filled out some paperwork. The urologist office was supposed to fax the paperwork to the facility, but she did not know if it happened. She said she should have made a note about the phone call with the urologist office. During an interview on 10/26/22 at 5:57 p.m., the Administrator said he had only been at the facility for 1 month. He said when he found out Resident #7 did not have shoes or diabetic shoes, he sent the Social Worker to the store for something to preserve his dignity. He said the facility had contacted the family for assistance with cost of the diabetic shoes, but they were not responding. He 676051 Page 15 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some said the facility would probably have to purchase the diabetic shoes. The ADM said he expected the nursing staff to follow doctor's orders and care plans. He said the facility did not have a full-time van driver, but they were normally responsible for appointments. 3. Record review of Resident # 13's face sheet dated 10/26/22 revealed she was admitted to the facility on [DATE] with diagnoses which included Rett's Syndrome (is a rare genetic neurological and developmental disorder that affects the way the brain develops), muscle weakness, acid reflux and intellectual disabilities (is a term used when there are limits to a person's ability to learn at an expected level and function in daily life). Record review of a Quarterly MDS assessment dated [DATE] indicated Resident # 13 rarely understands and was sometimes understood. Resident # 13 had a score of 03 on the cognitive skills for daily decision making which indicated Resident # 13 was severely cognitively impaired. The MDS indicated Resident # 13 required total assist for toileting, personal hygiene, bathing and eating, extensive assist with bed mobility and dressing. The MDS did not indicated Resident # 13 required a lap strap for positioning. Record review of Resident # 13's care plan dated 10/26/22 indicated the following: Problem: Falls, Care Area: indicated resident continues to require device to maintain ability to sit evenly in wheelchair with equal hip distribution. Without support to maintain positioning in broad chair resident will lean forward on impulse and has a significant increase of falls. Interventions: assist resident with ADLs as needed. The care plan did address lap strap for repositing and safety until after surveyor intervention. During an observation on 10/24/22 at 9:03 a.m., Resident #13 was sitting up in her wheelchair noted a positioning strap between legs and hip area. During and observation on 10/25/22 at 9:36 a.m., Resident #13 was in facility day room watching TV, with positioning straps between legs and hip area. During an observation and interview on 10/26/22 at 9:20 a.m., Resident #13 was sitting in wheelchair with positioning straps between thighs and hip area. LVN U said he was not sure why Resident # 13 had positioning straps between her legs. LVN said he had only been at facility about two weeks and was unsure why Resident # 13 had the device or how to use the positioning straps. LVN U said this surveyor needed to ask the CNA's because they were the ones who applied the positioning strap. LVN U said he thought it may be used to keep her from falling but again he was not sure. LVN U said he could potential see if Resident #13 was supposed to have on the positioning device and it was not on at all or placed properly, she could fall out of chair and hurt herself. During an interview on 10/26/22 at 2:00 p.m. LVN V said she did not see anything on Resident #13's care plan about a positioning strap or device. LVN V said the positioning device needed to be on care plan as it was part of her care and failure to have it on care plan could hinder her care. During an interview on 10/26/22 at 2:50p.m., COTA N reported Resident #13 used the straps for positioning and safety. COTA N said Resident #13 was on therapy case load but does not recall a recent 676051 Page 16 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0656 in-service to staff on positioning device. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/26/22 at 3:00p.m., the DON said staff was orientated on resident care during orientation. The DON said the positioning strap was used for positioning and safety on Resident #13. The DON said the positioning strap should be care plan as it was part of Resident #13's care. The DON said if Resident #13 did not have on her positioning strap while up in wheelchair she could fall and hurt herself. Residents Affected - Some During an interview on 10/26/22 at 3:05 p.m., RN F said staff should be taught in facility orientation on how to properly care for all residents. RN F said Resident #13 should have an order and a care plan on lap strap for positioning and safety. RN F said the process should be the charge nurse writes an order, nurse manager double checks the order(s), the DON does a baseline care plan (if new admit), MDS nurse does the comprehensive care plan and then interdisciplinary department heads meet to have a quarterly meeting to discuss residents care and update care plans as needed. RN F said failure to have positioning lap strap on Resident # 13 could lead to a fall and potential injury. During an interview on 10/26/22 at 3:15 p.m., the Administrator said he has only been at facility a short while but expected some form of documentation to be in place to guide staff on how to take care of residents. The Administrator said he expected the DON and MDS to make sure all residents had a care plan. The Administrator said failure to have Resident #13's positioning lap strap could cause her to fall with possible injuries. Record review of the facility's policy Care Plan Process dated February 12, 2020, indicated The Interdisciplinary Team will coordinate with the resident and their legal representative an appropriate care plan for the resident's needs or wishes based on the assessment and reassessment process within the required time frames. The team directs care planning toward attaining and maintaining the highest optimal physical, psychosocial, functional status and signs the approved Plan of Care. 676051 Page 17 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision, and assistance to prevent accidents for 2 of 17 residents reviewed for assistive device maintenance. (Resident #39, Resident #65) The facility failed to ensure Resident #39 and Resident #65's wheelchair did not have loose, missing, or thin padded arm rests. This failure could place residents at risk for skin issues, discomfort, and injury. Findings included: 1. Record review of the consolidated physician orders dated 10/26/22 revealed Resident #39 was a [AGE] year-old female, admitted on [DATE] with diagnoses including muscle weakness, weakness, and lack of coordination. Record review of the annual MDS dated [DATE] revealed Resident #39 was understood and understood others. The MDS revealed Resident #39 had a BIMS of 15 which indicated intact cognition and required supervision for transfers. The MDS revealed Resident #39 mobility device was a wheelchair. Record review of Resident #39's care plan dated 06/27/22 revealed fall risk related to fall and high fall risk score as evidence by problem with balance and assistive device used: wheelchair. An intervention was to remind resident to utilize the wheelchair. During an observation and interview on 10/24/22 at 11:53 a.m., Resident #39 said she used her wheelchair to get around the facility. She said she complained to therapy about her missing armrest and lack of cushion about 6 months ago. Resident #39's wheelchair was missing a left arm rest and the right armrest cushion was thin and loose. She said transferring could be uncomfortable sometimes because of her armrest issues. 2. Record review of the consolidated physician orders dated 10/26/22 revealed Resident #65 was [AGE] years old, male, and admitted on [DATE] with diagnoses including lack of coordination, muscle weakness, repeated falls, and orthostatic hypotension (is a condition in which your blood pressure quickly drops when you stand up from a sitting or lying position). Record review of the quarterly MDS dated [DATE] revealed Resident #65 was usually understood and usually understood others. The MDS revealed Resident #65 had a BIMS score of 12 which indicated moderately impaired cognition. The MDS revealed Resident #65 required limited assistance for. The MDS revealed Resident #65 mobility device was a wheelchair. Record review of Resident #65's care plan dated 03/16/22 revealed Resident #65 had impaired physical mobility related to moderate assistance for bed mobility. Interventions included assist as needed with wheelchair mobility and provide appropriate level of assistance to promote safety of the resident. Record review of the maintenance forms/logs dated 04/22-10/22 did not reveal forms related to 676051 Page 18 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0689 Resident #39 and Resident #65's wheelchair maintenance request. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 10/24/22 at 2:16 p.m., Resident #65 was sitting in his wheelchair watching television. He said he was told by a nurse, he could not remember her name, he was placed on a maintenance waiting list about 4-5 months ago to fix his thin and wobble armrests. He said it had not been fixed yet. He said the thin armrest had caused bruises on his forearms. Residents Affected - Few During an interview on 10/26/22 at 7:09 a.m., the maintenance supervisor said he was also the part time van driver. He said the facility had maintenance forms for staff to fill out when they needed something fixed. He said he normally signed off the form when he completed the tasks. He said lately he had not been signing off the forms when he completed a task. He said he did not know about Resident #39 or Resident #65's wheelchair issues. He said sometimes staff did verbally tell him about maintenance issues and he may have forgotten. During an interview on 10/26/22 at 9:39 a.m., COTA N said she did not know about Resident #39 and Resident #65's wheelchair maintenance issues. She said Resident #39 was discharge from therapy service and Resident #65 was currently receiving therapy services. She said maintenance was responsible for wheelchair maintenance, but he may not know they needed to be fixed. She said it was important to have safe, functioning wheelchairs for safety, comfort, and infection control. She said she fixing the wheelchairs was not her responsibility, but she would immediately go take care of it. During an interview on 10/26/22 at 3:10 p.m., CNA M said she had been working at the facility for a month and half. She said if a resident complained about their wheelchair, she would verbally notify the maintenance supervisor about the issue. She said she did not know about a maintenance form to fill out. She said if maintenance took too long to fix the wheelchair issue, she would notify the DON. During an interview on 10/26/22 at 3:53 p.m., the DON said if a nurse could not change the arm rest on a wheelchair, then it was maintenance responsibility to fix it. She said therapy also helped with the maintenance of resident's wheelchairs. She said she did not know about Resident #39 or Resident #65's wheelchair issues. She said all staff knew to fill out a maintenance form to report issues to the maintenance supervisor. She said if there was some staff who did not know about the maintenance forms, then she needed to perform an in-service. She said it was important for the resident to have safe, functional equipment because it was their mode of transportation. During an interview on 10/26/22 at 5:57 p.m., the Administrator said all staff was responsible for wheelchair maintenance if they see a problem with a resident's wheelchair. He said the maintenance supervisor was mainly responsible and should keep an accurate log of the resident's wheelchair issues and when he took care of the issues. He said a resident's wheelchair was important because it was how they got around. Record review of the facility's policy, Supplies and Equipment, dated 08/06 revealed .equipment must be ready for use at all times of the day and night to serve the resident's needs .report all needed repairs to the environmental services/maintenance director . 676051 Page 19 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the menu was followed for 2 of 2 lunch meals (10/24/22 and 10/25/22)reviewed for following the menu. The facility failed to follow the posted menu for lunch on 10/24/22 and 10/25/22. This failure could place residents at risk of decreased appetite, poor intake, and/or weight loss. Findings included: Record review of the facility menu dated October 24, 2022, indicated, Noon meal indicated the following was to be served: Entrée: Cheese ravioli with marinara sauce or hot dog with cheese. Vegetable: tossed salad or beet and onion salad. Bread: garlic bread stick. Dessert/Fruit: marbled sour cream pound cake or fresh fruit. Record review of a menu dated October 25, 2022, indicated, the alternate meal was hamburger steak, mashed potatoes/gravy, cream style corn, fresh fruit, milk whole, coffee, hot tea, and butter spread. During an interview on 10/24/2022 at 10:40 a.m., Resident #62 said the kitchen kept changing the menu. Resident #62 said within a 3-day period recently she was served chili dogs for dinner twice. During an observation on 10/24/2022 at 12:04 p.m., meal service was in progress in the dining room. Ravioli and salad were being served along with cake. There were rolls being served instead of garlic bread sticks. Some residents had hot dogs. Residents were being served fruit cocktail instead of fresh fruit. During an interview on 10/25/2022 at 9:10 a.m., Resident #62 said every time fresh fruit was offered on the menu the residents are served canned fruit cocktail. She said she wanted the fresh fruit that was offered on the menu. During an observation and interview on 10/25/2022 at 11:00 a.m., [NAME] O prepped puree option for residents. [NAME] O did not puree rice for the cream of rice option of the menu. The dietary manager said pureeing rice was hard and required a lot of products to get the right consistency, so they stopped making it. She said they normally bought a product to add water to and it looked like rice. She said she had not bought the product in a while either. She said she normally served the residents who required a puree diet mashed potato instead. During an observation in the kitchen on 10/25/2022 at 12:30 p.m., [NAME] O served a chocolate chip cookie instead of sugar cookie, residents who received puree got mashed potatoes instead of cream of 676051 Page 20 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0803 Level of Harm - Minimal harm or potential for actual harm rice, resident who received finger food got roasted potatoes instead of rice patties, mashed potato pancakes or corn fritters and no rolls, and canned mandarin oranges instead of fresh fruit. During an observation on 10/25/2022 at 12:40 p.m., canned mandarin oranges on trays being passed on the A Hall. Residents Affected - Some During an interview on 10/25/2022 at 1:01 p.m., the dietician said the fruit on the trays were canned mandarin oranges. She said, She tries not to buy canned. During an interview on 10/26/2022 at 9:48 a.m., the Registered Dietician said the menu was planned by the corporation. She said the menu options were broken down into seasons and the facility just started the fall/winter menu. She said the menu could not be changed for 30 days. She said after the 30 days, she could ask the VP of the company to make changed to the menu. She said residents should be notified ahead of time if the menu had changes. She said she created slips to notify residents something was not going to be served and to see the dietary manager. She said she did not know if the facility was consistently using the slips. During an interview on 10/26/2022 at 10:43 a.m., [NAME] O said she had worked at the facility for 8 years. She said she tried to follow the menu as closely as possible. She said some items on menu we know the residents do not like. She said she could only cook with the ingredients provided to her. During an interview on 10/26/2022 at 11:11 a.m., the dietary manager said if there was a change in the menu, she tried to notify the residents right before the meal was served or placed I'm sorry for the inconvenience slips on the trays. She said she also came out during dining service or had an aide notify the resident of the menu change. She said she did not serve the garlic bread sticks because the resident's preferred rolls. She said she ran out of fresh fruit so had to use canned fruit. She said the company just sent the fall/winter menu and she could not make changes for 4 weeks. She said she could only make changes to the alternative menu but not a lot. A policy for following the menu was requested at this time. During an interview on 10/26/22 at 5:57 p.m., the Administrator said some of the menu changes was due their vendor not having some items. He said he asked the resident council members to allow the dietary manager to attend the meeting so she could explain some of the issues and she could hear their complaints. A policy for following the menu was not received prior to exit. FACILITY Kitchen 10/24/22 09:02 AM Main area Flies 2 pans of rolls exposed 676051 Page 21 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0803 2 box of juice w/o date (apple blend and cranberry) Level of Harm - Minimal harm or potential for actual harm Unit #3 Fridge 2 unopened boxes precooked sliced bacon w/o date Residents Affected - Some bag of ham w/o label and date 1 bag unopened meat w/o label 1 box of pulled turkey w/o date 1 box of opened peas (keep frozen or at 0 degrees F) check temp 28 degrees 2 boxes of closed peas 1 bag of ham w/o label and date 1 storage container (labeled gray) with 7 scoopers with a died fly and dried orange film around edges 1 storage container (labeled green) with 1 scooper cracked container with yellow dried film Picture of [NAME] temp/[NAME] log Unit #2 Fridge 36 degrees 5 bags of tortillas w/o label or date Unit #1 Fridge 1 opened/ used jug of sweet/sour sauce dated 6/10/21 with mold around lid 1 opened jug of barq sauce no opened date 1 unopened jug of pimento spread no date 2 clear containers of clear liquid w/o label or date 2 glass clear containers of purple liquid w/o label or date 3 cups of purple liquid w/o label or date 1 cup of creamy white liquid no label or date Freezer 4 degrees 676051 Page 22 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0803 1 opened box of ice cream sandwiches w/o date Level of Harm - Minimal harm or potential for actual harm 2 racks of frozen ribs no date dry storage Residents Affected - Some 1 opened container of instant puree bread mix w/o date 1 opened container of instant mashed potatoes w/o date low temp dishwasher 100ppm 130 temp dishwasher log missing temps- breakfast 10/3, lunch & dinner 10/1 and 10/2 Dietary manager- [NAME] 11:00 puree 11:30 temp 10/24/22 lunch menu cheese ravioli/[NAME] sauce tossed salad garlic bread stick marbled sour cream pound cake or hot dog/cheese beet and onion salad fresh fruit what was served instead beet salad 676051 Page 23 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0803 fruit cocktail Level of Harm - Minimal harm or potential for actual harm roll 10/25/22 11:00 AM Residents Affected - Some puree chicken, spatula used to stir puree touched pipe cleaned machine in sink then put on gloves, no hand washing? added more broc after puree 1st time 7 mech 9 puree 2 cracked spatulas 5 pans with carbon edges can opener dirty flies on floor and on storage racks dead fly in ladle (hanging rack) Temps: 11:59 am 170 chicken 195 beef 175 corn 161 rice 168 baked chicken 161 broc 160/167 2 pots of mashed potatoes 120/182 puree broc 174 mech chicken 154 puree chicken no temp: roasted potatoes, mech beef, beef patties no in sauce 676051 Page 24 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0803 issues: used same wipe to clean therm; dropped therm all the way in food Level of Harm - Minimal harm or potential for actual harm Styrofoam plates used for memory care , ran out; plastic ware utensils choc chip cookie instead of sugar cookie Residents Affected - Some 676051 Page 25 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 3 of 4 unit refrigerators (Unit #1, Unit #2, Unit #3), 1 of 1 freezer , the facility's only kitchen, observed for kitchen sanitation and storage. The facility failed to label and date all food items stored in the refrigerators and freezer. The facility failed to discard a container with fuzzy, green material. The facility failed to label and date all food items stored in the pantry. The facility failed to store food at the manufacture's specification. The facility failed to maintain clean storage containers for utensils. The facility failed to discard pans with carbon build up and utensils with broken, cracked edges. The facility failed to fill out the dishwasher temperature log after 3 meals. The facility failed to maintain a clean ice machine. The facility failed to puree food in a sanitary manner and serve at an acceptable internal temperature. The facility failed to measure the temperature of steam table item of three items during lunch service. These failures could place residents at risk of food-borne illness. Findings included: During an observation of unit #3 refrigerator on 10/24/22 at 9:03 a.m., revealed the following items: *2 unopened boxes of precooked sliced bacon with no received date; *1 bag of unknown meat with no label or date; *1 unopened bag of unknown meat with no label; *1 box of pulled turkey with no received dated; *1 box of opened peas with a keep frozen or at 0 degrees Fahrenheit; *2 unopened boxes of peas with a keep frozen or at 0 degrees Fahrenheit with no received date; and 676051 Page 26 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0812 *1 bag of unknown meat with no date or label. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/24/22 at 9:10 a.m., the dietary manager said the frozen peas were stored in the refrigerator because she did not have enough storage in the freezer. She said she was going to cook the frozen peas this week. She said the peas should stay 0 degrees F while in the refrigerator. The dietary manager checked the peas temperature, and they were 28 degrees Fahrenheit. The dietary manager said she did not know why the manufacture recommend the peas stay frozen. Residents Affected - Some During an observation on the main area of the kitchen on 10/24/22 at 9:15 a.m., revealed the following: *1 clear storage container with 7 scoopers, a dead fly inside, and dried orange film around the bottom edges; and *1 clear storage container with 1 scooper cracked with dried yellow film around the bottom edges. During an observation of unit #2 refrigerator on 10/24/22 at 9:17 a.m., revealed 5 bags of an unknown flat, white food item, with no date or label. During an observation of unit #1 refrigerator on 10/24/22 at 9:25 a.m., revealed the following items: *1 opened jug of orange sauce dated 06/10/21 with fuzzy, green material around the lid; *1 opened jug of barbeque sauce with no date; *1 unopened jug of pimento cheese with no received date; **2 clear containers with clear liquid with no date or label; *2 clear cups of purple liquid with no date or label; and *1 cup of creamy white liquid with no date or label. During an observation of the freezer in the main are of the kitchen on 10/24/22 at 9:40 a.m., revealed 1 opened box of ice cream sandwiches with no date and 2 racks of frozen ribs with no ribs with no received date. During an observation of the dry storeroom in the kitchen on 10/24/22 at 9:45 a.m., revealed 1 opened container of instant puree bread mix with no date and 1 opened container of instant mashed potatoes with no date. Record review of the dishwasher temp log hanging in the dishwasher area dated 10/2022 revealed missing temp for the dishwasher on 10/1/22 and 10/2/22 (lunch and dinner) and 10/3/22 (lunch). During an observation of the ice machine in the dining room on 10/24/22 at 9:55 a.m., revealed a moderate area of a brown/black film on the inside compartment where ice was held. During an observation on 10/25/22 at 11:00 a.m., [NAME] O pureed chicken in the blender and used a 676051 Page 27 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some spatula with cracked, broken edges that was laid on the prep table touching d the rubber piping. [NAME] O used that spatula to stir the pureed chicken to serve for lunch. Underneath the prep table were five medium square metal pans and three large rectangular shaped metal pans with carbon buildup around the edges. During an observation on 10/25/22 at 11:59 a.m., [NAME] O performed internal temp checks on prepared entrée for lunch. [NAME] O cleaned the thermometer after she checked each entrée but did not use a new alcohol wipe. [NAME] O did not wait a period of time after she wiped the thermometer tip with an alcohol wipe before she placed it in another entrée. [NAME] O placed the thermometer at a 90-degree angle in 4 entrees (rice, broccoli, 2 pans of mashed potatoes). [NAME] O did not check the internal temperature for 3 entrees (roasted potatoes, mechanical hamburger steak, hamburger steak without sauce). [NAME] O served pureed chicken at an internal temperature of 154 degrees Fahrenheit. During an interview on 10/26/22 at 9:48 a.m., the Registered Dietician said she started rounding on this facility August 2022. She said she thought chicken's internal temperature had to be 140 degrees to serve. She said when checking internal temperatures on food items the thermometer should be inserted at a 45-degree angle. She said a new wipe should be used after each food item was checked and the alcohol should dry before you placed it in the next food item. She said all entrees served to resident had to be temped before serving. She said all food items in the refrigerator, freezer, and storeroom should be labeled and dated. She said any food item with mold should be discarded. She said storage containers should be cleaned and free of pests. She said the dishwasher log should not have had missed temps. She said dishes not cleaned properly could cause foodborne illnesses. She said the frozen peas should not have been in the refrigerator thawed because it could cause foodborne illness. She said she did a monthly audit and looked for cleanliness, food service line, dining service, staff wearing appropriate clothing and hair restraints, and maintenance concerns. She said she sent the report to the Dietary Manager, DON, Regional DON, and ADM so the facility could address the issues. She said she had not done an audit this month. During an interview on 10/26/22 at 10:43 a.m., [NAME] O said she worked at the facility for 8 years. She said her responsibility included prep food, cooking, cleaning the refrigerator, temp log, sweep/mop, and clean steam table. She said all food items are supposed to be labeled and dated. She said the cooks and dietary aides were responsible for cleaning the storage containers that hold the scoopers. She said she knew to check the internal temperature of meat at an angle but not the other food types. She said she cleaned the thermometer tip each time but may have not used a clean wipe each time. She said no one told her she had to wait until the alcohol dried to check the next food item. She said she knew all food on the steam table had to temp before it was served. She said she was nervous and forgot. She said the internal temperature for chicken was 165 degrees Fahrenheit, she said she did not realize it was only 154 degrees. She said pans should not have carbon buildup because it could get into the food while cooking and it caused fires. She said utensils should be without cracked and broken edges to prevent pieces from possible falling in the food. She said if the spatula touched the rubber pipe during purees, then it was cross contamination and could make the residents sick. She said it was important label and date food items to know when it was open and when to discard. She said this prevented resident getting served bad food and getting foodborne illnesses. She said mold items should be discarded because it could be poisonous to the residents. She said she did not know how the jug of sweet and sour sauce with mold around the edges was not discarded. During an interview on 10/26/22 at 11:02 a.m., Dishwasher P said she had been working at the facility since June 2022. She said she was responsible for washing and putting up dishes, wrapping 676051 Page 28 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some silverware, and runner during meal services. She said dishwashers were responsible for the dishwasher temperature/sanitation log. She said properly doing it and filling out the log was important to make sure dishes were clean properly and keep accurate record. She said unclean dishes could make residents sick causing them to go to the hospital or die. She said she knew if she opened something, she was supposed to label and date it. She said it was important to label and date to know if it was fresh, so resident did not get sick. She said she had only seen water and juice labeled if thicker was added to it or a hot drink. During an interview on 10/26/22 at 11:11 a.m., the dietary manager said all cups of drinks should be dated but most of the drinks were served the same day. She said all food items should be labeled and dated so you know what to use first. She said spoiled food could make the resident sick and die. She said cleanliness prevented rodents which could make residents sick. She said it was her responsibility to make sure all these things were done. She said maintenance was responsibility for the cleanliness of the ice machine. She said an accurate dishwasher log would ensure all dishes were washed and sanitize correctly. She said unclean dishes could cause cross contamination and make residents sick. She was responsible for making sure the dishwasher log was completed every day. She said carbon buildup on pans was not safe due to possibility of cross contamination and fires. She said she tried to discard pans with carbon buildup as soon as possible and it was her responsibility. She said spatulas with cracked edges should not be used because it could fall off in the food and hurt resident. During an interview on 10/26/22 at 2:56 p.m., the maintenance supervisor said he was responsible for the cleanliness of the ice machine. He said he did not keep a log and cleaned it the last week of September 2022. He said he should clean it once or twice a month to keep it mildew free. He said the ice machine should be mildew free, so the resident did not get sick from the ice. During an interview on 10/26/22 at 3:53 p.m., the DON said she expected the kitchen staff to follow the facility's policies and procedures regarding labeling and dating, discarding expired food items, maintaining accurate logs, cleanliness, and temping food. She said all things were important for the safety of the residents. She said it was the dietary managers responsibility to make sure it was done. She said the maintenance supervisor was responsible for the ice machine and she expected it to be free of mildew. During an interview on 10/26/22 at 5:57 p.m., the Administrator said he expected the kitchen staff the label and date all food items. He said he expected anything with mold on it to be discarded. He said he expected the staff to maintain cleanliness of the kitchen area, utensils, and storage containers. He said the dietary manager was responsible for these things. He said he expected maintenance to keep the ice machine mildew free. He said resident could get sick if the kitchen staff did not follow facility's policies and procedures. Record review of the facility's Cleaning Dish in Dish Machine policy dated 08/01/18 revealed .dishes and cookware are washed and sanitized after each meal .check the dish machine gauges and chemicals at the start and throughout the use .log data as instructed . Record review of the facility's Dish Machine Temperature Log policy dated 08/01/18 revealed .dish machine temperatures are monitored and recorded to ensure proper sanitizing of dishes .a temperature and sanitizing monitoring log will be posted .temperatures and sanitizer are monitored and recorded at each meal . 676051 Page 29 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the facility's Taking Food Temperatures policy dated 08/01/18 revealed .insert the thermometer at a 45-degree angle to the middle of the food item taking care not to touch the container .immediately clean with a fresh alcohol swab .allow the probe to air dry before inserting into food .repeat this procedure until all hot food temperatures have been taken . Record review of the facility's Food Storage policy dated 08/01/18 revealed .storeroom .all containers are accurately labeled with the item and date opened .refrigerator .all food are covered, labeled, and dated .freezer .foods are covered, labeled, and dated .any item out of the original case must be properly secured and labeled . 676051 Page 30 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** FACILITY Kitchen Residents Affected - Some 10/24/22 09:02 AM Main area Flies 2 pans of rolls exposed 2 box of juice w/o date (apple blend and cranberry) Unit #3 Fridge 2 unopened boxes precooked sliced bacon w/o date bag of ham w/o label and date 1 bag unopened meat w/o label 1 box of pulled turkey w/o date 1 box of opened peas (keep frozen or at 0 degrees F) check temp 28 degrees 2 boxes of closed peas 1 bag of ham w/o label and date 1 storage container (labeled gray) with 7 scoopers with a died fly and dried orange film around edges 1 storage container (labeled green) with 1 scooper cracked container with yellow dried film Picture of [NAME] temp/[NAME] log Unit #2 Fridge 36 degrees 5 bags of tortillas w/o label or date Unit #1 Fridge 1 opened/ used jug of sweet/sour sauce dated 6/10/21 with mold around lid 676051 Page 31 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0925 1 opened jug of barq sauce no opened date Level of Harm - Minimal harm or potential for actual harm 1 unopened jug of pimento spread no date 2 clear containers of clear liquid w/o label or date Residents Affected - Some 2 glass clear containers of purple liquid w/o label or date 3 cups of purple liquid w/o label or date 1 cup of creamy white liquid no label or date Freezer 4 degrees 1 opened box of ice cream sandwiches w/o date 2 racks of frozen ribs no date dry storage 1 opened container of instant puree bread mix w/o date 1 opened container of instant mashed potatoes w/o date low temp dishwasher 100ppm 130 temp dishwasher log missing temps- breakfast 10/3, lunch & dinner 10/1 and 10/2 Dietary manager- [NAME] 11:00 puree 11:30 temp 10/24/22 lunch menu cheese ravioli/[NAME] sauce tossed salad garlic bread stick 676051 Page 32 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0925 marbled sour cream pound cake Level of Harm - Minimal harm or potential for actual harm or hot dog/cheese Residents Affected - Some beet and onion salad fresh fruit what was served instead beet salad fruit cocktail roll 10/25/22 11:00 AM puree chicken, spatula used to stir puree touched pipe cleaned machine in sink then put on gloves, no hand washing? added more broc after puree 1st time 7 mech 9 puree 2 cracked spatulas 5 pans with carbon edges can opener dirty flies on floor and on storage racks dead fly in ladle (hanging rack) Temps: 11:59 am 170 chicken 195 beef 175 corn 161 rice 676051 Page 33 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0925 168 baked chicken Level of Harm - Minimal harm or potential for actual harm 161 broc 160/167 2 pots of mashed potatoes Residents Affected - Some 120/182 puree broc 174 mech chicken 154 puree chicken no temp: roasted potatoes, mech beef, beef patties no in sauce issues: used same wipe to clean therm; dropped therm all the way in food Styrofoam plates used for memory care , ran out; plastic ware utensils choc chip cookie instead of sugar cookie Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for the entire facility reviewed for the environment. The facility did not maintain an effective pest control program to ensure the facility was free of flies. This could place residents at risk for an unsanitary environment. Findings include: During an observation in the main area of the kitchen on 10/24/22 at 9:03 a.m., three-four flies were noted flying around. In one of the storage containers holding scoopers, a dead fly was noted inside on the bottom edge. During an observation in the main area of the kitchen on 10/25/22 at 11:00 a.m., several flies were noted flying around and crawling on the floor. Some of the flies were on a metal rack holding resident's plates. The kitchen had a hanging rack of ladles and tongs for serving, a dead fly was noted in one of the ladles. During an observation in the main area of the kitchen on 10/25/22 at 11:59 a.m., several flies were noted flying around and crawling on the floor. During a resident group meeting on 10/25/2022 at 3:00p.m., 11 residents said they were unhappy by the number of flies inside the building because the flies affect their ability to eat and sleep like normal happy people. At AR-1 stated they were disgusted by the number of flies in the building. AR-1 stated it was impossible to eat in peace without four or five flies landing on their table, drinking glass and sometimes their food. AR-1 stated they read somewhere flies vomit each time they land, and it made them lose their appetite while eating. AR-1 stated they had abandoned their meal tray more than once before finishing because of flies landing in their food. At 3:07 p.m., AR-2 stated the 676051 Page 34 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0925 Level of Harm - Minimal harm or potential for actual harm flies were in the resident rooms and crawled on their face while they tried to sleep. AR-2 stated they had 2 fly swatters in their room and each night before bed attempted to kill as many as possible so they could get a decent night sleep. At3:10p.m., AR-4 stated they brought 2 fly swatters to the dinner table each meal because they were not sharing their food with the flies. AR-4 stated it made them angry to be pestered by flies while they ate. Residents Affected - Some During an interview on 10/26/22 at 7:09 a.m., the Maintenance Supervisor said a pest control company serviced the facility twice a month. He said the company sprayed for all types of pests unless the facility notified the company of an issue. He said the company provided granules to kill the flies that was sprinkled at all entrance and exit doors. He said the biggest problem areas were the kitchen and the doors the smoking areas. During an interview on 10/26/22 at 7:43 a.m., the pest control company said they serviced the facility once a month. He said it was important to know what type of flies the facility had. He said he would head to the facility to assess the issue and handle the problem. During an interview on 10/26/22 at 9:48 a.m., the Registered Dietician said the kitchen and dining room did have a lot of flies, but the facility had the fly machines on the walls to attract them. She said flies in the kitchen was unsanitary and dead ones in storage containers and ladles was not good either. During an interview on 10/26/22 at 11:11 a.m., the Dietary Manager said the kitchen had a fly issue. She said the facility had tried fly bait and zappers, but nothing completely gets rid of them. She said flies were gross and she would not want them in her kitchen at home. She said they may have to reconsider the hanging utensils in the main kitchen area because of the flies. Review of the facility's Pest Control invoices, provided by the facility, dated 01/20/22 to 10/26/2022 revealed: *01/20/22.Maintenance reported no issues at this time .completed an exterior treatment of the perimeter at the foundation, around windows, and PTAC's entryways, and more. Conditions revealed .dining room door opened frequently to let smoking residents in and out allowing flies to enter. *05/31/22 .Attempted contact with Maintenance and Administrator and neither were on site on this date .only exterior was treated on this date. Conditions revealed .dining room door continues to be opened frequently. Kitchen door propped open, and this could be contributing to the flies. *06/23/22 .Treated for roaches and flies in interior baseboards, common areas, entryways, dining room, memory care and treated exterior perimeter. *09/09/22 .There was no maintenance on site and Administrator was unavailable and dietary said no issues .but allowed pest control to treat all interior baseboards, entryways, common areas and more .also maintained fly light glue boards, exterior also treated . *10/26/2022 .Extensive treatment/bait for flies to exterior of building at request of administrator . During an interview on 10/26/2022 at 7:10 a.m. CNA E stated the flies on the memory care unit had been an ongoing issue. CNA E said she had worked at the facility for four years. CNA E stated that 676051 Page 35 of 36 676051 10/26/2022 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0925 administration and maintenance were aware of the issue. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/26/2022 at 3:05p.m., the Administrator said he expected the environment for residents to be a homelike environment. He did not know the specific schedule of pest control, he was aware they had been out on this date for flies, and he said it was not acceptable for there to be flies or any pests in the facility. He said residents need to feel clean and happy and pest issues could affect that. The Administrator stated whatever the bait that was put out today had pushed all the flies from the parameter of the building to the nurse's station and hopefully with the weather change they would die soon. Residents Affected - Some Record review of the maintenance logbook dated January 2022-October 2022 revealed no documentation of pest control issues. A facility Pest Control Policy was requested on 10/26/2022 and one was not provided prior to exit. 676051 Page 36 of 36