Health inspection·November 15, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on observations, interviews, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 7 of 24 confidential residents. The facility failed to ensure 7 of 24 confidential residents were provided, through postings in prominent locations, the Grievance Procedure, access to the Grievance forms, information of who the facility's grievance official was and their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings included: Interviews during Resident Council on, 11/14/2024 at 10:00 AM, attendees 7 of 24 confidential residents stated they did not know about the grievance process. They also stated they did not know where to obtain or submit a grievance form. They stated they did not know they could file a Grievance anonymously. They stated the Grievance procedure had never been discussed in Resident Council. They also stated they had not observed a posting of the Grievance procedure in prominent locations. Residents attending the group meeting did not know how to file a grievance. Residents did not know where to obtain a grievance form, who to turn the form into, and what should happen once a grievance was filed. The Residents did not know they had the right to receive a written decision once their grievance was resolved. Seven Residents attended the meeting, and the seven Residents in attendance had all been Residents of the facility for 6 months or longer. Observation and interview on 11/14/2024 at 11:30 AM: there was no visible signage or area designated for grievance forms with instructions informing residents of how/where to file a grievance. During an interview with the DON, the DON was unable to locate blank grievance forms available to residents and could not identify the location residents could have turned in an anonymous grievance form. In an interview with the DON on 11/14/2024 at 3:10 PM; the DON stated the facility planned to add an area for grievance forms near the foyer of the facility with a box to allow residents to file anonymous grievances. The DON stated there was not a previous system in place to file anonymous grievances. The DON stated there used to be grievance forms near the foyer for residents to access, but they were moved, and she was not sure when or why. The DON stated, on this day, grievance forms were not available for residents. The DON stated the ADM was responsible for grievance forms and for ensuring grievances were followed up on. The DON stated, to her knowledge, grievances were discussed during Page 1 of 5 676077 676077 11/15/2024 Stonewall Living Center 931 N Broadway Aspermont, TX 79502

F 0585 resident council and the activities director relayed any concerns voiced by the residents. Level of Harm - Minimal harm or potential for actual harm In an interview with the AD on 11/15/2024 at 9:43 AM; the AD stated she discussed concerns and complaints during resident council and if the residents had any concerns she relayed them to the ADM for resolution. The AD stated she did not recall a process that would have allowed a resident to file an anonymous grievance, and she was unsure of where the grievance forms were kept. The AD stated the ADM was responsible for resolving grievances. Residents Affected - Some In an interview with the ADM on 11/15/2024 at 9:30 AM; the ADM stated grievance forms had been at the front of the facility and available to residents, but at some point they had been moved and she was not sure when or why. The ADM stated there was not a previous system in place allowing a resident to file an anonymous grievance. The ADM stated the facility was working on adding a location at the front of the facility for residents to find grievance forms and to file them anonymously. The ADM stated grievances were usually voiced during resident council and the AD would relay the concerns. The ADM stated it was her responsibility to ensure grievances were resolved. The ADM stated when grievances were reported to her, she would gather additional information and try to resolve the grievance as soon as possible. The ADM stated this process involved speaking to residents, family, and staff to find a resolution. The ADM stated the previous system was completed via a verbal process, mostly. The ADM stated not having a written process in place could have left out residents who did not feel comfortable voicing their grievance verbally. The ADM stated it was her expectation to resolve grievances and acknowledge a resident's concern immediately or work to find a resolution as soon as possible. The ADM stated it was every staff's responsibility to report a resident's complaint or concern, but it was ultimately her responsibility to ensure grievances were resolved. The ADM stated if a resident could not file a grievance, a concern could go unseen and unresolved because the facility was not made aware of it. Record Review of the undated document titled PATIENT COMPLAINT AND GRIEVANCE PROCESS , revealed the following: PURPOSE: To provide guidance to staff in handling patient complaints or grievances DEFINITIONS: o Grievance: A written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoP) or accrediting organization standards, or a Medicare beneficiary billing complaint related to rights and limitations. o How Received: E-mail and faxed complaints are accepted and subject to the same process. Information obtained from satisfaction surveys will be handled in the same manner if patient identifiable information is provided. Any verbal communication from a patient or his/her legal representative in which he/she requests investigation or requests a response is handled per this process. 676077 Page 2 of 5 676077 11/15/2024 Stonewall Living Center 931 N Broadway Aspermont, TX 79502

F 0585 PROCEDURE: Level of Harm - Minimal harm or potential for actual harm Information provided to the patient upon request shall include: o Residents Affected - Some Whom the patient contacts to file a grievance (Patient Advocate, Grievance Coordinator) and the contact information o How to reach the Patient Advocate or Grievance Coordinator o The form in which a grievance may be filed; verbal or written o Brief description of the patient complaint/grievance process o The reasons for submitting a grievance, i.e., quality of care concerns or premature discharge perception NOTE: The Joint Commission has a patient complaint service. The Department of Health in several states requires posting of complaint contact information. Medicare beneficiaries must be provided with information about filing a complaint. 676077 Page 3 of 5 676077 11/15/2024 Stonewall Living Center 931 N Broadway Aspermont, TX 79502

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 observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services., in that: 1. Dietary director failed to wash hands properly. 2. Cook A failed to wash hands properly and change gloves. These failures could place residents at risk for food contamination and foodborne illness. The findings included: During an observation on 11/13/24 at 11:55 AM observed the Dietary Director washed her hands; she used the used paper towel to turn off water. During an observation on 11/13/24 at 12:04 PM observed [NAME] A wash her hands and turned water off with bare hands. During an observation on 11/13/24 at 12:12 PM observed [NAME] A picked up a piece of paper off the floor with her gloved hand. [NAME] A threw away the paper and continued temping food on the steam table. No observation of glove changes or hand washing. During an observation on 11/13/24 at 12:21 PM observed [NAME] A carrying a pan to dishwash area with gloves on and returned to food prep area to puree veggies with the same gloves on. No observation of [NAME] A changing gloves or washing hands. During an observation on 11/13/24 at 12:30 PM observed [NAME] A walking to dishwash area and returned to food prep area with same gloves on. No observation of [NAME] A changing gloves or washing hands. During an interview on 11/14/24 at 03:15 PM with [NAME] A, she stated after washing and drying her hands she should have used a clean paper towel to turn off the water. She stated she was trained to change gloves and wash hands any time she left the food prep area. She stated she just got nervous and forgot. She stated she had been trained on handwashing and glove changes. She stated the potential negative outcome could be spread of germs. During an interview on 11/15/24 at 09:57 AM with the Dietary Director, she stated she should have used a clean paper towel to turn the water off. She stated all staff have been trained on proper glove usage and handwashing. She stated [NAME] A should have changed her gloves and washed hands before entering the food prep area. She stated the shift leader and herself were responsible for monitoring staff for compliance. She stated the potential negative outcome could be food contamination and a resident becoming sick. 676077 Page 4 of 5 676077 11/15/2024 Stonewall Living Center 931 N Broadway Aspermont, TX 79502

F 0812 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/15/24 at 11:00 AM with the ADM, she stated the dietary director was responsible for monitoring all kitchen staff for compliance with handwashing and glove usage. She stated water should be turned off using a clean paper towel. She stated gloves should be changed anytime you leave the food prep area. She stated all staff have been trained. She stated her expectations were for staff to follow policy and understand the reasoning. She stated the potential negative outcome was infection control. Residents Affected - Some Record review of the facility policy, titled Handwashing, dated March 2021 reflected the following: Policy: Employees are to wash hands: . Between handling of dirty and clean dishes, equipment/utensils, and food . After touching objects that may be a source of contamination if the next contact with the hands is food or food contact surfaces . Procedure: . 2h. Use another paper towel to turn off water and to avoid contamination of hands . 4. The use of gloves or the use of hand sanitizer does not replace handwashing. Record review of the facility policy titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices dated March 2021 reflected the following: Policy: Food Service employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Procedure: . 6. Employees must wash their hands: . d) Before coming in contact with any food surfaces; . f) After handling soiled equipment or utensil. g) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or h) After engaging in other activities that contaminate the hands . 9. Foodservice employees will be trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness. 10. Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper handwashing . 676077 Page 5 of 5