Health inspection·September 5, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify a Grievance Official who was responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions, and leading any necessary investigations by the facility for 1 of (Resident #1) of 3 residents reviewed for grievances. 1. The facility failed to ensure the Grievance Official was aware of a grievance for Resident #1. The Grievance Official failed to investigate a grievance for Resident #1. The facility's failure could place the residents at risk for concerns not being reported and addressed. Findings included: Review of Resident #1's MDS quarterly assessment, dated 07/26/24, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her BIMS score was 3. Her cognitive status was severely impaired. Her diagnoses included Non-Alzheimer's Dementia (decline in cognitive abilities that can affect a person's ability to think, remember, and make decisions). Review of Resident #1's Grievance Tracking Log for 08/15/24 reflected: Resident #1: Inappropriate behavior from a resident, DON notified, grievance addressed on 08/16/24. Review of Resident #1's Grievance Form, dated 08/15/24, and filled out by the SW reflected: Resident #1's Representative reported to the SW, that on 7/31, she had gone to visit Resident #1 in the Memory Care Unit. Out of nowhere, another resident sat on her lap. Resident #1's Representative had to sit there watching them since no one was around to intervene and was getting agitated with another resident sitting on her lap. Corrective Action: There will be 24-hour staff available to monitor the residents, and staff will also be present in the hallway. An observation and interview on 09/05/24 at 5:00 PM in the Memory Care Unit revealed Resident #1 was sitting on the sofa close to other residents. She said she was doing well and did not have issues with other residents. There were three other staff present. Page 1 of 3 676098 676098 09/05/2024 The Plaza at Richardson 1301 Richardson Dr Richardson, TX 75080

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview on 09/05/24 at 4:20 PM with the SW, revealed it was reported to her by the Representative for Resident #1 that she had to keep watch in the Memory Care Unit because an unknown resident sat on Resident #1's lap. The SW said she told the DON and the Administrator about the grievance. She said she put an intervention in place for staff to be available 24 hours per day, but that was already required in the Memory Care unit . She said no other interventions or investigation was completed . She said she did not know who the other resident was or which day for sure that the incident occurred. An interview on 09/05/24 at 4:26 PM with the Representative for Resident #1 revealed on 08/15/24, she was visiting the resident. She said she told the SW there was a woman that kept trying to sit on Resident #1's lap. She said she did not know the exact day and she did not know who the other resident was. She said the resident wanted to sit in Resident #1's seat. She said the staff were somewhere down the hallway attending to another resident. An interview on 09/05/24 at 5:10 PM with the DON revealed for the grievance process, anyone could report it and the SW would do the investigation. The DON said he did not know who the grievance official was, and he was not notified about a grievance for Resident #1. The DON said the SW was responsible for ensuring all grievances were addressed and she was supposed to report them to the DON and Administrator. The DON said he should oversee the grievances daily and grievances were supposed to be reviewed during the morning stand-up meeting . He said there should not be an instance when he was not notified about a grievance related to nursing. He said Resident #1 was going to be assessed, staff were going to be interviewed and that there was going to be a meeting with Resident #1 and her Representative. He said there were not any residents in the Memory Care Unit who would sit on the laps of other residents. He said he did not know for sure what day the incident occurred. The DON said the resident could be negatively affected if their grievance was not addressed. An interview on 09/05/24 at 5:25 PM with the Administrator revealed for the grievance process a complaint or concern would be reported and the facility was to resolve it as soon as possible. He said the SW was to notify him as the Grievance Official of all grievances. He said the grievance could involve all departments, but that he was not made aware of the grievance for Resident #1. He said it was his responsibility to review all grievances and make sure they were addressed. Review of the facility policy for Grievances, revised 11/02/2016, reflected: .2. The grievance official of this facility is the administrator or their designee. 3. The grievance official will: o Oversee the grievance process o Receive and track grievances to their conclusion 676098 Page 2 of 3 676098 09/05/2024 The Plaza at Richardson 1301 Richardson Dr Richardson, TX 75080

F 0585 o Level of Harm - Minimal harm or potential for actual harm Lead any necessary investigations by the facility o Residents Affected - Few Maintain the confidentiality of all information associated with grievances o Issue written grievance decisions to the resident o Coordinate with state and federal agencies as necessary . 676098 Page 3 of 3