Health inspection·July 7, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the nurse's station. She stated she was happy at the facility, and she had friends there. She stated she enjoyed the group activities at the facility but did not remember anyone asking if she wanted any special activities just for her. Review of the undated face sheet for Resident #15 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of anxiety disorder, physical debility, and dementia. Review of the care plan for Resident #15 dated 01/24/23 reflected the following: (Resident #15) has impaired cognitive function/dementia or impaired thought processes. The plan included no care planning for activity preferences for Resident #15 Review of the annual MDS for Resident #15 dated 11/13/22 reflected a BIMS score of 12 indicating moderate impairment. Review of the section titled Preferences for Customary Routine and Activities reflected the following were very important to Resident #15: having books, magazines, and newspapers to read; and going outside to get fresh air when the weather was good. Review the section titled Care Area Assessment reflected the following instructions: For each triggered Care Area, indicate whether a new care plan, care plan revision, or continuation of current care plan is necessary to address the problem(s) identified in your assessment of the care area. The Care Planning Decision column must be completed within 7 days of completing the RAI (MDS and CAA(s)). Check column B if the triggered care area is addressed in the care plan. Cognitive Loss/Dementia, ADL function, Urinary Continence, Falls, Nutritional Status, Pressure Ulcers, and Psychotropic Drugs were all marked. Activities was present but not marked. Observation and an interview on 07/06/23 revealed Resident #15 laying in his bed and watching television. He stated he did not enjoy the activities at the facility and the only activity he would want to do was fishing. He stated the facility staff invited him to a variety of activities, but he never wanted to go. Review of the face sheet for Resident #6 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Alzheimer's disease and depressive episodes. Review of the annual MDS for Resident #6 dated 10/06/22 reflected a BIMS score of 13 indicating an intact cognitive response. Review of the section titled Preferences for Customary Routine and Activities reflected the following were very important to Resident #6: having books, magazines, and newspapers to read, listening to music she liked, doing things with groups of people, doing her favorite activities, going outside to get fresh air when the weather is good, and participating in religious services or activities. Review the section titled Care Area Assessment reflected the following instructions: For each triggered Care Area, indicate whether a new care plan, care plan revision, or continuation of current care plan is necessary to address the problem(s) identified in your assessment of the care area. The Care Planning Decision column must be completed within 7 days of completing the RAI (MDS and CAA(s)). Check column B if the triggered care area is addressed in the care plan. ADL function, Urinary Continence, Falls, and Nutritional Status, and Pressure Ulcer were all marked. Activities was present but not marked. Review of the care plan for Resident #6 dated 10/12/22 reflected the following: (Resident #6) has impaired cognitive function/dementia or impaired thought processes r/t Alzheimers. The plan included no care planning for activity preferences for Resident #6. Observation on 07/05/23 at 11:37 AM revealed Resident #6 sitting in a wheelchair inside her room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676117 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bertram Nursing and Rehabilitation 540 E State Hwy 29 Bertram, TX 78605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 looking out a window. She refused an interview. Level of Harm - Minimal harm or potential for actual harm Review of the undated face sheet for Resident #11 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia, anxiety disorder, and major depressive disorder. Residents Affected - Some Review of the annual MDS for Resident #11 dated 08/18/22 reflected a BIMS score of 00 indicating a severe cognitive impairment . Review of the section titled Preferences for Customary Routine and Activities reflected the staff assessed her interests as: reading books, magazines, and newspapers, listening to music she liked, doing things with groups of people, doing her favorite activities, spending time with pets, going outside to get fresh air when the weather is good, and participating in religious services or activities. Review the section titled Care Area Assessment reflected the following instructions: For each triggered Care Area, indicate whether a new care plan, care plan revision, or continuation of current care plan is necessary to address the problem(s) identified in your assessment of the care area. The Care Planning Decision column must be completed within 7 days of completing the RAI (MDS and CAA(s)). Check column B if the triggered care area is addressed in the care plan. Cognitive Loss/Dementia, Communication, Urinary Continence, Falls, and Nutritional Status, and Pressure Ulcer were all marked. Activities was present but not marked. Review of the care plan for Resident #11 dated 08/24/22 reflected the following: (Resident #11) has a history of depression. The plan included no care planning for activity preferences for Resident #11. Observation on 07/05/23 at 09:35 AM revealed Resident #11 reclined in a geri chair near the nurse's station. The AD was seated next to her and stroking her hair. Resident #11 did not respond to efforts to interview her. Review of the undated face sheet for Resident #42 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of chronic pain syndrome and major depressive disorder. Review of the annual MDS for Resident #42 dated 11/17/22 reflected a BIMS score of 15 indicating intact cognitive response. Review of the section titled Preferences for Customary Routine and Activities reflected no activities were very important to Resident #42, but the following were somewhat important: having books, magazines, and newspapers to read, listening to music he liked, being around animals such as pets, keeping up with the news, doing things with groups of people, doing her favorite activities, and going outside to get fresh air when the weather is good. Review of the section titled Care Area Assessment reflected the following instructions: For each triggered Care Area, indicate whether a new care plan, care plan revision, or continuation of current care plan is necessary to address the problem(s) identified in your assessment of the care area. The Care Planning Decision column must be completed within 7 days of completing the RAI (MDS and CAA(s)). Check column B if the triggered care area is addressed in the care plan. ADL function, Urinary Continence, Mood State, Falls, Nutritional Status, Psychotropic Drugs, and Pressure Ulcer were all marked. Activities was present but not marked. Review of the care plan for Resident #42 dated 12/01/22 reflected the following: (Resident #42) voiced being depressed after hearing his (FM) report to the IDT that he cannot return home. She cannot manage his disease process in the community. (Resident #42) will voice less to no feelings of depression. And begins to adjust to new living arrangement. The plan included no care planning for activity preferences for Resident #42. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676117 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bertram Nursing and Rehabilitation 540 E State Hwy 29 Bertram, TX 78605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation and interview on 07/06/23 at 11:41 AM revealed Resident #42 seated in his wheelchair in his room, dozing. He sat up when approached and stated they treat him well at the facility. He stated he did not like the group activities and mostly liked to keep to himself. He stated the AD had asked him if there was anything he would like to do, and he could not think of anything. Review of the undated face sheet for Resident #25 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of major depressive disorder, vascular dementia, and anxiety disorder. Review of the quarterly MDS for Resident #25 dated 06/08/23 reflected a BIMS score of 15 indicating intact cognitive response. Review of the admission MDS for Resident #25 dated 08/12/22 section titled Preferences for Customary Routine and Activities reflected the staff assessed her interests as: spending time away from the nursing home. Review of the section titled Care Area Assessment reflected the following instructions: For each triggered Care Area, indicate whether a new care plan, care plan revision, or continuation of current care plan is necessary to address the problem(s) identified in your assessment of the care area. The Care Planning Decision column must be completed within 7 days of completing the RAI (MDS and CAA(s)). Check column B if the triggered care area is addressed in the care plan. Activities was marked in this area. Review of the care plan for Resident #25 dated 06/15/23 reflected the following: (Resident #25) has diagnosis of depression, and hx of behaviors of embellishing on facts and repeating peer gossip. (Resident #25) will show decreased episodes of s/sx of depression through the review date. The plan included no care planning for activity preferences for Resident #25. Observation and interview on 07/06/23 at 09:04 AM revealed Resident #25 was in her room looking out her window. She stated she had most of her activity needs met by leaving the facility for dialysis, and the rest she gets met by looking out the window at the bird feeders and the gas station across the street. She stated she did not know what other activities she might like to do. During an interview on 07/07/23 at 11:27 AM, the AD stated the role she held in creating comprehensive care plans was to provide information during the care plan meetings. She stated she also set up the care plan meetings and called family members to invite them. She stated she had no hand in entering information in the actual care plan in the EMR. She stated she did not know what went in a care plan, exactly, or how to enter one. The AD stated she did complete the activities section of the MDS, and she did quarterly activities assessments in the EMR. The AD stated having activities in the care plan was important, because then the people who read the care plans would know the residents. During an interview on 07/07/23 at 12:03 PM, the RCNC stated the creation of comprehensive care plans was usually a team effort. She stated in many buildings, the activity director completed the activities portion of the care plans, but she was not sure if that happened at the facility. The RCNC stated care plans should have activity preferences for many reasons, for example if they had to suddenly evacuate, the receiving community would need to know what the resident needs were. The RCNC stated their company tried to get floor nurses in the habit of reading the care plans, but she did not elaborate on how they did this. During a telephone interview on 07/07/23 at 02:00 PM, the MDSN stated she was primarily responsible for care planning. The MDSN stated she did not add the activities section to the care plans but that the AD did that. The MDSN stated she was not sure what training the AD or other department heads had on how to add items to care plans. She stated she thought the training when the new company took (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676117 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bertram Nursing and Rehabilitation 540 E State Hwy 29 Bertram, TX 78605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some over a few years prior was not the greatest and it was largely up to the facility staff to learn on their own. The MDSN stated she was not aware of anyone from corporate training the department heads on entering care plan items, but the MDSN was pretty sure the AD had always been responsible for adding her own care plan items to the care plans even before the new company took over. The MDSN stated she could not see that there would be a negative impact on residents, because activities were not like a nursing care plan item in which the resident had to have certain care based on a diagnosis. During an interview on 07/07/23 at 02:11 PM, the DON stated she communicated with the MDS nurse daily, and she was very familiar with the process for creating a care plan The DON stated when they had an admission, nursing created an acute care plan within 48 hours. The DON stated after that, they had to create the comprehensive care plan, and they would add things as needed based on a meeting they had once a week where the entire IDT went over things. The DON stated the MDSN attended those meetings and usually added new items to the care plans right then and there. The DON stated the process for monitoring compliance in care planning was the MDS reviewed the care plans to make sure they were comprehensive. The DON stated there should have been an activity care plan, and she did not know why there was no care planning for activity preferences for Residents #28, 15, 6, 11, 42, and 25. The DON stated she had heard the MDSN instruct the AD to enter care plan items for the activity program, and the facility had just had a mock survey, so the DON could not understand why this issue was missed. The DON stated it was important to have care planning for activities, because all residents were different. She stated a potential negative outcome for not having a care plan for activities was the resident could be bored or depressed. During an interview on 07/07/23 at 02:29 PM, the ADM stated care planning was a team effort, and everyone should have been in the care plans adjusting them to make sure they were comprehensive. The ADM stated the charge nurses were able to add falls and other changes in the care plans so they could get into the care plan immediately. When asked how he monitored for compliance, he stated he had emphasized to his department heads that they needed to review what was completed, and he relied on the expertise of the MDSN and DON to oversee the process. He stated each discipline should have reviewed the care plans for their own areas of expertise and given input into that area. The ADM stated it was outside of his scope whether it would be the DON or MDS who needed to make sure the care plans were compliant. When asked if it was important to care plan for activities, he said care plans should have been individualized. He stated a possible negative outcome was the residents' psychological well-being could be affected which could also spill over into physiological well-being. He stated they wanted the world to be as perfect as possible for their residents. Review of undated facility policy titled Comprehensive Care Planning reflected the following: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the followingThe services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being. When developing a comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services. If a Care Area Assessment (CAA) is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing or currently has a weakness or need associated with that CAA, and how the risk, weakness, or need affects the resident. Documentation regarding these assessments and the facilities rationale for deciding whether to proceed with care planning for each area triggered will be recorded in the medical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676117 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bertram Nursing and Rehabilitation 540 E State Hwy 29 Bertram, TX 78605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 record. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676117 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bertram Nursing and Rehabilitation 540 E State Hwy 29 Bertram, TX 78605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of 24 residents (Resident #25) reviewed for infection control. Residents Affected - Few Specifically, the facility failed to ensure staff were following hand hygiene procedures when involved in direct resident contact providing peri-care for Resident #25; specifically, hand hygiene with glove change was not conducted when performing peri-care when going from dirty to clean. This failure could place all residents at risk of developing communicable diseases and infections. The findings included: Review of Resident #25's Quarterly MDS dated [DATE] revealed a diagnosis of Diabetes Mellitus Type 2, End Stage Renal Disease, and Hemodialysis. Observation conducted on 07/06/23 at 09:16 AM of mechcanical lift transfer and peri-care for Resident #25. CNA C and SCNA E conducted hand hygiene and secured blue lift vest to the mechanical lift and transferred Resident #25 from her wheelchair to her bed. Hand hygiene conducted and gloves donned. Resident's brief was removed, and front perineum cleansed. Hand hygiene and glove change was not conducted by CNA C, who was providing peri-care while SCNA E assisted with turning. Resident was turned to right side by SCNA E and resident's bottom was cleansed by CNA C. Clean brief applied, pants pulled up and resident was transferred via mechanical lift from bed and back to wheelchair. Gloves removed and hand hygiene performed, trash removed from the room. Interview with CNA C on 07/06/23 at 12:00 PM revealed she cleaned Resident #25 from front down the middle and side to side, then on bottom down the middle and side to side, and then put on a clean brief. When asked what she was supposed to do, CNA C did not recall further information. Hand hygiene and glove change was not observed when transitioning from Resident #25's peri area to bottom, from dirty to clean. CNA C stated she had been nervous and had been trained to wash hands and change gloves when going from dirty to clean and when gloves become were soiled. Interview conducted on 07/06/23 at 02:07 PM with the DON revealed her expectation during peri-care was for the CNAs to change their gloves and perform hand hygiene when going from dirty to clean, from peri area to bottom. DON stated, When staff don't change their gloves and perform hand hygiene when going from dirty to clean, they can pass infection on to the next resident or to themselves. DON stated in-services were conducted on PPE, hand hygiene and glove changes every month and demonstrations were conducted at a sink in DON office. Review conducted on 07/06/23 at 02:15 PM of In-service documentation dated 6/09/23 reflected Proper glove wearing included to change gloves when they are dirty, and during and after changing residents. CNA C participated in the in-service conduced on 7/06/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676117 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bertram Nursing and Rehabilitation 540 E State Hwy 29 Bertram, TX 78605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review and interview, the facility failed to ensure all mechanical, electrical, and patient care equipment was in safe operating condition for one of eight residents (Resident #38) reviewed for safe operating patient care equipment. Residents Affected - Few Resident #38's electric bed remote was not maintained in safe operating condition according to manufacturer's recommendations, and more specifically Resident #38's electric bed remote cord had cracked casing and exposed wiring. This failure could put all residents in the facility at risk of injury or electric shock. The findings included: Interview conducted on 07/05/23 at 10:52 AM with Resident #38 revealed she was receiving good care in the facility. Resident #38 stated she was concerned about her bed remote cord exposed wire. Observation conducted on 07/05/23 at 10:55 AM revealed Resident #38 sitting up in wheelchair in her room near her electric bed. The electric bed remote was on the floor between bed and window, and the casing on the cord was cracked with wiring exposed. Resident #38 stated she was unsure how long it had been like that. Interview conducted on 07/06/23 at 02:17 PM with CNA C revealed if there was damage to a call light or bed control cord, she would notify maintenance. CNA C was not aware of damage to the bed control cord. Interview conducted on 07/07/23 at 02:22 PM with the DON revealed with exposed wires there could be risk of electric shock, and not supposed to have exposed wires. DON stated she would notify maintenance immediately. Interview conducted on 7/07/23 at 09:54 AM with SCNA E revealed she would make sure to clip a call device or bed remote on where it would be reachable for them and would let the charge nurse know about damaged equipment or frayed cords. Hazards to the resident include they could be injured by a damaged cord. Interview conducted on 07/07/23 at 10:00 AM with MAINT revealed he followed a weekly check list to check beds, wheelchairs, call lights, toilet, and other equipment in rooms and a general check of each room, and a schedule that was checked each day. MAINT revealed the QR Code on wall or on Maintenance Care was where staff could report needs and it would send an alert, and they also can post on maintenance bulletin board or just tell him when repairs were needed. MAINT stated electrical shorts and beds up against plugs and sockets can cause electrical shock. MAINT further stated a bed not working properly can cause a fall, and beds not in the right position and doors not shutting can pose a fire hazard. MAINT revealed using electrical tape for the repair of bed control cord for Resident #38, as Resident #38 reported exposed wiring on her bed remote a week ago during Champion rounds. MAINT further stated when the staff and family move remote wires under the bed, then lower the bed can often pinch the wire, or pulling the device so hard it comes apart. MAINT stated Ambassador checks include checking call lights, bed controls, and other checks are done daily. MAINT stated supplies come in on Thursday, including electrical tape. MAINT stated local hardware store doesn't always have what is needed. MAINT stated inspection of equipment includes a checklist and includes call cords, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676117 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bertram Nursing and Rehabilitation 540 E State Hwy 29 Bertram, TX 78605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few door alarms, some days include doing outside inspection for ant beds and other pests. MAINT stated Resident #38 had reported the damaged bed remote cord directly to me this past Wednesday. Interview conducted on 07/07/23 at 11:21 AM with MAINT revealed the bed remote in Resident 38's room had been taped up with electrical tape, and this was the third replacement bed controller in her room. MAINT revealed the CNAs had taken the cord under the bed. Interview on 07/07/23 at 02:23 PM with Administrator revealed the impact of equipment with damaged wiring could shock the resident and could cause something to burn. Administrator stated his expectation would include to immediately remove the damaged bed remote and replace it with a new one or remove the damaged equipment and replace it. Monitoring of equipment in the facility included assigning management to conduct champion rounds, and every department manager has rooms they make rounds in. Administrator further stated he had not been made aware of the damaged bed remote cord and would ensure the maintenance supervisor does due diligence in checking on the equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676117 If continuation sheet Page 9 of 9