Health inspection·March 22, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents had the right to and the facility promoted and facilitated resident self-determination through support of resident choice, which included but not limited to the right to make choices about aspects of his or her life in the facility that were significant to the resident for 3 of 20 residents (Resident #13, Resident # 37, anonymous resident) reviewed for self-determination. A. The facility failed to ensure Resident #13 was allowed to have cereal when he expressed, he would like cereal after breakfast. B. The facility failed to ensure Resident #37 was allowed to choose the type of foods he preferred when he expressed, he would like bacon at breakfast like all the other residents were served. C. In a confidential interview one resident stated he asked for toast and was told no by the DM. This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that were important in their life and a decrease in their quality of life. Findings include: Record review of Resident # 13's face sheet revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include chronic kidney disease, moderate protein calorie malnutrition, post-traumatic stress disorder, heart disease and hypertension. Record review of comprehensive MDS assessment dated [DATE] revealed Resident # 13 was always understood. The MDS revealed Resident # 13 had a BIMS of 13 which indicated the resident's cognition was intact. Section K indicated Resident #13 had no swallowing disorders and had no dental issues. Record review of a care plan, dated 01/16/24 for Resident # 13 revealed the following: Problem: Resident has potential problem with Malnutrition Interventions: Monitor/record/report to MD signs and symptoms of malnutrition. Weight loss muscle wasting. Offer snacks between meals. Provide/serve diet as ordered. Problem: Resident has regular diet. Page 1 of 30 676157 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0550 Interventions: Provide and serve diet as ordered. Level of Harm - Minimal harm or potential for actual harm Record Review of the monthly Physician's Orders revealed Resident #13 was on regular diet, regular texture, regular liquids. Residents Affected - Few Record review of Resident # 13's weight log, January 2024 -March 2024, indicated there was no significant weight loss at the time of survey. Record Review of Resident #13's RD Annual Nutritional assessment dated [DATE] revealed the goals were to encourage adequate food intake, honor food preferences when able and maintain skin integrity. Record review of Resident #13's Food Preference List dated 9/4/23 revealed resident likes all foods and has no allergies and has no food restrictions. Record Review of Resident #13's ticket ray had no foods listed on it. Record review of Resident # 37's face sheet revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include Parkinsonism, peripheral vascular disease, bipolar disorder in remission, heart disease and muscle weakness. Record review of comprehensive MDS assessment dated [DATE] revealed Resident # 37 was always understood. The MDS revealed Resident # 37 had a BIMS of 10 which indicated the resident's cognition was moderately impaired. Section K indicated Resident #37 had no swallowing disorders and had no dental issues. Record review of a care plan, dated 8/13/22 for Resident # 37 revealed the following: Problem: Resident has potential nutritional problem due to Parkinson's. Interventions: Provide, serve diet as ordered. Record Review of the monthly Physician's Orders dated 2/15/24 documents resident was on regular diet, mechanical soft texture, regular liquids. Record review of Resident # 13 weight log, January 2024 -March 2024, indicated there was no significant weight loss at the time of survey. Record Review of the RD Annual Nutritional assessment dated [DATE] revealed the goals were to encourage adequate food intake, honor food preferences when able and maintain skin integrity. Record review of the Tray ticket revealed the only entry was Mechanical Soft, Regular Diet, Regular liquids. Record review of Resident Food Preference List dated 2/16/24 revealed resident liked bacon, has no allergies and had no food restrictions. In an interview and observation on 3/4/24 at 9:30 am Resident #13 asked this writer for a bowl of Cheerios. The DM was present at the time of the resident's request and stated to this writer he would have to look on the tray ticket to see if Resident #13 could have it. He stated to this writer if 676157 Page 2 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0550 it is not on his tray ticket, he cannot have it. Level of Harm - Minimal harm or potential for actual harm In an interview on 3/4/24 at 2:00 pm, Resident # 13 stated he was not given any Cheerios when he had asked this morning. He stated he was still hungry after breakfast and wanted Cheerios to help fill him up after breakfast. He stated he is told no by the DM every time he asks for more food and it makes him really mad. He stated he should get the foods he asks for. Residents Affected - Few In an interview on 3/5/24 at 3:00 pm the DM stated he did not give Resident #13 any Cheerios as requested because he is on a mechanical soft diet and the Cheerios are not mechanical soft. He also stated the Cheerios were not on the tray ticket. He stated he spoke to the ST, and she agreed Resident #13 could not have Cheerios as he is on a mechanical soft diet. In an interview on 3/6/24 at 11:00 am Resident #37 stated he has asked for bacon every day and he was never given bacon. He stated this week the other residents got bacon on Monday and Wednesday(today). He stated he sees other residents eating bacon and does not know why he could not have bacon. Resident #37 stated it makes him feel discriminated against to not get what he asked for when other residents have gotten bacon. Resident #37 stated he was told the bacon was not on his tray slip and that is why he could not have it. In a confidential interview with a facility employee on 3/6/24 at 11:20 am the employee stated another resident always requested extra bacon and had always gotten extra bacon almost every day. The employee stated they ask for bacon for Resident #37 when he requests bacon, but they were told it was not on the tray ticket or there was not enough bacon for Resident # 37. In a confidential interview one resident stopped this wrier in the hall and stated he had asked for toast to take with his medications as he would have an upset stomach if his medications are not taken with food. The resident stated he was told no by the DM. The resident also stated he was given sausage every day and he does not want sausage every day. The resident stated he does not get bacon even when it is served to other residents. The resident stated he had tried to speak to the DM about his meals and it is hard asking for anything from the kitchen because the DM gives him a hard time. When asked what hard time meant, he stated the DM argues with him , tells him the requests are not on the tray ticket and they were not on his diet. the resident stated he did not know what the DM awas talking about because he has a regular diet and can eat whatever he wants to. The resident stated the DM just makes excuses so he can save money. In an interview on 3/6/24 at 10:00 am the Speech Therapist (ST) stated she had not spoken to the DM about Resident # 13 not being able to have Cheerios. She stated Resident # 13 could have the Cheerios if he wanted them. The ST stated the DM is concerned with saving money from the budget. In an interview on 3/6/24 at 1:25 pm the MD stated the residents in the facility can have what they want foodwise. He stated if the residents ask for something foodwise they should get it. He further stated Resident #13 could have Cheerios if he wanted it. Record review of the facility's policy titled, Menu Planning, revised June 2019 revealed: Menus will be prepared for each facility by their food vendor. Menus are updated twice each year and intermittently based on resident preference. The menus will include week at a glance menu, standardized recipes, a nutritional analysis, a production guide and an order guide. The menus are to be reviewed and approved by the Dietitian. The menu will be signed and dated by the dietician. An 676157 Page 3 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0550 approved copy of the menus will be kept on file in the DM office. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy titled, Liberalized Diets, dated October 2018 revealed: The facility believes residents eat best when allowed to choose their diets. Residents Affected - Few 676157 Page 4 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, Interview and Record Review the facility failed to ensure residents were free from abuse, for 6 of 7 residents (Resident #'s 61, 73, 86, 90, 104 and 112) reviewed for abuse. This failure could place these residents at risk of continued abuse on the locked unit of the facility. The failure was identified as past noncompliance as the facility had instituted adequate corrective measures to prevent reoccurrence of the non-compliance. Findings included: On 3/4/24 at 9:02AM an interview with Resident #110 was attempted but was unable be completed due to resident's level of cognitive decline. Interviews with Resident #'s 61, 73, 86, 90, 104 and 112 were attempted, but were unable to be completed due to resident's level of cognitive decline. Record review revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of, but not limited to, Alzheimer's Disease with Late Onset; Major Depressive Disorder, Recurrent Severe, without Psychotic Features; Anxiety Disorder, Unspecified and Psychotic Disorder with Hallucinations due to known Psychological Conditions. Record review of a Nursing Progress Note dated 12/3/23 at 3:23PM indicated Resident #110 showed signs and symptoms of aggressive behavior today on shift. He was aggressive towards staff and other residents. (Other resident names were not recorded in the notes). When attempting to redirect resident from climbing over the wall in the dining area and redirecting him from going into other residents' room, he became aggressive with the staff. During outbursts resident would direct his aggressive tone towards other residents. Family member was here with resident, and he is calm and watching T.V. Family Member was updated on his behaviors today. She stated on yesterday's shift, Resident #110 shoved one of the other residents when he got too close to her. Will continue to monitor. Record review of a Nursing Progress Note dated 12/4/23 at 3:19PM indicated the House Psychiatrist was notified of an incident between Resident #110 and another resident. (Other resident's name was not recorded in the notes). The House Psychiatrist had not had an initial encounter with Resident #110 and could not prescribe medication to mitigate his behaviors. The PRN orders for Olanzapine 5mg tablet; one half tablet two times daily and Hydroxyzine 25mg; Give on tablet one time daily were continued until a visit with the House Psychiatrist was arranged. Record review of a Change in Condition Evaluation dated 12/4/23 at 3:40PM indicated that Resident #110 was a danger to himself and others. Record review of a Nursing Progress Note dated 12/4/23 at 3:59PM indicated the following: This nurse was sitting at nurse's station, charting, when I heard yelling. Ran to resident's room to find this resident (Resident #110) standing over roommate (Other resident's name was not recorded in the notes) with his hands around roommate's neck. Pulled this resident off of roommate and this resident 676157 Page 5 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0600 Level of Harm - Minimal harm or potential for actual harm attempted to punch me. I told him to get out of the room. He looked at me for a minute and I told him again that he needs to leave the room immediately. He has swollen knuckles on his right hand and redness to the right side of face. Administered PRN medication. Will continue to monitor. The victim was not harmed. Facility staff completed an assessment. No physical injuries were noted and the resident appeared unaffected by the encounter. Residents Affected - Some Resident #110 was placed on 1:1 supervision on 12/4/23. On 12/5/24, he tested positive for COVID so he was in isolation in his room. Another COVID + resident was also in the room. The staff person providing 1:1 supervision was stationed outside the room. The facility also used video baby monitors to monitor the COVID + rooms. Record review of Resident #110's Base-line Care Plan dated 12/5/23 revealed a problematic manner in which the resident acts, characterized by ineffective coping, and verbal/physical aggression. The goal was stated as the resident will not strike or verbally abuse others, with an Intervention of documentation of each episode, noting the cause, successful intervention, frequency, and duration of aggressive symptoms. Additionally documented was the use of Psychotropic Medication related to Behavior Management. The goal was the resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, or constipation/impaction/cognitive/behavioral impairment through the target date of 12/10/23. The intervention was administering psychotropic medication as ordered by physician and monitoring for side effects and effectiveness, every shift. A Nursing Progress Note dated 12/6/23 at 7:45PM indicated the following: This nurse found resident with his arms wrapped around another resident (Other resident's name was not recorded in the notes). He was squeezing very hard and when this nurse asked him to stop, he just looked at me and squeezed again. I asked him to leave the room and asked why he was doing this. He left the room and responded, We're playing Nam. This resident also laid on the floor at beginning of shift pretending to shoot his gun like a sniper. 1:1 monitoring continued. Plan of Care on-going. Record review of a Nursing Progress Note dated 12/6/23 at 8:30PM a indicated the following: This nurse walked into a different resident's (Other resident's name was not recorded in the notes) room while looking for this resident (Resident #110). Resident #110 had his arms wrapped around other resident while standing behind that resident's wheelchair. He was squeezing him as hard as he could and when this nurse asked him to let go, he just stared at me, and then let him go. Removed him (Resident #110) from other resident's room and performed skin assessment. No injuries found upon assessment. When I asked him (Resident #110) why he was doing that he stated' We're playing Nam and then walked away. Notified family, RN Sup, on call, & House Psychiatrist. Plan of Care on-going. Record review of a Change of Condition Evaluation dated 12/7/23 at 2:00AM was initiated due to behavioral symptoms, other signs of delirium and physical aggression toward self and others. The recommendations from House Psychiatrist were giving medicine as prescribed, continue 1:1 monitoring and send out for inpatient psychological evaluation. Plan of Care on-going. Record review of Nursing Progress Notes dated 12/7/23 at 10:22AM revealed the facility notified Resident #110's responsible party that, with her permission, arrangements were being made to discharge Resident #110 to a Behavioral Health Hospital in town or a Behavioral Health Hospital in a town about an hour away, for further observation. Plan of Care on-going. Record review of Nursing Progress Notes dated 12/7/23 at 2:24PM revealed the facility notified 676157 Page 6 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #110's responsible party and House Psychiatrist the resident had been denied placement at two inpatient psychological hospitals and notification from a judge, denied emergency placement. Plan of Care on-going. Record review of a Nursing Progress Note dated 12/9/23 at 11:58AM indicated Resident #110 was pacing around unit, grabbing items, and throwing them; grabbing other resident's (Other resident's name was not recorded in the notes) wheelchair, attempting to open doors pushing and yelling I just want to get out of here; Resident very agitated and anxious, not easily redirected at this time. Call placed to House Psychiatrist. Record review of a Nursing Progress Note dated 12/11/23 at 3:42PM indicated Resident #110 was observed approaching another resident (Other resident's name was not recorded in the notes) where he grabbed his chair and hit the chair with his fists, while shaking the chair. This nurse went to Resident #110 and redirected him by asking him to come with me to his room to talk. Resident was compliant, he is delusional and hallucinating. With the help of two CNAs, Resident #110 was able to lay down and relax. House Psychiatrist was notified at 3:44PM. Plan of Care on-going. A Change of Condition Evaluation dated 12/11/23 at 3:49PM was initiated for Resident #110 due to altered mental status and behavioral symptoms during this altercation. Record review of a Nursing Progress Note dated 12/11/23 at 5:00PM indicated House Psychiatrist's NP stated via telephone, there was nothing else she could do at this time; continued medications and 1:1 observation was recommended. Plan of Care on-going. Record review of a Nursing Progress Note dated 12/26/23 at 12:43PM reflected the following: This nurse called House Psychiatrist's office regarding continued behaviors from Resident #110. He was agitated, delusional, hallucinating, and aggressive towards staff and at times, towards other residents. He was pacing; not sleeping well at night or resting much during the day and was not redirectable during these episodes; he was very aggressive towards staff. Nurse Practitioner called back with orders to increase Zyprexa to 20mg pill, once per day and continue PRN Hydroxyzine 50mg every four hours for 5 more days. Resident will continue with 1:1 observation; will continue to monitor. Plan of Care on-going. Record review of a Nursing Progress Note dated 12/27/23 at 2:42PM reflected Resident #110 started exhibiting agitation, aggression, and pacing around the unit. Refused care; refused medications. Attempted to hit two other residents. (Other resident's names were not recorded in the notes). Resident #110 was redirected by staff and finally took his medications. PRN medication was given. Resident was in room with 1:1 observation outside of his door. Plan of Care on-going. Record review of a Nursing Progress Note dated 12/29/23 at 4:39PM reflected Resident #110 continued 1:1 monitoring. Resident was pleasant on the morning part of our shift. Resident was up for all meals. Resident remained calm and relaxed until around 2pm, when he started trying to pace and circle the unit. Refused to take medications. Attempted to hit one of the CNAs; escorted him into his room to calm down. After a few minutes in his room, he took his medication along with PRN dose of Hydroxyzine; able to redirect resident after about 30 minutes; he was still agitated but remained in his room, more relaxed. Stated he was sleepy so 1:1 CNA helped him lay down to rest. Call light in reach and bed locked in low position. Will continue to monitor. Plan of Care on-going Record review of Resident #110's clinical record revealed that the facility is continuing the 1:1 676157 Page 7 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0600 Level of Harm - Minimal harm or potential for actual harm supervision, has educated staff and also obtained psychiatric care for Resident #110. Resident #110 has not exhibited any physically aggressive behavior since early January. The interventions the facility took are documented in his clinical record. Residents Affected - Some 676157 Page 8 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview and Record Review the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment for 1 of 23 residents (Resident #110) reviewed for accurate assessments. This failure could place residents at risk of not receiving the care needed to maintain their highest, most practicable, physical, social, and psychosocial level of well-being. Findings included: On 3/4/24 at 9:02AM an interview with Resident #110 was attempted but was unable be completed due to resident's level of cognitive decline. Record review on 3/4/24 at 2:19PM revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of, but not limited to, Alzheimer's Disease with Late Onset; Major Depressive Disorder, Recurrent Severe, without Psychotic Features; Anxiety Disorder, Unspecified and Psychotic Disorder with Hallucinations due to known Psychological Conditions. Record review of a Nursing Progress Note dated 11/30/23 at 5:42PM indicated a 14-day PRN prescription from the Primary Care Nurse Practitioner for Olanzapine 5mg tablet; Give one half tablet two times daily for increased agitation/aggression and Hydroxyzine 25mg; Give one tablet one time daily for aggression toward roommate, along with 1:1 observation and referral to psychiatric services for in-house psychological care. Record review of a Nursing Progress Note dated 12/3/23 at 3:23PM indicated Resident #110 showed signs and symptoms of aggressive behavior today on shift. He was aggressive towards staff and other residents. When attempting to redirect resident from climbing over the wall in the dining area and redirecting him from going into other residents' room, he became aggressive with the staff. During outbursts resident would direct his aggressive tone towards other residents. Family member was here with resident, and he is calm and watching T.V. Family Member was updated on his behaviors today. She stated on yesterday's shift, Resident #110 shoved one of the other residents when he got too close to her. Will continue to monitor. Record review of a Nursing Progress Note dated 12/4/23 at 3:19PM indicated the House Psychiatrist was notified of an incident between Resident #110 and another resident. The House Psychiatrist had not had an initial encounter with Resident #110 and could not prescribe medication to mitigate his behaviors. The PRN orders for Olanzapine 5mg tablet; one half tablet two times daily and Hydroxyzine 25mg; Give on tablet one time daily were continued until a visit with the House Psychiatrist was arranged. Record review of a Change in Condition Evaluation dated 12/4/23 at 3:40PM indicated that Resident #110 was a danger to himself and others. Record review of a Nursing Progress Note dated 12/4/23 at 3:59PM indicated the following: This nurse was sitting at nurse's station, charting, when I heard yelling. Ran to resident's room to find this resident (Resident #110) standing over roommate with his hands around roommate's neck. Pulled this 676157 Page 9 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident off of roommate and this resident attempted to punch me. I told him to get out of the room. He looked at me for a minute and I told him again that he needs to leave the room immediately. He has swollen knuckles on his right hand and redness to the right side of face. Administered PRN medication. Will continue to monitor. Record review of a tele-health visit dated 12/5/23 at f11:47AM reflected a visit was conducted by the Nurse Practitioner for the House Psychiatrist. The PRN order for Olanzapine was discontinued and Olanzapine 5mg. tablet was prescribed once daily for psychotic disorder with hallucinations due to known physiological condition, along with Buspar 10mg. once daily for Unspecified Anxiety Disorder and Mirtazapine 15mg. once daily for Major Depressive Disorder. Record review of Resident #110's Base-line Care Plan dated 12/5/23 revealed a problematic manner in which the resident acts, characterized by ineffective coping, and verbal/physical aggression. The goal was stated as the resident will not strike or verbally abuse others, with an Intervention of documentation of each episode, noting the cause, successful intervention, frequency, and duration of aggressive symptoms. Additionally documented was the use of Psychotropic Medication related to Behavior Management. The goal was the resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, or constipation/impaction/cognitive/behavioral impairment through the target date of 12/10/23. The intervention was administering psychotropic medication as ordered by physician and monitoring for side effects and effectiveness, every shift. The admission MDS from 11/27/23 was not updated to reflect the Change of Condition due to increased behaviors. Record review of a Nursing Progress Note dated 12/6/23 at 7:45PM indicated the following: This nurse found resident with his arms wrapped around another resident. He was squeezing very hard and when this nurse asked him to stop, he just looked at me and squeezed again. I asked him to leave the room and asked why he was doing this. He left the room and responded, We're playing Nam. This resident also laid on the floor at beginning of shift pretending to shoot his gun like a sniper. 1:1 monitoring continued. Plan of Care on-going. Record review of a Nursing Progress Note dated 12/6/23 t 8:30PM a indicated the following: This nurse walked into a different residents' room while looking for this resident (Resident #110). Resident #110 had his arms wrapped around other resident while standing behind that resident's wheelchair. He was squeezing him as hard as he could and when this nurse asked him to let go, he just stared at me, and then let him go. Removed him (Resident #110) from other resident's room and performed skin assessment. No injuries found upon assessment. When I asked him (Resident #110) why he was doing that he stated' We're playing Nam and then walked away. Notified family, RN Sup, on call, & House Psychiatrist. Plan of Care on-going. Record review of a Change of Condition Evaluation dated 12/7/23 at 2:00AM was initiated due to behavioral symptoms, other signs of delirium and physical aggression toward self and others. The recommendations from House Psychiatrist were giving medicine as prescribed, continue 1:1 monitoring and send out for inpatient psychological evaluation. Plan of Care on-going. Record review of Nursing Progress Notes dated 12/7/23 at 10:22AM revealed the facility notified Resident #110's responsible party that, with her permission, arrangements were being made to discharge Resident #110 to a Behavioral Health Hospital in town or a Behavioral Health Hospital in a town 676157 Page 10 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0636 about an hour away, for further observation. Plan of Care on-going. Level of Harm - Minimal harm or potential for actual harm Record review of Nursing Progress Notes dated 12/7/23 at 2:24PM revealed the facility notified Resident #110's responsible party and House Psychiatrist the resident had been denied placement at two inpatient psychological hospitals and notification from a judge, denied emergency placement. Plan of Care on-going. Residents Affected - Some Record review revealed an order was received from the House Psychiatrist on 12/7/23 at 3:58PM to increase Olanzapine 5mg tablet, once daily to Olanzapine 10mg tablet, once daily. NP stated that if resident was still having behaviors tonight, call the office and she will give additional orders. Plan of Care on-going. The admission MDS from 11/27/23 was not updated to reflect the Change of Condition due to increased behaviors. Record review of a Nursing Progress Note dated 12/9/23 at 11:58AM indicated Resident #110 was pacing around unit, grabbing items, and throwing them; grabbing other resident's wheelchairs, attempting to open doors pushing and yelling I just want to get out of here; Resident very agitated and anxious, not easily redirected at this time. Call placed to House Psychiatrist. Voices to give one time dose of Zyprexa 10mg now and start resident on Vistaril PRN 50mg every 4 hour for 14 days. Orders have been updated and responsible party has been made aware of all new orders and agrees upon. Plan of Care on-going. Record review of a Nursing Progress Note dated 12/11/23 at 3:42PM indicated Resident #110 was observed approaching another resident where he grabbed his chair and hit the chair with his fists, while shaking the chair. This nurse went to Resident #110 and redirected him by asking him to come with me to his room to talk. Resident was compliant, he is delusional and hallucinating. With the help of two CNAs, Resident #110 was able to lay down and relax. House Psychiatrist was notified at 3:44PM. Plan of Care on-going. A Change of Condition Evaluation dated 12/11/23 at 3:49PM was initiated for Resident #110 due to altered mental status and behavioral symptoms during this altercation. Record review of a Nursing Progress Note dated 12/11/23 at 5:00PM indicated House Psychiatrist's NP stated via telephone, there was nothing else she could do at this time; continued medications and 1:1 observation was recommended. Plan of Care on-going. The admission MDS from 11/27/23 was not updated to reflect the Change of Condition due to increased behaviors. Record review of a Nursing Progress Note dated 12/26/23 at 12:43PM reflected the following: This nurse called House Psychiatrist's office regarding continued behaviors from Resident #110. He was agitated, delusional, hallucinating, and aggressive towards staff and at times, towards other residents. He was pacing; not sleeping well at night or resting much during the day and was not redirectable during these episodes; he was very aggressive towards staff. Nurse Practitioner called back with orders to increase Zyprexa to 20mg pill, once per day and continue PRN Hydroxyzine 50mg every four hours for 5 more days. Resident will continue with 1:1 observation; will continue to monitor. Plan of Care on-going. 676157 Page 11 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0636 Level of Harm - Minimal harm or potential for actual harm Record review of a Nursing Progress Note dated 12/27/23 at 2:42PM reflected Resident #110 started exhibiting agitation, aggression, and pacing around the unit. Refused care; refused medications. Attempted to hit two other residents. Resident #110 was redirected by staff and finally took his medications. PRN medication was given. Resident was in room with 1:1 observation outside of his door. Plan of Care on-going. Residents Affected - Some Record review of a Nursing Progress Note dated 12/29/23 at 4:39PM reflected Resident #110 continued 1:1 monitoring. Resident was pleasant on the morning part of our shift. Resident was up for all meals. Resident remained calm and relaxed until around 2pm, when he started trying to pace and circle the unit. Refused to take medications. Attempted to hit one of the CNAs; escorted him into his room to calm down. After a few minutes in his room, he took his medication along with PRN dose of Hydroxyzine; able to redirect resident after about 30 minutes; he was still agitated but remained in his room, more relaxed. Stated he was sleepy so 1:1 CNA helped him lay down to rest. Call light in reach and bed locked in low position. Will continue to monitor. Plan of Care on-going Record review of a Nursing Progress Note dated 12/31/23 at 5:08AM revealed Resident #110 made sexually inappropriate comments toward 1:1 CNA; told her to get into bed with him so he could fuck her. Resident attempted to inappropriately touch 1:1 CNA multiple times. Plan of Care on-going. Record review of an Administrator's Progress Note dated 1/2/24 at 6:08PM stated she had made rounds on the locked unit and had found Resident #110 trying to get away from his 1:1 CNA by walking rapidly away from her and pacing the unit. Plan of Care on-going. A Change of Condition Evaluation on 1/10/24 at 4:53PM a was initiated due to Resident-to-Resident Contact. The required evaluation indicated the following: The CNAs reported that there had been an incident between residents. CNAs stated that Resident #110 had attempted to take away another resident's soda. Resident #110 picked up the cup and other resident attempted to take it back when Resident #110 grabbed ahold of the other resident's arm. The two CNAs separated the residents. Resident #110 continued to attempt to get ahold of the other resident after the separation. CNA took other resident behind nurse's station to remove him from the area. Nurse notified ADON, On-call Supervisor, and responsible parties for both residents. Plan of Care on-going. The admission MDS from 11/27/23 was not updated to reflect the Change of Condition due to increased behaviors. In an interview on 3/4/24 at 3:39PM the MDS Coordinator revealed that the MDS had not been updated since the resident's admission to the facility. The MDS Coordinator was asked why the evaluations had not been done and updated. He stated that he, would be happy to do another one, right now, if I would like him to. When asked what the negative outcome of not updating resident records was, he stated, I guess they wouldn't get the care that they might need. In an interview on 3/4/24 at 3:59PM the Administrator stated she was not aware that the records for Resident #110 were inaccurate and had not been corrected or updated to reflect his current mental status. 676157 Page 12 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview and Record Review the facility failed to review and revise the resident's care plan after each assessment for 1 of 23 residents (Resident #110) reviewed for care plan accuracy. Residents Affected - Few This failure could place residents at risk of not receiving the care needed to maintain their highest, most practicable, physical, social, and psychosocial level of well-being. Findings Included: On 3/4/24 at 9:02AM an interview was attempted with Resident #110 but could not be completed due to resident's level of cognitive decline. Record review on 3/4/24 at 2:19PM revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of, but not limited to, Alzheimer's Disease with Late Onset; Major Depressive Disorder, Recurrent Severe, without Psychotic Features; Anxiety Disorder, Unspecified and Psychotic Disorder with Hallucinations due to known Psychological Conditions. Record review of a Nursing Progress Note dated 12/4/23 at 3:19PM indicated the House Psychiatrist was notified of an incident between Resident #110 and another resident. The House Psychiatrist had not had an initial encounter with Resident #110 and could not prescribe medication to mitigate his behaviors. The PRN orders for Olanzapine 5mg tablet; one half tablet two times daily and Hydroxyzine 25mg; Give on tablet one time daily were continued until a visit with the House Psychiatrist was arranged. Record review of a Change in Condition Evaluation dated 12/4/23 at 3:40PM indicated that Resident #110 was a danger to himself and others. Record review of a Nursing Progress Note dated 12/4/23 at 3:59PM indicated the following: This nurse was sitting at nurse's station, charting, when I heard yelling. Ran to resident's room to find this resident (Resident #110) standing over roommate with his hands around roommate's neck. Pulled this resident off of roommate and this resident attempted to punch me. I told him to get out of the room. He looked at me for a minute and I told him again that he needs to leave the room immediately. He has swollen knuckles on his right hand and redness to the right side of face. Administered PRN medication. Will continue to monitor. Record review of Resident #110's Base-line Care Plan dated 12/5/23 revealed a problematic manner in which the resident acts, characterized by ineffective coping, and verbal/physical aggression. The goal was stated as the resident will not strike or verbally abuse others, with an Intervention of documentation of each episode, noting the cause, successful intervention, frequency, and duration of aggressive symptoms. Additionally documented was the use of Psychotropic Medication related to Behavior Management. The goal was the resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, or constipation/impaction/cognitive/behavioral impairment through the target date of 12/10/23. The intervention was administering psychotropic medication as ordered by physician and monitoring for side effects and effectiveness, every shift. Record review of a Nursing Progress Note dated 12/6/23 at 7:45PM a indicated the following: This 676157 Page 13 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0637 Level of Harm - Minimal harm or potential for actual harm nurse found resident with his arms wrapped around another resident. He was squeezing very hard and when this nurse asked him to stop, he just looked at me and squeezed again. I asked him to leave the room and asked why he was doing this. He left the room and responded, We're playing Nam. This resident also laid on the floor at beginning of shift pretending to shoot his gun like a sniper. 1:1 monitoring continued. Plan of Care on-going. Residents Affected - Few Record review of a Nursing Note dated 12/6/23 at 8:30PM indicated the following: This nurse walked into a different residents' room while looking for this resident (Resident #110). Resident #110 had his arms wrapped around other resident while standing behind that resident's wheelchair. He was squeezing him as hard as he could and when this nurse asked him to let go, he just stared at me, and then let him go. Removed him (Resident #110) from other resident's room and performed skin assessment. No injuries found upon assessment. When I asked him (Resident #110) why he was doing that he stated' We're playing Nam and then walked away. Notified family, RN Sup, on call, & House Psychiatrist. Plan of Care on-going. Record review of a Change of Condition Evaluation dated 12/7/23 at 2:00AM was initiated due to behavioral symptoms, other signs of delirium and physical aggression toward self and others. The recommendations from House Psychiatrist were giving medicine as prescribed, continue 1:1 monitoring and send out for inpatient psychological evaluation. Plan of Care on-going. Record review revealed on 12/7/23 at 10:22AM the facility notified Resident #110's responsible party that, with her permission, arrangements were being made to discharge Resident #110 to a Behavioral Health Hospital in town or a Behavioral Health Hospital in a town about an hour away, for further observation. Plan of Care on-going. Record review revealed on 12/7/23 at 2:24PM the facility notified Resident #110's responsible party and House Psychiatrist the resident had been denied placement at two inpatient psychological hospitals and notification from a judge, denied emergency placement. Plan of Care on-going. Record review revealed on 12/7/23 at 3:58PM an order was received from the House Psychiatrist to increase Olanzapine 5mg tablet, once daily to Olanzapine 10mg tablet, once daily. NP stated that if resident was still having behaviors tonight, call the office and she will give additional orders. Plan of Care on-going. The Base-line Care Plan from 12/5/23 was not updated to reflect the Change of Condition due to increased behaviors. Record review of a Nursing Progress Note dated 12/9/23 at 11:58AM indicated Resident #110 was pacing around unit, grabbing items, and throwing them; grabbing other resident's wheelchairs, attempting to open doors pushing and yelling I just want to get out of here; Resident very agitated and anxious, not easily redirected at this time. Call placed to House Psychiatrist. Voices to give one time dose of Zyprexa 10mg now and start resident on Vistaril PRN 50mg every 4 hour for 14 days. Orders have been updated and responsible party has been made aware of all new orders and agrees upon. Plan of Care on-going. Record review of a Nursing Progress Note dated 12/11/23 at 3:42PM indicated Resident #110 was observed approaching another resident where he grabbed his chair and hit the chair with his fists, while shaking the chair. This nurse went to Resident #110 and redirected the resident by asking him to come with me to his room to talk. Resident was compliant, he is delusional and hallucinating. With the 676157 Page 14 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0637 Level of Harm - Minimal harm or potential for actual harm help of two CNAs, Resident #110 was able to lay down and relax. House Psychiatrist was notified at 3:44PM. Plan of Care on-going. Record review revealed a Change of Condition evaluation was initiated on 12/11/23 at 3:49PM due to altered mental status and behavioral symptoms during this altercation. Residents Affected - Few Record review of a Nursing Progress Noted dated 12/11/23 at 5:00PM indicated House Psychiatrist's NP stated via telephone ther was nothing else she could do at this time; continued medications and 1:1 observation were recommended. Plan of Care on-going. The Base-line Care Plan from 12/5/23 was not updated to reflect the Change of Condition due to increased behaviors. On 12/26/23 at 12:43PM a Nursing Progress Note reflected the following: This nurse called House Psychiatrist's office regarding continued behaviors from Resident #110. He was agitated, delusional, hallucinating, and aggressive towards staff and at times, towards other residents. He was pacing; not sleeping well at night or resting much during the day and was not redirectable during these episodes; he was very aggressive towards staff. Nurse Practitioner called back with orders to increase Zyprexa to 20mg pill, once per day and continue PRN Hydroxyzine 50mg every four hours for 5 more days. Resident will continue with 1:1 observation; will continue to monitor. Plan of Care on-going. Record review of a Nursing Progress Note dated 12/27/23 at 2:42PM reflected Resident #110 started exhibiting agitation, aggression, and pacing around the unit. Refused care; refused medications. Attempted to hit two other residents. Resident #110 was redirected by staff and finally took his medications. PRN medication was given. Resident was in room with 1:1 observation outside of his door. Plan of Care on-going. Record review of a Nursing Progress Note dated 12/29/23 at 4:39PM a reflected Resident #110 continued 1:1 monitoring. Resident was pleasant on the morning part of our shift. Resident was up for all meals. Resident remained calm and relaxed until around 2pm, when he started trying to pace and circle the unit. Refused to take medications. Attempted to hit one of the CNAs; escorted him into his room to calm down. After a few minutes in his room, he took his medication along with PRN dose of Hydroxyzine; able to redirect resident after about 30 minutes; he was still agitated but remained in his room, more relaxed. Stated he was sleepy so 1:1 CNA helped him lay down to rest. Call light in reach and bed locked in low position. Will continue to monitor. Plan of Care on-going Record review of a Nursing Progress Note dated 12/31/23 at 5:08AM revealed Resident #110 made sexually inappropriate comments toward 1:1 CNA; told her to get into bed with him so he could fuck her. Resident attempted to inappropriately touch 1:1 CNA multiple times. Plan of Care on-going. Record review of an Administrator's Progress Note dated 1/2/24 at 6:08PM stated she had made rounds on the locked unit and had found Resident #110 trying to get away from his 1:1 CNA by walking rapidly away from her and pacing the unit. Plan of Care on-going. Record review of a Change of Condition Evaluation dated 1/10/24 at 4:53PM reflected it was initiated due to Resident-to-Resident Contact. The required evaluation indicated the following: The CNAs reported that there had been an incident between residents. CNAs stated that Resident #110 had attempted to take away another resident's soda. Resident #110 picked up the cup and other resident attempted to take it back when Resident #110 grabbed ahold of the other resident's arm. The two CNAs 676157 Page 15 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0637 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few separated the residents. Resident #110 continued to attempt to get ahold of the other resident after the separation. CNA took other resident behind nurse's station to remove him from the area. Nurse notified ADON, On-call Supervisor, and responsible parties for both residents. Plan of Care on-going. The Base-line Care Plan from 12/5/23 was not updated to reflect the Change of Condition due to increased behaviors. In an interview on 3/4/24 at 3:39PM the MDS RN stated the Care Plan for Resident #110 had not been updated since the resident's admission to the facility. When asked what the negative outcome of not updating resident records was, he stated, I guess they wouldn't get the care that they might need. In an interview on 3/4/24 at 3:59PM the Administrator stated she was not aware that the Care Plan for Resident #110 was inaccurate and had not been corrected or updated to reflect his current mental status. 676157 Page 16 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 1 of 23 residents (Resident #79) reviewed for accuracy of MDS assessments. Residents Affected - Some -The facility did not correctly identify anticoagulation therapy for Resident #79 on his MDS assessment. This failure to ensure accurate assessments could affect all residents by placing them at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services. Finding include: Record review of Resident #79's clinical record revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include schizoaffective disorder, depressive type, dementia in other diseases classified elsewhere, unspecified severity, with psychotic disturbance, muscle weakness (generalized), anxiety disorder, unspecified, vascular dementia, moderate, with other behavioral disturbance, delusional disorders. Record review of Resident #79's last MDS, dated [DATE], revealed that Resident #79 was receiving anticoagulants. Record review of Resident #79's active medication orders revealed that Resident #79 is not on any type of anticoagulant. Record review of Resident #79's discontinued medication orders from date of admission revealed that Resident #79 had never been on an anticoagulant. During an interview on 03/07/24 at 10:36 AM with LVN G was asked if he could assist in finding if Resident #79 was on an anticoagulant. LVN G reviewed Resident 79's active medication orders and could not discover an anticoagulant. During an interview on 03/07/24 at 10:39 AM with MDS RN, MDS RN reviewed Resident #79's medication list and stated, It was an error, and I can correct it. MDS RN stated Not having the correct information and quality measures will be incorrect. MDS RN was asked what guidelines were followed to perform and MDS. MDS RN stated, The RAI. During an interview on 03/07/24 10:53 AM DON was asked what a negative outcome would be for a MDS having incorrect information. DON stated, The veterans wouldn't receive the correct care. DON was asked what policy was used to perform the MDS. DON stated that the Section 8-Comprehensive assessments Frequency and Types of assessments policy should be utilized for MDS assessments. 676157 Page 17 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 2 (Hall 800 medication cart and Hall 500 medication cart) of 4 Medication Carts. There was 1 medication bottle with no expiration date and 3 loose pills in the Hall 800 Medication Cart. There were 2.5 loose pills were in the Hall 500 Medication Cart. The facility's failure could result in residents not receiving an accurate dose of medication as well as not being maintained at their best therapeutic level. Findings include: On [DATE] at 10:09 AM Observation of Hall 800 Medication Cart with LVN H revealed 3 loose pills and an Aspirin bottle with no expiration date on the bottle. LVN H stated that all medications are to have an expiration date on the medication. Loose pills could not be identified by LVN H. On [DATE] at 10:25 AM Observation of Medication Cart for 500 Hall with LVN I revealed 2.5 loose pills. Pills were unidentified by LVN I. Interview on [DATE] at 10:09AM LVN H stated a negative outcome for giving an expired medication, was it would not be the right dosage. Interview on [DATE] at 10:25AM LVN I stated that the process for destroying loose medications was, The loose pills are placed in a drug buster (Drug Disposal System). Interview on [DATE] at 2:27PM DON stated, It's hard to keep pills in the packets. I've passed meds and they can pop out. It's just laziness on the nurse's part. Record Review of facility policy titled, 'Medication and Preparation Administration' , undated, states the following: Medication and Preparation Administration and Delivery 1.1 Preparation of Medication Facility staff should comply with Facility Policy, Applicable Law, and the State Operations Manual when preparing medications. The following guidelines should be utilized during preparation of medication: -medication should not be administered if not appropriately labeled 676157 Page 18 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0761 -facility staff should place an opened-on date on the medication label for medications with limited expiration date upon opening Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 676157 Page 19 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interviews and record reviews, the facility failed to ensure the menus met the nutritional needs of the residents in accordance with established national guidelines, and failed to ensure menus were followed, and failed to ensure menus reflected input received by residents /groups for 3 of 3 days of menus reviewed. The facility failed to: A. Follow the menu from the Menu Management Corporation as written. B. Ensure lunch items served on 03/04/24 and 03/6/24 reflect what was on the DM's menu. C. Ensure all residents recieved Bread/Rolls for the 3/4/24 lunch meal. D. Condiments were available for residents' meals. These failures affected all residents that received meals from the facility kitchen and put them at risk for malnutrition, dissatisfaction of meals and weight loss. Findings include: In an interview and record review on 3/4/24 at 9:30 am, the DM provided and reviewed the following facility menu documenting the meals for the week. The menu read: Menu Management for the week of Winter Spring 2024 Week I diet Regular documented: Monday Lunch- Oven fried chicken with cream gravy, mashed potatoes, seasoned spinach, biscuit, a smore's cup. Monday dinner meal - Blackened fish, seasoned pinto beans, broccoli with cheese, cornbread, and fruit cobbler. Tuesday lunch- BBQ brisket, potato salad, fried okra, sliced bread, vanilla [NAME] dessert, and a drink. Tuesday Dinner-Pork stir fry, fried rice, honey soy glazed carrots, egg roll, mandarin oranges, and a fortune cookie. Wednesday lunch meal- Smothered chicken, fluffy rice, zucchini and tomatoes, dinner roll, milk, and summer fruit cup. 676157 Page 20 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The DM then provided and reviewed a different handwritten list of his own meals, stating this was the menu he was serving the residents. The DM stated he just moved the meals around and was still serving the correct meals. He stated the Dietician knew he was doing this and had no problem with his changing the menu around. He stated he does this based on what food he has in stock so he can use up the food he has and therefor save on costs for ordering food. The DM stated he had saved the facility a lot of money by doing this. He stated the budget was his big concern. The DM stated he was serving BBQ Brisket for lunch on Monday 3/4/24 (today) at lunch and he planned to serve Brisket leftovers for the evening dinner meal on Tuesday 3/5/24 night as a BBQ sandwich. The DM stated he does put leftover rice into soups to make them go farther. The DM stated he did not give residents anything if it was not on the meal ticket. He stated he had spoken to the Speech Therapist about what residents can eat. He stated he had not spoken to the MD about what residents could eat. The DM hand written menu was listed as Monday lunch(3/4/24) - Beef brisket, baked potato, chef choice vegetable, (which was mixed vegetables), roll and a brownie. Tuesday lunch (3/5/24)- Pork/Chicken Tamales, Mexican rice, refried beans, and a churro. Tuesday Dinner- BBQ sandwiches (made from the beef brisket he served on3/4/24), coleslaw, fries, and ice cream. Wed lunch-(3/6/24) BBQ Chicken, loaded mashed potatoes, chef choice vegetables, roll and chocolate chip cookie. In an interview and observation of the lunch meal service on 3/4/24 at 11:45 am, a 4 oz scoop was placed on the serving line. When surveyor stated the 4-ounce scoop was too small for the food serving size, the DM stated it is a 4-ounce scoop and the residents will get two scoops to make an 8-ounce portion. Surveyor requested the recipes for review. The DM stated he would get it out later. In an observation and interview on 3/4/24 at 12:00 pm the resident meal trays going to hall D were plated with no hot rolls on the trays. This writer spoke to the ADM who stated she would take a basket of rolls to the hall and pass the rolls out. In a confidential interview on 3/4/24 at 12:23 pm a resident asked for chili for a hot dog. This writer asked the DM for chili for the hot dog. The DM stated there was no chili. He stated the menu listed a hot dog not a chili dog for the alternate. In an interview on 3/5/24 at 8:40 am the Dietician stated she is aware the DM was not following the menu and stated the DM does not substitute but rotates what is on the menu already. She stated this was ok. The dietician stated the DM gives her a handwritten weekly menu based on what he had served for the week. When asked about the dissatisfaction voiced by the residents about rice and potatoes at every meal, she stated she was aware of the complaints, and this was a new menu rotation so she hoped there would be less complaints, but it was too early to tell yet. The Dietician acknowledged the DM was trying to save money on meals for the residents. The dietician stated she was aware of the other conditions in the kitchen such as serving sizes being too small and had spoken to the DM in the past. In a Resident Council Interview on 3/5/24 at 1:30 pm, revealed seventeen confidential group members announced during the group interview that they wanted to talk about the issues with the food and 676157 Page 21 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dining services. A member of the group stated the food issues have been talked about in past council meetings and have not been resolved. All the residents agreed to this and the group members began discussing different issues with the food. The residents stated that the Dietary Manager has been told about the concerns with the food and nothing has changed. The group said the meals have potatoes or rice at every meal. The Dietary Manager puts leftover rice in everything to save money and make the food go farther. The facility serves the same vegetables at each meal. Confidential group members also stated the menu is not followed and they never know what will be served daily. Most of the meals do not taste good. Other comments were food here sucks; portions are too small; chili bowl is too small; enchiladas in soup instead of [NAME] chicken; eggs are cooked too hard; hard time getting breakfast early if they have an appointment; get too much rice; rice for 7 days straight; shows up in soup the next day; too much coleslaw as well; veterans ate rice the whole time they were deployed; don't want rice anymore; 5 year contract for kitchen manager; what they have on the menu doesn't get served. In an interview on 3/5/24 at 3:45 pm the ADM stated the residents should get what they want to eat as well as seconds if requested. If the residents, ask for something she expected the resident to get it. The ADM stated she expected the DM to accommodate the residents' requests. The ADM stated she was aware the DM is more concerned with the budget than with the resident requests and needs. In an interview on 3/6/24 at 8:45 am the Activity Director (AD) stated she also assists residents with the Food Committee which is a resident driven meeting like resident Council where the residents discuss food issues and present the findings to the Land Board Manager. She stated eleven residents attend the meetings and have has complaints since January about the food. She stated the residents have complained about too much rice, that mixed vegetables are served more than other vegetables, and there are too many potatoes. The AD stated she does a grievance report about the resident concerns after each meeting, and it was given to the Land Board Manager ( an employee of the Vetrans Land Board ( A person who is stationed in the facility as a representative for the residents) who makes sure the results are sent to the appropriate department. In a confidential employee interview on 3/6/24 at 10:10 am a group of employees stated the residents do not get seconds on anything. The staff is not allowed to ask for anything without a tray ticket. If it is not on the tray ticket the residents cannot have it. All employees agreed this happens with all residents daily. The employees stated the residents should get what thy want. Another employee stated the residents on a pureed diet only get a pudding with their pureed meals every day. The only reason they got a brownie on Monday was because the State was here. The residents on pureed diets would eat the cookies or brownies if they were served it. All employees agreed the rice is served almost daily. A lot of the residents were only served rice to eat for months. Some of the residents are triggered by getting rice at meals because it reminds them of the war when that was all they had to eat for months at a time. One employee stated there are people on diets that are supposed to get gravy on the food. The employees stated there is never gravy on the food. Especially on the pureed meals. Another employee stated all the residents like oatmeal in the mornings and it should be put on everyone's trays, but it is not. The employees stated when they ask for oatmeal at a resident request, they are told they cannot have it. When the residents ask for extra the DM states the kitchen does not cook enough and when the meal is over the kitchen staff eat the food. The employee's stated management is aware of these issues but does not do anything about it. In a confidential interview on 3/6/24 at 11:00 am one employee from the kitchen stated the residents do get rice at every meal and the employee has heard the residents complain about being served 676157 Page 22 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0803 Level of Harm - Minimal harm or potential for actual harm potatoes and rice at each meal. The employee stated the DM knows the residents are upset about the food and ignores the complaints. The employee stated the residents should get what they want to eat, and they do not get it. The employee stated the DM is more concerned with saving money on the budget he will not serve what is required for a resident to have a nutritionally adequate meal. The employee stated every day an employee will ask for a food item for a resident and the DM will say no, the resident cannot have it. Residents Affected - Few In an interview on 3/6/24 at 11:30 am, the Land Board Manager stated she is aware of the resident complaints about the food. She stated she has spoken to the ADM about these issues. She stated the residents have told her they do not want the rice served as much. The Land Board Manager stated these residents have fought in the wars and have been served rice for months at a time. She stated some residents have post-traumatic stress over rice being served. She stated the residents have complained that their requests for extra portions were denied and the requests for a different menu go unresolved. She stated she was aware the DM was adding leftover rice to the soups to make it go farther and that the DM used the leftover brisket for sandwiches on 3/5/24. The Land Board Manager stated she is aware the DM has told the facility staff he is more concerned with the budget and has saved the facility a lot of money. In an observation of the meal service on 3/6/24 at 12:02 pm, revealed 3 residents with pureed meals were not served pureed bread or a pureed cookie. The pureed potatoes were regular mashed potatoes and not loaded mashed potatoes as the menu indicated. The scoop size of the mashed potatoes was a 4-ounce size. There was no butter, sour cream, bacon bits or cheese served with the meal. The scoop size of the BBQ chicken and mixed vegetables was a 4 oz scoop size. There were no double scoops on the resident's plates. In an observation of lunch in the dining room on 3/6/24 at 12:05 pm revealed the residents with regular diets were served I piece of chicken with BBQ sauce, a roll, mixed vegetables, 1 small cookie and regular mashed potatoes. The mixed vegetables were the same type of mixed vegetables that were served on 3/4/24. There were no butter, sour cream, or bacon bits served with the meal. In an interview on 3/6/24 at 12:30 pm, one resident asked this writer for gravy for his potatoes. This writer asked [NAME] A if all residents had been served to which he said yes. This writer asked for gravy for a resident. [NAME] A stated No, I don't have any gravy. It's BBQ Chicken today. We did not make gravy. This writer stated a resident was asking for gravy for the potatoes. [NAME] A shrugged his shoulders and turned away. There was no move made to get the residents any gravy. In a confidential interview on 3/6/24 at 12:32 pm one employee stated 2 of the 3 residents with pureed meals would eat everything they were given but they rarely get bread or dessert. The employee stated the only reason two of the residents with pureed meals got the brownie on Monday 3/4/24 was because State was in the building. The employee stated she has asked the kitchen staff for extra food for the residents but is always told no, the residents cannot have extra. The employee stated one resident who gets a pureed meal will squeeze a hand if he wants to say yes. The employee asked the resident if he wanted a cookie, and he squeezed her hand yes. The DM was asked for a pureed cookie. The DM stated if it is not on the tray ticket the resident could not have it. In an interview on 3/6/24 at 1:25 pm the MD stated the residents in the facility can have what they want foodwise. He stated if the residents ask for something foodwise they should get it. In an interview on 3/6/24 at 2:30 pm, the DM denied he was aware of the complaints about the food. 676157 Page 23 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The DM stated the resident's had not complained to him about having too much rice served. The DM was told the residents had complained in Resident Council and in the Food Committee about having been served rice in the war and did not want rice so much. The DM stated he had not seen the complaints and was not aware of any complaints with the food. The DM stated he was not aware of the complaints with the taste of the food. The DM stated the residents could not have anything extra if it was not on the resident's meal ticket. The DM stated of the rolls not being on the trays for Hallway 8 that the staff must have just missed it. When the DM was told the residents with pureed meals did not get bread or dessert, he stated the staff must have just missed it. The DM was asked about the consequences of residents not getting all foods listed on the menu. The DM just looked at this writer. The DM had to be prompted to answer weight loss, hunger and dissatisfaction with meals could be a concern. Record Review of the menus from Menu Management did not list potion sizes on the menu. Recipes for the week's meals were requested on 3/4/24, 3/5/24, and 3/6/24 during the survey but were never furnished. Record review of the resident tray tickets revealed there was no listing of foods for the meals they received on that date and no portion sizes were listed. Some tray tickets only listed standing orders and dislikes. There were no facility policies on portion sizes. 676157 Page 24 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure general sanitary conditions in the kitchen were maintained during preparation and serving of food. 2. The facility failed to ensure hairnets and beard covers were worn. 3. The facility failed to ensure the food items were properly stored, labeled, and dated. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings include: In an interview and observation on 3/4/24 at 8:15 am [NAME] A was observed in the kitchen preparing food with no beard cover. [NAME] A stated, Yes, I should have a beard cover on. I just did not grab one. My bad. In an interview and observation on 3/4/24 at 8:17 am, the DM was observed in the kitchen prep area with no beard cover over his beard and moustache. The DM stated, It is not a beard. It is just a 2-day growth. Observation of the freezer on 3/4/24 at 8:20 am revealed the following: 1. (1) plastic bag of biscuits, no label or date, not in original box. 2. (1) brown bag of food, no label or date, not in original box, sitting on top of a box of frozen potatoes. Observation of the walk-in cooler on 3/4/23 at 8:21 am revealed the following: 1. An opened package of turkey ham lunchmeat, no date. Observation of the kitchen prep area on 3/4/24 at 8:22 am revealed the following: 1. The front and sides of the fryer had food splatters and food debris on the sides of the fryer. 676157 Page 25 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0812 There was a pool of grease in the corner of a tray covering the fryer oil. Level of Harm - Minimal harm or potential for actual harm 2. Residents Affected - Many There were 7 cups of orange drink sitting under a cabinet on a tray in the kitchen prep area. The drinks had no lid or covering. The drink glasses were warm to the touch. The drinks were not sitting in any ice. [NAME] C stated the drinks were for lunch. In an interview and observation on 3/4/24 at 10:40 am, the DM was observed in the kitchen prep area with no beard cover. The DM was observed to have shaved off his beard but still had a moustache. The DM stated he had shaved off his beard, so he did not have to wear a beard cover. The DM stated he did not need a beard cover with just a moustache. The DM made no move to get a beard cover to cover his moustache. In an interview and observation on 3/4/24 at 10:50 am, [NAME] A was observed in the kitchen prep area cutting meat with gloved hands. [NAME] A touched the counter of the prep table and the cutting board. [NAME] A picked up a pan of meat and moved the two pans of the meat from one place to another with both hands. [NAME] A picked up the knife and cut more meat using his right hand to hold the knife and his left hand to hold the meat. When [NAME] A transferred the cut meat into the pan from the cutting board, he used his left gloved hand to move the meat to the pan. [NAME] A continued to pick up the meat with his gloved hand and continue to cut more meat. [NAME] A did not wash his hands or change his gloves. [NAME] A stated he should have washed his hands and changed his gloves. [NAME] A stated time was running out and he had to get the meat cut. In an interview and observation on 3/4/24 at 10:55 am, [NAME] B was observed in the kitchen prep area with gloved hands. [NAME] B was observed touching the baked potatoes while cutting slits in the baked potatoes that were on a sheet pan. [NAME] B touched the counter with both gloved hands. [NAME] B opened the door of the warmer and took out a second pan of baked potatoes covered with foil. [NAME] B put the second pan of potatoes on the counter and turned around to close the warmer door. [NAME] B moved the pan of potatoes on the counter back from the edge of the counter with both hands. [NAME] B removed the foil and picked up the potatoes on the sheet pan one by one, squeezing the potatoes open, before then placing the potatoes in the second pan. When the second pan was full [NAME] B took the palm of his hand and pushed the top potatoes into the pan, replaced the foil and opened the door to the warmer. [NAME] B picked up the pan of potatoes and put the potatoes into the oven and shut the door. [NAME] B did not wash his hands or change his gloves. [NAME] B stated he did not realize he had touched other surfaces and should have changes his gloves. In an interview and observation on 3/4/24 at 11:07 am, [NAME] C was observed in the kitchen prep area with the front half of her hair and the sides of her hair not being covered by the hair. [NAME] C stated she should have all her hair covered. She stated it slipped off. In an observation on 3/4/24 at 11:30 am, the DM was observed in the kitchen at the prep table with gloved hands touching the kitchen surfaces, the prep table, and a pan of mashed potatoes. The DM opened several small plastic packages of sour cream and squeezed the sour cream into the potatoes. The DM picked up a package of shredded cheese, pulled open the top of the cheese package and reached into the package of cheese with his gloved hand. The DM dropped the handful of cheese into the pan of potatoes. The DM put his hand into the cheese package and pulled out a second handful of cheese and dropped the cheese into the potatoes. The DM did not change his gloves or wash his hands. 676157 Page 26 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many In an observation on 3/4/24 at 11:41 am, the DM was observed in the kitchen at the noon meal making grilled cheese sandwiches on the grill. The DM was observed touching various kitchen surfaces in the kitchen then using his hand to turn the sandwiches over on the grill. The DM picked up a utensil in one hand and turned the sandwiches over using one hand to assist in the turning of the sandwich. The DM put the utensil down and picked up a pan of melted butter and poured butter onto the grill. The DM picked up the utensil and continued to use his gloved hand to turn the sandwiches over. In an interview and observation on 3/4/24 at 12:03 am, [NAME] B was observed in the kitchen serving the noon meal. [NAME] B picked up a plate, then picked up a serving utensil and placed the meat on the plate. [NAME] B put the serving utensil down and picked up a baked potato with his gloved hands and placed the potato on the plate. [NAME] B plated the rest of the foods then set the plate on the tray. [NAME] B then picked up a plate and a serving utensil. [NAME] B put meat on the plate then picked up a baked potato with his gloved hand. This occurred with three plates of food. [NAME] B did not change his gloves or wash his hands. [NAME] B stated he did not realize he did that, and he should have used tongs for the potatoes. In an interview and observation on 3/4/24 at 12:05 am, [NAME] D was observed in the kitchen serving area with gloved hands. [NAME] D was observed touching the bars of the serving tray line, the hot food rolling carts and the food trays. [NAME] D touched a tray, picked up a container of cheese, placed the container on the tray then picked up a roll with her gloved hand and placed the roll on the tray. [NAME] D carried the tray to the food cart opened the cart door placed the food tray into the cart then closed the door. [NAME] D returned to the serving line, picked up a container of cheese and put the cheese on the tray. [NAME] D picked up a roll and placed it on the plate. [NAME] D picked up the tray and put the tray in the cart. [NAME] D returned to the line and picked up a container of cheese placed it on the tray and picked up a roll with her gloved hand. [NAME] D did not change her gloves or wash her hands. [NAME] D stated, I have gloves on. Cook D stated she should have used tongs to touch the bread. The residents could get cross contamination. Observations of the kitchen freezer and walk in cooler on 3/5/24 at 10:30 AM revealed the brown bag of frozen food, the biscuits in the freezer and the lunchmeat in the walk-in cooler were still unlabeled and undated. In an interview and observation on 3/5/24 at 10:42 am, [NAME] E was observed in the kitchen prep area with no hair net and no beard cover. [NAME] E stated he had just forgotten to put the hair net and beard cover on. [NAME] E stated he was aware he was to wear the hairnet and beard cover so he would not cause cross contamination. In an interview on 3/7/24 at 2:32 pm, the DM stated of the issues in the kitchen with unlabeled and undated food the employees must have just missed those items and all food items should be labeled and dated. The DM stated he expects all staff to be cleaning daily. The DM stated he does spot checks for cleaning on a regular basis. When asked who trains the staff on the kitchen issues and cleaning practices, the DM stated he does the training. The DM stated he has already given the staff an in-service on hairnets and beard covers and labeling and dating food. The DM stated food borne illnesses and unsanitary surfaces are a consequence of not cleaning the kitchen,and not changing gloves and could make residents sick. He stated residents could get sick from the hairnets and beard covers not being worn. Record Review of the policy dated October 2018 titled Employee Sanitation documented: 676157 Page 27 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0812 Level of Harm - Minimal harm or potential for actual harm Hairnets, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food contact surfaces. Employees must wash hands and exposed portions of their arms before engaging in food preparation including working with exposed food, clean equipment and utensils and unwrapping single service and single use foods . when switching between working with raw food and working with ready to eat foods, during food preparation including working with exposed food, clean equipment, and utensils. Residents Affected - Many Gloves are not a substitute for thorough and frequent hand washing. When using gloves, always wash hands before touching or putting on new gloves. Use single use gloves for one task. Change gloves between each food preparation task, after touching items, utensils or equipment not related to task, when leaving the food prep area for any reason, when damaged soiled or when interrupted, every hour for all tasks taking longer than one hour. Do not store gloves in pockets or apron. Record Review of the policy dated October 2018 titled General Kitchen Sanitation documented: Keep food contact surfaces of all cooking equipment free of encrusted grease deposits and other accumulated soil. Clean all non-foods contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt food particles and otherwise in a clean and sanitary manner. Record Review of the policy dated June 2019 titled Food Storage documented: All containers must be labeled and dated. Date label and seal all refrigerated food. Store frozen food in moisture proof wrap or containers that are labeled and dated. Record Review of the policy dated October 2018 titled Food Holding and Service documented: Take cold foods from the refrigerator only as needed. Keep foods covered to maintain temperature. Rapidly cool all foods requiring refrigeration after preparation by placing food in 2-inch-deep pans and chill for 2 hours. Record Review of the policy dated June 2019 titled Food Holding and Service documented: Take cold foods items from the refrigerator only as needed. Ice down Record Review of the policy dated October 2018 titled Handwashing documented: Hands should be washed after the following occurrences: handling raw food, touching un-sanitized equipment, work surfaces . 676157 Page 28 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 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 to help prevent the development and transmission of communication diseases and infections. Residents Affected - Few -MH failed to use proper hand hygiene techniques when preparing a beverage for himself in the dining area. -CNA L failed to use proper hand hygiene techniques when assisting 2 unidentified residents to eat during lunch meal service. These failures had the potential to affect all residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases. Findings included: During an observation on 03/04/24 at 11:50 AM revealed MH walking into the dining area with gloves on into the beverage preparation area of the dining area and obtaining a drink for himself. MH did not take off his gloves while doing this activity and then took the beverage with gloves still on and left the dining area. Hand hygiene was never performed. During an interview on 03/04/24 at 03:01 PM Maintenance Supervisor regarding MH not performing HH or removing gloves before obtaining a beverage for himself. Maintenance Supervisor stated that he has already spoken to MH and that what he did was a huge No! No! Big time and to never do it again. Maintenance Supervisor stated that a negative outcome would be, a huge infection control issue. During and observation on 03/05/24 at 12:31 PM revealed CNA L feeding 2 different unidentified residents at lunch service in the dining room. CNA L did not perform hand hygiene in between feeding the 2 separate unidentified residents. During an interview on 03/05/24 at 12:36 pm CNA L was asked why hand hygiene was not performed in between each resident. CNA L stated, I thought about that when I sat down to feed them. CNA L was asked about a negative outcome, she stated that it would be cross-contamination. During an interview on 03/05/24 at 02:11 PM MH stated that he knows what he did wrong and was asked what a negative outcome would be, MH stated, You can spread diseases and germs everywhere. During an interview on 03/06/24 at 02:24pm DON stated that by staff not performing HH it could lead to a negative outcome of cross contamination between residents. Record Review of facility provided policy Infection Prevention and Control Program, dated Revised August 2016, revealed, .2. Policies and Procedures a. 676157 Page 29 of 30 676157 03/22/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0880 Policies and procedures are utilized as the standards of the infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm b. Residents Affected - Few The infection prevention and control committee, Medical Director, Director of Nursing Services, and other key clinical and administrative staff review the infection control policies at least annually. The review will include: (1). Updating and supplementing policies and procedures as needed; (2.). Assessment of staff compliance with existing policies and regulations; and (3). Any trends or significant problems since the previous review. No hand hygiene policy was provided by facility. 676157 Page 30 of 30