Health inspection·January 27, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety 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 interview and record review, the facility failed to ensure all residents were free from abuse for one (Resident #1) of four residents reviewed for abuse. Residents Affected - Few The facility failed to keep Resident #1 safe from being yelled at, humiliated, and being denied care by CNA B. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/24/2025 at 5:42 PM . While the IJ was removed on 01/25/2025 at 2:45 PM, the facility remained out of compliance at a level 2 of no actual harm at a scope of isolated that was no immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of abuse, injury and psychosocial harm. Findings included: Review of Resident #1's face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnoses of multiple sclerosis (a chronic autoimmune disease that affects the central nervous system, which includes the brain and spinal cord), muscle wasting and atrophy (loss of muscle mass and strength), other reduced mobility (a situation where someone has difficulty moving around due to a condition), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), and unspecified lack of coordination (difficulty with movement coordination where the exact cause is not identified). Review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 required partial/moderate assistance (staff does less than half the effort, holds supports trunk or limbs) with shower/bathing, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. Further review reflected Resident #1 usually required partial/moderate assistance with chair to bed/bed to chair transfers, toilet transfers, sit to stand and lying to sitting on edge of bed. Review of quarterly MDS reflected no BIMS was conducted. Review of Resident #1's care plan dated 07/22/2023 revealed resident had multiple sclerosis. Her goals included: resident will maintain optimal status and quality of life within limitations imposed by disease processed. Resident #1 had an ADL self-care performance deficit related to multiple sclerosis and weakness, interventions included that toilet use and transfers required staff participation. Further review of Resident #1's care plan revealed Resident #1 was a risk for falls related to weakness and interventions included: encourage use of call light for assistance as needed. Page 1 of 7 676220 676220 01/27/2025 Granite Mesa Health Center 1401 Max Copeland Dr Marble Falls, TX 78654

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview on 01/24/2025 at 12:15 PM, Resident #1 stated that she had a grievance with CNA B last month. She stated she still had issues with CNA B. Resident #1 stated that CNA B worked nights and yelled at her. She stated that it made her really uncomfortable when she had to wait and see if CNA B was going to be on shift for the evening. Resident #1 stated that usually she was able to do most transfers by herself but by the evening she got tired and needed help. Resident #1 stated that CNA B came into her room and yelled at her and told Resident #1 you can do it (transfer) yourself, you do not need help. Resident #1 started a few weeks ago and CNA B refused to help her go to the bathroom. Resident #1 stated that she ended up having an accident in her brief and that CNA B did not transfer her to the toilet. Resident #1 stated that another time CNA B yelled over her while she was laying in bed to another CNA that Resident #1 did not need help and could do it herself. Resident #1 stated that she told the ED about her concerns a few weeks ago. Resident #1 stated that she told ED that CNA B yelled at her, but she was unsure what the outcome was. Resident #1 stated that ED told her he had to do his due diligence regarding the concerns. Resident #1 stated she was not sure what due diligence meant. Resident #1 stated she did not think she should continue getting yelled at. Resident #1 stated she recently told ED again about her continued issues with CNA B still bullying her, and she asked him if he had done his due diligence and , she felt the ED brushed her off and laughed after she spoke with him. Resident #1 stated that CNA B made her feel bad about herself because she could not do everything by herself and needed help. Resident #1 stated that CNA B made her feel bad about her diagnoses. Resident #1 stated she should be able to do things by herself, but she could not all the time and gets tired. Resident #1 stated that she liked to try to be independent. Resident #1 stated she got nervous when CNA B worked because she knew she would have to strain herself by transferring herself without help. During an interview on 01/24/2025 at 1:22 PM, Resident #1 stated that she also told CNA C that CNA B yelled at her, and CNA C told Resident #1 that was not right. Resident #1 stated she told ED time was up and asked if he had done his due diligence, and it was not right for her to continue to get bullied. Resident #1 stated she also told CNA C her concerns the other day and he told her that no residents on the hall like CNA B. During an interview on 01/24/2025 at 12:40 PM, SW stated that she did not follow up with Resident #1 after her grievance in December, and that she probably should have made sure everything was okay. SW stated she had not received any additional complaints regarding CNA B. During an interview on 01/24/2025 at 1:22 PM, Resident #1's FM stated that she did not believe Resident #1 should have had to put up with being bullied in her own home and wanted the issues with CNA B to be addressed. During an interview on 01/24/2025 at 1:25 PM, RN A stated that she had witnessed CNA B talking down to residents multiple times. RN A stated that she talked with ED about her concerns and she felt CNA B retaliated and refused to talk with RN A for the rest of the shift or help with resident care. RN A stated that she received complaints at least every shift about CNA B. RN A stated CNA B refused to assist Resident #1, and Resident #1 could perform that care herself. RN A stated that Resident #1 often felt talked down to because she could not always transfer t on her own. RN A stated that generally CNA B would tell residents with dementia you do not have a clue what is going on. RN A stated CNA B also yelled down the hall for staff not to help another resident because she did not do anything by herself. RN A stated that she also was not able to find CNA B during their shift, and CNA B would often be on her phone during her shift. During an interview on 01/24/2025 at 2:00 PM, ED stated that he did not remember the day or time 676220 Page 2 of 7 676220 01/27/2025 Granite Mesa Health Center 1401 Max Copeland Dr Marble Falls, TX 78654

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few regarding Resident #1's grievance. ED stated that Resident #1's grievance was that CNA B's interactions were less courteous than Resident #1 liked. ED stated that he did customer service training with CNA B and reminded her of his expectations to be courteous and answer call lights timely. ED stated CNA B was surprised and stated all the residents love me, I will be more courteous. ED stated Resident #1 had an additional concern this month (January 2025) that Resident #1 had continued customer services concerns. ED stated Resident #1 had concerns that CNA B was not very polite and did no answer call light as quickly as Resident #1 had liked. ED stated that Resident #1 did not tell him that CNA B yelled at her or refused to provide care for her. ED stated RN A did bring up concerns to him regarding CNA B on 1/15/2025. ED stated that RN A was concerned that she could not find CNA B while she was on her shift and that CNA B was on her phone. ED stated that RN A did not let him know CNA B talked down to residents or refusing to provide care to Resident #1. ED stated he provided additional customer service training and reminded her again of expectations of interactions and customer service. During an interview on 01/24/2025 at 2:10 PM, CNA C stated that Resident #1 did not like CNA B. CNA C stated that when he worked with both, CNA B and Resident #1, he provided the care for Resident #1 because CNA B and Resident #1 did not get along. CNA C stated that he believed Resident #1 and CNA B had personality differences. CNA C denied Resident #1 telling him that CNA B yelled at her. During an interview on 01/24/2025 at 2:53 PM, CNA D stated that Resident #1 may need more assistance with transfers after exercise or bathing, but other than that she could usually do transfers herself. CNA D stated some tasks made Resident #1 more tired and then she may ask for her help. During an interview on 01/24/2025 at 3:05 PM, DOR stated that Resident #1 sometimes needed increased assistance and when that occurred it was usually in the afternoon, but it was inconsistent. DOR stated that therapy educated Resident #1 to ask for assistance when she was more fatigued. During an interview on 01/24/2025 at 4:33 PM, CNA B stated she was familiar with Resident #1. She stated she usually went into Resident #1's room with another staff because Resident #1 made an allegation about her. CNA B stated that Resident #1 had stated CNA B was mean and that she did not like handicapped people. CNA B denied having ever raised her voice to Resident #1 or denying her care. CNA B denied telling Resident #1 she could transfer herself and that Resident #1 usually only wanted assistance with pulling up her brief or having it changed. CNA B stated she was not abusive to Resident #1, During an interview on 01/24/2025 at 4:38 PM, Resident #1 stated she felt CNA B's behavior toward her was abusive. Resident #1 appeared worried and asked if CNA B would be returning to the facility over the weekend. During an interview on 01/24/2025 at 5:35 PM, ED stated that CNA B was scheduled to work 01/26/2025 in the morning. Review of facility in-service dated 01/16/2025 reflected that all staff were in-serviced on Abuse and Neglect. Review of facility policy titled Abuse: Prevention of and Prohibition Against with revision date of 12/2023 reflected the following; Each resident has the right to be free from abuse, neglect and misappropriation of resident 676220 Page 3 of 7 676220 01/27/2025 Granite Mesa Health Center 1401 Max Copeland Dr Marble Falls, TX 78654

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few property, exploitation and mistreatment. Abuse is the willful infliction of intimidation or mental anguish and includes deprivation by a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Mental abuse includes, but is not limited to humiliation, harassment and threats or punishment or deprivation. Facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or her supervisor or facility administrator immediately. Some cases of abuse are not directly observed, understanding resident outcomes of abuse can assist in identifying whether abuse is occurring or has occurred; possible indicators could include sudden or unexplained changes in behavior or activities (fear of a person or place, feels of guilt or shame). The ED and DON were notified on 01/24/2025 at 5:42 PM that an IJ had been identified and an IJ template was provided and a POR was requested. The following POR was approved on 01/25/2024 at 11:57 AM and indicated: Plan of Removal Immediate Jeopardy On 1/24/25 an abbreviated survey was initiated at [facility]. On 1/24/25 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Threat states as follows: The facility needs to take immediate action in order to prevent psychosocial harm to other residents. Action: CNA B terminated. Start Date: 1/24/25 Responsible: ED Action: Medical Director notified of IJ Start Date: 1/24/25 Responsible: DON, ED Action: Train the trainer in-service given to ED and DON on Abuse. Start Date: 1/24/25 Responsible: Clinical Resource 676220 Page 4 of 7 676220 01/27/2025 Granite Mesa Health Center 1401 Max Copeland Dr Marble Falls, TX 78654

F 0600 Action: Safe surveys will be completed on all residents with a BIMS score 12 and higher. Level of Harm - Immediate jeopardy to resident health or safety Start Date: 1/24/25 Residents Affected - Few Responsible: ED/DON/Designee End Date: 1/24/25 Action: Training and knowledge skill checks completed with all staff regarding abuse/neglect who are at facility currently. Prior to any other staff working the floor they will be in-serviced on abuse/neglect. All staff will not be allowed to work until completing the training and knowledge checks. The training will also be included in new hire orientation. Staff training on abuse and neglect was completed by ED/ DON or designee by 1/25/25. Knowledge check completed. Start Date: 1/24/25 End Date: 1/25/25 Responsible: ED/DON/Designee Action: An Ad hoc QA meeting will be completed. Attendees will include ED, DON, ADON, Clinical Resource, and Medical Director. Meeting will include the Plan of Removal and interventions. Start Date: 1/24/25 End Date: 1/24/25 Responsible: ED/DON Action: ED or Designee will verify staff knowledge on abuse prevention with 10 staff weekly using the abuse and neglect knowledge checks. This will be completed weekly following the initial training and knowledge checks. Start Date: 1/26/25 End Date: 4/26/25 Responsible: ED/Designee Action: Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks beginning 1/24/25 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Start Date: 1/24/25 End Date: 5/26/2025 Responsible: ED/DON 676220 Page 5 of 7 676220 01/27/2025 Granite Mesa Health Center 1401 Max Copeland Dr Marble Falls, TX 78654

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Action: Resident #1 Licensed Social Worker reassessed resident. Resident feels safe and does not feel anxious. Start Date: 1/24/24 End Date: 1/24/25 @21:20 Residents Affected - Few Responsible: SW Action: Ombudsman will be notified of the IJ. Start Date: 1/25/25 End Date: 1/25/25 @9:45am Responsible: ED Surveyor monitored the POR on 01/25/2025 as followed: During an interview on 01/25/2025 at 11:45 AM, ED stated that he sent all the recommended changes to the PM that morning. ED stated Ombudsman was contacted 01/25/2025 at 9:45 AM about the incident. CNA B was terminated on 1-24-2025 by phone. ED stated SW reassessed Resident #1 on 01/24/2025 and 01/25/2025 and Resident #1 stated she felt safe. All staff that were in the building on 01/25/2025 have been trained on abuse and neglect. Staff were reached by phone and would have training prior to the start of their shift. New hires would be trained in orientation. No new policies were implemented, and no changes were made to existing polices. ED stated safe surveys were completed on 01/24/2025 for all residents with BIMS over 12 and this was conducted by DON. Clinical Resource provided training to ED and DON on abuse and neglect on 01/24/2025. ED, DON and assigned designee conducted trainings. AD Hoc QA meeting was completed on 01/24/2025 and will be done weekly until substantial compliance and continued monthly for 90 days. ED stated 10 staff weekly will be tested on their knowledge of abuse and neglect. Review of Alleged Perpetrator Termination notice reflected date of 01/24/2025. Review of abuse/neglect in-service conducted on 01/24/2025 and 01/25/2025 reflected all staff were in-serviced who were present at work and prior to beginning their shift. Review of resident safe surveys dated 01/24/2025 reflected no concerns with residents. Review of ad hoc QAPI sign-in sheet reflected meeting was completed 01/24/2025. During an interview on 01/25/2025 at 12:20 PM, Resident #1 appeared neat and well-groomed sitting in bed eating her lunch. The resident stated she was safe and very pleased that CNA B was no longer working in facility. Resident #1 stated she was very relieved and so was her FM that CNA B was no longer at the facility. Resident #1 stated that all the other staff were wonderful, and she did not have any issues or concerns, and she was very thankful that the situation had been resolved. 676220 Page 6 of 7 676220 01/27/2025 Granite Mesa Health Center 1401 Max Copeland Dr Marble Falls, TX 78654

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During interviews on 01/25/2025 between 12:20 PM and 2;40 PM, 5 CNAs, 1 MA, 1 NA, 1 LVN, 1 RN, DON, HSK, and DA stated they were aware of who to report any alleged abuse, to report immediately and provided examples of potential abuse. The ED was notified on 01/25/2025 at 2:45 PM that the IJ had been removed. While the IJ was removed, the facility remained out of compliance at a level of no actual harm that is not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. 676220 Page 7 of 7