Health inspection·March 29, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the Administrator for one (Resident #1) of eight residents reviewed for abuse. The facility failed to ensure LVN A immediately reported an allegation of abuse, on 03/12/24, when Resident #1 stated he did not want to work with his overnight staff because they were rude to him, to the Administrator (Abuse Coordinator). This failure could place residents at risk of emotional, physical, and mental abuse. findings included: Record review of Resident #1's face sheet, printed on 03/27/24, revealed Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] with acute systolic congestive heart failure, muscle weakness, chronic obstructive pulmonary disease (restricted airflow and breathing problems), essential hypertension(normally high blood pressure), paroxysmal atrial fibrillation(quivering or irregular heartbeat, or arrhythmia), irritable bowel syndrome, gastroesophageal reflux(stomach acid repeatedly flows back into the tube connecting the mouth and stomach), and constipation. Record review of Resident #1's admission MDS assessment, dated 03/13/24, reflected Resident #1 had a BIMS of 15, which indicated Resident #1 was cognitively intact. Section GG -Functional Abilities and Goals indicated Resident #1 required substantial physical assistance with ADLs of toileting, bathing, dressing, and required moderate physical assistance with ADLs of personal hygiene. In an interview on 03/27/24 at 5:05 PM, LVN A stated he last worked with Resident #1 on the 2:00 PM to 10:00 PM shift on 03/12/24. LVN A stated while he provided toileting assistance to Resident #1 towards the end of that shift, Resident #1 asked him if he would be his night nurse. LVN A stated he notified Resident #1 that he would not be his night nurse and Resident #1 told him, he wish he were because he did not want to work with his night staff because they were rude to him. LVN A stated Resident #1 did not specify what happened or the staff involved , so he asked the oncoming nurse (LVN B), if anything had transpired the night prior and she stated nothing had happened. LVN A stated he told LVN B to call him if he was needed and went to his hall for the 10:00 PM to 6:00 AM shift. LVN A stated he did not report the conversation he had with Resident #1 because he notified his assigned nurse, LVN B, and figured she would report the statement to the administrator. In an interview on 03/27/24 at 5:30 PM, the Administrator stated she was unaware of the statement Page 1 of 4 676317 676317 03/29/2024 The Harrison at Heritage 4600 Heritage Trace Parkway Fort Worth, TX 76244

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #1 made to LVN A on 03/12/24. The Administrator stated LVN A should have immediately notified her of the statement made by Resident #1, as it was the responsibility of all staff to report allegations of abuse. The Administrator stated not appropriately reporting allegations of abuse could cause uncertainty for the resident, as they would believe their reports would go unaddressed. The Administrator stated she did not receive any complaints from Resident #1 or his family regarding staff behavior. The Administrator stated she h ad not received any complaints or grievances regarding any rude staff members. The Administrator states she would begin an in-service on abuse, neglect and reporting. An interview with Resident #1 was attempted at a local hospital on [DATE] at 2:43 p.m. but was unsuccessful. In an interview on 03/28/24 at 2:55 PM, LVN B stated she was Resident #1's assigned night nurse on 03/12/24. LVN B stated LVN A asked her if anything happened between her and Resident #1 the night prior, but LVN A did not state why he asked her that. LVN B stated Resident #1 had never reported any rude staff behavior to her nor did she recall being rude to Resident #1. Telephone interviews were attempted with CNA C, CNA D, CNA E and CNA F (all aides on the night shift for 03/11/24 and 03/12/24) on 03/28/24 from 3:00 PM to 3:30 PM but were unsuccessful. In an interview on 03/28/24 at 4:46 PM, the DON stated she was unaware of the statement Resident #1 stated to LVN A on 03/12/24. The DON stated it was the facility's expectation for all allegations of abuse be reported immediately to herself and the facility's Abuse Coordinator, who was the Administrator. The DON stated all facility staff were responsible for reporting allegations of abuse. The DON stated she had not received a complaint regarding staff behaviors from Resident #1 or his family. The DON stated not reporting allegations of abuse could keep residents near the alleged abuse. The DON stated she would begin to in-service facility staff on abuse and neglect reporting and dignity. In a follow-up interview on 03/28/24 at 5:15 PM, the Administrator stated LVN A was suspended pending the investigation and she had reported the incident to the State Agency. Record review of the facility's policy entitled Abuse Prohibition Protocol, dated April 2019, read in part: 1. The patient has the right to be free from abuse, neglect, mistreatment of resident property, and exploitation .8. Any person observing an incident of patient abuse or suspecting patient abuse must immediately report such incidents to the Charge Nurse or Abuse Coordinator . 676317 Page 2 of 4 676317 03/29/2024 The Harrison at Heritage 4600 Heritage Trace Parkway Fort Worth, TX 76244

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide residents who were unable to carry out activities of daily living with the necessary services to maintain grooming and personal hygiene for one (Residents #2) of eight residents reviewed for facial hair. Residents Affected - Few The facility failed to remove Resident #2's facial hair. This failure could place residents at risk for social isolation, loss of dignity, and self-worth. Findings included: Record review of Resident #2's indicated face sheet indicated Resident #2 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of influenza, Poly osteoarthritis, hypothyroidism, transient visual loss, age related choroidal atrophy, peripheral vascular disease, and hypertension. Record review of Resident #2's Annual MDS assessment, dated 04/12/23, revealed Resident #2 had a BIMS of 11, which indicated Resident #2 had moderate cognitive impairment. Section GG - Functional Abilities and Goals, Question GG0130. Self-Care revealed Resident #2 required moderate assistance with ADLs of oral hygiene, bathing, dressing, personal hygiene and required substantial assistance with the ADL of toileting. Record review of Resident #2's care plan, effective 04/13/22, indicated the following: Problems: [Resident #2's] ADL functions: Bed Mobility Extensive x2 Transfers Extensive x2. Dressing Extensive x2 Eating Supervision Toileting Extensive x2 Bathing Extensive x1 Uses WC for mobility. 5/2/2023 Transfers Extensive x2 Toileting Limited x1 . Interventions: Encourage independence, praise when attempts are made. Assist with ADL's as needed . In an interview and observation on 03/27/24 at 2:37 PM, Resident #2 stated she was well and 676317 Page 3 of 4 676317 03/29/2024 The Harrison at Heritage 4600 Heritage Trace Parkway Fort Worth, TX 76244

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility staff treated her well. Resident #2 was observed sitting in a recliner in her room with several white hairs on her chin, roughly .25 inches in length. Resident #2 stated she would like to her have hairs shaven and could not recall the last time someone asked if she would like to be shaved. She stated she had tried to get a nurse to cut her facial hair and nails but had not been successful. On 03/27/24 at 2:39 PM, the surveyor notified LVN G that Resident #2 had facial hair that she would like shaved. LVN G stated she was uncertain of where Resident #2's aide or nurse was, but she would ensure Resident #2's chin was shaved. LVN G was observed to ask Resident #2 if she wanted her chin hairs shaved. Resident #2 agreed and LVN G shaved her chin. In an interview on 03/27/24 at 4:32 PM, RA H stated she was the restorative aide for the facility. RA H stated her responsibilities included providing showers to residents, assisting with grooming and whatever was needed on the floor during her shift. RA H stated Resident #2's family member would normally visit her and pluck her chin hairs, but she believed she had not visited recently to pluck them. RA H stated she was unaware that Resident #2 was observed with long chin hairs and stated she would ask Resident #2 if she would like her chin shaved. In an interview on 03/27/24 at 5:05 PM, LVN A stated he was the 2:00 PM to 10:00 PM nurse for Resident #2. LVN A stated it was expected for nursing staff to groom residents daily; including shaving residents. LVN A stated he did not recognize the facial hair on Resident #2's chin. LVN A stated it was the responsibility of the aides and nurses to ensure residents were groomed to their liking. LVN A stated not being groomed could affect residents' self-image. In an interview on 03/27/24 at 5:30 PM, the Administrator stated she was unaware of the facial hair observed on Resident #2's chin. The Administrator stated it was the facility's expectation for residents to be groomed during showers and daily as needed. The Administrator stated women having facial hair could be a dignity issue. The Administrator stated she would begin to in-service staff on ADLs, grooming and dignity, and she would have facility management staff to do ADL checks to ensure all grooming was provided as needed. Record review of the facility's policy entitled Activities of Daily Living, dated May 2016, read in part: 1. Every effort must be made to assure that assignments of nurses and nurse aides to patients are as consistent possible . 676317 Page 4 of 4