Health inspection·September 8, 2023

F 0610 Respond appropriately to all alleged violations. 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 ensure that all alleged violations involving exploitation were thoroughly investigated and results reported of all investigations to the State Survey Agency, within 5 working days of the incident for 1 (Resident #49) of 5 residents reviewed for exploitation. Residents Affected - Few The facility Abuse Coordinator/Administrator failed to thoroughly investigate a reported allegation of exploitation of Resident #49 by CNA A. This failure could place residents at risk of exploitation. Findings included: Record review of Resident #49's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included spinal stenosis (lumbar and thoracic region), paraplegia, type 2 diabetes, hyperlipidemia, morbid (severe) obesity. Record review of Resident #49's Quarterly Minimum Data assessment dated [DATE], revealed Resident #49's Brief Interview for Mental Status score was 13 (cognitively intact). Resident #49 required extensive assistance for bed mobility, dressing, locomotion on/off unit, and personal hygiene. Record review of Resident #49's Comprehensive Care Plan initiated 06/26/23 revealed she had little, or no activity involvement related to immobility preferring to spend most of her time in her room. Observation of Resident #49 on 09/06/23 at 9:15 a.m., revealed Resident #49 was in her room lying in bed. She was awake, alert and in her own personal clothing. Room was clean and well lit. During an interview on 09/06/23 at 09:21 a.m., Resident #49 said sometime in 03/2023, while CNA A was in her room providing care, she complained about having money issues. Resident #49 said she does not remember the reason CNA A needed the money, but she said she offered to help with her with $40. Resident #49 said she told CNA A she could pay her back in payments and she agreed. Resident #49 said the next day CNA A paid her back $20. Resident #49 said she voluntarily loaned her the $40. out of the kindness of her heart. Resident #49 said after making 1 payment of $20. CNA A had not made any other payments until 2 months ago (did not remember the exact month or day) Resident #49 said CNA A sent the remaining $20. with another CNA (last name unknown). She said she had not told anyone of the loan she made to CNA A but had a strange feeling someone had recorded their conversation. Resident #49 said she did not have any ill feelings towards CNA A saying it was just money and wanted to help her out. Resident #49 said about two months ago, the administrator, the social worker and ADON 1 Page 1 of 10 676446 676446 09/08/2023 Mission Valley Nursing and Transitional Care 1200 S Bryan Rd Mission, TX 78572

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few went to her room to ask about the loan she had made to CNA A. Resident #49 said the administrator asked if it was true, she had loaned CNA A money and why. Resident #49 said the administrator told her she was not supposed to be lending staff money and told her not do it again. Resident #49 said she had not seen CNA A in two months because she was transferred to another hall. During an interview on 09/06/2023 at 1:30 p.m., CNA A said sometime in March 2023, while in Resident #49's room she noticed bottles of perfume on Resident #49's dresser. She said Resident #49 said her sister brought them and were for sale. CNA A told Resident #49 she was interested in buying two bottles of perfume for a total of $200. Resident #49 agreed and told her she could pay her back in payments. CNA A said she told Resident #49 she would make a $20.00 to $25.00 payment each time she got paid, so she agreed. CNA A said she kept her word and made bi-weekly payments until she paid off the entire balance (sometime in 06/2023). She said she would give Resident #49 the money for her to give to her sister. CNA A said sometime in 07/ 2023, Resident #49 told her she still owed her sister $60.00. CNA A said she told Resident #49 she had already paid her $200. She said Resident #49 insisted CNA A owed her money and that she was going to talk to her sister about it. CNA A said sometime in mid-August 2023 the administrator approached her and asked her if she owed Resident #49 money. CNA A said she told the administrator she had purchased two bottles of perfumes from Resident #49's sister back in 03/2023 but had already finished paying her back. CNA A said she told the administrator Resident #49 was saying she still owed her money but was not true. CNA A said she was counseled, in-serviced on resident rights and was moved to a different hall. CNA A said the administrator reminded her not to be buying anything from residents. CNA A said the administrator reminded her if she was offered a gift, it must be less than $25.00 and it must be shared with all staff. CNA A said the administrator told her she was going to conduct her own investigation into the matter. CNA A said 3 days after she was counseled, she asked the administrator what the outcome of her investigation was and was told by the administrator the investigation was complete and closed but did not give her any details. CNA A said has not had any contact with Resident #49 since August 2023. CNA A said she had been trained in resident rights when she was hired and said I made a mistake in buying the perfume bottles from Resident #49. She said, I learned my lesson and it was a big error on my part. CNA A said she did not feel she was doing anything wrong because she bought the perfumes from Resident #49's sister and not the resident. During an interview on 09/06/2023 at 2:00 p.m., Resident #49 was asked about the perfume bottles. She said her sister came to visit her and brought her one bottle of perfume. Resident #49 said her sister expected her to pay her back. She said she left the perfume bottle on her bedside table and when CNA A came into her room and asked if she was selling the perfume. Resident #49 said she told CNA A she would sell it to her for $120.00 and CNA A agreed to buy it from her. Resident #49 said she agreed to sell the bottle of perfume to CNA A because she did not have the money to pay her sister back. Resident #49 said CNA A paid her the $120.00 on her next payday (not sure of date). Resident #49 said the administrator wanted to make it seem like the money CNA A owed her was for the perfume, but it was not. Resident #49 said she loaned CNA A the $40.00 after she purchased and paid off the perfume. During an interview on 09/06/2023 at 2:07 p.m. The Social Worker said Resident #49 was saying something about a CNA I don't remember the name of the cna's name The Social Worker said the information received was third party and did not remember the details but said it was about money being owed to Resident #49. The Social Worker said during a care plan meeting The administrator, ADON 2 and himself met with Resident #49 to discuss the allegations. The social worker said it was not really care planned as the facility uses the word care plan loosely he said it was not an official care plan meeting they had but an informal meeting. The social worker though he had taken some 676446 Page 2 of 10 676446 09/08/2023 Mission Valley Nursing and Transitional Care 1200 S Bryan Rd Mission, TX 78572

F 0610 Level of Harm - Minimal harm or potential for actual harm notes regarding the meeting with Resident #49, after about 5 minutes, the social worker said he was not able to find any notes saying he must have forgotten take any notes. He said the administrator had done all the talking. The social worker said he does not speak Spanish and did not remember any details of the meeting but did say it was determined Resident #49 did not lend money to CNA A. Residents Affected - Few Interview on 09/06/2023 at 2:30 p.m., The administrator said she was approached by CNA B (former employee) that while she was providing care to Resident #49, she made an outcry about CNA A owing her money. The administrator said she immediately got together with, ADON 1, and the social worker all went to talk to Resident #49. The administrator said she asked, Resident #49, I understand you told CNA B, one of our CNA's (CNA A) owed you money (between $30.00-$60.00) The administrator said Resident #49's response was CNA A said she needed money, and I offered to help her out. The administrator said after meeting with Resident #49, she brought CNA A to her office and advised her there was an allegation of her owing money to a resident. The administrator said CNA A immediately asked, are talking about Resident #49. She said CNA A told her Resident #49's sister sells perfumes and had brought perfume bottles to Resident #49 for her to sell. She said CNA A confessed to buying 2 bottles and offered sell them to other CNA's at the facility. CNA A said she purchased 2 bottles and the transaction had taken place in Resident #49's room. The administrator said she got upset with CNA A and told her that could be considered exploitation/solicitation and said she would be conducting her own investigation into the matter. The administrator said she went back to Resident #49 and told her CNA A had said the money owed was for a perfume bottle and not a loan. She said the resident agreed. The administrator said she in-serviced CNA A on the topic of resident rights/solicitation and transferred CNA A to a different hall just in case Resident #49's memory was triggered if she saw her again. The administrator said Resident #49 wanted to make money as she believes prior to being admitted to the facility Resident #49 used to sell at local flea markets. The administrator said she did not remember the exact date of the allegation or when she conducted her own investigation. During an interview via phone on 09/06/2023 at 3:30 p.m., CNA #2 said she was busy and would call back after 5:00 p.m. Interview via phone on 09/06/2023 at 5: 15 p.m., CNA B (former employee) called back and said she was no longer employed at facility but remembered the incident. She said Resident #49 was alleging CNA A was exploiting her. She said Resident #49 said the first time she loaned CNA A money was $100.00 and claimed there were two other times for a total of $500.00. She said Resident #49 was told by CNA A she needed the money to bail her son out of jail, pay her light bill, and fix her truck. She said Resident #49 told her CNA A had been making payments but still owed her money. She said she recorded Resident #49 while she was telling her about CNA A because she knew the administrator would not believe her because CNA A had been working at the facility longer than her. CNA B said she only recorded Resident #49's voice and did it without knowledge/consent. I immediately told my supervisor, ADON 2 and asked him what I needed to do. He said, let us go to the administrator's office to let her know. Once we were in the administrator's office, I advised the administrator what Resident #49 had told me. CNA B said the administrator told her she did not need to do a statement because she was going to do it. CNA B said that was a mistake she made of not writing her own statement within her own words because I do not know what she wrote or even if she made a statement. CNA B said the only thing the administrator did was to move CNA A to a different hall. CNA B said the weekend before she reported the incident to the administrator Resident #49 told me to call CNA A to her room and I did. CNA B said she went to assist another resident right across Resident #49's room and overheard CNA A yelling at Resident #49 telling her No te vas hacer [NAME] con el dinero que te estoy pagando, ya [NAME] de pagarte y no te [NAME] a seguir pagando (you are not going to get rich with the money 676446 Page 3 of 10 676446 09/08/2023 Mission Valley Nursing and Transitional Care 1200 S Bryan Rd Mission, TX 78572

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few I'm paying you, I already finished paying you and I don't plan on paying you anymore). CNA B said she could hear CNA A yelling at Resident #49 from across the hall. CNA B said there were nurses out in the hall, but no one went to check on Resident #49. CNA B said she had advised the administrator. she had recorded the conversation between Resident #49 and herself and she said yes. CNA B said the administrator was surprised to know she had a recording and asked to her if she could listen to the recording. After listening to the recording CNA B said the administrator questioned her saying she did not hear any names being mentioned and did not believe the voice in the recording belonged to Resident #49. Interview on 09/07/2023 at 9:43 a.m., ADON B said he recalled CNA B came to him with an allegation regarding money owed to Resident #49. He said he did not remember the exact date but said he immediately escorted CNA B to the administrator/abuse coordinator to inform her of the situation. He said he does not know what the outcome was since he let the administrator manage the situation. Interview on 09/07/2023 at 3:30 p.m. During resident council meeting, Resident #2, Resident #3, Resident #4, and Resident #5 were interviewed regarding staff asking them for money or voicing they had money issues, and all said they had not experienced any staff members asking them for money or voicing they had money issues. Interview via phone on 09/07/2023 at 4:20 p.m. CNA C (former employee) said she was the person CNA A asked to give the remaining $20.00 to Resident #49. According to her, CNA A told her Resident #49 had loaned her $40.00 and still owed her $20.00. She said CNA A sent her $20.00 via cash app and she in turn gave Resident #49, $20.00 in cash. As per CNA C she said Resident #49, later told her she had voluntarily loaned CNA A $40.00 because she had voiced, she was having money issues. CNA C said she personally knows of staff members who have purchased perfume bottles from Resident #49's sister. She said Resident #49 keeps the perfume bottles in her room and collects the money for her sister. Interview via phone on 09/08/2023 at 8:05 AM, Resident #49's sister said she has never sold any perfume bottles in the facility. She said she did take a couple perfume bottles to Resident #49 but were bottles she had requested for her grandchildren but has never told Resident #49 to sell them to staff at the facility. Interview on 09/08/2023 at 8:30 am., ADON A said she remembers meeting with Resident #49, the administrator, and the social worker to discuss about a CNA owing her money. She said she does not speak Spanish, so she did not know the outcome of the meeting. Interview on 09/08/2023 at 2:04 p.m., The administrator said she had investigated the possible exploitation allegation (selling perfumes/loan) which involved Resident #49 and CNA A. She said she had only spoken to CNA A, CNA B (former employee who reported the allegation) and Resident #49. The administrator said she did not request a written statement from CNA B when she informed her of the alleged allegation of exploitation, the administrator said no. The administrator said just recently she was told by her management they no longer needed a written statement from the person making an allegation. She said she was told she just needed to write a summary of what they were alleging. The administrator said she did not have a written summary of what CNA B had alleged. The administrator said there are time in which she does request a written statement from the person making allegations and sometimes she doesn't. The administrator was not able to say under what circumstances she does request a written statement. The administrator said had not interviewed other staff members and/or staff to see if they had purchased any perfumes from Resident #49 and/or her sister and she said no. 676446 Page 4 of 10 676446 09/08/2023 Mission Valley Nursing and Transitional Care 1200 S Bryan Rd Mission, TX 78572

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The administrator said by not conducting a thorough investigation, Resident #49 could negatively be affected by it could worry the resident by thinking staff owes her money. She said she in-serviced all staff members on Abuse, Neglect, and exploitation on 07/18-20/2023. Record review of Complaint/Grievance Follow-Up Report dated 07/12/2023 (completed by the administrator) revealed Receipt of Concern/Grievance: Name of person contacted: The social worker The nature of the complaint: Resident is alleging a CNA (CNA A) owes her money Documentation of facility follow-up: date: 0712/23, Name of person notified: The social worker, Comments: Care Plan will be held. Resolution of concern/grievance: Date received: 07/12/2023 Date of notification: 07/12/2023 Person notified of resolution: Resident #49 Final resolution: ADON, SW, & Admin spoke to resident about money owed. Resident denied giving or receiving money. Stated her sister was the one selling perfumes. Resident was encouraged to speak to any of us about any further incidents. Resident was in good spirits. Record review of Employee Counseling Report dated 07/12/2023 completed by the Administrator. Verbal Warning Level two Offenses: accepting gifts from residents or visitors/buying or purchasing gifts from visitors. Other offenses: Violation of any other policy or procedure contained in Employee's Manuall: Resident Rights/Solicitation Incident Description: A resident told a CNA, that CNA A owed her money from a personal loan. Upon investigation, it was determined that (she) CNA A had bought a perfume from the resident's sister but had paid the sister directly. CNA A should not be conducting transactions with visitors, family members or residents. Record review of the facility's Employee's Handbook revised 02/2019 #6-solicitation revealed: #6-Solicitation No employee shall solicit for any cause or organization during his or her working time or during the working time of the employee or employees at whom such activity is directed. No employee shall distribute, circulate, or post any printed material in work areas at any time, or 676446 Page 5 of 10 676446 09/08/2023 Mission Valley Nursing and Transitional Care 1200 S Bryan Rd Mission, TX 78572

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few during his or her working time or during the working time of the employee or employees at whom such activity is directed. Work areas include resident care areas, resident waiting areas, resident lobby areas, nurse's stations, resident corridor, and in any areas where medical services are provided. Under no circumstances will non-employees be permitted to solicit or to distribute written material for any purpose or Employer property. Record review of the facility's policy on abuse, neglect and exploitation implemented on 08/15/2022 revealed: Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriations of resident property. Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of property; b. Establish policies and procedures to investigate any such allegations; and c. Include training for new and existing staff on activities that constitute abuse, neglect exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention; 2. The facility will designate and Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey and other officials in accordance with state law. The components of the facility abuse prohibition plan are discussed herein: II. Employee Training A. New employees will be educated on abuse, neglect, exploitation, and misappropriation of resident 676446 Page 6 of 10 676446 09/08/2023 Mission Valley Nursing and Transitional Care 1200 S Bryan Rd Mission, TX 78572

F 0610 property during initial orientation. Level of Harm - Minimal harm or potential for actual harm B. Existing staff will receive annual education through planned in-services and as needed. Residents Affected - Few III. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: Investigating different types of alleged violations. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and other who might have knowledge of the allegations. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and Providing complete and thorough documentation of the investigation. A. The administrator will follow up the government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. 676446 Page 7 of 10 676446 09/08/2023 Mission Valley Nursing and Transitional Care 1200 S Bryan Rd Mission, TX 78572

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one of eight residents (Resident #48) reviewed for comprehensive care plans, in that: Resident #48's last fall was not reflected in her comprehensive care plan. This failure could place residents at risk for not receiving necessary care and services. The findings were: Record review of Resident #48's admission record dated 09/07/23 reflected she was re-admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis (weakness of one entire side of the body) ,epilepsy (condition with recurring seizures), and dementia (decline in cognitive abilities). Record review of Resident #48's quarterly MDS assessment dated [DATE] reflected indicated Resident #48 had severe cognitive impairment and a fall since admission or re-entry, with no injury Record review of Resident #48's comprehensive care plan initiated on 04/12/21 and revised on 01/09/23 reflected is at high risk for falls r/t unsteadiness, other lack of coordination weakness, history of falls with interventions that included to ensure floor mats in place. Resident had an actual fall, unwitnessed with no injury, as per resident, she had rolled over from bed. This care plan was dataed 04/06/23. Interventions included to ensure bed to lowest position for safety with floor mats in place, dated 04/05/23. Record review of the Incident Report dated 08/02/23 for Resident #48 reflected Resident #48 Was noted sitting on floor on top of the pad, on the right side of the bed, bed was at lowest position. Resident unable to give description. No injuries observed at time of incident. Observation and interview on 09/05/23 at 2:12 pm with Resident #48 revealed Resident #48 was in low bed, awake, with call lights in her hand and floor mats on each side of bed. Resident #48 was not able to respond to greeting from surveyor due to cognitive impairment. Interview on 09/07/23 at 3:00 pm with MDS/LVN D revealed as an IDT staff collaborate information to determine what could be done as a preventive for falls. MDS/LVN D said the resident's care plans were updated for falls as they occurred and added new interventions as needed to help prevent further falls. The MDS /LVN D said the IDT reviewed incident reports during their morning meetings to ensure if there was a need to update care plans. MDS/LVN D said she should have updated Resident #48's care plans in the concern area of falls. MDS/LVN D said it was her responsibility to update Resident #48's care plans to include the last unwitnessed fall on 08/02/23. Interview on 09/07/23 at 3:33 pm with CNA E revealed Resident #48 tried to get up from bed without 676446 Page 8 of 10 676446 09/08/2023 Mission Valley Nursing and Transitional Care 1200 S Bryan Rd Mission, TX 78572

F 0656 calling for help and was very forgetful. Level of Harm - Minimal harm or potential for actual harm Interview on 09/08/23 at 9:46 am with ADON 1 revealed all nurses had access to the care plans. ADON 1 said staff had meetings every morning with the IDT group and they reviewed falls, behaviors, etc. to determine if a care plan needed to be updated or revised. Residents Affected - Few Interview on 09/08/23 at 9:53 am with the DON revealed all staff had access to care plans in their computers. Resident #48 had a fall on 08/03/23 that had not been care planned or new interventions added to prevent further falls. The DON said the IDT met as a group to determine if care plans needed to be updated or revised. The last fall for Resident #48 had not been care planned to add a new intervention. The DON stated it was his responsibility to ensure care plans were updated or revised as needed. Record review of the facility policy titled Fall Prevention Program dated 08/15/22 reflected Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. When any resident experiences a fall, the facility will review the resident's care plan and update as indicated. 676446 Page 9 of 10 676446 09/08/2023 Mission Valley Nursing and Transitional Care 1200 S Bryan Rd Mission, TX 78572

F 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 kitchen reviewed in that; Residents Affected - Few Air conditioner vent near the food preparation area had condensation that was dripping a clear liquid onto the floor Air conditioner vent had brown stains around the edges and in the middle Ceiling tiles (2) adjacent to the air condition vent had brown stains This failure could place staff at risk of injury while preparing meals for residents. Findings included: During an observation of the kitchen on 09/07/2023 at 10:53 a.m., surveyor observed a clear liquid was dripping from the air condition vent near where food is prepared onto the floor. Upon further observation, there were brown stains on the vent and ceiling tiles adjacent to the air conditioner vent. During an interview on 09/07/2023 at 10:55 a.m., Dietary Manager said he had not noticed any clear liquid dripping from the air conditioner vent in the past and claimed it was the first day it happened. He said he would be putting in a work order for the maintenance department to fix it. During an interview on 09/08/2023 at 3:00 p.m., The administrator said the dietary manager advised her of an air conditioner vent in the kitchen that had a clear liquid dripping onto the floor. She said she had placed a work order for it to be fixed. The administrator said the facility did not have a policy related to workorders but stated if management staff need to enter a workorder they utilize a computer software program called TELS. If a non-management staff need to enter a workorder they utilize the kiosks located throughout the facility. She said all facility staff members have access to entering a workorder if something needs to be repaired. The administrator said she has access to verify pending workorders and how long it took the maintenance department to fix the problem. She said the facility also gets a weekly report from their headquarters indicating workorders still pending after 1 week. 676446 Page 10 of 10