Health inspection·November 7, 2023

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 that all alleged violations involving abuse of residents were reported immediately to the administrator for 1 of 10 residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure all allegations of abuse or neglect were reported to the Administrator/Abuse Coordinator immediately. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of the facility's Abuse and Neglect policy dated [DATE] indicated .If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be report immediately to the administration and to other officials according to state law. Record review of a face sheet indicated Resident #1 was a [AGE] year-old, initially admitted to the facility on [DATE] with readmission date of 9/5/2023. Her diagnoses included epileptic seizures (interruptions of the normal connections between nerve cells in the brain), bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), unspecified psychosis (a symptom that refers to a loss of touch with reality), anxiety disorder (persistent and excessive worry that interferes with daily activities) and cognitive communication deficit (difficulty with thinking and how someone uses language). Record review of a MDS assessment dated [DATE] indicated Resident #1 was able to make herself understood and understand others. She had a BIMS of 8 (moderate cognitive impairment). She required supervision and limited assistance for most ADLs (activities of daily living). She was frequently incontinent of bladder and bowel. Record review of Resident #1's care plan dated 08/09/23 indicated Resident #1 exhibited manipulative behavior and would defecate and urinate on herself to punish staff. An intervention included for staff to be firm and direct when approaching the resident about behaviors. Record review of Resident #1's care plan dated 09/19/23 indicated she was taking psychotropic medications and was at risk for adverse reactions and behaviors. Interventions included to assess for Page 1 of 2 455642 455642 11/07/2023 Dayton Nursing and Rehabilitation 310 E Lawrence St Dayton, TX 77535

F 0609 mood changes & specific behaviors every shift and if present document. Level of Harm - Minimal harm or potential for actual harm During a telephone interview on 11/7/23 at 8:30 a.m., Housekeeper A said on 11/05/23 around 8:00 am MA B made Resident #1 drag her dirty linen bag down the hall to the laundry closet. She alleged MA B abused Resident #1 when she made the resident drag it. Residents Affected - Few During a telephone interview on 11/7/23 at 6:30 p.m., Housekeeper A said after she witnessed the incident, she attempted to call the Administrator on 11/05/23 regarding her suspicions of abuse, but she did not answer. Housekeeper A denied notifying the charge nurse or supervising nurse of her suspicions of abuse at the time of the incident. Housekeeper A said she notified the DON and Administrator the next day on 11/06/23 during a disciplinary meeting while she, Housekeeper A, was being escorted out of the facility for unprofessional behavior. Housekeeper A said she showed them a video she had taken on 11/5/23 of Resident #1 dragging her dirty linens to the laundry closet while MA B watched. Housekeeper A denied she was trained on reporting abuse and neglect of residents immediately to Administrator/Abuse Coordinator. During an interview on 11/7/23 at 10:18 am, the Administrator said she was the abuse coordinator. She said she first learned of Housekeeper A's allegation of abuse on 11/6/23 at 2:30-3:00 pm a disciplinary action meeting when Housekeeper A was being reprimanded for a HIPAA violation, for previously taking pictures and videos of multiple residents and staff without consent. The Administrator said Housekeeper A denied taking videos or pictures of residents but had to be escorted out of the facility because she continued to argue and behave unprofessionally (verbally disruptive). She said once outside the facility, Housekeeper A admitted she took videos and pictures of residents and then showed the Administrator and DON a video with Resident #1. She said Housekeeper A said she was suspicious of abuse because MA B made Resident #1 drag her dirty linens to the dirty laundry closet. The Administrator said she was unable to hear any communications between Resident #1 and MA B in the video. The Administrator said she and the DON immediately started an investigation regarding the video and the housekeeper's allegation and reported the abuse allegation to HHS. During an interview on 11/7/23 at 11:09 a.m., Resident #1 said she recalled the incident involving her and MA B that happened on 11/5/23. Resident #1 said MA B entered her room to assist her with personal care and to change the bed linens after she urinated on the blanket on her bed. Resident #1 said MA B did not force or make her take or drag her dirty linens to the linen closet. Resident #1 said MA B offered to help her transport the dirty linen, but she (the resident) refused the offer. She said MA B did not physically, verbally, mentally, or sexually abuse her. Record review of personnel file for Housekeeper A indicated that she received training on abuse, neglect, exploitation, reporting abuse, HIPAA, and resident rights on 5/17/23. During interview on 11/7/23 at 7:00 pm, the Administrator said the expectations was for the facility staff to report all suspicions or allegations of abuse to her, as the abuse coordinator, immediately. She said if she was not available, staff should report to the supervisor in charge. 455642 Page 2 of 2