Health inspection·December 19, 2024

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect one resident (Resident #1) out of seven residents reviewed for abuse and neglect in that: CNA A slapped Resident #1 on his head in the front lobby in the presence of the facility's Receptionist and the Van Driver from another facility. This noncompliance was identified as PNC. The deficient practice occurred on 11/30/2024 and in-service was completed on 12/03/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of abuse, injury, and psychosocial harm. Findings included: Review of Resident #1's undated care plan reflected a [AGE] year-old male that was admitted to the facility on [DATE] with re-admission date of 10/27/2024 with diagnoses including Cerebral infarction, Hemiplegia and hemiparesis following cerebral infraction, acute respiratory failure with hypercapnia, bipolar disorder, Review of Resident #1's quarterly care plan assessment, dated 11/29/24, reflected a BIMS score of 0, indicating he had a severe cognitive impairment. It was also noted a staff assessment for mental status was conducted which indicated short-term memory problem and cognitive skills for daily decision-making being moderately impaired. Section E (Behaviors) reflected he had not exhibited any physical or verbal behaviors. Review of Resident #1's quarterly care plan, initiated 08/30/24, reflected Resident #1 had ADL self-care deficit performance related to weakness and impaired vision; revised on 12/10/2024 reflected Resident #1 had the potential to be physically aggressive related to diagnosis of bipolar disorder, he had behavior problems related to him being physically aggressive with staff and others with interventions as follow: Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Review of Resident #1's skin assessment report reflected a skin assessment was completed on Page 1 of 7 455771 455771 12/19/2024 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0600 11/30/2024 with no apparent injury on his head, bilateral toes DTI/flaky skin. Level of Harm - Actual harm Review of Resident #1's progress notes written by RN B dated 11/30/2024 at 2:35 pm reflected: this nurse was called to the front lobby by (RN D) at 12:20, who stated that it was reported to her that a CNA hit the Residents Affected - Few resident on his forehead while trying to transfer him to a different wheelchair. On getting to the front lobby, found resident sitting up on the wheelchair. Assessed his forehead and found no mark of bruising and resident denies any discomfort or pain on the area. The incident was witnessed by () the receptionist and () the transporter from (another facility), , Tx. Received a written statement from (Receptionist). Abuse coordinator (Administrator) DON and NP on call for MD were all notified. Complete head to toe assessment of the resident has been done and no skin lesion noted. During a phone interview on 12/16/2024 at 09:55 am the local law enforcement officer stated he was assigned to the case regarding Resident #1 few days after the incident. The Law enforcement officer stated the allegation of the crime was made, Resident #1 pressed charges and he spoke with the 2 witnesses to the crime. He stated the physical abuse/assault was witnessed by one of the facility's staff and another facility staff (Van Driver). He stated based on his investigation, there was probable cause for assault to an elderly committed by CNA A and a warrant for her arrest was out. On 12/16/2024 at 10:03 am, attempts were made to speak with the Van Driver from the other facility and was told she was in an emergency and would call at her earliest convenience. During a phone interview on 12/16/2024 at 11:14 am, the facility's Receptionist stated she witnessed an incident with Resident #1 and CNA A on 11/30/2024 in the facility's lobby. The Receptionist stated while Resident #1 was about to be transfer to another facility, CNA A was called to assist Resident #1 transfer from one wheelchair to the other. The Receptionist stated Resident #1 made a kicking movement towards CNA A and CNA A stated, (Resident #1) we are not doing this today, CNA A backed up in the process and walked back to Resident #1 and slapped his head loud that they heard the sound from the pop as it echoed. The Receptionist stated the Van Driver from the other facility then asked CNA A if she had just slapped (Resident #1) on the head and CNA A stated no, she (CNA A) was removing a bug from Resident #1's head. The Receptionist stated that was not the case, Resident #1 did not have a bug on his head, and she could not understand why CNA A was so comfortable slapping Resident #1 in public like that. The Receptionist stated the Van Driver requested the state's complaint number, she (Receptionist) notified the manager on duty, the Administrator was called to the facility, the nurse was called to assess Resident #1. The Receptionist stated she was interviewed by the Administrator, and she wrote a statement regarding the incident. She stated they were in-serviced on abuse and neglect. During an interview on 12/16/2024 at 12:11 pm RN B stated she was the nurse on duty on 11/30/2024 for Resident#1 when the incident for physical abuse happened. RN B stated she did not witness the incident but was called to the front lobby to assess Resident #1. RN B stated she did a full skin assessment on Resident #1 and there were on apparent injury noted. RN B stated CNA A was pulled off the floor from working with other residents, full skin assessment was completed on all residents assigned to CNA A. RN B stated she had never seen CNA A hit another resident. She also stated facility's staff were in-serviced on abuse and neglect, the types of abuse, how to report and who to report to. During an interview on 12/16/2024 at 09:37 am the Van Driver stated on 11/30/2024 at about 12:20 pm she went to pick up (Resident #1) and Resident #3 to transport them to another facility. She stated 455771 Page 2 of 7 455771 12/19/2024 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0600 Level of Harm - Actual harm Residents Affected - Few while Resident #1 was being transferred from one wheelchair to the other in the front lobby, he made a kicking movement, pointing to the cushion in his old chair, trying to communicate to CNA A to put the cushion in his new chair. She stated CNA A stated not today Resident #1 and slapped Resident #1 on his head, it was loud, and she and the Receptionist heard it. The Van driver stated she was shocked at what she had just seen and asked CNA A, Did you just slapped his head? The Van driver stated CNA A stated she was removing something from Resident #1's head. The Van driver stated she then asked the receptionist for the State's complaint number, told her co-worker that went with her and called her Administrator. She stated she gave the facility's administrator a written statement of the incident after he got to the facility. During an interview on 12/16/2024 at 3:00 pm the Administrator stated he was the abuse and neglect coordinator. He stated staff were expected to report concerns of abuse and neglect to him. He stated if the instance of abuse and neglect resulted in injury, he has 2 hours window to report to Health and Human Services. He stated it was not his expectation for staff to hit a resident. He stated he was notified by his HR staff who was the manager on duty, and he immediately went to the facility to initiate an investigation. He stated CNA A was removed from the floor, suspended pending investigation, and has since been terminated. He stated he interviewed all witnesses, in-serviced staff on abuse and neglect, conducted safe survey with other residents without negative outcome and completed skin assessments on all residents assigned to CNA A on the day of the incident. He also stated he notified the police and there was an officer investigating the allegation. Surveyor was unable to interview the HR staff who was the manager on duty on 11/30/2024 due to her being overseas. During interview on 12/16/2024 through 12/19/2024 with 2 RNs, 3 CNAs, 1 CMA, the Receptionist revealed they were in-serviced on abuse and neglect after the incident with Resident #1 and CNA A. Staff denied seeing CNA A physically abusing other residents. Staff also stated they had not seen CNA A in the facility since the incident. Review of facility's in-services reflected an in-service dated 11/30/2024 through 12/03/2024 for all facility staff. In-service: Attach Lesson Plan with behavioral objectives, core curriculum, method(s) of teaching, method of evaluation. 1. Abuse, Neglect, Exploitation and Misappropriation Prevention Program 2. Abuse and Neglect Coordinator- Administrator (Administration) 3. Report immediately to the administrator. Review of CNA A's personnel file reflected she was terminated on 12/02/2024. 455771 Page 3 of 7 455771 12/19/2024 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0600 Review of facility's investigation dated 12/06/2024 reflected a thorough investigation was completed, and the allegation of physical abuse was confirmed . Level of Harm - Actual harm Residents Affected - Few Review of facility's Policy revised April 2021 titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program reflected: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff. b. other residents. c. consultants. d. volunteers. e. staff from other agencies. f. family members. g. legal representatives. h. 455771 Page 4 of 7 455771 12/19/2024 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0600 friends. Level of Harm - Actual harm i. Residents Affected - Few visitors; and/or j. any other individual. Ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and high turnover rates. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. 455771 Page 5 of 7 455771 12/19/2024 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that medical records were accurately documented for one (Resident #2) of five residents reviewed for accurate clinical records. The facility failed to ensure LVN C documented any follow-up observations or assessments of Resident #2 after she initiated treatments for his uncontrolled coughing. This failure could result in errors in care and treatment. Findings included: Review of Resident #2's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), disturbances of salivary secretion, and unspecified dementia. Review of Resident #2's quarterly MDS assessment, dated 11/25/24, reflected a BIMS score of 7, indicating a severe cognitive impairment. Section O (Special Treatments, Procedures, and Programs) reflected he did not receive tracheostomy care. Review of Resident #2's quarterly care plan, dated 09/27/24, reflected he had a tracheostomy stoma with an intervention of covering the trach with dry gauze and securing with tape. Review of Resident #2's progress notes, dated 12/14/24 at 1:32 PM and documented by LVN C, reflected the following: At about 9:29 am this writer was notified by [Resident #2]'s roommate that [Resident #2] is coughing. Upon assessment [Resident #2] seen coughing none [sic] stop, form [sic] like secretion coming out of his trach. Vital signs taken T 97.9, O2 97, P 134. BP 131/74. [Resident #2] C/O of dizziness and tiredness. NP on call called 9:29 am, called back 9:30 am, she ordered stat guanfacine 20mls. Stated should cont to suction and monitor the resident, PRN Levalbuterol HCl Inhalation Nebulization Solution, was given. Med was mild effective, [Resident #2] continue to cough with secretions from his trach and pulse rate still on [sic] 120's, [Resident #2] looks weak, NP notified again on the res condition @ 12:20 pm, called back at 12:23 pm ordered to send [Resident #2] to emergency room for further evaluation . During a telephone interview on 12/16/24 at 1:59 with, LVN C stated she worked with Resident #2 on the morning of 12/14/24. She stated he was coughing non-stop, having secretions from his stoma that were foam-like, and was in respiratory distress. She stated she contacted the NP on-call (NP D) and she provided her with orders for a nebulizer treatment, suctioning of his stoma, continuing to monitor him, and calling her back if his oxygen levels dropped. She stated the suctioning helped with the secretions and saw an improvement with his condition with the nebulizer treatment. She stated he was not in respiratory distress and his cough had subsided. She stated approximately three hours later, she noticed Resident #2 looked more tired and was complaining of feeling dizzy. She stated his heart rate was elevated and he did not look normal. She stated she then contacted NP D again who gave her orders to send him to the ER. She stated she was not sure why she had not documented that his condition had changed but remembered she had written it as one note in his progress notes. 455771 Page 6 of 7 455771 12/19/2024 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0842 Level of Harm - Minimal harm or potential for actual harm During an interview on 12/16/24 at 3:00 PM, the DON stated she remembered getting called by LVN C regarding Resident #2's condition on 12/14/24. She stated she had communicated to her about his improving condition and then when his condition worsened again, she sent him to the ER. She stated she would expect for all of the times she assessed Resident #2 to be documented in his progress notes to ensure he was receiving timely and appropriate care. Residents Affected - Few During an interview on 12/19/24 at 10:18 AM, Resident #2 stated on the morning of 12/14/24 he could not stop coughing and that was why he was sent to the hospital. He stated the nurse had given him a breathing treatment and he was taken good care of. He stated the nurse did what she was supposed to do, and she did not wait too long to send him to the hospital. Interviews with NP D were attempted on 12/16/24 and 12/19/24. A returned call was not received prior to exiting. Review of the facility's Change of Condition Policy, dated 2003, reflected when to notify the NP of a resident's change in condition. It did not have anything related to nursing documentation. 455771 Page 7 of 7