Health inspection·May 17, 2025

F 0726 Level of Harm - Minimal harm or potential for actual harm Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Purpose of Visit: Investigations Residents Affected - Some Entrance Date: [DATE] Facility Census: 75 Complaint Intakes: 1010357 TX00543373 The following acronyms were used in the document: CNA - Certified Nurse Aide DON - Director of Nursing HR- Human Resources NAR-Nurse Aide Registry Based on interviews and record review, the facility failed to ensure sufficient nursing staff with appropriate competencies and skills set to provide nursing and related services for 3 (CNA A, CNA B, CNA C) of 10 employees reviewed for staff qualifications. The facility failed to ensure CNA A, CNA B, and CNA C had a current nurse aide certification while employed at the facility and actively providing care for residents. This failure could result in residents being provided care by staff who have not provided documentation of training and competency in providing care. Findings include: Record review of CNA A's NAR. Certificate registry date [DATE], revealed CNA As certification expired on [DATE]. Record review of CNA A's Timecard Report for [DATE]-[DATE], revealed CNA A worked a total of 5 Page 1 of 2 455823 455823 05/17/2025 Treemont Healthcare and Rehabilitation Center 5550 Harvest Hill Rd Dallas, TX 75230

F 0726 shifts scheduled 10:00pm-6:00am. Level of Harm - Minimal harm or potential for actual harm Record review of CNA B's NAR. Certificate registry date [DATE], revealed CNA Bs certification expired on [DATE]. Residents Affected - Some Record review of CNA B's Timecard Report for [DATE]-[DATE], revealed CNA B worked a total of 3 shifts scheduled 2:00pm-10:00pm. Record review of CNA C's NAR. Certificate registry date [DATE], revealed CNA Cs certification expired on [DATE]. Record review of CNA C's Timecard Report for [DATE]-[DATE], revealed CNA C worked a total of 7 shifts scheduled 10:00pm 6:00am. Attempted interview on [DATE] at 3:20pm with CNA B via phone, the attempt was unsuccessful. Attempted interview on [DATE] at 3:22pm with CNA C via phone, the attempt was unsuccessful. In an interview with CNA A on [DATE] at 3:25pm revealed she was responsible for notifying HR and the Administrator when licensed expired. CNA stated she did not inform staff that her license had expired. In an interview on [DATE] at 4:00pm, the DON stated HR was expected to complete background and registry checks routinely. The DON stated background checks and registry checks should be completed prior to hire and annually once hired. The DON stated staff were responsible for notifying HR that their licenses/certifications are expired. The DON stated the risk of staff working with an expired license or certification can result in incompetent staff, residents at risk for abuse and neglect, and a lack of quality of care. In an interview with the Administrator on [DATE] at 4:40pm, the Administrator stated HR was responsible for completing background checks and registry checks prior to hire and annually once hired. The Administrator stated an HR coordinator was just hired 30 days ago. The Administrator stated it was the responsibility of the staff to notify HR that their license or certification has expired or close to being expired. The Administrator stated completing checks annually was how the facility monitors criminal history, expired licenses, and certifications. The Administrator stated if an aide's certification was expired or close to expiring, it was their responsibility to renew their certification. The Administrator stated if an aide's certification is expired, an aide cannot perform duties until their certification is renewed. The Administrator stated CNA A, CNA B, and CNA C's certifications expiration dates were [DATE] and [DATE]. The Administrator stated the risk of staff working with an expired license or certification can cause a lack of skills and affect the quality of care the resident would receive. The Administrator stated staff working with an expired license or certification can result in termination. A policy for nurse aide registry verification was requested from the Administrator on [DATE] but was not received at the time of exit. 455823 Page 2 of 2