Health inspection·March 11, 2025

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 report an alleged violation involving neglect, misappropriation of resident property, exploitation, or mistreatment, and does not result in serious bodily injury not later than 24 hours to the administrator of the facility and to other officials, including to the State survey and certification agency and adult protective services in accordance with State law for one (Resident #1) of four residents reviewed for misappropriation of resident's property and exploitation. The Housekeeper failed to report to the facility administrator who was the abuse coordinator that Resident #1 was missing money totaling $90 when Resident #1 first reported the missing money weeks prior to 03/11/25. This failure could place residents at risk of not receiving timely investigations and reporting of misappropriation of resident's property and exploitation. Findings included: Review of Resident #1's admission record dated 03/11/25 revealed a [AGE] year-old female with an initial admission date of 12/31/24. Her diagnosis included vascular dementia (this is brain damage that is caused by multiple strokes causes memory loss and or cognitive decline), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (this is paralysis after having a stroke affecting the right side of the body), Cerebral infraction (Stroke), acquired absence of other specified parts of digestive tract (missing part of digestive tract), and type 2 diabetes (uncontrolled blood sugar disorder). Resident #1 was her own responsible party. Review of Resident #1's quarterly MDS (this is a set of standardized assessments done on admission, quarterly, and with a significant change of condition, on each resident), dated 02/19/25 revealed a BIMS (this is a standardized assessment to measure long and short-term memory) score of 13 out of 15 indicating intact cognition. Further review of the MDS revealed Resident #1 was dependent for bed mobility, transfers, toileting, and personal hygiene. Review of Resident #1/s care plan initiated 12/31/24, revealed Resident #1 had impaired cognitive function/impaired thought process related to dementia. The interventions were to break down large or complex tasks into smaller, more manageable parts or segments to improve focus and short-term memory issues. In an interview with Resident #1 on 03/11/25 at 11:09 AM who stated, I have had money stolen here Page 1 of 3 455903 455903 03/11/2025 Lake Lodge Nursing & Rehabilitation 3800 Marina Dr Lake Worth, TX 76135

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few at the facility. She said the money was in her bedside table drawer [pointed to the side table by her bed]. She said it happened a month ago. She stated she had $60 first stolen then a few days later $30 was also stolen. She stated a total of $90 was stolen from her. Resident #1 said she could not remember the exact dates. Resident #1 said she did not have a lock box and that she did not ask for one. Resident #1 stated that she did not report the incident but everyone in the facility knew that there was someone going around robbing residents. Resident #1 said a CNA told her that information about the robberies, but she declined to name the staff members name, stating I don't want her to get in trouble. In an interview with the Housekeeper on 03/11/25 at 11:35 AM, revealed she was aware of Resident #1's missing money. She stated Resident #1 informed her a few weeks ago about the stolen money. The Housekeeper stated she had found some money ($30) laying around in Resident #1's room and Resident #1 asked her to help her secure it, so the Housekeeper went to the business office, got an envelope and placed the money inside the envelope then placed the sealed envelope inside a [book name] in Resident #1's drawer. She stated she could not remember the exact dates, a few weeks ago. The Housekeeper stated Resident #1 told her that she had reported the missing money and so she did not report it herself because it was already reported. The Housekeeper stated she did not even think of helping Resident #1 get a lock box for her money. She said Resident #1 was a holder and liked to carry her belongings with her, therefore she would not have agreed to a lock box. The Housekeeper stated she knew what misappropriation and exploitation meant in regard to Abuse and Neglect. She stated misappropriation and exploitation was not just money but any residents' personal belongings being taken or befriending the residents so that they can trust you with personal information and you misuse it. She stated misappropriation and exploitation should be reported to the administrator immediately. Interview with CNA A and CNA B on 03/11/25 at 11:40 AM revealed they did not know nor had heard of any robberies in the facility, and they did not know anything about any resident's money being stolen. Both CNA A and CNA B stated they had done in-services on ANE in the past month. They stated they would report missing money or any resident's property to the DON and Administrator immediately. In an interview with the Business Office on 03/11/25 at 1:46 PM she stated Resident #1 withdraw $30 on 1/14/25, $30 on 1/22/25, $30 on 02/10/25 and $30 on 02/25/25. The Business office said that no one had reported to her that Resident #1 was missing money. She stated Resident #1 wanted two small fridges for her drinks and butter and it was likely that Resident #1 had spent the money on the items. She stated if she had known about the money missing, she would have reported to the abuse coordinator right away. She stated misappropriation and exploitation are to be reported to the abuse coordinator, the administrator. Interview with ADM on 03/11/25 at 2:33 PM, revealed she was not aware of Resident #1 missing money. She stated she reported the incident after finding out today 3/11/25. She stated the expectation was that the housekeeper should have reported the incident to her. She said the risk was misappropriation and exploitation. In an interview with DON on 03/11/25 at 2:52 PM, revealed she was not aware of Resident #1's missing money until the ADM told her today. She stated the expectation was that the incident was reported immediately. DON stated the facility had lock boxes and the residents were aware and one could be provided if they wanted one. She stated she would rather have 11 people report the same incident than for them to say, someone already reported the incident. The DON stated she had in-served on ANE, and the expectation was that all staff follow the ANE policy and report incidents immediately. 455903 Page 2 of 3 455903 03/11/2025 Lake Lodge Nursing & Rehabilitation 3800 Marina Dr Lake Worth, TX 76135

F 0609 Review of Resident #1's statement titled Resident Statement Landscape reflected Resident #1 withdraw a cash on the following dates: Level of Harm - Minimal harm or potential for actual harm $30 cash on 01/14/25, Residents Affected - Few $30 cash on 01/22/25, $30 cash on 02/10/25, $30 cash on 02/25/25. Review of facility In-Service training attendance roster titled Abuse and Neglect lead by DON dated 02/28/25 was signed by Housekeeper, CNA A, CNA B, and 36 other staff members from nursing and other departments. Record review intake [number] reported on 03/11/25 by ADM allegation Exploitation/Misappropriation. Review of facility policy titled Abuse and Neglect, dated 09/09/24, reflected: The facility Reportable Incident Protocol, Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 2024-14 dated 8/29/24. a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. b. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. 455903 Page 3 of 3