Health inspection·June 3, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interviews and record review, the facility failed to ensure all alleged violations involving abuse and neglect were reported immediately but not later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency for 1 of 1 facility reviewed for reporting. The facility failed to report to the State Survey Agency when the facility was without power from 05/28/24 to 05/31/24. This failure could place residents at risk for harm to include neglect and diminished quality of life. Findings included: In an observation on 05/31/24 at 9:30 AM the fire truck was observed leaving the facility. In an interview on 05/31/24 at 9:32 AM the Front Desk Receptionist revealed the electricity turned on 15 minutes before surveyor entered. The Front Desk Receptionist revealed the electricity had been off since Tuesday because of the inclement weather. In an interview on 06/03/24 at 11:15 AM, with the DON revealed the facility lost power on 05/28/24 and power returned on 05/31/24. The DON revealed the Administrator was responsible for reporting incidents to the state. The DON revealed the Administrator was absent, she is the next in charge to report incident to the state. The DON revealed management and staff were on the floor providing care for the residents and were very busy. The DON revealed that residents were not at any risk because the generator worked. In an interview on 6/03/24 at 11:45 AM, with the Administrator revealed the facility lost power 05/28/24 to 05/31/24. The Administrator revealed he did not report the incident to the State Agency because his liaison stated as long as the generators were working the incident did not need to be reported to the state. The Administrator revealed he was responsible for reporting facility self-reported incidents. The Administrator revealed the staff monitored the residents constantly and the heat was at 80 degrees inside the facility during the power outage. Record review of facility policy Nursing Administration-Section: Resident Rights-, Subject: Abuse prevention - Reporting and Investigating (revised November 2016) revealed the following in part: All alleged violations will be reported via phone or in writing within 24 hours to the state Page 1 of 2 675081 675081 06/03/2024 Golden Acres Living and Rehabilitation Center 2525 Centerville Rd Dallas, TX 75228

F 0609 Licensing Agency . Level of Harm - Minimal harm or potential for actual harm Record review of Long- Term Care Regulatory Provider Letter PL 19-17 dated 7/10/19 revealed the following: Residents Affected - Some .A NF must report to HHSC the following types of incidents in accordance with applicable state and federal requirement: . emergency situation that pose a threat to resident health and safety Immediately, but not later than 24 hours after the incident occurs or is suspected . 675081 Page 2 of 2