Health inspection·September 7, 2024

F 0609 allegation of sexual abuse to HHSC at 2:25 PM. Level of Harm - Minimal harm or potential for actual harm Observation and interview on 09/07/2024 at 11:03 AM with Resident #1 revealed she could not remember the incident and could not provide any details of the alleged incident. Residents Affected - Few Interview on 09/07/2024 at 09:58 AM, the forensic nurse revealed she saw Resident #1 at the local hospital to complete a SANE Examination (Forensic evidence collection process from sexual assault victims) on 09/05/2024. She stated Resident #1 reported to her that she was raped the previous night (09/04/2024). Interview on 09/07/2024 at 10:57 AM with Resident #1's Family Member B revealed Resident #1 told Family Member C on 09/05/2024 morning (exact time not known) that she was raped the previous night (09/04/24). The Family Member B stated the Family Member C immediately reported this to the charge nurse and took Resident #1 to the hospital for evaluation. Interview on 09/05/24 at 2:16 PM with the DON revealed on 09/05/24 around 9:30 AM, Resident #1 told Family Member C and LVN A that she was raped the previous night. The DON stated LVN A could not talk with the resident because the family member took the resident to the hospital for evaluation. Interview with the DON revealed the Administrator was the Abuse Coordinator. The DON stated the Administrator was responsible for reporting an allegation of abuse to the state agency within 2 hours of learning about the incident. Interview revealed the DON did not know if this allegation of sexual abuse was reported to the state agency within 2 hours. Interview on 09/05/2024 at 3:23 PM with the Social Services Assistant revealed she was attending the morning staff meeting on 09/05/24. The Social Services Assistant stated LVN A came to the meeting room and told the Administrator about Resident #1's sexual abuse allegation around 10 AM. Interview on 09/05/2024 at 03:36 PM with the Administrator revealed he was the Abuse Coordinator. He stated his expectation of the staff was to notify him of any concerns of abuse immediately. The Administrator stated he first learned about Resident #1's sexual abuse allegation around 10:30 AM from a staff member. He stated Resident #1's family took the resident to the hospital and returned to the facility around 3:30pm. The Administrator stated he then notified the local police. Interview revealed the local police came to the facility to talk with Resident # 1. The Administrator stated he followed the abuse reporting time as per the Long-Term Care Provider Letter Number PL 19-17, and it was supposed to be reported to the state within 2 hours. He stated he reported this allegation to the state sometime in the afternoon, he could not remember the exact time. The Administrator then provided the copy of the email reporting the incident to the state and it showed the incident was reported to the state on 09/05/2024 at 02:25 PM. Telephone interview on 09/07/24 at 5:14 PM with LVN A revealed she was in the dining room when Family Member C asked her to reach out to the doctor to test the resident. Interview with LVN A revealed Resident #1 came to the dining room crying and said she was raped last night. LVN A stated she immediately called the Administrator's office, but he did not answer. LVN A then called the conference room but no one answered the phone. Interview revealed around 8:45 am she tried to call the Administrator's phone, but he did not answer. LVN A stated she went to look for the Administrator and found him in a meeting with other staff. Interview revealed she notified the Administrator about the allegation of sexual abuse made by Resident #1. Review of the facility policy, the Long-Term Care Provider Letter Number PL 19-17 dated 06/10/2019, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675081 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675081 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Acres Living and Rehabilitation Center 2525 Centerville Rd Dallas, TX 75228 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm reflected Abuse, neglect, exploitation, misappropriation of resident property and other incidents that a nursing facility must report to the health and human services commission. Abuse with or without serious bodily injury required to report immediately but not later than two hours after the incident occurs or is suspected. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675081 If continuation sheet Page 3 of 3