Health inspection·August 28, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure dignity was maintained for 1 of 14 residents (Resident #1) reviewed for respect and dignity. The Administrator failed to respect and ensure Resident #1's dignity when he made an obscene hand gesture towards the resident. This failure placed residents at risk for loss of self-worth and emotional distress and failed to ensure the residents' right to be treated with dignity and respect.Findings included: Record review of Resident #1's Transfer/Discharge Report dated 08/27/25 reflected the [AGE] year-old male resident was re-admitted to the facility on [DATE] with a diagnosis of paraplegia. Record review of Resident #1's quarterly MDS dated [DATE] reflected the resident was admitted to the facility on [DATE]. He was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated cognitively intact). In an interview on 08/27/25 at 8:18 AM, the SW stated she began her employment at the facility in April 2025. She stated there was staff turnover around May 2025. She stated on 05/08/25 she was asked to conduct Safe Surveys with the residents due to complaints about the Administrator's inappropriate comments to staff and the residents. She stated the Administrator was suspended 2-3 days while the investigation was conducted by the RNC, but she did not know the specifics. She stated none of the residents she interviewed reported any complaints or concerns regarding the Administrator. In a telephone interview on 08/27/25 at 8:48 AM, the former DON stated Resident #1 informed her the Administrator made an obscene gesture, the middle finger which the resident found to be disrespectful. She stated the obscene gesture and unprofessional comments the Administrator had made to staff and residents to the RDO. She stated about a week after she made the comments the RNC came to investigate. She stated the RNC suspended the Administrator a few days while she conducted the investigation. She stated the RNC did not report the allegations to the State Agency but should have been as required. The former DON stated Resident #1 was not interviewed by the RNC about the specific allegations regarding the Administrator and she believed. She stated the RNC terminated her employment and brought the Administrator back the day after her termination. She stated she believes her termination was retaliation for reporting the Administrator. Record review of the former DON's Disciplinary Action Form dated 05/12/25 revealed, a statement from the former DON, which read, in part, this is done in retaliation to me reporting Administrator, who not only verbally abuse - but also emotionally abused a resident. The form was signed by the former DON and RNC on 05/12/25. Record review of an email from the former DON to the RDO dated 04/30/25 at 7:42 PM which read, in part, I am writing to you today to inform you about something that has been going on in the facility since the Administrator has arrived to the facility. Today a resident by the name of Resident #1 came into my office to explain to me that he felt like he was being mistreated by the administrator. This is not the first time that the resident has voiced to me ill treatment from the Administrator. In this particular instance, the resident came into my office and informed me that yesterday (04/29/25) while he was in the smoking room, Page 1 of 13 675093 675093 08/28/2025 Lakeside Rehabilitation and Care Center 4306 24th St Lubbock, TX 79410

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the Administrator came up to him in front of an employee and stated Hey Resident #1, I have something for you. At that time the Administrator went into his pocket and pulled out his fist and flipped him off. The resident then informed me that former Housekeeper A saw him do this. He said he felt like this was inappropriate and at no time have he and the Administrator had a relationship in which they would joke around with each other the resident went on to tell me that he and the Administrator do not have a relationship in which it would ever be ok to do those things. In a telephone interview on 08/27/25 at 9:27 AM, the RNC stated the RDO received an email from the former DON alleging the Administrator had verbally abused Resident #1. She stated she suspended the Administrator 3 days, maybe more, while she interviewed the staff who all denied the allegations. She stated she did not interview Resident #1 about the allegations, but she had the SW conduct Safe Surveys and none of the residents, including Resident #1 reported any issues. She stated the decision was made to treat the incident internally and not report the incident to the State Agency. When the RNC was asked by the Investigator if the facility policy was followed regarding reporting, she stated that's a tricky one because everyone denied the allegations. Record review of the RNC's investigation conducted on 05/08/25 reflected a copy of the email from the former DON to the RDO dated 04/30/25, the Safe Surveys conducted by the SW with the residents on 05/08/25 and the RDO's interviews with staff: - The Administrator denied the allegation. - An interview with former Housekeeper B on 5/8/2025 at 2:49 PM reflected, Have you ever been witness to any administrative staff saying or doing anything to a resident/or other staff member that would be considered out of a professional role? If so, can you tell me when, by whom and directed towards who? I was in the smoke room at the same time with Resident #1 when the Administrator came in and spoke with all of us and then told Resident #1, I have something for you and then the Administrator pulled out his hand and flipped Resident #1 off but then tell him he was just playing and then Resident #1 said boy and then they both laughed. Did you report that to anyone? No ma'am I did not I thought they were just playing. - The SW conducted Safe Surveys with 46 residents on 05/08/25, the questions included general questions regarding which included if they were comfortable asking for assistance, if staff treated them with dignity and respect, if they felt safe in the facility, if they felt comfortable telling staff about concerns, if staff had ever physically harmed them and if staff member ever yelled or cursed at them. Resident #1 responded he did not feel comfortable asking staff for assistance; however, there was no further documentation regarding his response. Resident #1 reported no other issues during the Safe Survey. Record review of the Grievances from May 2025 - August 2025 reflected no grievances regarding Resident #1 or the Administrator. In an interview on 08/27/25 at 9:55 AM, the Administrator stated he was informed by the RNC of the allegations made against him and he was interviewed by the RNC. He stated he denied all the allegations in the former DON's email. He stated he did not want to discuss specifics because of legal action taken by the former DON and ADON. He stated he was suspended for an abuse allegation and was off 3 to 4 days pending the outcome of the investigation. He stated he was not privy to whether the incident was reported to the State Agency. He said the facility follows the Provider Letter as the policy regarding investigating and reporting abuse allegations. He stated he feels Corporate probably looked at the Provider Letter and made decisions based on it. He stated the facility had no other policy besides the Provider Letter. Record review of the Long-Term Care Regulation Provider Letter Number: PL 2024-14 dated 08/29/25 reflected a nursing facility must report to the State Agency Abuse, in accordance with applicable state and federal requirements. Allegations of abuse were to be reported immediately, but no later than two hours after the incident occurs or is suspected. During an observation on 08/27/25 at 11:14 AM, Resident #1 was asleep in bed with the covers over his head. In a 675093 Page 2 of 13 675093 08/28/2025 Lakeside Rehabilitation and Care Center 4306 24th St Lubbock, TX 79410

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few telephone interview on 08/27/25 at 12:12 PM, former Housekeeper A stated she and former Housekeeper B were on a break out smoking and Resident #1 was outside with them. She stated she heard the Administrator tell Resident #1 he had something for him, but she did not see the hand gesture. She stated former Housekeeper B heard and saw the gesture. She stated Resident #1 said he thought the Administrator was taking things too far with the hand gesture. She stated the RNC came to the facility to investigate the allegations, but the RNC did not interview her. She stated former Housekeeper B did report the incident to the RNC because former Housekeeper B was bothered by the incident. In a telephone interview on 08/27/25 at 12:36 PM, former Housekeeper B stated she was outside on a smoke break with former Housekeeper A and Resident #1. She stated she hear the Administrator tell Resident #1 I have something for you, and then she saw the Administrator take his hand out of his pocket and flip Resident #1 off. She stated Resident #1 told the Administrator Don't disrespect me like that. She stated the Administrator told Resident #1 he was just playing. She stated the Administrator went back inside and Resident #1 said to her, did you see what he did that isn't cool. She stated she reported the incident to the DON and the ADON. She stated she was interviewed by the RNC and told the RNC about the incident. She stated she told the RNC the Administrator was making her and Resident #1 uncomfortable with his inappropriate comments. She stated after she reported the incident the Administrator began kissing Resident #1's ass. In a telephone interview on 08/27/25 at 12:50 PM, former ADON said the former DON sent corporate an email regarding the allegation about the Administrator. She stated Resident #1 came into the office with the former DON to express to us that while he was in the smoke room, the Administrator came in and told him he had something for him, the Administrator went into his pocket, pulled out his hand, and then flipped the resident off. She stated the RNC came to conduct the investigation but did not even interview Resident #1. She stated the Safe Surveys were done but were not specific to allegations regarding the Administrator. She stated, after the DON was terminated, she believed the allegations were not really investigated by the RNC, so she sent the RDO an email and he responded to her email and stated she was terminated. Record review of the email exchange between the former ADON and the RDO dated 05/15/25 reflected at 8:28 AM the former ADON sent the RDO an email entitled URGENT CRITICAL MATTER which read in part, around about on April 29th when Resident #1 came into the office with the DON and myself to express to us that while he was in the smoke room, the Administrator came in and told him he had something for him, went into his pocket, pulled out his hand, and then flipped him off. Resident #1 asked the DON to make the Administrator stop talking to him because he did not like him and they did not have a relationship in which it was considered ok to do those things to him. During the RNC's investigation it was brought to my attention that she failed to talk to half the nursing staff (she only spoke with the staff that worked that date), and she never spoke with the resident (Resident #1) with the compliant. At 2:18 PM the RDO responded via email, thank you for bringing this to our attention. I appreciate your concern, and for sharing these details, I am placing you on a temporary suspension while we conduct an investigation into this matter. Please do not consider this a punitive action but a necessary step in order to conduct a full and fair investigation into these allegations. In an interview on 08/27/25 at 1:54 PM, the SW stated, regarding the Safe Surveys dated 05/08/25, she did not ask the residents anything specifically about the Administrator. She stated she asked the residents the general questions on the Safe Survey sheet. In an interview and observation on 08/27/25 at 2:30 PM, Resident #1 was in bed in his room, his roommate was out of the room. He stated he was reluctant to speak to the investigator because the incident had been a long time ago, the Administrator apologized, and everything had been fine since. He stated the Administrator did flip him off when he was in the smoking area, and he 675093 Page 3 of 13 675093 08/28/2025 Lakeside Rehabilitation and Care Center 4306 24th St Lubbock, TX 79410

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few just looked at the Administrator and did not respond. Resident #1 stated he was fine, and the incident did not affect him negatively. He stated he did not feel intimidated and had not changed his usual patterns in the facility. He stated he likes to stay up late and sleep late and staff accommodate him and let him do the things he wants to do. In a telephone interview on 08/27/25 at 4:05 PM, the RNC stated Housekeeper B told her about the incident with Resident #1 and the Administrator's hand gesture. She stated she did not speak to Resident #1, but he did not report any issues in the Safe Survey. She stated she did not feel it was a reportable incident of abuse because a lot of time had passed (from 04/29/25 - 05/08/25 ten days). She stated the Administrator was verbally counseled regarding the incident, but it was not a written counseling. She stated in response to the incident and residents' responses on the Safe Surveys dated 05/08/25 an in-service on abuse was conducted, but no further investigations were conducted into any of the allegations on the surveys. In a telephone interview on 08/27/25 at 4:09 PM, the RDO stated he over saw 20 facility's and it had been sometime since the incidents so he might not remember all the details or the timeline. He stated the former DON and ADON's complaints about theAdministrator were emailed to him. He stated the RNC was tasked with investigating the DON's complaint. He stated he could not remember the details of the complaint or the timeline to say if the allegation was reportable. He stated he believed the RNC shared the results of her investigation with him. He stated the finger gesture was bordering on reportable but sounded like it was reportable. He stated he was not aware Resident #1 was not interviewed by the RNC. He stated he was not sure what action was taken regarding the incident, but he thinks the Administrator was counseled. In a confidential telephone interview it was stated they heard about the Administrator flipping Resident #1 off. They stated they heard Resident #1 tell the former ADON, I don't know why he would feel comfortable doing that with me because we don't have a relationship like that. During the exit conference on 08/28/25 at 1:04 PM the Administrator stated he disagrees with findings. He adamantly denied the allegation he flipped Resident #1 off. He stated he was not counseled by the RNC and all she said was, if you did it don't do it again. Record review of the facility's Resident Rights policy dated December 2016 reflected employees shall treat all residents with kindness respect and dignity. 675093 Page 4 of 13 675093 08/28/2025 Lakeside Rehabilitation and Care Center 4306 24th St Lubbock, TX 79410

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, observation, and record review, the facility failed to ensure an allegation of abuse was reported immediately to the State Agency as required for 1 of 14 residents (Resident #1) reviewed for abuse reporting. Resident #1 alleged the Administrator made an obscene hand gesture. The allegation was not reported to the State Agency. This failure resulted in the residents' right to be free from abuse not protected, eliminated the opportunity for a timely investigation by the State Agency and placed all the residents at risk for abuse and psychological harm, which resulted in substandard quality of care. Record review of Resident #1's Transfer/Discharge Report dated 08/27/25 reflected the [AGE] year-old male resident was re-admitted to the facility on [DATE] with a diagnosis of paraplegia. Record review of Resident #1's quarterly MDS dated [DATE] reflected the resident was admitted to the facility on [DATE]. He was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated cognitively intact). In an interview on 08/27/25 at 8:18 AM, the SW stated she began her employment at the facility in April 2025. She stated there was staff turnover around May 2025. She stated on 05/08/25 she was asked to conduct Safe Surveys with the residents due to complaints about the Administrator's inappropriate comments to staff and the residents. She stated the Administrator was suspended 2-3 days while the investigation was conducted by the RNC, but she did not know the specifics. She stated none of the residents she interviewed reported any complaints or concerns regarding the Administrator. In a telephone interview on 08/27/25 at 8:48 AM, the former DON stated Resident #1 informed her the Administrator made an obscene gesture, the middle finger which the resident found to be disrespectful. She stated the obscene gesture and unprofessional comments the Administrator made to staff and residents to the RDO. She stated about a week after she made the comments the RNC came to investigate. She stated the RNC suspended the Administrator a few days while she conducted the investigation. She stated the RNC did not report the allegations to the State Agency but should have been as required. The former DON stated Resident #1 was not interviewed by the RNC about the specific allegations regarding the Administrator and she believed the RNC terminated her employment and brought the Administrator back the day after her termination. She stated she believes her termination was retaliation for reporting the Administrator. Record review of the former DON's Disciplinary Action Form dated 05/12/25 revealed, a statement from the former DON, which read, in part, this is done in retaliation to me reporting Administrator, who not only verbally abuse - but also emotionally abused a resident. The form was signed by the former DON and RNC on 05/12/25. Record review of an email from the former DON to the RDO dated 04/30/25 at 7:42 PM which read, in part, I am writing to you today to inform you about something that has been going on in the facility since the Administrator has arrived to the facility. Today a resident by the name of Resident #1 came into my office to explain to me that he felt like he was being mistreated by the administrator. This is not the first time that the resident has voiced to me ill treatment from the Administrator. In this particular instance, the resident came into my office and informed me that yesterday (04/29/25) while he was in the smoking room, the Administrator came up to him in front of an employee and stated Hey Resident #1, I have something for you. At that time the Administrator went into his pocket and pulled out his fist and flipped him off. The resident then informed me that former Housekeeper A saw him do this. He said he felt like this was inappropriate and at no time have he and the Administrator had a relationship in which they would joke around with each other the resident went on to tell me that he and the Administrator do not have a relationship in which it would ever be ok to do those things. In a telephone interview on 08/27/25 at 9:27 AM, the RNC stated the RDO received an email from the former DON 675093 Page 5 of 13 675093 08/28/2025 Lakeside Rehabilitation and Care Center 4306 24th St Lubbock, TX 79410

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few alleging the Administrator had verbally abused Resident #1. She stated she suspended the Administrator 3 days, maybe more, while she interviewed the staff who all denied the allegations. She stated she did not interview Resident #1 about the allegations, but she had the SW conduct Safe Surveys and none of the residents, including Resident #1 reported any issues. She stated the decision was made to treat the incident internally and not report the incident to the State Agency. When the RNC was asked by the Investigator if the facility policy was followed regarding reporting, she stated that's a tricky one because everyone denied the allegations. Record review of the RNC's investigation conducted on 05/08/25 reflected a copy of the email from the former DON to the RDO dated 04/30/25, the Safe Surveys conducted by the SW with the residents on 05/08/25 and the RDO's interviews with staff: - The Administrator denied the allegation. - An interview with former Housekeeper B on 5/8/2025 at 2:49 PM reflected, Have you ever been witness to any administrative staff saying or doing anything to a resident/or other staff member that would be considered out of a professional role? If so, can you tell me when, by whom and directed towards who? I was in the smoke room at the same time with Resident #1 when the Administrator came in and spoke with all of us and then told Resident #1, I have something for you and then the Administrator pulled out his hand and flipped Resident #1 off but then talk him he was just playing and then Resident #1 said boy and then they both laughed. Did you report that to anyone? No ma'am I did not I thought they were just playing. - The SW conducted Safe Surveys with 46 residents on 05/08/25, the questions included general questions regarding which included if they were comfortable asking for assistance, if staff treated them with dignity and respect, if they felt safe in the facility, if they felt comfortable telling staff about concerns, if staff had ever physically harmed them and if staff member ever yelled or cursed at them. Resident #1 responded he did not feel comfortable asking staff for assistance; however, there was no further documentation regarding his response. Resident #1 reported no other issues during the Safe Survey. Record review of the Grievances from May 2025 - August 2025 reflected no grievances regarding Resident #1 or the Administrator. In an interview on 08/27/25 at 9:55 AM, the Administrator stated he was informed by the RNC of the allegations made against him and he was interviewed by the RNC. He stated he denied all the allegations in the former DON's email. He stated he did not want to discuss specifics because of legal action taken by the former DON and ADON. He stated he was suspended for an abuse allegation and was off 3 to 4 days pending the outcome of the investigation. He stated he was not privy to whether the incident was reported to the State Agency. He said the facility follows the Provider Letter as the policy regarding investigating and reporting abuse allegations. He stated he feels Corporate probably looked at the Provider Letter and made decisions based on it. He stated the facility had no other policy besides the Provider Letter. Record review of the Long-Term Care Regulation Provider Letter Number: PL 2024-14 dated 08/29/25 reflected a nursing facility must report to the State Agency Abuse, in accordance with applicable state and federal requirements. Allegations of abuse were to be reported immediately, but no later than two hours after the incident occurs or is suspected. During an observation on 08/27/25 at 11:14 AM, Resident #1 was asleep in bed with he covers over his head. In a telephone interview on 08/27/25 at 12:12 PM, former Housekeeper A stated she and former Housekeeper B were on a break out smoking and Resident #1 was outside with them. She stated she heard the Administrator tell Resident #1 he had something for him, but she did not see the hand gesture. She stated former Housekeeper B heard and saw the gesture. She stated Resident #1 said he thought the Administrator was taking things too far with the hand gesture. She stated the RNC came to the facility to investigate the allegations, but the RNC did not interview her. She stated former Housekeeper B did report the incident to the RNC because former Housekeeper B was bothered by the incident. In a 675093 Page 6 of 13 675093 08/28/2025 Lakeside Rehabilitation and Care Center 4306 24th St Lubbock, TX 79410

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few telephone interview on 08/27/25 at 12:36 PM, former Housekeeper B stated she was outside on a smoke break with former Housekeeper A and Resident #1. She stated she hear the Administrator tell Resident #1 I have something for you, and then she saw the Administrator take his hand out of his pocket and flip Resident #1 off. She stated Resident #1 told the Administrator Don't disrespect me like that. She stated the Administrator told Resident #1 he was just playing. She stated the Administrator went back inside and Resident #1 said to her, did you see what he did that isn't cool. She stated she reported the incident to the DON and the ADON. She stated she was interviewed by the RNC and told the RNC about the incident. She stated she told the RNC the Administrator was making her and Resident #1 uncomfortable with his inappropriate comments. She stated after she reported the incident the Administrator began kissing Resident #1's ass. In a telephone interview on 08/27/25 at 12:50 PM, former ADON said the former DON sent corporate an email regarding the allegation about the Administrator. She stated Resident #1 told came into the office with the former DON to express to us that while he was in the smoke room, the Administrator came in and told him he had something for him, the Administrator went into his pocket, pulled out his hand, and then flipped the resident off. She stated the RNC same to conduct the investigation but did not even interview Resident #1. She stated the Safe Surveys were done but were not specific to allegations regarding the Administrator. She stated, after the DON was terminated, she believed the allegations were not really investigated by the RNC, so she sent the RDO an email and he responded to her email and stated she was terminated. Record review of the email exchange between the former ADON and the RDO dated 05/15/25 reflected at 8:28 AM, the former ADON sent the RDO an email entitled URGENT CRITICAL MATTER which read in part, around about on April 29th when Resident #1 came into the office with the DON and myself to express to us that while he was in the smoke room, the Administrator came in and told him he had something for him, went into his pocket, pulled out his hand, and then flipped him off. Resident #1 asked the DON to make the Administrator stop talking to him because he did not like him and they did not have a relationship in which it was considered ok to do those things to him. During the RNC's investigation it was brought to my attention that she failed to talk to half the nursing staff (she only spoke with the staff that worked that date), and she never spoke with the resident (Resident #1) with the compliant. At 2:18 PM the RDO responded via email, thank you for bringing this to our attention. I appreciate your concern, and for sharing these details, I am placing you on a temporary suspension while we conduct an investigation into this matter. Please do not consider this a punitive action but a necessary step in order to conduct a full and fair[PH1] investigation into these allegations. In an interview on 08/27/25 at 1:54 PM, the SW stated, regarding the Safe Surveys dated 05/08/25, she did not ask the residents anything specifically about the Administrator. She stated she asked the residents the general questions on the Safe Survey sheet. In an interview and observation on 08/27/25 at 2:30 PM, Resident #1 was in bed in his room, his roommate was out of the room. He stated he was reluctant to speak to the investigator because the incident had been a long time ago, the Administrator apologized, and everything had been fine since. He stated the Administrator did flip him off when he was in the smoking area, and he just looked at the Administrator and did not respond. Resident #1 stated he was fine, and the incident did not affect him negatively. He stated he did not feel intimidated and had not changed his usual patterns in the facility. He stated he likes to stay up late and sleep late and staff accommodate him and let him do the things he wants to do. In a telephone interview on 08/27/25 at 4:05 PM, the RNC stated Housekeeper B told her about the incident with Resident #1 and the Administrator's hand gesture. She stated she did not speak to Resident #1, but he did not report any issues in the Safe Survey. She stated she did not feel it was a reportable incident of abuse because a 675093 Page 7 of 13 675093 08/28/2025 Lakeside Rehabilitation and Care Center 4306 24th St Lubbock, TX 79410

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few lot of time had passed (from 04/29/25 - 05/08/25 ten days). She stated the Administrator was verbally counseled regarding the incident, but it was not a written counseling. She stated in response to the incident and residents' responses on the Safe Surveys dated 05/08/25 an in-service on abuse was conducted, but no further investigations were conducted into any of the allegations on the surveys. In a telephone interview on 08/27/25 at 4:09 PM, the RDO stated he over saw 20 facility's and it had been sometime since the incidents so he might not remember all the details or the timeline. He stated the former DON and ADON's complaints about theAdministrator were emailed to him. He stated the RNC was tasked with investigating the DON's complaint. He stated he could not remember the details of the complaint or the timeline to say if the allegation was reportable. He stated he believed the RNC shared the results of her investigation with him. He stated the finger gesture was bordering on reportable but sounded like it was reportable. He stated he was not aware Resident #1 was not interviewed by the RNC. He stated he was not sure what action was taken regarding the incident, but he thinks the Administrator was counseled. In a confidential interview on 08/28/25 at 7:22 AM, it was said they heard about the Administrator flipping Resident #1 off. They stated they heard Resident #1 tell the former ADON, I don't know why he would feel comfortable doing that with me because we don't have a relationship like that. They stated they followed up with the resident about a week later and the resident said no one had come to talk with him about it but he was told it's been taken care of. They stated they were not interviewed by the RNC regarding the allegation. They stated all the staffing changes made them not feel comfortable to report anything to the Administrator or Corporate. During the exit conference on 08/28/25 at 1:04 PM, the Administrator stated he disagrees with findings. He adamantly denied the allegation he flipped Resident #1 off. He stated he was not counseled by the RNC and all she said was, if you did it don't do it again. 675093 Page 8 of 13 675093 08/28/2025 Lakeside Rehabilitation and Care Center 4306 24th St Lubbock, TX 79410

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure allegations of abuse were promptly and thoroughly investigated for 7 of 14 residents (Resident #1, #3, #4, #6, #8, #9, and #12) reviewed for abuse prevention. 1) Resident #1 alleged the Administrator made an obscene hand gesture. Resident #1 was not interviewed regarding the allegation and the incident was not reported to the State Agency as required. 2) Residents #3, #4, #6, #8, #9, and #12 alleged staff members were rude and/or yelled at them. The residents' allegations were documented on the Safe Surveys conducted on 05/08/25, the facility did not initiate an investigation on any of the residents' statements. These failures placed all the residents at risk for abuse and psychological harm, which resulted in substandard quality of care. Findings included: Record review of Resident #1's Transfer/Discharge Report dated 08/27/25 reflected the [AGE] year-old male resident was re-admitted to the facility on [DATE] with a diagnosis of paraplegia. Record review of Resident #1's quarterly MDS dated [DATE] reflected the resident was admitted to the facility on [DATE]. He was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated cognitively intact). In an interview on 08/27/25 at 8:18 AM, the SW stated she began her employment at the facility in April 2025. She stated there was staff turnover around May 2025. She stated on 05/08/25 she was asked to conduct Safe Surveys with the residents due to complaints about the Administrator's inappropriate comments to staff and the residents. She stated the Administrator was suspended 2-3 days while the investigation was conducted by the RNC, but she did not know the specifics. She stated none of the residents she interviewed reported any complaints or concerns regarding the Administrator. In a telephone interview on 08/27/25 at 8:48 AM. the former DON stated Resident #1 informed her the Administrator made an obscene gesture, the middle finger which the resident found to be disrespectful. She stated she the obscene gesture and unprofessional comments the Administrator had made to staff and residents to the RDO. She stated about a week after she made the comments the RNC came to investigate. She stated the RNC suspended the Administrator a few days while she conducted the investigation. She stated the RNC did not report the allegations to the State Agency but should have been as required. The former DON stated Resident #1 was not interviewed by the RNC about the specific allegations regarding the Administrator and she believed. She stated the RNC terminated her employment and brought the Administrator back the day after her termination. She stated she believes her termination was retaliation for reporting the Administrator. Record review of an email from the former DON to the RDO dated 04/30/25 at 7:42 PM, which read, in part, I am writing to you today to inform you about something that has been going on in the facility since the Administrator has arrived to the facility. Today a resident by the name of Resident #1 came into my office to explain to me that he felt like he was being mistreated by the administrator. This is not the first time that the resident has voiced to me ill treatment from the Administrator. In this particular instance, the resident came into my office and informed me that yesterday (04/29/25) while he was in the smoking room, the Administrator came up to him in front of an employee and stated Hey Resident #1, I have something for you. At that time the Administrator went into his pocket and pulled out his fist and flipped him off. The resident then informed me that former Housekeeper A saw him do this. He said he felt like this was inappropriate and at no time have he and the Administrator had a relationship in which they would joke around with each other the resident went on to tell me that he and the Administrator do not have a relationship in which it would ever be ok to do those things. In a telephone interview on 08/27/25 at 9:27 AM. the RNC stated the RDO received an email from the former DON alleging the Administrator had verbally abused Resident #1. She stated she suspended the Administrator 3 days, maybe more, while she interviewed the Residents Affected - Some 675093 Page 9 of 13 675093 08/28/2025 Lakeside Rehabilitation and Care Center 4306 24th St Lubbock, TX 79410

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff who all denied the allegations. She stated she did not interview Resident #1 about the allegations, but she had the SW conduct Safe Surveys and none of the residents, including Resident #1 reported any issues. She stated the decision was made to treat the incident internally and not report the incident to the State Agency. When the RNC was asked by the Investigator if the facility policy was followed regarding reporting, she stated that's a tricky one because everyone denied the allegations. Record review of the RNC's investigation conducted on 05/08/25 reflected a copy of the email from the former DON to the RDO dated 04/30/25, the Safe Surveys conducted by the SW with the residents on 05/08/25 and the RDO's interviews with staff: - The Administrator denied the allegation. - An interview with former Housekeeper B on 5/8/2025 at 2:49 PM reflected, Have you ever been witness to any administrative staff saying or doing anything to a resident/or other staff member that would be considered out of a professional role? If so, can you tell me when, by whom and directed towards who? I was in the smoke room at the same time with Resident #1 when the Administrator came in and spoke with all of us and then told Resident #1, I have something for you and then the Administrator pulled out his hand and flipped Resident #1 off but then talk him he was just playing and then Resident #1 said boy and then they both laughed. Did you report that to anyone? No ma'am I did not I thought they were just playing. - The SW conducted Safe Surveys with 46 residents on 05/08/25, the questions included general questions regarding which included if they were comfortable asking for assistance, if staff treated them with dignity and respect, if they felt safe in the facility, if they felt comfortable telling staff about concerns, if staff had ever physically harmed them and if staff member ever yelled or cursed at them. Resident #1 responded he did not feel comfortable asking staff for assistance; however, there was no further documentation regarding his response. Resident #1 reported no other issues during the Safe Survey. Residents #3, #4, #6, #8, #9, and #12, responded Yes, to the question, Has a staff member ever yelled or cursed at you?, the notes indicated Residents #6, #8, #9, and #12 reported staff was rude no staffs' names were disclosed and/or documented. Resident #4 reported she was yelled at by unnamed female staff. Resident #3 reported staff threatens her that she will be put out if not behaving and staff were rude. Record review of Resident #3's Transfer/Discharge Report dated 08/27/25 the [AGE] year-old female resident was re-admitted to the facility on [DATE] with a diagnosis of bipolar disorder. Record review of Resident #3's quarterly MDS dated [DATE] reflected she was admitted to the facility on [DATE]. She was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated cognitively intact). Record review of Resident #4's Transfer/Discharge Report dated 08/27/25 reflected the [AGE] year-old female was re-admitted to the facility on [DATE] with a diagnosis of diabetes. Record review of Resident #4's annual MDS dated [DATE] reflected she was admitted to the facility on [DATE]. She was cognitively intact with a BIMS score of 14 (a score of 13-15 indicated cognitively intact). Record review of Resident #6's Transfer/Discharge Report dated 08/27/25 reflected the [AGE] year-old female resident was re-admitted to the facility on [DATE] with a diagnosis of acute respiratory failure. Record review of Resident #6's quarterly MDS dated [DATE] reflected she admitted to the facility on [DATE]. She was cognitively intact with a BIMS score of 13 (a score of 13-15 indicated cognitively intact). Record review of Resident #8's admission Record dated 08/28/25 reflected the [AGE] year-old male resident was admitted to the facility on [DATE] with a diagnosis of femur fracture. Record review of Resident #8's quarterly MDS dated [DATE] reflected his BIMS score was 13 which reflected he was cognitively intact (a score of 13-15 indicated cognitively intact). Record review of Resident #9's admission Record dated 08/28/25 reflected the [AGE] year-old female resident was admitted to the facility on [DATE] with a diagnosis of multiple sclerosis. Record review of Resident #9 quarterly MDS dated [DATE] reflected her BIMS score was 12 which 675093 Page 10 of 13 675093 08/28/2025 Lakeside Rehabilitation and Care Center 4306 24th St Lubbock, TX 79410

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some reflected she was moderately cognitively impaired (a score of 8-12 indicated moderate impairment). Record review of Resident #12's admission Record dated 08/28/25 reflect the [AGE] year-old male resident was admitted to the facility on [DATE] with a diagnosis of sepsis. Record review of Resident #12's quarterly MDS dated [DATE] reflected he was cognitively intact with a BIMS score of 14 (a score of 13-15 indicated cognitively intact). Record review of the facility's Grievances from May 2025 to August 2025 did not reveal any grievances or investigations related to the results of the Safe Surveys conducted on 05/08/25. There were no grievances regarding the Administrator. In an interview on 08/27/25 at 9:55 AM, the Administrator stated he was informed by the RNC of the allegations made against him and he was interviewed by the RNC. He stated he denied all the allegations in the former DON's email. He stated he did not want to discuss specifics because of legal action taken by the former DON and ADON. He stated he was suspended for an abuse allegation and was off 3 to 4 days pending the outcome of the investigation. He stated he was not privy to whether the incident was reported to the State Agency. He said the facility follows the Provider Letter as the policy regarding investigating and reporting abuse allegations. He stated he feels Corporate probably looked at the Provider Letter and made decisions based on it. He stated the facility had no other policy besides the Provider Letter. Record review of the Long-Term Care Regulation Provider Letter Number: PL 2024-14 dated 08/29/25 reflected a nursing facility must report to the State Agency Abuse, in accordance with applicable state and federal requirements. Allegations of abuse were to be reported immediately, but no later than two hours after the incident occurs or is suspected. During an observation on 08/27/25 at 11:14 AM Resident #1 was asleep in bed with he covers over his head. In a telephone interview on 08/27/25 at 12:12 PM, former Housekeeper A stated she and former Housekeeper B were on a break out smoking and Resident #1 was outside with them. She stated she heard the Administrator tell Resident #1 he had something for him, but she did not see the hand gesture. She stated former Housekeeper B heard and saw the gesture. She stated Resident #1 said he thought the Administrator was taking things too far with the hand gesture. She stated the RNC came to the facility to investigate the allegations, but the RNC did not interview her. She stated former Housekeeper B did report the incident to the RNC because former Housekeeper B was bothered by the incident. In a telephone interview on 08/27/25 at 12:36 PM, former Housekeeper B stated she was outside on a smoke break with former Housekeeper A and Resident #1. She stated she hear the Administrator tell Resident #1 I have something for you, and then she saw the Administrator take his hand out of his pocket and flip Resident #1 off. She stated Resident #1 told the Administrator Don't disrespect me like that. She stated the Administrator told Resident #1 he was just playing. She stated the Administrator went back inside and Resident #1 said to her, did you see what he did that isn't cool. She stated she reported the incident to the DON and the ADON. She stated she was interviewed by the RNC and told the RNC about the incident. She stated she told the RNC the Administrator was making her and Resident #1 uncomfortable with his inappropriate comments. She stated after she reported the incident the Administrator began kissing Resident #1's ass. In a telephone interview on 08/27/25 at 12:50 PM, former ADON said the former DON sent corporate an email regarding the allegation about the Administrator. She stated Resident #1 told came into the office with the former DON to express to us that while he was in the smoke room, the Administrator came in and told him he had something for him, the Administrator went into his pocket, pulled out his hand, and then flipped the resident off. She stated the RNC same to conduct the investigation but did not even interview Resident #1. She stated the Safe Surveys were done but were not specific to allegations regarding the Administrator. She stated, after the DON was terminated, she believed the allegations were not really investigated by the RNC, so she sent the RDO an email and he 675093 Page 11 of 13 675093 08/28/2025 Lakeside Rehabilitation and Care Center 4306 24th St Lubbock, TX 79410

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some responded to her email and stated she was terminated. Record review of the email exchange between the former ADON and the RDO dated 05/15/25 reflected at 8:28 AM the former ADON sent the RDO an email entitled URGENT CRITICAL MATTER which read in part, around about on April 29th when Resident #1 came into the office with the DON and myself to express to us that while he was in the smoke room, the Administrator came in and told him he had something for him, went into his pocket, pulled out his hand, and then flipped him off. Resident #1 asked the DON to make the Administrator stop talking to him because he did not like him and they did not have a relationship in which it was considered ok to do those things to him. During the RNC's investigation it was brought to my attention that she failed to talk to half the nursing staff (she only spoke with the staff that worked that date), and she never spoke with the resident (Resident #1) with the compliant. At 2:18 PM the RDO responded via email, thank you for bringing this to our attention. I appreciate your concern, and for sharing these details, I am placing you on a temporary suspension while we conduct an investigation into this matter. Please do not consider this a punitive action but a necessary step in order to conduct a full and fare investigation into these allegations. In an interview on 08/27/25 at 1:54 PM, the SW stated, regarding the Safe Surveys dated 05/08/25, she did not ask the residents anything specifically about the Administrator. She stated she asked the residents the general questions on the Safe Survey sheet. In an interview and observation on 08/27/25 at 2:30 PM, Resident #1 was in bed in his room, his roommate was out of the room. He stated he was reluctant to speak to the investigator because the incident had been a long time ago, the Administrator apologized, and everything had been fine since. He stated the Administrator did flip him off when he was in the smoking area, and he just looked at the Administrator and did not respond. Resident #1 stated he was fine, and the incident did not affect him negatively. He stated he did not feel intimidated and had not changed his usual patterns in the facility. He stated he likes to stay up late and sleep late and staff accommodate him and let him do the things he wants to do. In a telephone interview on 08/27/25 at 4:05 PM, the RNC stated Housekeeper B told her about the incident with Resident #1 and the Administrator's hand gesture. She stated she did not speak to Resident #1, but he did not report any issues in the Safe Survey. She stated she did not feel it was a reportable incident of abuse because a lot of time had passed (from 04/29/25 - 05/08/25 ten days). She stated the Administrator was verbally counseled regarding the incident, but it was not a written counseling. She stated in response to the incident and residents' responses on the Safe Surveys dated 05/08/25 an in-service on abuse was conducted, but no further investigations were conducted into any of the allegations on the surveys. In a telephone interview on 08/27/25 at 4:09 PM, the RDO stated he over saw 20 facility's and it had been sometime since the incidents so he might not remember all the details or the timeline. He stated the former DON and ADON's complaints about theAdministrator were emailed to him. He stated the RNC was tasked with investigating the DON's complaint. He stated he could not remember the details of the complaint or the timeline to say if the allegation was reportable. He stated he believed the RNC shared the results of her investigation with him. He stated the finger gesture was bordering on reportable but sounded like it was reportable. He stated he was not aware Resident #1 was not interviewed by the RNC. He stated he was not sure what action was taken regarding the incident, but he thinks the Administrator was counseled. In an interview on 08/28/25 at 5:35 PM, the Administrator stated he was suspended and not privy to the investigation of the allegations. He stated today (08/28/25) was the first time he had seen the results of the safe surveys, but he believes most of the issues identified in the Safe Surveys have been addressed. He stated he did not flip Resident #1 off and that is not something he does in his personal life and certainly would not do it in his professional life In a confidential staff telephone 675093 Page 12 of 13 675093 08/28/2025 Lakeside Rehabilitation and Care Center 4306 24th St Lubbock, TX 79410

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some interview on 08/28/25 at 7:22 AM, staff stated they heard about the Administrator flipping Resident #1 off. The staff stated they heard Resident #1 tell the former ADON, I don't know why he would feel comfortable doing that with me because we don't have a relationship like that. The staff stated they followed up with the resident about a week later and the resident said no one had come to talk with him about it but he was told it's been taken care of. The staff stated they were not interviewed by the RNC regarding the allegation. The staff stated all the staffing changes made them not feel comfortable to report anything to the Administrator or Corporate. In an interview on 08/28/25 at 9:30 AM, Resident #4 stated staff were not rude or abusive to her. She stated sometimes staff tell her they are going to do something and then they don't. In an interview on 08/28/25 at 10:08 AM, the Administrator stated, regarding the residents' responses to the Safe Surveys and the lack of Grievances, the first week in April 2025 the facility had a re-certification survey, and grievances was cited, so he completed his plan of correction for the process. He stated the responses were from 05/08/25 and he could narrow down who the staff in question was. He stated he has done customer service and resident rights in-services but a lot of the staff working during this time, May 2025, were no longer working because the facility had an 80% turnover in aides. In an interview on 08/28/25 at 10:15 AM, Resident #3 stated she liked the facility and did not report any abuse or rudeness from the staff. In an interview on 08/28/25 at 10:52 AM, Resident #8 reported no issues with his care and treatment in the facility. In an interview on 08/28/25 at 10:56 AM, Resident #6 reported no issues or concerns regarding her care or treatment in the facility. In an interview on 08/28/25 at 10:58 AM, Resident #9 had no complaints about her care or treatment in the facility. In interview on 08/28/25 at 11:05 AM Resident #12 reported no issues with his care or treatment in the facility. In an interview on 08/28/25 at 11:38 AM, the SW stated she did the Safe Surveys and gave them to the RNC on 05/08/25, but the RNC did not give her any further instructions. She stated when the Administrator returned from his suspension she gave him a copy of the Safe Surveys. She said she could not remember if she gave him a physical copy or emailed a copy to him In an interview on 08/28/25 at 11:43 AM, the SW said she had no record of emailing the Safe Surveys to the Administrator so she must have handed a copy to him. During the exit conference on 08/28/25 at 1:04 PM, the Administrator stated he disagrees with findings. He adamantly denied the allegation he flipped Resident #1 off. He stated he was not counseled by the RNC and all she said was, if you did it don't do it again. 675093 Page 13 of 13