Health inspection·October 22, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs and preferences for 1 of 25 residents (Resident #20) reviewed for administration. Residents Affected - Few The facility failed to ensure all staff providing direct care to residents in the facility identify themselves by name and job title. This failure could affect resident in the facility by placing them at risk of not having needs met. Findings included: During and observation upon entrance to the facility on [DATE] at 9:28 a.m. LVN F was not wearing a name tag while in a resident care area. During and observation upon entrance to the facility on [DATE] at 9:40 a.m CNA B was not wearing a name tag while in a resident care area. During and observation upon entrance to the facility on [DATE] at 9:45 a.m. MA C was not wearing a name tag while in a resident care area. During and observation upon entrance to the facility on [DATE] at 9:50 a.m. NA-A was not wearing a name tag while in a resident care area. During and observation upon entrance to the facility on [DATE] at 10:30 a.m. the DON was not wearing a name tag that identified her current role while in a resident care area. During an interview with Resident #1 on 10/21/2023 at 11:56 a.m., Resident #1 said she had a hard time hearing some staff and understanding them. She described a staff member providing care to her and said she did not know their name at first and then after seeing the staff member she learned their name after having several interactions while the staff member assisted her in her room. Resident #1 said she was finally able to remember the staff members name because when she was younger her brother had a dog with the same name. Resident #1 explained being hard of hearing made it difficult for her to understand staff sometimes so being able to see a name and their title helps. Record review of Resident #1's face sheet, dated 10/22/2023, revealed an [AGE] year-old with diagnoses that included: bilateral hearing loss (hearing loss in both ears), Parkinson's disease (a brain Page 1 of 4 675428 675428 10/22/2023 Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few disorder that causes unintended or uncontrollable movements, such as shaking, stiffness and difficulty with balance and coordination), need for personal assistance with personal care, and cognitive communication disorder. During an interview with LVN F on 10/21/2023 at 3:55 p.m. LVN F said she did not have a name tag on this morning when she opened the door for this surveyor to enter the facility, she said this was her second time to work at this facility and she had not been given a name tag. During an interview with CNA B on 10/21/2023 at 2:40 p.m. CNA B stated they were supposed to wear name tags but no one had given her one but sometimes the facility would give a name tag to staff if they forget their name tag and then explained the staff that did that before is not at the facility on the weekends. During an interview with MA C on 10/21/2023 at 3:01 p.m., MA C stated she had never been given a name tag by this facility but did have one that could be worn and went on to say everyone should wear name tags so the residents know who was providing care to them. During an interview with NA-A on 10/21/2023 at 3:50 p.m., NA-A said she was not wearing a name tag but she was supposed to wear a name tag, so the residents know who people are and what they do. During an interview with the DON on 10/21/2023 at 4:00 p.m., the DON had a name tag with her name and ADON on the name tag beside her name. When asked if she was the DON or the ADON, she said the DON and had not received a new name tag with DON. The DON said she had been the DON for over 6 months. During an interview with the Administrator on 10/21/2023 at 4:15 p.m., the Administrator said all staff are required to wear name tags. The Administrator went on to say the facility does have a policy on staff wearing name tags the staff are expected to follow the policy, so residents and families know who they are and what their roles are. The Administrator did have a plastic name tag sleeve on with her standard business card identifying her within the plastic sleeve and clipped to her shirt. The Administrator provided a policy, Identification Name Badges, with the following Policy Statement: In order to promote safety and security measures established by our facility, each employee must wear his/her identification name badge at all times while on duty. Policy revised January 2008. 675428 Page 2 of 4 675428 10/22/2023 Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064

F 0728 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. Based on interview and record review the facility filed to ensure 1(NA A) of 3 Nurses' Aides were not working in the facility longer than four months without being enrolled in or having completed an approved training course. The facility failed to ensure NA A was certifed within the required time frame. This failure place residents at risk for receiving care from an individual whose skill level was not known. Findings include: Record review of the facility staff roster provided upon entrance revealed: Nurses' Aide A was listed at a Nursing Assistant with an 08/01/2022 hire date. During an interview with Nurses' Aide A on 10/21/2023 at 3:50 p.m. Nurses' Aide A explained previously taking the CNA written portion of the exam and not passing it. Nurses' Aide A explained she had not rescheduled the test since taking it in May 2022 and was waiting on the facility to register her for a CNA class. Nurses' Aide A explained she completes all services a Certified Nurses' Aide did in the facility. During an interview with HR specialist on 10/21/2023 at 4:40 p.m., HR specialist stated the Nurses' Aide did have a start date of employment at the facility on 03/01/ 2022 and did not know if she had taken any type of CNA test for certification but did know Nurses' Aide was listed on the staff list and in the facility records as a Nursing Assistant and not a CNA. During an interview with the DON on 10/21/2023 at 4:54 p.m., the DON said she did not think Nurses' Aide A was a CNA at this time and was not aware when or if Nurses' Aide previously took any type of CNA test. The DON explained the facility continued to allow Nurses' Aide because they had been given information on a PL that have approval for staff who had not completed a CNA course or testing an extension on the initial grace period granted during COVID- 19 (COVID-19- Corona Virus Disease- A severe acute respiratory syndrome aka SARS-COV-2). During an interview with the Administrator at 5:10 p.m. on 10/21/2023, the Administrator said Nurses' Aide A was a CNA at this time and was not aware when or if Nurses' Aide A previously took any type of CNA test or scheduled for any type of testing at this time. The Administrator explained the facility continued to allow the Nurses' Aide because they had been given information on a PL that have approval for staff who had not completed a CNA course or testing an extension on the initial grace period granted during COVID19. The Administrator provided an email on 10/22/2023 containing the following information: Work Experience and Training Requirements for Existing Temporary Nurse Aides Temporary nurse aides hired during the COVID-19 public health emergency were allowed under state regulations to use work experience and training obtained at a nursing facility to satisfy the 100-hour 675428 Page 3 of 4 675428 10/22/2023 Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064

F 0728 training requirement needed in order to take the exam for full certification. Level of Harm - Minimal harm or potential for actual harm Per 26 TAC §556.100, these temporary nurse aides were required to test and become fully certified by Oct. 15, 2023 (four months following the end of the COVID-19 public health emergency). Residents Affected - Few Beginning July 5, 2023, the online portal used by nurse aide applicants to request testing for certification has experienced some technical issues. Due to the delays caused by these unforeseen issues, HHSC will not enforce the Oct. 15, 2023, deadline but instead require certification before May 1, 2024. Until this date, a facility may continue to use temporary nurse aides who were hired and who completed their 100-hour training requirement before Oct. 15, 2023. Note: Federal regulations require that temporary nurse aides become certified within four months of their hire date. So, there may be some individuals who can apply the 100-hour work experience and training obtained while working as a temporary nurse aide towards the certification requirements but who still may be prohibited from working in a facility until they become certified. Nursing facilities must ensure that their temporary nurse aides register for testing and maintain documentation of registration and test dates on file. Any existing temporary nurse aides not certified before May 1, 2024, must complete a traditional Nurse Aide Training and Competency Evaluation Program (NATCEP) to be approved to take an exam and become certified. 675428 Page 4 of 4