Health inspection·June 28, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 1 of 8 residents (Resident #1) reviewed for abuse and neglect. Residents Affected - Few The facility failed to notify the physician and/or family members for Resident #1 of potential abuse and neglect. This failure could place residents at risk of lack of communication with families and providing physicians following allegations of Abuse, Neglect, and Exploitation. Findings include: Record review of Resident #1's face sheet on 6/28/23 revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses include but are not limited to unspecified dementia, anxiety disorder, insomnia, acute on chronic diastolic (congestive) heart failure (heart disease that affects pumping action of the heart muscles), emphysema (lung disease), and chronic obstructive pulmonary disease (COPD) (lung disease resulting in shortness of breath and obstruction airflow to the lungs). Resident #1's resident representative and acting physician contact information is provided on face sheet. Record review of Resident #1's MDS, dated [DATE], on 6/28/23 revealed a BIMS (brief interview of mental status) of 5 indicating severe cognitive impairment (needs assistance with memory, thinking, and problem solving). Record review of incident report on 6/28/23 made by facility ADM revealed an incident of abuse involving Resident #1 and CNA B on 6/10/23 at 12:00 PM. Incident indicated that previous employee of facility was verbally told by Resident #1 that CNA B had kicked her. Record review of Resident #1's progress notes on 6/28/23 revealed no documentation on 6/10/23 relating to incident that was reported. Record review of Resident #1's Situation, Background, Assessment, and Recommendation (SBAR) noted on 6/28/23 revealed no documentation of notification to family or physician. Interview with Resident #1's family member #1 on 6/28/23 at 8:54 AM revealed that family member was not made aware of incident involving abuse between Resident #1 and CNA B with no notification provided. Page 1 of 2 675498 675498 06/28/2023 Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119

F 0607 Level of Harm - Minimal harm or potential for actual harm Interview with HM on 6/28/23 at 10:21 AM revealed being notified of the incident by HK and reporting to DON. Interview with DON on 6/28/23 at 10:45 AM revealed DON entered facility on a Saturday to investigate allegation. Residents Affected - Few Interview with Resident #1's family member #2 on 6/28/23 at 3:50 PM revealed they were not made aware of incident. Interview with ADON on 6/28/23 at 5:04 PM, revealed that Abuse, Neglect, Exploitation, and Mistreatment incidents are to be reported immediately to supervisor, person will be suspended as well as notification to family and physician. ADON stated there is no instance where the family or the physician should not be notified. Negative outcomes stated are injuries that weren't addressed and termination. Interview with DON on 6/28/23 at 5:09 PM revealed they would have to review policy prior to answering and allegations are reported to ADM who is also ANE coordinator. DON stated that clarification based on the policy would be needed for who to notify and negative outcomes would be not following facility guidelines and best patient outcomes. Interview with ADM on 6/28/23 at 5:12 PM revealed unable to quote policy and would have to look at it. ADM indicated that allegations are to be reported within 2 hours and it is reported to the state. ADM reported that education to notify the family and usually the physician if there is injury. ADM identified negative outcomes as Its not really harm to a resident. There could be stuff that happened to their loved one that they do not know about. Mental anguish. It's not harming a resident, but it would upset the family if they found out afterwards. Record review of facility policy Abuse, Neglect, Misappropriation of Property, no date, on 6/28/23 revealed under Section III: Organizational Ethics, Number 7-Line B- Document the assessment in the medical record and Line D- Notify the attending physician and the resident's/patient's legally responsible party. 675498 Page 2 of 2