Health inspection·February 28, 2024

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 and record review, the facility failed to report the results of all investigations to the State Survey Agency (HHSC), within 5 working days of the incident for 1 of 3 facility self-reported incidents (Incident Intake ID: 483847)reviewed for reporting to HHSC. The facility failed to submit a Provider Investigation Report to HHSC within 5 working days of reporting an incident involving allegations of quality of care, administration/personnel, and resident rights regarding Resident #1 on 02/12/24. This failure could place the residents at risk for not having investigations reported within the timeframe as required. Findings included: Record review of the face sheet printed on 02/28/24 indicated Resident #1 was a [AGE] year-old female admitted on [DATE] with diagnoses including vascular dementia severe with agitation (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), cerebral atherosclerosis (build-up of plaque in the blood vessels of the brain), and high blood pressure. Record review of the admission MDS dated [DATE] indicated Resident #1's cognition was severely impaired with a BIMS score of 00. Record review of Resident#1 care plan, dated 02/05/24, indicated Resident #1 had impaired thought process due to dementia and had behaviors. Resident #1 was noted to have behavior problems due to being physically aggressive and resistive to care as evidenced by refusal for staff to provide incontinence care and activities of daily living rule out dementia. The care plan reflected: Intervention: Allow Resident #1 to make decisions about treatment regime, to provide sense of control. Review of TULIP reflected the DON reported an incident (Incident Intake ID: 483847) on 02/12/24 at 5:00 PM. The incident involved Resident #1 and CNA A with allegations of administration/personnel, quality of care, and resident rights. Further review of the TULIP record reflected no evidence a Provider Investigation Report had been submitted for this incident as of 02/28/24. Interview on 02/28/24 at 2:27 PM with the DON revealed she was notified by a family member on 02/12/24 that they heard CNA A walking down the hall with other staff stating she could not wait to get out of the facility because the residents were mean. CNA A was then observed pointing towards Page 1 of 2 675703 675703 02/28/2024 Cross Timbers Rehabilitation and Healthcare Center 3315 Cross Timbers Rd Flower Mound, TX 75028

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #1's room. The DON stated after learning of the incident she notified the Administrator, called the intake in to the State Survey Agency, and CNA A was suspended. She stated she was aware the Provider Investigation Report was supposed to be completed within 5 days. Interview on 02/28/24 at 3:35 PM with the Administrator revealed the family member reported the incident happened on the hallway on 02/10/24, and they notified the DON on 02/12/24. The DON notified him, since he was out of the office, and he told the DON to report to the State Survey Agency and suspend the CNA. The Administrator stated he was aware of the regulations he was supposed to submit the investigation report within 5 days, but he did not because he could not get ahold of CNA A for an interview. He stated there was no abuse, and he felt it was not reportable because this was unprofessional behavior on the hallway. CNA A was suspended, although she had already given her resignation letter to the facility, and that week was her last working at the facility. The Administrator stated he had not seen CNA A since that day. He stated failure to submit the investigation report could have caused the problem to continue or reoccur. He stated he did in-service training on abuse and neglect on 02/17/24, and he did safe surveys with interviewable residents, which resulted in no issues or concerns being reported. Review of the in-service record, dated 02/17/24, on the topic of Abuse and Neglect revealed the staff were trained on the types of abuse, reporting of allegations of abuse to the Administrator, who was the facility's Abuse Coordinator, immediately. The training also reflected if an allegation was reported to a supervisor, it should also be reported to the Administrator. Record review of the facility's current Abuse policy, dated 11/07/23, reflected: .3. The facility will report the results of the investigations to the enforcement agency in accordance with state law, including the stated survey and certification agency. .5. Investigations will be prompt, comprehensive and responsive to the situation and contain founded conclusions 675703 Page 2 of 2