Health inspection·December 1, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident had the right to be free from abuse for 1 of 5 residents (Resident #1), reviewed for abuse. The facility failed to ensure a safe environment free from abuse when Activities worker A called Resident #1 a Llorona (Spanish for crybaby or weeping woman) in the dining room. This failure could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotion distress, serious harm, and death. Findings include: Record Review of Resident #1's face sheet dated 12/01/23 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses to include type 2 diabetes mellitus (high blood sugar), chronic obstructive pulmonary disease (lung disease), and essential hypertension (high blood pressure). Record review of Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] documented that Resident #1 was understood and had a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. During an interview on 12/01/23 at 10:40 AM, Resident #1 stated an incident happened with Activities worker A during lunch around Thanksgiving, she could not remember the exact date. Resident #1 stated she approached Activities worker A in the dining room and wanted to know what was on the menu for lunch. Resident #1 stated Activities worker A told her, What do you want Llorona (Spanish for crybaby or weeping woman)? Resident #1 stated she told Activities Worker A that she could not call her by that name, she needed to call her by her real name. Resident #1 stated she did not like being called a crybaby in Spanish and it made her upset. Resident #1 stated she did not know if anyone else heard this and she did not tell any of the staff members. Resident #1 stated she called the State (HHSC) right away because she knew she shouldn't be treated like this. Resident #1 stated she feels uncomfortable being around Activities worker A. During an interview on 12/01/23 at 11:18 AM, Activities worker A was asked if she called Resident #1 a Llorona during a lunch meal. Activities worker A stated during their Thanksgiving meal, unknown the exact date, she went to the facility to help pass out the food. Activities worker A stated Resident #1 approached her and she did call Resident #1 a Llorona. Activities worker A stated she did not mean it to be rude and thought she was playing/joking with Resident #1. Activities worker A stated Page 1 of 3 675874 675874 12/01/2023 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she has been trained to call Residents by their real names, not by a nickname. Activities worker A stated she should not have called Resident #1 a Llorona and she will not do it again. During an interview on 12/01/23 at 11:37 AM, the Adm stated she was not aware of the incident that happened between Activities worker A and Resident #1. The Adm stated she expects staff to call residents by their real name, not any other name. The Adm stated as the abuse coordinator for the facility, she was responsible for ensuring staff were following the abuse policies. The Adm stated she knows Activities worker A has completed abuse training at the facility and she will have to look up the dates. The Adm stated the potential negative outcome to a resident being called a negative name was they could feel bad about themselves. The Adm stated she will follow the facility policy regarding abuse allegations now that she was aware of the incident between Resident #1 and Activities worker A. Record review of a facility document titled, Orientation Framework and Checklist for Activities worker A with a hire date of 08/02/23 reflected: Resident Abuse Reporting: Relias (online training)- Preventing, Recognizing & Reporting Abuse was completed on 08/02/23. Record review of a facility in-service training attendance sheet, dated 10/13/23, regarding Reporting Abuse and Neglect: If you witness or suspect abuse or neglect, it is your responsibility to report it to the administrator immediately! If you do not report it immediately, you are just as guilty as the person who is suspected or is committing the act. The administrator is the abuse coordinator. In the event they are not available, report to the DON immediately. Activities worker A's signature was noted on the attendance sheet. Record review of a facility in-service training attendance sheet, dated 11/30/23, regarding Abuse Guidance . reflected Activities worker A's signature was noted on the attendance sheet. Record review of facility policy, titled Abuse Guidance: Preventing, Identifying and Reporting, with a revised date of 10/22 reflected the following: Compliance Guidelines: Every resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents should not be subjected to abuse by anyone, including, but not limited to, community team members, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals . -If anyone harms or threatens to harm a resident/patient, neglects their care, takes their property, or violates their dignity, the resident, has the right to file a complaint with the community administrator or with the Texas Department of Aging and Disability Services by calling [PHONE NUMBER]. Types of Abuse -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation of goods or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing . -Verbal abuse is the use of oral, written, or gestured language that willfully includes the use of 675874 Page 2 of 3 675874 12/01/2023 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720

F 0600 Level of Harm - Minimal harm or potential for actual harm disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include threats of harm or frightening a resident by telling a resident that he or she will never be able to see his or her family again . -Mental abuse includes humiliation, harassment, threats of punishment, or deprivation Residents Affected - Few 675874 Page 3 of 3