Health inspection·September 20, 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 interviews and record review the facility failed to ensure residents were free from abuse for 1 of 7 residents (Res #1) reviewed for abuse. The facility failed to ensure CNA A did not verbally and physically abuse Resident #1 during ADL care. This failure placed residents at risk of abuse, decreased feelings of dignity, self-worth, and humiliation. Findings include: Record review on 9-20-2023 of the facility's face sheet reflected Res # 1 was born on [DATE] and was admitted to the facility on [DATE]. Res # 1 was diagnosed with dementia and cognitive communication deficit. Record review on 9-20-2023 of a ring doorbell video clip, date stamped 6-22-2023 at 7:32:06 AM, reflected two CNAs, CNA A and CNA B, in Res # 1's room having performed ADL care. The video showed CNA A having stood over Res # 1 and having spoken to Res # 1 in an aggressive manner in response to Res # 1 attempted touching of CNA B's body. CNA A was viewed having restricted both of Res # 1's forearms and having aggressively told Res # 1 not to touch women like that. CNA A continued to speak to Res # 1 in an aggressive tone about touching people. CNA A stated that people don't like that. Res # 1 was heard telling CNA A to be quiet, which sparked CNA A having responded with you be quiet! CNA A then leaned forward towards Res # 1, which prompted Res # 1 to having raised their left arm to a defensive position. In response to Res # 1's arm being raised, CNA A threatened Res # 1 having stated, I wish you would, I wish you would, I want you to! When CNA A stated, I want you to, she raised her right hand in the air and shook their first 4 times in unison with the syllables, I want you to! CNA A continued to state, come on; do it! Res # 1 was overheard telling CNA A that she would be on the floor. In response to Res # 1's response, CNA A stated, no I won't, you're going to be on the floor. CNA A told Res # 1 they would call the police if Res # 1 struck them. CNA B was overheard having told Res #1 that the police would take him to jail. Interview on 9-20-2023 at 12:55 PM with the DON revealed a family of Res # 1, LAR # 1, contacted the facility on 6-22-2023 after LAR # 1 viewed the incident on the ring camera. LAR # 1sent the video to the DON and the previous ADM. The DON stated that they substantiated the abuse and non-reporting based on the video. The DON stated, the ADM and the DON, brought both CNA A and CNA B into the office and terminated them both. The DON stated she assessed Res # 1 to find no injuries. Page 1 of 2 675924 675924 09/20/2023 Woodway Rehabilitation and Healthcare Center 7801 Woodway Dr Waco, TX 76712

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 9-20-2023 at 10:25 AM with LAR # 1 revealed CNA A spoke harshly to, and handled roughly, Res # 1 over an electronic monitoring video clip. LAR # 1 stated that they sent the video to the ADM to address the issue. LAR # 1 stated that Res # 1 most likely wouldn't remember the incident. She stated that he was diagnosed with dementia. Interview on 9-20-2023 at 1:20 PM with Res # 1 revealed that Res # 1 did not remember any incident where he was abused by staff. Res # 1 stated he feels safe at the facility. Record review on 9-20-2023 of CNA A's personnel file reflected CNA A was terminated from employment from the facility on 6-22-2023 for unprofessionalism and behavior. CNA A's date of hire was 4-14-2022. CNA attended ANE training on 4-14-2022, 8-3-2022, 2-28-2023, and 5-26-2023. CNA A received 1 hour of training on safeguarding residents' rights on 10-11-2022 and 4-29-2023.An Employee Misconduct Registry searches was performed on 4-27-2022. Record review on 9-20-2023 of CNA B's personnel file reflected CNA B was terminated from employment from the facility on 6-22-2023 for not reporting abuse, neglect, or exploitation. CNA B's date of hire was 3-16-2023. CNA A attended ANE training on 3-16-2023, and 5-26-2023. CNA B received 1 hour of training on safeguarding resident's rights on 4-5-2023. An Employee Misconduct Registry searches was performed on 3-14-2022. Record review of the facility's undated ANE policy indicated that suspected incidents of resident abuse, mistreatment, neglect, or injury of unknown source is reported. If the investigation revealed that the allegations are founded, the employee will be terminated. 675924 Page 2 of 2