Health inspection·January 16, 2025

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 interview and record review, the facility failed to ensure resident was free from abuse and neglect for 1(Resident #1) of 3 residents reviewed for abuse, neglect, and exploitation. The facility failed to ensure that Resident #1 was free from neglect when ST-A entered the code to the door to let Resident #1 out of the facility. Resident #1 was seen by another staff and brought back into the facility. This failure could place residents at risk of neglect, injury, and psychosocial harm. Findings included: Record review of Resident #1's face sheet, dated, 01/07/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included age related cognitive decline ( a gradual decline in some thinking abilities), type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), anxiety disorder (a mental health disorder characterized by feelings of worry, or fear that are strong enough to interfere with one's daily activities), and hypertension (a condition in which the force of the blood against the artery walls is too high). Record review of Resident #1's Discharge MDS Assessment, dated 01/07/25, reflected the BIMS should not be conducted because the resident is rarely/never understood, indicated the section would be skipped. Record review of Resident #1's Comprehensive Care Plan, completed on, 01/07/2024, reflected Resident #1 was an elopement risk/wanderer r/t age related cognitive decline. Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book resident prefers. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Resident #1 was potential for falls. Interventions: Encourage and monitor Resident #1 for continued independence. Record review of Resident #1's Elopement Evaluation dated 01/06/25 reflected the assessment scale was 0-4 and Resident #1's assessment score was 4.0. Record review of the facility investigation report, dated 01/07/25, reflected Resident #1 admitted from home on the evening of 1/6/25, approximately 7:22 PM. On the morning of 1/7/25 Resident #1 was Page 1 of 4 675934 675934 01/16/2025 LA Dora Nursing and Rehabilitation Center 1960 Bedford Rd Bedford, TX 76021

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few observed in the dining area socializing with other residents. Around 7:30 AM Resident #1 proceeded from the dining room to the front lobby. At 7:34 AM Resident #1 asked [ST-A] if she could open the door. [ST-A] assumed Resident #1 was a visitor and proceeded to let Resident #1 out the front door. Shortly after the resident proceeded through the front door, [PT-B] approximately 7:35 AM recognized the resident from the window of a resident's room. [PT-B] then proceeded to let the other staff know there was a resident outside of the facility. Code Pink was immediately called, and staff members immediately proceeded outside to redirected and accompanied Resident #1 inside the facility. Provider Response: initiated 1 on 1 by assigned staff, completed a head count, head to toe assessment, notified RP, Physician Ombudsman, in-services (Emergency Procedure for missing resident Drill, Abuse and Neglect, Dementia), updated and completed elopement evaluations/binder, obtained consent for secured unit, Resident #1 discharged to secured unit, changed the code to front door, suspended staff [ST-A] until further investigation, witness statements, and safe survey. Record review of Resident #1's incident report, dated 01/07/25, reflected, Incident Location: Outside; Incident Description: Notified MD/NP/DON/ADON/Administrator that resident was observed outside the facility by the Therapist. Notified by staff that resident was accompanied back inside the facility by aides, therapist, and Charge Nurse. No distress noted. Resident is being monitored by staff to ensure safety. Head to toe assessment performed w/o any abnormal findings. No distress noted. Resident is a new admission. Resident ambulates independently without assistive device or physical assistance. Resident is alert and verbal. Record review of ST-A's personnel record reflected she completed training on Preventing, Recognizing, and Reporting Abuse on 09/09/24, Alzheimer's Disease and Related Disorders: Behaviors was completed 09/09/24, Abuse, Neglect, and Exploitation completed 09/09/24. In a Face-to-Face interview on 01/16/25 at 11:37 AM with PT-B he revealed he was in a resident's room when he noticed Resident #1 outside the window. He stated he alerted the staff, and they called a code pink (used to notify the building of missing resident). He stated he had been in the room about five minutes when he saw Resident #1 outside the window. He stated he did not know who was responsible for Resident #1 when she was outside. He stated he went outside with other staff to guide Resident #1 back into the building. He stated he did not see any marks or bruises on Resident #1 when he saw her outside. He stated the resident had been at risk of going into the street and she could have gotten lost. In a telephone interview on 01/16/25 at 11:53 AM with ST-A, she revealed she had been employed as a ST at the facility. She stated on 01/07/25 she was in the lobby making copies when she was approached by Resident #1. She stated she was not aware that Resident #1 was a resident at the facility. She stated Resident #1 told her she needed to get out and go home. She stated she entered the door code to let Resident #1 out of the building and returned to the therapy office. She stated about two minutes later she was notified that the person she opened the door for was Resident #1. She stated when she learned that she headed to the front of the building to re-direct the resident back inside the building when she saw Resident entering the building with PT-B. She stated she had received training on abuse and neglect and how to handle a resident who tried to elope the facility. She stated the resident was at risk of harm if she had gone into the street or the weather if she did not have on a coat. In a face-to-face interview on 01/16/25 at 3:20 PM with Administrator revealed, interviews with staff determined Resident #1 was outside for about five minutes. ST-A had received training on A/N/E. He stated after ST-A opened the door for Resident #1 she was re-educated and suspended. He stated he 675934 Page 2 of 4 675934 01/16/2025 LA Dora Nursing and Rehabilitation Center 1960 Bedford Rd Bedford, TX 76021

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few thought the alleged neglect occurred because ST-A was careless and did not use her critical thinking skills and as a result she was terminated. He stated the action taken to respond to concerns was re-education of all facility staff, in-services on abuse and neglect, an elopement drill was conducted, and the code on the front door was changed. He stated actions taken to prevent further potential neglect after his investigation was completed, he spoke with the therapy team to be aware of surroundings, staff, and residents. He stated he ordered visitor tags to be worn by all visitors when they have entered the building. He stated he would send out a message to all staff and family that the visit tags should be worn to protect the residents. He stated Resident #1 was at risk of harm if she had gone into traffic, gotten lost, or gotten hurt while outside. Record review of facility Abuse and Neglect policy dated April 2021 reflected, Residents have the right to be free from abuse, neglect. 1. Protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including, but not necessarily limited to: a. Facility staff 2. Develop and implement policies and protocols to prevent and identify: a. Abuse or mistreatment of residents; b. Neglect of residents 6. Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse Record review of facility wandering and elopement policy dated March 2019 reflected The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 2. If an employee observes a resident leaving the premises, he/she should: 675934 Page 3 of 4 675934 01/16/2025 LA Dora Nursing and Rehabilitation Center 1960 Bedford Rd Bedford, TX 76021

F 0600 a. Level of Harm - Minimal harm or potential for actual harm Attempt to prevent the resident from leaving in a courteous manner; b. Residents Affected - Few Get help from other staff members in the immediate vicinity c. Instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises. 675934 Page 4 of 4