Health inspection·May 18, 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 that residents that had the right to be free from abuse for 1 of 9 residents (Resident #1) that were reviewed in that: 1) The facility staff failed to respect the Resident #1s rights by publicly displaying degrading negative statements about her hygiene. to refuse treatment of blood sugar monitoring. This failure could lead to residents' embarrassment, poor self-worth and self-esteem, diminished quality of life, as well as emotional and psychological degression. The findings include: Resident #1 Record review of the face sheet of Resident #1 dated 05/18/23 revealed a [AGE] year-old female admitted on [DATE]. Diagnoses included: Alcoholic cirrhosis of the liver with ascites (disorder from overuse of alcohol resulting in the fluid buildup in the liver), Chronic Hepatitis (inflammation of the Liver, unspecified, Cognitive Communication Deficit, Type 2 diabetes mellitus without complications, Major Depressive Disorder, recurrent, moderate (mood disorder). Record review of the Quarterly assessment, MDS documentation for Resident #1 revealed a BIMS score of 11 indicating moderate cognitive impairment and resident needs 1 staff assistance for ADL's. the resident's admission MDS was not due. Record review of Resident #1s care plan dated 04/01/23 revealed a Resident #1 was noncompliant with fluid, restriction .Educate resident and family on risk and compliant, with fluid restriction and diet, positive reinforcement when resident is compliant. Resident is at risk for unstable blood sugars related to DX of diabetes .provide program encouraging choices, self-expression, and responsibility .resident has an ADL self-care performance Deficit r/t activity intolerance. Resident will maintain dignity of being clean dry, odor free, and well-groomed and well-groomed through next review date. In an interview with Resident #1 on 5/18/23 at 12:00 pm. revealed she overheard the ADON saying she smelled bad, over, and over and asking that the windows be opened. She said she was saddened and proceeded to cry in her room. She said it happened last week 5/09/23, and she did not tell anyone until 05/16/23. She did not recall other staff present other than the MR staff. She told the Administrator because she was sad at first then angry that she treated her this way. She was afraid to tell. She feels safe now that the ADON she is gone. She met with counselor and reported she was doing well Page 1 of 3 675995 675995 05/18/2023 University Rehabilitation Center 2244 Brinker Rd Denton, TX 76208

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and not sad or depressed. She said this has never happened before. The staff have been nice and respectable maintaining her dignity since being placed here. In an interview with RN S on 5/18/23 at 2:00 pm. revealed she was not working the day of the alleged incident; however, she was notified upon returning to work that the resident was verbally abused. She denies seeing the ADON or other staff making derogatory statements about residents at the facility as this was neglect and should not be tolerated. She attended the in-service for verbal abuse. The date of the in-service was on 05/16/23. In an interview with LVN G, on 05/18/23 at 2:30 PM revealed she was not working on 05/9/23, therefore she did not observed the incident involving ADON and Resident #1. In an interview on 05/18/23 at 2:45 p.m. with CNA-B, revealed she was working on 05/9/23 and did not witness the incident of abuse from the ADON stating residents smelled bad as this was a dignity issues. She reported attending in-service and reporting at once. In an interview on 05/18/23 at 4:30 p.m. with MR staff revealed she was asked to assist the ADON with moving Resident #1 back to her room. She said as she and the ADON were standing outside the door, the ADON walked down the hall complaining about the odor in Resident #1s room. The MR said the ADON continued to pace up and down the hall saying the smell was awful and someone should give her a mask and open the windows for air to circulate. The MR said she was standing outside Resident#1s room observing and hearing her talk about the smell. MR said she was sure that the Resident#1 overheard this as well. MR did not report the incident to any to leadership staff, as she was frustrated by the ADON's action. She did not observe the resident being sad or crying, but she did say it was embarrassing for Resident #1. She said this incident occurred on 05/09/23, and she was interviewed on 5/16/2023 and coached by DON and Administrator on 05/17/23. She said she realized now that she should have reported the incident, but she was fearful of reporting as this was a nurse manager and leadership person and could endure backlash. She entered the room with the help of a CNA and called for help assist the resident in the restroom. She could not recall the name of the aide working. A review of the working schedule dated 5/9/23 revealed the CNA G, however she was not at work and did not respond to call In an interview with the DON on 05/18/23 at 4:45 p.m. revealed she talked with Resident #1 after reporting the incident to the administrator on 5/16/2023 at approximately 4:40 p.m. Resident #1 reported that the ADON, and MR staff entered her room to assist in moving her things back to her old room. Resident #1 told the DON that she had a bowel movement and told the ADON and MR. Resident #1 said at that time the ADON left the room, and she could hear both employees were whispering and giggling, and she felt as though they were both talking about her. The resident said she heard the ADON say she's too old to be having accidents. Resident #1 said she the ADON was always nice to her, and she was acting different toward her since (avoiding her and not acknowledging when passing in the facility). The DON and Administrator interviewed MR together to gain additional information. MR said she recalled the ADON saying over and over about the smell of the room and asking someone to open the windows. This DON and Administrator in-serviced MR on the Abuse and Neglect policy and procedures and the importance of reporting any type of abuse and neglect. A review ADONs written statement dated 05/16/23, reflected the ADON went into where Resident #1s was residing, and upon entering the room and opening the door she could smell an odor. At that time, she asked the resident if she had a bowel movement, to which she responded, yes. The ADON said out 675995 Page 2 of 3 675995 05/18/2023 University Rehabilitation Center 2244 Brinker Rd Denton, TX 76208

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few loud we need to open up the window because it stinks. The ADON said she never directed the statement toward the resident. She said, I honestly can't remember when I walked into the room if I said it smells. If I did was like an Oh, it smells but I'm sure I wasn't the only one. This was an week ago. She said she would never verbally abuse Resident #1. In an interview with the Administrator on 05/18/23 at 5:10 pm. she said Resident #1 entered her office on 05/16/23 at approximately 4:40 p.m. crying. She reported that the ADON and MR entered her room to announce they would be moving her back to her former room , as the roommate was no longer on quarantine for conjunctivitis. She overheard the ADON saying that the smell was bad, and she was too old to have incontinent accidents. Resident #1 said she was afraid to tell anyone, and the incident occurred last week 05/09/23. Resident #1 said she was hurt and embarrassed as everyone could hear the ADON making statements. The Administrator called the DON to have the ADON come to her office at once and she was sent home pending an investigation. The investigation was completed today and after speaking with leadership, the staff's employment was terminated. The administrator has met with the MR and a written coaching was conducted with the staff as the resident reported the MR did not say anything about her smelling. The resident representative was notified, MD and social worker to meet with the resident for emotional response and psychological needs. Resident was referred for psychological services to which she said that she was not depressed just hurt and angry about the ADON's statement. A review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021. Residents have the right to be free from abuse and neglect this includes but not limited freedom of verbal and mental abuse by providing staff trainings and orientations that include the topic such as abuse prevention, identification, and reporting abuse. 675995 Page 3 of 3