Health inspection·June 5, 2024

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care of 4 (Resident #85, Resident #87, Resident #137, and Resident #185) of 4 residents reviewed for baseline care plan completion. The facility failed to complete the social services section in the baseline care plan for Resident #85, Resident #87, Resident #137, and Resident #185 within the required 48-hour timeframe. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified. Findings included: 1. Resident #85 Record review of the resident #85's face sheet dated 06/03/2021 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: unspecified fracture of T11-T12 vertebra (spinal fracture), muscle weakness, cognitive communication deficit, protein-calorie malnutrition, anemia, legal blindness, hypertension (high blood pressure), chronic atrial fibrillation (chronic irregular heart rhythm), and heart failure (heart disease). Record review of Resident #85's admission MDS dated [DATE] revealed: a BIMS score of 12 which indicated moderate cognitive impairment. Further review of the MDS Section D - Mood revealed resident had no self-isolation, hallucinations, or delusions. He did have verbal behavioral symptoms directed toward others that occurred 1 to 3 days. Record review of Resident #85's baseline care plan dated 05/22/2024 revealed the Social Services section was not completed. Record review of Resident #85's electronic medical record accessed on 06/05/2024 revealed comprehensive care plan was completed on 05/31/2024. 2. Resident #87 Record review of Resident #87's face sheet dated 06/03/2024 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: injury of cauda equina (injury that Page 1 of 12 676090 676090 06/05/2024 Wesley Court Health Center 2617 Antilley Road Abilene, TX 79606

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some damaged or compressed a bundle of nerve roots at the bottom of the spinal cord), hypothyroidism (low thyroid hormone), protein-calorie malnutrition, obesity, hypertension (high blood pressure), spinal stenosis (narrowing of spinal canal), and fall. Record review of Resident #87's entry MDS dated [DATE] revealed: The resident was admitted to facility on 05/29/2024 from short-term general hospital. Record review of Resident #87's baseline care plan dated 05/29/2024 revealed the Social Services section was not completed. Record review of Resident #87's electronic medical record accessed on 06/05/2024 revealed comprehensive care plan had not been completed. 3. Resident #137 Record review of Resident #137's face sheet dated 06/03/2024 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: fracture of lesser trochanter of right femur (right leg bone fracture), fear of injury, pain in right leg, cognitive communication deficit, need for assistance with personal care, chronic obstructive pulmonary disease (lung disease), hypertension (high blood pressure), atrial fibrillation (irregular heart rhythm), and muscle weakness. Record review of Resident #137's admission MDS dated [DATE] revealed: a BIMS score of 10 which indicated moderate cognitive impairment. Further review of the MDS Section D - Mood revealed resident had no self-isolation, hallucinations, or delusions. Record review of Resident #137's care plan dated 05/21/2024 revealed the Social Services section was not completed. Record review of Resident #137's electronic medical record accessed on 06/05/2024 revealed comprehensive care plan was completed on 05/31/2024. 4. Resident #185 Record review of the resident #185's face sheet dated 05/30/2024 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: atrial fibrillation (irregular heart rhythm), muscle weakness, cognitive communication deficit, need for assistance with personal care, acute respiratory failure with hypoxia (inability for lungs to function and low oxygen level), anxiety disorder, anemia, hypertension (high blood pressure), heart failure (heart disease), and gastro-esophageal reflux disease without esophagitis (stomach gasses move into the esophagus). Record review of Resident #185's entry MDS dated [DATE] revealed: The resident was admitted to facility on 05/30/2024 from skilled nursing facility. Record review of Resident #185's baseline care plan dated 05/30/2024 revealed the Social Services section was not completed. During a phone interview on 06/05/2024 at 10:36 a.m., LVN A stated she was responsible with the other nurses to perform baseline assessments on admission. She stated that the assessment will populate in the UDA for nurses to perform as soon as possible. The LVN stated she did not fill in the social 676090 Page 2 of 12 676090 06/05/2024 Wesley Court Health Center 2617 Antilley Road Abilene, TX 79606

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some service section. She stated at one time someone else would fill in that section. She stated that she would print out the baseline care plan when she was done filling in the areas that she could so the resident or the responsible party could sign. During an interview on 06/05/2024 at 11:25 a.m., the DON stated she and the MDS nurse were responsible for monitoring that baseline care plans were completed. She stated she would expect that the social services section be filled in by a social worker or designee of the social worker. She stated nurses are responsible for performing the baseline care plan and that was why the section was not filled in on the baseline care plan. She stated the Social Worker assists with comprehensive care plan. The DON stated not filling out social service section could lead to psychosocial needs not being assessed and not being med potentially. During an interview on 06/05/2024 at 1:50 p.m., the interim ADMN stated the DON monitored that the baseline care plans were completed. He stated his expectation would be for each section to be addressed. He stated that he did not know why the social services section had not been filled in on the baseline care plans but he felt it may have been because the facility did not have a Social Worker at the time. The interim ADMN stated no negative outcome occurred to the residents because the facility was providing services to meet the residents' needs. During an interview on 06/05/2024 at 3:13 p.m., the MDS coordinator stated she and the DON monitored that baseline care plans were completed. She stated her expectation would be that the baseline plans have a discharge plan. She stated if the resident had a social service needed, then the facility would need to put something in place. She stated the social services section may not have been filled out because the facility did not have a Social Worker at that time. The MDS coordinator stated that if the resident had a need of social services, then the resident possibly would not get social services timely. Record review of facility policy titled; Care Plans-Baseline dated March 2022 revealed; The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care, and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. Physician orders; c. Dietary orders; d. Therapy services; e. Social services; and f. PASARR recommendation, if applicable. The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan (no later than 21 days after admission). 676090 Page 3 of 12 676090 06/05/2024 Wesley Court Health Center 2617 Antilley Road Abilene, TX 79606

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were addressed for 1 of 5 residents (Resident #28) reviewed for unnecessary medications, psychotropic medications, and medication regimen review. The facility failed to address the Pharmacist Consultant recommendations for April 2024 and May 2024 for Resident #28 regarding psychotropic medications. These failures could place residents on psychotropic medications at risk for possible adverse side effects, adverse consequences, and decreased quality of life. Findings included: Review of Resident #28's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: anxiety, prediabetes, and fracture of right lower leg. Review of Resident #28's admission MDS assessment dated [DATE] revealed: a BIMS score of 15 which indicated no cognitive impairment. Further review of the MDS Section N Medications revealed no antianxiety medications taken in the last 7 days during the look back period (assessment period). Further review of MDS revealed the use of antipsychotics in the last 7 days during the look back period (assessment period). Review of Resident #28's Care plan initiated 04/26/2024 revealed: Focus: Resident uses anti-anxiety medications (hydroxyzine) related to anxiety disorder. Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness EVERY-SHIFT. Monitor/document/report PRN any adverse reactions to ANTI-ANXIETY therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggressive or impulsive behavior, or hallucinations. Further review of care plan revealed: Focus: Resident uses psychotropic medications (risperidone) related to patient reported Tourette syndrome. Goal: The resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment through review date. Interventions: Administer PSYCHOTROPIC medications as ordered by physician. Monitor for side effects and effectiveness EVERY-SHIFT. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate at least quarterly. Monitor/document/report PRN any adverse reactions of PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Review of Resident #28's Medication Regimen Review, dated 04/30/2024, revealed: Please clarify how long to be on PRN hydroxyzine- PRN psych meds should only be used for 14 days unless specified by the physician. Please clarify if patient should stay on med for 14 days or needs to be extended. 676090 Page 4 of 12 676090 06/05/2024 Wesley Court Health Center 2617 Antilley Road Abilene, TX 79606

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #28's Medication Regimen Review, dated 05/29/2024, revealed: Please clarify how long to be on PRN hydroxyzine- PRN psych meds should only be used for 14 days unless specified by the physician. Please clarify if patient should stay on med for 14 days or needs to be extended. Review of Resident #28's electronic Physicians Orders revealed: Hydroxyzine HCl Oral Tablet 25 MG give 1 tablet by mouth every 8 hours as needed for anxiety, dated 04/25/2024 with no stop date. Review of Resident #28's Medication Regimen Review, dated 04/30/2024, revealed: Please monitor for side effects of antipsychotics since patient is on Risperdal (Risperidone). Review of Resident #28's Medication Regimen Review, dated 05/29/2024, revealed: Please monitor for side effects of antipsychotics since patient is on Risperdal (Risperidone). Review of Resident #28's electronic Physicians Orders revealed no evidence of an order to monitor for side effects of antipsychotics prior to 06/03/2024. Review of Resident #28's Medication Regimen Review, dated 04/30/2024, revealed: Resident is receiving the antipsychotic agent Risperdal 4mg at bedtime but lacks an allowable diagnosis to support its use. Currently, the diagnosis reads for depression .If clinically indicated, please identify one of the above diagnoses for our records to appropriately identify the use of this antipsychotic in this patient. If not, then please consider discontinuing this medication. Review of Resident #28's Medication Regimen Review, dated 05/29/2024, revealed: Resident is receiving the antipsychotic agent Risperdal 4mg at bedtime but lacks an allowable diagnosis to support its use. Currently, the diagnosis reads for depression .If clinically indicated, please identify one of the above diagnoses for our records to appropriately identify the use of this antipsychotic in this patient. If not, then please consider discontinuing this medication. Review of Resident #28's electronic Physicians Orders revealed: Risperidone oral tablet 4 mg 1 tablet at bedtime related diagnosis depression, dated 04/25/2024 . During an interview on 06/05/2024 at 4:15 PM, the DON stated her and the ADON shared the responsibility of monitoring and addressing the pharmacy recommendations. She stated pharmacy recommendations should ideally be addressed within 72 hours of receiving them. The DON stated that the letters to the physicians were faxed to the physicians immediately and it was her and the ADONs responsibility too follow-up and monitor. The DON stated the same recommendations should never be repeated on the following month recommendations because they should have been addressed. The DON stated Resident #28's April recommendations should have been addressed before the May recommendations were sent out. The DON stated the delay could have been due to the Medical Director not addressing psychotropic medications and the letters having to be sent to the psych doctor who responds in a less timely manner. The DON then acknowledged that these specific recommendations could have been fixed without notification from the doctor and she did not know why it was missed or not addressed until 06/03/2024 after the state surveyors entered the facility. She stated the effect on the resident could be receiving unnecessary medications. Review of the facility policy titled, Psychotropic Medication Use dated July 2022, revealed: Policy Statement: Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation: 1. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. 2. Drugs in the 676090 Page 5 of 12 676090 06/05/2024 Wesley Court Health Center 2617 Antilley Road Abilene, TX 79606

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: a. Anti-psychotics; b. Anti-depressants; c. Anti-anxiety medications; and d. Hypnotics . 12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. A. PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are not antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include a duration for the PRN order. (2) For psychotropic medications that are antipsychotics; PRN orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. Review of Drugs.com for Hydroxyzine accessed on 06/05/2024 at https://www.drugs.com/hydroxyzine.html revealed: hydroxyzine also reduces activity in the central nervous system, it can be used as a sedative to treat anxiety and tension. This medication may impair your thinking or reactions. Hydroxyzine is for short-term use only. You should not take this medicine for longer than 4 months. Review of Drugs.com for Risperidone accessed on 06/05/2024 at https://www.drugs.com/risperidone.html revealed: Risperidone is an antipsychotic medicine that works by changing the effects of chemicals in the brain. Risperidone is also used to treat symptoms of bipolar disorder (manic depression) in adults. 676090 Page 6 of 12 676090 06/05/2024 Wesley Court Health Center 2617 Antilley Road Abilene, TX 79606

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to ensure residents with PRN orders for psychotropic drugs were limited to 14 days for 1 (Resident #28) of 5 residents reviewed for pharmacy services. The facility failed to ensure Resident #28 had stop dates for PRN hydroxyzine (medicine used to treat the symptoms of anxiety). This failure could place residents at risk for psychotropic medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications. Findings included: Review of Resident #28's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: anxiety, prediabetes, and fracture of right lower leg. Review of Resident #28's admission MDS assessment dated [DATE] revealed: a BIMS score of 15 which indicated no cognitive impairment. Further review of the MDS Section N Medications revealed no antianxiety medications taken in the last 7 days during the look back period (assessment period). Review of Resident #28's Care plan initiated 04/26/2024 revealed: Focus: Resident uses anti-anxiety medications (hydroxyzine) related to anxiety disorder. Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness EVERY-SHIFT. Monitor/document/report PRN any adverse reactions to ANTI-ANXIETY therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggressive or impulsive behavior, or hallucinations. Review of Resident #28's electronic Physicians Orders revealed: Hydroxyzine HCl Oral Tablet 25 MG give 1 tablet by mouth every 8 hours as needed for anxiety, dated 04/25/2024 with no stop date. Review of Resident #28's MAR, dated June 2024, revealed Hydroxyzine being administered daily. Review of Resident #28's Medication Regimen Review, dated 04/30/2024, revealed: Please clarify how long to be on PRN hydroxyzine- PRN psych meds should only be used for 14 days unless specified by the physician. Please clarify if patient should stay on med for 14 days or needs to be extended. Review of Resident #28's Medication Regimen Review, dated 05/29/2024, revealed: Please clarify how long to be on PRN hydroxyzine- PRN psych meds should only be used for 14 days unless specified by the physician. Please clarify if patient should stay on med for 14 days or needs to be extended. Review of Resident #28's physician progress notes from March 2024- June 2024 revealed no documented rationale for the continued provision of hydroxyzine or reason not to make it a scheduled medication . 676090 Page 7 of 12 676090 06/05/2024 Wesley Court Health Center 2617 Antilley Road Abilene, TX 79606

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 06/05/2024 at 4:15 PM, the DON stated her and the ADON shared the responsibility of monitoring and addressing the pharmacy recommendations. She stated pharmacy recommendations should ideally be addressed within 72 hours of receiving them. The DON stated the letters to the physicians were faxed to the physicians immediately and it was her and the ADONs responsibility too follow-up and monitor. The DON stated the same recommendations should never be repeated on the following month recommendations because they should have been addressed. The DON stated Resident #28's April recommendations should have been addressed before the May recommendations were sent out. The DON stated the delay could have been due to the Medical Director not addressing psych medications and the letters having to be sent to the psych doctor who responds in a less timely manner. The DON then acknowledged that these specific recommendations could have been fixed without notification from the doctor and she did not know why it was missed. She stated the effect on the resident could be receiving unnecessary medications. Review of facility policy titled, Psychotropic Medication Use dated July 2022, revealed: Policy Statement: Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation: 1. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. 2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: a. Anti-psychotics; b. Anti-depressants; c. Anti-anxiety medications; and d. Hypnotics . 12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. A. PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are not antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include a duration for the PRN order. (2) For psychotropic medications that are antipsychotics; PRN orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. Review of Drugs.com for Hydroxyzine accessed on 06/05/2024 at https://www.drugs.com/hydroxyzine.html revealed: hydroxyzine also reduces activity in the central nervous system, it can be used as a sedative to treat anxiety and tension. This medication may impair your thinking or reactions. Hydroxyzine is for short-term use only. You should not take this medicine for longer than 4 months. 676090 Page 8 of 12 676090 06/05/2024 Wesley Court Health Center 2617 Antilley Road Abilene, TX 79606

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interviews and record review, the facility failed to maintain an ongoing Quality Assurance & Performance Improvement (QAPI) committee that included at minimum, the director of nursing services, the Medical Director or his/her designee, and at least three other members of the facility's staff, at least one of who must be the Administrator, owner, a board member, or other individual in a leadership role; and meets at least quarterly for 2 of 4 quarterly meetings (July 2023 & January 2024). Residents Affected - Few The facility failed to ensure they held QAA quarterly meetings and had documentation that the required members were present in the meetings between April 27, 2023, to October 5, 2023, and between October 5, 2023, to March 28, 2024. This failure could place residents in the facility at risk for a reduced quality of care and life due to lack of efficiently identifying and resolving resident and facility issues. Findings included: Record review of the facility's Quality Assurance Performance and Improvement (QAPI) meeting minutes sign in sheets from May 2023 to May 2024 revealed one meeting on 10/05/2023 with the following attending: the Administrator, the Medical Director, the Director of Nursing, the Pharmacy Consultant, the Business Office Manager, the Director of Rehabilitation, and the Executive Director. The facility was unable to provide a sign in sheet for the meeting in July 2023. Record review of the facility's Quality Assurance Performance and Improvement (QAPI) meeting minutes sign in sheets from May 2023 to May 2024 revealed one meeting on 02/29/2024 with the following attending: the Administrator, the Pharmacy Consultant, the Business Office Manager, the Clinical Liaison, the Director of Rehabilitation, the Director Plant Operations, and the Assistant Director of Nursing. No signature found that the DON and the Medical Director or his/her designee attended. The facility was unable to provide a sign in sheet for the meeting in January 2024. During an interview on 06/04/2024 at 1:42 p.m., the ED stated he had provided all the QAPI sign in sheets that he had found. He stated another ADMN worked at facility during that time that the sign in sheets were missing. He stated he took over after the previous ADMN left the company and she had been keeping track of meetings on paper. The meeting paperwork was being stored in a desk and then it was moved into a bankers' boxes for storage. He stated he could not locate the sign in sheets. The ED verified that he was the acting ADMN after the original ADMN left the company and he verbally verified the meetings had been performed but was unable to provide proof. He stated that no negative effects were had on the residents. During an interview on 06/04/2024 at 2:47 p.m., the DON stated she and ADMN were responsible to ensure the sign in sheets at the QAPI meetings were filled out and retained. She stated she had been working for the facility since November 2022 full time and could verbally verify that the QAPI meetings had been held monthly. She stated she was not able to provide the sign in sheets from the meetings because they were moved into file boxes, and she was unable to locate them. She stated the acting ADMN after the original ADMN left the facility was the ED but now they have hired a new ADMN. The DON stated she did not feel any negative effects occurred on the residents since the meetings were performed. She stated the facility had now changed the process for retaining the sign in sheets and the 676090 Page 9 of 12 676090 06/05/2024 Wesley Court Health Center 2617 Antilley Road Abilene, TX 79606

F 0868 facility will be uploaded into computer to prevent future meeting sign in sheets from being lost. Level of Harm - Minimal harm or potential for actual harm Record review of facility policy titled Quality Assurance & Performance Improvement (QAPI) Program Plan dated 08/31/2022 revealed: the facility will maintain documentation and demonstrate evidence of its ongoing QAPI efforts that serve to identify report, investigate, analyze, and prevent adverse events. Documentation will reflect the development, implementation, and evaluation of corrective actions or performance improvement initiatives. Upon request, and as required by state and federal regulations, our QAPI program plan will be made available to state and federal survey agencies .At a minimum, the QAPI committee and associated meetings will be conducted on a quarterly basis. Residents Affected - Few 676090 Page 10 of 12 676090 06/05/2024 Wesley Court Health Center 2617 Antilley Road Abilene, TX 79606

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on interviews and record review, the facility failed to ensure 2 of 8 (CNA-B and CNA-C) employees whose in-service records were reviewed had not received the required minimum 1-hour annual in-service training for Dementia. The facility failed to provide the required annual Dementia training to CNA-B, and CNA-C. This failure placed residents at risk for unmet needs due to untrained staff. Findings included: Record review of Personnel Files revealed: - Employee record for CNA-B revealed a hire date of 04/09/2024 and had no evidence of the required minimum 1-hour annual in-service training for Dementia. - Employee record for CNA-C revealed a hire date of 03/27/2024 and had no evidence of the required minimum 1-hour annual in-service training for Dementia . During an interview on 06/4/2024 at 5:25 PM the ADMN stated that the HR and the DON monitored staff trainings. He stated the facility protocols for Dementia training was a yearly 1-hour course but stated he did not know what the policies were. The ADMN stated he did not feel there would have been a negative impact for residents. He stated he would have to look further into what the failure would have been and stated his expectations for staff Dementia trainings to have been that all staff complete their required training upon orientation. Record Review of the facility policy titled In-Service Training, All Staff, Revised October 2023, revealed the following: Policy statement: All staff must participate in orientation and annual in-service training. Policy interpretation and implementation: 1. All staff are required to participate in regular in-service education. In-service education participation is considered working time for which staff are paid their regular wages. 2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers. 3. 676090 Page 11 of 12 676090 06/05/2024 Wesley Court Health Center 2617 Antilley Road Abilene, TX 79606

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training .6. Required training plan topics include the following: .c. (3) dementia management and resident abuse prevention 7. Training Plans are developed and implemented for onboarding, annual, and as necessary based on the facility assessment, team member specific competency per regulatory guidelines. Additional training may include: . g. person-centered care: . l. intellectual disability; and/or m. mental disorders. 8. Completed training is documented for staff with HRIS program to include: a. the date and time of the training; b. the topic of the training; c. a summary of the competency assessment as applicable. 676090 Page 12 of 12