Health inspection·December 19, 2024

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview. and record review, the facility failed to ensure they did not employ an individual who was found guilty of a criminal offense barring employment by a court of law for 1 (MA A) of 9 employees reviewed for abuse and neglect. Residents Affected - Few The facility did not ensure MA A was disqualified from working in the facility when her criminal history, searched on 04/18/24 indicated a criminal conviction (on 03/05/24) barring employment in a nursing facility. MA A worked in the facility from 04/24/24 through 07/12/24. This noncompliance was identified as PNC. The deficient practice began on 04/24/24 and ended on 07/12/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for possible abuse, neglect, or exploitation. Findings included: Record review of the employee file for MA A reflected she was hired on 04/24/24. Her initial criminal history check was completed on 04/18/24 and reflected a misdemeanor conviction for an offense that barred employment. During an interview on 10/07/24 at 9:56 AM, the DCS stated MA A was terminated the day after the facility was made aware that a misdemeanor conviction for the offense barred the MA from employment. She stated the facility downloaded the list of barrable offenses from the state website and all the HR staff were trained on barrable offenses and background checks. During an interview on 10/07/24 at 2:58 PM, the HRD described the hiring process. She stated once the application was completed and signed, it was forwarded to the department manager for consideration and interview. If the manager wanted to hire, HR was notified. She stated one of the HR generalists would run the background checks. The checks included the Nurse Aide Registry, the Employee Misconduct Registry, criminal background, and others. She stated they ran the background check on MA A, and she saw the conviction on the record. She stated she believed because the offense was a misdemeanor, she was eligible for employment. She stated the HR department had training and reviewed the barrable offenses on the list. She stated she learned any conviction for the listed offenses made the person not eligible to work in the facility. She stated, since the training, if there is any conviction of any kind, the generalists sent it to her for final review. She stated employee files were audited by two staff to ensure they were accurate and completed. She stated the audits were reviewed at the QAPI meetings. During an interview on 12/19/24 at 10:39 AM, the HRD stated as soon as they learned MA A's Page 1 of 3 676266 676266 12/19/2024 Longhorn Village 12001 Longhorn Parkway Austin, TX 78732

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few conviction was barrable, they downloaded the list of barrable offenses (State of Texas, Health & Safety Code, Chapter 250 subsection 250.006 Convictions Barring Employment). She stated the conviction was a misdemeanor and she was specifically looking for a felony. She stated it was a mistake, a misunderstanding. She stated each employee in the HR department now had a copy of the list for reference. She stated she and the other two staff in the department had training about the barrable offenses, provided by the Nurse Consultant and the DCS on 07/15/24. During an observation and interview on 12/19/24 at 10:57 AM, HRE B was seated at her desk. Posted on the wall to her left, a copy of the barrable penal code list was observed. She stated she initiated background checks on new employees. She stated if the person had not lived in the state for the last five years, there was a different background check conducted that pulled information from other states. She stated if there was any conviction on the report, she compared it with the list then it was reviewed by the HR director for final approval. She stated she had training on the barrable offense list in July of this year. During an observation and interview on 12/19/24 at 11:03 AM, HRE C was sitting at her desk. On the wall behind the desk, a copy of the barrable penal code list was observed. She stated she conducted background checks. She stated she first had to make sure the application was signed because she could not proceed without the signature. She stated if any background check came back with a conviction, she sent it to the HRD for review. During an interview on 12/19/24 at 1:30 PM the ADM, stated she was out of town when the facility learned that MA A had a barrable offense but she was notified. She stated MA A was terminated and the HR staff were trained by the Nurse Consultant and the DCS. She stated it was her expectation that any conviction on the background check was reviewed by the HR manager. She stated employee file audits are a topic at their QAPI meetings. She stated background checks must be accurate as a wrong spelling or wrong number could give information on the wrong person. Immediate Response: DCS and administration aware. Downloaded and printed list of barrable offenses. MA A was terminated. HR department was trained on background checks and barrable offenses. Audits of employee files conducted by two staff. 676266 Page 2 of 3 676266 12/19/2024 Longhorn Village 12001 Longhorn Parkway Austin, TX 78732

F 0607 Actions: Level of Harm - Minimal harm or potential for actual harm 07/11/24 - DCS and HRM downloaded and printed the barrable offense list. Each of the three HR staff were given a copy of the list. Residents Affected - Few 07/12/24 - MA A was terminated. 07/15/24 - HRM and the two HR employees trained on background checks and barrable offenses. Conclusion: Confirmed. MA A worked at the facility from 04/24/24 through 07/12/24 with a conviction for a barrable offense. Review of 9 undated personnel files, including MA A, reflected required background checks, reference checks, and orientation training on abuse/neglect/exploitation, resident rights, and dementia care. The background checks were completed prior to the date of hire. The audit sheets reflected initials from two HR staff. Review of the facility Abuse prevention policy updated November 2016 reflected in part . This community will not knowingly employ any individual convicted of resident abuse, neglect, or misappropriation of property. The community will not knowingly employ any direct care staff convicted of any of the crimes listed in the State Criminal History of Nurse Aides an Other Unlicensed Employees, or with a finding of abuse listed on the Nurse Aide Registry or criminal history background check. Prior to a new employee starting a work schedule, this community will: 1.1 initiate a reference check from previous employers, in accordance with community policy. 1.2 Obtain a copy of the state license . 1.3 If applicant is a nursing assistant, obtain a copy of the person's state nurse aide registry report from the state department. 1.4 Obtain a limited criminal history. Review of in-services conducted reflected the HR staff were in-serviced on background checks and barrable offenses on 07/15/24. This noncompliance was identified as PNC. The deficient practice began 04/24/24 and ended on 10/12/24. The facility had corrected the noncompliance before the survey began. 676266 Page 3 of 3