Health inspection·February 12, 2024

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that the resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 1 residents (Resident #1) whose care was reviewed in that: CNA A told Resident #1 she was going to go to bed even though Resident #1 did not want to go to bed. This failure could place residents at risk of psychosocial harm and a diminished quality of life. Findings included: Review of the face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on 01/11/2024 with diagnoses of Cerebral infarction, pain, generalized anxiety disorder, disorders of the circulatory and respiratory systems, abnormalities of gait and mobility, unspecified lack of coordination, and cognitive communication deficit. Review of the annual MDS for Resident #1, date unknown, reflected a BIMS score of 8, indicating mild cognitive impairment. Review of the employee disciplinary form dated 11/01/23 reflected CNA A received a verbal warning because the DON received two complaints from residents because CNA A raised her voice at residents, told residents to be quiet, and spoke to residents as if they were children and told them what to do. Review of Future Performance Requirements dated 11/06/23 reflected CNA A's employment with the facility would be terminated if she did not maintain resident rights, remember she was coming into the residents' home, and not raise her voice to residents. Review of Record of Termination dated 01/23/24 reflected CNA A's employment was involuntary terminated because she failed to meet performance expectations, disregarded coworkers/ customer/clients, violated company policies/rules, violated company policies and failed evaluation period. Page 1 of 2 676290 676290 02/12/2024 Spjst Rest Home 1 1810 Old Granger Road Taylor, TX 76574

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of CNA A's statement dated 01/19/24 reflected CNA A told Resident #1, I explained to her there is one of me and 16 of them. Review of the interview DON had with Resident #1 dated 01/19/24 revealed Resident #1 told the DON that she told CNA A that she did not want to go to bed, and CNA A made her go to bed. Resident #1 said, I have the right to stay up if I want to. The DON told Resident #1 that she has the right to stay up if she wants to and it is the residents right to remain up or to go to bed. Resident #1 said she feels safe in the facility but is afraid of CNA A. Interview on 02/12/24 with CNA at 3:41 pm revealed she tried to get Resident #1 in bed and Resident #1 was agitated. CNA A said Resident #1 was very aggressive physically and verbally to CNA A. Interview on 02/12/24 with LVN B at 1:39 pm revealed CNA A was ready to put Resident #1 to bed but Resident #1 did not want to go to bed. LVN B said she felt CNA A was inappropriate with Resident #1 because Resident #1 did not want to go to bed. LVN B said CNA A was short tempered and had yelled at other residents, but LNV B did not reveal the residents' names of the residents LVN A was short tempered with. Interview on 02/12/24 with the DON at 3:47 pm revealed that the residents had the right to go to bed when they want to, and it was a violation of Resident #1's rights to tell her she had to go to bed. Interview on 02/12/24 with Resident #1 at 1:34 pm revealed she was not really sure what happened with CNA A. Review of the Resident Rights policy, undated, revealed it is the policy of the facility that all resident rights be followed per state and federal guidelines as well as other regulative of agencies. the resident has the right to be treated with consideration, respect, and full recognition of his or her dignity and individuality. To be free from verbal, sexual, mental or physical abuse, corporal punishment, involuntary seclusion and any physical or chemical restraint imposed for purposes of discipline or convenience or for other than treating medical symptoms. 676290 Page 2 of 2