Health inspection·August 3, 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 interviews and record reviews, the facility failed to ensure resideents the right to be free from abuse and/or neglect for 1 (Resident #1) of 7 residents reviewed for abuse and/or neglect. CNA A yelled or spoke loudly at Resident #1. The facility's failure to provide a safe environment free of verbal abuse places residents at risk of psychosocial harm. Findings included: Record review of Resident #1's face sheet, dated 8/3/23, revealed Resident #1 is a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included but are not limited to unspecified dementia with other behavioral disturbance (deterioration of memory, language, and other thinking abilities), systemic lupus erythematosus (autoimmune disease possibly causing skin rash, erosion of joints or kidney failure), hyperlipidemia (high cholesterol), hypothyroidism (underactive thyroid gland). Record review of Resident #1's MDS (Minimum Data Set), Section C (cognition), dated 6/1/23, revealed an absent BIMS (Brief Interview of Mental Status) score due to question C0100 being answered with 0. No (Resident is rarely/never understood). Record review of Resident #1 care plan, dated 3/8/23, reflected a goal of Behaviors: Impaired social Interaction: Resident #1 has impaired social interaction as evidenced by swinging and cursing at staff and refusing care. Record review of Resident #1 progress notes revealed incident of verbal abuse between Resident #1 and CNA A on July 25th, 2023 was not documented in patient chart. Record review of written witness statement signed by CNA B, dated 7/25/23, revealed that Resident #1 was standing in front of the television and CNA A approached Resident #1 yelling to sit down and take the book CNA A was offering. Resident #1 slapped the book out of CNA A's hand and CNA B told CNA A to leave her alone. CNA B also identified LVN A advised CNA A to leave resident alone. Record review of written witness statement signed by LVN A, dated 7/25/23, revealed LVN A heard CNA A speaking to Resident #1 in a loud voice. When CNA A offered Resident #1 a book, CNA A spoke loudly to Resident #1 and stated Sit down. Here. Here. LVN A had written that she verbally instructed CNA Page 1 of 2 745022 745022 08/03/2023 Ware Memorial Care Center 1510 S Van Buren St. Amarillo, TX 79101

F 0600 A to leave Resident #1 alone and walk away. Level of Harm - Minimal harm or potential for actual harm Record review of written witness statement signed by LVN B, dated 7/26/23, revealed CNA A yelled at Resident #1 during incident and stated, No ma'am. Leave her alone. She isn't doing anything to you. Come sit down. LVN B revealed LVN A asked CNA A to leave the resident alone. Residents Affected - Few During an interview with CNA A on 8/2/23 at 3:42 PM, CNA A stated abuse and neglect was verbal, physical, sexual, and financial. CNA A stated she received trainings regularly. CNA A revealed during interview that a negative outcome could be a down fall for the resident and the resident can be severely injured. The family should be involved, physical harm, and emotional harm. Interview with CNA B on 8/3/23 at 10:17 AM revealed that CNA A began yelling at Resident #1 after incident of resident physically chasing another staff member into another resident's room on 7/25/23. CNA B identified that Resident # 1 was not aggressive at the time CNA A began yelling at the resident. CNA B confirmed CNA B and LVN A told CNA A to leave Resident #1 alone. Interview with LVN A on 8/3/23 at 10:27 AM, revealed LVN A had seen CNA A yelling at Resident #1 stating here, here, here while waving a book in Resident #1's face. LVN A reported she told CNA A to walk away. LVN A reported that CNA B verbally told CNA A to leave her alone. Interview with DON on 8/3/23 at 11:59 AM stated that the resident was assessed after the incident and appeared smiling, calm, wasn't crying, and did not seem anxious. Interview with CNA A on 8/3/23 at 1:01 PM, stated CNA A knew where they went wrong in the situation by using a stern, raised voice. CNA A verified that abuse and neglect can be a situation a person is put in against their will whether it is a sexual, verbal, or financial situation. Interview with CNA D on 8/3/23 at 1:44 PM stated that CNA A was real firm and loud with Resident #1. Record review of CNA A's training revealed training on the following dates: Abuse, Neglect, and Exploitation dated 3/29/23. Dementia Care: Understanding Alzheimer's Disease dated 3/28/23; Essentials of Resident Rights dated 3/28/23 and Knowing the Rights of Residents dated 4/20/23. Record review of Abuse and Neglect Policy, dated 2/19/20, revealed that the resident has the right to be free from verbal .abuse. Residents must not be subjected to abuse by anyone including facility staff. 745022 Page 2 of 2