Health inspection·November 10, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect of residents for 1 of 4 residents (Resident #1) reviewed for neglect. Residents Affected - Few The facility failed to implement their Abuse policy and ensure all allegations that resulted in serious bodily injury were reported to HHSC within 2 hours of the allegation for Resident #1 who had a fall on 10/21/2023 at 4:53 AM. This failure could place residents at risk of being neglected and lack of oversight by a state agency. Findings included: Record review of a facility policy titled Abuse Investigation and Reporting with a revised date of October 15, 2022, indicated, .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. Reporting: 2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury . Record review of a face sheet for Resident #1 dated 11/8/2023 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of unspecified glaucoma (eye disease that causes blindness), peripheral vascular disease (reduced blood flow to the legs), sickle cell disease (an inherited blood disease that causes the blood cells to stick together), blindness in left eye, age related osteoporosis (brittle bones), nontraumatic subarachnoid hemorrhage (bleeding in the brain) and nontraumatic subdural hemorrhage (bleeding inside of the head, between the skull but outside of the brain). Record review of a Significant Change MDS assessment dated [DATE] for Resident #1 indicated she had severe impairment in thinking with a BIMS score of 5. She required substantial/maximal assistance with toileting hygiene. She had recent falls since admission/entry or reentry or prior assessment that included one with major injury-subdural hematoma (brain bleed). She took high risk drug that included antiplatelets (medication that prevents blood clots from forming) during the 7 day look back period. Record review of a care plan dated 9/6/2023 for Resident #1 indicated she was a high risk for falls Page 1 of 5 455673 455673 11/10/2023 Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904

F 0607 Level of Harm - Minimal harm or potential for actual harm related to gait/balance problems, vision/hearing problems, unaware of safety needs. She had an actual fall related to poor balance, unsteady gait dated 10/21/2023 with interventions dated 10/23/2023 that family requested resident to ambulate, declined wheelchair offered. She had an ADL self-care performance deficit related to impaired balance, limited mobility, and required extensive assistance by one staff for toileting and transfers. Residents Affected - Few Record review of a progress noted dated 10/21/2023 at 4:53 AM by LVN B for Resident #1 indicated, .CNA reported to this nurse that resident had fallen in bathroom. This nurse down to resident's room and observed resident lying on floor in shower area/bathroom. Resident alert and able to respond to questions. Blood noted from left ear, resident states she hit her head. CNA states that she was assisting resident to toilet, resident reached out to walker, and walker slid out from under resident. CNA states she was unable to catch resident from falling. Placed call to hospice, spoke to nurse, orders given to send resident to ER for further eval and treatment. Resident's [family member request resident be sent to local hospital. 911 in route . Record review of a CT scan of head dated 10/21/2023 for Resident #1 indicated she had a small right temporoparietal subdural hemorrhage and left frontal subarachnoid hemorrhage. Record review of TULIP for the facility did not indicate a self-report was submitted to report the serious bodily injury of Resident #1. During an interview on 11/10/2023 at 9:30 AM, the Administrator said she had been employed at the facility since January 2023. She said the incident on 10/21/2023 with Resident #1 was a witnessed fall and CNA A was doing everything correctly during her transfer. She said her understanding of reporting to the state agency was if staff dropped someone while using a mechanical lift or if the facility had done something wrong, then the incident should be reported to the state agency. She said CNA A was asked to provide a demonstration of the incident to her and the DON. She said Resident #1 lost her balance and was mobile. She said after discussion with the DON and Regional Nurse, and going into the bathroom of Resident #1, it was determined that that incident was not a reportable incident. She said going forward she would ensure that no matter if the incident was alleged or not, she would report any serious injury. She said she was the abuse coordinator, and the incident should have been reported within 2 hours to the state agency according to the facility policy. During an interview on 11/10/2023 at 11:11 AM, the DON said she had been employed at the facility since August 2022. She said they questioned with the ADON and the Administrator and discussed the incident to see if the incident was reportable or not. She said they determined that it did not follow what was in the Provider Letter 19-17 and the Regional Nurse looked over the information and said the Provider Letter changed from 2016 and it was a group decision that it was not a reportable incident, and she called the Medical Director to inform him, and he was ok with the decision they made. She said after discussing the incident with this Surveyor and reviewing the information in the Provider Letter that talked about serious bodily injury along with having a better understanding of what serious bodily injury was; the incident on 10/21/2023 with Resident #1 should have been reported to the state agency. 455673 Page 2 of 5 455673 11/10/2023 Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily for 1 of 4 residents (Resident #1) reviewed for neglect. The facility did not report to the state agency within 2 hours when an allegation of neglect occurred on 10/21/2023 that involved Resident #1 who had a fall and sustained a small cut to her left ear and two brain bleeds. This failure could place vulnerable residents at risk of harm due to delays in reporting an allegation of neglect. Findings included: Record review of a face sheet for Resident #1 dated 11/8/2023 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of unspecified glaucoma (eye disease that causes blindness), peripheral vascular disease (reduced blood flow to the legs), sickle cell disease (an inherited blood disease that causes the blood cells to stick together), blindness in left eye, age related osteoporosis (brittle bones), nontraumatic subarachnoid hemorrhage (bleeding in the brain) and nontraumatic subdural hemorrhage (bleeding inside of the head, between the skull but outside of the brain). Record review of a Significant Change MDS assessment dated [DATE] for Resident #1 indicated she had severe impairment in thinking with a BIMS score of 5. She required substantial/maximal assistance with toileting hygiene. She had recent falls since admission/entry or reentry or prior assessment that included one with major injury-subdural hematoma (brain bleed). She took high risk drug that included antiplatelets (medication that prevents blood clots from forming) during the 7 day look back period. Record review of a care plan dated 9/6/2023 for Resident #1 indicated she was a high risk for falls related to gait/balance problems, vision/hearing problems, unaware of safety needs. She had an actual fall related to poor balance, unsteady gait dated 10/21/2023 with interventions dated 10/23/2023 that family requested resident to ambulate, declined wheelchair offered. She had an ADL self-care performance deficit related to impaired balance, limited mobility, and required extensive assistance by one staff for toileting and transfers. Record review of a progress noted dated 10/21/2023 at 4:53 AM by LVN B for Resident #1 indicated, .CNA reported to this nurse that resident had fallen in bathroom. This nurse down to resident's room and observed resident lying on floor in shower area/bathroom. Resident alert and able to respond to questions. Blood noted from left ear, resident states she hit her head. CNA states that she was assisting resident to toilet, resident reached out to walker, and walker slid out from under resident. CNA states she was unable to catch resident from falling. Placed call to hospice, spoke to nurse, orders given to send resident to ER for further eval and treatment. Resident's [family member request resident be sent to local hospital. 911 in route . 455673 Page 3 of 5 455673 11/10/2023 Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904

F 0609 Level of Harm - Minimal harm or potential for actual harm Record review of a CT scan of head dated 10/21/2023 for Resident #1 indicated she had a small right temporoparietal subdural hemorrhage and left frontal subarachnoid hemorrhage. Record review of TULIP for the facility did not indicate a self-report was submitted to report the serious bodily injury of Resident #1. Residents Affected - Few During an interview on 11/9/2023 at 4:24 AM, CNA A said she had been employed at the facility since November 16, 2022. She said was doing her last round around 4-5 am on 10/21/2023 and assisted Resident #1 to the bathroom with a rollator walker that had a seat. CNA A said she assisted Resident #1 out of the bed, and they walked to the bathroom using a walker and CNA A was holding onto her back with one hand and the other hand was on the walker to help balance. She said when they made it in the bathroom, she placed the walker close to the wall, not in the resident's way and positioned Resident #1 in front of the toilet. She said Resident #1 was trying to help pull down her brief and CNA A stepped to the side because she could not get the brief out of her bottom. CNA A said one hand was on Resident #1's right arm and her other hand was trying to pull the brief out of her bottom because it was bunched up. She said Resident #1 was trying to help pull down the brief in the front as she was pulling it down in the back and Resident #1 lost her balance and fell on her left side. She said before the fall the staff were transferring her in the wheelchair and the family requested for her to use the walker. She said she went and told Resident #1's nurse. She said Resident #1 had started trying to get up and she told her she had to wait. She said she stayed with Resident #1 until the ambulance arrived. She said following the incident she had a training by the DON to be cautious of transferring of the residents and to make sure everything was out of the way and to make sure they get to the bathroom properly. She said she wished she could have prevented the fall, but it happened so fast that she did not have time to react. She said if she would have been transferring Resident #1 with a wheelchair, she would have put Resident #1 in front of the grab bar for support but using the walker she was not steady enough to walk with it. She said prior to the incident she had a check off with the ADON's on transfers with residents. Record review of a facility in-service dated 10/23/2023 by the DOR was conducted on proper gait belt/safety/transfers and CNA A was in attendance with her signature noted. Record review of a one-on-one staff education dated 10/23/2023 for CNA A by ADON for toileting and transfers was conducted. Plan for improvement included in-service and training on safe transfers and toileting if you have questions or request additional training/assist please see nurse management. During an observation and interview on 11/9/2023 at 9:51 AM, Resident #1 was in her room sitting up in bed, dressed and alert to person with confusion noted. She kept saying that she wanted to go home. Resident #1 said she was blind. She was pointing to the wall by her bed and asked if this surveyor could see the house. She asked if one of her family members worked at the facility. Resident #1's bed was in a low position with bed bolsters on the mattress. A fall mat was noted on the floor by the bed. Resident #1 was asked about a fall that happened a few weeks ago but she could not remember and kept saying she wanted to go home. She had one stitch noted to the inside of her left ear. During an interview on 11/10/2023 at 9:30 AM, the Administrator said she had been employed at the facility since January 2023. She said the incident with Resident #1 was a witnessed fall and CNA A was doing everything correctly during her transfer. She said her understanding of reporting to the state agency was if staff dropped someone while using a mechanical lift or if the facility had done something wrong, then the incident should be reported to the state agency. She said CNA A was asked to provide a demonstration of the incident to her and the DON. She said Resident #1 lost her balance 455673 Page 4 of 5 455673 11/10/2023 Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904

F 0609 Level of Harm - Minimal harm or potential for actual harm and was mobile. She said after discussion with the DON and Regional Nurse, and going into the bathroom of Resident #1, it was determined that that incident was not a reportable incident. She said going forward she would ensure that no matter if the incident was alleged or not, she would report any serious injury. She said she was the abuse coordinator, and the incident should have been reported within 2 hours to the state agency because Resident #1 had a fall with major injury. Residents Affected - Few During an interview on 11/10/2023 at 11:11 AM, the DON said she had been employed at the facility since August 2022. She said they questioned with the ADON and the Administrator and discussed the incident to see if the incident was reportable or not. She said they determined that it did not follow what was in the Provider Letter 19-17 and the Regional Nurse looked over the information and said the Provider Letter changed from 2016 and it was a group decision that it was not a reportable incident and called the Medical Director to inform him and he was ok with the decision they made. She said after discussing the incident with this Surveyor and reviewing the information in the Provider Letter that talked about serious bodily injury along with having a better understanding of what serious bodily injury was the incident on 10/21/2023 with Resident #1 should have been reported to the state agency. Record review of a facility policy titled Abuse Investigation and Reporting with a revised date of October 15, 2022, indicated, .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management. Reporting: 2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury . 455673 Page 5 of 5