Health inspection·December 2, 2023

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change for one (Resident #1) of three residents reviewed for notification of changes, in that: The facility failed to ensure Resident #1 was properly assessed after being found on the floor of her room on 11/10/23. Resident #1 was picked up by CNA B, there was no assessment documented by the nurse, the on-coming nurse nor NP were notified of the fall. On 11/15/23 she was sent to the ER and diagnosed with a left hip fracture requiring surgery. An Immediate Jeopardy (IJ) existed on 11/16/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. This failure could place residents at risk of experiencing unmanaged pain, a decreased quality of life, and hospitalization. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including fracture of right humerus (long bone in the arm or forelimb that runs from the shoulder to the elbow), dementia, and unspecified protein-calorie malnutrition. Review of Resident #1's quarterly MDS assessment, dated 11/03/23, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section GG (Functional Abilities and Goals) reflected she required supervision or touching assistance with transferring and chair/bed-to-chair transfers. Section J (Health Conditions) reflected she had not had any falls since admission. Review of Resident #1's quarterly care plan, revised 09/24/23, reflected she was at risk for falls with an intervention of educating resident/family/caregivers about safety reminders and what to do if a fall occurred. Review of Resident #1's NP progress note, dated 11/14/23, reflected the following: Today, [Resident #1] was seen in the day room, sitting up in her WC. AAOx3 with mild impairment. [Resident #1] reports her legs hurt x 4 days. She describes it being a constant, deep/dull pain, Page 1 of 20 455771 455771 12/02/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0580 Level of Harm - Immediate jeopardy to resident health or safety ranging from the hips to above the knees. [Resident #1] reports she has never had this feeling before. [Resident #1] can't remember if she fell or not over the weekend. There were no reports of any falls from staff, but [Resident #1] does have new bandages on both elbows. No new bruises on [Resident #1]'s body. Staff reports that the pain has been very disabling to [Resident #1]. [Resident #1] normally would be a [NAME]-by or contact assist with ADLs, but today, [Resident #1] has been having difficulties transferring to toilet from WC d/t pain in her lower extremities. Residents Affected - Some Abdominal swelling generalized: Ordered ultrasound of abdomen and pelvis. Pain in right and left leg: Order x-ray of femur. Added Tylenol 500mg tid for pain x 7 days. Review of Resident #1's physician order, dated 11/14/23, reflected the following: Acetaminophen tablet 500 MG - Give 1 tablet by mouth three times a day for pain for 7 days. Review of Resident #1's physician order, dated 11/14/23, reflected the following: Muscle Rub External Cream 10-15% (Menthol-Methyl Salicylate) - Apply to thighs and knees topically two times a day for pain. Review of Resident #1's progress notes in her EMR, dated 11/15/23 at 10:57 AM, reflected the following: [Resident #1] appears comfortable but with distended abdomen and a bulging area on the left side of the abdomen. Has order for abdominal ultrasound which has not been done . Called and notified NP and asked if [Resident #1] can be sent to ER for evaluation, she objected to that. Called (x-ray company) for ETA for the procedures and the don't have any at this time but will come today. Review of Resident #1's progress notes in her EMR, dated 11/15/23 at 4:21 PM, reflected the following: Returned to the floor following lunch break at 3:30 PM and received a note that the ultrasound tech called and will not be coming in to perform the procedure today. No specific date or time was given. Called NP and rec'd phone order to send [Resident #1] to ER for evaluation/treatment . Review of Resident #1's progress notes in her EMR, dated 11/16/23 at 7:19 AM, reflected the following: Called (hospital ER) this morning and was informed that [Resident #1] was admitted and will be going for surgery this morning - left hip fracture. Review of the facility's investigation regarding Resident #1's injury, dated 11/16/23, reflected the following: Description of Allegation: The facility was informed of a fracture of left hip of [Resident #1] on morning of 11/16 by hospital staff. 455771 Page 2 of 20 455771 12/02/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0580 Initial Investigation: Level of Harm - Immediate jeopardy to resident health or safety Upon investigation, [CNA A] informed Administrator that she was informed by [CNA B] on morning of 11/17 that on 11/12 [Resident #1] had slid out of bed during her shift with [LVN C] being informed of incident. The fall was reported to have happened in the early hours of Saturday (11/11/23). Residents Affected - Some [CNA B], worked 11/10/23 10p - 6am [CNA B] stated that around midnight she witnessed [Resident #1] sitting next to her bed with her left hip against the bed and she (Resident #1) had been in bed previously. [CNA B] tried to locate [LVN C] but was unable to at that time due to resident care. [CNA B] placed [Resident #1] in wheelchair with no complaints of pain. Shortly thereafter, [Resident #1] complained of pain with [LVN C] giving her medication. [LVN C], worked 11/10/23 10p - 6am [LVN C] stated that it was reported to her that [Resident #1] had slid out of bed and had been placed in wheelchair when she was notified of incident. [LVN C] stated that [Resident #1] had tried to get out of bed without help. [LVN C] stated she assessed [Resident #1]'s left leg/hip and vitals with no concerns. [LVN C] noted two skin tears that she treated on [Resident #1]'s elbow. [Resident #1] agreed to take pain medication. [LVN C] reported having message the physician and passed along to the following nurse. [LVN C] admitted that no incident report was generated, or nurses note made regarding the incident. [CNA D], worked 11/11/23 6a - 10p [CNA D] noted [Resident #1]'s change with mobility however did not report change to nurse. Educated that all changes need to be investigated. [RN E], worked 11/11/23 6a - 6p [RN E] stated she was unaware of fall and was not informed of any changes with [Resident #1] from [LVN C]. [CNA A], worked 11/13/23 6a - 10pm [CNA A] informed NP that she noticed [Resident #1] having change of mobility during her rounds. [LVN G] worked 11/13/23 6a - 10pm [LVN G] received an order for Acetaminophen TID, and a muscle rub cream medication continued to be given. [CNA A], worked 11/15/23 6a - 10pm [CNA A] stated that [Resident #1] still had difficulty with mobility and was aware we were waiting on x-ray and ultrasound. [RN E], worked 11/15/23 6a - 6pm 455771 Page 3 of 20 455771 12/02/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some [RN E] contacted (x-ray company) as ultrasound of abdomen and x-ray of bilateral hips had not been conducted. At approximately 3:30pm, [RN E] received a message that they will be unable to perform ultrasound. [RN E] notified NP of issue with ultrasound and was notified to send to ER. Immediate actions taken: Pain medication ordered for comfort and effective. Abdominal ultrasound and x-rays of both hips ordered, however was unable to obtain. [Resident #1] has a history of bruising easy with NP stated she noted swelling in the abdomen, however, did not visualize anything during assessment that would even suggest a fracture. Post actions taken: - Nursing staff educated on change of condition and reporting expectations, ensuring that nurses are informed of any pending procedures/orders at shift change, completing of incident report, notification of DON, Physician, and RP. - Skin assessments completed on all residents in Memory Care Unit with no skin findings to falls. - Pain assessment conducted on all residents in Memory Care Unit with no concerns noted. - [LVN C] was terminated due to failure to complete incident report, pass on information during shift transfer, and notify physician, family, and DON. - All falls and discharges are to be reported to DON in a timely manner. Review of an in-service entitled Incident and Accident Reporting, dated 07/31/23, reflected CNA B and LVN C had been in attendance for the in-service given on notifying the ADM and DON for all incidents and accidents, all falls, etc. Review of an in-service entitled CNA Fall Procedure, dated 11/16/23 and conducted by the ADON, reflected CNAs were in-serviced on the following: When a resident is on the floor, whether witnessed or not witnessed, at no point should you lift resident off the floor or move them without a nurse assessing that resident. If resident complains of pain when moving resident, leave resident and follow fall protocol through the nurse. At no circumstance should a CNA or MA lift a resident from the floor without a nurse assessing the resident. Failure to comply will lead to disciplinary action up to termination. Review of an in-service entitled Nurse Fall Procedure, dated 11/16/23 and conducted by the ADON, reflected nurses were in-serviced on the following: When a CNA reports a fall, whether witnessed or un-witnessed, nurse need to follow the following protocols: - Assessment of resident, head to toe, vitals, and range of motion. If resident is in pain or 455771 Page 4 of 20 455771 12/02/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0580 Level of Harm - Immediate jeopardy to resident health or safety cannot bear weight, call for help and call on-call for order to either transfer the resident to the hospital of non-weight bearing. - Follow physician instructions. - Notify DON/ADM. Residents Affected - Some - Notify family. - Do proper documentation - incident report, nursing notes, pain and fall evaluation. - If reside is in pain and cannot get x-ray on time, get order to send resident out for further evaluation. Failure to follow these procedures will lead to disciplinary action up to termination. Review of an in-service entitled Fall Precautions and Interventions, dated 11/16/23, reflected all staff were in-serviced on fall precaution educating and fall interventions to reduce falls. During an interview on 12/02/23 at 12:11 PM, the DCO stated she did meet with the NP on 11/14/23 after she assessed Resident #1 but she did not make the situation sound as dire as it had been documented in the progress note. She stated the aide should have never gotten Resident #1 off the floor without notifying a nurse first so that appropriate assessments could have been conducted. She stated the nurse (LVN C) admitted to not completing an incident report. She stated it was unacceptable that Resident #1 did not receive the proper care or treatment due to the fall not being reported. She stated LVN C was terminated and the staff were in-serviced on fall precautions, who to notify, and what assessments needed to be done after a witnessed or un-witnessed fall. During an interview on 12/02/23 at 1:46 PM, CNA H stated she had been in-serviced on falls and notifying nurses of changes-in-condition. She stated she would never try to pick a resident up off the floor if they had fallen. She stated she would get a nurse immediately. She stated the nurses needed to conduct their assessments to ensure residents were not hurt or bleeding. During an interview on 12/02/23 at 2:32 PM, LVN I stated she expected CNAs to notify her when there was any kind of change-in-condition regarding a resident, especially a fall. She stated when a resident falls, she assessed them, checked their range of motion, completed an incident report, documented in the resident's chart, and notified the NP and resident RP. During an interview on 12/02/23 at 2:41 PM, LVN J stated of a resident was found on the ground by an aide, she would expect the aide to notify her immediately. She stated she would check vitals, conduct a full-body assessment, conduct neuro checks, notify the NP, complete an incident report, and ensure she notified the on-coming nurse. During an interview on 12/02/23 at 2:49 PM, CNA K stated if she found a resident on the ground, she would immediately notify a nurse. She stated a nurse needed to be notified so they could ensure the resident was not bleeding or had a broken bone. During an interview on 12/04/23 at 2:05 PM, Resident #1's NP stated she was never notified of the fall that occurred. She stated she saw Resident #1 on Friday 11/10/23 and she was doing great - she 455771 Page 5 of 20 455771 12/02/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some was acting completely normal, making jokes, and there were no issues. She stated on Tuesday 11/14/23, staff informed her that Resident #1 was having difficulty with transferring. She stated Resident #1 was usually able to transfer herself with minimal assistance. She stated the resident was complaining of pain whenever she moved her legs. She stated she did a skin assessment and noted no bruising. She stated the only thing that could have suggested she had a fall were two bandages on her elbows that were dated 11/11/23. She stated she asked the charge nurse who was working who stated he had not heard of Resident #1 sustaining a fall over the weekend. She stated it was her expectation that she be notified of every fall. She stated even if a resident falls over the weekend, their on-call team should be notified. She stated she ordered x-rays on 11/14/23 and was not aware they had not gotten done that day until she was called in the morning of 11/15/23 by a nurse requesting to send Resident #1 to the hospital because she was complaining of pain. She stated she did not want her to go to the hospital since she had personally called the x-ray order to put in the order and she had PRN pain medication. She stated the nursing staff from the night before on 11/15/23 should have followed up on the x-rays because they should have been done that day. She stated it was unacceptable they were not followed-up on or at least should have called the on-call medical team. She stated when she calls in a STAT x-ray, she had rarely seen it take over an hour for them to get to the facility. She stated once she was notified later in the day on 11/15/23 that the x-rays still had not been done, she requested Resident #1 be sent to the ER immediately. An attempt to interview CNA B was made on 12/04/23 at 3:08 PM. A returned phone call was not received. An attempt to interview CNA B was made on 12/04/23 at 3:13 PM. A returned phone call was not received. Review of the facility's Change in a Resident's Condition or Status Policy, revised February 2021, reflected the following: 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discovery of injuries of an unknown source . 8. The nurse will record in the resident's medical record information relative to change in the resident's medical/mental condition or status. 455771 Page 6 of 20 455771 12/02/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0600 Level of Harm - Immediate jeopardy to resident health or safety 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 interview and record review, the facility failed to ensure the residents had the right to be free from neglect for one (Resident #1) out of three residents reviewed for neglect. Residents Affected - Some The facility failed to ensure Resident #1 was properly assessed after being found on the floor of her room on 11/10/23. Resident #1 was picked up by CNA B, there was no assessment documented by the nurse, the on-coming nurse nor NP were notified of the fall. On 11/15/23 she was sent to the ER and diagnosed with a left hip fracture requiring surgery. An Immediate Jeopardy (IJ) existed on 11/16/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. This failure could place residents at risk of experiencing unmanaged pain, a decreased quality of life, and hospitalization. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including fracture of right humerus (long bone in the arm or forelimb that runs from the shoulder to the elbow), dementia, and unspecified protein-calorie malnutrition. Review of Resident #1's quarterly MDS assessment, dated 11/03/23, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section GG (Functional Abilities and Goals) reflected she required supervision or touching assistance with transferring and chair/bed-to-chair transfers. Section J (Health Conditions) reflected she had not had any falls since admission. Review of Resident #1's quarterly care plan, revised 09/24/23, reflected she was at risk for falls with an intervention of educating resident/family/caregivers about safety reminders and what to do if a fall occurred. Review of Resident #1's NP progress note, dated 11/14/23, reflected the following: Today, [Resident #1] was seen in the day room, sitting up in her WC. AAOx3 with mild impairment. [Resident #1] reports her legs hurt x 4 days. She describes it being a constant, deep/dull pain, ranging from the hips to above the knees. [Resident #1] reports she has never had this feeling before. [Resident #1] can't remember if she fell or not over the weekend. There were no reports of any falls from staff, but [Resident #1] does have new bandages on both elbows. No new bruises on [Resident #1]'s body. Staff reports that the pain has been very disabling to [Resident #1]. [Resident #1] normally would be a [NAME]-by or contact assist with ADLs, but today, [Resident #1] has been having difficulties transferring to toilet from WC d/t pain in her lower extremities. Abdominal swelling generalized: Ordered ultrasound of abdomen and pelvis. Pain in right and left leg: Order x-ray of femur. Added Tylenol 500mg tid for pain x 7 days. 455771 Page 7 of 20 455771 12/02/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0600 Review of Resident #1's physician order, dated 11/14/23, reflected the following: Level of Harm - Immediate jeopardy to resident health or safety Acetaminophen tablet 500 MG - Give 1 tablet by mouth three times a day for pain for 7 days. Residents Affected - Some Muscle Rub External Cream 10-15% (Menthol-Methyl Salicylate) - Apply to thighs and knees topically two times a day for pain. Review of Resident #1's physician order, dated 11/14/23, reflected the following: Review of Resident #1's progress notes in her EMR, dated 11/15/23 at 10:57 AM, reflected the following: [Resident #1] appears comfortable but with distended abdomen and a bulging area on the left side of the abdomen. Has order for abdominal ultrasound which has not been done . Called and notified NP and asked if [Resident #1] can be sent to ER for evaluation, she objected to that. Called (x-ray company) for ETA for the procedures and the don't have any at this time but will come today. Review of Resident #1's progress notes in her EMR, dated 11/15/23 at 4:21 PM, reflected the following: Returned to the floor following lunch break at 3:30 PM and received a note that the ultrasound tech called and will not be coming in to perform the procedure today. No specific date or time was given. Called NP and rec'd phone order to send [Resident #1] to ER for evaluation/treatment . Review of Resident #1's progress notes in her EMR, dated 11/16/23 at 7:19 AM, reflected the following: Called (hospital ER) this morning and was informed that [Resident #1] was admitted and will be going for surgery this morning - left hip fracture. Review of the facility's investigation regarding Resident #1's injury, dated 11/16/23, reflected the following: Description of Allegation: The facility was informed of a fracture of left hip of [Resident #1] on morning of 11/16 by hospital staff. Initial Investigation: Upon investigation, [CNA A] informed Administrator that she was informed by [CNA B] on morning of 11/17 that on 11/12 [Resident #1] had slid out of bed during her shift with [LVN C] being informed of incident. The fall was reported to have happened in the early hours of Saturday (11/11/23). [CNA B], worked 11/10/23 10p - 6am [CNA B] stated that around midnight she witnessed [Resident #1] sitting next to her bed with her left hip against the bed and she (Resident #1) had been in bed previously. [CNA B] tried to locate [LVN C] but was unable to at that time due to resident care. [CNA B] placed [Resident #1] in wheelchair 455771 Page 8 of 20 455771 12/02/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some with no complaints of pain. Shortly thereafter, [Resident #1] complained of pain with [LVN C] giving her medication. [LVN C], worked 11/10/23 10p - 6am [LVN C] stated that it was reported to her that [Resident #1] had slid out of bed and had been placed in wheelchair when she was notified of incident. [LVN C] stated that [Resident #1] had tried to get out of bed without help. [LVN C] stated she assessed [Resident #1]'s left leg/hip and vitals with no concerns. [LVN C] noted two skin tears that she treated on [Resident #1]'s elbow. [Resident #1] agreed to take pain medication. [LVN C] reported having message the physician and passed along to the following nurse. [LVN C] admitted that no incident report was generated, or nurses note made regarding the incident. [CNA D], worked 11/11/23 6a - 10p [CNA D] noted [Resident #1]'s change with mobility however did not report change to nurse. Educated that all changes need to be investigated. [RN E], worked 11/11/23 6a - 6p [RN E] stated she was unaware of fall and was not informed of any changes with [Resident #1] from [LVN C]. [CNA A], worked 11/13/23 6a - 10pm [CNA A] informed NP that she noticed [Resident #1] having change of mobility during her rounds. [LVN G] worked 11/13/23 6a - 10pm [LVN G] received an order for Acetaminophen TID, and a muscle rub cream medication continued to be given. [CNA A], worked 11/15/23 6a - 10pm [CNA A] stated that [Resident #1] still had difficulty with mobility and was aware we were waiting on x-ray and ultrasound. [RN E], worked 11/15/23 6a - 6pm [RN E] contacted (x-ray company) as ultrasound of abdomen and x-ray of bilateral hips had not been conducted. At approximately 3:30pm, [RN E] received a message that they will be unable to perform ultrasound. [RN E] notified NP of issue with ultrasound and was notified to send to ER. Immediate actions taken: Pain medication ordered for comfort and effective. Abdominal ultrasound and x-rays of both hips ordered, however was unable to obtain. [Resident #1] has a history of bruising easy with NP stated she noted swelling in the abdomen, however, did not visualize anything during assessment that would even suggest a fracture. 455771 Page 9 of 20 455771 12/02/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0600 Post actions taken: Level of Harm - Immediate jeopardy to resident health or safety - Nursing staff educated on change of condition and reporting expectations, ensuring that nurses are informed of any pending procedures/orders at shift change, completing of incident report, notification of DON, Physician, and RP. Residents Affected - Some - Skin assessments completed on all residents in Memory Care Unit with no skin findings to falls. - Pain assessment conducted on all residents in Memory Care Unit with no concerns noted. - [LVN C] was terminated due to failure to complete incident report, pass on information during shift transfer, and notify physician, family, and DON. - All falls and discharges are to be reported to DON in a timely manner. Review of an in-service entitled Incident and Accident Reporting, dated 07/31/23, reflected CNA B and LVN C had been in attendance for the in-service given on notifying the ADM and DON for all incidents and accidents, all falls, etc. Review of an in-service entitled CNA Fall Procedure, dated 11/16/23 and conducted by the ADON, reflected CNAs were in-serviced on the following: When a resident is on the floor, whether witnessed or not witnessed, at no point should you lift resident off the floor or move them without a nurse assessing that resident. If resident complains of pain when moving resident, leave resident and follow fall protocol through the nurse. At no circumstance should a CNA or MA lift a resident from the floor without a nurse assessing the resident. Failure to comply will lead to disciplinary action up to termination. Review of an in-service entitled Nurse Fall Procedure, dated 11/16/23 and conducted by the ADON, reflected nurses were in-serviced on the following: When a CNA reports a fall, whether witnessed or un-witnessed, nurse need to follow the following protocols: - Assessment of resident, head to toe, vitals, and range of motion. If resident is in pain or cannot bear weight, call for help and call on-call for order to either transfer the resident to the hospital of non-weight bearing. - Follow physician instructions. - Notify DON/ADM. - Notify family. - Do proper documentation - incident report, nursing notes, pain and fall evaluation. 455771 Page 10 of 20 455771 12/02/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0600 - If reside is in pain and cannot get x-ray on time, get order to send resident out for further evaluation. Level of Harm - Immediate jeopardy to resident health or safety Failure to follow these procedures will lead to disciplinary action up to termination. Review of an in-service entitled Fall Precautions and Interventions, dated 11/16/23, reflected all staff were in-serviced on fall precaution educating and fall interventions to reduce falls. Residents Affected - Some During an interview on 12/02/23 at 12:11 PM, the DCO stated she did meet with the NP on 11/14/23 after she assessed Resident #1 but she did not make the situation sound as dire as it had been documented in the progress note. She stated the aide should have never gotten Resident #1 off the floor without notifying a nurse first so that appropriate assessments could have been conducted. She stated the nurse (LVN C) admitted to not completing an incident report. She stated it was unacceptable that Resident #1 did not receive the proper care or treatment due to the fall not being reported. She stated LVN C was terminated and the staff were in-serviced on fall precautions, who to notify, and what assessments needed to be done after a witnessed or un-witnessed fall. During an interview on 12/02/23 at 1:46 PM, CNA H stated she had been in-serviced on falls and notifying nurses of changes-in-condition. She stated she would never try to pick a resident up off the floor if they had fallen. She stated she would get a nurse immediately. She stated the nurses needed to conduct their assessments to ensure residents were not hurt or bleeding. During an interview on 12/02/23 at 2:32 PM, LVN I stated she expected CNAs to notify her when there was any kind of change-in-condition regarding a resident, especially a fall. She stated when a resident falls, she assessed them, checked their range of motion, completed an incident report, documented in the resident's chart, and notified the NP and resident RP. During an interview on 12/02/23 at 2:41 PM, LVN J stated of a resident was found on the ground by an aide, she would expect the aide to notify her immediately. She stated she would check vitals, conduct a full-body assessment, conduct neuro checks, notify the NP, complete an incident report, and ensure she notified the on-coming nurse. During an interview on 12/02/23 at 2:49 PM, CNA K stated if she found a resident on the ground, she would immediately notify a nurse. She stated a nurse needed to be notified so they could ensure the resident was not bleeding or had a broken bone. During an interview on 12/04/23 at 2:05 PM, Resident #1's NP stated she was never notified of the fall that occurred. She stated she saw Resident #1 on Friday 11/10/23 and she was doing great - she was acting completely normal, making jokes, and there were no issues. She stated on Tuesday 11/14/23, staff informed her that Resident #1 was having difficulty with transferring. She stated Resident #1 was usually able to transfer herself with minimal assistance. She stated the resident was complaining of pain whenever she moved her legs. She stated she did a skin assessment and noted no bruising. She stated the only thing that could have suggested she had a fall were two bandages on her elbows that were dated 11/11/23. She stated she asked the charge nurse who was working who stated he had not heard of Resident #1 sustaining a fall over the weekend. She stated it was her expectation that she be notified of every fall. She stated even if a resident falls over the weekend, their on-call team should be notified. She stated she ordered x-rays on 11/14/23 and was not aware they had not gotten done that day until she was called in the morning of 11/15/23 by a nurse requesting to send Resident #1 to the hospital because she was complaining of pain. She stated she did not want her to go to 455771 Page 11 of 20 455771 12/02/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the hospital since she had personally called the x-ray order to put in the order and she had PRN pain medication. She stated the nursing staff from the night before on 11/15/23 should have followed up on the x-rays because they should have been done that day. She stated it was unacceptable they were not followed-up on or at least should have called the on-call medical team. She stated when she calls in a STAT x-ray, she had rarely seen it take over an hour for them to get to the facility. She stated once she was notified later in the day on 11/15/23 that the x-rays still had not been done, she requested Resident #1 be sent to the ER immediately. An attempt to interview CNA B was made on 12/04/23 at 3:08 PM. A returned phone call was not received. An attempt to interview CNA B was made on 12/04/23 at 3:13 PM. A returned phone call was not received. Review of the facility's Falls and Fall Risk Policy, revised April 2022, reflected the following : According to the MDS, a fall is defined as unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Review of the facility's Abuse and Neglect Policy, revised April 2021, reflected the following: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. 455771 Page 12 of 20 455771 12/02/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care, in that: Residents Affected - Some The facility failed to ensure Resident #1 was properly assessed after being found on the floor of her room on 11/10/23. Resident #1 was picked up by CNA B, there was no assessment documented by the nurse, the on-coming nurse nor NP were notified of the fall. On 11/15/23 she was sent to the ER and diagnosed with a left hip fracture requiring surgery. An Immediate Jeopardy (IJ) existed on 11/16/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. This failure could place residents at risk of experiencing unmanaged pain, a decreased quality of life, and hospitalization. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including fracture of right humerus (long bone in the arm or forelimb that runs from the shoulder to the elbow), dementia, and unspecified protein-calorie malnutrition. Review of Resident #1's quarterly MDS assessment, dated 11/03/23, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section GG (Functional Abilities and Goals) reflected she required supervision or touching assistance with transferring and chair/bed-to-chair transfers. Section J (Health Conditions) reflected she had not had any falls since admission. Review of Resident #1's quarterly care plan, revised 09/24/23, reflected she was at risk for falls with an intervention of educating resident/family/caregivers about safety reminders and what to do if a fall occurred. Review of Resident #1's NP progress note, dated 11/14/23, reflected the following: Today, [Resident #1] was seen in the day room, sitting up in her WC. AAOx3 with mild impairment. [Resident #1] reports her legs hurt x 4 days. She describes it being a constant, deep/dull pain, ranging from the hips to above the knees. [Resident #1] reports she has never had this feeling before. [Resident #1] can't remember if she fell or not over the weekend. There were no reports of any falls from staff, but [Resident #1] does have new bandages on both elbows. No new bruises on [Resident #1]'s body. Staff reports that the pain has been very disabling to [Resident #1]. [Resident #1] normally would be a [NAME]-by or contact assist with ADLs, but today, [Resident #1] has been having difficulties transferring to toilet from WC d/t pain in her lower extremities. Abdominal swelling generalized: Ordered ultrasound of abdomen and pelvis. 455771 Page 13 of 20 455771 12/02/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0684 Pain in right and left leg: Order x-ray of femur. Added Tylenol 500mg tid for pain x 7 days. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #1's physician order, dated 11/14/23, reflected the following: Residents Affected - Some Review of Resident #1's physician order, dated 11/14/23, reflected the following: Acetaminophen tablet 500 MG - Give 1 tablet by mouth three times a day for pain for 7 days. Muscle Rub External Cream 10-15% (Menthol-Methyl Salicylate) - Apply to thighs and knees topically two times a day for pain. Review of Resident #1's progress notes in her EMR, dated 11/15/23 at 10:57 AM, reflected the following: [Resident #1] appears comfortable but with distended abdomen and a bulging area on the left side of the abdomen. Has order for abdominal ultrasound which has not been done . Called and notified NP and asked if [Resident #1] can be sent to ER for evaluation, she objected to that. Called (x-ray company) for ETA for the procedures and the don't have any at this time but will come today. Review of Resident #1's progress notes in her EMR, dated 11/15/23 at 4:21 PM, reflected the following: Returned to the floor following lunch break at 3:30 PM and received a note that the ultrasound tech called and will not be coming in to perform the procedure today. No specific date or time was given. Called NP and rec'd phone order to send [Resident #1] to ER for evaluation/treatment . Review of Resident #1's progress notes in her EMR, dated 11/16/23 at 7:19 AM, reflected the following: Called (hospital ER) this morning and was informed that [Resident #1] was admitted and will be going for surgery this morning - left hip fracture. Review of the facility's investigation regarding Resident #1's injury, dated 11/16/23, reflected the following: Description of Allegation: The facility was informed of a fracture of left hip of [Resident #1] on morning of 11/16 by hospital staff. Initial Investigation: Upon investigation, [CNA A] informed Administrator that she was informed by [CNA B] on morning of 11/17 that on 11/12 [Resident #1] had slid out of bed during her shift with [LVN C] being informed of incident. The fall was reported to have happened in the early hours of Saturday (11/11/23). [CNA B], worked 11/10/23 10p - 6am [CNA B] stated that around midnight she witnessed [Resident #1] sitting next to her bed with her 455771 Page 14 of 20 455771 12/02/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some left hip against the bed and she (Resident #1) had been in bed previously. [CNA B] tried to locate [LVN C] but was unable to at that time due to resident care. [CNA B] placed [Resident #1] in wheelchair with no complaints of pain. Shortly thereafter, [Resident #1] complained of pain with [LVN C] giving her medication. [LVN C], worked 11/10/23 10p - 6am [LVN C] stated that it was reported to her that [Resident #1] had slid out of bed and had been placed in wheelchair when she was notified of incident. [LVN C] stated that [Resident #1] had tried to get out of bed without help. [LVN C] stated she assessed [Resident #1]'s left leg/hip and vitals with no concerns. [LVN C] noted two skin tears that she treated on [Resident #1]'s elbow. [Resident #1] agreed to take pain medication. [LVN C] reported having message the physician and passed along to the following nurse. [LVN C] admitted that no incident report was generated, or nurses note made regarding the incident. [CNA D], worked 11/11/23 6a - 10p [CNA D] noted [Resident #1]'s change with mobility however did not report change to nurse. Educated that all changes need to be investigated. [RN E], worked 11/11/23 6a - 6p [RN E] stated she was unaware of fall and was not informed of any changes with [Resident #1] from [LVN C]. [CNA A], worked 11/13/23 6a - 10pm [CNA A] informed NP that she noticed [Resident #1] having change of mobility during her rounds. [LVN G] worked 11/13/23 6a - 10pm [LVN G] received an order for Acetaminophen TID, and a muscle rub cream medication continued to be given. [CNA A], worked 11/15/23 6a - 10pm [CNA A] stated that [Resident #1] still had difficulty with mobility and was aware we were waiting on x-ray and ultrasound. [RN E], worked 11/15/23 6a - 6pm [RN E] contacted (x-ray company) as ultrasound of abdomen and x-ray of bilateral hips had not been conducted. At approximately 3:30pm, [RN E] received a message that they will be unable to perform ultrasound. [RN E] notified NP of issue with ultrasound and was notified to send to ER. Immediate actions taken: Pain medication ordered for comfort and effective. Abdominal ultrasound and x-rays of both hips ordered, however was unable to obtain. [Resident #1] has a history of bruising easy with NP stated she 455771 Page 15 of 20 455771 12/02/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0684 noted swelling in the abdomen, however, did not visualize anything during assessment that would even suggest a fracture. Level of Harm - Immediate jeopardy to resident health or safety Post actions taken: Residents Affected - Some - Nursing staff educated on change of condition and reporting expectations, ensuring that nurses are informed of any pending procedures/orders at shift change, completing of incident report, notification of DON, Physician, and RP. - Skin assessments completed on all residents in Memory Care Unit with no skin findings to falls. - Pain assessment conducted on all residents in Memory Care Unit with no concerns noted. - [LVN C] was terminated due to failure to complete incident report, pass on information during shift transfer, and notify physician, family, and DON. - All falls and discharges are to be reported to DON in a timely manner. Review of an in-service entitled Incident and Accident Reporting, dated 07/31/23, reflected CNA B and LVN C had been in attendance for the in-service given on notifying the ADM and DON for all incidents and accidents, all falls, etc. Review of an in-service entitled CNA Fall Procedure, dated 11/16/23 and conducted by the ADON, reflected CNAs were in-serviced on the following: When a resident is on the floor, whether witnessed or not witnessed, at no point should you lift resident off the floor or move them without a nurse assessing that resident. If resident complains of pain when moving resident, leave resident and follow fall protocol through the nurse. At no circumstance should a CNA or MA lift a resident from the floor without a nurse assessing the resident. Failure to comply will lead to disciplinary action up to termination. Review of an in-service entitled Nurse Fall Procedure, dated 11/16/23 and conducted by the ADON, reflected nurses were in-serviced on the following: When a CNA reports a fall, whether witnessed or un-witnessed, nurse need to follow the following protocols: - Assessment of resident, head to toe, vitals, and range of motion. If resident is in pain or cannot bear weight, call for help and call on-call for order to either transfer the resident to the hospital of non-weight bearing. - Follow physician instructions. - Notify DON/ADM. - Notify family. 455771 Page 16 of 20 455771 12/02/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0684 - Do proper documentation - incident report, nursing notes, pain and fall evaluation. Level of Harm - Immediate jeopardy to resident health or safety - If reside is in pain and cannot get x-ray on time, get order to send resident out for further evaluation. Residents Affected - Some Review of an in-service entitled Fall Precautions and Interventions, dated 11/16/23, reflected all staff were in-serviced on fall precaution educating and fall interventions to reduce falls. Failure to follow these procedures will lead to disciplinary action up to termination. During an interview on 12/02/23 at 12:11 PM, the DCO stated she did meet with the NP on 11/14/23 after she assessed Resident #1 but she did not make the situation sound as dire as it had been documented in the progress note. She stated the aide should have never gotten Resident #1 off the floor without notifying a nurse first so that appropriate assessments could have been conducted. She stated the nurse (LVN C) admitted to not completing an incident report. She stated it was unacceptable that Resident #1 did not receive the proper care or treatment due to the fall not being reported. She stated LVN C was terminated and the staff were in-serviced on fall precautions, who to notify, and what assessments needed to be done after a witnessed or un-witnessed fall. During an interview on 12/02/23 at 1:46 PM, CNA H stated she had been in-serviced on falls and notifying nurses of changes-in-condition. She stated she would never try to pick a resident up off the floor if they had fallen. She stated she would get a nurse immediately. She stated the nurses needed to conduct their assessments to ensure residents were not hurt or bleeding. During an interview on 12/02/23 at 2:32 PM, LVN I stated she expected CNAs to notify her when there was any kind of change-in-condition regarding a resident, especially a fall. She stated when a resident falls, she assessed them, checked their range of motion, completed an incident report, documented in the resident's chart, and notified the NP and resident RP. During an interview on 12/02/23 at 2:41 PM, LVN J stated of a resident was found on the ground by an aide, she would expect the aide to notify her immediately. She stated she would check vitals, conduct a full-body assessment, conduct neuro checks, notify the NP, complete an incident report, and ensure she notified the on-coming nurse. During an interview on 12/02/23 at 2:49 PM, CNA K stated if she found a resident on the ground, she would immediately notify a nurse. She stated a nurse needed to be notified so they could ensure the resident was not bleeding or had a broken bone. During an interview on 12/04/23 at 2:05 PM, Resident #1's NP stated she was never notified of the fall that occurred. She stated she saw Resident #1 on Friday 11/10/23 and she was doing great - she was acting completely normal, making jokes, and there were no issues. She stated on Tuesday 11/14/23, staff informed her that Resident #1 was having difficulty with transferring. She stated Resident #1 was usually able to transfer herself with minimal assistance. She stated the resident was complaining of pain whenever she moved her legs. She stated she did a skin assessment and noted no bruising. She stated the only thing that could have suggested she had a fall were two bandages on her elbows that were dated 11/11/23. She stated she asked the charge nurse who was working who stated he had not heard of Resident #1 sustaining a fall over the weekend. She stated it was her expectation that she be notified of every fall. She stated even if a resident falls over the weekend, their on-call team should be notified. She stated she ordered x-rays on 11/14/23 and was not aware they had not gotten 455771 Page 17 of 20 455771 12/02/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some done that day until she was called in the morning of 11/15/23 by a nurse requesting to send Resident #1 to the hospital because she was complaining of pain. She stated she did not want her to go to the hospital since she had personally called the x-ray order to put in the order and she had PRN pain medication. She stated the nursing staff from the night before on 11/15/23 should have followed up on the x-rays because they should have been done that day. She stated it was unacceptable they were not followed-up on or at least should have called the on-call medical team. She stated when she calls in a STAT x-ray, she had rarely seen it take over an hour for them to get to the facility. She stated once she was notified later in the day on 11/15/23 that the x-rays still had not been done, she requested Resident #1 be sent to the ER immediately. An attempt to interview CNA B was made on 12/04/23 at 3:08 PM. A returned phone call was not received. An attempt to interview CNA B was made on 12/04/23 at 3:13 PM. A returned phone call was not received. Review of the facility's Change in a Resident's Condition or Status Policy, revised February 2021, reflected the following: 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discovery of injuries of an unknown source . 8. The nurse will record in the resident's medical record information relative to change in the resident's medical/mental condition or status. 455771 Page 18 of 20 455771 12/02/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #2) of three residents reviewed for medications. The facility failed to ensure Resident #2 was administered her scheduled morphine every six hours as prescribed by the physician. This failure could place residents at risk for not receiving therapeutic effect of their medications as ordered by the physician. Findings included: Review of Resident #2's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] on hospice services with diagnoses including cancer, agitation, anxiety, and pain. She was discharged from the facility on 11/28/23. Review of Resident #2's initial MDS assessment, dated 11/21/23, reflected it was created for entry to the facility from the hospital. Review of Resident #2's baseline care plan, dated 11/21/23, reflected she had chronic pain with an intervention of monitoring/documenting for side effects of pain medication. Review of Resident #2's physician order, dated 11/21/23, reflected Morphine Sulfate Solution 100/5ML Take 0.25ML (5MG) by mouth every six hours. Review of Resident #2's Controlled Substance Administration Record, from 11/22/23 - 11/27/23, reflected she was administered the Morphine three times a day and not every six hours as prescribed: 11/22/23 - 8:00 AM 11/22/23 - 1:15 PM 11/23/23 - 8:00 AM 11/23/23 - 1:00 PM 11/23/23 - 3:00 PM 11/24/23 - 1:00 AM 11/24/23 - 7:47 AM 11/24/23 - 7:00 PM 11/25/23 - 7:00 AM 455771 Page 19 of 20 455771 12/02/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0755 11/25/23 - 12:00 PM Level of Harm - Minimal harm or potential for actual harm 11/25/23 - 7:00 PM 11/26/23 - 7:00 AM Residents Affected - Some 11/26/23 - 12:00 PM 11/26/23 - 7:00 PM 11/27/23 - 1:00 AM During a telephone interview on 12/02/23 at 10:17 AM, Resident #2's FM L stated she did not feel as though Resident #2 was getting all of her doses of morphine while at the facility. She stated Resident #2 never seemed fully relaxed or comfortable. She stated Resident #2 was unable to express if she was in pain, but she just never looked right to her. During an interview on 12/02/23 at 12:11 PM, the DCO stated it was not acceptable that Resident #2 was administered Morphine three times a day instead of every six hours. She stated she was unaware the Morphine was being administered incorrectly. She stated it was her expectation that physician orders were followed as ordered. She stated it was very important to follow physician orders to ensure residents' symptoms were being alleviated appropriately. Review of the facility's Medication Orders Policy, revised November of 2014, reflected it did not focus on following physician orders, rather recording of the orders. 455771 Page 20 of 20