Health inspection·July 12, 2023

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for one of six residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure CNA A provided appropriate supervision and care to Resident #1 who had advanced Alzheimer's and did not follow facility's Dementia Management Policy, subsequently CNA A redirected Resident #1 out of another resident's room inappropriately, which resulted in her falling backwards and sustaining a right femur (hip) fracture. Resident #1 required hospitalization and surgery to repair her hip fracture which increased her risk of heart attack, stroke, blood clot, pneumonia or death. The Noncompliance was identified as PNC. The IJ began on 06/21/23 at 6:40 PM and ended on 06/22/23 at 11:30 AM. The facility had corrected the noncompliance before the survey began. This failure could place all residents at risk of not getting adequately trained staff to provide appropriate care to them which could result in hospitalization and surgical procedures increasing the resident's risk of heart attack, stroke, blood clots, pneumonia or death. The findings include: Record review of Resident #1's Order Summary Report, dated 06/24/23, revealed an 86-year- old female who was admitted to the facility on [DATE] with diagnoses which included Hypertension, Edema (puffiness around body tissues) , Gastro-intestinal reflux disease (stomach acid), protein-calorie malnutrition (inadequate food intake), and Alzheimer's disease with late onset . Resident #1 had orders for house shake dated 12/06/22. Record review of Resident #1's Quarterly MDS Assessment, dated 05/24/23, revealed she had a BIMS score of 2, which indicated severe cognitive impairment. The MDS also indicated the resident walked with supervision, walk and turn was not steady but able to stabilize without staff assistance and no upper or lower impairments and no use of mobility devices. Record review of Resident #1's Care Plans, dated 03/08/22, revealed, I have been evaluated as a wandering risk related to decreased safety awareness, confusion and wandering behavior .Goal: I will remain free of injuries associated with wandering behaviors . Interventions: Check my location frequently, encourage me to participate in activities, engage me in diversional activities when indicated, I will be evaluated every quarter for placement on the memory care unit, observe me for Page 1 of 6 455930 455930 07/12/2023 Cedar Ridge Rehabilitation and Healthcare Center 1700 N Washington Pilot Point, TX 76258

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few signs/symptoms of agitation, pacing, repetitive verbalizations of wanting to leave/go home, restlessness, report increased behaviors to nurses for further interventions, provide re-orientation as needed, re-evaluate continued need for memory care unit quarterly and as needed .revised date 02/23/23 uses anti-depressant and anti-psychotic medications .dated 06/24/22 The resident is at high risk for fall related to confusion, gait/balance problems, vision/hearing problems, wandering, rejects care .revised date 03/15/22. The resident has impaired cognitive function/dementia or impaired thought processes related to Alzheimer's, Dementia, difficulty making decisions, impaired decision making, long-term memory loss, short term memory loss Record review of Resident #1's Hospital Discharge Summary revealed on 06/22/23 [Resident #1] admitted .with dementia presenting after a fall and found to have a femoral hip fracture [broken hip] .discharge diagnosis Right Intertrochanteric hip fracture S/P and on 06/22/23 [Resident #1] had an orthopedic procedure: Cephalomedullary (implant device) nailing of right intertrochanteric hip fracture and on 06/26/23 resident discharged the hospital with orders to follow-up with orthopedic Doctor in two weeks and OT/PT .Assessment/Plan dated 06/22/23 by Attending Doctor I discussed risk, benefits, and alternatives of surgical intervention in the form of Cephalomedullary nailing with patient's son. Specifically discussed the risk of bleeding, infection, wound issues, nonunion, malunion, stiffness, arthrosis, poor mobilization, and need for further procedures. I also discussed the medical complications associated with surgery including heart attack, stroke, blood clot, pneumonia, and even death Record review of Resident #1's Provider Investigation Report written by the Administrator, dated 06/22/23, revealed on 06/21/23 at 6:30 PM Resident #1 fell, at 6:45 PM the resident was assessed by LVN C, and at 7:30 PM the resident was treated by LVN C. Description of the allegation: The resident had a fall on 06/21/23 and was sent to the hospital for X-ray and evaluation. The hospital reported positive X-ray for femur fracture investigation revealed video surveillance and incorrect redirection provided by CNA A on duty. On 06/22/23 Resident #1's fall was reported to HHSC. Actions: allegedly resulted in this fall. Assessment: Head to toe assessment done, neuro checks initiated, assisted the resident to a wheelchair and to her bed. 2 tabs of ibuprofen 200 mg . given for pain. The Nurse reported right leg sensitive to touch. The resident was sent out via 911 for X-ray and further evaluation. The hospital X-ray reported positive for femur fracture via nurse to nurse report. Provider Response: All staff Inservice on approaches, activities and interventions in response to behaviors of people with Alzheimer's and Dementia, abuse and neglect Inservice initiated, complete skin assessment completed on all residents on unit, alleged perpetrator suspended, police report initiated. Were other parties notified: Family, MD and NP, Corporate Support Team and Ombudsman. On 06/24/23 Investigation completed by State Surveyors, terminated alleged perpetrator - CNA A terminated and second CNA B witness. Completed a robust QA plan as a response to this incident, posttest given with dementia training, continue approaches, activities and interventions in response to behaviors of people with Alzheimer's and dementia education with all new hires and agency staff prior to working. Findings: Confirmed. Observation on 06/24/23 of the video footage, dated 06/21/23 at 6:40 PM, revealed Resident #1 was already in another resident's room when CNA A and CNA B walked into the room with another resident. CNA A and CNA B were telling Resident #1 to leave and go to her own room. CNA A's tone when speaking to Resident #1 was very stern in his attempt to re-direct Resident #1 out of the other resident's room by saying You need to go right now .this is not your room what do you need to get. CNA A was then seen getting within inches in front of Resident #1 and his left hand touched Resident #1's upper forearm. CNA A took two to three steps forward which caused Resident #1 to walk backwards and caused her to fall to the floor on her buttocks and against the hall exit door. 455930 Page 2 of 6 455930 07/12/2023 Cedar Ridge Rehabilitation and Healthcare Center 1700 N Washington Pilot Point, TX 76258

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview on 06/24/23 at 11:51 am, Resident #1's Family Member stated he received a call on 06/21/23 around 6:30 pm or 7:00 pm to go to the facility, because Resident #1 fell. He stated when he arrived he was told Resident #1 was walking towards a door and stopped and turned around to go back into the room and fell backwards, He stated the Administrator stated they had video of CNA A grabbing Resident #1 trying to get her to leave another resident's room and she fell. He stated they sent Resident #1 to the hospital and put a rod in her leg and the Administrator said she terminated CNA A after they looked at the video. He stated the next day on 06/22/23, Resident #1 had surgery and the Doctor had to put a steel rod with pins into her hip bone. He stated Resident #1 was currently doing fine and was able to stand up and walk 4 or 5 steps before having to be laid back down. He stated the hospital was discharging Resident #1 soon He stated CNA A should not have put his hands on his mother. He stated Resident #1 had not fallen in the past, but this facility did not need to be open because the staff were not qualified to work at this facility. He stated before Resident #1 fell on [DATE], she used to walk without a problem and socialized with everyone. Interview on 06/24/23 at 1:53 PM, the Administrator stated after she received the video from 06/21/23 from a family member and could see CNA A and CNA B entered a resident's room, and they attempted to redirect Resident #1 but the manner with how CNA A redirected Resident #1 was not in this facility's policy and procedure. She stated CNA A's actions caused Resident #1 to fall because she saw CNA A's left hand grab Resident #1's right hand and he let go and he did not believe he pushed her but Resident #1 was walking backwards and he was still trying to redirect her. She stated it was hard to tell if he pushed Resident #1 and after review of the video, they suspended CNA A and CNA B as of today, 06/24/23, they decided to terminate the two CNA's. She stated CNA A was being terminated for allegation of neglect with not following the policy of dementia training. CNA B was still suspended during this investigation but due to her response during the incident and she was not considered and alleged perpetrator. She stated CNA B should have intervened despite providing care to another resident because she heard Resident #1 and CNA A's interactions and had she tried to intervene Resident #'1 may not have fallen. She stated currently Resident #1 was still at the hospital with a femur [hip] fracture. Interview by telephone on 06/24/23 at 5:02 PM, CNA A stated Resident #1's fall was an unfortunate accident that happened on 06/21/23 around 7:45 PM. He stated he and CNA B were trying to put another resident to bed but Resident #1 was in the room and as Resident #1 walked out of the door she turned around. He stated he told Resident #1 To please go, you need to leave then Resident #1 said, she needed to get her stuff first and he said he responded with, [Resident #1] this is not your room, your stuff is in your room. He stated Resident #1 kind of backed up then she came up to him with her hands and stumbled back and fell up against the exit door. He stated Resident #1 fell against the door then slide down to the floor, then LVN D came down to assess Resident #1. He stated they transferred her to her bed, then Resident #1's family member arrived at the facility, and they explained what happened about her falling. He stated Resident #1 left the facility during the 8:00 PM hour. He stated he's had dementia care training over the year and a month ago by the corporate office representative and his last abuse/neglect in-service training was within the last month. He stated he did not touch Resident #1 or push her and she kind of came at him and tripped back and fell to the doorway. He stated redirecting a resident he would say Come on let me show you where your room was by showing them family pictures and every case was different and varied. He stated the staff should never ever jerk on the residents, should use verbal cues and get other staff involved. He stated he was suspended since last Thursday, 06/22/23 until further notice after looking through everything. He stated the Administrator told him to go home and they would get back with him . Interview on 06/24/23 at 2:32 PM, LVN C 455930 Page 3 of 6 455930 07/12/2023 Cedar Ridge Rehabilitation and Healthcare Center 1700 N Washington Pilot Point, TX 76258

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few stated he was the charge nurse on 6/21/23 and around 6:45 PM or 7:00 PM he heard Resident #1 screaming and noticed she was in a sitting up position at the end of the hallway and her back was against the wall, by the exit door and resident's room door. He stated he asked CNA A what happened and was told Resident #1 was going to go back to her room and stopped, saying she needed to get something out of the room then put her hands on CNA A. He stated CNA A said he did not push Resident #1. He stated he assessed Resident #1 and she had right leg pain and could tell she was in a lot of pain, level was a 9 or 10. He stated she could move the left leg then they transferred her to her room. He stated he called Resident #1's family member who said he would give the information to a second family member because he was too far away. He stated he called Resident #1's doctor and an order for Ibuprofen was ordered and x-ray then Resident #1 was given Ibuprofen and was calm. He stated the second family member arrived at the facility and the resident appeared to be calm and not in pain but was in pain to touch, of her right leg, and was waiting for the X-ray tech to arrive, but they were taking too long. He stated around 8:20 PM he called 911 and the paramedics came around 8:30 PM and at 8:40 PM Resident #1 left the facility. He stated Resident #1 walked without assistance but was very confused. Interview on 06/24/23 at 5:41 PM, the DON stated on 06/21/23 she received a text at 7:16 PM from LVN C that Resident #1 fell, and he was currently trying to find out what happened, and the resident's Doctor had been called and Resident #1's family member was at the facility. She stated LVN C said he was pending getting an X-ray and had given Resident #1 Ibuprofen, then she received a text that Resident #1 was sent to the hospital around 8:40 PM. She stated Resident #1 fell in the hallway outside of another resident's door. She stated after she reviewed the video from 06/21/23 she could hear CNA A's tone when talking to Resident #1 was not right and it was hard for her to tell where Resident #1 and CNA A hands were. She stated she tried to look very carefully and did see forward movement but was not sure if hands were up and it was difficult for her to see what was going on in the video. She stated just based off of what they saw was enough for CNA A's dismissal. She stated she could not see if CNA A hit or made contact or not with Resident #1 but saw forward movement and both of CNA A hands were up. Interview on 06/24/23 at 6:44 PM, the DON stated CNA A should have approached Resident #1 calmly with a soft voice and relaxed demeaner and hands open by his side to be invited into Resident #1's space. She stated if he had experienced combativeness from Resident #1, he should have stepped back, or he could have distracted the resident with activity and if he noticed she was aggravated he needed to remove what was aggravating the resident until the resident was calm. She stated the biggest problem was CNA A should have had a calm demeanor and tone of voice. She stated since Resident #1's fall incident they were monitoring the staff interactions with the residents three times weekly. She stated the Administrator was also doing spot checks to look at how the staff engaged with the residents and with their tones when speaking and redirecting the residents. She stated monitoring would also include if the residents looked fearful and if a problem were identified they would immediately take action by removing the Alleged Perpetrator and suspend and investigate it further. She stated she would be doing random monitoring of the staff interactions with the residents three times weekly which included the weekends by herself, the Administrator and the Weekend Supervisor. The noncompliance was identified as PNC. The IJ began on 06/21/23 at 6:40 PM to 06/22/23 at 11:30 AM. The Administrator was notified and provided with the IJ template on 07/12/23 at 3:06 PM. The facility had corrected the noncompliance before the survey began. Interview on 06/24/23 at 8:20 PM, the Administrator stated after they received notice from the hospital on [DATE] at 5:30 AM, about Resident #1's femur fracture, they requested the video footage from 455930 Page 4 of 6 455930 07/12/2023 Cedar Ridge Rehabilitation and Healthcare Center 1700 N Washington Pilot Point, TX 76258

F 0689 Level of Harm - Immediate jeopardy to resident health or safety a family member and received it around 11:00 AM on 06/22/23 to review. She stated they suspended CNA A and CNA B on 06/22/23 around 11:30 AM and they had not returned to work since then and as of this day, 06/24/23, they were both terminated. Interview on 06/24/23 at 8:05 PM, the Corporate RDO (Regional Director of Operations) stated he reported this incident to HHSC around 7:00 PM on 6/22/23. Residents Affected - Few Interview on 06/24/23 at 8:11 PM, the Administrator stated all staff which included CNA A were trained on 06/15/23 and 06/16/23 on Dementia care and Management, a week prior to this incident by their Corporate Educational liaison. She stated after Resident #1's fall, on 06/24/23, they in-serviced the staff on Dementia Care, Abuse and Neglect and had them complete comprehensive tests and continued to monitor the staff and did random checks weekly including the weekends of the staff for any discrepancies they needed to correct in their QA meetings and re-educate and remove staff if needed . Interviews on 06/24/23 between 12:32 PM to 3:58 PM, LVN C, CNA D, CNA E, LVN F, LVN G who worked the Weekend Shift stated they were re-trained on Dementia Care, Abuse/neglect and completed post-tests and discussed the techniques they used to re-direct the residents. Interviews on 07/12/23 between 12:20 PM to 3:33 PM, LVN H, LVN I, MA J, MA K, CNA L, LVN M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, LVN T who worked the Weekday shift revealed they were re-trained on Dementia Care and Abuse/neglect and completed post-tests and discussed the techniques they used to re-direct the residents. Record review of CNA A's training records revealed he was trained on abuse with a post test on 05/26/22, Dementia training 11/10/22 and his signatures were on the group trainings Dementia Basics/Sensory Changes/Behavior Management on 06/15/23, Memory Care Program Training on 04/26/23, Communicating with Non-Verbal and Dementia residents on 06/06/23. Record Review of CNA A's employee records were completed without any adverse actions noted until 06/22/23, a disciplinary Action Form revealed CNA A was suspended because The company is conducting an internal investigation in which I am Involved signed by CNA A. And on 06/24/23 another Disciplinary Action Form revealed, As part of our investigation related to intake #432324, CNA A will be terminated signed by Corporate RDO. Record review of CNA B's Employee Records were completed without any adverse actions noted until 06/22/23 a disciplinary Action Form revealed CNA B was suspended because the company is conducting an internal investigation in which I am Involved) . Record review of the, undated, staff roster revealed the facility had 81 employees. Record review of the In-service trainings dated 06/22/23, for all employee revealed 62 employee signatures on topic which included: approaches, activities and interventions in response to behaviors with Alzheimer's and Dementia - General - verbal anxiety - Repetitive calling out, yelling, screaming - verbal, abusive language - expression of display of sadness/depression - short attention span. Record review of the facility's Dementia policy, revised 06/22/23, revealed, Redirection: Introduce a favorite snack, introduce a favorite/familiar hobby/task, Introduce a meaningful activity, Introduce a change in environment or change or scenery (go to a quieter area, an area with familiar activity, or go outside, introduce an object, activity, prop, conversation, don't try to explain or 455930 Page 5 of 6 455930 07/12/2023 Cedar Ridge Rehabilitation and Healthcare Center 1700 N Washington Pilot Point, TX 76258

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few reason, just talk and listen, don't try to correct .During redirection, always remember: Initiate the interaction by starting at a safe distance from the resident - remember sensory changes related to dementia affect all senses, including their field of vision. Approach the resident from the front (in their line of sight, but make sure to leave safe space so that resident doesn't become afraid or intimidated .never use any pushing/pulling motions, never raise you voice or use words that may seem harsh Record review of the facility's Fall Prevention Policy, dated Jan. 2023, revealed, Policy: All residents will be assessed for the risk of fall at the time of admission, on a quarterly basis, and upon significant change in condition thereafter .Definition: A fall can be defined as: when a resident is found on the floor .Procedure: 2. Residents identified at being at risk will have interventions identified in their plan of care to minimize falls The Noncompliance was identified as PNC. The IJ began on 06/21/23 at 6:40 PM and ended on 06/22/23 at 11:30 AM. The facility had corrected the noncompliance before the survey began. The facility failed to ensure CNA A provided appropriate supervision and care to Resident #1 who had advanced Alzheimer's and did not follow facility's Dementia Management Policy, subsequently CNA A redirected Resident #1 out of another resident's room inappropriately, which resulted in her falling backwards and sustaining a right femur (hip) fracture. Resident #1 required hospitalization and surgery to repair her hip fracture which increased her risk of heart attack, stroke, blood clot, pneumonia or death. 455930 Page 6 of 6