Health inspection·March 13, 2024

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 interviews and record review, the facility failed to develop and implement written policies and procedures that ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made for 1 of 5 residents (Resident #1) reviewed for reportable incidents. On 3/2/2024, Resident #1 had an unwitnessed fall with a laceration on the head requiring staples and the facility failed to report it to State Agency. This failure can result in physical or mental harm, physical or mental decline, and continued patient neglect. Findings include: Record review of Resident #1's face sheet, undated, revealed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Diagnoses included but were not limited to Dementia (decline in cognitive abilities that impacts a person's ability to perform everyday activities), repeated falls, major depressive disorder (persistent feeling of sadness and loss of interest), and muscle weakness. Record review of Resident #1's MDS, dated [DATE], revealed a BIMS score of 03 which indicated severe cognitive impairment. This MDS documented that Resident #1 had had two falls with no inuries. Record review of Resident #1's care plan updated 3/8/24 revealed a goal that the resident would remain free of injuries and falls. Interventions included assess footwear for proper fit and non-skid soles or socks, wander alarm, physical therapy referral, encourage use of call light, instruct resident on safety measures and keep call light within reach. Record review of Resident #1's event report, dated 3/2/24, reflected Resident #1 had an unwitnessed fall with a laceration to the back of the head. Record indicated Resident #1 was transferred to hospital for evaluations and treatment. Record review of resident's progress note written by ADON, dated 3/12/24, reflected the ADON removed staples from resident. In an interview on 3/13/24 at 3:24 PM, the FM of Resident #1 stated Resident #1 fell and hit her head a couple of weeks ago. The FM stated Resident #1 had to go to the emergency room. Page 1 of 2 455989 455989 03/13/2024 Avir at Borger 1316 S Florida Borger, TX 79007

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 3/13/24 at 4:30 PM, the DON stated Resident #1 had a fall with injury and received three staples. The DON stated RN A working that evening reported the incident to him. The DON stated he contacted the ADM, and the incident was not reported because it was not a significant injury. The DON stated the facility reported head bleeds, fractures, things like that from what he had understood. In an interview on 3/13/24 at 4:46 PM with the ADM and CRN, the ADM stated the facility looked at all falls and the ones that are considered significant are reported. The ADM stated fractures, brain bleeds, hematomas, and others. The ADM stated an unwitnessed fall with a laceration to the head requiring three staples was not considered a significant injury. The ADM stated the DON consulted with her, the CRN and the vice president when falls are reported. The ADM stated the DON contacted her and reported Resident #1 sustained an injury. The ADM stated Resident #1 was found scooting across the floor. The CRN joined the interview via telephone and stated she was looking at the event that was created and progress notes. The CRN stated no additional charting was located. The ADM stated the DON received full report. The ADM confirmed Resident #1's injuries were sustained from an unwitnessed fall. The ADM stated a negative outcome of not reporting was the survey could result in a tag. In an interview on 3/13/24 at 5:12 PM, the DON stated RN A reported Resident #1 had fallen, obtained a laceration, and Resident #1 was transferred to the hospital. The DON reviewed event record and verified Resident #1's fall was unwitnessed. In an interview on 3/13/24 at 5:20 PM, Resident #1 stated she does not remember falling and does not remember how she hurt her head. Resident #1 stated she had staples, but they were taken out the day before. In an interview on 3/13/24 at 5:27 PM, RN A stated two staff members notified her about Resident #1's fall. RN A stated Resident #1 was not able to tell her what had happened, and her head was bleeding. RN A stated Resident #1 was not aware she was bleeding. RN A stated Resident #1 never cried, said she was hurting, or realized she had fallen. RN A stated Resident #1 was attempting to use her wheelchair as a walker and that was how RN A assumed she fell. RN A stated she notified the DON, ADM, FMs, and NP. RN A stated the ambulance was called per her judgement since Resident #1 had hit her head and was bleeding. RN A stated she did advise DON it was an unwitnessed fall with injury. On 3/13/24, ADM provided policy titled Accidents and Incidents- Investigating and Reporting , revised July 2017, and attached HHSC Long-Term Care Regulatory Provider Letter, Number: PL 19-17 (Replaces PL 17-18), Title Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a July 10, 2019. The facility's policy did not address reporting incidents to the state agency. Record review of TULIP, electronic system that increases the efficiency of the licensure process, revealed no report of Resident #1's fall. 455989 Page 2 of 2