Health inspection·December 6, 2023

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 was made for 1 (Resident #1) of 5 residents reviewed for reporting of alleged violations. The facility failed to report to the state agency, incidents of neglect regarding a possible injury and fracture to the Resident #1's left elbow, after a fall in her room that occurred on 10/14/2023. The possible fracture to the left elbow was not reported to the state until 10/16/2023 which was two days after the incident occurred. This failure could place facility residents at risk of injury of unknown origin, abuse, and neglect. Findings included: Observation on 12/6/23 at 11:04 a.m. with Resident #1, revealed her sitting in a wheelchair near the nurse's station. A CNA pushed her wheelchair into her room. She looked well-groomed and there were no visible injuries on her body. In her room, there was a floor mat on both sides of the bed. The bed was in a low position. Resident #1 was not cable of being interviewed. During an interview on 12/6/2023 at 1:49 p.m. with Resident #1's family member who was also in the room with her, said Resident #1 fell twice in one day. She said one of the falls was due to an anxiety attack. She said the facility notified her of both falls. She said with one of the falls, Resident #1 had an x-ray completed at the hospital for a possible fracture. She said Resident #1 has been at the facility since October 2023. She said she had dementia. She said Resident #1 cannot stand on her own. She said when Resident #1 fell another time, she believes the partial in her mouth cut her gums which was why she was bleeding from the mouth. Record Review of Resident #1's face sheet revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnosis dementia, psychotic disturbance (a mental disorder characterized by a disconnection from reality), muscle weakness, gastro-esophageal reflux disease without esophagitis (a type of GERD that does not involve inflammation of the esophagus), and anxiety disorder. Record Review of Resident #1's Comprehensive MDS dated [DATE] revealed Resident #1 had a BIMS score of 02 indicating the resident was severely cognitively impaired. Resident #1 required partial/moderate assistance with eating, substantial/maximal assistance with oral hygiene, substantial/maximal Page 1 of 3 675214 675214 12/06/2023 Solidago Health and Rehabilitation 1720 N Logan St Texas City, TX 77590

F 0609 Level of Harm - Minimal harm or potential for actual harm assistance with upper and lower body dressing, and she was dependent with showering and toileting hygiene. Record Review of the Provider Investigation Report dated 10/16/2023 revealed that the incident occurrent 10/14/2023 at 2:30 a.m. and it was not reported to the state until 10/16/2023 at 9:40 p.m. Residents Affected - Few Record Review of the Provider Investigation Report dated 10/16/2023 revealed, On 10-14-2023 at 2:30 a.m., Resident #1 was found on the floor for the second time of the night shift. The nurse attempted to perform a head-to-toe assessment but Resident #1 was anxious and would not allow the nurse to perform the assessment. Record Review of the Provider Investigation Report revealed, On 10/16/2023 at 8:30 a.m., after seeing the x-ray results, the DON notified the Administrator, Resident #1 had a fall over the weekend and her x-ray results revealed possible left elbow fracture. Record Review of the Intake Investigative worksheet dated 10/16/2023 revealed, The fall was not reported to the Administrator until 9-16-23 at 8:30 a.m., that the x ray revealed a possible fracture of the left elbow. The Administrator said she meant 10-16-2023 and not 9-16-2023. During an interview on 12/6/2023 at 1:54p.m, with the DON, said the incident with Resident #1 was reported to her by LVN A. She said she did not notify the Administrator because she does not call the Administrator at night. She said one of the nurses should have called her. She said the nurse that does the reporting was responsible for reporting it to the Administrator. She said LVN A wrote the incident report, and she was the night nurse. During an interview with the Administrator on 12/6/2023 at 2:00 p.m., said she was told that a resident had fallen with no injury until it was confirmed that there was an injury. She said she talked to staff about reporting in a timely manner. She said the DON reports incidents and falls to the Administrator. She said the nurses might not have known to report it to her. She said the reporting was supposed to be done within 24 hours. She said it was called in late because she was notified about the incident late. She said the nurse was supposed to notify the RP, the Doctor, and the DON and she did. She said the DON will notify her. She said it is important to report any incident in a timely manner because the state requires it, and it was important to conduct the investigation in a timely manner. LVN A was not available to be interviewed because she was not at the facility during the time of the investigation, and she never answered the phone and nor did she return any phone calls to the surveyor. Record Review of the facility's policy titled Leadership Policies and Procedures, (revised 12/2009) read in part .The facility's Leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment, and misappropriation of a patient's/resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately. 2. The Facility shall report 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 injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency and 675214 Page 2 of 3 675214 12/06/2023 Solidago Health and Rehabilitation 1720 N Logan St Texas City, TX 77590

F 0609 Level of Harm - Minimal harm or potential for actual harm adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. The facility's Leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect or exploitation or mistreatment and will implement immediate action to safeguard resident. The facility will provide notification to the proper authorities, and, when required, the release of information to those agencies, pursuant to applicable federal and/or state law. Residents Affected - Few 675214 Page 3 of 3