Health inspection·February 8, 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 reviews the facility failed to immediately report allegations that involved abuse neglect, exploitation or mistreatment, including injuries of unknown source or misappropriation of resident property to the administrator of the facility and to HHSC, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse, or result in serious bodily injury for one of five residents (Resident #1) reviewed for injury of unknown origin. The facility's staff did not report Resident's #1's unwitnessed fall to the administrator. The facility did not report a fracture of unknown origin to Resident #1's 7th rib and punctured lung until the second day after it was identified. This failure placed residents at risk of not having abuse or neglect identified promptly and thus being subjected to further abuse or neglect. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia (loss of thinking, remembering, and reasoning skills), cognitive communication disorder (difficulty communicating because of injury to the brain), unspecified abnormalities of gait and mobility (a change to your walking pattern), vitamin d deficiency, and unspecified osteoarthritis (a progressive, degenerative joint disease). Review of the Quarterly MDS for Resident #1 dated [DATE] reflected a BIMS score of 9, indicating a moderate cognitive impairment. It reflected she used a walker to assist with mobility. It reflected her status for moving on and off the toilet and surface-to-surface transfers required supervision or touching assistance. Review of the undated care plan for Resident #1 reflected the following: Resident #1 is at risk for falls related to her diagnosis of abnormalities of gait and mobility. She will receive no injury related to falls through the review date. Assess for change in condition. Ensure resident has properly fitting non-skid shoes for transfers. Give verbal reminders to call for assistance with transfers. Review of an un-witnessed fall incident report for Resident #1 dated [DATE] at 02:30 PM and completed by LVN A reflected Resident #1 had an unwitnessed fall at 02:30 PM. Resident #1 was found to be sitting on the floor of the doorway with her back against the wall. Per roommate resident did not hit her head. Resident #1 was assessed and assisted off the floor and to her bed. Resident #1 denied Page 1 of 6 675369 675369 02/08/2024 Grandview Nursing and Rehabilitation Center 301 W Criner St Grandview, TX 76050

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few any pain or discomfort at this time. Head to toe assessment completed. No apparent injuries noted at this time. Review of the progress notes for Resident #1 dated [DATE] at 02:30 PM written by LVN A reflected, Called to room by CNA staff. Found resident to be sitting on the floor of the doorway with her back against the wall. Per roommate resident did not hit her head. This Nurse and CNA staff assisted resident up off the floor and to her bed. Resident wanted to lay down. Resident denied any pain or discomfort at this time. Vital signs obtained 141/70-66-19-97.4 O2 Sat 95% RA. Head to toe assessment completed. No apparent injuries noted at this time. Review of the progress notes for Resident #1 dated [DATE] at 05:21 PM written by LVN A reflected, 141/70-66-19-97.4 O2 Sat 95% RA. Remains on hospice service with no change in condition noted. Alert and oriented X 2. Respirations even and unlabored. Denies SOB and dyspnea. Forgetful and confused. Abdomen soft and nontender with active Bowel signs x 4 quadrants. Eats all meals in room with tray setup assist. Appetite remains good. Toilets independently often and performs own peri care. Refuses to allow staff to assist with toileting or peri care. Uses rolling walker for mobility. Requires limited assist X 1 with ADLs and transfers. Move about facility with walker. No apparent delayed injuries noted from fall. No callout of pain or discomfort noted. Eating supper with no distress noted. Review of the progress notes for Resident #1 dated [DATE] at 11:10 PM written by LVN B reflected, Resident cried out in pain. Call in to on-call Hospice and talked with on- call nurse. On-call nurse states she will call family and then call me back. Received call back from Hospice nurse and the family wanted me to call them. At approximately 11:55 PM, I called resident's family member, and explained to her what had happened. Family member states if resident is in that much pain to go ahead and call ambulance. Review of the x-ray results for Resident #1 dated [DATE] at 05:05 AM reflected the following 1. Moderate to large right pneumothorax with 5 cm of pleural separation at the right lung base anteriorly. This is not significantly changed from chest x-ray earlier today 2. Acute mildly displaced fracture of the anterolateral aspect right seventh rib. 3. Moderate scoliosis of the thoracolumbar spine. 4. Grade 1 degenerative spondylolisthesis of L2 on L3 on L4 on L5 with moderate to severe central canal stenosis. 5. There are scattered lobular hypo enhancing lesions involving liver likely cysts the largest segment 8 near the dome 3 cm., Likely cysts. Review of an HHSC 3613 Provider Investigation Report reflected the date of the incident was [DATE] at 02:30 PM. The incident was reported to the State Agency on [DATE] at 12:36 PM and reflected the following: At 2:30-3:00 PM on [DATE] Resident fell in her bathroom. This fall was unwitnessed. Resident called for help and CNA entered the room and called Nurse for help. Nurse checked Resident and with the help of CNA they got Resident up. No bruising noted. Resident was put to bed where she rested. After 10-6 PM shift started Resident began complaining of pain. Nurse contacted the on-call hospice nurse. Hospice nurse called family and they asked that Resident be sent to the hospital. It was at the hospital that the broken rib and punctured lung was identified. Nurse was suspended pending the investigation. During an interview on [DATE] at 12:00 PM, CNA A stated on [DATE] at 02:30 PM, she heard Resident's #1's roommate saying , Help, Help, Help. CNA A stated Resident #1 was sitting on the floor against the wall with her walker outside the bathroom door. CNA A stated she went to the door and called for the Nurse. CNA A stated LVN A assessed Resident #1 prior to them placing her in bed. CNA A said Resident #1 had a small skin tear on her right arm and did not call out in pain. CNA A stated after 675369 Page 2 of 6 675369 02/08/2024 Grandview Nursing and Rehabilitation Center 301 W Criner St Grandview, TX 76050

F 0609 Level of Harm - Minimal harm or potential for actual harm supper Resident #1 asked for 2 Tylenol. CNA A stated for the remaining of her shift, Resident #1 did not complain of pain. CNA A stated per policy, due to her being the first person to witness Resident #1, she should have been given a form to complete regardless of if there was a visible injury or not. CNA A stated the worse that could happen without reporting the resident falling, she could have something wrong, and no one was aware that she had an unwitnessed fall. Residents Affected - Few During an interview on [DATE] at 12:25 PM, MA A stated she administered Resident #1 pain medication after dinner on [DATE] at 08:00 PM. MA A stated Resident #1 was acting normal and not in severe pain. MA A stated when a Resident falls, they must call the Nurse to assess and check vital signs. MA A stated staff must immediately notify the hospice, the doctor, family, and the ADM. MA A stated hospice will then send out a hospice nurse to assess the resident . MA A stated although Resident #1 appeared to be okay and was not in a lot of pain, the worse that could happen was, she could have died from no one being notified of the fall. During an interview on [DATE] at 12:50 PM, LVN A stated CNA A called her to Resident #1's room on [DATE] at 02:30 PM. LVN A stated when she arrived at the room, Resident #1 was sitting on the floor with her back against the wall in the bathroom. LVN A stated she completed a head-to-toe assessment and pain assessment. LVN A stated CNA A assisted with placing Resident #1 in bed as Resident #1 voiced that was where she wanted to go. LVN A stated Resident #1 did not complain of pain or cry out in pain. LVN A stated there was no grimacing or shortness of breath, at this time. LVN A stated Resident #1 ate dinner on the side of her bed. LVN A stated she failed in her job by not properly notifying hospice, the doctor, the family, nor the ADM immediately. LVN A stated if a CNA was a witness, or first on the scene, the CNA must complete a Witness Statement. LVN A stated she did not give a Witness Statement to CNA A to complete, CNA A told her verbally. LVN A stated if it was before 5PM, Incident Reports are given to the ADON and after 5PM to the Nurse Supervisor. LVN A stated she would then complete the Incident Report and every paper completed (Skin Assessment, X-Ray, etc.) should be faxed to the doctor. LVN A stated the DON, and the ADM would normally be notified by the ADON. LVN A stated over the weekend, any incidents should be reported to the RN Supervisor. LVN A stated the worse that could happen was Resident #1 could have potentially died. LVN A stated Resident #1 could have developed shortness of breath, internal bleeding, a break, or a fracture. LVN A stated Policy was not followed. During an interview on [DATE] at 01:20 PM, the HRN stated she was informed about the fall the next day during her morning meeting. The HRN stated the facility contacted the overnight nurse to inform them the family wanted Resident #1 sent out due to severe back pain. The HRN stated she was told Resident #1 had a fall the day prior around 02:30 PM. The HRN stated hospice was not notified until right before Resident #1 was sent out at 11:02 PM. The HRN stated they ask facilities to contact them regarding any falls or Change of Conditions. The HRN stated if no visit was required, they would still follow-up with the Resident the next day. During an interview on [DATE] at 01:45 PM, RN A stated Resident #1 fell and LVN A failed to complete an Incident Report at the time. RN A stated Resident #1 started complaining of pain during the night shift and she was sent out. RN A stated once Resident #1 was admitted to the hospital was when they learned of the fracture. RN A stated if you witness or were notified of a resident falling, or observed on the floor, you record vitals and assess prior to moving them. RN A stated you would then notify hospice, the doctor, and the family. RN A stated the doctor determines if a Resident needs to be sent out, or just monitored. RN A stated the doctor determines the next steps. During an interview on [DATE] at 02:50 PM, the DON stated although there were no injuries at the 675369 Page 3 of 6 675369 02/08/2024 Grandview Nursing and Rehabilitation Center 301 W Criner St Grandview, TX 76050

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few time, Hospice, the doctor, the family, nor the oncoming Charge Nurse was notified of the fall. The DON stated when Resident #1 initially fell at 2:30 PM, she was assessed and did not complain of pain. The DON stated Resident #1 complained of pain around 8:00 PM and was given Tylenol PRN. The DON stated Resident #1 complained of pain again after 10PM during the next shift and was sent out to the hospital for further assessment and was diagnosed with one fractured rib and a punctured lung. The DON stated the facility started an internal investigation and suspended LVN A for not notifying anyone and not even informing the oncoming Charge Nurse. The DON stated during their investigation, Resident #1's roommate reported everything the Nurse told them. The DON stated they did not feel it was reportable due to not knowing for certain if the fall caused the fractured rib and punctured lung. The DON stated they know Resident #1 had a fall, but at the time, the fall did not result in a visible serious injury. The DON stated LVN A attended to Resident #1, and they did not expect any abuse. The DON stated they wrote LVN A up for not notifying anyone of the fall. The DON stated their last Abuse and Neglect In-service was earlier during the day the fall occurred. The DON stated LVN A was suspended initially and now pending this investigation she is being re-suspended. The DON stated the worse that could happen was Resident #1 would not be monitored as she should. The DON stated, thank goodness Resident #1 was verbal because she would have just laid there in pain. During an interview on [DATE] at 3:25 PM, the ADM stated the DON called her on [DATE] at 11:45 PM and informed her Resident #1 had fallen earlier that day and was being sent to the hospital. The ADM stated the DON told her the fall had not been given in a report and the oncoming Nurse was not aware of the fall until Resident #1's roommate told her. The ADM stated she told the DON they need to suspend LVN A pending the investigation. The ADM stated during the investigation, they determined from speaking with LVN A she said she assessed Resident #1, got her up and placed her in bed and there were no complaints of pain. The ADM stated Resident #1 ate dinner on the side of her bed and still did not complain of pain. The ADM stated CNA A said LVN A arrived quickly to the room, and she assisted LVN A in placing Resident #1 in bed. The ADM stated CNA A said a couple hours after dinner, Resident #1 was complaining of side pain and asking for Tylenol, so she told LVN A. The ADM stated she interviewed Resident #1's roommate and she said she woke up to the resident on the floor sitting against the wall with her walker behind her. The ADM stated Resident #1's roommate did not hear her complain of pain and she got up and ate dinner. The ADM stated Resident #1's roommate said Resident #1 got up to use the restroom a second time and she told her to sit down because she should not be up. The ADM stated Resident #1's roommate said the next thing she knew Resident #1 was complaining of pain and they were sending her out. The ADM stated LVN A did not follow policy, she did not call the family, hospice, the doctor, nor inform the oncoming Nurse. The ADM stated the worse that could happen was Resident #1 could have just laid there and passed away. The ADM stated what if Resident #1 was non-verbal and could not call out for help. The ADM stated moving forward, they have in-serviced the staff on notifying hospice, doctors and re-educated them on policy. Review of facility policy titled, Abuse, Neglect and Exploitation reflected the following: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, . within specified timeframes: 675369 Page 4 of 6 675369 02/08/2024 Grandview Nursing and Rehabilitation Center 301 W Criner St Grandview, TX 76050

F 0609 a. Level of Harm - Minimal harm or potential for actual harm 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 Residents Affected - Few b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Review of facility policy titled, Fall Prevention Program reflected the following: 1. When any resident experiences a fall, the facility will. d. Notify physician and family. Review of facility policy titled Notification of Changes reflected the following under Compliance Guidelines: The facility must .consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. 1. Accidents a. Resulting in injury. b. Potential to require physician intervention. Review of facility policy titled Hospice Services Facility Agreement reflected the following: . e. A provision that the facility will immediately notify the hospice about the following: i. A significant change in the resident's physical, mental, social, or emotional status. ii. Clinical complications that suggest a need to alter the plan of care. 675369 Page 5 of 6 675369 02/08/2024 Grandview Nursing and Rehabilitation Center 301 W Criner St Grandview, TX 76050

F 0609 iii. Level of Harm - Minimal harm or potential for actual harm A need to transfer the resident from the facility for any condition. Residents Affected - Few 675369 Page 6 of 6