Health inspection·January 2, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 5 residents reviewed for care plans. (Resident #1) The facility failed to implement the comprehensive person-centered care plan for Resident #1 by not having a fall mat beside the bed when the resident fell. This failure could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services. Findings include: Record review of a face sheet dated 12/28/23 revealed Resident #1 was [AGE] years old and was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (chronic lung disease), heart failure, and anxiety. Record review of the most recent MDS dated [DATE] indicated Resident #1 had a BIMS score of 10 which indicated moderate cognitive impairment. The MDS indicated Resident #1 was dependent on staff for assistance with ADLs. The MDS indicated Resident #1 had not had any falls since admission . Record review of a care plan last revised on 12/21/23 indicated Resident #1 was at risk for falls related to multiple previous falls. There was an intervention for a fall mat while in bed. Record review of a video dated 12/19/23 at 10:00 p.m., revealed Resident #1 was in bed. She fell out of the bed onto the floor. There was not a fall mat beside the bed . Record review of a Progress Note dated 12/19/23 at 11:36 p.m. indicated, upon entering room resident onb floor next to be on lt (left) side, wrapped in blanket which helped cusion resident. 2cm (centimeter) X 3 cm s/t (skin tear) noted to lt (left) elbow, cleaned and steri/stripps applied as well as non-stick dressing. Neuro vs (vital signs) wnl (within normal limits). Placed in bed and call light in easy reach, bed in low position. Message left on (responsible party's) phone . Record review of a Progress Note dated 12/20/23 at 9:26 a.m. indicated, knot and bruise observed on tope left side of scalp r/t (related to) fall, rsd (resident) denies pain, VS (vital signs) stable) at last neuro check .hospice nurse .stated no new orders at this time. Page 1 of 4 675553 675553 01/02/2024 Quitman Wellness & Rehabilitation 1026 E Goode St Quitman, TX 75783

F 0656 Level of Harm - Minimal harm or potential for actual harm Record review of a staff Assignment Sheet dated 12/19/23 indicated the staff for the 6 p.m. to 6 a.m. shift were LVN A, CNA B, and CNA C. On 12/28/23 at 11:30 a.m., a call was attempted to LVN A. There was no answer. The mailbox was full. A detailed text message was sent requesting a return call. Residents Affected - Few On 12/28/23 at 12:59 p.m., a second call was attempted to LVN A. There was no answer. The mailbox was full. A detailed text message was sent requesting a return call. No call was received prior to exit. On 12/28/23 at 1:38 p.m., a call was attempted to CNA B. There was no answer. The call went straight to voicemail. A detailed message was left, requesting a return call. On 12/28/23 at 1:40 p.m., a call was attempted to CNA C. The call went straight to voicemail. The voicemail box was full. On 1/02/24 at 10:46 a.m., a call was attempted to CNA B. There was no answer. The call went straight to voicemail. A detailed message was left, requesting a return call. No return call was received prior to exit. On 01/02/24 at 10:47 a.m., a call was attempted to CNA C. The call went straight to voicemail. The voicemail box was full. No return call was received prior to exit. During an interview on 01/02/24 at 11:06 a.m., the Administrator said he had reached out to CNA B and CNA C and was unable to reach them. He said they had worked the previous night shift and he would continue to reach out to them. During an interview on 01/02/24 at 11:25 a.m., the DON said she would have expected for the care plan to have been followed by staff. She said she would have expected for there to have been a fall mat beside the bed of Resident #1 when she fell. She said not having a fall mat or other fall interventions to have not been implemented appropriately could lead to injury . During an interview on 01/02/24 at 11:45 a.m., the Administrator said he would have expected for there to have been a fall mat beside the bed of Resident #1 when she fell out of bed. He said fall preventions not being in place could cause fall injuries to be more significant. Review of a Care Plans, Comprehensive Person-Centered facility policy dated December 2016 indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 675553 Page 2 of 4 675553 01/02/2024 Quitman Wellness & Rehabilitation 1026 E Goode St Quitman, TX 75783

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to in accordance with accepted professional standards and practices, maintain medical records on each resident that was accurately documented for 1 of 5 residents (Resident #1) reviewed for accuracy of medical records. The facility failed to ensure LVN A did not falsify Neurological Assessments for Resident #1. This failure could place residents at risk for inaccurate assessments and monitoring. Findings include: Record review of a face sheet dated 12/28/23 revealed Resident #1 was [AGE] years old and was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (chronic lung disease), heart failure, and anxiety. Record review of the most recent MDS dated [DATE] indicated Resident #1 had a BIMS score of 10 which indicated moderate cognitive impairment. The MDS indicated Resident #1 was dependent on staff for assistance with ADLs. Record review of a care plan last revised on 12/21/23 indicated Resident #1 was at risk for falls related to multiple previous falls and had actual falls. There was an intervention to, Monitor for changes in condition, document and report to MD/NP; localized swelling, c/o (complaints of) pain, increased lethargy, abnormal neuro vital signs . Record review of Neurological assessment dated [DATE] - 12/20/23 indicated LVN A completed neurological assessments on Resident #1 on 12/19/23 at 10:30 p.m., 10:45 p.m., 11:00 p.m., 11:15 p.m., 11:45 p.m. and on 12/20/23 at 12:15 a.m., 1:15 a.m., 2:15 a.m., 3:15 a.m., 04:15 a.m. and 05:15 a.m. Record review of a Progress Note dated 12/19/23 at 11:36 p.m. indicated, upon entering room resident onb floor next to be on lt (left) side, wrapped in blanket which helped cusion resident. 2cm (centimeter) X 3 cm s/t (skin tear) noted to lt (left) elbow, cleaned and steri/stripps applied as well as non-stick dressing. Neuro vs (vital signs) wnl (within normal limits). Placed in bed and call light in easy reach, bed in low position. Message left on (responsible party's) phone . Record review of a Progress Note dated 12/20/23 at 9:26 a.m. indicated, knot and bruise observed on tope left side of scalp r/t (related to) fall, rsd (resident) denies pain, VS (vital signs) stable) at last neuro check .hospice nurse .stated no new orders at this time. Record review of a video dated 12/19/23 at 10:00 p.m., revealed Resident #1 was in bed. She fell out of the bed onto the floor. There was not a fall mat beside the bed. The resident said to staff that she hit her head. Record review of a Provider Investigation Report dated 12/28/23 and concerning Resident #1 indicated, .staff was witnessed on camera in resident room to not perform neuro checks periodically after resident had an unwitnessed fall in her room. Resident assessment was performed after the fall with family alleging that the nurse did not continue to monitor her condition over time . The nurse was 675553 Page 3 of 4 675553 01/02/2024 Quitman Wellness & Rehabilitation 1026 E Goode St Quitman, TX 75783

F 0842 Level of Harm - Minimal harm or potential for actual harm identified as LVN A. The LVN was suspended immediately pending investigation. The report indicated the resident fell on [DATE]. The report indicated, .The nurse in question wrote a statement confirming that the nurse did not perform neuro evaluations correctly . The investigation findings were confirmed. The report indicated, .Nurse was terminated after conclusion of investigation for failure to document neuro checks as required . Residents Affected - Few Record review of an undated handwritten statement signed by LVN A indicated, Called to room by CNA's. Resident on floor next to bed wrapped in blanket .I did fill out a neuro VS. (vital sign) sheet at end of shift, but did not turn it in. The break in protocol was not doing neuro VS. I just did not have the time .I apologize for the break in protocol. On 12/28/23 at 11:30 a.m., a call was attempted to LVN A. There was no answer. The mailbox was full. A detailed text message was sent requesting a return call. On 12/28/23 at 12:59 p.m., a second was call attempted to LVN A. There was no answer. The mailbox was full. A detailed text message was sent requesting a return call. No call was received prior to exit. During an interview on 01/02/24 at 11:25 a.m., the DON said she would have expected for LVN A to have completed neurological checks per protocol for Resident #1. She said LVN A did admit that he falsified the neurological assessments he did chart. She said falsifying documentation could lead to a change in condition not being noticed. She said the Neurological Assessment sheet filled in by LVN A was left on a clipboard at the nurse's station . During an interview on 01/02/04 at 11:45 a.m., the Administrator said LVN A did admit to falsifying the neuro assessment documentation. He said he would have expected LVN A to have completed neuro checks on Resident #1 and to have accurately documented them. He said LVN A said he did do the first set of neurological checks, but he made up the rest of the documentation. He said after LVN A confessed to falsifying the documentation, he was terminated immediately for resident safety. He said a nurse falsifying documentation he would be afraid something clinically might not be recognized. He said there could be an adverse reaction. Review of an Assessing Falls and Their Causes facility policy dated April 2022 indicated, .if a resident has just fallen or is observed on the floor without a witness to the even, evaluate for possible injury to the head .observe for delayed complications of a fall .and will document findings in the medical record . Review of a Charting and Documentation facility policy dated July 2017 indicated, .Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate . 675553 Page 4 of 4