Health inspection·February 28, 2024

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure if a hospice care was furnished through an agreement, a provision that the LTC facility immediately notified the hospice about a significant change in the resident's physical, mental, social, or emotional status for 1 of 1 resident (Resident #1) reviewed for hospice care. The facility failed to immediately notify Resident #1's hospice agency of falls and change of condition that occurred on 2/22/24 and 2/25/24. This failure could place residents at risk to a decline in health. Findings include: Record review of Resident #1's electronic face sheet, dated 02/28/2024, reflected a [AGE] year-old male who was admitted to the facility 08/30/22. Resident #1 had diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), muscle wasting and atrophy (decrease in size and wasting of muscle tissue). Record review of Resident #1's comprehensive care plan, revised 01/18/2024, reflected Resident #1 had a terminal prognosis regarding Alzheimer's(type of dementia) and was on hospice. Interventions listed on Resident #1's care plan included working cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs were being met. Record review of Resident#1's quarterly MDS, dated [DATE], reflected the BIMS was not completed. Record review of the nursing note, authored by LVN A, dated 02/22/24 at 3:45 PM, reflected Nurse called to room by ADON observed resident laying on fall mat beside bed. Residents bed in lowest position. Resident confused/disoriented head to toe assessment neurological checks able to [NAME](sic) noted 1cm bruise under right eye 1.5 cm skin tear to right forearmno (sic) signs/symptoms of pain or discomfort resident assisted back in bed incontinent care provided. Bed in lowest position fall mat in place cleansed skin tear right forearm with n/s tao dressing applied. NP/DON/wife notified skull xray ordered. Record review of nursing note, authored by LVN A, dated 02/22/24 at 3:45 PM, reflected Change in Condition : Symptoms or signs noted of Condition change: Falls Refer to elNTERACT Change in Condition for Full Evaluation Page 1 of 3 675579 675579 02/28/2024 Beacon Harbor Healthcare and Rehabilitation 6700 Heritage Parkway Rockwall, TX 75087

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Vital Signs: Blood pressure 124/74 - 2/22/2024 15:45 [ 3:45PM] Position: Lying Ieft/arm Pulse 74 2/22/2024 15:45[3:45PM] Pulse Type: Regular Rate 18.0 - 2/22/2024 15:45 Temperature 97.5 - 2/22/2024 15:45 Route: Forehead (non-contact) 02 97.0 % - 2/22/2024 15:45[3:45PM] Method: Room Air Notifications: Reported to primary care clinician: [ Nurse practitioner ] Date and time of clinician notification: 02/22/2024 4:00 PM Name of family member or resident representative notified: [family member] Date and time family or representative notified: 02/22/2024 4:30 PM Record review of nursing notes, authored by LVN B, dated 2/25/24 at 8:33PM, reflected Refer to elNTERACT Change in Condition for Full Evaluation Vital Signs: BP 120/74 - 2/25/2024 20:45 Position: Standing I/arm P 72 - 2/25/2024 20:45 Pulse Type: Regular R 18 - 2/25/2024 20:45 T 97.4 - 2/25/2024 20:47 Route: Forehead (non-contact) 02 95 % - 2/25/2024 20:46 Method: Room Air Notifications: Reported to primary care clinician: [ NP] Date and time of clinician notification: 02/25/2024 8:50 PM Name of family member or resident representative notified: [family member] Date and time family or representative notified: 02/25/2024 9:00 PM 675579 Page 2 of 3 675579 02/28/2024 Beacon Harbor Healthcare and Rehabilitation 6700 Heritage Parkway Rockwall, TX 75087

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the nursing notes, authored by LVN B dated 2/25/24 at 21:01 [9:01PM], reflected Resident found on the floor mattress x 3 episodes this evening no injuries apparent. patient is fighting, staff when they attempt to place him back in bed. will continue to monitor closely. Review of the incident report authored by LVN B dated 02/25/24 with no time refelcted , resident found on mattress, head to toe assessement completed, placed back in bed , large body pilow placed in bed with resident to aid fall. Bed lowered to lowest level, floor mattress placed besided bed neurological check and frequent montioring began. notified wife, DON and Nurse practioner Interview on 02/28/24 at 10:00 Am with Hospice Supervising Nurse revealed she was not informed by the facility regarding Resident#1's fall however was informed by the hospice aide. The Hospice Supervising nurse stated the facility should be calling to inform of any falls or change in condition even it a hospice aid is in the facility daily. Interview on 02/28/24 at 10:50 AM with LVN C revealed if a resident was receiving hospice services, hospice, the family, the doctor and the DON all should be notified of any fall or change in condition that occurred with the resident. LVN C revealed once hospice was notified it should be documented in the nursing notes. Interview on 02/28/24 at 11:00 AM with LVN D revealed if a resident was receiving hospice services, then hospice, the DON, the doctor and the family should all be notified if there was a fall or change in condition regarding the resident. LVN D revealed notification of falls or change in condition should have been documented in the nursing notes. Interview on 02/28/24 at 2:14 PM with the DON revealed the nursing staff did not document hospice was notified of the falls that occurred on 02/22/24 and 02/25/24, however he was notified as well as the physician and the family member. The DON stated he verbally notified the hospice nurse on 02/26/24 of both falls, however it was not documented. The DON stated the nursing staff should have notified hospice immediately regarding any change in condition regarding residents who received hospice services. The DON stated there was no risk to residents due to hospice not being notified due to the physician being notified. Record review of the facility policy Significant change in condition, response, revised 2022, reflected The Nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions. Record review of the facility policy End of life care, hospice and/or palliative care, revised 2023, reflected It is the policy of this facility to provide dignified and compassionate end of life care for terminally ill or dying residents. Through continuing interdisciplinary assessment, individualized plans will be developed and implemented to address prevention and relief of symptoms and the resident's physical, intellectual, emotional, social, spiritual, and practical needs. Support and reassurance for family and friends close to the resident will be an integral part of the plan. 675579 Page 3 of 3