Health inspection·August 15, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 2 of 2 residents (Residents # 1 and #2) reviewed for accidents. 1. The facility failed to ensure Residents #1 and #2 were provided adequate staff supervision during a smoking session. 2. The facility failed to increase supervision of the residents even though they had negative altercations prior to the altercation in the courtyard. This failure could place residents at risk for further altercations, which could result in injury, pain, and hospitalization. 3. Facility prematurely prepared Resident #3, who required a two-person assisted transfer, using a mechanical lift, for transfer. By the resident having to wait for a second staff to assist with the transfer, she became impatient and attempted to transfer herself, which resulted in a fall. This failure could place residents at risk for accidents or serious injury. Findings Include: A record review of Resident #1's Face Sheet dated 08/07/23, revealed a [AGE] year-old female. She was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Alzheimer's Disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), difficulty in walking, lack of coordination, Anxiety Disorder (persistent and excessive worry that interferes with daily activities), Bipolar Disorder (a mental health condition that causes extreme mood swings that include emotional highs [mania {increased talkativeness, rapid speech, a decreased need for sleep, racing thoughts, distractibility, increase in goal-directed activity, and psychomotor agitation} or hypomania {periods of over-active and high energy behavior that can have a significant impact on your day-to-day life}] and lows [depression]). A record review of Resident #1's Care Plan, dated 05/30/23 at 10:07 AM, reflected she had limited mobility related to muscle weakness and Dementia. She had a mood problem related to bipolar disorder and anxiety disorder. Interventions: She required a wheelchair to self-propel. She required monitoring and observation for impaired judgment or safety awareness. Also, monitoring for increased anger or agitation. Resident #1 is/has potential to be verbally aggressive related to Dementia, Ineffective Page 1 of 6 675703 675703 08/15/2023 Cross Timbers Rehabilitation and Healthcare Center 3315 Cross Timbers Rd Flower Mound, TX 75028

F 0689 coping skills, Mental / Emotional illness, Poor impulse control Level of Harm - Minimal harm or potential for actual harm yelling/screaming, abusive language, threatening behavior at staff and residents. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Assess resident's coping skills and support system. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Give the resident as many choices as possible about care and activities. Monitor behaviors Qshift. Document observed behavior and attempted interventions. Psychiatric/Psychogeriatric consult as indicated. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Residents Affected - Few No updates to the residents care plan in reference to the altercations between Resident #1 and Resident #2 were noted. A record review of Resident #1's MDS dated [DATE] at 10:12 AM, revealed a BIMS assessment score of 15, which indicated the resident was cognitively intact. She had verbally aggressive behaviors toward staff and other residents. A record review of the Progress Note created by RA A, dated 07/30/23 at 10:41 PM, for Resident #1 reflected the following, Resident got in physical altercation with another resident. This physical altercation was not witnessed by me, however, I cleaned up resident's hands. Resident had two scratches on left hand and one on right. Cleaned residents wounds and put triple antibiotic on top and covered with bandaid. Wound on right hand was not covered with bandaid. Resident denied being pain. A record review of the Progress Note created by RN F, dated 08/02/23 at 1:29 PM, for Resident #1 reflected the following, At about 12 noon, another nurse called me to the resident's room. As I entered the room, the resident stated that she was out on the patio and another resident came and grabbed her from behind, so she grabbed her hands too. The resident fell backwards onto the ground. Staff intervened. Head to toe assessment done. Scratches on the right side of her cheek, chin and left arm are noted. Dressings done. Vital signs taken and recorded. Administrator, DON, MD and family were all informed. A record review of the Progress Note created by the Social Worker, dated 08/02/23 at 2:12 PM, for Resident #1 reflected the following, Late entry. Resident had physical altercation with another resident. She has a history of bipolar disorder and her mood swings have been unmanageable. She becomes angry and a few minutes later she is crying. She is agreeable to go to a psychiatric hospital for medication management and mood stabilization. A record review of Resident #2's Face Sheet dated 08/07/23, revealed a [AGE] year-old female. She was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Cognitive Communication Deficit (difficulty with thinking and how someone uses language), Anxiety Disorder, Major Depressive Disorder Personal history of Transient Ischemic Attack (a stroke that lasts only a few minutes) and Cerebral Infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Hypertension, and Chronic Obstructive Pulmonary Disease. A record review of Resident #2's MDS dated [DATE] at 10:20 AM, revealed a BIMS score of 13, which 675703 Page 2 of 6 675703 08/15/2023 Cross Timbers Rehabilitation and Healthcare Center 3315 Cross Timbers Rd Flower Mound, TX 75028

F 0689 indicated she was cognitively intact. No behaviors were noted. She required a wheelchair for ambulation. Level of Harm - Minimal harm or potential for actual harm A record review of Resident #2's Care Plan, dated 05/30/23 at 10:25 AM, reflected she had potential to be physically aggressive (with other residents) r/t Depression, Poor impulse control. 8/2/23- Resident is on one-to-one supervision and family has also agreed to help provide supervision. Interventions: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Monitor each shift. Document observed behavior and attempted interventions in behavior log. Monitor/document/report as needed any signs/symptoms of resident posing danger to self and others. Residents Affected - Few A record review of the Progress Note created by Nurse G, dated 08/01/23 at 6:11 PM, for Resident #2 reflected the following, This resident remains with no injury and denies pain after incident with other resident. Doctor and family notified. No further concern at this time. A record review of the Progress Note created by the ADON, dated 08/02/23 at 3:39 PM, for Resident #2 reflected the following, spoke with [family member] regarding episode of aggression in detail-Stated that resident becomes very mean and sees things when she has a UTI and resident 'needs IV antibiotics when she gets them'-Spoke with Np regarding the above and new order written for ceftriaxone 1gm IM x 3days A record review of the Progress Note created by the Social Worker, dated 08/02/23 at 4:53 PM, for Resident #2 reflected the following, SW spoke with resident's[family member], regarding recent aggressive behaviors. She is agreeable to Psych referral. SW sent referral this date and sent text message to the Psychatrist to request face time visit asap. Resident is on one-to-one supervision and family has also agreed to help provide supervision. A record review of the Progress Note created by RN H, dated 08/05/23 at 6:22 PM, for Resident #2 reflected the following, Lidocaine HCl Injection Solution 1 % Inject 2.1 ml intramuscularly in the evening for mix with Ceftriaxone, until 08/05/2023 23:59 mix 2.1 ml with Ceftriaxone ABX was ordered for 3 days initial dose was given on the 8/2/23. Thus, all doses were given. Record Review of Physician's Orders for Resident #2 on 08/15/23 at 10:49 AM, revealed cefTRIAXone Sodium Injection Solution Reconstituted 1 GM Inject 1 gram intramuscularly one time a day for UTI for 3 Days Completed 08/02/2023 08/02/2023 08/05/2023 _________ _________ Lidocaine HCl Injection Solution 1 % Inject 2.1 ml intramuscularly in the evening for mix with Ceftriaxone. until 08/05/2023 23:59 mix 2.1 ml with 675703 Page 3 of 6 675703 08/15/2023 Cross Timbers Rehabilitation and Healthcare Center 3315 Cross Timbers Rd Flower Mound, TX 75028

F 0689 Ceftriaxone Level of Harm - Minimal harm or potential for actual harm Completed 08/02/2023 08/03/2023 08/05/2023 _________ _________ Macrobid Oral Capsule 100 MG Give 1 capsule by Residents Affected - Few mouth two times a day for UTI for 5 Days An interview with the Administrator on 08/15/23 at 9:35 AM, revealed he stated on 08/01/23, during lunch time, the two residents got into a physical altercation. He stated no actual hits made contact; however, Resident #1 was scratched. He stated the residents were separated, assessed, then placed on 1:1. He stated physicians and families were notified. He stated on 08/02/23, Resident #2 saw Resident #1 exiting the building, so she followed her out. He stated Resident #2 attempted to punch Resident #1, however, Resident #1 grabbed her arm; however, in doing so, she lost balance and fell over in her wheelchair. He stated the staff ran to stop them but didn't get to them in time to prevent it. He stated Resident #1 sustained abrasions on the right side of her head and on her right arm. He stated Resident #2 was placed on 1:1. The physicians and families were notified, and she was sent out for psychiatric evaluation. He stated Resident #1 said that on 07/30/23, she and Resident #2 got into an argument, but no punches were thrown . He stated Resident #1 said she told RA A about it. When he asked RA A about it, she confirmed Resident #1 told her, but she did not think it was serious enough to report it to him. He stated he placed her on a final level disciplinary action and re-educated her. He stated they conducted an in-service and Quality Assurance Assessment afterward. He stated Resident #2 was discharged from the facility on 08/14/23. On 08/15/23 at 10:12 AM, a record review of a written statement by the Activities Director, reflected, I was up by the nurse's station and when the door tot he courtyard was opened, I heard Resident #1 yelling. I [NAME] to the courtyard, the Central Supply Clerk was at the door as well. Resident #2 was trying to get in the door, the Central Supply Clerk helped her inside and Resident #1 was laying, wiht her wheelchair flipped on it back. She was still in a sitting position with her head and back on the sidewalk. We called a nurse. RN H came out and assessed her. We moved her wheelchair and helped her stand up and get back into her wheelchair. She was upset and said that Resident #2 came behind her and hit her and flipped her over backwards. When we got to her room, we got her some ice water and talked to her for a little bit to get her to cool off. On 08/15/23 at 10:17 AM, a record review of a written statement of an interview by the Administrator with Resident #2, revealed Resident #2 stated she did try to hit Resident #1 because she called her a bitch the day before and she does not like that lady. She stated she did follow Resident #1 into the courtyard and it was intentional. The Administrator added that there were not injuries to Resident #2. On 08/15/23 at 10:24 AM, a record reivew of a written statement from the ADON, reflected I was notified that there was an incident regarding Resident #1 and Resident #2 in the enclosed patio area by the Activities Director. Resident #1 was observed in her wheelchair and was escorted to her room with htis author and another staff member. Resident #1 stated she was outside in the patio area when the other resident reached for her from behind and she grabbed Resident #2's arms and fell backward from her wheelchair. Resident #2 was also escorted to her room. Upon interview, stated that she followed Resident #1 outside. She came up behind her and reached forward to hit her. Resident #1 grabbed her arms and subsequently Resident #1 fell while in a wheelchair. Resident #2 stated, 'I was trying to hit her .cause she called me a bitch yesterday.' Resident #2 remained in her room with a staff member. 675703 Page 4 of 6 675703 08/15/2023 Cross Timbers Rehabilitation and Healthcare Center 3315 Cross Timbers Rd Flower Mound, TX 75028

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview with Resident #1 on 05/18/23 at 2:19 PM, revealed she and Resident #2 had exchanged words at lunch one day because she was talking to someone else and then Resident #2 told her to be quiet. She stated she already did not like Resident #2, but could not give a reason why she did not like her. She stated they began to argue because she was not going to let Resident #2 tell her what to do. She stated staff pulled them apart because they were trying to hit each other. She stated the next evening, she had gone to the courtyard to smoke and Resident #2 came out there. She stated Resident #2 did not say anything to her, she just came toward her and tried to hit her. She stated she grabbed her arm to keep her from hitting her and because of how she had to lean while holding onto her arm, it caused her to fall back. She stated she got a few scrapes, but at least Resident #2 did not get to hit her. She stated staff came out to help her and the nurse checked her out. She stated she thought the whole thing was done with, but Resident #2 would not let it go. She stated she had not seen Resident #2 for a while and she was glad she had not seen her. An interview with the C.N.A B on 08/15/23 at 4:58 PM, revealed Resident #1 was never happy. She liked to smoke and when she didn't have cigarettes, she would torture everyone. She stated Resident #1 picked fights with residents. She stated she fusses and fights with residents and staff. She stated Resident #1 did not like Resident #2 and would always talk badly about her to her face and to others and say it loudly. She stated she was never told to keep the two residents separated or to keep an eye on them. She stated she felt it was just good to always watch Resident #1 because she messed with everyone. She stated she believed if they had been told to keep an eye on the two of them, specifically, because if that was the case, someone would have seen when Resident #2 followed Resident #1 outside and prevented the incident in which Resident #2 attempted to hit Resident #1 and Resident #1 grabbed her arm and ended up falling backward in her wheelchair. An additional interview with the Administrator on 08/15/23 at 4:50 PM, revealed C.N.A. C had gotten the mechanical lift and had asked Nurse E to come assist her with the resident's transfer. He stated she was at the door of the room, looking for assistance, when the resident became impatient and started trying to maneuver out of bed on her own, and was reaching for the lift. Then C.N.A. C ran to catch her because she was slipping. He stated the sit-to-stand board had already been placed under the resident and that is how she was able to scoot and reach for the mechanical lift. He stated if C.N.A. C had not started the process without assistance present, the fall most likely would not have happened. On 08/15/23 at 6:15 PM, record review of the Psychiatric Evaluation for Resident #2, dated 08/03/23 revealed an evaluation was compted by the Psychiatrist and a recommendationf or the discontinuation of the 1:1 monitoring was issued. On 08/15/23 at 6:21 PM, record review of documents entitled 1:1 Monitoring for Resident #2, dated 08/02/23 - 08/03/23, revealed staff began monitoring the resident at 2:00 PM and continued with hourly documentation through 5:00 PM on 08/03/23. Review of Resident #3's Face Sheet, dated 08/15/23, revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left non-dominant side, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Major Depressive Disorder, Anxiety Disorder, Hypertension, and Osteoarthritis. Review of Resident #3's Minimum Data Set (MDS) Assessment, dated 05/19/23, reflected the resident's Brief Interview of Mental Status score of 15, which means she was cognitively intact. She required extensive two-person for bed mobility, transfer, locomotion off unit, dressing, and toilet use. 675703 Page 5 of 6 675703 08/15/2023 Cross Timbers Rehabilitation and Healthcare Center 3315 Cross Timbers Rd Flower Mound, TX 75028

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #3's Care Plan dated revised on 05/30/23 reflected, the resident was at high risk for falls related to gait/balance problems, incontinence, unaware of safety needs with interventions included: Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs and follow facility fall protocol. The Care Plan did not address the resident's transfer requirements. A record review of the Progress Note dated 08/09/23 at 6:50 AM, for Resident #3 reflected the following, 5:00 AM one of the CNA calls this nurse announcing the patient is on the floor. Resident is seated on the floor and next to her back is a commode. resident who is alert and oriented x 4 says she slid off the commode on transfer. She denied being hurt although the sling rubbed hard on my left shoulder as i went to the floor. she also denies banging self in the process. Spouse informed through a telephone message. Medical Director (MD) and Director of Nursing (DON) notified. x ray order of the sacral in the witnessed fall is made. An interview with the Administrator on 08/15/23 at 2:40 PM, revealed Resident #3 cursed staff out every chance she got. He stated on the morning of the fall, C.N.A. C was assisting Resident #3 to the toilet, and the resident slipped and fell to the floor. The resident's legs were pinned underneath her. He stated C.N.A. C called for help and Nurse E entered and assisted C.N.A. C with lifting the resident from the floor. Nurse E then conducted a head-to-toe assessment on the resident and found no injuries. He stated the incident was reported to him by the resident. On 08/15/23 at 3:19 PM, record review of a written account of a phone conversation between the Administrator and Resident #3, reflected I received a call from Resident #3, stating she had a complaint from the morning (08/09/23) at 5:00 AM. She stated C.N.A. C was helping her to the toilet when she slipped and fell. She stated the weight of her body was on her shoulder. C.N.A. C called for help and Nurse E then helped C.N.A. finish. He added, Nurse E performed a body check where no injuries were noted. An additional interview with the Administrator on 08/15/23 at 4:50 PM, revealed C.N.A. C had gotten the mechanical lift and had asked Nurse E to come assist her with the resident's transfer. He stated she was at the door of the room, looking for assistance, when the resident became impatient and started trying to maneuver out of bed on her own, and was reaching for the lift. Then C.N.A. C ran to catch her because she was slipping. He stated the sit-to-stand board had already been placed under the resident and that is how she was able to scoot and reach for the mechanical lift. He stated if C.N.A. C had not started the process without assistance present, the fall most likely would not have happened. An interview with C.N.A. D on 08/15/23 at 5:13 PM, revealed she stated Resident #3 is a very particular lady. She stated the resident hates to have a bowel movement in her brief. She stated the resident can scoot and grab the lift, when they put her on the sit-to-stand board. She stated the resident will try to do things for herself, as much as she can. She stated whenever she responds to the resident's call light, she will go in and see what the resident needs. She stated when the resident tells her she needs to go to the toilet, she will tell her ok and that she will be back with someone to help her with getting her to the bathroom. She stated the resident says ok and waits, with no problem. She stated if the resident were to ever get impatient and try to get out of bed on her own, she would try to talk to her to calm her and explain to her that she needs to wait for assistance, so she won't fall and hurt herself. 675703 Page 6 of 6