Health inspection·November 21, 2023

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect a resident's right to be free from abuse for 2 (RES # 1 and RES #2) of 15 residents who were reviewed for abuse. The facility failed to protect RES# 1 and RES # 2 from engaging in a resident-on-resident physical altercation on 10-3-2023 at 8:30 PM in the front lobby of the facility, which resulted in physical harm to both residents. This failure could place all residents at the facility at risk for physical harm. Findings included: Record review of the facility's PIR, dated 10-3-2023 at 8:45 PM, reflected a resident-on-resident altercation occurred on 10-3-2023 at 8:30 PM in the front lobby at the facility. The resident-on-resident altercation was between RES # 1 and RES # 2, which resulted in physical harm to both residents. The PIR Summary, written by the ADM, reflected the facility attempted to send RES # 1 to a psych hospital, but the EMTs refused to transport; instead, sent her, RES # 1, to the local hospital. RES # 1 was tested and proved positive for a UTI, and infection of the urinary system. RES # 1 was treated and prescribed antibiotics for her UTI. When RES # 1 returned to the facility, she, RES # 1, was placed on observation for at least 24 hours after the antibiotics were in place and working. RES # 1 was relocated to the other side of the facility to prevent and further interaction and incidents. In the days following the incident, both residents, RES # 1 and RES # 2, became more cooperative with their communication and began to speak about the incident. RES # 1 was seen by the psych NP, nurse practitioner, and communicated that RES # 2 was the one that initiated the incident. The results of the PIR indicated RES # 1 and RES # 2, were both at fault in the incident. Record review of RES # 1's AR, dated 11/21/2023, indicated RES # 1 was a [AGE] year-old female and was admitted to the facility on [DATE]. RES # 1 was diagnosed with paralysis and muscle weakness to side of her body R/T, related to, disrupted blood flow to her brain; decreased in size and wasting of muscle; loss of ability to understand or express speech; impaired ability to remember, think, or make decisions, difficulty with thought and how to understand language; and an infection of her urinary tract. Record review of RES # 1's Quarterly MDS, dated [DATE], Section C-Cognitive Patterns was not completed and did not indicate a BIMS Score. Section E-Behavior reflected a code of 0, zero, for (A.) Physical behavior symptoms directed towards others, such as kicking, pushing, scratching, grabbing, and Page 1 of 6 675748 675748 11/21/2023 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0600 Level of Harm - Actual harm Residents Affected - Few abusing others sexually; (B.) Verbal behavioral symptoms directed toward others, such as threatening others, screaming at others, or cursing others; and (C.) Other behavioral symptoms not directed toward others, such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal and vocal symptoms like screaming or making disruptive sounds. A code of 0, zero, indicated that the behavioral symptoms for A., B., and C. were not exhibited by RES # 1. Record review of RES # 1's PN reflected RES # 1 engaged in a physical altercation with RES # 2 in the lobby of the facility on 10/03/2023. The PN, entry dated 10/03/2023 at 8:48 PM by the ADON, reflected she responded to a report from a visitor that two residents were actively involved in an altercation in the lobby of the facility. The ADON wrote that she went to the front of the building immediately and noticed RES # 2 with scratch marks to her face and arms yelling stop it! The ADON wrote that she separated the residents immediately. After the separation, the ADON wrote that RES # 1 denied hitting or scratching RES # 2. The ADON wrote that an examination of RES # 1's hands revealed blood under her fingernails. Upon the examination, RES # 1 stated 'I did do it; furthermore, RES # 1 was sent to the hospital to be evaluated for harm to self and others. Record review of RES # 1's PN reflected an Event Follow-up note for the resident-on-resident altercation. The PN, entry dated 10/04/2023 at 3:15 AM by RN/LPN A, indicated a follow up visit with RES # 1, who expressed no new injury and no complaint of pain. RES # 1 received visual checks every 30 minutes. Record review of RES # 1's PN reflected a Physician's Order Note on 10/04/2023 at 7:56 AM. The PN, entry date 10/04/2023 at 7:56 AM by the ADON, indicated RES # 1 was prescribed an antibiotic, Ciprofloxacin 500 MG by mouth 2 times daily, for a UTI, which was an infection of RES # 1's urinary tract. Record review of RES # 1's PN reflected a Nurses Note on 10/04/2023 at 9:06 AM. The PN, entry date 10/04/2023 at 9:06 AM by LPN A, indicated RES # 1 received consent, from her responsible party, for a psychological evaluation. Record review of RES # 1's PN reflected an Event Follow-up note for the resident altercation. The PN, entry date 10/04/2023 at 12:15 PM by LPN B, reflected RES # 1 complained of no new injury was compliant with separating from RES # 2 by staying in room. Record review of RES # 1's PN reflected an Event Follow-up Note for the resident-on resident altercation. The PN, entry date 10/04/2023 at 5:35 PM by LN C, indicated RES # 1 was prescribed Melatonin 3 MG by mouth at bedtime, as a sleep aid, and Lexapro 10 MG by mouth daily, for depression and anxiety. RES # 1 complained of no new injury and received visual checks every 30 minutes for behavioral monitoring, while RES # 1 and RES # 2 remained separated. Record review of RES # 1's PN reflected an Event Follow-up note for the resident-on resident altercation. The PN, entry date 10/05/2023 at 2:54 AM by RN/LPN B, indicated that RES # 1 had no new injuries and no complaints of pain. RES # 1 was compliant with staying in room and received visual checks every 30 minutes. Record review of RES # 1's PN reflected an Event Follow-up note for the resident-on resident altercation. The PN, entry date 10/05/2023 at 12:19 PM by LPN B, indicated that RES # 1 had no new issues and RES # 1 moved to room [ROOM NUMBER]A, which was on the opposite side of the facility to separate 675748 Page 2 of 6 675748 11/21/2023 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0600 the residents. Level of Harm - Actual harm Record review of RES # 1's PN reflected an Event Follow-up note for the resident-on resident altercation. The PN, entry date 10/06/2023 at 2:38 PM by LN B, indicated that RES # 1 had no new issues. Residents Affected - Few Record review of RES # 1's CP, initiated 8/2/2021, indicated RES # 1 had impaired cognitive function/dementia or impaired thought process related to dementia. The goal, revised on 6/26/2023, indicated RES # 1 would maintain current level of decision-making ability by the target date of 12/26/2023. The interventions for the CNA were to monitor and document any changes in cognitive function, specifically changes in decision making ability, memory, recall, general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mantal status. Record review of RES # 1's CP, initiated 09/29/2023, indicated RES # 1 refused to allow staff to cut her fingernails. The goal, initiated on 9/29/2023, reflected RES # 1's goal was to allow staff to maintain nails short, trimmed, and filed through the target date of 12/26/2023. The interventions on RES # 1's CP indicated RES # 1 refused the ADON to cut her nails on 9/29/2023, so RES # 1 was encouraged to attend an activity called 'pretty nails,' in the activity room. On 10/02/2023, RES # 1 refused to allow the DON to cut her fingernails. An update to RES # 1's CP, initiated on 10/03/2023, reflected RES # 1 agreed to allow staff to cut her fingernails; on 10/04/2023, RES # 1 allowed staff to trim her nails. Record review of RES # 1's CP, initiated 10/2/2023, indicated RES # 2 had an altercation with another resident related to her mood and a UTI, which was an infection of her urinary tract. The goal, initiated on 10/2/2023, was for RES # 1 to be free of altercations through the target date of 12/26/2023. The interventions on RES # 1's CP indicated RES # 1 received antibiotics for her UTI initiated on 10/04/2023; changed rooms on 10/09/2023; has trim nails beginning on 10/9/2023; and was referred for psychological assessment on 10/9/2023. Interview on 11-21-2023 at 10:10 AM with RES # 1 revealed no memory or knowledge of the resident-on-resident altercation, which occurred on 10-3-2023 at 8:30 PM. RES # 1 stated she felt safe at the facility. Record review of RES # 2's AR, dated 11/21/2023, indicated RES # 2 was a [AGE] year-old female and was admitted to the facility on [DATE]. RES # 2 was diagnosed with a disorder that affected her ability to move and maintain balance, a mental disorder marked by extreme changes in mood, thought, energy, and behavior, and limitations with social skill, language, and self-care. Interview and observation on 11-21-2023 at 10:00 AM with RES # 2 revealed some details of the resident-on-resident altercation, which took place on 10-3-2023 at 8:30 PM. RES # 2 recalled that she and RES # 1 engaged in a physical altercation, which occurred by the front door in the lobby of the facility. RES # 2 stated that she struck RES # 1 with her right hand and mimicked her actions when she demonstrated with her right arm. RES # 2 stated that RES # 1 scratched her arm and her face; and RES # 2 pointed to her right arm, where three visible marks to the skin were still present. RES # 2 was unable to explain how the argument happened and was unable to recall who was the first to assault the other. Res # 2 stated that she did not interact with RES # 1 anymore because RES # 1 moved. Record review of RES # 2's Quarterly MDS, dated [DATE], Section C-Cognitive Patterns indicated RES # 2 had a BIMS Score of 8. A BIMS Score of 8 suggested RES # 2 was assessed with moderate cognitive impairment. Section E-Behavior indicated a code of 1, one, for (A.) Physical behavior symptoms 675748 Page 3 of 6 675748 11/21/2023 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0600 Level of Harm - Actual harm Residents Affected - Few directed towards others, such as kicking, pushing, scratching, grabbing, and abusing others sexually. A code of 1, one, indicated that the behavioral symptoms for A. occurred with RES # 2 one to three days since the last MDS assessment. Section E-Behavior indicated a code of 0, zero, for (B.) Verbal behavioral symptoms directed toward others, such as threatening others, screaming at others, or cursing others; and (C.) Other behavioral symptoms not directed toward others, such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal and vocal symptoms like screaming or making disruptive sounds. A code of 0, zero, indicated that the behavioral symptoms for B. and C. were not exhibited by RES # 2 at the time of the assessment. Record review of RES # 2's PN reflected Res # 2 engaged in a physical altercation with RES # 1 in the lobby of the facility on 10/03/2023. The PN, entry dated 10/03/2023 at 8:49 PM by the ADON, reflected she responded to a report from a visitor that two residents were actively involved in an altercation in the lobby of the facility. The ADON wrote that she went to the front of the building immediately and noticed RES # 2 with scratch marks to her face and arms yelling stop it! The ADON wrote that she separated RES # 1 and RES # 2 immediately and brought RES # 2 back to the nurse's station for assessment. RES # 2 stated that RES # 1 'hit me, she hit me, she scratched me.' The ADON wrote vital signs were obtained, head-to-toe assessment was completed, then ADM, the DON, and responsible party were notified. Record review of RES # 2's PN reflected an Event Follow-up note for the resident-on-resident altercation. The PN, entry dated 10/04/2023 at 5:37 AM by LN A, indicated a follow up visit with RES # 2, who expressed no new injury and did not ask for pain medications. RES # 2 received wound care with normal saline and triple antibiotic ointment monitored for infection. Record review of RES # 2's PN reflected an Event Follow-up note for the resident-on-resident. The PN, entry dated 10/04/2023 at 1:04 PM by LPN A, indicated a follow up visit with RES # 2, who expressed no new injury, but discomfort to scratches above mouth. RES # 2 received wound care with normal saline and triple antibiotic ointment. Record review of RES # 2's PN reflected an Event Follow-up note for the resident-on-resident altercation. The PN, entry dated 10/04/2023 at 6:31 PM by SM A, indicated a follow up visit with RES # 2, who expressed no new injury, but complained of scratches that itched and hurt. RES # 2 received PRN Acetaminophen, which was pain reducer, and ointment for the scratches. Record review of RES # 2's PN reflected an Event Follow-up note for the resident-on-resident altercation. The PN, entry dated 10/05/2023 at 2:48 AM by LN A, indicated a follow up visit with RES # 2, who expressed no new injury. RES # 2 was monitored for infections. Record review of RES # 2's PN reflected an Event Follow-up note for the resident-on-resident altercation. The PN, entry dated 10/05/2023 at 3:12 PM by LPN A, indicated a follow up visit with RES # 2, who expressed no new injury. RES # 2 received triple antibiotic ointment and was monitored for infection. Record review of RES # 2's PN reflected an Event Follow-up note for the resident-on-resident altercation. The PN, entry dated 10/06/2023 at 3:18 AM by LN A, indicated a follow up visit with RES # 2, who expressed no new injury. RES # 2 received triple antibiotic ointment. Record review of RES # 2's CP, initiated on 10/02/2023, indicated that RES # 2 had another 675748 Page 4 of 6 675748 11/21/2023 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0600 Level of Harm - Actual harm Residents Affected - Few altercation with another resident, which resulted with scratches to face and right arm R/T, related to, behaviors. The goal, initiated on 10/2/2023, was for RES # 2 to be free of altercations within the next review period with a target date of 1/8/2023. The interventions on RES # 2's CP indicated psychological services initiated on 10/9/2023; avoid altercations to other residents initiated on 10/9/2023; and provided medical care to the scratches on RES # 2's face and right arm. Interview on 11-21-2023 at 11:50 AM with the ADON revealed a family member of a resident at the facility pointed out to the ADON that two residents, RES # 1 and RES # 2, were observed hitting each other in the front of the facility. The ADON immediately went to the front of the facility where RES # 2 was observed with scratches to her face and arms and overheard yelling 'stop it.' The ADON immediately separated the residents. RES # 2 was brought to the nurse's stations for medical assessment and treated for scratches. Next, RES # 1refused medical assessment and denied hitting or scratching RES # 2. When blood was discovered under RES # 1's fingernails on her right hand, RES # 1 admitted she scratched RES # 2. RES # 1 was unable to expressed why she did it. RES # 1 was sent to the local hospital where she was diagnosed with a UTI, an infection to her urinary tract, and returned to the facility with antibiotics. The ADON stated that neither resident have displayed aggression towards each other or other residents Interview on 11-21-2023 at 12:30 PM with the AAD revealed residents involved in a resident-on-resident altercation were to be immediately separated and medically assessed by a member of nursing staff. The next steps were to report the incident to the abuse coordinator, who was the ADM. The AAD stated staff has received training and in-service education on abuse. Interview on 11-21-2023 at 2:45 PM with CNA A revealed how she was trained to immediately separate residents if they engaged in an altercation and let nursing staff know to have the residents medically assessed. CNA A stated that the nursing staff made necessary notifications to the DON and the ADM. CNA A stated she was trained on how to respond to resident-on-resident altercations. Interview on 11-21-2023 at 2:50 PM with MA A revealed to immediately separate residents if they engaged in a resident-on-resident altercation and let the nursing staff know right away. The nursing staff would then medically assess the residents and inform the DON and the ADM. MA A stated she wrote a statement on 10-4-2023, which indicate RES # 2 admitted to hitting RES # 1 first. Interview on 11-21-2023 at 3:00 PM with CNA B revealed that residents involved in an altercation were to be separated immediately and let nursing staff know so that could provide medial assessment. CNA B stated she recently attended an in-service on abuse. Interview on 11-21-2023 at 3:05 PM with RN A revealed that residents were to be immediately separated if involved in an altercation. After the residents were safe from more harm, the nursing staff would medically assess. The DON and the ADM were to be notified immediately. RN A stated she recently attended an in-service class on abuse. Interview and record review on 11-21-2023 at 3:30 PM with the DON revealed RES # 2 was not on a behavior monitoring plan at the time of the resident-on-resident altercation on 10/3/2023 but had been receiving psychological services since her admission date of 1/18/2022. The DON presented RES # 2's psychiatric progress notes for 8/22/2023 and 10/11/2023, which indicated RES # 2 was seen by Physician A for medication review and displayed behaviors. The progress note, dated 8/22/2023, reflected remarks to continue counseling, increase Seroquel (an antipsychotic) to 150 MG by mouth twice a day, and commence Ativan (anti-anxiety) 1 MG by mouth every 12 hours. The progress note, dated 10/11/2023, 675748 Page 5 of 6 675748 11/21/2023 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0600 reflected remarks to continue to monitor mood, behaviors, and potentials side effects of medications; and to increase Seroquel (an antipsychotic) to 170 MG by mouth twice a day. Level of Harm - Actual harm Residents Affected - Few Interview on 11-21-2023 at 4:00 PM with the LPC revealed RES # 2 received counseling services since January 2022. The LPC stated goals were for RES # 2 to keep hands to self and respect boundaries. The LPC stated counseling serviced continued two times a week. Interview on 11-21-2023 at 4:45 PM with the DON revealed staff was instructed to monitor RES # 2 to ensure RES # 2 did not ambulate to the other side of the facility where RES # 1 resided. Both RES # 1 and RES # 2 had updated CP that addressed the resident-on-resident altercation on 10/3/2023 and that all the residents were safe. The DON stated that the resident-on-resident altercation was not the result of staff failure. Interview on 11-21-2023 at 5:00 PM with the ADM revealed RES # 2 received psychological and counseling services and continued to do so. The facility staff were educated and made aware of RES # 1 and RES # 2's behavior and instructed to anticipate similar incidents and provide preemptive redirection. It was important to protect residents from physical altercations because it could cause physical and emotional pain. The facility staff cannot stop a behavior from happening but can only respond to behaviors, and work to correct them moving forward. The ADM stated that the resident-on-resident altercation was not a result of staff failure. Record review of a statement written by MA A, written 10/4/2023, stated RES # 2 admitted she struck RES # 1 first on 10/3/2023 at 8:30 PM and that she continued hitting RES # 1. Record review of a facility in-service education for staff dated 10-10-2023 reflected training on Alzheimer's Disease, Abuse, Neglect, and Trauma Informed Care. Record review of the facility's Abuse Prevention Program, dated 10-3-2018, reflected the facility's policy statement, which stated 'Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The facility policy defined abuse as: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. The facility policy defined willful as: The individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 675748 Page 6 of 6