Health inspection·November 13, 2023

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 interview and record review, the facility failed to investigate an injury of unknown origin and report to HHSC for 1 out of 2 residents (Resident #1) reviewed for injury of unknown origin. The facility failed to report an injury of unknown origin, swelling and bruising around Resident #1's right eye, to HHSC. This failure could place residents at risk of abuse, fear, and a diminished quality of life. Findings include: Record review of Resident #1's electronic face sheet, dated 11/3/23 revealed she was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses to include anxiety disorder, dementia, and scoliosis (a sideways curve of the spine). Review of Resident #1's progress notes dated 10/28/23, time entered 7:35 AM indicated During incontinence care (of Resident #1) CNA A noted swelling and a bruise to the right brow, the resident is unable to explain what happened, no other injuries were noted, no discomfort or distress is noted, will continue to monitor swelling and bruising. Record review of incident report dated 10/28/23 titled injury of, for Resident #1, prepared by LVN B indicated: During incontinence care, CNA A noted swelling and a bruise to the right brow. Resident unable to give description. No other injuries were noted. During an interview on 11/6/23 at 10:30 PM, LVN B stated that there was an injury located above Resident #1's right eye. She stated that she had no idea how Resident #1 got the bruise. She stated that she increased monitoring of Resident #1 for the rest of her shift and let morning staff know. She stated she put an incident report in the system like she did with every incident. She stated after she inputs an incident, it's up to the Admin to do everything from there. She stated the Admin never came to her to talk with her about the bruise above Resident #1's eye. She stated at the time, there was an agency DON, so she is not sure if the DON even looked at the incident reports. During an interview on 11/3/23 at 11:30 AM, the Admin stated she oversaw and makes sure investigations are done correctly. She stated that she works with the department head to do all investigations. She stated she has no pending investigations going on at this time. During an interview on 11/13/23 at 11:45 AM, the Admin stated that the bruise just looked like a Page 1 of 3 675769 675769 11/13/2023 Harmony Care at Stamford 1003 Columbia Stamford, TX 79553

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bruise and she did not think anything of it; that was why she did not report. She stated she interviewed the night aide and the night nurse the next day regarding the injury, but she had no documentation of those interviews. She stated she does all investigations and reporting regarding abuse and neglect because she is the abuse/neglect coordinator. Record review of facility's Abuse Investigation and Reporting policy dated 7/2017 indicated: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. 675769 Page 2 of 3 675769 11/13/2023 Harmony Care at Stamford 1003 Columbia Stamford, TX 79553

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to investigate an injury of unknown origin and report to HHSC for 1 out of 2 residents (Resident #1) reviewed for injury of unknown origin. Residents Affected - Few The facility failed to complete an investigation of swelling and bruising around Resident #1's right eye first observed on 10/28/23. This failure could place residents at risk of abuse, fear, and a diminished quality of life. Findings include: Record review of Resident #1's electronic face sheet, dated 11/3/23 revealed she was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses to include anxiety disorder, dementia, and scoliosis (a sideways curve of the spine). Review of Resident #1's progress notes dated 10/28/23, time entered 7:35 AM indicated During incontinence care (of Resident #1) CNA A noted swelling and a bruise to the right brow, the resident is unable to explain what happened, no other injuries were noted, no discomfort or distress is noted, will continue to monitor swelling and bruising. Record review of incident report dated 10/28/23 titled injury of, for Resident #1, prepared by LVN B indicated: During incontinence care, CNA A noted swelling and a bruise to the right brow. Resident unable to give description. No other injuries were noted. During an interview on 11/6/23 at 10:30 PM, LVN B stated that there was an injury located above Resident #1's right eye. She stated that she had no idea how Resident #1 got the bruise. She stated that she increased monitoring of Resident #1 for the rest of her shift and let morning staff know. She stated she put an incident report in the system like she did with every incident. She stated after she inputs an incident, it's up to the Admin to do everything from there. She stated the Admin never came to her to talk with her about the bruise above Resident #1's eye. She stated at the time, there was an agency DON, so she is not sure if the DON even looked at the incident reports. During an interview on 11/3/23 at 11:30 AM, the Admin stated she oversaw and makes sure investigations are done correctly. She stated that she works with the department head to do all investigations. She stated she has no pending investigations going on at this time. During an interview on 11/13/23 at 11:45 AM, the Admin stated that the bruise just looked like a bruise and she did not think anything of it; that was why she did not report. She stated she interviewed the night aide and the night nurse the next day regarding the injury, but she had no documentation of those interviews. She stated she does all investigations and reporting regarding abuse and neglect because she is the abuse/neglect coordinator. Record review of facility's Abuse Investigation and Reporting policy dated 7/2017 indicated: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. 675769 Page 3 of 3