Health inspection·March 22, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority the resident representative(s) when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention for 1 (Resident #1) of 5 residents reviewed for notification of change. The facility failed to: 1. Notify the physician when Resident #1 had a significant change in condition marked by when he suffered an unwitnessed fall out of bed with noted bruising to the left side of his forehead, the top of his head, skin tears to his right earlobe and right elbow, his left elbow had abrasions, and his right toes were bleeding and he complained of pain to his right knee. This resulted in Resident #1 being sent to the ER where he was observed with altered mental status and a large hematoma (a pool of mostly clotted blood that forms in an organ, tissue, or body space) to his face and head but CT negative for subdural hematoma. His mental status did not improve and he was unable to swallow safely. He was not a candidate for BiPAP (Bilevel positive airway pressure). This failure could place residents at risk of not receiving interventions, treatments, and care by recognizing and addressing the physical, mental, and neurological dysfunctions such as altered state of consciousness, nausea, vomiting, cognitive decline, confusion, memory loss, and changes in behavior in an effective and timely manner to prevent residents from further harm or injury. Findings included: Record review of Resident #1's undated face sheet, printed on 03/21/24, revealed that he was a [AGE] year-old male first admitted to the facility on [DATE] with diagnoses that included dementia, dysphagia (difficulty swallowing), cardiomyopathy (disease of the heart muscle), paroxysmal atrial fibrillation (irregular heartbeat), congestive heart failure, PVD (peripheral vascular disease), chronic respiratory failure, chronic kidney disease (stage 3), morbid (severe) obesity and muscle weakness. Record review of Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 12 indicating moderately impaired cognition. In Section G (Functional Abilities and Goals) it stated that Resident #1 was independent to roll left and right, sit to lying and lying to sitting on side of bed. In Section J (Health Conditions) it stated Resident #1 had no falls since admission/entry. Further review revealed that Resident #1 was on continuous oxygen. Under Section K (Swallowing/Nutritional Status) reflected he required a therapeutic diet (diabetic). Page 1 of 6 675797 675797 03/22/2024 Avir at Weston 2505 S 37th St Temple, TX 76504

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's undated care plan revealed Resident #1 was a high risk for falls related to debility (weakness caused by an illness, injury, or aging), weakness, and poor balance with an intervention of be sure Resident #1's call light is within reach and encourage Resident #1 to use it for assistance as needed. Further review revealed Resident #1 had risk for pain related to arthritis/gout with an intervention to monitor/document for side effects of pain medication, observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria (a state of unease or generalized dissatisfaction); nausea; vomiting; dizziness and falls. Report occurrences to the physician. Record review of Resident #1's progress notes on EHR revealed a progress note written by the ADON with an effective date of 03/18/24 at 6:23 pm that stated at 05:40 pm staff was alerted by another resident that Resident #1 had rolled out of bed and is currently laying on the floor. EMS promptly called and requested to respond. Resident #1's bed had been raised back by him to a high position and he rolled out of bed while trying to reach for his white board and marker. Resident #1 was assessed by staff and noted to have a large hematoma to frontal lobe but was bleeding from an area below his right ear, left elbow had abrasions, and right toes were bleeding. Resident was laying prone (lying flat, especially face downward) with his head facing towards his right shoulder. Resident's right leg was bent, and his toes were near the caster (bed frame wheel). Three nurses are with Resident #1 at this time along with two aides. Resident #1 stated he was reaching for his gray pen when he fell out of bed. The Fire Department arrived approximately 10 minutes after EMS to assist with lifting Resident #1 off the floor. There was no mention of the MD being notified. Record review of Resident #1's progress notes on EHR revealed a progress note written by LVN A with an effective date of 03/18/24 at 6:32 pm that stated at 05:37 pm, CNA A alerted I, along with multiple staff members, that Resident #1 had fallen to the floor. Upon entering the room, I witnessed RN A already in the room tending to Resident #1 and assessing his injuries. The ADON along with the HA were in the room as well. Resident #1 was face down and had fallen from his bed. Resident #1 was educated previously that the bed being at its lowest point would be preferred as it is safest for him. RN A informed me upon her assessing Resident #1 there were two large hematomas on his head, and he was complaining of pain all over his body including his ribs. LVN A stated it is also noted that his medication list was checked, and he is currently on 5 mg apixaban (anticoagulant to prevent and treat blood clots). LVN A stated at this time, I decided to call 911 which was at 05:40 pm. LVN A stated she was on the phone with dispatch for 6 minutes giving all the information they required. LVN A stated dispatch informed her not to move the resident until the paramedics arrive. LVN A stated as soon as they gave her this instruction, she informed RN A and the ADON along with the CNA and HA that were in the room not to move Resident #1 at all. There was no mention of the MD being notified. Record review of Resident #1's progress notes on EHR revealed a progress note written by the ADON with an effective date of 03/18/24 at 06:55 pm that stated another resident yelled out that he heard a thump at 05:35 pm. I went to Resident #1's room and he was on the floor on his stomach. Resident #1 was awake, and alert and he stated, I was reaching for the gray pen, and I fell out of bed. Resident #1 has control of the bed remote and had been educated numerous times to keep his bed in a low position and verbalizes understanding, but then puts the bed back into a high position. On arrival to Resident #1's room his respirations were even and slightly labored. I told Resident #1 not to move his neck and keep still until the ambulance arrives. On ambulance arrival, Resident #1 was turned by log roll by paramedics and fire department onto his right side. Resident #1 had two large hematomas. One to the left side of his forehead and another on the top of his head. Resident #1's right earlobe had a laceration, avulsion (the action of pulling or tearing away) to right side of neck, and 675797 Page 2 of 6 675797 03/22/2024 Avir at Weston 2505 S 37th St Temple, TX 76504

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few right elbow with skin tear actively bleeding. Resident #1 stated he was hurting all over. Resident #1 had just returned from the hospital today at 02:45 pm from being admitted for hypoxia (low levels of oxygen in your body tissues, causing confusion, bluish skin, and changes in breathing and heart rate) from 03/11/2024 to 03/18/2024. Resident #1's bilateral legs were wrapped due to mild drainage and him weeping from previous wounds that were still healing. Resident #1 denied pain to his neck and spine when gently palpated. Resident #1's O2 was in place continuously at 4-8 liters. Resident #1 was alert when the ambulance arrived and cooperative. There was no mention of the MD being notified. During an interview on 03/21/24 at 02:55 pm, Resident #2 located kitty corner (diagonally opposite someone or something) to Resident #1's room stated he heard a thump and saw Resident #1 laying on the floor faced down. Resident #2 stated no one was in the room with Resident #1 at the time. Resident #2 stated HA A was in his room delivering dinner and turned around when they heard the noise. Resident #2 stated when the two female paramedics arrived, they had to wait for the Fire Department to assist with picking Resident #1 up off the floor. Resident #2 stated it took about four people to pick Resident #1 up because he is a big guy. During an interview on 03/21/24 at 03:40 pm, Resident #3 stated he was eating supper across the hall in his room. Resident #3 stated he heard a loud noise and heard someone say Resident #1 fell. Resident #3 stated he saw a worker running down the hall. Resident #3 stated he rolled himself into Resident #1's room and asked him if he was alright, and Resident #1 said, Yeah. Resident #3 stated he then rolled back into the hall and hollered for help. Resident #3 stated the ADON was running down the hall. Resident #3 stated Resident #1 was in the room by himself. Resident #3 stated when the nurses arrived at Resident #1's room, he went back to his own room and finished eating his supper and watching television. Resident #3 stated when the paramedics brought Resident #1 out of the room, he had a knot on his head and was bleeding. Resident #3 stated the female paramedics could not pick Resident #1 by themselves and the fire department had to come help pick him up. During an interview on 03/21/24 at 03:50 pm, Resident #1's roommate stated Resident #1 returned from the hospital earlier the same day of the fall on 03/18/24. His roommate stated Resident #1 hardly ever got out of bed and when he did, he would be in his wheelchair. Resident #1's roommate stated when he left out of the room to go to the dining room for dinner, he saw Resident #1 trying to put his feet on the floor and he told him to wait for his dinner. Resident #1's roommate stated when he returned from dinner, Resident #1 was being wheeled out. During an interview on 03/21/24 at 04:05 pm, CNA A stated someone got him and said, Resident #1 fell out of bed. CNA A stated he arrived at the room and the resident was laying on the floor on his stomach. CNA A said he assisted HA A with moving the bed and the wheelchair to allow EMS access to the resident. CNA A said due to there already being enough staff in the room, he left the room and went back to checking on the remaining residents. CNA A stated if a CNA finds a resident on the floor, they are not to move the resident and must report it to the Nurse immediately. CNA A stated with the MD and NP not being notified at that time, or immediately thereafter due to it being an emergency, it would have still been the same outcome due to Resident #1 having to be sent to the ER immediately. During an attempted interview with Shift Key LVN A on 03/21/24 at 05:00 pm, she did not answer, nor respond to surveyor's text message. During an attempted interview with Shift Key RN A on 03/21/24 at 05:10 pm, she did not answer, nor respond to surveyor's text message. 675797 Page 3 of 6 675797 03/22/2024 Avir at Weston 2505 S 37th St Temple, TX 76504

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 03/22/24 at 09:10 am, the ADON stated Resident #1 was alert, oriented and headstrong. The ADON stated Resident #1 knew how he liked things and would figure out how to get it done. The ADON stated she was in her office completing Resident #1's readmission paperwork from the hospital (3/11 thru 3/18). The ADON stated she heard another resident yell, Resident #1 is on the floor, Resident #1 is on the floor. The ADON stated she ran down and saw Resident #1 on the floor. The ADON stated there were three nurses, one Aide and one CNA assisting her. The ADON stated RN A was assessing Resident #1's head and trying to keep him still. The ADON stated the HA and CNA were clearing and moving the furniture out of the way. The ADON stated she was assisting with keeping Resident #1 still. The ADON stated EMS arrived and immediately tried to turn Resident #1 over without assessing him and refused to put a Cervical-Spine Brace on him. The ADON stated she made EMS stop rocking Resident #1 while trying to turn him because he was wedged between the bed and his arm was under him and it was preventing Resident #1 from turning. The ADON stated she instructed EMS on how to turn him while she kept Resident #1 calm. The ADON stated she stood at the foot of the bed while EMS placed an IV in Resident #1's arm and took his blood pressure. The ADON stated the Fire Department had to assist with lifting Resident #1 because EMS did not want the facility staff to assist. The ADON stated it was two EMS and two Firefighters that lifted Resident #1 up and placed him on the gurney. The ADON stated she asked Resident #1 how his bed got up so high and he responded, I keep my bed up high, I like it this way. The ADON stated she asked Resident #1 if he was in pain and he said, Yes. The ADON stated she asked Resident #1 about pain again when EMS arrived and Resident #1 responded, I am hurting all over. The ADON stated Resident #1 stated his ribs hurt and he had a hematoma towards the right side above the brow and one on the top of his head. The ADON stated Resident #1 was bleeding behind his right ear and had an abrasion on the right side of his neck. The ADON stated Resident #1's left shoulder had an abrasion and was bleeding, and his right foot had blood (she was unsure of which toe). The ADON stated Resident #1's body was faced down, but his face was more turned to the left. The ADON stated she asked Resident #1 again what happened, and he said, I was reaching for my silver pen. The ADON stated she notified the DON. The ADON stated she instructed LVN A to notify the Doctor. The ADON stated the worst that could happen when the MD or the NP is not notified, it could lead to a change in condition, change in cognition, delay in care and services, or death. The ADON said basically, you would be delaying the quality of care for the resident. The ADON said where she could have done better was instructed the nurses not to leave the facility until she checked over all their work and made sure everything was followed through. During an interview on 03/22/24 at 10:10 am, the HA A stated she was passing food trays across the hall around 5:30 PM on 03/18/24. HA A stated she knows Resident #1 is bedridden and when she looked in his room, she did not see him in bed. HA A stated she said she did a double-take and saw Resident #1 on the floor. HA A stated she went to Resident #1's room and asked him if he was okay and he said, I just need someone to come and get me off the floor. HA A stated she told Resident #1 to just stay there and then she yelled down the hall and ran and told the ADON that Resident #1 is on the floor bleeding and needs help getting up. HA A stated no one was in Resident #1's room and his roommate was in the dining room. HA A stated it was about five staff members in the room assisting Resident #1 and she was instructed to move the bed and his wheelchair to make room for EMS. HA A stated she was not in the room when EMS arrived. HA A stated she was informed if she ever sees a resident on the floor, to get assistance and do not touch or attempt to move them. HA A stated not notifying the MD he would not know the whereabouts or condition of Resident #1 and it could delay medical interventions when he returns to the facility. During an interview on 03/22/24 at 10:40 am with the NP, she stated she was not notified of 675797 Page 4 of 6 675797 03/22/2024 Avir at Weston 2505 S 37th St Temple, TX 76504

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #1's fall when it occurred, so she does not have a lot of information to provide. The NP stated she was never notified, and she was on-call at that time on 03/18/24 until 7PM. The NP stated she is unsure why they did not call her because typically they do call. The NP stated the chart does not state the facility staff attempted to reach the on-call service. The NP stated they did call EMS, which was the priority. The NP stated if there is an emergent situation going on, they have the staff handle it first if they already know they need to be calling EMS. The NP stated they allow the facility time to deal with that and get the resident situated and transferred. The NP stated if it is not such a critical situation where they can take orders from her or the MD and tend to the resident in the building, they like for them to call them first. The NP stated it depends on the nurse as well and what their experience is because they use a lot of agency staff (temporary workers), and they are not so familiar with the protocols and procedures. The NP stated from reading the notes, it appears the staff was pretty on top of it and thorough with their documentation. During an interview on 03/22/24 at 11:00 am with the MD, he stated he does not recall if he was notified about the fall. The MD stated Resident #1 had just readmitted to the facility that day and was there for less than 3 hours. The MD looked through his messages and stated he did not see where he was notified. The MD stated he was neither notified at the time, nor after the fact. The MD stated his biggest concerns for Resident #1 was his heart failure. The MD stated Resident #1 had a lot of diagnoses in which any one of them could be potentially terminal. The MD stated Resident #1 was on a lot of oxygen and had a lot of issues with fluid retention. The MD stated Resident #1 was going in and out of the hospital with exacerbation of that and had ulcers of the legs. The MD stated Resident #1 had kidney disease, and it was always complicating his treatment for his heart failure. The MD stated per policy, he is normally contacted. The MD stated in this situation, he believes the nurses did the right thing by calling 911 and should not have wasted their time calling him because he would have instructed them to send him out to the ER absolutely. The MD stated especially the fact that Resident #1 was on an anticoagulant with a head injury. The MD stated Resident #1 was really sick and months ago he felt like Resident #1's life expectancy was not that great because of the severity of his medical illnesses. The MD stated Resident #1's fall was pretty tragic, but he was pretty sick and had suffered for a long time. During an interview on 03/22/24 at 11:25 am, the DON stated Resident #1 readmitted to the facility earlier during the day on 03/18/24, and fell around 5:35 PM. The DON stated she was notified by the ADON via phone that Resident #1 fell out of bed. The DON stated her understanding of the policy is you contact the doctor and the NP with any change of conditions. The DON stated during 911 situations, they let the doctor, or the NP know they sent them out to the ER. The DON stated she does not think anything could have been done different to change the outcome. The DON stated she believes the staff acted appropriately under the circumstances. The DON stated nothing would have changed. The DON stated they are going to start in-services on even if it is an emergency, they must still notify After-hours, and the MD or NP the next day. The DON stated the MD, or the NP could not have done anything. The DON stated staff got Resident #1 assessed, called 911 immediately and got him sent out to the hospital immediately. During an interview on 3/22/24 at 11:55 am, the ADM stated Resident #1 had just readmitted to the facility earlier during the day on 03/18/24, from the hospital due to Hypoxia (shortness of breath) and Pneumonia. The ADM stated there were three nurses assisting, and he did not see anything concerning with their actions. The ADM stated Resident #1 was able to explain what had occurred and the injuries were consistent with his fall. The ADM stated they continued to re-educate Resident #1 on keeping his bed in a low position and to use his call light for assistance. The ADM stated it was an emergency, and the best thing was to send Resident out. 675797 Page 5 of 6 675797 03/22/2024 Avir at Weston 2505 S 37th St Temple, TX 76504

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The ADM stated the only thing he could think of is if it were something that could have been prevented by calling the doctor first. The ADM stated policy should have been adhered to and a follow-up with the MD and NP should have occurred. Record review of the hospital paperwork provider notes dated 03/20/24, revealed Resident #1 is a [AGE] year-old male nursing home resident with CAD, CHF (EF 20-25%), AFIB (on Eliquis), PVD, COPD, chronic respiratory failure with hypoxia (on 4L oxygen), HTN, CKD3, OSA, history of stroke, chronic venous stasis, and chronic descending aortic dissection who was brought to the ED from the nursing home for unwitnessed fall with altered mental status. He sustained a large hematoma to his face and head, but CT was negative for SDH. Record review of the undated Change of Condition Reporting Policy revealed, When to report to MD/NP/PA: Immediate Notification Any symptom, sign or apparent discomfort that is: o Acute or Sudden in onset, and: o A Marked change (i.e., more severe) in relation to usual symptoms and signs, or o Unrelieved by measures already prescribed 675797 Page 6 of 6