Health inspection·August 3, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement written policies and procedures that Prohibit and prevent abuse for 1 of 5 Residents (Resident #1) whose record were revived for abuse. Residents Affected - Few The facility failed to report an allegation of abuse involving Resident #1 within 2 hours per HHSC regulation. This deficient practice could affect any resident and contribute to further abuse. The findings were: Review of Resident #1's admission, dated [DATE], revealed he was admitted to the facility on [DATE] with diagnoses including UTI (A urinary tract infection is an infection that affects part of the urinary tract.), Major Depressive Disorder (clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems) and Anxiety Disorder (the mind and body's reaction to stressful, dangerous, or unfamiliar situations. It's the sense of uneasiness, distress, or dread you feel before a significant event). Review of Resident #1's quarterly MDS assessment dated , [DATE], revealed his BIMS was 6 out of 15 indicative of severe cognitive impairment. Review of incident report, dated [DATE], documented at 04:03 AM by RN A revealed Resident #1 was noted with 2 large bumps to right side of his forehead. Resident #1 reported he was hit on the head by an English speaking male and it happened earlier in the day at4 PM per RN A. Review of Provider Investigation Report, dated [DATE] and written by the ADM, revealed the allegation of abuse involving Resident #1 was reported to the ADM on [DATE] at 8 AM. Observation and attempted interview on [DATE] at 1:45 PM revealed Resident #1 was lying down in bed fully dressed. Attempted interview revealed Resident #1 was confused and in-coherent. He was not interviewable. Interview on [DATE] at 3:20 PM with the ADM revealed she was the abuse coordinator and she reported all allegations of abuse/neglect. She stated Resident #1 was very confused and his story changed about how he got the red marks/bumps on his forehead. She stated she was not sure who exactly told her about Resident #1's injuries but thought it was the morning nurse who told her at about 8 AM. She stated she reported it to HHSC soon afterwards. The ADM reviewed RN A's statement, dated [DATE], documented at 04:03 AM by RN A, which stated she noted the 2 bumps and red marks on Resident #1 during Page 1 of 6 675800 675800 08/03/2023 LA Vida Serena Nursing and Rehabilitation 711 Kings Way Del Rio, TX 78840

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her last round. The ADM stated the allegation was not reportable right away because she had to determine whether or not abuse happened. After discussing the federal regulation and after reading the facility policy it clearly stated an allegation of abuse should be reported within 2 hours. The ADM read RN A's statement again and stated yes it was an allegation of abuse and it should have been reported within 2 hours. Telephone interview on [DATE] at 3:51 PM with RN A revealed she had worked the night shift as of [DATE]. Her statement, dated [DATE] was read to RN A and she stated she remembered the injuries on Resident #1. RN A stated Resident #1 first said he did not know what happened but then stated a big white man hit him. RN A believed she told the previous DON, and remembered taking a picture of Resident #1 and sending it to the DON. RN A stated she did not tell the ADM. RN A stated she was uncertain how soon she should have reported the incident to her immediate supervisor who was the DON. She stated she did not know the time frame the facility had to report the allegation of abuse to HHSC. However, commented she thought it was probably immediately. RN A stated she did not report Resident #1's allegation of abuse to the DON right away. RN A further stated she completed abuse training when she was first hired but did not remember anything afterwards. Interview on [DATE] at 4:50 PM with the DON revealed RN A called her about Resident #1 injuries after 6 AM as RN A was ending her shift. The DON stated she called the ADM right after and told the ADM about the injuries. The DON stated RN A should have reported the allegation of abuse immediately to her and or the ADM. The DON stated an allegation of abuse should be reported immediately per facility policy. She stated she did not in-service RN A about the timeframe for reporting an allegation of abuse. The DON stated she provided abuse/neglect training before assuming her current position. Review of facility policy, Abuse/Neglect, revised [DATE], read: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. 1. Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. E. Reporting 3. Facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report the allegation to HHSC. a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. 675800 Page 2 of 6 675800 08/03/2023 LA Vida Serena Nursing and Rehabilitation 711 Kings Way Del Rio, TX 78840

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 observation, interview and record review the facility failed to ensure in response to allegations of abuse, that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made for 1 of 5 Residents (Resident #1) whose records were revived for abuse. The facility failed to report an allegation of abuse involving Resident #1 within 2 hours per HHSC regulation. This deficient practice could affect any resident and contribute to further abuse. The findings were: Review of facility policy, Abuse/Neglect, revised [DATE], read: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. 1. Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. E. Reporting 3. Facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report the allegation to HHSC. a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. Review of Resident #1's admission, dated [DATE], revealed he was admitted to the facility on [DATE] with diagnoses including UTI (A urinary tract infection is an infection that affects part of the urinary tract.), Major Depressive Disorder (clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems) and Anxiety Disorder (the mind and body's reaction to stressful, dangerous, or unfamiliar situations. It's the sense of uneasiness, distress, or dread you feel before a significant event). Review of Resident #1's quarterly MDS assessment dated , [DATE], revealed his BIMS was 6 out of 15 indicative of severe cognitive impairment. Review of incident report, dated [DATE], documented at 04:03 AM by RN A revealed Resident #1 was noted with 2 large bumps to right side of his forehead. Resident #1 reported he was hit on the head by an English speaking male and it happened earlier in the day at4 PM per RN A. Review of Provider Investigation Report, dated [DATE] and written by the ADM, revealed the allegation of abuse involving Resident #1 was reported to the ADM on [DATE] at 8 AM. Observation and attempted interview on [DATE] at 1:45 PM revealed Resident #1 was lying down in bed fully dressed. Attempted interview revealed Resident #1 was confused and in-coherent. He was not interviewable. Interview on [DATE] at 3:20 PM with the ADM revealed she was the abuse coordinator and she reported all allegations of abuse/neglect. She stated Resident #1 was very confused and his story changed about how he got the red marks/bumps on his forehead. She stated she was not sure who exactly told her about Resident #1's injuries but thought it was the morning nurse who told her at about 8 AM. She 675800 Page 3 of 6 675800 08/03/2023 LA Vida Serena Nursing and Rehabilitation 711 Kings Way Del Rio, TX 78840

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated she reported it to HHSC soon afterwards. The ADM reviewed RN A's statement, dated [DATE], documented at 04:03 AM by RN A, which stated she noted the 2 bumps and red marks on Resident #1 during her last round. The ADM stated the allegation was not reportable right away because she had to determine whether or not abuse happened. After discussing the federal regulation and after reading the facility policy it clearly stated an allegation of abuse should be reported within 2 hours. The ADM read RN A's statement again and stated yes it was an allegation of abuse and it should have been reported within 2 hours. Telephone interview on [DATE] at 3:51 PM with RN A revealed she had worked the night shift as of [DATE]. Her statement, dated [DATE] was read to RN A and she stated she remembered the injuries on Resident #1. RN A stated Resident #1 first said he did not know what happened but then stated a big white man hit him. RN A believed she told the previous DON, and remembered taking a picture of Resident #1 and sending it to the DON. RN A stated she did not tell the ADM. RN A stated she was uncertain how soon she should have reported the incident to her immediate supervisor who was the DON. She stated she did not know the time frame the facility had to report the allegation of abuse to HHSC. However, commented she thought it was probably immediately. RN A stated she did not report Resident #1's allegation of abuse to the DON right away. RN A further stated she completed abuse training when she was first hired but did not remember anything afterwards. Interview on [DATE] at 4:50 PM with the DON revealed RN A called her about Resident #1 injuries after 6 AM as RN A was ending her shift. The DON stated she called the ADM right after and told the ADM about the injuries. The DON stated RN A should have reported the allegation of abuse immediately to her and or the ADM. The DON stated an allegation of abuse should be reported immediately per facility policy. She stated she did not in-service RN A about the timeframe for reporting an allegation of abuse. The DON stated she provided abuse/neglect training before assuming her current position. 675800 Page 4 of 6 675800 08/03/2023 LA Vida Serena Nursing and Rehabilitation 711 Kings Way Del Rio, TX 78840

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain clinical records that were complete and/or accurate for 3 of 6 (Resident #2, Resident #3, and Resident #4) residents reviewed for clinical records in that: Resident #2, Resident #3 & Resident #4 did not have a discharge summary sheet signed by their physician. This deficient practice could place residents at risk for not getting the required documentation to facilitate a proper discharge. The findings were: 1. Review of Resident #2's face sheet, dated 8/3/23, revealed he was admitted to the facility on [DATE] with diagnosis including unspecified fracture of right femur (breakage of a thigh bone). Further review revealed Resident #2 was discharged on 5/30/23. Review of Resident #2's electronic record revealed a Discharge summary, dated [DATE], revealed Resident #2 was discharged to the hospital. Further review revealed the physician did not sign the discharge summary. Interview on 8/3/23 at 2:30 PM with Medical Records revealed she stated the MD did not sign Resident #2's discharge summary. She stated she did not know when the MD should sign it after discharge. Interview on 8/3/23 at 2:45 PM with the ADM revealed she thought the physician should sign the discharge summary within 30 days after resident discharge. She reviewed Resident #2's discharge summary and stated the physician did not date it and she would not know when he signed it. The ADM stated Medical Records was responsible for ensuring the physician signed the residents discharge summary. 2. Review of Resident #3's face sheet, dated 8/3/23, revealed she was admitted to the facility on [DATE] with diagnosis including COVID-19. Further review revealed Resident #3 was discharged on 1/13/23. Review of Resident #3's electronic record revealed a Discharge summary, dated [DATE], revealed the resident was discharged to another facility. Further review revealed the physician did not sign the discharge summary. Interview on 8/3/23 at 2:30 PM with Medical Records revealed she stated the MD did not sign Resident #3's discharge summary. She stated she did not know when the MD should sign it after discharge. Interview on 8/3/23 at 2:45 PM with the ADM revealed she thought the physician should sign the discharge summary within 30 days after resident discharge. She reviewed Resident #3's discharge summary and stated the physician did not sign it. The ADM stated Medical Records was responsible for ensuring the physician signed the residents discharge summary. 3. Review of Resident #4's face sheet, dated 8/3/23, revealed he was admitted to the facility on [DATE] with diagnosis including unspecified Dementia, unspecified severity with behavioral 675800 Page 5 of 6 675800 08/03/2023 LA Vida Serena Nursing and Rehabilitation 711 Kings Way Del Rio, TX 78840

F 0842 disturbance. Further review revealed Resident #4 was discharged on 12/6/22. Level of Harm - Minimal harm or potential for actual harm Review of Resident #4's electronic record revealed a Discharge summary, dated [DATE], revealed Resident #4 was discharged to the hospital on [DATE]. Further review revealed the physician did not sign the discharge summary. Residents Affected - Some Interview on 8/3/23 at 2:30 PM with Medical Records revealed she would complete the discharge form and then the physician would sign it while making rounds at the facility. She stated she did not know when he should sign it after discharge. Interview on 8/3/23 at 2:45 PM with the ADM revealed she thought the physician should sign the discharge summary within 30 days after resident discharge. She reviewed Resident #4's discharge summary and stated the physician did not sign it. The ADM stated Medical Records was responsible for ensuring the physician signed the residents discharge summary. Review of facility policy titled, Discharge Summary/Discharge Plan, dated December 2015, read: The entire discharge summary will be completed with each resident that discharges regardless of where they discharge to, or if they expire in house. For electronic discharge summaries, once completed, the DC summary will be printed on blue paper, a white copy made to be placed in the medical record and the original will be sent out for physician's signature. The white copy will remain in place until the signed original returns. 675800 Page 6 of 6