Health inspection·September 11, 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 observations, interviews, and record reviews, the facility failed to notify local authorities of a suspicious injury for 1 of 1 resident reviewed for injuries of unknown origin in that: Residents Affected - Few Resident #1 had an injury of unknown origin The facility failed to implement their policy by not reporting suspicions of abuse for a resident with injuries of unknown source. This failure could place residents at risk for potential criminal activity without consequences The findings included: A record review of Resident #31's face sheet dated 08/30/21 revealed an original admission date of 08/30/21 with diagnoses including COPD, Respiratory failure with hypoxia, emphysema, anxiety, immunodeficiency, heart failure, falls, muscle wasting and weakness, and osteoporosis. A record review of Resident #1's MDS dated [DATE] documented a BIMS of 12, indicating moderate cognitive impairment. A record review of Resident #1's care plan dated 08/31/21 documented the risk for bruising related to the use of anticoagulants with an initiation date of 09/02/23. Resident #1 had a risk for falls related to a history of falls created on 08/31/21. Resident #1 had a terminal condition and was placed on hospice care on with an initiation date of 08/27/21. A record review of the facility provider investigation summary and conclusion dated 09/08/23 revealed the morning of 09/02/23 Resident #1 was interviewed and could not recall how the raised area to her head and discoloration occurred. Resident #1 denied being struck on the head or any additional falls. Resident #1 was on Plavix & aspirin and the size of the discoloration could have been exacerbated as a result of the anticoagulant properties of these medications. Resident #1 also had episodes of confusion due to chronic respiratory failure, COPD, and emphysema which contribute to low oxygen saturation levels, along with compliance with oxygen use per nasal cannula. The facility was unable to definitively determine the cause of the discoloration of Resident #1's arm/eye/raised area to the forehead but Resident #1 likely hit her head on the enabler bar that was recently attached to her bed by hospice and subsequently removed by hospice for a smaller one. A record review of the nurse's notes dated 03/06/23 to 09/07/23 documented that Resident #1 had multiple falls due to self-transfers. Page 1 of 2 675850 675850 09/11/2023 Avir at Portland 221 Cedar Dr Portland, TX 78374

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An observation of Resident #1 on 09/08/23 at 8:05 am revealed a frail, small female with oxygen on and sitting on the bedside feeding herself. There was bruising to Resident #1's face with bilateral black eyes and bruising across the bridge of the nose. Resident #1 was alert and oriented and did not know how she attained the bruising to her face. There was a fall mat next to her bed, she wore non-skid socks, and the bed was in its lowest position with a scoop mattress. Her room was neat and tidy without obstructions. There was a sign on her wall reminding her to call for assistance when getting out of bed. Interviews with the ADON and DON on 09/06/23 at 11:40 am stated the LVN A caring for her saw no bruising on the night of 09/01/23, then saw a bump on Resident #1's right forehead the morning of 09/02/23. A telephone interview with the HOS on 09/06/23 from 3:42 pm to 4:18 pm revealed she spoke with the ADM regarding the unknown injury to Resident #1 and was prompted to report to the state after speaking with their corporate nurse because the bruising to Resident #1's face was of an unknown origin. The HOS stated everything changed over the last week or so, (meaning the resident was more paranoid, confused, hallucinating, and was more agitated) and hospice thought Resident #1 may have been transitioning (meaning near death). The HOS stated she did not think the facility was at fault, and that maybe Resident #1 rolled herself into the side rail. An interview with the LVN A on 09/07/23 at 7:25 a.m. revealed she initially saw Resident #1 on 09/01/23 around 11:00 p.m. and did not notice any bruising. The LVN A stated around 6:00 am on 09/02/23, she saw a bump on Resident #1's right forehead but no discoloration to the right eye, and she notified Hospice and the DON. LVN A stated Resident #1 could not recall how the raised area to her head and discoloration occurred and denied being struck on the head or any additional falls. An interview with the ADM on 09/08/23 at 8:35 a.m. revealed he did not call local authorities regarding the suspicious injury on Resident #1's head. The ADM stated he did not call the local authorities because he did not think he needed to. Record review of the facility policy titled Abuse Guidelines: Preventing, Identifying, and Reporting on page 3 under Reporting Allegations or Suspicions of Abuse: Allegations of, or incidents of, or suspicions of abuse or neglect are reportable to state and local authorities .Local and/or state authorities should be notified of reports of abuse described above which alleges that: 5. A resident has suffered bodily injury, because of alleged or suspicion of abuse or neglect. Page 6, Definitions: Injuries of unknown source- An injury should be classified as an injury of unknown source when all the following criteria are met: The source of the injury was not observed by any person .could not be explained by the resident, and the injury is suspicious . 675850 Page 2 of 2