Health inspection·October 9, 2023

F 0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. 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 nursing staff failed to immediately notify the physician of a significant change in the resident's physical status for 1 of 2 residents reviewed for an unknown injury (Resident #2) LVN B and RN A failed to immediately notify Residents' Physician when a large bruise was discovered on his ankle, which was discovered to be a fracture. This failure may have resulted in Resident #2 experiencing pain from a fracture for 4-5 days. Findings included: Review of the face sheet for Resident #2's revealed he was a [AGE] year-old male initially admitted on [DATE], latest readmission on [DATE]. Resident #2 diagnoses include osteoporosis (fragile bones), repeated falls, cerebral palsy (impaired muscle coordination), and cognitive communication deficit. Review of the Annual Minimum Data Set (MDS) for Resident #2's, dated 7/12/23, revealed a Brief Interview for Mental Status (BIMS) score was not assessed due to Resident #2 being rarely/never understood. Review of Resident #2's Care Plan, initiated 6/8/2019, revealed the following focus: The resident has a Hx (history) of bone fracture to lower end of R (right) femur and has an old Fx (fracture) to R tibia (lower leg bone) r/t (related to) Osteoporosis. The focus was last updated on 10/07/2020. The interventions listed for the focus area include monitoring, documenting, and reporting as needed for edema, bruising/discoloration of skin, skin temperature changes and loss of sensation below fracture. Review of a Skin Observation Tools for Resident #2 dated 9/30/23, revealed the treatment nurse (RN A) documented a bruise to the right ankle. Continued review of the tool revealed the sections designated to size measurement were blank. Review of the Facility Incident Reports from 7/1/2023 through 10/7/2023 revealed on 10/4/23 a report written by LVN A indicated that Resident #2 had approached the nurse after breakfast at 0800, pointing to his right lower extremity (RLE) (Resident is nonverbal). Upon inspection, nurse noticed bruise to Tib/Fib area. When asked if he was experiencing pain? Resident #2 shook his head no. When asked by LVN A if he had fallen? Patient shook his head no. Resident #2's RP and NP were notified. STAT Page 1 of 12 676026 676026 10/09/2023 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0580 x-ray was ordered by nurse. Level of Harm - Actual harm Review of a Radiology Report dated 10/4/23. Reason for exam Contusion of right ankle, initial encounter, contusion of right lower leg. Results: There is diffused bone demineralization. There is an impacted fracture deformity involving the medial malleolus (ankle) without callus (healing tissue around fracture). Distal fibula ( 2nd lower leg bone) appears grossly intact as visualized on this limited positioned exam. Residents Affected - Few Review of Resident #2's Nursing Notes from 9/29/23 thru 10/7/23 revealed no mention of a bruise to Resident #2's ankle until 10/4/23. LVN A documented at 9:57 am the following: Resident approached nurse after breakfast at 0800, pointing at his RLE (Resident nonverbal). Upon inspection, nurse noticed bruise to Tib/Fib area. When patient was asked if he was experiencing pain? Patient shook his head no. When asked by nurse if he had fallen? Patient shook his head no. V/S 128/54, 62, 17, 97.2. RP, NP notified. STAT x-ray was ordered by nurse. Review of Resident #2's hospital records revealed an Attestation by MD on 10/6/2023 at 7:12am. Impression Right minimally displaced distal tibia/fibula fracture in non-ambulator. Plan: No surgery indicated. The fracture will be treated in a closed manner. X ray imaging results noted a evaluation is significantly limited due to severe osteopenia (reduced bone mass). Review of Resident #2's Treatment Administration Record for the month of September 2023 revealed there is no mention of bruise to ankle. Continued review of October 2023 TAR revealed an order dated 9/30/2023 to, Monitor bruising to right ankle for any changes until resolved every day shift. On 10/1 through 10/4 there are initials of RN A indicating monitoring took place. Interview on 10/7/23 at 12:46pm Resident #2's Responsible Party (RP) stated he was informed by the facility of the injury. He did not know how it happened but realized that the day before he had been notified of the fracture, he had visited Resident #2 to feed him lunch. The RP stated during that visit Resident #2 kept pointing to his right leg. The RP stated Resident #2 does do pointing frequently, so that does not always indicate an injury, but he wonders how long the injury was there before they found it. The RP stated that Resident #2 did not act like he was in pain during his visit, but he usually does not indicate pain. The RP stated there is a history of fractures as Resident #2 has weak bones. Interview on 10/7/23 at 11:07 am with LVN A revealed that on 10/4/23 he noticed that Resident #2 pointed to his right leg while he was talking to him. LVN A stated he lifted Resident #2's pant leg and noticed a bruise that he had not been aware of. LVN A stated he is aware that Resident #2 has a history of brittle bones and fractures, so he notified the NP got orders for a STAT X-ray and notified Resident #2's RP. LVN A stated the bruise was purple and reddish, so it was not an old bruise. The X-rays showed a fracture and Resident #2 had sent to the hospital and is still there. Interview on 10/7/23 at 4:20pm with LVN B revealed she was the Charge Nurse on 9/30/23 when a CNA asked her if she knew about a bruise on Resident #2 . LVN B stated at the same time she was walking in Resident #2's room RN A, who is the Treatment Nurse was coming into the same room. LVN B stated that RN A told her she would assess the bruise. LVN B stated she asked Resident #2 if he was in pain, and he said no. She noticed an approximately one-inch bruise on the side of Resident #2's foot but was not able to remember all the details about it because she left it to RN A to assess. LVN B stated 676026 Page 2 of 12 676026 10/09/2023 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0580 RN A told her she had added monitoring to the Treatment Administration Record to occur daily . LVN B stated she had not asked RN A if she notified the doctor of the injury. Level of Harm - Actual harm Residents Affected - Few Interview on 10/9/23 at 9:30am with RN A Treatment Facility Nurse, revealed on 9/30 she had put in a standing order to monitor Resident #2's bruise. RN A stated she saw the bruise on Friday the 29th of September. RN A stated on that Friday, the charge nurse (LVN B) called me over and asked if I had seen the bruise on Resident #2's ankle. RN A stated she had not seen the bruise before LVN B pointed it out. RN A stated she did not measure the bruise but did make a Skin Tool note on 9/30/23, the day after seeing the bruise and put an order in to monitor. RN A confirmed she did not know the cause of the bruise . RN A confirmed she had not notified the Nurse Practitioner (NP) or Doctor of the bruise. RN A stated she had received counseling from the DON and realizes she should have measured and described the bruise, made an IR, called the doctor and RP. RN A stated she had assumed at the time that LVN B was notifying the doctor and documenting in the progress notes. She stated she should not have made that assumption. When asked if she could estimate the size or show with her hands, RN A placed her hands fingertip to fingertip and held her hands apart to make a circular shape. She stated it was right over Resident #2's right ankle. When asked if the area she was making with her hands was about 4-5 inches she confirmed it was. RN A stated it was a significant injury. She stated she does not know if the bruise was related to the fracture but at the time she saw it, she asked Resident #2 if he was in pain, and he indicated he was not. RN A stated the area was not swollen. Interview on 10/7/23 at 10:58 am CNA C revealed she has worked at the facility for 4 years. She stated she works with Resident #2 frequently. CNA C revealed he is a two person transfer but there are times that he will get out of his low bed by himself because he wants to play by with his toys. CNA C stated Resident #2 is nonverbal, but he can make is needs known with pointing and grunting. She stated she became aware of the fracture on 10/4/23, when x-rays were taken and that prior to that Resident #2 had not complained of pain. Interview on 10/7/23 at 11:55 am with CNA D, she stated she has worked with Resident #2 for a little over a year. CNA D stated that she has not worked on Resident #2's hall in a while but she does still see him in the halls. CNA D stated the day before the fracture was found Resident #2 had passed her as he was going to an activity. CNA D stated Resident #2 was pointing to his right leg area, so she touched his foot and said here? Resident #2 shook his head yes and she thought he wanted her to scratch him because of itching like he usually does she stated she scratched his foot and asked him all better and he said yes. CNA D stated he did not indicate he was in pain; she did not see a bruise and that in the past he has indicated pain by making an ow ow sound, but he had not done that. Interview on 10/7/23 at 3:40 pm, the Facility DON revealed she had thought Resident #2's injury was first recognized on 10/4/23 when the LVN A discovered it and got orders for an x-ray. She stated she asked several staff to write out statements for an investigation into the injury of unknown origins. RN A who is the Facility Treatment Nurse, wrote that she had seen a bruise on 9/29/23 after the Charge Nurse (LVN B) had pointed it out to her. The DON stated that neither RN A or LVN B reported the injury to her, the Doctor or the NP as was expected. The DON confirmed that there also was no size of the bruise documented as it should have been on 9/29/23 . The DON stated that the statement by RN A was written on 10/6/23 and that is when she found out it was either the same bruise where the fracture is or another. On 10/9/23 at 9:15am the DON reported that she had written disciplinary actions for LVN B and RN A due to their failure to report the bruise to the NP or Doctor. She stated that she had spoken to both and the verbal descriptions, although described in different but similar areas on Resident #2, by the two different nurses, indicate a significant injury which is supposed to be reported. 676026 Page 3 of 12 676026 10/09/2023 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0580 Level of Harm - Actual harm Interview on 10/9/23 at 11:08am with the Facility NP revealed she had been notified for the first time of Resident #2's injury/bruise on 10/4/23 when LVN A reported the need for x-rays. The NP stated that she should have been notified of the bruise that was found on 9/29/23 or 9/30 but was not. She stated Resident #2 has osteoporosis, so his bones are dry. Residents Affected - Few Review of the Facilities Policies and Procedures revealed a policy titled Change in Resident's Condition or Status, revised 2/2021, includes on pg 1, #1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discovery of injuries of unknown source. Continued review revealed an Abuse policy, revised 12/2009, contained a section titled Investigating Unexplained Injuries, which includes a policy statement: An investigation of all unexplained injuries (including bruises, abrasions and injuries of unknown source) will be conducted by the Director of Nursing Services, and/or other individual appointed by the Administrator, to ensure that the safety of our residents has not been jeopardized. Policy Interpretation and Implementation, #1. includes the Nurse Supervisor on duty must complete an accident/incident form and record such information into the resident's clinical record. 676026 Page 4 of 12 676026 10/09/2023 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to report to the administrator and/or designee, physician, and failed to investigate an injury of unknown source for 1 of 2 (Resident #2) reviewed for incident reporting. Residents Affected - Few LVN B and RN A failed to reported an injury of unknown origins on Resident #2 to the Nurse Practitioner or Doctor, to receive orders of care. This failure could place residents at risk of a delay in needed treatment. Findings included: Review of the face sheet for Resident #2's revealed he was a [AGE] year-old male initially admitted on [DATE], latest readmission on [DATE]. Resident #2 diagnoses include osteoporosis (fragile bones), repeated falls, cerebral palsy (impaired muscle coordination), and cognitive communication deficit. Review of the Annual Minimum Data Set (MDS) for Resident #2's, dated 7/12/23, revealed a Brief Interview for Mental Status (BIMS) score was not assessed due to Resident #2 being rarely/never understood. Review of Resident #2's Care Plan, initiated 6/8/2019, revealed the following focus: The resident has a Hx (history) of bone fracture to lower end of R (right) femur and has an old Fx (fracture) to R tibia (lower leg bone) r/t (related to) Osteoporosis. The focus was last updated on 10/07/2020. The interventions listed for the focus area include monitoring, documenting, and reporting as needed for edema, bruising/discoloration of skin, skin temperature changes and loss of sensation below fracture. Review of a Skin Observation Tools for Resident #2 dated 9/30/23, revealed the treatment nurse (RN A) documented a bruise to the right ankle. Continued review of the tool revealed the sections designated to size measurement were blank. Review of the Facility Incident Reports from 7/1/2023 through 10/7/2023 revealed on 10/4/23 a report written by LVN A indicated that Resident #2 had approached the nurse after breakfast at 0800, pointing to his right lower extremity (RLE) (Resident is nonverbal). Upon inspection, nurse noticed bruise to Tib/Fib area. When asked if he was experiencing pain? Resident #2 shook his head no. When asked by LVN A if he had fallen? Patient shook his head no. Resident #2's RP and NP were notified. STAT x-ray was ordered by nurse. Review of a Radiology Report dated 10/4/23. Reason for exam Contusion of right ankle, initial encounter, contusion of right lower leg. Results: There is diffused bone demineralization. There is an impacted fracture deformity involving the medial malleolus (ankle) without callus (healing tissue around fracture). Distal fibula ( 2nd lower leg bone) appears grossly intact as visualized on this limited positioned exam. Review of Resident #2's Nursing Notes from 9/29/23 thru 10/7/23 revealed no mention of a bruise to Resident #2's ankle until 10/4/23. LVN A documented at 9:57 am the following: Resident approached 676026 Page 5 of 12 676026 10/09/2023 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0607 Level of Harm - Actual harm nurse after breakfast at 0800, pointing at his RLE (Resident nonverbal). Upon inspection, nurse noticed bruise to Tib/Fib area. When patient was asked if he was experiencing pain? Patient shook his head no. When asked by nurse if he had fallen? Patient shook his head no. V/S 128/54, 62, 17, 97.2. RP, NP notified. STAT x-ray was ordered by nurse. Residents Affected - Few Review of Resident #2's hospital records revealed an Attestation by MD on 10/6/2023 at 7:12am. Impression Right minimally displaced distal tibia/fibula fracture in non-ambulator. Plan: No surgery indicated. The fracture will be treated in a closed manner. X ray imaging results noted a evaluation is significantly limited due to severe osteopenia (reduced bone mass). Review of Resident #2's Treatment Administration Record for the month of September 2023 revealed there is no mention of bruise to ankle. Continued review of October 2023 TAR revealed an order dated 9/30/2023 to, Monitor bruising to right ankle for any changes until resolved every day shift. On 10/1 through 10/4 there are initials of RN A indicating monitoring took place. Interview on 10/7/23 at 12:46pm Resident #2's Responsible Party (RP) stated he was informed by the facility of the injury. He did not know how it happened but realized that the day before he had been notified of the fracture, he had visited Resident #2 to feed him lunch. The RP stated during that visit Resident #2 kept pointing to his right leg. The RP stated Resident #2 does do pointing frequently, so that does not always indicate an injury, but he wonders how long the injury was there before they found it. The RP stated that Resident #2 did not act like he was in pain during his visit, but he usually does not indicate pain. The RP stated there is a history of fractures as Resident #2 has weak bones. Interview on 10/7/23 at 11:07 am with LVN A revealed that on 10/4/23 he noticed that Resident #2 pointed to his right leg while he was talking to him. LVN A stated he lifted Resident #2's pant leg and noticed a bruise that he had not been aware of. LVN A stated he is aware that Resident #2 has a history of brittle bones and fractures, so he notified the NP got orders for a STAT X-ray and notified Resident #2's RP. LVN A stated the bruise was purple and reddish, so it was not an old bruise. The X-rays showed a fracture and Resident #2 had sent to the hospital and is still there. Interview on 10/7/23 at 4:20pm with LVN B revealed she was the Charge Nurse on 9/30/23 when a CNA asked her if she knew about a bruise on Resident #2 . LVN B stated at the same time she was walking in Resident #2's room RN A, who is the Treatment Nurse was coming into the same room. LVN B stated that RN A told her she would assess the bruise. LVN B stated she asked Resident #2 if he was in pain, and he said no. She noticed an approximately one-inch bruise on the side of Resident #2's foot but was not able to remember all the details about it because she left it to RN A to assess. LVN B stated RN A told her she had added monitoring to the Treatment Administration Record to occur daily . LVN B stated she had not asked RN A if she notified the doctor of the injury. Interview on 10/9/23 at 9:30am with RN A Treatment Facility Nurse, revealed on 9/30 she had put in a standing order to monitor Resident #2's bruise. RN A stated she saw the bruise on Friday the 29th of September. RN A stated on that Friday, the charge nurse (LVN B) called me over and asked if I had seen the bruise on Resident #2's ankle. RN A stated she had not seen the bruise before LVN B pointed it out. RN A stated she did not measure the bruise but did make a Skin Tool note on 9/30/23, the day after seeing the bruise and put an order in to monitor. RN A confirmed she did not know the cause of the bruise . RN A confirmed she had not notified the Nurse Practitioner (NP) or Doctor of the 676026 Page 6 of 12 676026 10/09/2023 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0607 Level of Harm - Actual harm Residents Affected - Few bruise. RN A stated she had received counseling from the DON and realizes she should have measured and described the bruise, made an IR, called the doctor and RP. RN A stated she had assumed at the time that LVN B was notifying the doctor and documenting in the progress notes. She stated she should not have made that assumption. When asked if she could estimate the size or show with her hands, RN A placed her hands fingertip to fingertip and held her hands apart to make a circular shape. She stated it was right over Resident #2's right ankle. When asked if the area she was making with her hands was about 4-5 inches she confirmed it was. RN A stated it was a significant injury. She stated she does not know if the bruise was related to the fracture but at the time she saw it, she asked Resident #2 if he was in pain, and he indicated he was not. RN A stated the area was not swollen. Interview on 10/7/23 at 10:58 am CNA C revealed she has worked at the facility for 4 years. She stated she works with Resident #2 frequently. CNA C revealed he is a two person transfer but there are times that he will get out of his low bed by himself because he wants to play by with his toys. CNA C stated Resident #2 is nonverbal, but he can make is needs known with pointing and grunting. She stated she became aware of the fracture on 10/4/23, when x-rays were taken and that prior to that Resident #2 had not complained of pain. Interview on 10/7/23 at 11:55 am with CNA D, she stated she has worked with Resident #2 for a little over a year. CNA D stated that she has not worked on Resident #2's hall in a while but she does still see him in the halls. CNA D stated the day before the fracture was found Resident #2 had passed her as he was going to an activity. CNA D stated Resident #2 was pointing to his right leg area, so she touched his foot and said here? Resident #2 shook his head yes and she thought he wanted her to scratch him because of itching like he usually does she stated she scratched his foot and asked him all better and he said yes. CNA D stated he did not indicate he was in pain; she did not see a bruise and that in the past he has indicated pain by making an ow ow sound, but he had not done that. Interview on 10/7/23 at 3:40 pm, the Facility DON revealed she had thought Resident #2's injury was first recognized on 10/4/23 when the LVN A discovered it and got orders for an x-ray. She stated she asked several staff to write out statements for an investigation into the injury of unknown origins. RN A who is the Facility Treatment Nurse, wrote that she had seen a bruise on 9/29/23 after the Charge Nurse (LVN B) had pointed it out to her. The DON stated that neither RN A or LVN B reported the injury to her, the Doctor or the NP as was expected. The DON confirmed that there also was no size of the bruise documented as it should have been on 9/29/23 . The DON stated that the statement by RN A was written on 10/6/23 and that is when she found out it was either the same bruise where the fracture is or another. On 10/9/23 at 9:15am the DON reported that she had written disciplinary actions for LVN B and RN A due to their failure to report the bruise to the NP or Doctor. She stated that she had spoken to both and the verbal descriptions, although described in different but similar areas on Resident #2, by the two different nurses, indicate a significant injury which is supposed to be reported. Interview on 10/9/23 at 11:08am with the Facility NP revealed she had been notified for the first time of Resident #2's injury/bruise on 10/4/23 when LVN A reported the need for x-rays. The NP stated that she should have been notified of the bruise that was found on 9/29/23 or 9/30 but was not. She stated Resident #2 has osteoporosis, so his bones are dry. Review of the Facilities Policies and Procedures revealed a policy titled Change in Resident's Condition or Status, revised 2/2021, includes on pg 1, #1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discovery of injuries of unknown source. 676026 Page 7 of 12 676026 10/09/2023 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0607 Level of Harm - Actual harm Residents Affected - Few Continued review revealed an Abuse policy, revised 12/2009, contained a section titled Investigating Unexplained Injuries, which includes a policy statement: An investigation of all unexplained injuries (including bruises, abrasions and injuries of unknown source) will be conducted by the Director of Nursing Services, and/or other individual appointed by the Administrator, to ensure that the safety of our residents has not been jeopardized. Policy Interpretation and Implementation, #1. includes the Nurse Supervisor on duty must complete an accident/incident form and record such information into the resident's clinical record. #2. Injury of unknown source is defined as an injury that meets both of the following conditions: a. The source of injury was not observed by any person or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of: (1) the extent of the injury; or (2) the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma); or (3) the number of injuries observed at one particular point in time; or (4.) the incident of injuries over time. # 3. Documentation shall include information relevant to the risk factors and conditions that could cause or predispose someone to similar signs and symptoms (e.g., receiving anticoagulants, having osteoporosis, having a movement disorder that results in thrashing movement, etc ) Any descriptions in the medical record shall be objective and sufficiently detailed (e.g., size and location of bruises), and should not speculate about causes. #4 The nursing staff shall discuss the situation with the attending Physician or Medical Director to consider whether medical conditions or other risks factors could account for the findings . Continued review revealed a section titled Reporting Abuse to Facility Management, which includes; it is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source and theft or misappropriation of resident property to facility management. 676026 Page 8 of 12 676026 10/09/2023 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to immediately, or within 2 hours, report injuries of unknown source to the administrator and/or designee and to other officials for 1 of 2 residents reviewed for an injury of unknown origins (Resident #2) LVN B and RN A did not report an injury of unknown origins on Resident #2 to the Nurse Practitioner or Doctor, to receive orders of care. This failure could place residents at risk of a delay in needed treatment. Findings included: Review of the face sheet for Resident #2's revealed he was a [AGE] year-old male initially admitted on [DATE], latest readmission on [DATE]. Resident #2 diagnoses include osteoporosis (fragile bones), repeated falls, cerebral palsy (impaired muscle coordination), and cognitive communication deficit. Review of the Annual Minimum Data Set (MDS) for Resident #2's, dated 7/12/23, revealed a Brief Interview for Mental Status (BIMS) score was not assessed due to Resident #2 being rarely/never understood. Review of Resident #2's Care Plan, initiated 6/8/2019, revealed the following focus: The resident has a Hx (history) of bone fracture to lower end of R (right) femur and has an old Fx (fracture) to R tibia (lower leg bone) r/t (related to) Osteoporosis. The focus was last updated on 10/07/2020. The interventions listed for the focus area include monitoring, documenting, and reporting as needed for edema, bruising/discoloration of skin, skin temperature changes and loss of sensation below fracture. Review of a Skin Observation Tools for Resident #2 dated 9/30/23, revealed the treatment nurse (RN A) documented a bruise to the right ankle. Continued review of the tool revealed the sections designated to size measurement were blank. Review of the Facility Incident Reports from 7/1/2023 through 10/7/2023 revealed on 10/4/23 a report written by LVN A indicated that Resident #2 had approached the nurse after breakfast at 0800, pointing to his right lower extremity (RLE) (Resident is nonverbal). Upon inspection, nurse noticed bruise to Tib/Fib area. When asked if he was experiencing pain? Resident #2 shook his head no. When asked by LVN A if he had fallen? Patient shook his head no. Resident #2's RP and NP were notified. STAT x-ray was ordered by nurse. Review of a Radiology Report dated 10/4/23. Reason for exam Contusion of right ankle, initial encounter, contusion of right lower leg. Results: There is diffused bone demineralization. There is an impacted fracture deformity involving the medial malleolus (ankle) without callus (healing tissue around fracture). Distal fibula ( 2nd lower leg bone) appears grossly intact as visualized on this limited positioned exam. Review of Resident #2's Nursing Notes from 9/29/23 thru 10/7/23 revealed no mention of a bruise to 676026 Page 9 of 12 676026 10/09/2023 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0609 Level of Harm - Actual harm Residents Affected - Few Resident #2's ankle until 10/4/23. LVN A documented at 9:57 am the following: Resident approached nurse after breakfast at 0800, pointing at his RLE (Resident nonverbal). Upon inspection, nurse noticed bruise to Tib/Fib area. When patient was asked if he was experiencing pain? Patient shook his head no. When asked by nurse if he had fallen? Patient shook his head no. V/S 128/54, 62, 17, 97.2. RP, NP notified. STAT x-ray was ordered by nurse. Review of Resident #2's hospital records revealed an Attestation by MD on 10/6/2023 at 7:12am. Impression Right minimally displaced distal tibia/fibula fracture in non-ambulator. Plan: No surgery indicated. The fracture will be treated in a closed manner. X ray imaging results noted a evaluation is significantly limited due to severe osteopenia (reduced bone mass). Review of Resident #2's Treatment Administration Record for the month of September 2023 revealed there is no mention of bruise to ankle. Continued review of October 2023 TAR revealed an order dated 9/30/2023 to, Monitor bruising to right ankle for any changes until resolved every day shift. On 10/1 through 10/4 there are initials of RN A indicating monitoring took place. Interview on 10/7/23 at 12:46pm Resident #2's Responsible Party (RP) stated he was informed by the facility of the injury. He did not know how it happened but realized that the day before he had been notified of the fracture, he had visited Resident #2 to feed him lunch. The RP stated during that visit Resident #2 kept pointing to his right leg. The RP stated Resident #2 does do pointing frequently, so that does not always indicate an injury, but he wonders how long the injury was there before they found it. The RP stated that Resident #2 did not act like he was in pain during his visit, but he usually does not indicate pain. The RP stated there is a history of fractures as Resident #2 has weak bones. Interview on 10/7/23 at 11:07 am with LVN A revealed that on 10/4/23 he noticed that Resident #2 pointed to his right leg while he was talking to him. LVN A stated he lifted Resident #2's pant leg and noticed a bruise that he had not been aware of. LVN A stated he is aware that Resident #2 has a history of brittle bones and fractures, so he notified the NP got orders for a STAT X-ray and notified Resident #2's RP. LVN A stated the bruise was purple and reddish, so it was not an old bruise. The X-rays showed a fracture and Resident #2 had sent to the hospital and is still there. Interview on 10/7/23 at 4:20pm with LVN B revealed she was the Charge Nurse on 9/30/23 when a CNA asked her if she knew about a bruise on Resident #2 . LVN B stated at the same time she was walking in Resident #2's room RN A, who is the Treatment Nurse was coming into the same room. LVN B stated that RN A told her she would assess the bruise. LVN B stated she asked Resident #2 if he was in pain, and he said no. She noticed an approximately one-inch bruise on the side of Resident #2's foot but was not able to remember all the details about it because she left it to RN A to assess. LVN B stated RN A told her she had added monitoring to the Treatment Administration Record to occur daily . LVN B stated she had not asked RN A if she notified the doctor of the injury. Interview on 10/9/23 at 9:30am with RN A Treatment Facility Nurse, revealed on 9/30 she had put in a standing order to monitor Resident #2's bruise. RN A stated she saw the bruise on Friday the 29th of September. RN A stated on that Friday, the charge nurse (LVN B) called me over and asked if I had seen the bruise on Resident #2's ankle. RN A stated she had not seen the bruise before LVN B pointed it out. RN A stated she did not measure the bruise but did make a Skin Tool note on 9/30/23, the day after seeing the bruise and put an order in to monitor. RN A confirmed she did not know the cause 676026 Page 10 of 12 676026 10/09/2023 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0609 Level of Harm - Actual harm Residents Affected - Few of the bruise . RN A confirmed she had not notified the Nurse Practitioner (NP) or Doctor of the bruise. RN A stated she had received counseling from the DON and realizes she should have measured and described the bruise, made an IR, called the doctor and RP. RN A stated she had assumed at the time that LVN B was notifying the doctor and documenting in the progress notes. She stated she should not have made that assumption. When asked if she could estimate the size or show with her hands, RN A placed her hands fingertip to fingertip and held her hands apart to make a circular shape. She stated it was right over Resident #2's right ankle. When asked if the area she was making with her hands was about 4-5 inches she confirmed it was. RN A stated it was a significant injury. She stated she does not know if the bruise was related to the fracture but at the time she saw it, she asked Resident #2 if he was in pain, and he indicated he was not. RN A stated the area was not swollen. Interview on 10/7/23 at 10:58 am CNA C revealed she has worked at the facility for 4 years. She stated she works with Resident #2 frequently. CNA C revealed he is a two person transfer but there are times that he will get out of his low bed by himself because he wants to play by with his toys. CNA C stated Resident #2 is nonverbal, but he can make is needs known with pointing and grunting. She stated she became aware of the fracture on 10/4/23, when x-rays were taken and that prior to that Resident #2 had not complained of pain. Interview on 10/7/23 at 11:55 am with CNA D, she stated she has worked with Resident #2 for a little over a year. CNA D stated that she has not worked on Resident #2's hall in a while but she does still see him in the halls. CNA D stated the day before the fracture was found Resident #2 had passed her as he was going to an activity. CNA D stated Resident #2 was pointing to his right leg area, so she touched his foot and said here? Resident #2 shook his head yes and she thought he wanted her to scratch him because of itching like he usually does she stated she scratched his foot and asked him all better and he said yes. CNA D stated he did not indicate he was in pain; she did not see a bruise and that in the past he has indicated pain by making an ow ow sound, but he had not done that. Interview on 10/7/23 at 3:40 pm, the Facility DON revealed she had thought Resident #2's injury was first recognized on 10/4/23 when the LVN A discovered it and got orders for an x-ray. She stated she asked several staff to write out statements for an investigation into the injury of unknown origins. RN A who is the Facility Treatment Nurse, wrote that she had seen a bruise on 9/29/23 after the Charge Nurse (LVN B) had pointed it out to her. The DON stated that neither RN A or LVN B reported the injury to her, the Doctor or the NP as was expected. The DON confirmed that there also was no size of the bruise documented as it should have been on 9/29/23 . The DON stated that the statement by RN A was written on 10/6/23 and that is when she found out it was either the same bruise where the fracture is or another. On 10/9/23 at 9:15am the DON reported that she had written disciplinary actions for LVN B and RN A due to their failure to report the bruise to the NP or Doctor. She stated that she had spoken to both and the verbal descriptions, although described in different but similar areas on Resident #2, by the two different nurses, indicate a significant injury which is supposed to be reported. Interview on 10/9/23 at 11:08am with the Facility NP revealed she had been notified for the first time of Resident #2's injury/bruise on 10/4/23 when LVN A reported the need for x-rays. The NP stated that she should have been notified of the bruise that was found on 9/29/23 or 9/30 but was not. She stated Resident #2 has osteoporosis, so his bones are dry. Review of the Facilities Policies and Procedures revealed a policy titled Change in Resident's Condition or Status, revised 2/2021, includes on pg 1, #1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the 676026 Page 11 of 12 676026 10/09/2023 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0609 resident; b. discovery of injuries of unknown source. Level of Harm - Actual harm Continued review revealed an Abuse policy, revised 12/2009, contained a section titled Investigating Unexplained Injuries, which includes a policy statement: An investigation of all unexplained injuries (including bruises, abrasions and injuries of unknown source) will be conducted by the Director of Nursing Services, and/or other individual appointed by the Administrator, to ensure that the safety of our residents has not been jeopardized. Policy Interpretation and Implementation, #1. includes the Nurse Supervisor on duty must complete an accident/incident form and record such information into the resident's clinical record. Residents Affected - Few 676026 Page 12 of 12