Health inspection·December 27, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 all allegations involving abuse and neglect were immediately reported no later than 24 hours after an allegation was made for 2 of 4 residents (Resident #1 and #2) reviewed for grievances, in that: 1. The facility failed to report Resident #1's incident to the SA. On 12/6/23, CNA A bumped Resident #1's forehead against a bed side table during perineal care and did not report the incident to a charge nurse. Resident #1's family reported they noticed a small bump on Resident #1's forehead. Resident #1 was assessed and found to have a quarter-sized bump on her forehead. 2. The facility failed to report Resident #2's incident to the SA. On 12/8/23, the OT reported to the DOR that she observed the PTA being pushy and demanding with Resident #2. Resident #2 expressed to the OT she did not want the PTA to work with her after the interaction. These deficient practices could place residents at risk of abuse or neglect. Findings included: Resident #1 Record review of Resident #1's admission record, dated 12/27/23, reflected an [AGE] year-old female who was readmitted to the facility on [DATE], initially admitted on [DATE], had a RP/POA, and with diagnoses including unspecified heart failure, generalized muscle weakness, abnormal posture, need for assistance with personal care, vascular dementia, other recurrent depressive disorders, and unspecified anxiety disorder. Record review of Resident #1's discharge MDS assessment, dated 12/6/23, reflected Resident #1 was discharged on 12/6/23 to a short-term general hospital. Resident #1 required supervision partial/moderate assistance with toileting and personal hygiene, which indicated helper did and provided less than half the effort. Resident #1 was also dependent on showering and required substantial/maximal assistance with bed mobility and transfers, which indicated helper did and provided more than half the effort. Record review of Resident #1's quarterly MDS assessment, dated 10/17/23, reflected no BIMS score. Resident #1 was dependent with toileting, showering, personal hygiene, bed mobility, and transfers. Record review of Resident #1's comprehensive care plan, dated 11/6/23, reflected she had episodes Page 1 of 12 676222 676222 12/27/2023 Bastrop Lost Pines Nursing and Rehabilitation Cent 430 Old Austin Hwy Bastrop, TX 78602

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some of bowel incontinence and required perineal care after each episode. Resident #1 also had an ADL self-care performance deficit and required two staff members for repositioning and turning in bed, toilet use, and transfers and one staff member for personal hygiene. Record review of the facility's incident log from 11/1/23 through 12/27/23 reflected Resident #1's incident on 12/6/23 at 2:30 p.m. under procedure related incidents . Record review of the facility's grievance/complaint form, dated 12/6/23, reflected ADM and DON was contacted and assigned to resolved the complaint/grievance. The nature of the complaint indicated, Family member in to visit and noticed a small bump on [Resident #1's] forehead. Documentation of facility follow-up indicated, DON assessed [Resident #1's] forehead and noted a quarter-sized area to the left over eyebrow. No redness was seen. [Resident #1] denied pain when [DON] touched it. Vital signs taken (stable) [Resident #1] made eye contact with [DON] when [DON] assessed. Alert but nonverbal which is [Resident #1's] baseline. Resolution of concern/grievance indicated, [Resident #1's] family requested for her to be sent out to the ER for further evaluation. During an interview on 12/27/23 at 4:33 p.m., CNA A stated she provided Resident #1 with perineal care on the day of Resident #1's incident. CNA A stated she was by herself when Resident #1's incident occurred. CNA A stated Resident #1's bedside table was too close to Resident #1's head. CNA A stated she nicked Resident #1's head against Resident #1's bedside table. CNA A stated she asked Resident #1 if she was okay and if she needed a nurse. CNA A stated Resident #1 told her she was okay and did not want a nurse to assess her. CNA A stated she did not receive help from her second CNA. CNA A stated she was told by the DON and ADM that Resident #1's family observed a bump on Resident #1's head. CNA A stated she did not notify a nurse of Resident #1's incident because Resident #1 told her that she was okay and did not want a nurse to assess her. CNA A stated she asked Resident #1 multiple times if she was okay. CNA A stated she was responsible for notifying a nurse. CNA A stated the ADM was responsible for reporting abuse and neglect to the SA immediately. CNA A stated she was not paying attention when the bedside table was too close and she began rolling Resident #1 to her side. CNA A stated she observed Resident #1's bedside table was elevated to its highest position, which was abnormal. CNA A stated the position of the bedside table to Resident #1's bed was often placed in the same area. CNA A stated Resident #1's head barely touched the bedside table when she rolled Resident #1. During an interview on 12/27/23 at 6:07 p.m.,. CNA C stated she and Resident #1's family noticed Resident #1's bump when she went to give pain medications to Resident #1 . CNA C stated she notified the DON and ADON of her observation. CNA C stated CNA A told her that she reported Resident #1's incident to the nurses. CNA C stated Resident #1's incident was reportable to the SA. Record review of Resident #1's hospital clinical, dated 12/8/23, indicated, Per EMS report, [Resident #1] bumped her left side of the head while facility staff was rolling her in the bed. [Resident #1] has had struck the bedside table. No LOC reported. [Resident #1] did not follow up of the bed. This happened between 12[noon] and 2:00 p.m. [Resident #1's family] came to visit and noticed a small bump on her forehead and started asking questions when she noticed that [Resident #1] seemed to have decreased consciousness level so she was sent to ER for evaluation. At baseline [Resident #1] is confused but can articulate now AMS described as [Resident #1] is not able to speak. Clinicals also indicated, CT head was negative. Clinicals indicated, After evaluation of [Resident #1] and review of the relevant imaging findings, [Resident #1] has no injuries requiring surgical intervention. Record review of Resident #1's progress notes, documented by RN A on 12/6/23 at 4:00 p.m., 676222 Page 2 of 12 676222 12/27/2023 Bastrop Lost Pines Nursing and Rehabilitation Cent 430 Old Austin Hwy Bastrop, TX 78602

F 0609 Level of Harm - Minimal harm or potential for actual harm reflected the following: At 4:15 p.m. [Resident #1]s family] alerted me to room. Found [Resident #1] to have a hematoma to Left side of forehead. AMS noted. Obtunded, not responding to verbally. Flat affect, eyes open but lack of awareness. Notified NP. Obtained order to send to ER for evaluation and treatment. [Resident #1's family] called EMS prior to the given order. Left facility to transfer to ER at 4:40 p.m. via EMS to hospital per [Resident #1's family] request. Notified DON and ADON at 4:15 p.m. Residents Affected - Some During an observation on 12/27/23 at 2:19 p.m., Resident #1 was sleeping in bed. Resident #1 was clean, comfortable, and had no bumps on her forehead. During an observation on 12/27/23 at 2:30 p.m., Resident #1 was sleeping in bed. Resident #2 Record review of Resident #2's admission record, dated 12/27/23, reflected an [AGE] year-old female who was admitted to the facility on [DATE], was her own RP, and with diagnoses including muscle wasting and atrophy, delusional disorders, other specified depressive episodes, other dissociative and conversion disorders, unsteadiness on feet, other lack of coordination, cognitive communication deficit, need for assistance with personal care, pain in unspecified foot, and repeated falls. Record review of Resident #2's comprehensive MDS assessment, dated 11/10/23, reflected a BIMS score of 13, indicating she was cognitively intact. Resident #2 required substantial/maximal assistance bed mobility and transfers. Record review of Resident #2's clinical record reflected she did not have a comprehensive care plan. Record review of the facility's grievance/complaint form, dated 12/8/23, reflected ADM was contacted and DOR was assigned to resolve the complaint/grievance. The nature of the complaint indicated, Bedside manor of therapist. See attached. That attached statement reflected the following: Resident #2 complained that PTA was rude and her bedside manner was unwelcoming. Resident #2 stated PTA was very pushy when working with her. Resident #2 was trying to sit up to start therapy and PTA told her she did not have time for her to be lazy as she had other patients to see. Resident #2 stated she was not lazy, just sick and weak. Resident #2 stated she needed assistance getting in a sitting up position. Resident #2 stated PTA told her she needs assistance because she has been lazy. Resident #2 stated she asked PTA to be patient that she was tired and very sick. Resident #2 stated PTA also stated that's how she got in this situation by being lazy. Resident #2 stated she told PTA she hopes she never is in a situation where she needs help because she is sick. Resident #2 stated that she told PTA that she hopes she never gets sick, and needs helps. Resident #2 stated PTA told her she would never get sick and needs help because she works out and isn't lazy. Resident #2 also said there was another therapist, OT, with them who was very kind and kept trying to interject when PTA would be rude, but PTA would talk over OT. I (Unknown who) asked OT if Resident #2's statement was true, OT confirmed these events did happen. OT also stated she told the DOR about the incident. Resident #2 has stated she does not want to work with PTA. During an interview on 12/27/23 at 3:07 p.m., OT stated she worked with PTA a few weeks ago. OT stated PTA was being pushy and demanding with Resident #2. OT stated Resident #2 stated she hoped PTA never had someone treat her the way she was treating Resident #2 and PTA told Resident #2 that she exercised every day and would not be in that situation. OT stated she reported the incident to the DOR 676222 Page 3 of 12 676222 12/27/2023 Bastrop Lost Pines Nursing and Rehabilitation Cent 430 Old Austin Hwy Bastrop, TX 78602

F 0609 Level of Harm - Minimal harm or potential for actual harm within a few hours and on the same day of the incident. OT stated she believed the incident would probably be verbal abuse. OT stated the ADM was the abuse and neglect coordinator. OT stated abuse and neglect were supposed to be reported as soon as possible or the same day of the incident. OT stated she did not know who reported abuse and neglect to the SA. OT stated abuse and neglect were supposed to be reported to the ADM, DON, or DOR. Residents Affected - Some During an interview on 12/27/23 at 3:54 p.m., DOR stated OT informed her about Resident #2's incident the afternoon it occurred, which was on 12/1/23. DOR stated OT informed her not to put PTA on Resident #2's schedule because the session did not go well. DOR stated Resident #2's incident constituted as verbal abuse. DOR stated the ADM was the abuse and neglect coordinator. DOR stated the ADM reported abuse and neglect incidents to the SA. DOR stated abuse and neglect must be reported as soon as possible or up to two hours. DOR stated she was not sure if the ADM reported the incident to the SA. DOR stated ADM and OT notified her of Resident #2's incident. DOR stated the ADM showed her the grievance, which was dated for 12/8/23. During an interview on 12/27/23 at 2:48 p.m., PTA stated she worked at the facility for seven years. PTA stated she never provided care or services to Resident #2. PTA denied calling Resident #2 names. PTA stated if a resident alleged they were abused or neglected, she was trained to determine when the incident occurred, who was involved, and report it to the DOR. PTA stated she did not know who the abuse and neglect coordinator was. PTA stated if she observed a resident had a bump on their forehead, she was trained to notify the DOR. During an interview on 12/27/23 at 11:41 a.m. , ADM stated in an email response to the surveyor requesting the abuse and neglect and incident reporting policies and procedures and self-reports from the last two months, Abuse and Neglect also covers Injury of Unknown Origin, we also go off the provider letter. We have no Abuse and Neglect Self Reports for November and December. During an interview on 12/27/23 at 3:30 p.m., ADM stated in an email response to the surveyor asking if Resident #2's incident was reported to the SA, I received a complaint of rude customer service and unprofessionalism, no incident report or state report was made. The incident was documented via our grievance process. During an interview on 12/27/23 at 3:39 p.m., ADM stated he did not constitute Resident #2's incident as verbal abuse because Resident #2 was not slandered or yelled at by PTA. ADM stated he documented Resident #2's incident on a grievance form and investigated the grievance. ADM stated he did not report the incident to the SA because he believed it was not considered abuse or neglect. ADM stated he did not report Resident #1's incident as injury of unknown origin because staff determined how Resident #1 sustained the bump on her forehead. ADM stated during mid-December 2023, a CNA was rotating Resident #1 on one-side of her body, and Resident #1 bumped her head on the bedside table that was too close to her bed. ADM stated the CNA asked Resident #1 if she was okay and if Resident #1 needed a nurse. ADM stated Resident #1 told the CNA that she did not need a nurse, was fine and not in pain. ADM stated the CNA did not notify a nurse or charge nurse about Resident #1's incident because Resident #1 said she was fine, not in any pain, and did not want a nurse. ADM stated Resident #1's family came in later on in the afternoon and observed a bump. ADM stated Resident #1's family requested Resident #1 be sent out to the hospital. ADM stated Resident #1's family made informed decisions regarding Resident #1's care and Resident #1 had the capacity to verbalize responses. During an interview on 12/27/23 at 11:55 a.m., LVN A stated she worked at the facility for 12 years. LVN A stated ADM or DON reported incidents to the SA. 676222 Page 4 of 12 676222 12/27/2023 Bastrop Lost Pines Nursing and Rehabilitation Cent 430 Old Austin Hwy Bastrop, TX 78602

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation and interview on 12/27/23 at 1:53 p.m., Resident #2 was laying in bed. Resident #2 was clean, comfortable, and had her call light next to her. Resident #2 told the surveyor she did not want to say if staff interacted with her in a kind and professional manner and if staff called her names. During an interview on 12/27/23 at 2:04 p.m., LVN B stated she worked at the facility for a month. LVN B stated if a resident alleged staff called them names, she was trained to notify the ADON or a charge nurse. LVN B stated she did not know who the abuse and neglect coordinator was. LVN B stated if a resident had a change of condition, she was trained to notify the NP, determine how the resident sustained a change of condition, and notify the resident's family. During an interview on 12/27/23 at 2:26 p.m., MA A stated she worked at the facility for 9 years. MA A stated if a resident had a change of condition, she was trained to notify a nurse. MA A stated the ADM was the abuse and neglect coordinator. MA A stated she did not have to report abuse or neglect in the last three months. During an interview on 12/27/23 at 2:31 p.m., RN B stated he worked at the facility for seven months. RN B stated if a resident had a change of condition, he was trained to notify the MD, DON, ADON, RP and follow MD's instructions. During an interview on 12/27/23 at 4:26 p.m., CNA B stated she worked at the facility for one year. CNA B stated she did not have to report abuse or neglect in the last three months. CNA B stated the ADM was the abuse and neglect coordinator. CNA B stated an incident was constituted as verbal abuse if a staff member called a resident lazy. CNA B stated if a staff member called a resident names, she was trained to intervene, notify a nurse, and report the incident to the ADM or DON. CNA B stated if a resident bumped their head on a bedside table, she was trained to notify a nurse. CNA B stated she would notify a nurse despite the resident telling her that they were fine and did not need a nurse to assess them. CNA B stated the ADM reported abuse and neglect incidents to the SA. During an interview on 12/27/23 at 4:49 p.m., ADON stated she worked at the facility for a year and a half. ADON stated a staff calling a resident lazy did not constitute as verbal abuse. ADON stated if a staff member called a resident names, she trained staff to notify a supervisor of the incident. ADON stated the ADM was the abuse and neglect coordinator. ADON stated the ADM reported abuse and neglect to the SA. ADON stated she reported abuse and neglect immediately to the ADM. ADON stated if a resident bumped their head during care, she trained staff to notify a nurse, the nurse notified her, and she notified the DON. ADON stated a CNA who did not report an incident to the nurse to an extent constituted as neglect. ADON stated she was notified at the end of the day of Resident #1's incident by the DON. ADON stated her and the DON spoke with Resident #1's family, who was upset with the bump on Resident #1's head. ADON stated Resident #1 had a quarter-sized bump on her forehead. ADON stated Resident #1 was not very verbal, but she would express if she was in pain. During an interview on 12/27/23 at 5:22 p.m., MDS Nurse A stated he worked at the facility for a year. MS Nurse A stated an incident was constituted as verbal abuse if a staff member called a resident lazy. MDS Nurse A stated if a staff member called a resident names, he was trained to report the incident to the ADM and a supervisor. MDS Nurse A stated the ADM was the abuse and neglect coordinator. MDS Nurse A stated ADM and DON were responsible for reporting abuse and neglect to the SA within 24 hours. MDS Nurse A stated a CNA must report an incident, such as a bump on the head, to the nurse despite the resident telling them not to get a nurse and they were fine. MDS Nurse A stated incidents in which a resident is sent to the hospital for an injury must be reported. MDS Nurse A stated if 676222 Page 5 of 12 676222 12/27/2023 Bastrop Lost Pines Nursing and Rehabilitation Cent 430 Old Austin Hwy Bastrop, TX 78602

F 0609 the resident did not have a injury, the incident did not need to be reported to the SA. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/27/23 at 5:38 p.m., DON stated she worked at the facility for 11 months. DON stated a staff calling a resident lazy did not constitute as verbal abuse. DON stated the ADM was the abuse and neglect coordinator. DON stated the ADM was responsible for reporting abuse and neglect to the SA within two hours. DON stated a CNA should report to a charge nurse if a resident bumped their head despite the resident telling them they were fine and did not need an assessment. DON stated the facility would investigate the incident and determine if it needed to be reported to the SA. DON stated she assessed Resident #1 and found Resident #1 had a grazed area. DON stated she was called into Resident #1's room when Resident #1's family visited Resident #1. DON stated Resident #1's family wanted to know why and how Resident #1's incident happened. DON stated Resident #1 was alert, but she did not speak a whole lot, and did not speak all the time. DON stated she interviewed staff and determined a CNA on the previous shift was rolling Resident #1 over to the bed, the bedside table was too close, and Resident #1 slightly bumped her head. DON stated she did not know if CNA A knew the bedside table was too close when repositioning Resident #1 in bed. DON stated CNA A told her that she did not report the incident because Resident #1 said she was okay. DON stated Resident #1's family made informed decisions on behalf of Resident #1. Residents Affected - Some During an interview on 12/27/23 at 6:20 p.m., ADM stated he worked at the facility for a year and a half. ADM stated he did not believe Resident #2's incident met the criteria for verbal abuse and believed it was poor customer service. ADM stated OT reported Resident #2's incident. ADM stated Resident #1's family visited Resident #1 the day of Resident #1's incident and notified him of a bump the size of a dime on her head. ADM stated he interviewed staff and found CNA A repositioned Resident #1, Resident #1's bedside table was too close to her bed, and Resident #1 bumped her head. ADM stated CNA A told him that she offered to get a nurse for Resident #1, but Resident #1 refused and reported no pain. ADM stated Resident #1's family requested Resident #1 be sent out to the ER and staff sent Resident #1 out. ADM stated he did not know if CNA A was aware that Resident #1's bedside table was too close to Resident #1's bed when she rolled Resident #1 on her side. ADM stated he believed Resident #1's bedside table was too close. ADM stated CNA A told him that she saw Resident #1's bedside table was too close to Resident #1's bed and did not move it when she rolled Resident #1 on her side. ADM stated he did not constitute Resident #1's incident as reportable to the SA because it did not meet the criteria for neglect and injury of unknown origin. ADM stated reportable incidents were those involving abuse, neglect, and injury of unknown origin. ADM stated incidents were reported within four hours if a resident sustained a serious injury and within 24 hours for all other incidents. Record review of Tulip reflected there were no self-reports from the facility related to Resident #1's and Resident #2's incidents. Record review of the facility's provider letter, dated 7/10/19, reflected the following: This letter provides guidance for reporting incidents to SA. A NF must report to HHSC the following types of incidents, in accordance with applicable state and federal requirements: Abuse Neglect 676222 Page 6 of 12 676222 12/27/2023 Bastrop Lost Pines Nursing and Rehabilitation Cent 430 Old Austin Hwy Bastrop, TX 78602

F 0609 Suspicious injuries of unknown source Level of Harm - Minimal harm or potential for actual harm Abuse (with or without serious bodily injury); or neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, that result in serious bodily injury must be reported immediately, but not later than two hours after the incident occurs or is suspected Residents Affected - Some An incident that does not result in serious bodily injury and involves: neglect must be reported immediately, but not later than 24 hours after the incident occurs or is suspected. Abuse: SA rules define abuse as: The negligent or willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident; or sexual abuse, including involuntary or nonconsensual sexual conduct that would constitute an offense under Penal Code §21.08 (indecent exposure) or Penal Code Chapter 22 (assaultive offenses), sexual harassment, sexual coercion, or sexual assault.11 CMS defines abuse as: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. SA rules define neglect as, the failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. CMS defines neglect as, the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Note: an injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one point in time or the incidence of injuries over time. Record review of the facility's abuse, neglect and exploitation policy and procedure, dated 8/15/22, reflected the following: 676222 Page 7 of 12 676222 12/27/2023 Bastrop Lost Pines Nursing and Rehabilitation Cent 430 Old Austin Hwy Bastrop, TX 78602

F 0609 Definitions: Level of Harm - Minimal harm or potential for actual harm Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Residents Affected - Some Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mental abuse also includes abuse that is facilitated or caused by nursing home staff taking or using photographs or recording in any manner that would demean or humiliate a resident(s). Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Mistreatment means inappropriate treatment or exploitation of a resident. Policy Explanation and Compliance Guidelines: 2. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. Employee Training: 4. Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources Identification of Abuse, Neglect and Exploitation: B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse 2. Physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident's body 3. Physical injury of a resident, of unknown source 5. Verbal abuse of a resident overheard 8. Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning & positioning 10. Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame. 676222 Page 8 of 12 676222 12/27/2023 Bastrop Lost Pines Nursing and Rehabilitation Cent 430 Old Austin Hwy Bastrop, TX 78602

F 0609 Reporting/Response: Level of Harm - Minimal harm or potential for actual harm A. The facility will have written procedures that include: 1. Residents Affected - Some Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. Record review of the facility's incidents and accidents policy and procedure, dated 8/15/22, reflected the following: Policy: It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Definitions: Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. An incident is defined as an occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization. This can involve a visitor, vendor, or staff member. Policy Explanation: The purpose of incident reporting can include: o Alert administration of occurrences that could result in reporting requirements. o Meeting regulatory requirements for analysis and reporting of incidents and accidents. Compliance Guidelines: 676222 Page 9 of 12 676222 12/27/2023 Bastrop Lost Pines Nursing and Rehabilitation Cent 430 Old Austin Hwy Bastrop, TX 78602

F 0609 3. Incidents that rise to the level of abuse, misappropriation, or neglect, will be managed and reported according to the facility's abuse prevention policy. Level of Harm - Minimal harm or potential for actual harm 4. The following incidents/accidents require an incident/accident report but are not limited to: Residents Affected - Some o Alleged abuse o Observed accidents/incidents o Resident injuries due to staff handling o Unobserved injuries 7. The supervisor or other designee will be notified of the incident/accident. If necessary, law enforcement may be contacted for specific events. 8. The nurse will contact the resident's practitioner to inform them of the incident/accident, report any injuries or other findings, and obtain orders, if indicated, which may include transportation to the hospital dependent upon the nature of the injury(ies ). 10. The resident's family or representative will be notified of the incident/accident and any orders obtained or if the resident is to be transported to the hospital. 14. If an incident/accident was witnessed by other people, the supervisor or designee will obtain written documentation of the event by those that witnessed it and submit that documentation to the Director of Nursing and/or Administrator. 676222 Page 10 of 12 676222 12/27/2023 Bastrop Lost Pines Nursing and Rehabilitation Cent 430 Old Austin Hwy Bastrop, TX 78602

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #2) of five residents reviewed for care plans, in that: The facility failed to develop and implement a comprehensive person-centered care plan for Resident #2. This deficient practice could place residents at risk of not having their individual care needs met in a timely manner or diminished quality of life. Findings included: Record review of Resident #2's admission record, dated 12/27/23, reflected an [AGE] year-old female who was admitted to the facility on [DATE], was her own RP, and with diagnoses including muscle wasting and atrophy, delusional disorders, other specified depressive episodes, other dissociative and conversion disorders, unsteadiness on feet, other lack of coordination, cognitive communication deficit, need for assistance with personal care, pain in unspecified foot, and repeated falls. Record review of Resident #2's comprehensive MDS assessment, dated 11/10/23, reflected a BIMS score of 13, indicating she was cognitively intact. Resident #2 required substantial/maximal assistance bed mobility and transfers. Record review of Resident #2's clinical record reflected she did not have a comprehensive care plan. During an interview on 12/27/23 at 11:55 a.m., LVN A stated she worked at the facility for 12 years. LVN A stated her and MDS Nurse A prepared residents comprehensive care plans. LVN A stated MDS Nurse A prepared care plans for residents who were staying at the facility for a short-term. LVN A stated she prepared care plans for residents who were staying at the facility for a long-term. During an interview on 12/27/23 at 12:28 p.m., LVN A stated comprehensive care plans were completed seven days after the MDS assessment was completed. LVN A stated she was not sure why Resident #2's comprehensive care plan was not completed after Resident #2's MDS assessment was completed on 11/20/23. During an interview on 12/27/23 at 12:42 p.m., LVN A stated Resident #2's comprehensive care plan was completed, but it was not signed. LVN A stated she and MDS Nurse A checked to ensure residents' comprehensive care plans were signed. LVN A stated she and MDS Nurse A missed checking Resident #2's comprehensive care plan to make sure it was signed. During an interview on 12/27/23 at 5:22 p.m., MDS Nurse A stated he worked at the facility for a year. MDS Nurse A stated residents comprehensive care plans must be completed seven days after their MDS assessment was completed. MDS Nurse A stated residents comprehensive care plans were completed and up to date. MDS Nurse A stated staff still needed to sign off on residents' comprehensive care 676222 Page 11 of 12 676222 12/27/2023 Bastrop Lost Pines Nursing and Rehabilitation Cent 430 Old Austin Hwy Bastrop, TX 78602

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few plans. MDS Nurse A stated there were no other residents except Resident #2 in which he was waiting for staff to sign off on the comprehensive care plans. MDS Nurse A stated Resident #2's comprehensive care plan was not signed off because there was a miscommunication between him and LVN A. MDS Nurse A explained he thought LVN A verified the signatures were completed on Resident #2's comprehensive care plan and LVN A thought he verified the signatures were completed. MDS Nurse A stated residents' until all parties signed off on the plan. During an interview on 12/27/23 at 5:38 p.m., DON stated she worked at the facility for 11 months. The DON stated the facility had two MDS nurses who completed residents' comprehensive care plans. DON stated the MDS nurses split up completing the care plans by long-term and skilled care. DON stated residents' comprehensive care plans must be completed within seven days. DON stated she was not sure who verified to make sure residents' comprehensive care plans were completed within required timeframes. DON stated residents could be negatively impacted if their comprehensive care plans were not completed in a timely manner. During an interview on 12/27/23 at 6:20 p.m., ADM stated he worked at the facility for a year and a half. ADM stated the facility's two MDS nurses were responsible for revising residents' comprehensive care plans. ADM stated he was not sure what the timeframes were for completing residents' comprehensive care plans. Record review of the facility's comprehensive care plans policy and procedure, dated 10/24/22, reflected the following: . 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 676222 Page 12 of 12