Health inspection·October 18, 2023

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 that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, when the events that cause the allegation involved abuse or resulted in serious bodily injury for one of eight residents (Resident #1) reviewed for injury of unknown origin. The facility did not report a fracture of unknown origin to Resident #1's tibia until the fourth day after it was identified. This failure placed residents at risk of not having abuse or neglect identified swiftly and thus being subjected to further abuse or neglect. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of multiple sclerosis (a disease that affects central nervous system), trigeminal neuralgia (chronic painful disease which affects the trigeminal nerves present in the face), and osteoporosis/osteopenia (a condition when bone strength weakens and is susceptible to fracture). Review of the Quarterly MDS for Resident #1dated 08/16/23 reflected a BIMS score of 15, indicating an intact cognitive response. It reflected she required total dependence of two people for transfer. It reflected her status for moving on and off the toilet and surface-to-surface transfers was not steady, only able to stabilize with staff assistance. Review of the care plan for Resident #1 dated 04/06/23 reflected the following: I am at risk for falls r/t my disease process and side effects of medications. I will remain fall free through my end of review date. Implement exercise program that targets strength, gait and balance as ordered. Increased staff supervision with intensity based on resident need. Keep call light within reach. Keep personal belongings within reach. It also reflected: I have chronic pain r/t my dx of Chronic pain syndrome and Multiple sclerosis. I will be free of pain, discomfort and adverse side effects this review period. Assess and note for signs and symptoms related to chronic pain such as weakness, decreased appetite, weight loss, changes in body posture, sleep pattern disturbance, anxiety, irritability, agitation, or depression. Review of an incident report for Resident #1 dated 10/05/23 and completed by the DON reflected Page 1 of 4 676290 676290 10/18/2023 Spjst Rest Home 1 1810 Old Granger Road Taylor, TX 76574

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #1 had a fracture of unknown origin to the proximal tibia and fibula identified on 10/05/23 at 07:28 PM. Review of x-ray results for Resident #1 dated 10/05/23 at 04:35 PM reflected the following Examination is limited by patient positioning. There is a mildly impacted fracture of the proximal (close to the knee rather than the ankle) tibia (lower leg bone) of indeterminate age and there is a non-displaced fracture of the proximal fibula (lower leg bone) of indeterminate age . Bony structures are osteoporotic (brittle and susceptible to fracture). Osteophytes (bony growths that form in your joints) extend from the lateral tibial plateau (top of the shin at the knee). Calcification of the lateral meniscus is present. No effusion (accumulation of fluid in the knee joint) is identified. Vascular calcification (mineral deposits on the walls of your arteries and veins) is present. There is no dislocation. Review of progress notes for Resident #1 dated 10/05/23 at 07:28 PM reflected the following: Received x-ray results with impression: 1. There is a mildly impacted fracture of the proximal tibia of indeterminate age and there is a nondisplaced fracture of proximal fibula of indeterminate age. 2. There are moderate degenerative changes in the knee. Call placed to [family member] answering service and received a call back from on-call NP states to leave for facility NP in a.m. unless resident is in excruciating pain, increased, swelling, or diminished pulse. Review of an HHSC 3613 Provider Investigation Report reflected the date of the incident was 10/05/23 at 01:42 PM. The incident was reported to the state Agency on 10/09/23 and reflected the following: During wound care charge, nurse was performing wound care, and upon turning resident to her left side, charge nurse noticed a protrusion to the lateral side of Residents right lower extremity just below the knee charge. Nurse brought the findings to the DON. DON informed charge nurse to immediately have NP assessed resident. NP assessed resident in ordered stat x-rays of right lower extremity. X-ray results received at 07:28 PM stating: a mildly impacted fracture of the proximal tibia of indeterminate age, and there is a nondisplaced fracture of the proximal fibula of indeterminate age. There was (sic) moderate degenerative changes of the knee. Provider response: upon receiving results, charge, nurse, call, placed to on-call answering service and received callback from on-call NP stating to leave for facility NP in a.m. unless resident is in excruciating pain, increased swelling, or diminished pulse. Facility NP ordered for staff to call and make orthopedic appointment the following morning. Multiple orthopedic offices called and earliest appointment was booked for October 13, 2023. Staff in-serviced to inform charge nurse, DON, or NP of any changes noted in residents. Examples: discoloration of skin, protrusion to any parts of the body, foul odors, or other situation's that would need a provider to evaluate the resident. Review of the State Agency online reporting database on 10/18/23 reflected that the fracture of Resident #1's fracture was reported on 10/09/23 at 9:15 AM. Review of an orthopedist report for Resident #1 dated 10/13/23 reflected the following: Displaced, proximal, tibial plateau fracture. Displaced bicondylar (refers to a joint near the knee) fracture of right tibia. Resident has a long history of MS that has left her unable to move the lower extremities. She requires the use of a motorized chair and lift. She is unable to stand, weight-bearing, or otherwise ambulate. She has a right sided proximal tibial fracture of indeterminate age, but it does appear to be healing with bony callus (bony deposit formed between and around the broken ends of a 676290 Page 2 of 4 676290 10/18/2023 Spjst Rest Home 1 1810 Old Granger Road Taylor, TX 76574

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few fractured bone during normal healing). Given her above complicated medical history, no further treatment indicated. During observation and interview on 10/18/23 at 12:27 PM, revealed Resident #1 was lying in bed with her call button within reach and an overbed table across her lap with her personal belongings on it. Resident #1 stated she had been informed she had a fractured knee and was completely shocked. She stated she had been to the orthopedist on Friday 10/13/23 and had another appointment on 11/14/23. She stated she had learned at the orthopedist that the fracture was just below her knee. She stated she had thought it was somewhere between her knee and her ankle, but it was just below her knee. Resident #1 stated she got up for activities sometimes. She stated she got up once or twice a week usually if she was feeling well. Resident #1 stated she got up using a mechanical lift and two staff members were always present for the transfer. Resident #1 stated the Hoyer transfers had always felt safe, and she had never been dropped or hit her legs or anything like that. She stated she had no unusual pain. She stated since she had multiple sclerosis, she often had nerve pain, but there was no other kind of pain. She stated the DON and the ADM had asked her two different times if anything happened that she thought could have caused the fracture, but she could not think of anything. Resident #1 stated she had an electric wheelchair and drove it herself, but she did not recall hitting her leg on anything. She stated she received showers, and she was moved in the shower sling, but she never fell or hurt herself in the shower, either. She stated she took Lyrica for pain and occasionally a Tylenol. Resident #1 stated the facility staff took care of her really well. She stated they were very careful and there had been nothing that occurred that could have caused the fracture, but she thought her bones just broke easily. During an interview on 10/18/23 at 01:28 PM, the NP stated Resident #1 had severe osteoporosis and the NP believed Resident #1 had another fracture in the past not knowing how it occurred. The NP stated the fracture could have occurred with any type of movement. The NP stated she had no concerns of care by the facility. The NP stated Resident #1 required total care, so they had to move her, and a fracture could have occurred during regular movements, during therapy, or while the resident was self-ambulating. The NP stated they did not even know when the fracture occurred, because it was age-indeterminate and had already started to heal. During an interview on 10/05/23 at 02:30 PM, the ADON stated they had no idea when or how Resident #1's fracture happened. He stated he knew they had the State Agency in the building that day, and that must have been distracting. The ADON stated they should have reported any fracture from unknown cause within 24 hours. He stated he thought the ADM was close to reporting within the 24 hours but did not quite make it. The ADON stated he was not sure when they learned it was actually a fracture, since sometimes they did not get the x-ray results until the next day. When he looked at the dates and times on the incident reports, he noted that the fracture was identified four days before it was reported to the State Agency. He stated he helped to take statements from floor staff who had cared for Resident #1, and none of them knew what had happened. During an interview on 10/05/23 at 02:38 PM, the DON stated she was in her office when the wound care nurse came and notified her of a bulge on Resident #1's knee. The DON stated the first thing they did was spoke to Resident #1 that afternoon on 10/05/23, but the resident had no idea how an injury might have occurred. The DON stated they ordered an x-ray and were contacted that night (10/05/23) with the results. The DON stated the NP on call told them to wait and let the facility NP see the resident the following day and make an appointment with an orthopedist. The DON stated the day the x-rays came back was Thursday 10/05/23, a state surveyor walked in Friday morning 10/06/23 at 09:15 AM while they were in morning meeting, and that threw off her train of thought for that morning to have 676290 Page 3 of 4 676290 10/18/2023 Spjst Rest Home 1 1810 Old Granger Road Taylor, TX 76574

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the ADM report it as an injury of unknown origin. The DON stated they discussed that Resident #1 had a fracture, but she did not provide details to the ADM, and she did not mention the term self-report. The DON stated she remembered on Monday morning 10/09/23 and they sat right down and made the report. The DON stated they had not performed any corrective action related to the failure to submit a self-report within time frames. She stated the ADM was responsible for overseeing the reporting process, but he relied on the clinical information she provided to determine what needed to be reported, so she had a role in the process, as well. The DON stated a possible negative outcome on the residents were more serious, the residents would have to wait longer to have abuse and/or neglect identified. During an interview on 10/05/23 at 02:56 PM, the ADM stated Resident #1 presented with a fracture of unknown origin on 10/05/23. He stated he and his management team interviewed staff and residents to see if anyone knew what had happened, and no one did, including Resident #1, on 10/05/23 and 10/06/23. The ADM stated as soon as the x-ray came back, they said they had to report to the State Agency. He stated they reported to the State Agency and continued the investigation. The ADM stated he was trying to remember if the incident was reported within the timelines. He stated he thought it might not have been, but he had to look at the incident report to remember. The ADM stated they should have reported and realized they had not on Monday 10/09/23. The ADM stated his understanding was they had 24 hours to report. He stated they did not usually wait 24 hours to report. The ADM stated ultimately it was his responsibility to oversee the incident reporting process. The ADM stated the failure could have had all sorts of negative effects on residents. He stated the fracture could have cause clots or a stroke, and that could have been fatal . Review of facility policy titled Resident Abuse/Neglect Policy reflected the following: Findings and actions: when abuse, or neglect is believed to have occurred, the administrator/designee will immediately telephone the licensing agency and other appropriate officials and will submit a written report to the licensing agency within five working days. Should the administrator not be available to make this telephone report, the next designee is the assistant administrator, the Director of Nursing, then the assistant, Director of Nursing. Should none of these designees be available, the charge nurse should telephone the licensing agency. ( .) Reporting: All alleged violations and all substantial incidents will be reported to the state agency and other agencies as required. All necessary corrective actions will be taken to prevent further occurrences. Occurrences will be analyzed to determine appropriate actions and policy and procedure changes that may be necessary. 676290 Page 4 of 4