Health inspection·January 14, 2026

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 residents ( Resident #1) reviewed for adequate supervision. The facility failed to provide adequate supervision to prevent Resident #1 from falling to the floor and injuring himself during patient care on 01/09/26 and resulted in a laceration to his upper lip which required stitches. This deficiency could expose residents to harm and injury, due to not being adequately monitored. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Immobility Syndrome (Paraplegic), Muscle weakness (generalized), cognitive communication deficit, Hyperlipidemia, Unspecified, Contracture of muscle, unspecified site, Dysphagia, Oral Phase, and Need for assistance with personal care. Review of Resident #1's MDS assessment dated [DATE], section C revealed no BIMS score. Section G regarding the resident's Activities of Daily Living (ADL) Assistance revealed the resident needed supervision and two persons assisting with bed mobility, transferring, and toilet use. It also revealed the resident required two-person assistance with dressing and personal hygiene. Record review of Resident #1's care plan dated 11/12/2025 revealed Resident #1 was care planned for falls. ADL Self-Care Performance Deficit: requiring two-person assist with all ADL except for eating. Record review of CMA-A's signed statement dated 01/09/26 revealed she was providing patient care for Resident #1. The statement read in part, .Resident #1 became agitated. So, I stopped to calm him down, and after he calmed down. I started providing patient care again; however, Resident#1 became agitated again, and as I was wiping him, he fell to the floor, landing face down and on his left side. I observed blood, and I called for help. Record review of Resident #1's hospital record dated 01/09/26 revealed that Resident #1 was diagnosed with a fall, which resulted in a laceration to his upper lip. Resident #1 received stitches to treat his upper lip. Record review of Resident #1's progress note dated 01/09/26 revealed that he returned to the facility at 7:48 p.m. with one stitch to his upper lip due to sustaining a laceration from a fall. Record review of the facility's Provider Investigation Report dated 01/20/2026 and signed by the Administrator revealed, . CMA (CMA A) provided care to Resident (Resident #1) alone when his care plan called for two-person assist. He rolled out of bed on to the floor . Resident (Resident #1) sustained a laceration to his lip during the fall . Order received and carried out to send Resident (Resident #1) to (a local acute care hospital) ER for evaluation and treatment . All staff were trained (In-services on transfers, mechanical lift transfers, bed mobility, and repositioning with return demonstration) and CMA (CMA A) was terminated as it was found she failed to care for him without getting the assistance of a second staff member. Ad-hoc QAPI was held regarding fall . An audit was done on January 9-10 2026 to ensure residents care plans accurately reflected each resident's assessment needs . In an interview on 01/13/26 at 9:45 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 455682 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455682 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Afton Oaks Nursing and Rehabilitation Center 7514 Kingsley St Houston, TX 77087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)