Health inspection·November 20, 2023

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 observation, interview, and record review the facility failed to provide adequate supervision and assistive devices to prevent accidents for 1 (Resident # 1) of 9 reviewed for falls. The facility failed to provide adequate supervision for Resident # 1 , by ensuring all staff were awake while on duty, which resulted in Resident # 1 falling on 11/14/2023 and sustaining a right superior and inferior pubic rami fracture. This failure could resulted in Resident # 1 with a fracture of the right superior and inferior pubic rami fracture and the other residents at risk from injuries. Findings include: Review of Resident # 1's face sheet dated 11/14/2023 revealed a [AGE] year-old female admitted on [DATE]. Resident # 1's diagnoses include Chronic obstructive pulmonary disease with exacerbation (a group of lung diseases that block airflow and make it difficult to breathe with increasing symptoms), schizoaffective disorder, bipolar type (feelings of euphoria, racing thoughts, and risky behavior), and Other specified disorders of bone density and structure (a bone disease that develops when bone mineral density and bone mass decreases). Review of Resident # 1's hospital discharge paperwork dated 11/14/2023 revealed a CAT scan of the pelvis report revealed acute posttraumatic right superior and inferior pubic rami fracture. Review of Resident # 1's Quarterly MDS dated [DATE] revealed a BIM score of 1 (0-7 severely impaired cognition) and a transfer-coding of one person assist. MDS indicated that Resident # 1 requires supervision with the use of an assistive device for mobility in the room and on the unit. Review of Resident # 1's care plan revealed Focus initiated on 11/28/2022, moderate risk for falls related to deconditioning (the decline in physical function of the body because of physical inactivity). interventions include 11/28/2022 following facility fall protocol. Review of Resident # 1's medical record revealed progress notes dated 11/14/2023 written by LVN C while performing rounds the resident was noted sitting on her bottom, to the right side of her bed. At the time of the fall Resident# 1 was treated for a skin tear Upon follow-up for the fall approximately 15 minutes later revealed right leg and hip pain, and the resident was medicated, Nurse practitioner and Resident representative were notified and then transferred to hospital for evaluation. Page 1 of 3 675139 675139 11/20/2023 Windsor Healthcare Residence 1025 W Yeagua Groesbeck, TX 76642

F 0689 Review of Resident #1 's Fall Assessment completed 08/15/2023 revealed a Moderate Fall risk. readmission assessment on 11/14/2023 fall assessment remained at Moderate fall risk. Level of Harm - Actual harm Residents Affected - Few Observation on 11/20/2023 at 11:45 am of Resident # 1 revealed she was sitting up in the dining room, well groomed, walker at her chairside. Resident # 1 was oriented to name only; the resident denied any pain and no signs and symptoms of pain. 11/20/2023 at 12:15 pm attempted to contact LVN C, no answer, A voice message was left requesting a phone call. 11/20/2023 at 12:20 pm Attempted to contact CNA A, no answer, A voice message was left requesting a phone call. 11/20/203 at 1:30 pm attempted to contact CAN B, no answer, A voice message was left requesting a phone call. Interview on 11/20/2023 at 12:30 pm with the DON, during the investigation of the incident on 11/15/2023 in a phone interview LVN C reported to the DON she discovered CNA A sleeping on the couch near the nurse's station on 11/14/2023 while attempting to locate her to assist move Resident # 1 from the floor per the eye witness statement the resident was found on the floor at 12:50 am there is no time documented on when the CNA was found sleeping. CNA A was suspended pending the investigation. The DON stated that supervision of the resident while on duty was their job and failure to do that could lead to possible negative incomes. DON stated during the investigation CNA A stated that she completed rounds and laid down on the couch at 12:15 am and LVN C found the resident on the floor at 12:50 am. CNA A usually works days and agreed to pick up the night shift. Staffing at night includes 2 CNAs, one for the secure unit and one on the other halls, and an LVN. Resident # 1 resides in the secure unit and that was CNA A's assignment. CNA A was referred to the Nurse registry by the facility on 11/20/2023. Interview on 11/20/2023 at 1:00 pm with the ADM revealed his expectation were that when staff member reports to work, they perform their job duties which always includes supervision of residents. He stated that the failure of a staff member to supervise a resident can have a potential negative outcome. He stated that sleeping while on duty is unacceptable and against policy and grounds for immediate termination. He stated sleeping on the job can cause potential harm due to lack of supervision. Record review on 11/20/2023 at 130 pm of CNA A employee record revealed employee was terminated per company policy on 11/15/2023. Record Review on 11/20/2023 at 130 pm of Inservice records revealed the following in-services were completed on 11/15/2023 for all staff. Rounding, Staff tips on staying awake at night, Fall Prevention, Abuse, neglect and exploitation, and Company policy regarding sleeping while on the clock. Record review of the Provider investigation report on 11/20/2023 revealed that the Staff assigned to the unit that Resident #1 resided completed an in-service on 11/15/2023 that stated incontinent rounds every 2 hours for the resident. Investigated revealed resident did not utilize the call light, a bed alarm was ordered by the facility with anticipation of delivery on 11/21/2023. MD order and care plan will be updated when equipment is delivered. Plan in place for frequent rounds and offer the resident the restroom every 2 hours until equipment is in place. 675139 Page 2 of 3 675139 11/20/2023 Windsor Healthcare Residence 1025 W Yeagua Groesbeck, TX 76642

F 0689 Level of Harm - Actual harm Residents Affected - Few Record review of Witness statement of LVN C dated 11/15/2023 on 11/20/2023 at 130 pm revealed that LVN C reported she found CNA A was sleeping on the couch when she went to get help after finding Resident#1 on the floor. Record review of witness statement of CNA A dated 11/15/2023 on 11/20/2023 at 1:30 pm revealed that CNA A did admit to laying down on the couch and she does not remember going to sleep , she did remember LVN C waking her up. 675139 Page 3 of 3