Health inspection·January 8, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained free of accident and hazards for 3 of 5 residents (Resident #1, #2 and #3) reviewed for accident hazards. The facility did not ensure Resident #1 had on slip proof footwear. The facility did not ensure the floor of secured unit hallway was free of water, where Resident #1, #2 and #3 routinely wandered. These failures could place residents at risk for falls, injury and decreased quality of life. Findings included: 1.Record review of the face sheet for Resident #1 dated 1/8/24 indicated she was [AGE] years old admitted to the facility on [DATE] with diagnoses including, dementia, rheumatoid arthritis (chronic inflammatory disorder affecting many joints. In rheumatoid arthritis, the body's immune system attacks its own tissue, including joints), history of stroke, hemiplegia and hemiparesis affecting the left non-dominant side (paralysis/ weakness to one side of the body). Record review of the MDS dated [DATE] indicated Resident #1 understood others and made herself understood. The MDS indicated she had severe cognitive impairment (BIMS of 02). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #1 wandered daily. The MDS indicated she was frequently incontinent of bowel and bladder. Record review of the care plan dated 12/20/23 indicated Resident #1 was at a high risk of falls due to her history of frequent falls, and risk factors including weakness, cognitive deficit and incontinence. The care plan interventions included ensure the resident is wearing appropriate footwear when mobilizing in her wheelchair and provide a safe environment with even floors, free from spills and/or clutter . Record review of Resident #1's incident and accident reports from 12/13/23 to 1/8/24 indicated Resident #1 had a fall without injury on 12/22/23 and a fall with injury on 12/26/23. Record review of the incident report on 12/26/23 indicated Resident #1 had a witnessed fall in the hallway of the secured unit in which she hit her head on her bedroom door and sustained a four-centimeter laceration to the right side of her face, next to her right eye . The incident report stated Resident #1 was independent with bed mobility but required staff assistance with toileting, Page 1 of 6 675267 675267 01/08/2024 Greenbrier Nursing & Rehabilitation Center of Tyle 3526 W Erwin St Tyler, TX 75702

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some transferring and walking. The incident report also stated Resident #1 had an unsteady gait, leaned forward and had a balance problem. The incident report did not identify a lack of appropriate footwear as a causative element. During an observation on 1/5/24 at 1:30 p.m., Resident #1 was sitting in her wheelchair in the hallway of the secured unit. Resident #1 was noted with bruising and steri-strips (porous surgical tape strips which can be used to close small wounds) in place to the right side of her face. Resident #1 had black and white plaid, thick fuzzy socks on her feet. Resident #1 wandered the secure unit hallway in her wheelchair. Resident #1 was not interviewable. During an interview on 1/5/24 at 1:33 p.m., CNA B said Resident #1 had sustained the bruising as result of her last fall (12/26/23) as well as a cut where the steri-strips were applied. During an observation at 1/5/24 at 1:34 p.m., a yellow caution sign was noted in the center of the hallway of the secured unit. There was a small amount of water on the floor under the caution sign (the area of water on the floor was approximately 4-5 centimeters). A few drops of water were noted on the floor just beside the caution sign. During an observation on 1/5/24 at 1:40 p.m., Resident #1 was sitting in her wheelchair in the hallway of the secured unit. Her wheelchair was positioned up against the glass entrance door of the secure unit. Resident #1 reached out with her hands, grabbed the handle of the door and pulled herself into a standing position infront of her wheelchair. Resident #1 had black and white plaid, thick fuzzy socks on her feet. MA C went into the secured unit and assisted Resident #1 back into her wheelchair. During an observation and interview on 1/5/24 at 1:45 p.m., Resident #1 sat in her wheelchair in the hallway of the secured unit. CNA B and MA C stood beside her. CNA B said it was important to for residents to have appropriate footwear on to prevent slips and falls. CNA B explained, appropriate footwear meant shoes with tread or socks with slip resistant tread. CNA B said it was important to ensure residents on the secure unit had appropriate footwear and were well supervised because they (residents on the secure unit) had a lack of safety awareness. CNA B looked at the bottom of Resident #1's socks when requested by the surveyor. CNA B said Resident #1's socks had no gripping traction on the sole and were not slip proof. CNA B said Resident #1 should have appropriate footwear on her feet. CNA B said she had not placed the socks on Resident #1 and did not notice the socks did not have gripping traction. During an observation and interview on 1/5/24 at 1:47 p.m., Resident #1 sat in her wheelchair in the hallway of the secured unit. CNA B and MA C stood beside her. MA C said it was very important to ensure residents on the secure unit had appropriate footwear and were well supervised because they (residents on the secure unit) had a lack of safety awareness. During an interview on 1/5/24 at 2:00 p.m., LVN A said she was the nurse for the secured unit. LVN A said it was important to ensure residents on the secure unit had appropriate footwear and were well supervised because they (residents on the secure unit) had a lack of safety awareness and several of the secured unit residents independently wandered on the secure unit. LVN A said she made rounds every 2 hours and would correct inappropriate footwear if she noticed any during her rounds. LVN A said CNAs remained on the secure unit at all times and usually ensured appropriate footwear was worn by the residents. 675267 Page 2 of 6 675267 01/08/2024 Greenbrier Nursing & Rehabilitation Center of Tyle 3526 W Erwin St Tyler, TX 75702

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Record review of the face sheet for Resident #2 dated 1/8/24 indicated she was [AGE] years old admitted to the facility on [DATE] with diagnoses including, Parkinson's disease ( a disorder of the central nervous system that affects movement, often including tremors) dementia, restless leg syndrome, muscle weakness, unsteadiness on feet, and lack of coordination. Record review of the MDS dated [DATE] indicated Resident #2 usually understood others and usually made herself understood. The MDS indicated she had moderate cognitive impairment (BIMS of 08). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #2 had wandered 1-3 days during the 7-day look back period. daily. The MDS indicated she was occasionally incontinent of bladder. Record review of the care plan updated 4/4/23 indicated Resident #1 was at a high risk of falls due to her history of frequent falls, as well as risk factors including:; unsteady gait and frequent urinary incontinence. The care plan interventions included provide a safe environment with even floors, free from spills and/or clutter . Record review of Resident #2's incident and accident reports from 10/1/23 to 1/5/24 indicated she had fallen without significant injury on the following dates:; *10/17/23, *10/19/23, *10/25/23, *10/27/23, *11/7/23, *11/29/23, *11/30/23, *12/1/23, *12/5/23, *12/27/23, *12/31/23, and *1/4/24. During an observation at 1/5/24 at 1:34 p.m., a yellow caution sign was noted in the center of the hallway of the secured unit. There was a small amount of water on the floor under the caution sign (the area of water on the floor was approximately 4-5 centimeters). A few drops of water were on the floor just beside the caution sign. During an observation on 1/5/24 at 2:00 p.m., Resident #2 was independently wandering on the 675267 Page 3 of 6 675267 01/08/2024 Greenbrier Nursing & Rehabilitation Center of Tyle 3526 W Erwin St Tyler, TX 75702

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some secured unit hallway with her walker. The yellow caution sign remained in the center of the hallway of the secured unit. The small amount of water on the floor also remained on the floor. During an observation on 1/5/24 at 3:45 p.m. the yellow caution sign remained in the center of the hallway of the secured unit. The area of water was larger, and formed a puddle approximately 7 inches in diameter. Water dripped from the ceiling tile above. 3. Record review of the face sheet for Resident #3 dated 1/8/24 indicated she was [AGE] years old re-admitted to the facility on [DATE] with diagnoses including, dementia and senile degeneration of the brain (he mental deterioration (loss of intellectual ability). Record review of the MDS dated [DATE] indicated Resident #3 understood others and made herself understood. The MDS indicated she had severe cognitive impairment (BIMS of 02). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #3 had wandered 4-6 days during the 7-day look back period. The MDS indicated she was independent with ambulation. The MDS indicated she was frequently incontinent of bowel and bladder. Record review of the care plan updated 11/9/23 indicated Resident #3 was at a high risk of falls due to her history of frequent falls, and unsteady gait. The care plan interventions included provide a safe environment with even floors, free from spills and/or clutter . Record review of Resident #3's incident and accident reports from 10/1/23 to 1/5/24 indicated she had fallen without significant injury on the following dates (times are listed when multiple falls occurred on the same day): *10/26/23 at 9:28 p.m., *10/26/23 at 10:15 p.m. , *10/28/23, *11/3/23, *11/24/23 at 7:07 a.m., *11/24/23 at 1:15 p.m., *11/27/23, and *12/24/23 at 4:45 p.m. Record review of the incident report dated 11/28/23, indicated Resident #3 was ambulating down secured unit hallway and attempted to change direction which caused her to stumble backwards and hit her head on a door. The report indicated Resident #3 sustained a small 2-centimeter laceration to the back of her head. The report indicated she was sent to the hospital for evaluation and no additional injuries were found. Record review of the incident report dated 12/24/23 at 9:04 p.m., indicated Resident #3 was sitting in her wheelchair when she stood up and began to ambulate, fell and bumped her head. The incident 675267 Page 4 of 6 675267 01/08/2024 Greenbrier Nursing & Rehabilitation Center of Tyle 3526 W Erwin St Tyler, TX 75702

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some report indicated Resident #3 sustained a laceration to left eyebrow measuring 2 centimeters x 0.2 centimeters. She was sent to the hospital for evaluation and no additional injuries were found. During an observation at 1/5/24 at 1:34 p.m., a yellow caution sign was noted in the center of the hallway of the secured unit. There was a small amount of water on the floor under the caution sign (the area of water on the floor was approximately 4-5 centimeters). A few drops of water were on the floor just beside the caution sign. During an observation on 1/5/24 at 1:50 p.m., Resident #3 was walking down the secure unit hall independently. The yellow caution sign remained in the center of the hallway of the secured unit. The small amount water on the floor remained on the floor. During an observation on 1/5/24 at 2:00 p.m., Resident #2 was wandering on the secured unit hallway with her walker. The yellow caution sign remained in the center of the hallway. During an observation on 1/5/24 at 3:45 p.m. the yellow caution sign remained in the center of the hallway of the secured unit. The area of water was larger, and formed a puddle approximately 7 inches in diameter. Water dripped from the ceiling tile above. During an interview on 1/5/24 at 3:47 p.m., CNA B said she noticed the sign earlier in the day (1/5/24) but could not say for sure if it was there when she came to work. CNA B said it was a new and guessed it occurred today (1/5/24) because of the heavy rain. CNA B said she had been told there was a ceiling tile leaking and that maintenance was working on it. CAN B said she could not recall who told her maintenance was working on the area. CNA B said she did not notice the water on the floor getting larger. CNA B said the water in the floor posed a fall risk, especially for the residents who regularly wander the hall on the secured unit as they (secured unit residents) have decreased safety awareness. CNA B said Residents #1, #2 and #3 regularly wandered on the secure unit and was keeping a close eye on them because of the water in the floor. During an interview on 1/5/24 at 3:55 p.m., the maintenance director said he had been notified of a ceiling leak on the secured unit that morning (1/5/24) he said he thought it was around 10:00 am this morning. He said at that time he called a roofing company to assess the area and provide an estimate for repair but was told it would be Monday (1/8/24) before they could come. The maintenance director said he had cleaned the water and instructed the staff on the secured unit to notify him if it (the water on the floor) had gotten worse. The maintenance director said he had not been notified the water had gotten worse and would take care of it. During an interview on 1/8/24 at 3:49 p.m., LVN A said CNA B had pointed out the leaking ceiling tile to her earlier in the morning (1/5/24) and she knew maintenance was working on it. LVN A said she did not notice the water on the floor increasing when she made her rounds on 1/5/24 . LVN A said the leaking ceiling tile was new and there had not been issues before today (1/5/24). LVN A said the water in the floor posed a fall risk, especially for residents on the secured unit as they (secured unit residents) have decreased safety awareness and decreased cognitive awareness. During an interview on 1/8/24 at 3:02 p.m., the DON said she expected staff to ensure that residents had appropriate footwear to give traction and prevent falls. The DON said the water in the floor was a fall hazard especially on the secured unit because residents on the secure unit were not as easily redirected and had decreased or no safety awareness. The DON said she had not been notified of the leaking ceiling tile on the secured unit until the late in the afternoon on 1/5/24, so would have 675267 Page 5 of 6 675267 01/08/2024 Greenbrier Nursing & Rehabilitation Center of Tyle 3526 W Erwin St Tyler, TX 75702

F 0689 Level of Harm - Minimal harm or potential for actual harm not known to check on it. The DON said the facility performed champion rounds, which involved a head of department rounding on a specific area of the building for care issues. The DON said that would include fall hazards such as water in the floor. The DON said she would not expect the department head to ensure socks were skid/slip proof, as they (the department head) would have to lift up the feet of every resident. The DON said it was the CNAs responsibility to ensure appropriate footwear were on the residents feet. Residents Affected - Some During an interview on 1/8/24 at 3:31 p.m. the Administrator said she expected staff to ensure residents had slip proof shoes or socks on their feet when they were not in bed to prevent falls. The Administrator said any liquid on the floor poses a risk of slips and falls. The Administrator said she expected staff to promptly clean the area of liquids (including water) and place a caution sign up. The Administrator said that the caution sign would not be as effective on the secured unit as people with dementia have a decreased safety awareness . Record review of the facility policy and procedure titled, Fall Risk Mini Manual, dated 2003 stated . 4. (fall) Risk factors will be identified for all residents. Risk factors that cane be reduced will be addressed accordingly. Reducing Environmental hazards . (2) Look for uneven surfaces, slippery floors, obstacles in the walkway or absence of handrails . Post signs and clean spills on surfaces immediately .Evaluate Footwear (1) Evaluate shoes for comfort, size, sole (firm, non-rigid, non-skid). (2) Avoid high heels and walking in socks or loose slippers. Record review of the facility policy and procedure titled, Preventive Strategies to Reduce Fall Risk, revised October 5, 2016 stated, Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility . 9. Footwear: Footwear, shoes, slippers, etc., worn by residents should fit properly and have slip resistant soles . (1) Shoes and slippers with rubber or crepe soles will be used to provide adequate slip resistance on floors. Socks with nonskid tread are also a good choice . (11) Assessment: .Conduct environmental safety rounds on a daily basis .(12)Nursing Car: .Provide properly fitting, non-slip footwear . (13) Environment: . Maintain nonslip floor surface. Keep hallway clear . 675267 Page 6 of 6