Health inspection·July 13, 2023

F 0689 and found without injury. Level of Harm - Minimal harm or potential for actual harm Record review of the facility incident report dated 7/10/23, titled Fall with injury for Resident #1 indicated nurses were in the middle of shift change when they heard a loud crash. The incident report indicated Resident #1 was assessed and 1.5 inch laceration was noted to the back of his head. The incident report indicated Resident #1 was sent to the hospital for evaluation. Residents Affected - Few Record review of the fall risk evaluation dated 7/12/23 indicated Resident #1 had a score of 16 and was considered at high risk for falls. During an interview on 7/13/23 at 12:55 p.m., CNA B said she regularly took car of Resident #1 on the 12 hour day shift. CNA B said Resident #1 just got back from the hospital because of a fall. CNA B said most of the residents on the secure unit are at risk for falls because they wander and have decreased safety awareness. CNA B said it was important for residents at high risk for falls to have prevention (and mitigation) interventions in place. CNA B said these interventions included fall mats at the side of bed. CNA B said Resident #1 always had a brown floor mat at his bedside. CNA B she could not say for sure if the fall mat was in place at the time of his fall because she had not went in the room on 7/10/23 because both nurses responded. During an observation on 7/13/23 at 12:58 p.m., Resident #1 was laying in his bed on the secured unit. There was no fall mat to the left or right of his bed. A blue fall matt was folded leaned on the wall at the head of his roommate's bed. There were no other fall mats in the room. Resident #1's bed was in the lowest possible position and his call light was in reach. During an observation and interview on 7 /13/23 at 12:59 p.m., OT D came into Resident #1's room and knelt down by his bedside. OT D said Resident #1 usually had a fall matt in place. During an interview on 7/13/23 at 1:07 p.m., LVN A said she took care of Resident #1 Monday through Thursday on the 6:00 a.m. -2:00 p.m. shift. LVN A said Residents on the secure unit tend to be at increased risk for falls because they have decreased or no safety awareness. LVN A said Resident #1 had just returned from the hospital yesterday (7/12/23). LVN A said it was especially important to ensure Resident #1 had fall interventions in place with his recent fall history. LVN A said Resident #1's fall interventions included the placement fall mat at the side of his bed. LVN A said the when Resident #1 fell on 7/10/23, his fall mat was in place. LVN A said herself and LVN C were counting the med-cart in the hallway when they hear Resident #1 fall. LVN A said both herself and LVN C went to check on him. LVN A said he was just pat the fall matt towards the end of the bed and the bed was in the lowest position. LVN A said Resident #1's fall matt was usually in place because she usually tripped over it when she administered meds. During an observation on 7/13/23 at 2:00 p.m., Resident #1 was laying in his bed. There was no fall mat to the left or right of his bed. A blue fall mat was folded leaned on the wall at the head of his roommate's bed. There were no other fall mats in the room. Resident #1's bed was in the lowest possible position and his call light was in reach. During an interview on 7/13/23 at 2:44 p.m., LVN C said she regularly took care of Resident #1 on the 2:00 p.m. - 10:00 p.m. shift. LVN C said Resident #1 had recently returned from the hospital from a fall. LVN C said she would consider it especially important to ensure Resident #1 had fall interventions in place due to his recent fall. LVN C said Resident #1's fall interventions included a fall mat placed at the side of his bed. LVN C said when Resident #1 fell on 7/10/23, his fall mat was in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 2 of 4 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm place. LVN C said the unwitnessed fall occurred during shift change, so herself and LVN A were counting the med-cart in the hallway when they hear Resident #1 fall. LVN C said both herself and LVN A went to check on him. LVN C said he was just pat the fall matt towards the end of the bed and the bed was in the lowest position and hic walker was out infront of him. LVN C said she thought he fell while reaching for the walker. Residents Affected - Few During an interview and observation on 7/13/23 at 2:50 p.m., Resident #1 was laying in his bed. There was no fall mat to the left or right of his bed. A blue fall mat was folded leaned on the wall at the head of his roommate's bed. There were no other fall mats in the room. LVN C said someone must have moved the mat while providing care. LVN C said Resident #1 should have had a fall mat in place. Resident #1's bed was in the lowest position. During an interview on 7/13/23 Resident #1's representative said she visited the facility often and Resident #1 usually had a fall mat by his bed when she was there. 2. Record review of Resident #2's face sheet indicated she was [AGE] years old and readmitted to the facility on [DATE] with diagnoses including dementia, lack of coordination, and unsteadiness on feet. Record review of the MDS dated [DATE] indicated Resident #2 had severe cognitive impairment (BIMS of 0). The MDS indicated Resident #2 required extensive assistance with bed mobility, transfers, locomotion in her wheelchair, dressing, eating, toilet use and personal hygiene. The MDS indicated she required limited assistance with walking and was totally dependent on staff for bathing. The MDS indicated Resident #2, with balance during transitions and walking, was not steady and only able to stabilize with staff assistance. The MDS indicated she was always incontinent of bowel and bladder. Record review of the care plan revised on 4/2/23 indicated Resident #2 was at risk for falls with actual fall history. The care plan interventions included non-slip footwear. Record review of the facility incident log from 2/13/23 to 7/13/23 indicated Resident #2 had not had any falls between 2/13/23 and 7/13/23. During an observation on 7/13/23 at 12:40 p.m., Resident #2 sat in her wheelchair in the secure unit dining room. Resident #2 had white socks on her feet. Resident #2 had no shoes on her feet. There was no slip resistant surface on the bottom of the socks. During an interview on 7/13/23 at 12:55 p.m., CNA B said she regularly worked on the secure unit on the 12 hour day shift. CNA B said most of the residents on the secure unit are at risk for falls because they wander and have decreased safety awareness. CNA B said it was important for residents at risk for falls to have prevention (and mitigation) interventions in place. CNA B said these interventions included fall mats at the side of the bed, and appropriate footwear. CNA B clarified appropriate footwear meant footwear that was not slick on the bottom. CNA B said without appropriate footwear a resident could easily slip. During an interview on 7/13/23 at 1:07 p.m., LVN A said she worked on the secured unit Monday through Thursday on the 6:00 a.m. -2:00 p.m. shift. LVN A said Residents on the secure unit tend to be at increased risk for falls because they have decreased or no safety awareness. LVN A said she tried to mitigate residents' fall risk by monitoring frequently, ensuring residents had slip proof footwear, and keeping beds in the lowest position and ensuring residents with fall mats had them in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 3 of 4 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 675367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Gardens 3500 Park St Greenville, TX 75401 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 7/13/23 at 1:58 p.m., Resident #2 sat in her wheelchair in the secure unit dining room. Resident #2 had white socks on her feet. Resident #2 had no shoes on her feet. There was no slip resistant surface on the bottom of the socks. During an interview and observation on 7/13/23 at 2:55 p.m., Resident #2 sat in her wheelchair in the secure unit dining room. Resident #2 had white socks on her feet. Resident #2 had no shoes on her feet. There was no slip resistant surface on the bottom of the socks. LVN C looked at the socks on Resident #2's feet. LVN C said the socks could cause her to slip and fall. LVN C said the socks were not appropriate footwear as they did not have any tread or grip to the sock. During an interview on 7/13/23 at, 3:30 p.m., the DON said she expected staff to ensure residents had care planned fall prevention measures in place. The DON said Resident #1 should have had a fall mat in place especially given his recent fall. The DON said Resident #1 did a fall mat at his bedside the day of the fall. The DON said Resident #2 should have had slip proof footwear on her feet. During an interview on 7/13/23 at 3:45 p.m., the Administrator said, he expected staff to ensure residents had care planned fall prevention measures in place. The Administrator said nurses/nurse aides should be rounding every 2 hours to ensure fall prevention measures were implemented and ongoing monitoring to prevent falls should take place throughout their shifts as they provided care. The Administrator said the system in place to oversee nursing staff in the implementation of fall prevention/intervention was ambassador rounds. The Administrator said ambassador rounds were rounds performed by administrative staff daily to ensure various care areas including fall prevention measures, were in place. Record review of the facility policy and procedure titled Fall Evaluation and Prevention, revised August 2020, found the policy stated Purpose: to ensure the resident's environment remains free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents. Policy: The facility will evaluate residents for their fall risk and develop interventions for preventing . extrinsic risk factors inappropriate foot wear (soft-cushion soles or ill-fitting shoes) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675367 If continuation sheet Page 4 of 4