Inspection·January 5, 2024

F 0689 showed no signs of pain. The nursing notes also indicated LVN A set eyes on the resident around 5:10am and the resident was in the recliner with feet up and covered up with a cover . Level of Harm - Actual harm Residents Affected - Few During a telephone interview on 1/4/2024 at 8:55 p.m., LVN A said the Hospice aid came in to provide the activities of daily living for resident #1 between 4:30 a.m. and 5:00 a.m. on 12/18/2023. LVN A stated Resident #1 was found on the floor just after the Hospice aid left (approximately 10 minutes). LVN A stated she laid eyes on Resident #1 after the aid left and Resident #1 was in the recliner. LVN A was informed the resident had fallen by CNA A about 5:15 a.m., the resident was on the floor, in the doorway between the room, and the hallway. LVN A performed a nurse assessment which revealed a goose egg on the left side of the head, a skin tear, and a swollen purple zig zagged nose. We cleaned up the resident and I sent her and the aid to the be assessed at the hospital. LVN A stated there was no bed alarm or chair alarm in the room from what she could see after performing the assessment. During a telephone interview on 1/4/2024 at 9:20 a.m., CNA A stated she was taking the trash out on 12/18/2023 at 5:15 a.m. and heard a loud sound. She stated she discovered Resident #1 on the floor of a room in the hallway. CNA A stated she reported the incident to LVN A. CNA A stated the resident was treated by LVN A and transferred to the hospital . CNA A did not note a bed/chair alarm in place at the time of the incident. During a telephone interview on 1/5/2024 at 10:14 a.m., the Hospice aide stated she helped a facility aide (name unknown) place the resident in the recliner in her room before leaving the morning of 12/18/2023. There was no bed/chair alarm in the room at this time. The Hospice Aide stated she did place non-slip socks on Resident #1 and left with the call light within reach of Resident #1 . During a telephone interview on 1/5/2024 at 6:12 p.m., the relative of Resident #1 indicated he was informed about the fall on 12/18/2023 at about 6:15 a.m. and met Resident #1 at the Emergency Room. He was told Resident #1 was found face first on the floor and broke her nose. The hospital wanted to perform surgery, but he refused due to her inability to manage anesthesia . During an observation of Resident #1 and interview of LVN B on 1/5/2024 at 2:15 p.m., Resident #1 was lying in bed with the bed alarm in place. LVN B tested the bed alarm, and it was in proper working order at that time. LVN B stated when the alarm goes off it rings at the nurse's station, and they must go to the resident, and ensure her safety . During an interview on 1/5/2023 at 3:15 p.m., the DON and the Administrator stated the facility expects staff to adhere to care plans and the interventions in place to keep residents safe. This resident does have an order for a bed/chair alarm and a care plan noting its use. It is also the expectation of staff to follow the policy and protocols set in place. The bed/chair alarm not being utilized appropriately does not meet the expectation set by the policy. Review of the faciliy's Policy, Falls/ Ambulation Difficulty, MM FR 03-2.0, revealed the following: [in part] Prevention of Unsafe Transfers or Ambulation Adaptive equipment to include Chairs that prevent rising or alarms may be necessary as the least restrictive type of restraint. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675572 If continuation sheet Page 2 of 3 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 675572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glen Rose Nursing and Rehab Center 1019 Holden St Glen Rose, TX 76043 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 Preventive Strategies to Reduce Fall Risk Level of Harm - Actual harm 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. Residents Affected - Few Procedure: - The facility will complete a fall risk assessment on each resident at the time of admission to the facility. The Fall Assessment Tool will be used to assess the resident's risk of falls. - Residents that score in the high risk category (10 points or greater) will be placed on fall precautions and care planned for fall prevention. - The clinical record and resident will be flagged to alert personnel of the resident' s risk status. Interventions will be designed to protect the resident's privacy. - After risk is assessed, individualized nursing care plans will be implemented to prevent falls. The resident and family members will be educated on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family, implementing rehabilitation programs to improve functional ability, and care monitoring of medication side effects. - Medical Strategies: a) Identify residents at risk for falls, b) Identify sign/symptom of underlying disease or medication effect that requires a clinician' s attention in order to rule out reversible acute problems, c) Identify chronic medical conditions that may contribute to fall risk and treat appropriately, d) Assess medications, e) Provide PT/OT evaluation and treatment as needed. - Residents who fail to respond or improve with medical treatment and continue to remain fall risks may respond to a number of rehabilitative strategies. Rehabilitative strategies will be evaluated for all high risk residents . - Incident Reporting: Reported falls will be thoroughly investigated to assess fall risk factors and contributing factors in order to provide a safe environment for the resident(s). - Nursing Care: Maintain regular toileting schedules. Use bedside commodes during hours of sleep, if needed. Provide properly fitting, nonslip footwear. Place confused residents close to nurses' station for close observation, if possible. Establish frequent nursing rounds on high risk residents. Provide assistive ambulation. Encourage daily exercise. Increase nursing staff. - Environment: Place the call light and other objects within easy reach. Use bed/chair alarm systems to monitor unsafe activity as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675572 If continuation sheet Page 3 of 3