Health inspection·August 3, 2023

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure nurse aides are competent in skills and techniques necessary to care for Resident's needs identified through assessments and described in the plan of care. The facility failed to utilize two caregivers to provide incontinent care for Resident #2 as described in her plan of care. The aide stated in an interview she performed incontinent care by herself for Resident #2, the resident had rolled off the bed and sustained injures on 8/01/23 two days earlier. This failure could result in falls or injuries for residents who require two person assistance for transfers and repositioning. Findings included: Review of the Face Sheet for Resident #2 reflected she was admitted to the facility on [DATE] with diagnosis of: Sequelae of Cerebral Infarction, Chronic Atrial fibrillation, Hemiplegia and Hemiparesis affecting right side , Dementia, Anxiety, Type 2 Diabetes, Congestive Heart Failure (CHF) and Osteoporosis . Review of the Annual MDS assessment for Resident #2 dated 5/30/23 reflected a BIMS score of 15 indicating normal cognitive functioning. Her functional assessment reflected she required extensive assistance for all ADLs except eating which required set up assistance . She was assessed as always incontinent of bowel and bladder. Review of the Care Plan for Resident #2 dated 8/03/23 reflected interventions were in place for: post stroke care including physical weakness and deficits, Bilateral Hemiplegia, a High risk for falls, and an actual fall on 8/02/23 with major injury. Interventions for the fall included 2-person assist with repositioning and personal care (dated 8/03/23), Staff education on assisting with proper bed mobility when low air loss mattress is used. Resident #2 had interventions related to pain management and a pathological bone fracture-subchondral insufficiency fracture to the anterior latera tibial plateau r/t Vitamin D deficiency and Osteoporosis (dated 8/02/23). Review of a progress note for Resident #2 dated 8/01/23 reflected the nurse was notified by the CNA at 4:55 am the resident had rolled off the bed during a brief change. The nurse found the resident laying on the floor on her left side. Blood was noted by the nurse on the floor with skin tears to the left and right forearm. EMS was called for transfer to local emergency room and departed the Page 1 of 3 675942 675942 08/03/2023 Towers Nursing Home 372 Hill Road Smithville, TX 78957

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility at 5:17 am. The notes reflected hospital staff reported no damage found in a CT of the head and spine. A small 1 centimeter subchondral insufficiency fracture anterior lateral tibial plateau was found on x-ray. Resident #2 returned to facility at 1:35 pm. Review of the sign up sheet for Resident #2's updated Care Plan post fall dated 08/01/23 reflected CNA S was present for inservice on Resident #2 on 8/01/23. In an interview and observation on 8/03/23 at 12:05 pm, Resident #2 stated she had a fall two days ago. She stated she did not know how the fall occurred, but she woke up on the floor on her back and could not recall any details. Resident #2 was observed to have a blackened/bruised left eye and a bruise to the front of her left forehead. She stated she was on blood thinners since her heart surgery some time ago. She stated she had one sided weakness from a stroke. Resident #2 stated she had previously stayed at the facility after breaking her hip and insisted on coming back to Towers because she thought care was good. In an interview on 8/03/23 at 12:56 pm, Resident #2's son stated he was concerned after his mother rolled off the bed on 8/01/23. He stated interventions to remedy the fall risk was to have two persons providing her care and repositioning. He stated when he visited his mother on 8/02/23, he observed one staff member providing care . He stated he was upset about bruising to his mother's face and left eye and a fracture to the left knee bone. In an interview on 8/03/23 at 12:42 pm, CNA S stated on 8/02/23 she was assigned to the middle hall (300 hall). She stated the aide she was working with went on break and she was answering call lights. She stated she went into Resident Halls room and she requested pericare. She stated she was new and did not know all the resident's names and needs. She stated she did not receive the in-service about Resident #2 needing 2-person care at all times. She stated the son of the resident came in at the end of care, she covered the resident, and the son made no mention of any issues to her. She stated she did Resident #2's care slowly and carefully. No falls occurred and Resident #2 was not injured. She stated the Resident was moderately incontinent of urine and she had since received the in-service care. In an interview on 8/03/23 at 12:00 pm, LVN B stated he was charge nurse for the 300 hall. He stated Resident #2 was the only person who had experienced a fall on 300 recently. He stated she had bruising to her face and side and was to have two-person assist for all care. He stated fall prevention was in place. In an interview on 8/03/23 at 12:10 pm, RN H stated she normally worked on Hall 300 with Residents but today she was filling in. She stated most staff work the same halls daily. She stated Resident #2 had fall prevention and the falling star program in place for her safety. In an interview on 8/03/23 at 12:26 pm, the ADON stated Resident #2 went to the ER on [DATE] and returned a few hours later. She stated an in-service education was held the same day and everyone was aware Resident #2 was to be a two person assist for all care and repositioning. The ADON stated the care plan was updated. She stated there was sufficient staff for a two person assist around the clock. She stated normal staffing was one nurse and 2 aides for each shift. In an interview on 8/03/23 at 2:50 pm, the Nurse Aide Trainer stated CNA S was present for the in-service on Resident #2's Care on 8/01/23. She stated she performed the in-service herself. She stated she did training for Group A and then group B right after, she stated the timing at change of shift 675942 Page 2 of 3 675942 08/03/2023 Towers Nursing Home 372 Hill Road Smithville, TX 78957

F 0726 Level of Harm - Minimal harm or potential for actual harm worked out perfectly. She stated the PRN people and part timers have to sign off before they go to their areas. In an interview on 8/03/23 at 2:55 pm CNA U stated she received the in-service education on providing two-person assistance to Resident #2 for all care. Residents Affected - Few In an interview on 8/03/23 at 3:05 pm, the ADON stated she expected all staff would provide care as prescribed in each Resident's care plan according to their needs . She acknowledged CNA S had signed the in-service education sheet dated 8/01/23. In an interview the Administrator stated he was working to resolve the complaints of Resident #2's son. He stated she had sustained a fall on 8/01/23 and was injured. He stated during pericare her low air loss mattress went flat and she rolled off the edge of the bed while one person (CNA T) was providing care. Resident #2 sustained injuries and as a result of the incident her interventions were updated to include that she must have two person assist for care at all times. The Administrator stated he received a report on 8/02/23 that the son entered the facility and one aide was changing his mom. The Administrator stated the aide (CNA S) may not have received the in-service education for Resident #2 as she had recently transferred to the facility. He stated CNA S had admitted she was performing care for Resident #2 by herself. He stated his expectation was all staff would receive the in-service education and provide two person assistance/care to Resident #2. 675942 Page 3 of 3