Health inspection·August 7, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of eight residents reviewed for accidents.The facility failed to ensure Resident #1, assessed as high fall risk, had a floor mat in place while in bed upon observation on 08/07/2025 at 10:53 AM and 11:43 AM. This failure could place residents at risk of injury, resulting in a decreased quality of life.Findings included:In record review of Resident #1's Face Sheet dated 08/07/2025 revealed he was a [AGE] year-old admitted from an acute care hospital on [DATE]. Relevant diagnoses included traumatic brain injury (outside force/injury to the brain,) major depressive disorder (persistent feeling of sadness and loss of interest,) and repeated falls. In record review of Resident #1's Quarterly MDS dated [DATE] revealed he was moderately impaired cognitively with a BIMS score of 08. Resident #1 required substantial/maximal staff assistance with shower/bathing and personal hygiene. He was frequently incontinent of bladder and always incontinent of bowel. In record review of Resident #1's Fall Risk Evaluation dated 07/28/2025 revealed he was assessed as a high fall risk. In record review of Resident #1's Physician Orders on 08/07/2025 at 11:47 AM revealed no evidence of a physician order for a fall mat. In record review of Resident #1 Comprehensive Care Plan dated 08/07/2025 revealed he had an alteration in neurological status related to traumatic brain injury (outside force/injury to brain;) he required cueing and reorientation as needed. Additionally, he had unwitnessed falls on 05/21/2025, 06/18/2025, 06/20/2025, 06/29/2025, 07/10/2025, and 07/28/2025; he required:-Floor mat while in bed- Encouragement to use his call light-Therapy, fall prevention and safety awareness-Physical therapy evaluation and treatment-Speech therapy evaluation and treatment-Medication Review-Ensure resident has proper footwear and nonskid socks In observation of Resident #1 on 08/07/2025 at 10:53 AM and 11:43 AM he was resting in his bed. No fall mat was present upon observation. An attempt to interview Resident #1's on 08/07/2025 at 10:53 AM and 11:43 AM was unsuccessful due to his cognitive abilities. In interview with CNA S on 08/07/2025 at 11:43 AM, she stated there was not a fall mat in his room and she was not sure if he was required to have one. CNA S was given the opportunity to review her charting system and did not see any instructions for Resident #1 to have a fall mat. She stated the purpose of a fall mat was to reduce injury in the event of a fall, but she would check with the nurse if Resident #1 needed one. In interview with Resident #1's Nurse Practitioner and Provider on 08/07/2025 at 11:39 AM, she stated that a fall mat would be appropriate and expected to reduce injury for Resident #1. She stated she was aware of his frequent falls and would expect the facility to do all they could to reduce injury for Resident #1 for safety purposes. In interview with facility's DON on 08/07/2025 at 1:12 PM, she stated Resident #1 should have a fall mat at the bedside while he was in bed. She stated he had frequent falls, and a fall mat was an intervention to protect his safety. She stated while it was everyone's job to ensure Resident#1 had a fall mat at the bedside, it was her Page 1 of 2 675967 675967 08/07/2025 Northgate Plaza 2101 Northgate Dr Irving, TX 75062

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few responsibility to ensure it was there. In interview with facility's Administrator on 08/07/2025 at 1:47 PM, she stated her expectations were for any residents that need fall precautions have them in place. She stated fall mats for residents reduce injury and she expected the DON to ensure this was completed. In record review of facility policy, Fall Management System, rev 12/2023 revealed 2. Residents with high risk factors identified on the Fall Risk Evaluation will have an individualized care plan developed that includes measurable objectives and timeframes. a. The care plan interventions will be developed to prevent falls by addressing the risk factors and will consider the particular elements of the evaluation that put the resident at risk. 675967 Page 2 of 2