Health inspection·November 21, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety 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 review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accidents.The facility failed to provide adequate supervision with Resident #1 on 08/11/2025 while completing perineal care in bed. CNA A provided perineal care and Resident #1 rolled off the bed to the floor. Resident #1 initially complained of pain in his right arm after this fall. Resident #1 was sent to the hospital for further evaluation on 08/11/2025.The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 8/11/2025 and was removed on 08/11/2025. The facility corrected the noncompliance before the investigation began.These failures placed residents at risk for hospitalization, harm and serious injury. Findings included: Record review of Residents #1's face sheet reflected a [AGE] year-old male with an admission date of 5/05/2025. Resident #1's diagnoses included morbid obesity, need for assistance with personal care, and lack of coordination. Record review of Resident #1's Optional State Assessment MDS, dated [DATE], indicated Resident #1 had a BIMS score of 12 (moderate cognitive impairment). It indicated under functional status; his bed mobility was a number 3 (2 + persons physical assist). Record review of Resident #1's Care Plan Report dated 04/07/2025 indicated, The resident is at risk for falls. This care plan did not specify how many staff were to assist the resident. Record review of Resident #1's order summary, dated 11/19/2025, indicated a pressure redistribution mattress to bed every shift with a start date of 12/17/2024. Record review of the Provider Investigation report, dated 08/15/2025, indicated on 08/11/2025 the resident was receiving care from the CNA, who reported that peri-care had been nearly completed, and a clean brief was being applied when the resident unexpectedly rolled out of bed. The CNA immediately called for assistance. The charge nurse responded promptly. The resident was found lying on his abdomen, face forward on the floor. A head-to-toe assessment was conducted, and vital signs were obtained. No visible skin abnormalities were noted, and vital signs were within normal limits. With the assistance of two staff members and a (name of brand) lift, the resident was safely transferred back to bed. At that time, the resident voiced pain in his right arm. A PRN dose of Tylenol was administered for discomfort. The physician was notified of the fall. Orders were received for X-rays of the skull, right knee, bilateral (both sides) tibia/fibula (lower legs), bilateral shoulders and arms, right ribs, and both feet. The resident's [family member] was contacted by both the charge nurse and the DON. The [family member] consented for the resident to remain in the facility for X-ray imaging. X-ray results were received, showing acute fractures of the right 5th and 6th ribs. The [family member] was notified of the results and requested the resident be sent to the hospital for further evaluation. The resident was transferred to (hospital name) in (name of city), TX. Approximately six hours later, the resident returned to the facility. Hospital documentation indicated no fractures but confirmed osteoporosis. Both the physician and the resident's [family member] were updated Page 1 of 3 675975 675975 11/21/2025 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few accordingly. Record review of the mobile x-ray radiology interpretation, dated 08/11/2025, indicated .the acute right 5th and 6th rib fracture is present. No other fractures were mentioned in this report. Record review of hospital record diagnostic imaging report, dated 08/11/2025, did not state whether there were rib fractures or not. It stated the resident was there for bilateral knee pain and pain after fall.and pain after trauma. The x-rays provided stated no acute findings for chest, spine, head, and knees. Record review of the Medical Director's statement dated 11/20/2025 revealed he reviewed the hospital x-rays and there were no findings of rib fractures. In an interview on 11/19/2025 at 9:54 AM and 11/21/2025 at 9:13 AM with CNA A, it was revealed he changed Resident #1 by himself, and he rolled off the bed. He is a big boy and does not normally inch to either side. He stated he gained no injuries, that I know of. He stated, I heard he was really sore the next day. CNA A stated he was suspended immediately after the fall. He stated at the time the Kardex (electronic health record section that includes how residents are assisted) had Resident #1 as one assist for bed mobility. After the fall, everyone was re-trained, and it was changed to 2-assist. He stated anyone that provided direct care to residents should verify how residents were assisted in the Kardex. He stated the DON and the Administrator provided training to the staff. CNA A stated if the protocol was not followed for assisting a resident, it could cause an injury to the resident or to the staff member that was providing assistance. In an interview on 11/19/2025 at 10:40 AM and 11/21/2025 at 9:08 AM with LVN B, it was revealed she did not think Resident #1 had injuries after that fall. LVN B stated nurses and CNAs were to look up in the electronic health record how residents should be assisted. LVN B stated the resident could fall and get hurt or the staff member assisting could get hurt. She stated, It is very dangerous. In an interview on 11/19/2025 at 1:18 PM with the Administrator and the DON revealed CNA A was suspended immediately. The Administrator stated he was retrained before he returned to work. The Administrator stated before the fall, Resident #1 was one assist in the Kardex. After the fall, they did a complete audit of their Kardex, Care Plans, and MDS assessments, and found they did not all match. The Kardex had one-assist, and the care plan and MDS had two-assist for Resident #1. They have fixed the discrepancy in the three areas. The DON and the Administrator both stated they were told there were no rib fractures in the report given by the hospital. In an interview on 11/19/2025 at 2:32 PM with Resident #1 revealed he was in a lot of pain after his fall. He stated, his chest and knees hurt. He stated he did not have rib fractures, and he had not had any incidents since that fall. In an interview on 11/21/2025 at 9:32 AM with the DON revealed CNA's and nurses assisted residents for bed mobility. She stated the DON and physical therapy provided in-services over transferring and bed mobility to staff. The expectation was for staff to use proper equipment, right number of staff, and ensure safety. The DON stated, the Kardex should be viewed by staff to determine a resident's level of assistance. She stated not providing the correct assistance could cause injury to self or patient. In an interview on 11/21/2025 at 10:34 AM with the Administrator, it revealed the Kardex was the main place for staff to look for the required assistance for each resident. She stated the CNA or anyone providing direct care was responsible for looking at the Kardex. She stated the DON and the ADON were responsible for training staff about transfer and bed mobility. LVN C was responsible for ensuring all three areas matched in the electronic health record. She stated LVN C was very new and needed to be educated in this area. She stated LVN C knows now that all three records need to be checked to ensure they have the same information. The Administrator stated the resident being transferred incorrectly or incorrect bed mobility being done could put the resident at harm and potential for falls. In an interview on 11/21/25 at 11:18 AM with LVN C, it was revealed she was a new care plan nurse and was still learning. She stated the Kardex, MDS, and the Care plan 675975 Page 2 of 3 675975 11/21/2025 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few did not match up. She has since been re-trained. The possible outcome for a resident that was not transferred properly could be a fall or injury to the resident. Record review of the facility's Safe Handling and Moving Protocol policy, dated 07/18/2018, indicated .ensure implementation of this policy to identify, assess, and develop strategies to control risk of injury to residents and nursing staff associated with the lifting, transferring, repositioning or movement of a resident.expectations of assessment and communication.in order to ensure accurate level of assistance is communicated the charge nurse will notify current floor staff providing care;.via Electronic Health Record ADL and care guide set up.precautions and considerations.bariatric needs (obesity). The Administrator was notified on 11/19/25 at 2:00 p.m., that a past non-compliance IJ situation had been identified due to the above failures. It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation on 08/11/2025. The facility took the following actions to correct the non-compliance on 08/11/2025: Record review of a document titled Ad Hoc QAPI dated as signed off on 08/11/2025 revealed these interventions were put in place before this surveyor's entrance on 11/18/2025. Issues: Resident #1 fell from bed while peri care was being provided by CNA. No injuries noted per hospital evaluation. Immediate actions:- Resident #1 received full head-to-toe assessment.- Resident #1 interviewed regarding fall.- The facility obtained statements from the AP and was suspended pending an investigation.- X-ray ordered per MD.- Family and MD notified.- Risk Management completed.- Immediate In-services initiated:-Neglect-Safe Peri Care and bed mobility for high-risk residents-Kardex Utilization- Comprehension quizzes completed after the in-services.- Life satisfaction rounds- Peer reviews and witness statements gathered.- Police were notified.- Ombudsman notified.- The residents care plan and Kardex were updated immediately to specify 2-person assist for peri care and bed mobility.- Facility wide care plan and Kardex audit were completed for required transfer assistance.Ongoing monitoring was initiated for 7 days, followed by weekly checks for four weeks. - Spot checks were completed and corrective actions taken, if needed Record review of in-service trainings titled, Abuse, Neglect, and Resident Rights, Training on Neglect and Prevention Response, Safe Peri-Care and Bed Mobility for High-Risk Residents, and Abuse, Neglect, and Drill Evaluation were all completed with signatures on 08/11/2025. All trainings included CNA A's signature. Interviews conducted all shifts beginning on 11/19/2025 at 9:42 AM through 11/21/2025 at 11:30 AM with the following staff CNA A, LVN B, LVN C, LVN D, CNA E, CNA F, MA G, CNA H, LVN I, LVN J, CNA K, CNA L, the Administrator, and the DON indicated they knew where to find how residents were to be transferred or level of bed mobility. The staff were able to verbalize understanding and information provided in the in-service/training. Record review of the facility folder that included all of the Facility Provider Report documentation included statements by resident and staff, x-ray results, risk management documentation, comprehension quizzes, all completed in-services, life satisfaction rounds, documentation of police and ombudsman notification, and complete audit documentation of Kardex, care plan, and the MDS assessments. Record reviews of random sample residents (Resident #1, Resident #2, Resident #3, and Resident #4) found no inconsistencies between the MDS, the Care Plan, and Kardex between 11/18/2025 through 11/21/2025. An observation of perineal care and bed mobility was completed on 11/19/2025 at 1:34 PM by CNA K and LVN J, no noncompliance found during this observation. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 8/11/2025 and was removed on 08/11/2025. The facility corrected the noncompliance before the investigation began. 675975 Page 3 of 3