Health inspection·December 4, 2025

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 reviews the facility failed to ensure that licensed nurses have the specific competencies, and skill sets necessary to care for residents' needs for 1 (LVN A) of 3 staff reviewed for nursing competency assessments after a fall for Resident # 1.The facility failed to ensure LVN A assessed Resident #1 for injuries after a fall. This failure could potentially affect the residents by placing them at risk for injuries. Findings include: Record review of Resident #1's face sheet, dated 09/19/2025, revealed Resident #1 was an [AGE] year-old-female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Alzheimer's disease (a progressive brain disorder that destroys memory and thinking skills, leading to the inability to perform the simplest daily tasks), other specified bone density and structure, unspecified site (a bone disorder that changes the bone's density or structure but without a specific location or site being identified) and, secondary hypertension (high blood pressure that is caused by another medical condition). Record review of Resident #1's Quarterly MDS Assessment, dated 09/04/2025, reflected Resident #1 was rarely/never understood. She had poor short- and long-term memory recall. She had disorganized thinking (rambling and irrelevant conversation). Resident #1 required partial/moderate assistance with transfers (helper does more than half the effort). Resident #1 had a history of falls. Record review of Resident #1's Comprehensive Care Plan reflected (problem initiated on 11/16/2022) Resident #1 was at risk for falls related to unaware of safety, lack of coordination (difficulty controlling one's movements to be smooth, balanced, and purposeful). Record review of the facility's in-service on fall protocol on 06/23/2025 given by the Administrator reflected LVN A attended the in-service meeting, and the fall policy was reviewed during the in-service. Observation and interview on 09/19/2025 at 10:15 AM Resident #1 was propelling herself in the common area of the facility leading into the dining room. She did not respond to any questions about her recent fall. Resident #1 made eye contact and continued to propel herself in the common area. Interview on 09/19/2025 at 9:40 AM LVN A stated she was informed on 08/27/2025 by CNA B Resident #1 was on the floor in Resident #1's room. LVN A stated she entered Resident #1's room and observed Resident #1 on the floor beside her wheelchair. She stated Resident #1 had some blood from a cut on Resident #1's head. LVN A stated she instructed CNA B to transfer Resident #1 from the floor to the bed. She stated she assessed Resident #1 from head to toe and completed vital signs after Resident #1 was in bed. LVN A stated she was expected to complete head to toe assessment and vital signs prior to transferring Resident#1 from the floor to the bed. She stated she forgot to assess Resident #1 prior to moving her from the floor. LVN A stated it was the protocol for residents not to be moved from the floor or anywhere after a fall until the resident is assessed head to toe and staff obtain vital signs. She stated a resident may have a broken bone or some other type of injury and nurses were expected to do complete assessments before moving a resident. LVN A stated she did not follow the proper Page 1 of 2 676089 676089 12/04/2025 Winnie L Nursing & Rehabilitation 2104 N Karnes Cameron, TX 76520

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few protocol. She stated she had watched videos and received in person training on what the nurses were expected to do when assessing a resident after the fall. LVN A stated she had been instructed not to move a resident until after gathering information such as vital signs and complete head to toe assessment. LVN A stated the last time she was in-service was in June or July of 2025. She stated she was unsure what may happen to a resident after a fall if they were transferred prior to completing assessments. She stated she was having a stressful day the day Resident #1 fell. Interview on 09/19/2025 at 10:20 AM CNA B stated LVN A did not complete vital signs or head to toe assessment on Resident #1 until after Resident #1 was transferred from the floor to the bed. CNA B stated she had been in-serviced on fall protocol, and she learned to follow the nurses' directions. Interview on 09/19/2025 at 1:30 PM the Director of Nurses stated anytime a resident is found on the floor after a fall the nurse's best practice was not to move the resident until a head-to-toe assessment is completed and vital signs are obtained by the nurse. She stated the head-to-toe assessment includes but not limited to check for injuries of the skin, any pain near bone areas, movement of extremities, any abnormal position of extremity and any change of condition. She stated the following vital signs were expected to be obtained prior to moving resident after a fall: blood pressure (a number representing the pressure when the heart beats and when the heart rests between beats), respiratory rate (the number of breaths a person takes per minute), heart rate (the speed at which the heart beats, and O2 stats (percentage of oxygen in the blood). She stated LVN A was expected not to give directions to CNA B to move Resident #1 from the floor to the bed. She stated LVN A did not follow proper fall protocol. She stated she did not recall the last in-service given on fall protocol. The Director of Nurses stated anytime fall protocol in-service was given the facility policy was given to each employee and they review the policies. She stated the expectations of assessing residents and obtaining vital signs prior to moving the resident was discussed in the in-services. Interview on 09/19/2025 at 3:20 PM, The Hospice Physician stated assisting a resident from the floor to the bed prior to completing head to toe assessment or vital signs was very unlikely for the resident to obtain any type of injury or fracture. She stated she was familiar with Resident #1, and she does have a history of falls. Interview on 09/19/2025 at 3:32 PM, The Medical Director Doctor stated in her opinion if a resident was transferred from the floor to the bed prior to the nurse completing head to toe assessment or receiving vital signs, this would not result in a fracture or injury. She did not have an issue of the assessments being completed after transfer from the floor to the bed. Record Review of the Facility's Policy on Competency Nursing Job Description, dated 2014, reflected knowledge base:Ability to organize workflow, respond to emergencies.Give directions to Nurses' Aides for appropriate care of residents.Implement established nursing policy and procedures, educating support staff regarding care needs of residents. The ability to effectively multi-task and work in a stressful environment are also essential functions to this job. Record Review of the Facility's Policy of Falls, not dated, reflected in instances where fall risks do not prevent a fall, the resident will be assessed immediately for injury. Vital signs and first aid measures will be completed immediately. 676089 Page 2 of 2