Health inspection·December 17, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 4 out of 5 residents (Resident #2, Resident #3, Resident #4, and Resident #5), reviewed for care plans. - The facility failed to document Resident #2's fall from 8/29/25, and interventions put in place, which included a low bed, and a clutter free area.- The facility failed to document Resident #3's falls from 11/17/25 and 11/27/25, and interventions put in place, which included a low bed.- The facility failed to document Resident #4's falls from 10/22/25, 11/18/25, 11/27/25, and 12/3/25, and interventions put in place which included increased rounding, ordering labs, work up for tachycardia, a low bed, and a clutter free area.- The facility failed to document Resident #5's falls from 9/23/25 and 9/24/25, and interventions put in place which included increased toileting, HS snack, a low bed, and a clutter free area. These failures could place residents at risk for receiving delayed treatment and not obtaining/maintaining their highest practicable wellbeing. Findings included: 1. Record review of Resident #2's undated face sheet revealed he was a [AGE] year-old male, admitted on [DATE] with diagnoses of cerebral infarction (stroke), lack of coordination, dysarthria after stroke (slurred, slow, soft, or monotone speech), hemiplegia and hemiparesis affecting right side after stroke (paralysis and weakness), aphasia (trouble speaking), unsteadiness on feet, type 2 diabetes (body unable to produce insulin or resists it), muscle weakness, muscle wasting and atrophy, muscle weakness, and lack of coordination. Record review of Resident #2's Annual MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15, which indicated moderately impaired cognition. The resident had an impairment on one side of his upper and lower extremities and used a wheelchair for mobility. Resident #2 was dependent (helper does all the effort and resident does none) for all ADLs and was always incontinent of bowel and bladder. The assessment indicated the resident had 1 fall since admission/entry or the prior assessment, but he did not have any injuries. He was not receiving therapy services. Record review of Resident #2's Care Plan dated 1/23/24 revealed the resident had an actual fall r/t impaired mobility on 3/27/25 with no injuries, and 8/29/25 with no injuries (Initiated 5/1/25 Revised 11/24/25. The goal was to resume usual activities without further incident through the review date (Initiated 5/1/25 Revised 12/4/25). Interventions included: continue interventions on the at-risk plan (Initiated 5/1/25), for no injuries determine/address causative factors of fall (Initiated 5/1/25), monitor/document/report PRN x 72hr to MD s/sx of pain, bruises, change in mental status, new onset confusion, sleepiness, or agitation (Initiated 5/1/25), neuro checks as ordered (Initiated 5/1/25), PT consult for strength and mobility (Initiated 5/1/25). The resident also had a low bed and a clutter free area that was not updated for the fall on 8/29/25. Record review of Resident #2's Progress Notes dated Page 1 of 6 676170 676170 12/17/2025 St Dominic Village Rehabilitation and Nursing Cent 2409 E Holcolm Blvd Houston, TX 77021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 8/29/25 at 9:13pm revealed the resident fell from his wheelchair to the floor after his shower. A CNA was in the room and witnessed it. The resident said he was trying to get his clothes that were on the sink, and he slid from his wheelchair to the floor. He did not hit his head. The charge nurse found the resident lying on his left side on the floor, facing the sink, with his gown on. Neuro checks were started, and no visible injuries were noted. Resident was assisted back to bed. Record review of Resident #2's Progress Notes dated 8/30/25 at 1:02pm revealed the resident was s/p fall day 2 and he was in his w/c propelling himself around the unit. Record review of Resident #2's Physician Orders reviewed on 12/16/25 from MD R revealed the following orders: - Falls monitoring: Keep bed low in locked position- Falls monitoring: Keep resident area clutter free In an observation on 12/16/25 at 1:58pm, Resident #2 had a low bed and a fall mat to the side of his bed. The resident was not in the room. 2. Record review of Resident #3's undated face sheet revealed she was an [AGE] year-old female admitted on [DATE] with diagnoses of Alzheimer's disease, type 2 diabetes, complete traumatic amputation at level between left hip and knee (missing left leg at thigh level), gastrostomy (tube into stomach for nutrition), muscle weakness, contracture of right ankle, muscle wasting and atrophy, lack of coordination, and atrial fibrillation (irregular heart beat). Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15, which indicated severely impaired cognition. The resident was dependent for all ADLs and had an impairment on one side of her upper and lower extremities. The assessment revealed she was always incontinent of bowel and bladder. The assessment indicated the resident had had 1 fall since admission/entry or the prior assessment, with an injury that was not major (skin tears, abrasions [skin rubbed off], superficial bruises [bruises that are not deep], sprains). She was not receiving therapy services. Record review of Resident #3's Care Plan dated 12/18/23 revealed she had an actual fall r/t impaired balance on 8/9/24 with no injuries (Initiated 11/18/24). The goal was to resume usual activities without further incident through the review date (Initiated 11/18/24 Revised 12/4/25). Interventions included: 8/9/24-fall mats to side of bed (Initiated 8/9/24), continue interventions on the at-risk plan (Initiated 11/18/24), monitor/document/report PRN x 72hr to MD s/sx of pain, bruises, change in mental status, new onset confusion, sleepiness, or agitation (Initiated 11/18/24), Neuro checks as ordered (Initiated 11/18/24), and PT consult for strength and mobility (Initiated 11/18/24). The fall from 11/17/25 and 11/27/25 were not on the Care Plan, along with the interventions that were put in place which included a low bed. Record review of Resident #3's Progress Notes dated 11/17/25 at 4:14am revealed the resident was found on the floor during nursing rounds at 3:30am. The resident was near the bed on the right side with her bed sheets and blankets. Her head was upright. Neuros were started and there were no injuries or complaints of pain. Record review of Resident #3's Progress Note dated 11/27/25 at 4:44am revealed the resident was found lying on the floor. There were no visible signs of injuries, and an assessment was performed. Record review of Resident #3's Physician Orders reviewed on 12/16/25 by MD R revealed the following order: - Fall Precautions: Keep bed in low position and locked. In an observation on 12/16/25 at 1:54pm Resident #3 was lying in bed with a PEG tube (tube into stomach for nutrition). The bed was in a low position, and the bed was locked. The resident was not interviewable. Record review of the facility's Fall Committee binder reviewed on 12/17/25, revealed Resident #3's 11/17/25 fall was reviewed on 11/21/25. The new interventions was for PT to screen the resident. The fall from 11/27/25 was reviewed on 11/27/25 and the new intervention was to keep the bed in a low position. 3. Record review of Resident #4's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses of traumatic subarachnoid hemorrhage (brain bleed), cerebral infarction, hemiplegia and hemiparesis, neuromuscular dysfunction of bladder (bladder will not 676170 Page 2 of 6 676170 12/17/2025 St Dominic Village Rehabilitation and Nursing Cent 2409 E Holcolm Blvd Houston, TX 77021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some empty), neurogenic bowel (bowel will not empty), hearing loss, lack of coordination, unsteadiness on feet, muscle wasting and atrophy, lack of coordination, dementia, muscle weakness, and abnormalities of gait and mobility. Record review of Resident #4's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 8 out of 15, which indicated moderately impaired cognition. The resident had an impairment on one side of his upper and lower extremities. The assessment revealed the resident was supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance) with all ADLs and used a w/c for mobility. Resident #4 had 1 fall since admission/entry or the prior assessment and did not have an injury from it. According to the assessment he was receiving ST, OT, and PT. Record review of Resident #4's Care Plan dated 1/29/25 revealed he had an actual fall r/t muscle weakness 1/25/25 with no injury (Initiated 1/29/25). The goal was to resume usual activities without further incident through the review date (Initiated 1/29/25 Revised 11/13/25). Interventions included: 1/25/25-Encourage resident to use call light for assistance (Initiated 1/29/25), continue interventions on the at-risk plan (Initiated 1/29/25), for no acute injuries determine and address causative factors of fall (Initiated 1/29/25), PT consult for strength and mobility (Initiated 1/29/25). The falls from 10/22/25, 11/18/25, 11/27/25, and 12/3/25 were not on the Care Plan. Also, their interventions were not on the Care Plan which included: increased rounds, labs ordered, work up tachycardia, low/locked bed, and clutter free area. Record review of Resident #4's Progress Notes dated 10/22/25 at 10:24am revealed the Nurse went to administer medication to the resident, she found him sitting on the floor, near his w/c. The resident said he slid from his w/c. No injuries seen and resident denied any pain. Neuros started and resident helped back to bed. Record review of Resident #4s Progress Notes dated 11/18/25 at 7:03am revealed a Nurse found the resident lying on the floor with the bed linen and a pillow under him. He was facing the door. He did not remember what happened and thought he fell. No injuries were found, and no complaints of pain were noted. Record review of Resident #4's Progress Notes dated 11/19/25 at 6:12am revealed the resident was s/p fall day 1 of 3. The bed was at the lowest position, the fall mat was in place, and the call light was within reach. Record review of Resident #4's Progress Notes dated 11/27/25 at 7:06am revealed the incoming day shift Nurse found the resident lying on the floor in a fetal position. There were no visible injuries, but the resident seemed confused. The resident was sent to the ER for further examination. Record review of Resident #4's Progress Notes dated 11/27/25 at 1:23pm revealed the resident went to the ER at 8:15am and came back to the facility at 11:15am. CT scan performed at the ER was negative, along with the COVID and flu tests. Record review of Resident #4's Progress Notes dated 11/30/25 at 6:42am read, no c/o pain from fall 11/27. Resident got up about 2am. Took off his brief and urinated on the floor by his bed. Cna then cleaned up him and his bed. Put a pull up on him. Resident then took that off and put on his regular pants and put self back to bed. At some point earlier resident had urinated in front of the toilet. Resident reminded to use call light for assist. Staff reminded to use pullup instead of brief. Staff monitored resident frequently. Neuro vital wnl. Ll [call] light within reach. Bed in lowest position. ( resident normally wears briefs). Record review of Resident # 4's Progress Notes dated 12/1/25 at 2:27pm read, resident Lab result seen by resident [NP]. no new orders given. Record review of Resident #4's Progress Notes dated 12/3/25 at 6:38am read, Resident is in bed resting with eyes closed, on fall precaution, bed at the lower position, fall mat in place, no s/s of distress or discomfort at this time, call light within reach, willcontinue to monitor. Record review of Resident #4's Progress Notes dated 12/3/25 at 3:21pm revealed the resident was observed on the floor at 12:40pm. The resident was assessed, and no injuries were noted. The resident was put back in his w/c and neuros were initiated. Record review of Resident #4's 676170 Page 3 of 6 676170 12/17/2025 St Dominic Village Rehabilitation and Nursing Cent 2409 E Holcolm Blvd Houston, TX 77021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Progress Notes dated 12/4/25 at 12:52pm read, Dr. ordered STAT EKG, for low heart rate of 44. Record review of Resident #4's Physician Orders reviewed on 12/16/25 revealed the following orders from MD R: Falls monitoring: Keep bed low in locked position- Falls monitoring: Keep resident care area clutter freeCBC and BMP (labs) In an observation on 12/16/25 at 2:01pm, the resident was not in his room. The bed was in a low position, and he had a fall mat next to his bed. Record review of the facility's Fall Committee Binder on 12/17/25 revealed Resident #4's fall from 10/22/25 was reviewed on 10/24/25, and the new intervention was a therapy evaluation. The fall from 11/18/25 was reviewed on 11/21/25 with a new intervention to increase rounding. His fall from 11/27/25 was reviewed on 11/27/25 and labs were ordered as a new intervention. The fall from 12/3/25 was reviewed on 12/3/25 with a new intervention to work up the resident's tachycardia (it should be bradycardia, low heart rate). 4. Record review of Resident #5' undated face sheet revealed he was an [AGE] year-old male admitted on [DATE] with diagnoses of syncope and collapse (dizziness and fainting), type 2 diabetes, muscle weakness, muscle wasting and atrophy, lack of coordination, atrial fibrillation, and emphysema (lung disease making it hard to breathe). Record review of Resident #5's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 7 out of 12, which indicated moderately impaired cognition. The resident was substantial/max assist (helper does more than half the effort) with all ADLs and used a wheelchair for mobility. He was always incontinent of bowel and bladder. The assessment indicated the resident had had 1 fall since admission/entry or the prior assessment with no injuries. He was not receiving therapy services. Record review of Resident #5's Care Plan dated 3/22/25 revealed he had an actual fall r/t impaired mobility. Actual fall 4/25/25 with no injuries. Actual fall 4/26/25 with no injuries. Actual fall 6/4/25 with no injuries. Actual fall 6/20/25 with a bruise to the left ear. Actual fall 10/1/25 with no injuries. (Initiated 4/30/25 Revised 10/25/25). The goal was to resume usual activities without further incident through the review date (Initiated 4/30/25 Revised 11/18/25). The interventions included: continue interventions on the at-risk plan (Initiated 4/30/25), fall mat to side of bed (Initiated 4/25/25), monitor/document/report PRN x 72hr to MD s/sx of pain, bruises, change in mental status, new onset confusion, sleepiness, or agitation (Initiated 4/30/25), PT consult for strength and mobility (Initiated 4/30/25), and send to ER for evaluation and treatment (Initiated 4/25/25). The falls from 9/23/25 and 9/24/25 along with the interventions, which included increased toileting and a snack at night, were not updated on the Care Plan. Record review of Resident #5's Progress Notes dated 9/23/25 at 11:01am revealed the nurse was informed the resident was on the floor. She saw the resident lying with both legs resting on the rails of the bed and his body on the floor. There were personal items scattered across the floor. The resident said he was trying to pick something up from the floor. The resident had an abrasion to his right cheek and left elbow which were cleaned and bandaged. The resident was educated to use the call light. Record review of Resident #5's Progress Notes dated 9/24/25 at 7:27am revealed the resident was found lying on the floor next to his bed. He said he was going to go eat. There were no visible injuries, was assisted back to bed, and neuros were started. Record review of Resident #5's Progress Notes dated 9/24/25 at 8:26am read, nurse writer interviewed resident about his fall this morning. Resident stated he was trying to get out of bed and added he was very hungry. nurse writer educated him on using the call light and re reciprocated information. After stating he was hungry, nurse writer provided breakfast sandwich to resident, assisted to sitting position while in bed and resident ate without issue. floor mat is placed to right side of bed for fall risk. Record review of Resident #5's Progress Notes dated 9/24/25 at 10:30 by MD E read, On 09/23/2025, had an unwitnessed fall while attempting to pick an item from the floor; no acute injury identified. Neuro checks initiated and ongoing; patient remains 676170 Page 4 of 6 676170 12/17/2025 St Dominic Village Rehabilitation and Nursing Cent 2409 E Holcolm Blvd Houston, TX 77021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some clinically stable with stable vital signs.Patient has been participating in physical therapy with some functional improvement noted, though he remains frail with generalized weakness.Patient requires minimum to moderate assistance with his Activities of Daily Living (ADLs), including meal set up and personal care. He is wheelchair to bed bound. He is totally dependent for toileting and is incontinent of bowel and bladder. Cognitively, the patient is alert and oriented to person and place but has periods of confusion and is a poor historian.The patient is at high risk for falls, with recent unwitnessed falls on 09/23/2025 and 09/24/2025. Fall prevention measures, including a floor mat by the bedside and call light education, have been implemented. Neurochecks are ongoing. He is participating in PT/OT for strength and function improvement. Record review of Resident #5's Progress Notes dated 12/10/25 at 10:45am by MD R read.No falls reported. Participating in restorative therapy for muscle strengthening. Record review of Resident #5's Physician Orders reviewed 12/16/25 revealed the following orders by MD R: - Falls Monitoring: Keep bed low in locked position- Falls Monitoring: Keep resident area clutter free- Floor mat at bedside- Provide a nighttime snack at bedtime In an observation on 12/16/25 at 2:01pm Resident #5 was not in his room. The bed was in a low position and there was a fall mat next to his bed. Record review of the facility's Fall Committee binder reviewed on 12/17/25 revealed Resident #5's fall on 9/23/25 was reviewed on 9/26/25 with a new intervention to toilet more frequently. His fall on 9/24/25 was reviewed on 9/26/25 and the new intervention was to give a snack at bedtime. In an interview on 12/16/25 at 3:10pm, the DON said after a fall happened, education was provided to the staff on the floor about new interventions to put in place to help prevent another fall. He said they had a Fall Committee that met every Friday and discussed the falls from that week, ensured new interventions were in place, and discussed the Care Plan updates. The DON said the Fall Committee consisted of therapy, restorative, activities, and nursing. He said they discussed the falls, came up with a plan of action, and ensured everything was done like neuros, and fall assessments. He said the Care Plan was updated by MDS and as needed by the Unit Managers. He said the MDS Coordinator would be the one who updated the falls on the Care Plan. The DON said the Care Plan should be updated after each fall with a new intervention to help mitigate another fall from happening. The DON said however, the interventions were already put in place by the nurse when the fall happened. So even though the Care Plan was not updated, the interventions were already in place. He agreed that the Care Plan should be updated with each fall and intervention, but they kept the information in other areas as well that the floor staff had access to. In an interview on 12/16/25 at 3:38pm, the MDS Coordinator said she had been working in MDS for 1.5yr. She said this (12/16/25) was her first day back in 6 weeks. She said the Fall Committee met every Friday, and MDS was not part of the Committee. She said the Fall Committee decided what interventions to update the Care Plan with and then the Unit Manager emailed her the date of the fall and what interventions to include. She said she did not go on her own and update the falls without being told first what to update. The MDS Coordinator said if the Fall Committee did not email her to let her know about a fall, she would not know how to update the Care Plans. In an interview on 12/17/25 at 11:12am, LVN M said the Care Plan was where someone would find the interventions for a fall risk resident, and that the floor staff did not update the Care Plans. She said the Care Plan was not the only place to find the interventions and that when staff gave report during shift change they told each other who was a fall risk and what interventions were in place. LVN M said some fall interventions included a low bed, increased rounds, and bringing the resident to the nurse's station. In an interview on 12/17/25 at 11:19am, RN B said interventions for a fall would be on the Care Plan, but staff also discussed them at shift change. She said after a fall happened, the staff discussed the new intervention also. She said fall 676170 Page 5 of 6 676170 12/17/2025 St Dominic Village Rehabilitation and Nursing Cent 2409 E Holcolm Blvd Houston, TX 77021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some interventions included increased rounds, a low bed, fall mats, and reminding the resident to use the call light. In an interview on 12/17/25 at 11:30am, CNA C said interventions for a fall could be found on a Care Plan. She said she also got updates about fall risk residents and interventions, in shift change. She said if she was not sure, she would ask her Unit Manager. CNA C said some of the fall interventions included keeping the bed and wheelchair locked, making rounds, and keeping the residents' items within reach. In an interview on 12/17/25 at 3:13pm with both the ADM and DON, the ADM said leadership met with the floor staff after the Fall Committee to inform them of the updated interventions. The DON said the Unit Managers were the ones who would go back to the nurses and inform them. Then the nurses would inform the CNAs. The DON said the Unit Managers met with the nurses daily and then at 2pm, and they had a shift change meeting and a meeting with the oncoming RN Manager. The DON said the evening Manager had a meeting with the nighttime Manager at shift change, and then the nighttime Manager had a meeting with the Unit Managers. The ADM said after the interventions were put in place, the Unit Managers, ADON, and the DON made rounds to ensure the interventions were there. The ADM said the MDS Coordinator was notified of the fall updates by other means and not just an email. The ADM said they had other safety meetings where falls were discussed, and the MDS were in attendance. The ADM and the DON both admitted that staff were implementing fall interventions, they were just not documented. They said they had an IDT meeting and were going to update every Care Plan. Record review of the facility's policy and procedure on Falls and Injuries (written June 2025) read in part: It is the policy of [NH] to minimize the risk of incidents or injuries to residents. The purpose of this policy is to establish a comprehensive, interdisciplinary program for. the standardized procedure for responding to a fall incident to protect residents from injury and promote their highest practicable physical well-being. Review and update the resident's fall risk assessment and care plan based on the findings of the investigation. The Falls committee will regularly review fall incidents, trends, and data to identify patterns (e.g., time of day, location, staff present). The program will be continuously evaluated for effectiveness, and adjustments to policies and procedures will be made as needed. Record review of the facility's policy and procedure on Health Care Plans (Revised March 2024) read in part: It is the policy of [NH] to involve all disciplines in the development of a resident health care plan that recognizes the resident's right to achieve his/her personal health goals. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' condition changes. Residents are re-assessed, and the care plan is updated at least every three (3) months or when a change in the resident condition occurs, such as weight loss or gain, decubitus ulcers development, dehydration, etc. 676170 Page 6 of 6