Health inspection·October 23, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for supervision. The facility failed to provide adequate supervision for Resident #1 during a routine incontinent change which involved CNA A and CNA B which led to Resident #1 hitting their head on the bedside table. This failure could place residents at risk of injury. Findings include: Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #1's Care Plan dated 6/19/2025 reflected Resident #1 had diagnoses which included Dementia (Decline in cognitive abilities such as memory, thinking, problem solving, judgment), Hypertension (High blood pressure), Chronic Kidney Disease (Kidneys lose the ability to filter waste), Osteo Arthritis (Joint disease that causes pain in the joints), Neuropathy (Damaged nerves), Constipation (Difficulty passing stool), Depression (Mental health disorder that significantly impacts mood, thought, behavior), Anxiety Disorder (Mental health disorder of excessive worry, fear, or nervousness), Alzheimer's (Neurodegenerative disorder that affects memory, thinking, behavior), Hyperparathyroidism (Parathyroid gland produce too much hormone), Muscle Weakness (Decrease in muscle strength and function), Cognitive Communication Deficit (Difficulty communicating because of memory, attention, function) and Tinea Unguium (Fungal infection of the nails). Resident #1 required 2 person assist. Resident #1 had Activities of Daily Living self care performance deficit related to Alzheimer's, confusion, and dementia. Interventions were listed as bed mobility, roll left to right-partial/moderate assist, sit to [NAME]-substantial/maximum assist, [NAME] to sit-substantial/maximum assist, Sit to stand-substantial/maximum assist. Personal Hygiene was documented as substantial/maximum assist. Bowel and bladder incontinent related to Alzheimer's and Dementia. 10/17/2025 documented Resident #1 had Right eyebrow laceration. 10/17/2025 documented to maintain proper alignment while turning and repositioning. Record review of CNA B's, undated, employee witness statement, reflected she was performing care on Resident #1 with CNA A. Resident #1 hit her head on the bedside table as she was being turned over. Record review of Resident #1's MDS record dated 10/4/2025 revealed Resident #1 had a bims of 00 (severe cognitive impairment). Resident #1 had a score of 01 (Dependent) for Toileting Hygiene and Roll left and right. Record review of CNA A's employee witness statement, dated 10/14/2025, reflected she was performing perineal care (cleaning or washing of the genitals) on Resident #1 with CNA B. Resident #1 began to fall out of the bed while they were in the middle of turning her over. They were able to prevent the fall by keeping her in a secure position on the bed but were unable to prevent her from hitting her head on the bedside table. The injury caused bleeding. Record review of Resident #1's weekly skin check, dated 10/14/2025, reflected Resident #1 had injuries to the following: Bruise to the right eye, and Laceration to the right eyebrow. Record review of the incident report, completed on 10/14/2025, by LVN C, reflected Resident #1 was being assisted Page 1 of 4 676293 676293 10/23/2025 Forest Park Nursing & Rehabilitation 6825 Harry Hines Blvd Dallas, TX 75235

F 0689 Level of Harm - Actual harm Residents Affected - Few by CNA A and CNA B when the accident occurred. During her assessment she observed a straight line injury on top of the right eyebrow and a swollen black eye. She cleansed with normal saline, pat dry and applied dressing. She administered pain medication, Tylenol 325 mg 2 tablets. Vitals were taken with normal ranges. Blood Pressure 120/80, Temperature 97.3, Pulse 80, Oxygen 97% on room air. She repositioned Resident #1. Notifications were made to the responsible party, Medical Director, and Director of Nursing. She documented Resident #1 as being alert and oriented. Record review of Resident #1's X-Ray results, dated 10/15/2025, reflected Resident #1 had an X-Ray to the facial bones which showed no serious injury. The reason the X-Ray was performed was because of localized swelling, mass, and lump. The radiology results reflected Resident #1 did not have fracture. The osseous structure was intact. The sinus appeared clear. Soft tissues appeared unremarkable. Record review of Neuro Evaluation Check, completed on 10/15/2025, reflected Resident #1 had normal vitals and was alert and oriented. Record review of Resident #1's weekly skin check, dated 10/16/2025, reflected Resident #1 had injuries to the following: Right eye discoloration from the incident on 10/14/2025, Right eyebrow laceration from the incident on 10/14/2025. Observation of Resident #1 on 10/23/2025 at 11:00 AM revealed Resident #1's had a large discolored yellow bruise about 3 inches by 4 inches on the upper right side of her face. Interview was attempted but unsuccessful due to Resident #1's cognitive function. Interview on 10/23/2025 at 10:10 AM with Director of Nursing E, revealed Resident #1 received a black eye as result of her injury on 10/14/2025. She stated Resident #1 was assessed by both a skin assessment and a neuro assessment. She stated an incident report was completed and Resident #1 had normal vital signs. She stated the physician ordered imaging which showed the resident did not have any fracture to her facial bones. She stated there was bruising because the resident hit her head on a bedside table during incontinent care. She stated the Resident had a gash above her right eye. She stated Resident #1 was monitored and assessed at every single shift after the incident. At first it was just a gash. Then it became a black eye. Then they did the assessment and X-ray. The physician came in and did a head to toe assessment himself with the nurse practitioner. She stated Resident #1 hit her eye on the bedside table because the table was too close to the bed. She stated she received statements from staff and performed inservices accordingly. There were 2 staff in the room, CNA A and CNA B. The staff made notifications at the time of injury to the Physician, ADON, DON, and POA. Then inservices were performed on incontinent care, and environment. The resident was not verbal. She stated the staff should not have assumed the table was not that close. She stated they should have moved the table further away but the resident moved in the middle of them turning her over. She stated that the facility has inserviced care staff on Safety Environment Training, Incontinent Care Assistance, Abuse/Neglect, Incidents and Accidents. Interview on 10/23/2025 at 11:15 AM with ADON F, revealed the facility performed inservices for incontinent care, positioning, abuse/neglect, and decluttered rooms (physical environment). The X-ray was done within 24 hours of the incident occurring. The bruise on the resident's face showed up when the incident occurred. The bruising was a result of a staff member turning Resident #1 over during incontinent changing. The face had no fracture. The soft tissue was unremarkable. Resident #1 is 2 person assist and there were 2 staff members in the room at the time assisting with Resident #1's incontinent care. They injury occurred because Resident #1 hit her head on the bedside table when they rolled her over. During the turn Resident #1 made a sudden movement. Interview on 10/23/2025 at 11:30 AM with Physician H, revealed the facility did not have to send Resident #1 to the hospital as long as there was not a change in her neuro status and if the incident was witnessed and not suspicious. He stated the bruise looks like a laceration on the eye-lid. Sometimes blood trickled down and could make it look worse than it actually was. An 676293 Page 2 of 4 676293 10/23/2025 Forest Park Nursing & Rehabilitation 6825 Harry Hines Blvd Dallas, TX 75235

F 0689 Level of Harm - Actual harm Residents Affected - Few injury could look worse later. Interview on 10/23/2025 at 12:30 PM with Nurse Practitioner G revealed he was the one who ordered the X-rays after the facility notified him of the incident. He stated he did a complete check on Resident #1 after it was reported to him. He stated her injury was the result of hitting the bedside table. He stated the injury looked worse than it was because of the way a bruise could develop over time. He stated she shouldn't have any lasting effects as a result of this injury. He stated, it's basically just a bad bruise around her eyes and a little bit of swelling. It shouldn't have any long-lasting effect. He stated there was harm, but it was not a significant injury. The X-ray showed no acute fracture . Once the incident happened the facility did everything they were supposed to do after the incident had already occurred. He stated he knew there were inservices that were completed so the staff didn't have this incident again moving forward. Interview on 10/23/2025 at 2:00 PM with CNA B, revealed she was turning Resident #1 with CNA A assisting her when mid turn Resident #1 began to move unpredictably. She stated that was what caused the accident. She stated Resident #1 almost fell off of the bed, but since there were two of them in the room on each side of the bed they were able to make sure she didn't fall. She stated Resident #1 hit the bedside table hard with the side of her face. She stated she immediately reported it to the nurse. She stated she was sorry it happened. She stated the night table was very close to her bed and when Resident #1 leaned over in that direction she hit her head on the bedside table. She stated Resident #1 began to bleed a little bit above her eye. She stated that the bedside table was beside the bed but it was not touching the bed or hovering over the bed. Resident #1 leaned over the side of the bed and hit the table. She stated that the facility has inserviced care staff on Safety Environment Training, Incontinent Care Assistance, Abuse/Neglect, Incidents and Accidents. Interview on 10/23/2025 at 3:00 PM with LVN C, revealed she assessed Resident #1 after the CNA notified her of the incident. She stated CNA A and CNA B tried to change the resident and during the rotation of the turn, Resident #1 pushed against them with her upper half. The resident almost fell off of the bed because she flung her upper torso against the direction the staff were rotating her. She stated CNA A and CNA B did not drop the resident nor did Resident #1 fall. She stated CNA B realized there was blood on Resident #1's forehead. She stated she took vitals and performed a neuro check. She stated everything was okay. She stated she contacted the responsible party, director of nursing, and physician. She stated that the facility has inserviced care staff on Safety Environment Training, Incontinent Care Assistance, Abuse/Neglect, Incidents and Accidents. Interview on 10/23/2025 at 3:15 PM with Administrator D revealed she had already investigated the case and assessed the environment. She stated CNA A and CNA B both told her what had happened. She stated she was told Resident #1 began to move while they were turning her. She stated she already educated the staff and performed inservices. Resident #1 was 2 person assisted and the staff successfully followed the facility policies. The facility investigation determined that it was an accident. Record review of Inservice Training Report completed on 10/15/2025 reflected 23 care staff received Safety Environment Training on 10/15/2025. Record review of Inservice Training Report, completed on 10/16/2025, reflected 18 care staff received Incidents and Accidents Training on 10/16/2025. Record review of Inservice Training Report, completed on 10/17/2025, reflected 25 care staff received Incontinent Care Assistance Training on 10/17/2025. Record review of Inservice Training Report, completed on 10/17/2025, reflected 23 care staff received Abuse and Neglect Training on 10/17/2025. Record Review of the facility Abuse/Neglect policy reflected the facility successfully followed their policies for Abuse/Neglect. Record Review of the facility Perineal Care policy stated the staff are to turn residents to their side and reposition resident. Record Review of the facility Care policy stated all residents receive the necessary care and services based 676293 Page 3 of 4 676293 10/23/2025 Forest Park Nursing & Rehabilitation 6825 Harry Hines Blvd Dallas, TX 75235

F 0689 Level of Harm - Actual harm Residents Affected - Few on an individualized comprehensive assessment process. Residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being level of an environment that enhances quality of life in the scope of a long-term care facility. Care and services are provided in a manner that consistently enhances self-esteem and self-wroth. The police stated the facility provides care and services to residents with reasonable accommodations of each resident's individual needs and preferences. Record Review of the facility Quality of Life policy stated the facility staff provides care and services that ensure that resident's abilities in activities of daily living, including: hygiene, mobility, elimination, dining, communication, speech, language and other methods of communication do not diminish while in the care of the facility, except when unavoidable as evidence by clinical condition. 676293 Page 4 of 4