Health inspection·December 4, 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 observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, for one of four residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure CNA A performed a 2-person assist while conducting incontinent and bed mobility care for Resident #1 on 03/18/2025 which led to Resident #1 sustaining a fall. This failure could place residents at risk for falls, injuries and a decline in health.Findings include: Record review of Resident #1's admission record dated 10/04/2025 revealed Resident #1 was a [AGE] year-old female, who initially admitted on [DATE] and readmitted on [DATE]. Resident #1 was admitted with multiple diagnoses including: Parkinson's disease (movement disorder) with dyskinesia (involuntary muscle movement), age related osteoporosis (weakening bone) without current pathological fracture (break under normal stress), and arthritis (inflammation of joints). Record review of Resident #1's Quarterly MDS dated [DATE] revealed, Resident #1 had a BIMS score of 6 which meant she was severely cognitively impaired. Additionally, Resident #1 was dependent of staff for all ADLs. Record review of Resident #1's care plan date initiated 05/30/2024 revealed, I have a Self-Care deficit r/t Parkinson's, OA multiple sites. Goal: Resident will experience safe transfers through next review date, and I will maintain or improve my ability to participate in my care with ADLs through my next review date. Interventions: Bed mobility: x2-person assistance. Bathing/Showering Care: x 2-person assistance. Toileting/Incontinent care: x 2-person assistance. Record review of CNA A's 03/18/2025 witness statement revealed description of Incident I [DON] called [CNA A] to get information regarding the incident of a fall from bed (witnessed). CNA A stated I was performing incontinent care prior to wound care. She was extremely soiled, so I was providing partial bed bath x1 person. I knew she was a two person assist and knew that was the case on the KARDEX, but I felt I could do it. I rolled her over and fell as a result of my actions. Signed by DON. Record review of CNA A's 03/18/2025 written witness statement revealed, description of incident I was asked by the wound care nurse to clean resident before she could start wound care. As I checked the resident, I found she was extremely soiled about 3 times her usual.At that moment my CNA coworker was busy with another resident. I was afraid the feces would get into her suprapubic hole and wound, I felt it would be careless and loss of dignity if I left her sitting in her own feces for an additional 30 minutes. I took it upon myself to do the incontinent care myself. (knowing she was a 2 person assist like stated on KARDEX) .After I was done, I logged rolled her to change the sheet she was on an air mattress and the air shifted causing her legs to slide first then her torso ultimately caused the fall. I checked on the resident and then called for help immediately. Signed by CNA A on 03/18/2025. Record review of the ER record dated 03/18/2025 and discharged [DATE] revealed resident did not experience any major injury. No fracture or traumatic malalignment is seen. - no concerns noted. During a phone interview on 10/04/2025 at 3:48PM, 10/05/2025 at 8:03AM and 12:58PM CNA A stated she no Page 1 of 3 676313 676313 12/04/2025 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few longer worked at the facility and would call back when she was available. CNA A did not return call prior to exit conference. During an observation and interview on 10/04/2025 at 10:38AM Resident #1 was assisted by CNA B and CNA C to transfer via bed mobility. Both CNA B and CNA C utilized a draw sheet that was situated under Resident #1. Through the duration of the transfer care, there were no observable concerns. During an interview with Resident #1 while Resident #1's family member was present, both stated the fall on 03/18/2025 was an accident, and stated CNA A was a good CNA. Resident #1 and family member stated the clinical staff are nice and provide good care. Both Resident #1 and family member stated when Resident #1 needs assistance the staff help her and verbalized no concerns regarding any form of care. During an interview on 10/05/2025 at 11:35AM with both CNA B and CNA C, both stated they were not present during Resident #1's fall on 03/18/2025. Both stated as part of their normal shift procedure, they will review the plan of care on their KARDEX, to ensure they provide the necessary safety measures when providing care to each resident. Both stated once they review the plan of care in the beginning of their shift, they would begin providing rounding care. Both stated they work with Resident #1, and when Resident #1 needs incontinent care, transfer care, and bed mobility care, they will always utilize a two-person approach. Both stated, if Resident #1 needed care and no person is readily available, they will look for other clinical staff members to assist with care. Both stated they will never provide care for Resident #1 independently when the plan of care necessitates a two-person assist. Both stated the reason they incorporate a two-person assist with Resident #1 was to minimize Resident#1 falling and also to ensure Resident #1's safety. Both stated if they were to perform care independently without another clinical staff member, the well-being for Resident #1 could be compromised. Both stated they attended the 03/18/2025 in-service regarding transfer care and reviewing the plan of care for every resident. During an interview on 10/04/2025 at 4:12PM, LVN B stated when he was made aware of the incident, he was in the hallway and heard someone scream help. LVN B stated he then rushed into room Resident #1's room to which he found CNA A by herself, with Resident #1 on the floor ensuring her safety. LVN B stated he followed the facility protocol and sent Resident #1 to the emergency room for evaluation and treatment. LVN B stated once Resident #1 was gone, he asked for additional details of what had transpired to which CNA A stated she attempted to turn Resident #1, and while she turned Resident #1 over, the moment of Resident #1 moved further than expected and Resident #1 landed on her face. LVN B stated when he entered Resident #1's room, he immediately conducted a thorough head to toe assessment followed by sending Resident #1 to the emergency room for evaluation and treatment but did not sustain any major injury. LVN B stated he reeducated CNA A that she should have waited for an available person to assist her with Resident #1's care regardless how saturated Resident #1's brief was. LVN B stated CNA A verbalized her awareness of Resident #1's 2-person assist with care, but that she believed it would have compromised her dignity. LVN B stated he reeducated CNA A the reason why Resident #1 was a 2-person assist was to ensure her safety and by not following the plan of care, CNA A could have compromised Resident #1's well-being if Resident #1 had sustained a major injury. LVN B stated by CNA A not following Resident #1's plan of care, Resident #1 could have sustained a neck of facial fracture but fortunately did not. During an interview on 10/05/2025 at 12:09PM ADON, A stated she was not present during the incident on 03/18/2025, however when she was made aware of the situation, the facility commenced a facility wide in-service regarding transfer status and to review the plan of care (KARDEX) upon commencement of shift. ADON A stated CNA A had no professional concerns as CNA A was a good CNA. ADON A stated Resident #1's fall on 03/18/2025 was an accident. ADON A stated CNA A should have utilized a two-person assist with Resident #1 to ensure Resident #1's safety, however there were no major injuries. 676313 Page 2 of 3 676313 12/04/2025 Laredo Nursing and Rehabilitation Center 1701 Tournament Trail Dr Laredo, TX 78041

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ADON A stated CNA A could have jeopardized Resident#1's well-being but was fortunate that Resident #1 did not have a major injury. ADON A stated all staff member are expected to review the plan of care for each resident upon commencement of shift. ADON A stated CNA A had no other prior incidents/falls during her employment. During an interview on 10/05/2025 at 12:28PM the DON, stated when he was conducting his phone investigation with CNA A, she stated that she was attempting to provide incontinent care on Resident #1, but that Resident#1 slipped and fell from bed. DON stated that CNA A did not verbalize that she was attempting to log roll resident, and that Resident #1 remained on her back. The DON stated, while CNA A's written statement dated 03/18/2025 was reviewed, CNA A should have waited for another staff member to help her with Resident #1. The DON stated CNA A should have followed the plan of care for Resident #1, which called for a 2-person assist with incontinent care and bathing. The DON stated the reason Resident #1 was a 2-person assist was to ensure Resident #1's safety which may have been compromised when CNA A provided incontinent care independently. The DON stated Resident #1 fortunately did not sustain any major injury on 03/18/2025. The DON stated after Resident #1's 03/18/2025 fall, all staff members were in-serviced to follow the plan of care directive and to follow KARDEX daily. Record reviewed CNA A's Nurse Aid Registry form dated 06/14/2025 no noted concerns. Record reviewed CNA A's background check report completed date 03/28/2024 no concerns noted. Record review of the facility's 03/18/2025-3/20/2025 in-service revealed Topic: ADL assist, KARDEX review, fall prevention, care plan timelines, reviewed on laptop how to access KARDEX, reviewed KARDEX definitions (example: x1, x2 person assist), ADL assistance process, and fall prevention. CNA A was in attendance. Record review of the facility's Routine Resident Care policy and procedure date implemented: 03/14/2019 revealed, resident should receive the necessary assistance to maintain good grooming, person/oral hygiene and safety.Care is taken to maintain resident safety at all times. 676313 Page 3 of 3