Health inspection·February 13, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review; it was determined the facility failed to ensure that in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete, accurately documented, and readily accessible for 1 of 6 residents reviewed for clinical records (Resident #1) in that: The facility failed to conduct a fall risk assessment for Resident #1. This failure could place residents at risk of increased falls. The findings included: Record review of Resident #1's Face sheet, dated 02/13/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included, but were not limited to, Hemiplegia and hemiparesis (weakness in one leg, arm or side) the left dominant side following cerebrovascular disease (stroke), anemia and hypertension. Record review of Resident #1's quarterly MDS assessment, dated 02/04/2025, revealed he had a BIMS of 12 out of 15, which indicated he had mild cognitive impairment. Resident #1 needed maximal assistance for sit to stand and chair to bed transfer. Resident #1 needed moderate assistance for toilet transfer. Resident #1's assessment also revealed he had fallen since admission to the facility. Record review of Resident #1's care plan, updated on 02/04/2025, revealed the following: Resident #1 is a high risk for falls related to CVA with interventions anticipating and meeting resident's needs. Record review of Resident #1's clinical record relating to Fall Risk Assessment revealed the last Fall Assessment conducted for Resident #1 was on 11/18/2023 as a post fall assessment, which indicated he was a moderate risk for falls. There was no documentation relating to quarterly fall assessments in Resident #1's clinical record . In an interview and observation on 2/13/2025 at 4:35 PM, revealed Resident #1 was sitting in his wheelchair eating dinner, Resident #1 stated he had not fallen in a while and had no concerns. In an interview on 02/13/2025 at 7:09 PM, the DON stated she could not find any quarterly fall risk assessments for Resident #1. The DON stated Resident #1's fall risk assessments were overlooked Page 1 of 2 676389 676389 02/13/2025 Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244

F 0842 Level of Harm - Minimal harm or potential for actual harm because the EHR system did not trigger the assessment because he had been a resident for some time. The DON stated fall risk assessments were only triggered at admission or after a fall. The DON stated she was responsible for ensuring charge nurses completed admission, quarterly and as needed Fall Risk Assessments on each resident and a possible negative outcome for not completing one would be a resident could get hurt . Residents Affected - Few In an interview on 02/13/2025 at 7:14 PM, RN A stated charge nurses were responsible for ensuring fall risk assessments were completed on residents. RN A was unsure when the assessments were to be completed. RN A stated a possible negative outcome for not doing an assessment would be a resident could get hurt. In an interview on 02/13/2025 at 7:20 PM, LVN B stated a possible negative outcome for not doing a risk assessment for falls would be a resident could get hurt if there were no interventions. LVN B did not know when fall risk assessments were to be completed. In an interview on 02/13/2025 at 7:40 PM, the ADM stated charge nurses were the ones responsible for completing fall risk assessments, but she was the one ultimately responsible for ensuring the documentation was completed. The ADM stated a possible negative outcome for not having the fall risk assessments completed would be a resident could be overlooked as a fall risk. Record review of the facility's, undated, Fall and Post Fall Management Policy revealed the following: Each resident must be assessed on admission, quarterly and any change in condition for potential risk for falls in order to take a preventative approach for resident as well as staff safety. Fall Risk Assessment: .The interdisciplinary team will complete the following: 1. Complete a Fall Risk Assessment a. Upon admission b. Following any significant change of status of fall c. Quarterly documentation assessment 676389 Page 2 of 2