Health inspection·July 2, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of CR #1's medical record revealed a Fall Risk Observation/Assessment from 4/19/24 at 8:00 am by LVN A, that revealed the resident was a low risk for falls. Record review of CR #1's medical record revealed a nurse's note from LVN A on 4/19/24 at 8:51am that read, This nurse heard beeping coming from resident's room and went to check Enteral Feeding Machine [nutrition going into stomach by machine]. Upon entering room this nurse noticed that Air Mattress was on the Right side of the bed, unsecured to frame and resident was on the floor wrapped in his sheets and blankets. Resident was awake and alert, lowly moaning. Resident was laying on his Right side facing the bed w/ his right arm extended awkwardly out behind him. This nurse replaced mattress back on bed .Resident did display facial and verbal signs of pain when moved .resident is contracted in BUE and BLE .Sending resident to [hospital] ER for eval/treat as indicated to R/O head trauma. Record review of CR #1's medical record revealed an SBAR from LVN A on 4/19/24 at 9:13am that read, The Change in Condition/s reported on this CIC Evaluation are/were: Falls .Blood Pressure: 114/74 Lying L arm, Pulse: 112, RR: 18, Temp: 98.6 Forehead, Weight: 122.4lb Hoyer, Pulse Oximetry: 97% Room Air .Nursing observations, evaluation, and recommendations are: it appears that resident fell out of bed d/t air mattress not being secured to bed frame. Record review of CR #1's hospital records from 4/19/24 at 5:08pm read .Pt fell at SNF and was taken to the ER today. At baseline pt is AOx1 and bedbound The hospital records did not indicate there were any injuries from the fall. Interview with the family on 4/20/24 at 2:45pm, she said CR #1 was sent to the hospital after falling out of bed. She said the hospital staff asked her how CR #1 fell out of bed since he was contracted and could not move. She was unsure how the fall happened, but knew the staff had to turn him because he could not turn himself. Interview with LVN A on 7/2/24 at 12:05pm, he said he was the nurse who found CR #1 on the floor on 4/19/24. He said he heard beeping coming from the room and knew it was the PEG tube beeping. He said he found the resident wrapped up in sheets on the floor and the air mattress standing up on the side of the bed. He said Maintenance was responsible for putting the air mattresses on the beds and securing them. He said if he was in the room when Maintenance was applying one, he would double check to make sure it was secured, but typically he assumed it was if it was already there. He said when he found CR #1 on the floor, the mattress was not secured to the bed like it was supposed to be and he felt bad for the resident. Interview with the DON on 7/2/24 at 12:19pm, she said Maintenance puts the air mattresses on the beds and ensured they were strapped on and secured. She said the nurses only ensured they were plugged in and aired up. The DON said after CR #1 fell and they realized the air mattress was not secured to the bed, they performed a facility wide air mattress sweep and no other air mattresses were found unsecured. The DON also said she performed in-service training on abuse, neglect, fall reporting, and resident monitoring with all the staff after the incident. She said leadership added inspection of air mattresses to their Ambassador Rounds, which happened every morning. The DON said Ambassador Rounds were when leadership would round on the residents every morning and ensured they had their needs met and did not have any grievances. She said the Maintenance Director at the time said he secured it, but apparently it was not. She said the Maintenance Director no longer worked at the facility. She also said CR #1 did not have an order for the air mattress, but they automatically put residents on them if they had a Stage II Pressure Ulcer or higher. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676434 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Houston Transitional Care 9814 Grant Rd Houston, TX 77070 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the ADM on 7/2/24 at 2:19pm, he said his expectations were for the air mattresses to be maintained in a working order and applied safely to the beds. He said the Maintenance Director was ultimately responsible for putting the air mattress on the bed and for checking them routinely to ensure they were attached properly. He said the air mattresses were checked during room rounds now, so everyone ensured they were secured. The ADM said if the air mattress was not secured to the bed, when the resident's weight was shifted the resident could topple over and fall on the ground. Record review of the facility's air mattress bed sweep conducted on 4/28/24 by the previous Maintenance Director, revealed there were 5 other air mattresses in the facility with a note that said, All accounted for, no holes .witnessed [in] air mattresses-secured, no broken frames. Record review of the facility's current Room Check: Mattresses performed by the current Maintenance Director, for the month of June revealed, there were 5 rooms with air mattresses that were all checked on different days in June with no problems. Record review of the facility's In-Service Training Report conducted on 4/22/24 at 1pm by the DON revealed, it was conducted on notification of all falls, accidents, and hazards, checking on all residents frequently; especially high-risk residents, wounds, air mattress, fall mats .frequently for changes. Record review of the facility's policy and procedure on Assessing Falls and Their Causes (revised March 2018) read in part: The purpose of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall .Falls are a leading cause of morbidity and mortality among the elderly in nursing homes .Falling may be related to underlying clinical or medical conditions .and/or environmental risk factors. Residents must be assessed upon admission and regularly afterward for potential risk of falls. Relevant risk factors must be addressed promptly .Complete an incident report for resident falls no later than 24 hours after the fall occurs. The incident report form should be completed by the nursing supervisor on duty at the time and submitted to the Director of Nursing Services. After an observed or probable fall, clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred .Within 24 hours of a fall, begin to try to identify possible of likely causes of the incident .Evaluate chains of events or circumstances preceding a recent fall .Continue to collect and evaluate information until the cause of falling is identified or it is determined that the cause cannot be found . A policy on Accidents/Hazards and/or Air Mattresses was requested on 7/2/24 but the facility did not provide one. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676434 If continuation sheet Page 3 of 3