Fall Creek Rehabilitation And Healthcare Center

F-F689- Accidents/supervision

Problem:

Facility failed to ensure CR#1 received adequate supervision and interventions to prevent falls with injuries.

Facility failed to update CR#1's care plan even after her fall risk increased in short periods of time. Out of a score of 28.0 (most severe) for fall evaluations completed by the facility, CR#1's score peaked recently at 26. CR#1 sustained serious injury from falls and is currently hospitalized with a brain bleed and stitches above

the right eye.

The facility failed to implement preventive measures for CR#1's continuous falls, which resulted in severe injuries. On 1/11/2025 resident fell at 2:17pm with minor injuries and again 22 minutes later at 2:39pm resulting in serious injuries requiring hospitalization . The resident was returned to the facility at 1/12/25 at 3:33am and at 7:37am resident transferred to hospital for another unwitnessed fall.

Immediate action:

1. 1/ 13/25 The facility administrator completed a self-report incident to HHSC due to unwitnessed fall with major injury.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 22 676412 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676412 B. Wing 02/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fall Creek Rehabilitation and Healthcare Center 14949 Mesa Dr Humble, TX 77396

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 2. 1/16/25The facility Don/Designee conducted an audit of residents with fall risk assessment. risk scores 0-9 mean no risk for fall and scores 10-30 means at risk for fall, to ensure their comprehensive person-centered Level of Harm - Immediate care plans are appropriate and meet their individual needs. No new concerns were identified. Completed jeopardy to resident health or 1/17/25 safety 3. On 1/16/25 The Don/Designee immediately initiated an audit of residents' currently residing in the facility Residents Affected - Few comprehensive care plans who have had falls in the last 16 days, 6 residents with 8 falls where reviewed, to ensure fall prevention interventions are objective, measurable and timely. No new concerns were identified. Completed 1/16/25

4. On 1/16/25 The Corporate nurse conducted a 1:1 in-service with the DON on the facility Fall Prevention Program Policy focusing on timely implementation of person center care plans to include adding measures that objectively meet the resident's needs. Completed 1/17/15.

Interventions:

5. On 1/16/25 the DON/Designee initiated an in-service with the facility Licensed nursing staff on The Fall Prevention program. This included an explanation of Risk Assessments indicating fall risk and or no risk and

the different interventions based on Fall risk assessment as well as the licensed nurse responsibility to immediately implement interventions to prevent or further prevent residents falls and injuries. Projected completion 1/17/25

6. On1/16/25 the DON/Designee initiated an in-service with nursing staff, rehab, housekeeping and department heads on the Fall Prevention Program Policy to include the Falling Star Program. A gold Star is added to the Resident name on the door, on their wheelchair/Walker and above their bed to alert Staff, the resident has had a fall and is at risk for additional falls. Department heads ensure compliance during morning resident/room rounds. Any identified concerns are reported to the Administrator/DON immediately. Projected completion on 1/17/25.

7. On 1/16/25 the DON/Designee initiated an in-service with licensed nurses on immediately reporting all resident falls to the DON and or Administrator to seek guidance and ensure appropriate interventions are put

in place following a residents fall. Projected completion 1/17/25

8. On 1/16/25 the Regional Corporate nurse/Designee initiated and in-service with the nurse managers and licensed nurses on the Facility Policy for Comprehensive Care Plans focusing on promptly updating resident plan of care following each fall with interventions to meet the residents' individualized needs, DON/MDS nurse and Designee will monitor care plans for appropriateness and completion. Completion date 1/17/25

Ongoing Projected completion 1/17/25

Any staff member not present or in service will not be allowed to assume their duties until in- [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 22 676412