Faith Memorial Nursing Home

F-F684: Quality of Care

The facility failed to obtain emergency services for unwitnessed fall for Resident #1 after a fall on 7/24/24 that resulted in bruising to a subdural hematoma to the left side of her head. Resident #1 arrived at the ER approximately two and a half hours after the injury had occurred.

On 7/24/24 Resident #1 was transferred to the hospital.

LVN A was suspended pending investigation 7/25/24 based on Self Report to HHSC.

The Administrator and Director of Nursing notified the Medical Director of the IJ on 7/26/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 11 675321 Department of Health & Human Services Printed: 09/17/2025 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 675321 B. Wing 07/29/2024

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

Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502

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 0684 The Regional Nurse Consultant provided 1:1 education with the DON on 7/26/24 on the following topics:

Level of Harm - Immediate o Conducting an Investigation Post Falls jeopardy to resident health or safety o Fall Management

Residents Affected - Few o Changes of Condition Warranting 911 Transfer

o Neuros Vital Signs Status Post Falls

The Director of Nursing initiated education with Licensed staff members on 7/26/24 on:

o Fall Management

o Change of Condition Warranting 911 Transfer

o Neuro Vital Signs Status Post Falls

o Incident & Accident Quick Guide

*All License Staff will be Educated Prior to Working & Complete Post Test to Demonstrate Competency.

All Training to be Completed by 7/27/24.

Audit of Resident Falls x last 30 Days Completed; DON & ADON Assessed Residents Identified to ensure there were no adverse effects status post fall that had not been addressed.

Assessments Completed 7/26/24.

Ad Hoc QAPI Conducted 7/26/24 with Medical Director, Administrator, DON, & ADON.

Monitoring Day 1: Saturday July 27th, 2024

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 11 675321 Department of Health & Human Services Printed: 09/17/2025 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 675321 B. Wing 07/29/2024

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

Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502

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 0684 In an interview on 7/27/24 at 4:08 PM with the DON, she stated she was educated on doing neuro checks and what the time frame was. The neuro documentation sheets were changed to front and back copies to Level of Harm - Immediate help keep up with them. She discussed that if there were any changes in neuro responses, it was an acute jeopardy to resident health or change and it was an emergency. There was also a quick guide for falls created a copy is held at each safety nurse's station for them to review. The quick guide gives examples for everything that was required and considerations of what to do after a fall. Fall management covered that prior to a fall, and doing a fall Residents Affected - Few assessment, nurses needed to pay attention to the score. They were responsible for recognizing the score and putting something in place at that time. Some patients have fall injuries and may need a fall mat. If it is a trip hazard, nurses have to wave that out. Nurses need to make sure that anytime there is a fall intervention

in place it makes sure that we are looking at each person's care plan. The nurse can add interventions in the risk management, and it will be reviewed by the IDT team and DON in the morning. In the event of a fall, herself and the Regional Nurse covered to make sure they did skin assessment, initiated neuro checks, evaluated cause of fall, and did a complete vital sign, neuro check, and range of motion. Staff must notify her of all falls and if the doctor they are trying to reach had not responded in 1 hour, they must notify the Medical Director. Nurses must notify RP and if a resident is their own RP, instead of leaving blank that section blank

in the documentation, nurses are to add the resident's name to state they are their own RP. Everything must be documented and passed on to the report. If the condition was life threatening, they would notify EMS, then they would call the doctor and notify the DON. They also covered in the education that anytime a resident changes the level of plane it is still a fall. Unless there was evident of something otherwise, if a resident is on the floor, then a fall is considered to have happened. The DON stated she discussed with nurses the signs of a head Injury such as unequal pupils, loss of consciousness, change in cognition, nausea and vomiting, and/or a headache. If the resident already had a something nurses were monitoring like aspirin or blood thinners, the nurse would send the resident out to be evaluated. The facility added a table for what type of treatment would need to be done for time frames to be viewed at the nurses station as well. If there were any abnormal neuro changes, muscle or skeletal issues, they needed to be in the ER within an hour. If there was any bleeding or anything with large lacerations, residents could be sent out, stating that They are nurses and should still be ale to use judgement.

In an interview on 7/27/24 at 4:38 PM, LVN B stated that she had worked at the facility for 5 months and worked from 6AM- 6PM. She stated for the fall protocol, they covered the procedure for and an unwitnessed and witnessed fall. An unwitnessed fall automatically needed neuro checks. They were to do assessments, vitals before they have been moved, and check for pain and any possible dislocations. Nurses were to do a whole assessment, notify the doctor and receive orders, and notify the DON, and family. Witnessed falls with head injury called for the same procedure except they would medicate immediately, do neuro checks, and vitals. If there was an emergency and they needed to call 911, nurses can call them and let the doctor and family know. Some examples of emergencies were an acute change in cognition, head injuries, suspected dislocation, pain upon movement, headaches, and suspected bleeding. Everything that needed to be documented after a fall would be the SBAR, risk management, pain assessment, skin assessment, fall assessment, and neuros. LVN B stated that the quick guide for fall assessments was located at the nurse's station and they gave each nurses a copy after the in-service.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 11 675321 Department of Health & Human Services Printed: 09/17/2025 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 675321 B. Wing 07/29/2024

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

Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502

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 0684 In an interview with on 7/27/24 at 4:47 PM with LVN C, she stated that she had started work at the facility on 6/5/24 and worked the 6AM- 6PM shift. She explained the fall protocol was to assess the patient before the Level of Harm - Immediate touched them for injuries and check their vitals. If it was an unwitnessed fall she would we do neuro checks jeopardy to resident health or and check head to toe to make sure there was no other pain. Nurses will also make sure the doctor and safety DON was aware. If on blood thinners, they would send the resident to the hospital. Vitals should be monitored and if they have major symptoms like bleeding, unresponsiveness, not alert and oriented, she Residents Affected - Few would send them out because she did not want to take any chances. LVN C also stated that the doctor, family, and DON must be aware. For every fall, nurse complete a SBAR, fall assessment, pain assessment, skin assessment, and do neuro checks. Neuro checks were especially completed if the fall was unwitnessed or witnessed with a head injury. If there was an emergency like the patient was unresponsive or a mood change in condition, she would call 911 first and the call the doctor. She explained that they have quick sheets for fall protocols and book for the neuros that she kept at her desk at the nurse's station.

In an interview on 7/27/24 at 4:53 PM with LVN D, she stated she started working at the facility on 06/01/24 and she worked the 6AM- 6PM shift. She explained that in the fall protocol in-service, they covered what to do in a witnessed and unwitnessed fall. Nurses have to do an incident t report and SBAR. If the CNAs found

the resident first, she would make sure they don't touch them, and continue with vitals, neuro checks, and check for broken bones. She would also check to see if the resident was on blood thinners and if there was

an emergency, she would call 911 immediately without waiting on a response from the doctor. Examples of emergencies would be if they were on a blood thinner and hit their head, visibly bleeding profusely, broken limbs, unconscious, headaches, seizures, and if there was something she couldn't control. She explained when was had to call 911 for emergency, she would notify the DON, she would stay with the resident, and assign someone else to call 911. She would also doctor or on call if they take too long, she would call the Medical Director and notify the family. If the resident was their own RP, she would write that in the risk management assessment and SBAR, as well as in her own progress note. There was a fall protocol quick note sheet she was given during the education that she placed at her desk and she stated that she also kept all of the paperwork from facility in-services in her work bag. Nursing also had a flow sheet for monitoring neuros, which was just updated. LVN C said for neuros, they have to follow up every 30 minutes, for up to 72 hours and it was self-explanatory.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 11 675321 Department of Health & Human Services Printed: 09/17/2025 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 675321 B. Wing 07/29/2024

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

Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502

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 0684 In an interview on 7/27/24 at 5:15 PM with the ADON, she stated that in the fall protocol nurses went over

the steps of what to do when there was a fall, what documentation, and who to notify when you can and Level of Harm - Immediate cannot notify the physician. The documentation was the risk assessment of incident report, SBAR, fall jeopardy to resident health or assessment, pain assessment, and skin assessment. They were to make sure to notify the physician and RP safety if there was one and the DON for protocol because there was a change in condition. She stated she also does a progress note. It the fall was unwitnessed and with a head injury, nurses have to start neuros. When Residents Affected - Few a resident falls, they go to the resident and let CNA's know not to touch them. They perform a full head to toe assessment, do range of motion, and check skin integrity for any tears bumps bruising. Then she would assess if they were in pain and if so, immediately address with PRN pain meds, and if none I get an order form the physician. Nurses do not have to contact the physician first if there was a 911 situation. She explained she would do what was best based off her nursing judgment. Emergencies would be any changes

in head or skin, nonstop bleeding, headaches non-retractive, unstable vitals, changes in neurological conditions, and vomiting. If they contact the doctor and they have not responded after 15-20 minutes, she would contact the DON and the medical director by phone call to let them know what is going on. The fall quick notes are kept at the nurse's station and it outlined step by step what also needed to be done in care of

a fall, including neuro checks done every 30 minutes.

In an interview on 07/27/24 at 5:30 PM with the WCN, she stated she been here since 4/22/24, and worked Monday through Friday from 8AM- 6PM. She stated that in the fall protocol, they went over what the policies were if the fall was witnessed or unwitnessed, neuro checks, and what the procedures were. When a resident falls, she would do a head-to-toe assessment, vital signs, and contact the physician and notify the family. If the fall was unwitnessed, she would start her neuro checks. She stated that she would count the vitals she did initially as her first check and start from there. Assessments completed were the neuro assessment, pain assessment, progress note, SBAR, fall assessment, range of motion, and skin assessment. If the resident was nonverbal, we look for verbal cues. Nurses can call 911 if there was an emergency and they needed medical attention before contacting the doctor. These emergencies included bleeding, possible fracture, unresponsiveness, seizures, change in condition, headaches, injuries, or bleeding. If she could not reach the doctor, she would still have to notify the DON, ADON, and the medical director. The fall protocol quick sheets were kept at the nursing stations. If the form said RP on the neuro check sheet and the resident was their own RP, she would still contact the emergency contact because she wanted to let someone know what was going on.

Day 2: Sunday July 28th, 2024

In an interview on 07/28/24 at 1:10 PM with LVN E, said she was in-serviced on fall protocol policy. She said

a head-to-toe assessment, neuro checks, SBAR, fall assessment, pain assessment and skin assessment had to be completed for residents who had a witness or unwitnessed fall. She said vital signs and range of motion had to be completed and documented. She said a resident who was bleeding, took blood thinners, vital sign out of normal range, unconscious, broken bones would be sent out 911. She said she would make notifications to the RP, Administrator, DON, ADON and the physician. She said there was a cheat sheet located at the nurses' station for reference if needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 675321 Department of Health & Human Services Printed: 09/17/2025 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 675321 B. Wing 07/29/2024

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

Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502

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 0684 In an interview on 07/28/24 at 1:37 PM with LVN F said she was in-serviced on fall protocols. She said there was a binder at the nurse's station to refer to if needed. She said residents who had a change in condition, Level of Harm - Immediate unresponsive, on blood thinners/had bleeding, fractures would be sent out 911. She said the Doctor, DON, jeopardy to resident health or ADON, Administrator and RP would be notified. She said a head-to-toe assessment would be completed safety along with SBAR, range of motion, pain, skin and fall assessments. She said neuro checks would be completed in various intervals indicated on the neuro check form. Residents Affected - Few

In an interview on 07/28/24 at 2:03 PM with LVN G said with a fall and a resident has a head injury he would do assessment head to toe, take vital signs, check range of motion and call the Doctor, DON, Administrator and family. He said he would document in the nursing notes along with neuros checks, pain, fall and skin assessment. If they hit their head, we send the resident out 911 if there was bleeding, on anticoagulants, unresponsive and change of condition that was not at the resident's baseline. He said we have a binder at

the nursing station to refer to if needed on the steps to take after a fall.

In an interview on 07/28/24 at 2:09 PM with LVN H said she had been in-serviced and was aware of the steps to follow after a witness or unwitnessed fall. She said a head-to-toe assessment would be completed with range of motion to detect any fractures. She said residents with fractures, bleeding, on anticoagulants, and unresponsive would be sent out by 911. She said residents who had a witness or unwitnessed fall, neuro checks, SBAR, fall assessment, pain assessment and skin assessment had to be completed. She said

the DON, Administrator, Family and Doctor is notified. He said there was a quick guide at the nurses' station with all of the fall protocol steps.

In an interview on 07/28/24 at 2:29 PM with LVN I said he was aware of the fall protocols. He said he would check a resident's vitals, range of motion and head to toe assessment for unwitnessed or witnessed falls. He said if a resident was not responsive, bleeding, on blood thinners, change in condition, or broken bones the resident would be sent out 911. He said after a resident had a fall, neuros, fall, pain, and skin assessments had to be completed. He said there was a reference guide at the nurses' station with the fall protocol. He said the steps taken after a fall had to be documented and notifications made to the doctor, family, DON and Administrator.

In an interview on 07/28/24 at 2:48 PM with LVN J said after a fall all steps taken had to be documented. She said a quick guide for falls was located at the nurse's station. She said a SBAR, risk management, pain assessment, skin assessment, fall assessment, and neuros had to be completed. She said when there was a change in condition, bleeding, head injuries, unconscious or fractures a resident would be seen out 911. She said notifications should be made to the family, DON, ADON, Administrator and the physician.

In an interview on 7/28/24 at 7:12 AM with LVN K said she was in serviced on the facility's fall policy. She said all actions taken after a fall had to be documented. She said a fall assessment, neuro checks, skin and pain assessments had to be completed. She said notifications to the physician, family and DON should be completed. She said the facility placed a quick guide at the nurses' stations to reference the steps after a fall.

She said residents would be sent out 911 after a fall, if they had bleeding, unconscious, range of motion issues that indicated broken bones, and abnormal vitals.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 675321 Department of Health & Human Services Printed: 09/17/2025 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 675321 B. Wing 07/29/2024

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

Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502

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 0684 Record review of facility Education In-services on Quick Guide - Falls, Change in Condition Communication, Neurological Neuro Checks, Fall Management, Investigation of Falls, Fall Management Post Test dated Level of Harm - Immediate 7/26/24-7/28/24 revealed all staff were trained on the Fall Management Policies and tested on knowledge of jeopardy to resident health or the policies. safety

The Admin was informed the Immediate Jeopardy (IJ) was removed on 7/28/24 at 7:09 PM. While the IJ Residents Affected - Few was removed, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 675321