Health inspection·November 19, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety 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 interview and record review the facility failed to ensure residents remained free from accidents, hazards and each resident received adequate supervision and assistance when being transferred for 1(resident #1) of 5 residents reviewed for accidents and hazards.The facility failed to ensure a safe transfer with a mechanical/Hoyer lift to assist in the transfer of Resident #1 on 11/7/2025 when CNA A did not follow the protocol of having two staff to operate the Hoyer lift resulting in Resident #1 falling and sustaining a fractured right humerus (upper arm) and a closed head injury.This failure could result in serious injuries to residents and potentially death.The noncompliance was identified as PNC. The facility was provided with the IJ template on 11/18/2025. The facility had corrected the non compliance before the survey began.Findings include:Record review of Resident #1's progress notes, Facility investigation report revealed that on 11/7/2025. CNAA called for nursing assistance as Resident #1 had fallen from the Hoyer lift. Record showed that Resident #1 was found face first on the floor in a vertical position with toes touching the back legs of the lift frame. Resident was noted to have sever right arm pain to touch and a skin tear to her left arm. CNAA reported to the nurse that Resident #1 hit her face on the floor very hard. Records revealed that while LVNA assessed Resident #1 the ADONs contacted EMS, nursing administration, medical provider and the family of the residents. Records also revealed that CNA was asked to write a statement and then was escorted from the building and is no longer permitted to work within the facility.Record review of Resident #1s chart revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Schizoaffective Disorder, Dementia, Generalized anxiety, history of breast cancer, Cognitive communication deficit, and Major depressive disorder.Record review of the MDS dated [DATE] revealed Resident #1 had a BIMS of 03 indicating significant impairment.In an interview and observation on 11/18/2025 at 1:00 PM Resident #1 was sitting in her wheelchair at the nurse's station. The resident is pleasantly confused she was eating a sucker and talking with LVNA. Resident #1 was not able to say how her arm was broken but when asked about her arm she began stating she wanted her son. LVNA and Surveyor informed the Resident that they had both been told he was coming to see her later in the day. Resident #1's arm was in a sling for support. Resident #1 had a history of tremors in her hand and struggled to grip items. When Resident #1 dropped an item, she was not able to move to reach for it and relied on staff for assistance.Record review of the care plan for Resident #1 dated 10/2/2025 revealed the problem that Resident #1 has impaired physical functioning with interventions initiated on 1/27/2025 to utilize Hoyer lift and 2 staff for transfers. and utilizes the following for ambulation wheelchair for mobility.Record Review of the hospital ER records dated 11/7/2025 reflected Resident#1 was diagnosed with a closed head injury and a fracture to the right humerus.In an interview on 11/18/2025 at 10:00 AM with the Administrator, he stated that the agency the alleged perpetrator, CNA A worked for had been dragging their feet on giving them further information on her. He stated they Page 1 of 5 455486 455486 11/19/2025 Ennis Care Center 1200 S Hall St Ennis, TX 75119

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few were trying to obtain her competency and personnel file from the agency. He stated on 11/7/2025 CNA A decided to use the Hoyer lift by herself, and Resident #1 was fidgeting and fell face first out of the lift. He stated CNA A immediately called for the nurse to assess and they sent the resident to the hospital. He stated Resident #1 returned to the facility later that same day with a diagnosis of a broken humerus (upper arm). He stated CNA A reported other staff were busy and she should have waited but did not. He stated since the incident on 11/7/2025 the facility has in-serviced staff and had completed competency check offs for use of the Hoyer lift and all staff knew that two people were required at all times. He stated they had been attempting to obtain competency check offs for CNA A from her agency, but they had not responded. He denied requesting the info prior to employing agency staff prior to the incident on 11/7/2025. He stated the agency CNA, CNA A was asked to leave after completing her statement and had been placed on their do not return list. He stated they were no longer utilizing agency staff.In interview on 11/18/2025 at 10:53 AM with the Director of Clinical Operations, he stated following the incident on 11/7/2025 where Resident #1 fell from the Hoyer lift, Maintenance checked all equipment and made sure it was in working order. He stated they immediately in-serviced staff on abuse and neglect, safe resident handling and transfers. He stated they did competency checkoffs with therapy instruction. He stated the training was completed with all CNAs, CMAs, LVNs, and RNs. He stated going forward all agency staff, as well as employed staff, would be trained and have competency check offs where they must demonstrate proper use of the mechanical lift prior to working unsupervised.In an interview on 11/18/2025 at 12:58 PM with LVNA, she stated the policy on the use of a Hoyer lift is always 2 people to transfer a resident. She stated that she preferred to have 3 people performing lifts and transfers with the Hoyer. She stated all transfers must be a CNA, CMA, or nurse (LVN or RN). She stated that on 11/7/2025 a call came into the facility resulting in the nurses needing to check on each resident. She stated when she and other nurses were headed back towards the nurse's station CNAA stepped out and was waving calling for help and she went in the room and Resident #1 was face first on the ground the sling was still in the air attached with only 3 loops to the mechanical lift. She stated she did not move Resident #1 and secured her head until EMS arrived. She stated she could immediately see that Resident #1's right arm was broken. She stated that CNA A told her that she had moved the resident on her own as the other aide was called away. She stated that the straps and loops on the sling all appeared intact. She stated Resident #1 cannot make sudden large moves. She stated the resident does move her hands and arms on occasion. She stated in her opinion if Resident #1 had been placed on the sling appropriately she should not have fallen. She stated the front right strap was hanging down. She stated that since the incident the staff had been in-serviced on policies regarding abuse, neglect, transfers and mechanical lifts prior to returning to shift. She stated therapy trained them on Hoyer lifts and transfers and they had competency checks. She stated all staff reviewed training videos on Hoyer lifts and transfers. She stated that they have developed an additional competency check for agency staff since the incident.In an interview on 11/18/2025 at 1:27 PM with the ADON, she stated that the facility frequently in-serviced staff on abuse neglect, falls, transfers, and mechanical lifts. She stated that prior to the incident that occurred with Resident #1 they did not perform competency checks of agency staff due to the agencies claimed that they ensured agency staff were competent in skills. She stated she was not sure if the agencies provided them with proof of competencies prior to an agency staff coming to work within the facility. She stated that policy for use of the Hoyer lift required that the equipment is in working order and to always use 2 staff when lifting a resident. She stated it is her expectation that there are always at least two staff assisting to move a resident with a Hoyer lift. She 455486 Page 2 of 5 455486 11/19/2025 Ennis Care Center 1200 S Hall St Ennis, TX 75119

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few stated that prior to the incident a non-related call came in that resulted in all nurses needing to check on the residents. She stated that as she was walking down the hall she saw LVN A had gone into Resident #1's room and Resident #1 was on the floor. The ADON stated CNA A, who is an agency staff, was standing next to the lift and stated she had used the lift alone. She stated once Resident #1 left with EMS she spoke further with CNA A. The ADON stated she had CNA A write a statement and asked her to leave the facility. The ADON stated that CNA A stated the resident was kicking and that the other aide had left. The ADON stated that CNA A's story was not consistent. She stated LVN A assessed Resident #1 and EMS was called to take the resident to the hospital. ADON stated that she contacted the DON and Administrator to report the incident, and she collected other statements. She stated that following the incident they did a mandatory in-service on abuse, neglect, transfers and mechanical lifts. They now have a check-off for competencies for the agency staff. She stated that the therapy department assisted in training all CNAs, CMAs, RNs, and LVNs on proper transfer and mechanical lift procedures. On the hallways there is a list of who requires a Hoyer lift and in PCC the CNAs and CMAs can see the required transfer methods ordered by physicians. She stated nurses can also see the care plan and the physician's orders on transfers.In an interview on 11/18/2025 at 2:37 PM with CNA A she stated that she was an agency aide and on 11/7/2025 she worked her 4th shift at the facility. She stated although she was aware that a mechanical lift requires two staff, she did not follow protocol. She stated she had performed the task with Resident #1 alone due to everyone being busy. She stated she should not have attempted the lift alone. She stated she had performed competencies with her agency on proper use of a mechanical lift. She stated that when she was transferring Resident #1, she was moving around, and Resident #1 fell and hit her head. CNA A stated she called for help, and the nurses came and assisted her. She stated she had not worked at the facility since the incident.Record review of facility policy, Safe Resident Handling and Transfers dated reviewed and revised 5/15/2025 revealed, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines.' Compliance guidelines include: Two staff members must be utilized when transferring residents with a mechanical lift. Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur. The staff must demonstrate competence in the use of mechanical lifts prior to use and annually with documentation of that competency placed in their education file. Resident lifting and transferring will be performed according to the resident's individual plan of care. Staff will perform mechanical lifts/transfers according to the manufacturer's instructions for use of the device.Record review of in-services completed on 11/7/2025 on safe resident handling, transfers, patients lift, abuse, neglect, and exploitation revealed all staff had been trained.Record review of a validation checklist for the mechanical lifts revealed all staff were checked for competence following the incident upon their next shift. Reviewed 47 employee Hoyer lift check off sheets dated between 11/10/2025 and 11/14/2025.Record review of logs provided revealed that Maintenance inspected the two Hoyer lifts on 11/11/2025 and ensured they were in proper working order.On 11/18/2025 at 9:38 AM Nurse Surveyor over saw the use of the mechanical lift involved a minimum of two employees and was performed in accordance with facility policy.Reviewed document the facility had developed, Competency check-off list for agency staff, to complete prior to working unsupervised. The document included: use of gait belts, mechanical lifts (require 2 persons), requesting assistance if unsure. The DON stated that this document would be used for all agency staff as they currently had chosen not 455486 Page 3 of 5 455486 11/19/2025 Ennis Care Center 1200 S Hall St Ennis, TX 75119

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to utilize agency following the incident.In an interview on 11/18/2025 at 2:26 PM with CNAB she stated she has worked several roles at the facility for over 12 years. She stated she is frequently in-serviced on abuse, neglect, falls, transfers and mechanical lifts. She stated she often comes in on the weekend to work extra shifts as a CNA. She stated an example of abuse or neglect would be a staff member talking badly to a resident or if a resident is sitting there and not being fed. She denied witnessing abuse or neglect in the facility. She stated if she did witness abuse or neglect, she would immediately report it to the Administrator who is the abuse coordinator. She stated when using a Hoyer lift there should always be 2 people assisting at all times. She stated if a 2nd person is not available staff should always wait for assistance and never lift a resident alone. She stated she was in the facility on 11/7/2025 but does not know the details of the incident involving resident #1. She stated all CNAs and CMA have access to transfer type orders in PCC which is their electronic medical record. She stated that since 11/7/2025 they have had multiple in-services on lifts and transfers and have been reminded that all lifts require two people. She stated they did a training with therapy on proper techniques to transfer and lift residents with the Hoyer lift.In an interview on 11/18/2025 at 3:04 PM with CNAC stated she has worked at the facility for 4 years. She stated she is frequently in-serviced on abuse, neglect, falls, transfers and mechanical lifts. She stated that an example of abuse or neglect would be leaving a resident wet. She denied witnessing abuse or neglect while working at the facility. She stated that if she witnessed abuse or neglect, she would immediately report it to the Administrator who is the abuse coordinator. She stated that a Hoyer lift always required 2 people. She denied any staff ever having to use a Hoyer lift alone to her knowledge she stated she always gets either a CNA, CMA or a nurse to assist or she will wait and ensure the resident is in a safe position. She stated that in PCC in the Kardex shows what type of transfer or lift is required. She stated they have a list on each hall in the linen closet that states what size sling is needed for each resident. She stated that she was working on 11/7/2025 on the memory care unit and she was not present for the incident that occurred for Resident #1 but she knows that she went to the hospital. She stated that she does occasionally get assigned to care for Resident #1. She stated she has never had an issue when transferring Resident #1 and stated she does not move around much when she is being transferred. She denied knowing CNA A. She stated that the Agency CNAs would now have a competency check-off sheet that must be completed prior to working unsupervised. She stated all staff had training with the therapy department and had to show that they were competent in the use of the Hoyer lift and transfers.In a telephone interview on 11/18/2025 at 3:18 PM CNAD she stated she has worked at the facility for over 5 years. She stated she is frequently in-serviced on abuse, neglect, falls, transfers and mechanical lifts. She stated an example of abuse or neglect would be a staff snatching something out of a resident's hand, not changing, feeding or bathing a resident. She denied witnessing abuse or neglect at the facility. She stated if she witnessed abuse or neglect she would secure the resident and immediately contact the Administrator. She stated if unable to reach the Administrator she will contact the DON. She stated her immediate concern is to protect her resident. She stated that when using a Hoyer lift there should always be two staff. She stated one person is controlling the lift while the other is stabilizing the resident. She stated that to her knowledge no coworkers use the Hoyer lift alone. She stated that she feels they always have sufficient staff to have a minimum of two people lifting. She stated that on 11/7/2025 she worked the 6:00am to 2:00pm. She stated that the CNAs give each other a report each shift on each resident and discuss transfers, lifts, incontinence and other things that occur with the residents they are assigned. She stated that they performed competency checks last week with the Hoyer lift after review from the 455486 Page 4 of 5 455486 11/19/2025 Ennis Care Center 1200 S Hall St Ennis, TX 75119

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few therapy department and they reviewed policies on abuse, neglect, transfers and mechanical lifts.In an interview on 11/18/2025 at 3:40 PM with LVNB she stated she has worked at the facility for five years. She stated she is the MDS coordinator but has worked the floor at times. She stated she is frequently in-serviced on abuse, neglect, falls, transfers and mechanical lifts. She stated an example of abuse would be not providing a resident food or items they request for comfort. She denied witnessing abuse or neglect within the facility. She stated that if a resident falls or falls out of the Hoyer lift a nurse would assess them prior to moving them and typically call 911 to have them further assessed at a hospital. She stated that if she witnessed abuse or neglect, she would stop the abuse and report it to the Administrator immediately. She stated that when using a lift they must have two people at all times. She denied any knowledge of anyone using a Hoyer lift with only one person and stated there is no reason to only have one staff operating the lift. She stated the ADON and herself were here on 11/7/2025 and received a call that led to the nurses checking on each resident. She stated she was not the nurse who checked Resident #1s room and is unaware who did. She stated she and the other nurses walked back up the hall and noted that CNA A was requesting assistance and LVN A assessed the resident while she called 911 and the ADON questioned CNA A. She stated to her knowledge prior to 11/7/2025 agency staff did not have competency checkoffs within the facility that they relied on the agency to ensure their staff were competent. She stated that since 11/7/2025 they have had in-services on abuse, neglect, transfers and mechanical lifts. She stated that they had therapy department train and checkoff each staff member on transfers and mechanical lifts. She stated they watched a video on proper transfer and mechanical lifts and now they have a competency check-off sheet for all agency staff to complete prior to working alone. She stated the CNAs and CMAs can see how to transfer and or lift a resident in the electronic medical record under the Kardex. She stated that CNA A did have access to the electronic medical record as she set up access, she stated that they have a standard login for the agency staff.The noncompliance was identified as PNC. The facility was provided with the IJ template on 11/18/2025. The facility had corrected the non compliance before the survey began. 455486 Page 5 of 5