Inspection·July 11, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few high back wheelchair. He said 2 staff transferred him with the mechanical lift. Resident #17 states he was not able to use his legs related to pain and weakness. In an interview on 07/10/24 at 03:01 PM with LVN A, she stated Resident #17 was transferred with a mechanical lift. She stated Resident #17 could get combative with staff during transfers. LVN A stated transfer assist level would be located within the task bar on the EMR. She stated there should have been a physician's order for residents transferring using a mechanical lift. She stated physical therapy would establish the amount of assistance a resident would require with an evaluation. The therapy department would then communicate the safest transfer status to the nursing staff. LVN A stated luckily for this resident he is cognitive enough he would not allow anyone to transfer him with one person, however if a new CNA were to come on shift it could lead to injury of the resident. In an interview and observation on 07/10/24 at 03:10 PM with -CNA B she stated this is her 1st day in this building she works for agency staffing. She stated she did get report from the off going CNA related to resident's needs. She was able to demonstrate [NAME] access to see what assistance Resident #17 would be. She reported Resident #17 was assist x 1 staff with transfers. CNA B stated if she was unsure of transfer status, or she felt uncomfortable she could always ask the nurse for clarification. She stated if she were to transfer the resident unsafely it could result in injury to the resident. In an interview on 07/11/24 at 11:47 am with MDS LVN, she stated she had been working at this facility almost 1(one) year. She was responsible for the MDS assessment and most of the care plans. She stated when Resident #17 was admitted , the admitting nurse had completed the baseline care plan with a transfer assistance level of 1 (one) staff with a gait belt. It was never reported that staff were using a mechanical lift to transfer Resident #17. His transfer status was never updated within the [NAME] or care plan. She stated if staff were to feel uncomfortable during a transfer, they could always use more assistance. This would include using the lift to assist with the transfer. MDS LVN stated the care plans were updated daily. For Resident #17, there was never a progress note or change in condition notification related to the increased need for assistance during his transfers. Those notifications came from the charge nurses. The DON, ADON, and MDS nurses review the notifications daily and update the care plans accordingly. She stated the negative effects for the Resident #17 being improperly transferred could have resulted in injury to employee or resident. In an interview on 7/11/24 at 12:59 PM with the DON, she stated nurses completed admission assessments and based on the resident's acuity at that time is how the care plan and [NAME] were created. The IDT updates the care plan based off clinical progress notes and changes in condition. Staff were educated to report changes in residents' conditions as soon as they are noticed. Staff were constantly educated to report all changes in condition and review the [NAME] for accuracy. Nursing staff were educated to always ask when they are unsure of a residents transfer status. She stated she was not sure why Resident #17's transfer status was not changed. She stated Resident #17 is currently receiving therapy for his weakness and unsteady gait. She stated the risk for the resident for having an improper transfer status could be injury or a fall. Record review of the facility's policy titled Safe Resident Handling/Transfers dated February 2006 reflected it is the policy of this community to ensure that patients/resident are handled and transferred safely to prevent or minimize risk for injury and provide and promote a safe, secure, and comfortable experience for the patient/resident while keeping the team members safe in accordance with current standards and guidelines. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455503 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 455503 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosewood Heights 5700 E Central Texas Expwy Killeen, TX 76543 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete #5 Handling aids may include gait belt, transfer boards, slings, and/or slide devices per the individuals care plan. Record review of the facility's policy titled Care Plans dated February 2017 reflected the community develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a residents medical nursing mental and psychosocial needs that are identified in the comprehensive assessment. Event ID: Facility ID: 455503 If continuation sheet Page 3 of 3