Health inspection·March 31, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm 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 observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, for one of four residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure CNA A used a gait belt to transfer Resident #1 from the bed to the wheelchair . This failure could place residents at risk for falls, injuries and a decline in health. Findings include: Record review of Resident #1's face sheet, dated 03/30/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 with diagnoses which included muscle wasting and atrophy , abnormalities of gait and mobility, lack of coordination, cerebral infarction (stroke) affecting left non-dominant side, and hemiplegia (paralysis of one side of body) and hemiparesis (weakness on one side of the body). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS score of 14, which meant mild cognitive impairment. Resident #1 needed partial to moderate assistance for chair/bed-to-chair transfer. Resident #1 was coded to have neurological deficits of cerebrovascular accident, transient ischemic attack or stroke and hemiplegia or hemiparesis. Resident #1 was coded for having functional limitation of range of motion with both impairment on one side for both upper and lower extremities. Record review of Resident #1's care plan problem start date 10/17/2024 edited on 10/28/2024 revealed ADLs Functional Stat/Rehabilitation Resident requires assistance/supervision for ADL and mobility tasks status post CVA with residual left hemiplegia weakness, impaired balance poor endurance activity tolerance. He has reduced ROM to left upper extremity. He attempts ADLs per self, does not use call light or assist at times, is at risk for falls/injuries. Approach (Interventions): Assist resident with shower three times per week per schedule and PRN. Resident Requires physical x1 staff assistance. Encourage resident to participate to the fullest extent possible with each interaction, task. Encourage resident to turn and reposition Q2 hours and PRN while in bed and up in wheelchair. He is independent for bed mobility and turning and repositioning tasks. Encourage/remind resident to use bell to call for assistance. Check on resident at routine intervals and to assess needs, monitor safety issues and offer/provide assistance as needed. He requires extensive assist x1 staff for dressing and clothing changes daily and PRN. Monitor for changes in functional status and independence for Page 1 of 3 455557 455557 03/31/2025 The Palms Nursing & Rehabilitation 5607 Everhart Rd Corpus Christi, TX 78411

F 0689 Level of Harm - Minimal harm or potential for actual harm ADLs, strength, balance, safety. Make appropriate referrals PRN. Resident is mobile using wheelchair. He requires supervision and set-up assistance for locomotion on and off of the unit. He is only able to walk very short distances with extensive assistance. Resident requires limited x 1 staff assistance for personal hygiene tasks. The care plan had a revision date of 03/30/2025 to include He is independent for transfer tasks. Residents Affected - Few Record review of Resident #1's care plan problem start date 10/17/2024 edited on 03/30/2025, revealed potential for falls due to history of falling, history of CVA with resident left hemiplegia, weakness, impaired balance, unsteady gait, impaired cognitive functioning/ safety awareness/ problem solving with dementia (cognitive impairment) neuropathy (nerve deficit), seizure disorder (brain disorder), arthritis (joint disorder), muscle spasm and cardiovascular, psychotropic, and neuroleptic medication administration. Approach (approach) bed in lowest position, call light in easy reach. Remind resident to call for staff assist when needed and answer call promptly. Check on resident at routine intervals to assess needs, monitor safety issues and offer assist as needed. Intervene with resident to minimize or reduce fall occurrences. Provide adequate staff assistance and support for tasks. During an observation on 03/29/2025 at 4:42 PM revealed Resident #1 engaged the call light system in his room and began to situate himself on the side of his bed. CNA A entered Resident #1's room and turned off the call light and asked Resident #1 what he needed. Resident #1 stated he needed to utilize the restroom. Upon initial observation there was observable left sided deficit on both Resident #1's left leg and left arm. CNA A proceeded to retrieve Resident #1's wheelchair and secured it on Resident #1's left side. CNA A then proceeded to assist Resident #1 to stand while she simultaneously grabbed Resident #1's left arm and with strength assisted him into the wheelchair. During Resident #1's transfer, Resident #1 pivoted to the wheelchair, and was observed to struggle while he staggered when pivoting from bed to wheelchair. Resident #1 was observed to have compromising balance as he was observed to be struggling while transferring to the wheelchair. Resident #1 was successful in transferring to the wheelchair while CNA A utilized his left arm to assist him. Throughout the transfer CNA A did not utilize a gait belt . During an interview on 03/29/2025 at 5:17 PM, CNA A stated she should have used a gait belt to assist Resident #1 to transfer onto his wheelchair. CNA A stated she should not have used Resident #1's left arm to transfer and should have used a gait belt . CNA A stated she was unaware Resident #1 had a left arm deficit however during this bed to wheelchair transfer, Resident #1 struggled to transfer into the wheelchair. CNA A was asked if she utilized a gait belt when transferring Resident #1, CNA A gave no definitive answer. CNA A stated she left her gait belt in her locker and did usually keep it on her person. CNA A stated she did not use a gait belt because she had left the gait belt in her locker. CNA A stated she was supposed to use a gait belt for transfers but did not have access to it as it was in a destination that was not near Resident #1's room. CNA A stated by not using a gait belt Resident #1 could have fallen and was fortunate that he did not fall. CNA A stated going forward she would ensure to always keep a gait belt with her and would utilize the gait belt when she transferred any resident. CNA A stated she could not recall when she was last in-serviced about resident transfers. During an interview on 03/29/2025 at 5:43 PM, the DON stated she was made aware of the observation by CNA A. The DON stated CNA A should have used a gait belt when transferring Resident #1 from the bed to the wheelchair as not only a safety precaution but also to maintain Resident #1's wellbeing. The DON stated CNA A may have compromised Resident #1's well-being as Resident #1 may have fallen. The DON stated all CNAs were supposed to keep a gait belt on their persons. The DON stated going forward she would conduct an impromptu in-service regarding gait belt transfers. 455557 Page 2 of 3 455557 03/31/2025 The Palms Nursing & Rehabilitation 5607 Everhart Rd Corpus Christi, TX 78411

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 03/30/2025 at 11:47 AM, ADON B stated Resident #1 was independent during transfers. ADON B stated as she pointed out while reviewing Resident #1's care plan, Resident #1 was independent with transfers, however when asked about the edited date of 03/30/2025, ADON B did not give a definitive answer. ADON B while reviewing Resident #1's MDS stated it appeared Resident #1 was coded for needing assistance with transfer from bed to chair. ADON B stated CNA A could have compromised Resident #1's well-being by not using a gait belt as he could have fallen. ADON B stated CNA A should have used a gait belt while transferring Resident #1 given he was coded for hemiparesis (paralysis) and hemiplegia (weakness). ADON B stated she facilitated an impromptu in-service regarding transfer with gait belts on 03/29/2025. Record review of CNA A's 03/08/2025 Lifting, Moving, Positioning, and Transferring competency revealed CNA A completed Transfer Resident from Bed to Chair/Wheelchair or Chair/Wheelchair to bed: A. (1) Person *Use of Gait Belt. B. (2) Person *Use of Gait Belt. Record review of the facility's gait belt usage in-service, dated 03/29/2025, documented CNA A in attendance. Record review of the facility's, undated, One Person Transfer with Gait Belt-Check Off reflected , .4. Position and secure belt properly. 5. Grasp belt on either side of resident, assist resident to move toward edge of bed. 6. Place feet firmly on floor under resident. 8. Face resident, squat with knees bent and your waist at resident's waist level, with back straight use leg muscles to lift to standing position. Record review of the facility's, undated, Safe Lifting and Movement of Residents reflected, 1.Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of resident. 2.Manual lifting of resident shall be eliminated when feasible. 4.Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. All manual lifting devices will be made available for use, when necessary, in resident transfer with staff training on usage implement. 5. Mechanical lifting devices shall be used for heavy lifting, including lifting, and moving resident when necessary. 455557 Page 3 of 3