Inspection·November 21, 2023

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents. CNA B failed to have assistance from another staff member when she transferred Resident #1, who required 2-person assist with transfers, via a mechanical lift resulting in Resident #1 sustaining a shoulder fracture. This failure placed residents at risk for accidents and injuries. Findings included: Review of Resident #1's face sheet, dated 11/21/23, revealed the resident was a [AGE] year-old female, who admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis of the left dominant side, contracture (deformity and rigidity of joint), muscle wasting and atrophy, and history of stroke. Review of Resident #1's MDS assessment, dated 10/28/23, reflected the resident's severe cognitive impairment with a BIMS score of 5 and she required total assistance of two-person assistance for transfers. Review of Resident #1's care plan, dated 08/15/23, revealed: [Resident #1] has ADL Self Care Performance Deficit r/t immobility secondary to CVA, contracture, hemiplegia (paralysis). Will remain free of complications related to immobility, including contractures, thrombus formation (formation of blood clots), skin-breakdown, fall related injury through the next review date. Will be safe through the review. TRANSFER: Requires x2 staff participation with transfers. may use Hoyer lift. Interview on 11/21/23 at 9:06 AM with the Interim DON revealed when using the Hoyer lift, facility policy stated two people were to assist when completing transfers with the mechanical lift. The Interim DON stated CNA B did not wait for assistance from staff to use the Hoyer lift. Instead, CNA B used the lift incorrectly by using the Hoyer lift alone resulting in Resident #1's fall to the floor from her wheelchair. The Interim DON stated that CNA B was suspended pending investigation. However, CNA B called HR during her suspension and resigned. CNA B's training record revealed she was trained on Hoyer lifts during her orientation. Therefore, CNA B was aware of the correct Hoyer lift procedure prior to this Hoyer lift transfer. The Interim DON revealed staff failed to have another person present when completing the transfer with the mechanical lift per policy and procedure which resulted (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 455576 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 455576 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Richland Hills Rehabilitation and Healthcare Cente 3109 Kings CT Fort Worth, TX 76118 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)