Health inspection·October 22, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the residents' practicable physical, mental, and psychosocial well-being for 1 (Resident #2) of 10 residents reviewed for care plans.The facility failed to implement a person-centered fall prevention care plan with interventions for Resident #2 to meet medical, nursing, mental and psychosocial needs.The facility failed to implement added interventions of providing a therapy evaluation, failed to drop the seat of his wheelchair, and failed to add non-skid material to wheelchair after fall resulting in fracture. These failures could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services.Record review of an undated face sheet revealed Resident #2 was an [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of traumatic subarachnoid hemorrhage (a type of brain injury where bleeding occurs in the space between the brain and the thin membrane covering it), hemiplegia (paralysis of one side of the body), and convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles and associated especially with brain disorders).Record review of an admission MDS assessment dated [DATE] revealed Resident #2 had a BIMS of 12 which indicated a mild cognitive impairment. Resident #2 required partial to moderate assistance with ADLs such as toileting, transfer, and bathing. Resident #2 had 1 fall with major injury, had a seizure disorder, and had verbal and other behaviors 4 to 6 days per week.Record review of a care plan conference worksheet dated 10/02/2025 revealed a care plan conference was held with Resident #2 and his family members along with the DON, ADON, Administrator and Social Worker to discuss Resident #2's recent fall. The worksheet revealed interventions agreed upon by the family for therapy to evaluate Resident #2's wheelchair to drop the seat.Record review of a care plan dated 10/03/2025 titled History of Falls with major injury stated Resident #2 leaned forward to lock his wheelchair and fell out of his wheelchair. His interventions were listed as therapy evaluation for a restorative program, non-skid material to seat, and x ray of bilateral hips related to complaint of pain. Facility failed to follow interventions of therapy evaluation, and non-skid material to seat of wheelchair.During an interview on 10/20/2025 at 10:00 a.m., Family Member #1 of Resident #2 stated they attended a care plan meeting on 10/02/2025 after a fall that caused a fractured hip. She stated they discussed therapy evaluating Resident #2 for safety and to drop his seat. Family Member #1 stated therapy never evaluated Resident #2 even after they confirmed his hip fracture, he had surgery and returned to the facility, nor did they drop his seat to increase his safety. Family Member #1 stated that put Resident #2 at risk for a repeat fall with a surgically repaired fracture.During an interview on 10/20/2025 at 11:00 a.m., LVN C stated she was the nurse for Resident #2 when he fell. She stated Resident #2 was in his wheelchair and reached forward, locking his Page 1 of 9 455879 455879 10/22/2025 Marshall Manor West 207 W Merritt St Marshall, TX 75670

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some brakes and slid in slow motion to the floor. She stated she was surprised he had a fracture from the fall because it was a slow soft fall. LVN C stated the interventions were for Resident 2 to be evaluated by therapy, Resident #2's wheelchair seat was to be dropped to prevent him from sliding out when locking his brake. LVN C stated Resident #2 was to have nonskid material in his seat as well. LVN C stated she was told therapy could not evaluate him because of his payer source. LVN C stated she never saw Resident #2 in a wheelchair with a drop seat or nonskid material in his chair.During an interview on 10/22/2025 at 10:00 a.m., the MDS Coordinator stated it was the job of the DON and herself to update all care plans. She stated she was unsure how she missed adding the care plan interventions for a therapy evaluation and a dropped seat for safety. She stated she was also uncertain why the intervention of nonskid material to the chair was not carried out. She stated it was the job of the entire facility to read the care plans and carry out the interventions.During an interview on 10/22/2025 at 11:00 a.m., the DON stated Resident #2 was private pay and had no funding for therapy services. She stated a restorative nursing plan was written for Resident #2. She stated it was initiated 10/13/2025 when he returned from the hospital where he had surgery on his hip. She stated therapy had to evaluate him and drop his seat if it was a safe intervention and they would have provided the nonskid material to put in his chair, but because he was not evaluated before he went to the hospital on [DATE], he had not gotten the nonskid material. She stated not following interventions decided on during the care plan meeting could have resulted in further injury to the residents from another fall. During an interview on 10/22/2025 at 11:30 a.m., the Administrator stated it was important to follow interventions decided on by the IDT (interdisciplinary team). He stated it was important because the interventions were put in place to keep the residents healthy and safe. The Administrator stated Resident #2 had a care plan meeting on 10/02/2025 following a fall that injured the resident. He stated it was decided that therapy would evaluate him for safety in his wheelchair. Resident #2 was not evaluated by therapy because he was private pay, and the cost had to be approved by the family. Resident #2 eventually went to the hospital to have surgery on his fractured hip. The Administrator stated therapy evaluated him for a restorative program when he returned from the hospital, but he was not evaluated for a dropped seat or nonskid material for his wheelchair.Record review of the facility's policy dated 07/20/2021 titled ‘Comprehensive Care Planning revealed The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility will establish, document, and implement the care and services to be provided for each resident to assist in attaining or maintaining his or her highest practical quality of life. 455879 Page 2 of 9 455879 10/22/2025 Marshall Manor West 207 W Merritt St Marshall, TX 75670

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 observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 1 of 3 residents reviewed for transfers. (Residents #1)The facility failed to keep Resident #1 free from injury after he was improperly transferred by CNA A on 10/19/25 causing extensive bruising to his chest and multiple rib fractures.This failure resulted in the identification of an Immediate Jeopardy (IJ) on 10/21/25 at 11:35 a.m. While the IJ was removed on 10/22/25 at 11:30 a.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.This failure could place residents at risk of injury from accident and hazards.Record review of the face sheet dated 10/20/25 revealed Resident #1 was a [AGE] year-old male. Resident #1 was initially admitted on [DATE] with diagnoses including dementia, abnormalities of gait and mobility, and assistance with personal care. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #1 was usually understood and sometimes understood others. The MDS indicated a BIMS was not conducted due to Resident #1 being rarely to never understood. The MDS indicated Resident #1 required moderate assistance with chair/bed-to-chair transfers. Record review of the care plan last revised on 08/25/25 indicated Resident #1 had a poor transfer status related to age, diminished strength, diminished sensation, and problems with vision and/or hearing. The care plan indicated an intervention dated 06/11/25 for Resident #1 to be transferred with a mechanical lift and 2-person assistance. Record review of a Nurses Note for Resident #1 dated 10/19/25 at 11:00 p.m. by LVN B indicated, .Res (Resident #1) noted (with) large swollen and bruised are to (left upper) chest area and bruising mid chest area. (Resident #1) also has discoloration to (left upper) area. (Skin tear) to (right) arm with transparent dressing. Record review of a Nurses Note for Resident #1 dated 10/20/25 at 4:30 a.m. by LVN B indicated, Area to mid chest more darker area, larger than when first found. Record review of an Emergency Medicine Note dated 10/20/25 at 11:35 a.m. indicated, (Resident #1).presented to the Emergency Department with chest bruising.he has chest swelling and bruising, which he seems to attribute to being picked up by a 300 pound guy. The time of onset is uncertain but he states he was picked up yesterday; he experiences pain only when pressure is applied to the area. No history of falling is reported.He denies any acute fall or trauma. The author of the note was the Emergency Department Physician. Record review of an ED (emergency department) Note indicated, .Family called, to update, family stated (Resident #1) been telling her they pick him up and it hurts. The note was signed by the emergency room RN. Record review of Intake Report Child Protective Service dated 10/20/25 at 12:21 p.m. indicated, .(Resident #1) is unable to walk or transfer independently.On 10/20/25 (Resident #1) was brought to the ER (emergency department) from the nursing home for bruising to his chest wall. (Resident #1) was found to have bruising all throughout his upper chest extending across both shoulders. The bruising was black, purple, and yell in coloration and appeared to be in multiple stages of healing and associated swelling throughout. (Resident #1) denied any recent falls or trauma and was echoed by the nursing home. When (Resident #1) was alone, he stated that there is a man at the facility that is 300 pounds who regularly picks him up incorrectly. (Resident #1) stated that the man will pick him up by his body under his arms despite (Resident #1) having a hoyer lift that should be used. (Resident #1) stated that he frequently tells this person being picked up that way hurts, but that his complaints are ignored. It is uncertain if there is only one person lifting (Resident #1) incorrectly as his memory is not always accurate., and information that he's shared 455879 Page 3 of 9 455879 10/22/2025 Marshall Manor West 207 W Merritt St Marshall, TX 75670

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few with family in the past about the man who lift him incorrectly has not lined up with that person's schedule or presence at the facility. The reporter was the hospital emergency department Health Unit Assistant. Record review of CT Chest results dated 10/20/25 at 12:43 p.m. for Resident #1 indicated, .Left 11 and 12 posterior (back of the body) lateral (side, away from the middle of the body) rib fractures may be recent or subacute (recent onset). Right 10th and 11th lateral rib fractures appear recent/subacute. Old sternal fracture.Impression: Left 11 and 12 rib and right 10th and 11th rib fractures appear recent/subacute.Record review of hospital records dated 10/20/25 indicated, .Primary Diagnosis.Contusion (bruising) of chest wall. There was a note that indicated, .Please take caution when helping patient transfer. The note was signed by the Emergency Department Physician on 10/20/25 at 1:39 p.m. There was a photograph of Resident #1 included in the hospital records. The photograph showed extensive dark bruising to the left and right upper chest and a dark bruise to the left upper arm. The report indicated, Problem List and Treatment Plan:.(Resident #1) presented with chest wall swelling, bruising, and localized tenderness following recent physical handling, without a history of fall or trauma.Exam revealed chest wall bruising and swelling. The records indicated, .Diagnoses.Contusion of chest wall.Traumatic injury of rib. During an interview on 10/20/2025 at 2:51 p.m., the hospital Emergency Department Health Unit Assistant said Resident #1 was brought to the emergency department with bruising across the top of his chest. She said he denied any falls or any other injuries. She said he was brought to the emergency department by transport van. She said the bruising went from shoulder to shoulder. She said staff had gone in the room to ask him what happened, and he said a 300-pound man always picked him up to move him from the wheelchair to the bed. She said Resident #1's family member told them she had witnessed CNA A transferring the resident yesterday (10/19/25) and not use the mechanical lift. She said the family member said Resident #1 had been complaining to her that a CNA had been picking him up to transfer him and it hurt. She said the family member said Resident #1 had asked the CNA to not to pick him up the way he was picking him up.During an interview on 10/20/25 at 3:00 p.m., the Emergency Department Physician said he had evaluated Resident #1 the emergency department. He said Resident #1 had extensive bruising across his chest and had some rib fractures. He said some of the rib fractures could be older injuries. He said Resident #1 said that a 300-pound man had been lifting him up. The Emergency Department Physician said he did not feel anyone had done anything malicious to the resident. He said he felt maybe someone had been picking the resident up from behind with their arms around the chest and they had been overly rough.During an interview on 10/20/25 at 3:05 p.m., Resident #1's family member said CNA A had been transferring Resident #1 and not using the mechanical lift. The family member said on 10/19/25, she had witnessed CNA A picking up the resident with his hand under the resident's arms. She said CNA A transferred Resident #1 from the couch to the wheelchair. She said CNA A was in front of the resident when he transferred the resident.During an observation and interview on 10/20/25 at 3:07 p.m., Resident #1 was sitting in a wheelchair in his room. There was a mechanical lift pad under him. Resident #1 denied pain. The resident had dark purple bruising across the upper left chest and across the upper right chest. There was also a dark purple bruise with a skin tear on the upper left arm. The bruising to the chest and arm appeared to be new. He said he was injured by CNA A picking him up under his arms. He said CNA A had picked him up more than once.During an interview on 10/20/25 at 3:20 p.m., the Emergency Department RN said she was Resident #1's nurse in the emergency department. She said she was very concerned about the bruising to Resident #1's chest. She said she did ask Resident #1 if anyone had abused him. She said he denied abuse. She said he did say that someone had been picking him up like a baby and it hurt. She said she felt the bruising was in various stages of healing and his 455879 Page 4 of 9 455879 10/22/2025 Marshall Manor West 207 W Merritt St Marshall, TX 75670

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few cat scan results showed rib fractures.During an interview on 10/20/2025 at 3:46 p.m., CNA A said Resident #1 was a regular resident of his. He said he was the CNA for Resident #1 on 10/19/25. CNA A said they usually used a mechanical lift to transfer Resident #1 to prevent what has happened yesterday (10/19/25). CNA A said 10/19/25 the mechanical lift pad was not available and was not under Resident #1 in the wheelchair. CNA A said, on 10/19/25, he did transfer Resident #1 without using the mechanical lift. CNA A said he used a gait belt. CNA A said he transferred Resident #1 from the wheelchair to the couch, from the couch back to the chair for dinner, and then from the chair to the bed. CNA A said he used the gait belt for all three transfers. CNA A said Resident #1 was often combative. CNA A said on 10/19/25, Resident #1 was not combative. CNA A said Resident #1 was scared he was going to fall and pressed himself against him. CNA A said when he went to put Resident #1 to bed on 10/19/25, he took Resident #1's shirt off and he had a skin tear to his arm and there was a little patch of discoloration to his nipple area. CNA A said in the past, they had used a gait belt to transfer Resident #1. CNA A said recently Resident #1 declined. CNA A said using a gait belt was just not safe for Resident #1 anymore, so they had started using a mechanical lift.During an interview on 10/20/25 at 4:15 p.m., Resident #1's family member said on 10/19/25, CNA A did not use a gait belt to transfer Resident #1. The family member said CNA A lifted Resident #1 under his arms and tight to his body and transferred him from the wheelchair to the couch and then later back from the couch to the wheelchair. The family member said CNA A was not the only one transferring Resident #1 this way. The family member said other CNAs were doing the same thing. The family member said Resident #1 had broken his sternum in a car accident about 12 years ago.During an interview on 10/21/2025 at 8:12 a.m., Resident #1 said on 10/19/25, CNA A did not use a gait belt to transfer him. Resident #1 said CNA A used his hands to carry him to the next room.During an interview on 10/21/25 at 3:03 p.m., CNA D said on the night of 10/19/25, she was rounding with another CNA and found bruising to Resident #1's chest. She said he had small bruising in the middle of his chest and both sides of the upper chest was bruised. She said Resident #1 said, That Big Ole Boy did it. She said she reported it to the nurse and the nurse reported it to the DON and Administrator. She said Resident #1 required two-person assistance with a mechanical lift for transfers.During an interview on 10/21/2025 at 3:45 p.m., LVN B said she was Resident #1's nurse the night of 10/19/25. She said she assessed Resident #1. She said the bruising was mostly on the left breast and appeared to be swollen. She said there was some discoloration in the middle of his chest. She said Resident #1 said that a Big Ole Boy did it. She said she asked him again what happened, and LVN B stated what Resident #1 said made no sense. She said she then reported the bruising to the DON so it could be investigated.During an interview on 10/22/25 at 11:03 p.m., the DON said she was notified of the bruising to Resident #1's chest after 11:00 p.m. on 11/19/25. She said she immediately reported the bruising to the Administrator. She said when she got to the facility, she assessed the resident. She said he denied abuse to her. She said CNA A was then suspended on 10/20/25. She said he was then terminated on 10/21/25 due to improper transfer.During an interview on 10/22/25 at 12:08 p.m., the DON said when she interviewed Resident #1 on the morning of 10/20/25, Resident #1 told her a 300-pound man had picked him up and moved him from one room to the other. She said she then called CNA A. She said CNA A told her he transferred Resident #1 three different times on 10/19/25. She said CNA A told her that he had used the gait belt to transfer the resident. She said CNA A said Resident #1 did not appear to have any pain. She said CNA A did tell her that Resident #1 had a skin tear to his arm and he had notified the nurse. She said she spoke to Resident #1's family member and she told her that CNA A did not used the gait belt. She said Resident #1 had been a two-person transfer with a mechanical lift since 06/14/25. She said she would 455879 Page 5 of 9 455879 10/22/2025 Marshall Manor West 207 W Merritt St Marshall, TX 75670

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few have expected Resident #1 to have been transferred with two staff members using a mechanical lift. She said residents who were not transferred appropriately could lead to injury. During an interview on 10/22/25 at 12:30 p.m., the Administrator said he interviewed Resident #1. He said Resident #1 told him a 300-pound man had picked him up and carried him to bed. He said CNA A should have used two staff members and a mechanical lift to transfer Resident #1 on 10/19/25. The Administrator said a resident not being transferred appropriately had the potential to lead to an injury. Record review of an Assisting With Transfers and Reposition facility policy dated 05/02/18 indicated, .Purpose: Safely handle, reposition, transfer and protect Resident and staff from injury during transfers and repositioning.Mechanical lifts are used to transfer resident who: are totally dependent (non-weight bearing) or weigh more than 100 lbs.are too heavy for staff to transfer.For bed to wheelchair/chair or wheelchair/chair to bed transfers Stand and Pivot transfers with transfer belts (gait belts) for those resident whose: legs are strong enough to bear some weight (partial weight bearing, the resident is cooperative and can follow directions, the resident can assist with the transfer. The Administrator was notified of an IJ on 10/21/25 at 11:35 a.m. and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 10/21/25 at 5:15 p.m. and included the following:1. Description of Immediate Jeopardy SituationThe facility failed to ensure Resident #1 was protected from accident hazards during transfers. On 10/19/25, CNA A performed improper manual transfers without the required mechanical lift. As a result, Resident #1 sustained extensive bruising and bilateral rib fractures. This deficient practice resulted in Immediate Jeopardy because it had the potential to cause serious injury and did cause actual harm.________________________________________2. Immediate Actions Taken to Remove Jeopardy Administrator and DON were retrained by Regional Nurse consultant on Free of Accidents/Supervision/Devices and the importance of accurately identifying transfer status. Completed 10/21/2025 at 12:30 p.m. On 10/20/25 at 12:30 a.m., CNA A was immediately removed from resident care and suspended pending investigation. CNA A was terminated on 10/21/2025 at 12:10 p.m. Beginning at 12:45 p.m. on 10/21/25, the DON initiated a facility-wide audit of all residents requiring transfer assistance to ensure transfer methods were accurate and safe. All Care plans were updated with ADL status as well as the amount of staff members. On admission therapy screens for safe transfer status. Rescreens are performed after any change of condition or decline. Initiated 10/21/2025 12:45 p.m. Completed 10/21/2025 5:00 p.m. Licensed nurses completed head-to-toe skin and injury assessments on all residents to identify any additional injuries. Initiated 10/21/2025 12:30 p.m. Completed 10/21/2025 5:00 p.m. The RN Supervisor notified Resident #1's physician and family of the incident and injuries. Initiated 10/21/2025 12:40 p.m. Completed 10/21/2025 12:41 p.m. All CNA and nursing staff were immediately, or prior to next shift, re-educated on safe transfer procedures, use of gait belts, and use of mechanical lifts. Staff were also inserviced about following care plans on amount of assistance with each ADL such as transfers. Staff were inserviced on the risk of injury of not transferring residents correctly. Staff were inserviced on not to lift resident under arms or pull on their clothing or limbs. Initiated 10/21/2025 12:30 p.m. Completed 10/21/2025 5:00 p.m. 3. Identification of Residents at RiskAll residents requiring staff assistance for transfers were identified through review of the MDS, care plans, and transfer assessments. Each resident was evaluated to determine current transfer status and ensure appropriate assistive device was in use. No additional injuries were found during head-to-toe skin assessments.________________________________________4. Systemic Measures Implemented to Prevent Recurrence Mandatory education and return demonstrations on safe transfers, mechanical lift operation, and two-person assistance policy were conducted immediately, or prior to the next shift, for all direct care staff by the 455879 Page 6 of 9 455879 10/22/2025 Marshall Manor West 207 W Merritt St Marshall, TX 75670

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few DON/ADON/Designee. Initiated 10/21/2025 12:30 p.m. Completed 10/21/2025 5:00 p.m. DON/ADON/Designee verified and updated transfer status in EMR system for all residents to reflect accurate transfer assistance requirements. Initiated 10/21/2025 12:30 p.m. Completed 10/21/2025 5:00 p.m. DON revised New admission Procedure to include required transfer evaluation and documentation by licensed nursing staff upon admission before any transfer occurs. Initiated 10/21/2025 12:30 p.m. Completed 10/21/2025 5:00 p.m. DON/ADON/Designee reviewed and updated Care plans to ensure transfer interventions matched resident needs. Initiated 10/21/2025 12:30 p.m. Completed 10/21/2025 5:00 p.m. A process was implemented requiring licensed staff to immediately update transfer status on the resident care plan after any change in conditions. The licensed staff will then update the resident's ADL sheet and flag and communicate through 24 hour report for oncoming staff. Initiated 10/21/2025 12:30 p.m. Completed 10/21/2025 5:00 p.m.________________________________________ 5. Monitoring to Ensure Ongoing ComplianceThe DON/ADON/Designee will complete daily audits for 14 days on all resident transfers to ensure: Correct transfer method is used Proper assistive device (Hoyer, sit-to-stand, gait belt) is in place EMR system documentation matches transfer method Audit results will be reviewed daily during clinical meetings and reported to the Administrator. Any non-compliance will result in immediate staff re-education and corrective action. After the 14-day period, weekly audits will continue for 30 days to immediate corrective actions were initiated on 10/21/25 and ongoing monitoring will continue as outlined. The surveyor's verification of the Plan of Removal from 10/22/25 was as follows:Record review of Safety and Supervision of Residents in-service indicated, .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes.When accident hazards are identified, the QAPI/Safety Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible.Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable.Our individualized, resident-centered approach safety addresses safety and accident hazards for individual residents.Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include.Safe lifting and Movement of Residents. The in-service indicated that the Administrator and DON were educated by the Regional Nurse Consultant on 10/21/25. The in-service indicated the Certified Occupational Therapist Assistant and the Physical Therapist Assistant were then educated by the DON. Record review of the employee file for CNA A indicated CNA A was hired on 12/17/24. The employee file included a Personal Change Notice. The notice indicated CNA A was terminated on 10/21/25. The reason for termination was improper transfer. The notice indicated CNA A was not eligible for rehire. Record review of a Resident List Report indicated on 10/21/25, the DON completed an audit of all residents to ensure transfer methods were accurate and safe. Record review of 10 of 51 residents care plans indicated each care plan had been updated with the ADL status as well as the amount of staff members needed for transfer. Care plans were reviewed on 10/22/25 for Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, and Resident #14. Each reflected the ADL status as well as the amount of staff members needed for transfers. Record review of 10 of 51 residents skin assessments indicated residents had been assessed head to toe. Skin assessments were reviewed on 10/22/25 Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, 455879 Page 7 of 9 455879 10/22/2025 Marshall Manor West 207 W Merritt St Marshall, TX 75670

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #11, Resident #12, Resident #13, and Resident #14 on 10/21/25. There were no concerns.Record review of a Nurse's Notes for Resident #1 indicated physician was notified of the bruising on 10/19/25 at 11:16 p.m. by LVN B.Record review of a Nurse's Note for Resident #1 indicated call was placed, and a message was left for Resident #1's power of attorney on 10/19/25 at 11:28 p.m. by LVN B.Record review of Hoyer, Two Person Hoyer (Mechanical) Lift Check Off forms indicated 26 nurses and CNAs were re-educated on safe transfer procedures on 10/21/25. Record review of Clinical Skills Checklist and Competency Evaluation forms indicated 26 nurses and CNAs were re-educated on safe transfer procedures using a gait belt on 10/21/25. Record review of a Staff In-Service Training titled, Safe Resident Transfers & Following Care Plan Instructions dated 10/21/25 indicated 38 nurses and CNAs were in-serviced on .correct transfer method and assistive device every time.Never lift a resident under their arms or pull on their clothing or limbs.Never transfer alone if the care plan says 2-person assist or mechanical lift required.Shortcutting or guessing a transfer method is never allowed.If a resident seems different during a transfer, STOP and NOTIFY THE NURSE immediately.A nurse must reassess the resident and update the transfer status and care plan before transfer continues.Why This Matter: Prevents serious injuries.Keeps Resident safe.Meets federal regulation.Protects your CNA license and your job.Required by state law and facility policy.Transfers must always be done safely, correctly, and according to the care plan.STOP-THINK-ASK-GET HELP. Record review of 10 or 51 residents' electronic medical records accessed on 10/22/25 between 7:30 a.m. and 11:30 a.m. indicated Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, and Resident #14's record reflected accurate transfer assistance requirements.Record review of an Assisting with Transfers and Reposition facility policy revised on 10/21/25 and signed by the Administrator, DON, and ADON indicated, .Safely handle, reposition, transfer and protect Resident and staff from injury during transfers and repositioning.Upon admission readmission or change in condition, the charge nurse will assess the residents' transfer status and document on the Resident Data Collection Form. Nursing can review Therapy notes from the hospital, previous facility, family, etc. Revision 10/21/25: Charge nurse will then communicate the transfer status to floor staff via the Baseline Care plan and the ADL sheet.The Charge nurse will also notify assigned nursing assistant of transfer status verbally and document transfer status on Nurse Aide's Information Sheet and care plan.The facility charge nurse will assess residents whose transfer status has changed due to decline or improvement and notify nursing assistant of change in transfer status and document status change on Nurse Aide's information sheet. During an interview on 10/21/25 at 2:20 p.m., CNA A said he had been terminated by the Administrator and that he was told his license was being referred. During interviews conducted on 10/22/25 beginning at 8:45 a.m. through 10:30 a.m., 29 of 38 CNAs and nurses in-serviced (LVN B, CNA D, Restorative Aide E, CNA F, CNA G, CNA H, Restorative Aide J, CNA K, CNA L, CNA M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, Restorative Aide T, CNA U, CNA V, CNA W, LVN X, LVN Y, LVN Z, the ADON, the MDS Nurse, LVN BB, LVN CC, LVN DD, and LVN B) were interviewed. All said they were educated on safe resident transfers and following the care plan. Each said educated on using the correct transfer method and assistive device every time. They said they were educated on never lifting a resident under their arms or pull on their clothing or limbs, never transfer alone if the care plan says 2-person assist or mechanical lift required. They said they were not to guess on the transfer method. They said when a resident declined the CNAs were to notify the nurse. The nurse must then reassess the resident and update the transfer status and care plan. They each said this was to prevent injury of the resident. During interviews conducted on 10/22/25 beginning at 8:45 a.m. through 10:30 a.m., 13 of 26 CNAs and nurses in-serviced (Restorative Aide E, CNA F, CNA G, CNA H, 455879 Page 8 of 9 455879 10/22/2025 Marshall Manor West 207 W Merritt St Marshall, TX 75670

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Restorative Aide J, CNA K, CNA U, LVN X, LVN Y, LVN Z, the ADON, LVN AA, and Restorative Aide T) indicated they had been checked off in-person on safe transfer procedures for mechanical lift transfers and gait belt transfers. Each staff member was able to verbalize step by step instructions on how to identify the type of transfer each resident required and how to safely perform a mechanical lift transfer or a gait belt transfer. During an interview on 10/22/25 at 9:50 a.m., the Certified Occupational Therapist Assistant said the DON had in-serviced herself and the Physical Therapist Assistant on 10/21/25 concerning screening each resident on admission for safe transfer status and re-screening residents after any change of condition or decline. She said she then assisted in re-educating staff on safe mechanical lift and gait belt transfers. During an interview on 10/22/25 at 10:25 a.m., the ADON said she had been in-serviced by the DON on 10/21/25 on safe transfer techniques, to assess a resident with a decline and update their care plan to reflect accurate transfer requirements, risk of injury for not transferring residents correctly, and not lifting a resident under the arms or pulling or their clothing or limbs. She said after she was re-educated, she then assisted in head-to-toe assessments of each resident and re-educating other staff. During an interview on 10/22/25 at 10:44 p.m., the Administrator said on 10/21/25, he was trained by the Regional Nurse on Safety and Accidents. He said on 10/19/25 at approximately 11:00 p.m. or 11:30 p.m. He was notified of the bruising to Resident 1's chest. He said the DON called and told him at that time. He said the DON suspended CNA A the next morning after determining he may have improperly transferred Resident #1. The Administrator said on 10/21/25 at 12:10 p.m. he called CNA A, and he was terminated. He said CNA A had not returned to the facility at any time after the injury was discovered. During an interview on 10/22/25 at 11:03 p.m., the DON said she was trained on re-assessing, transfer statuses, and appropriate transfer statuses. She said she was trained on preventing injuries of the residents. She said the Regional Nurse in-serviced herself and the Administrator. She said CNA A was suspended on 10/20/25. She said he was then terminated on 10/21/25 due to improper transfer. She said she, the Administrator, and the Patient Care Advocate rounded on each resident to see if they had injuries or any concerns regarding CNA A. She said no concerns were identified. She said on the week of 10/07/25, she had audited each resident's chart and documented how much assistance each resident required for transfers. She said on 10/21/25 she reviewed this audit to make sure it was correct, and nothing needed to be updated. She said head-to-toe assessments were conducted of each resident in the facility on 10/21/25 by herself, the ADON, two nurses, and the wound care nurse. She said no injuries were found. She said she checked off the ADON, Restorative Aide J, and two therapy staff members. She said they then in-serviced the CNAs and the nurses. She said nurses and CNAs that were not present, were in-serviced over the phone and would be checked off in person when they return to work at the facility. She said if a resident had a status change, the care plan would be updated, and the CNAs would be notified prior to any transfers. She said if she or the MDS nurse was not present, the charge nurse would update the care plan, notify the aide, and update the nurse aide information sheet.During an interview on 10/22/2025 at 11:25 a.m., the MDS Coordinator stated she was aware of the in-service done related to transferring safety. She said to always use 2 people with a mechanical lift and two people with gait belt transfer if their care plan stated that was what was needed. She stated the nurses could update the resident care plan for change of condition on transfer status or they could let her know what needed to be corrected, and she would correct it.On 10/22/25 at 11:30 a.m., the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and a severity level actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. 455879 Page 9 of 9