Health inspection·January 29, 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 observations, interviews, and record reviews the facility failed to ensure that the resident's environment remained as free of accident hazards as possible, and that the resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accident hazards. CNA A failed to use a transfer belt while attempting to transfer Resident #1 from the bed to the wheelchair. This failure could place residents at risk of unsafe transfers, resulting in falls, injuries, and a decreased quality of life. Findings included: Record review of Resident #1's clinical records revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had a diagnoses which included Unspecified Systolic (congestive) Heart Failure ( a condition of the heart where the heart is weak and the left ventricle cannot contract normally when the heart beats), Urinary Tract Infection, site not specified, Other Abnormalities of Gait and Mobility, Unspecified Dementia, moderate, with Anxiety, Muscle weakness (generalized), Cognitive Communication Deficit (communication difficulty cause by cognitive impairment), Cellulitis of Right Lower limb (Infection of the skin), Pain in unspecified shoulder, Dementia in other diseases classified elsewhere, Unspecified severity, with Other Behavioral Disturbance, Altered mental status, unspecified, Heart failure, unspecified, and Acute Respiratory Failure with Hypoxia (impairment of gas exchange between the lungs and the blood, causing shortness of breath, anxiety and confusion). Resident #1 had a BIMS score of 02, which indicated severe cognitive impairment. Her Morse Fall Scale dated 12/13/2024 revealed a history of falling related to a secondary diagnosis, the use of a walker for ambulation, a weak gate, and an overestimation of her physical limitations. Record review of Resident #1's Quarterly MDS dated [DATE] revealed Resident #1's bed mobility and transfers were extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-person physical assist. Record review of Resident #1's Care Plan dated 01/02/2025 revealed Resident #1's Problem of ADL Functional Status/Rehabilitation Potential, a Goal of Resident will achieve maximum functional mobility and an Approach of Bed mobility amount of assist: extensive x 1 assist and Transferring amount of assist: extensive x 1 assist. Resident #1's Care Conference Notes indicated Resident #1 needed substantial assistance to both sit up and stand, as her condition was declining, and she received Hospice services. Page 1 of 2 455989 455989 01/29/2025 Avir at Borger 1316 S Florida Borger, TX 79007

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In a phone interview 01/28/2025 at 2:27PM Resident #1's POA revealed she had video surveillance from a [NAME] which had been place in Resident #1's room, prior to her death in the facility on 01/11/2025. The POA stated the video clearly showed an improper transfer being done by CNA A, where she first lifts Resident #1 from a supine (laying on the back) position to a sitting position by lifting her from the back of her neck to aid Resident #1 in sitting up. The POA stated CNA A then helped Resident #1 to a sitting position on the edge of the bed and began to lift Resident #1 by pulling on the resident's outstretched arms, trying to bring Resident #1 to a standing position. The video was reviewed by the state surveyor and the POA's observations proved to be correct. The POA stated Resident #1 was not hurt in any way during the attempted transfer, but the manner in which the transfer was attempted, was concerning. An interview with the Administrator, the DON and the Corporate Nurse on 01/29/2025 at 12:55PM revealed a competency checklist was used by the ADON and DON to evaluate CNA competency in transfers from bed to wheelchair and were to be done using a transfer belt. The administrator stated Resident #1 did not like the transfer belt but was told its use was for her safety. She stated she did not know why CNA A had not used a transfer belt, as was revealed in the supplied video from the resident's POA. Phone interviews with CNA A were attempted on 01/29/2025 at 11:12AM and 1:22PM but were unsuccessful. She was unable to be reached and there was no voicemail set up to request a return call. Record review of the CNA Transfers Competency Checklist read as follows: Before assisting to stand, resident is assisted to a sitting position with feet flat on the floor. Before assisting to stand, apply transfer belt securely at the waist over clothing/gown. Before assisting to stand, provide instructions to enable resident to assist in the transfer including a prearranged signal to alert when to begin standing. Stand facing the resident, positioning self to ensure safety of resident during transfer. Count to three (or say prearranged signal) to alert resident to begin standing. On signal, gradually assist resident to stand by grasping transfer belt on both sides with an upward grasp (resident's hands are in an upward position) and maintain stability by standing knee-to-knee or toe-to- toe with the resident. Record review of CNA A's checklist reflected it was signed by the ADON as competent on 12/26/2024. The ADON was not available for interview. 455989 Page 2 of 2