Health inspection·June 28, 2024

F 0689 Level of Harm - Actual harm revealed CNA A stated resident pushed hard against the wheelchair and caused the wheelchair to move away from the sliding board. She started to lean so I lowered her to the floor. The report said Resident #1 was hollering call the EMS and complained of pain to lower back and hips bilaterally. The incident report revealed 911, Resident#1's physician and Resident #1's responsible party were notified. Residents Affected - Few Record review of Resident #1's hospital diagnostic results revealed an x-ray was completed of the right knee, 06/24/2024 at 5:27pm. The results of the x-ray revealed a subtle fracture proximal tibia and fibula. Record review of hospital physician progress note, dated 06/25/2024 at 11:28am, stated patient was evaluated by ortho and it is recommended to remain non weight bearing to her right LE and wear a knee immobilizer for 6 weeks. Xrays are to be repeated at 6 weeks to verify healing. Record review of facility investigation document, undated, provided by the Administrator, revealed under the investigation/conclusion summary, CNA A also mentioned that the resident was beginning to fall forward and turned the resident around so that she could assist her to the floor on her buttocks. The resident's legs were twisted upon her being turned around and this potentially caused the fractures. During an interview with Resident #1's family member, 06/26/2024, the family member stated she was notified on 06/24/2024 that Resident #1 was lowered to the ground during a sliding board transfer, was complaining of pain and was being sent to the hospital. She said she was notified by the hospital on [DATE] that Resident #1 sustained fractures to Resident #1's tibia and fibula. Resident #1's family member stated she was aware that Resident #1 was using a sliding board for transfers and said Resident #1 told her the wheelchair was not locked and it moved away from the sliding board. Record review of a handwritten statement signed by CNA A, dated 06/24/2024, stated while setting up for the slide board transfer, check points were made to ensure the safety of the resident and employee. The wheelchair in use was locked and placed directly next to the bed, and the proper clothing and tennis shoes were being worn by both the employee and resident. After the sliding board was properly placed under the resident, they attempted to place more of their body on the board and grabbed the arm of the wheelchair for assistance and stability. This caused an imbalance leading to the resident pushing the wheelchair away from the bed. Resident started to slide down slowly; employee the lowered resident to the floor; landing them softy on their back. During an interview on 06/27/2024 at 12:10p.m., CNA A stated she received training from another CNA on using the sliding board for transfers for Resident #1 to and from the bed to the wheelchair. CNA A said on 6/24/2024, she set up the sliding board between the wheelchair and the bed and locked the wheelchair brakes. CNA A said Resident #1 was sitting on the board and CNA A bent down to move Resident #1's feet so she could slide down the board onto the wheelchair. CNA A said Resident #1 became anxious and pushed on the wheelchair causing it to move and Resident #1 begun falling forward. CNA A said she was trying to prevent Resident #1 from falling on her face so, in a quick reaction, turned Resident #1's upper torso thinking she would be able to sit her down on her buttocks. CNA A said Resident #1's legs got tangled up under the wheelchair because Resident #1 was unable to move her legs. CNA A said she realized, after the fact, that she should not have tried to turn Resident #1 while lowering her to the floor. CNA A was asked if she was using a gait belt for the transfer and she said, I'm not going to lie, no I didn't. CNA A said she was trained to use a gait belt during orientation and was aware that the facility required all staff to use a gait belt during resident transfers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675095 If continuation sheet Page 2 of 4 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 675095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hallettsville Nursing and Rehabilitation 825 W Fairwinds Hallettsville, TX 77964 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 0689 Level of Harm - Actual harm Residents Affected - Few During an interview on 06/27/2024 at 12:42p.m., LVN B said on 06/26/2024, she was returning from break and CNA A called her and told her Resident #1 had a fall and was on the ground in her room. LVN B said when she entered the room, Resident #1 was lying on the ground on her back, the wheelchair was next to the bed, and she observed the wheelchair wheels in the locked position. LVN B said Resident #1 was complaining of pain in her lower back and hips, so LVN B reported it to the physician and called 911. LVN B said she called and notified Resident #1's family member of the fall and pending transport to the hospital. LVN B said CNA A told her that CNA A was using the sliding board and Resident #1 had her hand on the wheelchair and Resident #1 pushed on it and it caused her to launch forward and fall. During an interview on 06/27/2024 at 1:49p.m., the PT stated Resident #1 was on therapy services in March 2024, April 2024 and again on 06/17/2024. The PT stated Resident #1 was able to safely perform a sliding board transfer with one person assist. The PT stated Resident #1 was taught to use the sliding board transfer with one person when she was on therapy services from 03/16/24 through 05/15/2024. The PT stated therapy provided training to staff on using the sliding board transfer. The PT stated she would not have turned Resident #1 while lowering her to the ground and would have tried to counter the motion of Resident #1 falling forward and would lower her to the ground in the direction Resident #1 was falling. During an interview with the DON, 06/27/2024 at 2:35p.m., the DON stated Resident #1 was a one person transfer with a sliding board. The DON stated CNA A received training on using a gait belt during orientation and completed competency skills check on completing transfers with a gait belt. The DON stated the expectation was all transfers are completed with the use of a gait belt. The DON said residents are at risk for injuries if staff do not use a gait belt and stated, if the CNA was wearing her gait belt, it would have been easier for her to lower Resident #1 to the ground. The DON also stated CNA A should not have twisted Resident #1 around when she was lowering her to the floor. The DON said, the proper way to lower a person to the ground includes a gait belt and lowering the person down in the direction they are falling. The DON stated no other residents in the facility use a sliding board as a device for transfers. During an interview with the Administrator and DON, 06/28/2024 at 9:18a.m., the DON stated the facility-initiated in-services on fall prevention and completed return demonstration with direct care staff regarding the use of gait belts for transfers and how to properly lower residents to the floor during an assisted fall. The Administrator and DON stated no direct care employees would work the floor until they had received the training and performed return demonstration. Record review of facility document titled, One on One Inservice and dated 06/25/2024, revealed sliding board reenactment, sliding board reeducation with return demonstration with therapy. The return demonstration outcome stated, staff member able to properly demonstrate sliding board transfer. The document was signed by CNA A, DON, and PTA. Record review of facility document revealed CNA A completed an online training certificate of completion for a course titled, Falls, Assessment and Prevention, completed on 05/06/2024. Record review of facility document titled, C.N.A. Competency Skills Check List, revealed CNA A received a competency check off on transfer (gait belt use) on 05/08/2024. Record review of a document titled, Inservice Training Report, dated 06/25/2024, revealed staff received education on fall management and abuse and neglect and was signed by 28 employees. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675095 If continuation sheet Page 3 of 4 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 675095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hallettsville Nursing and Rehabilitation 825 W Fairwinds Hallettsville, TX 77964 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 0689 Level of Harm - Actual harm Residents Affected - Few Record review of a document titled, Inservice Training Report, dated 06/27/2024, stated the summary of the training was resident safety during transfers and properly lowering a resident to the floor and resident safety during transfers utilizing a gait belt. The undated or titled document attached to the in-service training listed the steps for lowering a patient to the floor as 1. If a patient starts to fall and you are close by, move behind the patient and take one step back. Look and be attentive to cues if a patient is feeling dizzy of weak. 2. Support the patient around the waist or hip area or grab the gait belt. Bend your leg and place it in between the patient's legs. Hand placement allows for a solid grip on the patient to guide the fall. 3. Slowly slide the patient down your leg, lowering yourself at the same time. Always protect the headfirst. Lowering yourself with the patient prevents back injury and allows you to protect the patient's head from hitting the floor or hard objects. 4. Once the patient is on the floor, assess the patient for injuries prior to moving. Assesses patient's ability, or need for additional help, to get off the floor. 5. Provide reassurance and seek assistance if required. If required, stay with the patient, and call out for help. The in-service was signed by 52 employees. Record review of a document labeled, direct care staff and undated, had 53 employee names listed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675095 If continuation sheet Page 4 of 4