Health inspection·November 13, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few appropriate notifications. LVN B was later notified by Resident #1' s family the resident was complaining of right leg and ankle pain. The NP was notified, and an x-ray was ordered. The x-ray revealed no fractures. Interview on 11/13/24 at 11:30 AM with LVN B revealed when she assessed Resident #1, the resident had been showered and put back in bed. She stated CNA A did not know how the skin tear had occurred. She stated CNA A did not notice it until she was putting the resident back to bed. LVN B stated the injury did not require a dressing because there was no bleeding. Record review of the Social Worker's written statement, dated 09/05/24 reflected she was contacted on 09/03/24 by Resident #1's family complaining the resident had been handled roughly during a transfer to the shower chair, resulting in a skin tear to her arm. The Social Worker initiated a grievance for Resident #1. The resident's family visited the Social Worker on 09/05/24 and informed her that after viewing video footage from Resident #1's room the resident had refused a shower, but the CNA had proceeded with the transfer and shower. Interview on 11/13/24 at 11:49 AM with the Social Worker revealed she had not been shown the video footage the family referenced, and her notes and the grievance report were from her communication with Resident #1's family. Record review of the facility's Provider Investigation Report, signed and dated by the DON on 09/12/24, reflected on 09/03/24 Resident #1 sustained a skin tear to her right arm, measuring 1 cm x 1.5 cm, when she was transferred from her bed to a shower chair by CNA A. The family reported the occurrence to the facility after seeing the incident on video recorded in the resident's room. The Provider Investigation Report reflected after the facility learned of the incident, they suspended CNA A on 09/03/24 and then terminated her employment. Observation of the video, dated 09/03/24 at 11:40 AM, provided by Resident #1's family, included audio. The video revealed Resident #1 in bed and CNA A attempting to transfer the resident from bed to a shower chair that was on the left side of the bed. CNA A had Resident #1 sitting up in bed with her legs off the side of the bed, with Resident #1 holding onto CNA A's shirt. Without using a gait-belt, CNA A held Resident #1 up with her hand on the back of the resident's neck. Resident #1 fell back on to the bed. CNA A then lifted Resident #1 up with her hands under the resident's left arm and by the right arm. CNA A counted to three and then put the resident into a shower chair. The resident complained of pain to her leg after being put into the shower chair. The video clip did not show the resident being combative or verbally/physically resisting care. Interview on 11/13/24 at 2:26 PM with the Administrator and the DON revealed the family had not provided them with the video of the transfer. During this interview, they were shown the video, and the Administrator stated he did not know the transfer was that bad. He added that was why CNA A was terminated. The DON stated she did not see CNA A use a gait-belt, which was against policy, as was lifting the resident by their arms. The DON stated she had done a one-on-one in-service with CNA A on resident rights and customer service immediately and before CNA A was suspended, but not on transfers or accident prevention. Telephone interview was attempted on 11/13/24 at 1:10 PM and 2:35 PM with CNA A, but the attempts were unsuccessful. Record review of the facility's Transfers of Residents policy, dated 09/02/24, reflected: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675153 If continuation sheet Page 2 of 3 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 675153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage House at Keller Rehab & Nursing 1150 Whitley Road Keller, TX 76248 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 - Minimal harm or potential for actual harm The goal is to ensure the safety of the resident when moving from one place to another, to prevent injuries to the resident .Use a gait belt around the resident to protect both the resident and yourself, unless contraindicated and as applicable. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675153 If continuation sheet Page 3 of 3