Health inspection·June 30, 2023

F 0689 Right shoulder (2 or more views): Level of Harm - Minimal harm or potential for actual harm - A fracture of the right humeral neck. This fracture may be subacute. Right humerus-2 view: Residents Affected - Few - A fracture of the right humeral neck. This fracture may be subacute. Right forearm-2 view: - No acute fracture or dislocation of the right forearm. Record review of radiology report, dated 06/26/23, revealed the following: Right shoulder (2 or more views): - No acute fracture or dislocation of the right shoulder. Record review of in-service titled Mechanical Lift, dated 06/23/23, revealed staff, including CNA A, were trained on mechanical lift transfer protocol. Interview on 06/30/23 at 10:00 AM, the DON stated she was at the facility on 06/23/23 when Resident #1 fell from the mechanical lift. She stated CNA A yelled for her help from Resident #1's room, and when she went in, and she found the resident and CNA A on the floor. The DON stated CNA A reported that she had just given Resident #1 a shower and was transferring her from the shower chair to the bed when the mechanical lift tilted over. The DON stated Resident #1 complained of slight pain to right shoulder but stated she was fine. The DON stated Resident #1 was assessed head-to-toe and there were no visible injuries. The DON stated the medical doctor was immediately notified and an x-ray was ordered for Resident #1. The DON stated the initial x-ray was completed on 06/23/23 and results showed a fracture to the right humeral neck/shoulder, possibly subacute, and the MD was notified of results. The DON stated a sling and follow-up appointment with an orthopedic surgeon was ordered for Resident #1. The DON stated that over the next couple of days, Resident #1 denied being in pain and refused to keep the sling on her arm. The DON stated Resident #1 had full range of motion and was able to move her right arm without pain. Resident #1 informed them she had injured her right arm during a fall several years ago, and it always gave her problems. The DON stated due to Resident #1 denying pain and being able to use her right arm, a second x-ray was ordered and completed on 06/26/23 which revealed negative results for a fracture or dislocation but showed signs of osteopenia. The DON stated the MD came out on 06/27/23 to assess Resident #1 and reviewed the x-ray, and the MD stated there were no apparent issues clinically consistent with a fracture or abnormalities. The DON stated the portable x-ray machines were not always efficient, and the initial x-ray results were inaccurate. The DON stated CNA A knew not to transfer with the mechanical lift without a second qualified staff there to assist based on the training she had received and her experience since CNA A had worked at the facility for several years. The DON stated the risk of using a mechanical lift without assistance could be the resident falling and possibly sustaining serious injuries. Interview on 06/30/23 at 11:20 AM, Resident #1 denied being in pain and stated that she was feeling good. Resident #1 recalled having a fall during a mechanical lift transfer on 06/23/23 after receiving a shower. She stated normally two staff would transfer her but on that day CNA A transferred her alone. Resident #1 stated her right arm hurt a little after the fall, but she denied any major (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675270 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 675270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kennedale 413 E Mansfield Cardinal Kennedale, TX 76060 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 Residents Affected - Few injuries. Resident #1 stated she fractured her right arm from a fall years ago and any slight agitation causes it to act up. Resident #1 stated she felt safe during all other transfers in the mechanical lift and denied being abused or neglected. Interview on 06/30/23 at 3:15 PM, CNA A revealed she had worked at the facility for five years. She stated she had been trained on using a mechanical lift at least annually and in-serviced as needed. CNA A stated all mechanical lift transfers required two staff; however, Resident #1 wanted a shower very early on the morning of 06/23/23, before all staff had arrived on shift. CNA A stated the shower went well and when it was time to get Resident #1 back in bed, she was unable to find another CNA to assist her. She stated there was a nurse assigned to the hall, but she was administering medications and was not available. CNA A stated she turned on Resident #1's call light and waited several minutes, but no one came to assist her. She stated she heard the housekeeper in the hall and called for her to assist with the transfer. CNA A stated she knew that the housekeeper was not trained to assist, but she did not know what else to do. CNA A stated once she had Resident #1 in the mechanical lift, she felt that she could handle it and told the housekeeper that she could leave. She stated as she was guiding Resident #1 towards the bed from the side of the mechanical lift tilted forward. CNA A stated the weight of the mechanical lift forced her to the floor first, and Resident #1 fell on top of her. CNA A stated she cushioned Resident #1's fall and if anyone was going to be hurt it would have been her. Interview on 06/30/23 at 4:00 PM, the Administrator stated her expectation was for all mechanical lift transfers to be conducted by two qualified staff per the facility's policy. She stated the housekeepers were not qualified to assist with the care of residents. The Administrator stated Resident #1 was secure in the shower chair and CNA A should have let her remain there until a second qualified staff was available to assist. She stated CNA A was written up and received re-education on mechanical lift transfers. The facility's policy titled Mechanical Lift, dated October 2017, revealed in part the following: Policy: It is the policy of this home to utilize the Mechanical (or similar) lift when it is necessary to safely transfer a resident due to body weight or physical condition. These are general guidelines only. The specific product utilization by the home may vary per the manufacturer recommendations. Lifting a resident with a mechanical lift is always a two-person procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675270 If continuation sheet Page 3 of 3