Inspection·August 22, 2023

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #2's Progress notes dated 8/18/2023 at 11:52 pm revealed read in part: .Health Status Note: Xray of right leg done for c/o of pain, resident stated it happen during therapy family aware .RP request xrays be done.MD notified and xrays ordered and were done, results pending . Record review of Resident #2's facility's X-ray results dated 8/19/23 at 9:52 am revealed read in part: .Radiology Interpretation: Acute appearing fracture of the distal femoral metaphysis . Residents Affected - Few Record review of Resident #2's Hospital Records dated 8/19/23 read in part: XXX[AGE] year-old woman with history of vascular dementia, hypertension, CKD, OSA, stage IV decubitus ulcer presented here with right leg pain. Patient resides in a nursing facility and was evaluated by physical therapy and transferred from wheelchair back to bed. While pivoting to her right leg Twisted and reports severe pain after was brought into the ER was noted to have x-rays done which show a minimally displaced predominantly transverse supracondylar fracture in the distal metaphysis. Orthopedic surgery has been consulted by the ER and now awaiting for further evaluation. Given fractures likely patient will be placed in a splint will defer that to orthopedic surgeon for further recommendations. Impression and Plan Diagnosis Femur fracture, right . Record review of Resident#2's PT Evaluation & Plan of Treatment dated 8/15/23 revealed read in part: .Functional Mobility Assessment: Transfers=Did Not Test (Patient at baseline of dependence for OOB with hoyer lift . In an interview on 8/22/23 at 8:14 a.m., with the Administrator, she said Resident #2 was due for quarterly MDS Part B for therapy. She said the Therapy department did an evaluation and the Patient agreed. She said the RP was not notified by the therapy department that the Pt was placed under their services. The Rehab Manager was out, and it was an oversight on their part. She said she called the hospital to confirm if the fracture was on the same knee that happened prior within this year. Hospital said it was new fracture. She said Pt was 2 person transfer but the PTA did one person transfer and had been suspended pending investigation. PTA's last working day was 8/18/23. In a telephone interview on 8/22/23 at 9:01 a.m., with Resident #2's Responsible party, she said last week, the facility started doing physical therapy with the resident. She said the family did not request therapy; the facility initiated it themselves. On Friday evening, 08/18/23, the resident reported her right leg was hurting. She said she removed the covers and noted that her right knee was swollen to the size of small basketball. The leg was also hot to the touch. The resident reported that physical therapy took her to down to therapy. Once back in her room, the therapy staff member got the resident's leg caught under the wheelchair during transfer. The physical therapy staff was transferring the resident to the bed by herself. She said the resident required two people transfer via hoyer lift. The resident's right leg did not move during the transfer and the resident felt her right leg twist around. The resident yelled out in pain. The therapy staff got some bio freeze and put it on her leg. she said she asked a nurse for a stat x-ray. she said she was notified of the x-ray results on 8/19/23. The facility reported a fracture to her right distal femur. Observation and interview on 8/22/23 at 9:21 a.m., with Resident #2 revealed she was resting in bed. She said she had returned from the hospital last night (8/21/23). She said her right leg got caught under the wheelchair while physical therapist was transferring her from wheelchair back to bed. She said she was in pain and the nurse had given her pain medication this morning. In an interview on 8/22/23 at 9:33 a.m., with LVN A, she said Resident #2 required 2 people assist (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 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 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 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 - Immediate jeopardy to resident health or safety with transfers from shower chair to bed using a hoyer lift. She said resident returned last night (8/21/23) from the hospital. In an interview on 8/22/23 at 9:39 a.m., with CNA CC, she said Resident #2 required 2 people transfer with a hoyer lift and sling. She said resident refused to get out of bed. Resident only got out of bed on her shower days. Residents Affected - Few In an interview on 8/22/23 at 9:43 a.m., with the Rehab Director, she said Resident #2 was receiving services in the past and had gotten a custom wheelchair. She said Resident had wound and the resident laid in bed all the time that put her at risk. She said the Physical Therapist did an evaluation on Resident #2 and added her to the services sometime last week. Record review and interview on 8/22/23 at 9:45 a.m., with the Physical Therapist, she said Resident #2 was due for MDS quarterly screen. She said she found from the nursing staff that resident had not gotten out of bed. Resident only got up for showers. She said in the past resident had received physical therapy and part of the plan was for her to use the custom wheelchair so she could get out of bed. She said resident had wound which the resident laid on all day. She said she felt that resident would benefit from the therapy. She said the protocol was that the Physical Therapist completed the evaluation and created a plan of treatment and the treating Physical Therapy Assistant was to follow that plan of treatment. Physical Therapist reviewed the PT Evaluation & Plan of Treatment dated 8/15/23 with the Surveyor. Physical Therapist said under section Functional Mobility Assessment for Transfers patient was at baseline of dependence for OOB with hoyer lift. Physical Therapist said that meant the Resident was not treated for transfer because there were no goals for transfer. If Resident needed to get out of bed, then the hoyer lift was a safer way. When asked how the Physical Therapist checked to see if Physical Therapist Assistant was following the plan of treatment. Physical Therapist said she read the weekly progress notes to see what PTA had been treating. She said she looked to see if goals have been met or needed to be upgraded which required discussion with Physical Therapist. Physical Therapist said Physical Therapist Assistant was a licensed therapist, she did not need to be followed/spot checked during therapy sessions with Residents. Physical Therapist said she had her own case load and to work efficiently, the treating therapist was assigned one patient at a time and PTA were to follow the Physical Therapist's plan of treatment. She said, it was important to follow the plan of treatment, so PT and PTA were working toward the same goals. It puts them on the same page. She said PTA could have grabbed an aide to assist her with Hoyer transfer. In an interview on 8/22/23 at 10:07 a.m., with CNA DD, she said Resident #2 required a Hoyer lift to move between surfaces. She said Resident#2 always needed 2 persons to assist. She said Resident#2 did not like getting out of bed. She said Resident only got out of bed on her shower days which were Tuesday, Thursday and Saturdays. She said two staff transferred resident from bed to shower chair via hoyer lift on her shower days. In a telephone interview on 8/22/23 at 10:21 a.m., with Physical Therapist Assistant, she said Resident #2 was placed under therapy services sometime last week. She said she asked Resident#2 if she was ready to get up. Resident agreed. She said she moved her blankets, helped her sit on the edge of the bed. She said she performed lateral scoot partial stand pivot transfer with gait belt and draw sheet from edge of bed to wheelchair. When asked if she reviewed the Physical Therapist's plan of treatment dated 8/15/23 under transfer it mentioned the use of hoyer lift when out of bed. PTA said, I did look over it briefly. I scanned PT's evaluation she had sitting balance goal and wheelchair mobility goal. PTA said, I use gait belt on everyone. To increase trunk control and functional independence. PTA said hoyer lift was used when the Patient could not sit up, assist with transfer or can (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 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 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 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 - Immediate jeopardy to resident health or safety Residents Affected - Few not hold their balance. she said she had worked with Resident#2 in the past and Resident was able to sit up. She said when resident was done eating her lunch. She asked Resident#2 if she was ready to get back in bed. Resident agreed. PTA said she did partial stand pivot with lateral scoot from wheelchair to edge of bed. Once in standing, Resident#2 reported increased pain in her right leg. She said she took her foot and slid her right foot forward to take pressure of resident's leg and assisted with positioning resident onto the edge of bed. Resident reported that right knee was still hurting. She said she tried to reposition for comfort. Placed pillows under knees. She said she asked nurse on duty, if resident could get pain medication as resident was reporting increased pain in the right side following treatment and transfer back to bed. The nurse explained that resident had pain medications prior to treatment and could not get them at that time. She said she asked resident if she would like her to get bio freeze and the resident agreed. She said she applied bio freeze to bilateral knees per request. She said she asked resident again if her pain was better or worse the resident reported that it was a little better but still hurting. In an interview on 8/22/23 at 12:08 p.m., with the DON, she said she found out on Saturday (8/19/23) from the Unit Manager that relied to her that x-ray results showed fracture. She said she was not aware of x-rays order and there was no incident report. She said she was then told about the rehab session on Friday (8/18/23). She said per the resident her legs got caught in wheelchair during transfer. she said after the incident was reported to HHSC on 8/19/23 and the facility began the investigation. She said she interviewed staff to determine the transfer status of Resident #2. She said the facility identified Resident #2 was a 2-person transfer. She said PTA should have asked for help with transfer. Record review of facility's In-service Education Program record dated 8/21/23 conducted by the Administrator on 8/21/23 to staff on Abuse Neglect protocal, Reporting/types of abuse. Record review of facility's In-service Education Program record dated 8/21/23 conducted by the DON on 8/21/23 to staff on Abuse & Neglect/ Transfer/Admssion/ POC documentation. Record review of facility's In-service Education Program record dated 8/21/23 conducted by the Administrator on 8/21/23 to Rehab department revealed read in part: .Therapist/PTA must follow the plan of care for treatment any concern regarding the plan of care must be communicated to DON/ED & MD . Record review of the facility's Safe Lifting and Movement of Residents policy (revised July 2017) read in part: .Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. 2. Manual lifting of residents shall be eliminated when feasible.3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan such assessment shall include the following: b. Resident's mobility (degree of dependency): d. Weight-bearing ability: g. The resident's goals for rehabilitation, including restoring or maintain functional abilities. 8. Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. Back-up battery packs on remote chargers shall be provided as needed so that lifts can be used 24 hours a day while batteries are being charged . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 4 of 4