Health inspection·November 13, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few for not leaving sliding boards in resident rooms unattended. Review of the Employee Statement from RN D dated 11/11/2025 revealed that she was notified by a CNA C that Resident #1 had a fall. Resident #1 was on the floor. She stated that she went to the room as soon as possible and saw Resident #1 on the ground in a sitting position in front of her bed. She asked Resident #1 what happened and was informed that CNA A was transferring Resident #1 to the bed with a sliding board. She stated that Resident #1 had fallen and hit her head on the floor. Upon assessment the resident was noted to have a hematoma to the left side of her head and bruises to both of her hands. Review of the incident report dated 11/07/2025 by RN D revealed a witnessed incident. Resident #1 was oriented. Bruising was noted to Resident #1's right hand, left hand, face, and a hematoma on top of scalp. Documented the incident occurred during a transfer. Notifications were made to the physician and family member at 4:00 PM. Review of the Employee Statement from CNA C, not dated, revealed that he was working on 11/07/2025. He stated he was walking in the hall and happened to be walking by Resident #1's room at the time of the incident. He stated that he saw CNA A attempting to transfer Resident #1. He stated that he heard the sound of the fall, and he went back to the room to see what had happened. He stated he saw Resident #1 on the floor. He stated he went to notify the charge nurse immediately. Review of the Hospital Report dated 11/07/2025 revealed Resident #1 was sent to the hospital on [DATE] at 4:27 PM. Resident #1 was an [AGE] year-old female with past medical history of hypertension (high blood pressure) and left sided deficits from a prior stroke. Resident #1 presented to the emergency department for evaluation of a fall with a head strike. Resident #1 reported no pain. No other injuries. Resident #1 took blood thinners for A-fib (irregular and often very rapid heart rhythm). CT (Computed Tomography) X-Ray scan of the head/brain with contrast revealed Resident #1 suffered a small amount of subarachnoid hemorrhage in the posterior left temporal lobe (bleeding in the space below one of the thin layers that cover and protect your brain.). Review of the Employee Statement from CNA A dated 11/10/2025 revealed that she was called to Resident #1's room by Therapy Assistant B to make the bed for Resident #1. She stated she made the bed and decided to transfer Resident #1 back to bed using the sliding board. She stated Resident #1 fell and hit her head on the floor. She stated she called the nurse to come check on her. In an interview on 11/13/2025 at 10:00 AM, Administrator E revealed that CNA A transferred Resident #1 inappropriately which resulted in Resident #1 falling to the ground. She stated this was a facility self-reported incident. Resident #1 was a 2 person Hoyer lift transfer. CNA A attempted the transfer without the help of a second caregiver and with a sliding board instead of a Hoyer lift. She stated CNA A was suspended on 11/11/2025. She stated that the facility had already completed an action plan, plan of removal, and was continuing to monitor. Administrator E stated staff have been in-serviced on abuse and neglect. Administrator E stated staff have been in-serviced on how to correctly perform transfers. She stated Resident #1 returned to the facility and was doing fine. She stated the therapy department worked with Resident #1 on sliding board transfers, but the nursing staff were not supposed to use the sliding board. In an interview on 11/13/2025 at 10:30 AM with Resident #1 revealed that CNA A had never worked with her before the day of the incident. She stated that she wanted to get into bed and CNA A stated that she knew how to use the sliding board. She stated that CNA A obviously didn't know how to use the sliding board because she walked to the other side of the bed. She stated that normally the therapist would perform the transfer by having her sit on the board first and then begin to slide her up into bed. She stated that she had been working on sliding board transfers for a while now and had become good at it. She stated that normally she could do it without much assistance. In an interview on 11/13/2025 at 10:35 AM with Therapy Assistant B revealed she was working with Resident #1 in therapy and had taken her back to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675790 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 675790 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garland Nursing and Rehabilitation 321 N Shiloh Rd Garland, TX 75042 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 her room. She stated that she informed CNA A to make the bed for Resident #1 so that she could put her in bed. She stated that she went to assist another resident in the hall while CNA A made the bed. At that time CNA A attempted to perform the sliding board transfer by herself, and Resident #1 fell to the ground and hit her head. She stated that the therapy department are allowed to transfer Resident #1 with a sliding board. She stated that the nursing staff are not allowed to transfer Resident #1 with a sliding board. She understood the policies regarding sliding boards. She stated that the therapy staff recently performed inservices for sliding boards. In an interview on 11/13/2025 at 2:00 PM, CNA A stated Resident #1 was brought back to her room from therapy services. She stated that Therapy Assistant B asked her to make the bed for Resident #1 so that Therapy Assistant B could transfer Resident #1 to her bed. Therapy Assistant B informed CNA A that she would be back after a few minutes and left the sliding board in the room. CNA A stated Resident #1 asked CNA A to put her in bed. CNA A stated that she knew how to perform a sliding board transfer and Resident #1 agreed to let her perform the transfer. CNA A stated that she had not been trained on performing the sliding board transfer for Resident #1 and that Resident #1 was normally a 2-person assist. She stated she was a Hoyer assist that needs 2 people. She stated that she had been trained on sliding boards in the past. She stated she placed the sliding board under Resident #1 and she walked to the other side of the bed to prepare her bed. At that time Resident #1 attempted to scoot forward onto the sliding board from her wheelchair. Resident #1 lost balance and fell over to her side and hit the floor with her head. She stated that she was not ready for Resident #1 to start the transfer at that time. She stated that she could not prevent Resident #1 from falling because she was on the other side of the bed. She stated, CNA C notified RN D then came to assist and assess Resident #1. She stated she attempted the sliding board transfer by herself without the help of another staff member. She stated that the facility had since then performed in-services for transfers and abuse/neglect for the care staff but placed her on suspension pending investigation. In an interview on 11/13/2025 at 2:00 PM, Attending Physician G stated that he was notified of the fall that occurred on 11/07/2025. He stated that a fall during a sliding board transfer from a staff member who was not properly trained on that kind of transfer technique did put Resident #1 at a mild to severe risk of injury. He stated that the fall could have resulted in a fracture risk in combination with a brain bleed which would be a severe risk of injury. In an interview on 11/13/2025 at 2:30 PM, Administrator E revealed that it was the facility's policy to perform a Hoyer lift with two caregivers for Resident #1. She stated that the facility performed training after the incident and was continuing to train the staff before they began their next shift. She understood the policies regarding mechanical lifts, sliding boards, and the use of a Hoyer lift. She stated that he recently performed inservices for Mechanical lifts, sliding boards, and the use of a Hoyer lift. In an interview on 11/13/2025 at 3:00 PM, CNA C revealed that he was working at the time of the incident. He stated, he was walking in the hallway when he heard the sound of someone falling. He stated he went to check to see what happened and saw CNA A and Resident #1. He stated Resident #1 was on the ground. He went to get the nurse immediately to assess Resident #1. He understood the policies regarding mechanical lifts, sliding boards, and the use of a Hoyer lift. He stated that he recently performed inservices for Mechanical lifts, sliding boards, and the use of a Hoyer lift. In an interview on 11/13/2025 at 3:15 PM, Therapy Director F stated that the nursing staff should not be using the sliding board for Resident #1. He stated that the therapy department had been working with Resident #1, and she had been making progress. He stated that the nursing staff would have to be trained to perform the sliding board transfer, but that CNA A was not delegated to perform that type of transfer. He understood the policies regarding sliding boards. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675790 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 675790 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garland Nursing and Rehabilitation 321 N Shiloh Rd Garland, TX 75042 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 FORM CMS-2567 (02/99) Previous Versions Obsolete stated that the therapy staff recently performed inservices for sliding boards. Review of the facility Accident and incidents policy dated 2017 revealed, The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instruction. 1. At least (2) nursing assistants are needed to safely move a resident with a mechanical lift. Review of the Lifting Machine, Using a Mechanical policy dated 2001 revealed, The facility is in compliance with current rules and regulations governing accidents and/or incidents involving a medical device. Review of the Care Planning - Interdisciplinary Team policy dated 2024 revealed The interdisciplinary team is responsible for the development of the resident care plans.g. other staff as appropriate or necessary to meet the needs of the resident, or as requested by the resident. Review of the facility Fall Risk Management policy dated 2018 revealed Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. A Facility Transfer Policy specific to transfers and transfer techniques was requested but not provided. The facility took the following actions to correct the non-compliance on 11/11/2025: 1. Physician G, Director of Nurses H, and Resident #1's Responsible Party were notified of the fall on 11/07/2025. Documented in the incident report and confirmed with interview. 2. CNA A was suspended on 11/11/2025. Confirmed with interview. 3. Resident #1 was transferred to the emergency room (ER) on 11/07/2025 and returned on 11/12/2025. Confirmed with hospital records and interview. 4. In-services were conducted by the Administrator E and DON H and will continue to be conducted until every staff member has received the in-service at the start of their shift: a. Appropriate Transfer for all residents dated 11/11/2025. 33 Care staff check for all resident transfers. Demonstrations were given and staff returned demonstrations. b. Abuse and Neglect dated 11/11/2025. 43 Care staff check for Abuse and Neglect training. c. Gait Belts and Transfers for all residents dated 11/13/2025. 30 Care staff check for Gait Belts and Transfers. d. Lifting Machine Using a Mechanical dated 11/13/2025. 29 Care Staff check for Mechanical Lift Competency. e. Use of Sliding Board Transfers dated 11/12/2025. 10 Therapy Staff check off for not leaving sliding boards in resident rooms unattended. 5. Residents were audited to ensure the MDS matches the residents' current transfer status. 6. Resident rooms were audited for sliding boards. All sliding boards were removed until therapy can educate and check off the CNA's and communicate which residents are appropriate for sliding board transfers. 7. CNA's and Charge Nurses checked off with the Hoyer lift competency to ensure understanding and proper transfers. 8. Competency Checkoffs with direct care staff on how to check the Kardex (Nursing Documentation System) and proper transfers performed 5 times a week x4 weeks to ensure competency. Interviews on 11/13/2025 with CNA A, Administrator E, Therapy Director F, Therapy Assistant B, CNA C, DON H, CNA I, CNA J, ADON K, DON L, LVN M, CNA N, CNA O revealed they understood the policies regarding mechanical lifts, sliding boards, and the use of a Hoyer lift. They stated they recently performed inservices for Mechanical lifts, sliding boards, and the use of a Hoyer lift. On 11/13/2025 at 10:30 AM and 11:09 AM CNA J and CNA N were observed transferring Resident #2 and Resident #3 with a mechanical lift using good technique. Event ID: Facility ID: 675790 If continuation sheet Page 4 of 4