Health inspection·February 25, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 4 residents reviewed for accidents. On 2/22/2025 Certified Nurse Aide (CNA) A attempted to perform a 1-person transfer, with a Hoyer lift, on Resident #1 who required a 2-person transfer with a Hoyer lift. CNA A was unable to complete the transfer and dropped Resident #1 on the floor. This was determined to be past non-compliance immediate jeopardy from 2/22/2025 to 2/22/2025 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk of serious injury or death. The findings included: Review of the Care Plan dated 2/25/2025 documented Resident #1 was a [AGE] year old female admitted on [DATE]. Resident #1 had diagnoses including Dysphagia, Lymphedema, Alzheimer's Disease, Depression, Rheumatoid Arthritis, Psychotic Disorder Hallucinations, Aphasia, Anxiety Disorder, and Hypertension. The resident has an Activities of Daily Living self care performance deficit. Resident #1 is totally dependent in bathing, bed mobility, dressing, eating, personal hygiene, toilet use, and transferring. Resident #1 requires the use of a Hoyer lift with 2 or more person assist related to impaired physical mobility. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was a total dependence of 2 persons for transfers. Resident was unable to be assessed for a Brief Interview for Mental Status (BIMS) because the resident was unable to complete the assessment indicating an inability to communicate or severe cognitive impairment. Review of Resident #1's Face Sheet dated 2/22/2025 revealed the resident requires 2 person transfers via Hoyer lift. Review of Resident #1's progress noted written by Licensed Vocational Nurse D that was striked out, dated 2/22/2025 at 10:37 AM documented on 2/22/2025 at 9:45 am Resident #1 slid out of the Hoyer sling and was guarded to the floor gently by CNA A. Director of Nursing, Physician, Responsible Party were all notified. Resident #1 was sent to the hospital for assessment at the Responsible Parties Page 1 of 4 675811 675811 02/25/2025 Victoria Gardens of Frisco 10700 Rolater Dr Frisco, TX 75035

F 0689 request. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #1's progress noted written by Director of Nursing dated 2/22/2025 at 11:06 AM documented Nurse summoned to residents' room by CNA, resident observed lying on the floor by the Hoyer lift, face up, resident slid off the Hoyer sling to the floor. Resident assessed for injury per charge nurse, no apparent physical injury noted. Residents Affected - Few Review of Resident #1's progress noted written by Licensed Vocational Nurse D dated 2/22/2025 at 1:24 PM documented Resident #1 was assessed and able to move all extremities. Vitals were taken. Temperature 97.6, Pulse 73, Respiration 18, Blood Pressure 131/75. No injury. Responsible Party visited the facility and requested that Resident #1 be sent to the hospital. Review of the Hospital Report dated 2/22/2025 documented Resident #1 received no injuries. Review of the Incident Report dated 2/24/2025 revealed Resident #1 was transferred via Hoyer without a second caregiver assisting by CNA A. Appropriate safety precautions and devices were not in place which resulted in Resident #1 falling to the floor. Observation of the video on 2/25/2025 at 12:56 PM revealed CNA A attempted to transfer Resident #1 without the help of second caregiver. Resident #1 fell to the floor while she was being positioned on the sling. Resident #1's roommate can be heard yelling for help. CNA A immediately left the room and returned with the nurse to assess Resident #1. Record review of a facility statement from CNA A dated 2/24/2025 documented she had been a CNA for almost eight years. She stated she was trained, and the Hoyer should only be used with at least two people at all times. She stated she was trained during orientation and again during in-services. She was trained that a Hoyer lift was only to be used in the presence of 2 or more people at all times. In an interview on 2/25/2025 at 1:30 PM, LVN F said Resident #1 could not be transferred by 1 person because she requires a Hoyer lift. The resident is totally dependent (cannot help). In a telephone interview on 3/03/2025 at 4:00 PM, Nurse Practitioner (NP) stated a fall during a Hoyer transfer could have put Resident #1 at a great risk of injury. She stated that the risk from a fall could have resulted in a bone break, brain bleed if she had hit her head, or worse. In an interview on 2/25/2025 at 12:10 PM, Director of Nurses (DON) C revealed it was the facilities policy to perform a Hoyer lift with two caregivers. She stated she performed trainings immediately after the incident and was continuing to train the staff before they begin their next shift. Review of Proficiencies for CNA A revealed she passed the Mechanical Lift Skills assessment dated [DATE]. Review of the facility Safe Lifting and Movement of Residents policy dated 1/12/2024 stated 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. Review of the facility Lifting Machine Policy dated 9/8/24 stated General Guidelines (4.) Lift designs and operation vary across manufacturers and the Administrator or designee will ensure that instructions and competencies for each lift are utilized and staff will be trained and demonstrate 675811 Page 2 of 4 675811 02/25/2025 Victoria Gardens of Frisco 10700 Rolater Dr Frisco, TX 75035

F 0689 competency using the specific machines or devices utilized in the facility. Level of Harm - Immediate jeopardy to resident health or safety Review of the Manufacturer User Manual for Lift Model Number MDS700EL revealed that when transferring from bed, a second caregiver is needed to roll the patient onto one side and pull the remainder of the sling from the other side of the patient so that the sling lays flat. Residents Affected - Few It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation on 2/22/2025. The facility took the following actions to correct the non-compliance on 2/22/2025: In an interview on 2/25/2025 at 9:30 M, the Administrator B revealed that CNA A transferred Resident #1 inappropriately which resulted in Resident #1 falling to the ground. Resident #1 was a 2 person Hoyer lift transfer. CNA A attempted the transfer without the help of a second caregiver. He stated CNA A was immediately suspended on the day of the accident 2/22/2025 and terminated on 2/24/2025. He stated that the facility has already completed a plan of correction, plan of removal, and are continuing to monitor. Staff have been inserviced on Abuse and Neglect. Staff have been inserviced on how to correctly perform a Hoyer lift transfer. Record review of facility In-services conducted by the DON and ADON on the following: a. Safety with Hoyer Transfers dated 2/22/2025. All Hoyer lifts require 2 staff members present to perform mechanical lift. b. Safe Transfers Interview on 2/25/2025 at 12:10 PM the Director of Nursing stated in-services will continue to be conducted until every staff member that has not presented to work has received the inservice at the start of their shift. Record Review of the Mechanical Lift Skills Assessments revealed that the facility performs random monitoring by observation and supervision thereafter by the DON and ADON to monitor proper Hoyer lift use and transfer of residents in the facility. These assessments documented that staff completed a facility Hoyer return to competency demonstration/proficiency check off. The assessments started on 2/22/2025 by DON and ADON and will be conducted until every staff member who has not presented to work has demonstrated proficiency. Review of the Confidential Employee Corrective Action Plan Form dated 2/24/2025 documented CNA A was terminated. Employee transferred a Hoyer lift patient w/o assistance resulting in the resident sliding to the floor. Employee falsified her statement to her charge nurse stating, she was gently lowered to the floor. Observation on 2/25/2025 at 2:15 PM revealed CNA H and CNA I were observed transferring Resident #3 with a mechanical lift using good technique. Interview on 2/25/2025 at 2:20 PM with CNA H revealed they understood the policies regarding mechanical lifts and the proper use of a Hoyer lift. They indicated that they recently received inservice training on 2/22/2025. They stated that when using a mechanical lift there should be 2 person assist at all times. They stated that they passed the Hoyer demonstration assessment on 2/22/2025. Interview on 2/25/2025 at 2:25 PM with CNA I revealed they understood the policies regarding 675811 Page 3 of 4 675811 02/25/2025 Victoria Gardens of Frisco 10700 Rolater Dr Frisco, TX 75035

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few mechanical lifts and the proper use of a Hoyer lift. They indicated that they recently received inservice training on 2/24/2025. They stated that when using a mechanical lift there should be 2 person assist at all times. Interview on 2/25/2025 at 2:50 PM with CNA J revealed they understood the policies regarding mechanical lifts and the proper use of a Hoyer lift. They indicated that they recently received inservice training on 2/24/2025. They stated that when using a mechanical lift there should be 2 person assist at all times. Interview on 2/25/2025 at 2:55 PM with CNA K revealed they understood the policies regarding mechanical lifts and the proper use of a Hoyer lift. They indicated that they recently received inservice training on 2/24/2025. They stated that when using a mechanical lift there should be 2 person assist at all times. They stated that they passed the Hoyer demonstration assessment on 2/24/2025. Interview on 2/25/2025 at 1:30 PM with LVN F revealed they understood the policies regarding mechanical lifts and the proper use of a Hoyer lift. They indicated that they recently received inservice training on 2/24/2025. They stated that when using a mechanical lift there should be 2 person assist at all times. They stated that they passed the Hoyer demonstration assessment on 2/24/2025. Interview on 2/25/2025 at 10:30 AM with LVN L revealed they understood the policies regarding mechanical lifts and the proper use of a Hoyer lift. They indicated that they recently received inservice training on 2/24/2025. They stated that when using a mechanical lift there should be 2 person assist at all times. They stated that they passed the Hoyer demonstration assessment on 2/24/2025. Interview on 2/25/2025 at 10:50 AM with LVN M ADON revealed they understood the policies regarding mechanical lifts and the proper use of a Hoyer lift. They indicated that they recently received inservice training on 2/24/2025. They stated that when using a mechanical lift there should be 2 person assist at all times. They stated that they passed the Hoyer demonstration assessment on 2/24/2025. Interview on 2/25/2025 at 1:35 PM with LVN N revealed they understood the policies regarding mechanical lifts and the proper use of a Hoyer lift. They indicated that they recently received inservice training on 2/24/2025. They stated that when using a mechanical lift there should be 2 person assist at all times. They stated that they passed the Hoyer demonstration assessment on 2/24/2025. Interview on 2/25/2025 at 3:00 PM with RN O revealed they understood the policies regarding mechanical lifts and the proper use of a Hoyer lift. They indicated that they recently received inservice training on 2/22/2025. They stated that when using a mechanical lift there should be 2 person assist at all times. They stated that they passed the Hoyer demonstration assessment on 2/24/2025. Interview on 2/25/2025 at 1:10 PM with CNA P revealed they understood the policies regarding mechanical lifts and the proper use of a Hoyer lift. They indicated that they recently received inservice training on 2/22/2025. They stated that when using a mechanical lift there should be 2 person assist at all times. They stated that they passed the Hoyer demonstration assessment on 2/22/2025. 675811 Page 4 of 4