Health inspection·November 24, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm 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 observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 Resident (Resident #1) of 3 residents reviewed for accident hazards/devices. The facility failed to ensure CNA A and CNA B used the required assistive device (gait belt) to transfer Resident# 1 to prevent accidents. This failure could place residents at risk of avoidable falls, injuries, and reduced safety during transfers.Findings included: Record review of Resident #1's MDS Assessment, dated 08/01/25, reflected the resident was a [AGE] year-old male who originally admitted to the facility on [DATE]. He had a BIMS score of 09, indicating moderate cognitive impairment. His diagnoses included Anemia (A condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body), hypertension (a condition where the blood pressure is lower than normal), Renal Insufficiency (a condition where the kidneys do not function properly and cannot filter waste products from the blood), Diabetes Mellitus (a chronic metabolic disorder characterized by high blood sugar (glucose) levels that occur when the body does not produce enough insulin or does not use insulin effectively), Parkinson Diseases(a progressive neurodegenerative disorder that affects movement, balance, and coordination), Anxiety, and schizophrenia (Schizophrenia is a serious mental health condition that affects how people think, feel and behave). Record review of Resident #1's care plan, initiated 08/28/2025, reflected the following: Focus: The resident has an ADL Self Care Performance Deficit r/t blind. Interventions/Tasks transfer: The resident requires 2 staff total participation with transfers. In an observation on 09.24.2025 at 11:49AM revealed CNA A and CNA B entered Resident#1's room. CNA A and CNA B introduced themselves and notified Resident# 1 that they were going to transfer him from the wheelchair to the bed. CNA A was on the right side and CNA B was on the left side. CNA A and CNA B placed their arms under the resident's arm and pulled the resident to a standing position, then pivoted the resident toward the bed. No gait belt was used in the transfer. In an interview on 09/24/2025 at 11:55AM with CNA A revealed that Residents# 1 required two people for transfers. She stated that she should have used a gait belt. She stated that the risk to the residents when a gait belt was not used was fall and injuries to the resident's shoulder. CNA A stated she had been in serviced on how to transfer with a gait belt. In an interview on 09/24/2025 at 11:57 AM with CNA B revealed that she did not work with Resident#1 and was assisting CNA A with the transfer. She stated that she knew she should have used a gait belt to transfer Resident#1 and there was no reason why they did not use one. She stated that the risk to the resident when a gait belt was not used was injury to the resident and the resident could fall. CNA B stated she had been in serviced on how to transfer with a gait belt. In an interview with 09/24/2025 at 12:00PM with LVN C revealed that Resident#1 required two people for transfers. She stated that every resident should be transferred using a gait belt. She stated that the risk to the resident when a gait belt was Page 1 of 2 675817 675817 11/24/2025 FT Worth Southwest Nursing Center 5300 Alta Mesa Blvd Fort Worth, TX 76133

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not used with transfers was injuries such as broken bones due to falls. In an interview on 09/24/2025 at 12:49PM with the DON revealed that his expectation was that staff used a gait belt with all transfers. He stated that the risk to the resident was fall, injury to the resident and the staff and skin issues. He stated that staff had been in-serviced on safe transfers and the use of gait belts with all transfers unless contraindicated. He stated that Resident#1 had no restrictions for gait belt use. Record review of the facility's policy, revised 06/2020, and Titled Transfer of Residents Reflected: To provide the form of transfer best suited to the residents' needs and to maintain resident safety during the procedure. i. A Licensed Nurse and/or the Director of Rehabilitation Services assess and determine lifting and transfer requirements, and the procedure used for each resident. the procedure is recorded in the residents ‘s care plan. ii. Residents must be lifted or transferred according to the determined procedure. iii. Residents who require assistance in transferring will be transferred using a gait/transfer belt or with a lift. iv. Member of the Nursing Staff are trained to use good body mechanics, knowing the proper procedures and properly operating assistive devices. v. Mechanical lift procedures are used on any resident unable to independently pivot or transfer. B. Two-Person Assisted Transfer i. Place the chair on the convenient side of the bed with the back of the chair parallel to the foot of the bed and facing the head of the bed. ii. If using a wheelchair, make sure footrests are not in the way and wheels are locked. iii. Place appropriate pressure-reducing devices into chairs. iv. Turn residents onto their side and pivot the residents to sitting positions, with legs dangling over the side of bed. v. Assist residents in daily attire as requested. vi. May apply gait belt (unless contraindicate) around residents' waist securely enough to prevent sliding up over ribs. vii. Each person will stand facing the resident with one on either side of the resident. viii. Provide a broad base of support by spreading feet and placing foot farthest from the resident slightly in front of the other. ix. Each person will extend their arm closest to the resident forward between the resident side and elbow. With fingers pointing downward, grasp the gait belt firmly. x. Instruct the residents to place their hand between your body and your arm grasping the gait belt holding onto the back of your upper arm, if used. xi. On a verbal command, draw the resident gently but firmly forward and upward to a standing position, brace his knee with yours to prevent buckling. xii. Pivot or turn the resident so that their back is towards the chair. xiii. Remove gait belt, if used xiv. Make sure the resident is comfortable. xv. Utilize Postural support and/or positioning devices per attending Physician order and resident need. xvi. Make sure the call bell is within residents reach before leaving. 675817 Page 2 of 2