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 the
observation, interview, and record review, the facility failed to ensure that the residents environment
remains free of accidents hazards as possible and each resident receives adequate supervision to prevent
accidents for 1 (Resident #1) of 2 residents reviewed for accidents and supervision.
The facility failed to ensure CNA B secured the brakes on a mechanical lift when lowering Resident #1 to
bed.
This failure could place residents at risk for falls or injury.
The findings included:
Record review of Resident #1's face sheet dated 1/2/25 revealed a [AGE] year-old female who was
re-admitted to the facility on [DATE] with diagnoses of vascular dementia (common type of dementia that
happens when there's decreased blood flow to areas of your brain), muscle weakness, and hemiplegia
(paralysis on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral
infraction (is a type of stroke that occurs when a blood vessel in the brain is blocked, causing damage to
brain tissue).
Record review of Resident #1's annual MDS assessment dated [DATE] revealed BIMS score of 00,
indicating her cognition was severely impaired, and she was dependent on staff for transfers.
Record review of Resident #1's care plan dated 11/06/24 revealed a focus area for requires mechanical lift/
2 person transfers with interventions that included safety measures- including strategies to reduce the risk
of infection, falls, injury initiated as appropriate and goal was will remain free from injury.
In an observation on 1/2/25 at 10:20 am, CNA A and CNA B assisted with Resident #1's mechanical lift
transfer. Resident #1 was informed of the procedure and reminded to cross her arms over her chest. The
brakes on the lift were secured. CNA A supported Resident #'s 1 legs and provided reassurance while CNA
B released the brakes and moved Resident #1 to the bed. As CNA B lowered Resident #1 to the bed, the
brakes were not applied, causing slight movement of the mechanical lift. CNA B quickly secured the brakes
in place. The transfer was completed without incident, and no anxiety was observed.
In an interview on 1/2/25 at 10:34 am, CNA B stated that she should have applied the brakes on the
mechanical lift before lowering Resident #1, but forgot to do so. CNA B stated the potential risks included
the resident swinging, tipping over, and possibly falling. CNA B stated she had received
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
675831
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
675831
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/02/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Edgemere Estates
10880 Edgemere Blvd
El Paso, TX 79935
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
training on proper mechanical lift transfer procedures.
Level of Harm - Minimal harm
or potential for actual harm
In an interview on 1/2/25 at 1:24 pm, the Director of Nursing (DON) explained that it was always expected
for two staff members to assist with mechanical lift transfers. The DON stated staff were instructed to check
the battery and ensure the lift was working properly, prepare the resident, position the sling, and secure the
sling hooks. The DON stated brakes were to be engaged before lifting or lowering the resident to prevent
movement and released only when ready to move the lift. The DON stated one CNA maneuvered the
mechanical lift, while the other guided the resident. The DON stated that failing to apply the brakes could
result in movement of the lift, increasing the risk of a resident fall or injury. The DON stated staff received
training on mechanical lift transfers upon hire, including when the facility transitioned ownership, and
quarterly random competency checks were conducted by the DON and lead CNA.
Residents Affected - Few
In an interview on 1/2/25 at 2:53 pm, the Administrator stated that mechanical lift transfers were performed
by direct care staff who were trained at hire, annually, and as needed during competency checks. The
Administrator stated nurse managers and lead CNAs were responsible for that training. The Administrator
stated that brakes should always be secured before lifting or lowering the resident. The Administrator stated
the risk of not following those steps included potential injury to the resident or staff.
Record review of the facility's Full mechanical lift safety guidelines policy dated November 2022 read in part
when transferring from/to a wheelchair, shower chair or bed, make sure that the wheels are in the locked
position on the wheelchair, shower or bed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675831
If continuation sheet
Page 2 of 2
