Health inspection·October 24, 2024

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 observation, interview, and record review the facility failed to ensure adequate supervision and assistance devices was provided for 1 of 3 residents reviewed for transfers (Resident #1). The facility failed to assess Resident #1 for safe transfer practices as she was non-weight bearing. This deficient practice has the potential to affect residents in the building who required extensive assistance which could result in residents having pain, falls or injuries. The findings included: Review of Resident #1's Resident Face Sheet, dated 10/24/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included heart failure, arthritis, dementia, muscle weakness, and limitation of activities due to disability. Review of Resident #1's Quarterly MDS Assessment, dated 8/12/24, revealed: She had a mental status score of 9 of 15 (indicating moderate cognitive impairment) She was dependent on staff for transfers from bed to chair. Review of current MDS did not indicate how many people were needed for transfers. Review of Resident #1's Care Plan, edited 9/6/24, revealed: Problem: Limited physical mobility related to osteoarthritis/disability. Short term goal: will remain free of complications related to immobility, including contractures, thrombus formation (formation of blood clots); skin breakdown, fall related injury through next review date. Long Term Goal: will maintain current level of mobility through review date. Identified approaches included: provide with supportive care, assistance with mobility as needed. Review of current Care Plan did not indicate how many people were needed for transfers. Review of current EHR revealed no assessment regarding transfers. On 10/24/24 at 3:47 p.m. revealed CNA A helped Resident #1 sit up without locking the wheels on resident's bed. CNA A raised the bed to above the level of the wheelchair, moved the wheelchair Page 1 of 3 675881 675881 10/24/2024 Avir at Pecos 1819 Memorial Dr Pecos, TX 79772

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few perpendicular to the bed and locked the wheelchair. Resident #1's feet did not touch the ground. CNA A placed the gait belt around Resident #1's waist and made sure it was tight enough. CNA A slid Resident #1 from the bed into the wheelchair while holding the gait belt. CNA A explained to Resident #1 what she was doing in Spanish the entire time. Interview on 10/24/24 at 4:05 p.m. CNA A stated Resident #1 could not bear weight and even when she did stand, she bent over completely. CNA A said Resident #1 was not a two-person transfer because she felt she could safely transfer Resident #1 on her own and there were times it was only her on the floor. CNA A stated she had told people she needed help and sometimes the nurses would help. CNA A said there were times she told the nurses that Resident #1 was non- weight bearing but nothing changed. Interview on 10/24/24 at 5:09 p.m. LVN B stated Resident #1 was non weight bearing. LVN B stated she thought one person could safely transfer Resident #1. LVN B stated she has performed a one-person transfer with Resident #1 in the past Interview on 10/24/24 at 5:27 p.m. the DON stated Resident #1 was weight bearing and was able to pivot. The DON stated a resident who was non-weight bearing was not safe to transfer with one person. The DON stated residents were assessed for transfer needs on admission, re-admission, and when the aides told the nurses that there was a change with residents ADL needs. The DON said they relied on the aides to tell the staff what a proper transfer was. The Regional Consultant who also present stated residents were assessed on admission, readmission, change of condition, and then usually when the MDS was done assessment needs were looked at. The Regional Consultant added they looked at transfer ability on therapy's recommendation and family request. The Regional Consultant stated the transfer ability was formally on the admission/re-admission assessment but nowhere else. The Regional Consultant stated there was not a form for a transfer ability assessment. Interview on 10/24/24 at 7:01 p.m. the MDS Coordinator stated Resident #1 was not weight bearing and as far as she knew Resident #1 was a one-person transfer. The MDS Coordinator stated she was unaware of a formal transfer assessment that the facility used. The Treatment Nurse who was also present stated she worked at the facility 20 years and was unaware of a formal transfer assessment they were just asked on admission and re-admission. Review of the facility's policy and procedure of Safe Lifting and Movement of Residents, revised February 2014, revealed: 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. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 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 assessments shall include: Resident's mobility (degree of dependency) 675881 Page 2 of 3 675881 10/24/2024 Avir at Pecos 1819 Memorial Dr Pecos, TX 79772

F 0689 - Level of Harm - Minimal harm or potential for actual harm Resident's size - Residents Affected - Few Weight bearing ability Cognitive status Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: Involves employees in identifying problem areas and implementing workplace safety and injury-prevention strategies. Continually evaluates the effectiveness of workplace safety and injury-prevention strategies. 675881 Page 3 of 3