Health inspection·September 28, 2023

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a MDS assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 3 of 7 (Resident #5, Resident #6, and Resident #7) reviewed for MDS information. Residents Affected - Some The facility failed to encode, complete, and submit a discharge MDS for Resident #5 and Resident #6. The facility failed to encode, complete, and submit a death in facility MDS for Resident #7. This deficient practice could place residents at risk of not having records completed and submitted to the CMS system in a timely manner as required. Findings included: 1.Record review of Resident #5's face sheet undated revealed an [AGE] year-old male that admitted to the facility on [DATE] and discharged on [DATE]. Record review of Resident #5's admission MDS dated [DATE], section Q0300 of the MDS revealed: 1. Expects to be discharged to the community. Record review of Resident #5's MDS assessment completion list did not reveal a Discharge MDS had been completed. 2. Record review of Resident #6's face sheet undated revealed a [AGE] year-old male that admitted to the facility on [DATE] and discharged on [DATE]. Record review of Resident #6's admission MDS dated [DATE], section Q0300 of the MDS revealed: 1. Expects to be discharged to the community. Record review of Resident #5's MDS assessment completion list did not reveal a Discharge MDS had been completed. 3. Record review of Resident #7's face sheet undated revealed a [AGE] year-old male that admitted to the facility on [DATE] and expired in facility on [DATE]. Record review of Resident #7's significant change MDS dated [DATE], section Q0400 of the MDS Page 1 of 13 675960 675960 09/28/2023 Castle Pines Health and Rehabilitation 2414 W Frank Ave Lufkin, TX 75904

F 0640 Level of Harm - Minimal harm or potential for actual harm revealed: A. Is active discharge planning already occurring for the resident to return to the community? Coded: No. Record review of Resident #7's MDS assessment completion list did not reveal a Death in Facility MDS had been completed. Residents Affected - Some During an interview on [DATE] at 9:04 AM with the MDS LVN, she said she had a scheduler built into the electronic health record. She did not know why Resident #5 and Resident #6 did not have a Discharge MDS or why Resident #7 did not have a Death in Facility MDS. The MDS LVN said that DON did not routinely manage her to ensure that resident MDS's were due or needed to be completed and submitted. She said she did MDS assessments per facility policy. She said there was also a list of opened assessments in the electronic health record. She said they had a corporate consultant that audits MDS completions. During an interview on [DATE] at 9:10 AM with the MDS RN, she said there was a built-in schedule that pops up in the electronic health record when MDS assessments were due. She said both the MDS LVN and MDS RN opened the discharge assessments. She said they both did the discharges together. The MDS RN said she did not know why those assessments were missed without looking. She said they completed assessments per their facility policy. She said discharge assessments should have been completed within 14 days of the event per the facility policy. During an interview on [DATE] at 9:30 AM with the DON, she said that she only signed MDS's if the MDS RN was out of the building. She said that she did not manage the MDS nurse to know if she had missed any resident's MDS's. She said she had to refer to the facility policy to know what MDS's should be completed and in what time frame they should be completed in. She said a death in facility assessment should be done within 14 days of the event date. She said she was not sure what the discharge assessment was used for and does not want to assume. During an interview on [DATE] at 9:45 AM with the Administrator, she said the purpose of the discharge MDS was to close out the resident's record. She said she would refer to the facility policy and it stated a death in facility should be completed within 14 days of the event. She said the policy does not address a discharge from facility assessment. She said there was a scheduler in the computer that the MDS nurses go by and there was a companywide MDS consultant that oversees and audits the MDS that were completed. She said most things in the electronic health record will turn red if not completed timely. The Administrator said she does not know why the MDS were not completed timely. Record review of the undated facility policy labeled Creative Solutions P&P MDS Transmission Reference Chapter 5 Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual undated revealed: Tracking Information Transmission: For Entry and Death in Facility tracking records, information must be transmitted within 14 days of the Event Date. Record review of the Resident Assessment Instrument Manual accessed on [DATE] at LONG TERM CARE FACILITY (cms.gov) revealed a Discharge Tracking Assessment was to be completed within 7 days of discharge. 675960 Page 2 of 13 675960 09/28/2023 Castle Pines Health and Rehabilitation 2414 W Frank Ave Lufkin, TX 75904

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #10) reviewed for quality of care in that: Residents Affected - Few Resident #10 did not receive neurological checks after an unwitnessed fall on 9/16/23. This failure could affect residents who sustain falls and place them at risk for head injury or decline in condition. The findings were: Record review of a facility face sheet for Resident #10 dated 9/28/23 indicated that he was a [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: convulsions (a type of seizure), pneumonia (infection in the lungs), Alzheimer's disease, and history of falling. Record review of Resident #10's MDS dated [DATE] indicated that he was unable to complete the interview for BIMS score and had severely impaired cognition. Question J1800 indicated that he had not had any falls since admission to the facility. Record review of Resident #10's care plan with revision date of 9/26/23 indicated that he was at risk for falls related to impaired cognition, impaired communication, impaired safety awareness, history of hip fracture, incontinence, opioid medication, antidepressant medication use, diagnosis of intellectual disability, and convulsions. Record review of a fall nurses note for Resident #10 dated 9/16/23 at 3:45 pm signed by LVN L indicated that resident sustained an unwitnessed fall on 9/16/23. Record review on a neurological assessment dated [DATE] at 3:45 pm indicated that a neurological assessment was done at that time for Resident #10. Record review of Resident #10's electronic medical record assessments tab indicated that another neurological assessment was due on 9/16/23, no time indicated, and was currently 11 days overdue and showing in red lettering indicating that it had not been completed. No further neurological assessments were done until 9/17/23 at 08:41 am, which indicated that Resident #10 had missed 11 neurological assessments from 9/16/23 to 9/17/23. During an observation on 9/27/23 at 1:00 pm Resident #10 was observed lying in bed sleeping. Resident did not rouse and speak when spoken to. Fall mat was noted on floor at bedside on resident's left side. Right side of bed was observed next to wall. Call light was in reach. During a joint interview on 9/27/23 at 10:00 am LVN F and LVN L both said that any unwitnessed fall should have neurological checks done due to the possibility that the resident could have hit their head. They said the schedule for neurological checks would automatically populate in PCC when the incident report was generated. They both said that the schedule for neurological checks was every 15 minutes X 4, every 30 minutes X 2, every hour X 2, and then every 8 hours. They both said that they 675960 Page 3 of 13 675960 09/28/2023 Castle Pines Health and Rehabilitation 2414 W Frank Ave Lufkin, TX 75904

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few did not utilize a specific document or flow sheet when providing care down the hall, but they both would write assessments down on a scratch piece of paper and just remembered when to do the assessments without having to rely on the computer to remind them. During an interview on 9/27/23 at 10:17 am, the DON said that any unwitnessed fall should have neurological checks done to assess for decline in condition and for head injury. During an interview on 9/27/23 at 12:30 pm, the DON said that nurses were aware of the schedule for neurological checks after a fall but that they did not have a specific policy stating the schedule. She said that in PCC each assessment would be triggered once the assessment scheduled before it was completed. She said that if an assessment were missed and not completed, the next one would not trigger, and it could throw the schedule off. She said that they did not have any kind of paper documentation or flow sheet to help the nurses remember to assess neurological checks while working down the hall and away from the computers. During an interview on 9/27/23 at 1:45 pm, LVN L said that there had been no baseline changes noted with Resident #10 from before his fall and that his condition today was the same as it was both before and after his fall. She said that sometimes he has a good day and might do better, but that most days he was the same as he was today and mostly nonverbal. During an interview on 9/27/23 at 1:50 pm, LVN J said that Resident #10 was still at the same level of functioning as he was the day of the fall on 9/16/23. She said that he would sometimes have a good day and be more active, but that being nonverbal and less active was his baseline. She said that she had noticed no changes in his functional abilities or cognitive status since the fall. During an interview on 9/28/23 at 9:00 am, the DON said that she knew the neurological assessments for Resident #10 had been missed and she would be conducting an in-service for nurses regarding this. She said that LVN M was a new nurse and did not have much experience, and just a lack of knowledge and not understanding the process on 9/16/23 after Resident #10 fell could have led to LVN M not completing the neurological assessments. She said that LVN M no longer worked at the facility. She said that she would be monitoring falls and risk management going forward and have meetings with day and evening shift nurses to ensure that all nursing staff were aware of expectations going forward. She said that residents could suffer a decline in condition resulting in injury and hospitalization if neurological assessments were not completed. Record review on 9/27/23 of a handwritten schedule provided by the DON indicated that neurological check schedule should be every 15 minutes X 4, every 30 minutes X 2, every hour X 2, every 2 hours X 2, and then every shift X 8. Management & Evidence-Based Best Practices dated 4/2023 read .After a fall: .the NF should investigate the fall, including: Check and document vital signs (with orthostatic vitals), symptoms, neuro exam . retrieved from https://www.hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/providers/long-term-care/qmp/qmp-fall-ris Record review on 9/28/23 of www.cdc.gov page titled Deaths from Fall-Related Traumatic Brain Injury United States, 2008-2017 read .Falls can cause serious injuries, including a traumatic brain injury (TBI). Unintentional falls represent the second leading cause of TBI-related death . retrieved from https://www.cdc.gov/mmwr/volumes/69/wr/mm6909a2.htm?s_cid=mm6909a2_w' 675960 Page 4 of 13 675960 09/28/2023 Castle Pines Health and Rehabilitation 2414 W Frank Ave Lufkin, TX 75904

F 0684 Level of Harm - Minimal harm or potential for actual harm Record review of a facility policy titled Neurological Checks dated 2003 with revision date of May 2016 read .Neurological checks are a combination of objective observations and measurements done to evaluated neurological status. The results of the checks assist to determine nervous system damage and/or deterioration . Residents Affected - Few 675960 Page 5 of 13 675960 09/28/2023 Castle Pines Health and Rehabilitation 2414 W Frank Ave Lufkin, TX 75904

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 the residents environment remained free from accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 3 of 5 residents (Residents #4, #8, and #9) reviewed for accidents, hazards, and supervision. 1.The facility failed to adequately supervise Resident #4 when being transferred. Resident #4 sustained a fracture of the proximal tibia (broken bone below the knee) when the Hoyer lift tipped over while being transferred with a Hoyer lift device (a mobility device with a U-shaped base and an overhead horizontal bar with hooks on top. A sling suspended by loops or metal clips attached to the overhead bar with hooks. The lift is used to lift and transport people who cannot safely walk or put weight on either leg) by CNA A on 09/07/23. 2. The facility failed to ensure that on 9/26/23 at 10:26 am CNA B and CNA C opened the legs to stabilize base of Hoyer lift during transfer of Resident #9 from geri-chair to bed. 3. The facility failed to ensure that on 9/26/23 at 11:36 am CNA D and CNA E opened the legs to stabilize base of Hoyer lift during transfer of Resident #8 from shower bed to geri-chair. An Immediate Jeopardy (IJ) was identified on 9/26/23 at 2:50 pm. The IJ template was provided to the facility on 9/26/23 at 3:01 pm. While the IJ was removed on 9/27/23, the facility remained out of compliance at a severity level of actual harm that is not an immediate jeopardy and scope of isolated due to the facility's need evaluate and monitor the effectiveness of corrective systems. These failures placed residents at risk of falls, fractures, and death. Findings include: 1. Record review of a face sheet dated 9/26/23 for Resident #4 indicated that he was a [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: nondisplaced fracture of right tibial tuberosity (fractures that occur in the bony prominence on the front of the tibia (shin bone) near the knee), Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), and multiple sclerosis (a potentially disabling disease of the brain and spinal cord (central nervous system). Record review of Resident #4's Annual Comprehensive MDS, dated [DATE], indicated that he had a BIMS score of 15, which indicated no cognitive impairment. The MDS further indicated the resident's functional status was a 3 for transfers which indicated he required extensive assistance and a 3 for support in transfers which indicated he required two or more persons assist. Record review of a care plan for Resident #4 with revision date of 10/9/20 read .requires total assist X 2 staff with use of Hoyer lift . Record review of a facility in-service sheet dated 8/17/23, titled read CNAs - get a gait belt and keep one on you. You must use a gait belt for transfers you assist with other than Hoyer lifts. 675960 Page 6 of 13 675960 09/28/2023 Castle Pines Health and Rehabilitation 2414 W Frank Ave Lufkin, TX 75904

F 0689 Hoyer lift transfer requires 2 people indicated that CNA A had signed the in-service sheet. Level of Harm - Immediate jeopardy to resident health or safety Record review of a nurses note for Resident #4 dated 9/7/23 at 10:45 am read Summoned to shower room by ADON [name] stating that resident was on the floor. This nurse entered shower room and observed resident lying on the floor in the middle of the shower room on his back. Resident assessed for injuries no apparent injuries noted. Resident c/o slight pain to right hip 3-10 and pain 7-10 to right knee. Resident refused to go to ER stating that he did not think he needed to go. Resident requested to be put back into his bed. This nurse 2 other nurses and shower tech assisted resident off the floor and back into his bed via mechanical lift. Report to [name], PA for Dr. [name] residents fall and refusal to go to ER. [Name] gave orders for mobile X-ray, 2 view of right knee and 2 view of right hip. [Name] imaging called, and orders placed for x-rays. RP and DON aware of incident and orders received. Signed by LVN G. Residents Affected - Few Record review of a witness statement dated 9/7/23 and signed by CNA A, read I, [name], CNA tried to transfer [name (Resident #4)] to his chair from the shower bed with the Hoyer lift. The Hoyer lift leg hit the shower bed leg and caused it to flip. I hurry hold the lift pad and put [name (Resident #4)] down on the floor to prevent from get hurt. I asked him if he hit his head, he said no. The accident was report. Record review of a nurses note for Resident #4 dated 9/7/23 at 2:10 pm read received x-ray results and impressions indicate possible Fx [fracture] to the left femur. Right knee is negative for any acute fractures this nurse reported findings to [name] PA for Dr. [name] and received new orders for 2 view x-ray of the left hip and femur. Resident continues to deny pain to bilateral hips and reports pain 5/10 to right knee. Signed by LVN G. Record review of a nurses note for Resident #4 dated 9/7/23 at 9:08 pm read Impression to left hip negative for Fx, [family member] and [name] PA notified of results signed by LVN H. Record review of a nurses note for Resident #4 dated 9/8/23 at 7:30 pm read Resident's RP [name] in facility, stated resident continued to have pain to RLE (right lower extremity). Noted slight swelling to leg, no redness or warmth noted. No bruising noted. Per RP request, resident to be sent to ER for eval and tx on 9/9/23 at 11 am. Refused transportation at this time, stated not this late. Transportation set up. Signed by LVN J. Record review of a nurses note for Resident #4 dated 9/9/23 at 11:00 am indicated that resident was transferred to ER at that time for MRI related to recent fall. Record review of hospital records for Resident #4 indicated that resident was admitted to the hospital on [DATE] at 2:46 pm with diagnosis of Impacted Fracture of proximal right tibia (A break in the shinbone just below the knee). Hospital course read .Patient was admitted with right knee pain. X-ray of the leg did not show any acute fractures although osteopenia was seen. He continued to have significant knee pain and MRI was done which showed impacted fracture of the proximal tibia which appears late acute/subacute. Orthopedics was consulted and did not recommend any acute surgical interventions. Non weight bearing, no range of motion and knee immobilizer was recommended for the next 4 to 6 weeks . Record review of a nurses note for Resident #4 dated 9/13/23 at 5:20 pm indicated that resident returned to facility at this time via ambulance transfer. 675960 Page 7 of 13 675960 09/28/2023 Castle Pines Health and Rehabilitation 2414 W Frank Ave Lufkin, TX 75904

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 2. Record review of a face sheet dated 9/26/23 for Resident # 9 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: seizures (sudden, uncontrolled movements), hypokalemia (low potassium levels in the blood), diabetes (uncontrolled blood sugars), and hypertension (high blood pressure). Record review of Resident #9's Comprehensive MDS dated [DATE] indicated that she was unable to complete the interview for a BIMS score, and she was severely cognitively impaired. The MDS further indicated the resident's functional status was a 3 for transfers which indicated she required extensive assistance and a 3 for support in transfers which indicated she required two or more persons assist. Record review of a care plan for Resident #9 with date of 10/26/22 read .mechanical lift with staff X 2 to assist with transfers . 3. Record review of a face sheet dated 9/26/23 for Resident #8 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: epilepsy (seizures), cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), and bradycardia (low heart rate). Record review of Resident #8's Comprehensive MDS dated [DATE] indicated that she was unable to complete the interview for a BIMS score, and she was severely cognitively impaired. The MDS further indicated the resident's functional status was a 3 for transfers which indicated she required extensive assistance and a 3 for support in transfers which indicated she required two or more persons assist. Record review of a care plan for Resident #8 with revision date of 9/8/23 read .requires X 2 staff participation with transfers via mechanical lift . During an observation on 9/26/23 at 10:26 am, Resident #9 was observed being transferred from Geri-chair to bed by CNA B and CNA C. CNA B pushed the lift under the resident's Geri chair and both CNAs placed the sling on the red straps in the lift. Resident was lifted out of the chair and rolled over to the bed with the lift legs closed. The lift legs were rolled under the bed and the resident was lowered to the bed. During a joint observation and interview on 9/26/23 at 11:10 am, the Administrator and DON both said that Resident #4 was not actually in the shower when he fell, but in the common area of the room where transfers occurred. Observation of the shower room showed that there were multiple showers off one common open room for residents to transfer from shower beds or shower chairs to their regular chairs or beds. DON said that resident was found on floor in this common room after the fall while being transferred from the shower bed to his chair. During an observation on 9/26/23 at 11:36 am, Resident#8 was observed being transferred in the shower room from shower bed to Geri chair by CNA D and CNA E. CNA D moved the lift under the shower bed, the sling was attached at the green strap. Resident was lifted off the bed and CNA D pulled the lift back with resident in the air. Resident was pushed across the room with the lift. CNA D was in the process of pushing the lift under the Geri chair when LVN F opened the door to ask the CNA a question and said, make sure the legs are open. CNA D then opened the legs on the lift to the widest position. The resident was then lowered into the Geri chair. During an observation and interview on 9/26/23 at 1:20 pm, Resident #4 was observed up in a mechanical wheelchair with a Hoyer lift sling underneath him. Knee immobilizer was in place on right knee, 675960 Page 8 of 13 675960 09/28/2023 Castle Pines Health and Rehabilitation 2414 W Frank Ave Lufkin, TX 75904

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few with obvious swelling noted. He said that on the day that he fell, he was being transferred from the shower bed to his wheelchair and something went wrong with the leg on the lift, he was unsure what occurred, but the lift tilted over, and the bars were on his stomach and his leg/knee. He said that he believed that was how the fracture occurred. He said that the bars were very heavy and uncomfortable until they got them off him and got him up. He said he was immediately put back to bed with a lift and there were several staff members using the lift at the time they put him to bed after the fall. He said that the nurses looked over him well and tried to get him to go to the ER, but he did not think he needed to go at that time. He said he continued hurting despite pain medications and he did go to the ER a couple of days later. He said that CNA A had been caring for him for years and had always done the transfers by herself. He said that he did not know to tell her to get another staff member to transfer him. He said that he had an appointment tomorrow with an orthopedic doctor. He said that he would never allow any staff to transfer him without 2 people anymore because he was too nervous and afraid that something else might happen. During an interview with Resident #4's family member on 9/25/23 at 3:45 pm, she said that she was notified of the fall from the Hoyer lift on the day it occurred. She said that she could not remember what time she was notified, but that she had no issues with the way the facility handled it. She said that he seemed fine after the fall, but the next day started complaining of knee pain. She said that she did not want him sent out that day because it was too late but had him sent to the ER on Saturday 9/9/23. She said that the ER went back and forth over whether his leg was broken, but he ended up being admitted for a UTI. After admission, she said that they did tell her it was broken. A knee immobilizer was placed, and he would see an orthopedic doctor in the next couple of days. She said that it was her understanding that the employee was suspended pending investigation due to the accident and that she understood that the employee no longer worked here. She said that Resident #4 had multiple sclerosis and had been there about 7 years. During an interview on 9/26/23 at 9:20 am, the Administrator said that CNA A had been suspended and terminated after the incident with Resident #4 and was no longer employed by the facility. She said that CNA A and all other nursing staff had been in-serviced regarding using 2 people for Hoyer lift transfers immediately after the fall. During an attempted telephone interview on 9/26/23 at 10:36 am with CNA A, phone went to message that said not accepting calls at this time and there was no option to leave voicemail. During an interview on 9/26/23 at 10:38 am, CNA C said that she had been in-serviced on mechanical lift transfers but was not sure when. She said she got distracted by the other resident in the room yelling out cuss words while they were transferring Resident #9 and was just nervous and forgot to open the legs of the lift. She said the purpose of opening the legs on the lift was to allow more room to put the resident in the chair or bed. She said there must always be 2 people in the room to do a transfer with the lift. She said that she had been working as a CNA at the facility for about 3 years. During an interview on 9/26/23 at 10:40 am, CNA B said that she had been in serviced about doing transfers with a lift about a month ago. She said she was always supposed to have two people. She said she forgot to open the legs on the lift because the other resident in the room had said a cuss word that had distracted her while they were transferring Resident #9. She said she knew the legs were supposed to be open to help balance the lift. During an interview on 9/26/23 at 10:58 am, CNA K said that she was in serviced on Hoyer lifts upon 675960 Page 9 of 13 675960 09/28/2023 Castle Pines Health and Rehabilitation 2414 W Frank Ave Lufkin, TX 75904

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few hire, and she was hired 1 ½ years ago. She said there was always supposed to be 2 people for all Hoyer lift transfers. During an interview on 9/26/23 at 11:05 am, the Administrator said that she did not have another telephone number for CNA A. During an interview on 9/26/23 at 11:38 am, CNA E said she was in serviced about a month ago. She said she normally opened the legs of the lift and does not know why CNA D didn't open the legs. She said the purpose of opening the legs was for easier access to get the legs around the Geri chair. During an interview on 9/26/23 at 11:42 am, CNA D said she had worked at the facility for 1 year. She said she was in serviced on Hoyer lifts about a week ago. She said they were always supposed to have 2 people in the room for a Hoyer lift transfer. She said she did not open the legs on the lift all the way because the way things were arranged in the shower room, she couldn't maneuver the lift with the legs open. She said when she got the resident over the Geri chair that was when she opened the legs on the lift to fit around the Geri chair properly. During an interview on 9/26/23 at 1:05 pm, LVN F said when she walked into the shower room, from where she was standing it did not look like the legs to the lift were open. She said that was why she told CNA D to make sure the legs of the lift were open. She said they had just received an in-service about a week ago regarding Hoyer lifts. During an interview on 9/27/23 at 3:30 pm, the DON said that the legs of the Hoyer lift should be opened to provide stability to the lift to prevent it from tipping over. She said that the CNAs should have opened the legs on the base of the lift while moving resident. She said that she would be in-servicing staff and expected her staff to always use at least 2 people for Hoyer transfers and to have the legs open for stability. She said that improper Hoyer transfers could put residents at risk for injury, falls, and fractures. She said she had in-serviced staff after the fall with Resident #4, and she was ultimately responsible for training CNAs on proper transfers. She said that CNAs were supposed to check the [NAME] for proper methods to transfer residents and she would be doing more in-services with them. Record review of a facility policy titled Hydraulic Lift, undated read .8. Prepare the lift by setting the adjustable base to its widest position . This was determined to be an Immediate Jeopardy (IJ) on 9/26/23 at 2:50 pm. The Administrator and DON were notified. The Administrator was provided with the IJ template at 3:01 pm. The following Plan of Removal submitted by the facility was accepted on 9/27/23 at 8:11 am and included the following: Interventions: * Suspend and terminate CNA A, 9-7-23. * Disciplinary action given for CNA B,C,D,E 9-26-23 by Administrator/HR * 1on1 Hoyer transfer training with return demonstration given to CNA B,C,D,E by DON/ADON/Therapy on 9-26-23 3:15pm 675960 Page 10 of 13 675960 09/28/2023 Castle Pines Health and Rehabilitation 2414 W Frank Ave Lufkin, TX 75904

F 0689 * MD notified of IJ 9-26-23 at 3:15pm Level of Harm - Immediate jeopardy to resident health or safety * Ad hoc QAPI held with Medical Director 9-26-23 4:30pm * All residents were assessed and evaluated for transfer assistance by DON/ADON/MDS/Therapy 9-26-23 4pm Residents Affected - Few * All resident care plans reviewed for accuracy of transfer assistance by MDS 9-26-23 4pm. * All nursing staff checked off on mechanical lift transfers by DON/ADON/Therapy 9-26-23 6:05pm Any staff member not present or in-serviced will not be allowed to assume their duties in providing Hoyer transfer until in-serviced. The following in-services were initiated by Admin/DON on .9/26/23 at 3:15pm. Any direct care staff not present or in-serviced will not be allowed to assume their duties until in-serviced. * Hoyer transfer x 2 staff, prepare lift by setting base to widest position to transfer by DON/ADON/Therapy/MDS 9-26-23 4pm, any staff member not present or in-serviced will not be allowed to assume their duties in providing Hoyer transfer until in-serviced. * How to use the [NAME] in PCC to determine the transfer status of a resident 9-26-23 4pm By DON/MDS/ADON/Designee * Following the care plan interventions including how much staff and the proper equipment required for transfers by DON/MDS/ADON/Designee 9-26-23 4pm * If unable to provide the required staff or equipment to perform a transfer, do not perform until staff are available by DON/ADON/MDS/Designee 9-26-23 4pm * If the required number of staff or equipment is not listed for transfers, contact the Charge Nurse, ADON, and or DON immediately by DON/ADON/MDS/designee 9-26-23 4pm Observations, interviews, and record reviews were conducted on 9/27/23 from 2:00 pm to 4:20 pm and included (Administrator, DON, ADON, 3 LVN's, 3 MA's, and 8 CNA's) to ensure these interventions had been completed. Record review of an employee disciplinary report dated 9/15/23 indicated that CNA A was terminated on 9/15/23. Record review of 4 employee disciplinary action request forms dated 9/26/23 indicated that CNAs B, C, D, and E were disciplined with written counseling on 9/26/23 for failure to follow hydraulic lift policy and procedure. Record review of an in-service training sheet with check off sheets indicated that CNAs B, C, D, and E were trained on Hydraulic Lift policy and procedure and were checked off on 9/26/23. Record review of the ad hoc QAPI form indicated that MD was notified of IJ on 9/26/23 at 3:15 pm. Record review of a sign in sheet indicated that ad hoc QAPI was held with Medical Director on 675960 Page 11 of 13 675960 09/28/2023 Castle Pines Health and Rehabilitation 2414 W Frank Ave Lufkin, TX 75904

F 0689 9/26/23 at 4:30 pm. Level of Harm - Immediate jeopardy to resident health or safety Record review of the attestation form dated 9/26/23 indicated that all residents were assessed and evaluated for transfer assistance by DON/ADON/MDS/Therapy on 9/26/23 at 4:00 pm. Residents Affected - Few Record review of the attestation form dated 9/26/23 indicated that all resident care plans had been reviewed for accuracy of transfer assistance by MDS on 9/26/23 at 4:00 pm. Record review of the skills check off sheets indicated that 60 staff members had been checked off with return demonstration on mechanical lift transfers on 9/27/23 at 4:00 pm. Record review of a facility in-service sign-in sheet titled Hydraulic Lift policy and procedure x 2 staff; prepare lift base to widest position indicated that 49 staff members had been in-serviced as of 9/27/23 at 4:00 pm. Record review of a facility in-service sign-in sheet titled [NAME] training for CNAs. Instructed how to access the [NAME] through POC Kiosk for every resident. [NAME] has to be accessed for every resident to determine the requirements of staff when performing care including transfers, bed mobility, dressing, toileting, bathing, eating. The [NAME] also provides information on the method the resident requires for transfers indicated that 45 staff members had been in-serviced as of 9/27/23 at 4:00 pm. Record review of a facility in-service sign-in sheet titled Accessing CP, CP information pulls the [NAME]. [NAME] training for CNAs. Instructed how to access [NAME] for each resident. [NAME] has to be assessed for every resident to determine the requirement for staff when performing care including transfers, bed mobility, dressing, toileting, bathing, and eating The [NAME] also provides information on the method the resident requires for transfers indicated that 14 CNAs had been in-serviced as of 9/27/23 at 4:00 pm. Record review of a facility in-service sign-in sheet titled if unable to provide the required staff or equipment to perform tasks/transfer, do not perform until staff x 2 are available. DO NOT RUSH indicated that 45 staff members had been in-serviced as of 9/27/23 at 4:00 pm. Record review of a facility in-service sign-in sheet titled if the required number of staff or equipment is not listed for transfers, contact charge nurse, ADON, or DON immediately indicated that 46 staff members had been in-serviced as of 9/27/23 at 4:00 pm. Nursing staff were able to appropriately indicate they would only transfer residents using a Hoyer lift if there were at least 2 persons to assist and would only transfer residents with the base open to its widest position. Nursing staff were able to identify resident's care plans, the [NAME] system and how to find required level of resident care. CNAs and MAs were able to demonstrate the use of the Kiosk system to find resident care needs. The following staff from day and evening shift were able to verbalize and demonstrate understanding of all in-services given: 675960 Page 12 of 13 675960 09/28/2023 Castle Pines Health and Rehabilitation 2414 W Frank Ave Lufkin, TX 75904

F 0689 MA S on 9/27/23 at 2:00 pm Level of Harm - Immediate jeopardy to resident health or safety CNA O on 9/27/23 at 2:00 pm Residents Affected - Few CNA K on 9/27/23 at 2:15 pm CNA N on 9/27/23 at 2:05 pm LVN J on 9/27/23 at 2:20 pm ADON on 9/27/23 at 2:22 pm MA L on 9/27/23 at 2:25 pm MA M on 9/27/23 at 2:30 pm LVN H on 9/27/23 at 2:30 pm CNA P on 9/27/23 at 2:40 pm CNA Q on 9/27/23 at 2:45 pm CNA U on 9/27/23 at 3:10 pm CNA R on 9/27/23 at 3:15 pm CNA T on 9/27/23 at 3:20 pm The Administrator was informed that the Immediate Jeopardy was removed on 9/27/23 at 4:20 pm. The facility remained out of compliance at a severity level of actual harm that is not an immediate jeopardy and scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 675960 Page 13 of 13