Health inspection·October 7, 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 provide assistance devices and adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents. The facility failed to ensure CNA A utilized a gait belt and had assistance from another staff member during a bed to wheelchair transfer on 11/19/24 which resulted in Resident #1 having a fall and complaints of pain. Resident #1 was sent to the local hospital emergency room where she was found to have fractured neck bones. She was care flighted to another hospital out of town for surgery to the neck. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 11/19/24 and ended on 12/05/24. The facility had corrected the noncompliance before the investigation began.This failure could place residents at risk for falls resulting in injury, pain, hospitalization, and possible death. Findings included:Record review of a face sheet dated 05/19/25 indicated Resident #1 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included kidney failure (condition where the kidney reaches advanced state of loss of function), gastrointestinal hemorrhage (bleeding from the small intestine or large intestine), gastroenteritis (inflammation that spreads from your stomach into your intestines), colitis (inflammation in the colon), pain, anemia (not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), osteoarthritis (a degenerative joint condition that causes pain, stiffness, and inflammation), depression (mental illness that negatively affects how you feel, the way you think and how you act), hypertension (a condition in which the force of the blood against the artery walls is too high), and chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe).Record review of a care plan initiated on 11/06/24 indicated Resident #1 required transfer assistance by 2 staff.Record review of the admission MDS dated [DATE] indicated Resident #1 cognitively intact with a BIMS of 15 out of 15. She was dependent ( Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.) for chair/bed-to-chair transfers. She was 71 inches tall (5 foot 11 inches) and 229 pounds.Record review of Resident #1's progress notes indicated:* an entry dated 11/19/24 at 10:30 a.m. At 07:08 a.m. LVN B was notified of resident being on the floor by bedside by CNA A. Resident was noted on floor by the window on her left side. Resident said she fell face first (forward) laceration and redness noted on the bridge of her nose. Further assessment indicated a laceration to the left upper extremity. Resident was provided a pillow to rest head on to wait for EMS. EMS arrived around 07:15 a.m. Resident asked to get up complained of pain to the left upper extremity, right lower extremity, and crook in neck; and nausea. LVN B assist with board onto stretcher.* an entry dated 11/19/24 at 01:02 p.m. indicated LVN B was informed by Resident #1's RP resident was being transferred to another hospital due to neck fracture (C1-C2) from the fall this morning. LVN B also called the hospital emergency room and a diagnosis of neck fracture was given.Record review of the facility's Page 1 of 4 676109 676109 10/07/2025 Calder Woods 7080 Calder Beaumont, TX 77706

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few investigation report dated 11/26/24 indicated on 11/19/24 Resident #1 had a fall and had initial signs of a laceration to her nose. Resident #1 was having significant pain and EMT's isolated her neck with a collar then transferred her by board to stretcher. The Administrator and DON interviewed CNA A. CNA A explained that she transferred Resident #1 from the bed to the chair, with one assist per plan of care. CNA A said Resident #1 leaned forward. CNA A was unable to stabilize the resident and she fell forward to floor. The investigation indicated that a gait belt was not in use at time of transfer. Resident #1 received a C-1 and C-2 fracture and will be required to wear a neck brace for a period of time. During an interview on 10/06/25 at 03:56 p.m. LVN B said she was coming on shift when the incident involving Resident #1 occurred. She said CNA A called and said she needed assistance to transfer Resident #1 so she and the night shift nurse went down to the room and Resident #1 was on the floor. She said CNA A said Resident #1 started falling and she tried to catch her. LVN B said Resident #1 had a cut on her nose. LVN B said Resident #1 complained of pain so EMS was contacted to send her to the hospital. LVN B said Resident #1 complained of pain to her neck when EMS arrived so they put a cervical collar on her. LVN B said she was contacted by Resident #1's family that she was being care flighted to another hospital due to a broken neck. She said Resident #1 usually was a 2-person transfer. She said a gait belt should always be used with 1 or 2 person transfers. During an interview on 10/06/25 at 04:32 p.m., the ED said CNA A was transferring Resident #1 without using the gait belt and a second staff on 11/19/24. She said Resident #1 fell forward hitting her face. She said the resident complained of pain and was sent to the local hospital emergency room. She said the family notified the facility the resident was being sent to another hospital because her neck was broken. She said CNA A was suspended from 11/19/24 through 11/26/24 and allowed to return to work after she received 1:1 training on gait belt use and transferring residents. She said all staff were trained on transfers with gait belt when hired. During an observation and interview on 10/07/25 at 02:25 p.m. Resident #1 was in her room sitting up in her chair. She was clean, neatly groomed, and had no offensive odors. She was not able to turn her head completely to the left to look at surveyor. She was not wearing a collar at the time. She said she was doing fine. She said the girl was helping her to go to the bathroom and she fell hurting her neck. She said she only had to wear the collar sometimes especially if she was riding in a vehicle. She said there are 2 staff that help her transfer and they put a belt on her. Record review of a Procedural Guideline #39-Assisting Resident to Transfer to Chair or Wheelchair revised 01/22 indicated 1. Purpose: To transfer resident to chair or wheelchair without trauma or avoidable pain. 2. Guidelines and Precautions for Moving an Lifting Residents:.C. Request assistance as needed prior to the move and use good body mechanics.4. Assisting Resident to Transfer to Chair or Wheelchair using Transfer Belt:.B. Show the resident the transfer belt and explain its use as a safety device. C. Apply the transfer belt over the resident's clothing around the waist and check the fit by inserting your fingers under it.E. Grasp the transfer belt with an under-hand grip and move the resident forward so his or her feet are flat on the floor.The surveyor attempted to contact CNA A for an interview on 10/07/25 10:45 a.m. There was a provider message saying the customer you are trying to reach was either restricted or unavailable. Surveyor was not able to leave a message for the CNA. On 10/07/25, the surveyor confirmed the facility implemented appropriate measures to ensure the safety of residents after the incident on 11/19/24 involving Resident #1 by: Record review of an Educational Summary Report dated 11/19/24 indicated staff were in-serviced regarding transfers and gait belt use.Record review of an In-Service Training Report dated 11/25/24 indicated staff were in-serviced regarding transfers and gait belt use.Record review of an In-Service Training Report dated 11/26/24 indicated CNA A had 1:1 training regarding transfers and gait 676109 Page 2 of 4 676109 10/07/2025 Calder Woods 7080 Calder Beaumont, TX 77706

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few belt use. Record review of an In-Service Training Report dated 12/05/24 indicated staff were in-serviced regarding transfers and gait belt use.Record review of Proficiency Trainings provided to staff upon hire and annually which included training on Transferring Residents, Use of Gait Belt with Transfers, and Abuse and Neglect.Record review of Proficiency Trainings provided to staff upon hire after the incident on 11/19/24 which included training for transfers and gait belt use received by MA E; CNA F and CNA G; and LVN C and LVN D. Record review of an In-Service on 11/19/24 after the incident on 11/19/24 included training for transfers and gait belt use received by LVN H, CNA J, CNA K, CNA L, CNA M, and CNA N.Record review of an In-Service on 11/25/24 after the incident on 11/19/24 included training for transfers and gait belt use received by CNA M, CNA N and CNA O.Record review of an In-Service on 12/05/24 after the incident on 11/19/24 included training for transfers and gait belt use received by LVN H, CNA J, CNA M, CNA N and CNA O.During an interview and record review on 10/06/25 at 02:16 p.m. indicated the Incident log from 11/19/24 through 10/07/25 there were 6 falls with injuries but only one of the falls with injury resulted in a fracture, Resident #1's fall. The DON said the other 5 injuries were bruises, abrasions, and skin tears. Observation of staff with transfer of Resident #2 on 10/06/25 at 02:34 p.m. indicated staff used 2 person for transfer and a gait belt was used. There were no observed concerns with transfer assistance. During an interview on 10/06/25 at 01:18 p.m. CNA J, CNA K, CNA L, CNA O, and CNA P said they worked the 06:00 a.m. to 06:00 p.m. shift. They said they were trained on gait belt use and transfers. They verbalized understanding of how to use the gait belt during a transfer. They said a manual transfer was 1 or 2 person depending on the residents' needs. During an interview on 10/06/25 at 01:35 p.m. LVN R said she was an agency nurse, She said she filled in 06:00 a.m. to 06:00 p.m. and 06:00 p.m. to 06:00 a.m. shifts at times. She said she received training on transfers and gait belt use with her staffing agency. She said all residents with manual transfers with 1 or 2 staff were to use a gait belt. She said she could find the information as to how many staff were needed to transfer a resident by looking in the resident chart or she could ask the staff working with the residents. During an interview on 10/06/25 at 01:45 p.m. MA E said she received training when hired on transfers and using a gait belt. She verbalized understanding of how to use the gait bet and how to properly transfer a resident using 1 or 2 staff members.During an interview on 10/06/25 at 03:56 p.m. LVN B said she received training on transfers and using a gait belt a couple of times after the incident on 11/29/24. She verbalized understanding of how to use the gait bet and how to properly transfer a resident using 1 or 2 staff members. During a phone interview on 10/07/25 at 07:00 a.m. LVN D said she received training when hired on transfers and using a gait belt. She verbalized understanding of how to use the gait bet and how to properly transfer a resident using 1 or 2 staff members.During a phone interview on 10/07/25 at 07:06 a.m. CNA N said she received training on transfers and using a gait belt several times after the incident on 11/29/24. She verbalized understanding of how to use the gait bet and how to properly transfer a resident using 1 or 2 staff members.During a phone interview on 10/07/25 at 07:07 a.m. CNA M said she received training on transfers and using a gait belt several times after the incident on 11/29/24. She verbalized understanding of how to use the gait bet and how to properly transfer a resident using 1 or 2 staff members.During a phone interview on 10/07/25 at 07:13 a.m. LVN C said she received training when hired on transfers and using a gait belt. She verbalized understanding of how to use the gait bet and how to properly transfer a resident using 1 or 2 staff members.During a phone interview on 10/07/25 at 07:35 a.m. CNA F said she was trained when hired on transfers and using a gait belt. She verbalized understanding of how to use the gait bet and how to properly transfer a resident using 1 or 2 staff members.During a phone interview on 10/07/25 at 10:50 a.m. CNA Q said she 676109 Page 3 of 4 676109 10/07/2025 Calder Woods 7080 Calder Beaumont, TX 77706

F 0689 Level of Harm - Immediate jeopardy to resident health or safety received training on transfers and using a gait belt several times after the incident on 11/29/24. She verbalized understanding of how to use the gait bet and how to properly transfer a resident using 1 or 2 staff members.The noncompliance was identified as PNC. The Immediate Jeopardy began on 11/19/24 and ended on 12/05/24. The facility had corrected the noncompliance before the investigation began. Residents Affected - Few 676109 Page 4 of 4