Health inspection·December 1, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 12 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1 was transferred with the appropriate number of qualified staff required when using a mechanical lift. This failure could place the residents at risk of injury by not following the resident's care plan and clinical standards of practice. Findings included: Record review of Resident #1's electronic health record reflected a [AGE] year-old female, with an admission date of 04/08/202. Resident #1 had diagnoses which included: Generalized anxiety disorder (excessive persistent worry about everyday things), Muscle wasting and atrophy (thinning or loss of muscle tissue), Rheumatoid arthritis (autoimmune disease causing swelling, pain and stiffness of joints), Lack of Coordination, Sequelae Cerebral Infarction (physical, cognitive, & emotional impairments such as one-sided weakness or paralysis, speech problems, memory problems), Hypomagnesemia (low magnesium in the blood causing weakness, seizures, muscle cramps), Vascular Dementia with mood disturbance (decline in cognition due to reduced blood flow to the brain and can include depression, irritability or sudden anger), Schizoaffective Disorder (condition combining schizophrenia such as hallucinations and disorganized thinking, and mood disorder like bipolar or depression), End stage renal disease (kidney failure and can no longer perform their function). Resident #1 had a BIMS of 09, which indicated moderate cognitive impairment. Record review of Resident #1's electronic health record reflected the most recent Care Plan, dated 09/11/25, date initiated 02/02/2021, revealed, transferring: requires staff x2 for assistance use [mechanical lift]. Record review of Resident #1's electronic health record reflected the MDS dated [DATE], Section GG, Chair/bed-to-chair transfer requires 01-Dependent- Helper does all 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. Record review Resident #1's electronic health record reflected the MDS dated [DATE], Section GG, Chair/bed-to-chair transfer requires 01-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. In an observation on 11/29/25 at 3:12 p.m., CNA A wheeled a mechanical lift out of Resident #1's room and placed it against the wall and walked back into Resident #1's room. CNA A rolled Resident #1 to her side towards CNA A's body and removed the sling from under Resident #1. No other staff member was in the room. Resident #1 did not have any injuries noted. In an interview on 11/29/25 at 3:12 p.m., CNA A stated she transferred Resident #1 from her wheelchair to the bed with the mechanical lift on her own because Resident #1 wanted to lay down. CNA A stated it was her first day at the facility and she was orientating. She stated she had not been trained on mechanical lift transfers by the facility. CNA A stated she had been a Page 1 of 3 676121 676121 12/01/2025 Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few CNA for 20 years and she knew there were supposed to be two people to use a mechanical lift to transfer a resident. CNA A stated everyone was busy and the staff she was supposed to be orientating with, CNA B, was down the hall changing other patients because the previous shift did not change their patients. She stated she took it upon herself to transfer Resident #1 with the mechanical lift, and she did not ask anyone for help with the transfer. CNA A stated Resident #1 was not injured. When asked how the residents could be affected, CNA A stated when a facility was short staffed, staff did one-person mechanical lift transfers and nothing bad happened to the residents. In an interview on 11/29/25 at 4:57 p.m., Resident #1 stated staff used a mechanical lift to transfer her. She stated CNA A transferred her by herself with the mechanical lift, but she did not get hurt. Resident #1 stated she did not remember how many people the staff used normally but she has never been hurt during a transfer. In an interview on 11/29/25 at 5:28 p.m., LVN C stated she was CNA A's direct supervisor, and she was in the dining room talking to a resident when CNA A transferred Resident #1. She stated she was not aware CNA A needed assistance with Resident #1, and she had not been asked to help. LVN C stated staff knew where she was and knew the expectation was to use two people to transfer a resident with a mechanical lift. LVN C stated she did not know where CNA B was at the time of the incident. In an interview on 11/29/25 at 6:00 pm, LVN D stated she did not know CNA A was transferring Resident #1 with a mechanical lift by herself and she had not asked her for any assistance. LVN D stated she did not know where CNA B was at the time of the incident. In an interview on 11/29/25 at 6:07 p.m., CNA B stated she was trained on mechanical lift transfers by the facility. She stated she was orientating CNA A since 6:00 a.m. that morning. CNA B stated she was in the bathroom at the time of the incident, and she told CNA A she was going to the bathroom and then they would put Resident #1 down together. CNA B stated her, and CNA A had done mechanical lift transfers together during the shift and CNA A knew she was supposed to wait and use two people to transfer with a mechanical lift. CNA B stated she was not sure why CNA A transferred Resident #1 without a second person other than they were busy because one staff came in late and a second staff did not take good care of the residents, so she assisted those residents as well as her assigned residents. In an interview on 11/29/25 at 7:00 p.m., HR stated CNA A had not yet been trained on mechanical lift transfers by the facility. HR stated today was CNA A's first day working on the floor and staff had 14 days before all training had to be completed. She stated CNA A was orientating today, and her and CNA B knew they were to work together. In an interview on 11/29/25 at 7:56 p.m., Resident #4 stated he was a mechanical lift transfer, and they always used two, sometimes three, people to operate and transfer him with the mechanical lift. He stated he felt safe and had not been hurt during a mechanical transfer. In an interview on 11/30/25 at 11:13 a.m., Resident #6 stated staff use a mechanical lift to get her up and put her back down in bed. She stated the staff used two or three people for mechanical transfer her and she had not been hurt. In an interview on 11/30/25 at 1:29 p.m., CNA E stated she had been trained on mechanical lift transfers upon hire by the facility. She stated to always use at least two people but to also follow the care plan and to use as many people as needed to make the residents comfortable. In an interview on 11/30/25 at 8:42 p.m., the mechanical lift manufacturer's recommendations were requested from the ADM. This was not provided by exit from the facility. In an interview on 12/01/25 at 1:30 p.m., the DON stated all staff knew to use two people and follow the care plan on mechanical lift transfers. Staff were trained upon hire and were in-serviced regularly. The DON stated CNA A was removed from the floor and suspended and not sure if she was going to be able to return as she had 20 years' experience. The DON stated there was no resident harm and this type of incident was not tolerated because it could cause injury to the resident if the mechanical lift tipped or 676121 Page 2 of 3 676121 12/01/2025 Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few something went wrong. The DON stated CNA A should have asked a nurse for help or waited on the other aide for help. In an interview on 12/01/25 at 2:05 p.m., the ADM stated staff were trained on mechanical lift transfers when hired and that was why they were orientated. The ADM stated she did not feel there was any reason to ever transfer a resident with a mechanical lift with one person, and it was not what was allowed at the facility. She stated CNA A should have waited for CNA B or went and asked a nurse for assistance before completing the transfer. The ADM did not state why this is important. Record review of Nursing Direct Care message from the ADM, dated 11/29/25 at 3:19 p.m., reflected Whenever you are transferring a resident, always follow their individualized plan of care. For example, if the care plan requires a two-person assist, ensure that two staff members are present. If a mechanical lift is indicated, use the mechanical lift with two staff members as directed. Adhering to these guidelines ensures the safety of both the residents and the staff. Do not attempt to transfer a resident alone if the care plan specifies the use of a mechanical lift. Mechanical lift must always be used with two trained staff members.Record review of the facility's, undated, Comprehensive Care Planning policy, reflected The services provided or arranged by the facility, as outlined by the comprehensive care plan, will meet professional standards of quality. ‘Professional standards of Quality' means that care and services are provided according to accepted standards of clinical practice. Record review of the facility's, undated, Hydraulic Lift policy reflected the number of staff to provide assistance with the transfer should be determined by the manufacturer's recommendations. Record review of OSHA Nursing Home Guidelines reflected in Figure 1 Transfer to and from bed to chair, chair to toilet, chair to chair, or car to chair: If patient is uncooperative or if patient does not have upper extremity strength to use full body sling lift and 2 caregivers. Record review of the FDA Patient Lifts Safety Guide recommended most lifts require two or more caregivers to safely operate lifts and handle a patient. 676121 Page 3 of 3