Health inspection·October 6, 2023

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, through past non-compliance, to implement an intervention to reduce the risk of a fall for 1 of 17 Residents (Resident #1) in that: Resident #1 sustained a fall with injuries while being transferred by CNA-C who did not use a gait belt during the resident transfer. This failure could place residents at risk for their safety needs not being met with unsafe transfers. The findings included: Record review of Resident #1's face sheet, dated 10/5/23 ,revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease unspecified (a group of lung diseases that block air flow and make it difficult to breathe), heart failure unspecified (a condition in which the heart is unable to pump blood correctly), and acute kidney failure unspecified (a disease in which the kidney is unable to remove waste and balance fluids). Record review of Resident #1's care plan, dated 2/5/23, revealed the resident was a fall risk for gait and mobility. Record review of Resident #1s MDS assessment, dated 2/8/23, revealed the resident's transfers required a one person assist with extensive assistance needed. Record review of the most recent CNA competencies skills checklist for CNA-C dated 4/25/22 revealed competency attainment in resident transfers using a gait belt. Record review of fall incident report dated 3/17/23, completed by ADON-B, for Resident #1 who was being transferred into her wheelchair by CNA-C noted Resident #1 sustained injuries as a result of the fall including: laceration on her scalp, an abrasion on her right upper arm, a skin tear on the back of her left hand, and a skin tear on her left lower leg. The size parameters of the various injuries was not noted. Record review of undated statement from CNA-C regarding the fall of Resident #1 on 3/17/23 revealed Resident #1 was being transferred from her recliner to the wheelchair by CNA-C who was completing the transfer without the use of a gait belt. Page 1 of 2 676138 676138 10/06/2023 The Heights of Gonzales 701 N Sarah Dewitt Gonzales, TX 78629

F 0689 Level of Harm - Minimal harm or potential for actual harm During an observation on 10/5/23 at 1:25pm revealed CNA-D transferring Resident #2 in her room from bed to wheelchair using a gait belt with proper technique. During an observation on 10/5/23 at 1:36pm revealed CNA-E transferring Resident #3 in her room from bed to wheelchair using a gait belt with proper technique. Residents Affected - Few During an interview on 10/5/23 at 2:15pm the DON revealed that CNA-C did not use a gait belt during the transfer of Resident #1 on 3/17/23 from her recliner to her wheelchair. The DON stated that the gait belt should have been used to help prevent the fall. She stated that nursing administration does random checks on all shifts for gait belt usage compliance; she stated that staff have been in-serviced on gait belt usage and showed surveyor a storage room which contained new gait belts for staff use. The DON stated that gait belts are used by CNA staff on all resident transfers. The DON stated that CNA-C was suspended at the time of the resident fall on 3/17/23 and did not return to work due to termination. During an interview on 10/5/23 at 2:30pm the Administrator stated that CNA staff use gait belts on resident transfers and that CNA-C did not return to work after the 3/17/23 fall incident and was terminated. During an interview on 10/6/23 at 2:20pm CNA-I hired 10/13/22 stated that gait belts were used for resident transfers for fall prevention and was aware of where they were stored. During an interview on 10/6/23 at 2:30 pm NA-H, hired on 9/2/21, stated that gait belts were used for resident transfers for fall prevention and was aware of where they were stored. During an interview on 10/6/23 at 2:35pm CNA-G, hired 11/1/10, stated gait belts were used for resident transfers for fall prevention and was aware of where they were stored. During an interview on 10/6/23 at 2:45pm CNA-F, hired 3/7/23, stated gait belts were used for resident transfers for fall prevention and was aware of where they were stored. Record review of staff training forms dated 8/9//22 and 3/18/23 revealed staff in-service on gait belt usage for resident transfers. Record review of Conduct and Workplace notice dated 3/24/23 revealed employee termination action for CNA-C. Record review of facility policy named Safe Resident Handling/Transfers dated 12/1/21 revealed the need for gait belts to be used on resident transfers. 676138 Page 2 of 2