Health inspection·September 11, 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 observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 2 of 16 residents (Resident #3 and Resident #4) reviewed for accidents/hazards. The facility failed to remove worn and damaged mechanical lift slings from service. This deficient practice could place residents at risk of a loss of quality of life due to injuries. Findings included: Record review of a facility face sheet dated 9/10/24 for Resident #3 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including: anxiety disorder, dysphagia (trouble swallowing) and aphasia (a brain disorder that affects speaking or understanding language). Record review of a Comprehensive MDS assessment dated [DATE] for Resident #3 indicated that she had a BIMS score of 9, which indicated that she had a moderate cognitive impairment. She was dependent for transfers. Record review of a comprehensive care plan dated 7/24/24 for Resident #3 indicated that she had as ADL self-care deficit and interventions included: .The resident requires extensive assist X2 staff participation with transfers. Hoyer Lift . Record review of a facility face sheet dated 9/10/24 for Resident #4 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: paraplegia (a form of paralysis that mostly affects the movement of the lower body), dysphagia (trouble swallowing), and aphonia (inability to speak). Record review of a Quarterly MDS assessment dated [DATE] for Resident #4 indicated that the Brief Interview for Mental Status should not be conducted due to resident being rarely/never understood. She had a severe cognitive impairment. She was dependent for transfers. Record review of a comprehensive care plan dated 8/27/24 for Resident #4 indicated that she had an ADL self-care deficit and interventions included: .The resident requires Mechanical Aid, Sling, for transfers . Page 1 of 3 676147 676147 09/11/2024 Stallings Court Nursing and Rehabilitation 4616 NE Stallings Dr Nacogdoches, TX 75965

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 9/10/24 at 12:15 PM Resident #4 was observed up in chair in common area of facility with blue mesh lift sling observed underneath her. The colors of the loops were faded in color. During an observation on 9/10/24 at 12:20 PM Resident #3 was observed up in dining room in chair with a blue mesh mechanical lift sling underneath her. The colors of the loops on sling were observed to be faded in color . During an observation on 9/10/24 at 1:00 PM CNA A and CNA B were observed to use Hoyer lift (mechanical lift used to transfer dependent residents). They were observed to transfer Resident #4 from her chair to her bed with the lift pad that was underneath her with the faded colored loops. During an interview on 9/10/24 at 1:30 CNA B said using lift slings that were faded meant they were worn and could cause a resident to fall . During an interview on 9/11/24 at 1:35 PM CNA A said faded colors on the slings were a sign of wear and tear, and those slings should not be used. She said using slings that have signs of wear and tear could cause a resident to get hurt . During an interview on 9/11/24 at 9:15 AM DON said laundry was responsible for checking slings before sending them back out to the floor for use and CNAs were responsible for checking before using to ensure safety for the residents. During a joint interview on 9/11/24 at 12:25 PM Housekeeping supervisor and Laundry Aide both said that slings were washed in warm water and air dried. Both said bleach was not used on slings. Both said they look for rips, stains, and discoloration. Both said that slings were not sent back to floor for use, but CNAs were responsible for coming to laundry to get one when they needed it. Both said that residents could be at risk for injury if unsafe slings were used . During an interview on 9/11/24 at 12:30 PM DON said that residents could be at risk of ending up in the floor if unsafe slings were used. He said that Unit Managers would be expected to inspect all slings weekly going forward and remove any that were worn or faded. During an interview on 9/11/24 at 12:35 PM Administrator said that residents could be at risk for falls if unsafe slings were used. He said that they will be doing in-services and education with nursing staff and laundry to prevent unsafe slings from being used and ensuring staff know when to remove slings. Record review of a facility in-service dated 8/8/24 titled Hoyer Lift, stand-up Lift, and Transfer with objectives of educate staff on proper usage of Hoyer Lift and Stand-up lift and transfer. Video demonstration provided Signature page was signed by CNA A, indicating that she had received training on usage of Hoyer lift. Record review of a facility skills validation form titled Mechanical/Hydraulic Lift signed by CNA B and dated 9/2/23 indicated that CNA B had been trained on use of Hoyer Lift. Record review of a facility policy titled Lifting Machine, Using a Portable dated 2001 and revised in April 2007 indicated that policy did not address inspecting the slings before use to monitor for wear and tear . 676147 Page 2 of 3 676147 09/11/2024 Stallings Court Nursing and Rehabilitation 4616 NE Stallings Dr Nacogdoches, TX 75965

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of guidance titled Full Body Slings: Instructions for Use retrieved from www.medline.com on 9/11/24 read .Always inspect slings prior to each use. Signs of rips, tears, or frays indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use . and .Do not remove sling labels. If sling labels are removed or no longer legible, sling must be immediately removed from use . 676147 Page 3 of 3