Health inspection·December 2, 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 interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 1 resident reviewed for care plans in that: The facility failed to ensure CNA D followed the comprehensive person-centered care plan for a proper transfer on 11/10/25 with Resident #1. This failure could place residents in the facility at risk of injury, not receiving the necessary care and services and having personalized plans developed to address their needs.Based on interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 1 resident reviewed for care plans in that: The facility failed to ensure CNA D followed the comprehensive person-centered care plan for a proper transfer on 11/10/25 with Resident #1. This failure could place residents in the facility at risk of injury, not receiving the necessary care and services and having personalized plans developed to address their needs.Findings include: Record review of Resident #1's face sheet dated 12/01/25, revealed an admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #1's facility history and physical dated 12/02/25, revealed, an [AGE] year-old female diagnosed with cerebral palsy (a group of neurological disorders that affect movement, balance, and posture), repeated falls, difficulty in walking, muscle wasting and atrophy, unsteadiness on feet, lack of coordination, symptomatic epilepsy (a type of epilepsy where seizures are caused by an identifiable, underlying issue in the brain) and osteoarthritis (the most common type of arthritis, characterized by the breakdown of joint cartilage, which causes bone-on-bone friction). Record review of Resident #1's quarterly MDS assessment dated [DATE], revealed moderate impaired cognition to be able to recall or make daily decision BIMS score of 9. Resident #1 was dependent and needed 2 or more helpers with toilet transfer, tub/shower transfer and chair/bed-to-chair transfer. Resident #1 was marked as a wheelchair for mobility device. Resident #1 was diagnosed with difficult in walking, lack of coordination, and Cerebral Palsy. Record review of Resident #1's Care Plan dated 11/7/25, revealed the resident has an ADL self-care performance deficit related to limited mobility, pain and fluctuations in cognition related to cerebral palsy. Bathing/ showering: The resident is totally dependent on staff x2 to provide shower. Bed mobility: The resident requires extensive staff assist x2 bed mobility. Toilet use: The resident requires extensive staff assist x2 for toileting. Transfer: The resident requires extensive staff assist x2 to move between surfaces. During an interview on 12/01/25 at 3:11 P.M., with CNA A she said she was coming from hall 300 and went through the shower door when she saw CNA D and she said Resident #1 was sliding down on 11/10/25. CNA A Page 1 of 3 676187 676187 12/02/2025 Heritage House of Marshall Health & Rehabilitation 5915 Elysian Fields Road Marshall, TX 75672

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few said Resident #1 had a shower and was fully dressed trying to transfer from the shower chair to her wheelchair. CNA A said Resident #1 was a 2-person assist, but CNA D was transferring her from the shower chair to her wheelchair by herself. CNA A said Resident #1 started sliding down to the floor and she told CNA D they were not going to put Resident #1 in the wheelchair; they lowered Resident #1 to the floor. CNA A said she went to get the charge nurse and explained to him what happened. CNA A said Resident #1 should be a 2-person assist. During an interview on 12/01/25 at 4:05 P.M., Resident #1 said she does not remember the incident in the bathroom when she was lowered to the floor by CNA D and CNA A. Resident #1 said when staff transferred her from her bed to her wheelchair it was usually 2 people. During an interview on 12/01/25 at 4:46 P.M., with the Regional Compliance Nurse she said the aide could go to the resident's plan of care in point click care (an electronic health record) and pull it up in the kardex (a genericized trademark for a nursing record-keeping system) to see what assistance a resident need for a transfer. She said if the aides were unsure how to transfer a resident, they could ask the charge nurse or the DON how the resident was supposed to be transferred. During an interview on 12/01/25 at 4:55 P.M., with LVN B said the aides could look up the resident's kardex in point click care to see how a resident was supposed to be transferred. During an interview on 12/01/25 at 4:57 P.M., with LVN C she said the aides know how to transfer a resident by the kardex and by word of mouth. During an interview on 12/01/25 at 5:01 P.M., with Regional Compliance Nurse she said the MDS Nurse said the care plan was generated on 2/17/25 and he documented Resident #1 was a 1-person assist. She said the MDS Nurse said he opened another care plan on 2/18/2025 and documented Resident #1 was a 2-person assist, but it should have been resolved. During an interview on 12/02/25 at 9:16 A.M., with CNA D she said on 11/10/25 Resident #1 was a 1-person assist. She said she used a gait belt while transferring her. CNA D admitted she was transferring Resident #1 by herself. CNA D said Resident #1 was standing and assisting with the transfer from the shower chair to the wheelchair. CNA D said Resident #1 got weak and said she needed to sit down. CNA D said CNA A came into the bathroom and helped her lower Resident #1 to the floor; then CNA A went and got the charge nurse. CNA D said the charge nurse assessed Resident #1 and they put the resident in her wheelchair. CNA D said she knew where to find what assistance a resident required; she said the information was in the resident's kardex in point click care. During an interview on 12/02/25 at 10:05 A.M., with the Staffing Coordinator she said the Kardex asked the staff if a resident was a 1 or 2-person assist. She said if an aide was unsure how a resident should be transferred, they should go to their charge nurse and ask them how the resident was to be transferred. She said she was not sure if Resident #1 was a 1 or 2-person assist before the incident. She said when she worked with Resident #1, she would pivot. She said when Resident #1 had a bad day she would tell staff and they would have to get another person to help transfer her. During an interview on 12/02/25 at 10:12 A.M., with CNA A she said staff could find the information in the kiosk if a resident was a 1 or 2-person assist. She said the day she assisted CNA D with Resident #1 she was a 2- person assist. During an interview on 12/02/25 at 10:47 A.M., with the Regional Compliance Nurse she said she was not here on 11/10/25 and she did not know why the kardex, and the care plan did not match. She said she would not deny there were 2 different care plans. She said she resolved the 2-person assistance in the care plan for 2/18/25. She said she educated the staff on the care plans yesterday and updated them. She said she had staff audit the care plans so that all knew how the residents should be transferred. During an interview on 12/02/25 at 11:18 A.M., with the MDS Nurse he said he was educated on updating the care plans. He said he agreed that there was a discrepancy with Resident #1's care plan. He said Resident #1 was a 2-person assist now, but before the incident she was supposed to be a 1-person assist. He 676187 Page 2 of 3 676187 12/02/2025 Heritage House of Marshall Health & Rehabilitation 5915 Elysian Fields Road Marshall, TX 75672

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few said on 2/18/2025 he saw Resident #1 was a 2-person assist, but she was supposed to be a 1-person assist. He said he was updating the care plans and made the mistake of documenting her as a 2-person assistant on 2/18/25. He said he took full responsibility for the mistake. He said the negative effect of an incorrect care plan was a big error and it throws everyone caring for the residents off. He said an improper transfer could be performed due to an incorrect care plan and a fall could occur. During an interview on 12/02/25 at 11:41 A.M., with the Director of Nursing she said the staff had been educated to update the care plans. She said the MDS Nurse was responsible for updating changes in the care plans and reporting changes to the care plan. She said Resident #1 was a 1-person assistant. She said the Regional Compliance Nurse told her not to create a new care plan; she was supposed to update the original care plan. She said she agreed on 2/18/25 that Resident #1's care plan was documented as a 2-person assist and it should have been resolved. She said all nursing staff needed to be knowledgeable of how the care plan works. She said she expected the staff to follow the care plan when transferring the residents. She said if the care plan was not accurate staff could not give adequate care. During an interview on 12/02/25 at 11:57 A.M., with the Administrator she said she expected the staff to follow the resident's care plan. She said she expected the care plan and the kardex to match, because the aides could not see the care plans. She said a negative effect of an incorrect care plan was if a resident was a 2-person assist and was transferred by 1-person, they were more than likely to be injured. Record review of the CNA Proficiency Aduit- Competency Evaluation, dated 11/18/25, reflected CNA A met the performance criteria for transfers, with no comments noted. Record review of the CNA Proficiency Aduit- Competency Evaluation, dated 11/18/25, reflected CNA D met the performance criteria for transfers, with no comments noted. Record review of Comprehensive Care Planning policy undated revealed The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to make a resident medical, nursing, and mental psychosocial needs are that are identified in the comprehensive assessment. Comprehensive care plans may include, but are not limited to resident Kardex records, baseline care plans, and task listings. The comprehensive care plan will describe the following.The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Record review of Moving A Resident, Bed to Chair/Chair To Bed policy undated revealed The purpose of this procedure are to allow the resident to be his or her bed as much as possible and provide for a safe transferring of the resident.9. b. If transferring the resident to a wheelchair: i. If the resident requires, two persons (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or her in the chair. 676187 Page 3 of 3