Health inspection·September 5, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few arm pit to transfer a resident. The Administrator stated the risk of an inappropriate transfer could result in injury to the resident. The Administrator stated they taught staff to use a gait belt for all transfers for safety and to prevent injury to themselves and the residents. Observation and attempted interview on 09/05/24 at 8:15 AM, Resident #1 was seated in her wheelchair in her room with Family Member B present. Resident #1 was smiling and appeared to be in a good mood. Resident #1 was not able to answer questions appropriately. Interview on 09/05/24 at 8:25 AM, LVN C revealed Resident #1 was a two-person transfer at all times. Follow-up interview at 10:59 AM revealed Resident #1 was a two-person transfer with a gait belt for all transfers. LVN C was asked about the hand placement for a two-person transfer, LVN C stated you are to hold onto the gait belt during the transfer. LVN C was asked if transferring a resident by grabbing under a resident's armpit was appropriate and LVN C stated no armpit transfers are allowed you risk causing injury to a resident. Interview on 09/05/24 at 11:38 AM, CNA A revealed the observation of pictures from the video of Resident #1's transfer on 09/04/24. CNA A confirmed he was the staff member in the pictures from the video. CNA A stated he did not use a gait belt for the transfer and had been trained on safe transfers. CNA A knew Resident #1 was a two-person assist with transfers and to always use a gait belt. CNA A was asked about the placement of his arms in the pictures from the video and CNA A stated he had his arms under Resident #1's armpits which was incorrect. CNA A stated he knew he needed help with Resident #1's transfer and did not ask for help since help was not always readily available. CNA A stated he would use a gait belt for transfers and not place his arms under the Resident's armpits during transfers moving forward. CNA A stated that the risk of transferring a resident inappropriately could result in dislocation of a shoulder or bruising. Interview on 09/05/24 at 1:45 PM, PT D revealed Resident #1 was a two-person transfer with a gait belt for all transfers. PT D stated that they did not use a resident's armpit during a transfer because it was not safe for the resident and could cause an injury. Interview on 09/05/24 at 2:00 PM, the ADON revealed Resident #1 was a two-person transfer with a gait belt for all transfers. The ADON stated the staff were not supposed to place their arms in a resident's armpit during a transfer since that could pull a resident's shoulder out of socket. Interview on 09/05/24 at 2:05 PM, the DON revealed Resident #1 was always a two-person transfer with a gait belt since that was standard practice. The DON stated the staff were not supposed to use a resident's armpits during a transfer because that could result in injury to resident or staff. Review of the facility's In-Service Training Report dated 09/03/24, Topic-Transfers-Hoyer's, Gait belts reflected: .gait belts are to be used with all transfers other than Hoyer transfers. Facility is a zero-lift facility; therefore, all transfers require use of Hoyer or gait belt. No exceptions. CNA A had signed as being in attendance for the in-service listed. Review of Reference E Clinical Nursing Skills and Techniques 9th edition page 276 reflected: . Patients should never be lifted by or under their arms. Review of the facility's policy, Transfers: Method, Equipment and Preparation, dated 06/14/06, reflected, .use gait belt on all assisted transfers. Patient's shoulders or arms are not appropriate to pull, push or lift upon. Cup your hand under the gait belt for greater control .Using a Transfer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676249 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Carlyle at Stonebridge Park 170 Stonebridge Lane Southlake, TX 76092 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Belt .Belt should be used on any Patient who requires any type of level of assistance with transfers or ambulation .Assistant's hand should always be cupped under the gait belt to ensure proper grasp and security .Transfers .Maximal Assistance .Place belt around the Patient's waist . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676249 If continuation sheet Page 3 of 3