Inspection·November 10, 2023

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received adequate supervision with the use of a mechanical lift to prevent accidents for 1 of 2 residents reviewed for accidents (Resident #2). The facility failed to ensure adequate supervision while utilizing the mechanical lift to move Resident #2 in the shower room, resulting in Resident #2 having a fractured nose and a laceration to the hand. The failure contributed to Resident #2's fractured nose and laceration of the hand. This failure could place residents who required the use of a mechanical lift for accidents. Findings included: Record review Face Sheet dated 11/09/2023 indicated Resident #2 was a [AGE] year-old admitted on [DATE] with the diagnosis of Charcot's Join, multiple sites (joint disease that causes pain), morbid obesity (more than 80 to 100 pounds over ideal body weight), lack of coordination and major depressive disorder (feeling sad for a larger percentage of time over a prolonged period for no particular reason). Record review of an MDS dated [DATE] indicated Resident #2 had a BIMS of 15, indicating the resident was cognitively intact. The same MDS indicated Resident required total dependence for bathing-self performance and one-person physical assist for bathing: support provided. In addition the MDS reflected Resident #2 required extensive assistance and two+ persons physical assist for transfer-how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet). Record review of a Care Plan most recently updated on 06/09/2022 reflected during the time of the incident, Resident #2 required (physical assistance) with transferring. Hoyer lift when transferring to shower bed on Shower Day, transfer: requires assistance with (weight bear, pivot, use arms to support). The intervention reflected a start date of 03/09/21 and a revision date of 06/09/2022. Record review of the most recent care plan on 11/09/2023 reflected Resident #2 required physical help from staff for bathing and resident to use shower bed for showers requires assistance with: transfers with mechanical lift x 2 persons with a revision dated of 06/22/2023. Record review of Nursing Home to Hospital Transfer Form dated 6/22/2023 stated Resident was being transferred from showed bed to wheel chair via hoyer lift when hoyer became unsteady and fell to its side with resident about two feet in the air near wheel chair. Hoyer lift fell over and struck resident in her forehead and gave her a skin tear under her right eye. During a phone interview on 11/08/2023 at 3:05 p.m., CNA C (a former employee of the facility), said she alone utilized the mechanical lift to get Resident #2 to and from the shower bed in the shower room on 06/22/2023. CNA C said she asked for help but was unable to get another staff member to help and she wanted Resident #2 to be able to have her preference of getting a shower using the shower bed. CNA B said she now knows she should not have done that but at the time the transfer took place (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676281 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 676281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westover Hills Rehabilitation and Healthcare 9922 State Hwy. 151 San Antonio, TX 78251 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 - Actual harm Residents Affected - Few she did not. CNA C said at the time she received training in the facility for mechanical lift transfers she was told one person could use the mechanical lift with a resident if needed. CNA C said Resident #2 was injured during the transfer using the mechanical lift. CNA C explained she did not know exactly what happened to make the lift move during the transfer but remembered Resident #2 jarred their head into the lift when the attempt was made to move Resident #2 from the shower bed to the wheelchair and believed that was the possible cause. During an interview on 11/08/2023 at 1:44 p.m., Resident #2 said she and CNA C were the only two people in the shower room on 06/22/2023 when she sustained an injury to her nose and her hand. Resident #2 said she did not know exactly what happened but did her nose and hand were injured when being transferred from the shower bed to her wheelchair, I felt my face and hand hit the cold floor, I think I had my eyes closed. During a phone interview on 11/09/2023 at 1:28 p.m., ADON B (a former employee of the facility), said at the time she was at the facility during her training of CNA staff she did provide education that one person can use a mechanical lift if needed however best practice was always to use two staff members when using the mechanical lift with a resident. ADON B said, it just depends on the patient. ADON B was no longer employed by the facility and did not comment further. During an interview on 11/10/2023 at 9:48 a.m., the Administrator said Resident #2 sustained and injury on 06/22/2023 in the shower room while being transferred by one CNA C described using the mechanical lift alone. The Administrator said, at that time and now best practice for use of the mechanical lift was two persons, however the manufacturer's recommendation was two person use with the lift but it can handle one person transfers depending on the healthcare professionals judgement. The Administrator said he believed CNA C, with her experience, felt confident in being able to transfer the resident along with Resident #2's approval and request. The Administrator said he did not know for sure how the Resident was injured. During an interview on 11/10/2023 at 3:57 p.m., LVN D said she was the charge nurse for Resident #2's hallway. LVN D said, she nor any other staff was in the shower room at the time of Resident #2's sustained an injury on 06/22/2023, she did not know what happened further stating, I didn't see I was not in the room. Record review of the hospital records dated 06/22/2023 indicated Resident #2 was seen on 06/22/2023 and treated for a nasal bone fracture, facial trauma, and a hand contusion. Record review of an undated Hydraulic Lift policy provided by the facility Administrator indicated Hydraulic Lift- Follow manufacturers transfer and maintenance recommendations. A Review of the facility provided owner's manual revealed the following information on page 24 of 52: the company name recommends that two assistants be used for all lifting preparation and transferring to/from procedures; however, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the health care professional for each individual case. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676281 If continuation sheet Page 3 of 3