Health inspection·December 6, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 to ensure each resident environment remains as free of accident hazards as is possible for 2 of 5 residents (Residents #2, and #68 ) reviewed for accidents and hazards in that: CNA B, CNA C, and CNA D failed to lock Resident #2 and Resident #68's wheelchair during transfers. This deficient practice could place residents at risk for avoidable injuries during transfers. The findings included: Review of Resident #2's admission Record, dated [DATE], revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including heart failure, history of falls, and difficulty walking. Review of Resident #2's Annual MDS Assessment, dated [DATE] revealed: She scored a 9 of 15 on her mental status exam indicating moderate cognitive impairment. She needed extensive assistance of two or more staff for transfers. She had no falls in the previous look back timeframe. Review of Resident #2's Care Plan revealed: Focus updated [DATE]: Resident requires assist with ADLs. Goal: Resident is able to perform self-care to optimal level and maintain strength, and endurance. Interventions included: mechanical lift for all transfers; provide level of support to complete transferring needs every shift. Focus updated [DATE] Focus: Resident has limited physical mobility related to non-weight bearing to Right lower extremity. Goal: the resident will remain free of complication relate to immobility, including contractures, skin breakdown, fall-related injury through the next review date. Interventions included: non-weight bearing to right lower extremity until further notice. Focus updated [DATE]: Resident has a history of falling, history of falls. Goal: Resident will not experience any injury from falls for 90 days. Interventions included: mechanical lift for all transfers (dated [DATE]) Page 1 of 5 676348 676348 12/06/2023 Madison Medical Resort 5001 Office Park Drive Odessa, TX 79762

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #2's Order Summary Report, dated [DATE] revealed orders dated [DATE] for Mechanical lift for all transfers. Observation on [DATE] at 2:53 p.m. Resident #2 up in her wheelchair. CNA B and CNA C hooked Resident #2 to the mechanical lift. CNA B prompted Resident #2 to cross her arms as CNA C operated the lift. As the lift was rising, Resident #2's hip bumped against the side of the wheelchair causing the wheelchair to move. Resident #2 became visibly upset (facial expression changed and she appeared tense) when the wheelchair moved and began gripping CNA B's hand and murmuring in Spanish. It was noted that only one side of the wheelchair was locked. Once in the air, CNA B folded the wheelchair and moved the wheelchair to the side. CNA B steadied Resident #2 as CNA C maneuvered the mechanical lift. CNA B steadied Resident #2 as CNA C lowered Resident #2 to the bed. Interview on [DATE] at 3:37 p.m. CNA B said the lift transfer went ok. She said the room was small and she had to fold the wheelchair just so the mechanical lift could move Resident #2 to the bed. CNA B said Resident #2 was afraid of the lift. CNA B said the facility trained staff to do a mechanical lift with two people, open the legs of the lift, put the sling on the hooks, have the resident cross their arms and lift the resident. CNA B said the wheelchair wheels needed to be locked. She stated she did not lock Resident #2's wheelchair. Review of Resident #68's admission Record, dated [DATE], revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including abnormal gait, dementia, stroke with paralysis to the right side, generalized muscle weakness, and reduced mobility. Review of Resident #68's Quarterly MDS Assessment, dated [DATE], revealed: He scored a 5 of 15 on his mental status exam, indicating severe cognitive impairment. He needed extensive assistance of two or more staff for transfers. He had one fall with no injury in the previous look back timeframe. Review of Resident #68's Care Plan revealed: Focus updated [DATE]: Resident is at risk for falls due to new environment and/or age. No other indicator that would suggest high fall risk. Goal: the resident will be free of falls through the review date. Interventions included: Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs and ensure that resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. Focus updated [DATE]: Resident has history of falling, fall [DATE] and [DATE]. Goal: Resident will not experience any injuries from falls for 90 days. Interventions included: anticipate and meet resident's needs, bathroom before and after meals, ensure that resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, and may have anti-roll backs on wheelchair every shift. Observation on [DATE] at 3:20 p.m. revealed Resident #68 slouched down in his wheelchair in a way that his shoulders were on the seat of the wheelchair his head was propped on the back of the wheelchair, his bottom hung off the wheelchair and his feet rested on the bed. Resident #68's responsible party gave permission for the transfer to be observed. Because of Resident #68's position, three CNAs 676348 Page 2 of 5 676348 12/06/2023 Madison Medical Resort 5001 Office Park Drive Odessa, TX 79762

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some were needed to lift him safely. As CNA B lifted Resident #68's shoulders up to place the gait belt, the wheelchair moved, and the responsible party told the aides they needed to lock the wheelchair or Resident #68 would fall. All CNAs stopped what they were doing, and CNA D locked the wheelchair. CNA B was then able to safely place the gait belt on Resident #68 and she and CNA C attempted to lift him back into a sitting position in the wheelchair but due to how far down he had sunk in the wheelchair they were unable to lift him. CNA D then held onto Resident #68 in a hug-like grip while CNA B and CNA C lifted the resident from under his arms using the gait belt and pulled him up into a sitting position in the wheelchair. In an interview on [DATE] at 3:35 p.m. the DON stated that her expectation was that during transfers, wheelchairs were to be locked by staff to prevent accidents or injuries to the residents and staff. She stated that during a routine stand pivot transfer, the wheelchair should always be close by, and the wheels should absolutely be locked. The DON stated that sometimes, because of the lack of space in the resident rooms, it was easier for staff to not lock the wheelchair when performing a mechanical lift transfer because the wheelchair was smaller and easier to maneuver than the lift. She explained that once the resident was placed in the sling and lifted from the bed, the wheelchair could be moved around easier and tilted to better position the resident comfortably into the wheelchair. The DON stated that when moving a resident out of a wheelchair with a mechanical lift the wheelchair should be locked. She stated that Resident #2 was fearful of being transferred with the mechanical lift due to her history of falls and that staff was aware to be cautious when transferring her. When the transfer involving Resident #68 was described to her, she had no comments. Review of facility in-service dated [DATE] topic New admission and Resident Transfers revealed in part: All admissions need assistance; 2 person transfer at all times, wheelchair use ONLY prior to therapy evaluation. Review of facility in-service dated [DATE] topic Hoyer Lift revealed in part: All Hoyer lift transfers require 2 people at all times during the use of this machine, no exceptions. Review of undated facility policy titled One Person Pivot Transfer revealed, in part: Procedure: 1. Explain procedure to resident. 2. Clear obstacles. Lock wheels/brakes; remove leg rests and/or wheelchair arms if able. Position wheelchair next to bed. Review of undated facility policy titled Two Person Pivot Transfer revealed, in part: Procedure: 676348 Page 3 of 5 676348 12/06/2023 Madison Medical Resort 5001 Office Park Drive Odessa, TX 79762

F 0689 1. Level of Harm - Minimal harm or potential for actual harm Explain procedure to resident. 2. Residents Affected - Some Clear obstacles. Lock wheels/brakes; remove leg rests and/or wheelchair arms if able. Position wheelchair next to bed. Review of undated facility policy titled Two Person Hoyer (Mechanical) Lift revealed, in part: Procedure: 1. Gather equipment and bring to bedside. 2. Position wheelchair so that you can maneuver the lift safely from the bed to over the chair. Lock the wheels/brakes. 676348 Page 4 of 5 676348 12/06/2023 Madison Medical Resort 5001 Office Park Drive Odessa, TX 79762

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to store all drugs and biologicals in locked compartments for 1 of 1 treatment cart reviewed for medication storage and security. The facility staff failed to ensure the treatment cart was secured when it was left unattended and unsupervised. These failures could place clients at risk for drug diversion or accidental ingestion. Findings included: During an observation on 12/03/23 at 09:44 AM the facility treatment cart was observed unlocked and unattended by facility staff. Inside the cart were bottles of normal saline, medication ointments, antifungal powder, fungal creams, fingernail clippers, containers of zinc oxide and scissors. During an interview on 12/06/23 at 10:38 AM treatment nurse A said the treatment cart was supposed to be locked when unattended. Treatment nurse A said the cart was supposed to be locked to prevent others such as residents getting into the treatment medications, scissors and such. The treatment nurse said she was not the treatment nurse that was working the floor on 12/03/2023. During an interview on 12/06/23 at 03:08 PM the Administrator said it was his expectation for staff to lock the treatment cart and take the keys with them when they were not using the cart. The Administrator said if the cart was left unlocked and unattended residents or other staff could get into the cart. During an interview on 12/06/23 at 03:15 PM the DON said her expectation was for the treatment cart to be locked if it was left unattended. The DON said the cart was supposed to be locked to keep the items secured. The DON said it was a shared cart and any one with the keys could have left it unlocked. The DON said it was not okay for it to be left unlocked. Record review of the facility's undated document titled Medication cart, administration of drugs indicated in part: Purpose: To administer medication more quickly and efficiently. If the cart is left at any time during medication pass due to an emergency, it must be locked. 676348 Page 5 of 5