Health inspection·December 22, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety 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 reviews, the facility failed to provide adequate supervision for 1 of 5 residents reviewed for accidents and supervision. (Resident #1)The facility failed to ensure Resident #1 was provided a mechanical lift transfer by two staff to move between surfaces which resulted in a transfer with injuries including an acute fracture of the greater trochanter (femur) which was slightly displaced on 11/29/2025.The non-compliance was identified as past non-compliance. The immediate jeopardy began on 11/29/2025/and ended on 12/05/2025. The facility had corrected the noncompliance prior to the start of the survey. The facility had implemented corrective actions and returned to compliance before the investigation began.This failure had the potential to affect other residents and could result in residents not receiving appropriate supervision, placing them at risk for serious injury, harm, or death. Findings included:Record review of Resident #1's face sheet reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included nondisplaced fracture of greater trochanter of left femur, initial encounter for closed fracture ( a crack in the outer part of the top of the left thigh bone), acute kidney failure (sudden loss of kidney function), anxiety (a feeling of worry or fear), gastroesophageal reflux disease (condition where acidic gastric fluids flows backward into the esophagus, resulting in heartburn), dementia (memory loss), abnormality of gait (noticeable change from typical walking pattern) and muscle weakness (lack of muscle strength). Record review of Resident #1's care plan with a revised date of 03/13/2024 reflected [Resident #1] has an ADL self-care performance deficit related to dementia. The care plan reflected the following intervention: .requires a mechanical lift by two staff to move between surfaces and as necessary. Record Review of Resident #1's MDS Assessment, dated 12/10/2025, reflected Resident #1 was unable to complete the brief interview for mental status. Resident #1 had poor short-term memory recall. Her decision-making ability was severely impaired. Record review of the facility's incident report dated 12/02/2025 revealed a statement It was reported by staff the morning of 12/03/2025 that Resident #1 had returned from the ER late last night with DX of left Femur fracture and UTI. New orders sent for Levaquin for UTI. Family aware and was at ER with resident. She was medicated for pain after returning and is now sleeping. Staff report no visible bruising or discoloration noted at this moment to the area. May be slight swelling but hard to tell. No shortening of leg or external rotation noted. Record review of hospital discharge records dated 12/02/2025 reflected Resident #1 was taken to the hospital for an assessment with the chief complaint of lower extremity pain. The resident's symptoms was located in the area of the left hip, left thigh, and left knee. Resident #1's results revealed acute fracture of the left greater trochanter which is slightly displaced. Resident #1 was discharged from the hospital to the facility. Record review of Resident #1's PCP facility visit dated 12/03/2025 reflected ortho felt non-operable due to comorbidities. I spoke with Resident #1's RP, and we both agreed that surgery would not be in her best interest as long as we can Page 1 of 3 676386 676386 12/22/2025 West Rest Haven 503 Meadow Drive West, TX 76691

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few keep her in bed/chair and control pain. In an interview on 12/22/2025 at 10:30 AM with Resident #1, she stated she did not recall having a fractured hip. Resident #1 stated she did not have any pain. In a telephone interview on 12/22/2025 at 10:14 AM with CNA A, she stated when she was transferring Resident #1 from her bed to the wheelchair. She stated she (CNA A) was holding onto the resident's pants while the resident was pivoting from her bed to her wheelchair. She stated she was told by a staff member to put the sling underneath the resident and if the resident was not having combative behaviors, she could transfer the resident using a gait belt. She stated she did not grab an assignment sheet, which gave direction on what assignments were to be completed by staff, at the beginning of her shift. In an interview on 12/22/2025 at 10:20 AM with the DON, she stated that Resident #1 needed a mechanical lift with two staff for every transfer. She stated assignment sheets were at each nurse's station for staff to obtain upon arrival of their shift. She stated it tells which residents they would have, how the resident transfers, and how much assistance is needed. She stated her expectation is for staff to follow the level of assistance on the assignment sheets for each resident. She stated if a resident's transfer status changes, the nursing supervisor would update the assignment sheets. She stated all staff were in-serviced on abuse, neglect, and transfers. She stated all residents' transfer status was reviewed weekly as an ongoing process and discussed in the morning meeting. She stated the nursing supervisor was responsible for keeping up with the transfer training and how to use the facility equipment with new staff. She stated interventions were put in place for all agency staff. She stated staff are given an agency staff information sheet to read, sign, and date, would be uploaded into the agency portal, staff would be educated on the facility's transfers policy, and how to use facility devices; staff will sign and date the transfer device form. She stated a binder is kept at each of the nurse's station with signed education. In an interview on 12/22/2025 at 12:50 PM with the RN, she stated she has been trained on abuse, neglect and transfers. She stated she was also trained on the assistive devices used in the facility. She stated assignment sheets were kept at the nurse's station for staff to receive at the beginning of each shift which shows what residents the CNAs will be working with and the type of assistance each resident needs for transfers. She stated if a resident transfer status changed, the nursing supervisor would update the assignment sheets. She stated the nursing supervisor was responsible for making sure all agency staff are trained on transfers and assistive devices used in the facility. She stated a binder is kept at each of the nurse's station with signed education. She stated she was not working on the memory care unit when the incident with Resident #1's happened, but she heard the resident was transferred incorrectly, and the resident had a fractured hip. Attempted a call to Resident #1's RP on 12/22/2025 at 1:10 PM, no response. In an interview on 12/22/2025 at 6:20 PM with the LVN, she stated all staff were in-serviced on abuse, neglect, and transfers. She stated Resident #1 needed a mechanical lift with two staff for every transfer. She stated assignment sheets were at each nurse station for staff to obtain upon arrival of their shift, that tells which residents they will have, how the resident transfers, and how much assistance is needed. She stated all the residents' transfer statuses were reviewed, which is also done weekly, ongoing process, and discussed in morning meeting. She stated if there was a change in a resident's transfer status, she would update the assignment sheets. She stated a binder was kept at each nurse's station for new agency employees that need to be trained on transfers, and assistive devices used at the facility. She stated she looks at the schedule to see if there are any new agency employees scheduled so she could train them on transfer process and use of equipment with staff. In an interview with on 12/22/2025 at 6:42 PM with CNA B she stated she was in-serviced on abuse, neglect, transfers and assistive devices used in the facility. She was able to give 676386 Page 2 of 3 676386 12/22/2025 West Rest Haven 503 Meadow Drive West, TX 76691

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few examples of abuse and neglect. She stated if she witnessed abuse or neglect she would report to the administrator, which is also the abuse coordinator. She stated Resident #1 was a mechanical lift two person assist for every transfer. She stated assignment sheets are at each nurse station for staff to obtain upon arrival for their shift, that tells what resident's they will have and how the resident transfers, and how much assistance is needed. She stated if the resident had a change in status the charge nurse would update the assignment sheets. She stated she was not working on the day of the incident with Resident #1. In an interview on 12/22/2025 at 6:44 PM with CNA C, she stated she was in-serviced on abuse, neglect, transfers, and assistive devices used for transfers. She stated if she witnessed abuse or neglect, she would report to the charge nurse and Administrator, which was also the abuse coordinator. She was able to give examples of abuse and neglect. She stated Resident #1 was a mechanical lift, two-person assist for every transfer. She stated assignments were at each nurse station for staff to obtain upon arrival for their shift that tells what residents they will have, how the resident transfers, and how much assistance is needed. She stated if a resident had a change in status, the charge nurse would update the assignment sheet. In an interview on 12/22/2025 at 6:46 PM with CNA D, she stated she was agency staff. She stated was in-serviced on abuse, neglect, transfers and assisted devices used in the facility. She stated if she witnessed abuse or neglect she would immediately report to her supervisor and administrator, which is also the abuse coordinator. She stated assignment are at each nurse station for staff to obtain upon arrival for their shift, that tells what resident's they will have and how the resident transfers, and how much assistance is needed. She stated if the resident had a change in status, the charge nurse would update the assignment sheet. She stated she was not working on the day of incident with Resident #1. During observation on 12/22/2025 at 6:48 PM, this surveyor observed a mechanical lift transfer with two person assist. Proper techniques used for transfer, proper footwear/nonskid socks were used while transferring. No concerns noted During an observation on 12/22/2025 at 6:55 PM, this surveyor observed a stand aid transfer with one person assist. Proper techniques used for transfer, proper footwear/nonskid socks were used while transferring. No concerns noted. On 12/22/2025 at 8:18 PM, the acting Administrator was informed of IJ. The non-compliance was identified as past non-compliance. The IJ began on 11/29/2025 and ended on 12/05/2025. The facility had corrected the noncompliance before the investigation began. The interventions and plan for correction included: Record review of the undated facility assignment sheet for memory care reflected group 1,2, and 3, the resident name, cognition, behaviors, transfers, assist x1 or x 2, ADL reminders, stand aid, mechanical lift, gait belt, incontinent care, memory care door code, nutrition room door code, memory care door code to outside parking lot and patio. Review of the facility's in-services dated 12/03/2025 -12/04/2025 revealed all staff were educated regarding resident transfers, resident abuse and neglect, and pain management. Staff were instructed to make sure they are using proper techniques when transferring, especially using two staff members with the mechanical lift. Staff were also educated on where to find information on how a resident was transferred. For CNAs, the information was on the group assignment sheets, and for nurses, the information was on residents' care plan, Review of the facility's undated Transfer with mechanical lift policy reflected, Purpose. A resident who is non weight bearing, has weight bearing restrictions, has lower extremity weakness, or has difficulty standing will be transferred using a mechanical lift to reduce the risk of injury to resident and staff 676386 Page 3 of 3