Health inspection·December 22, 2025

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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676386 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 676386 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Rest Haven 503 Meadow Drive West, TX 76691 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 - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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 Event ID: Facility ID: 676386 If continuation sheet Page 3 of 3