Health inspection·October 14, 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 ensure the resident environment remains as free of hazards as is possible; and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Residents #1) of 4 residents reviewed for accidents and supervision. On 8/29/25 Resident #1, while being transferred by CNA A and CNA B via mechanical lift from bed to wheelchair, hit her left foot against the mast of the mechanical lift. CNA A failed to protect Resident #1's feet during the mechanical lift transfer. Resident #1's x-ray results: acute third digit proximal phalanx shaft and neck fracture (The largest and longest phalanx bone, it is the base of the toe.) An Immediate Jeopardy was identified on 10/10/2025. The Immediate Jeopardy template was provided to the facility on [DATE] at 02:59 p.m. While the Immediate Jeopardy was removed on 10/11/2025 at 6:10 p.m. the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that was not an immediate jeopardy because of the facility's need for continued monitoring of implemented procedures. These failures placed residents at risk of injuries. The findings included: Record review of Resident #1's face sheet dated 10/9/2025 reflected an [AGE] year-old female with an admission date of 11/30/2024 with DX. cerebral infarction (stroke), spinal stenosis (spinal space surrounding the spinal cord becomes narrowed.) Record review of Resident #1's quarterly MDS dated [DATE] reflected a Brief Interview for Mental Status scored 14 (no cognitive impairment). Resident #1 had functional limitations in range of motion on upper and lower extremities. Resident#1 was totally dependent for transfers. Record review of Resident #1's comprehensive care plan dated 09/17/2025 revealed she required 2-person assistance for transfers and bed mobility. Record review of Resident #1's x-ray results: acute third digit proximal phalanx shaft and neck fracture (The largest and longest phalanx bone, it is the base of the toe.)Record review of facility policies indicated facility did not have a policy on mechanical lift.During an interview on 10/8/25 at 11:00 a.m. Resident #1 said that during a transfer she was on the mechanical lift and when the CNA turned her, her foot bumped to the mast of the mechanical lift. Resident#1 said that she told CNA A and B that she had felt pain in that instant. Resident #1 said she went to Occupational Therapy and voiced to Occupational Therapist Assistant (OTA) that she had severe pain to her left foot. During an interview on 10/8/25 at 3:11 p.m. OTA said Resident#1 went to therapy between 1:00pm - 2:30pm on 8/29/2025 and Resident#1 complained of pain to her left foot. OTA said she observed that Resident#1's left foot had a bruise. OTA said that she reported to the DOR and then DOR reported to LVN C. OTA said LVN C conducted an assessment and noted a purple discoloration to Resident#1's left foot. OTA said that LVN C immediately notified NP and got orders for x rays. During an interview on 10/8/25 at 3:20pm DOR said that OTA informed her that Resident#1 was complaining of pain to her left foot. DOR said that she went to notify LVN C on 8/29/2025. During an interview on 10/8/25 at 3:32 pm LVN C said she was informed on 8/29/25 by the DOR of Resident # 1 having had Page 1 of 3 676398 676398 10/14/2025 Fox Hollow Post Acute 310 America Dr Brownsville, TX 78526

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few pain to her left foot. LVN C said she immediately assessed Resident #1 and she noted discoloration to her left foot and notified the nurse practitioner. LVN C said that the nurse practitioner ordered X-Rays. During a phone interview on 10/8/25 at 4:39 p.m. CNA A said she and CNA B around 8:30 AM were transferring Resident # 1 on 8/29/2025 from the bed to the wheelchair. CNA A said that during the transfer, CNA B moved the resident to the left which caused her to bump her foot against the mast of the mechanical lift. CNA A said, Resident # 1 did not complain of pain, we continued with the transfer and did not report to LVN C because I thought it was not significant. During an interview on 10/9/25 at 10:00 a.m. CNA B said while she and CNA A transferred Resident # 1 on 8/29/25 from bed to wheelchair via mechanical lift, she was in charge of guiding Resident # 1 to her wheelchair. CNA B said Resident #1 grunted at the moment her foot hit the mast of the mechanical lift. CNA B said after the transfer she and CNA A looked at her left foot and did not notice anything wrong. CNA B said she had failed to report the incident to LVN C. During an interview on 10/9/2025 at 11:00 a.m. DON said CNAs did not report the incident because it was only a tap against the mechanical lift and that Resident#1 did not complain of pain. DON said that investigation and assessments were initiated immediately after being notified by the Director of Rehabilitation. DON said that the facility does not have a policy on mechanical lifts. An Immediate Jeopardy was identified on 10/10/2025. The Immediate Jeopardy template was provided to the administrator's facility on 10/10/2025 at 02:59 p.m. Verification of IJ: Started on 10/11/2025 at 09:00 a.m. and included:Record review of an In-Service with subject of Change of Condition, dated 09/15/2025, indicated that working staff signed the in-service record. Record review of an In-Service with subject of Hoyer Transfer, dated 08/29/2025, indicated that working staff signed the in-service record. Record review of an In-Service with subject of Hoyer Transfer and training, dated 10/09/2025, indicated that working staff signed the in-service record.Record review of an In-Service with subject of Abuse, Neglect, and Exploitation, dated 08/29/2025, indicated that working staff signed the in-service record. Record review of Resident #1 pain assessment done on 10/10/2025. Record review of Resident #1 head to toe assessment done on 10/10/2025. Record review of QAPI with subject of notification of changes condition,, dated 10/11/2025, indicated that Director of Nurses, Director of Rehabilitation, Dietary Representative, Activities representative, and MDS participated in the QAPI meeting. Record Review of updated change in condition policy dated 10/10/25. Record review of 24 hour review and random mechanical lift transfer monitoring done on 10/10/2025. Record review of safety/abuse survey on random residents dated 10/10/25. During interviews on 10/11/2025 from 9:00 a.m., to 6:00 p.m. CNAs A, B, E, G, I, P, S were from the 6 am to 2 pm shift, CNAs F, H, J, K, L, M, Q, R, T from the 2 pm to 10 pm shift, CNAs N, O, and from the 10 pm to 6 am shifts revealed. were all knowledgeable of the expectation that if when providing care to a resident a change was noticed CNAs were to stop the care and inform the charge nurse verbally and with the stop and watch form. CNAs indicated where the stop and watch form was located at the nurses' station. LVNs C, U, and V from the 7 a.m. to 7 p.m. shift and RN W from the 7 a.m. to p.m. shift and DOR from the 8 am to 5 pm shift, revealed were knowledgeable of the procedure of that the CNAs should follow when a change was noted in a resident. LVNs interviews revealed LVNs should immediately assess resident after CNAs notified them of a change. A mechanical lift observation was done on 10/11/25 at 11:00 a.m., for Resident#1 assisted by CNAs A and B revealed CNAs follow procedure to transfer resident from wheelchair to bed using mechanical lift. CNAs used a bed sheet to assist with bed reposition as instructed by training. A mechanical lift observation was done on 10/11/25 at 12:00 p.m., for Resident #2 assisted by CNAs A and B revealed CNAs follow procedure to transfer resident from wheelchair to bed using mechanical lift. CNAs used a bed sheet to assist with bed reposition as instructed 676398 Page 2 of 3 676398 10/14/2025 Fox Hollow Post Acute 310 America Dr Brownsville, TX 78526

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few by training. A mechanical lift observation was done on 10/11/25 at 01:58 p.m., for Resident #3 assisted by CNAs A and B revealed CNAs follow procedure to transfer resident from wheelchair to bed using mechanical lift. CNAs used a bed sheet to assist with bed reposition as instructed by training. A mechanical lift observation was done on 10/11/25 at 02:40 p.m., for Resident #4 assisted by CNAs A and B revealed CNAs follow procedure to transfer resident from wheelchair to bed using mechanical lift. CNAs used a bed sheet to assist with bed reposition as instructed by training. A mechanical lift observation was done on 10/11/25 at 03:20 p.m., for Resident #5 assisted by CNAs A and B revealed CNAs follow procedure to transfer resident from wheelchair to bed using mechanical lift. CNAs used a bed sheet to assist with bed reposition as instructed by training. The Administrator was informed that the Immediate Jeopardy was removed on 10/11/2025 at 6:10 p.m., however, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated due to the facility need to evaluate the effectiveness of the corrected system. 676398 Page 3 of 3