Health inspection·September 5, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 (Resident #2) reviewed for care plans.CNA L and CNA X failed to follow the care plan for Resident #2 and transferred Resident #2 without a mechanical lift on 08/16/2025. This deficient practice could place residents who are transferred at risk for injury.The findings included:Record review of an undated face sheet revealed Resident #2 was an [AGE] year-old female who admitted to the facility for hospice respite on 08/13/2025 with diagnoses that included Alzheimer's Disease (a progress disease that affects memory and other important mental functions) and Hypertension (high blood pressure). Record review of a facility form titled, Facility Order Form, dated 08/13/2025 revealed Resident #2's name and an order, Utilize [mechanical lift] to tx into high back wc. Record review of Resident #2's August 2025 physician order summary revealed an order, Utilize [mechanical lift] to transfer into high back wheelchair, dated 08/13/2025. Record review of Resident #2's care plan for ADL self-care performance revealed an intervention, TRANSFER: requires (x)2 staff participation with [mechanical] lift for transfers. Record review of Resident #2 Kardex provided by the MDS Nurse revealed, TRANSFER: requires (x) 2 staff participation with [mechanical] lift for transfers. Record review of a facility document titled, Provider Investigation Report, dated 08/21/2025 revealed on 08/21/2025 at 4:00 p.m. Resident #2 was transferred by 2 CNAs without the use of a [mechanical] lift. The document revealed the physician, and responsible party was notified, and staff was educated on reporting abuse and neglect, resident rights and transferring residents. During an interview with Resident #2's family member, 08/29/2025 at 9:06 a.m., the family stated Resident #2 was a mechanical lift transfer at home and Resident #2 was admitted to the facility on [DATE] for a 5 day respite stay and returned home on [DATE]. Resident #2's family member stated they were at the facility on 08/16/2025 and asked 2 CNAs to get Resident #2 out of bed so the family member could take Resident #2 to the dining room for dinner. The family member stated 2 CNAs entered the room and the family member stepped outside of the room while the resident was transferred from the bed to her wheelchair. The family member stated a mechanical lift was not in the room or and was not brought into the room for Resident #2's transfer. The family member stated she did not tell or remind the 2 CNAs that Resident #2 was a mechanical lift transfer. The family member stated she left the facility after feeding Resident #2 and was not present when Resident #2 was transferred back to bed. During an interview with CNA L, 08/29/2025 at 3:24 p.m., CNA L stated she would determine a resident's transfer status by reviewing the resident's Kardex that reflected how a resident was to be transferred from one surface to another. CNA L stated, if the resident Kardex did not reveal a transfer status, CNA L would have asked the Charge Nurse prior to transferring a Page 1 of 3 676478 676478 09/05/2025 Harbor Valley Health and Rehabilitation 6211 Old Pearsall Road San Antonio, TX 78242

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident. CNA L stated she had received training on reviewing a resident's transfer status on the Kardex prior to performing a transfer. CNA L stated Resident #2's family member requested CNA L and CNA X to get Resident #2 out of bed and into her wheelchair on 08/16/2025 before dinner. CNA L stated she did not review Resident #2's Kardex or ask the charge nurse about Resident #2's transfer status prior to performing the transfer with CNA X without the mechanical lift. CNA L stated she placed Resident #2's hands on CNA L's shoulders and CNA L wrapped her arms around Resident #2's waist and picked her up off of the bed like a bear hug and sat her down in Resident #2's wheelchair. CNA L stated CNA X was adjusting Resident #2's high back wheelchair during the transfer. CNA L stated she could not remember if she assisted Resident #2 back to bed that evening and stated she did not transfer Resident #2 out of bed on 08/17/2025. During an interview with the DON, 08/29/2025 at 6:45 p.m., the DON stated Resident #2 admitted to the facility on [DATE] and was a mechanical lift transfer. The DON stated CNA staff was made aware of a resident's transfer status by reviewing the Kardex and nurses would review a residents physician order and care plan. The DON stated the transfer status information in the Kardex was originated from the resident's care plan. The DON stated staff had been trained and educated on using the Kardex to identify transfer status during orientation upon hire and on quarterly competencies. The DON stated it was important for staff to use to correct transfer techniques and procedures to prevent injury or harm to residents and stated CNA L and CNA X received written counseling and was reeducated on using the Kardex to determine a resident's transfer status prior to transferring a resident. During an interview with CNA X, 08/30/2025 at 12:11 p.m. CNA X stated she had received training on resident transfers when CNA X began working at the facility in February 2025 and stated she was trained to look at a resident's Kardex to determine a resident's transfer status. CNA X stated she would ask the charge nurse about a resident's transfer status if CNA X did not see transfer status information in a resident's Kardex. CNA X stated she assisted CNA L with transferring Resident #2 from the bed to the wheelchair before dinner on 08/16/2025 and CNA X stated she did not check Resident #2's Kardex to determine Resident #2's transfer status prior to the transfer. CNA X stated Resident #2 was transferred with 2 people without using the mechanical lift. During an interview with CNA X, 08/30/2025 at 1:25 p.m., CNA X stated she assisted Resident #2 back to bed after dinner on the evening of 08/16/2025 with the assistance of another CNA and Resident #2 was transferred without the mechanical lift. During an interview with the MDS Nurse, 08/30/2025 at 3:40 p.m., the MDS Nurse stated she was responsible for adding individualized care plans to a resident's comprehensive plan of care and the MDS Nurse would add the care plan to each resident's Kardex. The MDS Nurse stated she added Resident #2's transfer status information into the Kardex the day after admission, that morning. The MDS Nurse stated a resident could sustain a skin impairment, fracture, or fall if the information on the transfer status for a resident on the Kardex was not followed when a staff member was providing care.During an interview with the Administrator, 09/03/2025 at 1:01 p.m., the Administrator stated he was notified by Resident #2's family member on 08/20/2025 that the family member observed 2 staff members transfer Resident #2 without the mechanical lift. The Administrator stated he reported the incident to HHSC because the facility staff failed to transfer Resident #2 correctly and it could have posed a risk to Resident #2. The Administrator stated CNAs should review a resident's Kardex prior to providing care and prior to transferring a resident and stated failure to follow the Kardex could result in physical harm or cause physiological complications. Record review of a facility policy titled, Care Plan (Copyright 2001 [company name] Revised August 2007), revealed a policy statement, our facility develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological 676478 Page 2 of 3 676478 09/05/2025 Harbor Valley Health and Rehabilitation 6211 Old Pearsall Road San Antonio, TX 78242

F 0656 Level of Harm - Minimal harm or potential for actual harm needs. The Policy and Interpretation and Implementation revealed, 2. The comprehensive care plan has been designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; c. Build on the resident's strengths; d. Reflect treatment goals and objectives in measurable outcomes; e. Identify the professional services that are responsible for each element of care; f. Prevent declines in the resident's functional status and/or functional levels. Residents Affected - Few 676478 Page 3 of 3