Health inspection·October 3, 2023

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of video captured on audio visual equipment supplied by FM 1 showed: On 09/23/23 at 6:42 AM. CNA C and NAIT D were assisting R#5 out of bed. During the transfer, NAIT D proceeded initiate sling placement under R#5 while CNA C left the immediate area to retrieve a wheelchair and bring it to area where mechanical lift was occurring. NAIT D did not verify placement of the sling loops or sling under resident and proceeded to engage the mechanical lift. Once R#5's bottom was off the bed enough, NAIT D started to swing resident towards the wheelchair. At the 0:54 second mark of video footage, the upper right loop can be seen dropping from hook, and R#5 being sent to the floor face first. CNA C then runs out of room to get assistance while NAIT D stays at R#5's side while on the floor. The sling shown on the video was all blue in color. It was unclear in the video, if the sling had a purple trim, but was clearly the incorrect sling as it was not grey with red trim (R #5's current sling size needed on 09/23/23). Record review of photographs supplied by FM 1 on 09/26/23 reflected Photo #1- R #5 with open laceration above left eyebrow and bruising around. Photo #2- R #5 with lacerations above left eyebrow and on nose of bridge with stitches. Bruising also noted to both eyes, nose, and left cheek bone dark purple in color. Photographs are not dated or timestamped. FM 1 indicated photographs were taken on 09/23/23 when R #5 was in the hospital. Record review of the hospital records dated 09/23/23 reflected R #5 fell from a lift while being transferred from bed to chair at about 7 AM. R #5 sustained a mild right temporal subdural acute hematoma (internal brain bleed), interhemispheric subdural hematoma (brain bleed between the two hemispheres of the brain), bilateral nasal bone fractures, left medial orbital (eye) fracture, forehead/nasal bridge lacerations, and 9 stitches (8 on top of his left eye and 1 on his nose bridge). Interview with FM 1 on 09/26/23 at 9:00 AM. FM 1 said the family was informed that R #5 fell off the lift machine. FM 1 said FM 1 have cameras in R #5's room. FM 1 said in the video, the staff put R #5 on the sling, but the staff must have not put it on right. FM 1 said when R #5 was being lifted to the chair, the sling snapped off the lift. FM 1 said FM 1 is not sure what happened or how the sling came off. FM 1 said the staff must have not clipped it on correctly. FM 1 said R #5 ended up falling face first to the floor from about 5 feet up. FM 1 said R #5 is heard grunting. FM 1 said one staff went to get a nurse or help. FM 1 said the other staff stayed with R #5. FM 1 said FM 1 was not sure who the staff were. FM 1 said R #5 was in the hospital and FM 1 took photos of R #5's face. FM 1 said R #5 had a cut on top of his left eye which required stitches. FM 1 said R #5 also had an internal bleed. FM 1 said R #5 was discharged back to the facility. Observation of R #5 on 09/26/23 at 1:30 PM. R #5's room was clean, free of odors, and had a homelike environment. R #5 appeared with good personal hygiene and was not in distress. R #5 had bruising to left eye area and bruising to his nose. R #5 had 8 stitches to his left eyebrow and 1 stitch to the bridge of his nose. Call light was within reach. Bedside fall mat beside bed on left side. Right side of bed was against the wall. Bed had grey infant bedside rails on both sides. Staff and resident interactions were appropriate. Staff knocked on the door before entering and provided privacy. No other concerns noted. Interview with CNA A on 09/26/23 at 1:55 PM. CNA A said some staff are not as experienced, so they really do not know how to use the lift properly. CNA A said CNA A did not really know the specifics of how to use the lift, until now, because they did the in-service recently on the lift, after R #5 had the incident. CNA A said CNA A had not been in-serviced or trained on how to use the lift until now. CNA A said she was not working during the incident with R #5 on 09/23/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745000 If continuation sheet Page 2 of 8 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 745000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576 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 Interview with CNA C on 09/26/23 at 3:20 PM. CNA C said CNA C worked on 09/23/23 when R #5 fell off the lift at around 6:40-6:50 AM. CNA C said CNA C assisted another resident and NAIT D went to get the lift. CNA C said NAIT D began putting R #5 into the sling and hooked R #5 onto the lift. CNA C said she went to the restroom to get R #5's wheelchair. CNA C said NAIT D raised the lift as CNA C brought the wheelchair. CNA C said NAIT D moved the lift and R #5 fell. CNA C said NAIT D had said that she clipped R #5 in right. CNA C said CNA C ran to ask for help and NAIT D stayed with R #5. CNA C said CNA C ran to the nurse's station to call the nurses. CNA C said the nurses went to R #5's room. CNA C said NAIT D stayed with R #5 the whole time. CNA C said CNA C went to get stuff that the nurses needed. CNA C said the nurses called for the ambulance right away. CNA C said R #5 had a cut on his eyebrow. CNA C said the nurses applied pressure to the cut and took care of R #5 until EMS arrived. CNA C said the ambulance took R #5 to the hospital. CNA C said NAIT D was ascertained that NAIT D put R #5 correctly on the lift. CNA C said NAIT D had hooked R #5 onto the lift while CNA C got the chair out to have the wheelchair ready. CNA C said that was when NAIT D turned the lift and R #5 fell. CNA C said CNA C has been working since March 2022. CNA C said when CNA C started working at the facility, CNA C was trained on the lift. CNA C said CNA C did not remember being trained again after that initial training. CNA C said R #5 was a two-person assist with the lift. CNA C said one staff operates and moves the lift, and the other staff should be holding the feet. CNA C said she did not think to hold R #5's feet. CNA C said CNA C did not think that NAIT D would not hook R #5 on correctly. CNA C said CNA C went for the wheelchair instead of holding R #5's feet. CNA C said either way, CNA C would not have been able to hold R #5 up because R #5 is a big man and CNA C is only 5 feet. CNA C said the sling was not torn. CNA C said CNA C does not know how the sling came off the lift. CNA C said they did trainings on the transfers before this incident happened, but she does not remember if the training included the lift. CNA C said she had stopped working and returned to work in May or June 2023. CNA C said she did not work for about 2 or 3 months before returning. CNA C said she does not remember if she received training on the lift after she returned in May or June 2023. CNA C said DCE, and DON do the trainings. CNA C said they sign their name on a sheet to indicate they received and understood the training. CNA C said after the incident with R #5, she did an in-service on the lift and transfers. CNA C said this was after the incident. CNA C said CNA C did not think that the trainings they had provided before this incident were enough. CNA C said DON and the ADM told her she was suspended and to go home. CNA C said they did not say when CNA C could return to work. CNA C said this type of incident had never happened before where a resident fell off the lift. CNA C said CNA C could not believe it and could not explain how R #5 fell. Interview with NAIT D on 09/26/23 at 3:45 PM. NAIT D said NAIT D worked on 09/23/23 when R #5 fell off the lift. NAIT D said her shift had just started at 6 AM. NAIT D said CNA C assisted another resident then got R #5's wheelchair from the restroom. NAIT D said NAIT D assisted R #5 onto the sling and then clipped the sling onto the lift. NAIT D said this was around 6:40 AM. NAIT D said there are 4 clips that need to be hooked onto the lift. NAIT D said NAIT D was sure the clips were secured. NAIT D said the straps were on the same colors on both sides as well. NAIT D said NAIT D lifted R #5 from the bed with the lift. NAIT D said when NAIT D turned the lift, the clip came off, NAIT D heard CNA C say, be careful, and R #5 fell to the floor. NAIT D said there was no time for NAIT D to try to catch R #5 as it all happened very fast. NAIT D said NAIT D stayed with R #5 and CNA C ran for help. NAIT D said NAIT D was talking to R #5, asking R #5 if he was pain, and R #5 was moaning/grunting. NAIT D said CNA C called the nurses. NAIT D said the nurses went to the room and assessed R #5. NAIT D said the nurses called 911 right away. NAIT D said NAIT D stayed in the room until EMS arrived and took R #5. NAIT D (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745000 If continuation sheet Page 3 of 8 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 745000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576 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 said R #5 had a cut and was bleeding. NAIT D said the nurses cleaned the cut and applied pressure to stop the bleeding. NAIT D said NAIT D has worked at the facility since May 2023. NAIT D said when NAIT D started working, she was trained over several things. NAIT D said NAIT D does not recall if the lift was included in those trainings. NAIT D said about every 2 weeks or frequently, they do trainings over everything. NAIT D said after the incident, she did the training again on transfers and the lift. NAIT D said DCE did the training. NAIT D said she signed the sheet that she was trained. NAIT D said NAIT D was sure everything was clipped on correctly. NAIT D said usually, the other staff should be holding the feet to move the resident. NAIT D said CNA C was getting the wheelchair from the restroom. NAIT D said maybe if CNA C was holding R #5's feet, R #5 would have fallen on top of CNA C. NAIT D said CNA C would not have been able to catch R #5 because R #5 was heavy, and CNA C was a short, small lady. NAIT D said maybe R #5 would have fallen on CNA C instead of the floor. NAIT D said ADM and DON explained to them that they had to be suspended. NAIT D said this has not happened to NAIT D before. Interview with RN A on 09/26/23 at 4:15 PM. RN A said RN A worked on 09/23/23 when R #5 fell off the lift. RN A said RN A had just received report from the previous shift when CNA C went to the nurse's station and said CNA C needed help with R #5. RN A said RN A ran to R #5's room. RN A said RN A saw R #5 on the floor, laying on his side, and R #5 was bleeding from a cut on top of his left eyebrow. RN A said RN A did not recall if CNA C said what happened and RN A was focused on R #5. RN A said there was another staff in the room, but RN A did not know that staff's name. RN A said RN A applied pressure to R #5's cut and gave administered Tylenol for pain. RN A said there were other nurses in the room that assisted but does not recall who. RN A said 911 was immediately called and RN A stayed with R #5 until EMS arrived. RN A said R #5's vitals were normal, and neuro-checks were also initiated. RN A said between RN A and the other staff, they did notify the family, the doctor, and the DON. RN A said once EMS arrived, EMS staff moved R #5 to the stretcher and transported R #5 to the hospital. RN A said RN A called the hospital to give the hospital nurse report. RN A said R #5 only had the cut above his eyebrow. RN A said R #5 did not have any other visible injuries at that time when R #5 was taken to the hospital. RN A said after the incident, all the staff were re-trained on the lift. RN A said RN A was working part time and had not been working at this facility for a few months because RN A was working on becoming an RN from an LVN. RN A said the facility might have done a training on the lift during the time RN A was not working, but RN A had not received a training on the lift since RN A returned to work. RN A said the DON is the one that usually does those trainings. RN A said on 09/23/23, the facility started doing trainings with everyone on the lift. RN A said RN A was trained on the lift on 09/23/23. RN A said RN A has worked at the facility since March 2023 and R #5 has always required a two-person assist with the lift since RN A has been working here. RN A said for the lift, usually one person moves the lift and the other is with the resident when the resident is on the sling to ensure the resident is safe. RN A said it should be two people to put the sling under the resident, two people to clip the sling on, and two people for the entire process of using the lift. RN A said there are also different slings for different weights. RN A said RN A did not know what happened or how R #5 fell off the lift. RN A said RN A did not see or was not informed that the sling was torn or that the lift was not working. RN A said the lift was not broken and when the staff checked the lift after the incident, the lift/sling were in good working condition. Interview with LVN A on 09/27/23 at 11:10 AM. LVN A said she worked on 09/23/23 when R #5 fell off the lift. LVN A said it was early in the morning between 6:40-6:50 AM. LVN A said CNA C went to the nurse's station and said CNA C needed help. LVN A said it was herself and RN A. LVN A said they went to R #5's room. LVN A said HR informed LVN A that R #5 had a fall, so LVN A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745000 If continuation sheet Page 4 of 8 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 745000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576 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 grabbed the blood pressure cuff, the pulse oximeter, and the thermometer to check R #5's vitals. LVN A said RN A was assigned to R #5 but when there is an emergency, all the nurses assist. LVN A said when she entered R #5's room, LVN A noted that R #5 on his left side, with a puddle of blood underneath R #5's head. LVN A said RN A had already called 911. LVN A said LVN A took R #5's vitals and the vitals were normal. LVN A said LVN A asked LVN B to get some gauze. LVN A said they applied pressure with the gauze to stop the bleeding which was coming from a laceration above R #5's eyebrow. LVN A said R #5 also had a hematoma on R #5's left cheek bone. LVN A said they applied pressure and ice. LVN A said R #5 had a very small laceration to the top of R #5's nose. LVN A said LVN A stayed in the room and tried not to move R #5 because of the severity of R #5's injury. LVN A said they waited for EMS to arrive. LVN A said LVN B administered Tylenol because R #5 was moaning and was in noticeable pain. LVN A said once EMS arrived, EMS transferred R #5 to the stretcher and transported R #5 to the hospital. LVN A said RN A had notified the doctor, the family, and the DON. LVN A said there was another staff helping CNA C, but LVN A did not know her name. LVN A said LVN A asked CNA C and the other staff what happened, and they said that the sling just came off, but they could not say exactly how. LVN A said when R #5 was still on the floor, the lift was towards his feet and the sling was still hanging from the lift. LVN A said one of the hooks from the sling was completely off the lift, but the sling was not torn. LVN A said one of the hooks came off. LVN A said LVN A works full time and before this incident, LVN A does not recall the facility doing trainings for the lift. LVN A said LVN A has been working at the facility since May 2023 and was not trained on the lift when LVN A first started. LVN A said LVN A, and all the staff were trained on the lift and how to transfer the resident from the bed to the wheelchair and the wheelchair to the bed with the lift. LVN A said each sling holds a different weight. LVN A said R #5 does require a certain sling color, but LVN A does not recall which color. LVN A said that is something that they can look up in PCC. LVN A said there should always be two people for the lift. LVN A said one person works the machine and the other is supposed to help with the resident, ensuring the resident does not hit the machine and that the resident is not freely hanging. LVN A said when the lift is raises the resident, it becomes kind of like a swing, so at that point the other staff should make sure the resident is secured and not just hanging around, guiding the resident to the chair. LVN A said this was covered in the recent training on 09/23/23 after the incident. LVN A said R #5 has always required a two-person assist with the lift for transfers. Interview with LVN B on 09/27/23 at 11:25 AM. LVN B said LVN B worked on 09/23/23 when R #5 fell off the lift. LVN B said LVN A told LVN B that R #5 had a fall and LVN A was running to R #5's room with the blood pressure machine. LVN B said LVN B went to R #5's room to assist. LVN B said LVN A and RN A were already assessing R #5 when LVN B arrived at the room. LVN B said LVN B could see blood to R #5's face and on top of R #5's eye. LVN B said they did not want to move R #5 much because R #5 had a fall, and they did not know the extent of R #5's injuries. LVN B said LVN B went to get gauze and LVN A applied pressure to R #5's cut. LVN B said RN A had called 911. LVN B said LVN B assisted with printing out the documents needed for the hospital transport. LVN B said EMS arrived and EMS moved R #5 onto the stretcher. LVN B said CNA C and NAIT D were the ones assisting R #5 when the incident happened. LVN B said LVN B spoke to CNA C and NAIT D afterwards, and CNA and NAIT D had no clue of how R #5 fell. LVN B said one of them, LVN B does not remember which one, told LVN B it tore. LVN B said LVN B went back to check the lift which still had the sling on it, and LVN B was able to see that the 3 of the 4 hooks were still connected. LVN B said the sling was not torn, but the hook probably just came off. LVN B said nothing was torn or broken. LVN B said LVN B has worked at the facility since April 2023 and LVN B was not trained on the lift when she started. LVN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745000 If continuation sheet Page 5 of 8 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 745000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576 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 B said LVN B did not recall being trained on the lift before this incident. LVN B said LVN B works full time, and sometimes when LVN B is off, the facility does trainings, but LVN B will make up the trainings later. LVN B said LVN B does not recall missing any trainings on the lift. LVN B said after the incident, all staff were trained on the lift. LVN B said the facility does do a lot of trainings, on different topics such as the gait belt, but not the lift specifically. LVN B said R #5 has always been that type of transfer, two-person with the lift. LVN B said there are not that many residents that use the lift. LVN B said usually it's always the CNAs that do those transfers, but whenever they are busy LVN B will go assist to do the transfer. LVN B said the facility did do trainings right after the incident on 09/23/23. LVN B said the trainings covered lift and transfers. LVN B said the staff were informed of how to do the entire process. LVN B said when LVN B was in school, LVN B was taught how to use the lift machine, so that is how LVN B would know how to use the lift before this incident even though LVN B had not been trained at this facility. LVN B said this had not happened before where a resident fell off the lift like this. Interview with ADM on 09/27/23 at 1:00 PM. ADM said ADM was the abuse/neglect coordinator and ADM trains staff on abuse and neglect mostly. ADM said DON and DCE would train and re-educate staff on transfers, anything to do with the care of residents or anything clinical. Interview with DON on 09/27/23 at 2:40 PM. DON said staff are trained upon being hired and staff go through a checklist to ensure the staff have received all training including training on the lift. DON said training is also ongoing and education is never ending. DON said the lift must be always used with two staff members. DON said the last training on the lift before the incident on 09/23/23 was on 07/24/23. DON said CNA C and NAIT D were trained on 07/24/23. DON said there is a competency assessment used for the lift to ensure staff understand the training. DON said the staff do not do a return demonstration, but the staff sign the roster that they understood the training and information being taught. DON said DON was immediately informed of the incident on 09/23/23 with R #5. DON said the staff followed the protocol for falls by notifying the nurse, providing medical attention, notifying the doctor, family, and DON. DON said CNA C and NAIT D could not explain how R #5 fell off the sling. DON said CNA C and NAIT D had effectively transferred R #5 all the time before this. DON said besides the laceration on top of R #5's eye, R #5 did have other injuries. DON said R #5 had a mild right temporal subdural acute hematoma, interhemispheric subdural hematoma, bilateral nasal bone fractures, left medial orbital fracture, and lacerations. DON said R #5 required 8 stitches to R #5's eyebrow and 1 stitch to R #5's nose. DON said CNA C and NAIT D were in-serviced on transfers and the lift on 09/23/23 before being suspended. DON said on 09/23/23, the facility also began in-services and re-educated all nursing staff on how to use the lift. DON said the lift used on 09/23/23 was removed from the floor. The lift was observed in DON's office. DON said the lift was not broken and it was in good working condition. DON said no issues had been reported with the lift/sling. DON said R #5 used to use a red sling because of R #5 was on average 135 pounds and within that weight limit (75-150 pounds). DON said R #5's transfer status was reviewed on 09/23/23 after the incident because the team did audits on all residents that require the lift. DON said the team decided R #5 should use a yellow sling (125-200 pounds) because R #5 has contractures and R #5 is tall, and the bigger sling provides extra room for R #5 to keep R #5's close to R #5's body. DON said on 09/23/23, R #5 would need the red sling. DON said the slings are grey and have the different color on the trimming only. DON said the sling used on 09/23/23 was not torn. DON said an all-blue sling would be an extra-large sling (275-500 pounds). DON said DON cannot say that using a sling too large for the resident would have caused R #5 to fall off the sling. DON said once the lift raises, the resident hangs in the sling, which causes the sling to sort of envelope the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745000 If continuation sheet Page 6 of 8 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 745000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576 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 inside, thus, a bigger sling would not cause the resident to fall off. Level of Harm - Immediate jeopardy to resident health or safety Interview with HR on 09/27/23 at 4:00 PM. HR said HR worked on 09/23/23 when R #5 fell off the lift. HR said HR was in the hall when HR saw the nurses running to R #5's room. HR said HR went to the room and saw R #5 on the floor. HR said HR could not see R #5's injury right away since the nurses were surrounding him. HR said HR could hear R #5 moaning. HR said HR saw R #5 had a cut on R #5's eyebrow and a bump on his cheek. HR said CNA C and NAIT D were in the room. HR said CNA C and NAIT D could not explain how R #5 fell off the lift, and CNA C and NAIT D were puzzled because they said they put R #5 correctly on the lift. HR said HR stayed in the room until EMS arrived. HR said EMS transported R #5 to the hospital and HR went back to HR's office. Residents Affected - Few Interview with DON on 09/28/23 at 11:15 AM. DON said the sling used on 09/23/23 was the sling observed at this time (all-blue sling with purple trim). DON said the sling was removed from the floor after the incident on 09/23/23. DON said the sling used was meant to be used in the shower because it has holes (more of a mesh material). DON said those slings were not supposed to be used anymore as that sling was for a previously used lift. DON said DON was not sure why that sling was on the floor, but it was not the sling to be used with the current lift. DON said the sling was a different brand and was not a sling for the brand of lifts the facility currently use. DON said DON was unsure of how this sling was still on the floor and DON was unsure of who would be responsible for removing discontinued slings/equipment. DON said corporate sends new equipment, but the facility has always had these same lifts since DON has been working here (since June 2021), a few months after the facility first opened. DON said DON will find out the weight limits for this specific sling. DON said the sling was not meant to be used for the lift. DON said staff are trained to ensure the proper sling was used for the specific lift. DON said that is part of the competency assessment checklist. DON said the only thing that the team thinks might have happened on 09/23/23 is that the hook was not all the way into the lift mechanism. DON said the team believes the hook was stuck in between the mechanism and when the lift raised the resident the hook snapped out of it. DON said now the facility has instructed the staff to tug on the straps on ensure the hooks are on correctly. DON said that was not part of the staff's training before. Interview with RA E on 09/28/23 at 12:15 PM. RA E said RA E has worked here for 2 years and the facility has always had the same lifts. RA E was shown the all-blue sling that was used on 09/23/23. RA E said that was a shower sling because it is mesh, but that is not a sling they use at this facility. RA E said RA E did not know why this sling was on the floor. RA E exhibited the current slings used with the current lifts in the facility. RA E said the hooks for the current slings are a little thinner and more flexible so the hooks would go into the lift mechanism easier. RA E said the shower sling is too thick and would probably not work on the lift. RA E said the staff must follow what they are trained on, and the staff is trained how to use the correct sling with the correct lift. Interview with DOM on 10/02/23 at 4:10 PM. DOM said DOM inspects the lifts every month. DOM said there had been no issues or reports that the lift/slings were not working properly or that they had been broken/torn. DOM said DOM has worked at the facility for 2 years and the brand for the lifts/slings has never changed, at least since DOM started working. DOM said DOM will now be inspecting the slings/lifts every week until DOM was instructed to go back to once a month. DOM said all staff were informed/trained to inspect the slings/lifts and if something was not in good condition, the staff must take the sling/lift to DON and do not leave it on the floor. Observation of R#5 on 10/03/23 at 11:35 AM of a transfer with mechanical lift. CNA P and CNA Q followed the proper steps noted on the competency assessment for using a mechanical lift machine. CNAs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745000 If continuation sheet Page 7 of 8 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 745000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576 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 checked the POC, ensured correct sling (grey with yellow trim) was brought to the room along with the lift, explained to R #5 the care provided, CNAs performed hand hygiene, provided privacy to R #5, communicated as they placed sling under R #5, hooked R #5 to lift, secured sling, lifted R #5 a few inches, ensured sling was secure by tugging on hooks, moved lift while CNAs guided R #5, placed the wheelchair in between the lift's legs, lowered R #5 to wheelchair, ensured R #5 head and extremities did not hit the lift, unhooked the sling from the lift and communicated to unhook same sides, moved the lift away ensuring R #5 was not hit, tucked in the sling under R #5, ensured R #5 was safe and comfortable, and removed the lift from the room to disinfect. CNAs communicated throughout the entire process, with each other as well as with R #5. CNAs also put on the breaks/took off the breaks as needed for the lift/wheelchair throughout the process. No further concerns were noted upon observation. Interview with DON on 10/03/23 at 1:17 PM. DON said the POR was followed and completed. DON said all nursing staff were re-trained on safe transfers, safe movement/repositioning, abuse/neglect, infection control, privacy, and fall prevention. DON said all staff were also re-educated on how to look up information in the system of communication in PCC that documents individualized resident care needs to verify the sling needed and other information regarding the resident's specific care needs. DON said all staff had the hands-on training and had to do a return demonstration before the competency was checked off to ensure staff knew how to carry out the process. DON said were trained to inspect the sling/lift before using it to make sure the equipment is in good working condition. DON said the staff were trained that the lift must be used with two staff and the two staff should be engaged during the entire process. DON said the focus of the transfer should be the resident's safety throughout the whole process. DON said the trainings began on 09/23/23 and were completed on 09/29/23. DON said the facility will be doing random spot checks every Monday, Wednesday, and Saturday for at least 3 months and then after, to ensure staff are following their trainings. DON said the spot checks will be documented in the monitoring log which they started doing yesterday, 10/02/23. DON said DON and DCE will be training new hired staff and the staff will need to do the competency assessment with return demonstration. DON said the risk management reports, progress notes, and 24-hour reports will be reviewed on a 24-hour basis, during the morning meetings. DON said DCE works on the weekends and DCE would take care of reviewing those documents on the weekends. DON said DON did view the video of the incident on 09/23/23 with R #5. DON said the staff were not paying attention and were not focused on the task. DON said if the staff had paid attention to what they were doing then all of this would have been avoided. DON said the staff should have been working together, both applying the sling, both close to each other, engaging the resident, engaging with each other, having the wheelchair close by before starting the process, and making sure the sling was applied well to the hooks. DON said the staff were not communicating with each other on what they were doing. DON said if staff were not properly trained, then that would place the residents at risk of injuries or incidents like this fall on 09/23/23. Interview with ADM on 10/03/23 at 2:15 PM. ADM said the team completed all trainings required with all staff. ADM said everything in the POR was completed and followed. ADM said DON has conducted spot check observations and has noted no concerns. ADM said DON, DCE, and clinical staff will be training new staff who will be required to do a return demonstration and ensure the staff are competent before working the floor. ADM said every morning, the team will review the risk management reports, progress notes, and 24-hour reports. ADM said on 09/23/23, ADM was immediately notified by R #5's FM 1. ADM said FM 1 always reaches out to ADM if there are any issues. ADM said FM 1 showed R #5 the video of the incident and that is why ADM implemented a plan right away because what ADM saw was not good. ADM said the lift[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745000 If continuation sheet Page 8 of 8