Inspection·February 21, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm 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 interview and record review, the facility failed to ensure the resident environment remained free of accidents hazards and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 3 residents reviewed for accidents hazards. The facility failed to ensure that Resident #1 who was a two-person transfer was transferred as a two person transfer instead of a one-person transfer. This failure could place residents at risk of falls or injuries. Findings included: Review of Resident #1's electronic face sheet dated 02/21/2024, revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities), Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), and hypertension (high blood pressure). Review of Resident #1's quarterly MDS dated [DATE], revealed Resident #1 had a BIMS of 01 which indicated severe cognitive impairment. Review of section GG titled functional abilities and goals indicated Resident #1 required two person assist for transfer from chair to bed. Review of Resident #1's care plan revised 03/16/2022 indicated focus areas included the following: Resident #1 had an ADL Self Care Performance Deficit. interventions included to TRANSFER: The resident requires mechanical Hoyer lift with two staff for assistance. Review of camera footage dated 02/12/2024 at 7:29 AM provided by Family A revealed CNA B had Resident #1 on the sling and hooked the sling up to the mechanical Hoyer lift. CNA B proceeded to lift Resident #1 off the bed and attempt to position him to transfer him to the wheelchair without assistance of another CNA. CNA B lifted Resident #1 from over the bed then put him back over the bed and left him hanging in the air while she went to get assistance. Observation on 02/21/2024 at 10:50 AM, Resident #1 was in his bed in the lowest position with a mat on the floor. Resident #1 was not able to complete an interview due to cognitive impairment. Interview on 02/21/2024 at 10:53 AM, CNA C stated she did assist CNA B with transferring; however, she was not sure if CNA B had attempted to transfer Resident #1 before she arrived to the room. CNA (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 745019 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 745019 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE James L West Center for Dementia Care 1111 Summit Ave Fort Worth, TX 76102 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)