Health inspection·October 6, 2023

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the residents environment remained as free from accident hazards as was possible; and that each resident received adequate supervision to prevent accident hazards for one resident (Resident #1) of 7 residents observed for accident hazards. -CNA A transferred Resident #1 in an unsafe manner resulting in a small skin tear and a large bruise to her left lower leg. This failure could affect all the residents at the facility by placing them at risk for accidents that lead to injuries such as bruising, skin tears, fractures, subdural hematomas, and feeling of isolation. Findings include: Record review of the clinical record for Resident #1 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include senile degeneration of the brain (a decreased in the ability to think, concentrate, or remember), heart failure (a condition in which the heart dose not pump blood as well as it should), dementia (a group of thinking and social symptoms that interferes with daily functioning), CAD (damage or disease in the hearts major blood vessels), malnutrition (lack of proper nutrition), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), pain, falls, and osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down). Record review of Resident #1's last MDS was a quarterly completed 5-23-2023 listing her with a BIMS of 10 indicating she was moderately cognitively impaired, and she had a functionality of requiring one-to-two-person assistance with activities of daily living. Resident #1 was listed and requiring two+ persons physical assist with: B. Transfer - how resident moves between surfaces including to or from: bed, chair wheelchair, standing position. Record review of Resident #1's clinical record revealed active orders as of 10-6-2023 with the following order: Stand-up lift for all transfers every shift. Order date - 5-6-2023 Record review of Resident #1's clinical record revealed a care plan with the following: admission Date: 10-7-2019 Page 1 of 4 745022 745022 10/06/2023 Ware Memorial Care Center 1510 S Van Buren St. Amarillo, TX 79101

F 0689 Focus: ADL's Level of Harm - Actual harm Intervention: Stand-up lift for all transfers. Date initiated - 5-24-2023. Residents Affected - Few Record review of facility provided record titled Clinical Tasks revealed the following: Resident #1 Date initiated: 10-7-2019. Last Revision Date: 10-5-2023 Standard Task: ADL - Transferring Instructions: Stand up lift with all transfers Position: Certified Nursing Aide -Per interview completed on 10-6-2023 at 1:40 PM with the DON who verified that this is in the task assignment area in the computer system that is to be reviewed by each CNA assigned to the resident prior to providing care. Record review of the facility provided Progress Note received 10-6-2023 revealed the following: Resident #1 Type: Incident Note Effective Date: 8-1-2023 Department: Nursing Position: LVN (Per interview with the DON this LVN was on vacation and unavailable), Note Text: Left outer lower leg bumped wheelchair during transfer. 1.5cm x 1.5cm skin tear with skin flap intake noted .Resident nor CNA noticed injury occurred at that time. Resident #1 Type: Skin/Wound Note Effective Date: 9-13-2023 Department: Nursing Noted Text: Called to elder room. Old skin tear re-opened and started bleeding, add 3 steri strips, large dark purple bruise noted on leg. During an interview on 10-6-2023 at 09:06 AM LVN B (the nurse responsible for Resident #1 today) 745022 Page 2 of 4 745022 10/06/2023 Ware Memorial Care Center 1510 S Van Buren St. Amarillo, TX 79101

F 0689 Level of Harm - Actual harm Residents Affected - Few reported that Resident #1 did have an injury to her left lower leg that LVN B did not witness when it occurred but heard that a staff member injured her during a transfer. LVN B reported that she has worked with Resident #1 for 4 years, and was very familiar with her care, Resident #1 was currently on hospice, and was expected for her health to deteriorate. LVN B verified that Resident #1 did have a large bruise and small skin tear to her left leg that LVN B offered to show to this surveyor. During an observation and interview completed on 10-6-2023 at 09:14 AM Resident #1 was in her room in her recliner with her feet elevated on a cushion. Resident #1 was noted to have a large dark purple bruise to her left shin approximately 5 inches by 3.5 inches and a small dry skin tear to her upper left shin that had two steri strips that were in the process of pealing. There was no noted drainage on the dressing when removed by LVN B. LVN B confirmed that Resident #1 did not have a fracture or any other injury. Resident #1 stated Another person dropped me, and I should have bopped her one. Resident #1 then went back before LVN B could complete rewrapping her leg and this surveyor could complete the interview. During an interview on 10-6-2023 at 10:08 AM the DON reported that Resident #1 was not dropped by a staff member, that they were transferring her from her wheelchair to her bed and Resident #1 bumped her leg. The DON verified that she had a report for the incident and that she would provide this surveyor with a copy. During an interview complete by phone on 10-6-2023 at 12:44 PM CNA A reported that she was the CNA that transferred Resident #1 on 8-1-2023, that she transferred Resident #1 by herself, that she had not worked with Resident #1 in a while and did not realize how weak Resident #1 had become. CNA A reported that the facility had enough staff that shift and she thought that Resident #1 was strong enough to assist with the transfer. CNA A reported that Resident #1 used to be fairly independent and could use her legs. CNA A reported that during the transfer Resident #1's knee buckled resulting in her bumping the bedrail. CNA A reported that Resident #1 had a small skin tear that CNA A immediately reported to the nurse (CNA A could not remember the nurses name) who assessed the wound, wrote the report, and that the bruise did not appear until the next day. CNA A reported that Resident #1 never fell, just bumped her left leg. When asked if she was aware that Resident #1 had orders and a care plan to be transferred by Standing Lift CNA A stated, I didn't realize that. She has always been able to stand, that is my bad. CNA A verified that she had been trained on the use of a Standing Lift. During an interview on 10-6-2023 at 1:40 PM the DON reported when a person is ordered to a Standing Lift that it is automatically considered a two-person lift when addressed on the MDS. The DON verified that Resident #1 was a Standing Lift resident and that a Standing Lift should always be used. The DON reported that CNA A should have checked the computer system first which gives instructions on how a resident is supposed to be transferred. The DON checked the point click care system for Resident #1 and under the Task assignments for the CNA (which CNA A has access to) found that Resident #1 was assigned to be a Standing Lift assist with all transfers. The DON reported that she believed CNA A got into a hurry, assumed she knew what she was doing because CNA A has worked that unit in the past, and then completed the transfer on Resident #1 incorrectly. The DON stated that transferring a resident incorrectly can result in somebody getting hurt. The DON verified that CNA A had been trained on the Standing Lift system when CNA A was hired. During an interview on 10-6-2023 at 3:03 PM the Administrator reported that a staff member not following the care plans or orders was a problem and that the facility has a policy that the staff are to follow care plans and orders. The Administrator reported that if staff do not follow care plans or order, then a resident can get injured. The Administrator reported that CNA A would be educated on 745022 Page 3 of 4 745022 10/06/2023 Ware Memorial Care Center 1510 S Van Buren St. Amarillo, TX 79101

F 0689 Level of Harm - Actual harm where to look for the proper transfer to be used on a resident in the resident's chart/computer system or to ask the charge nurse prior to providing care and that the education will be provided in writing. The Administrator reported that if this situation happens again then CNA A will be terminated. Residents Affected - Few Record review revealed the following: BCS Competency: Lift-Standing/Full Body -Competency completed by CNA A on 2-15-2023 and 4-20-2023. Record review of facility provided policy titled Resident Rights undated, revealed the following: Source: Nursing Facility Requirements for Licensure and Medicaid Certification Dignity and Respect: You have the right to-live in safe, decent, and clean conditions 745022 Page 4 of 4