The Hillcrest Of North Dallas

F-F689 Free of Accident Hazards/Supervision/Devices

On [DATE REDACTED] during a complaint survey at The Hillcrest of North Dallas at 18648 Hillcrest Road, Dallas, TX 75252. On [DATE REDACTED] the HHSC surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The facility allegedly failed to provide supervisory services. When resident #1 was being transferred at his nursing facility

he was dropped. Has a deformity to the R anterior tibia.

The notification of the alleged immediate jeopardy states as follows:

An [AGE] year-old male with a BIMS of 13 admitted to the facility on [DATE REDACTED]. His diagnoses include Age-related Osteoporosis, Osteopenia, Muscle Weakness, Lack of Coordination, Dementia, Acute Respiratory Failure, etc. He required a Hoyer when transferring and two therapists at bedside during therapy.

An in-house Stat X-Ray was performed, and he was sent out prior to the results. EMS transferred the resident to Medical City [NAME] where the hospital paperwork states he presented with RLE pain. Patient was being transferred at his nursing facility when he was dropped. Has a deformity to the R anterior tibia. Denies hitting his head and LOC.

Identify residents who could be affected.

All Residents who require assistance to be transferred have the potential to be affected.

Identify responsible staff/ what action taken.

1. Physical Therapist Student was immediately removed from the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 676315 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676315 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Hillcrest of North Dallas 18648 Hillcrest Rd Dallas, TX 75252

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 2. We contacted the school and informed them that the Physical Therapist Student was being removed from

the student fieldwork program and could not return to the facility. Level of Harm - Immediate jeopardy to resident health or In-Service conducted. safety 1. Therapy staff was re-educated on mechanical lifts and gait belts appropriate transfer training, transfer Residents Affected - Few status and protocol for falls which include do not move residents, call for assistance and have nurse to assess on [DATE REDACTED].

2. Education is being provided to nursing staff on fall prevention, and transfers with mechanical lifts and gait belts on [DATE REDACTED].

3. Education is being provided to nursing staff to check the KARDEX to know plan of care and transfer technique [DATE REDACTED].

Implementation of Changes

Change of policy for student supervision - Clinical supervisor must provide close, direct supervision and oversight to student clinicians Providing patient care in the following circumstances:

To make an initial determination of competence.

When a student clinician is performing assigned treatment or activity with a patient for the first time.

When the student clinician is learning a new skill or technique.

When the student clinician's performance assessment/evaluation identifies issues (e.g. conduct, clinical performance, capacity) with potential to interfere with delivery of competent, quality and ethical rehabilitative care.

In all other treatment circumstances, the student clinician must be in line of sight of the clinical supervisor when providing direct patient care. The clinical supervisor should be available to intervene and/or correct student performance, as necessary.

Director of Rehabilitation has been in-service on the new policy change [DATE REDACTED].

Clinical Instructors have been in-serviced on the new policy change [DATE REDACTED].

Audit of fall assessments and care plans are being completed and appropriate interventions will be put in place as needed by [DATE REDACTED].

Therapy staff was re-educated on mechanical lifts and gait belts appropriate transfer training, transfer status and protocol for falls which include do not move residents, call for assistance and have nurse to assess on [DATE REDACTED].

Education is being provided to nursing staff on fall prevention, and transfers with mechanical lifts and gait belts on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 676315 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676315 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Hillcrest of North Dallas 18648 Hillcrest Rd Dallas, TX 75252

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 Education is being provided to nursing staff to check the KARDEX to know plan of care and transfer technique [DATE REDACTED]. Level of Harm - Immediate jeopardy to resident health or Monitoring safety DOR/Designee will monitor staffing to ensure that any student therapist will be closely monitored to follow the Residents Affected - Few new policy. DOR/Designee will review the effectiveness of this daily X 7 days and weekly X 4 weeks, then X 3 monthly, continued monitoring will be ongoing and report any adverse findings to the QAPI committee. All concerns noted will be addressed at the time of discovery.

The Administrator/DON/Designee will be responsible for monitoring the implementation and effectiveness of in-service conducted on [DATE REDACTED] and ongoing.

The Administrator/DON will review the effectiveness of this daily X 7 days and weekly X 4 weeks, then X 3 monthly, continued monitoring will be ongoing and report any adverse findings to the QAPI committee. All concerns noted will be addressed at the time of discovery.

Involvement of Medical Director

The Medical Director met with the Interdisciplinary team on [DATE REDACTED] [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 676315