Seven Acres Jewish Senior Care Services, Inc

The facility failed to use the proper lift on Resident #35 because CNA A used a standing lift, at the request of

the family member, instead of following the plan of care which required a Hoyer lift for transfer resulting in an injury to the resident.

1. 1. On February 18, 2025, CNA A was terminated.
2. 2. On May 1, 2025, documentation of the identified accident was included in the Ad Hoc Quality Assurance

Performance Improvement (QAPI) meeting. The documentation confirmed that the CNA used the incorrect lift due to the family request and the incorrect number of staff to perform the transfer, despite having been trained regarding the appropriate procedure.

3. 3. On May 1, 2025, the CEO/LNHA, Director of Nursing, and Medical Director re-reviewed the [facility name]

policies on Reporting Accidents and Incidents and Transfer Techniques. No policy changes or recommendations were made because of this review.

4. 4. On May 2, 2025, Resident #35 had a therapy evaluation completed that revealed the resident continues to

require a full body mechanical lift for transfer. A meeting was held with the resident's family member, and she was informed of the findings that the resident continues to require a full body Hoyer mechanical lift for transfers.

5. 5. On May 2, 2025, the progress notes (nurses notes) were reviewed for Resident #35 from January 11,

2025, to February 11, 2025. The progress notes did not reveal that any other staff members utilized the stand-up lift to care for the resident.

6. 6. On May 2, 2025, Staff that cared for R#35 from January 11, 2025 to February 11, 2025, were interviewed

by the Director of Nursing to determine if they cared for the resident utilizing the stand-up lift. Some staff members interviewed admitted to using the standing lift to transfer Resident #35 per the family request.

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/04/2025 Seven Acres Jewish Senior Care Services, Inc 6200 N Braeswood Blvd Houston, TX 77074 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation.

7. 7. From May 1, 2025 through May 2, 2025 all nursing (CNA, CMA, LVN, RN) employees, were reeducated

by the Director of Nursing, Unit Manager, or Nursing Supervisors and a competency assessment was conducted for following the plan of care despite requests from family members and the location and use of

the resident transfer list assignment sheet. Nursing staff (CNA, CMA, LVN, RN) working after May 2, 2025, will not be allowed to work without completion of the competency assessment.

8. 8. On May 2, 2025, the DON, Unit Managers, and Supervisors conducted an audit to review all residents

requiring the use of a mechanical lift. Point of Care documentation and progress notes were reviewed for a two-person transfer using the appropriate lift from April 1, 2025 through April 30, 2025. New residents will be assessed by therapy on admission for transfer needs and the DON, Unit Managers, MDS Coordinators, or Nursing Supervisors will update the care plan and the transfer assignment sheet at that time of the evaluation. Existing residents with changes in transfer status will be referred to therapy for an evaluation and determination of the appropriate transfer method. At that time the DON, Unit Manager, MDS Coordinator, or Nursing Supervisor will update the care plan and the transfer assignment sheet.

Sincerely, Chief Executive Officer Monitoring of the plan of removal included the following (5/2/25 - 5/4/25 ): Monitoring observation on 05/02/2025 4:35 PM. Observation of sit to stand mechanical lift transfer for Resident #4 by CNA B and CNA L. Resident #4 sitting in wheelchair in room.

CNA B moved the lift in front of the Resident #4.

Resident #4 placed her feet on the platform.

CNAs placed the safety belt around the Resident #4's waist connected the loops to both hooks on both sides of the lift.

Resident #4 was holding on with both hands and began to lift. CNA's checked if they were high enough Resident #4 requested to go a little higher. Resident #4 was raised a small amount higher.

CNA L announced she was removing the chair and removed the chair from under the resident.

The lift was turned and positioned Resident #4 over the bed at the side of the bed.

Resident #4 was lowered and positioned on the side of the bed.

Tolerated well by Resident #4.

Record review of the Special Interview Report dated 2/12/25 indicated CNA A was suspended on 2/12/25

during investigation and terminated on 2/18/25.

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/04/2025 Seven Acres Jewish Senior Care Services, Inc 6200 N Braeswood Blvd Houston, TX 77074 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation.

Record review of the QAPI meeting sign in sheet indicated the QAPI meeting was held on 5/1/25 at 9:00 pm for removal of the IJ. The DON, ADON, MDS Coordinators, CEO, and Medical Director attended.

Record review of the PT Evaluation and Plan of Treatment dated 5/2/25 indicated Resident #35 required total assist for bed mobility and transfer activities. Hoyer lift was recommended as Resident #35 was not able to tolerate static sitting balance on the edge of the bed for more than 30 seconds. Stand up lift was not recommended.

Record review of the Curriculum Specific to the Plan of Removal dated 5/2/25, indicated all nursing staff were re-educated on Following the Plan of Care Despite Family Request, Location of the Lift Assignment Sheet.

Record review of the Competency Checklist for Total Mechanical Lift and Sit/Stand Mechanical Lift listed check points for pre-operations check and lift operation.

Interviews were conducted on 5/2/25 - 5/4/25 with staff on all shifts (7:00 a.m. - 3:00 p.m., 3:00 p.m. - 11:00 p.m., and 11:00 p.m. - 7:00 a.m.) and included RN B, RN C, LVN A, LVN B, LVN C, LVN D, CMA A, CMA B, CMA C, CNA B, CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, and CNA J to verify the in-services were conducted and to validate the staff understanding of the information presented to them. Nursing staff knew where to locate the transfer lift assignment sheet for the [NAME] and [NAME] Units. Nursing staff knew what to do in the event a new resident came into the facility and the resident was not listed on the assignment sheet. Nursing staff knew to follow the care plan despite any requests from family members regarding using

the type of lifts. Nursing staff knew mechanical lifts required 2-person assist.

The Chief Financial & Administrative Officer was notified on 5/4/25 at 12:22 p.m., the Immediate Jeopardy was removed. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

9. 2. Record review of Resident #1's undated face sheet reflected Resident #1 was an [AGE] year-old female

who admitted to the facility on [DATE REDACTED] with diagnoses which included: dementia (confusion and forgetfulness), acute kidney failure (kidneys suddenly cannot filter waste from the blood), weakness, and syncope and collapse (loss of consciousness).

Record review of Resident #1's Quarterly MDS Assessment, dated 03/13/2025, reflected Resident #1 had a BIMs score of 4, which indicated severe cognitive impairment.

Record review of Resident #1's revised care plan, dated 10/09/24, reflected that Resident #1 had cognition loss, confusion, and poor judgment. The interventions included no harm/injury.

Record review of Resident #1's Elopement Risk Assessment completed on 03/25/2025 indicated that she was not a high risk for elopement and did not display any abnormal behaviors or exhibit a change of mental status prior to elopement.

Record review of Resident #1's physician orders reflected a new order on 03/26/25 for placement of the Wander guard.

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/04/2025 Seven Acres Jewish Senior Care Services, Inc 6200 N Braeswood Blvd Houston, TX 77074 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation.

Record review of Resident #1's progress note dated 03/25/2025 at 9:30 PM, written by LVN A, revealed that Resident #1 was observed sitting in a wheelchair in the facility's parking lot at 8:45 PM by another resident's family member. The family member returned Resident #1 to the facility, and the supervisor and RP were notified of the incident.

During an observation and interview on 05/01/2025 at 12:05 PM Resident #1 was alert and oriented lying down in bed and said she did not remember the incident.

During an interview on 04/30/25 at 3:39 PM, CNA V said she was informed that Resident #1 was looking for her family member and was found outside the facility. She said she was a very confused resident who normally stays in her room. She said the doors were monitored by security when she leaves at 11 PM, so

she was unsure how the resident could get out. She said the risk to the resident was that the resident could fall out of her wheelchair, or someone could harm her. She said she was in-serviced on 03/28/25 on elopement because Resident #1 was found outside of the facility.

During an Interview on 04/30/25 at 4:12 PM, CNA C said she works the 3-11pm shift but was not at work when Resident #1 was found outside. She said she was in-serviced on elopement in March after the incident and was in-serviced on abuse and neglect approximately 1-2 weeks ago. She said the risk to the resident being found outside in the parking lot was that she could get injured.

Attempted telephone interview on 05/01/25 at 9:03 AM with RP, surveyor left a voicemail.

During an interview on 05/01/25 at 2:44 PM, the ADON said she left around 7-8 PM on the day of the incident and denied any change of condition with Resident #1. She said she was not exit-seeking before incident and was not at high risk for elopement. She said Resident # 1 was confused and forgetful and preferred staying in her room. She said the NP, RP, and DON were notified on the day of the incident. She said the NP ordered a Wander Guard that was placed on the resident's wheelchair. She said the Wander Guard was recently removed after frequent monitoring, and it was found that the resident was no longer exit-seeking. She said that it was not safe for a resident with cognition concerns to leave because they could get injured, or someone could harm them.

During an interview on 05/01/25 at 3:19 PM, LVN A said she was familiar with Resident #1 and remembered

the incident in March when she was found outside in the facility's parking lot. She said the resident went downstairs that day, and a family member saw her in the parking lot and brought her back into the facility.

She said she did not know how long she was outside but remembered seeing her in the hall 1 hour prior to returning to the floor. She said when she returned to the floor, she did a head-to-toe assessment, and no injuries were noted. She said she also did every 30-minute observation for her shift, and labs were drawn.

She said the NP, RP, and DON were notified of the incident immediately. LVN A denied that the resident was exit-seeking before or after the incident. She said the risk of her leaving the facility was falling out of the wheelchair or someone harming her.

During an interview on 05/01/25 at 3:43 PM, the administrator said the resident was talking with the security guard in the lobby at 8:30 PM. She stayed in the lobby for 5 mins (8:35 PM). She said she watched the video and could see the security guard on the phone and watching the resident on the camera. She said another resident's family member brought the resident back into the facility at 8:50 PM. She said the facility did an in-serviced after the incident on elopement, and the security guard on duty was not allowed to return to the facility. She said they also had other security staff in-serviced and educated on elopement procedures and protocols before they could work at the facility.

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/04/2025 Seven Acres Jewish Senior Care Services, Inc 6200 N Braeswood Blvd Houston, TX 77074 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation.

During an Interview on 05/01/25 at 4:09 PM, CNA K said she was not assigned to Resident #1 on the day of

the incident. She said that she was aware that the resident went downstairs and was found outside of the facility. She denied having any elopement concerns with Resident #1 before or after the incident. She said

after the incident the staff was trained to notify the charge nurse/supervisor if there was a missing resident.

CNA K said the risk of having an elopement was that Resident #1 could fall out of the wheelchair and injury herself.

During a telephone interview on 05/04/25 at 9:40 AM, the RP said the facility called him between 8 and 9 PM to inform him that Resident #1 was found outside the building. He said he was surprised because she had never tried to leave the facility before and preferred to stay in her room. He said he was also surprised because security was always at the front desk at 8:00 PM, and he was not sure how she could leave the facility. The RP denied injury to Resident #1 and said a wander guard was placed on her w/c that was recently removed.

Observation on the facility's security camera on 05/04/25 reflected: 03/25/25 at 8:35PM: Resident #1 left out of the facility's doors leading outside in her wheelchair following behind another resident's family member. 8:38PM: The family member who initially left returned to the front desk by the security guard and points towards outside. 8:39PM: The security officer can be seen checking the security cameras and calling on the phone. 8:43 PM: The resident can be seen via the outside security cameras in the parking lot sitting in her wheelchair. 8:44PM: The security officer goes outside to check on resident at the edge of the driveway, bending over next to the resident. 8:48 PM: The security officer returns and can be seen looking through a binder and using the phone. 8:49 PM: another resident's family member wheels Resident #1 back into the facility lobby.

Record review of the facility's policy titled Wandering and Elopement of Residents revised 10/13/2023, read

in part . Policy: To attempt to maintain the safety of our Residents, while allowing them maximum independence. Potential Risks for Wandering and Elopement: 2. Residents who have dementia/Alzheimer . 08/27/2025