Marshall Manor West

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

brakes and slid in slow motion to the floor. She stated she was surprised he had a fracture from the fall because it was a slow soft fall. LVN C stated the interventions were for Resident 2 to be evaluated by therapy, Resident #2's wheelchair seat was to be dropped to prevent him from sliding out when locking his brake. LVN C stated Resident #2 was to have nonskid material in his seat as well. LVN C stated she was told therapy could not evaluate him because of his payer source. LVN C stated she never saw Resident #2

in a wheelchair with a drop seat or nonskid material in his chair.During an interview on 10/22/2025 at 10:00 a.m., the MDS Coordinator stated it was the job of the DON and herself to update all care plans. She stated

she was unsure how she missed adding the care plan interventions for a therapy evaluation and a dropped seat for safety. She stated she was also uncertain why the intervention of nonskid material to the chair was not carried out. She stated it was the job of the entire facility to read the care plans and carry out the interventions.During an interview on 10/22/2025 at 11:00 a.m., the DON stated Resident #2 was private pay and had no funding for therapy services. She stated a restorative nursing plan was written for Resident #2. She stated it was initiated 10/13/2025 when he returned from the hospital where he had surgery on his hip. She stated therapy had to evaluate him and drop his seat if it was a safe intervention and they would have provided the nonskid material to put in his chair, but because he was not evaluated before he went to

the hospital on [DATE REDACTED], he had not gotten the nonskid material. She stated not following interventions decided on during the care plan meeting could have resulted in further injury to the residents from another fall. During an interview on 10/22/2025 at 11:30 a.m., the Administrator stated it was important to follow interventions decided on by the IDT (interdisciplinary team). He stated it was important because the interventions were put in place to keep the residents healthy and safe. The Administrator stated Resident #2 had a care plan meeting on 10/02/2025 following a fall that injured the resident. He stated it was decided that therapy would evaluate him for safety in his wheelchair. Resident #2 was not evaluated by therapy because he was private pay, and the cost had to be approved by the family. Resident #2 eventually went to

the hospital to have surgery on his fractured hip. The Administrator stated therapy evaluated him for a restorative program when he returned from the hospital, but he was not evaluated for a dropped seat or nonskid material for his wheelchair.Record review of the facility's policy dated 07/20/2021 titled ‘Comprehensive Care Planning revealed The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility will establish, document, and implement the care and services to be provided for each resident to assist in attaining or maintaining his or her highest practical quality of life.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Marshall Manor West

207 W Merritt St Marshall, TX 75670

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

FORM CMS-2567 (02/99) Previous Versions Obsolete

Restorative Aide J, CNA K, CNA U, LVN X, LVN Y, LVN Z, the ADON, LVN AA, and Restorative Aide T) indicated they had been checked off in-person on safe transfer procedures for mechanical lift transfers and gait belt transfers. Each staff member was able to verbalize step by step instructions on how to identify the type of transfer each resident required and how to safely perform a mechanical lift transfer or a gait belt transfer. During an interview on 10/22/25 at 9:50 a.m., the Certified Occupational Therapist Assistant said

the DON had in-serviced herself and the Physical Therapist Assistant on 10/21/25 concerning screening each resident on admission for safe transfer status and re-screening residents after any change of condition or decline. She said she then assisted in re-educating staff on safe mechanical lift and gait belt transfers. During an interview on 10/22/25 at 10:25 a.m., the ADON said she had been in-serviced by the DON on 10/21/25 on safe transfer techniques, to assess a resident with a decline and update their care plan to reflect accurate transfer requirements, risk of injury for not transferring residents correctly, and not lifting a resident under the arms or pulling or their clothing or limbs. She said after she was re-educated,

she then assisted in head-to-toe assessments of each resident and re-educating other staff. During an

interview on 10/22/25 at 10:44 p.m., the Administrator said on 10/21/25, he was trained by the Regional Nurse on Safety and Accidents. He said on 10/19/25 at approximately 11:00 p.m. or 11:30 p.m. He was notified of the bruising to Resident 1's chest. He said the DON called and told him at that time. He said the DON suspended CNA A the next morning after determining he may have improperly transferred Resident #1. The Administrator said on 10/21/25 at 12:10 p.m. he called CNA A, and he was terminated. He said CNA A had not returned to the facility at any time after the injury was discovered. During an interview on 10/22/25 at 11:03 p.m., the DON said she was trained on re-assessing, transfer statuses, and appropriate transfer statuses. She said she was trained on preventing injuries of the residents. She said the Regional Nurse in-serviced herself and the Administrator. She said CNA A was suspended on 10/20/25. She said he was then terminated on 10/21/25 due to improper transfer. She said she, the Administrator, and the Patient Care Advocate rounded on each resident to see if they had injuries or any concerns regarding CNA A. She said no concerns were identified. She said on the week of 10/07/25, she had audited each resident's chart and documented how much assistance each resident required for transfers. She said on 10/21/25 she reviewed this audit to make sure it was correct, and nothing needed to be updated. She said head-to-toe assessments were conducted of each resident in the facility on 10/21/25 by herself, the ADON, two nurses, and the wound care nurse. She said no injuries were found. She said she checked off the ADON, Restorative Aide J, and two therapy staff members. She said they then in-serviced the CNAs and the nurses. She said nurses and CNAs that were not present, were in-serviced over the phone and would be checked off in person when they return to work at the facility. She said if a resident had a status change, the care plan would be updated, and the CNAs would be notified prior to any transfers. She said if she or the MDS nurse was not present, the charge nurse would update the care plan, notify the aide, and update the nurse aide information sheet.During an interview on 10/22/2025 at 11:25 a.m., the MDS Coordinator stated

she was aware of the in-service done related to transferring safety. She said to always use 2 people with a mechanical lift and two people with gait belt transfer if their care plan stated that was what was needed.

She stated the nurses could update the resident care plan for change of condition on transfer status or they could let her know what needed to be corrected, and she would correct it.On 10/22/25 at 11:30 a.m., the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and a severity level actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Event ID:

Facility ID:

If continuation sheet