West Rest Haven
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
examples of abuse and neglect. She stated if she witnessed abuse or neglect she would report to the administrator, which is also the abuse coordinator. She stated Resident #1 was a mechanical lift two person assist for every transfer. She stated assignment sheets are at each nurse station for staff to obtain upon arrival for their shift, that tells what resident's they will have and how the resident transfers, and how much assistance is needed. She stated if the resident had a change in status the charge nurse would update the assignment sheets. She stated she was not working on the day of the incident with Resident #1. In an
interview on 12/22/2025 at 6:44 PM with CNA C, she stated she was in-serviced on abuse, neglect, transfers, and assistive devices used for transfers. She stated if she witnessed abuse or neglect, she would report to the charge nurse and Administrator, which was also the abuse coordinator. She was able to give examples of abuse and neglect. She stated Resident #1 was a mechanical lift, two-person assist for every transfer. She stated assignments were at each nurse station for staff to obtain upon arrival for their shift that tells what residents they will have, how the resident transfers, and how much assistance is needed. She stated if a resident had a change in status, the charge nurse would update the assignment sheet. In an
interview on 12/22/2025 at 6:46 PM with CNA D, she stated she was agency staff. She stated was in-serviced on abuse, neglect, transfers and assisted devices used in the facility. She stated if she witnessed abuse or neglect she would immediately report to her supervisor and administrator, which is also
the abuse coordinator. She stated assignment are at each nurse station for staff to obtain upon arrival for their shift, that tells what resident's they will have and how the resident transfers, and how much assistance is needed. She stated if the resident had a change in status, the charge nurse would update the assignment sheet. She stated she was not working on the day of incident with Resident #1. During
observation on 12/22/2025 at 6:48 PM, this surveyor observed a mechanical lift transfer with two person assist. Proper techniques used for transfer, proper footwear/nonskid socks were used while transferring. No concerns noted During an observation on 12/22/2025 at 6:55 PM, this surveyor observed a stand aid transfer with one person assist. Proper techniques used for transfer, proper footwear/nonskid socks were used while transferring. No concerns noted. On 12/22/2025 at 8:18 PM, the acting Administrator was informed of IJ. The non-compliance was identified as past non-compliance. The IJ began on 11/29/2025 and ended on 12/05/2025. The facility had corrected the noncompliance before the investigation began. The interventions and plan for correction included: Record review of the undated facility assignment sheet for memory care reflected group 1,2, and 3, the resident name, cognition, behaviors, transfers, assist x1 or x 2, ADL reminders, stand aid, mechanical lift, gait belt, incontinent care, memory care door code, nutrition room door code, memory care door code to outside parking lot and patio. Review of the facility's in-services dated 12/03/2025 -12/04/2025 revealed all staff were educated regarding resident transfers, resident abuse and neglect, and pain management. Staff were instructed to make sure they are using proper techniques when transferring, especially using two staff members with the mechanical lift. Staff were also educated on where to find information on how a resident was transferred. For CNAs, the information was on the group assignment sheets, and for nurses, the information was on residents' care plan, Review of the facility's undated Transfer with mechanical lift policy reflected, Purpose. A resident who is non weight bearing, has weight bearing restrictions, has lower extremity weakness, or has difficulty standing will be transferred using a mechanical lift to reduce the risk of injury to resident and staff
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West Rest Haven in West, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in West, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from West Rest Haven or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.