Health inspection·December 3, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident was treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #1) of 7 residents reviewed for dignity and respect, in that: LVN A spoke to Resident #1 in front of other residents, in the dining room, about Resident #1 sitting in the dining room in his underwear, making Resident #1 feel embarrassed. This failure could place residents at risk for embarrassment, isolation, and possible depression.The findings include: Record review of Resident #1's Face Sheet dated 09/30/25 documented a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of: Muscle Wasting and Atrophy(The loss of skeletal muscle mass.) , Heart Failure (A chronic condition in which the heart doesn't pump blood as well as it should.), Type 2 Diabetes (A chronic condition in which the body does not use insulin properly or does not produce enough insulin), Hypertension (a condition where the force of blood against the artery walls is consistently too high.), Chronic Obstructive Pulmonary (disease a group of lung diseases that cause airflow obstruction and breathing problems). Record review of Resident #1's Care Plan Dated 09/30/25 revealed requires assistance with activities of daily life, is at risk for shortness of breath related to Chronic Obstructive Pulmonary Disease, at risk for injury related to alteration in vision, at risk for falls, being treated for my hyperlipidemia and encourage to exercise and the resident is encouraged to participate in activities that will not depend on major physical exertion and encourage to get out of bed daily. Record review on 09/30/25 of Resident #1's MDS dated [DATE] revealed resident had a BIMS score of 15 which indicated intact cognition, meaning the individual's cognitive function, including memory and orientation, appears normal and unimpaired according to the scale's criteria. The Functional Abilities section indicated resident was independent no need for assistance. Record Review of Resident #1's progress note dated 09/06/25 revealed CNA B was concerned with Resident #1's sadness and depressed demeaner so CNA B asked Resident #1 what was wrong and Resident #1 stated he did not want to discuss anything with CNA B. The weekend manager was the SSA and she was notified of the incident that occurred between LVN A and Resident #1 that day. The incident involved LVA A who told Resident #1 in front of the other residents that he was wearing underwear briefs to bingo and needed to go change. The SSA was prompt in addressing the incident so it could be further investigated. In an interview on 09/30/25 at 2:30 PM with the Abuse Coordinator/ Administrator she stated Resident #1 was approached by a LVN A and Resident #1 was asked if he knew he had no pants on. The AC/Admin stated LVN A preceded to ask Resident #1 if he could go put on some clothes over his underwear briefs because there were female residents present in the dining room playing bingo. Resident#1 was helped to his room, and he never returned to the dining room that day. The AC/Admin stated she followed up on Resident#1 the next day to see if he had any issues with the way he was approached and he stated he had forgotten Page 1 of 3 455455 455455 12/03/2025 Meridian Care of Alice 218 219 N King St Alice, TX 78332

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few about it and was water under the bridge. The AC/Admin Stated she went a second time to follow up on the resident and he was fine and had no issues with staff or facility. In an Interview on 09/30/25 at 2:51 PM LVN A she stated the residents were playing bingo and Resident #1 was sitting playing in his underwear. LVN A stated she went up to Resident #1 and asked him if he knew that he had no pants. LVN A stated Resident #1 said he knew he did not have pants. LVN A asked Resident #1 if he could go put some pants on. LVN A stated Resident #1 was escorted to the room, and he never came back. LVN A stated she told him there were female resident in the dining room and Resident #1 said he did not care. LVN A stated she probably should have told him in a more privately manner instead of in front of the whole table. LVN A said she had not approached another resident in that manner again since the one incident in the dining room with Resident #1. LVN A stated she has a good rapport with Resident#1 and there was no ill will between them. The last time they had a training on Resident Rights was about 4 to 6 months ago. In an interview 09/30/25 4:41 PM with the Social Services Assistant she was the manager on duty that day doing rounds the CNA B had a concern with the Residents #1 and a LVN staff member. CNA B stated LVN A yelled at Resident #1 about him not wearing pants in the dining room with other residents playing bingo. The SSA stated Resident #1 told her about what LVN A had done and LVN A was just doing her job. The SSA stated the other residents in the dining room thought they were shorts and had no problem with him in the dining room dressed that way. The SSA stated Resident#1 told her he felt belittled after the LVN A spoke to him, so he went to his room. The SSA stated Resident #1 told her he had no clothes that fit him at the time of the incident and had called a family member to bring him clothes that fit. The SSA stated the Resident #1 might have thought he was wearing shorts and thought it was ok to wear. The SSA stated only the LVN nurse realized he was wearing was underwear in the dining room, but no one playing bingo had a problem with what he was wearing. The SSA stated no other incidents had occurred with LVN A and other residents being spoken to in this manner. The SSA stated Resident#1 was only staying in the facility for a short time for skilled nursing and had since moved to his apartment. The SSA could not say if he ever did activities again but was around the facility walking in the halls. The SSA stated no mental anguish, or distress was noted from the residents several days after the incident occurred. In an interview on 09/30/2025 at 5:02 PM CNA B he stated when he went to Resident's #1's room and he notices that everything was dark in the room, and he was upset. Resident #1 told him the LVN A told him in the dining room in front of other residents from across the table he needed to leave because he was not fully dressed. CNA B stated Resident #1 was not hard of hearing and maybe could have whispered it to him more privately. CNA B stated normally the resident was a very outgoing person and could tell the resident was upset. CNA B stated the next two days Resident #1 was not coming out of his room and then he got covid, so he had to stay in his room until he was out quarantine for 7 days. CNA B stated he did not know of any other incidents with the LVN A involved in the incident or the resident with any other resident or staff member. CNA B stated he Received dignity training on 09/22/25 along with other staff members. In an interview 10/01/25 at 9:06 PM with the Activities Assistant (AA) he stated the residents were playing bingo and the nurses were coming in to check vitals for some residents and because of this did not realize the incident with Resident#1 was in underwear and he thought they were shorts. The AA stated Resident #1 stated to him the nurse told him from across from across the table in front of other residents about how he was dressed. The AA stated he saw Resident #1 leave immediately after LVN A spoke to the resident and the resident never returned. The AA stated after some time had passed CNA B was pulled aside asked if he had observed what had occurred and he stated to the Administrator and DON that he did not observe or know what had occurred. The AA stated none of the 455455 Page 2 of 3 455455 12/03/2025 Meridian Care of Alice 218 219 N King St Alice, TX 78332

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents had made a comment about what he was wearing. The AA stated Resident #1 mannerism before the incident was good. The AA observed Resident #1 was being social, taking to residents and playing bingo. The AA stated when Resident #1 left and did not say anything about what occurred with the LVN A. The AA stated she did not see Resident#1 after the incident because Resident #1 tested positive for covid. The AA said if he would have known what was occurring, he would have gone to the activity's director and the administrator Immediately to report the incident. The AA stated his last training on resident's rights was one month ago when he was hired. The AA was able to identify the abuse coordinator as the administrator. The AA was able to describe the different types of abuse and what the steps are to report abuse. In an interview on 10-01-25 at 9:41 AM with Resident #1 he stated he was playing bingo and the LVN A was going to do finger stick to check his blood sugar when she asked him in front of the whole table why was he in his underwear in the dining room. Resident #1 stated after the LVN A said this I felt like crap! Resident #1 stated none of the resident's playing bingo complained about what he was wearing or even realized he was in his underwear. Resident#1 stated he just felt comfortable in what he was wearing and maybe he should not have gone to the dining room dressed this way. Resident #1 stated he did not want to get anyone in trouble, and he had put it past him and had a great stay in the facility. Record review of the facility's policy titled, Quality of Life - Dignity, revised 08/2009, revealed: 1. Residents shall be treated with dignity and respect at all times. 455455 Page 3 of 3