Health inspection·December 19, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for one (Resident #1) of five residents reviewed for residents rights. 1.The facility failed to maintain a resident's wheelchair in a sanitary and safe operating condition for Resident #1 who had dried vomit on her wheelchair. 2. The facility failed to maintain a homelike environment for Resident #1 who had a large portion of wood missing from her headboard. These failures could place residents at risk for a diminished quality of life due to the lack of a well-kept, home-like environment. Findings included: Review of Resident #1's face sheet, dated 12/19/23, reflected she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included unspecified intellectual disabilities (learning disabilities characterized by below average intelligence) and major depressive disorder (mental health disorder having episodes of psychological depression). Review of Resident #1's annual MDS assessment, dated 10/29/23, reflected she had a BIMS score of 08 indicating moderate cognitive impairment. Further review revealed Resident #1 utilized a wheelchair. Observation and interview on 12/19/23 at 9:30 AM with Resident #1 revealed she was sitting in her wheelchair in her room. Resident #1 had a dried brown substance on the right side of her wheelchair that was clumped up. Resident #1 said she threw up the other day but could not remember when it happened. Resident #1 said she knew the throw up was still on her wheelchair and did not like it being on there and wanted to have a clean wheelchair. Resident #1's headboard was also missing a large portion of it on the right side. Resident #1 said her headboard had been like that since she got to the facility and she did not like the way it looked since it was broken. Interview on 12/19/23 at 9:45 AM with LVN A revealed she was Resident #1's nurse. LVN A said she had not noticed Resident #1's wheelchair which had a brown and clumpy substance going down the right side of it. LVN A said Resident #1 told her it looked like vomit and she agreed it could have been that. LVN A said she was not sure how long the substance had been there but should have been cleaned (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 455475 Printed: 05/15/2026 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 455475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White Settlement Nursing Center 7820 Skyline Park Dr White Settlement, TX 76108 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)