Inspection·August 11, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wheelchair. Observation and interview on 08/11/25 at 10:41 AM revealed Resident #1 used her wheelchair for mobility throughout the facility. The arm pad covers on her wheelchair's armrests were torn and exposed the padding. The wheelchair had caked on food, dirt, and debris on both sides. Observation of Resident #1's arms revealed no findings of wounds, skin tears, or bruising. Resident #1 indicated she was mobile throughout the facility a lot, and she did not like her wheelchair to look dirty, Resident #1 did not indicate how having a dirty wheelchair made her feel. Resident #1 did not indicate if she ever asked for the wheelchair to be cleaned or if staff ever attempted to clean it. Interview on 08/11/25 at 11:26 AM with the DOR revealed Resident #1 was seen today (08/11/25) by a contracted vendor to get moldings for a new wheelchair. The DOR stated she noticed the need for a new wheelchair, so she placed a referral on 06/11/25. The DOR stated the reason for the new wheelchair was to assist Resident #1 with balancing and stability while sitting and propelling in the wheelchair. The DOR stated she was aware of how dirty Resident #1's wheelchair was with food and debris; however, she had not reported this to anyone. The DOR indicated she did not have a reason for not reporting the condition of the wheelchair The DOR stated there were times the therapy department would wipe down wheelchairs, but the CNAs on the overnight shift (10:00 PM - 6:00 AM) were responsible for cleaning resident wheelchairs. The DOR stated she noticed the padding on the wheelchair was worn; however, she had not noticed any injury to the resident's forearms. The DOR stated Resident #1 was provided with sleeve protectors, but the resident would remove them. The DOR stated having a dirty wheelchair could place residents at risk of contamination and infections. Interview on 08/11/25 at 11:44 AM with CNA A revealed she had not worked with Resident #1 lately; however, she had previously observed Resident #1's wheelchair had dried food on the sides. CNA A stated aides on the overnight shift were responsible for cleaning resident wheelchairs. CNA A stated if she was currently working with Resident #1 and observed residents with dirty wheelchairs, she would just clean it herself. CNA A further stated she would not want to sit in a dirty chair, so she could imagine residents did not want to sit in a dirty chair as well. CNA A stated when residents were in a dirty environment it placed them at risk of germs which would make them sick. Interview on 08/11/25 at 12:15 PM with the Physical Therapy Technician revealed CNAs on the overnight shift would be the first to notice when resident wheelchairs were dirty and needed to be cleaned, the 10:00 PM - 6:00 AM shift was responsible for cleaning wheelchairs. The Physical Therapy Technician stated when staff came in on the 6:00 AM - 2:00 PM shift and noticed chairs were dirty, they should be reporting to the DON, nurse, physical therapy, or the Maintenance Department. The Physical Therapy Technician revealed she noticed Resident #1's wheelchair needed to be cleaned, but she had never reported it, thinking the overnight shift would clean the wheelchairs. She stated not doing so placed Resident #1 at risk of infection. Observation and interview on 08/11/25 at 1:35 PM with CNA B revealed she worked with Resident #1, and she noticed Resident #1's wheelchair was dirty. CNA B stated it was the responsibility of the overnight shift to clean wheelchairs. CNA B stated Resident #1 fed herself, but she had difficulty due to the way she sat in her wheelchair. She stated it caused the resident to drop and spill a lot of her food and drink during meals, which landed on the wheelchair. CNA B could not recall the last time she attempted to clean Resident #1's wheelchair and could not recall the last time the chair was cleaned. Resident #1 was observed in the dining room drinking a cup of coffee, and there was a light brown thickened substance that appeared to have dripped down the entire right side of the resident's wheelchair. CNA B was asked if Resident #1 ate in the dining room and if she was monitored during lunch. CNA B stated Resident #1 was required to eat in the dining room where she could be monitored. CNA B further stated she did not see food spilled on the wheelchair. CNA B described Resident #1's wheelchair had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455475 If continuation sheet Page 2 of 3 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 08/11/2025 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)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete wasted, caked on food that had dried along with food from today's lunch. CNA B stated not taking the time to ensure Resident #1's wheelchair was clean placed her at risk of infections. Attempts to contact CNA C, CNA D, CNA E, LVN F on the overnight (10:00 PM - 6:00AM) shift were unsuccessful. Interview on 08/11/25 at 2:58 PM with the DON revealed the facility had ordered a new wheelchair for Resident #1; however, it was a custom wheelchair, so it was unknown how long it would take to deliver. The DON stated she had scrubbed the resident's wheelchair the first couple of weeks of her employment at the facility, but she could not find anything who would clean it. She stated it was hard to get into the smaller spaces. The DON stated the overnight shift had a wheelchair cleaning schedule they were supposed to go by. The DON stated aides would check-off when the task was completed; however, they did not indicate which resident chairs were cleaned. The DON stated she knew the arm pads on Resident #1's wheelchair were torn, but there were no injuries on the resident's arms. She stated although it was torn the padding was still intact. The DON stated not ensuring resident's wheelchairs were cleaned and safe placed residents at risk of a build-up of debris and created a dignity issue for residents. Interview on 08/11/25 at 3:24 PM with the Administrator revealed CNAs on the overnight shift were responsible for ensuring all wheelchairs were cleaned according to the schedule. The Administrator stated obviously the CNAs were not doing so, and the overnight nurses were responsible to ensure all the overnight tasks were being completed. The Administrator revealed when residents wheelchairs were not properly cleaned and maintained it placed them at risk of having an issue with dignity and safety. Record review of the facility's Homelike Environment policy, dated 04/24/25, reflected: This policy aims to provide a comprehensive framework for creating and maintaining a homelike environment in long-term care facilities. A homelike environment is essential for promoting the comfort, dignity, and quality of life of residents.Privacy and Dignity: Ensure that residents have privacy and that their dignity is maintained at all times.Creating a homelike environment in long-term care facilities is essential for promoting the well-being and quality of life of residents. By implementing the principles and guidelines outlined in this policy, facilities can create a supportive and nurturing environment that respects residents' individuality, fosters social connections, and enhances their overall experience of care.The facility policy provided did not include anything about resident equipment. Event ID: Facility ID: 455475 If continuation sheet Page 3 of 3