Health inspection·August 11, 2025

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 a resident had the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely and allowed the resident to use his or her belongings to the extent possible for 1 of 5 residents (Resident #1) reviewed for sanitary and comfortable environment.1. The facility failed to maintain Resident #1's wheelchair in a sanitary and safe operating condition leaving food, liquid, dirt, and debris to collect down both sides of the wheelchair. 2. The facility failed to ensure Resident #1's wheelchair padding on both arm rests were not torn and didn't expose padding on 08/11/25. These failures could place residents at risk of contamination, infections, skin tears and bruising. Findings include:Record review of Resident #1's Quarterly MDS, dated [DATE], reflected a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's had diagnoses which included contracture of right and left hands (a fixed tightening of muscles, tendons, ligaments, or skin that prevents normal movement of the hands), abnormalities of gait ad mobility (a walking abnormality), lack of coordination, speech disturbances (any condition that affects a person's ability to produce sounds that create words) and muscle wasting and atrophy (wasting or thinning of muscle mass). The MDS reflected a BIMS of 0, which indicated she was not able to complete the assessment. Resident #1 required use of a manual wheelchair, and she required set up or clean-up assistance with eating and required substantial/maximal assistance and dependent on staff for all other ADLs. Record review of Resident #1's current, undated, Care Plan reflected the following plans of care:- Resident #1 had an ADL self-care performance deficit related to musculoskeletal impairment, limited mobility, impaired balance. The care plan goals included the resident participating to the best of the resident's ability and maintaining the resident's current level of function. The care plan interventions included monitoring the resident after each meal to ensure the resident's clothes were clean and dry. Resident #1 required supervision during meals, had fragile skin related to the aging process, and was at risk for bruising easily and skin tears. The care plan goals included the resident's risk for the development of skin tears and bruising being minimized. The care plan interventions included using a clothing protector to protect the resident's skin and notifying the physician and responsible party when there was a change in the resident's status. Keep skin clean and dry. Interview on 08/11/25 at 9:33 AM with Resident #1's Family Member revealed Resident #1's wheelchair was filthy and nasty. The Family Member stated the wheelchair looked like it had never been cleaned, and it should be cleaned. The Family Member stated the facility refused to clean and sanitize the wheelchair. The Family Member stated the arm rests on Resident #1's wheelchair were worn down and could potentially cause bruises on the underside of the resident's forearms. The Family Member further stated, Any normal person would not want to sit in a dirty wheelchair, so why does the facility think its ok for [Resident #1] to sit in a dirty Page 1 of 3 455475 455475 08/11/2025 White Settlement Nursing Center 7820 Skyline Park Dr White Settlement, TX 76108

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 455475 Page 2 of 3 455475 08/11/2025 White Settlement Nursing Center 7820 Skyline Park Dr White Settlement, TX 76108

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 455475 Page 3 of 3