Health inspection·December 11, 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 treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Residents #1) of 6 residents reviewed for dignity. CNA A failed to ensure Resident #1 was provided with a dignified dining experience, when she stood over him as she was assisting him in eating his lunch in the dining room on 12/11/25. This failure could affect the residents by placing them at risk of not having a home-like dining experience and decreased self-esteem. Finding included: Record review of Resident #1's Face Sheet, dated 12/11/25, reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included Spastic Quadriplegic cerebral palsy (this is a condition which causes severe muscle stiffness of all limbs, trunk, and face), Unspecified intellectual disability, and major depression disorder (this is a mental health condition that significantly affects how you feel, think and behave). Record review of Resident #1's quarterly MDS assessment, dated 12/04/25, revealed a BIMS score of 00 indicating severe cognitive impairment. The MDS functional abilities reflected, Resident #1 was dependent on staff to eat; the helper does all the effort. Record review of Resident #1's Physician orders for December 2025 reflected:- Regular diet, puree texture, mildly thick consistency. Record review of Resident #1's care plan initiated on 07/01/25 reflected a focus of risk for potential nutritional problems related to contractures and diagnosis of CP, requires staff assistance of one for all meal in-take. Resident #1 was unable to sit up or bend at the waist and therefore must remain in a supine position (laying on back), this increases his risk for choking and aspiration (this is when food or liquid goes into the lungs) when consuming food or fluids. The goal was for Resident #1 to maintain adequate nutritional status as evidenced by no significant weight changes. Interventions included: Diet was regular puree with mildly thickened liquids and to educate, explain and reinforce to the residents the potential for choking and aspiration (food/liquids go into the lungs) and the consequences involved with his chosen positioning for meals. During dining room observation on 12/11/25 from 12:20PM to 12:44 pm of the lunch meal service, revealed CNA A was feeding Resident #1. CNA A was in a standing position with the dining table that had the food and drink behind her while assisting Resident #1 with the meal service. Resident#1 was in a reclined position in his wheelchair. CNA A picked up the plate of food that was behind her on the table and gave him a few bites of food. She then slightly turned and placed the plate back on the table behind her and gave Resident #1 a drink, then gave him a few more bites of his food while standing over him. Interview with CNA A on 12/11/25 at 2:13 PM revealed she had been helping Resident #1 eat his meals since his admission. CNA A said that Resident #1 was always in a flat reclined position during his meal and because of his condition (Cerebral Palsy) which prevented him from bending to sit upright in his chair. She said she always sat down when assisting him eat. She said she was looking for a chair to sit on Page 1 of 2 455592 455592 12/11/2025 West Side Campus of Care 1950 S Las Vegas Trail White Settlement, TX 76108

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few but did not see one that was clean. She said that Resident #1 got restless when he was not fed on time and she gave him a few bites while she waited for a coworker to look her way so that she could signal them to bring her a clean chair to sit on. She said that everyone was too busy but, she eventually got a chair herself and sat down. She said the risk of standing over the resident during mealtimes was loss of a dignified dining experience. Interview with DON on 12/11/25 at 3:00 PM, revealed that she expected the staff feeding residents to sit down to help promote the residents' dignity. The DON said CNA A told her that because of Resident #1's supine reclined position in his chair, it made her nervous to sit down while she was feeding him. The DON stated it was important to be at the same eye level to help the residents feel comfortable and to feel free to communicate their needs while assisting them to eat. She said sitting down during meal assistance promoted a respectful environment and dignity. In an interview with the Administrator on 12/11/25 at 4:06 PM, it was revealed he told CNA A to get a chair to sit when he saw her standing in the dining room while she helped Resident #1 to eat. He said the expectation was for residents to feel at home. He said the reclined position of Resident# 1 could make it a challenge to sit. He said the risk was not homelike dining experience. Record review of the facility policy titled, Resident Rights, revised 08/2020, reflected, All residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility including those specified in this policy. The Facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The Facility will protect and promote. 455592 Page 2 of 2