Inspection·February 8, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations, interview and record reviews, the facility failed to ensure the resident environment was as free of accident and hazards as possible for 3 of 5 halls (100 hall, 200 hall, and 300 hall) reviewed for accident and hazards, in that: 1. The facility failed to prevent a container of unsecured bleach wipes from being found on the 100 hallway. 2. The facility failed to ensure the door to the utility area was locked and the room housing hazardous material was locked on the 200 hallway. 3. The facility failed to ensure the supply room containing small objects and food items was unlocked on the 300 hallway which was a secure unit for residents with cognitive concerns. These deficient practices could result in residents coming into contact with dangerous materials which could place them at risk of injury or death. The findings were: 1. Observation on 02/08/2024 at 1:32 p.m. of the incontinent care cart on 100 hallway revealed a container of bleach wipes labeled, Danger and Keep Out of Reach of Children. During an interview with CNA A on 02/08/2024 at 1:35 p.m., CNA A stated, I haven't been told if it is or isn't allowed to be stored there and confirmed that the container of bleach wipes was usually stored on the incontinent care cart. During an interview with LVN B on 02/08/2024 at 1:50 p.m., LVN B stated the container of bleach wipes was usually stored on the incontinent care cart and when asked if a resident could come into contact with the wipes and potentially harm themselves, LVN B confirmed it was possible and stated, I had not thought of that. 2. Observation on 02/08/2024 at 2:00 p.m., revealed the utility area was unlocked and contained a room marked hazardous material, which was also unlocked, on the facility's 200 hallway. Further observation revealed the room did not contain hazardous material at the time of the observation, but did contain supplies to store hazardous material. (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: 455797 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 455797 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearsall Nursing and Rehabilitation Center 169 Medical Dr Pearsall, TX 78061 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)