Health inspection·March 25, 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 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 of 8 (Resident #1) reviewed for dignity in that: CNA A spoke to Resident #1 in a loud and harsh tone while attempting to assist the resident out of bed. This failure placed residents in the facility at risk of diminished quality of life, and loss of dignity and self-worth. Findings Include: Review of Resident #1's undated face sheet revealed he was a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of heart failure and secondary diagnoses of shoulder pain, low back pain, and muscle wasting (loss of muscle mass due to disuse or nerve problems). Review of a quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS score of 12 which indicated moderate cognitive impairment, and he required total assistance with toileting, putting on/taking off footwear; he required maximum assistance with showering/bathing and lower body dressing; he required moderate assistance with upper body dressing; he required setup assistance with personal and oral hygiene; he required no assistance eating. He was occasionally incontinent of bladder and frequently incontinent of bowel. A comprehensive care plan revised on 9/26/24 indicated Resident #1 had an ADL self-care performance deficit and Resident #1 did not always like to change his clothing daily or shower when scheduled. Interventions were in place to provide ADL care as needed, encouraging resident to participate to the fullest extent possible, and praising resident when attempts were made. A comprehensive care plan revised on 9/30/24 indicated Resident #1 had impaired cognition and was at risk for further decline related to encephalopathy (group of conditions that cause brain dysfunction) and dementia (altered cognition). Interventions were in place including explaining all procedures to resident and stopping and returning later if resident becomes agitated during care. During an interview on 3/24/25 at 12:21 PM, Resident #1 said CNA A came into his room and told him he needed to get up and out of bed. Resident #1 said he told CNA A he did not want to get up right then, and CNA A replied that he had to get up and then pulled his blanket off him. Resident #1 said Page 1 of 5 455986 455986 03/25/2025 Henderson Health & Rehabilitation Center 1010 W Main St Henderson, TX 75652

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the CNA attempted to assist him to his feet by pulling his legs over to the side of the bed and he told her again that he did not want to get up yet. Resident #1 said CNA A said, We don't play around here in loud and harsh voice and left the room. During an interview on 3/24/25 at 12:30 PM, Resident #3, who was Resident #1's roommate, said he remembered CNA A coming into their room on the morning of the incident. He said CNA A yelled at Resident #1 and told him he had to get out of bed. He said he did not remember CNA A pulling Resident #1 out of bed or jerking his leg. During an interview on 3/24/25 at 12:40 PM, Resident Representative said the facility notified him of the incident, and he accompanied Resident #1 to a meeting with the ADM. He said Resident #1 told the ADM he didn't think CNA A should be fired, but he did not want CNA A to be allowed in his room anymore. Attempted a telephone interview on 3/24/25 at 1:00 PM with CNA A. An automated voice recording indicated the correct number was reached and there was no voicemail box setup. During an interview on 3/24/25 at 3:10 PM, MA B said she went into Resident #1's room to check Resident #3's vital signs in preparation of a medication pass. MA B said she heard Resident #1 tell CNA A he did not want to get up and CNA A responded you need to get up or I'll get in trouble in a loud and harsh-sounding tone of voice. MA B said she left the room to get Resident #3's medication, and when she returned, Resident #1 was seated in his wheelchair dressing himself; CNA A was not in the room. During an interview on 3/25/25 at 11:00 AM, the DON said there was nothing in CNA A's background checks or job performance that indicated a risk to residents in the facility. She said CNA A was a large woman with a loud voice and she could have been intimidating to some residents, but there had been no previous allegations of mistreatment from any resident in the facility against CNA A. Second attempted telephone interview on 3/25/25 at 3:45 PM with CNA A. An automated voice recording indicated the correct number was reached and there was no voicemail box setup. During an interview on 3/25/25 at 4:00 PM, the ADM said CNA A had nothing in her background or job history that indicated a concern for resident safety. She said there had been no allegations of abuse or neglect against CNA A from any resident before this incident. She said CNA A was suspended while the facility investigated the allegation, and the decision was made to terminate CNA A based off MA B's witness statement. The ADM said CNA A was too direct and did not respect Resident #1's personal choice and that would not be tolerated at the facility. She said all CNAs were trained and expected to fully explain all care being provided and encourage residents to participate in care. Review of facility policy titled Promoting/Maintaining Resident Dignity last reviewed on 2/16/20 indicated all staff involved in providing resident care will promote and maintain resident dignity by .personal choices will be considered when providing care and services to meet the resident's needs and preferences . and .speak respectfully to residents . 455986 Page 2 of 5 455986 03/25/2025 Henderson Health & Rehabilitation Center 1010 W Main St Henderson, TX 75652

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 maintain a clean, sanitary, comfortable, and homelike environment for 1 of 8 residents (Resident #2) in that: 1. Resident #2's window, window blinds, and floor around his bed were soiled with visible dust, dirt, debris, and smudges. 2. Resident #2's bed sheets and pillowcase had scattered brown stains on them. This failure placed residents residing in the facility at risk for a diminished quality of life and a diminished clean, homelike environment. The findings include: Review of Resident #2's undated face sheet revealed he was a [AGE] year-old male readmitted to the facility on [DATE] with a primary diagnosis hemiplegia and hemiparesis following cerebral infarction of left non-dominate side (weakness or paralysis on one side of the body) and secondary diagnoses of cognitive or emotional deficit and aphasia (impaired ability to comprehend or formulate language). Review of a quarterly MDS assessment dated [DATE] indicated Resident #2 had a BIMS score of 3 which indicated severe cognitive impairment and he required total assistance with oral hygiene, toileting hygiene, shower/bathing, lower body dressing, putting on/taking off footwear, and personal hygiene; he required maximum assistance for upper body dressing; he required setup and clean up assistance with eating. He was always incontinent of bowel and bladder. A comprehensive care plan revised on 10/03/24 indicated Resident #2 exhibited verbal and physical aggressive behaviors with interventions in place including approaching and speaking to resident in a calm manner, clearly explaining all daily care activities, and early intervention when resident behaviors were escalating. Resident #2 had a history of violent behaviors and had hit staff at the facility on multiple occasions. The same comprehensive care plan included a revision on 12/05/25 which indicated Resident #2 had an ADL self-care performance deficit related to contracture of left hand, limited range of motion in upper and lower extremities, and hemiplegia/hemiparesis. An observation on 3/24/25 at 11:36 AM of Resident #2's room revealed there were scattered brown stains on his sheets and pillowcase. The window in his room had green and brown smudges on the glass and the window blinds had an accumulation of dust on them. The floor around his bed had an accumulation of dirt and debris. During an interview on 3/24/25 at 11:36 AM, Resident #2 said facility staff did change his bed linens and clean his room, but not daily. During an interview on 3/24/25 at 11:45 AM Housekeeper C said all resident rooms were cleaned every 455986 Page 3 of 5 455986 03/25/2025 Henderson Health & Rehabilitation Center 1010 W Main St Henderson, TX 75652

F 0584 Level of Harm - Minimal harm or potential for actual harm day. She said the daily cleaning consisted of cleaning the restroom, wiping down all surfaces, sweeping and mopping the floors, and taking out the trash. She said she doesn't always clean behind resident beds or underneath them because she would need help to move the beds away from the wall. She said Resident #2 never exhibited any violent behaviors that interfered with housekeeping staff's ability to clean his room, and his room had already been cleaned today. Residents Affected - Some An observation on 3/25/25 at 9:00 AM Resident #2's room revealed what appeared to be the same soiled bed linens and pillowcase on his bed. The floor, window, and window blinds appeared to have not been cleaned from previous observation. During an interview on 3/25/25 at 9:45 AM Housekeeper D said every resident room was cleaned daily and a daily cleaning included wiping down all surfaces, sweeping and mopping floors, and taking out the trash. Housekeeper C said she had enough time to complete all assigned duties and no resident behaviors had ever affected her ability to clean their rooms. During an interview on 3/25/25 at 10:05 AM, CNA E said the facility had been having problems running out of clean linens in the morning. She said sometimes she had to delay changing bed linens until laundry staff washed more linens. During an interview on 3/25/25 at 10:30 AM, EVS Manager said housekeepers were expected to clean each resident's room daily, which consisted of taking out the trash, wiping down all surfaces, and sweeping and mopping floors. She said, additionally, each housekeeper was assigned one room daily to be deep cleaned. She said a deep clean was cleaning everything in the room and it was also done for new resident admissions. She said CNAs were bringing soiled linens to the laundry room too late in the day to be washed and ready for the next morning, because laundry staff left at 2:00 PM. She said linens were provided late some days, but there was always clean linen available to accommodate resident needs. During an interview on 3/25/25 at 11:00 AM, the ADON said the facility had identified an issue with their laundry processing. The ADON said CNAs recently changed to a 12-hour shift, and left at 6:00 PM instead of 2:00 PM. She said CNAs were waiting until the end of their shift to bring linens to the laundry room and laundry staff left at 2:00 PM. The ADON said she wasn't satisfied with the quality of housekeeping services, and administration was in discussion with the company they were contracted with. An observation on 3/25/25 at 3:00 PM of Resident #2's room revealed what appeared to be the same soiled bed linens and pillowcase on his bed. The floor, window, and window blinds appeared to have not been cleaned from the initial observation. During an interview on 3/25/25 at 3:00 PM, Resident #2 said staff had helped him change his clothing that day, but his linens had not been changed in a few days. During an interview on 3/25/25 at 4:30 PM, the ADM said the facility had identified there was an issue with their laundry processing. She said CNAs were not emptying linen barrels early enough in the day to provide laundry staff time to wash them. The ADM said CNAs had been instructed to empty linen barrels earlier in the day. She said the facility always had clean linens available to accommodate resident needs. Review of a policy dated May 2003 titled Housekeeping Standards indicated the following: 455986 Page 4 of 5 455986 03/25/2025 Henderson Health & Rehabilitation Center 1010 W Main St Henderson, TX 75652

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some .The facility will provide a clean and sanitary living environment for the physical and emotional wellbeing of the resident . And .Daily cleaning schedules will be followed to provide a clean, safe, sanitary environment for residents, staff and visitors . 455986 Page 5 of 5