Health inspection·September 4, 2024

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 provide a safe, clean, comfortable, and homelike environment for 1 of 6 residents (Resident #1) reviewed for a clean and homelike environment. The facility failed to ensure Resident #1's urinal was emptied appropriately on 09/04/24. This failure placed residents at risk of decreased feelings of self-worth and a diminished quality of life. Findings included: A record review of Resident #1's face sheet dated 09/04/24 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnoses included personal history of traumatic brain injury (someone who had a previous traumatic brain injury), muscle wasting and atrophy (loss of muscle tissue), major depressive disorder (persistent low mood and loss of interest in activities that people enjoy), epileptic seizures (a sudden burst of electrical activity in the brain that cause symptoms such as jerking and shaking), primary essential hypertension (high blood pressure that doesn't have a known secondary cause), and muscle weakness (loss of muscle strength). A record review of Resident #1's Quarterly MDS assessment, dated 08/12/24, reflected Resident #1 had a BIMS score of 13, which indicated cognitively intact. Resident #1's Quarterly MDS Section GG Functional Abilities and Goals reflected that Resident #1 required substantial/maximal assistance in the area of toileting hygiene and partial moderate assistance in the areas of eating, oral hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. A record review of Resident #1's care plan, dated 09/04/24, reflected Resident #1 was care planned for ADL self-care performance deficit r/t disease process TBI, limited physical mobility r/t TBI, and impaired cognitive function/dementia or impaired thought process r/t neurological symptoms. During an observation on 09/04/24 at 9:20am, Resident #1's urinal had yellowish liquid in it that appeared to be urine. During an observation on 09/04/24 at 11:28am, Resident #1's urinal appeared to have yellowish liquid in it that appeared to be urine. During an observation on 09/04/24 at 1248pm, Resident #1's urinal appeared to have yellowish liquid in it that appeared to be urine. (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 3 Event ID: 675065 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 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cass Valley Healthcare Center 103 Teakwood St Centerville, TX 75833 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)