Health inspection·July 13, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few his wheelchair, with the urinary bag laying on his lap above his bladder. The staff transferred the resident to his bed and positioned him on the bed. Both staff then removed the residents' pants, revealing his catheter tubing was not secured to his leg. 2. Review of Resident #2's Quarterly MDS assessment dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. The Resident had a BIMs of 9, which indicated he was moderately cognitively impaired, had a urinary catheter and colostomy. No behaviors were indicated. Diagnoses included neurogenic bladder (lack of bladder control due to a brain, spinal cord, or nerve problem), quadriplegia, incomplete (paralysis affecting all four limbs) and bipolar disorder (mental illness that causes unusual shifts in mood). Review of Resident #2's Care Plan dated 03/22/23 reflected, Resident with Foley catheter use .Interventions included .Perform catheter care per facility policy as indicated . There were no interventions to ensure the catheter was anchored and secured documented. There were no behaviors documented about the resident's history of pulling catheter out. Review of Resident #2's Physician's order summary report as of 07/13/23 reflected, .Foley Cath care q shift .Change urinary catheter and drainage bag PRN plugged/out as needed .Monitor urinary output each shift . There were no orders to keep the urinary drainage bag below the bladder and secure the catheter tubing to resident's thigh. Review of Nurses progress note dated 05/29/23 at 2:27 p.m. reflected, .1:10 p.m. CNA reported that the resident had pulled out his FC with the bulb intact. This nurse entered room to check on resident. Resident is noted to be awake and alert, in bed, with HOB elevated about 30 degrees. FC was noted to be on the floor at bedside with bulb intact. Resident reports that he decided he no longer wanted a FC and went ahead and yanked it out. Observation on 07/13/23 at 01:30 p.m. revealed CNA C and CNA D enter Resident #2's room to provide Mechanical lift transfer from the bed to the wheelchair. Both staff rolled the resident from side to side to place the mechanical lift sling under the resident. The foley catheter tube was not secured to the resident's leg, which caused the tubing to become taut when rolling from side to side. CNA D positioned the mechanical lift over the resident's bed and both staff hooked up the sling to the lift. CNA D unhooked the urinary drainage bag from the bed while she began to raise the resident off the bed. Resident #2 stated, Be sure you don't pull out my catheter,. In an interview with Resident #2 on 07/13/23 at 1:40 p.m. he stated the staff pulled out his catheter a few months ago, so he is always cautions them when they are moving him or getting him up. In an interview with the ADON on 07/13/23 at 2:25 p.m. she stated staff were to always keep the urinary drainage bag below the resident's bladder to prevent the urine from backing up into the bladder which could cause risk of infection. She stated every resident who had a foley catheter should have the catheter anchored unless they had refused it. She stated if the resident had refused to have their catheter anchored, it should be care planned. She stated Resident #2 had a history of pulling out his catheter, and stated he was sent to the hospital in May as result of him pulling out his catheter. She stated those behaviors should be care planned. In an interview with the DON on 07/13/23 at 2:30 p.m. she stated the catheter was to be maintained below the level of the bladder. She stated placing the drainage bag in the resident's lap was not maintaining it below the bladder. She stated catheters should be secured to prevent accidental removal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675212 If continuation sheet Page 2 of 6 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 675212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Homestead of Denison 1101 Reba McEntire LN Denison, TX 75020 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of the catheter which could cause trauma to the urethra. She stated this, along with any behaviors should be care planned. In an interview with MDS Coordinator E on 07/13/23 at 2:40 p.m. she stated she and MDS Coordinator F are responsible for creating the comprehensive care plans. She stated any changes to the comprehensive care plan can be made by them or the nursing staff. She stated they all meet in daily clinicals and can easily update the care plans during that time. She stated any behaviors a resident was having should be care planned. In an interview with the Corporate MDS Coordinator on 07/13/23 at 2:45 p.m. she stated any resident who was admitted with a foley catheter needed to have all necessary interventions documented to reduce any risk of infections or injury. She stated if changes occurred after the initial comprehensive care plan was created it was normally the nurses who updated the care plan, but stated it was a team effort and anyone could update the care plan. She stated the care plan was one place that captured all the needs of the resident to ensure the most positive outcome possible. In an interview with MDS Coordinator F on 07/13/23 at 3:30 p.m. she stated she had not care planned the use of catheter straps for Resident #1 and Resident #2 because it was not on the physician orders. She stated she was not sure why Resident #2's behaviors for pulling out his catheter had gotten overlooked unless she was not present in the stand-up meetings when it was discussed. She stated all behaviors should be care planned. Review of the facility's undated policy titled Comprehensive Resident Care Plans , reflected, A comprehensive person-centered care plan is developed for each resident using the results of the comprehensive assessment. Each resident's care plan shall include measurable objectives and timetable to meet all resident needs identified in the comprehensive assessment. All items or services ordered to be provided or withheld shall be included in each resident's plan of care. The comprehensive care plan describes services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Resident's right to refuse care and treatment shall also be included in the comprehensive care plan .Each resident's plan of care shall be reviewed by an interdisciplinary team after each MDS assessment is conducted and revised as necessary to reflect the resident's current care needs . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675212 If continuation sheet Page 3 of 6 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 675212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Homestead of Denison 1101 Reba McEntire LN Denison, TX 75020 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for two (Resident #1 and Resident #2) of two resident reviewed for catheter care. 1. CNA A and CNA B failed to keep Resident #1's urine catheter bag below the level of the bladder during a mechanical lift transfer. 2. Facility staff failed to ensure Resident #1 and Resident #2's foley catheter was anchored to their inner thigh. This failure could place residents at risk for urinary tract infections and urethral trauma. Findings included: 1. Review of Resident #1's admission MDS assessment dated [DATE] revealed the resident was an [AGE] year-old male admitted to the facility on [DATE]. The resident was unable to complete the interview questions for mental status and the facility indicated he was severely cognitively impaired, had a urinary catheter and was incontinent of bowel. Diagnoses included dementia, spinal stenosis (narrowing of the spinal canal) and fusion of spine, lumbar region. Review of Resident #1's Care Plan dated 06/08/23 reflected, Resident with Foley catheter use for bladder incontinence r/t s/p fusion spinal lumbar laminectomy (a surgical procedure to remove bony pressure on the spinal canal) with decompression .Interventions included .Perform catheter care per facility policy as indicated . There were no interventions to ensure the catheter was anchored and secured documented. Review of Resident #1's Physician's order summary report as of 07/13/23 reflected, .Foley Care: output Q shift .Foley Cath care q shift . There were no orders to keep the urinary drainage bag below the bladder and secure the catheter tubing to the resident's thigh. Observation on 07/13/23 at 12:00 p.m. revealed CNA A and CNA B entered Resident #1's room to provide Mechanical lift transfer from the wheelchair to the bed. Both staff washed their hands and put on gloves. CNA A unhooked the urinary drainage bag from the wheelchair and placed it on Resident #1's lap, while CNA B positioned the mechanical lift over the resident. Both staff hooked the mechanical lift sling to the lift, and raised the resident from his wheelchair, with the urinary bag laying on his lap above his bladder. The staff transferred the resident to his bed and positioned him on the bed. Both staff then removed the residents' pants, revealing his catheter tubing was not secured to his leg. In an interview with CNA A on 07/13/23 at 2:00 p.m. revealed she had been taught to always keep the urinary bag below the bladder, because it could cause the urine to back up into the bladder but stated she had recently been told they could lay the bag in the resident's lap during the mechanical lift transfer. She stated the nurses put the catheter straps on the residents. She stated she had looked for a catheter strap a few days ago but could not find one. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675212 If continuation sheet Page 4 of 6 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 675212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Homestead of Denison 1101 Reba McEntire LN Denison, TX 75020 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm In an interview with CNA B on 07/13/23 at 2:05 p.m. she stated she had worked at the facility for 4 months. She stated she was told they were to lay the urinary catheter bag on the resident's lap during a mechanical lift transfer, so they did not risk it getting hung up on anything and pulling it out. She stated she had not seen any catheter straps on Resident #1 and stated she assumed the nurse would be responsible for putting those on a resident. Residents Affected - Few 2. Review of Resident #2's Quarterly MDS assessment dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. The Resident had a BIMs of 9, which indicated he was moderately cognitively impaired, had a urinary catheter and colostomy. No behaviors were indicated. Diagnoses included neurogenic bladder (lack of bladder control due to a brain, spinal cord, or nerve problem), quadriplegia, incomplete (paralysis affecting all four limbs) and bipolar disorder (mental illness that causes unusual shifts in mood). Review of Resident #2's Care Plan dated 03/22/23 reflected, Resident with Foley catheter use .Interventions included .Perform catheter care per facility policy as indicated . There were no interventions to ensure the catheter was anchored and secured documented. Review of Resident #2's Physician's order summary report as of 07/13/23 reflected, .Foley Cath care q shift .Change urinary catheter and drainage bag PRN plugged/out as needed .Monitor urinary output each shift . There were no orders to keep the urinary drainage bag below the bladder and secure the catheter tubing to the resident's thigh. Observation on 07/13/23 at 01:30 p.m. revealed CNA C and CNA D entered Resident #2's room to provide Mechanical lift transfer from the bed to the wheelchair. Both staff washed their hands and put on gloves. Both staff rolled the resident from side to side to place the mechanical lift sling under the resident. The foley catheter tube was not secured to the resident's leg, which caused the tubing to become taut when rolling from side to side. CNA D positioned the mechanical lift over the resident's bed and both staff hooked up the sling to the lift. CNA D unhooked the urinary drainage bag from the bed while she began to raise the resident off the bed. Resident #2 stated, Be sure you don't pull out my catheter, Both staff positioned the resident over the wheelchair, holding the urinary drainage bag below the resident bladder, and lowered him into his wheelchair. CNA D then hooked the drainage bag to the bottom of the wheelchair. In an interview with Resident #2 on 07/13/23 at 1:40 p.m. he stated the staff pulled out his catheter a few months ago, so he is always cautions them when they are moving him or getting him up. In an interview with CNA D on 07/13/23 at 1:45 p.m. she stated she had always been taught to keep the drainage bag below the bladder, but stated they were told this morning during an in-service on transfer that they could lay the drainage bag in the resident's lap. She stated this was not what she had been taught and she was confused. She stated the catheter was also supposed to be secured, but stated the nurses were the ones who did this. She stated she was not sure if Resident #2 had refused to have a strap or not. In an interview with CNA C on 07/13/23 at 1:50 p.m. she stated she had always been taught to keep the urinary bag below the bladder. She stated she was not sure about the catheter strap and assumed it was the nurse who placed those on the residents. In an interview with the ADON on 07/13/23 at 2:25 p.m. she stated staff were to always keep the urinary drainage bag below the resident's bladder to prevent the urine from backing up into the bladder (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675212 If continuation sheet Page 5 of 6 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 675212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Homestead of Denison 1101 Reba McEntire LN Denison, TX 75020 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few which could cause risk of infection. She stated every resident who had a foley catheter should have the catheter anchored unless they had refused it. She stated if the resident had refused to have their catheter anchored, it should be care planned. In an interview with the DON on 07/13/23 at 2:30 p.m. she stated the catheter was to be maintained below the level of the bladder. She stated placing the drainage bag in the resident's lap was not maintaining it below the bladder. She stated catheters should be secured to prevent accidental removal of the catheter which could cause trauma to the urethra. In an interview with the Corporate Director of Operations on 07/13/23 at 2:45 p.m. he stated they had been conducting in-service training this morning on mechanical lift transfers and one of the CNAs had asked how they were to secure the foley catheter bag during the transfers. He stated he was the one who had instructed them to place the drainage bag on the resident's lap to prevent the catheter from becoming hung up on something and getting pulled out. He stated he should have deferred the question to the Clinical staff. He stated they had since corrected this information to all the staff who had been misinformed. The facility's policy titled, Catheter Care, Urinary, dated September 2014, reflected, .The urinary drainage bag must be always held or positioned lower than the bladder to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder .Ensure the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675212 If continuation sheet Page 6 of 6