Inspection·December 6, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm assistance with upper and lower body dressing, and she was dependent with showering and toileting hygiene. Record Review of the Provider Investigation Report dated 10/16/2023 revealed that the incident occurrent 10/14/2023 at 2:30 a.m. and it was not reported to the state until 10/16/2023 at 9:40 p.m. Residents Affected - Few Record Review of the Provider Investigation Report dated 10/16/2023 revealed, On 10-14-2023 at 2:30 a.m., Resident #1 was found on the floor for the second time of the night shift. The nurse attempted to perform a head-to-toe assessment but Resident #1 was anxious and would not allow the nurse to perform the assessment. Record Review of the Provider Investigation Report revealed, On 10/16/2023 at 8:30 a.m., after seeing the x-ray results, the DON notified the Administrator, Resident #1 had a fall over the weekend and her x-ray results revealed possible left elbow fracture. Record Review of the Intake Investigative worksheet dated 10/16/2023 revealed, The fall was not reported to the Administrator until 9-16-23 at 8:30 a.m., that the x ray revealed a possible fracture of the left elbow. The Administrator said she meant 10-16-2023 and not 9-16-2023. During an interview on 12/6/2023 at 1:54p.m, with the DON, said the incident with Resident #1 was reported to her by LVN A. She said she did not notify the Administrator because she does not call the Administrator at night. She said one of the nurses should have called her. She said the nurse that does the reporting was responsible for reporting it to the Administrator. She said LVN A wrote the incident report, and she was the night nurse. During an interview with the Administrator on 12/6/2023 at 2:00 p.m., said she was told that a resident had fallen with no injury until it was confirmed that there was an injury. She said she talked to staff about reporting in a timely manner. She said the DON reports incidents and falls to the Administrator. She said the nurses might not have known to report it to her. She said the reporting was supposed to be done within 24 hours. She said it was called in late because she was notified about the incident late. She said the nurse was supposed to notify the RP, the Doctor, and the DON and she did. She said the DON will notify her. She said it is important to report any incident in a timely manner because the state requires it, and it was important to conduct the investigation in a timely manner. LVN A was not available to be interviewed because she was not at the facility during the time of the investigation, and she never answered the phone and nor did she return any phone calls to the surveyor. Record Review of the facility's policy titled Leadership Policies and Procedures, (revised 12/2009) read in part .The facility's Leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment, and misappropriation of a patient's/resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately. 2. The Facility shall report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675214 If continuation sheet Page 2 of 3 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 675214 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solidago Health and Rehabilitation 1720 N Logan St Texas City, TX 77590 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 0609 Level of Harm - Minimal harm or potential for actual harm adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. The facility's Leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect or exploitation or mistreatment and will implement immediate action to safeguard resident. The facility will provide notification to the proper authorities, and, when required, the release of information to those agencies, pursuant to applicable federal and/or state law. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675214 If continuation sheet Page 3 of 3