Health inspection·November 13, 2025

F 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. Based on observations, record review, and interviews, the facility failed to have a governing body who appointed a licensed administrator for 1 of 1 facilitiy reviewed for governing body.The facility did not have a licensed administrator since 09/22/2025.This failure could affect the safety and overall wellbeing of the residents and day-to-day operation of the facility.Findings included:During an interview on 11/13/2025 at 9:10 AM, the Administrator-in-training said she was the current administrator but did not have a license. She said the previous administrator was at the facility until sometime in September 2025. She said she had a corporate administrator who was not currently in the building and was not aware that a licensed administrator had to be in the building.During an interview on 11/13/2025 at 9:10 AM, the Administrator-in-training said she had called the corporate administrator to ask him if he could come by the facility and the corporate administrator told her he was in another facility who also had the state surveyors in another building. The Administrator-in-Training did not know the corporate administrator would not be coming in to work.During an interview on 11/13/2025 at 11:20 AM, the Administrator in Training said the corporate administrator had not worked 40 hours per week consistently in the facility since she started at the facility on September 22, 2025. She said he talked with him on the phone for his input. She said she was not aware that a license administrator had to be in the building for 40 hours 5 days a week. During an interview on 11/13/2025 at 12:45 PM, the Maintenance Supervisor said, the administrator of record had not been in the facility consistently for 40 hours per week since the Administrator in Training had been there since 9/22/2025, he said they did not have an Administrator in the facility regularly, he said the Administrator in Training had not fully completed her course work and was not eligible for state administrator licensure testing until completed.Upon request for human resource records, the HR department head was not present during the survey and there was no one else to obtain records.During an interview on 11/13/2025 at 12:55 PM, the DON said the corporate administrator had not been in the facility consistently for 40 hours per week since the Administrator in Training has been here 9/22/2025. She said he checks in by phone with the Administrator in Training.During an interview on 11/13/2025 at 1:30 PM, the Corporate Director of Nurses said she could not come up with documentable evidence of an administrator being physically present in the facility for 40 hours weekly. She said she was not aware that a license Administrator had to be in the building that many hours and days. She stated she would confirm and get back with the surveyor.During an interview on 11/13/2025 at 2:00 PM, the facility Social Worker said she has not seen the Corporate Administrator in the building in weeks.During an interview on 11/13/2025 at 2:30 PM, the Administrator in Training said, her first day was 09/22/2025. She said she found out she had one more required course to take, and it would not be completed until December 2025. She stated, then, she would be able to schedule for her test for the state administrator license.Record review of a printed staff roster, dated 11/13/2025 (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: 675460 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 675460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Highlands Nursing & Rehabilitation Center 711 Lucas St Athens, TX 75751 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)