Health inspection·September 28, 2023

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 observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, for 1 of 16 residents (Resident #23) reviewed for resident rights in that: Resident #23 was not served her meal timely with respect to residents sitting at the same table and was served 9 minutes later than other residents sitting at the same table. This failure could place residents needing assistance at risk for diminished quality of life, loss of dignity, and self-worth. The findings included: Record review of Resident #23's face sheet, dated 9/28/2023, reflected a [AGE] year-old resident most recently admitted to the facility on [DATE] with diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a group of conditions characterized by two brain functions such as memory loss and judgement, and intense, excessive, and persistent worry). Record review of Resident #23's MDS Assessment, dated 9/28/2023, reflected a BIMS score of 99, which indicates the resident chose not to participate, or the resident gave a nonsensical response. Observation on 9/25/2023 at 12:40 PM revealed staff began to pass trays for lunch meal service. Observation on 9/25/2023 at 1:08 PM revealed residents at Resident #23's table had been served. Resident #23 was not served at this time. Observation and interview on 9/25/2023 at 1:16 PM revealed Resident #23 was fidgeting and looking at the food of the residents sitting at her table. When Resident #23 was asked if she was hungry, resident stated yes. When Resident #23 was asked if it upsets her to wait while the others at her table have food, the resident nodded yes. Observation and interview on 9/25/2023 at 1:17 PM, GVN B stated she was not sure where Resident #23's meal tray was, but that she would get it for her. Resident #23 was then observed being served by GVN B. Interview on 9/27/2023 at 1:57 PM, GVN B stated staff attempt to serve residents at the same table (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 5 Event ID: 675489 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 675489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Devine Health & Rehabilitation 104 Enterprise Ave Devine, TX 78016 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)