Health inspection·October 2, 2024

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Administrator demonstrated how to correctly load and secure a resident in a wheelchair into the facility's van for transportation. During an interview and observation on 10/01/2024 at 2:30 p.m. the Maintenance Supervisor stated he was responsible for training new staff who would be doing transportation. The Maintenance Supervisor said he was trained by the corporate office. The Maintenance Supervisor said he watched videos and performed demonstrations to become trained. The Maintenance Supervisor said when he trains a new transportation aide, they watched the required videos and then performed safety demonstrations on securing residents who were in wheelchairs and who ambulate, using the lift, securing loose items, and driving the facility van. The Maintenance Supervisor demonstrated how to correctly load and secure a resident in a wheelchair into the facility's van for transportation. During an interview on 10/01/2024 at 3:02 p.m., CNA A stated she worked for a sister facility for several years but had been helping that facility for a couple of weeks when the incident happened. CNA A stated she picked up Resident #1 from the hospital and was on her way back to the facility. CNA A stated she came over a hill and a truck was stopped in the middle of the road. CNA A stated she hit the brakes and Resident #1 fell out of his wheelchair onto his hands and knees. CNA A stated Resident # 1's wheelchair was locked in, but she did not put the shoulder strap on because she did not think it would reach across him. CNA A stated she was terminated from both facilities for neglect. During an interview on 10/01/2024 at 3:20 p.m., the ADON stated she was notified on 08/20/2024 at 1:53p.m. by CNA A of the incident. The ADON stated she was informed Resident #1 had a scrape on his knee and a skin tear to his finger. The ADON stated following the phone call, she notified the DON and the Administrator of the incident. During an interview on 10/02/2024 at 12:50 p.m., the DON stated she was notified by the ADON of the incident. The DON stated when assessing Resident #1 he stated he was not wearing a seatbelt until after the incident. The DON stated Resident #1 had an abrasion to the right knee, and a bruise and skin tear on left hand. During an interview on 10/02/2024 at 1:25 p.m. the Administrator stated he and the Maintenance Supervisor were the only staff currently doing transportations. The Administrator stated only one resident in a wheelchair should be transported due to the van only being equipped to safely secure one wheelchair. The Administrator stated CNA A was terminated after an investigation was conducted. Record review of a facility's undated policy Vehicle Transportation and Safety of Residents indicated secure down all wheelchairs using the secure strap equipment. Always secure the strap to the frame of the wheelchair not the armrest or wheels. Place seatbelt around all residents including those in wheelchairs The facility's course of action prior to surveyor entrance included: Record review of the provider investigation report dated 08/20/2024 indicated Resident #1 was being transported by the facility van from the hospital to the facility when the transportation aide made a sudden stop and Resident # 1 fell out of his wheelchair. The provider investigation report indicated Resident #1 had an abrasion to the right knee, bruise and skin tear on left hand. X-rays were immediately ordered with results of no break, fracture or dislocation to the bruised area. The provider investigation report indicated CNA A was found negligent in her actions when failing to properly secure Resident #1in his wheelchair and was terminated following the investigation by the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675553 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 675553 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quitman Wellness & Rehabilitation 1026 E Goode St Quitman, TX 75783 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of an in-service dated 08/20/2024, topic: Abuse, and Neglect, description: all suspected, alleged, or actual abuse was to be reported immediately to the Abuse Coordinator, who was the Administrator. If for some reason staff are unable to reach the Abuse Coordinator, they are to notify he Director of Nurses. The in-service was signed by 31 employees. Record review of an in-service dated 08/21/2024 indicated the Administrator had been in-serviced on Vehicle Transportation and Safety of Residents, and hands on demonstration. Record review of a QAPI sign in sheet dated 08/22/2024 was signed by: Medical Director Administrator DON ADON Administrative Social Services Dietary Manager Record review of an in-service dated 08/27/2024 indicated the Maintenance Supervisor had been in-serviced on Vehicle Transportation and Safety of Residents, and hands on demonstration. The noncompliance was identified as past noncompliance IJ. The noncompliance began on 08/20/2024 and ended on 08/21/2024. The facility had corrected the noncompliance before the survey began. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675553 If continuation sheet Page 3 of 3