Health inspection·June 18, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 3 of 15 residents reviewed for quality of care, (Resident #14, Resident #36 and #209) in that: The facility failed to remove worn, damaged and bleached mechanical lift slings from service for Residents #14, Resident #36 and #209. This deficient practice could result in a loss of quality of life due to injuries. Findings included: Record review of a facility's face sheet dated 6/17/25 for Resident #14 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: End Stage Renal Disease (a permanent condition where the kidneys can no longer filter waste from the blood, and require a kidney transplant or dialysis to survive), Type 2 Diabetes Mellitus (a problem in the way the body regulates and uses sugar as a fuel), and Acquired absence of left leg below the knee. Record review of a Medicare 5-day MDS assessment dated [DATE] for Resident #14 indicated that he had a BIMS score of 10 indicating he had moderately impaired cognition. The assessment also indicated that he was totally dependent with transfers. Record review of a comprehensive care plan dated 5/08/25 indicated that Resident #14 was totally dependent on a mechanical lift with the assistance of 2 persons for transfers. Record review of a facility face sheet dated 06/17/2025 indicated Resident #36 was a [AGE] year-old male that admitted to the facility on [DATE] with diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), Type 2 Diabetes Mellitus (a problem in the way the body regulates and uses sugar as a fuel) and chronic obstructive pulmonary disease (a condition that limits airflow into and out of the lungs). Record review of a comprehensive care plan initiated 05/01/2025 indicated Resident #36 required transfer assist of 2 staff with a mechanical lift. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #36 had a BIMS score of 05 indicating severely impaired cognition. The resident required maximal assistance with transfers. Page 1 of 10 675691 675691 06/18/2025 Huntsville Health Care Center 2628 Milam Huntsville, TX 77340

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of a facility's face sheet dated 6/17/25 for Resident #209 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Left side hemiplegia following cerebral infarction (the pathologic process that results in an area of necrotic (death of tissue) tissue in the brain resulting in weakness or inability to use the left side of the body), heart failure (the heart muscle doesn't pump blood as well as it should), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of an admission MDS assessment dated [DATE] for Resident #209 indicated that she had a BIMS score of 15 indicating she was cognitively intact. The Assessment also indicated that she was totally dependent with transfers. Record review of a comprehensive care plan dated 5/21/25 indicated that Resident #209 was totally dependent on a mechanical lift with the assistance of 2 persons for transfers. During an observation on 06/16/2025 at 11:30 AM, of a mechanical lift sling under Resident #14 while he was sitting in his wheelchair, the colored straps were faded and light in color. During an observation on 06/16/2025 at 11:33 AM, of a mechanical lift sling under Resident #36 while he was sitting in his wheelchair, the colored straps were faded and light in color. During an observation on 06/16/2025 at 11:35 AM, of a mechanical lift sling under Resident #209 while she was sitting in her wheelchair, the colored straps were faded and light in color. During an observation and interview on 06/17/25 at 10:30 AM Resident #14 was in the common area of the facility watching TV dressed neatly. He denied any problems with staff. He was sitting in a wheelchair with a mechanical lift sling underneath him. The straps were faded in color and they all appeared to be a light blue- not bright blue, bright purple, or bright green. During an interview on 6/16/2025 at 12:00 PM with CNA E, she said she did use slings to assist with transfer of residents by mechanical lift. She stated the slings were inspected prior to use for any rips, tears or damage. She was not aware that the slings should also be inspected for fading. She did agree that the slings did have some fading to the sling but was unaware that faded slings should be taken out of service. During an interview on 6/17/2025 at 10:20 AM with the Housekeeping Supervisor, she said she had been working at the facility for 2 months. She stated lift pads were normally washed using the blanket setting, that did not include bleaching agent in the cycle. She stated if a lift pad was soiled then the pad cycle was used and a bleaching agent was used in the pad washing cycle. She said the nursing staff was responsible for inspecting lift pads prior to use and removing any damaged lift pads from service. During an interview on 6/17/2025 at 10:30 AM with Laundry Aide D, she said she has been working at the facility for 8 months. She said she always washed the lift pads on the blanket cycle. She stated a bleaching agent was not to be used with the lift pads. She stated lift pads were washed and hung to air dry. She said the nursing staff was responsible for removing damaged lift pads from service. During an interview on 6/17/2025 at 10:45 AM with the Director of Nursing, he said the staff was responsible for inspecting lift pads for any damage to the pad prior to placing under a resident. He stated staff were to inspect lift pads and remove from service any pad that showed signs of wear such 675691 Page 2 of 10 675691 06/18/2025 Huntsville Health Care Center 2628 Milam Huntsville, TX 77340

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some as fraying, tearing or rips. He said the staff had not been instructed to look at straps for fading. He stated the laundry was the first line of inspection and should remove any pads that had visible signs of wear and tear. He stated laundry staff should not use any bleaching agents while laundering the lift pads. He stated the laundry supervisor was new to her position and education would be provided to her on the laundering and inspection of lift pads by the laundry staff. During an inspection of a faded lift sling that was under Resident #14, the Director of Nursing agreed the color of the connection tabs was faded. He said all mechanical lift slings in the facility would be inspected and all faded and worn slings would be replaced. During an interview on 6/18/2025 at 9:15 AM with CNA G, she said prior to using a mechanical lift pad, she inspected the pad for any worn or stringy parts. She stated if the pad was worn or damaged the pad was taken to the supervisor and a new pad was used for the resident. She stated that they were now monitoring for fading of connection tabs on the lift pads. She stated a lift pad that was worn, torn or faded could put the resident at risk for injury during transfer. During an interview on 6/18/2025 at 9:25 AM CNA H stated the slings were inspected prior to use for any wear and tear or any faded loops. She stated any altered slings were taken to the supervisor to be taken out of service and a new sling was used for the resident. She said the resident was at risk for injury if a damaged sling was used with the mechanical lift. During an interview on 6/18/2025 at 9:35 AM CNA K stated mechanical slings were inspected by laundry staff and nursing staff. She stated laundry staff was to inspect pads for any wear and tear and if any damage was noted then the laundry was to take the lift pad out of service. She stated the nursing staff also inspected the lift pads prior to use for any rips, tears and fading. She said any damaged pads were removed from service and replaced with a new lift pad. She said the resident was at risk for injury if a damaged or altered lift pad was used during transfer. During an interview on 6/18/2025 at 9:45 AM with the Director of Nursing, he stated new lift slings were ordered. He stated the staff was also in serviced on inspecting the lift pads for tears, fraying and fading. He said any lift pads with signs of fading or tears were to be removed from service immediately. He said the resident could be at risk of injury if a worn or faded lift pad was used. He said laundry personnel and nursing staff were responsible for inspecting lift pads and removing them from service. He stated CNA K was responsible for ordering lift pads and would monitor the conditions of the lift pads in the facility and ensure replacement lift pads were available to staff. During an interview on 6/18/2025 at 9:55 AM, the administrator said she discussed the concerns of the faded lift slings with the DON . She stated that she was aware that staff was inspecting the slings prior to use but she was not aware that the slings were faded. She said that an altered lift sling could put a resident at risk for injury during use. She stated that 10 new slings had been ordered and that all slings would be inspected for tears, worn areas and fading prior to use by the laundry staff and direct care staff and any lift slings that were faded or worn would be taken out of service immediately. Record review of the facility's policy titled Safe Resident Handling/Transfers copyright 2023 reads .Slings will be laundered according to manufacturer's instructions and any damaged, broken or unsafe slings will be removed from service and replaced. Record review of manufacture guidelines Full Body Slings - Instructions for use accessed at www.medline.com on 06/18/25 read .Always inspect slings prior to each use. Signs of rips, tears, or frays 675691 Page 3 of 10 675691 06/18/2025 Huntsville Health Care Center 2628 Milam Huntsville, TX 77340

F 0689 Level of Harm - Minimal harm or potential for actual harm indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use . Residents Affected - Some 675691 Page 4 of 10 675691 06/18/2025 Huntsville Health Care Center 2628 Milam Huntsville, TX 77340

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #15) and 1 of 5 staff (Nurse Manager) reviewed for infection control. Residents Affected - Few Nurse Manager performed direct care to Resident #15 and failed to remove Personal Protective Equipment (PPE, gown, and gloves) prior to exiting Resident #15's room on 06/16/2025. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings included: Record review of an admission Record for Resident #15 dated 06/17/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Hemiplegia and Hemiparesis following cerebral infarction, Muscle wasting and Atrophy, Cognitive Communication Deficit, Hypertension. Schizoaffective Disorder, Bipolar Type, Epilepsy, Major Depressive Disorder and Dysphagia. Record review of a Quarterly MDS Assessment for Resident #15 dated 04/17/2025 indicated she had severe impairment in thinking with a BIMS score of 3. She was dependent on staff for application of nonsurgical dressings and personal hygiene (ADL care). Record review of a care plan for Resident #15 dated 11/29/2022 indicated she had an ADL self-care performance deficit related to a Cerebral Infarction with right side hemiplegia, bowel, and bladder incontinence. During an observation and interview on 6/16/2025 at 10:25 AM, the Nurse Manager did not follow the Enhanced Barrier Precautions for disposing of used PPE supplies consisting of a gown and gloves. The Nurse Manager exited Resident #15's room with contaminated PPE (gown and gloves) still on and took them off in the hallway and proceeded to put the contaminated PPE in the trash can on the medication cart across the hall. The Nurse manager said she just completed care on Resident #15's PICC line . During an interview on 06/16/2025 at 10:27 AM, with the Nurse Manager she said the PPE supplies did not have to be disposed of in a special trash can and could be disposed of in any trash can. During an interview on 06/18/2025 at 7:56 AM, with CNA A she said staff should use PPE supplies prior to performing direct care on a resident with ordered precautions. Once staff have competed resident care, staff should take off all PPE in the room and dispose of the PPE in a biohazard bag , wash their hands, and then exit the room. She said if the Resident has a physicians order for EBP the staff should use PPE supplies when providing care to the resident. She said if the PPE supplies are no used or discarded appropriately it may cause a spread of bacteria and germs to residents and staff that could cause residents and/or staff to become ill. During an interview on 06/18/2025 at 8:01 AM, with the Nurse Manager she said she read the enhanced barrier policy, and she did not follow the proper procedures when disposing of PPE supplies after performing direct care on Resident #15. She said if the PPE supplies were not used and disposed of 675691 Page 5 of 10 675691 06/18/2025 Huntsville Health Care Center 2628 Milam Huntsville, TX 77340

F 0880 correctly it could potentially spread germs. Level of Harm - Minimal harm or potential for actual harm During an interview on 06/18/2025 at 8:05am with RN B she said if a patient had orders for precautions the staff should use appropriate PPE when performing direct care to a resident and should dispose of used PPE in the trash can in the resident's room and wash their hands prior to exiting the room. She said residents could become ill from the spreading of germs and bacteria as well as staff could be exposed to germs and bacteria that could cause them to become ill. Residents Affected - Few During an interview on 06/18/2025 at 8:12am with MA C she said staff was supposed to use PPE when providing direct care to a resident on EBP. She said staff should remove PPE and wash their hands before exiting the resident's room. She said if the proper PPE procedures were not used the potential to spread germs increased and other residents could become ill. During an interview on 7/31/2024 at 10:04am with the ADON she said if staff were making direct contact with a resident that had orders for Enhanced Barrier Precautions staff should use PPE supplies. She said staff should put the PPE supplies on prior to rendering direct care to the resident. She said staff should dispose of used PPE in the trash can by the door in the patient's room. She said if PPE supplies were not used or disposed of properly it could cause infection control issues and possibly get other resident's sick. During an interview on 7/31/2024 at 10:10am with the Administrator, she said when staff entered the room of a resident on EBP they should be using EBP supplies prior to providing direct care. She said they should take used PPE off in the room and put it in the trash can in the resident's room. She said staff should never wear used PPE outside the room. She said when staff was done with resident care, they should wash their hands or use sanitizer prior to exiting the room or going on their next task. She said if PPE was not used or disposed of correctly there was a potential to spread infections. Record review of a facility policy titled Enhanced Barrier Precautions dated 2025 indicated, .3. D. Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. 675691 Page 6 of 10 675691 06/18/2025 Huntsville Health Care Center 2628 Milam Huntsville, TX 77340

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff through a communication system which relays the call directly to a staff member or a centralized staff work area from toilet and bathing facilities for 1 of 8 residents reviewed for call lights. (Resident #8). Residents Affected - Few The facility failed to ensure Resident #8's emergency call light in the bathroom would reach the floor. The call light cord for Resident #8 was three feet above the floor level. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life. Findings include: Record review of a face sheet dated 6/18/2025 indicated that Resident #8 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: dementia (confusion due to aging with inability to remember), muscle weakness, difficulty ambulating, and muscle wasting. Record review of a Quarterly MDS assessment dated [DATE] for Resident #8 indicated that she had a BIMS score of 3, indicating that she had severe cognitive impairment. The MDS indicated that the resident required supervision or touch assist of one person for toilet use. Record review of a comprehensive care plan with a revision date 6/06/2025, revealed Resident #8 was at risk for injuries related to falls and had a fall on 5/20/2025 with no injuries. During an observation on 06/17/25 at 10:57 a.m., the emergency call light in Resident #8's bathroom was approximately 3 feet above the floor and not accessible if lying on the floor. Resident #8 was ambulating independently in her room. Resident #8 said she used her restroom with minimum assistance and would call for help if needed. During an interview on 06/18/25 at 10:46 am LVN L said that the string being too short could cause the resident not to be able to reach it and not to be able to call for help if they had a fall in the bathroom. During an interview on 6/18/25 at 9:00 am, the Director of Maintenance said the call lights in bathrooms needed to be accessible because if a resident were to fall, they needed to be able to reach the string to call for help. He said he had only worked at the facility for a few months and would make a facility sweep to correct all strings to the required length. During an interview on 6/18/25 at 11:00 am, the Administrator said that call lights needed to be accessible always in case the resident needed assistance or if there were an emergency. She said the call lights in the bathroom needed to be accessible for a resident lying on the floor. The Administrator said if a resident were to fall, they needed to be able to reach the string to call for help. She said going forward, she would expect her staff to follow proper policy and procedure. Record review of an undated facility policy titled Call Lights indicated .7. The call system must be accessible to the resident at each toilet and bath or shower facility. The call system should be 675691 Page 7 of 10 675691 06/18/2025 Huntsville Health Care Center 2628 Milam Huntsville, TX 77340

F 0919 accessible to a resident lying on the floor . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675691 Page 8 of 10 675691 06/18/2025 Huntsville Health Care Center 2628 Milam Huntsville, TX 77340

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for one of four hallways (Hallway 200) reviewed for physical environment. The facility failed to maintain the walls, ceiling, and floor in the shared restroom for rooms [ROOM NUMBERS] located on the 200 hallway. The facility failed to remove a broken dresser from room [ROOM NUMBER] located on the 200 hallway. The potential outcome statement goes here Findings included: During an observation on 06/16/2025 at 9:53 AM, the shared restroom for room [ROOM NUMBER] and 210 had 6 holes one inch to one and a half inch in diameter in the sheetrock wall beside the toilet, the floor was dirty, discolored gray, brown with no visible wax or coating and worn. Black-brown dirt debris substance was around the bottom of the toilet that had clear caulk over it. Dirt-dust debris was on the wall underneath the sink. There was a 6-inch area on the ceiling where the ceiling texture was flaking off from prior water damage. During an observation on 06/16/2025 at 10:15 AM, room [ROOM NUMBER] had a dresser with a broken top, a ten-inch area of particle board was exposed which would not allow proper cleaning and disinfection of the surface and the vinyl trim was hanging loose from the left side edge of the dresser. During an interview on 6/17/2025 at 10:30 AM, LVN L said the dresser had been damaged due to staff raising and lowering the electric bed while providing care and catching the dresser edge. She said the dresser needed to be replaced due to it could not be properly cleaned. She said the dresser should be moved to another area in the room to prevent more damage. During an interview on 06/17/2025 at 11:30 AM, CNA M said she had only worked at the facility for a few weeks. She said she thought the broken dresser was not appropriate but did not know if it was acceptable or not or who exactly to report the broken dresser to. She said the broken dresser could not be properly cleaned and did not look nice. During an interview on 06/17/2025 at 2:30 PM, the Director of Maintenance said he had worked at the facility for a couples of months and had been busy making repairs needed. He said he was not aware of the needed repairs to the bathroom shared by rooms [ROOM NUMBERS] but he would put it on his list. During an interview on 6/18/2025 at 10:30 AM the Administrator said she expected the bathrooms to be maintained and furniture to be in good condition in the resident rooms. She said she would have the shared bathroom for room [ROOM NUMBER] and 210 holes cleaned and repaired. The Administrator said she had ordered new dressers for the resident rooms and would replace the dresser in room [ROOM NUMBER] She said the risk to the residents was to live in an environment that was not sanitary and safe. 675691 Page 9 of 10 675691 06/18/2025 Huntsville Health Care Center 2628 Milam Huntsville, TX 77340

F 0921 Level of Harm - Minimal harm or potential for actual harm Record Review of an undated facility policy titled, Resident Rooms reflected .Resident bedrooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents .10. Resident rooms will be furnished with functional furniture and arranged according to resident needs and preferences . Residents Affected - Few 675691 Page 10 of 10