Health inspection·September 25, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few gave her statement regarding CNA A purposefully tossing water on Resident #1. The DON then reported the incident to the Administrator who is the Abuse Coordinator. The DON said she immediately completed head to toe assessments on the residents in the locked unit. She said that psychosocial assessments were completed as well that afternoon. During an interview on 9/25/24 at 10:00 am the Administrator stated Witness B and Witness C had confirmed CNA A had tossed water on Resident #1 on 9/04/24 at approximately 12:45 pm. The Administrator stated she was notified by the DON after Witness A and Witness B had reported the incident to the DON when she arrived back from lunch on 9/04/24 at 1:00pm to 1:15 pm. the facility investigation confirmed abuse and CNA A was suspended by phone, since she had left for the day immediately after the incident. The Administrator said Resident #1's representative and medical doctor were notified of the incident immediately. The Administrator stated ongoing assessments had confirmed Resident #1 had no negative outcome from the incident and was unable to determine if Resident #1 was aware that the incident had occurred. The Administrator said in-services were conducted on ANE, Dignity and dementia care on 9/04/24. During a phone interview on 9/25/24 at 11:58 am CNA A said she was terminated from employment at the facility after the incident on 09/04/24. CNA A said that Resident #1 was at the dining room table in the locked unit. CNA A said Resident #1 had grabbed her arm as she was walking by, and she unintentionally spilled the water on herself and the resident. CNA A said that she was not assigned care of Resident #1 due to the resident was difficult and Resident #1 preferred to be assigned ADLs by another CNA working at the facility. CNA A said she had been educated on ANE numerous times and she knew better than to mistreat any resident. She said she felt the witnesses did not see the whole incident as Witness B was standing behind her and Witness C was standing at the exit door. During an observation and interview on 9/25/24 at 12:15 pm, Witness B revealed Resident #1 was sitting at the dining table in the locked unit with a blanket wrapped around her with just her face in view. Witness B said that was how she was covered on 9/4/24 when CNA A intentionally tossed ½ cup of water from white foam cup onto the front of her blanket with some water getting on her face. Resident #1 looked up and smiled when her name was called. Resident #1 was unable to answer any questions about the incident involving CNA A. On 9/25/24 at 10:05 am 11:18 am and 1:00 PM three attempts were made to interview Witness C but the attempts were unsuccessful. Unable to leave a message. Record review of the facility investigation reflected the incident was reported on 9/04/24 and occurred on the afternoon of 9/04/24 as reported during interview with the DON and Administrator. Record review of a witness statement dated 09/04/24 signed by Witness B indicated Witness B had walked back onto the secured unit to clean the dining room. The statement reflected Witness B had just entered the dining room when CNA A was walking towards the exit door to the outside area holding a cup in her hand. As she was walking by Resident # 1, she gestured as if she was throwing the cup towards her and tossed water all over the resident and kept walking towards the door. Witness B documented that they reported what they saw to the DON. Record review of a witness statement dated 09/04/24 signed by Witness C indicated Witness C was standing at the smoking area door facing inside the dining room when she saw CNA A walk by Resident #1 and tossed water on her. Witness C immediately went to check on the resident and clean her up. Afterwards she called the DON to have her come to the unit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675729 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 675729 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonecreek Nursing & Rehabilitation 451 S El Camino Crossing San Augustine, TX 75972 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of CNA A's Termination Statement dated 09/04/24 revealed CNA A was suspended per phone call on 09/04/24 and terminated on 09/04/24. Record review of the facility policy titled Dignity with revision date 2/2021 . indicated: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Record review of the Facility Policy titled Abuse Neglect dated 3/29/2018 indicated .the resident has a right to be free from abuse, neglect and misappropriation. ''Abuse is define as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Review of Abuse, Neglect and Exploitation In-service dated 09/04/24 revealed staff were in-serviced on abuse, neglect and exploitation, dementia care and dignity. Review of CNA A's employee record reflected she was hired 4/13/2023 and background checks were completed. Her last abuse prevention training was done 5/08/24 and there were no disciplinary actions. During an observation on 09/25/2024 at 9:35 AM revealed staff interacting at the facility respectfully with residents. During an interview on 09/25/2024 at 1:35 PM Resident #2 stated he thought the staff were competent and felt safe at the facility. He denied any abuse. During an interview on 09/25/2024 at 1:45 PM Resident #3 stated she felt safe and had no concerns for abuse or neglect. During interviews with staff present on morning and evening shifts 09/25/24 from 10:00 am until 3:15 pm, the staff were able to identify the abuse coordinator was the Administrator. The staff said that they would report any abuse immediately and had been trained on dignity and dementia care. During an interview on 09/25/2024 at 11:00 AM Witness B stated she was educated regarding the facility abuse and neglect policy and would notify their abuse coordinator, the Administrator. If she did not feel the situation was addressed by the abuse coordinator, she would notify HHSC. Review of Satisfaction Rounds by the Administrator dated 09/04/2024 revealed the DON completed satisfaction rounds with all residents with no additional concerns revealed. Review of Resident #1's Care plan dated 06/25/2024 revealed Resident #1's care plan was updated for recent trauma related to abuse for incident involving CNA A. The noncompliance was identified as PNC. The noncompliance began on 09/04/24 and ended on 09/04/24. The facility had corrected the noncompliance before the survey began. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675729 If continuation sheet Page 3 of 3