Health inspection·January 15, 2025

F 0839 Level of Harm - Minimal harm or potential for actual harm requested employees' information it was discovered one of the nurses chosen, RN A, had a license that expired in October of 2023. She said they ran all the other nursing staff today to ensure compliance and they had not found any other expired licenses. She said RN A had been taken off the schedule effective immediately and terminated until she was licensed. The Administrator said the BOM was responsible for checking nursing licenses. Residents Affected - Few During an interview on [DATE] at 3:40 PM, the DON said she was aware the ADONs license had expired because when the ADON realized it, she had come to her in a panic. The DON said she went through everything and made sure the ADON had not worked the floor and had not done any resident documentation. She said the Administrator was out that day and she did not report it to Administrator. She said the BOM was responsible for checking nursing licenses, but she just started doing them this month, the Administrator had been doing them prior. During an interview on [DATE] at 10:00 AM, the Administrator said she had been responsible for pulling licenses and background checks annually for nurses until August of 2023 when she handed it over to the BOM. She said RN A's license was current when she last checked in August of 2023. She said she had been checking the nursing licenses once a year. She said maybe she didn't train the BOM effectively and BOM did not know the background checks included the nursing licenses. She said it was ultimately her (administrator)'s responsibility to ensure the nursing licenses were current. During an interview on [DATE] at 10:15 AM, the BOM said she was responsible for running criminal background checks, OIG, EMR and NAR checks before hire and annually. She said she did not know she was also supposed to be verifying the nursing license as well. She said she learned that at the beginning of this month. She said going forward she would run them with the annual background checks. She said she would create some sort of system to check them monthly as well. She said she could not really think of any harm that could come to residents as a result of being cared for by unlicensed nurses. During a telephone interview on [DATE] at 11:40 AM, RN A said she thought she had renewed her license. She said she remembered renewing it and remembered paying her fee and she just never thought anything else about it. She said she did not know until the facility called her yesterday to let her know. She said she had since gone through all her bank statements but could not find any record of payment. She said she was working now on getting her license renewed. She said she could not think of any risks to residents by being cared for by an unlicensed nurse. During an interview on [DATE] at 1:10 PM, the DON said there were many risks to residents if they were cared for by unlicensed nurses. She said there could be a reason why they were not licensed, incorrect medications could be given, incorrect care could be provided. She said there was a reason for nurses to be licensed and went through the process of obtaining a license. She said going forward, licenses would be checked upon hire and annually. She said she would personally ensure all her nursing staff was licensed. She said she did not tell the Administrator about the ADON's license at the time, and she knew now that she should have done that. During an interview on [DATE] at 1:20 PM, the ADON said that time period was just very chaotic for her. She said she just forgot all about renewing her license. She said it was not something she would normally forget; she just was not in her normal frame of mind. She said she was sitting at her desk one day going through some files and saw a file with some of her CEU's and it hit her that she never renewed her license. She said she immediately told DON, and then she immediately got her license renewed. She said if nurses were not licensed and stayed up with their CEU's, the nurses may not (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 01/15/2025 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 0839 provide competent care to residents. Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 1:35 PM, the Administrator said she was not aware of either expiration until yesterday after the State Surveyor entrance. She said she was providing more training to the BOM, and they would work together to come up with a system to run licenses monthly to ensure this did not happen again. She said if nurses did not renew their license appropriately and keep their CEU's up to date, then they may not be aware of best practices. Residents Affected - Few Record review of the facility policy titled Credentialing of Nursing Service Personnel, dated [DATE], read .Nursing service personnel who require a license or certification to provide resident care or treatment without direction or supervision within the scope of the individual's license or certification must present verification of such license or certification prior to or upon employment .a copy of annual license renewals/certifications - ran annually by HR or designee .should the investigation reveal the applicant does not hold a valid license employee will be placed on probation until license is reinstated FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675729 If continuation sheet Page 3 of 3