Health inspection·January 12, 2026

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one of ten residents (Resident #1) reviewed for medically related social services. The facility failed to ensure a Social Worker assisted Resident #1that was under the age of 22, in obtaining additional resources and services related permanency. This failure could place all residents at risk of not having their needs and preferences met according to permanency planning regulations for those under the age of 22.Record Review of Resident #1's face sheet dated 12/31/2025, reflected she was [AGE] years old, admitted on [DATE]. The resident was diagnosed with Diffuse traumatic brain injury with loss of consciousness of unspecified duration, sequela ( a head injury that injured their brain, loss of conscience for an unknown period of time with lasting problems.), Dependence on Respirator [Ventilator] (relies on a mechanical ventilator to breathe) Tracheostomy (surgical hole created in the windpipe for breathing), Other Reduced Mobility (unable to walk.) (GERD) Gastro-Esophageal Reflux Disease Without Esophagitis (where stomach contents frequently come up into the esophagus (the tube that food passes from to the throat to the stomach) causing symptoms like heartburn.), Generalized Anxiety Disorder (excessive worrying) that hard to control.), and Depression, Unspecified (a mood disorder causing persistent sadness.). Record Review of Resident #1's Quarterly MDS dated [DATE] reflected resident had no speech, sometimes understood others, BIMS score indicated the resident severely impaired cognition as staff was unable to conduct the interview. Section D: Mood severity score of 0, indicating that she had not been observed with a mood disorder. Section E: Behaviors indicated the residents had no behaviors.Section GG: Functional Status reflected the resident the resident was dependent on staff for all ADL's, two persons assist. Section J: Health Conditions reflected the resident was at risk of dehydration and SOB. Section K Swallowing/Nutritional Status reflected Resident #1 required the use of Parenteral/IV feeding and feeding tube. Section M skin: reflected the resident was at risk of PU. Resident #1 required the use of a Pressure reducing mattress, applications of nonsurgical dressing, and ointments. Section N Medications reflected the resident took an antidepressant, antibiotic, anticoagulant. Sections O: special treatments and procedures addressed that the resident required the use of oxygen, suctioning, tracheostomy care, invasive mechanical ventilator, IV - access, and had no restraints or alarms. Record Review of Resident 1's Care Plan dated 10/02/2025 reflected she was dependent on the ventilator for breathing, required oxygen therapy, Seizure disorder, bowel incontinence, enhance barrier precautions (Gloves and gown should be donned if any of the following activities occurred: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity), adverse medication effect and behavior monitoring (Each shift monitor for and report any potential medication side effects or behaviors in the kiosk. If noted, also verbally Residents Affected - Few Page 1 of 4 675779 675779 01/12/2026 Marine Creek Nursing and Rehabilitation 3600 Angle Ave Fort Worth, TX 76106

F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few report to a licensed nurse.).Anticoagulant therapy (Monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged (pinkish),blurred vision, SOB, Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s.) had Tracheostomy (monitor trach ties for security at all times, respiratory rate.Monitor/document or restlessness, agitation, confusion, increased heart rate.resident was impairment to skin.impaired cognitive function/thought process.communication problem r/t trach.ADL care 2 staff for assistance. Fully dependent on staff for all needs due to no active involvement or immobility.Feeding tube at risk for malnutrition and dehydration, she had a PU. Antidepressant medication and monitoring. Record Review of Resident #1's MD orders dated 08/20/2025 reflected Enteral feed order, NPO diet, psychiatric services.full code.Facility Initiated PIP Data Collection for rehospitalization Prevention. May obtain vital signs. Pt may wear Bil hand/wrist orthosis (brace) daily as tolerated. Remove and check skin q shift.Probiotic Blend Oral Capsule (Probiotic Product), Eliquis Oral Tablet 5 MG (Apixaban), Assess before & after a treatment - O2 Sat, Resp. Rate, Pulse, Breath sounds(Key-0=Clear,1=Wheezing (whistle), 2=Pleural rub (creaking breathing sound), 3=Rales, 4= Stridor 5=Other breath sounds (if other document in Prog Note). Total time in minutes to assist with TX and assess.Verify vent settings and titrate as tolerated.every shift.Maintain and titrate O2 to maintain O2 sats greater than 90% .every shift and prn.Change Out Trach -[size]:6.0 Bivona (flexible tube) every night shift every 3 months(s) starting on the 3rd for 1 day(s).Change Yankauer (suction tube) Q Week. every night shifts every Sun.Change HME (Heat Moisture/ Dry Humidifier Exchanger) .every night shifts every Mon, Thu.Change Trach Ties. Every day shift every Mon, Wed, Fri, Sun, [and] every night shift every Tue, Thu, Sat.NPO diet, NPO texture, NPO consistency.Change Inner Cannula every shift.AMBU (bag valve mask) bag with O2 cylinder at bedside (used at 10-15 lpm) every shift Check resident Q2H for suctioning need, suction via trach PRN. every shift. Trach care. Record review of an email from PPC on 12/12/2025 at 9:52 AM reflected Good morning, [SW name] I am following up on the Permanency Plan information discussed yesterday. Record review of an email from PPC on 12/16/2025 at 9:16 AM reflected Good morning, [SW name], I am following up on the Permanency Plan information discussed Thursday, December 11, 2025. (view email below) Have you completed form 2437? Thank you [PPC name]. the email had the following attachments titled Letter to NF Providers.dated 01/02/2013 name Nursing Facility providers, Subject: Permanency Planning Contracts with [PPC NAME] with a blank copy of FORM 2437 titled Notification of Nursing Facility admission of Person Under age [AGE]. In accordance with Title 40, Part I, Chapter 19, Subchapter I, Rule S19.805 of the Texas Administrative Code permanency planning is required to be completed every six months for any individual under the age of 22 who resides in a nursing facility in Texas. Permanency planning laws in the State of Texas are designed to ensure that individuals under age [AGE] who are placed in institutions are placed there on a temporary basis. The objective of the permanency planning process is to ensure that the families received d information about supports and services that are available and develop a plan for the future.Previously, the permanency planning instrument was completed by Local Authorities (LA's) under contract with the Department of Aging and Disability Services (DADS). Under a new contract, [PPP] is now responsible for conducting Permanency Planning for all individuals under age [AGE] years who reside in nursing facilities in the State of Texas.[PPP] will be contacting you as the nursing facility to gather relevant information required to complete these plans. The Texas Health and Human Services Commission and DADS authorize [PPP] to access this information, and nursing facilities should cooperate with requests to do so. [PPP] staff are also authorized to visit the facility and may interact with the individual and staff or review records. As a reminder, your facility is still required within 3 days of admission of an individual under the age of 22, to contact 675779 Page 2 of 4 675779 01/12/2026 Marine Creek Nursing and Rehabilitation 3600 Angle Ave Fort Worth, TX 76106

F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DADS State Office to notify them of the admission.If you have questions about the Permanency Planning process, please contact me at [phone number], or [email address] Record review of the SW note dated 01/12/2026 at 1:58 PM reflected RE: [Resident #1] from [PPC name] Initially contacted by an individual stating that one of the residents had been flagged by the state and required assistance with a permanency placement due to their age (under 21). I advised that we are a nursing facility, and our residents are seniors, well over 21. She provided the resident's name and inquired about the resident's PASRR results, advising the resident qualified for positive eligibility. The information concerned me because the PL1 results indicated not eligible. I asked if the caller had spoken with the family? The caller indicated that once the Face sheet is received d, the family will be contacted. I felt uncomfortable continuing the conversation or providing further information without consulting the family. The caller advised that they would have the family contact me to initiate the process. The caller tried several times to obtain the family's contact information but did not want to set up a meeting with them. I advised the caller I would need to speak with the administrator, as the permanent placement process is new to me and to the facility. However, the caller decided to contact the administrator before I could. My concerns continued that the caller's attempt to identify herself as a representative of the state, yet did not have any qualifying information, the resident had been in the facility for over three months without any inquiries regarding her living arrangements. I inquired with staff members of the residents' need for permanent placement and whether the family had expressed any concerns about housing. To that end, there were no prior inquiries. Record review of an in-service dated 01/12/2026 completed by the DON with the SW. Education material titled Provider Letter to Nursing Facilities from the Office of health Coordination and Consumer Services. This was the letter provided initially to SW by the PPC on 12/11/2025. The in-service was signed by DON and SW as having the knowledge and understanding of permanency planning in the state of Texas. The ADM was not interviewed on 12/31/2025 or 01/12/2026, due to being out of the office. During an observation on 12/31/2025 at 11:00 AM of Resident #1, the resident was not interviewable, due to DX of TBI. Resident #1 was observed lying in bed with a ventilator, dated tubing equipment, no odor or smell, clean environment. Resident #1's eyes were open, and she turned her head and eyes following the surveyor and blinking during the observation. During an interview on 12/31/2025 at 11:30 AM, the CD said that permanency plans were completed for PASRR positive residents that were under the age of 22. She said the PASRR evaluation determined the resident was negative, so no further actions by the facility were completed. The CD said the SW reported that the requesting program had not provided a formal request, so the request was not completed.During an interview on 12/31/2025 at 1:00 PM with SW, was recently assigned the role of SW. She scheduled PASSR and care Plan meetings that included outside contractors and services. SW denied receiving a records request from PPP for Resident #1's permanency planning. During an interview on 12/31/2025 at 1:20 PM with the DON revealed she completed the initial PASRR at the time of admissions for Resident #1. She said once determining Resident #1 was positive, she completed the 2401 form notifying HHSC. The DON said the local PASSR agency was notified to schedule an evaluation. The DON said Resident #1 was evaluated by the QIDP on 08/26/2025. A letter noting that Resident #1 did not qualify for PASSR services. The DON said the family was notified in a meeting of the results. The family agreed to all the services for Resident #1. The DON said that the SW was assigned to contact the provider about the records request. During an interview on 01/12/2026 at 2:30 PM with the SW revealed that she received a phone call from the PPP requesting Resident #1's care files and related documents. The SW said she did not know what the term permanency planning meant. The SW said the PPP was unable to provide information regarding Resident #1's relation and 675779 Page 3 of 4 675779 01/12/2026 Marine Creek Nursing and Rehabilitation 3600 Angle Ave Fort Worth, TX 76106

F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few purpose of the requested information. The SW said she searched for permanency planning and was unable to determine the legitimacy of the request or PPP and she did not want to violate confidentiality of resident records, per HIPPA. During the interview, the SW denied receiving emails from the PPP. The SW said she did not document the information nor forward emails to the DON or ADM, but that the call was fraudulent in nature. The SW said she does not recall the date of contact with PPP, nor the agency or person's name and credentials. The SW said she did not contact HHSC, PPP, or a PPP superior for further information to determine the validity of the request. The SW stated she had not contacted the PPP since that date. It was unclear whether the SW received a phone call or email requesting the documents, so the surveyor requested emails, soft file notes, and review of phone calls for the contact information of the PPP from the DON and the SW. The SW provided the email documentation on 01/12/2026 at 2:47 PM. During an interview on 01/12/2026 at 3:30 PM, the DON reported that she contacted the PPP prior to the interview and provided all the information requested. She stated that upon reviewing the email, the PPP provided reference website information and phone contacts for the SW to call; and gain clarity on the request and agency. The DON said the SW failed to communicate timely and accurate information to leadership regarding the permanency request. The DON said SW would receive an in-service and coaching, and it was her expectation for staff receiving requests (The) to gather all needed information or seek assistance from leadership, PPP, and HHSC to ensure the residents received accommodation and services. SW was further responsible ensuring all information in the email request and correspondences with the provider were accurate for to address Resident #1's permanency planning. During another observation on 01/12/2026 at 3:26 PM of Resident #1, the resident was not interviewable, due to DX of TBI. Resident #1 was observed lying in bed on a ventilator, dated tubing equipment, no odor or smell, clean environment. Resident #1's eyes were open, and she turned her head and eyes following the surveyor and blinking during the observation. During an interview on 01/12/2026 at 4:15 PM with the PPC she requested records on 12/11/2025, 12/12/2025, 12/13/2025, and 12/16/2025. He did not receive a response. PPC stated that the email attachments provided information about HHS guidance on Permanency planning. PPC informed SW that she had 3 days to send records. PPC called the ADM to check the status of the records request, then she was transferred to SW. The PPC said the negative PASSR would not prevent the service for permanency planning, although she was unsure how the residents were PASRR negative with a TBI diagnosis. PPC would review upon receival and make the proper referrals for review. Record review of the SW's employee file reflected a hire date of 03/06/2025 at a sister facility and she transferred to the current facility on 11/17/2025. The facility policy for permanency planning coordination was requested from the DON and the CD on 12/31/2025 at 10:26 AM. A second request was made for the facility's policy on 01/12/2026 at 4:00 PM as follows: Please provide the policy for guidance S483.70 Administration . Permanency Planning. Both directors reported not having a policy related to Permanency Planning. 675779 Page 4 of 4