Health inspection·September 8, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to implement their written policies and procedures for reporting all allegations involving abuse, neglect, and injuries of unknown source in accordance with the state law for 1 of 1 resident (Resident #1) reviewed for abuse and neglect The facility failed to provide evidence that an allegation of abuse was reported to law enforcement officials immediately. The facility reported the allegation of abuse on 08/20/23. This failure could place the census of 99 residents at risk for abuse and neglect. Findings included: Review of the facility policy titled Abuse. Neglect, Exploitation or Misappropriation - Reporting and Investigating, last revised September 2022, reflected the suspicion of abuse must be immediately reported to law enforcement agencies. Review of Resident #1's electronic health record , indicated Resident #1 was [AGE] years old and admitted on [DATE] with diagnoses that included Macular degeneration (eye disease), insomnia, GERD (reflux), HTN (high blood pressure), depression, hallucinations, and Dementia without behavioral disturbance. Review of Resident #1's MDS dated [DATE] indicated Resident #1 had a BIMS of 5 . Resident #1's MDS indicated she utilized a wheelchair for mobility and required limited, one-person, physical assist for ADL's. Review of the provider investigation report dated 08/20/23 indicated an allegation of abuse was reported to the state agency on 08/20/23 regarding Resident #1. The investigation outlined an allegation of verbal Resident Abuse towards Resident #1 by an agency nurse. It was noted on the investigation report that police were not notified . The report concluded that the allegation investigation, which involved in-services, resident safety polls and witness statements, of abuse was unsubstantiated. Review of an in-service titled Abuse and Neglect dated 08/2023 was conducted, as well as review of in-services titled Abuse and Neglect, Resident Rights, Ethics and Dementia dated 08/29/23. During an interview on 09/08/23 at 3:56 PM, the DON stated she was unsure if the previous, now resigned, administrator s ubmitted a police report for the allegation of abuse against Resident #1. The DON stated she does not know why the incident was not reported to the police. She stated this would (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675886 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 675886 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coryell Health Rehabliving at the Meadows 110 Chicktown Rd Gatesville, TX 76528 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)