Health inspection·May 8, 2024

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some received training on abuse and neglect and was able to identify the Administrator as the Abuse Coordinator. CNA-A stated later after talking with Resident #1 they called and spoke to the ADON and told her what RN-B has said to them about Resident #1 crying wolf about the fall. During an interview on 5/2/2024 at 2:43 pm, RN-B stated she had been at work on 4/23/2024 when Resident #1 sustained an unwitnessed fall. She stated she assessed the resident and had not seen any injuries but Resident #1 wanted to be sent to the ER, so she had gone back to the nurse's desk to start the process. She stated Resident #1 has Generalized Anxiety Disorder and can be hyper-sensitive. She stated she never told Resident #1 that she would not send her out to the ER. She also stated that she had not said anything to anyone about the resident being overly dramatic or crying wolf. She stated when she provided information at the nurse's station at shift change she did not say Resident #1 was faking it or being overly dramatic. She stated she did not remember that she said anything to CNA-A in the hall about the fall. RN-B stated Resident #1 had a history of making false accusations and has had frequent somatic complaints. She said, the thought entered my mind that she had not fallen because the resident could not tell me how she got to sitting on the floor by her recliner. She stated Resident #1 had made accusations in the past that are not quite accurate from my viewpoint. RN-B She stated she had received training on ANE and how to recognize and report ANE. She stated they are supposed to report all ANE to the Abuse Coordinator who is the AD. RN-B denied any ANE of Resident #1. During an interview on 5/2/2024 at 3:49 pm, the ADON stated she had received a call from CNA-A after Resident #1 had fallen. She stated nothing was reported to her as abuse or neglect, there was just a concern that RN-B was not going to send Resident to ER. She stated she received no statements from staff stating RN-B stated Resident #1 was faking her fall or crying wolf. She stated if she had, she would have reported it to the Administrator. During an interview on 5/2/2024 at 4:13 pm, the AD stated she was aware of the fall incident with Resident #1 on 4/23/2024. She stated staff thought RN-B wasn't going to send Resident #1 out, but that staff didn't understand protocol for sending a resident to the ER. She stated she had no concerns about ANE and no concerns with how the incident was handled. During an interview on 5/3/2024 at 1:57 pm, CSM-C stated they were at work on 4/23/2024 and had been sitting at the nurse's station at shift change and heard CNA staff come up to the desk and tell RN-B that Resident #1 had fallen. RN-B stated that Resident #1 was faking it and CSM-C heard RN B say She's always crying wolf, there's nothing wrong with her, she didn't hit her head and I'm not sending her out.' CSM-C stated Resident #1 is the type of resident that will say things sometimes that staff think are not true. During another interview on 5/5/2024 at 1:36pm, CSM-C stated they had received training on abuse and neglect and was able to identify the AD as the person to report any ANE. CSM-C stated that it did not cross my mind that it might be abuse, referring to what she heard RN-B had said on 4/23/2024 and that RN-B wasn't being malicious about it, that's how they talk about Resident #1. During an interview on 5/3/2024 at 2:19 pm, CSM-D stated they had been working on 4/23/2024 and was at the nurse's desk about 5:15 pm. RN-B told her that Resident #1 had fallen and you know she's faking it, she did one of her fake falls,. CSM - D asked if Resident #1 had hit her head and RN-B stated, she says she did. CSM-D asked RN-B if she was going to send Resident #1 out and RN-B said no. CSM-D stated later that evening the DON called them and asked what happened at the nurse's desk earlier that day and CSM-D stated they told the DON that RN-B told me that Resident #1 fake fell and that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 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 675886 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 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)

F 0607 she wasn't sending her to the ER. Level of Harm - Minimal harm or potential for actual harm During another interview on 5/3/2024 at 4:09 pm, CSM-D stated at the time they did not think what RN-B said was abuse or neglect but looking back now they think that it was , and they should have reported it to the AD who is the abuse coordinator. CSM-D stated, I wanted to get out of the situation because of RN-B's attitude at the time. I know that's wrong, and I have been beating myself up over it. She stated the facility policy stated any concerns with ANE are to be reported to the abuse coordinator who is the administrator. Residents Affected - Some During an interview on 5/3/2024 at 4:59 pm, the DON stated she was aware of the fall incident with Resident #1 and that staff thought RN-B was not going to send Resident #1 out to the ER. She stated she does not recall any staff telling her that RN-B said it was a fake fall or that Resident #1 was crying wolf., I'm not saying they didn't, I don't recall, I don't remember; not to my recollection. She stated there was no reason to believe that there was any abuse or neglect going on by RN-B. She stated the events were reported to the AD in the morning meeting the next day on 4/24/24 and there was nothing reported in the morning meeting about RN-B refusing to send Resident #1 out to the ER. She stated she did have an informal discussion with RN-B on 4/24/24 at the nurse's station face to face to remind her if a resident wants to be sent out we have to send them out. Review of undated facility policy Prevention and Reporting of Suspected Resident Abuse and Neglect reflected: This facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect. This facility has implemented the following processes in an effort to provide residents and staff a comfortable and safe environment. The Administrator and Director of Nursing are responsible for the implementation and ongoing monitoring of abuse policies and procedures. Implementation and ongoing monitoring consist of the following policies: Screening, Training, Prevention, Identification, Protection, Investigation and Reporting .4. B. Any person with the knowledge or suspicion of suspected violations must report, immediately, without fear of reprisal. Notification will be to the Unit Charge Nurse (UCN) for the resident involved. The UCN is identified as responsible for initiating the reporting process and will notify the Director of Nursing and/or Administrator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 3 of 3