Health inspection·August 27, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment 1 of 3 halls (room [ROOM NUMBER]) reviewed for environment.The facility failed to repair the window in Resident #8's room [ROOM NUMBER] that had a broken frame that was frayed and splintered on 8/26/2025 and 8/27/2025.This failure could place the residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.Findings include:Record review of a face sheet for Resident #8 dated 8/26/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of severe intellectual disabilities (delay in language, motor, and social skills), expressive aphasia (difficulty speaking), and hypotension (low blood pressure). Record review of the maintenance log dated 7/30/2025 indicated that the window frame in Resident #8's room was reported and initialed by Maintenance. Record review of a care plan for Resident #8 dated 7/23/2025 indicated she had impaired functional abilities related to severe intellectual disabilities and she was dependent on staff for all adl's. Record review of a Quarterly MDS Assessment for Resident #8 dated 7/18/2025 indicated she was rarely/never understood and did not have a BIMS score. She was dependent on staff for all adl's. During an observation and interview on 8/26/2025 at 8:19 AM in Resident #8's room revealed she was in bed visiting with a friend . The window frame was frayed and splintered with pieces of wood sticking out. The friend said she had been working with Resident #8 for two weeks and had not noticed the window frame. She said the window frame was splintered it could be a hazard to the resident and said she was sure they would get it fixed. During an observation and interview on 8/26/2025 at 8:21 AM, CNA A was standing in the hallway of hall 100. She said she had been employed at the facility since April 2025. She said she reported the window frame in Resident #8's room last month to Maintenance. She said she had Maintenance go in the room and look at the window frame. She said she did not know if there was a logbook to report maintenance issues. She said she would report issues verbally to the nurse or would find Maintenance and report to him directly. She said the resident could get splinters, cuts, or injuries if the window frame was not repaired. During an observation on 8/27/2025 at 8:19 AM, Resident #8 was in bed resting with her eyes closed. The window frame was still not repaired and was splintered with pieces of wood sticking out. During an observation and interview on 8/27/2025 at 8:46 AM, the Maintenance Supervisor said he had been employed at the facility for three months. He said staff reported things that needed repair to him verbally but would log in the maintenance book that was kept outside of his office door. He said he checked the maintenance log daily. He observed the window in Resident #8's room and said it was splintered and needed to be repaired. He said he thought the staff were raising the bed too close to the window frames that was causing the frames to break. He said he was not aware of the window frame in Resident #8's room but would get it repaired. He said residents could get hurt if it was not repaired. During an interview on 8/27/2025 at 9:20 AM, the Page 1 of 17 675907 675907 08/27/2025 Diboll Nursing and Rehab 900 S Temple Dr Diboll, TX 75941

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Administrator said he was aware of the windowsills in some of the resident rooms that needed repair. He said the Maintenance Supervisor had been working to repair them. He was not aware the window in Resident #8's room had been on the log for about a month. He said the Maintenance Supervisor would get the window repaired. He said there could be a risk for injury if the window was not repaired. Record review of a facility policy titled Homelike Environment revised February 2021, .Residents are provided with a safe, clean, comfortable and homelike environment. 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary, and orderly environment . 675907 Page 2 of 17 675907 08/27/2025 Diboll Nursing and Rehab 900 S Temple Dr Diboll, TX 75941

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for 4 of 8 residents (Residents #9, #1, #4, and #21) reviewed for ADL care. 1.The facility failed to clean/groom Resident #9's fingernails that had a dark brown substance underneath them on 8/25/25 and 8/26/25.2.The facility failed to trim, clean/groom Resident #21's fingernails that were about 1/2 inch in length and had a dark, brown substance underneath them on 8/25/2025.3. The facility failed to trim, clean/groom Resident #4's fingernails that were about 1/2 inch in length on 8/25/2025 and 8/26/2025.4. The facility failed to trim, clean/groom Resident #1's fingernails that were about 1/2 inch in length and had a brown substance underneath them on 8/25/2025 and 8/26/2025. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care.Findings included:1. Record review of a facility face sheet dated 8/26/25 for Resident #9 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (uncontrolled blood sugar). Record review of Resident #9's Quarterly MDS assessment dated [DATE] indicated a BIMS score of 3 which indicated a severe cognitive impairment. She required maximum assistance with most ADLs. She was always incontinent of bowel and bladder. Record review of a comprehensive care plan dated 7/23/25 for Resident #9 indicated she had an ADL self-care performance deficit and had an intervention for substantial/maximal assistance with personal hygiene. Record review of a Point of Care History flowsheet dated 8/23/25 to 8/26/25 for Resident #9 indicated she was to have nail care done once a day on Monday, Wednesday, and Friday.During an observation and interview on 8/25/25 (a Monday) at 9:27 am Resident #9 was observed lying in bed. Her 2nd and 3rd fingernails on her left hand were observed with a dark brown, caked substance underneath them. She was asked when the last time her nails were cleaned and groomed, and she said she thought they trimmed them last week but could not say when the last time they were cleaned. She said she would like to have them cleaned. During an observation on 8/26/25 (a Tuesday) at 8:20 am Resident #9 was observed in bed finishing her breakfast. Her nails on her left hand were observed to still have a dark brown, cakey substance underneath them. 2. Record review of a Face Sheet for Resident #1 dated 8/26/2025 indicated he readmitted to the facility on [DATE] and was [AGE] years old with diagnoses of pressure ulcer of sacral region stage 3 (wound at the bottom of the spine that extends through the skin into the tissue and fat), diabetes mellitus, and malignant neoplasm of upper lobe of lung (lung cancer).Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated he had moderate impairment in thinking with a BIMS score of 10. He required substantial/maximal assistance with personal hygiene. Record review of a care plan for Resident #1 dated 10/28/2024 indicated he had an approach for nail care to be performed once a day on Monday, Wednesday, and Friday.During an observation and interview on 8/25/2025 at 1:41 PM, Resident #1 was in bed awake. His fingernails were about 1/2 inch in length and had a brown substance underneath them. He said the staff had cut and cleaned his nails before, but it had been a while. He said he would like to have his nails trimmed and cleaned.During an observation on 8/26/2025 at 9:07 AM, Resident #1 was in bed awake. His fingernails were still long in length and had a brown substance underneath them.3. Record review of a Face Sheet for Resident #21 dated 8/26/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia following cerebral infarction (Stroke) affecting left non-dominant side (paralyzed on one side of the body), type 2 diabetes, heart failure and GERD (acid reflux disease).Record review of a care plan for Resident #21 dated Residents Affected - Some 675907 Page 3 of 17 675907 08/27/2025 Diboll Nursing and Rehab 900 S Temple Dr Diboll, TX 75941

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 8/18/2025 indicated nail care to be done once a day on Monday, Wednesday, and Friday from 6 am-6 pm. She had impaired functional abilities related to hemiplegia with an approach for personal hygiene that indicated she was dependent on staff.Record review of an Annual MDS Assessment for Resident #21 dated 7/22/2025 indicated she had moderate impairment in thinking with a BIMS score of 11. She required substantial/maximal assistance with personal hygiene.During an observation and interview on 8/25/2025 at 1:19 PM, Resident #21 was in her room in bed. Her fingernails were about 1/2 inch in length and had a brown substance underneath them. She said the staff cut and cleaned her nails about once a month. She said she did not like long nails and liked to keep them short and clean.During an observation on 8/26/2025 at 2:58 PM, Resident #21 was sitting up in a wheelchair in her room watching tv. Her nails were still long and had a brown substance underneath them.4. Record review of a Face Sheet for Resident #4 dated 8/26/2025 indicated the resident admitted to the facility on [DATE] and was [AGE] years old with diagnoses of moderate intellectual disabilities (developmental delay that affects thinking) expressive language disorder (inability to use language and communicate effectively), and schizoaffective disorder (a mental illness that combines symptoms of mood disorders).Record review of a care plan for Resident #4 dated 7/23/2025 indicated nail care to be completed once a day on Tuesday, Thursday, and Saturday.Record review of an Annual MDS Assessment for Resident #4 dated 7/22/2025 indicated she had moderate impairment in thinking with a BIMS score of 11. She was dependent on staff for personal hygiene.During an observation on 8/25/2025 at 9:52 AM, Resident #4 was sitting by the front entrance in a wheelchair. She was staring out the front door and did not answer when she was spoken to. Her fingernails were about 1/2 inch in length. During an observation and interview on 8/26/2025 at 2:59 PM, Resident #4 was sitting by the front entrance in a wheelchair with a visitor present. Resident #4 did not respond when she was spoken to. Resident #4 still had long fingernails. Her visitor said she had been with the resident for about 5 months and the resident had never refused to allow the staff to trim her nails. She said the Activity Director or Treatment nurse would trim the resident's fingernails. She said residents could scratch themselves or injure others if their nails were long.During an interview on 8/26/2025 at 3:01 PM, the Activity Director said she was responsible for nail care along with the nurse aides. She said the nurse aides were to clean and trim nails on the resident's shower days and she provided nail care on Monday during activities that included cleaning, trimming, and painting. She said the nurse aides would try to cut Resident #1's his nails but he would refuse at times. She said for the dependent residents who stayed in bed she would trim or file their nails as a 1:1 activity. She said if resident's nails were dirty and long, they could spread infections.During an interview on 8/26/2025 at 3:13 pm, LVN B said the treatment nurse was responsible for nail care for the residents in the facility and her last day working at the facility was one day last week. She said the treatments had been split up between management staff that included the ADON and MDS who would all rotate days during the week to perform treatments that started the week of 8/25/2025. She said she was not aware of any residents' nails in the facility being long or that needed to be cleaned.During an interview on 8/26/2025 at 3:17 PM, CNA A said nail care included cutting/cleaning and was the responsibility of the nurse aides and it was to be done on shower days and as needed. She said if the resident was diabetic, then the nurses were responsible for cutting the resident's nails. She said Resident #21 and Resident #1 were both diabetic residents and she did not cut their nails. She said she was not sure about Resident #4 if she was diabetic or not. She said she had cleaned her nails in the past but never trimmed them. During an interview on 8/27/2025 at 9:00 am, the DON said nail care was the responsibility of the nurse aides and the person who was responsible for completing skin assessments. She said nail care should be done weekly three 675907 Page 4 of 17 675907 08/27/2025 Diboll Nursing and Rehab 900 S Temple Dr Diboll, TX 75941

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some times a week and as needed. Staff should trim, cut, file or clean as needed. She said nail care was taken care of on yesterday 8/26/2025 for the residents in the facility. She said residents could scratch themselves if nails were long and could get infections if not cleaned.During an interview on 8/27/2025 at 9:20 AM, the Administrator said nail care was the responsibility of the nurses and nurse aides. He said nail care should be done as needed. He said he planned to assign staff to perform nail care and have the administrative staff monitor daily during rounds. He said not having proper nail care could be a dignity issue and the residents could possibly scratch themselves or get ill from not having clean nails.Record review of a facility policy titled Nail Care dated 7/2025 indicated, .The purpose of this procedure is to provide guidelines for the provisions of care to a resident's nails for good grooming and health. 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule. Nail care will be provided between scheduled occasions as the need arises . 675907 Page 5 of 17 675907 08/27/2025 Diboll Nursing and Rehab 900 S Temple Dr Diboll, TX 75941

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that residents requiring respiratory care are provided care, consistent with professional standards of practices for 1 of 5 residents reviewed for respiratory care (Residents #21).The facility failed to ensure the external filters of Resident #21's oxygen concentrators was free of dust build up from 8/25/2025-8/27/2025.These failures could place residents who require respiratory care at risk for respiratory infections, breathing in dust and allergens, decreased effectiveness of oxygen concentrators, and exacerbation of respiratory distress.Findings included:Record review of a Face Sheet for Resident #21 dated 8/26/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia following cerebral infarction affecting left non-dominant side (paralyzed on left side of the body following a stroke), type 2 diabetes, heart failure (heart not able to pump effectively) and GERD (acid reflux). Record review of active physician orders for Resident #21 dated 8/26/2025 indicated an order to clean the oxygen concentrator filter weekly on Sundays with a start date of 6/12/2023. Record review of a care plan for Resident #21 dated 8/18/2025 indicated she needed oxygen therapy related to shortness of breath in an approach to administer oxygen as needed per MD orders. Record review of an Annual MDS Assessment for Resident #21 dated 7/22/2025 indicated she had moderate impairment in thinking with a BIMS score of 11. Special Treatments, Procedures, and Programs during the 14 day look back period, she did not use oxygen therapy. During an observation on 8/25/2025 at 9:58 AM in the room of Resident #21, she was on oxygen via a nasal cannula at 2 L/min, the external oxygen concentrator filter had a large amount of white dust buildup. During an observation on 8/26/2025 at 2:58 PM, Resident #21 was in her room sitting up in a wheelchair not wearing oxygen. The external filter on the oxygen concentrator still had a large amount of white dust buildup. Resident #21 said the staff changed the oxygen tubing weekly on Sundays but had never seen anyone clean the filter on the concentrator. During an observation on 8/27/2025 at 8:21 AM, in the room of Resident #21, the external oxygen concentrator filter still had dust buildup. Resident #21 was in bed resting with her eyes closed. During an observation and interview on 8/27/2025 at 8:51 AM, LVN B said the oxygen concentrator filters were designated to get cleaned by the weekend nursing staff on Sundays. LVN B observed the concentrator of Resident #21 and said the filter was dusty and needed to be cleaned. She said if the filters were not kept clean, the residents could get infections, or the concentrator may not work properly. During an observation and interview on 8/27/2025 at 9:00 AM, the DON said the weekend supervisors were responsible for cleaning the oxygen concentrator filters on Sundays. The DON observed the concentrator for Resident #21 and said the filter was dusty. She said residents could be at risk for infections. She checked the filters and said they were hard to remove and would get the resident another concentrator to use. During an interview on 8/27/2025 at 9:20 AM, the Administrator said nursing staff were responsible for cleaning the oxygen concentrator filters when they changed the tubing weekly and as needed. He said if the filters were not cleaned it could inhibit the flow of oxygen to the resident. Record review of a facility policy titled Oxygen Concentrator dated 7/2025 indicated, .The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators. 5. Care of the concentrator: a. Follow manufacture recommendations for the frequency of cleaning filter and servicing the device . Residents Affected - Few 675907 Page 6 of 17 675907 08/27/2025 Diboll Nursing and Rehab 900 S Temple Dr Diboll, TX 75941

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 1 of 5 months (February 2025) reviewed for pharmacy services. The facility failed to have 2 witness signatures on attached page of controlled substances at time of disposal on 2/11/25.This failure could put residents at risk for misappropriation and drug diversion.Findings include:Record review of facility drug destruction records dated August 2024 through August 2025 revealed that on February 11, 2025, the attached page containing controlled substances was signed by the consultant pharmacist and one witness, the DON, and did not contain 2 witness signatures as required.During an interview on 8/27/25 at 11:15 am the DON said she was responsible for drug destruction. She said she was unsure how the witness signature was missed on the attached sheet of controlled substances. She said she would ensure proper witness signatures were done going forward for drug destruction. She said a drug diversion could possibly occur, or drugs might not be properly destroyed.During an interview on 8/27/25 at 1:35 pm the Administrator said the DON was responsible for drug destruction and drugs could be misplaced if they were not properly destroyed according to the regulations.Record review of a facility policy titled Disposal of Medications and Medication-Related Supplies dated 6/1/22 read: .Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations . Record review of 22 TAC S303.1 Destruction of Dispensed Drugs accessed online 08/27/2025 at https://texas-sos.appianportalsgov.com/rules-and-meetings?$locale=en_US&interface=VIEW_TAC_SUMMARY&queryAsD indicated: (a) Drugs dispensed to patients in health care facilities or institutions.(C) The signature of the consultant pharmacist and witness(es) to the destruction and the method of destruction specified in subparagraph (B) of this paragraph may be on a cover sheet attached to the inventory and not on each individual inventory sheet, provided the cover sheet contains a statement indicating the number of inventory pages that are attached and each of the attached pages are initialed by the consultant pharmacist and witness(es).(D) The drugs are destroyed in a manner to render the drugs unfit for human consumption and disposed of in compliance with all applicable state and federal requirements.(E) The actual destruction of the drugs is witnessed by one of the following:(i) a commissioned peace officer;(ii) an agent of the Texas by the Texas State Board of Pharmacy to destroy drugs;(iv) an agent of the Texas Department of State Health Services, authorized by the Texas State Board of Pharmacy to destroy drugs; or(v) any two individuals working in the following capacities at the facility:(I) facility administrator;(II) director of nursing;(III) acting director of nursing; or(IV) licensed nurse. 675907 Page 7 of 17 675907 08/27/2025 Diboll Nursing and Rehab 900 S Temple Dr Diboll, TX 75941

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety requirements and kitchen sanitation.The facility failed to ensure all foods stored in the refrigerators were not kept past their expiration dates and were labeled and dated.The facility failed to ensure all foods stored in the dry storage area were not kept past their expiration dates.These failures could place residents at risk of foodborne illness and food contamination.Findings included: During an observation of the refrigerator on 8/25/2025 at 9:30 AM, the following items were observed:(1) 1 gallon container of unsweet tea dated 8/18/2025.(2) 1 gallon container of unsweet tea dated 8/19/2025.(3) 16 glasses of unsweet tea not labeled or dated.(4) 14 glasses of fruit punch not labeled or dated.(5) 2 glasses of orange juice not labeled or dated. During an observation of the dry storage area on 8/25/2025 at 9:30 AM, the following items were observed: (1) 5 bags of panko Japanese style toasted breadcrumbs 2.5 pounds with the expiration date of 9/27/2024.(2) 1 bag cookie pieces 2.5 pounds with the expiration date of 1/20/2025. During an observation and interview on 8/25/2025 at 9:30 AM, [NAME] C said the DM was not at the facility and did not know if she would be at the facility later. She said it was the DM's responsibility to check for expired foods and it was done on Mondays when they received their food truck. During an interview on 8/27/2025 at 9:40 AM Dietary Aide D said it was everyone's responsibility to check for expired food in the kitchen. She said they were supposed to check once a week and throw away any food that was past the expiration date. She said the refrigerator was last checked on 8/21/2025 or 8/22/2025 when they were checking to see what food needed to be ordered. She said the dry storage area was last checked on 8/18/2025 for expired food. She said if the residents consumed expired food, it could make them sick. During an interview on 8/27/2025 at 9:51 AM [NAME] C said it was the DM's responsibility to check for expired foods on Mondays when the food truck came. She said the DM did not come to the facility on 8/25/2025 the day the truck came and did not know why. She said if resident consumed food that was expired, they could get sick. During an interview on 8/27/2025 at 10:13 AM, the Administrator said it was the staffs and his responsibility to check for expired foods in the kitchen. He said they should be checking for expired foods daily. He said if the residents consumed expired foods, they could possibly get sick. Record review of facility policy titled Food Storage undated, indicated: .1. D. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. 2. D. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. E. Use all leftovers within 72 hours. Discard items that are over 72 hours old. 675907 Page 8 of 17 675907 08/27/2025 Diboll Nursing and Rehab 900 S Temple Dr Diboll, TX 75941

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 2 of 5 resident personal refrigerators reviewed for food safety (Resident #3 and Resident #14).The facility failed to ensure the refrigerator for Resident #3 did not contain expired cheddar cheese bars or canned sausage. The facility failed to ensure the refrigerator for Resident #14 did not contain expired pineapple tidbits, fruit cups or pineapple juice. This failure could place resident at risk for food borne illnesses.Findings include:1.Record review of Resident #3's electronic medical record and face sheet undated reflected she was admitted to the facility on [DATE]. Her diagnoses included: radiculopathy, cervical region (pain, weakness or numbness), cellulitis and abscess of mouth (bacterial infection of the skin and the deeper tissues beneath the skin), psychotic disorder with hallucinations (severe mental illness with false perceptions of things not there and false beliefs). Record review of Resident #3's quarterly MDS assessment dated [DATE] reflected She could understand others and be understood. She scored a 13 on her BIMS which signified she was cognitively intact. She could ambulate with a walker 10 feet with maximum assistance. Resident #3 required partial to moderate assistance from staff with his ADLs. Record review of Resident #3's comprehensive care plan date initiated 8/05/2025 indicated had impaired functional abilities related to chronic obstructive pulmonary disease with interventions that included: eating: set up and clean up assistance.During an observation and interview on 8/25/2025 at 10:51 AM, Resident #3 said her personal fridge was usually cleaned by her and the facility staff. Resident #3 said she gets items out of the fridge herself. Resident #3 said she did not know that the observed 4 cans of 4.6-ounce canned sausage that expired on 8/9/2025 sitting on top of the refrigerator had expired. She said she also did not know the bag containing 6 cheddar cheese bars of 2.75 ounce inside the refrigerator had also expired on 7/20/2025. She said she also did not know the observed container of 5.3-ounce Greek yogurt had expired on 7/22/2025. She said her family member had just brought the cheddar cheese to her last week. 2. Record review of Resident #14's electronic medical record and face sheet undated reflected he was admitted to the facility on [DATE] with the most recent readmission [DATE]. His diagnoses included: intestinal adhesions (scar tissue on the intestines), alcohol induced persisting dementia (brain damage resulting from long term heavy alcohol use), hypertension (high blood pressure).Record review of Resident #14's quarterly MDS assessment dated [DATE] reflected he could understand others and be understood. He scored a 11 on his BIMS which signified he had mild cognitive impairment. He could ambulate independently without devices or assistance. Resident #14 was independent with his ADLs. Record review of Resident #14's comprehensive care plan date initiated 3/28/2025 indicated he had impaired functional abilities with interventions that included: eating: set up and clean up assistance. During and observation and interview on 8/25/2025 at 10:21 AM, Resident #14 said he and the staff takes care of his personal refrigerator. He said he did not know that the 3 pineapple tidbits 4-ounce cups had expired on 8/21/2024. He said he did not know the 3 mixed fruit 3.23-ounce cups had expired on 3/23/2024. He said he did not know the 1.4 ounce can of pineapple juice had expired on 6/29/2025. He said could get food out of his refrigerator himself. During an interview on 08/27/2025 at 8:31 AM the Housekeeping supervisor said her and the Maintenance Director clean the residents' personnel refrigerators. She said they clean the fridges about twice a week and check for expired foods. She said they did not have a set schedule for cleaning the personal refrigerators. She said the nursing department helped with checking the temperatures. She said it had been about a month since Resident #14's refrigerator had been cleaned. She said Resident #3's refrigerator was cleaned last Residents Affected - Few 675907 Page 9 of 17 675907 08/27/2025 Diboll Nursing and Rehab 900 S Temple Dr Diboll, TX 75941

F 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few week, and they had thrown away milk and other expired foods and said these items must have just been missed. She said the potential hazard to resident by consuming foods would be stomach poisoning. During an interview on 08/27/2025 at 8:44 AM the Maintenance Director said housekeeping cleans the residents' personal refrigerators. He said he only moves them if needed. During an interview on 08/27/2025 8:56 AM the DON said it was housekeeping's responsibility to clean residents' personal refrigerators. She said she would have to check but assumed they would be cleaned 1 time a week. She said nursing will throw away food if they notice its expired, but housekeeping was responsible. She said it could make residents sick at their stomach by consuming expired food. During an interview on 08/27/2025 10:13 AM the Administrator said it was housekeeping's responsibility to clean residents' personal refrigerators. He said nursing should had not been designated to clean residents' personal refrigerators. He said they should be cleaned as needed. He said the residents could potentially get sick by consuming expired food. Record review of the facility policy Personal Resident Refrigerators dated 9/11/2023 indicated: The facility does not provide a refrigerator in the resident's room. However, it is the policy of this facility to ensure safe and sanitary use of any resident owned refrigerators. 3. Housekeeping and/or nursing staff as assigned shall clean the refrigerator weekly and discard any foods that are not in compliance. 675907 Page 10 of 17 675907 08/27/2025 Diboll Nursing and Rehab 900 S Temple Dr Diboll, TX 75941

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 5 residents (Resident's #1, #21, and #22) and 3 of 5 staff (CNA A, ADON and CNA E) reviewed for infection control. 1.The facility failed to ensure CNA A changed gloves and washed or sanitized her hands when providing care to Resident #21 on 8/25/2025.2. The facility failed to ensure ADON wore a gown during wound care to Resident #1 who was on enhanced barrier precautions on 8/26/2025.3. The facility failed to ensure CNA E wore a gown during incontinent care to Resident #22 who was on enhanced barrier precautions, and she failed to wash or sanitize her hands on 8/27/2025. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included:1. Record review of a Face Sheet for Resident #21 dated 8/26/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia following cerebral infarction (stroke) affecting left non-dominant side (paralyzed on one side of the body), type 2 diabetes, heart failure (heart is not able to pump effectively) and GERD (acid reflux disease).Record review of a care plan for Resident #21 dated 8/18/2025 reflected she had impaired functional abilities related to hemiplegia with an approach for personal hygiene that indicated she was dependent on staff.Record review of an Annual MDS Assessment for Resident #21 dated 7/22/2025 indicated she had moderate impairment in thinking with a BIMS score of 11. She required substantial/maximal assistance with personal hygiene. She was always incontinent of bowel/bladder.During an observation on 8/25/2025 at 10:19 AM, CNA A was in the hallway gathering supplies to provide incontinent care to Resident #21. She placed the supplies in a plastic bag that included: wipes, gloves, brief and linens. CNA A entered the room of Resident #21; washed her hands and donned (put on) a gown, gloves, and shoe covers. She closed the door and the window blinds. CNA A removed the sheet and blankets from the bed and placed them in a chair. The fitted sheet on the bed was wet and the resident's brief was pulled down between her thighs. CNA A removed wipes from the plastic bag, and she wiped both inner thighs and down the middle of the vagina from front to back and placed the wipes in the trash. Resident #21 was rolled onto her right side and the brief was removed and placed in the trash. CNA A removed wipes from the plastic bag and wiped the rectal area using multiple wipes and feces was present and she placed them in the trash. CNA A removed the fitted sheet from the bed and placed it in a plastic bag. She placed a clean fitted sheet on the bed using the same dirty gloves and then placed a clean brief under the resident's buttocks. She removed her gloves and placed them in the trash, applied gloves and did not sanitize or wash her hands. She applied barrier cream to the resident's buttocks and removed her gloves and placed them in the trash. She applied gloves to both hands and did not wash or sanitize them. She secured the brief and repositioned the resident in the bed. The trash was placed in a biohazard bag in the bathroom. She removed her gown, gloves, and shoe covers and washed her hands and exited the room.During an interview on 8/25/2025 at 10:46 AM, CNA A said during the care provided to Resident #21 she should have changed her gloves after she cleaned her rectal area. She said she did not sanitize her hands between glove changes because she did not have sanitizer with her and should have. She said she was nervous and forgot. She said she had been trained on performing incontinent care. She said there was a risk for cross contamination and infections if staff did not change gloves or wash/sanitize their hands. Record review of a perineal care return demonstration skills check off for CNA A dated 3/28/2025 indicated she was satisfactory with peri-care for a female resident. 2. Record review of a Face Sheet Residents Affected - Some 675907 Page 11 of 17 675907 08/27/2025 Diboll Nursing and Rehab 900 S Temple Dr Diboll, TX 75941

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for Resident #1 dated 8/26/2025 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of pressure ulcer of sacral region stage 3 (localized skin and soft tissue injuries that develop due to prolonged pressure exerted over specific areas of the body, typically bony prominences), diabetes mellitus, and malignant neoplasm (cancer) of upper lobe of lung.Record review of active physician orders for Resident #1 dated 7/3/2025 indicated an order for enhanced barrier precautions due to wound every shift with a start date of 7/3/2025.Record review of a care plan for Resident #1 dated 6/20/2025 indicated he had a pressure ulcer/injury with an approach for enhanced barrier precautions when performing wound treatment that started on 7/16/2024.Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated he had moderate impairment in thinking with a BIMS score of 10. He required substantial/maximal assistance with personal hygiene. He was at risk for developing pressure ulcer/injuries but did not have any unhealed pressure ulcer/injuries during the look back period (the time period over which the resident's condition or status is captured by the MDS assessment and ends at 11:59 p.m. on the day of the Assessment Reference Date (ARD).During an observation on 8/26/2025 at 9:07 AM, the ADON was in the doorway for Resident #1's room gathering wound care supplies. The ADON cleaned the overbed table and applied wax paper and placed wound care supplies on top of it. The ADON washed her hands and donned (put on) gloves but did not don a gown. The ADON opened Resident #1's brief and cleaned his sacrum with normal saline and a gauze, gloves were removed and placed in the trash; hands were sanitized, gloves were applied; collagen (dressing that helps with wound healing) was applied to the wound bed and covered with a dressing. The ADON washed her hands and applied gloves. Resident #1 was rolled and positioned on his left side. Dressing from his right hip was removed and placed in the trash along with her gloves; hands were sanitized; gloves were applied; she cleaned the wound with vashe solution (wound cleanser) and patted it dry, applied gentamycin ointment (antibiotic used to treat skin infections) to his hip using a tongue depressor and applied a dressing. She removed her gloves and washed her hands.During an interview on 8/26/2025 at 9:35 AM, the ADON said she was one of the staff responsible for training staff on infection control. She said during wound care that was performed on Resident #1, she forgot to put on a gown, and it was left on the cart in the hallway. She said the resident was on enhanced barrier precautions for his wound and all staff that provided care to him should wear a gown and gloves. She said EBP was in place to keep residents from getting germs from other staff. She said residents could be at risk for infections if staff did not wear the appropriate PPE when care was provided. During an interview on 8/27/2025 at 9:00 AM, the DON said the ADON conducted random audits on hand hygiene/pericare often in the facility with staff. She said gloves should be changed when they are soiled and when changing from dirty to clean things. She said staff should never touch clean items with dirty gloves and hand hygiene should be performed after gloves were removed. She said EBP was to protect the residents and when care was provided staff should wear a gown, gloves, mask, and face shield if necessary. She said residents who had wounds would have enhanced barrier precautions. She said staff should wear a gown and gloves when wound care was provided. She said she was aware of the incident with the ADON on 8/26/2025 when she did not wear a gown when wound care was provided. She said there was a risk for spreading infections if staff did not follow hand hygiene and wear the appropriate PPE.During an interview on 8/27/2025 at 9:20 AM, the Administrator said the DON and ADON were the IPs for the facility who were responsible for training staff on infection control. He said staff should take off and change gloves when changing from dirty to clean. He said staff should wear the appropriate PPE for residents who were on EBP that included residents with chronic wounds. He said staff should wear a gown and gloves when care was provided. He said there was a risk for spreading infections 675907 Page 12 of 17 675907 08/27/2025 Diboll Nursing and Rehab 900 S Temple Dr Diboll, TX 75941

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some if staff did not follow infection control practices.3. Record review of a facility face sheet dated 8/26/25 for Resident #22 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus (uncontrolled blood sugar).Record review of a Quarterly MDS assessment dated [DATE] for Resident #22 indicated a BIMS score of 6, which indicated the resident had severely impaired cognition. She was always incontinent of bowel and bladder. She required maximal assistance with most ADLs. Record review of a comprehensive care plan dated 6/3/25 for Resident #22 indicated she had a feeding tube related to dysphagia (trouble swallowing).Record review of a physician's order summary report for Resident #22 indicated she had the following physician's order dated 7/31/25: .initiate enhanced barrier precautions. Special Instructions: G/tube (a tube inserted into the stomach via the abdomen to provide nutrition). During an observation on 8/27/25 at 11:45 am CNA E was observed providing incontinent care for Resident #22. She did not wear a gown for enhanced barrier precautions, and she was not observed to wash or sanitize her hands between glove changes. During an interview on 8/27/25 at 12:10 pm CNA E said she knew she forgot to put her gown on for the enhanced barrier precautions. She said Resident #22 had a G-tube and she was supposed to wear a gown when providing care for infection control. She said she also forgot to bring her hand sanitizer into the room and did not sanitize her hands between her glove changes. She said residents could be at risk for infection if infection control policy was not followed properly. Record review of a facility policy titled Enhanced Barrier Precautions dated 6/2025 indicated, .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown, and gloves use during high contact resident care activities. 4. High-contact resident care activities include: h. wound care: any skin opening requiring a dressing .Record review of a facility policy titled Hand Hygiene dated 6/2025 indicated, .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 6 a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Hand hygiene table: either soap and water or alcohol-based hand rub: after handling contaminated objects; before and after handling clean or soiled dressing, linens, etc., when during resident care, moving from a contaminated body site to a clean body site . 675907 Page 13 of 17 675907 08/27/2025 Diboll Nursing and Rehab 900 S Temple Dr Diboll, TX 75941

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 ensure the resident's medical record included documentation that indicates the resident received education on the influenza and the pneumococcal immunizations of 4 of 5 residents (Residents #1, #4, #7, and #21) reviewed for immunizations.The facility failed to document education was offered for the influenza and pneumococcal vaccinations to Residents #1, #4, #7 and #21.These failures could place residents at risk for contracting a viral disease that could spread through the facility and cause respiratory complications, and potential adverse health outcomes.Findings include: 1. Record review of a Face Sheet for Resident #1 dated 8/26/2025 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of pressure ulcer of sacral region stage 3 (wound a the bottom of the spine that extends through the skin and tissue), diabetes mellitus, and malignant neoplasm of upper lobe of lung (lung cancer). Record review of a comprehensive care plan dated 7/3/2025 for Resident #1 indicated that he did not have any interventions for flu and pneumonia vaccinations. Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated that he had moderate impairment in thinking with a BIMS score of 10. Section O (Special Treatments, Procedures, and Programs) indicated that resident did not receive his influenza vaccine in the facility for this year's influenza season because it was offered and declined. He was not up to date on the pneumonia vaccination because it was offered and declined. Record review of Resident #1's electronic health record undated revealed on 10/4/2024 the influenza vaccine was refused by family. On 4/3/2024 the pneumonia vaccine was refused by the resident. 2. Record review of a Face Sheet for Resident #4 dated 8/26/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of moderate intellectual disabilities, expressive language disorder, and schizoaffective disorder. Record review of a comprehensive care plan dated 7/23/2025 for Resident #4 indicated that she did not have any interventions for the flu and pneumonia vaccinations. Record review of an Annual MDS assessment dated [DATE] for Resident #4 indicated that she had moderate impairment in thinking with a BIMS score of 11. Section O (Special Treatments, Procedures, and Programs) indicated that resident did not receive her influenza vaccine in the facility for this year's influenza season because it was offered and declined. She was not up to date on the pneumonia vaccination. She was up to date on the pneumonia vaccine. Record review of Resident #4's electronic health record undated revealed on 10/4/2024 the influenza was refused by family. She received the pneumonia vaccine on 11/19/2021. 3. Record review of a face sheet for Resident #7 dated 8/26/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Raynaud's syndrome (a condition that causes areas such as fingers and toes to feel numb and cold in response to cold temperatures), bipolar disorder (mood swings), and hypertension (high blood pressure). Record review of a Quarterly MDS Assessment for Resident #7 dated 8/12/2025 indicated she did not have any impairment in thinking with a BIMS score of 15. Section O (Special Treatments, Procedures, and Programs) indicated that resident did not receive her influenza vaccine in the facility for this year's influenza season because it was offered and declined. She did not receive the pneumonia vaccine because it was not offered. Record review of a care plan for Resident #7 dated 7/23/2025 indicated that she did not have any interventions for the flu and pneumonia vaccinations. Record review of the electronic health record for Resident #7 undated revealed the influenza vaccine was offered on 10/4/2024 and the resident refused. On 4/13/2024 the pneumonia vaccine was offered and the resident refused. 4. Record review of a Face Sheet for Resident #21 dated 8/26/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia following cerebral infarction affecting left non-dominant side Residents Affected - Some 675907 Page 14 of 17 675907 08/27/2025 Diboll Nursing and Rehab 900 S Temple Dr Diboll, TX 75941

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (paralyzed on left side of the body following a stroke), type 2 diabetes, heart failure (heart not able to pump effectively) and GERD (acid reflux). Record review of a care plan for Resident #21 dated 8/25/2025 indicated that she did not have any interventions for the flu and pneumonia vaccinations. Record review of an Annual MDS Assessment for Resident #21 dated 7/22/2025 indicated she had moderate impairment in thinking with a BIMS score of 11. Section O (Special Treatments, Procedures, and Programs) indicated that resident did not receive her influenza vaccine in the facility for this year's influenza season because it was offered and declined. She did not receive the pneumonia vaccine because it was offered and declined. Record review of an electronic health record for Resident #21 undated revealed on 10/4/2024 the influenza vaccine was offered and the family refused. On 10/25/2023 the pneumonia vaccine was offered and declined by the resident. During an interview on 8/27/2025 at 9:00 AM, the DON said the ADON was responsible for ensuring the residents received immunizations. She said when immunizations were given education was provided to the resident/family. She said she was not aware there was not any documentation for the refusals of the vaccines that were offered. She said residents could be at risk of not knowing what they were refusing if they were not provided education. During an interview on 8/27/2025 at 9:18 AM, the ADON said she was responsible for resident immunizations. She said she did not have any record of the declinations that were provided to the residents or families. She said they were in a binder somewhere but could not locate them and they were not in the electronic record. She said education was provided to the resident/family at the time vaccines were given along with information from the CDC. She said if they declined, they should be given the VIS statement detailing the risks of vaccine refusal and she would let them know that they could change their mind at any time and provided education to them. During an interview on 8/27/2025 at 9:20 AM, the Administrator said declinations for vaccines should include education on the pros and cons of getting immunizations along with proof of verbal educations. He said he was not sure of the regulations regarding the documentation that should be provided to the resident/family. Record review of a facility policy titled General Immunization/Vaccination dated 6/2025 indicated, .It is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from infectious disease by offering our residents, staff members, and volunteer workers immunization/vaccination against such diseases. 10. The resident's medical record or staff/volunteer's medical file will include documentation that the staff, volunteer, resident and/or the resident's representative was provided education regarding the benefits and potential side effects of immunization(s), and that the resident received or did not receive the immunization(s) due to medical contraindication or refusal . Record review of a facility policy titled Infection Prevention and Control Program dated 6/2025 indicated, .7. Influenza and Pneumococcal Immunization: c. Education will be provided to the residents and/or representative regarding the benefits and potential side effects of the immunizations prior to offering the vaccines. e. Documentation will reflect the education provided and details regarding whether or not the resident received the immunizations . 675907 Page 15 of 17 675907 08/27/2025 Diboll Nursing and Rehab 900 S Temple Dr Diboll, TX 75941

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 4 of 6 residents (Residents # 6, #22, #26, and #27) reviewed for resident call system.1.The facility failed to ensure Residents #6, #22, and #26 had a call light within reach on 8/25/25 and 8/26/2025.2.The facility failed to ensure Resident #27 had a call light that was functional. Resident #27 did not have a pull cord attached to the call box on 8/25/25.This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity. Findings included: 1.Record review of a facility face sheet dated 8/26/25 for Resident #6 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of Alzheimer's disease. Record review of a Comprehensive MDS assessment dated [DATE] for Resident #6 indicated a BIMS score of 11, which indicated she had moderate cognitive impairment. She was always incontinent to bowel and bladder. She required maximum to total assistance with all ADLs. Record review of a comprehensive care plan dated 6/4/25 for Resident #6 indicated she was at risk for falls and had an intervention to keep the call light within reach. Record review of a facility face sheet dated 8/26/25 for Resident #22 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of Type 2 Diabetes Mellitus (uncontrolled blood sugar). Record review of a Quarterly MDS assessment dated [DATE] for Resident #22 indicated a BIMS score of 6, which indicated the resident had severely impaired cognition. She was always incontinent to bowel and bladder. She required maximal assistance with most ADLs. Record review of a comprehensive care plan dated 6/3/25 for Resident #22 indicated she was at risk for falls and had an intervention to keep the call light within reach. Record review of a facility face sheet dated 8/26/25 for Resident #26 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of dementia. Record review of a Quarterly MDS assessment dated [DATE] for Resident #26 indicated a BIMS assessment should not be conducted due to the resident being rarely/never understood. She had severely impaired cognition. She was totally dependent with all ADLs. She had an indwelling urinary catheter and was always incontinent of bowel. Record review of a comprehensive care plan dated 8/25/25 for Resident #26 indicated she was at risk for falls and had an intervention to keep the call light within reach. 2. Record review of a facility face sheet dated 8/26/25 for Resident #27 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of acute respiratory failure with hypoxia (trouble breathing due to not having enough oxygen in the blood). Record review of a comprehensive MDS assessment dated [DATE] for Resident #27 indicated a BIMS score of 11, indicating moderate cognitive impairment. She was dependent with most all ADLs. She was always incontinent to bowel and bladder. Record review of a comprehensive care plan dated 6/18/25 for Resident #27 indicated she was incontinent of urine and had an intervention to keep the call light in reach. During an observation on 8/25/25 at 9:31 am Resident #6 was observed lying in bed sleeping. She did not speak when attempted to awaken. Her call light was observed on the floor between the bed and the wall, out of her reach. During an observation on 8/25/25 at 9:45 am Residents #22 and #26 were observed in their room. Resident #22 was observed lying in bed and her call light was observed on the floor behind the head of her bed, out of her reach. She did not answer questions appropriately. Resident #26 was observed lying in her bed. She did not speak. Her call light was observed on the floor out of her reach. During an observation and interview on 8/25/25 at 9:57 am Resident #27 was observed lying in bed. She said she did not use the call light very often, staff took care of her needs, and she said she had Residents Affected - Some 675907 Page 16 of 17 675907 08/27/2025 Diboll Nursing and Rehab 900 S Temple Dr Diboll, TX 75941

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some no complaints. No call light was observed within her reach and upon inspection, it was observed that there was no call light cord attached to the box on the wall for her. During an observation and interview on 8/25/25 at 2:00 pm Resident #27 was observed in bed awake and talking, but did not answer questions appropriately, she just kept repeating My name is and saying her name. There was still no call light cord from the box to her side of the room. No call light was observed within her reach. During an observation on 8/26/25 at 8:00 am Resident #22 was observed lying in bed, sleeping. Her call light was again observed lying on the floor at the head of the bed, out of her reach. During an observation on 8/26/25 at 8:05 am Resident #6 was observed in bed sleeping and her call light was observed clipped to the cord next to the box on the wall, out of her reach. During an observation on 8/26/25 at 8:15 am Resident #27 was observed in her room, lying in bed with the head of the bed elevated being assisted with breakfast by the COTA. Her call light was observed on her nightstand at the time the COTA was assisting with breakfast. During an observation on 8/26/25 at 9:15 am Resident #6 was observed lying in bed with her call light still clipped out of her reach. During an observation on 8/26/25 at 9:47 am Resident #27 was observed lying in bed with her call light still observed on the nightstand, out of her reach. During an observation and interview on 8/26/25 at 10:19 am the ADON was observed in Resident #27's room providing care. Upon exiting the resident room, the ADON did not place the call light within reach of the resident. After exiting the room with the ADON, she was asked if there was anything else that needed to be done. She walked back into the resident's room and looked around, and it was then she noticed the call light on the nightstand and she placed the call light within reach of Resident #27. She said residents should always have access to their call lights so they can call for help if needed. She said residents could be at risk of not being able to call for help and possibly dehydration if they could not ask for water, or skin breakdown if they could not call for help with incontinent care or repositioning. During an interview on 08/27/2025 at 12:03 pm the COTA said she was assisting Resident #27 with her breakfast yesterday on 8/26/25 and when she was done, her roommate needed something, so she then helped staff change the roommate and just must have forgotten to replace the call light within reach of Resident #27 when she left the room. She said residents could be hurt if they needed help and could not reach the call light to call for assistance. During an interview on 8/27/25 at 1:30 pm the DON said residents could not call for help if they needed assistance if they did not have access to call lights. During an interview on 8/27/25 at 1:35 pm the Administrator said residents may not get the help they need if they could not call for help. Record review of a facility policy titled Call Lights: Accessibility and Timely Response dated 7/1/25 read: .The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance . and .staff will ensure the call light is within reach of resident and secured, as needed . and .The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room . 675907 Page 17 of 17