Inspection·August 2, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable, and homelike environment for three (3) of twenty-two (22) residents (Resident #11, Resident #23, and Resident #39) reviewed in that: 1. There was a 1.5 inch by 18-inch scrape on the bathroom wall in room [ROOM NUMBER] in which Resident #11 and Resident #39 resided. 2. There was a hole in the wall and approximately one half of the baseboard along the same wall was loose in the bathroom of Resident #23's room. These failures could result in residents living in an environment that is not safe, clean, comfortable, and homelike in nature. The findings were: 1. Record review of Resident #11's face sheet, dated 08/02/2023, revealed the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses including: right femur fracture (fracture of the thigh bone), chronic obstructive pulmonary disease (a type of progressive lung disease), and asthma (a long-term inflammatory disease of the lungs). Record review of Resident #39's face sheet, dated 8/2/23, revealed the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses of cerebral infarction (a type of stroke that occurs when a blood vessel in the brain is blocked)., sick sinus syndrome (a group of abnormal heart rhythms), and COPD (a type of progressive lung disease). Record review of Resident #11's quarterly MDS assessment, completed on 6/23/23 revealed the resident had a BIMS score of 14 (a mental status test which showed an intact cognitive response). Record review of Resident # 39s annual MDS assessment, completed on 6/16/23 revealed the resident had a BIMS score of 15 (a mental status test which showed an intact cognitive response). Record review of Resident #1's most recent comprehensive MDS assessment, dated 06/01/2022, revealed Section I Active Diagnoses, Sub-section Psychiatric/Mood Disorder was left blank. During an observation in the room of Resident # 11 and Resident #39 on 7/31/23 at 9: 25am revealed a 1.5 inch by 18-inch scrape on the bathroom wall. (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 4 Event ID: 675947 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 675947 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Care Manor 2736 Farm to Market 775 LA Vernia, TX 78121 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)