Health inspection·October 31, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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 implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 11 of 14 residents (Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #13, and #14) reviewed for abuse and neglect. Residents Affected - Some The facility failed to implement their Abuse Policy and ensure all allegations of abuse were reported to HHSC within 2 hours of the allegation for Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #13, and #14. This failure could place residents at risk of further abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of the facility's Abuse and Neglect Policy revision date 09/14/23 indicated Abuse Prohibition Program Reporting/Response .2 The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily injury, exploitation with serious bodily injury, and injuries of unknown source with serious bodily injury immediately or within two hours of the allegation. 1. Record review of a face sheet dated 10/25/23 indicated Resident #2 was a [AGE] year-old male admitted on [DATE]. His diagnoses included paraplegia (injury to the spinal cord or brain that stops signals from reaching the lower body), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder (persistent and excessive worry that interferes with daily activities), and type 2 diabetes (chronic condition that affects the way the body processes blood sugar). Record review of a face sheet dated 10/25/23 indicated Resident #3 was a [AGE] year-old male admitted on [DATE]. His diagnoses included mood affective disorder (mental disorders that primarily affect a person's emotional state), impulse disorder (a group of mental health disorders that involve problems with self-control), hypertensive heart disease (caused by chronically high blood pressure), and hypertension (a condition in which the force of the blood against the artery walls is too high). Record review of a Provider Investigation Report dated 10/18/22 indicated an incident category of Abuse. A Description of the Allegation was on the morning of 10/11/22 Resident #3 threw up in his room and his roommate Resident #2 confronted him about cleaning it up or calling someone to come clean it up. Both Residents got into an argument and Resident #3 threatened to beat Resident #2 with his Page 1 of 21 675975 675975 10/31/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cane. The report indicated the incident occurred on 10/11/22 at 09:00 a.m. and it was reported to HHSC on 10/11/22 at 12:00 p.m. (3 hours after the incident occurred). 2. Record review of a face sheet dated 10/25/23 indicated Resident #4 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included legal blindness, functional quadriplegia (the complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the spinal cord), hypertension (condition in which the force of the blood against the artery walls is too high), low back pain, and chronic kidney disease (a disease or condition impairs kidney function causing kidney damage). Record review of a Provider Investigation Report dated 02/06/23 indicated an Incident Category of Abuse. A Description of the Allegation was Resident #4 could not remember the day, but CNA A and CNA B belittled her for going to the bathroom in her bed and telling her she was more than capable of using the bathroom instead of wetting her bed. The report indicated the incident was 02/01/23 at 09:00 a.m. and reported to HHSC on 02/02/23 at 10:35 a.m. (25 ½ hours after it was reported to the facility) 3. Record review of a face sheet dated 10/25/23 indicated Resident #5 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included heart failure (a condition that develops when the heart does not pump enough blood for the body's needs) , schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and anxiety disorder (persistent and excessive worry that interferes with daily activities). Record review of a face sheet dated 10/25/23 indicated Resident #6 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (loss of cognitive functioning), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), convulsions (neurological disorder that causes seizures or unusual sensations and behaviors). Record review of a Provider Investigation Report dated 02/06/23 indicated an Incident Category of Abuse. A Description of the Allegation was Resident #5 went to the nursing station and informed the DON Resident #6 had kicked her in the back while they were in the smoking area. Resident #5 said she was sitting in Resident #6's spot and Resident #6 told her to move. Resident #5 said when she did not move, Resident #6 kicked her in the back 4 times. The report indicated the incident occurred on 02/01/23 at 04:00 p.m. and was reported to HHSC on 02/02/23 at 04:30 p.m. (24 ½ hours after the incident occurred). 4. Record review of a face sheet dated 10/25/23 indicated Resident #7 was a [AGE] year-old male admitted on [DATE]. His diagnoses included bilateral below keen amputation (surgical removal of the leg below the knee, both legs), alcoholic cirrhosis of the liver (a condition in which healthy tissue is replaced with scar tissue due to alcohol), chronic viral hepatitis C (a virus that causes chronic liver inflammation and long-term damage), major depressive disorder(mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder (persistent and excessive worry that interferes with daily activities). 675975 Page 2 of 21 675975 10/31/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of a face sheet dated 10/25/23 indicated Resident #8 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (loss of cognitive functioning), dissociative fugue (a sudden, unexpected temporary loss of personal identity and impulsively travel away from one's home with an inability to recall some or all past events), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of a Provider Investigation Report dated 09/13/23 indicated an Incident Category of Abuse. A Description of the Allegation was Resident #7 and Resident #8 were in the dining room being playful with teases and joking around. Resident #8 came around the dining table and bit Resident #7 on the shoulder. The report indicated the incident occurred on 09/06/23 at 01:10 p.m. and was reported to HHSC on 09/06/23 at 06:37 p.m. (almost 4 ½ hours after the incident occurred). 5. Record review of Resident #5 face sheet dated 10/26/23 indicated she was a [AGE] year-old female initially admitted on [DATE] and readmitted on [DATE] with diagnoses including heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of the heart and brain to narrow, block, or spasm), schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), type 1 diabetes (a chronic condition in which the pancreas produces little or no insulin), and hypertension (a condition in which the force of the blood against the artery walls is too high). Record review of Resident #5's MDS dated [DATE] indicated she had a BIMS score of 15 which indicated she was cognitively intact. She required supervision and limited assistance in performing all activities of daily living. She was continent of bowel and occasionally incontinent of bladder. Record review of Resident #6 face sheet dated 10/26/23 indicated she was a [AGE] year-old female admitted on [DATE] with diagnoses including dementia (loss of cognitive functioning), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), stroke affecting right dominant side (a disease that affects the arteries leading to and within the brain affecting right dominant side of body)and hypertension (a condition in which the force of the blood against the artery walls is too high). Record review of Resident #6's MDS dated [DATE] indicated she had a BIMS score of 99 which indicated she was not able to complete the BIMS questionnaire. She required limited and extensive assistance in performing all activities of daily living. She was continent of bowel and occasionally incontinent of bladder. Record review of Resident #9 face sheet dated 10/26/23 indicated he was a [AGE] year-old male admitted on [DATE] with diagnoses including type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), migraines (a type of headache characterized by recurrent attacks of moderate to severe throbbing and pulsating pain on one side of the head), cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of the heart and brain to narrow, block, or spasm), and hypertension (a condition in which the force of the blood against the artery walls is too high). 675975 Page 3 of 21 675975 10/31/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #9's MDS dated [DATE] indicated he had a BIMS score of 13 which indicated he was cognitively intact. He required supervision and limited assistance in performing all activities of daily living. He was continent of bowel and occasionally incontinent of bladder. Record review of Resident #10 face sheet dated 10/26/23 indicated he was a [AGE] year-old male initially admitted on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), depression (medical illness that negatively affects how you feel, the way you think and how you act), seizures (a sudden, uncontrolled burst of electrical activity in the brain), and hypertension (a condition in which the force of the blood against the artery walls is too high). Record review of Resident #10's MDS dated [DATE] indicated he had a BIMS score of 15 which indicated he was cognitively intact. He required supervision assistance in performing all activities of daily living. He was continent of bowel and bladder. Record review of Resident #13 face sheet dated 10/26/23 indicated she was a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes type 2 (a chronic condition that affects the way the body processes blood sugar), age-related cognitive decline, depression (medical illness that negatively affects how you feel, the way you think and how you act), hypertension (a condition in which the force of the blood against the artery walls is too high), gout (a type of inflammatory arthritis that causes pain and swelling in your joints) and spinal stenosis (a narrowing of the spinal canal in the lower part of your back). Record review of Resident #13's MDS dated [DATE] indicated she had a BIMS score of 9 which indicated she was moderately impaired cognitively. She required limited and extensive assistance in performing all activities of daily living. She was incontinent of bowel and bladder. Record review of Resident #14 face sheet dated 10/26/23 indicated he was a [AGE] year-old male admitted on [DATE] with diagnoses including schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), dysphagia (swallowing difficulties), neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function), benign neoplasm of prostate (a noncancerous enlargement of the prostate gland), and hypertension (a condition in which the force of the blood against the artery walls is too high). Record review of Resident #14's MDS dated [DATE] indicated he had a BIMS score of 13 which indicated he was cognitively intact. He required supervision and limited assistance in performing all activities of daily living. He was continent of bowel and bladder. Record review of a Provider Investigation Report dated 08/17/23 indicated an Incident Category of AbuseA Description of the Allegation was prior AD acted inappropriately with residents (Resident #5, Resident #6, Resident #9, Resident #10, Resident #13, and Resident #14) she was assisting. The report indicated she was mad, yelling, and using profanity with the residents under her care. The report indicated the incident occurred on 08/17/23 at 12:30 p.m. and was reported to HHSC on 08/17/23 at 05:06 p.m. (4 ½ hours after the incident occurred). During an interview on 10/30/23 at 11:55 a.m. the Administrator said he was the Abuse Coordinator. He said he thought allegations of abuse without injury of serious harm had to be reported within 24 675975 Page 4 of 21 675975 10/31/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0607 hours. He said he did not realize the information had been updated to indicate all allegations of abuse with or without injury of serious harm were to be reported within 2 hours. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 675975 Page 5 of 21 675975 10/31/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made in accordance with State law through established procedures for 11 of 14 residents (Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #13, and #14) reviewed for abuse and neglect. The facility failed to report allegations of abuse immediately, but not later than 2 hours to HHSC when: *Resident #3 threatened to beat Resident #2 with his cane. *Resident #4 made an allegation of abuse regarding CNA A. *Resident #5 alleged Resident #6 kicked her in the back. *Resident #7 reported he was bit by Resident #8. *Community members accused the AD of being verbally abusive to Residents #5, # 6, #9, #10, #13, and #14 during a community outing. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1.Record review of a face sheet dated 10/25/23 indicated Resident #2 was a [AGE] year-old male admitted on [DATE]. His diagnoses included paraplegia (injury to the spinal cord or brain that stops signals from reaching the lower body), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder (persistent and excessive worry that interferes with daily activities), and type 2 diabetes (chronic condition that affects the way the body processes blood sugar). Record review of a face sheet dated 10/25/23 indicated Resident #3 was a [AGE] year-old male admitted on [DATE]. His diagnoses included mood affective disorder (mental disorder that primarily affects a person's emotional state), impulse disorder (a group of mental health disorders that involve problems with self-control), hypertensive heart disease (caused by chronically high blood pressure), and hypertension (a condition in which the force of the blood against the artery walls is too high). Record review of a Provider Investigation Report dated 10/18/22 indicated an incident category of Abuse. A Description of the Allegation was on the morning of 10/11/22 Resident #3 threw up in his room and his roommate Resident #2 confronted him about cleaning it up or calling someone to come clean it up. Both Residents got into an argument and Resident #3 threatened to beat Resident #2 with his cane. The report indicated the incident occurred on 10/11/22 at 09:00 a.m. and it was reported to HHSC on 10/11/22 at 12:00 p.m. (3 hours after the incident occurred). 2.Record review of a face sheet dated 10/25/23 indicated Resident #4 was a [AGE] year-old female 675975 Page 6 of 21 675975 10/31/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0609 Level of Harm - Minimal harm or potential for actual harm admitted on [DATE]. Her diagnoses included legal blindness, functional quadriplegia (the complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the spinal cord), hypertension (condition in which the force of the blood against the artery walls is too high), low back pain, and chronic kidney disease (a disease or condition impairs kidney function causing kidney damage). Residents Affected - Some Record review of a Provider Investigation Report dated 02/06/23 indicated an Incident Category of Abuse. A Description of the Allegation was Resident #4 could not remember the day, but CNA A and CNA B belittled her for going to the bathroom in her bed and telling her she was more than capable of using the bathroom instead of wetting her bed. The report indicated the incident was 02/01/23 at 09:00 a.m. and reported to HHSC on 02/02/23 at 10:35 a.m. (25 ½ hours after it was reported to the facility) 3.Record review of a face sheet dated 10/25/23 indicated Resident #5 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs) , schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and anxiety disorder (persistent and excessive worry that interferes with daily activities). Record review of a face sheet dated 10/25/23 indicated Resident #6 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (loss of cognitive functioning), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), convulsions (neurological disorder that causes seizures or unusual sensations and behaviors). Record review of a Provider Investigation Report dated 02/06/23 indicated an Incident Category of Abuse. A Description of the Allegation was Resident #5 went to the nursing station and informed the DON Resident #6 had kicked her in the back while they were in the smoking area. Resident #5 said she was sitting in Resident #6's spot and Resident #6 told her to move. Resident #5 said when she did not move, Resident #6 kicked her in the back 4 times. The report indicated the incident occurred on 02/01/23 at 04:00 p.m. and was reported to HHSC on 02/02/23 at 04:30 p.m. (24 ½ hours after the incident occurred). 4.Record review of a face sheet dated 10/25/23 indicated Resident #7 was a [AGE] year-old male admitted on [DATE]. His diagnoses included bilateral below keen amputation (surgical removal of the leg below the knee, both legs), alcoholic cirrhosis of the liver (a condition in which healthy tissue is replaced with scar tissue due to alcohol), chronic viral hepatitis C (a virus that causes chronic liver inflammation and long-term damage), major depressive disorder(mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder (persistent and excessive worry that interferes with daily activities ). Record review of a face sheet dated 10/25/23 indicated Resident #8 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (loss of cognitive functioning), dissociative fugue (a sudden, unexpected temporary loss of personal identity and impulsively travel away from one's home with an inability to recall some or all of past events), and major depressive disorder (mental 675975 Page 7 of 21 675975 10/31/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of a Provider Investigation Report dated 09/13/23 indicated an Incident Category of Abuse. A Description of the Allegation was Resident #7, and Resident #8 were in the dining room being playful with teases and joking around. Resident #8 came around the dining table and bit Resident #7 on the shoulder. The report indicated the incident occurred on 09/06/23 at 01:10 p.m. and was reported to HHSC on 09/06/23 at 06:37 p.m. (almost 4 ½ hours after the incident occurred). During an interview on 10/26/23 at 11:55 a.m., the Administrator said he was the Abuse Coordinator. He said he thought allegations of abuse without injury of serious harm had to be reported within 24 hours. He said he did not realize the information had been updated that all allegations of abuse with or without injury of serious harm were to be reported within 2 hours. Record review of Resident #5 face sheet dated 10/26/23 indicated she was a [AGE] year-old female initially admitted on [DATE] and readmitted on [DATE] with diagnoses including heat failure (a condition that develops when your heart does not pump enough blood for your body's needs), peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of the heart and brain to narrow, block, or spasm), schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), type 1 diabetes (a chronic condition in which the pancreas produces little or no insulin), and hypertension (a condition in which the force of the blood against the artery walls is too high). Record review of Resident #5's MDS dated [DATE] indicated she had a BIMS score of 15 which indicated she was cognitively intact. She required supervision and limited assistance in performing all activities of daily living. She was continent of bowel and occasionally incontinent of bladder. Record review of Resident #6 face sheet dated 10/26/23 indicated she was a [AGE] year-old female admitted on [DATE] with diagnoses including Dementia (loss of cognitive functioning), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), stroke affecting right dominant side (a disease that affects the arteries leading to and within the brain affecting right dominant side of body) and hypertension (a condition in which the force of the blood against the artery walls is too high). Record review of Resident #6's MDS dated [DATE] indicated she had a BIMS score of 99 which indicated she was not able to complete the BIMS questionnaire. She required limited and extensive assistance in performing all activities of daily living. She was continent of bowel and occasionally incontinent of bladder. Record review of Resident #9 face sheet dated 10/26/23 indicated he was a [AGE] year-old male admitted on [DATE] with diagnoses including type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), migraines (a type of headache characterized by recurrent attacks of moderate to severe throbbing and pulsating pain on one side of the head), cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of the heart and brain to narrow, block, or spasm), and hypertension (a condition in which the force of the blood against the artery walls is too high). 675975 Page 8 of 21 675975 10/31/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #9's MDS dated [DATE] indicated he had a BIMS score of 13 which indicated he was cognitively intact. He required supervision and limited assistance in performing all activities of daily living. He was continent of bowel and occasionally incontinent of bladder. Record review of Resident #10 face sheet dated 10/26/23 indicated he was a [AGE] year-old male initially admitted on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), depression (medical illness that negatively affects how you feel, the way you think and how you act), seizures (a sudden, uncontrolled burst of electrical activity in the brain), and hypertension (a condition in which the force of the blood against the artery walls is too high). Record review of Resident #10's MDS dated [DATE] indicated he had a BIMS score of 15 which indicated he was cognitively intact. He required supervision assistance in performing all activities of daily living. He was continent of bowel and bladder. Record review of Resident #13 face sheet dated 10/26/23 indicated she was a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes type 2 (A chronic condition that affects the way the body processes blood sugar), age-related cognitive decline, depression (medical illness that negatively affects how you feel, the way you think and how you act), hypertension (a condition in which the force of the blood against the artery walls is too high), gout (a type of inflammatory arthritis that causes pain and swelling in your joints) and spinal stenosis (a narrowing of the spinal canal in the lower part of your back). Record review of Resident #13's MDS dated [DATE] indicated she had a BIMS score of 9 which indicated she was moderately impaired cognitively. She required limited and extensive assistance in performing all activities of daily living. She was incontinent of bowel and bladder. Record review of Resident #14 face sheet dated 10/26/23 indicated he was a [AGE] year-old male admitted on [DATE] with diagnoses including schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), dysphagia (swallowing difficulties), neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function), benign neoplasm of prostate (a noncancerous enlargement of the prostate gland), and hypertension (a condition in which the force of the blood against the artery walls is too high). Record review of Resident #14's MDS dated [DATE] indicated he had a BIMS score of 13 which indicated he was cognitively intact. He required supervision and limited assistance in performing all activities of daily living. He was continent of bowel and bladder. Record review of an email to HHSC Complaint and Incident Intake reported date 08/17/23 at 5:06 pm indicated the name and title of the person making the initial report; [Administrator] the date and time the person became aware of the reportable incident; 08/17/23 approximately 12:30 p.m .a description of the allegation; AD acting inappropriately with the residents she was tending to. Stated she was mad, yelling and using profanity. Record review of the Provider Investigation Form indicated the following: *Date Reported to HHSC-08/17/23 675975 Page 9 of 21 675975 10/31/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0609 *Time: 05:06 pm Level of Harm - Minimal harm or potential for actual harm *Incident Category: Abuse *Incident Date: 08/17/23; and Residents Affected - Some *Time of Incident: 12:30 pm During an interview on 10/26/23 at 11:30 am, the Administrator said he was the Abuse Coordinator. He said on 08/17/23 around 11:45 am, while some of the residents (Resident #5, Resident #6, Resident #9, Resident #10, Resident #13, and Resident #14) were on a community outing to Walmart, he received phone calls from two people in the community reporting that the responsible staff member (prior AD) was fussing & cussing and yelling at the residents as they were getting on the van. He said witness statement was taken from one community person and he was unable to get a written witness statement with the other caller because they hung up before getting call back information but both callers were concerned with the way the staff member was speaking to the residents. He said the staff member (prior AD) was suspended and then terminated after the investigation. Record review of the facility's Abuse and Neglect Policy revision date 09/14/23 indicated Abuse Prohibition Program Reporting/Response .2 The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily injury, exploitation with serious bodily injury, and injuries of unknown source with serious bodily injury immediately or within two hours of the allegation. 675975 Page 10 of 21 675975 10/31/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure recommendations from PASARR evaluation were incorporated for 1 of 1 resident reviewed for coordination of PASARR services. (Resident #1) Facility failed to provide specialized services for PASARR positive residents as agreed to during Resident #1's IDT meeting or provide information the services were no longer needed by the required timeframe. This failure could place the residents with intellectual and developmental disabilities at risk of not receiving specialized services that would enhance their highest level of functioning. Findings included: Record review of a face sheet dated 10/25/23 indicated Resident #1 was a [AGE] year-old male who admitted on [DATE]. His diagnoses included epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors), muscular dystrophy, hydrocephalus (condition characterized by excess fluid build-up in fluid-containing cavities of the brain) with drainage device, gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), colostomy (an operation that creates an opening for the large intestine through the abdomen), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder (persistent and excessive worry that interferes with daily activities), type 2 diabetes (chronic condition that affects the way the body processes blood sugar), and hypertension (a condition in which the force of the blood against the artery walls is too high). Record review of a PASARR Level 1 Screening dated 03/30/23 indicated Resident #1 had intellectual disability and developmental disability. Record review of a PASARR Evaluation dated 04/03/23 indicated Resident #1 did meet criteria for DD. Record review of Resident #1's care plan initiated 04/06/23 indicated the facility IDT had determined that the resident PASARR positive due to diagnoses of cerebral palsy (congenital disorder of movement, muscle tone, or posture due to abnormal brain development). Interventions included follow up with agency representatives as needed to ensure recommendations are fully implemented. Record review of the admission MDS dated [DATE] indicated Resident #1 currently was considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition with intellectual disability marked and he had a BIMS score of 00 out of 15 indicating he had severely impaired cognition. Record review of Resident #1's PCSP form Quarterly IDT/SPT Meeting dated 9/21/23 indicated in section A2800. Nursing Facility Specialized Services: G. Specialized Occupational Therapy (OT) was coded 4 (discontinued), H. Specialized Physical Therapy (PT) was coded 4 (discontinued), and I. Specialized Speech Therapy (ST) was coded 4 (discontinued). Record review of an email dated 09/26/20 at 10:56 a.m. from the PASARR Unit- Program Specialist IDD 675975 Page 11 of 21 675975 10/31/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0644 Services indicated: Level of Harm - Minimal harm or potential for actual harm * the email was sent to the MDS Nurse and the Administrator. Residents Affected - Few * This email is to summarize our phone conversation regarding your facility's non-compliance with the requirements outlined in the Texas Administrative Code, Chapter 19, Subchapter BB, section §19.2704(i)(7)(A), which states your facility must initiate nursing facility specialized services within 20 business days after the date that the services are agreed to in the IDT meeting for the resident we spoke about. * As discussed on the phone, you will need to submit a NFSS request form for PASRR Specialized Services (Therapies and Assessments ST, OT and PT) by 9/25/2023 Regulatory Division and a complaint investigation will be conducted because of one of the following: o If the IDD PASRR Unit does not receive the NFSS request for specialized services in the LTC Portal by the specified due date(s) documented in this email. o If a NFSS request is denied and the Nursing Facility did NOT complete a follow up request to ensure services were approved for the resident. o The facility did not request a Service Planning Team (SPT) meeting with the resident's LIDDA by the noted due date to document changes, remove/update the services from the resident's comprehensive care plan in the portal on the PCSP form. (This would need to be completed if the individual's Medicaid is not active, if the PASRR specialized services are no longer needed or the resident is refusing services) Record review of the facility's undated PASARR Policy and Procedure indicated Nexion uses the most current version of PASRR Rules, TAC Title 40, Part 1 Chapter 19, Sub-chapter BB as they pertain to PASRR Level 1, Level 2 (PE), Specialized Services, and IDT meetings. During an interview 10/25/23 at 12:17 a.m. the MDS Nurse said she was responsible for following up with the PASARR services. She said it was important to follow up with the recommended services to help the resident. She said she submitted the NFSS form. During an interview on 10/31/23 at 01:45 p.m., the ADM said he was made aware facility failed to provide specialized services for PASARR positive residents as agreed to during Resident #1's IDT meeting. He said he was not aware of an email from the PASARR unit. 675975 Page 12 of 21 675975 10/31/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions for resident care needed to provide effective and person-centered care and provide a summary of the baseline care plan to the resident and/or their representative for 1 of 4 residents reviewed for new admissions (Residents #11). The facility did not have a completed baseline care plan, within 48 hours of admission and did not provide a written summary to the resident or their representative for Resident #11. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of a face sheet dated 10/26/23 indicated Resident #11 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included fracture of neck of right femur (fracture upper leg bone), anemia (condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells), diabetes type 2 (chronic condition that affects the way the body processes blood sugar), hypertension (condition in which the force of the blood against the artery walls is too high), heart failure(condition that develops when your heart doesn't pump enough blood for your body's needs), neuralgia (particular type of pain that often feels like a shooting, stabbing or burning sensation), kidney failure (when your kidneys have stopped working well enough for you to survive without dialysis or a kidney transplant). Record review of Resident #11's records revealed there was no baseline care plan implemented within 48 hours of admission to the facility for Resident #11. There were no initial admission or discharge goals. There was no resident immediate health and safety needs identified. There were no dietary interventions or goals identified. There were no instructions to provide effective and person-centered care that meets professional standards and quality care. The medications section was not marked for anticoagulant, anticonvulsant, cardiac (B/P) medications, diuretics, opioids, or black box medications. The Therapy Services section was left blank for skilled therapy services for rehabilitation care. The Social Services section was left blank for mental health needs, behavioral concerns, and depression screening; and there was no written summary of the baseline care plan provided to the resident or their representative. Record review of Resident #11's physician orders dated September 2023 indicated Resident #11 was to receive anastrozole (nonsteroidal aromatase inhibitors), amlodipine besylate (calcium channel blockers), atenolol (beta-blocker), lisinopril (angiotensin-converting enzyme inhibitor), atorvastatin (HMG-CoA reductase inhibitors (statins)), rivaroxaban (oral anticoagulant), gabapentin (anticonvulsant), Lasix (diuretic), and tramadol (opioid with black box warning). During an interview on 10/31/23 at 10:00 am, the DON said it was the admitting nurses' responsibility and other members of the interdisciplinary team to fill out the baseline care plan. She said it was her responsibility to ensure it was correct. She said a copy should have been provided to the resident or their representative. Record review of a facility Care Plans - Baseline policy revised March 2022 indicated: Policy 675975 Page 13 of 21 675975 10/31/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0655 Statement: A baseline plan of care to meet the resident ' s immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675975 Page 14 of 21 675975 10/31/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure medical records were maintained on each resident with accurate and complete documentation for 16 of 31 residents (Residents #2, #3, #4, #5, #6, #7, #8, #12, #15, #16, #17, #18, #19, #20, #21, and #22) reviewed for complete medical records. The facility did not have the required documentation and/or follow up documentation of incidents involving Residents #2, #3, #4, #5, #6, #7, #8, #12, #15, #16, #17, #18, #19, #20, #21, and #22. This failure could place residents at risk of the medical record by not being an accurate representation of their medical condition or medical needs. Findings included: 1.Record review of a face sheet dated 10/25/23 indicated Resident #2 was a [AGE] year-old male admitted on [DATE]. His diagnoses included paraplegia (injury to the spinal cord or brain that stops signals from reaching the lower body), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder (persistent and excessive worry that interferes with daily activities), and type 2 diabetes (chronic condition that affects the way the body processes blood sugar). Record review of a face sheet dated 10/25/23 indicated Resident #3 was a [AGE] year-old male admitted on [DATE]. His diagnoses included mood affective disorder (mental disorders that primarily affect a person's emotional state), impulse disorder (a group of mental health disorders that involve problems with self-control), hypertensive heart disease (caused by chronically high blood pressure), and hypertension (a condition in which the force of the blood against the artery walls is too high). Record review of a Provider Investigation Report dated 10/18/22 indicated on the morning of 10/11/22 Resident #3 threw up in his room and his roommate Resident #2 confronted him about cleaning it up or calling someone to come clean it up. Both Residents got into an argument and Resident #3 threatened to beat Resident #2 with his cane. Record review of Resident #2's medical records progress notes dated 10/11/22 through 10/14/22 recorded no account of the incident, name of witnesses, time that the physician and family were notified, physician orders received, condition of resident (vital signs, orthostatic BPs (Blood Pressure), mental status, physical status, etc), action to prevent a re-occurrence, follow up documentation regarding the resident's treatment and condition, and other pertinent data. Record review of Resident #3's medical records progress notes dated 10/11/22 through 10/14/22 recorded no account of the incident, name of witnesses, time that the physician and family were notified, physician orders received, condition of resident (vital signs, orthostatic BPs (Blood Pressure), mental status, physical status, etc), action to prevent a re-occurrence, follow up documentation regarding the resident's treatment and condition, and other pertinent data. 2.Record review of a face sheet dated 10/25/23 indicated Resident #4 was a [AGE] year-old female 675975 Page 15 of 21 675975 10/31/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some admitted on [DATE]. Her diagnoses included legal blindness (the better eye using the best possible methods of correction has visual acuity of 20/200 or worse or that the visual field is restricted to 20 degrees or less), functional quadriplegia (the complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the spinal cord), hypertension (condition in which the force of the blood against the artery walls is too high), low back pain, and chronic kidney disease (a disease or condition impairs kidney function causing kidney damage). Record review of a Provider Investigation Report dated 02/06/23 indicated on 02/01/23 Resident #4 could not remember the day, but CNA A and CNA B belittled her for going to the bathroom in her bed and telling her she was more than capable of using the bathroom instead of wetting her bed. Record review of Resident #4's medical records progress notes dated 02/01/23 through 02/10/23 recorded no documentation of time that the physician and family were notified, physician orders received, condition of resident (vital signs, orthostatic BPs, mental status, physical status, etc), action to prevent a re-occurrence, follow up documentation regarding the resident's treatment and condition, and other pertinent data. 3.Record review of a face sheet dated 10/25/23 indicated Resident #5 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs) , schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and anxiety disorder (persistent and excessive worry that interferes with daily activities). Record review of a face sheet dated 10/25/23 indicated Resident #6 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (loss of cognitive functioning), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), convulsions (neurological disorder that causes seizures or unusual sensations and behaviors). Record review of a Provider Investigation Report dated 02/06/23 indicated on 02/02/23 Resident #5 went to the nursing station and informed the DON Resident #6 had kicked her in the back while they were in the smoking area. Resident #5 said when she did not move Resident #6 kicked her in the back 4 times. Record review of Resident #5's medical records progress notes dated 02/02/23 through 02/10/23 recorded no documentation of name of witnesses, time that the physician and family were notified, physician orders received, condition of resident (vital signs, orthostatic BPs, mental status, physical status, etc), action to prevent a re-occurrence, follow up documentation regarding the resident's treatment and condition, and other pertinent data. Record review of Resident #6's medical records progress notes dated 02/03/23 through 02/10/23 recorded no documentation of circumstances surrounding the incident, name of witnesses, time that the physician and family were notified, physician orders received, condition of resident (vital signs, orthostatic BPs, mental status, physical status, etc), action to prevent a re-occurrence, follow up documentation regarding the resident's treatment and condition, and other pertinent data. 675975 Page 16 of 21 675975 10/31/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. Record review of a face sheet dated 10/25/23 indicated Resident #7 was a [AGE] year-old male admitted on [DATE]. His diagnoses included bilateral below keen amputation (surgical removal of the leg below the knee, both legs), alcoholic cirrhosis of the liver (a condition in which healthy tissue is replaced with scar tissue due to alcohol), chronic viral hepatitis C (a virus that causes chronic liver inflammation and long-term damage), major depressive disorder(mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder (persistent and excessive worry that interferes with daily activities ). Record review of a face sheet dated 10/25/23 indicated Resident #8 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (loss of cognitive functioning), dissociative fugue (a sudden, unexpected temporary loss of personal identity and impulsively travel away from one's home with an inability to recall some or all of past events), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of a Provider Investigation Report dated 09/13/23 indicated on 09/06/23 Resident #7 and Resident #8 were in the dining room being playful with teases and joking around. Resident #8 came around the dining table and bit Resident #7 on the shoulder. Record review of Resident #7's medical records progress notes dated 09/06/23 through 09/10/23 recorded no documentation of circumstances surrounding the incident, physician orders received, condition of resident (vital signs, orthostatic BPs, mental status, physical status, etc), action to prevent a re-occurrence, follow up documentation regarding the resident's treatment and condition, and other pertinent data. Record review of Resident #8's medical records progress notes dated 09/06/23 through 09/10/23 recorded no documentation of circumstances surrounding the incident, name of witnesses, time that the physician and family were notified, physician orders received, condition of resident (vital signs, orthostatic BPs, mental status, physical status, etc), action to prevent a re-occurrence, follow up documentation regarding the resident's treatment and condition, and other pertinent data. 5. Record review of Resident #12 face sheet dated 10/26/23 indicated she was a [AGE] year-old female initially admitted on [DATE] with diagnoses including: constipation (passing fewer than three stools a week or having a difficult time passing stool), urinary tract infection (infection in the kidneys, ureters, bladder, or urethra), peripheral neuropathy (happens when the nerves that are located outside of the brain and spinal cord (peripheral nerves) are damaged), osteoporosis (condition in which bones become weak and brittle), history of falls, depression (medical illness that negatively affects how you feel, the way you think and how you act) and chronic obstructive pulmonary isease (a lung disease that blocks airflow making it difficult to breathe). Record review of Resident #12's MDS assessment dated [DATE] indicated she had a BIMS score of 12 which indicated she was moderately impaired cognitively. She required limited assistance in performing all activities of daily living. She was continent of bowel and occasionally incontinent of bladder. Record review of Resident #12's care plan dated 01/18/23 indicated she had an actual fall 12/28/22, related to poor balance, poor communication/comprehension, unsteady gait. Care plan dated 1/20/23 indicated the resident is high risk for falls with intervention to review information on past falls 675975 Page 17 of 21 675975 10/31/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and attempt to determine cause of falls, record possible root causes, after remove any potential causes, if possible, educate resident/family/caregiver/IDT as to causes. Record review of Resident #12's medical records progress noted dated 12/28/22 revealed no documentation of the incident, name of witnesses, time that the physician and family were notified, physician orders received, condition of resident (vital signs, orthostatic BPs, mental status, physical status, etc), action to prevent a re-occurrence, follow up documentation regarding the resident's treatment and condition, and other pertinent data. 6. Record review of a face sheet dated 10/25/23 indicated Resident #15 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder (persistent and excessive worry that interferes with daily activities), elevated white blood cell count, strange and inexplicable behavior, delusional disorder (a disorder where a person has trouble recognizing reality), and profound intellectual disabilities (a condition that affects a person's ability to learn and function at an expected level). Record review of a Provider Investigation Report dated 12/22/22 indicated on 12/18/22 Resident #15 was noted to have discoloration on the top of her right eyelid and she did not know how she got it. Record review of Resident #15's medical records progress notes dated 12/18/22 through 12/25/22 recorded no documentation of circumstances surrounding the incident, name of witnesses, time that the physician and family were notified, physician orders received, condition of resident (vital signs, orthostatic BPs, mental status, physical status, etc), action to prevent a re-occurrence, follow up documentation regarding the resident's treatment and condition, and other pertinent data. 7. Record review of a face sheet dated 10/25/23 indicated Resident #16 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included chronic hepatitis C (a virus that causes chronic liver inflammation and long-term damage), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), congestive heart failure (a condition in which the heart's main pumping chamber (left ventricle) is weak and becomes stiff), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), and hypertension (a condition in which the force of the blood against the artery walls is too high). Record review of a Provider Investigation Report dated 12/29/22 indicated on 12/28/22 Resident #16 said a CNA was rough with changing her and was talking about her to another CNA. Record review of Resident #16's medical records progress notes dated 12/28/22 through 12/31/22 recorded no documentation of condition of resident (vital signs, orthostatic BPs, mental status, physical status, etc), action to prevent a re-occurrence, follow up documentation regarding the resident's treatment and condition, and other pertinent data. 8. Record review of a face sheet dated 10/25/23 indicated Resident #17 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included Alzheimer's disease (progressive disease that destroys memory and other important mental functions), congestive heart failure (a condition in which the heart's main pumping chamber (left ventricle) is weak and becomes stiff), hypertension (a condition in 675975 Page 18 of 21 675975 10/31/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some which the force of the blood against the artery walls is too high), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of a Provider Investigation Report dated 01/03/23 indicated on 12/30/22, Resident #17 said a CNA hit her leg with something hard, became angry with her, and said she was too needy. Record review of Resident #17's medical records progress notes dated 12/30/22 through 01/02/23 recorded no documentation of condition of resident (vital signs, orthostatic BPs, mental status, physical status, etc), action to prevent a re-occurrence, follow up documentation regarding the resident's treatment and condition, and other pertinent data. 9.Record review of a face sheet dated 10/25/23 indicated Resident #18 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included congestive heart failure (a condition in which the heart's main pumping chamber (left ventricle) is weak and becomes stiff), anxiety disorder (persistent and excessive worry that interferes with daily activities), and atrial fibrillation (a type of irregular heartbeat). Record review of a Provider Investigation Report dated 01/27/23 indicated on 01/22/23 Resident #18 had a new swollen area with redness to the back of her hand. Record review of Resident #18's medical records progress notes dated 01/22/23 through 01/24/23 recorded no documentation of condition of resident (vital signs, orthostatic BPs, mental status, physical status, etc), action to prevent a re-occurrence, follow up documentation regarding the resident's treatment and condition, and other pertinent data. 10. Record review of a face sheet dated 10/25/23 indicated Resident #19 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included Alzheimer's disease (progressive disease that destroys memory and other important mental functions), dementia (loss of cognitive functioning), anxiety disorder (persistent and excessive worry that interferes with daily activities), and hypertension (a condition in which the force of the blood against the artery walls is too high). Record review of a face sheet dated 10/25/23 indicated Resident #20 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included Alzheimer's disease (progressive disease that destroys memory and other important mental functions), anxiety disorder (persistent and excessive worry that interferes with daily activities), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and hypertension (a condition in which the force of the blood against the artery walls is too high). Record review of a Provider Investigation Report dated 02/06/23 indicated on 02/04/23 a CNA went into resident room and found Resident #20 in bed with Resident #19. Resident #20 had removed Resident #19's brief and was patting her vagina. Record review of Resident #19's medical records progress notes dated 02/04/23 through 02/07/23 recorded no documentation of circumstances surrounding the incident, name of witnesses, time that the physician and family were notified, physician orders received, condition of resident (vital signs, orthostatic BPs, mental status, physical status, etc), action to prevent a re-occurrence, follow up documentation regarding the resident's treatment and condition, and other pertinent data. 675975 Page 19 of 21 675975 10/31/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0842 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #20's medical records progress notes dated 02/04/23 through 02/07/23 recorded no documentation of circumstances surrounding the incident, name of witnesses, time that the physician and family were notified, physician orders received, condition of resident (vital signs, orthostatic BPs, mental status, physical status, etc), action to prevent a re-occurrence, follow up documentation regarding the resident's treatment and condition, and other pertinent data. Residents Affected - Some 11. Record review of a face sheet dated 10/25/23 indicated Resident #21 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (loss of cognitive functioning), chronic hepatitis C (a virus that causes chronic liver inflammation and long-term damage), schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs), congestive heart failure (a condition in which the heart's main pumping chamber (left ventricle) is weak and becomes stiff), and hypertension (a condition in which the force of the blood against the artery walls is too high). Record review of a Provider Investigation Report dated 03/24/23 indicated on 03/17/23 Resident #21 had a skin tear to the back of her hand. Record review of Resident #21's medical records progress notes dated 03/17/23 through 03/20/23 recorded no documentation of circumstances surrounding the incident, name of witnesses, time that the physician and family were notified, physician orders received, condition of resident (vital signs, orthostatic BPs, mental status, physical status, etc), action to prevent a re-occurrence, follow up documentation regarding the resident's treatment and condition, and other pertinent data. 12.Record review of a face sheet dated 10/25/23 indicated Resident #22 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included cerebral palsy (congenital disorder of movement, muscle tone, or posture due to abnormal brain development), anxiety disorder (persistent and excessive worry that interferes with daily activities), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of a face sheet dated 10/25/23 indicated Resident #7 was a [AGE] year-old male admitted on [DATE]. His diagnoses included bilateral below keen amputation (surgical removal of the leg below the knee, both legs), alcoholic cirrhosis of the liver (a condition in which healthy tissue is replaced with scar tissue due to alcohol), chronic viral hepatitis C (a virus that causes chronic liver inflammation and long-term damage), major depressive disorder(mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder (persistent and excessive worry that interferes with daily activities ). Record review of a Provider Investigation Report dated 09/29/23 indicated on 09/23/23 Resident #22 accused Resident #7 of taking $30.00 from her earlier in the day. Later in the day, Resident #7 entered Resident #22's room and the two began to argue over possessions each had obtained. Resident #7 had thrown items in Resident #22's room and called her a bitch. Record review of Resident #22's medical records progress notes dated 09/23/23 through 09/27/23 recorded no documentation of circumstances surrounding the incident, name of witnesses, time that the physician and family were notified, physician orders received, condition of resident (vital signs, orthostatic BPs, mental status, physical status, etc), action to prevent a re-occurrence, follow up 675975 Page 20 of 21 675975 10/31/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0842 documentation regarding the the resident's treatment and condition, and other pertinent data. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #7's medical records progress notes dated 09/23/23 through 09/27/23 recorded no documentation of circumstances surrounding the incident, name of witnesses, time that the physician and family were notified, physician orders received, condition of resident (vital signs, orthostatic BPs, mental status, physical status, etc), action to prevent a re-occurrence, , follow up documentation regarding the resident's treatment and condition, and other pertinent data. Residents Affected - Some During an interview on 10/26/23 at 11:40 a.m., the DON said nurses were to document all information regarding an incident involving a resident in the clinical record. She said they were to also to do follow-up documentation for 72 hours after an incident. She said she expected the nurses to do the documentation. She said if it was not done then the following shift staff would not be aware to monitor for possible issues related to the incident. Record review of the facility Policy for Resident Incident and Visitor Accident Report reviewed January 2023 indicated: Policy: B. Resident Incidents/Accidents: 2. Licensed Nurse must: a. Examine the resident and obtain vital signs. 3. Pertinent documentation to be completed: a. Incident Witness Statement b. Incident Report c. Incident Investigation d. Nurse Progress notes g. Follow up documentation every shift for 72 hours or more frequently if needed. Include: Vital signs, every shift; Neuro checks, if applicable; physical and mental status if resident, every shift. 5. Incident documentation in the medical record should include: date and time of incident, nature of injury, circumstances surrounding the incident, name of witnesses, time that the physician and family were notified, physician orders received, condition of resident (vital signs, orthostatic BPs, mental status, physical status, etc), disposition of resident (example: transferred to hospital, etc), action to prevent a re-occurrence, follow up documentation regarding the resident's treatment and condition, other pertinent data 675975 Page 21 of 21