Health inspection·January 15, 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 observation, interview and record review, the facility failed to ensure the resident had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for 2 of 20 residents (Resident #2 and #13) reviewed for environment. The facility failed to maintain a sanitary and comfortable homelike environment for Resident #2 and Resident #13's rooms. This failure could place residents at risk for a diminished quality of life due to the lack of a well-kept, home-like environment. Findings included: 1. Record review of Resident #2's face sheet dated 01/15/25 indicated he was [AGE] years old, admitted to the facility on [DATE] with diagnoses of bi-polar (disorder associated with episodes of mood swings), anxiety (mental health disorder with feelings of worry and fear) and depression (common mental disorder with loss of pleasure). Record review of the MDS significant change assessment dated [DATE] indicated Resident #2 BIMS (cognitive screening measure assessment) score was 13, which indicated he was cognitively intact. During an observation on 01/13/25 at 9:20 a.m., the Resident #2's room had discoloration (grayish to black spots) that extended out and around the light switch on the wall and electrical receptacle on the wall above the built in dresser drawers. There were 2 areas grayish black spots along left side of the door frames which were 1 by 6 inches of the room. During an interview on 1/15/25 at 9:30 a.m., Resident #2 said that the black and gray spots on the walls been there since he moved in. He said he would like the areas to be painted. 2. Record review of Resident#13's face sheet dated 01/15/25, indicated Resident #13 was a [AGE] year-old male admitted to the facility on [DATE]. Resident#13 was diagnosed with major depressive disorder (mental illness with persistently depressed mood) and chronic obstructive pulmonary disease (lung diseases that block airflow and make it hard to breath). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #13 was cognitively intact with a BIMS score of 14. Page 1 of 6 675975 675975 01/15/2025 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 01/14/25 at 9:40 a.m., Resident #13 had discoloration (grayish to black spots) that extended out and around the light switch on the wall and electrical receptacle on the wall above the built in dresser drawers. There were 2 areas grayish black spots along left side of the door frames which were 1 by 6 inches of the room. During an interview on 1/14/25 at 9:45 a.m., Resident #13 said his room had black and gray spots on the walls for months. He said an unnamed housekeeper would wipe around the door frame with a bleach rag. He stated, the mildew just comes back, and it needs to be fixed the right way. During an interview and observation on 1/15/25 at 11:45 a.m., the Administrator observed the areas, and she took pictures indicating she would get with the regional corporate maintenance and see what their plans were. She said they had received bids in November 2024 work on the water damage. She said the bids were sent to the corporate office. She said the areas in the resident's rooms would need to be fixed also and said she was unsure why that happened. The Administrator said her expectation was for the building to be maintained and would provide the survey team with the policy about maintaining the environment. During exit on 1/15/25 at 1:30 p.m., the Administrator said she was unable to find a policy on maintaining the environment. 675975 Page 2 of 6 675975 01/15/2025 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. Residents Affected - Some The facility failed to ensure Dietary Staff A and Dietary Staff B's hair was completely contained with an effective hair restraint. This failure could place residents at risk of being served unsanitary food. Findings included: During an observation and interview on 01/13/25 at 7:55 a.m., while preparing meal for residents in the dining room Dietary Staff A's hair was not totally contained in a hair restraint, at the back of the neckline. The hair restraint did not cover approximately 3 inches of the lower neckline. The Dietary Manager said the dietary staff's hair should have been completely contained. She informed Dietary Staff A her hair needed to be adjusted in a hair restraint after surveyor intervention. During an observation on 01/13/25 at 10:30 a.m., Dietary Staff A's hair remained outside of hair restraint at the neckline. Dietary Staff A was preparing tray carts for noon meal. During an observation and interview on 01/13/25 at 11:20 a.m., Dietary Staff A's hair was not completely contained in a hair restraint at the neckline. The hair restraint did not completely cover approximately 2 inches of the lower neckline. Lunch trays were being prepared for residents' meal. Dietary Staff A said she had been employed at facility approximately one month and had been trained on hair hygiene. During an observation and interview on 01/14/25 at 7:45 a.m. and 8:15 a.m., Dietary Staff B's hair was outside of the hair restraint with approximately 3-inch sprigs of hair eluding from the ears to neckline area. This occurred while preparation for breakfast meal was occurring in food service area. Dietary Staff B said she had been trained on hair restraint hygiene. The Dietary Manager acknowledged stated Dietary Staff B's hair had not totally been contained in a hair restraint and should have been. During an interview on 01/14/25 at 8:25 a.m., the Dietary Manager said her expectations were for all dietary employees to have their hair completely contained in hair restraints while involved with food preparation and serving from the kitchen. She said unsecured hair could play a role in hair landing in food while being prepared. During an interview on 01/15/25 at 11:15 a.m., the Administrator said her expectations were for dietary employees to have their hair completely contained in hair restraints while preparing food and meals for residents. She said hair that was not restrained could land in the food and was unsanitary. A facility policy dated October 2023 titled Staff Attire indicated All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. 675975 Page 3 of 6 675975 01/15/2025 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to 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 1 of 1 laundry area observed for infection control. Residents Affected - Many The facility failed to ensure that dirty and clean linen had a separation of the airflow in the laundry. These failures could place the residents at risk of cross-contamination and the development of infection. Findings included: During an observation on 01/15/25 at 8:39 a.m., the laundry area had a shear curtain between the clean and dirty linen. The air flow was not prevented from dirty to clean linen by the thin sheer curtain 2 foot by 4 feet and left opening on the bottom of the doorway an approximate 3-foot area not covered at all. During an interview on 01/15/25 at 8:45 a.m., the Laundry Supervisor said had requested for rubber curtain flaps back in November 2024 from the maintenance department. She said she was responsible for the laundry. She said the rubber flaps could prevent cross contamination. During an interview 0n 01/15/25 at 11:00 a.m., the Administrator said she was not aware of the laundry needing rubber curtain flaps. She said the rubber curtain flaps were here and had been put up after surveyor intervention. Record review of the Laundry Operations dated 06/2016 indicated . The laundry room must have a process in place to effectively sort soiled linen without cross contaminating clean linen. 675975 Page 4 of 6 675975 01/15/2025 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment for 2 of 4 linen/storage rooms (Hall 2 and Hall 3), 2 of 4 hall's ceiling vents (Hall 3 and Hall 4), and 1 of 1 nurses' station ceiling area reviewed for physical environment. The facility failed to maintain the ceiling in the Hall 2's linen/storage room. The facility failed to maintain the ceiling in Hall 3's linen/storage room and prevent odor. The facility failed to maintain the ceiling above 1 of 1 nurse's station free of stains. The facility failed to maintain the vent and ceiling around the vents on Hall 3. The facility failed to maintain the vents and ceiling around the vents on Hall 4. (2 of 3 vents) These failures could place residents, staff, and visitors at risk of being in unsafe, uncomfortable environment and decreased quality of life due to poor conditions of the facility. Findings included: During observations on 01/13/25 from 8:15 a.m. to 9:35 a.m., the following were observed: -The white ceiling above the 1 of 1 nurse's station had an area 2 feet by 2 feet of brown and yellowish stains around the vent and another area had an approximately 4-inch circle in the ceiling with an open area in the sheet rock. -On Hall 4, two of 3 vents were discolored around the vents in the ceiling. The vents had a grayish substance which extended on the ceiling 2-3 inches. During observations on 01/13/25 from 9:50 a.m. to 11:00 a.m., the following were observed: -Hall 3's linen storage room was not being used but there was a section of the ceiling that had been removed approximately 4 by 6 foot leaving the attic exposed. The section of the ceiling 3 by 6 foot which remained was covered with grayish black spots and the linen room had a musty smell. The top shelf was covered with a thick black substance which extended up the corner of the shelf. -Hall 2's linen/supply closet had a hole approximately 4 inches and water damage noted on the ceiling. During an interview on 01/13/25 at 1:00 p.m., the Maintenance Supervisor said the water damage happened back in October and November 2024, from the AC duct work sweating. He said the facility received bids but had not decided on the plans for fixing the duct and the sheet rock repairs needed. He said the repairs needed to be done to make the building look better. During an interview and observation on 1/15/25 at 11:45 a.m., the Administer observed the areas, and she took pictures indicating she would get with the regional corporate maintenance and see what their plans were. She said they had received bids in November 2024 work on the water damage. She said 675975 Page 5 of 6 675975 01/15/2025 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0921 Level of Harm - Minimal harm or potential for actual harm the bids were sent to the corporate office. The Administrator said her expectation was for the building to be maintained and would provide the survey team with the policy about maintaining the environment. During an exit interview on 1/15/25 at 1:30 p.m., the Administrator said she was unable to find a policy on maintaining the environment. Residents Affected - Some 675975 Page 6 of 6