Inspection·November 20, 2023

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few monthly weight report indicated in August 2023 he weighed133 pounds. The monthly weight report indicated in September 2023 Resident #1 weighed 135 pounds. The monthly weight report indicated in October Resident #1 weighed 152.6 pounds, which indicated a significant weight gain. The monthly weight report indicated in November 2023 he weighed 102 pounds, which indicated a significant weight loss. Record review of the Dietician's quarterly progress note dated 10/21/2023 indicated Resident #1 had a weight of 152.6 pounds. The progress noted indicated Resident #1 had a 13 percent weight gain x 1 month. The progress note indicated Resident #1's usual intake was 75% and he required assistance with feeding at times. The progress note indicated the Dietician recommended 1. Change Prostat to 30 milliliters twice a day 2. Reweigh to verify weight of 152 pounds. Record review of the monthly weights indicated Resident #1 had not been re-weighed in the month of October. Record Review of the progress noted dated 11/19/2023 indicated Resident #1 was sent to the hospital after a fall. Record review of the hospital admission record dated 11/20/2023 indicated Resident #1 was admitted on [DATE] with a diagnosis of dehydration. During an interview on 11/20/2023 at 10:13 a.m., CNA X said the assigned CNA weighed the residents in the facility. CNA X said the aides weigh the residents when assigned and turned the weight into the nurses. CNA X said it was the responsibility of the nurses and ADONs to ensure weights were being performed. CNA X said the importance of monitoring the residents' weights was to monitor for significant weight gain or loss. During an interview on 11/20/2023 at 12:48 p.m., LVN Y said the assigned CNA performed weights on residents in the facility. LVN Y said it was the responsibility of the DON and ADON's to ensure weights were being performed. LVN Y said the importance of monitoring the residents' weights was to monitor for significant weight gain or loss. LVN Y said Resident #1 required assistance with eating most of the time including set up and feeding. LVN Y said Resident #1 needed to be reminded to eat and drink. During an interview on 11/20/2023 at 11:58 a.m., the Regional Compliance Nurse said CNAs weighed the residents monthly and as ordered. The Regional Compliance Nurse said it was the nurse's responsibility to inform the CNA's who needed to be weighed and when. The Regional Compliance Nurse said the importance of weighing residents monthly and as ordered was to monitor for significant weight fluctuations which could indicate a need for change in diet consistency, trouble swallowing, and/or fluid overload. The Regional Compliance Nurse said the facility had standing orders if a resident had a significant change in weight to begin weighing them weekly for 4 weeks and to notify the dietician . The Regional Compliance Nurse said the ADON and DON were responsible for monitoring the weights and ensuring the residents were weighed. The Regional Compliance Nurse said the ADON and/or DON usually had an aide assist with weighing the residents. The Regional Compliance Nurse said if a resident had a significant change in weight the facility would notify the physician, dietician, and family. The Regional Compliance Nurse said it was the responsibility of the ADONs and DON to ensure orders were being followed and changes in condition including significant weight changes were reported to the physician, dietician (if indicated), and family. During an interview on 11/20/2023 at 3:32 p.m., the Regional Compliance Nurse said she was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676045 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Terrace Healthcare and Rehabilitation 2885 Stillhouse Road Paris, TX 75460 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm aware the Dietician had requested Resident #1 be weighed again. The Regional Compliance Nurse said they needed to establish a new baseline for Resident #1's weight upon his return from the hospital. She stated she is currently working on getting the weights completed through out the facility since the ADON, DON and staff had quit on Tuesday, November 14, 2023. The Regional Compliance Nurse said she had covered the vacant positions with other employees from the sister companies. Residents Affected - Few Record review of Nutrition policy revised 02/13/2007 indicated, All residents will be weighed by the 10th of the month and their weights documented correctly. The appropriate actions regarding significant changes will be carried out .The DON or designee will review all weights to determine the need for any re-weighs. Re-weighs will be completed within 24 hours of the first weight. Weight Loss: Significant weight loss (5% in 1 month, 7.5% in three months, or 10% in six months) .Significant Weight Gain - The facility review resident weights after monthly weights after monthly are obtained, to determine residents with significant weight changes . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676045 If continuation sheet Page 3 of 3