Inspection·December 7, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was asked if they worked well and she said yes. She was asked if any staff had ever touched her inappropriately or hit her and she said no. During a phone interview on 12/06/23 at 3:30 p.m., CNA A said he started working at the facility in September 2023 and had been a CNA for 20 years. He said Resident #1 would call him a black bastard and a nigger repeatedly. He said it was the end of his shift on 11/21/23 around 10 p.m. and as he was leaving the unit, he saw Resident #1 getting out of bed and into her wheelchair. He said he went into her room, and he offered to help her get back to bed and she declined. He said Resident #1 started cursing him. He denied any physical contact with the resident. He said on his way out he told oncoming staff, CNA B, that Resident #1 was up in her wheelchair and did not want to go back to bed. He said he had spoken to the Human Resource department and staffing about moving him off the unit so he would not be subjected to this behavior by residents. He said the next day the facility called to suspend him.He said upon hire, he was trained on facility policies re: abuse/neglect, dementia, resident rights, and customer service, etc. During a second interview on 12/07/23 at 11:30 a.m., CNA B said she could tell CNA A was pissed when he exited the secured unit on 11/21/23 during shift change. She said he told her Resident #1 had called him racial slurs and he was tired of it. She said he told her Resident #1 was out of bed and would not let him help her back to bed. CNA B said she immediately went to check on Resident #1. She said Resident #1 was standing in her doorway looking up and down the hallway. She said the resident told her she was looking for that black man because he had hit her behind her head. Resident #1 told CNA B the black man gave her a headache. She said she then had Resident #1 show her where her head hurt. CNA B said the area looked a little red and you could tell something happened. You could tell someone hit her or that something had happened. CNA B reported the resident's allegation and red area to the 10 p.m.-6 a.m. nurse (RN D) who assessed Resident #1. CNA B said this was all in the time span from 10-10:30 p.m. CNA B said she sat with Resident #1 in the dining area of the secured unit, and when the entrance doors would open or close, Resident #1 would jump and look toward the doors saying, I'm scared he is going to come back and get me. CNA B said she reassured Resident #1 she was safe. During an interview on 12/06/23 at 10:45 a.m., the Administrator said CNA A said he wanted to be reassigned off the secured unit the day of the incident (with Resident #1) on 11/21/23 due to racial slurs by residents. The Administrator said CNA A failed to return to the facility to sign his suspension form so he was terminated. She said CNA A wrote a statement which was emailed to her. She said it was a sad case as this one resident was always calling him a black bastard and did not call him by name. She said she was on the fence about the incident and hated to think it could have occurred. She said the resident resided on the secured unit, however the resident's recall of the events had stayed the same. She said she did not really know what to make of this incident. During an interview on 12/06/23 at 11:00 a.m., the DON said CNA A requested to Human Resources, to be removed from the secured unit due to comments made from Resident #1. She said they asked him to finish his shift for that day on the unit, as there was no staff available to switch out since the shift had started. The DON said they had no problem removing him from the secured unit and planned to do so. She said he failed to return to the facility after his shift. She said Resident #1's account of the incident never wavered except she had said she was hit with a phone book or had said it was some kind of book. She said there was a slight red area to the back of her head, but could not say if it was from being struck or if it was possible that she may have laid her head on something. She said CNA A was a new employee, and this was his first incident of any kind. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676108 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 676108 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vidor Health & Rehabilitation Center 470 Moore Dr Vidor, TX 77662 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/07/23 at 2:40 p.m., the SW said she interviewed Resident #1 on 11/22/23 and she didn't seem bothered by the alleged incident. Resident #1 told the SW she did not want to see that black man again. The SW said Resident #1 told her He came into my room without knocking like he owned the place. I was bent over putting shoes on and he called me an old white bitch and hit me with what felt like a book. The SW said Resident #1 did not appear to be frightened and said she did not want to see the CNA again. Record review of CNA A's personnel file: Hire date: 09/15/23. NAR checked 09/13/23. Certificate issued 08/11/04. Certification expires 06/20/24 Orientation Training included abuse/neglect, residents with dementia, and resident rights. The administrator was notified a past non-compliance situation had been identified due to the above failures on 12/7/23 at 4:00 p.m. Review of Abuse/Neglect policy dated 03/29/18 indicated the following. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility implemented the following interventions prior to surveyor entrance: -assessment of Resident #1. - completion of in-services regarding abuse/neglect, reporting of incidents, and behavior management policy. - identified residents at risk for abuse/neglect. - Staff re-educated as to interventions on handling residents with behaviors, abuse/neglect, and resident rights. These interventions were completed based on 6 staff (Administrator, DON, one 2-10 LVN, one 6-2 CNA, one 2-10 CNA, and social worker) interviews to ensure these interventions had been completed. Staff were able to appropriately define abuse, identify the abuse coordinator, and said they would immediately notify the administrator or DON of any abuse allegations. The non-compliance was identified as PNC. The non-compliance began on 11/21/23 and ended on 11/22/23. The facility had corrected the non-compliance before the survey began. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676108 If continuation sheet Page 3 of 3