Health inspection·August 5, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs, for 1 of 6 (Resident #19) residents reviewed.The facility failed to update Resident #19's care plans for her fall mat on 04/30/25. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.Findings included: Record review of Resident #19's face sheet, dated 08/05/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included, dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), hypertension (high blood pressure), and Osteoarthritis (OA) (a degenerative joint disease that causes cartilage breakdown, leading to pain, stiffness, and reduced mobility in affected joints). Record review of Resident 19's quarterly MDS assessment, dated 05/29/25, indicated Resident #19 was usually understood and was usually understood by others. Resident #19 BIMs score was 01 indicating she was severely cognitively impaired. The MDS indicated Resident #19 required maximum assistance with her ADLs. The MDS indicated she had a fall during the look-back period. Record review of Resident 19's Physician order dated 04/30/25 revealed Resident #19 had a Fall mat in place for safety precautions every shift. Record review of Resident #19's comprehensive care plan revision dated 07/31/25 revealed Resident #19 had a fall on 04/29/25, and 07/30/25. The interventions for staff were to assist resident with ambulation, transfers, utilizing therapy recommendations and increase rounding. The interventions did not indicate a fall mat. During an observation and interview on 08/05/25 at 2:49 p.m., the MDS nurse said she was responsible for the care plans. She looked in Resident #19's medical records and did not see a care plan for her fall mat. She said the care plan should have been updated when the quarterly MDS was done on 05/29/25 since the order was written before the MDS assessment. She said she was not employed at the time of the MDS assessment. She said care plan were done so the staff would know how to care for the resident. During an interview on 08/05/25 at 2:55 p.m., the DON said care plans were a team effort with the IDT. He said he was responsible for the acute care plans. The DON said the fall interventions should have been on the care plan for Resident #19. He said the purpose of care plans was for effective communication to the staff of the care the resident needed. He said without care plans proper care may not be given. During an interview on 08/05/25 at 3:29 p.m., the Administrator said the management nurses were responsible for the care plans. She said the MDS nurse was the overseer. She said fall intervention should have been on the Resident #19's care plans. She said care plans kept the staff aware of any changes or updates for the resident's care. Record review of the facility's policy titled, Care Planning, revised 09/2013, indicated, Policy: Our facilities care planning interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. #13 assessment of residents are ongoing, and Page 1 of 6 676142 676142 08/05/2025 Emory Health and Rehab 983 N Texas Street Emory, TX 75440

F 0656 care plans are revised as information about the resident and the residents' condition change. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 676142 Page 2 of 6 676142 08/05/2025 Emory Health and Rehab 983 N Texas Street Emory, TX 75440

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the environment was free of accidents and hazards for 1 of 6 (Resident #19) residents reviewed for accidents. The facility failed to ensure Resident #19's fall mat was beside her bed on 08/03/25. This failure could place residents at risk for fall related injuries.Findings included: Record review of Resident #19's face sheet, dated 08/05/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included, dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), hypertension (high blood pressure), and Osteoarthritis (OA) (a degenerative joint disease that causes cartilage breakdown, leading to pain, stiffness, and reduced mobility in affected joints). Record review of Resident #19's quarterly MDS assessment, dated 05/29/25, indicated Resident #19 was usually understood and was usually understood by others. Resident #19 BIMs score was 01 indicating she was severely cognitively impaired. The MDS indicated Resident #19 required maximum assistance with her ADLs. The MDS indicated she had a fall during the look-back period. Record review of Resident #19's Physician order dated 04/30/25 revealed Resident #19 had a Fall mat in place for safety precautions every shift. Record review of Resident #19's incident report dated 07/30/25 revealed she had a fall from her bed on 07/30/25. The incident report indicated she was sitting on her knees beside the bed on the fall mat holding onto the side rails. Record review of Resident #19's comprehensive care plan revision dated 07/31/25 revealed Resident #19 had a fall on 04/29/25, and 07/30/25. The interventions for staff were to assist resident with ambulation, transfers, utilizing therapy recommendations and increase rounding. The interventions did not indicate a fall mat. During an observation on 08/03/25 at 11:20 a.m., Resident #19 was in her bed without a fall mat beside her bed. During an observation on 08/03/25 at 1:02 p.m., Resident #19 was in her bed with the fall mat partially out at the head of the bed and the rest of the mat was under the bed. During an observation and interview on 08/03/25 at 3:42 p.m., CNA A walked into Resident #19's room and saw the fall mat was not on the floor beside her bed. CNA A said Resident #19 required a fall mat because she was at risk of falling. He said he was Resident #19's aide and should have made sure the fall mat was positioned beside her bed and not under the bed because she could have fallen and received an injury. During an interview on 08/05/25 at 1:39 p.m., LVN B said she was Resident #19's charge nurse. She said Resident #19 required a fall mat beside her bed. She said the aides were supposed to place the fall mat, but she was responsible for ensuring it was down by walking the halls. She said the fall mat was in place for safety. During an interview on 08/05/25 at 2:55 p.m., the DON said Resident #19 was supposed to have a fall mat beside her bed because she had a fall and was at risk for further falls. He said all staff was responsible for ensuring the fall mat was beside her bed. He said the fall mat was for fall prevention and to prevent an injury. During an interview on 08/05/25 3:27 p.m., the Administrator said if Resident #19 had an order for a fall mat, then she expected the fall mat to be beside her bed. She said the fall mat was for the prevention and safety of falls. Record review of the facility's policy titled, Fall and Fall Risk, Managing, revised 03/2018, indicated, Policy: based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and try to minimize complications from falling. Resident-centered approaches to managing falls and fall risk #1 the staff with the input of the attending physician will implement a resident centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. 676142 Page 3 of 6 676142 08/05/2025 Emory Health and Rehab 983 N Texas Street Emory, TX 75440

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 1 medication room reviewed for pharmacy services. The facility failed to ensure the Medication Storage Room did not contain Resident #18's expired ondansetron (nausea medication) with an expiration date of 06/11/25 or an expired Tums bottle with an expiration date of 09/2024. This failure could place the residents at risk of not receiving the intended therapeutic benefits of prescribed medications and medications being used passed their effective or expiration date.Findings included: During an observation and interview on 08/04/25 at 12:26 PM, the medication storage room was reviewed and Resident #18's ondansetron 4mg medication card containing 26 tablets was noted with an expiration date of 06/11/25. A bottle of Tums was also located in the medication storage room that had an expiration date of 09/2024. MA F said she checked her side of the medication room weekly. She said she was unsure of when the bottle of tums was placed inside the medication room because she checked the medication room for expired medications on Wednesday of the prior week and the bottle of Tums was not there. She said MA G was responsible for the other side of the medication room where Resident #18's ondansetron was found. MA G said he checked the medication room for expired medications as least monthly. He said he was unsure how the medication was missed. MA F said failure to remove expired medications could place the resident at risk for receiving an expired medication and could cause them to get sick. MA G said anyone on the cart was responsible for ensuring expired medications were removed from the medication room and carts. During an interview on 08/05/25 at 2:00 PM, the Administrator said there should not have been any expired medications in the medication room. She said the medication aide was responsible for ensuring expired medications were removed from the medication room or cart and if they were not the resident could be given an expired medication. During an interview on 08/05/25 at 2:20 PM, the DON said he did not see an issue with having expired medications in the medication room because the medications were not on the medication cart. He said if the staff followed the medication rights, then the resident would never receive the expired medications. Record review of the facility's policy Storage of Medications revised April 2019, indicated . The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 676142 Page 4 of 6 676142 08/05/2025 Emory Health and Rehab 983 N Texas Street Emory, TX 75440

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts (Nurse Cart) observed for medication storage. The facility failed to ensure the Nurse's cart did not contain Resident #2's undated NovoLog insulin bottle. This failure could place residents at risk for not receiving drugs and biologicals as needed and medications being used passed their effective or expiration date.Findings included: During an observation and interview on 08/04/25 at 11:00 AM, the Nurse's Cart was reviewed and a bottle of Resident #2's NovoLog insulin was noted to be opened and undated. LVN E looked at Resident #2's NovoLog insulin bottle and said there was not a date on it. She said the nurse who opened the insulin should have dated it. She said by not dating the insulin when opened the staff would not know if the insulin had gone past the shelf life. She said this could place the resident at risk for receiving a mediation that was out of date and not be strong enough. During an interview on 08/05/25 at 2:00 PM, the Administrator said she expected the insulin bottle to be dated when opened. She said the nurse who opened the insulin bottle was responsible for dating it. She said failure to date the insulin bottle could cause the insulin to be administered out of date. During an interview on 08/05/25 at 2:20 PM, the DON said he expected the insulin to be dated when opened. He said the nurse who first opened the insulin was responsible for dating it. He said by not dating the insulin the resident could have received a medication that was out of date. Record review of the facility's policy Administering Medications revised April 2019, indicated .When opening a multi-dose container, the date opened is recorded on the container. 676142 Page 5 of 6 676142 08/05/2025 Emory Health and Rehab 983 N Texas Street Emory, TX 75440

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and 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 15 residents reviewed for infection control practices (Resident #20). The facility failed to ensure CNA C changed his gloves and performed hand hygiene while providing incontinent care to Resident #20. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: Record review of the undated face sheet indicated Resident #2 was an [AGE] year-old male that admitted [DATE] with diagnoses that included: Dementia (a decline in mental abilities affecting daily life), cerebral infarction (a stroke, death of brain tissue due to lack of blood flow), and muscle wasting and atrophy (loss of muscle mass and strength). Record review of the quarterly MDS dated [DATE] indicated Resident #20 had a BIMS score of 8, indicating moderate cognitive impairment. He was always incontinent of bowel and bladder. Resident #20 required substantial/maximal assistance for toileting hygiene. Record review of the care plan dated 6/27/25 indicated Resident #20 had dementia and was at risk for increase in confusion and decline in ADL's as the disease progressed. Resident #20 had an ADL self-care performance deficit and required substantial assistance of 1 staff for toileting. During an observation on 8/05/2025 at 8:39 AM CNA C provided incontinent care, for Resident #20. CNA C cleaned Resident #20's backside and did not change his gloves or sanitize his hands before putting on Resident #20's clean brief, touching the clean bed pad, and the resident's pants. Then, he changed his gloves and sanitized his hands. During an interview on 8/05/25 at 8:51 AM, CNA C said he should have changed his gloves and sanitized his hands after cleaning Resident #20's backside and before touching clean things like his clean brief, bed pad, and his pants. He said there was a risk of cross-contamination and spreading infection. He said he was taught to always change his gloves and sanitize his hands when going from a dirty to a clean procedure. During an interview on 8/05/2025 at 12:32 PM, the ADON said staff should change their gloves and clean their hands anytime when going from a dirty procedure to a clean procedure. She said if a staff cleaned a resident's perineal area during incontinent care, they must change their gloves and wash their hands before touching anything clean. Otherwise, there was a risk of cross contamination and infection. During an interview on 8/05/2025 at 12:37 PM, the DON said staff should always change gloves when going from a dirty procedure to clean. He said if a staff was cleaning a resident during incontinent care and did not change gloves or clean their hands before touching clean items there was a risk of cross-contamination or infection. During an interview on 8/05/2025 at 12:42 PM the ADM said staff must change gloves after performing a dirty procedure before going to a clean procedure to prevent cross-contamination or infection to residents and staff. Record review of proficiency assessment dated [DATE] indicated CNA C was proficient in performing incontinent. Record review of a Perineal Care Policy with a revised date of February 2018 indicated: Purpose The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.For a male resident:.m. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks.n. Dry area thoroughly. 9.Discard disposable items into designated containers. 10. Remove gloves and discard into designated container. 11. Wash and dry your hands thoroughly. Residents Affected - Few 676142 Page 6 of 6