Health inspection·December 6, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews, the facility failed to ensure the residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 6 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from abuse. CNA A attempted to provide Resident #1 care on the bed by herself on 11/13/2025 which led to Resident #1 falling off the bed and sustaining a left forehead injury.An IJ was identified on 12/05/25 at 09:50 a.m. The IJ template was provided to the facility on [DATE] at 12:33 p.m. While the IJ was removed on 12/06/25 at 5:17 p.m., the facility remained out of compliance at a scope of isolated and severity level of no actual harm because all staff had not been trained on abuse/neglect, incident/accidents, and reporting. The failure could place residents at risk of abuse and serious harm. A review of the MDS quarterly assessment dated [DATE] reflected Resident#1 was a [AGE] year-old male admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including cerebrovascular accident (a medical emergency where blood flow to the brain is suddenly interrupted, causing brain cells to die from lack of oxygen, leading to potential disability or death), non-Alzheimer's dementia (forms of cognitive decline not caused by Alzheimer's disease), Parkinson's Disease (a progressive neurological disorder where brain cells producing dopamine die, leading to movement issues like tremors, stiffness, slow movement, and balance problems, alongside non-motor symptoms such as sleep issues, depression, and cognitive changes), dysphasia (difficulty swallowing food or liquids), and muscle weakness. No BIMS score was documented, and section C100-Cognitive Skills for Daily Decision Making was coded at (2) indicating moderate cognitive impairment. Section GG, which reflects functional abilities, indicated that Resident #1 was dependent, and required two-person assistance for showers, toileting, hygiene, and bed transfers.Review of the care plan dated 10/28/25 reflected that Resident #1 required two-person assistance for bed mobility, transfers and ADLs.Review of facility accident/incident report for the month of November 2025 revealed Witnessed Fall Incident [Resident#1] 11/13/2025 at 10:00 AM.Record review of the Witnessed Fall report by LVN B dated 11/13/25 10: 00 a.m. revealed 10:00 AM Received report that resident had a fall. Nurse responded to room and observed the resident on the floor lying on his left side. Nurse observed active bleeding to the left temporal area. Resident alert upon assessment with no loss of consciousness, pressure applied to site with a clean towel. 117/62, P 88, 97.4 RR 18 CNA A was witness to the incident stated while getting the resident dressed for the day, she turned the resident on his side and that was when the resident accidentally rolled off the bed. NP, DON, and Resident#1 RP notified. 911 notified Resident#1 transferred to Hospital. Resident#1 description: Resident#1 unable to give description.Record review of Witnessed Fall IDT meeting dated 11/17/25 note by DON revealed IDT met to review resident fall. Resident#1 was in bed and CNA A was assisting with getting him dressed and rolled him over and he somehow ended up falling off the bed sustained a fall with a laceration to his head. During Page 1 of 13 676146 676146 12/06/2025 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few investigation of the fall IDT determined that Resident#1 call light was within reach, CNA A was in the room with Resident#1 and resident failed to grab the rail and rolled off the bed. IDT determined that Resident#1 needed scoop mattress in place. Resident#1 is currently on therapy services, therapy plan of care updated to focus on strength and balance to prevent falls. Education was also given to the CNA A.Review of hospital records dated 11/13/25 for Resident#1 revealed Physical exam. 2 cm V shaped Laceration to left temporal region, superficial 1 cm laceration amenable to glue on scalp. date/time: 11/13/2025 2:38 p.m.location: forehead. Laceration length: 2 cm. Anesthesia: Local infiltration: Lidocaine 1% without epinephrine.wound skin closure material used: 5-0 fast gut x 4 (5-0 fast absorbing gut is a Monofilament, collagen-based, absorbable suture designed for rapid absorption (21-42 days) and 5-7 days of tensile strength). Number of sutures: 4.Procedure described (general) as Laceration repair.location: scalp. Laceration length: 1 cm .skin closure: glue. Repair type: simple.Record review revealed Resident#1 returned to the facility on [DATE] after the visit to ER with a left forehead dressing.In an interview on 12/03/25 at 12:24 p.m. over the phone, CNA A stated that on 11/13/25 she had been providing incontinent care to Resident #1. She stated that while turning Resident #1 on to his left side, Resident#1 rolled off the bed, hitting his head on the floor with active bleeding. CNA A reported that she immediately called for help. LVN B assessed Resident #1 and found out he sustain injury with active bleeding to his left forehead. She stated Resident#1 was sent to the hospital. CNA A stated she had been assigned to Resident#1 for a long time and was not aware that Resident #1 was a two-person assist. She explained that she had always provided care for him alone. CNA A stated she was supposed to check the Kardex (a vital, often summarized, patient care tool for nurses) in the electronic medical record system to know the level of assistance each resident required. She stated, she overlooked Resident#1's level of assistance. CNA A stated the DON did a one-to-one education with her the same day after the incident. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps they would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.In interview on 12/04/25 at 12:25 p.m. LVN B stated she was called to Resident#1's room by CNA A. She stated CNA A told her Resident#1 rolled off the bed when CNA A turned him to his left side and he ended up in the floor. LVN B stated Resident#1 sustained an injury to his left head with active bleeding. LVN B stated she got help from LVN C who came in and applied pressure on Resident#1 left forehead injury. LVN B stated he was alert and awake. LVN B stated she called 911 and sent Resident#1 to the ER, because of the injury and active bleeding. LVN B stated she notified Resident#1's PR, the DON, and MD. LVN B stated CNA A was performing incontinent care for Resident#1 by herself. LVN B stated CNA A did not request help. LVN B stated she knew from the care plan that Resident#1 required 2 persons assist for turning in the bed. LVN B stated since Resident#1 required mechanical lift transfer from the bed to wheelchair the CNAs working with him were supposed to request help. LVN B stated CNA A worked that Hall all the time, and she knew not to Resident#1 care/bed mobility by herself. LVN B stated the risk of not following the care plan/Kardex for residents' care was falls, and injury. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation She denied being aware of any abuse/neglect/exploitation at the facility.In interview on 12/04/25 at 2:46 PM the ADON stated she had just started in the facility when the 676146 Page 2 of 13 676146 12/06/2025 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few incident happened. She stated she was informed about what happened, and that Resident#1 had a fall. She stated it was the responsibility of the CNAs to check the Kardex for residents' level of assistance. She stated it was also the responsibility of the nurses in charge of each Hall to let the CNAs know if there were changes if residents had a decline. ADON stated the CNAs were supposed to get reports on the residents at the start of each shift. The ADON stated her expectation in this case was for CNA A to call another person to help her. ADON stated the risk for residents was falling, and injury. She reported that she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.In interview on 12/04/25 at 2:03 p.m. the DON stated, she interviewed CNA A involved in the incident and LVN B who responded to CNA A's call after the fall, who was assigned to Resident#1. She stated CNA A rolled Resident#1 over and he kept rolling and ended up in the floor. The DON stated she did not ask CNA A if she knew how many persons assist Resident#1 needed for his incontinent care/mobility in the bed. The DON stated she did not ask CNA A if she checked the Kardex, because the DON thought Resident#1 required one person assist since his admission. The DON stated Resident#1 had been living in the facility for six to seven years. She stated Resident#1 had declined but was still able to grab the side rail and help. The DON stated the Kardex stated two persons assist, and she learned that after the incident. She stated she educated the CNAs to check the Kardex daily for residents' level of assistance. She stated she was expecting CNA A to have a second person with her. She stated CNA A caused an injury to Resident#1, because she did not follow the facility policy, and that could be neglect from the CNA A side. She stated she spoke to other CNAs, about the incident, and the importance of following each resident's care needs indicated in the Kardex. She stated, after the incident she reviewed the Kardex for all the residents to make sure they are up to date. The DON stated she reported the incident to the Administrator. The DON further stated she should consider it a form of abuse/neglect and report it to HHSC.In a follow up interview with the DON on 12/05/25 at 3:30 PM she stated CNA A was as needed staff. DON stated CNA A finished her shift on the day of the incident on 11/13/25 she did not come back to work since that date (11/13/2025). In an interview with the Administrator on 12/04/25 at 2:19 p.m., the Adm. stated, she learned that Resident#1 had a fall when CNA A was providing care for him that day (11/13/25), and he ended up being sent to the hospital. She stated that the DON reported it to her. She stated she did not do any investigation, other than what the DON did. She stated she did not interview the staff to know how Resident#1 sustained the fall. She stated from her understanding it was an accident, CNA A knew Resident#1's routine, and he never had any incident. She stated Resident#1 was all the time a 1 person assist not 2 persons assist for positioning/turning in bed and there was a typo in his care plan, because sometimes it stated 1-2 person assist. She stated CNA A not checking the Kardex daily for Resident#1's care level was an oversight on CNA A's part. The Adm. stated her expectations were that the staff should look in the care plan, and Kardex to know what care level was needed for the residents. She stated without checking the care plan or the Kardex the staff would not know the appropriate care to provide for the residents, and that could be a potential neglect. She stated it was the responsibility of the charge nurses in the Hall to rely to CNAs the care level for the residents and make sure they were following residents' care plan instruction. She stated the risk to residents was falls and injury. Observations of CNA E on 12/03/25 at 10:02 a.m. of one-person in-bed peri-care per the resident care plan/Kardex revealed no concerns, and CNA E followed appropriate steps to ensure 676146 Page 3 of 13 676146 12/06/2025 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few care and resident safety.Observations of CNA E and MA F on 12/03/25 at 10:25 a.m. of two-person transfers using a mechanical lift revealed no concerns-staff appeared trained in mechanical lift usage. Observations of CNA J and CNA K on 12/04/25 at 10:26 a.m. of two-person in-bed peri-care per the resident care plan/Kardex revealed no concerns, and staff followed appropriate steps to ensure care and resident safety.Observations of CNA D and CNA L on 12/04/25 at 10:50 a.m. of two-person in-bed peri-care per Resident care/Kardex revealed no concerns, and staff followed appropriate steps to ensure care and resident safety.Observations of CNA G on 12/04/25 at 11:25 a.m. of one-person in-bed peri-care per the resident care plan/Kardex revealed no concerns, and CNA G followed appropriate steps to ensure care and resident safety.Interview on 12/03/25 at 1:15 p.m. with CNA E revealed that she had been in-serviced on Abuse/Neglect and assistance with mobility this week. She was aware of where to locate a resident's care needs in his/her care plan/Kardex, and she stated she would notify the nurse if there was conflicting information. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.Interview on 12/03/25 at 1:29 p.m. with CNA M revealed that she had been in-serviced on Abuse/Neglect and assistance with mobility this week. She was aware of where to locate a resident's care needs in his/her care plan/Kardex, and she stated she would notify the nurse if there was conflicting information. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.Interview on 12/03/25 at 1:33 p.m. with MA O revealed that she had been in-serviced on Abuse/Neglect and assistance with mobility this week. She was aware of where to locate a resident's care needs in his/her care plan/Kardex, and she stated she would notify the nurse if there was conflicting information. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.Interview on 12/04/25 at 10:42 a.m. with CNA J revealed that she had been in-serviced on Abuse/Neglect and assistance with mobility this week. She was aware of where to locate a resident's care needs in his/her care plan/Kardex, and she stated she would notify the nurse if there was conflicting information. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.Interview on 12/04/25 at 12:38 p.m. with CNA L revealed that she had been in-serviced on Abuse/Neglect and assistance with mobility this week. She was aware of where to locate a resident's care needs in his/her care plan/Kardex, and she stated she would notify the nurse if there was conflicting information. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of 676146 Page 4 of 13 676146 12/06/2025 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.Interview on 12/04/25 at 12:45 p.m. with CNA K revealed that she had been in-serviced on Abuse/Neglect and assistance with mobility this week. She was aware of where to locate a resident's care needs in his/her care plan/Kardex, and she stated she would notify the nurse if there was conflicting information. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.Interview on 12/04/25 at 12:50 p.m. with CNA G revealed that she had been in-serviced on Abuse/Neglect and assistance with mobility this week. She was aware of where to locate a resident's care needs in his/her care plan/Kardex, and she stated she would notify the nurse if there was conflicting information. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.Interview on 12/04/25 at 1:08 p.m. with CNA D revealed that she had been in-serviced on Abuse/Neglect and assistance with mobility this week. She was aware of where to locate a resident's care needs in his/her care plan/Kardex, and she stated she would notify the nurse if there was conflicting information. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.Interview on 12/04/25 at 1:14 p.m. with CNA H revealed that she had been in-serviced on Abuse/Neglect and assistance with mobility this week. She was aware of where to locate a resident's care needs in his/her care plan/Kardex, and she stated she would notify the nurse if there was conflicting information. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.Interview on 12/04/25 at 1:47 p.m. with MA Q revealed that she had been in-serviced on Abuse/Neglect and assistance with mobility this week. She was aware of where to locate a resident's care needs in his/her care plan/Kardex, and she stated she would notify the nurse if there was conflicting information. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.Interview on 12/04/25 at 1:56 p.m. with CNA/MA/Staffing coordinator revealed that she had been in-serviced on Abuse/Neglect and assistance with mobility this week. She was aware of where to locate a resident's care needs in his/her care plan/Kardex, and she stated she would notify the nurse if there was conflicting information. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and 676146 Page 5 of 13 676146 12/06/2025 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.An interview 12/03/25 at 1:44 p.m. with LVN C revealed she had been in serviced on Abuse/Neglect and mobility assistance this week. She stated it was the responsibility of all the staff to follow residents' care plan for their care. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.An interview on 12/04/25 at 1:41 p.m. with LVN I revealed he had been in serviced on Abuse/Neglect and mobility assistance this week. He stated it was the responsibility of all the staff to follow residents' care plan for their care. He reported that he had been in-serviced on abuse/neglect/exploitation. He provided various types/examples of abuse/neglect/exploitation. He reported the Administrator was the Abuse Coordinator. He verbalized facility policies and procedures, including the steps he would take, related to the prevention and response of abuse/neglect/exploitation. He denied being aware of any abuse/neglect/exploitation at the facility.An interview on 12/03/25 at 1:44 p.m. with LVN C revealed she had been in serviced on Abuse/Neglect and mobility assistance this week. She stated it was the responsibility of all the staff to follow residents' care plan for their care. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.An interview on 12/04/25 at 1:51 p.m. with LVN P revealed she had been in serviced on Abuse/Neglect and mobility assistance this week. She stated it was the responsibility of all the staff to follow residents' care plan for their care. She reported she had been in-serviced on abuse/neglect/exploitation. She provided various types/examples of abuse/neglect/exploitation. She reported the Administrator was the Abuse Coordinator. She verbalized facility policies and procedures, including the steps she would take, related to the prevention and response of abuse/neglect/exploitation. She denied being aware of any abuse/neglect/exploitation at the facility.A record review of in-services titled abuse/neglect/exploitation dated 12/03/25 and conducted by the DON showed all employees had signed the documentation.Record review of facility policy titled Abuse and neglect-Clinical Protocol revised October 15, 20222 revealed The facility will ensure that each resident has the right to be free from, among things, physical or mental abuse.A record review of CNA A's Perineal Care/Incontinent Care Competency dated 06/25/25 reflected that all observation points were marked as satisfactory.Review of facility policy titled Perineal Care revised in October 2010 revealed .Preparation: 1. Review the resident's care plan to assess for any special needs of the resident.A review of the facility's Fall Prevention Program policy, revised in November 2024, revealed Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.The Immediate Jeopardy (IJ) was identified on 12/05/2024 at 09:50 a.m. The IJ Immediate Jeopardy template was provided to the ADM on 12/05/25 at 12:33 p.m.Record review of the Plan of Removal dated 12/06/2025 reflected: C.N.A. A in-serviced w/ 1: 1 on 11/13/25 by DON on resident positioning, bed mobility, using draw sheet and get assistance when needed. Review of the in-service sheet dated 11/13/25 revealed CNA A was in serviced by the DON on resident positioning, bed mobility, using the draw sheet and get assistance as needed. Phone interview with CNA A on 12/03/25 at 12:42 PM revealed she was in serviced by the DON. C.N.A. A has not worked since 11/13/25 d/t PRN status. 676146 Page 6 of 13 676146 12/06/2025 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Employee is not available and has been terminated on 12/5/25. Review of the personnel action form dated 12/05/25 revealed the CNA A was terminated. Interview with DON on 12/05/25 at 3:30 pm revealed CNA A has not worked since 11/13/25. The DON stated CNA A was as needed staff. All staff were in-serviced on Abuse/ Neglect/ Exploitation, Incidents/ Accidents and how to safely care for dependent residents on 12/3/25-12/4/25. Completed by ADON who was instructed/ trained by Compliance Nurse. Review of the in-service sheet dated 12/03/25 revealed staff were in serviced ANE, incident/accident and how to safely care, add the Hoyer lift.All residents have the potential to be affected by this alleged practice.DON/ ADMIN in-serviced on Abuse, Neglect, Incidents and Investigating to include immediate suspension of employee accused of abuse/ neglect verbally on 12/3/25 and written on 12/5/25. Completed by Compliance Nurse. Review of the in-service record dated 12/05/25 revealed the DON/Administrator were in serviced on abuse/neglect and accident incident investigation and reporting to HHSC by the Compliance Nurse. 100% Audit completed to review plan of care, Kardex and care profile on residents who are dependent assistance 12/3/25 & 12/4/25. Completed by DON/ ADON or designee with Compliance nurse oversight. Review of the Residents care plan/Kardex audit done on 12/03/25 revealed no concernsCare guides were reviewed for compliance and accuracy on 12/3/25 & 12/4/25. Completed by DON/ ADON or designee with Compliance nurse oversight. Review of care guides revealed no concerns.Nursing staff was in-serviced on guidance for accessing Kardex, care plans and how to safely care for residents with positioning and incontinent care on 12/3/25 & 12/4/25. Completed by DON/ ADON/ designee. Weekend supervisor trained to monitor incidents/ accidents on weekends and immediately report any issues identified to Administrator / DON immediately by DON on 12/5/25.Reviewed all incidents and no other instances of abuse or neglect were noted from the audit. Completed by DON/Admin on 12/3/25 & 12/4/25. Review of in-service sheet dated 12/03/25 and 12/05/25 revealed nursing staff were in serviced on guidance of abuse/neglect prevention, accident and incident investigation/reporting.Reviewed all incidents and no other instances of abuse or neglect were noted from the audit. Completed by DON/Admin on 12/3/25 & 12/4/25. Review of incident reports from September 2025-November 2025 revealed no other instances of abuse or neglect. Incident occurred 11/13/25 w/ Resident #1 was self-reported via email by DON on 12/5/25. Investigation was initiated on 12/5/2025. The facility self-reported the incident on 12/05/25. Moving forward, all Abuse/Neglect allegations will be reported and investigated per policy. DON and Administrator will ensure the investigation will be completed timely. Administrator oversight provided by Regional [NAME] President of Operations. Interview revealed no employees will be allowed to return to work until they have been in-serviced on the Abuse/ Neglect policy and how to safely care for residents. Nurses will be responsible for ensuring. DON/ ADON/Admin will monitor.Incidents/ Accidents and Complaints will be reviewed daily by DON or designee, weekend supervisor and reported to Administrator immediately for investigation. Clinical review team (Admin, DON, ADON, MDS, Director of Operation) will discuss all incidents and accidents 5 days/ week. Admin/ DON will monitor to ensure compliance.Post plan of removal monitoring on 12/06/25:Observation on 12/06/25 at 09:22 a.m. revealed Resident#1 was sitting in his wheelchair, in the TV area. Resident#1 appeared clean, and stated he was doing fine. He denied having any new falls. Resident#1 did not remember the incident.In interview on 12/06/25 at 10:58 a.m. LVN R stated Abuse was physical, mental, chemical, verbal and Neglect was failing to provide care for a patient. She stated the most recent in-service she received on abuse/neglect and fall prevention was that week. LVN R stated if a resident was dependent on care, she would look at the care profile to find what level of care he/she needed and would call for assistance while providing care. She stated if a resident had a fall, she would immediately assess the resident for pain/injuries, and immediately notify Administrator, DON, doctor and 676146 Page 7 of 13 676146 12/06/2025 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few family. She stated she would send the resident out to the ER if needed. She stated resident safety was very important and she would document any incidents so other employees would know what happened and what to do. In interview on 12/06/25 at 11:10 a.m. LVN S stated the different types of abuse were physical, verbal, sexual, emotional, and Neglect was not doing something needed for a patient in a timely manner. She stated she would check on the resident care profile every day to ensure what level of care they needed. She stated she would call for assistance if a resident needed 2/3 person assist with incontinent care/transfers. She stated all the nurses had access to this information and the most recent in service she received on abuse, neglect, and how to safely care for dependent residents was that week. She stated if a resident had a fall, she would immediately notify the DON, Abuse coordinator, she would assess the resident for injuries/pain, she would notify the doctor, family, and send out to the hospital if needed. She stated she would document the incident in the progress note.In interview on 12/06/25 at 11:23 a.m. the Weekend Supervisor-RN stated abuse was physical, mental, chemical, verbal and Neglect was failing to provide care for a patient. She stated the most recent in-service she received on abuse/neglect, fall prevention was that week. She stated if a resident was dependent on care, she would look at the care profile to find what level of care he/she needed and would call for assistance while providing care. She stated if a resident had a fall, she would immediately assess the resident for pain/injuries, and immediately notify Administrator, DON, doctor and family. She stated she would send the resident out to the ER if needed. She stated resident safety was very important and she would document any incidents so other employees would know what happened and what to do. She stated she will review risk management every shift, ask the nurses of any falls, injuries, or incidents, and make sure all incidents are reported and documented. Interview on 12/06/25 at 11:44 a.m. CNA M stated forms of abuse were physical, mental, verbal, and Neglect was not providing bathing or feeding. She stated she would review resident's POC on Kardex to find what level of care that residents need during incontinent care/transfers, showers and seek assistance from other employees. She stated if a resident had a fall, she would immediately notify the charge nurse, DON, Administrator and assist them. She stated she received in services on abuse and neglect, and how to safely care for dependent residents that week. She stated she would document in POC of any incidents. Interview on 12/06/25 at 11:48 a.m. CMA F stated forms of abuse were physical, mental, verbal, and Neglect was not providing bathing or feeding. She stated she would review residents' PO 676146 Page 8 of 13 676146 12/06/2025 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the residents received adequate supervision and assistance to prevent accidents and hazards for 1 of 6 ( Resident #1) reviewed for accidents and hazards. CNA A failed to have another staff member help her with care, and as a result, the resident rolled out of bed and sustained a laceration on the forehead. This failure could place resident at risks for accidents and injuries. A review of the MDS quarterly assessment dated [DATE] reflected Resident#1 was a [AGE] year-old male admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including cerebrovascular accident (a medical emergency where blood flow to the brain is suddenly interrupted, causing brain cells to die from lack of oxygen, leading to potential disability or death), non-Alzheimer's dementia (forms of cognitive decline not caused by Alzheimer's disease), Parkinson's Disease (a progressive neurological disorder where brain cells producing dopamine die, leading to movement issues like tremors, stiffness, slow movement, and balance problems, alongside non-motor symptoms such as sleep issues, depression, and cognitive changes), dysphasia (difficulty swallowing food or liquids), and muscle weakness. No BIMS score was documented, and section C100-Cognitive Skills for Daily Decision Making was coded at (2) indicating moderate cognitive impairment. Section GG, which reflects functional abilities, indicated that Resident #1 was dependent, and required two-person assistance for showers, toileting, hygiene, and bed transfers.Review of the care plan dated 10/28/25 reflected that Resident #1 required two-person assistance for bed mobility, transfers and ADLs.Review of facility accident/incident report for the month of November 2025 revealed Witnessed Fall Incident [Resident#1] 11/13/2025 at 10:00 AM.Record review of the Witnessed Fall report by LVN B dated 11/13/25 10: 00 a.m. revealed 10:00 AM Received report that resident had a fall. Nurse responded to room and observed the resident on the floor lying on his left side. Nurse observed active bleeding to the left temporal area. Resident alert upon assessment with no loss of consciousness, pressure applied to site with a clean towel. 117/62, P 88, 97.4 RR 18 CNA A was witness to the incident stated while getting the resident dressed for the day, she turned the resident on his side and that was when the resident accidentally rolled off the bed. NP, DON, and Resident#1 RP notified. 911 notified Resident#1 transferred to Hospital. Resident#1 description: Resident#1 unable to give description.Record review of Witnessed Fall IDT meeting dated 11/17/25 note by DON revealed IDT met to review resident fall. Resident#1 was in bed and CNA A was assisting with getting him dressed and rolled him over and he somehow ended up falling off the bed sustained a fall with a laceration to his head. During investigation of the fall IDT determined that Resident#1 call light was within reach, CNA A was in the room with Resident#1 and resident failed to grab the rail and rolled off the bed. IDT determined that Resident#1 needed scoop mattress in place. Resident#1 is currently on therapy services, therapy plan of care updated to focus on strength and balance to prevent falls. Education was also given to the CNA A.Review of hospital records dated 11/13/25 for Resident#1 revealed Physical exam. 2 cm V shaped Laceration to left temporal region, superficial 1 cm laceration amenable to glue on scalp. date/time: 11/13/2025 2:38 p.m.location: forehead. Laceration length: 2 cm. Anesthesia: Local infiltration: Lidocaine 1% without epinephrine.wound skin closure material used: 5-0 fast gut x 4 (5-0 fast absorbing gut is a Monofilament, collagen-based, absorbable suture designed for rapid absorption (21-42 days) and 5-7 days of tensile strength). Number of sutures: 4.Procedure described (general) as Laceration repair.location: scalp. Laceration length: 1 cm .skin closure: glue. Repair type: simple.Record review revealed Resident#1 returned to the facility on [DATE] after the visit to ER with a left forehead dressing.In an interview on 12/03/25 at 12:24 p.m. over 676146 Page 9 of 13 676146 12/06/2025 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0689 Level of Harm - Actual harm Residents Affected - Few the phone, CNA A stated that on 11/13/25 she had been providing incontinent care to Resident #1. She stated that while turning Resident #1 on to his left side, Resident#1 rolled off the bed, hitting his head on the floor with active bleeding. CNA A reported that she immediately called for help. LVN B assessed Resident #1 and found out he sustain injury with active bleeding to his left forehead. She stated Resident#1 was sent to the hospital. CNA A stated she had been assigned to Resident#1 for a long time and was not aware that Resident #1 was a two-person assist. She explained that she had always provided care for him alone. CNA A stated she was supposed to check the Kardex (a vital, often summarized, patient care tool for nurses) in the electronic medical record system to know the level of assistance each resident required. She stated, she overlooked Resident#1's level of assistance. CNA A stated the DON did a one-to-one education with her the same day after the incident. In interview on 12/04/25 at 12:25 p.m. LVN B stated she was called to Resident#1's room by CNA A. She stated CNA A told her Resident#1 rolled off the bed when CNA A turned him to his left side and he ended up in the floor. LVN B stated Resident#1 sustained an injury to his left head with active bleeding. LVN B stated she got help from LVN C who came in and applied pressure on Resident#1 left forehead injury. LVN B stated he was alert and awake. LVN B stated she called 911 and sent Resident#1 to the ER, because of the injury and active bleeding. LVN B stated she notified Resident#1's PR, the DON, and MD. LVN B stated CNA A was performing incontinent care for Resident#1 by herself. LVN B stated CNA A did not request help. LVN B stated she knew from the care plan that Resident#1 required 2 persons assist for turning in the bed. LVN B stated since Resident#1 required mechanical lift transfer from the bed to wheelchair the CNAs working with him were supposed to request help. LVN B stated CNA A worked that Hall all the time, and she knew not to Resident#1 care/bed mobility by herself. LVN B stated the risk of not following the care plan/Kardex for residents' care was falls, and injury. In interview on 12/04/25 at 2:46 PM the ADON stated she had just started in the facility when the incident happened. She stated she was informed about what happened, and that Resident#1 had a fall. She stated it was the responsibility of the CNAs to check the Kardex for residents' level of assistance. She stated it was also the responsibility of the nurses in charge of each Hall to let the CNAs know if there were changes if residents had a decline. ADON stated the CNAs were supposed to get reports on the residents at the start of each shift. The ADON stated her expectation in this case was for CNA A to call another person to help her. ADON stated the risk for residents was falling, and injury. abuse/neglect/exploitation. In interview on 12/04/25 at 2:03 p.m. the DON stated, she interviewed CNA A involved in the incident and LVN B who responded to CNA A's call after the fall, who was assigned to Resident#1. She stated CNA A rolled Resident#1 over and he kept rolling and ended up in the floor. The DON stated she did not ask CNA A if she knew how many persons assist Resident#1 needed for his incontinent care/mobility in the bed. The DON stated she did not ask CNA A if she checked the Kardex. She did not fully investigate the incident because the DON thought Resident#1 required one person assist since his admission. The DON stated Resident#1 had been living in the facility for six to seven years. She stated Resident#1 had declined but was still able to grab the side rail and help. The DON stated the Kardex stated two persons assist, and she learned that after the incident. She stated she educated the CNAs to check the Kardex daily for residents' level of assistance. She stated she was expecting CNA A to have a second person with her. She stated CNA A caused an injury to Resident#1, because she did not follow the facility policy. In a follow up interview with the DON on 12/05/25 at 3:30 PM she stated CNA A was as needed staff. DON stated CNA A finished her shift on the day of the incident on 11/13/25 she did not come back to work since that date (11/13/2025). In an interview with the Administrator on 12/04/25 at 2:19 p.m., the Adm. stated, she learned that Resident#1 had a 676146 Page 10 of 13 676146 12/06/2025 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0689 Level of Harm - Actual harm Residents Affected - Few fall when CNA A was providing care for him that day (11/13/25), and he ended up being sent to the hospital. She stated that the DON reported it to her. She stated she did not do any investigation, other than what the DON did. She stated she did not interview the staff to know how Resident#1 sustained the fall. She stated from her understanding it was an accident, CNA A knew Resident#1's routine, and he never had any incident. She stated Resident#1 was all the time a 1 person assist not 2 persons assist for positioning/turning in bed and there was a typo in his care plan, because sometimes it stated 1-2 person assist. She stated CNA A not checking the Kardex daily for Resident#1's care level was an oversight on CNA A's part. The Adm. stated her expectations were that the staff should look in the care plan, and Kardex to know what care level was needed for the residents. She stated without checking the care plan or the Kardex the staff would not know the appropriate care to provide for the residents, and that could be a potential neglect. She stated it was the responsibility of the charge nurses in the Hall to rely to CNAs the care level for the residents and make sure they were following residents' care plan instruction. She stated the risk to residents was falls and injury. A record review of in-services titled abuse/neglect/exploitation dated 12/03/25 and conducted by the DON showed all employees had signed the documentation.Record review of facility policy titled Abuse and neglect-Clinical Protocol revised October 15, 20222 revealed The facility will ensure that each resident has the right to be free from, among things, physical or mental abuse.A record review of CNA A's Perineal Care/Incontinent Care Competency dated 06/25/25 reflected that all observation points were marked as satisfactory.Review of facility policy titled Perineal Care revised in October 2010 revealed .Preparation: 1. Review the resident's care plan to assess for any special needs of the resident.A review of the facility's Fall Prevention Program policy, revised in November 2024, revealed Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.Record review of the Plan of Removal dated 12/06/2025 reflected: C.N.A. A in-serviced w/ 1: 1 on 11/13/25 by DON on resident positioning, bed mobility, using draw sheet and get assistance when needed. Review of the in-service sheet dated 11/13/25 revealed CNA A was in serviced by the DON on resident positioning, bed mobility, using the draw sheet and get assistance as needed. Phone interview with CNA A on 12/03/25 at 12:42 PM revealed she was in serviced by the DON. C.N.A. A has not worked since 11/13/25 d/t PRN status. Employee is not available and has been terminated on 12/5/25. Review of the personnel action form dated 12/05/25 revealed the CNA A was terminated. Interview with DON on 12/05/25 at 3:30 pm revealed CNA A has not worked since 11/13/25. The DON stated CNA A was as needed staff. All staff were in-serviced on Abuse/ Neglect/ Exploitation, Incidents/ Accidents and how to safely care for dependent residents on 12/3/25-12/4/25. Completed by ADON who was instructed/ trained by Compliance Nurse. Review of the in-service sheet dated 12/03/25 revealed staff were in serviced ANE, incident/accident and how to safely care, add the Hoyer lift.All residents have the potential to be affected by this alleged practice.DON/ ADMIN in-serviced on Abuse, Neglect, Incidents and Investigating to include immediate suspension of employee accused of abuse/ neglect verbally on 12/3/25 and written on 12/5/25. Completed by Compliance Nurse. Review of the in-service record dated 12/05/25 revealed the DON/Administrator were in serviced on abuse/neglect and accident incident investigation and reporting to HHSC by the Compliance Nurse. 100% Audit completed to review plan of care, Kardex and care profile on residents who are dependent assistance 12/3/25 & 12/4/25. Completed by DON/ ADON or designee with Compliance nurse oversight. Review of the Residents care plan/Kardex audit done on 12/03/25 revealed no concernsCare guides were reviewed for compliance and accuracy on 12/3/25 & 12/4/25. Completed by DON/ ADON or designee with Compliance nurse oversight. Review of care guides revealed no concerns.Nursing staff 676146 Page 11 of 13 676146 12/06/2025 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0689 Level of Harm - Actual harm Residents Affected - Few was in-serviced on guidance for accessing Kardex, care plans and how to safely care for residents with positioning and incontinent care on 12/3/25 & 12/4/25. Completed by DON/ ADON/ designee. Weekend supervisor trained to monitor incidents/ accidents on weekends and immediately report any issues identified to Administrator / DON immediately by DON on 12/5/25.Reviewed all incidents and no other instances of abuse or neglect were noted from the audit. Completed by DON/Admin on 12/3/25 & 12/4/25. Review of in-service sheet dated 12/03/25 and 12/05/25 revealed nursing staff were in serviced on guidance of abuse/neglect prevention, accident and incident investigation/reporting.Reviewed all incidents and no other instances of abuse or neglect were noted from the audit. Completed by DON/Admin on 12/3/25 & 12/4/25. Review of incident reports from September 2025-November 2025 revealed no other instances of abuse or neglect. Incident occurred 11/13/25 w/ Resident #1 was self-reported via email by DON on 12/5/25. Investigation was initiated on 12/5/2025. The facility self-reported the incident on 12/05/25. Moving forward, all Abuse/Neglect allegations will be reported and investigated per policy. DON and Administrator will ensure the investigation will be completed timely. Administrator oversight provided by Regional [NAME] President of Operations. Interview revealed no employees will be allowed to return to work until they have been in-serviced on the Abuse/ Neglect policy and how to safely care for residents. Nurses will be responsible for ensuring. DON/ ADON/Admin will monitor.Incidents/ Accidents and Complaints will be reviewed daily by DON or designee, weekend supervisor and reported to Administrator immediately for investigation. Clinical review team (Admin, DON, ADON, MDS, Director of Operation) will discuss all incidents and accidents 5 days/ week. Admin/ DON will monitor to ensure compliance.Post plan of removal monitoring on 12/06/25:Observation on 12/06/25 at 09:22 a.m. revealed Resident#1 was sitting in his wheelchair, in the TV area. Resident#1 appeared clean, and stated he was doing fine. He denied having any new falls. Resident#1 did not remember the incident.In interview on 12/06/25 at 10:58 a.m. LVN R stated Abuse was physical, mental, chemical, verbal and Neglect was failing to provide care for a patient. She stated the most recent in-service she received on abuse/neglect and fall prevention was that week. LVN R stated if a resident was dependent on care, she would look at the care profile to find what level of care he/she needed and would call for assistance while providing care. She stated if a resident had a fall, she would immediately assess the resident for pain/injuries, and immediately notify Administrator, DON, doctor and family. She stated she would send the resident out to the ER if needed. She stated resident safety was very important and she would document any incidents so other employees would know what happened and what to do. In interview on 12/06/25 at 11:10 a.m. LVN S stated the different types of abuse were physical, verbal, sexual, emotional, and Neglect was not doing something needed for a patient in a timely manner. She stated she would check on the resident care profile every day to ensure what level of care they needed. She stated she would call for assistance if a resident needed 2/3 person assist with incontinent care/transfers. She stated all the nurses had access to this information and the most recent in service she received on abuse, neglect, and how to safely care for dependent residents was that week. She stated if a resident had a fall, she would immediately notify the DON, Abuse coordinator, she would assess the resident for injuries/pain, she would notify the doctor, family, and send out to the hospital if needed. She stated she would document the incident in the progress note.In interview on 12/06/25 at 11:23 a.m. the Weekend Supervisor-RN stated abuse was physical, mental, chemical, verbal and Neglect was failing to provide care for a patient. She stated the most recent in-service she received on abuse/neglect, fall prevention was that week. She stated if a resident was dependent on care, she would look at the care profile to find what level of care he/she needed and would call for assistance while providing care. She stated if a resident had a fall, she would immediately 676146 Page 12 of 13 676146 12/06/2025 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0689 Level of Harm - Actual harm Residents Affected - Few assess the resident for pain/injuries, and immediately notify Administrator, DON, doctor and family. She stated she would send the resident out to the ER if needed. She stated resident safety was very important and she would document any incidents so other employees would know what happened and what to do. She stated she will review risk management every shift, ask the nurses of any falls, injuries, or incidents, and make sure all incidents are reported and documented. Interview on 12/06/25 at 11:44 a.m. CNA M stated forms of abuse were physical, mental, verbal, and Neglect was not providing bathing or feeding. She stated she would review resident's POC on Kardex to find what level of care that residents need during incontinent care/transfers, showers and seek assistance from other employees. She stated if a resident had a fall, she would immediately notify the charge nurse, DON, Administrator and assist them. She stated she received in services on abuse and neglect, and how to safely care for dependent residents that week. She stated she would document in POC of any incidents. Interview on 12/06/25 at 11:48 a.m. CMA F stated forms of abuse were physical, mental, verbal, and Neglect was not providing bathing or feeding. She stated she would review residents' POC on Kardex to find what level of care that residents need during incontinent care/transfers, showers and seek assistance from other employees. She stated if a resident had a fall, she would immediately notify the charge nurse, DON, Administrator and assist them. She stated she received in services on abuse and neglect, and how to safely care for dependent residents that week. She stated she would document in POC of any incidents.Interview on 12/06/25 at 3:42 p.m. DON stated types of abuse are verbal, sexual, neglect, physical, exploitation, misappropriation, and the abuse coordinator is the administrator. She stated she was in-serviced on neglect 12/3 or 4th by the Compliance Nurse, who is providing oversight. She said neglect should be reported immediately to the administrator. She stated that going forward she will check the care plan which reflected resident was a x2 person assist and she would know it was neglect since it was one staff assisting the resident instead of 2.Interview on 12/06/25 at 4:48 p.m. The Adm. stated neglect is anything unusual including injury of unknown origin or when care isn't provided. She stated clinicals are reviewed daily with IDT which reviews incident reports, falls, weight issues, infection issues, incidents and accidents. She said neglect is when the resident doesn't get the services needed, or if the plan of care is not followed such as the correct number of staff that's not used for transfer. She stated the compliance nurse is providing oversight. She stated the policy states if neglect is identified and brought to her attention, the procedure is to initiate investigation, ensure resident is assessed, notify the physician, ensure family notified, and complete self-report immediately or within a 2-hours timeframe, and in-service on abuse. She stated she was in-serviced on abuse and neglect by the Compliance nurse, verbally on 12/3 and written on 12/5. She stated an investigation re: neglect includes suspend employee (s), ensure the resident is assessed, education with staff, interview potential witnesses, notify family, physician, conduct safe surveys. 676146 Page 13 of 13