Health inspection·February 3, 2026

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 1 of 7 residents reviewed for comprehensive care plans (Resident #1). The facility failed to ensure Resident #1 had a fall mat at his bedside while he was observed in bed on 02/03/2026 at 11:58 AM and 12:25 PM. This failure could place residents requiring supervision at risk for serious injury and death. Findings included: Review of Resident #1's Face Sheet on 02/03/2026 at 11:58 AM revealed he was an [AGE] year-old male admitted to the facility on [DATE] from an acute care hospital. Relevant diagnoses included dementia (decline in cognitive abilities,) respiratory failure (respiratory system cannot provide enough oxygen to the blood,) spinal stenosis (narrowing of the spine which compresses the nerves and/or spinal cord,) heart disease (disease which affects the heart,) and diabetes (chronic metabolic disease.) Review of Resident #1's Comprehensive Care Plan dated 12/26/2025 revealed resident had an actual fall with no injury with interventions that included:-floor mat-anticipate resident needs-ensure call light was in reach Review of Resident #1's MDS dated [DATE] revealed resident was severely cognitively impaired with a BIMS score of 01. He was always incontinent of bowel and bladder. He was documented with a recent fall and required a wheelchair for mobility and was completely dependent upon staff for transfers, toileting, showers, and dressing himself. Observation and attempted interview of Resident #1 on 02/03/2026 at 11:58 AM and 12:25 PM revealed he was in bed resting comfortably and his call light was in reach. No floor mat was observed beside resident's bed. Interview with Resident #1 was not successful due to his cognition. In interview with LVN A on 02/03/2026 at 12:25 PM she stated resident had a fall about a month ago. She stated Resident #1's fall precautions that should be in place and stated it included a fall mat. She stated Resident #1 should have a fall mat at the bedside and was not sure why it was not in place at this time. She stated fall mats were important for harm reduction if Resident #1 did fall. She stated it was her responsibility to ensure his fall mat was at his bedside while he was in bed. In interview with DON on 02/03/2026 at 1:55 PM she stated Resident#1 had a fall and one of the interventions was for a bedside floor mat while resting in bed. She stated it was the bedside nurse's responsibility to ensure the floor mat was present at the bedside when he was resting in bed. She stated it was important for harm reduction if Resident #1 did have a fall. In Interview with the Administrator on 02/03/2026 at 2:33 PM she stated her expectations were for Resident #1 to have a fall mat at the bedside while he was in bed. She stated it was the nurse's responsibility to ensure a fall mat was at his bedside as a measure of harm reduction if the resident does fall. She stated it was an important measure to keep her residents safe. Facility Administrator stated the facility does not have a specific fall mat policy but stated she expected the interventions listed on Resident #1's Comprehensive Care Plan to be implemented at the facility. Review of facility policy, Care Plans, Comprehensive Person-Centered, rev. 01/2025 revealed A comprehensive, person-centered care Page 1 of 2 676146 676146 02/03/2026 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0656 plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 676146 Page 2 of 2