Health inspection·August 28, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few room at 1:35 p.m. to feed Resident #1, and left the room at 1:40 p.m. The family member stated she noticed the aide being rough with Resident #1 by grabbing her hand. The family member stated she was not sure of the aide's name. The family member stated it was around 2:15-2:20 p.m. when she got to the facility. The family member stated she talked to the DON. The family member stated when she showed the DON the video, he said, hold on I need to go get the Administrator. The family member stated the Administrator and SW came to meet with her as well. The family member stated that the Administrator seemed concerned and upset. The administrator told her, I can assure you this is going to be handled promptly and swiftly. The Administrator asked for a copy of the video, and it was emailed to the SW on 7/25/23. The DON told the family member in keeping with appropriate measures, they would be reporting the incident to the State. The family member stated that the Administrator had gone to talk to the aide, but she had already left for the day. The family member said the staff were very willing to help, and they talked about how they were going to prevent future incidents of the resident not being fed. The family member stated she felt the staff handled this particular event appropriately, however, it was more about the continuity of care, denying Resident #1 the right to be fed. The family member stated that the facility called the police, they looked at the video and told the Administrator it did not look like abuse or neglect. During an interview on 8/24/23 at 9:15 a.m. CNA B stated she had worked in the facility for 2 years. CNA B stated Resident #1 was to go to the dining room for all her meals, then was to be put to bed. CNA B stated Resident #1 had days that she did not want to get up and would refuse to eat, and that she always notified the charge nurse if Resident #1 did not eat. During an interview on 8/24/23 at 9:40 a.m. LVN C stated she had worked in the facility since February of this year. LVN C stated Resident #1 usually went to the dining room for all her meals. However, sometimes she refused to get up and would also refuse to eat at times. LVN C said she had never seen Resident #1 try to hit another staff member. LVN C stated the aides took turn feeding residents, and she was always in the dining room for meals and assisted with the residents who needed assisting eating. During an interview on 8/24/23 at 9:51 a.m. CNA D stated she had worked in the facility for 7 years. CNA D stated Resident #1 did not eat very well at times. CNA D stated Resident #1 may take 2-3 bites of food but loved the health shakes. CNA D stated Resident #1 could be feisty at times and had swatted at her a few times usually during care or feeding time. CNA D stated she just jumped back if she saw it coming and that she had never reached for Residents #1's arm to stop her, as she knew better than that. During an interview on 8/24/23 at 10:07 a.m. LVN E stated she had worked in the facility since February of this year. LVN E stated she had witnessed Resident #1 trying to swat staff during care and had never seen any staff grab her arm to prevent getting hit. LVN E stated it may be the way other staff approached her. I explain everything to Resident #1. What I am going to do, and when I am going to touch her and have never had any problems with her trying to hit me. LVN E stated she had never noticed any signs of abuse when doing assessments or skin care and would report it to the DON if she did. During an observation and interview on 8/24/23 at 12:45 p.m. Resident #1 was sitting in the dining room in her wheelchair. Resident #1 was being assisted by CNA D with her meal. CNA D stated Resident #1 had taken 4 bites of her chicken, and 8 bites of her mashed potatoes and a few sips of tea. CNA D went to get Resident #1 a health shake. Resident said that no one had ever hurt her, and she knew the staff treated her good. CNA D returned with strawberry milkshake, and Resident #1 drank about (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676147 If continuation sheet Page 2 of 4 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 676147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stallings Court Nursing and Rehabilitation 4616 NE Stallings Dr Nacogdoches, TX 75965 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 0550 half of the 4 oz. carton and asked for more. Level of Harm - Minimal harm or potential for actual harm During an interview on 8/24/23 at 1:45 p.m., the DON stated he had worked in the facility since June of this year. The DON stated on 7/25/23, Resident #1's family member called and told him that Resident #1 did not get a lunch tray. DON stated he did not remember the time but it was after lunch and that trays had been picked up. DON stated he told CNA A and CNA F to get Resident #1 a tray. DON stated Resident #1 got her tray but she did not want to eat. The DON stated the Administrator went in Resident #1's room to see if he could get her to eat and offered a health shake which she refused. Shortly thereafter, the family member came to the facility and went into the social workers office. The DON stated the family member was very irritated and showed them a video of the aides feeding Resident #1 and CNA A grabbing a hold of the Resident #1's arm. The DON stated after the meeting CNA A had already left for the day. The DON tried to call CNA A to tell her she was suspended until the investigation was done, but she did not answer her phone. The Administrator came in the next morning around 6 before CNA A started work to suspend her. The DON stated the police were called and the officer reviewed the video and said it did not look like abuse to him, and that there appeared to be no intent to cause harm to the Resident #1. The DON said he began in-service training on ANE. The DON stated the incident would be discussed at the QA meeting next month. Residents Affected - Few During an interview on 8/24/23 at 2:05 p.m. The Administrator stated on 7/25/23, himself, the DON and the SW met with Resident #1's family member when she came to the facility after lunch. The Administrator stated family member was irate, and said, I saw this video, and I am pissed off. Family member stated she was going to call the State. The Administrator stated the family member shared a video she had with CNA A grabbing Resident #1's arm. The Administrator stated by the time they were done meeting, change of shift had taken place and CNA A had already left. The Administrator tried to call CNA A 3 times but she did not answer her phone. The Administrator stated he came in the next morning around 6:00 a.m. and told the charge nurse to send CNA A to his office when she arrived. The Administrator stated CNA A came into his office with an attitude. The Administrator stated they discussed the situation and he told CNA A she had to go home for 3 days. The Administrator stated he asked CNA A about knowing there was a camera in the room, and she stated, I know there is a camera, you think I'd go in there and do something stupid? The administrator stated the police were called and did not file a report as they did not see anything that they could prosecute. The officer told the Administrator to give his number to the family member and he would talk to her. During an interview on 8/28/23 at 10:50 a.m. CNA F stated she had worked at the facility for 1 year but had previously worked 5 years in the facility. CNA F stated on 7/25/23 she assisted CNA A in feeding Resident #1. CNA F stated she was not sure if Resident #1 was aggravated that day or not. CNA F stated Resident #1 could easily get aggravated and cuss them out when she didn't want to do something. CNA F stated while CNA A was feeding Resident #1, she raised her hand up in the air, and CNA A reached out and touched her arm to lower her hand. CNA F stated she had never seen CNA A be rough with any resident. CNA F stated CNA A was trying to lower Resident #1's hand so she would not get hit while attempting to feed her. CNA F stated she did not feel CNA A was intentionally trying to harm Resident #1. CNA F stated at the time of the incident, Resident #1 had a care giver every afternoon who would bathe, feed, and changed the bed for Resident #1. CNA F stated on that day, the care giver was leaving and told CNA A that Resident #1 was good to go, she had been bathed and put back to bed, and everything was done. CNA F stated that CNA A must have assumed the care giver fed Resident #1 as she normally did. Record review of an undated witness statement written by CNA F revealed the following: As I assisted CNA A in feeding Resident #1. I saw Resident #1 swing her hand over to the right and CNA A caught (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676147 If continuation sheet Page 3 of 4 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 676147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stallings Court Nursing and Rehabilitation 4616 NE Stallings Dr Nacogdoches, TX 75965 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 0550 her hand. Level of Harm - Minimal harm or potential for actual harm Record review of a witness statement dated 7/26/23 written by CNA A revealed the following: As I was feeding Resident #1, with the assistance of CNA F, Resident #1 took a few bites of food and drink. Resident #1 swung her hand and I blocked her hand from hitting me. I did NOT cause harm or damage to Resident #1. Residents Affected - Few Record review of the facility Form 3613A dated 7/29/23 indicated Resident #1's family member made the allegation that CNA A was feeding Resident #1 in a rough manner and pushed her arm down as Resident #1 attempted to stop the feeding. CNA A could be heard cussing as she left the room. Resident #1 does have a camera in her room and the family member had the episode on tape. The SW, ADON, DON, and Administrator have looked at the video several times and find that CNA A did not follow facility rules, policies and procedures and was disrespectful to Resident #1. CNA A had been terminated. Record review of portable xray reports dated 7/25/23 indicated Resident #1's right forearm, right elbow, right hand, right humerus, and right shoulder were all negative for fracture or dislocation. A facility Record of Disciplinary Measure form dated 7/31/23 indicated CNA A had been terminated and did not show up to sign paperwork. Record review of training records dated 7/25/23 indicated staff received training on abuse, neglect, and residents who needed to be fed. Record review of CNA A's training records indicated CNA A was hired on 2/8/23. CNA A received training on abuse, neglect, and resident rights, with signed acknowledgements dated 2/8/23. Record review of a facility policy titled Resident Rights dated October 2009, indicated employees shall treat all resident with kindness, respect, and dignity . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676147 If continuation sheet Page 4 of 4