Health inspection·February 18, 2026

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 1 facility, 1 of 1 dining room and 7 of 7 residents reviewed for environment. (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6)The facility failed to repair a leaking roof and ensure ceiling tiles were in good repair in the dining room, the area in front of the ice machine leading into the dining room, the rooms for Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7.This failure placed residents at risk of an uncomfortable environment and a decrease in quality of life and self-worth.During an observation on 02/18/26 at 9:35 a.m., in the far back right corner of the dining room above a metal cabinet there were 2 bulging ceiling tiles. There was a large area on both tiles that was discolored. The area were various shades of brown and appeared to be damp. There was another nearby tile that had a smaller brown stain.During an observation on 02/18/26 at 9:37 a.m., in the main area of the dining room there were 4 tiles with various sizes of brown stains. There was one light fixture in the dining room with a brown stain on the inside of the fixture.During an observation on 02/18/26 at 9:38 a.m., near the nurse's station there was one ceiling tile with a brown stain in the corner of the tile. There was another ceiling tile with 2 soft ball sized brown stains. There were 4 tiles in front of the ice machine, in the area leading into the dining room, with brown rings of different sizes.During an observation on 02/18/26 at 9:42 a.m., there was one ceiling tile a little more than halfway down the hall on the right, loose from the ceiling. Insulation was visible.During an interview on 02/18/26 at 9:58 a.m., the previous Maintenance Supervisor said the roof had been an on-going issue. He said he had worked at the facility for three years. He said his last day was 1/23/26. He said he did work to try to resolve the roof issue. He said he had patched the roof with a flexible tar-like substance on numerous occasions. He said there was a structural issue in the ceiling above the ice machine going into the dining room. He said the iron beams were actually starting to rust through in that area. He said corporate had known about this issue since day one. He said he had some of the rooms repaired and they would no longer leak until the patch work at worn off. He said hall three was the one where they would always have to move residents from their rooms due to leaking. He said especially in room [ROOM NUMBER] (Resident #4's room). He said he could never figure out how to repair the leak in the far back of the dining room. He said the rain soaked the insulation down and it would drip for days. He said there were areas where the insulation had been cut away. He said the tiles in the back dining room may have been stained, but he could not say if they were bulging. He said he was told to change the tiles out if they were really bad because that part of the dining room was the activity area and a lot of pictures were taken back there. He said he had changed out those tiles in the past. He said since he could not get the proper ways to fix the roof, the water would leak in and cause the tiles to Page 1 of 4 676154 676154 02/18/2026 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some fall in the area leading into the dining room. He said this area was a high traffic area for residents. He said in the ceiling there was a pan that caught the water from the roof and there was a pipe to drain the water to the outside. He said an ongoing issue was that the facility was planning remodeling but not addressing the roof. He said he did have a roofing company come out and patch the area he thought was causing the issue, but the roof continued leaking, and he felt like the water was funneling from somewhere else.During an observation of room [ROOM NUMBER] and interview on 02/18/26 at 11:05 a.m., Resident #1 was in her bed. Resident #3 was her roommate and in her bed. In the corner above Resident #3's bed was 1 tile that had large brown stain covering most of the tile. Resident #1 said approximately 3 weeks ago the ceiling in her room along the wall to outside was leaking. She said there were multiple tiles that were damaged other than the one still stained in the corner. She said the others had been replaced. She said a man had taken several of them down and replaced them. She said when the tiles were damaged, she could see the water dripping into her room. She said she had also seen the ceiling leaking in front of the ice machine leading into the dining room. She said she had seen water dripping into garbage cans in front of the ice machine.During an interview on 02/18/26 at 10:51 a.m., Resident #2 said the roof had been leaking. He said it leaked in front of the ice machine leading into the dining room. He said the facility had to keep replacing ceiling tiles in front of the ice machine. He said there was a spot in his room too. He said sometimes water dripped into his room from the ceiling.During an observation of room [ROOM NUMBER] on 02/18/26 at 11:01 a.m., in Resident #2's room in the corner near the outside wall at the head of the resident's bed there were two tiles with brown small brown stainsDuring an observation of room [ROOM NUMBER] and interview on 02/18/26 at 11:03 a.m., Resident #3 was in her bed in a room she shared with Resident #1. She said approximately 3 weeks ago the corner of the ceiling in her room was leaking. She said it was leaking in the corner near the head of her bed. She said water was actually dripping into her room. She said at the time it bothered her, but she was ok. There was one tile in the corner with more than half of the tile with a brown stain.During an interview on 02/18/26 at 10:49 a.m., Resident #4 said she had lived in her room, room [ROOM NUMBER], for approximately 1 year. She said the ceiling leaked one time in that year. She said she had to be move to another room while the ceiling was being repaired. She said the leak must have been repaired because during recent rains and ice, it did not leak. She said she had noticed bulging tiles in the corner of the dining room.During an interview on 02/18/26 at 10:55 a.m., a family member of Resident #4 said the facility had an issue with the roof. The family member said when there was a bad rain it leaked in front of the ice machine in the area leading into the dining room. The family member said when this area leaked the facility would use trash cans to catch the water. The family member said in the past ceiling tiles had fallen in this area. The family member said the facility had spent a bunch of money on the new sign out front and they had wondered why that money was not spent on fixing the roof.During an observation and interview on 02/18/26 at 11:49 a.m., Housekeeper A said the tiles in the far corner of the dining room were recently changed along with the ceiling tiles in front of the ice machine leading into the dining room. She said the tiles in the corner of the dining room started bulging after the recent ice storm at the end of January 2026. She said she thought the damage was coming from the roof leaking. She said some of the brown circles on the tiles were huge and an eye sore. She said some tiles fell in the dining room and in front of the ice machine. She said she had seen damaged ceiling tiles in residents' room. In Resident #5's, room [ROOM NUMBER], it was observed there were two missing tiles in one corner along the outside wall. From the opening you could see the roof. In Resident #5's room there was one tile with a brown stain. In Resident #6's room, room [ROOM NUMBER], there were two tiles with a 676154 Page 2 of 4 676154 02/18/2026 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some large faint stain on each tile. One of the tiles appeared to still be damp. The housekeeper said all of this was caused during the ice storm at the end of January 2026. She said during the ice storm she had to clean up tiles in the area in front of the ice machine.During an interview on 02/18/26 at 12:00 p.m., CNA B said roof has been leaking since she started working at the facility. She said she had been working at the facility for 6 years. She said the roof had been the whole six years. She said tiles were damaged during storms and they would be fixed. She said the ceiling had actually fallen through in places. She said they did something on the roof in the past and it was good for a while, but it went back to leaking again. She said the tiles in the dining room began bulging during the ice storm at the end of January 2026. She said she had not seen water actually leaking in resident's rooms, but she had seen where ceiling tiles have fallen. She said the area in front of the ice machine was not as bad as the area in the corner of the dining room but during the ice storm it leaked really bad. She said they used trash cans to catch the water and put a floor blanket down to dry the floor. She said if it were her home and the roof was leaking, she would be pretty upset.During an interview on 02/18/26 at 12:08 p.m., the MDS Coordinator said when it rained the roof had leaked at times. She said the maintenance supervisor had been up on the roof several times to get the leaks fixed. She said they had been without a maintenance supervisor a while and someone came in and did work on changing out ceiling tiles. She said she did not know if they did any repairs to the roof. She said it was hard for her to say how long the area had been bulging in the dining room. She said she did not go in there often. She said the area in front of the ice machine had leaked sometimes. She said it had not leaked very often. She said they put caution floor signs around it and the housekeepers got the water up. She said she had not noticed any damaged ceiling tiles in residents' rooms. She said she would be upset if her ceiling tiles were leaking and damaged. She said that was why they tried to fix them as diligently as possible.During an interview on 02/18/26 at 12:15 p.m., the Maintenance Supervisor said he began working at the facility approximately one week ago. He said he did not know how long the roof had been leaking. He said he was told during the winter storm they were having problems with the water leaking into the building. He said he had seen damaged ceiling tiles in the residents' room. He said he had planned to change them out. He said he was going to change the ones in the dining room later on today (02/18/26). He said he needed to spend some time on the roof to see what was going on with it.During an interview on 02/18/26 at 12:21 p.m., the ADON said she began working at the facility in November 2025. She said she had not noticed the ceiling tiles in the dining room. She said she did know that there had been tiles fixed in front of the ice machine, leading into the dining room. She said a few tiles fell and some were taken down to prevent them from falling in this area during the winter storm at the end of January 2026. She said the tiles were repaired the next day. She said with the ice storm there was a leak in Resident #3's room. She said she believed it was dripping water. She said there were wet tiles that had to be replaced in Resident #7's room, room [ROOM NUMBER]. She said leaks and stained tiles could make residents feel like they were not taking care of things. She said it was not very pretty to look at.During an interview on 02/18/26 at 12:27 p.m., the DON said she could not comment on how long the area in the dining room had been leaking. She said she had not noticed that this area was bulging. She said she did not know how long the area in front of the ice machine had been leaking. She said she did know it leaked during the winter storm at the end of January 2026. She said stained ceiling tiles in residents' rooms should have been replaced. She said she did not know anything about repairs on the roof. She said she was not sure what repairs had been made. She said ceiling tiles stained, missing, and leaking could make residents sad and depressed. She said this was their home.During an interview on 02/18/26 at 676154 Page 3 of 4 676154 02/18/2026 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 12:34 p.m., the Administrator said the previous Maintenance Supervisor had gotten up on the roof and done patchwork. She said roofers came out in May 2025 to repair the roof. She said that repair was supposed to have taken care of the issue. She said she was not aware of the bulging tiles in the dining room. She said they had been changed out several times. She said the area in front of the dining room was supposed to have been repaired in May 2025. She said the tiles were replaced after the recent ice storms along with ceiling tiles in residents' rooms. She said leaking, stained, missing, and bulging ceiling tiles could have a negative psychological impact on residents. She said the spots in front of the ice machine were all new, because they had been changed out after the ice storm in January 2026. She said she would expect for the ceiling and roof to be kept in good repair.Record review of an of an invoice dated 05/30/25 indicated roof repair was done. The invoice indicated, .Repair back corner, install flashing and piece of modified bitumen (Roll Roofing) to cover water entry from cinder block. Seal with silicone. The invoice indicated, .Replace general area.with modified bitumen. Limited warranty on repair due to nature of entire roof system. Remove current material and install new. Fix damaged would if any.Replace soffit (the exposed underside of a roof overhang, bridging the gap between siding and the roof edge to provide crucial attic ventilation, protect rafters from weather/pests, and enhance curb appeal) with wood area where soffit is hanging down. Caulk and seal, no paint.Record review of a Resident Rights facility policy last revised in February 2011 indicated, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the rights to.a dignified existence.Record review of a Homelike Environment facility policy last revised in February 2021 indicated, .Residents are provided with a safe, clean, comfortable and homelike environment.The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike environment. These Characteristics include.clean, sanitary and orderly environment. 676154 Page 4 of 4