Health inspection·September 18, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency for 1 of 6 residents (Resident #1) reviewed for abuse and neglect.The facility did not report to the State Survey Agency (HHSC) an incident in which Resident #1 tied the call light cord around his neck.This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. The findings included: Record review of Resident #1's face sheet, dated 09/18/2025, reflected an [AGE] year-old male with an initial admission date of 08/15/2025. Resident #1 had diagnoses which included chronic diastolic heart failure (a condition where the heart becomes stiff and cannot relax properly, making it difficult for the heart to fill with blood), severe intellectual disabilities (a condition characterized by significant limitations in cognitive functioning), and cognitive communication deficit (Communication difficulty stemming from an underlying problem with a person's thinking processes). Record review of Resident #1's admission MDS Assessment, dated 08/22/2025, reflected a BIMS score of 11, which indicated the resident was moderately impaired (a condition with a serious limitation in a specific area of functioning, requiring significant support or assistance to carry out daily tasks).Record review of Hospice Agreement dated and signed 09/09/25 reflected Resident #1 had been admitted to hospice. Record review of Resident #1's Progress Notes, dated 09/09/2025 written by the ADON, reflected, hospice mattress arrived res was very lethargic and very difficult to arouse for most of this shift. Family members arrived and expressed that it was [Resident #1's] wish to not eat - he is tired. family wants to keep meds on board to ease his discomfort [sic]. Record review of Resident #1's Care Plan, updated 09/09/25, reflected, [Resident #1] was admitted to Hospice with Terminal DX: CHF, DC all routine labs and radiological studies. Do not call 911 or send resident to hospital without calling Hospice. Call with any falls, occurrences or any change in condition. An interview on 09/18/25 at 2:37 PM with ADON revealed she had just talked to Resident #1 and his family prior to him tying the call light cord around his neck. She stated the family stated they had accepted that the resident was not going to get better and had placed him on hospice. She stated Resident #1 had not informed her of any suicidal plans and she had not seen any suicidal ideations when she visited his room that day or she would have reported it to the DON, the administrator, social services, and hospice. She stated the hospice representative was still in the building on 09/10/25 when Resident #1 tied the cord around his neck because she had just finished talking to him and his family.In a telephone interview on 09/18/25 at 3:13 PM with the NP revealed Resident #1 had never expressed to her that he wanted to harm himself. She stated she met with the dietitian, the family, and the previous DON regarding Resident #1 refusing to eat. She suggested Resident #1 received a feeding tube for nutrition, but the family refused. She stated hospice was suggested, and the family wanted to think about it for a few days. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 676178 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 676178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Duncanville Healthcare and Rehabilitation Center 419 S Cockrell Hill Rd Duncanville, TX 75116 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)