Inspection·January 31, 2024

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and visitors for 1 of 3 sections (north side of the facility which is referred to as the Nile) of the facility reviewed for environmental conditions. The facility failed to provide an area for specialized therapy services that was conducive to the well-being of its residents by providing diathermy (a specialized therapy treatment that uses electric currents to generate heat) to a resident in a room used for storage. The facility failed to ensure the Nile section of the facility was maintained in a secure, practical, and sanitary manner due to the storage of items which included therapy equipment, carpet floor fan, dirty linen and trash barrels, wheelchairs and wheelchair parts, pressure reducing devices, large bag of trash, wall pictures, rolling stool, foot ottoman, folding table, folding chair, filing cabinet, beds, mattresses, oxygen concentrator and other miscellaneous items along both sides of the hall, in a room being utilized for specialized treatments, and by the nurses' station. These failures could place the residents, staff, and visitors at risk of receiving services, working, and visiting in an unsafe, unsanitary and uncomfortable environment. Findings included: During observations of the Nile section of the facility on 01/30/2024 at 10:20 AM reflected a resident sitting in her wheelchair in room [ROOM NUMBER], receiving diathermy (diathermy is an electrically induced heat or high frequency electromagnetic current form of physical therapy.) to her left shoulder area. A therapy staff person was sitting in a chair a few steps behind the resident. A bed with 2 mattresses on it were against the outer wall. A towel was noted lying on the floor against the side wall. There was a round table and a rectangular table in the room with empty drinking cups and miscellaneous papers noted on the tops of the tables. There were 2 (two) pieces of therapy equipment noted in the room, namely, an electrotherapy muscle stimulator (E-Stim) and the diathermy machine. There was an oxygen concentrator and a table with boxes stacked on it in the corner just inside the room. There was loose debris on the floor. The bathroom in room [ROOM NUMBER] was noted to have a small refrigerator sitting in the opening of the shower area with the doors of the refrigerator open and facing inward to the shower. A towel was noted lying on the floor along the base of the refrigerator. The door to the room was noted to be open throughout the survey. During observations of the Nile section of the facility (located on the north side of the facility) on 01/30/24 at 03:00 PM reflected empty resident rooms #'s 101- 107. The DON, ADON, HR, and DOR were using some of the empty rooms on this end of the facility for offices. Other offices in this area included the ADM and MDS Nurses offices. The therapy room and conference room were also located in this area. Residents, staff, and visitors were noted to have free access to the north end of the facility. During observations of the Nile section of the facility on 01/31/24 at 02:10 PM reflected multiple items along the east wall of the hall from the entrance into the area to the end of the building and included the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676193 If continuation sheet Page 2 of 3 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 676193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Waterton Healthcare & Rehabilitation 2875 Shiloh Road Tyler, TX 75703 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2 barrels used for dirty linen and trash, 6 varied sizes of framed wall pictures leaning against the wall, unused office chair, geri chair, 1 large utility cart with numerous w/c leg/foot rests, 1 large utility cart with cloth foot/heel protectors, on the shelves and w/c cushions and bolster cushion on top, knee caddy, green positioning wedge, 1 small orange cone, w/c with small plastic box on floor beside it with items in it, a container for papers needing shredding with hand weights and peg boards on top, and a red balloon on the floor. During observations of the Nile section of the facility on 01/31/24 at 02:15 PM reflected multiple items along the west wall of the hall from the entrance into the area to the end of the building and included the following: carpet blower fan for drying floors, black 3-drawer vertical filing cabinet, 2 large brown boxes stacked, portable set of stair/steps used by therapy, folding chair. 12 multiple types of walkers, wheelchair, square ottoman/footrest, 2 physical therapy stationary bikes, wheelchair cushion, and 1 large bag of trash. During observations of the wall along the back side of the nurses' station located in the center of the Nile section of the facility on 01/31/24 at 02:20 PM reflected a set of parallel bars and a small tote bag with plastic bowling pins in it. On the front side of the nurses' station was a coffee table with a wheelchair and rolling stool beside it. During an interview on 01/31/24 at 02:27 PM, the DOR said therapy uses room [ROOM NUMBER] for storage. She said therapy does not store equipment in the hall. When asked about the items along the walls of both sides of the hall, the DOR said the hall was cluttered with therapy equipment. She said the pictures located along the wall were in the room she was now using for an office. She said she moved them to the hall. She said the pictures should be put in room [ROOM NUMBER]. The DOR said therapy staff use room [ROOM NUMBER] for diathermy and E-Stim. She said residents receiving diathermy and E-stim were receiving therapy in a storage area (room [ROOM NUMBER]). She said therapy staff work with the residents in the hall at times. She said if residents need to go to the bathroom while receiving therapy, the therapy staff either take the resident to his or her room or to the bathroom in room [ROOM NUMBER]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676193 If continuation sheet Page 3 of 3