Health inspection·September 25, 2024

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few in front of Resident #1 while she talked to Resident #1 aggressively, but there was no audio. ADON A said LVN B slapped Resident #1's hand away when Resident #1 raised her hand. ADON A said there was no reason for LVN B to physically abuse Resident #1. During an interview on 09/24/24 between 10:47 a.m. and 5:54 p.m., (2 LVN, 1 CNA, 1 MA, 1 shower teach) from day shift were interviewed on the facility in service on abuse/neglect. All staff interviewed were able to verbalize understanding of abuse/neglect in-services received. During an interview on 09/25/24 at 11:35 a.m., the DON said while she was making rounds on 12/05/23, a resident told her she heard loud noise last night (12/05/23). The DON said she reviewed the facility camera and saw LVN B standing in front of the medication cart by the nursing station when Resident#1 bumped into LVNA B. The DON said LVN B shoved Resident #1's wheelchair back forcefully, leaned forward to Resident #1, and pointed to Resident#1's face, but she could not hear what she said because the camera had no audio. The DON said LVN B's demeanor was intimidating, and it made her the DON sick. The DON said the video of the incident was not available to be reviewed when surveyors entered. The DON said she immediately reported it to HHSC. The DON said she called LVN B at home and told LVN B she could not return to the facility because of the incident, and LVN B was terminated after the facility investigation, which indicated LVN B abused Resident #1. During an interview on 09/25/24 at 11:43 a.m., the DON said they had QAPI about the incident, in-service with the staff on abuse/neglect, they did safe survey with residents, and the DON would train new staff upon hire on abuse/neglect. During an interview on 09/24/24 between 12:7 a.m. and 3:25 p.m., (3 LVN, and 1 CNA) from day shift were interviewed on the facility in service on abuse/neglect. All staff interviewed were able to verbalize understanding of abuse/neglect in-services received. Record review of the provider investigation report dated 12/05/23 revealed LVN B written statement reflected, I would never treat my patients in such a way. I was doing my job at the nurse's cart when the resident approached me demanding coffee. I told her that the kitchen was closed for the day, and she continued to try and roll past me. When she did, she ran into my foot and by reaction, I moved her continued to try and roll past me. When she did, she ran into my foot and by reaction, I moved her chair away to prevent injury to myself. I then attempted to redirect the resident by getting eye level with her and gestured to her, the kitchen is closed. She then attempted to hit me, so I attempted to block her from injuring me . the facility investigation reflected the incident happened on 12/5/23, and abuse was substantiated . Director of Nursing viewed security footage from around 7pm the night prior and noted an interaction between Resident #1 and LVN B. Footage revealed that Resident #1 was in her wheelchair rolling slowly towards the dining room. She stopped shortly next to LVN B at her nursing cart, at the nurse's station. Resident#1 then proceeded to propel herself slowly bumping LVN B's foot. In response, LVN B forcefully pushed Resident #1's wheelchair backwards and proceeded to point her finger at Resident #1. Verbal interaction took place between Resident #1 and LVN B. Resident #1 appeared to start yelling at the nurse and in return LVN B leaned forward into Resident#1's face. Resident #1 swung her hand toward the nurse and LVN B batted Resident #1 hand away. After review of footage, LVN B was suspended immediately pending investigation. The interventions during investigation were physician notified, responsible party notified, sheriff's department notified, safe surveys, abuse and neglect in services LVN suspended and terminated . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676194 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 676194 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mason Creek Transitional Care of Katy 21727 Provincial Blvd Katy, TX 77450 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Record review of the facility report of progress to the CQI Committee dated 12/12/23 reflected in part . PROBLEM Nurse became physically aggressive and intimidating to resident. CAUSAL FACTORS Residents Affected - Few nurse startled by being bumped into by resident wheelchair. Nurse reaction to dementia resident behavior INTERVENTION(S) a. On-going education for abuse and neglect, b. Re-educate facility staff on handing. residents with behaviors and dementia, c. DON/Designee to review all new hire background checks, d. Medical Director Notified, e. Safe Surveys f. RP notified, g. Police notified, h. Discuss on-going education and background checks in monthly QAPI. i. ensure Relias trainings are completed before new hires start training and are completely annually by all staff. Record review of LVN B employee file reflected the following: DOH: 03/27/2020. Criminal background checks completed 03/26/2020. DADS check completed 03/27/2020. EMR: 11/07/2023. Record review of the facility policy on abuse dated 11/2017, revision 12/2023 reflected in part .It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. It is also the policy of this Facility to recognize the resident right to personal privacy and confidentiality of their physical body, personal care, and personal space or accommodations . Physical Abuse includes but is not limited to hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676194 If continuation sheet Page 3 of 3