Health inspection·December 10, 2025

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly investigate an allegation of neglect for 1 (Resident #3) of 3 residents reviewed for neglect. The facility failed to conduct a thorough investigation when a family member of Resident #3 told staff that Resident #3 was found sitting in urine, feces and was dirty on 11/30/25. This failure could place residents at risk of skin breakdown.Findings included: Record review of Resident #3's face sheet, dated 12/10/25, reflected an [AGE] year-old female, who admitted to the facility on [DATE]. Resident #3 had diagnoses of Alzheimer's Disease (progressive brain disorder, the most common cause of dementia, characterized by gradual memory loss, thinking problems, and behavioral changes, stemming from brain cell death due to protein buildup (plaques and tangles)), encounter for attention to gastrostomy (medical visit for care of a feeding tube (G-tube)), and adult failure to thrive (syndrome of progressive global decline in physical and cognitive function). Record review of Resident #3's Nursing Home Comprehensive Item set MDS, dated [DATE], reflected Resident #3 did not conduct a brief interview for mental status as she was rarely/never understood. Resident #3's functional abilities implied she was dependent for eating, oral hygiene, toileting hygiene, shower/bathe/ upper/lower body dressing, putting on/taking off footwear and personal hygiene[. Resident #3 bladder and bowel revealed Resident #3 was always incontinent. During an interview on 12/10/25 at 10:27 a.m., Resident #3's Resident Representative stated that a family member had went to the facility on [DATE] to visit Resident #3 and when the family member arrived, they found Resident #3 sitting soaked in urine, feces and bed was dirty. Resident #3's Resident Representative stated that the family member had to go get the nurse to ask who the aide was who was supposed to provide care to Resident #3, the nurse did not know where the aide was, but the nurse was able to get another aide to change Resident #3. Resident #3's Resident Representative stated he sent an email to the facility Administrator on 12/02/2025 and the Administrator told him he would report this allegation to the State, and they were going to handle it and they did. Resident #3's Resident Representative stated the Administrator moved Resident #3 to a different hall with permanent staff to provide better continuity of care as the previous hall used a lot of agency staff. Resident #3's Resident Representative stated he has been fine with the care for Resident #3 since the incident. During an interview on 12/10/25 at 11:37 a.m., the Administrator stated that he was informed by Resident #3's family member on 12/02/2025 via email of an allegation of neglect of Resident #3. The email stated that Resident #3 was found by a family member soaked in urine, feces and was dirty and that the family member requested Resident #3 be changed, but the nurse was unable to locate the aide that was assigned to the resident and that this was negligent. The Administrator stated that after he read the email his priority was to go check on Resident #3, had the clinical staff perform a skin assessment to ensure no skin breakdown. Then he reported the allegation to the State and started his investigation. Also, he contacted Resident #3's Resident Representative to inform him that his concerns were being investigated. The Administrator stated that he found Residents Affected - Few Page 1 of 3 676326 676326 12/10/2025 Edgewood Rehabilitation and Care Center 1101 Windbell Dr Mesquite, TX 75149

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that the staff that cared for Resident #3 on 11/30/2025 were agency staff. The Administrator stated he contacted the agency but never received a response. The Administrator stated he tried to contact CNA B who was responsible for Resident #3's care but was unsuccessful. He did instruct the DON to ensure CNA B did not return the facility. The Administrator stated he did not contact the nurse that was on shift or the aide that changed Resident #3. The Administrator acknowledged that to find out how Resident #3 presented the aide who changed her should have been contacted. The Administrator stated that he and the DON conducted the investigation, because he allowed the DON to deal with the clinical staff. Record review of an email from Resident #3 family member to the Administrator dated 12/02/2025 sent at 8:32am revealed on 11/30/2025 at 11:45 a.m. Resident #3's family member walked into Resident #3's room and Resident #3 was soaked with feces and urine, and sheets were dirty. Resident #3's family member informed RN A that Resident #3 needed to be changed and asked RN A who was the aide assigned to Resident #3 and RN A found the aide asleep in her car. The aide that day was agency, this was unacceptable and negligent. During an interview on 12/10/2025 at 3:03 p.m., the DON revealed that she learned about the allegation of neglect from the Administrator who received an email from Resident #3's Resident Representative on 12/02/2025 after morning meeting. The DON stated her role in the investigation was to assign staff to complete Resident #3's skin assessment, get the agency contact information to the Administrator, and to contact the RN A and the CNA B that worked that day to gather facts, but was unsuccessful in contacting RN A and CNA B. The DON stated that she also instructed the facility staffing coordinator to place the aide on do not return. The DON stated that she did not contact the aide who changed the resident. During an interview on 12/10/2025 at 3:40p.m., RN A revealed that she was the agency nurse assigned to hall 100 on 11/30/2025. RN A stated that right before lunchtime a family member came to her and stated that their mother needed to be changed and asked who the aide for the room was. RN A stated that she did not see the aide assigned to that room on the hall but was able to get another aide to change Resident #3. RN A stated she went outside as she was informed there was someone sleeping in a car, but RN A stated she did not find anyone asleep in a car outside. RN A stated she did not know who the aide was who changed Resident #3 as she had not worked with her before and could not recall her name. RN A stated that the family member did not approach her in a way that she thought the family member implied Resident #3 was neglected, but in a manner, she thought Resident #3 was dirty and requested Resident #3 be changed. RN A stated she never went into the room so she could not provide a description of how Resident #3 looked. RN A stated that she called the staffing coordinator to locate the assigned aide and was informed she was on break. During an interview on 12/10/2025 at 3:52 p.m., the Staffing Coordinator revealed that on 11/30/2025 RN A contacted her to locate CNA B because she did not see her on the hall and was not informed, she left her assignment. The staffing coordinator stated she was able to reach CNA B and was informed she was on her lunch break. The staffing coordinator stated that on 12/02/2025 the DON informed her to place CNA B on do not return. The staffing coordinator stated that on 12/02/2025 she placed CNA B on do not return. The staffing coordinator stated that once the flag is placed the individual will no longer see available shift assignments for the facility. This was verified by observation of shiftkey (platform that connected facilities with independent licensed professionals) that showed the facility had CNA B flagged as do not return. During an interview on 12/10/2025 at 4:10 p.m., CNA B stated that she had picked up a shift on 11/30/2025 and was the assigned aide for Resident #3. CNA B stated that upon arrival she conducted rounds and was waiting for another aide as they had a call in, so she checked and changed approximately 13 residents. CNA B stated that she checked Resident #3 when she started her rounds and she was dry at about 7 a.m. Then checked again around 9:25 676326 Page 2 of 3 676326 12/10/2025 Edgewood Rehabilitation and Care Center 1101 Windbell Dr Mesquite, TX 75149

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a.m. and changed her. CNA B stated that Resident #3 received tube feedings and that can cause residents to urinate a lot and have loose stools. CNA B stated that after the other aide arrived, she took her break at 11:30 a.m. CNA B stated she did not know the other aides' name because they were all agency staff. CNA B stated that as she returned from her break there was an aide in Resident #3's room with family members; she entered the room and asked the aide if she needed any assistance, the aide responded no. CNA B said stepped out and started preparing for lunch. CNA B stated she had not been contacted by the facility, and this was the first time hearing there was an issue. Attempted to contact the other assigned aide, left a voicemail, but no returned call was received prior to exit. Record review of facility accident/incident reporting - patient/resident undated, reflected the following: Procedures:2. Witnesses of facility accident or incident provide immediate assistance and report objectiveinformation to the supervisor. Record review of facility abuse, neglect, exploitation or mistreatment policy undated, reflected the following:Component VI: Investigation:1. The facility maintains that all allegations of abuse, neglect, and misappropriation of property are thoroughly investigated, and appropriate actions are taken. 4. Investigations prompt, comprehensive and responsive to the situation and contain founded conclusions. 5. The investigation may include but not limited to the following:5e. written summaries of interviews with individuals having first-hand knowledge of the incident. Employees/witnesses will be interviewed by designated facility staff and the interviewer will record all witness accounts in a document, written, dated and signed by the interviewer. 7.Guidelines for investigation:7g. Interview individuals having firsthand knowledge of the incident and write summaries of the interviews. 676326 Page 3 of 3