Advanced Rehabilitation And Healthcare Of Athens

F 0550 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

caused her anxiety to think she would have to go to her doctor's appointment and embarrass herself due to not having any briefs that fit her. She said they had no wipes and no washcloths, so they didn't have anything to wipe her with either. Resident #5 said she felt, due to the shortage of wipes, the laundry could not keep up with the demand. She said an aide had taken two smaller briefs and put them together, but

they did not fit. Resident #5 said, on Sunday night, they were able to find a washcloth and she was cleaned up for her appointment on 8/11/25. She said the whole episode caused her a lot of anxiety and discomfort.

She said she was afraid to go to activities because she was afraid that she would embarrass herself.

Resident #5 said she was more concerned about going to her physician's appointment. She said that it was

a very upsetting weekend. She said on Saturday and Sunday they used the smaller briefs as best they could. She said one aide brought some wipes from home and left them in her room so she could have some. She said the briefs they had available would cut off her circulation if they were able to close them at all.Record review of Resident #6's BIMs score dated 7/23/25 indicated she was cognitively stable with a BIMS of 14. During an interview on 8/13/25 at 1:10 p.m., Resident #6 said she witnessed the lack of briefs over the weekend and witnessed her roommate's anxiety and frustration at the situation. During an

interview on 8/13/25 at 5:54 p.m., CNA F said she worked this weekend, and they did not have any large briefs. She said she had one resident on the hall that required bariatric briefs, and that was Resident #5.

She said she worked on 8/9/25 and 8/10/25, and they could only find one bariatric brief on her hall. She stated she used two medium briefs, layered them, and had to pull the resident's pants up to hold them in place. She said Resident #5 wanted to get up every day about 11:00 a.m., and she explained that there were no briefs. CNA F said Resident #5 said she could not lay in bed all day. CNA F said Resident #5 said

it was uncomfortable, but better than lying in bed all day Record review of Resident #4's quarterly MDS dated [DATE REDACTED] indicated he was cognitively stable with a BIMS of 15. During an interview on 8/13/25 at 3:35 p.m. Resident #4 said she had on a brief at the current time, but it was not the right size, and it was cutting into her skin. She said over the weekend they had found a couple of briefs that kind of fit her, but she did not have any problems getting up. Resident #4 said hopefully they would have some more briefs today because the ones they had were too tight for her. She said she was fine just a little uncomfortable. She said

she did not know what size it was, but it was a size to small.During an interview and observation on 8/13/25 at 1:20 p.m. of CNA B and two other staff were placing briefs in a room as an overflow. They said that they had got 3 1/2 pallets of supplies and they had plenty of large, extra-large, and bariatric briefs that had arrived today. During an interview on 8/13/25 at 3:40 p.m., LVN G said she worked at over the weekend on 8/9/25 and 8/10/25 and they did not have large briefs. She said some of those residents could not get up because they did not have briefs to fit them. Review of a purchase order dated 8/7/25 indicated the facility had order 22 boxes of briefs in different sizes and 21 boxes of wipes. The order indicated it was approved for purchase on 8/8/25.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Advanced Rehabilitation and Healthcare of Athens

121 Commons Drive Athens, TX 75751

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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

increased redness or drainage from a wound, notify the MD and request updated wound care orders. There were also true and false questions. During an interview on 8/15/25 at 11:45 a.m., the RNC said the facility's census was 103 today and they did 101 skin assessments. She said one resident was up and 1 resident refused, and they are going to try and get them later. She said they did the in services and had a return demonstration test for the nurses. They were not able to have all nurses do the testing because they had called some on the phone. She said they would do their testing later. The RNC said they had done chart audits and had the monitoring tool in place. She stated they were currently doing everything on paper due to the current computer system being down and they were transitioning to another system. During an

interview on 8/15/25 at 12:10 p.m., the DON said she in-serviced nurses on change in condition, when to notify the doctor, and the steps to take upon admission. The staff were given a test to determine if they knew what to do for a new admission and when to follow up. She said one resident had surgery and did not have any orders when he was admitted on how to treat the wound, the physician was contacted, and new orders were obtained. The DON said another resident had a tiny area on her bottom and they got an order for the treatment of the wound. She had in-serviced 20 nurses. She had 12 full time nurses and 8 PRN nurses. The DON said, on today, they had the ADON, who was acting as treatment nurse, and 3 charge nurses, in the building. She said Resident #2 had gone back to the hospital. They were doing paper charting on today. During an interview on 8/15/25 at 3:00 p.m., the Administrator said he would admit some mistakes were made with Resident #1. He said he did not agree with the IJ level of severity. He said however the interventions they had put into place with staff training, ensuring the physician was notified, and making sure documentation was in place, had fixed many issues. He said the morning oversight meetings should bring issues to the attention of administration, and they would be able to put systems in place to prevent future problems. He said they would form a habit of doing things the right way. Interviews conducted with nurses the following shift nurses on 8/15/25 between 12:15 p.m. and 2:15 p.m. determined staff were knowledge about the in-services and education provided. At 12:15 p.m. LVN I worked 6p to 6aAt 12:20 p.m. LVN J /ADON worked all shiftsAt 1:15 p.m. LVN L worked 6p to 6aAt 1:30 p.m. LVN M worked 6a to 6pAt 1:34 LVN G worked 6a to 6pAt 1:45 p.m. LVN N worked 6a to 6pAt 1:50 p.m. LVN C/treatment nurse worked all shiftsAt 1:57 LVN K- PRN worked all shiftsAt 2:10 p.m. LVN O worked PRN weekends At 2:15 p.m. LVN A worked 6a to 2p The Administrator, DON, and RNS were informed the IJ was removed on 8/15/25 at 3:35 p.m. The facility remained out of compliance at a severity level of potential harm with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Advanced Rehabilitation and Healthcare of Athens

121 Commons Drive Athens, TX 75751

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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

do the testing because they had called some on the phone. She said they would do their testing later. The RNC said they had done chart audits and had the monitoring tool in place. She stated they were currently doing everything on paper due to the current computer system being down and they were transitioning to another system. During an interview on 8/15/25 at 12:10 p.m., the DON said she in-serviced nurses on change in condition, when to notify the doctor, and the steps to take upon admission. The staff were given a test to determine if they knew what to do for a new admission and when to follow up. She said one resident had surgery and did not have any orders when he was admitted on how to treat the wound, the physician was contacted, and new orders were obtained. The DON said another resident had a tiny area on her bottom and they got an order for the treatment of the wound. She had in-serviced 20 nurses. She had 12 full time nurses and 8 PRN nurses. The DON said, on today, they had the ADON, who was acting as treatment nurse, and 3 charge nurses, in the building. She said Resident #2 had gone back to the hospital.

They were doing paper charting on today. During an interview on 8/15/25 at 3:00 p.m., the Administrator said he would admit some mistakes were made with Resident #1. He said he did not agree with the IJ level of severity. He said however the interventions they had put into place with staff training, ensuring the physician was notified, and making sure documentation was in place, had fixed many issues. He said the morning oversight meetings should bring issues to the attention of administration, and they would be able to put systems in place to prevent future problems. He said they would form a habit of doing things the right way. Interviews conducted with nurses the following shift nurses on 8/15/25 between 12:15 p.m. and 2:15 p.m. determined staff were knowledge about the in-services and education provided. At 12:15 p.m. LVN I worked 6p to 6aAt 12:20 p.m. LVN J /ADON worked all shiftsAt 1:15 p.m. LVN L worked 6p to 6aAt 1:30 p.m. LVN M worked 6a to 6pAt 1:34 LVN G worked 6a to 6pAt 1:45 p.m. LVN N worked 6a to 6pAt 1:50 p.m.

LVN C/treatment nurse worked all shiftsAt 1:57 LVN K- PRN worked all shiftsAt 2:10 p.m. LVN O worked PRN weekends At 2:15 p.m. LVN A worked 6a to 2p The Administrator, DON, and RNS were informed the IJ was removed on 8/15/25 at 3:35 p.m. The facility remained out of compliance at a severity level of potential harm with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Event ID:

Facility ID:

If continuation sheet