University Rehabilitation Center

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

of coordination and Spina Bifida spinal cord disorder.Record review of Resident #10's Comprehensive Care Plan, dated 8/25/25, did not reflect a care plan for smoking.Record review of Resident #10's Smoking assessment, dated 4/14/25, reflected the resident required supervision while smoking. In an interview and

observation on 09/11/25 at 9:15 AM, The Administrator observed Housekeeping W in the smoking area of

the facility with approximately 10 residents smoking. She was observed with her head down looking at her phone the entire time she was observed. The Administrator stated Housekeeping W was assigned to monitor residents in the smoking area to ensure they did not harm themselves when smoking. She stated staff was not to be on their phones when monitoring the resident to ensure they were safe.In an interview

on 09/11/25 at 2:22 PM Housekeeping W stated she was scheduled to monitor the residents when they were outside smoking. She stated staff were not allowed to be on their phones when watching the residents to ensure there were no accidents. She stated she would ensure that she was not on her phone anymore.

The facility's policy Uniform Smoke Free Policy (undated) reflected A resident who is assessed unsafe to smoke without supervision, will be notified of the facilities site-specific smoking times, at which time the resident will have supervision and assistance as needed

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

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

University Rehabilitation Center

2244 Brinker Rd Denton, TX 76208

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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

elopement drills. Staff were reminded to be alert to signs of exit seeking and to notify the charge nurse or DON to assess the resident as needed. Staff members were educated on their role when a code orange (elopement) was called in the facility. Census sheets were provided to cross reference and ensure each resident was present. The elopement drills included the designation of staff members to an assigned search area which included searching every room in the facility to ensure the resident was in the building and safe. If a resident was not located inside or outside the building, police, family, and the physician must be notified. No lack of knowledge or procedure was identified.

The facility initiated the following interventions prior to the state surveyor entry on 09/11/2025:

The facility door codes was changed and signs were placed at each exit door notifying all to not allow residents to exit the building.Record review of Resident #12's clinical file on 09/11/2025 at 11:15 AM reflected the following:-Resident #12's risk assessments on 06/23/2025 reflected the resident was not a high risk for elopement. The risk assessment completed on 07/13/2025 reflected the resident was at high risk for elopement. -Resident #12's Comprehensive Care Plan was updated with interventions on 06/23/2025 and 07/13/2025 after the resident exited the building.-Elopement risk assessments and care plans were updated on all residents in the building on 07/13/2025. -The medical doctor, psychiatrist, director of nurse, administrator, and Resident #12's family member was notified of the elopement on 06/23/2025 and 07/13/2025.-Documentation of education of staff on resident rights, abuse, neglect, and exploitation on 07/13/2025.-Documentation of education of staff on elopement prevention and response, exit seeking, and door protocols on 07/13/2025.-Documentation of elopement drills beginning 07/13/2025 and conducted weekly following the elopement. -Log of daily inspection of all exit doors beginning on 07/13/2025.- No additional elopements occurred and Resident #12 no longer resided at the facility.

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

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

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

University Rehabilitation Center

2244 Brinker Rd Denton, TX 76208

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 0695

Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of three residents (Resident #11) reviewed for respiratory care. The facility failed to ensure Resident 11's oxygen mask was properly stored in a bag when not in use on 09/11/25. This failure could place the residents at risk for respiratory infection and not having their respiratory needs met.Findings include: Record review of Resident #11's Face Sheet, dated 09/11/25, reflected he was a [AGE] year-old male admitted to the facility

on [DATE REDACTED]. Relevant diagnoses included Acute Respiratory Failure (lack of oxygen) and Chronic Obstructive Pulmonary Disease (lung disease). Record review of Resident #11's Quarterly MDS assessment, dated 9/02/25, reflected he had a BIMS score of 12 (moderate cognitive impairment). For ADL care, it reflected

the resident required total assistance and it reflected an active diagnosis of cardiorespiratory conditions.

Record review of Resident #11's Comprehensive Care Plan, dated 3/16/2025, reflected the resident had COPD and one of the interventions was to provide oxygen therapy to the resident as needed. Record

Review of Resident #11's Physician Orders, dated 9/11/25, reflected Ipratropium-Albuterol Inhalation Solution 0.5-2.5 MG/3ML inhale orallyevery 12 hours as needed for Bronchi muscle spasm resulting from COPD An observation on 09/11/25 at 12:43 PM, revealed Resident #11's oxygen mask unbagged, sitting

on the top of a three-drawer chest. In an interview and observation on 09/11/25 at 12:45 PM, RN M stated Resident #11 used his oxygen device on an as needed basis. She stated she did not know when the last time he had used the device. She stated when the breathing device was not in use, the breathing mask should be stored in a plastic bag to avoid an infection. She stated she would discard the mask and get the resident a new one. In an interview on 09/11/25 at 12:59 PM with ADON L, she stated Resident #11 did have a device for breathing treatments on an as needed basis. She was advised of Resident #11 not having his mask bagged and she stated that the mask should be removed or bagged when not in use to avoid an infection. In an interview on 09/11/25 at 4:12 PM, the DON stated he had been at the facility for seven months. He was advised of Resident #11 being observed with an oxygen mask, unbagged while not in use.

He stated he expected staff to remove the mask and then replace with a new one if needed or the mask should be bagged to avoid the resident getting an infection. Review of the facility's policy Oxygen Administration, undated, reflected Oxygen therapy includes the administration of oxygen (O2) in liters/minute by cannula or face mask to treat hypoxic conditions caused by pulmonary or cardiac diseases.

The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen. The resident will be free from infection.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet