Coryell Health Rehabliving At The Meadows

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

and line staff should improve. She provided photos of the heel injury. Treatment in place and hospice is aware.What Action Was Taken:Daily document of [Resident #1] dx and what is going on with her on 24-hour report. Set up a care plan meeting with and hospice to ensure we are all on the same page Administrator will attend care plan meeting. Resolved by the Administrator on [DATE REDACTED] Review of Resident #1's physician's order dated [DATE REDACTED] reflected: WOUND CARE NURSE TO CHANGE DRSG TO LEFT HEEL

ON MON & WED & FRIDAY/ BLISTER/DTI -ON MEDIAL LEFT HEEL/ CLEAN WITH VASHE/ APPLY BETADINE TO HEEL-ALLOW TO DRY/ APPLY ADAPTIC TO AREA/THEN COVER WITH TETRA NET ELASTIC DRSG / PLEASE DATE & INITIAL DRSG. USE HEEL BOOT AT ALL TIMES TO OFFLOAD PRESSURE/ USE LIDOCAINE SPRAY PRIOR TO WOUND CARE TO HELP CONTROL PAIN. Review of Resident #1's progress notes dated [DATE REDACTED] reflected Resident #1 expired on [DATE REDACTED]. During an interview on [DATE REDACTED] at 3:00 pm Resident #1's family stated a fluid filled blister was identified on Resident #1's left heel sometimes in April of 2025. Resident #1's family stated Resident #1 was noted with tennis shoes on after it was communicated with the ADON that Resident #1 didn't need the tennis shoes due to the pressure area

on Resident #1's heel. Resident #1's family stated she spoke with LVN A who stated Resident #1 was not supposed to be wearing tennis shoes. Resident #1's family stated she spoke with the CNA on duty that day and the CNA stated she did not know Resident #1 was not supposed to wear the tennis shoes. Resident #1's family stated she took the tennis shoes home. During an interview on [DATE REDACTED] at 12:09 pm, the Wound Care Nurse stated Resident #1 had a pressure area to her left heel which started as a fluid filled blister and DTI. The Wound Care Nurse stated she heard in conversation that Resident #1's tennis shoes were put on her. The Wound Care Nurse stated there should have been an order for Resident #1 to wear only socks or opened back house shoes. The Wound Care Nurse stated she or the ADON were responsible to put in the order. The Wound Care Nurse stated putting tennis shoes on Resident #1's foot with a pressure area would cause discomfort. The Wound Care Nurse stated the facility had boots ordered, they were offloading Resident #1's heels and providing positioning pillows and wedges and repositioning her every 2 hours and as needed. During an interview on [DATE REDACTED] at 1:12 pm, the ADON stated, when the blister had started on Resident #1's left heel, she and Resident #1's family had discussed that maybe the shoes were tight. The ADON stated she asked Resident #1's family if it was ok to a house shoe on the Resident #1 and the family agreed. The ADON stated she communicated with staff. The ADON stated 3-4 days after the discussion, an agency staff working with Resident #1 put the shoes on Resident #1 and the family was visiting and saw

the shoes on the Resident #1. The ADON stated that was the only time the shoes were put on Resident #1,

after that incident the shoes were not in the Resident #1's room. During an interview on [DATE REDACTED] at 12:57 pm

the DON stated it was discussed in a care plan meeting concerning Resident #1 not wearing her tennis shoes. The DON stated, I believe they had asked the family to take the shoes home, but the family didn't. I believe there was a missed communication with the CNAs, the charge nurse was supposed to notify the CNA. I will have to check with the ADON to find out if there was an in-service with the staff not to put the tennis shoes on Resident #1. I don't remember what the wound looked like back in June ([DATE REDACTED]) but once

it was agreed upon not to put the shoes on Resident #1, the staff shouldn't have put the shoe on the resident. Review of facility's in-services for the months of May, June, and [DATE REDACTED] reflected no in-service regarding Resident #1 not to wear tennis shoe due to pressure areaRequested Skin and wound Care policy from the Administrator on [DATE REDACTED] at 09:30 am and it was not provided.

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Facility ID:

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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

09/09/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Coryell Health Rehabliving at the Meadows

110 Chicktown Rd Gatesville, TX 76528

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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

medication aide stated she did not give Resident #1 pain medication at 6:00 pm. LVN A stated she gave Resident #1 her pain medication within the time frame, which was an hour before or an hour after. LVN A stated she would have given Resident #1 PRN pain medication as ordered but she was out of the time frame for medication administration. LVN A stated it depends on the day, some days Resident #1's was in so much pain and on other days she was not in pain. LVN A could say how much pain Resident #1 was in

on [DATE REDACTED]. During an interview on [DATE REDACTED] at 1:55 pm the DON stated if a resident was complaining of pain,

it was the expectation of the nurse to assess the resident's pain level. The DON stated not assessing the resident's pain level, they wouldn't be able to know what medication to give the resident or how to treat them. The DON reviewed Resident #1's MAR and TAR for [DATE REDACTED] and stated Resident #1 was supposed to be assessed for pain every time the nurses administered pain medication. The DON stated Resident #1's schedule Hydromorphone was schedule for 08:00 am, 12:00 noon, 4:00 pm and 8:00 pm so Resident #1 was not scheduled for pain medication at 6:00 pm. Review of facility's policy titled Pain - Clinical Protocol undated reflected: Assessment and Recognition1. The physician and staff will identify individuals who have pain or who are at risk for having pain.a. This includes reviewing known diagnoses and conditions that commonly cause pain; for example, degenerative joint disease, rheumatoid arthritis, osteoporosis (with or without vertebral compression fractures), diabetic neuropathy, oral or dental pathology, and post-stroke syndromes.b. It also includes a review for any treatments that the resident currently is receiving for pain, including complementary and non-pharmacologic treatments.2. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain.3. The staff and physician will identify the characteristics of pain such as location, intensity, frequency,pattern, and severity.a. Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level.4. The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated; for example, wound care, ambulation, or repositioning.5.

The staff and physician will evaluate how pain is affecting mood, activities of daily living, sleep, and the resident's quality of life, as well as how pain may be contributing to complications such as gait disturbances, social isolation, and falls.Monitoring1. The staff will reassess the individual's pain and related consequences at regular intervals, at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain.a. Review should include frequency, duration and intensity of pain, ability to perform activities of daily living (ADLs), sleep pattern, mood, behavior, and participation in activities.

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

09/09/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Coryell Health Rehabliving at the Meadows

110 Chicktown Rd Gatesville, TX 76528

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

the ABT was ordered, and Resident #1 was starting the ABT on [DATE REDACTED]. Resident #1 family stated she called on [DATE REDACTED] and spoke with LVN A and asked about Resident #1's ABT administration. Resident #1's family stated she was told by LVN A that Resident #1 did not get her morning and evening dose of ABT due to the medication not being put in the system. Resident #1's family stated LVN A stated she would put the orders in the computer system. Resident #1's family stated she did not complain to hospice, the DON, ADON or the Administrator because she couldn't process what to say. During an interview on [DATE REDACTED] at 09:04 am, LVN A stated she couldn't remember the exact incident regarding Resident #1's ABT orders because it has been a while. LVN A stated they may have started Resident #1's ABT the next day or so.

LVN A stated it might have been pharmacy issues. LVN A stated they could take the ABT from the e-kit, but there were lot of residents in the facility who also got medication from the e-kit and staff had to wait for the medication to be refilled in the e-kit. During an interview on [DATE REDACTED] at 10:52 am the DON stated if there is

an order for ABT, the nurses were expected to get it from the Cubex (e-kit). The DON stated hospice usually provided the medication once it was ordered. The DON stated, if hospice was unable to provide a medication, the facility provided it. The DON stated she did not recall an instance where Resident #1 was ordered an ABT, and she did not get the medication as ordered or the medication was not provided by hospice. Later the DON stated, she did not know why Resident #1's ABT was not given on [DATE REDACTED]. The DON stated she would check and see why. The DON stated the expectation was for the nurses to give the initial dose of the ABT from the e-kit /cubex and continue as ordered. The DON stated she couldn't remember from 3 months ago, but the process was to call the pharmacy to find out why the medication was not delivered; if they can't get the medication, they order it from the local pharmacy. The DON stated is Resident #'s ABT was not given as ordered, it should have been documented in Resident #1's progress why the medication was not given, and hospice and the MD should should have been notified. The DON again stated she couldn't find where the ABT was ordered, but the initial dose was given on [DATE REDACTED]. The DON stated maybe there was an error with when the medication being put in the computer system. The DON stated she couldn't tell who put the medication in the computer system, but the next dose was given

on [DATE REDACTED]. The DON stated not administering an ABT as ordered could have impact on the effectiveness of

the medication. Review of the facility's medication errors for the months of May, June and [DATE REDACTED] reflected no medication error for Resident #1. Review of the facility's policy titled Medication and Treatment Orders revised [DATE REDACTED] reflected: Policy Statement Orders for medications and treatments will be consistent with principles of safe and effective order writing.Policy Interpretation and Implementation7. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order.

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