The Crescent

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

her leg causing her a burn and pain. Resident was noted to have significant area of discolored skin to her right shin, that resulted from the burn. Resident #1 stated she was in pain and asked to go to the hospital emergency room, but the nurse did not respond to her request. Resident #1 stated the doctor did not see her until almost a week later. An observation / review of photos dated 04/03/2025 and 04/07/2025 conducted on 10/21/2025 at 4:23 PM, revealed Resident #1's burn on her right leg showed full thickness burn through two layers of skin to indicate a second-degree burn.An interview was attempted with CNA A

on 10/21/2025 at 5:14 PM, received voicemail and a message left to return call.An interview was attempted with LVN B on 10/21/2025 at 5:15 PM, received voicemail and a message was left to return call.In an

interview conducted with CNA A on 10/22/2025 at 11: 24 AM, CNA A stated the burn incident in April 2025 with Resident #1 was a simple accident. CNA A explained that Resident #1 had asked for either tea, coffee, or soup; however, the CNA could not recall which one. She stated Resident #1 normally ate soup a lot. CNA

A stated she obtained hot water from the dispenser in the coffee room next to the nurses' station and advised Resident #1 to let the water cool. CNA A reported she left the room to provide care for another resident and when she returned, Resident #1 had knocked over the cup and the liquid had spilled through

the covers. CNA A stated she removed the covers and noted Resdent#1's leg was wet, and Resident #1 was hurting. CNA A stated she notified the LVN B charge nurse, who came to assess Resident #1. CNA A stated Resident #1 did not have any visible marks that day, however the following day, some marks were noted. An interview was attempted two more times with LVN B on 10/22/2025 at 12:29 and 12:40 PM, a voicemail was left to return call.In an interview conducted on 10/23/2025 at 4:11 PM, the ED/ADM stated

he was responsible for reporting incidents to HHSC. He stated in the absence of the ED/ADM the DON or other Regional Staff would take on the responsibility. ED/ADM stated he does not know why the incident was not reported by the facility, he noted at the time of the incident there was a different ADM. ED/ADM stated not reporting incidents was potential for additional harm to residents.In an interview conducted on 10/23/2025 at 4:33 PM, the DON stated the ED reports incidents to HHSC. The DON stated if the ED is out,

she will report to HHSC. The DON stated the incident happened prior to her being hired at the facility. The DON stated the potential harm for not reporting incidents to HHSC could leave residents at risk for more harm.Review of facility's Abuse Prevention-Reporting Protocol dated June 2013 reflected:1. The Abuse Prevention Coordinator will:a. Immediately (within 24 hours) report to The Department of Aging and Disability Services (DADS) and other appropriate authorities incidents of Patient Abuse as required under applicable regulations and regulatory guidance. Report events that cause reasonable suspicion of serious bodily injury immediately (within 2 hours) after forming the suspicion to The Department of Aging and Disability Services (DADS) and other appropriate authorities as required under applicable regulations and regulatory guidance. b. Immediately (within 24 hours) suspend the employee for an abuse allegation until

an investigation is completed. Review of facility's Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated April 2021 reflected: 1. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.2. Investigate and report any allegations within timeframes required by federal requirements.Record review of the Long-Term Care Regulation Provider Letter Title Abuse, Neglect Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility Must Report to the Health and Human Services Commission reflected:Type of Incident to Report Neglect (Incident with or without serious bodily injury) When to report:Immediately, but not later than two hours after the incident occurs or is suspected.

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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

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Crescent

11353 Sugar Park Lane Sugar Land, TX 77478

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

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

passing score.In an interview on 10/23/2025 at 4:15 PM, the DON stated she was in serviced by the RVP

on Policy for Hot liquids and safely handling hot liquids with the resident. DON stated she and ED/ADM completed in-services with the nurse managers, nursing staff, 2 ADON, Unit Manager, Department Heads to include Dietary, Social Worker, MDS Coordinator, Business Office, Human Resources, Housekeeping, Medical Records, Activity Director, and Admissions Coordinator. DON stated 2 Monitor Hot Liquids Risk Binders were placed at each nurse's station. DON stated assessments will be completed at admission and quarterly. DON stated the DON, ADON, Nurse Unit Manger and weekend supervisor will monitor.Interviews conducted on 10/23/2025 with nurses from 6/2, 2/10, and 10/6 shifts between 4:35 PM -5:40 PM [LVN C, LVN D, LVN E, LVN G, LVN H, and RN I] indicated they participated in the mandatory in service training about Policy for Hot liquids and safely handling hot liquids with the resident. Each stated they completed quizzes following the in-services. They stated they received training on the Hot Liquid Safety Binder of at risk and not at risk binder located at the two nurse's stations. Interviews conducted on 10/23/2025 with 9 CNAs who worked the 6/2, 2/10, and 10/6 shift between 4:00PM-5:48 PM [CNA J, CNA K, CNA L, CNA M, CNA N, CNA O, CNA P, CNA Q, CNA R] indicated they participated in an in-service training on Policy for Hot liquids and safely handling hot liquids with the resident. The CNAs summarized the topic of discussion stating understanding handling of hot liquids and safety. Each CNA stated they completed the post test with passing scores.Interviews attempted via outbound calls to additional 5 CNAs and 1 RN the calls were unanswered and forwarded to an automated service that prompted to leave a voicemail. A return call was not received prior to the exit on 10/23/2025.Record Review of QAPI meeting attendance sheet (ED/ADM, RVP, DON, Unit Manager, ADON, and Regional Director of Clinical Services).Record Review on 10/23/2025 of the In-Service Training Sheets dated 10/23/2025 reflected all facility staff had been in-serviced on all training topics listed on the plan of removal. About 3 percent of signatures were still needed as those employees had not worked a shift, those employees will reconfirm understanding of the training and sign off prior to working their shift. Record Review on 10/23/2025 of Hot Liquid Evaluation dated 10/23/2025 reflected all 73 residents of the facility had been completed.Record Review of care plans

on 10/23/2025 reflected the 38 residents considered at risk from hot liquid evaluation was updated in the comprehensive care plan.The ED/ADM and DON were informed the Immediate Jeopardy was removed on 10/23/25 at 7:20 PM. The facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy and scope of isolated.

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