Peach Tree Place

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

was sitting at the desk in his wheelchair. She stated she based her assessment on the information received from the nurses and she did not receive information that he had a pressure area on that date or since that time. She stated it was her expectation that the nurses monitor the resident's skin and notify her of any condition changes or changes in their plan of care. She stated she would have ordered a pressure relieving mattress on his bed and to reposition the resident every 2 hours to avoid pressure on pressure points.

During an interview with the DON on 9/17/25, she stated she did attempt to notify Resident # 8's responsible party regarding the incident on 9/8/25, but she did not speak with him because he did not answer the phone. She stated she did not leave a message. She stated she should have documented this

in her progress note dated 9/8/25. She stated she did not know why she failed to do so. During an interview

on 9/18/25 at 11:30 PM with RN NB, she stated she did not notify the primary physician or the residents POA of the Stage 3 Pressure Area. She stated she was very busy and did contact wound care but failed to notify the Resident #8's family member/POA. She stated failure to notify the physician, and the family could prevent the resident from receiving timely and needed treatment. During an interview on 9/14/25 at 4:50 PM, the Primary physician of Resident #8, he stated he was not informed of the Stage 3 Pressure area on Resident #8 on 9/8/25. He stated he usually left wound care to the wound care physician since he was the expert in that area. During an interview on 9-18-2025 at 7:40 am with the wound care physician, he stated

the Resident # 8's Stage 3 pressure area on his right buttocks had decreased 44% since his last visit on 9/10/25. He stated 9/10/25 was the first time he saw Resident #8. He stated he was not notified prior to that date. Record review of the facility policy titled Resident Rights dated revised 11/28/16, stated in part: The resident has a right to a dignified existence self-determination and communication with an access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity, and care for each resident in a manner and in an environment which promotes maintenance or enhancement of his or her quality of life. Recognizing each resident's individuality, the facility must protect and promote the rights of the resident. Notification of Changes - The facility must immediately inform the resident, consult with the resident's physician, and notify consistent with his or her authority resident representatives when there is an accident involving the resident which results

in an injury and has the potential for requiring physician intervention. Of the significant change in the residence physical, mental, or psychosocial status that is a deterioration in health, mental, or psychosocial status, and either life threatening conditions or clinical complications.A need to alter treatment significantly, that is a need to discontinue or change an existing form of treatment due to adverse consequences or to commence a new form of treatment, or a decision to transfer discharge resident from the facility.

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

09/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Peach Tree Place

315 W Anderson St Weatherford, TX 76086

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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

the or care plan for resident specific interventions. During an interview with CNA I (6 PM to 6 AM shift) on 8/26/25 at 10:30 AM, she stated the types of abuse were verbal abuse, physical abuse, restraining any patient that's considered abuse, as well, locking them in their rooms, sexual and stealing from residents.

She stated you report abuse immediately. She stated she had never witnessed abuse in the facility. She stated if a resident became aggressive with staff or other residents she would make sure whoever's causing

the abuse and also the other residents were safe first and then report it. She stated she would report any kind of issues, even though it doesn't look that serious, to the Administrator or abuse coordinator for the facility . She stated they learned about rights. They have the right to not shower, if they don't want to leave

the room to go in the hallways they don't have to. She stated they have to respect their rights, and they have the right to be free from abuse, restraints, or isolation. Isolation is when they are in their room because

they can't get out, against their will or without their permission. It would be locking or holding them in their wheelchairs and not giving them their right to leave or move if they want to. She stated for behavior management you could play a game to divert their attention, look in their care plan for interventions, or just give them some attention, or just walk away if they were safe and didn't want to do something or don't want your attention. She stated you can always try later after they are calm. During an interview on 8/26/25 at 10:40 AM with the AD, she stated some types of behavior management required you to step back and give them some s[TRUNCATED]

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

09/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Peach Tree Place

315 W Anderson St Weatherford, TX 76086

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 0603 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

would give them space provide one-on-one food and snacks go a long way you could take them to the bathroom start an activity just go down the list basically until something works you could look in their care plan and see if there's any interventions in there.- check to see if they are wet or hungry or thirsty. She stated the facility is a restraint free facility. She stated she was inserviced8/26/25 and earlier in the week by

the RN corporate Nurse and she has a handout to keep in her pocket at all times for reference. During an

interview with CNA K on 8/26/25 at 11:10 AM. She stated she was Inserviced on 8/19/.25 and 8/26/25 on abuse and Neglect, resident rights, Trauma Informed Care ( an approach to care that recognized the widespread prevalence of trauma and its impact on individuals and promotes creation of a safe and supportive environment on residents that promotes healing and recovery from traumatic experiences, and Abuse and Neglect. She stated she learned about isolation. She stated the corporate Nurse Inserviced all

the staff again this morning and gave them a handout over the material to fold and keep in their pockets.

She stated all allegations of possible abuse must be reported immediately to the administrator, whether it's

an interim or permanent administrator . She stated abuse is to be reported immediately at the time it happens. She stated residents have the right to be abuse free. She stated that meant no restraints or involuntary seclusion and unnecessary confinement Trauma informed care assessment should be done on residents after incidents unauthorized restraint seclusion unreasonable confinement can cause unnecessary trauma. She stated they learned to be sure that residents having aggressive b[TRUNCATED]

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

09/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Peach Tree Place

315 W Anderson St Weatherford, TX 76086

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 0604 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

must be reported immediately to the Administrator, whether it's an interim or permanent Administrator. She stated abuse is to be reported immediately at the time it happens. She stated residents have the right to be abuse free. She stated that meant no restraints or involuntary seclusion and unnecessary confinement. She stated Trauma informed care assessments should be done on residents after incidents of unauthorized restraint or seclusion. She said unreasonable confinement can cause unnecessary trauma. She stated they learned to be sure that residents having aggressive behaviors are in an area where they will not harm themselves and redirect other residents from the area where the resident is being physically aggressive.

She stated, I know that you cannot restrain a resident, you cannot put them in a wheelchair and put the locks on if they can't get the lock off. She stated the Abuse Coordinator is the Administrator. During an

interview with the DM on 8/26/25 at 11:15 AM, she stated she had an inservice on 8/19/25 by the administrator, and again today on 8/26/25. She stated No restraints, involuntary seclusion, or unreasonable confinement are allowed. All allegations of possible abuse must be reported immediately to my administrator right whether it's an interim or permanent administrator. The restraint policy is no restraints.

We learned about resident rights that they have the right to be abuse free. Restraints, involuntary seclusion, and unnecessary confinement are all different types of abuse . Trauma assessment should be done after any incident of abuse or aggression, an incident of abuse can cause mental trauma. We were given a little cheat sheet to keep in our pocket. During an interview with the ADON on 8/26/25 at 11:40 AM, she stated

she was inse[TRUNCATED]

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

09/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Peach Tree Place

315 W Anderson St Weatherford, TX 76086

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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. During

an interview with the MDS Nurse on 8/26/25 at 11:40 AM, she stated she was Inserviced on 8/19/25. She stated she had a sheet to keep with her at all times. She stated the Inservice covered the following areas: Restraint Policy - restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights - that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care - the use of unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma or re-traumatization to a resident. Behavior management - how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. During an interview with the ADON on 8/26/25 at 11:40 AM, she stated she was inserviced one on one with the Corporate Nurse on 8/19/25. The topics included: Restraint Policy - restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. She showed a copy of the handout to the surveyor that she was given to keep in her pocket and it . Resident Rights -[TRUNCATED]

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

09/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Peach Tree Place

315 W Anderson St Weatherford, TX 76086

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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

you report abuse immediately. She stated she had never witnessed abuse in the facility. She stated if a resident became aggressive with staff or other residents she would make sure whoever's causing the abuse and also the other residents were safe first and then report it. She stated she would report any kind of issues, even though it doesn't look that serious, to the Administrator or abuse coordinator for the facility .

She stated they learned about rights. They have the right to not shower, if they don't want to leave the room to go in the hallways they don't have to. She stated they have to respect their rights, and they have the right to be free from abuse, restraints, or isolation. Isolation is when they are in their room because they can't get out, against their will or without their permission. It would be locking or holding them in their wheelchairs and not giving them their right to leave or move if they want to. She stated for behavior management you could play a game to divert their attention, look in their care plan for interventions, or just give them some attention, or just walk away if they were safe and didn't want to do something or don't want your attention.

She stated you can always try later after they are calm. During an interview on 8/26/25 at 10:40 AM with

the AD, she stated some types of behavior management required you to step back and give them some space. She said when you see a resident's eyes change you know they need personal space so this would be one technique you could use for behavior management. she said she would give them space, provide one-on-one, and food and snacks go a[TRUNCATED]

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

09/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Peach Tree Place

315 W Anderson St Weatherford, TX 76086

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 0940

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Level of Harm - Minimal harm or potential for actual harm

Based on record reviews and interviews the facility failed to develop implement and maintain an effective training program for all new and existing staff individuals providing services under a contractual management and volunteers consistent with their expected roles for 2 of 12 employees (LVN A and RN B) reviewed for required training. The facility failed to ensure LVN A and RN B had annual dementia and restraint reduction training. This failure could place residents at risk of receiving care from individuals who have not been properly trained. Findings include: Record review of employee training files reflected LVN A was hired 3/1/24 and her last dementia training was dated 3/15/24 . There was no evidence of restraint reduction training in her file other than a copy of a restraint reduction policy that was signed on 10/13/24.

Record review of RN B's Employee files reflected the date of hire as 1/16/25. Ungraded dementia test dated 1/16/25. No restraints training. During an interview on 8/23/25 at 1:30 PM, LVN A stated Everyone that works in that building has had training for dementia and behaviors. We have in-services. We were supposed to do an in-person course not too long ago on behaviors and dementia, but it got cancelled. We have all our courses online now, and that is where the dementia and behavior is located. At the beginning of the month, Admin staff will go over stuff before we get our check. The old ADM did it before. The HR lady that quit has also done it before. It's just verbal and then you sign it at the end. They read it and there has been other ones we read, and sign stated she doesn't remember dates. LVN A did not answer when her last training was on behaviors and dementia. During an interview on 8/23/25 at 0:00, RN B she stated: I don't recall any training on dealing with behaviors. They say no restraints or nothing like that, and I absolutely support that.

The interim administrator stated in an interview on 8/23/25 at 2:00 PM, the staff was responsible to complete their own training online. She stated each employee knows how to sign in and the trainings are assigned by the program for them to do. She stated the company had recently changed training programs which made it more difficult to keep up with the employee's progress. The administrator stated the facility was currently without an HR person, she recently resigned. She stated she would look for a training policy,

a policy was not provided by the time of exit.

Residents Affected - Some

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

Event ID:

Facility ID:

If continuation sheet