Inspection·October 5, 2023

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few A record review of Resident #1's Care Plan, dated 07/04/23, reflected she required psychotropic medications due to diagnosis of bipolar, anti-anxiety medication due to diagnosis of anxiety disorder, and antidepressant medication due to diagnosis of depression. The interventions included to administer medications as ordered. The Care Plan reflected Resident #1 had impaired cognitive function or impaired thought process due to dementia and the goal was to maintain current level of cognitive function. The interventions included Administer meds as ordered. Communicate with the resident/family/caregivers) regarding resident's capabilities and needs. Keep the resident's, routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. The Care Plan reflected Resident #1 had potential for delirium or an acute episode of confusion due to dementia diagnosis and the goal included resident will free of s/sx of delirium (changes in behavior, mood, cognitive function, communication, level of consciousness, restlessness. The interventions included: Consult with family and interdisciplinary team, review chart to establish baseline level of functioning. Discuss with resident/family/caregivers concerns about delirium . Educate the resident/family/caregivers to observe for and report any s/sx of delirium . Monitor/record/report to MD new onset s/sx of delirium: changes in [behaviour ] altered mental status, wide variation in cognitive function through the day, communication decline, disorientation, lethargy, restlessness, and agitation. Altered sleep cycle, dehydration, infection, delusions, hallucinations . Review medical records for a DX or HX of the most common causes of Delirium: Congestive Heart Failure, Infections especially of the Urinary Tract, Upper Respiratory System, or Pneumonia, Diabetes, Dehydration or Electrolyte Imbalance, Chronic Obstructive Pulmonary Disease, Medication Toxicity or Interactions; or Benzodiazepine Withdrawal. The plan reflected Resident #1 had ADL Self Care Performance Deficit due to her diagnosis of bipolar disorder and the goal included she would be neat, clean, well-groomed and appropriately dressed daily. The interventions included staff providing supervision and assist with dressing, personal hygiene routine. The plan reflected Resident #1 had had potential for mood problem due to bipolar, dementia, GAD, and stated she had previously felt ideations of self-harm, she would bite her arm, and had been placed on 1 to 1 monitoring. A record review of Resident #1's Progress Notes, written by LVN A on 08/21/23 at 1:16 PM reflected, ADON reported to this nurse that pt [family member (FM)] had c/o patient was having a hard time forming sentences and putting thoughts in place, nurse assessed patient, alert and oriented X, pt states it is true she is having more of a hard time forming sentences and putting thoughts into words, but is not a new issue [issue] has been a on going problem and appears to be getting worse with time, reported back to ADON and MD. MD gave new order for labs CBC, CMP, Depakote level (test measures the level of acid in a person's blood), lipid panel and UA with C&S. A record review of Resident #1's Progress Notes, written by LVN B on 08/24/23 at 4:34 PM reflected, Telehealth visit conducted and MD provided new verbal orders for Namenda 10mg QD and CT scan to rule out possible stroke. Also to have speech evaluate for cognition. Information given to transportation to schedule. MAR updated and resident pleased with new orders. No other issues present at this time. A record review of Resident #1's Progress Notes, written by LVN A on 09/14/23 at 2:23 PM reflected, PCP here evaluating pt, pt c/o tremors and increase in memory loss, MD gave verbal order to start Primidone 50mg 1 tab QHS and increase Namenda to twice a day, notified [FM] no answer message left for call back. Pt aware of changes and agrees to changes. A record review of Resident #1's Progress Notes, written by LVN A on 09/14/23 at 3:12 PM reflected, [FM] RP in facility, notified of changes to medication, RP declined to start Primidone and/or increase Namenda, requesting to speak with PCP first, PCP notified, medications D/C as requested and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 2 of 8 Printed: 05/15/2026 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 455592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Side Campus of Care 1950 S Las Vegas Trail White Settlement, TX 76108 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 Namenda decreased back to once a day as requested, PCP will contact RP. Level of Harm - Immediate jeopardy to resident health or safety A record review of Resident #1's Progress Notes, written by the DON on 09/15/23 at 10:27 AM reflected, [Resident #1], residents [FM], informed this nurse that her [FM] told her that she threw her phone away because she didn't think she wanted to speak with her. Resident has been seen by psych and will be seen by a neurologist per [FM] request. Residents Affected - Few A record review of Resident #1's Progress Notes, written by the ADON on 09/28/23 at 2:42 PM reflected, Resident sitting in lobby with some shorts, slides (sandals), and a gray tunic top on waiting for her ride per her. A record review of Resident #1's Progress Notes, written by the ADON on 09/28/23 at 3:07 PM reflected, Staff reported resident was currently next door at a fast-food restaurant, notified sister who was in the parking lot, she thanked staff and drove off. A record review of Resident #1's Progress Notes, written by the ADON on 09/28/23 at 3:08 PM reflected, Notified DON of residents were abouts. A record review of Resident #1's Progress Notes, written by the ADON on 09/28/23 at 3:11 PM reflected, Received a call from [police officer] of [police department] that resident had walked away from her [FM] and was requesting to be sent to [hospital]. Police notified ADON that resident was ignoring [FM] and acted as if she didn't know her. MD called and made aware. A record review of Resident #1's Progress Notes, written by LVN C on 09/28/23 at 9:59 PM reflected, Res (Resident) yet to be back to facility so writer reached out to the [FM] who then confirmed that she was admitted in [hospital] for further assessment. Text message sent to the DON. A record review of Resident #1's MAR, dated September 2023, reflected the following: Amlodipine Besylate Tablet 5 MG Give 1 tablet by mouth one time a day for HTN (Hypertension-when the pressure in your blood vessels is too high) Order Date 06/03/22. The MAR reflected the hour for the medication was 9:00 AM. In the box on 09/28/23, there was a 3 in the box, which indicated the medication was not given because the resident was away from the facility; Atenolol Tablet 25 MG Give 1 tablet by mouth one time a day for HTN Order Date 06/03/22. The MAR reflected the hour for the medication was 9:00 AM. In the box on 09/28/23, there was a 3 in the box, which indicated the medication was not given because the resident was away from the facility; Gemtesa Tablet 75 MG Give 1 tablet by mouth one time a day for Urinary Order date 06/03/22. The MAR reflected the hour for the medication was 9:00 AM. In the box on 09/28/23, there was a 3 in the box, which indicated the medication was not given because the resident was away from the facility; Namenda Oral Tablet 10 MG Give 1 tablet by mouth at bedtime related to Dementia Order Date 09/14/23. The MAR reflected the hour for the medication was 9:00 PM. In the box on 09/28/23, there was a 3 in the box, which indicated the medication was not given because the resident was away from the facility; Loratadine Tablet 10 MG Give 1 tablet by mouth one time a day for Allergies Order Date 06/03/22. The MAR reflected the hour for the medication was 9:00 AM. In the box on 09/28/23, there was a 3 in the box, which indicated the medication was not given because the resident was away from the facility; Benztropine Mesylate Tablet 1 MG Give 1 tablet by mouth two times a day related to Dementia. The MAR reflected the hours for the medication was 9:00 AM and 9:00 PM. In the box on 09/28/23 for 9:00 AM and 9:00 PM, there was a 3 in the box, which indicated the medication was not given because the resident was away from the facility; Buspirone HCI Oral Tablet 15 MG Give 1 tablet by mouth two times a day related to Bipolar Disorder The MAR reflected the hours for the medication was 9:00 AM and 9:00 PM. In the box on 09/28/23 for 9:00 AM and 9:00 PM, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 3 of 8 Printed: 05/15/2026 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 455592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Side Campus of Care 1950 S Las Vegas Trail White Settlement, TX 76108 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 there was a 3 in the boxes, which indicated the medication was not given because the resident was away from the facility; Divalproex Dodium Tablet Delayed Release 500 MG Give 1 tablet by mouth two times a day related to Bipolar Disorder The MAR reflected the hours for the medication was 9:00 AM and 9:00 PM. In the box on 09/28/23 for 9:00 AM and 9:00 PM, there was a 3 in the boxes, which indicated the medication was not given because the resident was away from the facility; Metformin HCI Tablet 500 MG Give 1 tablet by mouth two times a day for Diabetes. The MAR reflected the hours for the medication was 9:00 AM and 9:00 PM. In the box on 09/28/23 for 9:00 AM and 9:00 PM, there was a 3 in the boxes, which indicated the medication was not given because the resident was away from the facility; and Robaxin Tablet 500 MG Give 1 tablet by mouth two times a day for muscle spasms Order date 07/02/23. The MAR reflected the hours for the medication was 9:00 AM and 9:00 PM. In the box on 09/28/23 for 9:00 AM and 9:00 PM, there was a 3 in the boxes, which indicated the medication was not given because the resident was away from the facility. A record review of the facility's Resident Out On Pass Log reflected on 09/28/23 at 7:06 AM, Resident #1 printed her name and in the section that was labeled Accompanied By (Name, Relationship) was written Self. A record review of Resident #1's Medical POA reflected on 01/27/20 Resident #1 signed and gave permission to her FM to act as her Agent to make any and all health care decisions for me. This Medical Power of Attorney takes effect 01/27/2020. Section B of the POA reflected there were no limitations on the decision-making authority of the agent. Section D of the POA reflected I understand that his power of attorney exists indefinitely from the date I execute this document unless I revoke the power of attorney. The POA reflected it was notarized The State of Texas on 01/27/20. A record review of Resident #1's hospital records, dated 09/28/23, reflected the ER patient course notes, dated 09/28/23 at 2:20, reflected Patient is very minimally communicative, she stating that she no longer wants to go back to the nursing home or live with her [FM] that he wants to go to the downtown shelter . we are getting a behavioral health consult and case management consult . 1715 (5:15 PM) . behavioral health wanted to put on detention warrant, but police department did not seemed worried about her, as she end up becoming voluntarily to Behavioral Health unit . Discharge to Behavioral. The ER's final impression/diagnosis was depressive disorder anxiety state. The ER doctor medically cleared Resident #1 and reported she needed a psychiatric evaluation. Resident #1 consented to observations for emergent care in the [psychiatric hospital] and the Psychiatric ER doctor accepted Resident #1 for an evaluation on 09/28/23 at 4:40 PM. HPI notes on 09/28/23 at 6:39 PM reflected . Legal Status: Voluntary due to concern about harm to self . patient is slow to answer triage questions. Patient states, I want to go to the Downtown Shelter . Interview details: . appears confused. oriented, but slow to respond and may be internally preoccupied . Admits that last night she slept in a nursing home but does not want to return to a nursing home, group home, or her [FM]'s home. Adamant that she can go to the shelter. Patient is sunburned. On 09/28/23 at 9:41 PM the Psychiatric doctor noted, Principal Diagnosis: Schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression). [Resident #1] is being discharged from Observation Status. [Resident #1] will be admitted for inpatient psychiatric care and treatment. Review of medical record indicates that [Resident #1] did not stabilize for discharge to home during this observation period . [Resident #1]'s continued mental illness requires higher level of care. Psychiatric initial evaluation dated 09/29/23 at 10:10 AM She has prolonged latency (the delay before a transfer of data begins following an instruction for its transfer) but is able to respond to short, simple questions if given enough time to answer. She states she ran away from her nursing home for lots of reason one being that she can not stomach the food (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 4 of 8 Printed: 05/15/2026 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 455592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Side Campus of Care 1950 S Las Vegas Trail White Settlement, TX 76108 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 there anymore. Patent states she does not want to go back to a NH (nursing home), her [FM]'s house, or a group home because she would just run away and says she doesn't want to be controlled and follow the rules of these homes . She was unable to answer most questions due to it being hard to get her thoughts together. She states she likely wont remember what we have talked about today . In a phone interview on 10/02/23 at 3:27 PM, Resident #1's FM stated when Resident #1 first admitted to the facility she was in MC. The FM stated about one year ago they went to the facility to visit Resident #1 and the facility had removed Resident #1 from Memory Care (MC) to Long Term Care (LTC). The FM stated she asked the DON why was Resident #1 moved and she was told Resident #1's BIMS had gone from 6 to 8, so, she no longer met the criteria for MC. The FM stated the facility never contacted her or discussed it with her in a care plan meeting, and she was Resident #1's POA. The FM stated she preferred Resident #1 to stay in MC because she knew she would eventually run away, just as she did on 09/28/23. The FM stated on 09/28/23 she went to the facility around 11AM to pick up Resident #1 to take her to a doctor's appointment. The FM stated they had already spoken to the DON the previous day and asked that Resident #1 be ready with her paperwork she needed for the doctor's appointment at 12 PM. The FM stated the DON said she would have Resident #1 and the paperwork ready. The FM stated when she arrived one of the nurse's (does not know her name) said to her oh wow you're back already. The FM stated she was confused and told her she was there to pick Resident #1 up for her doctor's appointment. She said the nurse told her that Resident #1 left earlier in the morning for her doctor's appointment. The FM stated she went to Resident #1's room and her roommate (Resident #2) said Resident #1 left early in the morning for a doctor's appointment. The FM said Resident #2 told her that Resident #1 was acting confused that morning because she jumped up really early about 6:45 AM and said she was going to her doctor's appointment and left out of the room. The FM stated Resident #2 told her she did not even change her night clothes or brush her teeth and just left out. The FM stated Resident #2 told her she knew something was not right because the previous night Resident #1 told her the appointment was at 12 PM but let out so early. The FM stated she told the ADON Resident #1 was missing. The FM stated she was crying and upset and the ADON was acting as if she didn't care. The FM stated the ADON told her Resident #1 probably signed out of the facility and left. The FM stated she told the ADON she cannot sign herself out because she has dementia. The FM stated they went to the front and receptionist said Resident #1 said she had a doctor's appointment and signed out. The ADON showed the FM the sign out log. The FM stated the signature did not look like her sisters . The FM stated she told them she was her POA, and she was not able to sign herself out because she has dementia and mental issues. The FM stated the facility did not even call her to let her know she signed herself out. The FM stated the ADON said she was able to sign herself out because of her BIMS score and it was her right. The FM said she told the ADON again, Resident #1 could not herself out with her mental issues. The FM stated she asked the ADON to call the police and the ADON told her she couldn't because she signed herself out and they had to wait a certain time to call the police, due to their policy. The FM stated she left the facility and a few minutes later the ADON called her and said an employee saw her earlier at a fast-food restaurant near the facility. The FM stated she went to the fast-food restaurant and Resident #1 was sitting outside at a table. The FM stated Resident #1 was in her gray nightgown and flip flops. She stated Resident #1's skin looked red and was acting frantic. The FM stated she told Resident #1 she had a doctor's appointment and attempted to get her in the car. She said Resident #1 was pushing away from her and wouldn't talk to her. The FM stated Resident #1 said was not going with her or to the facility. The FM stated a worker from the fast-food restaurant came outside and told her they were just about to call an ambulance because Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 5 of 8 Printed: 05/15/2026 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 455592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Side Campus of Care 1950 S Las Vegas Trail White Settlement, TX 76108 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 #1 had been there for several hours, and they knew Resident #1 was not acting right. The FM stated Resident #1 started walking off down the busy access road, so she went to stop her and called 911. The FM stated the police came and Resident #1 was still refusing to go with her. She said she told police she cannot be out on her own because of her mental issues and she was her POA. The FM stated Resident #1 told the police she would not go with her, and she would go to the hospital. The FM stated the police asked Resident #1 about going back to the facility and she said no take her to a shelter. The FM stated the police called ambulance, who took her to the hospital. The FM stated the hospital would not discharge Resident #1 because of mental issues and admitted her into the psychiatric hospital. The FM stated in the last month she noticed Resident #1 had become more confused, her memory had gotten worse, and she had a difficult time forming sentences. The FM stated she talked to the facility about her decline and the doctor tried to give Resident #1 more medication. The FM stated she told the facility she did not want to give Resident #1 more medication and she wanted test done because she believed Resident #1could have had a stroke or something else was happening to make her memory get worse. The FM stated she was not able to remember a lot and her speech was getting worse. Stated she started looking around for her and could not find her. In an interview on 10/03/23 at 11:19 AM, Resident #2 stated Resident #1 walked out of the facility. Resident #2 stated a couple days ago Resident #1 got up early, said her FM was taking her to an appointment, walked out of the room, and she never saw her again. Resident #2 stated Resident #1's FM came to the room about 11:30/12:00 and asked where was Resident #1. Resident #2 stated she told the FM she thought Resident #1 was with her. Resident #2 stated she thought Resident #1 got confused because Resident #1 had previously told her the appointment was at 12PM but she left out of the room early at like 6:30/7:00 AM. Resident #2 stated Resident #1 did not get dressed and left out in her nightgown. She stated Resident #1 did not even wash her face or brush her teeth and didn't have on a bra or panties because she did not like to sleep in them. Resident #2 stated she just left out. She stated she spoke to Resident #1's FM later and they did not know where Resident #1 was for five hours. Resident #2 stated Resident #1 seems mentally ok sometimes but lately she seemed to be very confused about things all the time. A record review of Resident #2's Comprehensive MDS, dated [DATE], reflected her BIMS was 15, which indicated her cognition was intact. In an interview on 10/03/23 at 12:31 PM, the ADON stated on 09/28/23 she arrived at the facility about 6:45/7:00 AM and Resident #1 was sitting at the front with another resident. The ADON stated she said to Resident #1, you're up and dressed early and Resident #1 said her sister was coming to take her to a doctor's appointment. The ADON stated approximately 30 minutes later the receptionist contacted the nurse's station and said Resident #1 said her ride was there and she was signing herself out. The ADON said she told the receptionist she was aware that Resident #1 had an appointment. The ADON stated a couple hours later around 12 PM Resident #1's FM came to her asked where was Resident #1. She said she told the FM she thought she was with her because Resident #1 said she had an appointment. The ADON said Resident #1's FM was really upset and said, you just let her walk out. She stated she told the FM she signed herself out and didn't just walk out. The ADON said Resident #1's FM said Resident #1 had a mental disorder, so how did you all let her sign herself out. The ADON stated she went to the receptionist desk, checked the log and saw Resident #1 had signed out. She stated the receptionist said Resident #1 told her that her [FM] was there and signed out. The ADON stated she checked Resident #1's BIMS and she believed it was a 12, which meant she was able to sign herself out. The ADON stated Resident #1's FM got upset and was crying saying Resident #1 was out there alone with no money. The ADON stated Resident #1's FM wanted to call the police to do a missing person's report, but she told her their policy stated they had to wait (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 6 of 8 Printed: 05/15/2026 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 455592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Side Campus of Care 1950 S Las Vegas Trail White Settlement, TX 76108 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 72 hours. The ADON stated Resident #1's FM left the facility. She stated a staff member (does not remember who) heard Resident #1's FM talking about the situation and told her they went to a nearby fast-food restaurant for lunch and saw Resident #1. The ADON stated she called Resident #1's FM to tell her were Resident #1 was. The ADON stated [NAME] after that she received a call from a police officer, who asked did Resident #1 live at the facility and if Resident #1's FM was in fact her relative because Resident #1's FM was trying to get Resident #1 in the car, but she refused and was upset. The ADON stated she verified to police that Resident #1's FM was in fact her FM. She said the police officer said Resident #1 refused to go with the FM and said to take her to [hospital], so he called EMS. The ADON stated the resident's BIMS determined if they were able to sign themselves out. She stated she was not exactly sure what the BIMS score had to be, but Resident #1 was cognitive and able to make decisions. The ADON stated Resident #1 normally signed herself out and walked out to her FM's car. She stated she assumed that was what Resident #1 was doing on 09/28/23 when she signed herself out. During a record review and interview on 10/03/23 at 12:59, the DON stated Resident #1 signed herself out and went to a nearby fast-food restaurant. The DON stated Resident #1's FM came to pick her up for an appointment and got upset that she wasn't at the facility. She stated residents had to have a BIMS of 13 to sign themselves out and Resident #1 had a BIMS of 13. The DON stated she had to check PCC because believed Resident #1 had a BIMS of 13. The Investigator informed the DON that Resident #1's current MDS reflected a BIMS of 11 and showed the DON Resident #1's BIMS assessments in PCC, which reflected a BIMS assessment dated [DATE] with score of 11 and BIMS assessment dated [DATE] with a score of 8. The DON stated she thought maybe the assessment was incorrect because she believed Resident #1 had a BIMS of 13. When the Investigator asked the DON if she felt it was safe for Resident #1 to sign herself out, even though her current Care Plan, reflected Resident #1 had impaired cognitive function and thought process and episodes of confusion due to her dementia diagnosis, the DON stated yes, because Resident #1 was cognitive enough to make sound decisions. The DON stated she did not know exactly what the policy was regarding residents being able to sign themselves, but they had been allowing residents with BIMS of 13 or higher to sign themselves out. When the Investigator asked the DON, was Resident #1 allowed to sign herself out even though she was not her own RP, she stated Resident #1 was her own RP. When the Investigator went to show the DON in PCC that Resident #1 was not her own RP, the information had been changed and reflected Resident #1 as her own RP and Resident #1's FM was listed as emergency contact and not RP and the POA information had been removed. The Investigator pointed out to the DON that she had reviewed Resident #1's record when she first entered the facility and took a snippet of the information, which, reflected Resident #1 was listed as other and not RP and her FM was listed as RP and care and financial POA. When the Investigator asked the DON why the information was changed, since she entered the facility, she stated she didn't know and would have to check into, but she had not changed the information. During a record review and interview on 10/03/23 at 1:12 PM, the Regional Director (RD), she stated she was reviewing Resident #1's clinical record in PCC and accidentally changed her information. She stated she went back in PCC and corrected the information. When the Investigator refreshed her tablet, the clinical record reflected Resident #1 as her own RP and her FM as RP and Care and Financial POA. The Investigator pointed out that Resident #1 was now listed as her own RP, which was not listed as such during the initial review, the RD stated oh but did not provide an additional response. In an interview on 10/04/23 at 10:20 AM, LVN A stated she did write the progress noted on 09/14/23 at 3:12 PM. LVN A stated the MD was in the facility and assessed Resident #1, due to complaints of tremors and increased memory loss. She stated after the assessment the MD gave an order for Primidone for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 7 of 8 Printed: 05/15/2026 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 455592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Side Campus of Care 1950 S Las Vegas Trail White Settlement, TX 76108 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 tremors and increased dosage in Namenda. LVN A stated when she called Resident #1's FM about the new orders she stated she did not want her to take more medications. She stated she notified the MD, who d/c the orders. LVN A stated she updated PCC (electronic medical information platform). LVN A stated when residents sign themselves out, the facility receptionist are supposed to review the list and if the resident was highlighted on the list, they were supposed to call the nurses station to verify they could leave. She stated the receptionist always called to verify regardless of if the resident was highlighted or not. LVN A stated if she was covering a hall and was not familiar with the resident, then go to the front to check with SW regarding BIMS and if they were ok to sign out. Stated she was not exactly sure of what the policy was, but she was informed the residents had to be cognitive with BIMS of 13 to sign out by themselves. LVN A stated she did not know Resident #1's BIMS but she was cognitive, and she would not have interjected with her leaving the facility. LVN A stated if the resident was not their own RP, then you must call their RP before allowing them to sign out. LVN A stated before the resident left, you were supposed to check to see if they would be gone during the time their medication was supposed to be administered and if so, they were supposed to offer the residents their medications. In an interview on 10/04/23 at 11:48 AM, CNA D stated she was assigned to Resident 1's hall on 09/28/23 from 6AM-2:00 PM. CNA D stated about 6:45 AM she went to provide care to Resident #2 and Resident #1 was already up and said her FM was picking her up for a doctor's appointment. She stated Resident #1 did say what time her appointment was. CNA D stated she told LVN E, who was the nurse for Resident #1's hall, that she was leaving for an appointment with her FM. She stated about 15-20 minutes later, she saw Resident #1 heading towards the front of the facility to leave. CNA D stated Resident #1 did occasional get confused but for the most part she was ok. CNA D stated Resident #1 did stutter and took a while to get her words out. In an interview on 10/04/23 at 11:57, LVN E stated she was the nurse assigned to Resident #1's hall on 09/28/23 from 6AM-2:00 PM. LVN E stated Resident #1 was up early and dressed. She stated Resident #1 told her she had a doctor's appointment at 12PM. LVN E stated a little while later the receptionist called to the nurse's station and said Resident #1 was leaving out for an appointment with her FM. She stated the receptionist was told they were aware. LVN E stated she knew her appointment was at 12PM but she figured her FM was there early. LVN E stated the residents were required to be cognitive and have a BIMS of 13 to leave by themselves. LVN E stated if the resident was not their own RP, then they you were supposed to call POA/RP. LVN E stated she did not know Resident #1's BIMS score but she knew she was cognitive. LVN E stated she did not know Resident #1 was not her own RP. She stated Resident #1 mostly went out of the facility with her FM, but there had also been times she signed herself out. LVN E stated Resident #1 always returned and was not known to be an elopement risk. LVN E stated the nurses were supposed to offer the resident's medications if they will be out when the medications were supposed to be administered. She stated Resident #1 was not offered her medications on 09/28/23 because she left before they could offer. In an interview on 10/04/25 at 12:45 PM, the DON stated the process they had been using for resident's signing out was the receptionist checked the list at the front before allowing the resident to sign out. The DON stated the list had highlighted names, which meant those residents were not allowed to sign out by themselves and the receptionist had to contact the nurse. She stated the IDT determined whose names were highlighted and they[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 8 of 8