Health inspection·May 10, 2023

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure special eating equipment and utensils were provided for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks for 1 of 3 residents (Resident #69) reviewed for feeding assistance. Residents Affected - Few The facility failed to provide Resident #69 an adaptive aid to assist her to eat independently. The failure could place residents who required adaptive feeding equipment at risk for loss of self-worth and empowerment for independent eating, which could lead to unplanned weight loss. Findings: Record review of Resident #69s quarterly MDS assessment dated [DATE] reflected Resident #69 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses unspecified severe protein-calorie malnutrition (Malnutrition is an imbalance between the nutrients your body needs to function and the nutrients it gets) Rheumatoid arthritis (A chronic inflammatory disease that affects the joints. This results in painful joints, swelling and stiffness in the joints.), pain in right arm, unspecified lack of coordination, and muscle weakness generalized. Resident #69 BIMS was 15 which indicated cognitive intact. She required limited assistance with eating. Record review of Resident #69's Comprehensive Care Plan, dated 11/10/22, reflected the following: recommend use of divided plates for all meals . Goal: maintain adequate nutritional status . Interventions: follow diet ordered by physician and aid with meals as needed. Record review of Resident #69 weights revealed on 04/02/23, the resident weighed 86.2 lbs. On 05/03/2023, the resident weighed 86.2 pounds which is a 0.00 % Gain. On 12/02/22, the resident weighed 82.6 lbs. On 05/03/23, the resident weighed 86.2 pounds which is a 4.36 % Gain. Record review of Resident #69's orders revealed divided plate with all meals ordered by phone on 04/18/2023. Resident#69 orders revealed continue total assist with meals for weight loss ordered by phone on 01/20/23. During an interview and observation on 05/08/23 at 01:00 PM Resident #69 had trouble lifting her food off her plate. I get so tried trying to eat the food off of the plate, I give up most of the time. Resident#69 stated the divided plate was helpful and she did not have to chase her food around her plate. Resident#69 stated she was having trouble today gripping her utensil and she was still hungry and liked the food. Surveyor asked Resident#69 if she wanted staff to assist her and she stated no. During observation on 05/10/23 at 08:42 AM Resident#69's plate did not have dividers and Resident#69 had orange juice and was not ready to eat her breakfast plate. During interview and observation on 05/10/23 at 08:42 AM the DON stated that Resident#69'plate did not have dividers. DON stated it was the kitchen staff responsibility to make sure residents' food was plated on the correct plate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455904 If continuation sheet Page 2 of 4 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 455904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowlett Health and Rehabilitation Center 9300 Lakeview Pkwy Rowlett, TX 75088 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 0810 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During interview on 05/10/23 at 11:45 AM Occupational Therapist T stated patients could use the plate dividers to help lift food. Occupational Therapist T stated not having the plate dividers would not cause the resident harm, but it would make the process of eating take longer to do. Occupational Therapist T stated that Occupational Therapy and Speech Therapy work ed together to determine the residents needs and goals. Occupational therapist T stated they have tried different assistive equipment with the resident and saw what would work the best. The Dietary Manager and Charge nurse should receive printed tickets with special equipment needs noted. Occupational Therapist T stated someone is supposed to make sure she finished her meals. Occupational Therapist T stated one of Resident#69 goals are to independently feed herself. Occupational Therapist T stated the Ticket system recently changed at the beginning of last week. Occupational therapist T stated Occupational therapy made sure resident information was updated and correct. During interview on 05/10/23 at 12:05 PM, the Speech Therapist stated they usually consult ed with Occupational therapy to see what the best things for resident will be, copy of order for divided plate was given to kitchen and nursing. Speech Therapist M stated the care plan was updated with information for special equipment. Speech Therapist M stated the divided plates made it easier to eat. Speech T herapist M stated she had assisted Resident#69 with feeding her cereal and she was able to get toast on her own. During interview on 05/10/23 at 12:17 PM DON stated it would take the resident longer to finish eating if the plate did not have the dividers. The kitchen staff was supposed to check the tray to make sure residents are getting the right things. DON stated Resident#69 would have asked for help from nursing staff when she needed it. DON stated Resident#69 usually does not ask for assist. During interview and Record review a on 05/10/23 at 01:50 PM with Regional Dietitian, she stated not having the divided plates would mess up the resident by mouth intake and could cause weight loss. The Regional Dietitian stated the facility switched over to a new meal ticket system the previous week and she thought she had transferred all the information over. Record review revealed dietary instructions were in Resident#69 orders and care plan. During an interview and observation on 05/10/23 at 2:30 PM, the Dietary Manager stated dietary staff were made aware of orders for adapted devices such as divided plates for their meals. Dietary Manager stated the facility recently switched over to a new ticket system for their trays. Dietary Manager pointed to a section on the ticket titled Tray Instructions and stated any orders for things like divided plates and weighted silverware would show there. Dietary Manager stated in their other facilities, the ticket system communicated with the facility's Electronic Medical Record System-Point Click Care so orders automatically carried over. That was not the case in this facility, and they worked to correct it. Dietary Manager stated all new orders were sent to the Regional Dietitian, who manually entered all orders. She stated the Speech Therapist gave her a list of all residents requiring adaptive aides and that was sent to the Regional Dietitian as well. The Dietary Manager stated, without the dividers, the residents would be unable to get the food onto their utensil and food would wind up on the table, and not in their mouth. The Dietary Manager stated this could lead to weight loss and lack of nutrition needed for healing and well-being. Dietary Manager stated staff was in service on 05/10/23 on the new ticketing system. Record review of the facility physician orders (revised 05/2007), revealed no policy related to assistive devices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455904 If continuation sheet Page 3 of 4 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 455904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rowlett Health and Rehabilitation Center 9300 Lakeview Pkwy Rowlett, TX 75088 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain medical records on each resident that are complete, accurately documented and readily accessible for one (Resident #85) of five residents reviewed for clinical records. The facility failed to ensure that Resident #85's physician's orders for tramadol were written to be given orally and not enterally. This failure could place residents at risk of inaccurate medical records that could affect monitoring and medical services provided. Findings included: Review of Resident #85's face sheet, dated 05/10/23, revealed she was an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included cognitive communication deficit, unspecified dementia, and schizoaffective disorder. Review of Resident #85's physician's orders reflected: Tramadol tablet 50 MG, give 50 MG enterally every 6 hours as needed for for lower back pain [sic] with a start date of 09/11/20. Review of Resident #85's most recent quarterly MDS assessment, dated 01/10/23, reflected she had a BIMS of 01 indicating severe cognitive impairment. An observation and interview on 05/10/23 at 12:30 PM with Resident #85 revealed she was sitting in the dining room area at a table eating her lunch. Resident #85 was not able to answer questions but there was no indication she had a g-tube. An interview on 05/10/23 at 12:35 PM with MA G revealed she did not provide Resident #85 her PRN tramadol, but that the nurse did instead. MA G said Resident #85 should receive all her medications by mouth since she did not have a g-tube. An interview on 05/10/23 at 1:10 PM with LVN T revealed Resident #85 had not been provided her PRN Tramadol for a while because she had not needed it. LVN T said that Resident #85 did not use a g-tube and should receive all her medications by mouth instead. LVN T said she had only been at the facility for a little while and was not sure why the Tramadol order was written to be given to her enterally when that was not an option for her. An interview on 05/10/23 at 1:25 PM with the DON revealed Resident #85 did not have a g-tube and should receive her medications by mouth and not enterally. The DON said he was not sure why Resident #85's tramadol was written to be given enterally instead of by mouth. The DON did not provide a concern regarding the medication order written incorrectly. Review of the facility's policy, revised 05/07, reflected: 6. Orders for medications must include: .D. Route of administration if other than oral; . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455904 If continuation sheet Page 4 of 4