Health inspection·January 20, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident # 1's Progress Note dated [DATE] at 11:30 AM written by LVN A revealed, Entered resident room, resident noted to have episode of vomiting. Light brown tinged emesis noted on resident alert and oriented. Resident states he vomited and doesn't feel good. PRN Ondansetron administered at this time. Will continue to monitor. Record review of Resident # 1's Progress Note dated [DATE] at 11:41 AM written by LVN A revealed, Head to toe assessment completed on resident, resident in bed, head of bed raised 90 degrees. Resident alert and oriented xs3. Aware of situation and surroundings. No shortness of breath or labored breathing noted. Abdomen soft and non-distended resident last known bowel movement was [DATE]. NP [name] was present in the facility notified of resident having episode of vomiting and condition. Order given to send resident to ER for further evaluation. Record review of Resident # 1's Progress Note dated [DATE] at 12:50 PM written by LVN A revealed, Entered resident room, resident noted to have no respirations. Unable to obtain vital signs. at this time. Resident has DNR code status order. NP [name] Called and notified of resident findings. Record review of Resident # 1's Progress Note dated [DATE] at 2:02 PM written by RN C revealed, Resident lying supine in bed,pupils fixed and dilated,no chest movement noted,no pulse and no B/P,PRONOUNCED AT 13:45 PM. The progress notes did not indicate that Resident # 1's family was notified of the continued emesis that prompted the NP to order for him to be transferred to the hospital for further evaluation. An interview with Resident # 1's family member on [DATE] at 6:24 PM revealed the facility did not notify her that there was an order for Resident # 1 to be sent out to the hospital. She stated she was not contacted by the facility until 2pm on [DATE] when they called to inform her that Resident #1 had expired. An interview with LVN A on [DATE] At 11:36 AM, revealed anything about labs or patient condition changing from their baseline would constitute calling the family to notify of a change in condition. LVN A stated that if he called a family, he would document it. LVN A stated on [DATE] Resident #1 was having nausea and vomiting, his vitals were normal. LVN A stated he informed the nurse practitioner who subsequently ordered for Resident # 1 to be sent to the hospital. LVN A stated he called for non-emergency transport because Resident # 1's vital signs were normal. LVN A stated after he called for transport, he went back to assess Resident #1 and found that he did not have vital signs or respirations. LVN A stated the emesis would constitute a change of condition. LVN A stated he remembered calling the family of Resident #1 or perhaps it was the nurse (LVN B) that worked before his shift started that day that informed the family of the emesis. An interview with the DON on [DATE] at 12:06 PM revealed Resident # 1 always had emesis on an doff and that is why he had a PRN order for Zofran (a nausea medication). The DON stated one episode of emesis was not a change of condition for Resident #1; only continuous emesis with the color of ground coffee would be a change of condition. The DON stated the night nurse (LVN B) notified Resident # 1's family member that he was having emesis. The DON stated the documentation was not here, so there was an assumption that it was not done. An interview with LVN B on [DATE] at 1:02 PM, revealed she did not see Resident # 1's emesis as a change in condition. If the emesis was coffee ground in color and it was a large amount, she would see it as severe and notify the physician and the family. LVN B stated Resident # 1 only had a small (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675081 If continuation sheet Page 2 of 3 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 675081 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Acres Living and Rehabilitation Center 2525 Centerville Rd Dallas, TX 75228 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 0580 Level of Harm - Minimal harm or potential for actual harm amount of emesis and it was clear mucous on her shift. LVN B stated she did not call Resident# 1's family. She stated while she was waiting to be relieved from her shift the morning of [DATE] Resident #1's family member called the facility, and she answered the phone. LVN B stated she spoke with the family member briefly, informed her about the small emesis and that Zofran was given, and told the family member that LVN A would call her back. Residents Affected - Few An interview with ADM on [DATE] at 1:51 PM revealed LVN A should be notifying and documenting in the notes. The ADM stated the facility talked to Resident # 1's family member, but it was not documented so the DON went back to document on [DATE]. The ADM stated there should have been a follow up call to the family when the NP said to send Resident #1 out. The ADM stated it was their procedure for the nurse to document and they had started in-servicing staff on documentation. An interview with the NP on [DATE] at 9:38 AM revealed the nurse had informed her that Resident #1 had emesis but did not have shortness of breath, nor was in distress. When the emesis happened the second time in a short while, the NP stated she told the nurse to send him out for an ER evaluation because of his history of hospitalization due to colitis a few years ago. The NP stated depending on the condition, if the resident was alert, not in distress, and had no shortness of breath, the resident would be considered stable so non-emergency transport would be reasonable. She stated only if there were signs of distress would a 911 call be needed. Record Review of facility's policy titled, Change of Condition Reporting, dated 5/2007, revealed, Acute Medical Change .3. The responsible party, POA, or guardian will be notified that there has been a change in the resident's condition and what steps are being taken .Routine Medical Change 7. All attempts to reach the physician and responsible party will be documented in the nursing progress notes. Documentation will include time and response. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675081 If continuation sheet Page 3 of 3