Inspection·May 24, 2023

F 0725 Level of Harm - Actual harm Nursing description-Pt was found sitting on the floor in her room, by the door this morning. Pt has a large area that is swollen, on her right clavicle/neck area that is painful to palpation, and she has a skin tear to her right elbow. Residents Affected - Few Resident description-Resident states that she does not remember how she came to be sitting on the floor. Immediate Action Taken: Description- This nurse and CNA helped pt. to stand up and sit on the bed, vital signs taken, assessed pt. for any injuries or pain, provider on Spruce was notified of pt status, pt is resting quietly, alert but confused, no change in mental status or distress noted at this time. Mental Status: -Impulsive -Forgetful -Oriented to person -Lack of safety awareness Level of Pain-9 on scale of 1-10 Predisposing Environmental Factors: -Poor lighting Predisposing Physiological Factors: -Confused -Incontinent -Gait imbalance -Impaired memory -Weakness/fainted Review of the facility's Provider Investigation Report, dated 05/15/23, reflected the following: .Investigation Summary & Facility Response [Resident #1] was first observed on the floor by aide [Hospitality Aide]. During her last round on her shift she reported seeing [Resident #1] awake and sitting on the side of her bed. As [Resident #1] can use the toilet independently, [Hospitality Aide] continued down the hall to get another resident up for the day, which she said took about 30 minutes. After assisting the other resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 2 of 6 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 675185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Longmeadow Healthcare Center 120 Meadowview Dr Justin, TX 76247 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 0725 Level of Harm - Actual harm Residents Affected - Few [Hospitality Aide] said she was coming back up the hall and observed [Resident #1] sitting on the floor outside her bathroom door. [Hospitality Aide] said that she looked for the charge nurse, [LVN D], LVN, but did not find her. She said that she went to the secure doors for the unit, opened them and asked the aide at the 300-nursing station where [LVN D] was. [CNA E], the aide by the desk, responded that she did not know where [LVN D] was at that time. [Hospitality Aide] did not ask [CNA E] for assistance with [Resident #1]. [LVN D]was on the 300-hall doing her morning blood sugar checks and morning meds. The best timeline we have constructed through interviews with the staff is that [Resident #1] was sitting on the floor from sometime before 6:30am to about 7:15am when the day shift arrived and received a report that [Resident #1] was on the floor. [Hospitality Aide] was suspended pending the outcome of our investigation due to her inaction in getting assistance for [Resident #1] from the charge nurse or another aide. While [Hospitality Aide] checked on [Resident #1] repeatedly, she did not stay with her, and she did not exhaust all her resources to get assistance. Our investigation did not determine that [Hospitality Aide]'s inaction caused the physical injury to [Resident #1], but her inaction showed neglect in not doing more in a timely manner to address the situation. Upon assessment by the charge nurse, [RN B], [Resident #1] was found to be alert, but confused, at her normal baseline without increased confusion or decrease in mental status. The charge nurse and aide, [CNA A], CNA, got [Resident #1] up and returned her to her bed. [CNA A] cleaned [Resident #1] and put clean clothing on her. [RN B] tended to the skin tear on [Resident #1]'s right elbow. As a result of the assessment, the physician ordered [Resident #1] to be sent to .hospital for further evaluation and treatment. It was at the hospital that the x-ray and CT scans were conducted. The radiology results have been attached to this report. [Resident #1] returned from [hospital] the same day she was sent out, Sunday 5/7/23, with a sling on her right arm. Due to her Alzheimer's, she continues to remove the sling each time the staff place it on her. She does not understand why she should wear it and takes it off. When asked by the staff what had happened, [Resident #1]'s response was that she was going to the bathroom. When interviewed the next day, [Resident #1]'s answer was nonsensical. [Resident #1] ambulates independently, though often forgets to use her walker. [Resident #1] has not had a fall since being admitted to Longmeadow Healthcare until this incident. She walks a lot each day throughout the SecureCare unit. In-services on Abuse & Neglect and Fall Prevention were conducted with staff. Investigation Findings The investigation confirmed that [Resident #1] did sustain a fracture to her right clavicle as the result of an unwitnessed fall in her room. Observation on the secured unit and interview with Resident #1 on 05/17/23 at 11:14 AM, was unsuccessful due to her cognitive deficits. Resident #1 was unable to state how she fell and how long it took staff to help her. Resident #1's right clavicle was swollen. There were no other visible injuries, marks, or bruises. Resident #1's bed was in the lowest position and there was a fall mat on the floor next to the bed. There were no safety hazards or clutter observed in the room. Interview on 05/17/23 at 11:52 AM with CNA A revealed she had worked at the facility for about a year. She stated she worked weekdays 7:00 AM-7:00 PM on the secured unit. CNA A stated she worked on 05/07/23, the day Resident #1 had a fall. CNA A stated when she arrived at work at approximately 7:00 AM she found Hospitality Aide C, who worked the overnight shift and found Resident #1 on the floor, sitting at the nurse's station on the 300 hall, outside of the secured unit. CNA A stated she entered the secured unit and was immediately informed by RN B, who had also just made it onto the unit, that Resident #1 had fallen and was still on the floor. CNA A stated they went to Resident #1's room to assist her. CNA A stated Hospitality Aide C stated she was unable to move Resident #1 alone and was unable to find the nurse to assist her. CNA A stated she felt there was enough staff working on the secured unit during the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 3 of 6 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 675185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Longmeadow Healthcare Center 120 Meadowview Dr Justin, TX 76247 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 0725 day shift to properly supervise and care for all residents. Level of Harm - Actual harm Interview on 05/17/23 at 12:35 PM was conducted with the Administrator, ADON and Interim DON. The Interim DON stated it was reported that Resident #1 had a fall on 05/07/23 at approximately 6:45 AM, that resulted in a fractured clavicle bone. The ADON stated Resident #1 was diagnosed as having a history of falling but had never had a documented fall at the facility, although her gait was unsteady. The Interim DON stated that Hospitality Aide C was scheduled to work on the secured unit with LVN D, who was working between two halls, overnight on 05/06/23-05/07/23. The Interim DON stated it was reported that Hospitality Aide C was seen by oncoming morning shift staff sitting at a nurse's station outside of the secured unit while Resident #1 was still on the floor. The Administrator stated that during the facility's investigation, it was determined that Hospitality Aide C did not exhaust all of her resources to get immediate help for Resident #1 by not using a phone to call other staff, and she had been suspended pending the investigation. He stated the decision to terminate Hospitality Aide C due to neglect had since been made. He stated that LVN D was also pending termination for an unrelated reason. Residents Affected - Few Interview on 05/17/23 at 1:38 PM with RN B revealed she had worked at the facility for about 2 months. She stated she worked 7 AM-7 PM on the secured unit. RN B stated when she arrived at work on the morning of 05/07/23, she was met by Hospitality Aide C, who was sitting at a nurse's station outside of the secured unit. She stated she was informed by her that Resident #1 had fallen and was still on the floor because she was unable to move her alone and LVN D was not around. RN B stated LVN D was working two halls, which was typical for the overnight shift, and was on a different hall checking blood sugars when she arrived at approximately 7:00 AM. RN B stated she and CNA A immediately went to Resident #1's room to assist her. RN B stated she assessed Resident #1 and found that her clavicle looked swollen. RN B stated that Resident #1 was upset and in pain. RN B stated the physician was notified and Resident #1 was sent out to the hospital. Attempted interview on 05/17/23 at 1:48 PM with LVD D was unsuccessful due to no response to phone call. Interview on 05/17/23 at 2:20 PM with Hospitality Aide C revealed she had worked at the facility for five months. She stated she worked 7:00 PM-7:00 AM on the 400 hall (secured unit), and worked on 05/06/23-05/07/23 when the incident with Resident #1 occurred. Hospitality Aide C stated she started doing her end of shift rounds at approximately 5:30 AM and found Resident #1 sitting on her bed. She stated she went back down the hall around 6:45 AM and found Resident #1 on the floor of her room. Hospitality Aide C states she did not hear Resident #1 yell for help when she fell. Hospitality Aide C stated Resident #1 informed her that she had fallen hard and did not want Hospitality Aide C to move her alone. Hospitality Aide C stated she was alone on the secured unit and had not seen LVN D since 10:00 PM. She stated that was her first time working overnight with LVN D and that she did not have this problem with other nurses. Hospitality Aide C stated she went to the end of the hall to open the door and told CNA E to find LVN D because she needed help. She stated she did not have her personal cell phone to call for help and had not been trained to use the unit phone to page for help over the intercom. Hospitality Aide C stated that by the time she went to tell Resident #1 that help was coming, there was another resident yelling for help that she had to assist. Hospitality Aide C stated there was a lot going on with the residents on the secured unit and she did not have any help. She stated after she assisted the other resident and was making her way back to Resident #1, CNA A and RN B were coming on the unit to start their shift. Hospitality Aide C stated she informed them of what had happened with Resident #1, and they went to assist her. Hospitality Aide C denied sitting at the nurses' station outside of the secured unit and stated that she remained on the secured unit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 4 of 6 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 675185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Longmeadow Healthcare Center 120 Meadowview Dr Justin, TX 76247 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 0725 Level of Harm - Actual harm Residents Affected - Few the entire time. She denied that LVN D ever came to assist her. Hospitality Aide C stated the overnight shift was always staffed with one aide on the secured unit and they needed more staff due to the behaviors and needs of residents on that unit. She stated she had reported her concerns about staffing to management, but nothing changed. Hospitality Aide C stated she did not normally work with LVN D and had never experienced not having a nurse available until that day, which made it even harder on her. Interview on 05/17/23 at 4:40 PM with CNA E revealed she had worked at the facility for 3 months. She stated she worked 7 PM-7 AM on the 300 hall, which was directly across from the secured unit, and worked on 05/06/23-05/07/23 when the incident with Resident #1 occurred. CNA E stated she was unaware that Resident #1 had fallen until after she had left the facility when the Interim DON called her to get a statement. CNA E denied that Hospitality Aide C ever opened the doors to tell her she needed help on the secured unit because she would have helped her. CNA E stated that at the time it was reported that Resident #1 fell, she would have been busy getting residents on her hall dressed for the day and not sitting at the nurse's station. However, CNA E stated she would have heard someone yelling for help had Hospitality Aide C done so. CNA E stated LVN D was also assisting residents on the 300 hall at the time and would have also been available to help Hospitality Aide C. CNA E stated there was always one aide scheduled to work on the secured unit overnight, and she felt that was not sufficient to properly care for the residents. Interview on 05/18/23 at 1:40 PM with the Administrator revealed the facility's current resident to staff ratio was sufficient and was adjusted based on acuity level. He stated that one aide and one nurse floating between two halls was sufficient on the secured unit overnight with the current census of 22 residents. The Administrator stated if the secured unit was at its maximum capacity of 28 residents, they would consider adding an additional aide. He stated that during the overnight shift, although the nurse worked between two units, the expectation was for the nurse to be available to assist the aides when needed and make rounds at least every 2 hours. He stated the overnight shift was staffed lower due to the decreased ADL care requirements, such as showers and feedings. The Administrator stated the risk of not having sufficient staff available could be a delay in services which could lead to harm and injuries to the residents. Interview on 05/24/23 at 6:34 AM with LVN F revealed she had worked at the facility for 3 years. She stated she worked weekdays, overnight 7:00 PM-7:00 AM, on different halls. LVN F stated she worked on the 300 hall and 400 hall (secured unit) on this date. She stated she was the only nurse for both halls and this was common for the overnight shift. LVN F stated she felt that one nurse was sufficient for the nurse duties; however, two aides were needed for the secured unit, but it was usually staffed with one aide. LVN F stated that she remained available between both halls as they were across from each other. She stated she sat at the nurses' station on the 300 hall, which was in a central location and had a call light board that monitored lights for both halls. LVN F stated the aide assigned to the 300 hall would also do rounds and assist the aide on the secured unit when needed. Interview on 05/24/23 at 9:45 AM was conducted with the ADON revealed that Hospitality Aide C was hired under the COVID-19 waiver and had received the same trainings as all CNAs, and was prepared to test for certification; however, testing had not been scheduled. The ADON stated that Hospitality Aide C worked with a proctor for approximately 4 months and had to demonstrate acquired skills before being able to work alone. She stated Hospitality Aide C had only worked alone for about a month. The ADON stated she was confident in Hospitality Aide C's skills and abilities; however, she did sometimes show a lack in initiative and motivation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 5 of 6 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 675185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Longmeadow Healthcare Center 120 Meadowview Dr Justin, TX 76247 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 0725 Record review of the facility's census, dated 05/07/23, revealed there were 18 residents on the secured unit on that date. Level of Harm - Actual harm Residents Affected - Few Record review of the facility's staffing schedule for 7:00 AM-7:00 PM, dated 05/07/23, revealed there was one CNA scheduled to work the secured unit (Hall 400) and one LVN was scheduled to work between two halls (300 and 400 hall). Record review of an in-service titled Abuse & Neglect, dated 05/09/23, revealed staff were in-serviced on abuse/neglect. Record review of an in-service titled Fall Prevention, dated 05/09/23, revealed staff were in-serviced on fall prevention. Record review of facility's monitoring form revealed that alleged/actual abuse monitoring was conducted at the facility on 05/08/23-05/12/23. Record review of an in-service titled Nursing Dept. staff meeting, dated 05/16/23, revealed staff were informed to not attempt to move a resident who had fallen and to notify a nurse as soon as possible. The in-service also informed staff to never leave a resident who had fallen unattended and to stay by their side until a nurse arrived and could assess them. Record review of an in-service titled What to do when you have an emergency, dated 05/17/23, and as a result of the investigation, revealed staff were informed to immediately find assistance, use the unit phone to page overhead for assistance, or call 911 if no one responded. Record review of an in-service titled Rounding on your assigned hall, dated 05/17/23, revealed staff were informed to never leave the secured unit unattended. Review of Hospitality Aide C's training records, dated 12/21/22-02/23/23, revealed she had been trained on the following: - General Topics (included safety/emergency procedures) - Basic Nursing Skills (included recognizing abnormal changes in body functioning and the importance of reporting such changes to a supervisor) - Personal Care Skills - Mental Health and Social Service Needs - Care of Cognitively Impaired Residents - Basic Restorative Services - Residents' Rights On 05/18/23 at 2:00 PM, a facility staffing policy was requested from the Administrator, and he stated the facility did not have one. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 6 of 6