Health inspection·July 27, 2023

F 0580 1. Level of Harm - Immediate jeopardy to resident health or safety Resident #1 at high risk for falls related to muscle weakness, Goals: risks and injury potential will be minimized through the next review date. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. The resident needs a safe environment with even floors free from spills and or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. Residents Affected - Some 2. Resident #1 has an activities of daily living self-care performance deficit related to dementia, disease process. Goal: maintain current level of function in activities of daily living through the review date. Intervention: gather and provide needed supplies, observe/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Physical/Occupational therapy evaluation and treatment as per orders. Resident requires SKIN inspection at least weekly by licensed nurse. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. Resident requires extensive assist by 1 staff to turn and reposition in bed. Resident requires extensive assist by 2 staff to move between surfaces. Resident requires extensive assist of 1 staff to dress. Resident requires extensive assistance by 2 staff for toileting. 3. Resident #1 has potential for pain related to right foot drop. Goal: Resident will not have an interruption in normal activities due to pain through review date. Intervention: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions ever shift. Review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Observe/document for probable cause of each pain episode. Remove/limit causes where possible. Observe/document for side effects of pain medication. Observe/record/report to nurse any signs and symptoms of non-verbal pain: changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling outs, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Observe/record/report to nurse loss of appetite, refusal to eat and weight loss. Observe/record/report to nurse resident complaints of pain or requests for pain treatment. Provide non-pharmacological interventions. Report to nurse any change in usual activity attendance patterns or refusal to attend activities related to signs and symptoms of pain or discomfort. Therapy referral as indicated. 4. Resident #1 has Osteoporosis. Goal: Resident will remain free of injuries or complications related to osteoporosis. Interventions: Give analgesics PRN for pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 2 of 67 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 07/27/2023 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 0580 Resident may complain of pain, stiffness, or weakness. Document complaints. Level of Harm - Immediate jeopardy to resident health or safety Observe for risk of falls. Educate resident, family /caregivers on safety measures Residents Affected - Some that need to be taken in order to reduce risk of falls. Observe/document/report PRN s/sx or complications related to osteoporosis: Acute fracture, Compression fractures, Loss of height, Kyphosis (dowagers hump, thoracic curve), Pain. Record review of Resident #1's progress notes dated 06/25/23 - 07/17/23 revealed no mention or assessment of Resident #1 complaint of pain. Record review of Resident #1's progress notes dated 07/17/23 at 12:00 AM copy of documentation signed by Physician reflected, Follow up Physical exam, Elderly, frail female in some distress seen via video, Right lower extremity bent at ninety degrees, grimacing with palpation. Patient seen via telemedicine with nurse. 1. Pelvis and right femur x-ray. Concern for fracture status post transfer. 2. Tramadol 100mg po q6h PRN pain for 14 days if no allergies. 3. Follow up x-ray. Record review of Resident #1's progress notes dated 07/17/23 at 9:15 AM written by LVN C reflected, Late Entry CNA F reported that resident was complaining of pain during a brief change. I went and looked at her leg, and then messaged the doctor. The doctor video called, and we looked at the leg together. The doctor ordered x-rays and pain meds for resident. This nurse put in the orders. The x-ray techs showed up around 3:30 PM, and so did family member. X-ray showed femur break. This nurse reported that to doctor and called for transport to hospital. It was 5:45 PM before resident was transported to hospital due to ambulance being busy. Record review of Resident #1's progress notes dated 07/17/23 at 5:54 PM written by ADON reflected, Late Entry Resident reported leg pain to aide and aide notified nurse. Nurse assessed resident and did a telehealth video call and X-ray, and pain meds were ordered. Family member was at bedside during x-ray and when it was resulted. Right femur fracture. Upon further investigation, resident states she did fall out of bed last night onto her knees and a worker helped her up. Patient has good situational awareness. Sacred cross called and resident sent to hospital at 5:45 PM. Record review of Resident #1's progress notes dated 07/17/23 at 6:46 PM written by LVN C reflected, Resident #1 was transferred to a hospital on [DATE] 5:50 PM related to right femur fracture. Record review of Resident #1's progress notes dated 07/17/23 at 7:34 PM written by LVN U documented Resident #1 in hospital. Record review of Resident #1's progress notes dated 07/18/23 at 08:35 written by LVN C reflected, Spoke to family member in regards to resident. Resident is going to have surgery for repair the femur fracture, remove old hardware that has come out, and run a rod from her knee to pelvis. Resident will be non-weight bearing post-operation and will no longer be able to walk. Record review of the accident and incident reports dated 05/25/23 - 07/25/23 indicated Resident #1 had fracture incident on 07/17/23 3:30 PM. Record review of Resident #1's physician order revealed: Order date: 07/17/23 10:52 AM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 3 of 67 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 07/27/2023 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 0580 Order Summary: Xray of pelvis, Right hip, and femur one time only for right leg pain for 1 day Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's Final X-Ray Report dated 07/17/23 at 4:21 PM revealed: Residents Affected - Some Moderately displaced oblique fracture of distal diaphysis of femur of indeterminate age. 1. 2. Dislocation of right hip is present 3. Internal fixation of right femoral neck. Record review of Resident #1's hospital records dated 07/17/23 reflected: Chief complaint: Right leg pain from a fall Emergency department work up included a right femur x-rays revealed a displaced, evaluated distal femoral diaphyseal fracture. Resident completed surgery on 07/18/23. Record review of Resident #2's face sheet dated 07/25/23 revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, major depressive disorder, muscle wasting, abnormal posture, lack of coordination. Record review of Resident #2's annual MDS assessment, dated 05/23/23 revealed her BIMS score was 15 indicating Resident #2's cognition was intact. Her Functional Status for activities of daily living indicated she required extensive assistance with two person assist with bed mobility, transfers, and toileting. Extensive assistance with 2 persons assist with eating, dressing, personal hygiene, locomotion on and off the unit. Always incontinent with bowel and bladder. Adequate hearing, vision, and ability to understand others. Interview on 07/25/23 at 2:57 PM with Resident#1's family member/responsible party revealed she visited almost daily at 3:00 PM. When she entered the facility on Monday, 07/17/23, the receptionist stated there was something wrong with Resident #1. She stated on her way to Resident #1's room, LVN C also informed her Resident #1 had an injury. The family member stated when she entered the resident's room, Resident #1 was moaning, groaning and grimacing from pain. Both Resident #1 and her roommate, Resident #2, started to explain the cause of her pain, late Saturday night (07/15/23), early Sunday morning (07/16/23) about midnight, that she was reaching for the call button, fell and the Student Aide D came in and threw her back in bed. The family member stated Resident #1 told her she fell on her bottom and hit her head. The family member stated when she pulled the covers back, it was obvious when looking at her right leg that there was a fracture to her right femur. The family member stated she was upset the facility had not contacted her prior to her entering the facility. The family member stated in speaking with the Administrator he apologized, told her the facility should have contacted her immediately, and told her he would complete an investigation. Interview on 07/25/23 at 3:22 PM with Resident #2, who was Resident #1's roommate, revealed on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 4 of 67 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 07/27/2023 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 07/15/23 during the 7:00 PM -7:00 AM shift she met Student Aide D. Resident #2 stated Student Aide D entered the room three times throughout the night. At 9:00 PM, when Student Aide D assisted the resident to bed for the evening and at 12:30 AM when the resident requested a brief change and to be repositioned. Resident #2 stated she heard Resident #1 requesting to have her bed lifted, which should not have been done. Resident #2 stated about 1:45 AM she was awakened by a loud noise, and she heard Resident #1 complaining and moaning. Resident #2 stated she saw Student Aide D leaving the room. Resident #2 stated Resident #1 liked to get up at 5:30 AM, at that time different staff were working, and she was told Student Aide D left the facility. Resident #2 stated Resident #1 complained of pain when CNA E got her out of bed and prepared her for breakfast. Interview on 07/25/23 at 4:29 PM with CNA F revealed when she arrived to work on Sunday 07/16/23 for the 7:00 AM-7:00 PM shift, she observed Resident #1 sitting out by the nurses' station. The resident was complaining of pain and saying that her right leg was hurting. CNA F stated on this day she worked a different hall and was not sure what the aides or nurses on 200 Hall had done to treat Resident #1's leg pain. CNA F stated Resident #1 had complained of pain by tapping her right leg the whole time she was in the chair. CNA F stated she normally worked with her on 200 Hall and noted the resident's behavior was not normal so she advised the aides on 200 Hall (CNA G and Student Aide H) to put Resident #1 to bed around 3:00 PM- 4:00 PM. According to CNA F, she was told by aides on 200 Hall they had informed LVN B that Resident #1 was complaining about pain to her right leg. CNA F stated the next morning on 07/17/23, she returned to the 200 hall. CNA F stated she was notified Resident #1 remained in bed throughout the night and for breakfast due to her complaints of pain. CNA F stated she entered Resident #1's room to complete care, during that time she observed Resident #1's leg was bent and thought it was weird. CNA F stated she rolled Resident #1 to her right side, when she rolled her on her left side, she noticed Resident #1's right leg just fell to the side. CNA F stated at that point she went to alert LVN C for an assessment. Interview on 07/25/23 at 4:42 PM with the Nurse Practitioner revealed she was not on-call from 07/15/23-07/17/23. The Nurse Practitioner stated she was able to reveal on her phone that LVN C contacted the Physician through the communication app they used with the Medical Director on Monday 07/17/23 at 10:45 AM due to Resident #1's right leg being bent, the resident guarding that leg, complaining of right leg pain, and a notation that when the aide was completing care the aide felt movement in the right leg when transferring. The Nurse Practitioner stated the doctor saw the resident via video and was able to provide an order for x-ray and tramadol for pain. The Nurse Practitioner stated the information she received about the injury was speculation so she could not speak on the risk for the resident; however, she stated it was expected that the facility immediately notify the physician via their electronic communication app when residents had a change in condition. Interview on 07/25/23 at 4:55 PM with the DON revealed she was alerted during the morning clinical meeting that Resident #1 was complaining of pain and an x-ray had been ordered. The DON stated Resident #1 told them she fell out of bed and the night worker helped her back to bed. The DON stated Student Aide D was reassigned to the 200 Hall with Resident #1 which was whom Resident #1 was referring to the night worker. The DON stated after the fall Student Aide D did not notify anyone of Resident #1's fall or complaint of pain and left mid shift and had not returned to the facility. The DON stated LVN C was alerted of Resident #1's pain and injury on Monday 07/17/23 morning, contacted the Physician, followed orders for x-ray. The DON stated following findings of the x-ray Resident #1 was transferred to the hospital on [DATE] with findings of fractured femur which resulted in surgery. According to the DON, it was the facility policy for the charge nurse to contact the Physician immediately when residents were complaining of pain or had a change of condition. The DON stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 5 of 67 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 07/27/2023 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the charge nurse was also responsible for alerting the family or the responsible party and herself along with the Administrator (the abuse coordinator) when residents were exhibiting a change of condition or had been involved in an injury. The DON stated it was the responsibility of all staff to report any neglect or failure to treat residents to charge nurse, ADON, DON or to the abuse coordinator. According to the DON, the abuse and neglect policy was often reviewed during in-services. The DON stated LVN B should have completed a full assessment on Resident #1 to identify Resident #1's pain and then reported the findings to the Physician, DON, and the Administrator immediately. Interview on 07/26/23 at 9:48 AM with CNA E revealed she worked on the 7:00 PM-7:00 AM overnight shift on 07/15/23. CNA E stated she saw Student Aide D enter Resident #1's room three times throughout the shift and abruptly left the facility about 2:17 AM. After Student Aide D left the building, CNA E stated she did a round to Resident #1's room and observed the resident in bed sitting straight up sleeping. CNA E stated she left the room to prepare for a brief change. Upon returning Resident #1's room, the resident was making sounds of moaning and groaning which she thought was her normal communication to leave her alone. CNA E stated Resident #1 was not wet so she left her alone. CNA E stated when she returned to Resident #1's room at 5:30 AM to get her up for the day, the resident yelled out differently. She stated the resident's cry was deeper than her normal communication. CNA E stated her roommate commented that sound was different and that she thought Resident #1 was in pain. CNA E stated when she pushed Resident #1 to the hall Resident #1 grabbed her shirt and patted her knee indicating she was in pain. CNA E stated she thought Resident #1 just wanted to fix her pant leg which needed to be pulled down. CNA E then lifted Resident #1's right leg and the resident screamed. When she lowered Resident #1's leg, the resident screamed again patting her right knee. CNA E stated she then told LVN A that Resident #1 was in pain and may need Tylenol. CNA E stated she walked away and thought LVN A provided medication at that time. CNA E stated she did not observe LVN A do any type of assessment. CNA E stated the next night (07/16/23) Resident #1 was already in the bed sleeping. CNA E stated Resident #1 slept the whole night and did not wet the whole night. When she attempted to wake the resident the next morning, the residents grabbed the covers and requested water. CNA E stated the resident refused to get up for the day. CNA E stated she then alerted LVN A that Resident #1 had no incontinence care all night, refused to get up, and had requests for lots of water. CNA E stated she had completed training on resident abuse and neglect, that she understood to alert the charge nurse when there was a change in condition with residents. Interview on 07/26/23 at 12:01 PM with LVN C revealed she worked the 7:00 AM-7:00 PM shift on 07/17/23, after breakfast she was notified by CNA F that something was wrong with Resident#1's leg. LVN C stated Resident #1's right leg was usually 90% straight and left leg bent, but at this time she was in a butterfly position, with both heels touching her brief. LVN C stated she immediately contacted the Physician via their electronic communication app and had a video call within two minutes, and she received an order for Resident #1 to have an x-ray and Tramadol for pain. LVN C stated the x-ray was completed within four hours, and the x-ray revealed Resident #1 had a femur fracture of the right leg. LVN C stated at this time she prepared for Resident #1 to be sent out to the hospital. During her assessment, Resident #1's leg was swollen, warm to touch, and she was guarding with palpations. When she asked Resident #1 and Resident #2 how the injury took place, neither of them said anything until Resident #1's family member entered the room. It was not until then she heard Resident #1 say she fell out the bed. LVN C stated after the findings of the x-ray she was notified Resident #1 was not eating, had refused all three previous meals, not drinking, crying, and saying her knee was hurting. LVN C stated Resident #1 had not had any pain medications prior or while waiting to transfer to the hospital. LVN C stated Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 6 of 67 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 07/27/2023 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some #1 did not exit the facility for the hospital until 5:30 PM. According to LVN C not contacting the physician immediately over the weekend placed Resident #1 at risk for further damage to her leg, infection, becoming septic and prolonged time in pain. LVN C stated knowing what she knew now she should have used her nursing judgement and called 911 to send Resident #1 to the hospital immediately after observation and assessment of her leg. Interview on 07/26/23 at 12:59 PM with CNA T revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23. CNA T stated she walked past Resident #1 as she was out in the hallway. CNA T stated Resident #1 was stopping everyone and anyone trying to get their attention. CNA T stated Resident #1 was trying to say something, but because she did not work with her on a regular basis, she grabbed CNA G. CNA T stated Resident #1 was moaning, and she thought the resident said, Help me. According to CNA T because she worked on another hall, she did not see Resident #1 again. CNA T stated because she contacted the CNA that was working on her hall, she did not contact the nurse to notify him that Resident #1 was complaining of pain. CNA T stated not notifying the nurse that Resident #1 was expressing pain may have caused her prolonged pain. Interview on 07/26/23 at 1:13 PM with CNA G revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23, CNA G stated when she arrived Resident #1 was already sitting in her spot near the nurses' station. CNA G stated Resident #1 told her about having knee pain. CNA G stated when LVN B arrived she notified him about Resident #1's knee pain. CNA G stated, During breakfast, I was pushing Resident #1 down to the dining room and Student Aide H was telling me that Resident #1's leg was swinging, which I could not see because I was behind her and trying to get residents to breakfast. CNA G stated she brought Resident #1 to the dining room, but the resident wheeled herself back to the nurses' station. The resident refused breakfast, lunch, and dinner on that day. CNA G stated Resident #1 continued pointing to her knee saying it was hurting. CNA G stated she and Student Aide H discussed amongst themselves that something was wrong with Resident #1's leg, and they both had told LVN B about the resident's knee pain more than once. Interview on 07/26/23 at 2:03 PM with Student Aide H revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23. Student Aide H stated when she arrived to work, Resident #1 was in her usual spot near the nurses' station. Student Aide H stated she saw CNA G pushing Resident #1 down the hall and noticed her leg was swinging back and forth, she was crying, and complaining of pain in her leg that was swinging. Student Aide H stated she expressed to LVN B what she observed. Student Aide H stated she later put Resident #1 down for bed, completed care, and when she rolled her on her right side she screamed so loud. Student Aide H stated she then went to alert LVN B that Resident #1 was screaming in pain, and this was not normal for her. According to Student Aide H when she returned to put Resident #2 down for bed, she asked Resident #1 what happened, Resident #1 would agree to having a fall after she was asked a series of questions. Student Aide H stated she then returned to LVN B and shared that Resident #1 indicated she had a fall. Interview on 07/26/23 at 2:10 PM with LVN B revealed he worked the morning shift 7:00 AM-7:00 PM on 07/16/23. He stated Resident #1 was already up in her wheelchair and near the nurses' station when he arrived. LVN B stated Resident #1 appeared normal to him, and he did not recognize anything out of the normal with her. LVN B stated she did return from the dining room refusing breakfast stating her keen was hurting. LVN B stated he did not observe any bruising or redness after being told by staff Resident #1 was in pain. LVN B stated he did not conduct a full assessment for pain, and he did not administer any pain medication for Resident #1's pain. LVN B stated he could not recall doing anything to assist Resident #1's pain. LVN B also stated he did not follow-up with her throughout the day to see how she was feeling or to see if he needed to alert the Physician that the resident was in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 7 of 67 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 07/27/2023 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some pain, had a change of condition, or refused to eat. When LVN B was asked about risk to Resident #1's fractured femur not being assessed in a timely manner, he apologized for not being much help. Interview on 07/26/23 at 2:46 PM with LVN A revealed she worked on the overnight shift 7:00 PM-7:00 AM on 07/15/23 for 100 Hall and 200 Hall. LVN A stated she did not have any complaints of a fall. LVN A stated throughout the night Resident #1 rested fine, until she was getting out of bed between 5:30 AM-6:00 AM. LVN A stated when CNA E went to get the resident up, the resident stated her knee was hurting and it was reported she was sleeping in a weird position. Her head was up really high, her legs were sideways, and her legs stiff. LVN A stated when she went to check Resident #1, the resident was dressed, in a wheelchair in the hallway. LVN A stated at that time she did not think anything serious happened. LVN A stated she administered pain mediation prior to leaving on 07/16/23. LVN A stated when she returned the next day there were no complaints of pain, Resident #1 was in bed the entire shift. LVN A stated when she left on Monday morning 07/17/23, she got a call from the facility stating Resident #1 was injured. LVN A stated during the call she was informed Resident #1 complained of pain on Sunday 07/16/23, and the day nurse gave her pain medication. LVN A stated she did not complete an assessment to identify the source pain after CNA E and Resident #1 complained the resident was in pain. LVN A stated she did not contact the Physician, DON, or the oncoming nurse that she was informed Resident #1 was in pain. According to LVN A not completing a full assessment or identifying a change of condition could place residents at risk of not receiving immediate care. Review of facility's current Notifying the Physician of Change in Status policy, dated 03/11/13 reflected: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention . 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. 2. .the nurse will gather medications, vital signs, signs and symptoms, and interventions that have currently been implemented. 3. . the nurse is responsible for responding to a change of condition in a timely and effective manner. 4. If the situation is an emergency and the attempts to the physician was unsuccessful, the nurse will contact the nearest ambulance service for assistance. 5. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 8 of 67 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 07/27/2023 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 0580 Level of Harm - Immediate jeopardy to resident health or safety The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise This was determined to be an Immediate Jeopardy on 07/26/23 at 4:49 PM. The Director of Nursing was notified an Immediate Jeopardy had been identified. The Director of Nursing was provided with the Immediate Jeopardy on 07/26/23 at 5:38 PM. Residents Affected - Some The facility's Plan of Removal was accepted on 07/27/23 at 1:18 PM. The Plan of Removal reflected the following: o As of 7/26/23 [Resident #1] was assessed for pain. Orders received as of 7/26/23 for scheduled and PRN pain meds. o All residents in the facility were assessed for any increased pain by the DON, ADON and Charge Nurses as of 7/26/23. No additional issues were found. Education: All charge nurses were in-serviced on 7/26/23 by the Compliance Nurse/DON/ADON regarding the following and all nurses including agency staff, new hires, and PRN staff not in-serviced by 7/26/23 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse. o Notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits. o Implementation of physician orders immediately upon receipt including the administration of pain medications. o A head-to-toe assessment will be performed by the charge nurse on all residents who complain of increased pain. All nursing staff were in-serviced on 7/26/23 by the Compliance Nurse/DON/ADON. All staff not in-serviced on 7/26/23 including agency staff, new hires and PRN staff will not be allowed to work their assigned schedule until the completion of these in-services. o (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 9 of 67 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 07/27/2023 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 0580 Notify the charge nurse immediately if a resident is found on the floor. The resident will not be moved until assessed by a nurse. Level of Harm - Immediate jeopardy to resident health or safety o Residents Affected - Some Notification of change of condition to the physician immediately including falls, injuries, increased pain, decreased mobility, or a change in eating habits. o Pain: Signs and symptoms of pain verbal and non-verbal. (crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching Medical Director was notified by the DON on 7/26/23 at 8:18pm about the Immediate Jeopardies. An AD HOC QAPI meeting will be held on 7/27/23 by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. The Director of Nursing or designee will implement this written Plan of Removal and will continue to monitor completion and compliance of this written Plan of Removal. Monitoring: o The DON and/or designee will monitor Real Time clinical software and the PCC Dashboard for clinical alerts for any resident change of condition including new or increased pain at least 5 days per week to ensure physician/NP were notified. Monitoring began 7/26/2023 and will continue x 4 weeks. o The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 days per week, to ensure any new physician/NP orders were implemented immediately. Monitoring began 7/26/23 and will continue x 4 weeks. Interview on 07/27/23 at 2:14 PM with the ADON revealed in-services had been started to identify change of condition, charge nurse to complete full assessments, understanding signs and symptoms of pain both verbal and nonverbal, contacting the physician and implementing physician orders immediately. The ADON stated she completed in-services with aide staff regarding neglect, not moving[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 10 of 67 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 07/27/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the right to be free from abuse for one (Resident #1) of eleven residents reviewed for abuse. Residents Affected - Some The facility failed to ensure Resident #1 was free from deprivation of goods and services by staff regarding help with pain, assessing the resident as needed, and consulting with the physician from 07/16/23 midnight until 07/17/23 at 5:30 PM when Resident #1 was transported to the hospital. An Immediate Jeopardy was identified on 07/25/23, The Immediate Jeopardy template was provided to the facility on [DATE] at 5:38 PM. While the Immediate Jeopardy was removed on 07/27/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, and resident neglect and following facility policy. This failure placed residents at risk of a delay in treatment, and a worsening of their condition or could result in death. Findings included: Record review of Resident #1's face sheet dated 07/25/23 revealed Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included other abnormalities of gait and mobility, other lack of coordination, muscle wasting and atrophy, muscle weakness, reduced mobility, abnormal posture, repeated falls, foot drop, right foot (gait abnormality of the right foot). Record review of Resident #1's annual MDS assessment, dated 06/12/23 revealed her BIMS score was 99 indicating Resident #1 was unable to complete the assessment. Her Functional Status for activities of daily living indicated she required extensive assistance with one person assist with bed mobility, dressing and personal hygiene. The resident required extensive assistance from two people for ADLs to include eating, transfers and toileting. The resident also required supervision and set up assistance with locomotion on and off the unit. Record review of Resident #1's BIMS assessment dated [DATE] revealed her BIMS score was 0 indicating severe impairment. Interview on 07/25/23 at 2:57 PM with Resident #1's family member revealed she visited almost daily at 3:00 PM, when she entered the facility on Monday 07/17/23, the receptionist stated there was something wrong with Resident #1. She stated on her way to Resident #1's room LVN C followed expressing the same thing that Resident #1 had an injury. The family member stated when she entered the room Resident #1 was moaning, groaning and grimacing from pain. The family member stated both Resident #1 and her roommate started to explain the cause of Resident #1's pain. They informed her late Saturday night 07/15/23, early Sunday morning 07/16/23 about midnight, that she was reaching for the call button, fell and the aide came in and threw her back in bed. The family member stated Resident #1 told her she fell on her bottom and hit her head. The family member stated she pulled the covers back, and it was obvious there was a fracture to Resident #1's right femur. The family member stated she was upset the facility had not contacted her prior to her entering the facility. The family member stated in speaking with the Administrator he apologized and stated the facility should have contacted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 11 of 67 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 07/27/2023 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 0600 her immediately, and he would complete an investigation. Level of Harm - Immediate jeopardy to resident health or safety Interview on 07/25/23 at 3:22 PM with Resident #2, roommate to Resident #1, she revealed during the 7:00 PM -7:00 AM shift she met Student Aide D. Resident #2 stated Student Aide D entered the room three times throughout the night. She stated Student Aide D entered the room at 9:00 PM when she assisted her to bed for the evening and again at 12:30 AM when she requested a brief change and to be repositioned. The third time was when she overheard Resident #1 requesting to have her bed lifted, which should not have been done. Resident #2 stated about 1:45 AM she was wakened by a loud noise, and Resident #1 complaining and moaning, and she saw Student Aide D leaving the room. Resident #2 stated Resident #1 liked to get up at 5:30 AM, at that time different staff were working, and they was told Student Aide D left the facility. Resident #2 stated Resident #1 complained of pain when CNA E got her out of bed and prepared her for breakfast. Residents Affected - Some Interview on 07/25/23 at 4:29 PM with CNA F revealed when she arrived to work on Sunday 07/16/23, she observed Resident #1 sitting out by the nurses' station. The resident was complaining of pain, saying that her right leg was hurting. CNA F stated on that day she worked a different hall and was not sure what aides or nurses on 200 Hall had done to treat the resident's leg pain. CNA F stated Resident #1 had complained of pain by tapping her right leg the whole time she was in the chair. CNA F stated she normally worked with her on 200 Hall and noted the behavior was not normal so she advised the aides on 200 Hall to put Resident #1 to bed around 3:00 PM- 4:00 PM. According to CNA F, she was told by aides on 200 Hall they had informed LVN B that Resident #1 was complaining about pain to her right leg. CNA F stated the next morning 07/17/23, she returned to the 200 Hall. CNA F stated she was notified Resident #1 remained in bed throughout the night and breakfast due to her complaint of pain. CNA F stated she entered Resident #1's room to complete care, during that time she observed Resident #1's leg was bent and thought it was weird. CNA F stated she rolled Resident #1 to her right side, when she rolled her on her left side, CNA F stated she noticed Resident #1's leg just fell to the side. CNA F stated at that point she went to alert LVN C for an assessment. Interview on 07/25/23 at 4:42 PM with the Nurse Practitioner revealed she was not on-call from 07/15/23-07/17/23; however, she was able to reveal on her phone that LVN C used the facility's electronic communication app to contact the Physician on Monday 07/17/23 at 10:45 AM due to right leg pain, Resident #1's leg was bent, the resident guarding the leg, and when the aide was completing care she felt movement in the leg during a transfer. The Nurse Practitioner stated the Physician saw Resident #1 via video and was able to provide an order for x-ray and tramadol for pain. According to the Nurse Practitioner, the information she received about the injury was speculation so she could not speak on the risk for the resident; however, she stated it was expected that the facility immediately notify the physician using the electronic communication app when residents experienced a change in condition. Interview on 07/25/23 at 4:55 PM with the DON revealed she was alerted during the morning clinical meeting on 07/17/23 that Resident #1 was complaining of pain and an x-ray had been ordered. According to the DON, Resident #1 stated she fell out of bed and the night worker helped her back to bed. The DON stated Student Aide D was reassigned to the 200 Hall with Resident #1 which was whom Resident #1 was referring to the night worker. The DON stated after the fall Student Aide D did not notify anyone of Resident #1's fall or complaint of pain and left mid shift and had not returned to the facility. The DON stated LVN C was alerted to Resident #1's pain and injury on Monday 07/17/23 morning. She stated LVN C contacted the physician and followed orders for x-ray. The DON stated following findings of the x-ray Resident #1 was transferred to the hospital on [DATE] with findings of fractured femur which resulted in surgery. According to DON, it was the facility policy for the charge nurse to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 12 of 67 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 07/27/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some contact the Physician immediately when residents were complaining of pain or had a change of condition. The DON stated the charge nurse was also responsible for alerting the family or responsible party and herself along with the Administrator (Abuse Coordinator) when residents were exhibiting a change of condition or had been involved in an injury. The DON stated it was the responsibility of all staff to report any neglect or failure to treat residents to the charge nurse, ADON, DON or to the Abuse Coordinator. Interview on 07/26/23 at 9:48 AM with CNA E revealed she worked on the 7:00 PM - 7:00 AM overnight shift on 07/15/23. CNA E stated she saw Student Aide D enter Resident #1's room three times throughout the shift and abruptly left the facility about 2:17 AM. CNA E stated after Student Aide D left the facility, she did a round to Resident #1's room and observed the resident in bed sitting straight up sleeping. CNA E stated she left the room to prepare for a brief change, and when she returned to the room, Resident #1 was making moaning and groaning sounds which she thought was the resident's normal communication to leave her alone. She stated the resident was not wet so she left the resident alone. CNA E stated when she returned at 5:30 AM to get the resident up for the day the resident yelled out differently. She stated Resident #1's cry was deeper than her normal communication. CNA E stated her roommate commented that sound was different and that she thought Resident #1 was in pain. CNA E stated when she pushed Resident #1 to the hall Resident #1 grabbed her shirt and patted her knee indicating she was in pain. CNA E stated she thought Resident #1 just wanted to fix her pant leg which needed to be pulled down, CNA E then lifted Resident #1's right leg and the resident screamed. She stated she then lowered Resident #1's leg, and the resident screamed again patting her right knee. CNA E stated she then told LVN A that Resident #1 was in pain and may need Tylenol. CNA E stated she walked away and thought LVN A provided medication at that time. CNA E stated she did not observe LVN A do any type of assessment. The next night when she worked again, Resident #1 was already in the bed sleeping. She stated the resident slept the whole night and did not wet the whole night. When she attempted to wake the resident the next morning, the resident grabbed the covers and requested water. CNA E stated Resident #1 refused to get up for the day. CNA E then alerted LVN A that Resident #1 had no incontinence care all night, refused to get up, and her request for lots of water. CNA E stated she had completed training on resident abuse and neglect, that she understood to alert charge nurse when there was a change in condition with residents. Record review of Resident #1's care plan, last care conference 04/28/23, revealed: 1. Resident #1 at risk for falls related to muscle weakness, Goals: risks and injury potential will be minimized through the next review date. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. The resident needs a safe environment with: even floors free from spills and or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. 2. Resident #1 has an activities of daily living self-care performance deficit related to dementia, disease process. Goal: maintain current level of function in activities of daily living through the review date. Intervention: gather and provide needed supplies, observe/document/report as needed any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 13 of 67 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 07/27/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Physical/Occupational therapy evaluation and treatment as per orders. Resident requires extensive assist by 1 staff to turn and reposition in bed. Resident requires extensive assist by 2 staff to move between surfaces. Resident requires extensive assist of 1 staff to dress. Resident requires extensive assistance by 2 staff for toileting. Residents Affected - Some 3. Resident #1 has potential for pain related to right foot drop. Goal: Resident will not have an interruption in normal activities due to pain through review date. Intervention: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions ever shift. Review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Observe/document for probable cause of each pain episode. Remove/limit causes where possible. Observe/document for side effects of pain medication. Observe/record/report to nurse any signs and symptoms of non-verbal pain: changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling outs, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Observe/record/report to nurse loss of appetite, refusal to eat and weight loss. Observe/record/report to nurse resident complaints of pain or requests for pain treatment. Provide non-pharmacological interventions. Report to nurse any change in usual activity attendance patterns or refusal to attend activities related to signs and symptoms of pain or discomfort. Therapy referral as indicated. 4. Resident #1 has Osteoporosis. Goal: Resident will remain free of injuries or complications related to osteoporosis. Interventions: Give analgesics PRN for pain. Resident may complain of pain, stiffness, or weakness. Document complaints. Observe for risk of falls. Educate resident, family /caregivers on safety measures that need to be taken in order to reduce risk of falls. Observe/document/report PRN s/sx or complications related to osteoporosis: Acute fracture, Compression fractures, Loss of height, Kyphosis (dowagers hump, thoracic curve), Pain. Interview on 07/26/23 at 12:01 PM with LVN C revealed she worked the 7:00 AM-7:00 PM shift on 07/17/23, after breakfast she was notified by CNA F that something was wrong with Resident#1's leg. LVN C stated Resident #1's right leg was usually 90% straight and left leg bent, but at this time she was in a butterfly position, with both heels touching her brief. LVN C stated she immediately contacted physician via Spruce, video call within two minutes, and received an order for x-ray and Tramadol for pain. LVN C stated x-ray was completed within four hours indicating femur fracture of the right leg. LVN C stated at this time she prepared for Resident #1 to be sent out to the hospital. LVN C stated during her assessment Resident #1's leg was swollen, warm to touch, and she was guarding with palpations. According to LVN C, when she asked Resident #1 and Resident #2 how the injury took place neither of them said anything until Resident #1's family member entered the room, it was not until (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 14 of 67 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 07/27/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some then she heard Resident #1 say she fell out the bed. LVN C stated after the findings of the x-ray she was notified Resident #1 was not eating, had refused all three previous meals, not drinking, crying, and saying her knee was hurting. LVN C stated Resident #1 had not had any pain medications prior or while waiting to transfer to the hospital. LVN C stated Resident #1 did not exit the facility for the hospital until 5:30 PM. According to LVN C not contacting the physician immediately over the weekend placed Resident #1 at risk for further damage to her leg, infection, becoming septic and prolonged time in pain. LVN C stated knowing what she knew now she should have used her nursing judgement and called 911 to send Resident #1 to the hospital immediately after observation and assessment of her leg. Record review of Resident #1's progress notes dated 07/17/23 at 12:00 AM copy of documentation signed by Physician reflected: Follow up Physical exam, Elderly, frail female in some distress seen via video, Right lower extremity bent at ninety degrees, grimacing with palpation. Patient seen via telemedicine with nurse. 1. Pelvis and right femur x-ray. Concern for fracture status post transfer. 2. Tramadol 100mg po q6h PRN pain for 14 days if no allergies. 3. Follow up x-ray. Record review of Resident #1's progress notes dated 07/17/23 at 9:15 PM written by LVN C reflected the following late entry: [CNA F] reported that resident was complaining of pain during a brief change. I went and looked at her leg, and then messaged the doctor. The doctor video called, and we looked at the leg together. The doctor ordered x-rays and pain meds for resident. This nurse put in the orders. The x-ray techs showed up around 5:30 PM, and so did family member. X-ray showed femur break. This nurse reported that to doctor and called for transport to hospital. It was 5:45 PM before resident was transported to hospital due to ambulance being busy. Record review of Resident #1's progress notes dated 07/17/23 at 5:54 PM written by ADON reflected the following late entry: Resident reported leg pain to aide and aide notified nurse. Nurse assessed resident and did a telehealth video call and X-ray, and pain meds were ordered. Family member was at bedside during x-ray and when it was resulted. Right femur fracture. Upon further investigation, resident states she did fall out of bed last night onto her knees and a worker helped her up. Patient has good situational awareness. Emergency Transportation was called, and resident sent to hospital at 5:45 PM. Record review of Resident #1's progress notes dated 07/17/23 at 6:46 PM written by LVN C reflected: Resident #1 was transferred to a hospital on [DATE] 5:50 PM related to right femur fracture. Record review of Resident #1's progress notes dated 07/17/23 at 7:34 PM written by nurse documented: Resident #1 in hospital. Record review of Resident #1's progress notes dated 07/18/23 at 8:35 PM written by LVN C reflected: Spoke to family member in regards to resident. Resident is going to have surgery for repair the femur fracture, remove old hardware that has come out, and run a rod from her knee to pelvis. Resident will be non-weight bearing post-operation and will no longer be able to walk. Record review of accident and incident reports dated 05/25/23-07/25/23 indicated Resident #1 had fracture incident on 07/17/23 3:30 PM. Record review of order revealed: Order date: 07/17/23 10:52 AM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 15 of 67 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 07/27/2023 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 0600 Order Summary: Xray of pelvis, Right hip and femur one time only for right leg pain for 1 day Level of Harm - Immediate jeopardy to resident health or safety Record review of Final X-Ray Report, dated 07/17/23, revealed: Residents Affected - Some Moderately displaced oblique fracture of distal diaphysis of femur of indeterminate age. (bone broken at an angle that affected the knee and leg) 1. 2. Dislocation of right hip is present 3. Internal fixation of right femoral neck. Record review of Resident #1's July 2023 MAR revealed: Tramadol HCI oral tablet 100 MG (give 1 tablet by mouth every 6 hours as needed for pain for 14 days) for the month of July was not administered on July 17th prior to resident being sent out to the hospital. Tylenol Extra Strength Oral Tablet 500 MG (give 1 tablet by mouth every 6 house as needed for pain) for the month of July was not administered on July 15th, 16th or 17th prior to resident being sent out to the hospital. Record review of hospital records, dated 07/17/23, revealed: Chief complaint: Right leg pain from a fall. Emergency department work up included a right femur x-rays revealed a displaced, evaluated distal femoral diaphyseal fracture. Hospital records, dated 07/18/23 reflected the resident completed surgery on 07/18/23. Interview on 07/26/23 at 1:13 PM with CNA G revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23, CNA G stated when she arrived Resident #1 was already sitting in her spot near the nursing station. CNA G stated Resident #1 did tell her about her knee pain. CNA G stated when LVN B arrived she notified him of her pain. CNA G stated, during breakfast I was pushing Resident #1 down to the dining room and Student Aide H was telling me that Resident #1's leg was swinging, which I could not see because I was behind her and trying to get residents to breakfast. CNA G stated once she left Resident #1 in the dining room she wheeled herself back to the nursing station, she refused breakfast, lunch, and dinner on this day. CNA G stated Resident #1 continued pointing to her knee saying it was hurting. CNA G stated she and Student Aide H discussed amongst themselves that something was wrong with Resident #1's leg and that they both had told him about it more than once. Interview on 07/26/23 at 2:03 PM with Student Aide H revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23, Student Aide H stated when she arrived to work Resident #1 was in her usual spot near the nursing station. Student Aide H stated she saw CNA G pushing Resident #1 down the hall and noticed her leg was swinging back and forth, she was crying, complaining of pain in her leg that was swinging. Student Aide H stated she expressed to LVN B what she observed. Student Aide H stated she later put Resident #1 down for bed, completed care, and when she rolled her on her right side she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 16 of 67 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 07/27/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some screamed so loud. Student Aide H stated she then went to alert LVN B that she was screaming in pain, and this was not normal for her. According to Student Aide H when she returned to put Resident #2 down for bed, she asked Resident #1 what happened, Resident #1 would agree to having a fall after she was asked a series of questions. Student Aide H stated she then returned to LVN B and shared that Resident #1 indicated she had a fall. Interview on 07/26/23 at 2:10 PM with LVN B revealed he worked the morning shift 7:00 AM - 7:00 PM on 07/16/23. He stated Resident #1 was already up in her wheelchair and near the nursing station when he arrived. LVN B stated Resident #1 appeared normal to him and he did not recognize anything out of the normal with her. LVN B stated she did return from the dining room refusing breakfast stating her keen was hurting. LVN B stated he did not observe any bruising or redness after being told by staff Resident #1 was in pain. LVN B stated he did not administer a full assessment for pain and stated he did not administer any pain medication for Resident #1's pain. LVN B stated he could not recall doing anything to assist Resident #1's pain. LVN B also stated he did not follow up with her throughout the day to see how she was feeling or to see if he needed to alert the physician that she was indicating pain, change of condition, or her refusal to eat. When LVN B was asked about risk to Resident #1's fractured femur not being assessed in a timely manner he apologized for not being much help. Interview on 07/26/23 at 2:46 PM with LVN A revealed she worked on the overnight shift 7:00 PM-7:00 AM on 07/15/23 for 100 Hall and 200 Hall. LVN A she didn't have any complaints of a fall. LVN A stated throughout the night Resident #1 rested fine, until she was getting out of bed between 5:30 AM-6:00 AM. LVN A stated when the CNA E went to get Resident #1 up, the resident stated her knee was hurting, and it was reported she was sleeping in a weird position. Her head was up really high, legs were sideways, and legs stiff, when she went to check Resident #1 was dressed, in wheelchair, in the hallway. LVN A stated at that time she did not think anything serious happened. LVN A stated she administered pain mediation prior to leaving on 07/16/23. LVN A stated when she returned the next day there were no complaints of pain, Resident #1 was in bed the entire shift. LVN A stated when she left on Monday morning 07/17/23 she got a call from the facility stating Resident #1 was injured. LVN A stated during the call she was informed Resident #1 complained of pain on Sunday 07/16/23 and the day nurse gave her pain medication. LVN A stated she did not complete an assessment to identify the source pain after CNA E and Resident #1 complained resident was in pain. LVN A stated she did not contact physician, DON, or the oncoming nurse she was informed Resident #1 was in pain. According to LVN A not completing full assessment or identifying a change of conditions could place residents at risk of not receiving immediate care. Review of facility's current Abuse/Neglect policy, dated 03/29/18, reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined .Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. On 07/26/23 at 5:38 PM the DON was notified an Immediate Jeopardy had been identified. The facility's Plan of Removal was accepted on 07/27/23 at 1:18 PM. The Plan of Removal reflected the following: o (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 17 of 67 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 07/27/2023 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 0600 As of 7/26/23 [Resident #1] was assessed for pain. Orders received as of 7/26/23 for scheduled and PRN pain meds. Level of Harm - Immediate jeopardy to resident health or safety o Residents Affected - Some All residents in the facility were assessed for any increased pain by the DON, ADON and Charge Nurses as of 7/26/23. No additional issues were found. Education: All charge nurses were in-serviced on 7/26/23 by the Compliance Nurse/DON/ADON regarding the following and all nurses including agency staff, new hires, and PRN staff not in-serviced by 7/26/23 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse. o Notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits. o Implementation of physician orders immediately upon receipt including the administration of pain medications. o A head-to-toe assessment will be performed by the charge nurse on all residents who complain of increased pain. All nursing staff were in-serviced on 7/26/23 by the Compliance Nurse/DON/ADON. All staff not in-serviced on 7/26/23 including agency staff, new hires and PRN staff will not be allowed to work their assigned schedule until the completion of these in-services. o Notify the charge nurse immediately if a resident is found on the floor. The resident will not be moved until assessed by a nurse. o Notification of change of condition to the physician immediately including falls, injuries, increased pain, decreased mobility, or a change in eating habits. o Pain: Signs and symptoms of pain verbal and non-verbal. (crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 18 of 67 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 07/27/2023 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 0600 Medical Director was notified by the DON on 7/26/23 at 8:18 PM about the Immediate Jeopardies. Level of Harm - Immediate jeopardy to resident health or safety An AD HOC QAPI meeting will be held on 7/27/23 by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. Residents Affected - Some The Director of Nursing or designee will implement this written Plan of Removal and will continue to monitor completion and compliance of this written Plan of Removal. Monitoring: o The DON and/or designee will monitor Real Time clinical software and the PCC Dashboard for clinical alerts for any resident change of condition including new or increased pain at least 5 days per week to ensure physician/NP were notified. Monitoring began 7/26/2023 and will continue x 4 weeks. o The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 days per week, to ensure any new physician/NP orders were implemented immediately. Monitoring began 7/26/23 and will continue x 4 weeks. Interview on 07/27/23 at 2:14 PM with ADON revealed in-services had been started to identify change of condition, charge nurse to complete full assessments, understanding signs and symptoms of pain both verbal and nonverbal, contacting the physician and implementing physician orders immediately. The ADON stated she completed in-services with aides regarding neglect and not moving resident after a fall, contacting the charge nurse when resident had a change in condition or expressed pain. The ADON stated during morning shift with LVN A on 07/16/23 was the beginning of Resident #1 expressing pain. The ADON stated LVN B was notified by staff that Resident #1 expressed pain and he should have done a complete assessment for pain, administered pain medication and communicated the history of the day with the oncoming nurse for the next shift. The ADON stated when LVN A returned to the facility on [DATE] at 7:00 PM Resident #1 was in bed, and nobody notified LVN A that Resident #1 was in pain. The ADON stated if LVN B communicated the history of the day, LVN A could have completed proper care and follow up. The ADON stated LVN B not communicating that Resident #1 expressed pain throughout the day put her at risk of not receiving proper pain management and treatment. The ADON stated it was her expectation to address resident needs, follow up with the doctor, DON, family and depending on the situation the Administrator. Further monitoring on 07/27/23 during interviews consisting of both day and night shifts revealed the following: Interviews on 07/27/23 from 2:15 PM through 07/27/23 4:30 PM with the DON, ADON, LVN A, LVN B, LVN C, CNA E, CNA F, CNA G, Student Aide H, LVN I, LVN J, LVN K, LVN L, LVN M, Student Aide N, CNA O, CNA P, Student Aide Q, CNA R, LVN S who worked the shifts of 7:00 AM-7:00 PM, 7:00 PM-7:00AM were able to verify education was provided to them; nursing staff were able to accurately summarize abuse and neglect policy, definitions and examples of change of condition and how, who, and when to report changes. The nursing staff revealed signs and symptoms of residents complaining of pain, what to do and who to contact. The nursing staff expressed understanding of the importance of completing assessments and identify the source of pain and how that plays in part to resident safety. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 19 of 67 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 07/27/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During observations on 07/27/23 between 8:00 AM-5:00 PM revealed staff assessing residents who were exhibiting pain, residents who requested and were administered pain medications. Staff were observed engaging with residents, preforming full assessments, and interviewing residents to determine the source of pain, contacting the physician, documenting, and notifying resident's responsible party of change of condition. Record review of the facility plan of correction monitoring tool form undated titled Actual/Alleged Abuse Monitoring Ask 8-10 staff members per week, situational questions related to the neglectful action document any corrective actions on the back of the form .indicated log started on 07/24/23 with slots for date, time, staff name, responded correctly, who and how soon would they report suspected abuse? Ask 5 residents how staff is treating them. Document date/time, resident name, if there was any negative response. Document any corrective action if needed on the back of this form. During incident/event review in standup, was there any evidence of any potential neglect. While the IJ was removed on 07/27/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, completing full assess[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 20 of 67 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 07/27/2023 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse/neglect of a resident for one (Resident #1) of eleven residents reviewed for abuse. Residents Affected - Some The facility failed to ensure Resident #1 was free from deprivation of goods and services by staff when they failed to: pain management, assess the resident as needed, and consult with the physician from 07/16/23 midnight until 07/17/23 at 5:30 PM when Resident #1 was transferred to the hospital. An Immediate Jeopardy was identified on 07/25/23, The Immediate Jeopardy template was provided to the facility on [DATE] at 5:38 PM. While the Immediate Jeopardy was removed on 07/27/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, and resident neglect and following facility policy. This failure placed residents at risk of a delay in treatment, and a worsening of their condition or could result in death. Findings included: Record review of Resident #1's face sheet dated 07/25/23 revealed Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included other abnormalities of gait and mobility, other lack of coordination, muscle wasting and atrophy, muscle weakness, reduced mobility, abnormal posture, repeated falls, foot drop, right foot (gait abnormality of the right foot). Record review of Resident #1's annual MDS assessment, dated 06/12/23 revealed her BIMS score was 99 indicating Resident #1 was unable to complete assessment. Her Functional Status for activities of daily living indicated she required extensive assistance with one person assist with bed mobility, dressing and personal hygiene. Extensive assistance with 2 person assist with eating, transfers and toileting. Supervision and set ups with locomotion on and off the unit. Record review of Resident #1's BIMS assessment dated [DATE] revealed her BIMS score was 0 indicating severe impairment. Interview on 07/25/23 at 2:57 PM with family member revealed she visits almost daily at 3:00 PM, when she entered the facility on Monday the receptionist stated there was something wrong with Resident #1. She stated on her way to Resident #1's room LVN C followed expressing the same thing, (that Resident #1 had an injury), family member stated when she entered the room Resident #1 was moaning, groaning and grimacing from pain, both Resident #1 and roommate started to explain the cause of her pain, late Saturday night, early Sunday morning about midnight, that she was reaching for the call button, fell and the aide came in and threw her back in bed, Resident #1 stated to family member she fell on her bottom and hit her head. Family member stated she pulled the cover back and it was obvious there was a fracture to her right femur. Family member stated she was upset the facility had not contacted her prior to her entering the facility. Family member stated in speaking with the Administrator he apologized and stated the facility should have contacted her immediately and he would complete an investigation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 21 of 67 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 07/27/2023 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Interview on 07/25/23 at 3:22 PM with Resident #2, roommate to Resident #2 revealed during the 7:00 PM-7:00 AM shift she met Student Aide D. Resident #2 stated Student Aide D entered the room [ROOM NUMBER] times throughout the night, 9:00 PM when she assisted me to bed for the evening, 12:30 AM when she requested a brief change and to be repositioned, Resident #2 stated she heard Resident #1 requesting to have her bed lifted, which should not have been done. Resident #2 stated about 1:45 AM she was wakened by a loud noise, and Resident #1 complaining and moaning, and she saw Student Aide D leaving the room. Resident #2 stated Resident #1 liked to get up at 5:30 AM, at this time different staff were working and was told Student Aide D left the facility. Resident #2 stated Resident #1 complained of pain when CNA E got her out of bed and prepared her for breakfast. Interview on 07/25/23 at 4:29 PM with CNA F revealed when she arrived to work on Sunday 07/16/23, she observed Resident #1 sitting out by the nurses' station, complaining of pain, saying that her right leg was hurting. CNA F stated on this day she worked a different hall and was not sure what aides or nurses on 200 hall had done to treat her leg pain. CNA F stated Resident #1 had complained of pain by tapping her right leg the whole time she was in the chair. CNA F stated she normally worked with her on 200 and noted the behavior was not normal so she advised the aides on 200 hall to put Resident #1 to bed around 3:00 PM-4:00 PM. According to CNA F she was told by aides on 200 hall they had informed LVN B that Resident #1 was complaining about pain to her right leg. CNA F stated the next morning 07/17/23, she returned to the 200 hall. CNA F stated she was notified Resident #1 remained in bed throughout the night and breakfast due to her complaint of pain. CNA F stated she entered Resident #1's room to complete care, during this time she observed Resident #1's leg was bent and thought it was weird. CNA F stated she rolled Resident #1 to her right side, when she rolled her on her left side CNA F stated she noticed Resident #1's leg just fell to the side. CNA F stated at this point she went to alert LVN C for an assessment. Interview on 07/25/23 at 4:42 PM with the Nurse Practitioner revealed she was not on-call from 07/15/23-07/17/23; however, she was able to reveal on her phone that LVN C contacted the physician using the electronic communication app on Monday 07/17/23 at 10:45 AM due to right leg pain, Resident #1's leg was bent, and she was guarding, aide was completing care and felt movement in the leg with transferring. The Nurse Practitioner stated the doctor saw resident via video and was able to provide order for x-ray and tramadol for pain. According to the Nurse Practitioner stated the information she received about the injury was speculation so she could not speak on the risk for the resident, however she stated it was expected that the facility immediately notify the physician using the electronic communication app when residents have a change in condition. Interview on 07/25/23 at 4:55 PM with DON revealed she was alerted during morning clinical meeting that Resident #1 was complaining of pain and an x-ray had been ordered. According to DON Resident #1 stated she fell out of bed and the night worker helped her back to bed. The DON stated Student Aide D was reassigned to the 200 hall with Resident #1 which was whom Resident #1 was referring to the night worker. The DON stated after the fall Student Aide D did not notify anyone of Resident #1's fall or complaint of pain and left mid shift and had not returned to the facility. DON stated LVN C was alerted of Resident #1's pain and injury on Monday 07/17/23 morning, contacted the physician, followed orders for x-ray. DON stated following findings of the x-ray Resident #1 was transferred to the hospital on [DATE] with findings of fractured femur which resulted in surgery. According to DON it is facility policy for the charge nurse to contact the physician immediately when residents are complaining of pain or have a change of condition. The DON stated the charge nurse is also responsible for alerting family or responsible party and herself along with the Administrator (Abuse Coordinator) when residents are exhibiting a change of condition or have been involved in an injury. The DON stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 22 of 67 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 07/27/2023 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some it was the responsibility of all staff to report any neglect or failure to treat residents to charge nurse, ADON, DON or to the abuse coordinator. Interview on 07/26/23 at 9:48 AM with CNA E revealed she worked on the 7:00 PM - 7:00AM overnight shift on 07/15/23. CNA E stated she saw Student Aide D enter Resident #1's room [ROOM NUMBER] times throughout the shift and abruptly left the facility about 2:17 AM. CNA E stated after Student Aide D left the facility, she did a round to Resident #1's room and observed her in bed sitting straight up sleeping, she left the room to prepare for a brief change, upon returning Resident #1 was making sounds of moaning and groaning which she thought was her normal communication to leave her alone, she was not wet so she left her alone. CNA E stated when she returned at 5:30 AM to get her up for the day she yelled out differently, her cry was deeper than her normal communication. CNA E stated her roommate commented that sound was different and that she thought Resident #1 was in pain. CNA E stated when she pushed Resident #1 to the hall Resident #1 grabbed her shirt and patted her knee indicating she was in pain. CNA E stated she thought Resident #1 just wanted to fix her pant leg which needed to be pulled down, CNA E then lifted Resident #1's right leg and she screamed, she stated when she lowered Resident #1's leg she screamed again patting her right knee. CNA E stated she then told LVN A that Resident #1 was in pain and may need Tylenol. CNA E stated she walked away and thought LVN A provided medication at that time. CNA stated she did not observe LVN A do any type of assessment. The next night I worked again, Resident #1 was already in the bed, sleeping, she slept the whole night and did not wet the whole night. When I attempted to wake her the next morning, she grabbed the covers and requested water, she refused to get up for the day. I then alerted LVN A Resident #1 had no incontinent care all night, refused to get up and her request for lots of water. CNA E stated she had completed training on resident abuse and neglect, that she understood to alert charge nurse when there is a change in condition with residents. Record review of Resident #1's care plan, last care conference 04/28/23, revealed: 1. Resident #1 at risk for falls related to muscle weakness, Goals: risks and injury potential will be minimized through the next review date. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. The resident needs a safe environment with: even floors free from spills and or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. 2. Resident #1 has an activities of daily living self-care performance deficit related to dementia, disease process. Goal: maintain current level of function in activities of daily living through the review date. Intervention: gather and provide needed supplies, observe/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Physical/Occupational therapy evaluation and treatment as per orders. Resident requires extensive assist by 1 staff to turn and reposition in bed. Resident requires extensive assist by 2 staff to move between surfaces. Resident requires extensive assist of 1 staff to dress. Resident requires extensive assistance by 2 staff for toileting. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 23 of 67 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 07/27/2023 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 0607 3. Level of Harm - Immediate jeopardy to resident health or safety Resident #1 has potential for pain related to right foot drop. Goal: Resident will not have an interruption in normal activities due to pain through review date. Intervention: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions ever shift. Review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Observe/document for probable cause of each pain episode. Remove/limit causes where possible. Observe/document for side effects of pain medication. Observe/record/report to nurse any signs and symptoms of non-verbal pain: changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling outs, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Observe/record/report to nurse loss of appetite, refusal to eat and weight loss. Observe/record/report to nurse resident complaints of pain or requests for pain treatment. Provide non-pharmacological interventions. Report to nurse any change in usual activity attendance patterns or refusal to attend activities related to signs and symptoms of pain or discomfort. Therapy referral as indicated. Residents Affected - Some 4. Resident #1 has Osteoporosis. Goal: Resident will remain free of injuries or complications related to osteoporosis. Interventions: Give analgesics PRN for pain. Resident may complain of pain, stiffness, or weakness. Document complaints. Observe for risk of falls. Educate resident, family /caregivers on safety measures that need to be taken in order to reduce risk of falls. Observe/document/report PRN s/sx or complications related to osteoporosis: Acute fracture, Compression fractures, Loss of height, Kyphosis (dowagers hump, thoracic curve), Pain. Interview on 07/26/23 at 12:01 PM with LVN C revealed she worked the 7:00 AM - 7:00 PM shift on 07/17/23, after breakfast she was notified by CNA F that something was wrong with Resident#1's leg. LVN C stated Resident #1's right leg was usually 90% straight and left leg bent, but at this time she was in a butterfly position, with both heels touching her brief. LVN C stated she immediately contacted physician via electronic communication app, video call within 2 minutes, and received an order for x-ray and Tramadol for pain. LVN C stated x-ray was completed within 4 hours indicating femur fracture of the right leg. LVN C stated at this time she prepared for Resident #1 to be sent out to the hospital. LVN C stated during her assessment Resident #1's leg was swollen, warm to touch, and she was guarding with palpations. According to LVN C when she asked Resident #1 and Resident #2 how the injury took place neither of them said anything until Resident #1's family member entered the room, it was not until then she heard Resident #1 say she fell out the bed. LVN C stated after the findings of the x-ray she was notified Resident #1 was not eating, had refused all 3 previous meals, not drinking, crying, and saying her knee was hurting. LVN C stated Resident #1 had not had any pain medications prior or while waiting to transfer to the hospital. LVN C stated Resident #1 did not exit the facility for the hospital until 5:30 PM. According to LVN C not contacting the physician immediately over the weekend placed Resident #1 at risk for further damage to her leg, infection, becoming (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 24 of 67 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 07/27/2023 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some septic and prolonged time in pain. LVN C stated knowing what she knows now she should have used her nursing judgement and called 911 to send Resident #1 to the hospital immediately after observation and assessment of her leg. Record review of Resident #1's progress notes dated 07/17/23 at 12:00 PM copy of documentation signed by Physician reflected: Follow up Physical exam, Elderly, frail female in some distress seen via video, Right lower extremity bent at ninety degrees, grimacing with palpation. Patient seen via telemedicine with nurse. 1. Pelvis and right femur x-ray. Concern for fracture status post transfer. 2. Tramadol 100mg po q6h PRN pain for 14 days if no allergies. 3. Follow up x-ray. Record review of Resident #1's progress notes dated 07/17/23 at 9:15 PM written by LVN C reflected the following late entry: CNA F reported that resident was complaining of pain during a brief change. I went and looked at her leg, and then messaged the doctor. The doctor video called, and we looked at the leg together. The doctor ordered x-rays and pain meds for resident. This nurse put in the orders. The x-ray techs showed up around 5:30 PM, and so did family member. X-ray showed femur break. This nurse reported that to doctor and called for transport to hospital. It was 5:45 PM before resident was transported to hospital due to ambulance being busy. Record review of Resident #1's progress notes dated 07/17/23 at 5:54 PM written by ADON reflected the following late entry: Resident reported leg pain to aide and aide notified nurse. Nurse assessed resident and did a telehealth video call and X-ray, and pain meds were ordered. Family member was at bedside during x-ray and when it was resulted. Right femur fracture. Upon further investigation, resident states she did fall out of bed last night onto her knees and a worker helped her up. Patient has good situational awareness. Sacred cross called and resident sent to hospital at 5:45 PM. Record review of Resident #1's progress notes dated 07/17/23 at 6:46 PM written by LVN C reflected: Resident #1 was transferred to a hospital on [DATE] 5:50 PM related to right femur fracture. Record review of Resident #1's progress notes dated 07/17/23 at 7:34 PM written by nurse reflected: Resident #1 in hospital. Record review of Resident #1's progress notes dated 07/18/23 at 8:35 PM written by LVN C reflected, Spoke to family member in regards to resident. Resident is going to have surgery for repair the femur fracture, remove old hardware that has come out, and run a rod from her knee to pelvis. Resident will be non-weight bearing post-operation and will no longer be able to walk. Record review of accident and incident reports dated 05/25/23 - 07/25/23 indicated Resident #1 had fracture incident on 07/17/23 3:30 PM. Record review of order revealed: Order date: 07/17/23 10:52 AM Order Summary: Xray of pelvis, Right hip and femur one time only for right leg pain for 1 day Record review of Final X-Ray Report revealed: 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 25 of 67 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 07/27/2023 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Moderately displaced oblique fracture of distal diaphysis of femur of indeterminate age. (bone broken at an angle that affected the knee and leg) 2. Dislocation of right hip is present Residents Affected - Some 3. Internal fixation of right femoral neck. Record review of Resident #1's July 2023 MAR revealed: Tramadol HcL oral tablet 100 MG (give 1 tablet by mouth every 6 hours as needed for pain for 14 days) for the month of July was not administered on 07/17/23 prior to resident being sent out to the hospital. Tylenol Extra Strength Oral Tablet 500 MG (give 1 tablet by mouth every 6 hours as needed for pain) for the month of July was not administered on 07/15/23, 07/16/23, 07/17/23 prior to resident being sent out to the hospital. Record review of hospital records, dated 07/17/23, revealed: Chief complaint: Right leg pain from a fall Emergency department work up included a right femur x-rays revealed a displaced, evaluated distal femoral diaphyseal fracture. Hospital records dated 07/18/23 reflected the resident completed surgery on 07/18/23. Interview on 07/26/23 at 1:13 PM with CNA G revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23, CNA G stated when she arrived Resident #1 was already sitting in her spot near the nursing station. CNA G stated Resident #1 did tell her about her knee pain. CNA G stated when LVN B arrived she notified him of her pain. CNA G stated, During breakfast I was pushing Resident #1 down to the dining room and Student Aide H was telling me that Resident #1's leg was swinging, which I could not see because I was behind her and trying to get residents to breakfast. CNA G stated once she left Resident #1 in the dining room she wheeled herself back to the nursing station, she refused breakfast, lunch, and dinner on this day. CNA G stated Resident #1 continued pointing to her knee saying it was hurting. CNA G stated she and Student Aide H discussed amongst themselves that something was wrong with Resident #1's leg and that they both had told him about it more than once. Interview on 07/26/23 at 2:03 PM with Student Aide H revealed she worked the morning shift 7:00 AM 7:00 PM on 07/16/23, Student Aide H stated when she arrived to work Resident #1 was in her usual spot near the nursing station. Student Aide H stated she saw CNA G pushing Resident #1 down the hall and noticed her leg was swinging back and forth, she was crying, complaining of pain in her leg that was swinging. Student Aide H stated she expressed to LVN B what she observed. Student Aide H stated she later put Resident #1 down for bed, completed care, and when she rolled her on her right side she screamed so loud. Student Aide H stated she then went to alert LVN B that she was screaming in pain, and this was not normal for her. According to Student Aide H when she returned to put Resident #2 down for bed, she asked Resident #1 what happened, Resident #1 would agree to having a fall after she was asked a series of questions. Student Aide H stated she then returned to LVN B and shared that Resident #1 indicated she had a fall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 26 of 67 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 07/27/2023 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Interview on 07/26/23 at 2:10 PM with LVN B revealed he worked the morning shift 7:00 AM - 7:00 PM on 07/16/23. He stated Resident #1 was already up in her wheelchair and near the nursing station when he arrived. LVN B stated Resident #1 appeared normal to him and he did not recognize anything out of the normal with her. LVN B stated she did return from the dining room refusing breakfast stating her keen was hurting. LVN B stated he did not observe any bruising or redness after being told by staff Resident #1 was in pain. LVN B stated he did not administer a full assessment for pain and stated he did not administer any pain medication for Resident #1's pain. LVN B stated he could not recall doing anything to assist Resident #1's pain. LVN B also stated he did not follow up with her throughout the day to see how she was feeling or to see if he needed to alert the physician that she was indicating pain, change of condition, or her refusal to eat. When LVN B was asked about risk to Resident #1's fractured femur not being assessed in a timely manner he apologized for not being much help. Interview on 07/26/23 at 2:46 PM with LVN A revealed she worked on the overnight shift 7:00 PM-7:00 AM on 07/15/23 for 100 Hall and 200 Hall. LVN A she did not have any complaints of a fall. LVN A stated throughout the night Resident #1 rested fine, until she was getting out of bed between 5:30 AM - 6:00 AM. LVN A stated when the CNA E went to get her up, she stated her knee was hurting and it was reported she was sleeping in a weird position. Her head was up really high, legs were sideways, and legs stiff, when she went to check Resident #1 was dressed, in wheelchair, in the hallway. LVN A stated at this time she did not think anything serious happened. LVN A stated she administered pain mediation prior to leaving on 07/16/23. LVN A stated when she returned the next day there were no complaints of pain, Resident #1 was in bed the entire shift. LVN A stated when she left on Monday morning 07/17/23 she got a call from the facility stating Resident #1 was injured. LVN A stated during the call she was informed Resident #1 complained of pain on Sunday 07/16/23 and the day nurse gave her pain medication. LVN A stated she did not complete an assessment to identify the source pain after CNA E and Resident #1 complained resident was in pain. LVN A stated she did not contact physician, DON, or the oncoming nurse she was informed Resident #1 was in pain. According to LVN A not completing full assessment or identifying a change of conditions could place residents at risk of not receiving immediate care. Review of facility's current Abuse/Neglect policy, dated 03/29/18, reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined .Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. On 07/26/23 at 5:38 PM the DON was notified an Immediate Jeopardy had been identified. The facility's Plan of Removal was accepted on 07/27/23 at 1:18 PM. The Plan of Removal reflected the following: o As of 7/26/23 [Resident #1] was assessed for pain. Orders received as of 7/26/23 for scheduled and PRN pain meds. o (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 27 of 67 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 07/27/2023 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some All residents in the facility were assessed for any increased pain by the DON, ADON and Charge Nurses as of 7/26/23. No additional issues were found. Education: All charge nurses were in-serviced on 7/26/23 by the Compliance Nurse/DON/ADON regarding the following and all nurses including agency staff, new hires, and PRN staff not in-serviced by 7/26/23 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse. o Notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits. o Implementation of physician orders immediately upon receipt including the administration of pain medications. o A head-to-toe assessment will be performed by the charge nurse on all residents who complain of increased pain. All nursing staff were in-serviced on 7/26/23 by the Compliance Nurse/DON/ADON. All staff not in-serviced on 7/26/23 including agency staff, new hires and PRN staff will not be allowed to work their assigned schedule until the completion of these in-services. o Notify the charge nurse immediately if a resident is found on the floor. The resident will not be moved until assessed by a nurse. o Notification of change of condition to the physician immediately including falls, injuries, increased pain, decreased mobility, or a change in eating habits. o Pain: Signs and symptoms of pain verbal and non-verbal. (crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching Medical Director was notified by the DON on 7/26/23 at 8:18 PM about the Immediate Jeopardies. An AD HOC QAPI meeting will be held on 7/27/23 by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 28 of 67 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 07/27/2023 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 0607 Level of Harm - Immediate jeopardy to resident health or safety The Director of Nursing or designee will implement this written Plan of Removal and will continue to monitor completion and compliance of this written Plan of Removal. Monitoring: o Residents Affected - Some The DON and/or designee will monitor Real Time clinical software and the PCC Dashboard for clinical alerts for any resident change of condition including new or increased pain at least 5 days per week to ensure physician/NP were notified. Monitoring began 7/26/2023 and will continue x 4 weeks. o The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 days per week, to ensure any new physician/NP orders were implemented immediately. Monitoring began 7/26/23 and will continue x 4 weeks. Interview on 07/27/23 at 2:14 PM with ADON revealed in-services had been started to identify change of condition, charge nurse to complete full assessments, understanding signs and symptoms of pain both verbal and nonverbal, contacting the physician and implementing physician orders immediately. The ADON stated she completed in-services with aides regarding neglect and not moving resident after a fall, contacting the charge nurse when resident had a change in condition or expressed pain. The ADON stated during morning shift with LVN A on 07/16/23 was the beginning of Resident #1 expressing pain. The ADON stated LVN B was notified by staff that Resident #1 expressed pain and he should have done a complete assessment for pain, administered pain medication and communicated the history of the day with the oncoming nurse for the next shift. The ADON stated when LVN A returned to the facility on [DATE] at 7:00 PM Resident #1 was in bed, and nobody notified LVN A that Resident #1 was in pain. The ADON stated if LVN B communicated the history of the day, LVN A could have completed proper care and follow up. The ADON stated LVN B not communicating that Resident #1 expressed pain throughout the day put her at risk of not receiving proper pain management and treatment. The ADON stated it was her expectation to address resident needs, follow up with the doctor, DON, family and depending on the situation the Administrator. Further monitoring on 07/27/23 during interviews consisting of both day and night shifts revealed the following: Interviews on 07/27/23 from 2:15 PM through 07/27/23 4:30 PM with the DON, ADON, LVN A, LVN B, LVN C, CNA E, CNA F, CNA G, Student Aide H, LVN I, LVN J, LVN K, LVN L, LVN M, Student Aide N, CNA O, CNA P, Student Aide Q, CNA R, LVN S who worked the shifts of 7:00 AM-7:00 PM, 7:00 PM-7:00AM were able to verify education was provided to them; nursing staff were able to accurately summarize abuse and neglect policy, definitions and examples of change of condition and how, who, and when to report changes. The nursing staff revealed signs and symptoms of residents complaining of pain, what to do and who to contact. The nursing staff expressed understanding of the importance of completing assessments and identify the source of pain and how that plays in part to resident safety. During observations on 07/27/23 between 8:00 AM-5:00 PM revealed staff assessing residents who were exhibiting pain, residents who requested and were administered pain medications. Staff were observed engaging with residents, preforming full assessments, and interviewing residents to determine the source of pain, contacting the physician, documenting, and notifying resident's responsible party of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 29 of 67 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 07/27/2023 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 0607 change of condition. Level of Harm - Immediate jeopardy to resident health or safety Record review of the facility plan of correction monitoring tool form undated titled Actual/Alleged Abuse Monitoring Ask 8-10 staff members per week, situational questions related to the neglectful action document any corrective actions on the back of the form .indicated log started on 07/24/23 with slots for date, time, staff name, responded correctly, who and how soon would they report suspected abuse? Ask 5 residents how staff is treating them. Document date/time, resident name, if there was any negative response. Document any corrective action if needed on the back of this form. During incident/event review in standup, was there any evidence of any potential neglect. Residents Affected - Some While the Immediate Jeopardy was removed on 07/27/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, completing full assessments and identifying source for pain and resident neglect and following facility policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 30 of 67 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 07/27/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to report allegations of abuse/neglect for 1 (Resident #1) of 11 residents reviewed for abuse and neglect. The facility failed to report an allegation of abuse/neglect to the State agency after Resident #1 fell and was allegedly put back in bed by Student Aide D on 07/16/23 at midnight, and the resident complained of pain through 07/17/23 at 5:30 PM when she was transported to the hospital after x-rays revealed the resident sustained a fracture of the right femur and hip. This failure placed residents at risk of further injury or worsening of their conditions. Findings included: Record review of Resident #1's face sheet dated 07/25/23 revealed Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included other abnormalities of gait and mobility, other lack of coordination, muscle wasting and atrophy, muscle weakness, reduced mobility, abnormal posture, repeated falls, foot drop, right foot (gait abnormality of the right foot). Record review of Resident #1's annual MDS assessment, dated 06/12/23 revealed her BIMS score was 99 indicating Resident #1 was unable to complete assessment. Her Functional Status for activities of daily living indicated she required extensive assistance with one person assist with bed mobility, dressing and personal hygiene. Extensive assistance with 2 person assist with eating, transfers, and toileting. Supervision and set ups with locomotion on and off the unit. Section J indicated Resident #1 had a recent fall with a major injury (bone fractures). Record review of Resident #1's BIMS assessment dated [DATE] revealed her BIMS score was 0 indicating severe impairment. Record review of Resident #1's care plan, last care conference 07/25/23, revealed: 1. Resident #1 at risk for falls related to muscle weakness, Goals: risks and injury potential will be minimized through the next review date. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. The resident needs a safe environment with even floors free from spills and or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. 2. Resident #1 has an activities of daily living self-care performance deficit related to dementia, disease process. Goal: maintain current level of function in activities of daily living through the review date. Intervention: gather and provide needed supplies, observe/document/report as needed any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 31 of 67 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 07/27/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Resident requires extensive assist by 1 staff to turn and reposition in bed. Resident requires extensive assist by 2 staff to move between surfaces. Resident requires extensive assist of 1 staff to dress. Resident requires extensive assistance by 2 staff for toileting. Residents Affected - Few 3. Resident #1 has potential for pain related to right foot drop. Goal: Resident will not have an interruption in normal activities due to pain through review date. Intervention: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions ever shift. Review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Observe/document for probable cause of each pain episode. Remove/limit causes where possible. Observe/document for side effects of pain medication. Observe/record/report to nurse any signs and symptoms of non-verbal pain: changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling outs, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Observe/record/report to nurse loss of appetite, refusal to eat and weight loss. Observe/record/report to nurse resident complaints of pain or requests for pain treatment. Provide non-pharmacological interventions. Report to nurse any change in usual activity attendance patterns or refusal to attend activities related to signs and symptoms of pain or discomfort. Therapy referral as indicated. 4. Resident #1 has Osteoporosis. Goal: Resident will remain free of injuries or complications related to osteoporosis. Interventions: Give analgesics PRN for pain. Resident may complain of pain, stiffness, or weakness. Document complaints. Observe for risk of falls. Educate resident, family /caregivers on safety measures that need to be taken in order to reduce risk of falls. Observe/document/report PRN s/sx or complications related to osteoporosis: Acute fracture, Compression fractures, Loss of height, Kyphosis (dowagers hump, thoracic curve), Pain. Record review of Resident #1's progress notes dated 06/25/23-07/17/23 revealed no mention or assessment of Resident #1's complaint of pain. Record review of Resident #1's progress notes dated 07/17/23 at 12:00 AM copy of documentation signed by Physician reflected, Follow up Physical exam, Elderly, frail female in some distress seen via video, Right lower extremity bent at ninety degrees, grimacing with palpation. Patient seen via telemedicine with nurse. 1. Pelvis and right femur x-ray. Concern for fracture status post transfer. 2. Tramadol 100mg po q6h PRN pain for 14 days if no allergies. 3. Follow up x-ray. Record review of Resident #1's progress notes dated 07/17/23 at 9:15 AM written by LVN C reflected the following late entry: CNA F reported that resident was complaining of pain during a brief change. I went and looked at her leg, and then messaged the doctor. The doctor video called, and we looked at the leg together. The doctor ordered x-rays and pain meds for resident. This nurse put in the orders. The x-ray techs showed up around 3:30 PM, and so did family member. X-ray showed femur break. This nurse reported that to doctor and called for transport to hospital. It was 5:45 PM before (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 32 of 67 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 07/27/2023 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 0609 resident was transported to hospital due to ambulance being busy. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's progress notes dated 07/17/23 at 5:54 PM written by ADON reflected the following late entry: Resident reported leg pain to aide and aide notified nurse. Nurse assessed resident and did a telehealth video call and X-ray, and pain meds were ordered. Family member was at bedside during x-ray and when it was resulted. Right femur fracture. Upon further investigation, resident states she did fall out of bed last night onto her knees and a worker helped her up. Patient has good situational awareness. Emergency Transportation was called and resident sent to hospital at 5:45 PM. Residents Affected - Few Record review of Resident #1's progress notes dated 07/17/23 at 6:46 PM written by LVN C reflected: Resident #1 was transferred to a hospital on [DATE] 5:50 PM related to right femur fracture. Record review of Resident #1's progress notes dated 07/17/23 at 7:34 PM written by LVN U reflected: Resident #1 in hospital. Record review of Resident #1's progress notes dated 07/18/23 at 8:35 AM written by LVN C reflected: Spoke to family member in regards to resident. Resident is going to have surgery for repair the femur fracture, remove old hardware that has come out, and run a rod from her knee to pelvis. Resident will be non-weight bearing post-operation and will no longer be able to walk. Record review of accident and incident reports dated 05/25/23-07/25/23 revealed one incident report showing rthat Resident #1 had a fracture incident on 07/17/23 3:30 PM. Record review of Resident #1's order revealed: Order date: 07/17/23 10:52 AM Order Summary: Xray of pelvis, Right hip, and femur one time only for right leg pain for 1 day Record review of Resident #1's Final X-Ray Report, dated 07/17/23, revealed: 1. Moderately displaced oblique fracture of distal diaphysis of femur of indeterminate age. (bone broken at an angle that affected the knee and leg) 2. Dislocation of right hip is present 3. Internal fixation of right femoral neck. Record review of Resident #1's July 2023 MAR revealed: 1. Tramadol HcL oral tablet 100 MG (give 1 tablet by mouth every 6 hours as needed for pain for 14 days) for the month of July was not administered on 07/17/23 prior to resident being sent out to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 33 of 67 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 07/27/2023 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 0609 hospital. Level of Harm - Minimal harm or potential for actual harm 2. Tylenol Extra Strength Oral Tablet 500 MG (give 1 tablet by mouth every 6 hours as needed for pain) for the month of July was not administered on 07/15/23, 07/16/23, 07/17/23 prior to resident being sent out to the hospital. Residents Affected - Few Record review of Resident #1's hospital records revealed: Chief complaint: Right leg pain from a fall Emergency department work up included a right femur x-rays revealed a displaced, evaluated distal femoral diaphyseal fracture. Resident completed surgery on 07/18/23. Record review of Resident #2's face sheet dated 07/25/23 revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, major depressive disorder, muscle wasting, abnormal posture, lack of coordination. Record review of Resident #2's annual MDS assessment, dated 05/23/23 revealed her BIMS score was 15 indicating Resident #2's cognition was intact. Her Functional Status for activities of daily living indicated she required extensive assistance with two person assist with bed mobility, transfers, and toileting. Extensive assistance from two persons for ADLs to include eating, dressing, personal hygiene, locomotion on and off the unit. Always incontinent with bowel and bladder. Adequate hearing, vision, and ability to understand others. Interview on 07/25/23 at 2:57 PM with Resident# 1's family member/responsible party revealed she visited almost daily at 3:00 PM. When she entered the facility on Monday, 07/17/23, the Receptionist stated there was something wrong with Resident #1. She stated on her way to Resident #1's room, LVN C followed expressing the same thing that Resident #1 had an injury. The family member stated when she entered the room, Resident #1 was moaning, groaning and grimacing from pain. Both Resident #1 and her roommate, Resident #2, started to explain the cause of her pain. They stated late Saturday night (07/15/23), early Sunday morning (07/16/23) about midnight, that Resident #1 was reaching for the call button and fell. They stated Student Aide D came in and threw Resident #1 back in bed. Resident #1 stated to family member she fell on her bottom and hit her head. The Family member stated she pulled the covers back and it was obvious the resident's leg looked as if there was a fracture to her right femur. The family member stated she was upset the facility had not contacted her prior to her entering the facility. The family member stated in speaking with the Administrator he apologized and stated the facility should have contacted her immediately and he would complete an investigation. Interview on 07/25/23 at 4:29 PM with CNA F revealed when she arrived to work on Sunday, 07/16/23, she observed Resident #1 sitting out by the nurses' station, complaining of pain, saying that her right leg was hurting. CNA F stated Resident #1 had complained of pain by tapping her right leg the whole time she was in the chair. According to CNA F she was told by aides on 200 Hall they had informed LVN B that Resident #1 was complaining about pain to her right leg. CNA F stated she was notified Resident #1 remained in bed throughout the night and breakfast due to her complaint of pain. CNA F stated she entered Resident #1's room to complete care around 10:00 AM, during this time she observed Resident #1's leg was bent and thought it was weird. CNA F stated she rolled Resident #1 to her right side, when she rolled the resident on her left side CNA F stated she noticed Resident #1's leg just fell to the side. CNA F stated at this point she went to alert LVN C for an assessment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 34 of 67 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 07/27/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 07/25/23 at 4:55 PM with DON revealed she was alerted during morning clinical meeting that Resident #1 was complaining of pain and an x-ray had been ordered. According to the DON, Resident #1 stated she fell out of bed and the night worker helped her back to bed. The DON stated Student Aide D was reassigned to the 200 Hall with Resident #1 which was whom Resident #1 was referring to the night worker. The DON stated after the fall Student Aide D did not notify anyone of Resident #1's fall or complaint of pain and left mid shift and had not returned to the facility. The DON stated LVN C was alerted of Resident #1's pain and injury, contacted the physician, followed orders for x-ray. The DON stated following findings of the x-ray Resident #1 was transferred to the hospital on [DATE] with findings of fractured femur which resulted in surgery. The DON stated the charge nurse was responsible for assessing Resident #1 to identify where the pain was coming from and why resident was having a change of condition. According to the DON, it was facility policy for the charge nurse to contact the physician immediately when residents are complaining of pain or have a change of condition. The DON stated the charge nurse was also responsible for alerting family or responsible party and herself along with the Administrator (Abuse Coordinator) when residents were exhibiting a change of condition or had an injury. The DON stated it was not practice to neglect residents by not providing proper care. According to the DON, it was discussed with the Administrator about investigating and reporting during the clinical meeting, and we were all on the same page. The DON stated the Administrator was aware of the incident and began the investigation on how it resulted in Resident #1 having a fracture. Interview on 07/26/23 at 9:48 AM with CNA E revealed she worked on the 7:00 PM-7:00 AM overnight shift on 07/15/23. CNA E stated Student Aide D abruptly left the facility about 2:17 AM. CNA E stated after Student Aide D left the facility, she did a round to Resident #1's room and observed her in bed sitting straight up sleeping, she left the room to prepare for a brief change, upon returning Resident #1 was making sounds of moaning and groaning which she thought was her normal communication to leave her alone. CNA E stated when she returned at 5:30 AM to get her up for the day she yelled out differently, her cry was deeper than her normal communication. CNA E stated her roommate commented that sound was different and that she thought Resident #1 was in pain. CNA E stated when she pushed Resident #1 to the hall Resident #1 grabbed her shirt and patted her knee indicating she was in pain. CNA E stated she thought Resident #1 just wanted to fix her pant leg which needed to be pulled down. CNA E stated she then lifted Resident #1's right leg and the resident screamed. When she lowered Resident #1's leg, the resident screamed again patting her right knee. CNA E stated she then told LVN A that Resident #1 was in pain and may need Tylenol. CNA E stated the next night she worked again, Resident #1 was already in the bed, sleeping. CNA E stated Resident #1 slept the whole night and did not wet the whole night. CNA E stated when she attempted to wake Resident #1 the next morning, the resident grabbed the covers and requested water. She stated the resident refused to get up for the day. CNA E stated she then alerted LVN A Resident #1 had not had care all night, refused to get up, and her request for lots of water. Interview on 07/26/23 at 12:01 PM with LVN C revealed she worked the 7AM - 7PM shift on 07/17/23, after breakfast she was notified by CNA F that something was wrong with Resident#1's leg. LVN C stated Resident #1's right leg was usually 90% straight and left leg bent, but at this time she was in a butterfly position, with both heels touching her brief. LVN C stated she immediately contacted physician via electronic communication app, video call within 2 minutes, and received an order for x-ray and Tramadol for pain. LVN C stated x-ray was completed within 4 hours indicating femur fracture of the right leg. LVN C stated at this time she prepared for Resident #1 to be sent out to the hospital. LVN C stated during her assessment Resident #1's leg was swollen, warm to touch, and she was guarding with palpations. According to LVN C (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 35 of 67 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 07/27/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few when she asked Resident #1 and Resident #2 how the injury took place neither of them said anything until Resident #1's family member entered the room, it was not until then she heard Resident #1 say she fell out the bed. LVN C stated after the findings of the x-ray she was notified Resident #1 was not eating, had refused all 3 previous meals, not drinking, crying, and saying her knee was hurting. LVN C stated Resident #1 had not had any pain medications prior or while waiting to transfer to the hospital. LVN C stated Resident #1 did not exit the facility for the hospital until 5:30 PM. According to LVN C not contacting the physician immediately over the weekend placed Resident #1 at risk for further damage to her leg, infection, becoming septic and prolonged time in pain. LVN C stated she could not understand why Resident #1 was not already sent out prior to her shift. LVN C stated I followed protocol however, knowing what she knows now she should have used her nursing judgement and called 911 to send Resident #1 to the hospital immediately after observation and assessment of her leg. Interview on 07/26/23 at 12:59 PM with CNA T revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23, CNA T stated she walked past Resident #1 as she was out in the hallway. CNA T stated Resident #1 was stopping every and anyone trying to get their attention. CNA T stated Resident #1 was moaning, and she thought the resident said, Help me. According to CNA T, she did not contact the nurse to notify him that Resident #1 was complaining of pain. CNA T stated not notifying the nurse Resident #1 was expressing pain may have caused her prolonged pain. Interview on 07/26/23 at 1:13 PM with CNA G revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23, CNA G stated when she arrived Resident #1 was already sitting in her spot near the nurses' station. CNA G stated Resident #1 did tell her about her knee pain. CNA G stated when LVN B arrived she notified him of her pain. CNA G stated, During breakfast, I was pushing Resident #1 down to the dining room and [Student Aide H] was telling me that Resident #1's leg was swinging, which I could not see because I was behind her and trying to get residents to breakfast. CNA G stated after she brought Resident #1 to the dining room, the resident wheeled herself back to the nurses' station. CNA G stated Resident #1 refused breakfast, lunch, and dinner on that day. CNA G stated Resident #1 continued pointing to her knee saying it was hurting. CNA G stated she and Student Aide H discussed amongst themselves that something was wrong with Resident #1's leg and that they both had told LVN B about it more than once. Interview on 07/26/23 at 2:03 PM with Student Aide H revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23, Student Aide H stated when she arrived to work Resident #1 was in her usual spot near the nursing station. Student Aide H stated she saw CNA G pushing Resident #1 down the hall and noticed her leg was swinging back and forth, she was crying, complaining of pain in her leg that was swinging. Student Aide H stated she expressed to LVN B what she observed. Student Aide H stated she later put Resident #1 down for bed, completed care, and when she rolled her on her right side she screamed so loud. Student Aide H stated she then went to alert LVN B that she was screaming in pain. According to Student Aide H when she returned to put Resident #2 down for bed, she asked Resident #1 what happened, Resident #1 would agree to having a fall after she was asked a series of questions. Student Aide H stated she then returned to LVN B and shared that Resident #1 indicated she had a fall. Interview on 07/16/23 at 2:10 PM with LVN B revealed he worked the morning shift 7:00 AM-7:00 PM on 07/16/23. He stated Resident #1 was already up in her wheelchair and near the nurses' station when he arrived. LVN B stated Resident #1 appeared normal to him and he did not recognize anything out of the normal with her. LVN B stated the resident did return from the dining room refusing breakfast stating her knee was hurting. LVN B stated he did not observe any bruising or redness after being (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 36 of 67 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 07/27/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few told by staff Resident #1 was in pain. LVN B stated he did not conduct a full assessment for pain and stated he did not administer any pain medication for Resident #1's pain. LVN B stated he could not recall doing anything to assist Resident #1's pain. LVN B also stated he did not follow-up with her throughout the day to see how she was feeling or to see if he needed to alert the physician that she was indicating pain, change of condition, or her refusal to eat. When LVN B was asked about risk to Resident #1's fractured femur not being assessed in a timely manner he apologized for not being much help. Interview on 08/01/23 at 2:50 PM with the Administrator revealed he was alerted to Resident #1's right femur fracture after the results of her x-ray. The Administrator stated after interviews with staff, Resident #2, and family member it was confirmed that Resident #1 had a fall. The Administrator stated because Resident #1 was able to explain what happened, he decided the incident was not reportable. Record review of facility current Abuse/Neglect policy, dated 03/29/18, reflected: The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged neglect and situations that may constitute neglect to any resident in the facility. The facility will determine the direction of the investigation based on a thorough examination of events. Opportunities to prevent abuse will be managed accordingly. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from neglect must report this to the DON, administrator, stated and/or adult protective services. Facility employees must report all allegations of abuse, neglect, mistreatment of residents, exploitation, injury of unknown source to the facility administrator. The facility administrator or designee will report to Health and Human Service Commission all incidents that meet the criteria, if the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 37 of 67 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 07/27/2023 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 0610 Respond appropriately to all alleged violations. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have evidence that in response to alleged abuse/neglect a thorough investigation was conducted to prevent further potential abuse/neglect for 1 (Resident #1) of eleven residents reviewed for neglect. Residents Affected - Few The facility failed to conduct a thorough investigation into an allegation of abuse/neglect after Resident #1 fell and was allegedly put back in bed by Student Aide D on 07/16/23 at midnight, and the resident complained of pain through 07/17/23 at 5:30 PM when she was transported to the hospital after x-rays revealed the resident sustained a fracture of the right femur and hip. An Immediate Jeopardy was identified on 07/25/23, The Immediate Jeopardy template was provided to the facility on [DATE] at 5:38 PM. While the Immediate Jeopardy was removed on 07/27/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, and resident neglect and following facility policy. This failure placed residents at risk of further injury or worsening of their conditions. Findings included: Record review of Resident #1's face sheet dated 07/25/23 revealed Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included other abnormalities of gait and mobility, other lack of coordination, muscle wasting and atrophy, muscle weakness, reduced mobility, abnormal posture, repeated falls, foot drop, right foot (gait abnormality of the right foot). Record review of Resident #1's annual MDS assessment, dated 06/12/23 revealed her BIMS score was 99 indicating Resident #1 was unable to complete assessment. Her Functional Status for activities of daily living indicated she required extensive assistance with one person assist with bed mobility, dressing and personal hygiene. Extensive assistance with 2 person assist with eating, transfers, and toileting. Supervision and set ups with locomotion on and off the unit. Section J indicated Resident #1 had a recent fall with a major injury (bone fractures). Record review of Resident #1's BIMS assessment dated [DATE] revealed her BIMS score was 0 indicating severe impairment. Record review of Resident #1's care plan, last care conference 04/28/23, revealed: 1. Resident #1 at risk for falls related to muscle weakness, Goals: risks and injury potential will be minimized through the next review date. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. The resident needs a safe environment with even floors free from spills and or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 38 of 67 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 07/27/2023 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 0610 2. Level of Harm - Immediate jeopardy to resident health or safety Resident #1 has an activities of daily living self-care performance deficit related to dementia, disease process. Goal: maintain current level of function in activities of daily living through the review date. Intervention: gather and provide needed supplies, observe/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Resident requires extensive assist by 1 staff to turn and reposition in bed. Resident requires extensive assist by 2 staff to move between surfaces. Resident requires extensive assist of 1 staff to dress. Resident requires extensive assistance by 2 staff for toileting. Residents Affected - Few 3. Resident #1 has potential for pain related to right foot drop. Goal: Resident will not have an interruption in normal activities due to pain through review date. Intervention: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions ever shift. Review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Observe/document for probable cause of each pain episode. Remove/limit causes where possible. Observe/document for side effects of pain medication. Observe/record/report to nurse any signs and symptoms of non-verbal pain: changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling outs, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Observe/record/report to nurse loss of appetite, refusal to eat and weight loss. Observe/record/report to nurse resident complaints of pain or requests for pain treatment. Provide non-pharmacological interventions. Report to nurse any change in usual activity attendance patterns or refusal to attend activities related to signs and symptoms of pain or discomfort. Therapy referral as indicated. 4. Resident #1 has Osteoporosis. Goal: Resident will remain free of injuries or complications related to osteoporosis. Interventions: Give analgesics PRN for pain. Resident may complain of pain, stiffness, or weakness. Document complaints. Observe for risk of falls. Educate resident, family /caregivers on safety measures that need to be taken in order to reduce risk of falls. Observe/document/report PRN s/sx or complications related to osteoporosis: Acute fracture, Compression fractures, Loss of height, Kyphosis (dowagers hump, thoracic curve), Pain. Record review of Resident #1's progress notes dated 06/25/23 - 07/17/23 revealed no mention or assessment of Resident #1 complaint of pain. Record review of Resident #1's progress notes dated 07/17/23 at 12:00 PM copy of documentation signed by Physician reflected, Follow up Physical exam, Elderly, frail female in some distress seen via video, Right lower extremity bent at ninety degrees, grimacing with palpation. Patient seen via telemedicine with nurse. 1. Pelvis and right femur x-ray. Concern for fracture status post transfer. 2. Tramadol 100mg po q6h PRN pain for 14 days if no allergies. 3. Follow up x-ray. Record review of Resident #1's progress notes dated 07/17/23 at 09:15 written by LVN C reflected, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 39 of 67 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 07/27/2023 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Late Entry CNA F reported that resident was complaining of pain during a brief change. I went and looked at her leg, and then messaged the doctor. The doctor video called, and we looked at the leg together. The doctor ordered x-rays and pain meds for resident. This nurse put in the orders. The x-ray techs showed up around 3:30 PM, and so did family member. X-ray showed femur break. This nurse reported that to doctor and called for transport to hospital. It was 5:45 PM before resident was transported to hospital due to ambulance being busy. Residents Affected - Few Record review of Resident #1's progress notes dated 07/17/23 at 5:54 PM written by ADON reflected, Late Entry Resident reported leg pain to aide and aide notified nurse. Nurse assessed resident and did a telehealth video call and X-ray, and pain meds were ordered. Family member was at bedside during x-ray and when it was resulted. Right femur fracture. Upon further investigation, resident states she did fall out of bed last night onto her knees and a worker helped her up. Patient has good situational awareness. Emergency Transportation was called, and resident sent to hospital at 5:45 PM. Record review of Resident #1's progress notes dated 07/17/23 at 6:46 PM written by LVN C reflected, Resident #1 was transferred to a hospital on [DATE] 5:50 PM related to right femur fracture. Record review of Resident #1's progress notes dated 07/17/23 at 7:34 PM written by LVN U documented Resident #1 in hospital. Record review of Resident #1's progress notes dated 07/18/23 at 8:35 AM, written by LVN C reflected, Spoke to family member in regards to resident. Resident is going to have surgery for repair the femur fracture, remove old hardware that has come out, and run a rod from her knee to pelvis. Resident will be non-weight bearing post-operation and will no longer be able to walk. Record review of accident and incident reports dated 05/25/23 - 07/25/23 indicated Resident #1 had fracture incident on 07/17/23 3:30 PM. Record review Resident #1's of order revealed: Order date: 07/17/23 10:52 AM Order Summary: Xray of pelvis, Right hip, and femur one time only for right leg pain for 1 day Record review of Resident #1's Final X-Ray Report revealed: 1. Moderately displaced oblique fracture of distal diaphysis of femur of indeterminate age. 2. Dislocation of right hip is present 3. Internal fixation of right femoral neck. Record review of Resident #1's medication administration record revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 40 of 67 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 07/27/2023 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 0610 Level of Harm - Immediate jeopardy to resident health or safety 1.Tramadol HCI oral tablet 100 MG (give 1 tablet by mouth every 6 hours as needed for pain for 14 days) for the month of July was not administered on July 17th prior to resident being sent out to the hospital. 2. Tylenol Extra Strength Oral Tablet 500 MG (give 1 tablet by mouth every 6 hours as needed for pain) for the month of July was not administered on July 15th, 16th or 17th prior to resident being sent out to the hospital. Residents Affected - Few Record review of Resident #1's hospital records revealed: Chief complaint: Right leg pain from a fall Emergency department work up included a right femur x-rays revealed a displaced, evaluated distal femoral diaphyseal fracture. Resident completed surgery on 07/18/23. Record review of Resident #2's face sheet dated 07/25/23 revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, major depressive disorder, muscle wasting, abnormal posture, lack of coordination. Record review of Resident #2's annual MDS assessment, dated 05/23/23 revealed her BIMS score was 15 indicating Resident #2's cognition was intact. Her Functional Status for activities of daily living indicated she required extensive assistance with two person assist with bed mobility, transfers, and toileting. Extensive assistance with 2 persons assist with eating, dressing, personal hygiene, locomotion on and off the unit. Always incontinent with bowel and bladder. Adequate hearing, vision, and ability to understand others. Interview on 07/25/23 at 2:57 PM with Resident#1's family member/responsible party revealed she visits almost daily at 3:00 PM. When she entered the facility on Monday, 07/17/23, the Receptionist stated there was something wrong with Resident #1. She stated on her way to Resident #1's room, LVN C followed expressing the same thing, (that Resident #1 had an injury). The family member stated when she entered the room, Resident #1 was moaning, groaning and grimacing from pain. Both Resident #1 and roommate, Resident #2, started to explain the cause of her pain, late Saturday night (07/15/23), early Sunday morning (07/16/23) about midnight, that she was reaching for the call button, fell and the Student Aide D came in and threw her back in bed. Resident #1 stated to family member she fell on her bottom and hit her head. The family member stated she pulled the covers back and it was obvious, the leg looked as if there was a fracture to her right femur. The family member stated she was upset the facility had not contacted her prior to her entering the facility. The family member stated in speaking with the Administrator he apologized and stated the facility should have contacted her immediately and he would complete an investigation. Interview on 07/25/23 at 3:22 PM with Resident #2, who was Resident #1's roommate, revealed on 07/15/23 during the 7:00 PM-7:00 AM shift she met Student Aide D. Resident #2 stated Student Aide D entered the room three times throughout the night. At 9:00 PM, when Student Aide D assisted the resident to bed for the evening and at 12:30 AM when the resident requested a brief change and to be repositioned. Resident #2 stated she heard Resident #1 requesting to have her bed lifted, which should not have been done. Resident #2 stated about 1:45 AM she was awakened by a loud noise, and she heard Resident #1 complaining and moaning. Resident #2 stated she saw Student Aide D leaving the room. According to Resident #2 she did not see Resident #1 fall or on the floor but heard a loud noise that woke her. Resident #2 stated Resident #1 liked to get up at 5:30 AM, at that time different staff were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 41 of 67 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 07/27/2023 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few working, and she was told Student Aide D left the facility. Resident #2 stated Resident #1 complained of pain when CNA E got her out of bed and prepared her for breakfast. Interview on 07/25/23 at 4:29 PM, with CNA F revealed when she arrived to work on Sunday 07/16/23, she observed Resident #1 sitting out by the nursing station, complaining of pain, saying that her right leg was hurting. CNA F stated Resident #1 had complained of pain by tapping her right leg the whole time she was in the chair. According to CNA F she was told by aides on 200 Hall they had informed LVN B that Resident #1 was complaining about pain to her right leg. CNA F stated she was notified Resident #1 remained in bed throughout the night and breakfast due to her complaint of pain. CNA F stated she entered Resident #1's room to complete care around 10:00 AM, during that time she observed Resident #1's leg was bent and thought it was weird. CNA F stated she rolled Resident #1 to her right side, when she rolled her on her left side CNA F stated she noticed Resident #1's leg just fell to the side. CNA F stated at this point she went to alert LVN C for an assessment. Interview on 07/25/23 at 4:55 PM with the DON revealed she was alerted during morning clinical meeting that Resident #1 was complaining of pain and an x-ray had been ordered. According to the DON Resident #1 stated she fell out of bed and the night worker helped her back to bed. The DON stated Student Aide D was reassigned to the 200 Hall with Resident #1 which was whom Resident #1 was referring to the night worker. The DON stated after the fall Student Aide D did not notify anyone of Resident #1's fall or complaint of pain and left mid shift and had not returned to the facility. The DON stated LVN C was alerted of Resident #1's pain and injury, contacted the physician, followed orders for x-ray. DON stated following findings of the x-ray Resident #1 was transferred to the hospital on [DATE] with findings of fractured femur which resulted in surgery. The DON stated the charge nurse was responsible for assessing Resident #1 to identify where the pain was coming from and why resident was having a change of condition. According to the DON, it was facility policy for the charge nurse to contact the physician immediately when residents are complaining of pain or have a change of condition. The DON stated the charge nurse was also responsible for alerting family or responsible party and herself along with the Administrator as the abuse coordinator when residents are exhibiting a change of condition or have been involved in an injury. The DON stated it is not practice to neglect residents by not providing proper care. According to the DON it was discussed with the Administrator whether to investigate and report the incident during the morning clinical meeting on 07/17/23. The DON stated we were all on the same page to complete an investigation and report to the state agency. DON stated the Administrator was aware of the incident and began the investigation on how Resident #1 resulted in having a fracture. The DON stated she attempted to contact Student Aide D, however had not been successful. The DON stated the ball was left with the Administrator, he decided not to report the incident. Interview on 07/26/23 at 9:48 AM, with CNA E revealed she worked on the 7:00 PM-7:00 AM overnight shift on 07/15/23. CNA E stated Student Aide D abruptly left the facility about 2:17 AM. CNA E stated after Student Aide D left the facility, she did a round to Resident #1's room and observed her in bed sitting straight up sleeping, she left the room to prepare for a brief change, upon returning Resident #1 was making sounds of moaning and groaning which she thought was her normal communication to leave her alone. CNA E stated when she returned at 5:30 AM to get her up for the day she yelled out differently, her cry was deeper than her normal communication. CNA E stated her roommate commented that sound was different and that she thought Resident #1 was in pain. CNA E stated when she pushed Resident #1 to the Hall Resident #1 grabbed her shirt and patted her knee indicating she was in pain. CNA E stated she thought Resident #1 just wanted to fix her pant leg which needed to be pulled down, CNA E then lifted Resident #1's right leg and she screamed, when she stated when she lowered Resident #1's leg (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 42 of 67 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 07/27/2023 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few she screamed again patting her right knee. CNA E stated she then told LVN A that Resident #1 was in pain and may need Tylenol. CNA E stated the next night when she worked again, Resident #1 was already in the bed, sleeping. CNA E stated when she worked the next night, Resident #1 slept the whole night and did not wet the whole night. She stated when she attempted to wake Resident #1 up the next morning, the resident grabbed the covers and requested water. CNA E stated Resident #1 refused to get up for the day. CNA E stated she then alerted LVN A Resident #1 had not had care all night, refused to get up and her request for lots of water. Interview on 07/26/23 at 12:01 PM with LVN C revealed she worked the 7:00 AM-7:00 PM shift on 07/17/23, after breakfast she was notified by CNA F that something was wrong with Resident#1's leg. LVN C stated Resident #1's right leg was usually 90% straight and left leg bent, but at this time she was in a butterfly position, with both heels touching her brief. LVN C stated she immediately contacted physician via electronic communication app, video call within 2 minutes, and received an order for x-ray and Tramadol for pain. LVN C stated x-ray was completed within 4 hours indicating femur fracture of the right leg. LVN C stated at this time she prepared for Resident #1 to be sent out to the hospital. LVN C stated during her assessment Resident #1's leg was swollen, warm to touch, and she was guarding with palpations. According to LVN C when she asked Resident #1 and Resident #2 how the injury took place neither of them said anything until Resident #1's family member entered the room, it was not until then she heard Resident #1 say she fell out the bed. LVN C stated after the findings of the x-ray she was notified Resident #1 was not eating, had refused all 3 previous meals, not drinking, crying, and saying her knee was hurting. LVN C stated Resident #1 had not had any pain medications prior or while waiting to transfer to the hospital. LVN C stated Resident #1 did not exit the facility for the hospital until 5:30 PM. According to LVN C not contacting the physician immediately over the weekend placed Resident #1 at risk for further damage to her leg, infection, becoming septic and prolonged time in pain. LVN C stated she could not understand why Resident #1 was not already sent out prior to her shift. LVN C stated I followed protocol however, knowing what she knows now she should have used her nursing judgement and called 911 to send Resident #1 to the hospital immediately after observation and assessment of her leg. Interview on 07/26/23 at 12:59 PM, with CNA T revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23, CNA T stated she walked past Resident #1 as she was out in the hallway. CNA T stated Resident #1 was stopping every and anyone trying to get their attention. CNA T stated Resident #1 was moaning, she stated she thought the resident, Help me. According to CNA T, she did not contact the nurse to notify him that Resident #1 was complaining of pain. CNA T stated not notifying the nurse Resident #1 was expressing pain may have caused her prolonged pain. Interview on 07/26/23 at 1:13 PM with CNA G revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23, CNA G stated when she arrived Resident #1 was already sitting in her spot near the nursing station. CNA G stated Resident #1 did tell her about her knee pain. CNA G stated when LVN B arrived she notified him of her pain. CNA G stated, during breakfast I was pushing Resident #1 down to the dining room and [Student Aide H] was telling me that Resident #1's leg was swinging, which I could not see because I was behind her and trying to get residents to breakfast. CNA G stated after she left Resident #1 in the dining room, the resident wheeled herself back to the nurses' station CNA G stated Resident #1 refused breakfast, lunch, and dinner on this day. CNA G stated Resident #1 continued pointing to her knee saying it was hurting. CNA G stated she and Student Aide H discussed amongst themselves that something was wrong with Resident #1's leg and that they both had told LVN B about it more than once. Interview on 07/26/23 at 2:03 PM with Student Aide H revealed she worked the morning shift 7:00 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 43 of 67 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 07/27/2023 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few AM-7:00 PM on 07/16/23, Student Aide H stated when she arrived to work Resident #1 was in her usual spot near the nursing station. Student Aide H stated she saw CNA G pushing Resident #1 down the Hall and noticed her leg was swinging back and forth, she was crying, complaining of pain in her leg that was swinging. Student Aide H stated she expressed to LVN B what she observed. Student Aide H stated she later put Resident #1 down for bed, completed care, and when she rolled her on her right side she screamed so loud. Student Aide H stated she then went to alert LVN B that she was screaming in pain. According to Student Aide H, when she returned to put Resident #2 down for bed, she asked Resident #1 what happened, Resident #1 would agree to having a fall after she was asked a series of questions. Student Aide H stated she then returned to LVN B and shared that Resident #1 indicated she had a fall. Interview on 07/16/23 at 2:10 PM, with LVN B revealed he worked the morning shift 7:00 AM-7:00 PM on 07/16/23. He stated Resident #1 was already up in her wheelchair and near the nursing station when he arrived. LVN B stated Resident #1 appeared normal to him and he did not recognize anything out of the normal with her. LVN B stated she did return from the dining room refusing breakfast stating her knee was hurting. LVN B stated he did not observe any bruising or redness after being told by staff Resident #1 was in pain. LVN B stated he did not administer a full assessment for pain and stated he did not administer any pain medication for Resident #1's pain. LVN B stated he could not recall doing anything to assist Resident #1's pain. LVN B also stated he did not follow up with her throughout the day to see how she was feeling or to see if he needed to alert the physician that she was indicating pain, change of condition, or her refusal to eat. When LVN B was asked about risk to Resident #1's fractured femur not being assessed in a timely manner he apologized for not being much help. Interview on 08/01/23 at 2:50 PM with the Administrator revealed he was alerted to Resident #1's right femur fracture after the results of her x-ray. The Administrator stated after interviews with staff, Resident #2, and family member it was confirmed that Resident #1 had a fall. The Administrator stated although Resident #1's cognitive status was zero, Resident #1 was able to accurately explain what happened. Resident #1 was able to recall and state that she had a fall. According to the Administrator, he did not complete an investigation and he then decided the incident was not reportable to state agency based on his interview with Resident #1 and her ability to recount the incident. The Administrator stated he was not able to interview Student Aide D because she had avoided his phone calls and had not returned to the facility. Record review of facility's current Abuse/Neglect policy, dated 03/29/18, reflected: The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged neglect and situations that may constitute neglect to any resident in the facility. The facility will determine the direction of the investigation based on a thorough examination of events. Opportunities to prevent abuse will be managed accordingly. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from neglect must report this to the DON, administrator, stated and/or adult protective services. Facility employees must report all allegations of abuse, neglect, mistreatment of residents, exploitation, injury of unknown source to the facility administrator. The facility administrator or designee will report to Health and Human Service Commission all incidents that meet the criteria, if the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. On 07/26/23 at 5:38 PM the DON was notified an Immediate Jeopardy had been identified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 44 of 67 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 07/27/2023 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 0610 The facility's Plan of Removal was accepted on 07/27/23 at 1:18 PM. Level of Harm - Immediate jeopardy to resident health or safety The Plan of Removal reflected the following: Residents Affected - Few As of 7/26/23 [Resident #1] was assessed for pain. Orders received as of 7/26/23 for scheduled and PRN pain meds. o o All residents in the facility were assessed for any increased pain by the DON, ADON and Charge Nurses as of 7/26/23. No additional issues were found. Education: All charge nurses were in-serviced on 7/26/23 by the Compliance Nurse/DON/ADON regarding the following and all nurses including agency staff, new hires, and PRN staff not in-serviced by 7/26/23 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse. o Notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits. o Implementation of physician orders immediately upon receipt including the administration of pain medications. o A head-to-toe assessment will be performed by the charge nurse on all residents who complain of increased pain. All nursing staff were in-serviced on 7/26/23 by the Compliance Nurse/DON/ADON. All staff not in-serviced on 7/26/23 including agency staff, new hires and PRN staff will not be allowed to work their assigned schedule until the completion of these in-services. o Notify the charge nurse immediately if a resident is found on the floor. The resident will not be moved until assessed by a nurse. o Notification of change of condition to the physician immediately including falls, injuries, increased pain, decreased mobility, or a change in eating habits. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 45 of 67 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 07/27/2023 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 0610 o Level of Harm - Immediate jeopardy to resident health or safety Pain: Signs and symptoms of pain verbal and non-verbal. (crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching Medical Director was notified by the DON on 7/26/23 at 8:18 PM about the Immediate Jeopardies. Residents Affected - Few An AD HOC QAPI meeting will be held on 7/27/23 by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. The Director of Nursing or designee will implement this written Plan of Removal and will continue to monitor completion and compliance of this written Plan of Removal. Monitoring: o The DON and/or designee will monitor Real Time clinical software and the PCC Dashboard for clinical alerts for any resident change of condition including new or increased pain at least 5 days per week to ensure physician/NP were notified. Monitoring began 7/26/2023 and will continue x 4 weeks. o The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 days per week, to ensure any new physician/NP orders were implemented immediately. Monitoring began 7/26/23 and will continue x 4 weeks. Interview on 07/27/23 at 2:14 PM with ADON revealed in-services had been started to identify change of condition, charge nurse to complete full assessments, understanding signs and symptoms of pain both verbal and nonverbal, contacting the physician and implementing physician orders immediately. The ADON stated she completed in-services with aides regarding neglect and not moving resident after a fall, contacting the charge nurse when resident had a change in condition or expressed pain. The ADON stated during morning shift with LVN A on 07/16/23 was the beginning of Resident #1 expressing pain. The ADON stated LVN B was notified by staff that Resident #1 expressed pain and he should have done a complete assessment for pain, administered pain medication and communicated the history of the day with the oncoming nurse for the next shift. The ADON stated when LVN A returned to the facility on [DATE] at 7:00 PM Resident #1 was in bed, and nobody notified LVN A that Resident #1 was in pain. The ADON stated if LVN B communicated the history of the day, LVN A could have completed proper care and follow up. The ADON stated LVN B not communicating that Resident #1 expressed pain throughout the day put her at risk of not receiving proper pain management and treatment. The ADON stated it was her expectation to address resident needs, follow up with the doctor, DON, family and depending on the situation the Administrator. Further monitoring on 07/27/23 during interviews consisting of both day and night shifts revealed the following: Interviews on 07/27/23 from 2:15 PM through 07/27/23 4:30 PM with the DON, ADON, LVN A, LVN B, LVN C, CNA E, CNA F, CNA G, Student Aide H, LVN I, LVN J, LVN K, LVN L, LVN M, Student Aide N, CNA O, CNA P, Student Aide Q, CNA R, LVN S who worked the shifts of 7:00 AM-7:00 PM, 7:00 PM-7:00 AM were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 46 of 67 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 07/27/2023 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few able to verify education was provided to them; nursing staff were able to accurately summarize abuse and neglect policy, definitions and examples of change of condition and how, who, and when to report changes. The nursing staff revealed signs and symptoms of residents complaining of pain, what to do and who to contact. The nursing staff expressed understanding of the importance of completing assessments and identify the source of pain and how that plays in part to resident safety. During observations on 07/27/23 between 8:00 AM-5:00 PM revealed staff assessing residents who were exhibiting pain, residents who requested and were administered pain medications. Staff were observed engaging with residents, preforming full assessments, and interviewing residents to determine the source of pain, contacting the physician, documenting, and notifying resident's responsible party of change of condition. Record review of the facility plan of correction monitoring tool form undated titled Actual/Alleged Abuse Monitoring Ask 8-10 staff members per week, situational questions related to the neglectful action document any corrective actions on the back of the form .indicated log started on 07/24/23 with slots for date, time, staff name, responded correctly, [TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 47 of 67 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 07/27/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of eleven residents reviewed for quality of care. Residents Affected - Some LVN A and LVN B failed to address pain, complete an assessment, contact the physician, and provide effective pain treatment, for Resident #1 when she showed signs and symptoms of significant pain from midnight on 07/16/23 until 07/17/23 at 5:30 PM when Resident #1 was transported to the hospital after x-rays revealed the resident had a fracture to the right femur and hip at 3:30 PM on 07/17/23. An Immediate Jeopardy was identified on 07/25/23. The Immediate Jeopardy template was provided to the facility on [DATE] at 5:38 PM. While the Immediate Jeopardy was removed on 07/27/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, and resident neglect and following facility policy. These failures could put residents at risk for experiencing unnecessary pain and discomfort that could affect their health and quality of life. Findings included: Record review of Resident #1's face sheet dated 07/25/23 revealed Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included other abnormalities of gait and mobility, other lack of coordination, muscle wasting and atrophy, muscle weakness, reduced mobility, abnormal posture, repeated falls, foot drop, right foot (gait abnormality of the right foot). Record review of Resident #1's annual MDS assessment, dated 06/12/23 revealed her BIMS score was 99 indicating Resident #1 was unable to complete assessment. Her Functional Status for activities of daily living indicated she required extensive assistance with one person assist with bed mobility, dressing and personal hygiene. Extensive assistance with 2 person assist with eating, transfers, and toileting. Supervision and set ups with locomotion on and off the unit. MDS did not indicate any pain or shortness of breath. Section J indicated Resident #1 had a recent fall with a major injury (bone fractures). Record review of Resident #1's BIMS assessment dated [DATE] revealed her BIMS score was 0 indicating severe impairment. Interview on 07/25/23 at 2:57 PM with Resident#1's family member/responsible party revealed she visits almost daily at 3:00 PM. When she entered the facility on Monday, 07/17/23, the Receptionist stated there was something wrong with Resident #1. She stated on her way to Resident #1's room, LVN C followed expressing the same thing that Resident #1 had an injury. The family member stated when she entered the room, Resident #1 was moaning, groaning and grimacing from pain. Both Resident #1 and roommate, Resident #2, started to explain the cause of her pain, late Saturday night (07/15/23), early Sunday morning (07/16/23) about midnight, that she was reaching for the call button, fell and the Student Aide D came in and threw her back in bed. Resident #1 stated to family member she fell on her bottom and hit her head. The family member stated she pulled the cover back and it was obvious, the leg looked as if there was a fracture to her right femur. The family member stated she was upset (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 48 of 67 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 07/27/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the facility had not contacted her prior to her entering the facility. The Family member stated in speaking with the Administrator he apologized and stated the facility should have contacted her immediately and he would complete an investigation. Interview on 07/25/23 at 4:29 PM with CNA F revealed when she arrived to work on Sunday 07/16/23, 7:00 AM-7:00 PM shift, she observed Resident #1 sitting out by the nursing station, complaining of pain, saying that her right leg was hurting. CNA F stated on this day she worked a different hall and was not sure what aides or nurses on 200 hall had done to treat her leg pain. CNA F stated Resident #1 had complained of pain by tapping her right leg the whole time she was in the chair. CNA F stated she normally worked with her on 200 and noted the behavior was not normal so she advised the aides on 200 hall (CNA G and Student Aide H) to put Resident #1 to bed around 3:00 PM- 4:00 PM. According to CNA F she was told by aides on 200 hall they had informed LVN B that Resident #1 was complaining about pain to her right leg. CNA F stated the next morning 07/17/23, she returned to the 200 hall. CNA F stated she was notified Resident #1 remained in bed throughout the night and breakfast due to her complaint of pain. CNA F stated she entered Resident #1's room to complete care, during this time she observed Resident #1's leg was bent and thought it was weird. CNA F stated she rolled Resident #1 to her right side, when she rolled her on her left side, she noticed Resident #1's leg just fell to the side. CNA F stated at this point she went to alert LVN C for an assessment. During an observation and interview on 07/25/23 at 3:34 PM with Resident #1 revealed she was in bed resting, quiet, when she saw family member enter the room she started smiling and began talking. When asked about her knee she began speaking and pointing to the floor. Resident #1 stated she fell out of the bed and hurt her knee. Resident #1 patted on her right knee and stated, it hurt. According to Resident #1, she had been administered pain medication and was not in pain at this time. Interview on 07/25/23 at 4:42 PM with the Nurse Practitioner revealed she was not on-call from 07/15/23-07/17/23; however, she was able to reveal on her phone that LVN C contacted physician through electronic communication app (communication app with medical director) on Monday 07/17/23, 10:45 AM due to Resident #1 complaining of right leg pain, Resident #1's leg was bent, and she was guarding, aide was completing care and felt movement in the leg with transferring. The Nurse Practitioner stated the doctor saw resident via video and was able to provide order for x-ray and tramadol for pain. The Nurse Practitioner stated the information she received about the injury was speculation so she could not speak on the risk for the resident, however she stated it was expected that the facility immediately notify electronic communication app when residents had a change in condition. Interview on 07/25/23 at 4:55 PM with the DON revealed she was alerted during morning clinical meeting on 06/17/23 that Resident #1 was complaining of pain and an x-ray had been ordered. According to the DON, Resident #1 stated, she fell out of bed and the night worker helped her back to bed. The DON stated Student Aide D was reassigned to the 200 hall with Resident #1 which was whom Resident #1 was referring to as the night worker. The DON stated after the fall Student Aide D did not notify anyone of Resident #1's fall or complaint of pain and left mid shift and had not returned to the facility. The DON stated at about 10:30 AM LVN C was alerted of Resident #1's pain and injury, contacted the physician, and followed orders for x-ray. The DON stated Resident #1 was transferred to the hospital on July 17th with findings of fractured femur which resulted in surgery. According to the DON it was the facility policy for the charge nurse to contact the physician immediately when residents were complaining of pain or had a change of condition. The DON stated the charge nurse was also responsible for alerting family or responsible party and herself along with the Administrator as the abuse coordinator when residents were exhibiting a change of condition or had been involved in an injury. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 49 of 67 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 07/27/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Interview on 07/26/23 at 9:48 AM with CNA E revealed she worked on the 7:00 PM 7:00AM overnight shift on 07/15/23. CNA E stated she saw Student Aide D enter Resident #1's room [ROOM NUMBER] times throughout the shift and abruptly left the facility about 2:17 AM. CNA E stated after Student Aide D left the facility, she did a round to Resident #1's room and observed her in bed sitting straight up sleeping, she left the room to prepare for a brief change, upon returning Resident #1 was making sounds of moaning and groaning which she thought was her normal communication to leave her alone, she was not wet so she left her alone. CNA E stated when she returned at 5:30 AM to get her up for the day she yelled out differently, her cry was deeper than her normal communication. CNA E stated her roommate commented that sound was different and that she thought Resident #1 was in pain. CNA E stated when she pushed Resident #1 to the hall Resident #1 grabbed her shirt and patted her knee indicating she was in pain. CNA E stated she thought Resident #1 just wanted to fix her pant leg which needed to be pulled down, CNA E then lifted Resident #1's right leg and she screamed, when she stated when she lowered Resident #1's leg she screamed again patting her right knee. CNA E stated she then told LVN A that Resident #1 was in pain and may need Tylenol. The next night she worked again, Resident #1 was already in the bed, sleeping, she slept the whole night and did not wet the whole night. When she attempted to wake her the next morning, the resident grabbed the covers and requested water. CNA E stated Resident #1 refused to get up for the day. CNA E stated she then alerted LVN A Resident #1 had not had care all night, refused to get up, and her request for lots of water Record review of Resident #1's care plan, last care conference 04/28/23, revealed: 1. Resident #1 at risk for falls related to muscle weakness, Goals: risks and injury potential will be minimized through the next review date. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. The resident needs a safe environment with: even floors free from spills and or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. 2. Resident #1 has potential for pain related to right foot drop. Goal: Resident will not have an interruption in normal activities due to pain through review date. Intervention: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions every shift. Review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Observe/document for probable cause of each pain episode. Remove/limit causes where possible. Observe/document for side effects of pain medication. Observe/record/report to nurse any signs and symptoms of non-verbal pain: changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling outs, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Observe/record/report to nurse loss of appetite, refusal to eat and weight loss. Observe/record/report to nurse resident complaints of pain or requests for pain treatment. Provide non-pharmacological interventions. Report to nurse any change in usual (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 50 of 67 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 07/27/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some activity attendance patterns or refusal to attend activities related to signs and symptoms of pain or discomfort. Therapy referral as indicated. 3. Resident #1 has osteoporosis. Goal: Resident will remain free of injuries or complications related to osteoporosis through review date. Interventions: Give analgesics as needed for pain, Resident may complain of pain, stiffness, or weakness. Document complaints. Give medications as ordered. Observe/document for side effects and effectiveness. Observe for risk of falls. Observe/document/report as needed for signs and symptoms or complications related to osteoporosis: Acute fracture, compression fractures, loss of height, pain. Record review of Resident #1's progress notes dated 06/25/23 - 07/17/23 revealed no mention or assessment of Resident #1 complaint of pain. Record review of Resident #1's progress notes dated 07/17/23 at 12:00 AM copy of documentation signed by Physician reflected, Follow up Physical exam, Elderly, frail female in some distress seen via video, Right lower extremity bent at ninety degrees, grimacing with palpation. Patient seen via telemedicine with nurse. 1. Pelvis and right femur x-ray. Concern for fracture status post transfer. 2. Tramadol 100mg po q6h PRN pain for 14 days if no allergies. 3. Follow up x-ray. Record review of Resident #1's progress notes dated 07/17/23 at 9:15 PM written by LVN C reflected the following late entry: CNA F reported that resident was complaining of pain during a brief change. I went and looked at her leg, and then messaged the doctor. The doctor video called, and we looked at the leg together. The doctor ordered x-rays and pain meds for resident. This nurse put in the orders. The x-ray techs showed up around 3:30 PM, and so did family member. X-ray showed femur break. This nurse reported that to doctor and called for transport to hospital. It was 1745 before resident was transported to hospital due to ambulance being busy. Record review of Resident #1's progress notes dated 07/17/23 at 5:54 PM written by ADON reflected the following late entry: Resident reported leg pain to aide and aide notified nurse. Nurse assessed resident and did a telehealth video call and X-ray, and pain meds were ordered. Family member was at bedside during x-ray and when it was resulted. Right femur fracture. Upon further investigation, resident states she did fall out of bed last night onto her knees and a worker helped her up. Patient has good situational awareness. Emergency Transportation was called and resident sent to hospital at 5:45 PM. Record review of Resident #1's progress notes dated 07/17/23 at 6:46 PM written by LVN C reflected: Resident #1 was transferred to a hospital on [DATE] 5:50 PM related to right femur fracture. Record review of Resident #1's progress notes dated 07/17/23 at 7:34 PM written by LVN U reflected: Resident #1 in hospital. Record review of Resident #1's progress notes dated 07/18/23 at 08:35 written by LVN C reflected: Spoke to family member in regards to resident. Resident is going to have surgery for repair the femur fracture, remove old hardware that has come out, and run a rod from her knee to pelvis. Resident will be non-weight bearing post-operation and will no longer be able to walk. Record review of accident and incident reports dated 05/25/23 - 07/25/23 indicated Resident #1 had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 51 of 67 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 07/27/2023 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 0684 fracture incident on 07/17/23 3:30 PM. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's order revealed: Order date: 07/17/23 10:52 AM Xray of pelvis, Right hip, and femur one time only for right leg pain for 1 day Record review of Resident #1's Final X-Ray Report, dated 07/17/23, revealed: Residents Affected - Some 1. Moderately displaced oblique fracture of distal diaphysis of femur of indeterminate age. (bone broken at an angle that affected the knee and leg) 2. Dislocation of right hip is present 3. Internal fixation of right femoral neck. Record review of Resident #1's July 2023 MAR revealed: Tramadol HcL oral tablet 100 MG (give 1 tablet by mouth every 6 hours as needed for pain for 14 days) for the month of July was not administered at any time from 07/15/23, 07/16/23, and 07/17/23 prior to resident being sent out to the hospital. Tylenol Extra Strength Oral Tablet 500 MG (give 1 tablet by mouth every 6 hours as needed for pain) for the month of July was not administered at any time from 07/15/23-07/17/23 prior to resident being sent out to the hospital. Record review of hospital records dated 07/17/23 revealed: Chief complaint: Right leg pain from a fall. Emergency department work up included a right femur x-rays revealed a displaced, evaluated distal femoral diaphyseal fracture. Hospital records date 07/18/23 reflected the resident completed surgery on 07/18/23. Record review of Resident #2's face sheet dated 07/25/23 revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, major depressive disorder, muscle wasting, abnormal posture, lack of coordination. Record review of Resident #2's annual MDS assessment, dated 05/23/23 revealed her BIMS score was 15 indicating Resident #2's cognition was intact. Her Functional Status for activities of daily living indicated she required extensive assistance with two person assist with bed mobility, transfers, and toileting. Extensive assistance with 2 persons assist with eating, dressing, personal hygiene, locomotion on and off the unit. Always incontinent with bowel and bladder. Adequate hearing, vision, and ability to understand others. Interview on 07/26/23 at 12:01 PM with LVN C revealed she worked the 7:00 AM-7:00 PM shift on 07/17/23, after breakfast she was notified by CNA F that something was wrong with Resident#1's leg. LVN C stated Resident #1's right leg was usually 90% straight and left leg bent, but at this time she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 52 of 67 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 07/27/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some in a butterfly position, with both heels touching her brief. LVN C stated she immediately contacted physician via electronic communication app, video call within 2 minutes, and received an order for x-ray and Tramadol for pain. LVN C stated x-ray was completed within 4 hours indicating femur fracture of the right leg. LVN C stated at this time she prepared for Resident #1 to be sent out to the hospital. LVN C stated during her assessment Resident #1's leg was swollen, warm to touch, and she was guarding with palpations. According to LVN C when she asked Resident #1 and Resident #2 how the injury took place neither of them said anything until Resident #1's family member entered the room, it was not until then she heard Resident #1 say she fell out the bed. LVN C stated after the findings of the x-ray she was notified Resident #1 was not eating, had refused all 3 previous meals, not drinking, crying, and saying her knee was hurting. LVN C stated Resident #1 had not had any pain medications prior or while waiting to transfer to the hospital. LVN C stated Resident #1 did not exit the facility for the hospital until 5:30 PM. According to LVN C not contacting the physician immediately over the weekend placed Resident #1 at risk for further damage to her leg, infection, becoming septic and prolonged time in pain. LVN C stated knowing what she knows now she should have used her nursing judgement and called 911 to send Resident #1 to the hospital immediately after observation and assessment of her leg. Interview on 07/26/23 at 12:59 PM with CNA T revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23, CNA T stated she walked past Resident #1 as she was out in the hallway. CNA T stated Resident #1 was stopping everyone and anyone trying to get their attention. CNA T stated Resident #1 was trying to say something, but because she did not work with her on a regular basis, she (CNA T) grabbed CNA G. CNA T stated Resident #1 was moaning, CNA T stated she thought Resident #1 said, Help me. According to CNA T because she worked on another hall, she did not see Resident #1 again. CNA T stated because she contacted the CNA that was working on her hall, she did not contact the nurse to notify him that Resident #1 was complaining of pain. CNA T stated not notifying the nurse Resident #1 was expressing pain may have caused her prolonged pain. Interview on 07/26/23 at 1:13 PM with CNA G revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23, CNA G stated when she arrived Resident #1 was already sitting in her spot near the nursing station. CNA G stated Resident #1 did tell her about her knee pain. CNA G stated when LVN B arrived she notified him of her pain. CNA G stated, during breakfast I was pushing Resident #1 down to the dining room and [Student Aide H] was telling me that Resident #1's leg was swinging, which I could not see because I was behind her and trying to get residents to breakfast. CNA G stated after left Resident #1 in the dining room the resident wheeled herself back to the nurses' station, she refused breakfast, lunch, and dinner on that day. CNA G stated Resident #1 continued pointing to her knee saying it was hurting. CNA G stated she and Student Aide H discussed amongst themselves that something was wrong with Resident #1's leg and that they both had told him about it more than once. Interview on 07/26/23 at 2:03 PM with Student Aide H revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23, Student Aide H stated when she arrived to work Resident #1 was in her usual spot near the nursing station. Student Aide H stated she saw CNA G pushing Resident #1 down the hall and noticed her leg was swinging back and forth, she was crying, complaining of pain in her leg that was swinging. Student Aide H stated she expressed to LVN B what she observed. Student Aide H stated she later put Resident #1 down for bed, completed care, and when she rolled her on her right side she screamed so loud. Student Aide H stated she then went to alert LVN B that she was screaming in pain, and this was not normal for her. According to Student Aide H when she returned to put Resident #2 down for bed, she asked Resident #1 what happened, Resident #1 would agree to having a fall after she was asked a series of questions. Student Aide H stated she then returned to LVN B and shared that Resident #1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 53 of 67 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 07/27/2023 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 0684 indicated she had a fall. Level of Harm - Immediate jeopardy to resident health or safety Interview on 07/26/23 at 2:10 PM with LVN B revealed he worked the morning shift 7:00 AM-7:00 PM on 07/16/23. He stated Resident #1 was already up in her wheelchair and near the nursing station when he arrived. LVN B stated Resident #1 appeared normal to him and he did not recognize anything out of the normal with her. LVN B stated she did return from the dining room refusing breakfast stating her keen was hurting. LVN B stated he did not observe any bruising or redness after being told by staff Resident #1 was in pain. LVN B stated he did not administer a full assessment for pain and stated he did not administer any pain medication for Resident #1's pain. LVN B stated he could not recall doing anything to assist Resident #1's pain. LVN B also stated he did not follow up with her throughout the day to see how she was feeling or to see if he needed to alert the physician that she was indicating pain, change of condition, or her refusal to eat. When LVN B was asked about risk to Resident #1's fractured femur not being assessed in a timely manner he apologized for not being much help. Residents Affected - Some Interview on 07/26/23 at 2:46 PM with LVN A revealed she worked on the overnight shift 7:00 PM-7:00 AM on 07/15/23 for 100 Hall and 200 Hall. LVN A stated she did not have any complaints of a fall. LVN A stated throughout the night Resident #1 rested fine, until she was getting out of bed between 5:30 AM- 6:00 AM. LVN A stated when CNA E went to get the resident up, the resident stated her knee was hurting and it was reported she was sleeping in a weird position. Her head was up really high, her legs were sideways, and her legs stiff. LVN A stated when she went to check Resident #1, the resident was dressed, in a wheelchair in the hallway. LVN A stated at that time she did not think anything serious happened. LVN A stated she administered pain mediation prior to leaving on 07/16/23. LVN A stated when she returned the next day there were no complaints of pain, Resident #1 was in bed the entire shift. LVN A stated when she left on Monday morning 07/17/23, she got a call from the facility stating Resident #1 was injured. LVN A stated during the call she was informed Resident #1 complained of pain on Sunday 07/16/23, and the day nurse gave her pain medication. LVN A stated she did not complete an assessment to identify the source pain after CNA E and Resident #1 complained the resident was in pain. LVN A stated she did not contact the Physician, DON, or the oncoming nurse that she was informed Resident #1 was in pain. According to LVN A not completing a full assessment or identifying a change of condition could place residents at risk of not receiving immediate care. Review of facility current Notifying the Physician of Change in Status policy, dated 03/11/13, reflected: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention . 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. 2. . the nurse will gather medications, vital signs, signs and symptoms, and interventions that have currently been implemented. 3. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 54 of 67 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 07/27/2023 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 0684 . the nurse is responsible for responding to a change of condition in a timely and effective manner. Level of Harm - Immediate jeopardy to resident health or safety 4. If the situation is an emergency and the attempts to the physician was unsuccessful, the nurse will contact the nearest ambulance service for assistance. Residents Affected - Some 5. The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise. Record review of facility's Quality of Care revealed they did not have one however, provided Resident Rights policy revised 11/28/16 indicated The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must establish and maintain identical policies and practices regarding provision of services under the State plan for all residents regardless of payment source. This was determined to be an Immediate Jeopardy on 07/26/23 at 4:49 PM. The Director of Nursing was notified. an Immediate Jeopardy had been identified. The Director of Nursing was provided with the Immediate Jeopardy on 07/26/23 at 5:38 PM. The facility's Plan of Removal was accepted on 07/27/23 at 1:18 PM. The Plan of Removal reflected the following: o As of 7/26/23 Resident #1 was assessed for pain. Orders received as of 7/26/23 for scheduled and PRN pain meds. o All residents in the facility were assessed for any increased pain by the DON, ADON and Charge Nurses as of 7/26/23. No additional issues were found. Education: All charge nurses were in-serviced on 7/26/23 by the Compliance Nurse/DON/ADON regarding the following and all nurses including agency staff, new hires, and PRN staff not in-serviced by 7/26/23 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse. o Notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 55 of 67 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 07/27/2023 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 0684 o Level of Harm - Immediate jeopardy to resident health or safety Implementation of physician orders immediately upon receipt including the administration of pain medications. o Residents Affected - Some A head-to-toe assessment will be performed by the charge nurse on all residents who complain of increased pain. All nursing staff were in-serviced on 7/26/23 by the Compliance Nurse/DON/ADON. All staff not in-serviced on 7/26/23 including agency staff, new hires and PRN staff will not be allowed to work their assigned schedule until the completion of these in-services. o Notify the charge nurse immediately if a resident is found on the floor. The resident will not be moved until assessed by a nurse. o Notification of change of condition to the physician immediately including falls, injuries, increased pain, decreased mobility, or a change in eating habits. o Pain: Signs and symptoms of pain verbal and non-verbal. (crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching Medical Director was notified by the DON on 7/26/23 at 8:18pm about the Immediate Jeopardies. An AD HOC QAPI meeting will be held on 7/27/23 by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. The Director of Nursing or designee will implement this written Plan of Removal and will continue to monitor completion and compliance of this written Plan of Removal. Monitoring: o The DON and/or designee will monitor Real Time clinical software and the PCC Dashboard for clinical alerts for any resident change of condition including new or increased pain at least 5 days per week to ensure physician/NP were notified. Monitoring began 7/26/2023 and will continue x 4 weeks. o The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 days per week, to ensure any new physician/NP orders were implemented immediately. Monitoring began (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 56 of 67 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 07/27/2023 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 0684 7/26/23 and will continue x 4 weeks. Level of Harm - Immediate jeopardy to resident health or safety Further monitoring on 07/27/23 during interviews consisting of both day and night shifts revealed the following: Residents Affected - Some Interviews on 07/27/23 from 2:15 PM through 07/27/23 4:30 PM with the DON, ADON, LVN A, LVN B, LVN C, CNA E, CNA F, CNA G, Student Aide H, LVN I, LVN J, LVN K, LVN L, LVN M, Student Aide N, CNA O, CNA P, Student Aide Q, CNA R, LVN S who worked the shifts of 7:00 AM-7:00 PM, 7:00 PM-7:00AM were able to verify education was provided to them; nursing staff were able to accurately summarize abuse and neglect policy, definitions and examples of change of condition and how, who, and when to report changes. The nursing staff revealed signs and symptoms of residents complaining of pain, what to do and who to contact. The nursing staff expressed understanding of the importance of completing assessments and identify the source of pain and how that plays in part to resident safety. During observations on 07/27/23 between 8:00 AM-5:00 PM revealed staff assessing residents who were exhibiting pain, residents who requested and were administered pain medications. Staff were observed engaging with residents, preforming full assessments, and interviewing residents to determine the source of pain, contacting the physician, documenting, and notifying resident's responsible party of change of condition. Record review of the facility plan of correction monitoring tool form beginning 07/26/23, titled Real Time Monitoring indicated log started with slots for date, new pain, MD notified, new order implemented/medication given, initials/comments. Record review of the facility plan of correction monitoring tool form titled Change of Condition Monitoring indicated log ask 10 nurses per week what would they do if a resident had a change of condition, or it was reported to them that a resident had a change of condition. Date/Nurse name, Did they respond c[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 57 of 67 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 07/27/2023 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of eleven residents reviewed for pain. Residents Affected - Some The facility failed to address when Resident #1 screamed out in pain when her leg was moved, complete assessment, contact physician, and provide effective pain treatment, for Resident #1 when she showed signs and symptoms of significant pain from midnight on 07/16/23 until 07/17/23 at 5:30 PM when Resident #1 was transported to the hospital after x-rays revealed the resident had a fracture to the right femur and hip at 3:30 PM on 07/17/23, which required surgical intervention. An Immediate Jeopardy was identified on 07/25/23. The Immediate Jeopardy template was provided to the facility on [DATE] at 5:38 PM. While the Immediate Jeopardy was removed on 07/27/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, and resident neglect and following facility policy. These failures could put residents at risk for experiencing unnecessary pain and discomfort that could affect their health and quality of life. Findings included: Record review of Resident #1's face sheet dated 07/25/23 revealed Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included other abnormalities of gait and mobility, other lack of coordination, muscle wasting and atrophy, muscle weakness, reduced mobility, abnormal posture, repeated falls, foot drop, right foot (gait abnormality of the right foot). Record review of Resident #1's annual MDS assessment, dated 06/12/23 revealed her BIMS score was 99 indicating Resident #1 was unable to complete assessment. Her Functional Status for activities of daily living indicated she required extensive assistance with one person assist with bed mobility, dressing and personal hygiene. Extensive assistance with 2 person assist with eating, transfers, and toileting. Supervision and set ups with locomotion on and off the unit. The MDS did not indicate any pain or shortness of breath. Section J indicated Resident #1 had a recent fall with a major injury (bone fractures). Record review of Resident #1's BIMS assessment dated [DATE] revealed her BIMS score was 0 indicating severe impairment. Record review of Resident #1's care plan, last care conference 04/28/23, revealed: 1. Resident #1 at high risk for falls related to muscle weakness, Goals: risks and injury potential will be minimized through the next review date. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Ensure that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 58 of 67 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 07/27/2023 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. The resident needs a safe environment with even floors free from spills and or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. 2. Resident #1 has potential for pain related to right foot drop. Goal: Resident will not have an interruption in normal activities due to pain through review date. Intervention: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions every shift. Review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Observe/document for probable cause of each pain episode. Remove/limit causes where possible. Observe/document for side effects of pain medication. Observe/record/report to nurse any signs and symptoms of non-verbal pain: changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling outs, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Observe/record/report to nurse loss of appetite, refusal to eat and weight loss. Observe/record/report to nurse resident complaints of pain or requests for pain treatment. Provide non-pharmacological interventions. Report to nurse any change in usual activity attendance patterns or refusal to attend activities related to signs and symptoms of pain or discomfort. Therapy referral as indicated. 3. Resident #1 has osteoporosis. Goal: Resident will remain free of injuries or complications related to osteoporosis through review date. Interventions: Give analgesics as needed for pain, Resident may complain of pain, stiffness, or weakness. Document complaints. Give medications as ordered. Observe/document for side effects and effectiveness. Observe for risk of falls. Observe/document/report as needed for signs and symptoms or complications related to osteoporosis: Acute fracture, compression fractures, loss of height, pain. Interview on 07/25/23 at 2:57 PM with Resident#1's family member/responsible party revealed she visits almost daily at 3:00 PM. When she entered the facility on Monday, 07/17/23, the Receptionist stated there was something wrong with Resident #1. She stated on her way to Resident #1's room, LVN C followed expressing the same thing, (that Resident #1 had an injury). The family member stated when she entered the room, Resident #1 was moaning, groaning and grimacing from pain. Both Resident #1 and roommate, Resident #2, started to explain the cause of her pain, late Saturday night (07/15/23), early Sunday morning (07/16/23) about midnight, that she was reaching for the call button, fell and the Student Aide D came in and threw her back in bed. Resident #1 stated to family member she fell on her bottom and hit her head. The family member stated she pulled the cover back and it was obvious, the leg looked as if there was a fracture to her right femur. The family member stated she was upset the facility had not contacted her prior to her entering the facility. The family member stated in speaking with the Administrator he apologized and stated the facility should have contacted her immediately and he would complete an investigation. Interview on 07/25/23 at 4:29 PM with CNA F revealed when she arrived to work on Sunday 07/16/23, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 59 of 67 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 07/27/2023 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 7:00 AM-7:00 PM shift, she observed Resident #1 sitting out by the nursing station, complaining of pain, saying that her right leg was hurting. CNA F stated on this day she worked a different hall and was not sure what aides or nurses on 200 hall had done to treat her leg pain. CNA F stated Resident #1 had complained of pain by tapping her right leg the whole time she was in the chair. CNA F stated she normally worked with her on 200 and noted the behavior was not normal so she advised the aides on 200 hall (CNA G and Student Aide H) to put Resident #1 to bed around 3:00 PM-4:00 PM. According to CNA F she was told by aides on 200 hall they had informed LVN B that Resident #1 was complaining about pain to her right leg. CNA F stated the next morning 07/17/23, she returned to the 200 hall. CNA F stated she was notified Resident #1 remained in bed throughout the night and breakfast due to her complaint of pain. CNA F stated she entered Resident #1's room to complete care, during this time she observed Resident #1's leg was bent and thought it was weird. CNA F stated she rolled Resident #1 to her right side, when she rolled her on her left side, she noticed Resident #1's leg just fell to the side. CNA F stated at this point she went to alert LVN C for an assessment. During an observation and interview on 07/25/23 at 3:34 PM, with Resident #1 revealed she was in bed resting, quiet, when she saw family member enter the room she started smiling and began talking. When asked about her knee she began speaking and pointing to the floor. Resident #1 stated she fell out of the bed and hurt her knee. Resident #1 patted on her right knee and stated, it hurt. According to Resident #1, she had been administered pain medication and was not in pain at this time. Interview on 07/25/23 at 4:42 PM with the Nurse Practitioner revealed she was not on-call from 07/15/23-07/17/23; however, she was able to reveal on her phone that LVN C contacted physician through electronic communication app (communication app with medical director) on Monday 07/17/23, 10:45 AM due to Resident #1 complaining of right leg pain, Resident #1's leg was bent, and she was guarding, aide was completing care and felt movement in the leg with transferring. The Nurse Practitioner stated the doctor saw resident via video and was able to provide order for x-ray and tramadol for pain. The Nurse Practitioner stated the information she received about the injury was speculation so she could not speak on the risk for the resident; however, she stated it was expected that the facility immediately notify the physician via the electronic communication app when residents had a change in condition. Interview on 07/25/23 at 4:55 PM with the DON revealed she was alerted during morning clinical meeting on 07/17/23 that Resident #1 was complaining of pain and an x-ray had been ordered. According to the DON, Resident #1 stated, she fell out of bed and the night worker helped her back to bed. The DON stated Student Aide D was reassigned to the 200 Hall with Resident #1 which was whom Resident #1 was referring to as the night worker. The DON stated after the fall Student Aide D did not notify anyone of Resident #1's fall or complaint of pain and left mid shift and had not returned to the facility. The DON stated at about 10:30 AM LVN C was alerted of Resident #1's pain and injury, contacted the physician, and followed orders for x-ray. The DON stated Resident #1 was transferred to the hospital on [DATE] with findings of fractured femur which resulted in surgery. According to the DON, it was the facility policy for the charge nurse to contact the physician immediately when residents were complaining of pain or had a change of condition. The DON stated the charge nurse was also responsible for alerting family or responsible party and herself along with the Administrator (Abuse Coordinator) when residents were exhibiting a change of condition or had been involved in an injury. Interview on 07/26/23 at 9:48 AM, with CNA E revealed she worked on the 7:00 PM - 7:00AM overnight shift on 07/15/23. CNA E stated she saw Student Aide D enter Resident #1's room [ROOM NUMBER] times throughout the shift and abruptly left the facility about 2:17 AM. CNA E stated after Student Aide D left the facility, she did a round to Resident #1's room and observed her in bed sitting straight (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 60 of 67 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 07/27/2023 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some up sleeping, she left the room to prepare for a brief change, upon returning Resident #1 was making sounds of moaning and groaning which she thought was her normal communication to leave her alone, she was not wet so she left her alone. CNA E stated when she returned at 5:30 AM to get her up for the day she yelled out differently, her cry was deeper than her normal communication. CNA E stated her roommate commented that sound was different and that she thought Resident #1 was in pain. CNA E stated when she pushed Resident #1 to the hall Resident #1 grabbed her shirt and patted her knee indicating she was in pain. CNA E stated she thought Resident #1 just wanted to fix her pant leg which needed to be pulled down, CNA E then lifted Resident #1's right leg and she screamed, when she stated when she lowered Resident #1's leg she screamed again patting her right knee. CNA E stated she then told LVN A that Resident #1 was in pain and may need Tylenol. CNA E stated the next night when she worked again, Resident #1 was already in the bed, sleeping. CNA E stated the resident slept the whole night and did not wet the whole night. When she attempted to wake Resident #1 up the next morning, the resident grabbed the covers and requested water. CNA E stated the resident refused to get up for the day. CNA E stated she then alerted LVN A Resident #1 had not had care all night, refused to get up, and her request for lots of water. Record review of Resident #1's progress notes dated 06/25/23 - 07/17/23 revealed no mention or assessment of Resident #1 complaint of pain. Record review of Resident #1's progress notes dated 07/17/23 at 12:00 AM copy of documentation signed by Physician reflected, Follow up Physical exam, Elderly, frail female in some distress seen via video, Right lower extremity bent at ninety degrees, grimacing with palpation. Patient seen via telemedicine with nurse. 1. Pelvis and right femur x-ray. Concern for fracture status post transfer. 2. Tramadol 100mg po q6h PRN pain for 14 days if no allergies. 3. Follow up x-ray. Record review of Resident #1's progress notes dated 07/17/23 at 09:15 written by LVN C reflected the following late entry: CNA F reported that resident was complaining of pain during a brief change. I went and looked at her leg, and then messaged the doctor. The doctor video called, and we looked at the leg together. The doctor ordered x-rays and pain meds for resident. This nurse put in the orders. The x-ray techs showed up around 1530, and so did family member. X-ray showed femur break. This nurse reported that to doctor and called for transport to hospital. It was 5:45 PM before resident was transported to hospital due to ambulance being busy. Record review of Resident #1's progress notes dated 07/17/23 at 5::54 PM written by the ADON reflected the following late entry: Resident reported leg pain to aide and aide notified nurse. Nurse assessed resident and did a telehealth video call and X-ray, and pain meds were ordered. Family member was at bedside during x-ray and when it was resulted. Right femur fracture. Upon further investigation, resident states she did fall out of bed last night onto her knees and a worker helped her up. Patient has good situational awareness. Emergency Transportation was called and resident sent to hospital at 5:45 PM. Record review of Resident #1's progress notes dated 07/17/23 at 6:46 PM written by LVN C reflected: Resident #1 was transferred to a hospital on [DATE] 5:50 PM related to right femur fracture. Record review of Resident #1's progress notes dated 07/17/23 at 7:34 PM written by LVN U reflected: Resident #1 in hospital. Record review of Resident #1's progress notes dated 07/18/23 at 8:35 AM, written by LVN C reflected: Spoke to family member in regards to resident. Resident is going to have surgery for repair the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 61 of 67 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 07/27/2023 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some femur fracture, remove old hardware that has come out, and run a rod from her knee to pelvis. Resident will be non-weight bearing post-operation and will no longer be able to walk. Record review of accident and incident reports dated 05/25/23 - 07/25/23 indicated Resident #1 had fracture incident on 07/17/23 3:30 PM. Record review of Resident #1's order revealed: Order date: 07/17/23 at 10:52 AM, Xray of pelvis, Right hip, and femur one time only for right leg pain for 1 day Record review of Resident #1's Final X-Ray Report, dated 07/17/23, revealed: 1. Moderately displaced oblique fracture of distal diaphysis of femur of indeterminate age. (bone broken at an angle that affected the knee and leg) 2. Dislocation of right hip is present 3. Internal fixation of right femoral neck. Record review of Resident #1's July 2023 MAR revealed: Tramadol HcL oral tablet 100 MG (give 1 tablet by mouth every 6 hours as needed for pain for 14 days) for the month of July was not administered at any time from 07/15/23-07/17/23 prior to resident being sent out to the hospital. Tylenol Extra Strength Oral Tablet 500 MG (give 1 tablet by mouth every 6 hours as needed for pain) for the month of July was not administered at any time from July 15th - July 17th prior to resident being sent out to the hospital. Record review of hospital records, dated 07/17/23, revealed: Chief complaint: Right leg pain from a fall. Emergency department work up included a right femur x-rays revealed a displaced, evaluated distal femoral diaphyseal fracture. Hospital records dated 07/18/23 reflected the resident completed surgery on 07/18/23. Record review of Resident #2's face sheet dated 07/25/23 revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, major depressive disorder, muscle wasting, abnormal posture, lack of coordination. Record review of Resident #2's annual MDS assessment, dated 05/23/23 revealed her BIMS score was 15 indicating Resident #2's cognition was intact. Her Functional Status for activities of daily living indicated she required extensive assistance with two person assist with bed mobility, transfers, and toileting. Extensive assistance with 2 persons assist with eating, dressing, personal hygiene, locomotion on and off the unit. Always incontinent with bowel and bladder. Adequate hearing, vision, and ability to understand others. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 62 of 67 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 07/27/2023 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Interview on 07/26/23 at 12:01 PM, with LVN C revealed she worked the 7:00 AM - 7:00 PM shift on 07/17/23, after breakfast she was notified by CNA F that something was wrong with Resident#1's leg. LVN C stated Resident #1's right leg was usually 90% straight and left leg bent, but at this time she was in a butterfly position, with both heels touching her brief. LVN C stated she immediately contacted physician via electronic communication app, video call within 2 minutes, and received an order for x-ray and Tramadol for pain. LVN C stated x-ray was completed within 4 hours indicating femur fracture of the right leg. LVN C stated at this time she prepared for Resident #1 to be sent out to the hospital. LVN C stated during her assessment Resident #1's leg was swollen, warm to touch, and she was guarding with palpations. According to LVN C when she asked Resident #1 and Resident #2 how the injury took place neither of them said anything until Resident #1's family member entered the room, it was not until then she heard Resident #1 say she fell out the bed. LVN C stated after the findings of the x-ray she was notified Resident #1 was not eating, had refused all 3 previous meals, not drinking, crying, and saying her knee was hurting. LVN C stated Resident #1 had not had any pain medications prior or while waiting to transfer to the hospital. LVN C stated Resident #1 did not exit the facility for the hospital until 5:30 PM. According to LVN C not contacting the physician immediately over the weekend placed Resident #1 at risk for further damage to her leg, infection, becoming septic and prolonged time in pain. LVN C stated knowing what she knows now she should have used her nursing judgement and called 911 to send Resident #1 to the hospital immediately after observation and assessment of her leg. Interview on 07/26/23 at 12:59 PM, with CNA T revealed she worked the morning shift 7:00 AM - 7:00 PM on 07/16/23, CNA T stated she walked past Resident #1 as she was out in the hallway. CNA T stated Resident #1 was stopping every and anyone trying to get their attention. CNA T stated Resident #1was trying to say something, but because she did not work with her on a regular basis, she grabbed CNA G. CNA T stated Resident #1 was moaning, she thought the resident said, Help me. According to CNA T because she worked on another hall, she did not see Resident #1 again. CNA T stated because she contacted the CNA that was working on her hall, she did not contact the nurse to notify him that Resident #1 was complaining of pain. CNA T stated not notifying the nurse Resident #1 was expressing pain may have caused her prolonged pain. Interview on 07/26/23 at 1:13 PM with CNA G revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23, CNA G stated when she arrived Resident #1 was already sitting in her spot near the nursing station. CNA G stated Resident #1 did tell her about her knee pain. CNA G stated when LVN B arrived she notified him of her pain. CNA G stated, During breakfast I was pushing Resident #1 down to the dining room and Student Aide H was telling her that Resident #1's leg was swinging, which she could not see because she was behind her and trying to get residents to breakfast. CNA G stated once she left Resident #1 in the dining room she wheeled herself back to the nursing station, she refused breakfast, lunch, and dinner on this day. CNA G stated Resident #1 continued pointing to her knee saying it was hurting. CNA G stated she and Student Aide H discussed amongst themselves that something was wrong with Resident #1's leg and that they both had told him about it more than once. Interview on 07/26/23 at 2:03 PM, with Student Aide H revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23, Student Aide H stated when she arrived to work Resident #1 was in her usual spot near the nursing station. Student Aide H stated she saw CNA G pushing Resident #1 down the hall and noticed her leg was swinging back and forth, she was crying, complaining of pain in her leg that was swinging. Student Aide H stated she expressed to LVN B what she observed. Student Aide H stated she later put Resident #1 down for bed, completed care, and when she rolled her on her right side she screamed so loud. Student Aide H stated she then went to alert LVN B that she was screaming in pain, and this was not normal for her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 63 of 67 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 07/27/2023 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some According to Student Aide H when she returned to put Resident #2 down for bed, she asked Resident #1 what happened, Resident #1 would agree to having a fall after she was asked a series of questions. Student Aide H stated she then returned to LVN B and shared that Resident #1 indicated she had a fall. Interview on 07/26/23 at 2:10 PM, with LVN B revealed he worked the morning shift 7:00 AM - 7:00 PM on 07/16/23. He stated Resident #1 was already up in her wheelchair and near the nursing station when he arrived. LVN B stated Resident #1 appeared normal to him and he did not recognize anything out of the normal with her. LVN B stated she did return from the dining room refusing breakfast stating her keen was hurting. LVN B stated he did not observe any bruising or redness after being told by staff Resident #1 was in pain. LVN B stated he did not administer a full assessment for pain and stated he did not administer any pain medication for Resident #1's pain. LVN B stated he could not recall doing anything to assist Resident #1's pain. LVN B also stated he did not follow-up with Resident #1 throughout the day to see how she was feeling or to see if he needed to alert the physician that she was indicating pain, change of condition, or her refusal to eat. When LVN B was asked about risk to Resident #1's fractured femur not being assessed in a timely manner, he apologized for not being much help. Interview on 07/26/23 at 2:46 PM with LVN A revealed she worked on the overnight shift 7:00 PM-7:00 AM on 07/15/23 for 100 Hall and 200 Hall. LVN A she did not have any complaints of a fall. LVN A stated throughout the night Resident #1 rested fine, until she was getting out of bed between 5:30 AM-6:00 AM. LVN A stated when the CNA E went to get her up, she stated her knee was hurting and it was reported she was sleeping in a weird position. Her head was up really high, legs were sideways, and legs stiff, when she went to check Resident #1 was dressed, in wheelchair, in the hallway. LVN A stated at this time she did not think anything serious happened. LVN A stated she administered pain mediation prior to leaving on 07/16/23. (review of medication administration did not support LVN A administering any type of pain medication) LVN A stated when she returned the next day there were no complaints of pain, Resident #1 was in bed the entire shift. LVN A stated when she left on Monday morning 07/17/23 she got a call from the facility stating Resident #1 was injured. LVN A stated during the call she was informed Resident #1 complained of pain on Sunday 07/16/23 and the day nurse gave her pain medication. LVN A stated she did not complete an assessment to identify the source pain after CNA E and Resident #1 complained resident was in pain. LVN A stated she did not contact physician, DON, or the oncoming nurse she was informed Resident #1 was in pain. According to LVN A not completing full assessment or identifying a change of conditions could place residents at risk of not receiving immediate care. Record review of the facility's Pain Management, Assessment Scale Policy dated revised 05/25/16 indicated, complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility . Assess resident's physical symptoms of pain, physical complaints, and daily activities, perform comfort measures to promote relaxation, .have the resident rate pain on a scale of one to ten .Talk with resident about pain and assess for pain relief after interventions . This was determined to be an Immediate Jeopardy on 07/26/23 at 4:49 PM. The Director of Nursing was notified. an Immediate Jeopardy had been identified. The Director of Nursing was provided with the Immediate Jeopardy on 07/26/23 at 5:38 PM. The facility's Plan of Removal was accepted on 07/27/23 at 1:18 PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 64 of 67 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 07/27/2023 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 0697 The Plan of Removal reflected the following: Level of Harm - Immediate jeopardy to resident health or safety o As of 7/26/23 Resident #1was assessed for pain. Orders received as of 7/26/23 for scheduled and PRN pain meds. Residents Affected - Some o All residents in the facility were assessed for any increased pain by the DON, ADON and Charge Nurses as of 7/26/23. No additional issues were found. Education: All charge nurses were in-serviced on 7/26/23 by the Compliance Nurse/DON/ADON regarding the following and all nurses including agency staff, new hires, and PRN staff not in-serviced by 7/26/23 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse. o Notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits. o Implementation of physician orders immediately upon receipt including the administration of pain medications. o A head-to-toe assessment will be performed by the charge nurse on all residents who complain of increased pain. All nursing staff were in-serviced on 7/26/23 by the Compliance Nurse/DON/ADON. All staff not in-serviced on 7/26/23 including agency staff, new hires and PRN staff will not be allowed to work their assigned schedule until the completion of these in-services. o Notify the charge nurse immediately if a resident is found on the floor. The resident will not be moved until assessed by a nurse. o Notification of change of condition to the physician immediately including falls, injuries, increased pain, decreased mobility, or a change in eating habits. o (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 65 of 67 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 07/27/2023 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 0697 Pain: Signs and symptoms of pain verbal and non-verbal. (crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching Level of Harm - Immediate jeopardy to resident health or safety Medical Director was notified by the DON on 7/26/23 at 8:18 PM about the Immediate Jeopardies. Residents Affected - Some An AD HOC QAPI meeting will be held on 7/27/23 by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. The Director of Nursing or designee will implement this written Plan of Removal and will continue to monitor completion and compliance of this written Plan of Removal. Monitoring: o The DON and/or designee will monitor Real Time clinical software and the PCC Dashboard for clinical alerts for any resident change of condition including new or increased pain at least 5 days per week to ensure physician/NP were notified. Monitoring began 7/26/2023 and will continue x 4 weeks. o The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 days per week, to ensure any new physician/NP orders were implemented immediately. Monitoring began 7/26/23 and will continue x 4 weeks. Further monitoring on 07/27/23 during interviews consisting of both day and night shifts revealed the following: Interviews on 07/27/23 from 2:15 PM through 07/27/23 4:30 PM with the DON, ADON, LVN A, LVN B, LVN C, CNA E, CNA F, CNA G, Student Aide H, LVN I, LVN J, LVN K, LVN L, LVN M, Student Aide N, CNA O, CNA P, Student Aide Q, CNA R, LVN S who worked the shifts of 7:00 AM-7:00 PM, 7:00 PM-7:00AM were able to verify education was provided to them; nursing staff were able to accurately summarize abuse and neglect policy, definitions and examples of change of condition and how, who, and when to report changes. The nursing staff revealed signs and symptoms of residents complaining of pain, what to do and who to contact. The nursing staff expressed understanding of the importance of completing assessments and identify the source of pain and how that plays in part to resident safety. During observations on 07/27/23 between 8:00 AM-5:00 PM, revealed staff assessing residents who were exhibiting pain, residents who requested and were administered pain medications. Staff were observed engaging with residents, preforming full assessments, and interviewing residents to determine the source of pain, contacting the physician, documenting, and notifying resident's responsible party of change of condition. Record review of the facility Plan of Removal monitoring tool form beginning 07/26/23, titled Real Time Monitoring indicated log started with slots for date, new pain, MD notified, new order implemented/medication given, initials/comments. Record review of the facility plan of correction monitoring tool form titled Change of Condition Monitoring indicated log ask 10 nurses per week what would they do if a resident had a change of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 66 of 67 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 07/27/2023 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 0697 Level of Harm - Immediate jeopardy to resident health or safety condition, or it was reported to them that a resident had a change of condition. Date/Nurse name, Did they respond correctly? Corrective action? The Director of Nursing was informed the Immediate Jeopardy was removed on 07/27/23 at 5:00 PM. The facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 67 of 67