Health inspection·December 7, 2023

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of Resident #1's Hospital Records, dated 11/18/2023, reflected the resident had a diagnosis of heparin overdose and fluid overload. The resident had minor bleeding from the mouth/lip prior to admit. The treatment ordered to treat the heparin overdose was to hold the medication for two days. The resident had fluid overload and required diuretics and monitoring for six days. In an interview with Resident #1's [Hospital] nurse on 11/19/2023 at 10:40 AM, he stated Resident #1 was his patient for that day, and the resident was currently stable, with vital signs within normal limits. An observation and interview on 12/07/2023 at 2:30 PM with Resident #1 revealed she was seated in her wheelchair in her room. She said she was doing well and glad to be back home from the hospital. She said she did not have any concerns about her hospital stay and she did not realize on 11/18/23 she received too much heparin. She said the injection did not hurt. She said she did not have any side effects from the heparin. In interview with RN F on 11/19/2023 at 10:54 AM, he stated he was the residents nurse the evening of the incident. He stated the resident's medication was delivered on 11/18/2023 between 10:00 PM-12:00 AM and he administered Resident #1's medication around midnight. He stated heparin was typically provided in single dose vials and he administered the entire vial to Resident #1. He was aware now the vial was actually 10 doses (50,000 units) and it was inappropriate to administer the medication all at once. He stated the potential outcome could have been resident harm and/or additional illness. He stated the facility suspended him pending the investigation and he was extensively in-serviced on proper medication administration. In an interview with RN S on 11/19/2023 at 10:30 AM, she stated she was the weekend charge nurse during the time of the incident. She stated during her shift, it was discovered Resident #1 received the incorrect dose of heparin, and she reported it to her administrator, DON, and immediately initiated and investigated for the incident. She conducted an assessment on Resident #1 and closely monitored her for any adverse reactions. She stated Resident #1 was sent to [Hospital] for further evaluation and that was where she was currently. It was determined by her investigation that RN F administered a 50,000-unit vial of heparin to Resident #1, and not the 5,000 units as prescribed. She stated the resident's responsible party, physician, and nurse practitioner were informed. After a period of observation, Resident #1 was transferred to the hospital. She then stated she began extensive in-services in response to the incident. In an interview with the DON on 11/19/2023 at 12:00 PM, she stated her expectation was for nursing staff to provide her residents with medications as prescribed. She stated RN F was suspended pending the investigation, leadership in-serviced all relevant staff on medication administration, and nursing leadership conducted skills checkoffs with her staff who administer medications to residents to ensure the safety of her residents. In interview with the Administrator on 11/19/2023 at 12:30 PM, she stated her expectation was for nursing staff to provide residents with medications as prescribed. She stated RN F was suspended and was extensively in-serviced on medication administration. She further stated facility-wide in-services for relevant staff was ongoing to ensure the safety of the residents. She stated if staff did not adhere to proper medication administration of the 6 rights, an incident could happen that affected resident safety. Record review of the facility in-service, Patient rights, Medication policy, Five rights of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675418 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Manor at Seagoville 2416 Elizabeth LN Seagoville, TX 75159 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few administering medications, dated 11/18/2023, reflected Administrator educated on the Five Rights of Medication: Right Patient . Proper Medication . Correct Dose . Correct Route . and Fitting Time. Additionally, there are often three more rights that are included in modern medication administration practices Right Documentation . Right Reason . and Right to Refuse. Record review of the facility Employee Coaching and Counseling Record, dated 11/18/2023, reflected RN F was coached and suspended pending investigation due to [RN F] administered an inaccurate dosage of medication to a patient, posing potential harm to the individual. In response, [RN F] has been suspended pending the conclusion of the investigative process . Action To Be Taken . Employees must ensure strict adherence to the five rights of medication at all times. Failure to do so may result in escalated disciplinary measures, up to and including termination. Record review of the facility reference material located within the facility's system, Heparin, rev . 10/2023, reflected Uses: This medication is used to prevent and treat blood clots . Symptoms of overdose may include: easy/unusual bruising, easy/unusual bleeding (such as frequent nosebleeds), blood in urine, black stools. Record review of the facility's, undated, policy provided by the Administrator on 11/19/2023 at 12:30 PM, Medication Administration,, reflected 2. The 6 Rights of Medication Administration . a. Right Patient . b. Right Drug. Verify prescription label to [DATE] time in different ways i. Drug name ii. Drug strength . c. Right Dose. Verify the MAR to label, these MUST MATCH . d. Right Dosage Form. Verify the MAR to label, these MUST MATCH. e. Right Time . f. Right Route . g. Right Indication This was determined to be a PNC IJ from 11/18/2023-11/18/2023. The Administrator was notified of the PNC IJ on 12/07/2023 at 5:25 PM. The facility took the following action to correct the non-compliance on 11/18/2023 : Record review of in-services and actions taken by the facility on 11/18/2023 reflected: An emergency QAPI meeting was conducted on 11/18/2023, and the following performance improvement plan was initiated: Mandatory nurse skills checkoffs were conducted to enhance the proficiency of nursing staff in medication administration, accompanied by comprehensive in-service training on the five/six rights of medication. Additionally, employee survey questions were deployed to solicit feedback and insights into medication administration practices and testing the knowledge and competency of the nursing staff. To maintain adherence to medication administration protocols, routine weekly spot checks were being conducted. Findings from these checks and statements were diligently reported daily during Quality Assurance (QA) meetings for prompt review and necessary action. In-service and return demonstrations had been implemented on correctly entering medication orders on the computer to avoid errors. RN F was suspended pending investigation and was then terminated. RN F did not return to work at the facility after 11/18/23. The facility created a heparin check list that required the nurse to complete before administering a dose of heparin. The facility put in place that heparin doses had to be checked by two nurses prior to administration and if there were any questions about the dose, the nurse had to call the physician. Nurses had to complete a skills competency check-off with nursing administration and pharmacy services. Interviews with 5 nurses from all shifts, (LVN A, LVN B, LVN C, LVN D, and LVN E ) starting at 11:00 AM 6:00 PM, revealed they were in-serviced regarding Heparin dosages, medication errors, competency skills checkoffs, rights of medications, and to seek clarification from a doctor if needed for a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675418 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Manor at Seagoville 2416 Elizabeth LN Seagoville, TX 75159 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Heparin dose. Heparin had to be checked off with 2 nurses and a heparin check-off list had to be completed. Staff were also provided with a picture of a Heparin vial with 50,000 units/10 ml with an order to administer 5,000 units/1.0 ml. The nurses were able to verbalize the correct dose to give. An interview on 12/07/2023 at 6:10 PM with the DON revealed measures were in place to prevent future heparin overdoses. Currently there were no residents with heparin orders. The DON said she did weekly random monitoring of medication administration and the nurse completed skills checkoffs with administering medications. The DON said Heparin orders had to be double-checked with another nurse and the nurse had to call the physician if order clarification was needed. An interview on 12/07/2023 at 6:15 PM with the Administrator revealed measures were in place to prevent future heparin errors. The Administrator said nurses including new hires had to complete skills checkoffs with administrative staff and pharmacy staff. Additionally, heparin had a separate checklist had to be completed prior to administration. She said monitoring wound continue with facility QAPI meetings. The noncompliance was identified as PNC IJ. The IJ began on 11/18/2023 and ended 11/18/2023. The facility had corrected the noncompliance before the survey began . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675418 If continuation sheet Page 4 of 4