Health inspection·January 29, 2024

F 0880 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #3's comprehensive care plan dated, 05/16/23 reflected the following, Resident#3's was at risk for psychosocial well-being concern related to medically imposed restrictions related to COVID-19. Precautions Goal: Resident#3 will not exhibit COVID-19, through next care review. Resident #3 Intervention included: Educate Staff, Resident, family and visitors of COVID-19 signs and symptoms and precautions. indicating she had severe cognitive impairment. Residents Affected - Some Record review of Resident #4's quarterly MDS assessment, dated 01/08/24, reflected the following, Resident #4 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of She had a BIMS of 03 indicating she had severe cognitive impairment. Record review of Resident#4's comprehensive care plan dated, 09/18/23 reflected the following, Resident#4 was at risk for COVID-19 Risk - Resident is at risk for psychosocial. well-being concern related to medically imposed restrictions. Related to COVID-19 precautions. Goal: Resident#4 will not show a decline in psychosocial well-being or experience adverse effects through next care review. Resident #4 Intervention: Educate Staff, Resident, family and visitors of COVID-19 signs and symptoms and precautions. Record review of Resident #5's quarterly MDS assessment, dated 12/22/23 reflected Resident #5 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Unspecified infectious disease. Chronic and Local infection of the skin and subcutaneous tissue, He had a BIMS of 06 indicating he had severe cognitive impairment. Record review of Resident#5's care plan dated 01/26/21 reflected the following: Resident#5 required Isolation as evidenced by enhance barrier precautions. Intervention: Will not have any psycho-social concerns and will no longer require isolation within the next 90 days and Hand washing to prevent the spread of infection. Record review of Resident #6's quarterly MDS assessment, dated 12/20/2023 reflected the following, Resident #6's was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Bacterial infection, elevated white blood cell count, and vomiting. He had a BIMS of 05 indicating she had severe cognitive impairment. Record review of Residents #6's comprehensive care plan dated 09/17/22 reflected the following: Resident#6's was at risk for psychosocial well-being concern related to medically imposed restrictions related to COVID-19. Precautions: Will not have any psycho-social concerns and will no longer require isolation within the next 90 days. Goal: Resident will not show a decline in psychosocial well-being or experience adverse effects through next care review. Intervention: Follow Facility Protocol for COVID-19 Screening /Precautions and Inform staff and visitors of isolation requirements. In an interview on 01/29/24 at 9:00AM with the Administrator and Director of Nursing stated that all staff and visitors were to put on full Personal Protective Equipment when entering residents' room on isolation. The Administrator and Director of Nursing stated they had residents with Coronavirus Disease and residents on transmission-based precautions. In an observation on 01/29/24 at 9:30 AM revealed signage on Residents #1, #2, #3, #4, #5, and #6 doors read, that before entering the resident room everyone must put on full Personal Protective Equipment. Surveyor observed Carts outside the residents' doors with face mask, shields, gowns, and gloves. (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 01/29/2024 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 0880 In an observation on 01/29/24 between 12:30 PM till 1:00 PM revealed: Level of Harm - Minimal harm or potential for actual harm *The Certified Nurse Aide H wore a face mask when she entered Resident # 5 room to serve his lunch tray. The Certified Nurse Aide H did not put on full Personal Protective Equipment for Resident#5 who was on isolation for transmission-based precautions. The Certified Nurse aide H did not sanitize hands before she pulled another tray from the cart and proceeded to Resident #1 room. Residents Affected - Some *The Certified Nurse Aide H wore a face mask when she entered Resident # 1 room to serve her lunch tray. The Certified Nurse Aide H did not put on full Personal Protective Equipment for Resident#1 who was on isolation for transmission-based precautions. The Certified Nurse aide H did not sanitize hands before she pulled another tray from the cart and proceeded to Resident #2 and Resident#3 room. *The Certified Nurse Aide H wore a face mask when she entered Resident # 2 and Resident #3 room to serve them their lunch trays. The Certified Nurse Aide H did not put on full Personal Protective Equipment for Resident #2 and Resident #3 who were on isolation for COVID-19. The Certified Nurse aide H did not sanitize hands before she pulled another tray from the cart and proceeded to Resident #6's room. *The Certified Nurse Aide H wore a face mask when she entered Resident # 6 room to serve her lunch tray. The Certified Nurse Aide H did not put on full Personal Protective Equipment for Resident#6 who was on isolation for COVID-19. The Certified Nurse aide H did not sanitize hands before she pulled another tray from the cart and proceeded to Resident #4 room. *The Certified Nurse Aide H wore a face mask when she entered Resident # 4 room to serve her lunch tray. The Certified Nurse Aide H did not put on full Personal Protective Equipment for Resident#4 who was on isolation for COVID-19. The Certified Nurse aide H did not sanitize hands. In an interview on 01/29/24 at 1:10 PM, Certified Nurse Aide H stated she; did not realize that she did not put on the full Personal Protective Equipment. The Certified Nurse Aide H stated she served the residents with Coronavirus disease trays last. The Surveyor showed Certified Nurse Aide H the sign on the door that stated all that enter needed to put on full Personal Protective Equipment. The Certified Nurse Aide H stated the contamination could be passed around by not putting on the Personal Protective Equipment. In an interview on 01/29/24 at 1:30 PM, the Director of Nursing stated Resident #1 and Resident# 5 were on Transmission Based Precautions for urinary tract infection. The Director of Nursing stated Residents#2, #3, #4 and #6 had Coronavirus disease. The Director of Nursing stated all staff were expected to put on full Personal Protective Equipment when entering the residents' rooms on droplet precautions and isolation. The Director of Nursing stated staff could become contaminated and spread the infection. The Director of Nursing stated staff had been in serviced on infection control and all staff were responsible for following the precaution. In an interview on 01/29/24 at 3:31 PM with the central Supply Director stated proper Personal Protective Equipment should be worn by staff to prevent the spread of contamination. In an interview on 01/28/24 at 3:50 PM with the Activities Director stated full Personal Protective Equipment was worn by staff to prevent the spread of infections. Record review of the facility policy titled, Coronaviruses protocol, dated 08/10/23, read 4. (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 01/29/2024 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 0880 Utilize appropriate personal protective equipment (PPE) NIOSH Approved particulate respirators with N95 filters or higher, eye protection, gloves, and gown for certain patient care activities such as: Level of Harm - Minimal harm or potential for actual harm a. Caring for Covid positive individual. Residents Affected - Some b. Performing tasks such as . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675418 If continuation sheet Page 4 of 4