Health inspection·January 29, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative when there was significant change in the resident's physical, mental, or psychosocial status for one of four residents (Resident #2) reviewed for notification of changes. LVN C failed to notify the responsible party/resident representative when Resident #2 was transferred to the hospital due to change in condition. This failure could place residents at risk of not having their responsible parties notified of changes in their condition and deny them the right to participate in the care and treatment of the resident. The noncompliance was identified as past none compliance (PNC). The noncompliance began on 12/10/2024 and ended on 12/11/2024. The facility had corrected the noncompliance before the investigation began. Findings included: Review of facility electronic face sheet printed 01/29/2025, for Resident #2 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis that include but not limited to cerebral infarction (stroke), depression and anxiety disorder. Review of the of the responsible party's section had Resident#2's family listed and relationship type as all responsibilities. Review of Resident #2's admission MDS, dated [DATE], reflected a BIMS score of 02 indicating severe cognitive impairment. Review of section I titled active diagnosis indicated anxiety and depression. Review of Resident #2's care plan effective 11/26/2024 revealed Resident #2 was receiving antianxiety drugs on a regular basis. Ativan with interventions that included monitor for side effects of medication (drowsiness, loss of coordination, fatigue, mental slowness, confusion, constipation). Notify physician if side effects noted. Resident #2 was receiving antipsychotic drugs on a regular basis. Seroquel with intervention that included provide medication as ordered. Review of Resident #2's nurses note dated 12/10/2024 written by LVN C revealed LVN C assessed Resident #2 and found thick secretion, oxygen was 74% on 4 liters, breathing labors, resident unable to be aroused .Resident sent to emergency room .Resident own responsible party; no other family listed (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 675418 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 01/29/2025 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)