Health inspection·April 9, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few updated. The DON stated the risk of pneumonia not addressed on the care plan was missed needs of Resident #1 and potential issues for the resident. In an interview on 03/27/25 at 3:51 PM, the Administrator stated she was not sure why the pneumonia was not listed on Resident #1's Care Plan. She stated she would have to refer to her DON regarding the care plans and the risk of pneumonia not addressed, because that was not her lane. Record review of the facility's policy titled, Care Plans, Comprehensive, dated [DATE], reflected the following: Policy Statement A comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. g. incorporate identified problem areas h. incorporate risk factors associated with the identified problems m. Aid in preventing or reducing decline in the resident's functional status and/or element of care 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675806 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 675806 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurenwood Nursing and Rehabilitation 330 W Camp Wisdom Rd Duncanville, TX 75116 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 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of three residents (Resident #2) reviewed for infection control. Residents Affected - Few The facility failed to add Resident #2 to the infection control log when he was diagnosed with Pneumonia on 03/15/25. This deficient practice could place residents at-risk for infections. Findings included: Record review of Resident #2's face sheet, dated 03/27/25, reflected a [AGE] year-old male, with an initial admission date of 09/04/24, and a re-admission date of 03/21/25. Resident #1 had a diagnosis of Pneumonia (lung infection causing inflammation and fluid buildup), Acute Respiratory Failure (lungs cannot adequately supply oxygen to the blood), Alzheimer's Disease (progressive memory loss and cognitive decline), and Chronic Obstructive Pulmonary Disease (progressive lung disease that makes it hard to breathe). Record review of the progress notes on Resident #2's electronic record dated 03/15/25 reflected Resident #2's doctor ordered the resident to be sent to the hospital after the facility received results of his chest x-ray, which noted the resident had possible pneumonia. The progress notes noted Resident #2 was discharged from the hospital back to the facility on [DATE]. Record review of Resident #2's hospital record dated, 03/15/25, reflected Resident #2 had an encounter diagnosis of Pneumonia and Sepsis (life-threatening medical emergency caused by the body's overwhelming response to infection). The hospital record reflected the encounter diagnosis was, Pneumonia of the right lung due to infectious organism, unspecified part of the lung. Record review of the facility's Infection Surveillance Monthly Report did not reflect that Resident #2 had an infection. Resident #2 was not on the report. In an interview on 03/27/25 at 3:22 PM, the DON stated she was aware Resident #2 went to the hospital and was diagnosed with pneumonia. She stated Resident #2 was treated for pneumonia while at the hospital. The DON stated he returned to the facility around 03/21/25. She stated she was the infection control preventionist, and she was the one responsible for updates on the infection control log. The DON stated any infection that was identified at the facility, would be added to the infection control log. The DON stated she did not add Resident #2 to the infection control log, because he was treated for pneumonia at the hospital. The DON stated she felt there was no risk of Resident #2 not listed on the infection control log, because he was not diagnosed with pneumonia at the facility. The DON stated the facility did not have a policy on infection control logs. In an interview on 03/27/25 at 3:51 PM, the Administrator stated she would have to refer to the DON for information regarding the infection control log. She stated the DON was also the facility's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675806 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 675806 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurenwood Nursing and Rehabilitation 330 W Camp Wisdom Rd Duncanville, TX 75116 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 Level of Harm - Minimal harm or potential for actual harm infection preventionist. The Administrator stated she was not sure what needed to be on the infection control log. The Administrator stated she would also have to refer to the DON regarding the risk of a resident not listed on the infection control log when the resident was diagnosed upon admission to the hospital. Residents Affected - Few A general infection control policy was requested on 03/27/25 at 3:30 PM but not provided. Record review of the facility's policy titled, Infection Control Guidelines for All Nursing Procedures, dated December 2024, reflected the following: Purpose To provide guidelines for general infection control while caring for residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675806 If continuation sheet Page 4 of 4