Health inspection·July 13, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 07/13/23 at 1:00 PM with LVN A revealed about a month ago she became aware of Resident #1's customized wheelchair having one of the wheels come off. She stated Resident #1 what happened to her customized wheelchair and was told her roommate was trying to forcibly get by in the room and the wheelchair wheel came off. She stated she thought Maintenance Director had taken it out of the room to get it fixed. She stated she had not seen the customized wheelchair since then. She stated Maintenance Director and therapy were aware of Resident #1's customized wheelchair being broke so she did not follow up about it. She stated the customized wheelchair was fairly new for Resident #1. Interview on 07/13/23 at 1:20 PM with the Director of Rehab and OT B revealed Resident #1 did have a customized wheelchair evaluated for her specific needs. OT B stated Resident #1 had asked him about her customized wheelchair the past Tuesday (07/11/23). Both Director of Rehab and OT B stated they both had looked for the customized wheelchair in the therapy storage area of wheelchairs but were unable to find it. OT B stated he asked the Maintenance Director about it, and they had not been able to locate Resident #1's customized wheelchair. The Director of Rehab stated the vendor may have come out to look at it and took it to fix. Director of Rehab stated he would contact vendor to see if Resident #1's customized wheelchair was in their possession. Interview on 07/13/23 at 1:37 PM with PT C revealed she was aware of Resident #1's customized wheelchair being broken, one of the wheels coming off, about 2 weeks ago. She stated she became aware of it the next day after it was broken when she went into Resident #1's room and seeing the customized wheelchair with a wheel on top of it. She stated she asked what happened and Resident #1 told PT C her roommate was trying to get by forcibly and the wheel came off. She stated she told the Maintenance Director about it but she did not contact the vendor. She stated she was not responsible for notifying the vendor and thought the Maintenance Director did. Interview on 07/13/23 at 1:59 PM with CNA D revealed about two weeks ago she remembered coming into Resident #1's room seeing her customized wheelchair with a broken wheel sitting on top of it. She stated Resident #1 told her the roommate (Resident #2) got stuck on her wheelchair and the wheel came off. She stated the Maintenance Director was aware of the wheelchair being broken. She stated she had not seen the customized wheelchair since then and was not aware of what happened to it. Interview on 07/13/23 at 2:45 PM with the Director of Rehab revealed he had followed up with vendor to try to find out about Resident #1's customized wheelchair and found out they did not come out to the facility. He stated the vendor did not have Resident #1's wheelchair and they were still trying to locate it at this time. He stated the vendor came out to fix Resident #1's brakes on the customized wheelchair but did not know when exactly. He stated Resident #1's customized tilt wheelchair was assessed to meet her needs and not having the tilt wheelchair could place the resident at a greater fall risk. Interview on 07/13/23 at 3:32 PM with the Administrator revealed he became aware of Resident #1's customized wheelchair missing today. He stated he found out by Maintenance Director today that he did look at the customized wheelchair to attempt to fix the wheel but was not able to. He stated he would have expected a follow-up with the vendor on the customized wheelchair and to schedule to have them look at it. He stated they had not been able to locate Resident #1's customized wheelchair at this time . The Administrator stated he expected facility staff to follow-up to Resident #1 about the status of her customized wheelchair. Review of facility's Customized power wheelchair policy undated did not address customized manual wheelchairs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675882 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 675882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Gardens of Allen 310 S Jupiter Allen, TX 75002 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #2) of five residents reviewed for comprehensive care plans. Resident #2's care plan failed to address Resident #2's right sided limited range of motion. This failure placed residents at risk of not receiving the care and services they need. Findings included: Review of Resident #2's admission MDS assessment dated [DATE] reflected Resident #2 was admitted to the facility on [DATE] with diagnoses of stroke, diabetes, monoplegia upper limb following cerebral infraction affecting right dominant side (type of paralysis that impacts one limb, such as an arm or leg on one side of your body), contracture (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) of right upper arm muscle. Resident #2 had a BIMS of 15 indicating she was cognitively intact. Resident #2 required extensive assistance with ADLs. Resident #2 had impairment to the upper and lower extremities on one side. Review of Resident #2's comprehensive care plan last updated 06/30/23 reflected Resident #2 had an ADL self-care performance deficit related to history of CVA (cerebrovascular accident- damage to the brain from interruption of its blood supply). Interventions included bed mobility: The resident requires mod (moderate) assist by staff to turn and reposition in bed as necessary and Transfer: The resident requires mod by (X) staff to move between surfaces as necessary. The care plan did not specify right sided paralysis of upper limb. Review of Resident #2's Occupational Therapy Summary dated 06/22/23 reflected Resident #2 had a diagnosies of monoplegia upper limb following cerebral infraction affecting right dominant side. Review of Resident #2's Physical Therapy Discharge summary dated [DATE] reflected Resident #2 had a diagnosis of monoplegia upper limb following cerebral infraction affecting right dominant side. Resident #2 required partial/moderate assistance with bed mobility and transfers upon discharge. Resident #2 was generally dependent in mobility maneuvers, require help with basic ADLs. Observation and interview on 07/13/23 at 10:07 AM with Resident #2 revealed she had her right arm and hand down on to her right side while sitting in her wheelchair. She stated she could not use her right hand or arm but could only use her left hand to press the call light. She stated she had strokes which affected her use of her right arm and hand . She stated she was dependent on staff for ADLs including toileting and transfers. Interview on 07/13/23 at 1:00 PM with LVN A revealed Resident #2 had right sided limitation to her arm and shoulder due to history of stroke since admission. She stated Resident #2 used her left hand and arm to push the call button. She stated Resident #2 required assistance with transfers for safety due to the right sided limitation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675882 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 675882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Gardens of Allen 310 S Jupiter Allen, TX 75002 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 0656 Level of Harm - Minimal harm or potential for actual harm Interview on 07/13/23 at 1:20 PM with OT B revealed Resident #2 had right sided hemiplegia since admission and required assistance with transfers. Interview on 07/13/23 at 1:59 PM with CNA D revealed Resident #2 required extensive assistance with transfers and toileting. She stated Resident #2 had right sided weakness. Residents Affected - Few Interview on 07/13/23 at 3:00 PM with the MDS Coordinator revealed she was aware of Resident #2's right sided weakness and limitation since admission. She stated Resident #2's care plan should be specific about the one-sided weakness on right side and interventions the facility put in place to address the weakness. She stated she was responsible for completing all the MDS assessments and the care plans for the facility. She stated she made sure the care plan addressed the ADL assistance Resident #2 required so it would be on the CNA plan of care documentation for the aides to have. She stated she had not been able to update Resident #2's care plan to be resident centered . Review of facility's policy Comprehensive Resident Care Plans undated, reflected Each resident's care plan shall include measurable objectives and timetables to meet all resident needs identified in the comprehensive assessment. All items or services ordered to be provided or withheld shall be included in each resident's plan of care. The comprehensive care plan describes services furnished to attain or maintain the resident's highest practical physical, mental and psychosocial well-being .Each resident's plan of care shall be developed within seven days after completion of the comprehensive assessment. Comprehensive care plans are prepared by an interdisciplinary team that indicates resident participation and preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675882 If continuation sheet Page 4 of 4