Inspection·May 22, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 05/15/23 at 11:39 a.m., LVN A assisted Resident #32 to his room when he requested to be returned to bed as he was sitting up front in his wheelchair listening to music. During an interview with Resident #32 on 05/15/23 at 11:40 a.m. revealed on an unknown date, (Resident #32 was not sure of the date) LVN B entered his room and grabbed his right hand and twisted his fingers while forcefully performing a blood glucose test. Resident #32 stated he repeatedly told LVN B that he did not want the blood glucose tested and his requests were ignored by LVN B. He said he was trying to pull his finger away from LVN B's hand saying no stop, but the nurse continued the finger stick. Resident #32 alleged the nurse did this with the intention of hurting him. He said this made him angry. He said medical attention was provided immediately including x-rays in house. He said his finger was sore but not fractured. Resident #32 said the nurse that was involved no longer worked at the facility. An interview with LVN B was attempted on 05/15/23 at 1:00 p.m., however he did not return the surveyor's call. During an interview on 05/02/23 at 10:46 a.m., LVN A stated she assisted Resident #32 with meal set up, and care. She said Resident #32 likes to make his own choices, and there are times when he will refuse care. She said she was working the day of the incident; however, all staff were notified and in services on resident rights. She said all residents have a right to refuse care and that right should have been respected. She has not observed any incidents of other residents right to choose being violated. In an interview on 05/15/23 at 9:00 a.m. with CNA-C revealed she was not working the day of the alleged incident. She said Resident #32 told her the nurse pulled his finger and he pulled back, as he did not want his blood level test. She said Resident #32 does better when the staff are aware of his preferences and communicating in advance. She participated in an in service about resident choice and abuse last week. During an interview on 05/16//23 at 2:11 p.m., the DON stated when a staff conducts medical task for residents the resident should be asked to conduct the procedure, and if the resident refuses staff should notify leadership and respect the resident wishes. The DON said on the day of the incident se immediately assessed the resident finger for injuries. Resident #32 complained of pain and that the staff twisted his finger when he told him no. MD was notified, X rays were ordered for Resident #32 immediately. X-ray results determined he did not have a fracture. The staff was suspended after the incident pending investigation and later terminated for the incident with Resident #23. She expects her nursing staff to respect residents' choices. She also stated it has to do with dignity for the residents. The DON stated she initiated an in-service with all staff on choices, reporting, abuse and neglect, and respect/dignity. In an interview with the Administrator on 05/16/23 at 3:30 p.m. revealed she expected all staff to acknowledge and respect a resident's right to choose and seek guidance from leadership if a resident refused medical attention or routine assessments and blood level checks. The staff was removed pending an investigation and later terminated. A review of the facility policy titled Resident Rights Guidelines for All Nursing Procedures, reflected: .Purpose to provide general guidelines for resident rights while caring for resident. 1. Prior to having direct care responsibilities for residents, staff must have appropriate in-service on resident rights, including: Resident right of refusal (medication and treatment) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676036 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 676036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Ridge Nursing & Rehabilitation Center 700 E Vista Ridge Mall Dr Lewisville, TX 75067 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms, for 1 of 9 residents (Resident #1) that were reviewed investigated in that: The facility staff failed to respect the Resident #32's rights to refuse care. This failure could lead to residents' embarrassment, poor self-worth and self-esteem, diminished quality of life, as well as emotional and psychological degression. The facility staff failed to ensure Resident #32's rights related to choose was respected and acted upon when he refused glucose testing from the nurse. This failure could affect residents placed at the facility at risk for decreased awareness of their rights, diminished quality of life, loss of dignity, and decline in self-esteem. Findings included: Review of Resident #32's face sheet revealed dated 05/15/23 revealed an [AGE] year-old male with admission date of 05/02/2017. The resident's diagnoses include ddysphasia (difficulty swallowing - taking more time and effort to move food or liquid from your mouth to your stomach), convulsions (an episode of uncontrolled muscle spasm with altered consciousness), major depression (mood) cognitive communication deficit (difficulty talking and processing thoughts), thrombocytopenia (a condition that occurs when the platelet count in your blood is too low. Platelets are tiny blood cells that are made in the bone marrow from larger cells. When you are injured, platelets stick together to form a plug to seal your wound. This plug is called a blood clot). Review of Resident #32's Quarterly MDS dated [DATE] revealed a BIMS score of 14 no cognitive impairment. Resident was able to make his needs know to staff and make choices with care. He requires to people to transfer and conduct ADLs, as he has a deficit. Review of Resident #32's Care Plan dated 04/28/23 revealed Resident #32 was at risk for low blood levels that could affect his care, He was PASSR positive for diagnosis of Major Depressive disorder. indicating he meets the criteria for mental illness and additional services to assist with care, understanding and function while receiving services in the facility. Interventions include Resident #32 maintaining involvement in cognitive stimulation, social activities, encourage ongoing involvement with care and choices. He has a history of behaviors that include inappropriate talk in the presence of female aides and refusing care. Interventions include notifying the resident of scheduled care, educate, praise, and encourage participation with medical task, document behaviors. Review of Resident #32's MD orders revealed regular monitoring of resident #32s blood, requiring glucose monitoring daily, and as needed due to a diagnosis of Thrombocytopenia (a condition that occurs when the platelet count in your blood is too low. Platelets are tiny blood cells that are made in the bone marrow from larger cells. When you are injured, platelets stick together to form a plug to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676036 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 676036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Ridge Nursing & Rehabilitation Center 700 E Vista Ridge Mall Dr Lewisville, TX 75067 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 0600 seal your wound. An order for pain assessment, and behavior Level of Harm - Minimal harm or potential for actual harm During an interview with Resident #32 on 05/15/23 at 11:40 a.m. revealed the day of the incident LVN B entered his room (could not recall exact day) and grabbed his right hand and twisted his fingers. Resident #32 said the nurse initially pulled his finger when told him no to the procedures. Resident #32 also asked him to stop while proceeding with the procedure. He said this made him angry. He said medical attention was provided immediately including x-rays in house. He said his finger was sore but not fractured. Resident #32 said the nurse that was involved no longer work at the facility. Residents Affected - Few In an interview on 05/15/23 at 9:00 a.m. with CNA C revealed she was not working the day of the alleged incident. She said Resident #32 told her the nurse pulled his finger and he pulled back, as he did not want his blood level test. She said Resident #32 did better when the staff were aware of his preferences and communicating in advance. She participated in an in-service about resident choice and abuse. During an interview on 05/16//23 at 2:11 p.m., the DON stated after the incident she conducted an assessment of the resident's finger for injury. She did not see any abnormalities but ordered x-rays as the resident said his finger was sore and pain medication given. She said Resident #32 said the staff grabbed his finger and proceeded to stick when he told him no. The DON said in an interview with LVN B on 05/09/23 he reported he heard the resident say no and continued with the test. The DON suspended him pending an investigation and later determined LVN B employment due to abuse. She proceeded to conduct in-services on abuse and communicating resident rights and choices. She also conducted safe surveys, and there were no further complaints. All staff were expected to notify of the resident of the procedure being conducted, seek approval, then proceed, at any time during the procedure if a resident says tope, she expects her staff to do so. In an interview with the Administrator on 05/16/23 at 3:30 p.m. revealed she expected all staff to adhere by resident rights guidelines and failing to do so could lead to residents not being heard and rights respected. She expected that the resident rights be respected, and they were not abused or neglected. She expected immediate reporting to protect the resident from harm and danger, to allow leadership to meet and assess resident appropriately before concluding care, so that the family would be notified, and the MD, as well as educating the resident on the importance of care task. staff was suspended pending an investigation and later terminated for abuse of resident. The facility did not report the nursing license; however, the information was provided. A review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021 reflected: .Residents have the right to be free from abuse and neglect this includes but not limited freedom of verbal and mental abuse by providing staff trainings and orientations that include the topic such as abuse prevention, identification, and reporting abuse A review of facility policy dated March 2018 and titled Abuse and Neglect-Clinical approach reflected: Abuse, abuse was defined as the willful infliction of injury .mental anguish .including verbal abuse .The nurse will assess the individual and document related findings. Assessment data include injury, pain, and behavior assessment .notify physician and administrator for guidance FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676036 If continuation sheet Page 4 of 4