Health inspection·July 22, 2023

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #1 did not have a condition or chronic disease that would result in a life expectancy of less than 6 months. Resident #1 did experience significant unplanned weight loss in the past six months and used a feeding tube, was given insulin injections and anticoagulant medication. Review of Resident #1's care plan dated 02/05/23 reflected she had Diabetes Mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels) and was at risk for signs and symptoms and complications. Interventions were to monitor/document for side effects and effectiveness, dietary consult for nutritional regimen, fasting serum blood sugar as ordered by doctor, if infections was present than consult doctor regarding any changes in diabetic medications, inspect feet daily, and monitor/document/report signs and symptoms of hypoglycemia and infection to any open areas. Review of Resident #1's physician orders for June 20223 and July 2023 reflected a one-time order, CBC, CMP, A1C (start date 06/28/23 and ordered by PHY B), Insulin Lispro Injection Solution 100 UNIT/ML-Inject as per sliding scale: if 151-200 = 3 Units; 201-250 = 6 Units; 251-300 = 9 Units; 301-350 = 12 Units; 351-400 = 15 units Give insulin and call MD if BS >400, subcutaneously before meals (start date 04/25/23), Levemir Subcutaneous Solution-Inject 30 unit subcutaneously one time a day (06/22/2023). Review of Resident #1's CMP lab result on 06/29/23 reflected it was a critical result with her blood glucose at 480 (Reference range is 81 to115). The lab result electronically documented on the form that RN J was notified on 06/29/23 at 11:38 PM. Review of Resident #1's July 2023 MAR/TAR reflected on 07/01/23 at 8:54 AM, agency LVN D took Resident #1s blood sugar and it was 453. There was no indication any insulin was given at that time as the nurse did not reflect that sliding scale was administered and did not document any administration of insulin in a nursing note or an assessment of the resident. The MAR/TAR reflected, Inject as per sliding scale: .351-400=15 units; Give insulin and call MD if BS>400. There was no evidence through nursing documentation that the physician was notified, or the resident was assessed for any decline in condition. Resident #1's MAR/TAR reflected her last 24 hours of blood sugar readings prior on 06/30/23 were 252 at 7:00 AM, 218 at 11:30 AM and 385 at 4:30 PM. Review of nursing progress notes for Resident #1 on 06/29/23 through 07/02/23 revealed neither the physician or nurse practitioner were notified of the resident's critical lab result on 06/29/23 and of the elevated blood glucose reading on 07/01/23. Review of NP E's progress note on 07/03/23 reflected she had a face to face visit with Resident #1 and a facility nurse reported that the resident was not acting her normal self. NP E noted no moaning or facial grimaces during care/turning per the facility nurse. Resident #1 was seen lying in bed with eyes closed. She did not have any response to verbal, tactile stimuli and sternal rubs. Her respirations were even and unlabored and she did not appear to be in acute distress and her vital signs were stable. The NP ordered Resident #1 to be sent to the ER for altered mental status. NP E documented she reviewed a CMP lab dated 06/21/23 that she had previously ordered where Resident #1's glucose was 355. There was no evidence she reviewed the critical lab from 06/29/23 ordered by PHY B when her blood sugar was 480. Requested EMS Run Report and hospital records on 08/07/23, but investigator was unable to obtain the records. An interview with the overnight nurse RN J on 07/20/23 at 4:39 PM revealed she remembered Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676039 If continuation sheet Page 2 of 20 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 676039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Parks at Garland Healthcare and Rehab 3737 N Garland Avenue Garland, TX 75044 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few #1, but she did not remember receiving a critical lab result for the resident on 06/20/23 on the overnight shift. RN J stated, When a lab is critical, the lab company, you know I haven't received any, but they would call the facility, I haven't received any in, god, a long time, and they do call, ask who you are. Then the nurse would immediately call the doctor. Even overnight, you still attempt to call them and see. You would notify the family and you need to hear from the doctor. RN J stated the harm of not following up would be the resident could go into a coma if she began to have symptoms of hyperglycemia and it was not treated. RN J stated the facility nurse who the lab company contacted was responsible for documenting it in a progress note and complete a change in condition form, call the doctor and document results and complete vitals. RN J stated, I don't remember getting any such call, .As a nurse, communication is how I know if labs need to be followed up on the 24-hour form .I haven't gotten a call for a critical lab in a long time. I am talking way long time, three to six months. An interview with the DON on 07/20/23 at 2:15 PM revealed Resident #1 passed away in the hospital and she did not know what her was the cause of Resident #1's death. The DON confirmed as she observed Resident #1's nursing progress notes, an order for a CMP on 06/29/23 but she did not see where the critical lab was reported in the system by the nurse. The DON stated if a lab company could not reach a nurse at the facility for a critical lab, they can contact her and the treatment nurses 24/7. The DON stated the receiving nurse for the critical lab was supposed to call the nurse practitioner if it was Monday through Friday and the Physician if it was Saturday and Sunday and notify them and the nurse then would write a progress note and notate any new orders. Regarding Resident #1's high blood sugars on the MAR, the DON stated if a blood sugar was over 400, what should have happened was the doctor should have been notified, the resident given insulin and then her blood sugar re-checked and if it was still high, then notify the doctor and he would have decided to send her to the ER or not. The DON stated even if Resident #1's blood sugar readings the rest of that day were not under 400, it meant the insulin was not working properly. She stated the issue with using agency nurses was they did not know where a resident's baseline was at for vitals and condition. The DON stated the nurse who made the error (LVN D) with the lack of notification and documentation when Resident #1's blood sugar was over 400 was an agency nurse. She said when a resident's blood sugar was over 400, the nurse would also need to complete a significant event form for high blood sugar reading in e-charting software and that information would be reflected the next morning for management to review. An interview with the DON on 07/20/23 at 4:26 PM revealed, We dropped the ball with [Resident #1]'s lab. The DON confirmed the critical lab notification was made by the lab at 11:38 PM and the lab documented RN J was the person notified. The DON stated RN J was a facility nurse and knew the protocols, but the DON could not find a progress note or anything on the 24-hour report. She said the morning nurse (LVN A) did not remember being notified of a critical lab during change of shift report the next day. The DON stated again, I hate to admit it, but the ball was dropped. She said RN J was a seasoned nurse and had been at the facility for six years and knew better. The DON stated ADON H was going to start in-services on critical lab readings, who to notify and what steps to take. A follow up interview with the DON on 07/20/23 at 4:58 PM revealed she had pulled the hard copy of the 24-hour report that the nurses wrote on versus the one in the e-charting system and pointed to where RN J had hand-written on the 24-hour report for the shift on 06/29/23, that Resident #1's lab results were in, and the NP was notified. The DON stated, But she did not indicate it was a critical lab and she did not do the proper follow up notifications and receive orders as to how to proceed. The DON stated she was unaware of this error prior to investigator intervention. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676039 If continuation sheet Page 3 of 20 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 676039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Parks at Garland Healthcare and Rehab 3737 N Garland Avenue Garland, TX 75044 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the facility's 24-hour report for the overnight shift on 06/30/23 reflected revealed a hand written note that the nurse practitioner was notified of labs, next to Resident #1's name. The DON had verified in an earlier interview that it was the handwriting of RN J. An interview with NP E on 07/20/23 at 6:47 PM revealed she was unaware of the critical lab result for Resident #1 on 06/29/23 and she did not see any documentation where PHY B was notified either. NP E stated she rounded every Monday at the facility and last time she saw Resident #1 was on 07/03/23 and saw the critical lab and the resident did not look good to her, She stated Resident #1 was not responding and usually would moan when moved, but this time she did not. She did a sternal rub and Resident #1 still would not open her eyes, so she sent her to the ER. NP E stated her visit was three days after the critical lab result came in. NP E stated, They should notify us of critical lab results, but not all of them are doing it. We cannot check everyone's labs all the time, that is why we have the nurses let us know, so we can adjust the insulin. She said if she had seen Resident #1's critical lab and she was not in the condition she had been in, she would have just adjusted her insulin. Regarding the high blood sugar reading on 07/01/23, NP E stated even though Resident #1's blood sugar was high, she was on sliding scale to cover it, but she did not see any documentation where the resident's blood sugar was re-checked, and the nurse did not document that she gave insulin. NP E stated she wanted the nurses to contact her if a resident's blood sugar was over 400 and there was a sliding scale protocol. She stated, If it is way higher, we give insulin to lower it. I want them to call me if over 400, we have a sliding scale protocol. If it is way higher, we give extra insulin to lower it. NP E stated high blood sugar could cause a resident to go into diabetic ketoacidosis (develops when your body doesn't have enough insulin to allow blood sugar into your cells for use as energy.) and then a coma but she felt that the issue was not Resident #1's high blood sugar that caused the change in condition but could not be sure. An interview with PHY B on 07/21/23 at 10:30 AM revealed he did not receive a call from the facility to notify him of Resident #1's critical lab result. He said he knew Resident #1 well and she was in a very debilitated condition and had a recent stroke. PHY B stated Resident #1 had short and long acting insulin, so even though the facility did not notify him of the critical lab or blood sugars over 400, she was still covered for any sugar abnormalities. However, PHY B stated with critical labs, the nurse needed to be looking at signs and symptoms and if the blood sugar was more than 400/450 or something like that, they are supposed to call him, or the NP and they could make changes. PHY B stated, Like if 500, they call me and I know I am covering the insulin and sometimes I know someone is a brittle diabetic, like in her case, then what we do, if persistently going up and we add another 5 or 6 units of insulin short acting on top of sliding scale, then they would check again in four hours to make sure the glucose is covered. PHY B stated hyperglycemia above 800 could cause altered mental status, but not around 400. He said Resident #1's body was used to the high blood sugar. PHY B stated Resident #1 was sent to the hospital because she was unresponsive, it was not the blood sugar. In our mind, she had a stroke. Attempted interview with LVN D on 07/21/23 at 2:21 was unsuccessful. A voicemail was left with a request to return investigator's call. An interview with the DON on 07/22/23 at 2:19 PM revealed she talked to RN J about not reporting the critical lab for Resident #1 the night prior and RN J admitted that she forgot that she had received the lab notification, which was in contradiction to what she stated during the investigator's interview. RN J told the DON that she told another nurse working at that time that Resident #1 had a critical lab because it was that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676039 If continuation sheet Page 4 of 20 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 676039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Parks at Garland Healthcare and Rehab 3737 N Garland Avenue Garland, TX 75044 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few resident's nurse. However, RN J did not document that she notified that nurse of the critical lab and when the DON asked the other nurse about it, she said she was never notified of the critical lab. The nurse was only notified by a screen shot that a lab was completed for Resident #1, but the whole lab could not be seen. The DON stated, The critical values were not communicated at that point. So I have taken the necessary steps with her as well. The DON felt the IJ occurred because of documentation. She said the critical lab was not reported and the hand-written note on the 24-hour report was not accurate. She said it was human error. The DON stated that going forward, the facility nursing management would add spot checks to monthly nursing audits and the ADON would oversee that critical lab notifications were done and documented in the resident records. Review of the facility's policy titled, Lab and Diagnostic Test Results, revised November 2018, reflected, .Identifying Situations that Warrant Immediate notification: 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: -Whether the physician has requested to be notified as soon as result is received, -Whether the result should be converted to a physician regardless of other circumstances, -Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable of improving, or there are no previous results for comparison; .Options for Physician Notification: 1. A physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent, a. Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record and not on the lab results report, because test results should be correlated with other relevant information such as the individual's overall situation, current symptoms, advance directives, prognosis, b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment records needs review or clarification. The facility Administrator received the IJ template on 07/21/23 at 12:58 PM. The Plan of Removal (POR) was accepted on 07/21/23 at 5:23 PM and reflected: Plan for Removal-[Facility Name] / July 21, 2023 The Texas Department of Health and Human Services entered [Facility Name] on July 21, 2023. During their investigation, an IJ (Immediate Jeopardy) was cited on 7/21/23 at approx. 12:50pm regarding Resident Rights r/t Physician Notification of Change in Condition. The Facility failed to ensure that a physician was notified of a critical lab value for one resident on 6/29/23.

F580- Plan of Removal All nurses, to include agency staff, will be in-serviced on the following: o Inservice to include SBAR for critical labs. o Inservice for critical lab reporting and documentation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676039 If continuation sheet Page 5 of 20 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 676039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Parks at Garland Healthcare and Rehab 3737 N Garland Avenue Garland, TX 75044 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 7/20/23, the Director of Nursing began in-services with 2-10 shift nurses. The nursing leadership team also began calling nurses who were not on-shift at that time for verbal education and to provide immediate action and compliance. Any non-agency nurses who have not completed in-services will do so prior to the beginning of their next shift. All currently staffed nurses will not be allowed to work until completing competency. Agency nurses will be required to review in-services, located in a binder at nurse's station, prior to start of their shift. Compliance will be monitored by the DON daily with notification provided to any new agency nurse prior to start of their shift. The DON will provide all staffed nurses with a competency quiz to confirm understanding of in-services listed above. Quizzes will be completed prior to any staffed nurse working another shift, until all nurses have completed the competency. No nurse will work a shift until competency is completed. The nurse involved, [RN J], to be terminated effectively immediately by Administrator on 7/21/23. A daily audit tool will be utilized to monitor for critical labs and documentation of such including timely reporting to provider. This audit tool will include monitoring on the weekends. DON and ADON will complete an immediate audit of critical labs will be completed on 7/21/22, going back to 6/21/23, in order to confirm proper notification and documentation were completed and to ensure there are no active resident health or safety concerns related to lab services. On 7/20/23, an Ad Hoc QAPI meeting was held with the leadership team for root cause discussion. It was determined that the notification to physician was not completed per policy. PIPs will be initiated for physician notification with all in-services and audit tools attached for review in monthly QAPI. Administrator will host weekly Ad Hoc QAPI meetings to assist in monitoring audit tools and in-service tracking. The audits will be completed daily x 2 weeks, weekly x 4 weeks and monthly x2 or until substantial compliance is met. Findings will be corrected in real time and discussed monthly at QAPI by the interdisciplinary team. Monitoring interviews for the Immediate Jeopardy were started on 07/22/23 at 1:00PM with nursing staff across all three shifts , including weekdays and weekends, from the nursing, administration. The following staff's in-service logs and competency tests were reviewed and they were interviewed during the monitoring time frame and were able to articulate what they had been taught, protocols and procedures related to physician notification of critical labs, documentation protocol, and expectations for elevated blood sugar over 401: ADON H, LVN I, LVN K, RN P, LVN Q, LVN M, RN N, RN O, DON and ADM. Monitoring and review of all new lab results from 07/21/23 through 07/24/23 for all facility residents reflected two results came in for two different residents and were both abnormal, not critical. Proper notifications were made to the MD/NP and documentation was completed per facility protocol. The facility's ADM was notified the IJ was removed on 07/22/23 at 3:31 PM. While the Immediate Jeopardy was removed on 07/22/23, the facility remained out of compliance due to the facility's need to evaluate the effectiveness of the Plan of Removal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676039 If continuation sheet Page 6 of 20 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 676039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Parks at Garland Healthcare and Rehab 3737 N Garland Avenue Garland, TX 75044 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for one (Resident #1) of three residents reviewed for quality of care. Residents Affected - Few 1. The facility failed to assess and intervene for a potential change in condition or decline when Resident #1's had a critical CMP (comprehensive metabolic panel) lab with a glucose with a reading of 480. 2. The facility failed to ensure that when Resident #1's blood sugar was 453, that the physician was notified and it wss unclear if the resident received insulin. On 07/21/23 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/22/23, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure placed residents at risk for potential delay in medical intervention and decline in health or possible worsening of symptoms, including death. Findings included: Review of Resident #1's significant change MDS assessment dated [DATE] reflected she was an [AGE] year old female who admitted to the facility on [DATE]. Resident #1's active diagnoses included diabetes, non-Alzheimer's dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), aphasia (loss of ability to understand or express speech, caused by brain damage), stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), hemiplegia (paralysis of one side of the body), malnutrition (lack of proper nutrition), hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in the blood), GERD (a condition in which the stomach contents move up into the esophagus), hypertension (when the pressure in your blood vessels is too high (140/90 mmHg or higher) and dysphagia (swallowing difficulty). Resident #1 had no speech and was rarely/never understood and had adequate vision and hearing. Resident #1 had long and short term memory problems and severely impaired cognitive decision making skills. Resident #1 has signs/symptoms of delusions, including inattention and altered level of consciousness with vigilance (startled easily with sound or touch), but had no indicators of psychosis, wandering or rejection of care. Resident #1 was totally dependent on staff for all ADLs and had upper and lower range of motion impairment on both sides of her body and was incontinent of bowel and bladder. Resident #1 did not have a condition or chronic disease that would result in a life expectancy of less than 6 months. Resident #1 did experience significant unplanned weight loss in the past six months and used a feeding tube, was given insulin injections and anticoagulant medication. Review of Resident #1's care plan dated 02/05/23 reflected she had Diabetes Mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels) and was at risk for signs and symptoms and complications. Interventions were to monitor/document for side effects and effectiveness, dietary consult for nutritional regimen, fasting serum blood sugar as ordered by doctor, if infections is present than consult doctor regarding any changes in diabetic medications, inspect feet daily, and monitor/document/report signs and symptoms of hypoglycemia and infection to any open areas. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676039 If continuation sheet Page 7 of 20 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 676039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Parks at Garland Healthcare and Rehab 3737 N Garland Avenue Garland, TX 75044 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of Resident #1's physician orders for June 20223 and July 2023 reflected, CBC, CMP, A1C (start date 06/28/23 and ordered by PHY B), Insulin Lispro Injection Solution 100 UNIT/ML-Inject as per sliding scale: if 151-200 = 3 Units; 201-250 = 6 Units; 251-300 = 9 Units; 301-350 = 12 Units; 351-400 = 15 units Give insulin and call MD if BS >400, subcutaneously before meals (start date 04/25/23), Levemir Subcutaneous Solution-Inject 30 unit subcutaneously one time a day (06/22/2023). Review of Resident #1's CMP lab result on 06/29/23 reflected it was a critical result with her blood glucose at 480 (Reference range is 81 to115). The lab result electronically documented on the form that RN J was notified on 06/29/23 at 11:38 PM. Review of Resident #1's July 2023 MAR/TAR reflected on 07/01/23 at 8:54 AM, agency LVN D took her blood sugar, and it was 453. There was no indication that any insulin was given at that time as the nurse did not reflect that sliding scale was administered and did not document any administration of insulin in a nursing note or an assessment of the resident. The MAR/TAR reflected, Inject as per sliding scale: .351-400=15 units; Give insulin and call MD if BS>400. There was no evidence through nursing documentation that the physician was notified, or the resident was assessed for any decline in condition. Resident #1's MAR/TAR reflected her last 24 hours of blood sugar readings prior on 06/30/23 were 252 at 7:00 AM, 218 at 11:30 AM and 385 at 4:30 PM. Review of nursing progress notes for Resident #1 on 06/29/23 through 07/02/23 revealed neither the physician or nurse practitioner were notified of the resident's critical lab result on 06/29/23 and of the elevated blood glucose reading on 07/01/23. Review of NP E's progress note on 07/03/23 reflected she had a face to face visit with Resident #1 and a facility nurse reported that the resident was not acting her normal self. NP E noted no moaning or facial grimaces during care/turning per the facility nurse. Resident #1 was seen lying in bed with eyes closed. She did have any response to verbal, tactile stimuli and sternal rubs. Her respirations were even and unlabored and she did not appear to be in acute distress and her vital signs were stable. The NP ordered Resident #1 to be sent to the ER for altered mental status. NP E documented she reviewed a CMP lab dated 06/21/23 that she had previously ordered where Resident #1's glucose was 355. There was no evidence she reviewed the critical lab from 06/29/23 ordered by PHY B when her blood sugar was 480. Requested EMS Run Report and hospital records on 08/07/23, but investigator was unable to obtain the records. An interview with the overnight nurse RN J on 07/20/23 at 4:39 PM revealed she remembered Resident #1, but she did not remember receiving a critical lab result for the resident on 06/20/23 on the overnight shift. RN J stated, When a lab is critical, the lab company, you know I haven't received any but they would call the facility, I haven't received any in, god, a long time, and they do call, ask who you are. Then the nurse would immediately call the doctor. Even overnight, you still attempt to call them and see. You would notify the family and you need to hear from the doctor. RN J stated the harm of not following up would be the resident could go into a coma if she began to have symptoms of hyperglycemia and it was not treated. RN J stated the facility nurse who the lab company contacted was responsible for documenting it in a progress note and complete a change in condition form, call the doctor and document results and complete vitals. RN J stated, I don't remember getting any such call, .As a nurse, communication is how I know if labs need to be follow up on the 24-hour form .I haven't gotten a call for a critical lab in a long time. I am talking way long time, three to six months. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676039 If continuation sheet Page 8 of 20 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 676039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Parks at Garland Healthcare and Rehab 3737 N Garland Avenue Garland, TX 75044 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few An interview with the DON on 07/20/23 at 2:15 PM revealed Resident #1 passed away in the hospital and she did not know what her cause of death was. The DON verified she observed in Resident #1's nursing progress notes, an order for a CMP on 06/29/23 but she did not see where the critical lab was reported in the system by the nurse. The DON stated of a lab company could not reach a nurse at the facility for a critical lab, they can contact her and the treatment nurses 24/7. The DON stated the receiving nurse for the critical lab was supposed to call the nurse practitioner if it was Monday through Friday and the Physician if it was Saturday and Sunday and notify them and the nurse then would write a progress note and notate any new orders. Regarding Resident #1's high blood sugars on the MAR, the DON stated if a blood sugar was over 400, what should have happened was the doctor should have been notified, the resident given insulin and then her blood sugar re-checked and if it was still high, then notify the doctor and he would have decided to send her to the ER or not. The DON stated even if Resident #1's blood sugar readings the rest of that day were under 400, it still meant that the insulin was not working properly. She stated the issue with using agency nurses was they did not know where a resident's baseline was at for vitals and condition. The DON stated the nurse who made the error (LVN D) with the lack of notification and documentation when Resident #1's blood sugar was over 400 was an agency nurse. She said when a resident's blood sugar was over 400, the nurse would also need to complete a significant event form for high blood sugar reading in e-charting software and that information would be reflected the next morning for management to review. An interview with the DON on 07/20/23 at 4:26 PM revealed, We dropped the ball with [Resident #1]'s lab. The DON confirmed the critical lab notification was made by the lab at 11:38 PM and the lab documented RN J was the person notified. The DON stated RN J was a facility nurse and knew the protocols, but the DON could not find a progress note or anything on the 24-hour report. She said the morning nurse (LVN A) did not remember being notified of a critical lab during change of shift report the next day. The DON stated again, I hate to admit it, but the ball was dropped. She said RN J was a seasoned nurse and had been at the facility for six years and knew better. The DON stated ADON H was going to start in-services on critical lab readings, who to notify and what steps to take. Review of the facility's 24-hour report for the overnight shift on 06/30/23 reflected revealed a hand written note that the nurse practitioner was notified of labs, next to Resident #1's name. The DON had verified in an earlier interview that it was the handwriting of RN J. A follow up interview with the DON on 07/20/23 at 4:58 PM revealed she had pulled the hard copy of the 24-hour report that the nurses wrote on versus the one in the e-charting system and pointed to where RN J had hand-written on the 24-hour report for the shift on 06/29/23, that Resident #1's lab results were in and the NP was notified. The DON stated, But she did not indicate it was a critical lab and she did not do the proper follow up notifications and receive orders as to how to proceed. The DON stated she was unaware of this error prior to investigator intervention and was just discovering it. An interview with NP E on 07/20/23 at 6:47 PM revealed she was unaware of the critical lab result for Resident #1 on 06/29/23 and she did not see any documentation where PHY B was notified either. NP E stated she rounded every Monday at the facility and last time she saw Resident #1 was on 07/03/23 and saw the critical lab and the resident did not look good to her, She stated Resident #1 was not responding and usually would moan when moved, but this time she did not. She did a sternal rub and Resident #1 still would not open her eyes, so she sent her to the ER. NP E stated her visit was three days after the critical lab result came in. NP E stated, They should notify us of critical lab results, but not all of them are doing it. We cannot check everyone's labs all the time, that is why we have the nurses let us know, so we can adjust the insulin. She said if she had seen Resident #1's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676039 If continuation sheet Page 9 of 20 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 676039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Parks at Garland Healthcare and Rehab 3737 N Garland Avenue Garland, TX 75044 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few critical lab and she was not in the condition she had been in, she would have just adjusted her insulin. Regarding the high blood sugar reading on 07/01/23, NP E stated even though Resident #1's blood sugar was high, she was on sliding scale to cover it, but she did not see any documentation where the resident's blood sugar was re-checked, and the nurse did not document that she gave insulin. NP E stated she wanted the nurses to contact her if a resident's blood sugar was over 400 and there was a sliding scale protocol. She stated, If it is way higher, we give insulin to lower it. I want them to call me if over 400, we have a sliding scale protocol. If it is way higher, we give extra insulin to lower it. NP E stated high blood sugar could cause a resident to go into diabetic ketoacidosis (develops when your body doesn't have enough insulin to allow blood sugar into your cells for use as energy) and then a coma, but she felt that the issue was not Resident #1's high blood sugar that caused the change in condition but could not be sure. An interview with PHY B on 07/21/23 at 10:30 AM revealed he did not receive a call from the facility to notify him of Resident #1's critical lab result. He said he knew Resident #1 well and she was in a very debilitated condition and had a recent stroke. PHY B stated that Resident #1 had short and long acting insulin, so even though the facility did not notify him of the critical lab or blood sugars over 400, she was still covered for any sugar abnormalities. However, PHY B stated with critical labs, the nurse needed to be looking at signs and symptoms and if the blood sugar was more than 400/450 or something like that, they are supposed to call him, or the NP and they could make changes. PHY B stated, Like if 500, they call me and I know I am covering the insulin and sometimes I know someone is a brittle diabetic, like in her case, then what we do, if persistently going up and we add another 5 or 6 units of insulin short acting on top of sliding scale, then they would check again in four hours to make sure the glucose is covered. PHY B stated hyperglycemia above 800 could cause altered mental status, but not around 400. He said Resident #1's body was used to the high blood sugar. PHY B stated Resident #1 was sent to the hospital because she was unresponsive, it was not the blood sugar. In our mind, she had a stroke. Attempted interview with LVN D on 07/21/23 at 2:21 was unsuccessful. A voicemail was left with a request to return investigator's call. An interview with the DON on 07/22/23 at 2:19 PM revealed she talked to RN J about not reporting the critical lab for Resident #1 the night prior and RN J admitted that she forgot that she had received the lab notification, which was in contradiction to what she stated during the investigator's interview. RN J told the DON that she told another nurse working at that time that Resident #1 had a critical lab because it was that resident's nurse. However, RN J did not document that she notified that nurse of the critical lab and when the DON asked the other nurse about it, she said she was never notified of the critical lab. The nurse was only notified by a screen shot that a lab was completed for Resident #1, but the whole lab could not be seen. The DON stated, The critical values were not communicated at that point. So I have taken the necessary steps with her as well. The DON felt the IJ occurred because of documentation. She said the critical lab was not reported and the hand-written note on the 24-hour report was not accurate. She said it was human error. The DON stated that going forward, the facility nursing management would add spot checks to monthly nursing audits and the ADON would oversee that critical lab notifications were done and documented in the resident records. Review of the facility's policy titled, Nursing Care of the Older Adult with Diabetes Mellitus, revised November 2020, reflected, .Symptoms Associated with Diabetes: 1. Hyperglycemia. Uncontrolled diabetes from lack of insulin or inadequate insulin results in hyperglycemia (blood sugars above target levels). Signs and symptoms of hyperglycemia may include the following: a. Increased thirst, b. Frequent urination, c. Sugar in the urine, d. Fatigue, e. Headache; and f. Blurred vision; 2. Diabetic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676039 If continuation sheet Page 10 of 20 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 676039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Parks at Garland Healthcare and Rehab 3737 N Garland Avenue Garland, TX 75044 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 0684 Level of Harm - Immediate jeopardy to resident health or safety ketoacidosis (DKA)(diabetic coma). Ketoacidosis occurs when hyperglycemia is untreated, and the cells begin to metabolize fat for energy. The byproduct of fat metabolism is ketones, which build up quickly in the blood. Diabetic ketoacidosis is a life-threatening emergency that needs immediate medical attention; .Complications associated with Diabetes .1. Hyperglycemia and vascular damage can lead to: a. Cardiovascular and cerebrovascular disease, including heart disease and stroke .; Glycemic Targets .6. Establish provider notification protocols. Residents Affected - Few Review of the facility's policy titled, Change in Resident's Condition or Staus, revised May 2017, reflected, Our facility shall promptly notify the resident, his or her Attending Physicians, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): .d. Significant change to the resident's physical/emotional/mental condition; e. Need to alter the resident's medication significantly; .i. Specific instruction to notify the Physician of changes in the resident's condition . On 07/21/23 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/22/23, the facility remained out of compliance at a severity level of severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received the IJ template on 07/21/23 at 12:58 PM. The Plan of Removal (POR) was accepted on 07/21/23 at 5:23 PM and reflected: Plan for Removal-[Facility Name] / July 21, 2023 The Texas Department of Health and Human Services entered [Facility Name] on July 21, 2023. During their investigation, an IJ (Immediate Jeopardy) was cited on 7/21/23 at approx. 12:50pm regarding Resident Rights r/t Physician Notification of Change in Condition. The Facility failed to ensure that a physician was notified of a critical lab value for one resident on 6/29/23.

F684- Plan of Removal All nurses, to include agency staff, will be in-serviced on the following: o Inservice on policy and procedure + documentation for blood glucose monitoring o Inservice on SBAR for change in condition o Inservice on physician notification for blood glucose monitoring On 7/20/23, the Director of Nursing began in-services with 2-10 shift nurses. The nursing leadership team also began calling nurses who were not on-shift at that time for verbal education and to provide immediate action and compliance. Any non-agency nurses who have not completed in-services will do so prior to the beginning of their next shift. All currently staffed nurses will not be allowed to work until completing competency. Agency nurses will be required to review in-services, located in a binder at nurse's station, prior to start of their shift. Compliance will be monitored by the DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676039 If continuation sheet Page 11 of 20 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 676039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Parks at Garland Healthcare and Rehab 3737 N Garland Avenue Garland, TX 75044 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few daily with notification provided to any new agency nurse prior to start of their shift. The DON will provide all staffed nurses with a competency quiz to confirm understanding of in-services listed above. Quizzes will be completed prior to any staffed nurse working another shift, until all nurses have completed the competency. No nurse will work a shift until competency is completed. The nurse involved, [RN J], to be terminated effectively immediately by Administrator on 7/21/23. A daily audit tool will be utilized to monitor for critical labs and documentation of such including timely reporting to provider. This audit tool will include monitoring on the weekends. DON and ADON will complete an immediate audit of critical labs will be completed on 7/21/22, going back to 6/21/23, in order to confirm proper notification and documentation were completed and to ensure there are no active resident health or safety concerns related to lab services. On 7/20/23, an Ad Hoc QAPI meeting was held with the leadership team for root cause discussion. It was determined that the notification to physician was not completed per policy. PIPs will be initiated for physician notification with all in-services and audit tools attached for review in monthly QAPI. Administrator will host weekly Ad Hoc QAPI meetings to assist in monitoring audit tools and in-service tracking. The audits will be completed daily x 2 weeks, weekly x 4 weeks and monthly x2 or until substantial compliance is met. Findings will be corrected in real time and discussed monthly at QAPI by the interdisciplinary team. Monitoring interviews for the Immediate Jeopardy were started on 07/22/23 at 1:00PM with nursing staff across all three shifts , including weekdays and weekends, from the nursing, administration. The following staff's in-service logs and competency tests were reviewed and they were interviewed during the monitoring time frame and were able to articulate what they had been taught, protocols and procedures related to physician notification of critical labs, documentation protocol, and expectations for elevated blood sugar over 401: ADON H, LVN I, LVN K, RN P, LVN Q, LVN M, RN N, RN O, DON and ADM. Monitoring and review of all new lab results from 07/21/23 through 07/24/23 for all facility residents reflected two results came in for two different residents and were both abnormal, not critical. Proper notifications were made to the MD/NP and documentation was completed per facility protocol. The facility's ADM was notified the IJ was removed on 07/22/23 at 3:31 PM. While the Immediate Jeopardy was removed on 07/22/23, the facility remained out of compliance due to the facility's need to evaluate the effectiveness of the Plan of Removal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676039 If continuation sheet Page 12 of 20 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 676039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Parks at Garland Healthcare and Rehab 3737 N Garland Avenue Garland, TX 75044 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 0773 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record, the facility failed to promptly notify the ordering physician, physician assistant or nurse practitioner of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for one (Resident #1) of three residents reviewed for quality of care. The facility failed accurately document and follow up with the Resident #1's physician when Resident #1's had a critical CMP (comprehensive metabolic panel) lab with a glucose with a reading of 480. Due to the delay, the physician did not order necessary interventions. Resident #1 was admitted to the hospital three days later, where she died from unknown reasons. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. The facility Administrator received the IJ template on [DATE] at 12:58 PM. This failure placed residents at risk for potential delay in medical intervention and decline in health or possible worsening of symptoms, including death. Findings included: Review of Resident #1's significant change MDS assessment dated [DATE] reflected she was an [AGE] year old female who admitted to the facility on [DATE]. Resident #1's active diagnoses included diabetes, non-Alzheimer's dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), aphasia (loss of ability to understand or express speech, caused by brain damage), stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), hemiplegia (paralysis of one side of the body), malnutrition (lack of proper nutrition), hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in the blood), GERD (a condition in which the stomach contents move up into the esophagus), hypertension (when the pressure in your blood vessels is too high (140/90 mmHg or higher) and dysphagia (swallowing difficulty). Resident #1 had no speech and was rarely/never understood and had adequate vision and hearing. Resident #1 had long and short term memory problems and severely impaired cognitive decision making skills. Resident #1 has signs/symptoms of delusions, including inattention and altered level of consciousness with vigilance (startled easily with sound or touch), but had no indicators of psychosis, wandering or rejection of care. Resident #1 was totally dependent on staff for all ADLs and had upper and lower range of motion impairment on both sides of her body and was incontinent of bowel and bladder. Resident #1 did not have a condition or chronic disease that would result in a life expectancy of less than 6 months. Resident #1 did experience significant unplanned weight loss in the past six months and used a feeding tube, was given insulin injections and anticoagulant medication. Review of Resident #1's care plan dated [DATE] reflected she had Diabetes Mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels) and was at risk for signs and symptoms and complications. Interventions were to monitor/document for side effects and effectiveness, dietary consult for nutritional regimen, fasting serum blood sugar as ordered by doctor, if infections is present than consult doctor regarding any changes in diabetic medications, inspect feet daily, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676039 If continuation sheet Page 13 of 20 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 676039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Parks at Garland Healthcare and Rehab 3737 N Garland Avenue Garland, TX 75044 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 0773 monitor/document/report signs and symptoms of hypoglycemia and infection to any open areas. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #1's physician orders for [DATE] and [DATE] reflected, CBC, CMP, A1C (start date [DATE] and ordered by PHY B), Insulin Lispro Injection Solution 100 UNIT/ML-Inject as per sliding scale: if 151-200 = 3 Units; 201-250 = 6 Units; 251-300 = 9 Units; 301-350 = 12 Units; 351-400 = 15 units Give insulin and call MD if BS >400, subcutaneously before meals (start date [DATE]), Levemir Subcutaneous Solution-Inject 30 unit subcutaneously one time a day ([DATE]). Residents Affected - Few Review of Resident #1's CMP lab result on [DATE] reflected it was a critical result with her blood glucose at 480 (Reference range is 81 to115). The lab result electronically documented on the form that RN J was notified on [DATE] at 11:38 PM. Review of Resident #1's [DATE] MAR/TAR reflected on [DATE] at 8:54 AM, agency LVN D took her blood sugar, and it was 453. There was no indication that any insulin was given at that time as the nurse did not reflect that sliding scale was administered and did not document any administration of insulin in a nursing note or an assessment of the resident. The MAR/TAR reflected, Inject as per sliding scale: .351-400=15 units; Give insulin and call MD if BS>400. There was no evidence through nursing documentation that the physician was notified, or the resident was assessed for any decline in condition. Resident #1's MAR/TAR reflected her last 24 hours of blood sugar readings prior on [DATE] were 252 at 7:00 AM, 218 at 11:30 AM and 385 at 4:30 PM. Review of nursing progress notes for Resident #1 on [DATE] through [DATE] revealed neither the physician or nurse practitioner were notified of the resident's critical lab result on [DATE] and of the elevated blood glucose reading on [DATE]. Review of NP E's progress note on [DATE] reflected she had a face to face visit with Resident #1 and a facility nurse reported that the resident was not acting her normal self. NP E noted no moaning or facial grimaces during care/turning per the facility nurse. Resident #1 was seen lying in bed with eyes closed. She did have any response to verbal, tactile stimuli and sternal rubs. Her respirations were even and unlabored and she did not appear to be in acute distress and her vital signs were stable. The NP ordered Resident #1 to be sent to the ER for altered mental status. NP E documented she reviewed a CMP lab dated [DATE] that she had previously ordered where Resident #1's glucose was 355. There was no evidence she reviewed the critical lab from [DATE] ordered by PHY B when her blood sugar was 480. Requested EMS Run Report and hospital records on [DATE], but investigator was unable to obtain the records. An interview with the overnight nurse RN J on [DATE] at 4:39 PM revealed she remembered Resident #1 but she did not remember receiving a critical lab result for the resident on [DATE] on the overnight shift. RN J stated, When a lab is critical, the lab company, you know I haven't received any but they would call the facility, I haven't received any in, god, a long time, and they do call, ask who you are. Then the nurse would immediately call the doctor. Even overnight, you still attempt to call them and see. You would notify the family and you need to hear from the doctor. RN J stated the harm of not following up would be the resident could go into a coma if she began to have symptoms of hyperglycemia and it was not treated. RN J stated the facility nurse who the lab company contacted was responsible for documenting it in a progress note and complete a change in condition form, call the doctor and document results and complete vitals. RN J stated, I don't remember getting any such call, .As a nurse, communication is how I know if labs need to be follow up on the 24-hour form .I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676039 If continuation sheet Page 14 of 20 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 676039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Parks at Garland Healthcare and Rehab 3737 N Garland Avenue Garland, TX 75044 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 0773 haven't gotten a call for a critical lab in a long time. I am talking way long time, three to six months. Level of Harm - Immediate jeopardy to resident health or safety An interview with the DON on [DATE] at 2:15 PM revealed Resident #1 passed away in the hospital and she did not know what her cause of death was. The DON verified she observed in Resident #1's nursing progress notes, an order for a CMP on [DATE] but she did not see where the critical lab was reported in the system by the nurse. The DON stated of a lab company could not reach a nurse at the facility for a critical lab, they can contact her and the treatment nurses 24/7. The DON stated the receiving nurse for the critical lab was supposed to call the nurse practitioner if it was Monday through Friday and the Physician if it was Saturday and Sunday and notify them and the nurse then would write a progress note and notate any new orders. Regarding Resident #1's high blood sugars on the MAR, the DON stated if a blood sugar was over 400, what should have happened was the doctor should have been notified, the resident given insulin and then her blood sugar re-checked and if it was still high, then notify the doctor and he will decided to send her to the ER or not. The DON stated even if Resident #1's blood sugar readings the rest of that day were under 400, it still meant that the insulin was not working properly. She stated the issue with using agency nurses was they did not know where a resident's baseline was at for vitals and condition. The DON stated the nurse who made the error (LVN D) with the lack of notification and documentation when Resident #1's blood sugar was over 400 was an agency nurse. She said when a resident's blood sugar was over 400, the nurse would also need to complete a significant event form for high blood sugar reading in e-charting software and that information would be reflected the next morning for management to review. Residents Affected - Few An interview with the DON on [DATE] at 4:26 PM revealed, We dropped the ball with [Resident #1]'s lab. The DON confirmed the critical lab notification was made by the lab at 11:38 PM and the lab documented RN J was the person notified. The DON stated RN J was a facility nurse and knew the protocols but the DON could not find a progress note or anything on the 24-hour report. She said the morning nurse (LVN A) did not remember being notified of a critical lab during change of shift report the next day. The DON stated again, I hate to admit it, but the ball was dropped. She said RN J was a seasoned nurse and had been at the facility for six years and knew better. The DON stated ADON H was going to start in-services on critical lab readings, who to notify and what steps to take. Review of the facility's 24-hour report for the overnight shift on [DATE] reflected revealed a hand written note that the nurse practitioner was notified of labs, next to Resident #1's name. The DON had verified in an earlier interview that it was the handwriting of RN J. A follow up interview with the DON on [DATE] at 4:58 PM revealed she had pulled the hard copy of the 24-hour report that the nurses wrote on versus the one in the e-charting system and pointed to where RN J had hand-written on the 24-hour report for the shift on [DATE], that Resident #1's lab results were in and the NP was notified. The DON stated, But she did not indicate it was a critical lab and she did not do the proper follow up notifications and receive orders as to how to proceed. The DON stated she was unaware of this error prior to investigator intervention and was just discovering it. An interview with NP E on [DATE] at 6:47 PM revealed she was unaware of the critical lab result for Resident #1 on [DATE] and she did not see any documentation where PHY B was notified either. NP E stated she rounded every Monday at the facility and last time she saw Resident #1 was on [DATE] and saw the critical lab and the resident did not look good to her, She stated Resident #1 was not responding and usually would moan when moved, but this time she did not. She did a sternal rub and Resident #1 still would not open her eyes, so she sent her to the ER. NP E stated her visit was three days (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676039 If continuation sheet Page 15 of 20 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 676039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Parks at Garland Healthcare and Rehab 3737 N Garland Avenue Garland, TX 75044 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 0773 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few after the critical lab result came in. NP E stated, They should notify us of critical lab results, but not all of them are doing it. We cannot check everyone's labs all the time, that is why we have the nurses let us know, so we can adjust the insulin. She said if she had seen Resident #1's critical lab and she was not in the condition she had been in, she would have just adjusted her insulin. Regarding the high blood sugar reading on [DATE], NP E stated even though Resident #1's blood sugar was high, she was on sliding scale to cover it, but she did not see any documentation where the resident's blood sugar was re-checked and the nurse did not document that she gave insulin. NP E stated she wanted the nurses to contact her if a resident's blood sugar was over 400 and there was a sliding scale protocol. She stated, If it is way higher, we give insulin to lower it. I want them to call me if over 400, we have a sliding scale protocol. If it is way higher, we give extra insulin to lower it. NP E stated high blood sugar could cause a resident to go into diabetic ketoacidosis (develops when your body doesn't have enough insulin to allow blood sugar into your cells for use as energy) and then a coma but she felt that the issue was not Resident #1's high blood sugar that caused the change in condition but could not be sure. An interview with PHY B on [DATE] at 10:30 AM revealed he did not receive a call from the facility to notify him of Resident #1's critical lab result. He said he knew Resident #1 well and she was in a very debilitated condition and had a recent stroke. PHY B stated that Resident #1 had short and long acting insulin, so even though the facility did not notify him of the critical lab or blood sugars over 400, she was still covered for any sugar abnormalities. However, PHY B stated with critical labs, the nurse needed to be looking at signs and symptoms and if the blood sugar was more than 400/450 or something like that, they are supposed to call him or the NP and they could make changes. PHY B stated, Like if 500, they call me and I know I am covering the insulin and sometimes I know someone is a brittle diabetic, like in her case, then what we do, if persistently going up and we add another 5 or 6 units of insulin short acting on top of sliding scale, then they would check again in four hours to make sure the glucose is covered. PHY B stated hyperglycemia above 800 could cause altered mental status, but not around 400. He said Resident #1's body was used to the high blood sugar. PHY B stated Resident #1 was sent to the hospital because she was unresponsive, it was not the blood sugar. In our mind, she had a stroke. Attempted interview with LVN D on [DATE] at 2:21 was unsuccessful. A voicemail was left with a request to return investigator's call. An interview with the DON on [DATE] at 2:19 PM revealed she talked to RN J about not reporting the critical lab for Resident #1 the night prior and RN J admitted that she forgot that she had received the lab notification, which was in contradiction to what she stated during the investigator's interview. RN J told the DON that she told another nurse working at that time that Resident #1 had a critical lab because it was that resident's nurse. However, RN J did not document that she notified that nurse of the critical lab and when the DON asked the other nurse about it, she said she was never notified of the critical lab. The nurse was only notified by a screen shot that a lab was completed for Resident #1, but the whole lab could not be seen. The DON stated, The critical values were not communicated at that point. So I have taken the necessary steps with her as well. The DON felt the IJ occurred because of documentation. She said the critical lab was not reported and the hand-written note on the 24-hour report was not accurate. She said it was human error. The DON stated that going forward, the facility nursing management would add spot checks to monthly nursing audits and the ADON would oversee that critical lab notifications were done and documented in the resident records. Review of the facility's policy titled, Lab and Diagnostic Test Results, revised [DATE], reflected, .Identifying Situations that Warrant Immediate notification: 1. Nursing staff will consider the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676039 If continuation sheet Page 16 of 20 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 676039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Parks at Garland Healthcare and Rehab 3737 N Garland Avenue Garland, TX 75044 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 0773 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: -Whether the physician has requested to be notified as soon as result is received, -Whether the result should be converted to a physician regardless of other circumstances, -Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable of improving, or there are no previous results for comparison; .Options for Physician Notification: 1. A physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent, a. Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record and not on the lab results report, because test results should be correlated with other relevant information such as the individual's overall situation, current symptoms, advance directives, prognosis, b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment records needs review or clarification. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received the IJ template on [DATE] at 12:58 PM. The Plan of Removal (POR) was accepted on [DATE] at 5:23 PM and reflected: Plan for Removal- [Facility Name]/ [DATE]-The Texas Department of Health and Human Services entered [Facility] on [DATE]. During their investigation, an IJ (Immediate Jeopardy) was cited on [DATE] at approx. 12:50pm regarding Laboratory Services. The Facility failed to ensure that a physician was notified of a critical lab value for one resident on [DATE].

F773- Plan of Removal All nurses, to include agency staff, will be in-serviced on the following: o Inservice to include SBAR for critical labs. o Inservice for critical lab reporting and documentation. On [DATE], the Director of Nursing began in-services with 2-10 shift nurses. The nursing leadership team also began calling nurses who were not on-shift at that time for verbal education and to provide immediate action and compliance. Any non-agency nurses who have not completed in-services will do so prior to the beginning of their next shift. All currently staffed nurses will not be allowed to work until completing competency. Agency nurses will be required to review in-services, located in a binder at nurse's station, prior to start of their shift. Compliance will be monitored by the DON daily with notification provided to any new agency nurse prior to start of their shift. The DON will provide all staffed nurses with a competency quiz to confirm understanding of in-services listed above. Quizzes will be completed prior to any staffed nurse working another shift, until all nurses have completed the competency. No nurse will work a shift until competency is completed. The nurse involved, [RN J], to be terminated effectively immediately by Administrator on [DATE]. A daily audit tool will be utilized to monitor for critical labs and documentation of such (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676039 If continuation sheet Page 17 of 20 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 676039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Parks at Garland Healthcare and Rehab 3737 N Garland Avenue Garland, TX 75044 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 0773 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few including timely reporting to provider. This audit tool will include monitoring on the weekends. DON and ADON will complete an immediate audit of critical labs will be completed on [DATE], going back to [DATE], in order to confirm proper notification and documentation were completed and to ensure there are no active resident health or safety concerns related to lab services. On [DATE], an Ad Hoc QAPI meeting was held with the leadership team for root cause discussion. It was determined that the notification to physician was not completed per policy. PIPs will be initiated for physician notification with all in-services and audit tools attached for review in monthly QAPI. Administrator will host weekly Ad Hoc QAPI meetings to assist in monitoring audit tools and in-service tracking. The audits will be completed daily x 2 weeks, weekly x 4 weeks and monthly x2 or until substantial compliance is met. Findings will be corrected in real time and discussed monthly at QAPI by the interdisciplinary team. Monitoring interviews for the Immediate Jeopardy were started on [DATE] at 1:00PM with nursing staff across all three shifts , including weekdays and weekends, from the nursing, administration. The following staff's in-service logs and competency tests were reviewed and they were interviewed during the monitoring time frame and were able to articulate what they had been taught, protocols and procedures related to physician notification of critical labs, documentation protocol, and expectations for elevated blood sugar over 401: ADON H, LVN I, LVN K, RN P, LVN Q, LVN M, RN N, RN O, DON and ADM. Monitoring and review of all new lab results from [DATE] through [DATE] for all facility residents reflected two results came in for two different residents and were both abnormal, not critical. Proper notifications were made to the MD/NP and documentation was completed per facility protocol. The facility's ADM was notified the IJ was removed on [DATE] at 3:31 PM. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance due to the facility's need to evaluate the effectiveness of the Plan of Removal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676039 If continuation sheet Page 18 of 20 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 676039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Parks at Garland Healthcare and Rehab 3737 N Garland Avenue Garland, TX 75044 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to maintain medical records on each resident that are accurately documented for one (Resident #1) of three residents reviewed for clinical records. The facility failed to maintain a copy of Resident #2's urine analysis and culture and sensitivity test results when ordered by his physician. This failure can place residents at risk of inaccurate needs or services based on comprehensive assessment. Findings included: Review of Resident #2's quarterly MDS assessment dated [DATE] reflected he was an [AGE] year old male admitted to the facility on [DATE]. Resident #2's active diagnoses included gastronomy status, Parkinson's disease, Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), aphasia (loss of ability to understand or express speech, caused by brain damage), cerebrovascular accident (A stroke, also referred to as a cerebral vascular accident (CVA) or a brain attack, is an interruption in the flow of blood to cells in the brain), diabetes (a chronic condition that affects the way the body processes sugar/glucose), neurogenic bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems), hypertension (high blood pressure), hyperlipidemia (an elevated level of lipids - like cholesterol and triglycerides in the blood) and thyroid disease (a general term for a medical condition that keeps your thyroid from making the right amount of hormones). Resident #2 had no speech and was rarely/never understood, had severely impaired vision, severely impaired cognitive skills for decision making, and long/short memory impairments. Resident #2 had delirium as evidenced by continuous inattention and altered levels of consciousness, but no indicators of psychosis of rejection of care. Resident #2 was total physically dependent on one to two staff for all ADLs, had range of motion impairment on both sides of his upper and lower extremities, was always incontinent of bowel and used a catheter and a feeding tube. Review of Resident #2's care plan dated 04/20/23 reflected he used a foley catheter and interventions were, Assess need for continued use, Change catheter per facility policy. Review of Resident #2's physician orders reflected, UA C&S and Urine Culture one time only (Start Date 05/08/2023 by PHY B. Review of a nursing note for Resident #2 dated 05/08/23 reflected, Received N/O from [NP E] for UA and C&S and urine culture. Review of Resident #2's clinical chart revealed no evidence of a UA with C&S during his stay at the facility. Review of a progress note from the Infectious Disease NP Q on 5/12/2023 reflected, Reason for Consultation: ID consult requested for management of antibiotics and work up of any and all infectious causes that could complicate the patient's recovery process .5/9/23 UA cloudy yellow, negative nitrite, 2+ LE, 25-49 WBC, moderate bacteria. Start empiric Macrobid 100mg PO BID via G tube x7 days. Pt (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676039 If continuation sheet Page 19 of 20 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 676039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Parks at Garland Healthcare and Rehab 3737 N Garland Avenue Garland, TX 75044 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 0842 Level of Harm - Minimal harm or potential for actual harm admitted at [facility name] on 4/18/23, has the same SPC Foley since then, unknown last Foley exchange date. Need Foley exchange. Review of a follow up nursing note for Resident #2 dated 05/12/23 reflected, UA/C&S results in new order. Give Nitrofurantoin (also known as Macrobid) 100 mg BID for 7 days. Residents Affected - Few An interview with NP E on 07/20/23 at 6:47 PM revealed she was Resident #2's nurse practitioner and he had a chronic suprapubic catheter and a history of recurrent UTI's. NP E was not sure why she ordered a UA with C&S on 05/08/23; she stated she had not seen Resident #2 on that date for a face to face visit, so the facility must have called her about it. NP E stated on 05/13/23, she stated Resident #2 was noticed to have shortness of breath, phlegm, mucus and his oxygen saturation was 82 on room air. She stated that he was sent to the hospital as a result of his change in condition. An interview with the DON on 07/21/23 at 12:01 PM revealed she tried to contact the previous lab company the facility contracted with during May 2023 and they would not provide a copy of Resident #1's UA with culture results. The DON stated the facility terminated their contract with the lab company because of some issues and now the lab company would not cooperate with providing the lab. The DON acknowledged that the lab should have been uploaded in the e-charting system and confirmed that ID NP Q documented it was reviewed. A follow up interview on 07/22/23 at 2:19 PM with the DON revealed the previous lab company could not interface with the facility's e-charting system which was also another reason they terminated their contract with the lab company. The DON stated the previous ADON used to log into the online portal for the lab company every day and compare it with the labs uploaded into the facility's e-charting system to see what was done and what was not done. The DON stated the previous ADON, herself and the nurses could print out the lab reports from their portal and upload it into the facility's system for record keeping during that time frame. The DON stated it was important to keep a copy of a resident's lab and results in their clinical record because, We can use it as a baseline if a resident has a recurrent UTI or we are watching values over time to see if they are dropping or elevated or have returned to baseline. Review of the facility's policy titled, Lab and Diagnostic Test Results revised November 2018, and a policy titled, Charting and Documentation revised July 2017; however, neither of the policies addressed facility retention of labs in the resident's clinical record. The DON also provided a policy titled, Laboratory Services (not dated) which reflected, .Laboratory reports are filed in each resident's clinical record. Laboratory reports are dated and contain the name and address of the testing laboratory FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676039 If continuation sheet Page 20 of 20