Health inspection·June 6, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few then walks towards where the door is an is no longer seen. The facility is aware of the situation. At the time of talking wtih the granddaughter, the facility had not spoken with them about the situation. Upon my departure, the ADON was going into [Resident #1's] room. Prior to that I informed her of the incident. She told me they were aware and had all seen the video. I asked why the aide was once again in charge of her care on the night of 5/18 (reported by the granddaughter). She seemed unaware that had happened. Informed her that it was inappropriate and should not happen again Review of the video on 06/05/23 revealed CNA A entered Resident #1's room on 05/18/23 at 4:00 AM. Resident #1 and her roommate (Resident #2) were both in bed. CNA A walked past Resident #1 and said to Resident #2, You okay [Resident #2[ .It's just me [CNA A]. She proceeded to pull the privacy curtain between Resident #1 and Resident #2. When Resident #1 heard CNA A's voice, she began to make whimpering and moaning sounds. CNA A then dropped her shoulders and looked up at the ceiling in an exasperated motion. CNA A goes over to Resident #1's side of the room and says to Resident #1, Can I help you? Resident #1 whimpers/moans again, and CNA A CNA A responded, I don't understand what that means. CNA A then goes behind the curtain on Resident #1's side of the room outside of direct camera view from the foot of her bed towwards the head of the bed, and Resident #1 whimpers again. CNA A responded loudly, Stop it! Resident #2 hears CNA A and tries to communicate with CNA A. CNA A told her, I'm not talking to you [Resident #2] you just need to lay down and let me take care of it. The rest of the interaction between CNA A and Resident #1 was not visible because of the privacy curtain, and the video ended shortly thereafter. Interview on 06/05/23 at 1:50 PM with the Hospice Nurse revealed a video was brought to her attention by Resident #1's family where CNA A was speaking to the resident in a manner she found inappropriate. The Hospice Nurse said she reported the incident on 05/19/23 to her DON and the facility's ADON, who told her the facility had already been made aware of the situation. Interview on 06/05/23 at 2:00 PM with the Hospice ADON revealed Resident #1 was actively dying (near death) at the time of the incident and was not able to verbal communicate any longer. The Hospice Nurse stated she watched the video. She stated Resident #1's family was upset due to the way CNA A had spoken to the resident. The family decided to stay with the resident until she passed away, the following day after the incident on 05/18/23. Attempts to contact CNA A and Resident #1's family on 06/06/23 were unsuccessful. Interview on 06/06/23 at 1:24 PM with the ADON revealed Resident #1's family brought the video to her attention after the incident 05/19/23. The ADON said the actions in the video were considered poor customer service from CNA A and Resident #1's family had asked the CNA no longer care for the resident. The ADON reported the CNA's actions to the Administrator and the DON. CNA A was brought in and counseled/re-inserviced on proper customer service when providing care to the residents. Review of In-Service Training Report titled Customer Service/Professionalism dated 05/20 /23 provided by the ADON and signed by CNA A reflected the following: .is expected to maintain professionalism as it relates to performance, care of the residents. Customer service skills, language and (body language.) Interview on 06/06/23 at 2:04 PM with the Administrator revealed the video of CNA A and Resident #1's interaction had been brought to his attention by the ADON when she was made aware of the incident, 05/19/23. The Administrator stated the ADON had called in the CNA and re-inserviced her on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676335 If continuation sheet Page 2 of 3 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 676335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032 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 0550 resident customer service and the aide was removed from the care of Resident #1 at that time. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy titled Quality of Life - Dignity revised 10/04/22 reflected the following: Residents Affected - Few Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. 1. Resident shall be treated with dignity and respect at all times. .7. Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676335 If continuation sheet Page 3 of 3