Inspection·December 12, 2023

F 0695 Record review of Resident #1's TAR dated 12/1/23 to 12/12/23 revealed the following entry: Level of Harm - Minimal harm or potential for actual harm -Order: AutoSet PAP device ordered at a setting of 5-15 cm at QHS. -Frequency: Once a day Residents Affected - Few -Special Instructions: Machine to be used at night and whenever napping. Nurse to apply mask, remember to add distilled water (distilled water in room) -Diagnosis: Obstructive Sleep Apnea -Start/End date: 11/17/23-open ended The TAR entry reflected an administration time of 10:30 PM and did not reflect any other areas available to document CPAP use while napping. The entry was initialed as completed every day from 12/1/23 through 12/12/23. The entries dated 12/2/23, 12/4/23, 12/6/23, and 12/7/23 had asterisks next to the initials indicating a note was attached Review of the Administration Notes area of the TAR immediately beneath the order revealed the following: 12/2/23: Charted Date: 12/2/23 11:40 PM. Reasons/Comments: Late Administration: Charted Late. Created by LVN A. 12/4/23: Charted Date: 1:47 AM. Late Administration: Charted Late. Comment: Administered on time, chart late. Created By LVN B. 12/6/23: Charted Date: 11:33 PM. Late Administration: Charted Late. Comment: Administered on time, chart late. Created By LVN B. 12/8/23: Charted Date 3:46 AM. Late Administration: Charted Late. Comment: Administered on time, chart late. Created By LVN B. Record review of Resident #1's nursing progress notes dated 10/10/23 through 12/12/23 revealed there were no entries reflecting Resident #1 was using her CPAP machine while napping. An observation on 12/12/23 at 5:00 AM revealed Resident #1 was in her bed and appeared to be sleeping. She had a CPAP mask attached to her face and her machine was on. A camera was observed on her nightstand. An interview on 12/12/23 at 5:10 AM with LVN B revealed she typically worked the 10:00 PM to 6:00 AM shift and cared for Resident #1. She stated Resident #1 used her CPAP machine every night at bedtime. She stated her mask was usually on her when she arrived for her shift but she had worked a double shift and placed the mask herself around 9:00 PM the evening before (12/11/23). She stated, on occasion, Resident #1 was not ready to go to sleep or was having a snack so it would be placed later, and she sometimes wanted it earlier. LVN B denied ever hearing any complaints from the resident or her family related to her CPAP machine. An observation and interview with Resident #1 on 12/12/23 at 8:10 AM revealed she was sitting on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676388 If continuation sheet Page 2 of 5 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 676388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Creekwood 2100 Cannon Dr Mansfield, TX 76063 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 0695 Level of Harm - Minimal harm or potential for actual harm the side of her bed eating breakfast. She stated she had to wear her CPAP every night and it helped her sleep. She stated, They say I stop breathing if I don't wear it. Resident #1 stated the staff never forgot to put it on but sometimes it was late at night, and she had already fallen asleep . She stated she was unable to put her CPAP on by herself, and the staff placed it on for her. She stated she only wore her CPAP at night and not while she was napping. Residents Affected - Few In an interview with the DON on 12/12/23 at 10:15 AM, she stated she was aware of Resident #1's order for her CPAP machine. She stated Resident #1 had a camera in her room and she had received a complaint from a family member alleging facility staff were failing to place her CPAP on at night. She stated she checked with the staff who told her sometimes Resident #1 was not ready for it and they could not force her to wear it. She stated the nurses should make rounds and ensure she is wearing it while sleeping. The DON stated they had recently received another complaint from the family so she completed an in-service training about her CPAP. She stated she was not aware of any further issues. During a telephone interview on 12/12/23 at 10:38 AM, Resident #1's family member stated she was angry because she had to call many times at night to remind the staff to place Resident #1's CPAP. She stated it was as recently as two days ago. She stated Resident #1 had a sleep study and they learned she stopped breathing at times while she was sleeping. She stated she had already complained to the DON but it kept happening. She stated it recently happened again just last week. She stated she understood Resident #1 may not be ready to go to sleep and could refuse but her calls to the facility were usually between 11:00 PM and 1:00 AM and she could tell by the camera she was asleep. During the conversation, Resident #1's family member stated she was looking at the camera while we were speaking and Resident #1 appeared to be sleeping . She stated she knew the order was for her to wear it while napping as well and she could see she wasn't wearing it. The family member stated she could not go to sleep at night unless she knew Resident #1 was wearing her mask and she did not feel like she could trust them to place it on her timely. She stated she understood Resident #1 never complained about it because she did not know her family was calling to remind the nurses to put it on. During another observation of Resident #1 on 12/12/23 at 11:06 AM, revealed she was in her bed, lying on her left side under the blankets. She was wearing headphones. She was not wearing her CPAP device and her mask and tubing could be seen on her nightstand. Her eyes were closed, she did not respond to voice and appeared to be asleep. She was positioned with her back toward the camera. During an interview on 12/12/23 at 11:08 AM, CNA D was asked if Resident #1 was sleeping, she replied, Yeah, that's what she does. She stated, You try to talk to her, she has those noise cancelling headphones on. She stated she was not aware of a need to tell the nurse when she was napping and had never seen her wear her CPAP during the day shift. In an interview and observation on 12/12/23 at 11:10 AM, LVN C stated she had cared for Resident #1 since about January, 2023. She stated she occasionally worked a double shift and would apply her CPAP at bedtime for her. She stated she knew Resident #1 had a sleep study done and that was when it was prescribed. LVN C stated CPAP machines were important because they helped with breathing, if you don't put it on while sleeping, death can occur, you can get short of breath while sleeping and apnea. LVN C stated the order for Resident #1 was to wear it at night. She stated Resident #1 did occasionally nap during the day or listened to her music, if you call her name, she'll answer you. LVN C stated she had never placed Resident #1's CPAP during the day. She pulled up the order on her computer and was asked about the instructions regarding napping. She stated, During the day, she doesn't put it on. She stated, If I see her napping, I can ask her and she'll tell me if she wants her CPAP. She stated she had never offered to place her CPAP for her during the day shift. LVN C walked to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676388 If continuation sheet Page 3 of 5 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 676388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Creekwood 2100 Cannon Dr Mansfield, TX 76063 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #1's room and called her name. Resident #1 opened her eyes and sat up. She stated she was listening to her stories. LVN C asked her if she would like her to put her CPAP on and Resident #1 declined stating she only wore it at night. During another interview with CNA D on 12/12/23 at 12:57 PM, she stated she had worked at the facility for about a year and a half, mainly day shift and occasionally on nights. She stated she knew Resident #1 got her CPAP machine a few months ago. She stated Resident #1 napped on and off during the day and liked listening to her headphones. She got herself up and down to the bathroom. She stated Resident #1's family let her know she needed to have it on around 9:30 PM but sometimes Resident #1 was not ready for it. She stated she knew to remind the nurses in the evening if Resident #1 was ready to go to sleep because sometimes Resident #1 wanted to have a snack and would forget to hit her button. In another interview with LVN C on 12/12/23 at 1:05 PM, she pointed out on her computer the order was timed for 10:30 PM and would pop-up during the evening shift. When asked if she ever tried to offer it to Resident #1 during the day for her naps or encourage her to use it, she replied, No. In a follow-up interview with the DON on 12/12/23 at 1:12 PM, she stated she knew Resident #1's family had previously complained about her not wearing her CPAP. She asked the nurses and was told sometimes Resident #1 did not want it on and asked to wait . She stated, last week, her family called again and complained the machine was not on when she was checking her camera around midnight. The DON stated she did an in-service with all her nurses reminding them to ensure her CPAP was on at bedtime and while napping. She stated, to her knowledge, everything was fine. Resident #1's TAR was reviewed with the DON and she was asked about the late entries. She stated it was appropriate for the nurses to chart that way because sometimes they were out on rounds when placing her mask on and may not be near a computer. When asked where she expected the nurses to chart and CPAP use while the resident was napping, as there was no area on the TAR designated for PRN use, the DON stated they could use the nurses' notes at any time. The DON stated she expected the nurses to conduct rounds and, if Resident #1 was napping, offer to place her CPAP for her. Record review of an In-Service Summary and Attendance dated 12/4/23 revealed: Subject: CPAP/BIPAP. Type of Meeting: In-Service Individual Education/Inservice. Content: -Machine to be used at night and whenever napping -Nurse to apply Mask, remember to add distilled water -Ensure Documentation is Present if resident refuses -Order must be present in [computer software] with settings present The attached attendance record dated 12/4/23 reflected the signatures of 28 nursing staff members and included LVN B, LVN C and CNA D. Record review of the facility's policy and procedure, Subject: Respiratory Treatment, Care and Services Program, revised 05/05/23, revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676388 If continuation sheet Page 4 of 5 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 676388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Creekwood 2100 Cannon Dr Mansfield, TX 76063 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Policy: The Facility ensures the safe, appropriate and effective provision of respiratory treatment, care and services in accordance with professional standards of practice, the resident's plan of care and personal choice. Scope of Services: The Facility, in the presence of sufficient numbers oof qualified and competent staff and with resident population needs, may offer some or all of the following respiratory services: 1. Oxygen therapy 2. Non-invasive Ventilatory Support Modalities (BiPAP or CPAP) Procedures: .7. Documentation for Respiratory Care, Treatment and Services: Depending on the type of respiratory services received, licensed independent practitioner orders and the individualized plan of care, documentation includes the following, as appropriate and necessary: . I. Instructions for residents on how to participate or assist in respiratory care, treatment, and services, if applicable .8. Respiratory Care Plan Elements . B. Non-invasive Ventilatory Support: BiPAP/CPAP 1) Type of equipment and settings 2) When to administer, and 3) Identified risks and monitoring for complications FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676388 If continuation sheet Page 5 of 5