Health inspection·April 14, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some x 90 days. Interventions included, Encourage independence in performance of self-care and mobility within limitations, provide level of support to complete dressing, toilet use, personal hygiene, and bathing needs q shift, and provide level of support to complete transferring needs q shift. Record review of Resident #2's Face Sheet, dated 4/13/2023, revealed a [AGE] year-old-female with an admission date of 05/05/2019. Resident #2's diagnoses included Acute Respiratory Failure with Hypoxia (not enough oxygen in body tissue), Unspecified Atrial Fibrillation (heart's upper chambers beat chaotically and irregularly), Acute Respiratory with Hypercapnia (impairment of neuromuscular transmission, mechanical defect of ribcage and fatigue of the respiratory muscles), Atelectasis (collapse of part or all of a lung), Cellulitis (bacteria skin infection) of left lower limb, Body Mass (body fat) 50.0 - 59.9, and Type II Diabetes Mellitus (cells do not respond normally to insulin and pancreas makes more than needed). Record review of Resident #2's Quarterly MDS Nursing Home Comprehensive Item Set, dated 03/17/2023, revealed Resident #2 had a BIM score of 09, which signified moderate cognitive impairment. The Functional Status in Section G of the MDS indicated Resident #2 required limited assistance with one person assist in the areas of transfer and toilet use and supervision only with set up in the areas of locomotion, dressing, eating, and personal hygiene. Record review of Resident #2's Care Plan, dated 04/13/2023, revealed a focus area to be, At risk for injury/mobility due to need for quarter or half side rails to assist with turning and repositioning. Date initiated: 05/06/2019. The Goal was documented as, Will not experience any injuries due to the need for quarte or half side rails x 90 days. Interventions included, Assist to change positions as needed, check device daily to make sure it is in good condition and monitor for changes in condition that may indicate a decline in mobility and report to the physician. Under the section of ADLs, the focus stated, Resident requires assistance with ADLs. Initiated 10/04/2021. The goal was documented as, Resident is able to perform self-care to optimal level and maintains strength and endurance x 90 days. Interventions included, Encourage independence in performance of self-care and mobility within limitations, provide level of support to complete dressing, toilet use, personal hygiene, and bathing needs q shift, and provide level of support to complete transferring needs q shift. Record review of Resident #3's Face Sheet, dated 4/13/2023, revealed a [AGE] year-old-female with an admission date of 09/17/2019. Resident #3's diagnosis included Chronic Kidney Disease (progressive damage to kidneys), Heart Failure, Irritable Bowel Syndrome (repeated pain in your abdomen and change in your bowel movements), and Unspecified Dementia (most common type of dementia that begins with mild memory loss). Record review of Resident #3's Quarterly MDS, dated [DATE] revealed a BIMS of 08 which indicated moderate cognitive impairment. The Functional Status in Section G of the MDS indicated Resident #3's required limited assistance with one person assist in the ADL areas of bed mobility, dressing, eating, and toileting use. Record review of Resident #3's Care Plan, dated 04/13/2023, revealed a focus area to be, At risk for injury/mobility due to need for quarter or half side rails to assist with turning and repositioning. Date initiated: 09/20/2019. The Goal was documented as, Will not experience any injuries due to the need for quarte or half side rails x 90 days. Interventions included, Assist to change positions as needed, check device daily to make sure it is in good condition and monitor for changes in condition that may indicate a decline in mobility and report to the physician. Under the section of ADLs, the focus stated, Resident requires assistance with ADLs. Initiated 10/04/2021. The goal was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 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 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some documented as, Resident is able to perform self-care to optimal level and maintains strength and endurance x 90 days. Interventions included, Encourage independence in performance of self-care and mobility within limitations, provide level of support to complete dressing, toilet use, personal hygiene, and bathing needs q shift, and provide level of support to complete transferring needs q shift. Record review of Resident #4's Face Sheet, dated 4/13/2023, revealed an [AGE] year-old-female with an admission date 04/09/2021. Resident #4's diagnoses included Unspecified Dementia (most common type of dementia that begins with mild memory loss), Insomnia (sleep disorder involving difficulty falling and staying asleep), Dysphagia (difficulty swallowing), Cerebral Infarction (result of disrupted blood flow to the brain to blood vessels), Type II Diabetes (cells do not respond normally to insulin and pancreas makes more than needed), and Major Depressive Disorder (persistent feeling of sadness and loss of interest). Record review of Resident #4's Quarterly MDS, dated [DATE] revealed a BIMS of 06 which indicated severe cognitive impact. The Functional Status in Section G of the MDS indicated Resident #4 required limited assistance with one person assist with ADLs in the areas of bed mobility, transfer, eating, and toileting use. Record review of Resident #4's Care Plan, dated 04/13/2023, revealed a focus area to be, At risk for injury/mobility due to need for quarter or half side rails to assist with turning and repositioning. Date initiated: 04/12/2021. The Goal was documented as, Will not experience any injuries due to the need for quarte or half side rails x 90 days. Interventions included, Assist to change positions as needed, check device daily to make sure it is in good condition and monitor for changes in condition that may indicate a decline in mobility and report to the physician. Record review of Resident #5's Face Sheet, dated 4/13/2023, revealed a [AGE] year-old-female with an admission date of 01/02/2023. Resident #5's diagnoses included Acute Sinusitis (space inside your nose become inflamed and swollen), Abnormal Coagulation Profile (condition that affects the blood's clotting activities), Insomnia (sleep disorder involving difficulty falling and staying asleep), and Cerebral Infarction (result of disrupted blood flow to the brain to blood vessels). Record review of Resident #5's Quarterly MDS, dated [DATE] revealed a BIMS of 09 which signified moderate cognitive impairment. The Functional Status in Section G of the MDS indicated Resident #5 required extensive assistance and two-plus person assist with ADLs in the areas of bed mobility, transfer, eating, and toileting use. Resident #5 requires extensive assistance with one-person assist in the areas of locomotion, dressing, and personal hygiene. Record review of Resident #5's Care Plan, dated 04/13/2023, revealed a focus area to be, At risk for injury/mobility due to need for quarter or half side rails to assist with turning and repositioning. Date initiated: 01/02/2023. The Goal was documented as, Will not experience any injuries due to the need for quarte or half side rails x 90 days. Interventions included, Assist to change positions as needed, check device daily to make sure it is in good condition and monitor for changes in condition that may indicate a decline in mobility and report to the physician. Under the section of ADLs, the focus stated, Resident requires assistance with ADLs. Initiated 10/04/2021. The goal was documented as, Resident is able to perform self-care to optimal level and maintains strength and endurance x 90 days. Interventions included, Encourage independence in performance of self-care and mobility within limitations, provide level of support to complete dressing, toilet use, personal hygiene, and bathing needs q shift, and provide level of support to complete transferring needs q shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 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 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #6's Face Sheet, dated 4/13/2023, revealed an [AGE] year-old female with an admission date of 08/01/2022. Resident #6's diagnoses included Unspecified Convulsions (muscle contract and relax quickly causing the body to shake uncontrolled, involuntary), Depression (medical illness that negatively affects how you feel, the way you think, and how you act), Essential (Primary) Hypertension (abnormally high blood pressure that was not the result of a medical condition), and Cerebral Infarction (result of disrupted blood flow to the brain to blood vessels). Record review of Resident #6's Quarterly MDS, dated [DATE] revealed a BIMS of 04, which indicated severe cognitive impact. The Functional Status in Section G of the MDS indicated Resident #6 needs limited assistance with one-person assist in the ADL areas of bed mobility, transfer, walking, locomotion, eating, and toilet use. Record review of Resident #6's Care Plan, dated 04/13/2023, revealed a focus area to be, At risk for injury/mobility due to need for quarter or half side rails to assist with turning and repositioning. Date initiated: 08/01/2022. The Goal was documented as, Will not experience any injuries due to the need for quarte or half side rails x 90 days. Interventions included, Assist to change positions as needed, check device daily to make sure it is in good condition and monitor for changes in condition that may indicate a decline in mobility and report to the physician. Under the section of ADLs, the focus stated, Resident requires assistance with ADLs. Initiated 10/04/2021. The goal was documented as, Resident is able to perform self-care to optimal level and maintains strength and endurance x 90 days. Interventions included, Encourage independence in performance of self-care and mobility within limitations, provide level of support to complete dressing, toilet use, personal hygiene, and bathing needs q shift, and provide level of support to complete transferring needs q shift. During an interview on 4/13/2023 at 2:52 p.m., the DON said the CNAs can read and obtain the information of each resident's individual needs and pertinent tasks to care for each resident in the task section of the electronic record platform. The DON the information in the task list was specific to each resident and did not match up line for line with the care plan but included information needed for the CNAs to adequately do their job. The DON said the Care Plans were more cookie cutter because most resident are a fall risk, need assistance with ADLs, or at risk for pressure ulcers. The DON said the CNAs would document the specific interventions for each resident in the task section of the electronic record and not the care plan. During an interview on 4/14/2023 at 10:59 a.m., the MDS Coordinator said she had been at the facility since 2017. She said the half bars on the residents' bed were not triggered by the MDS but were determined by discussion of the need of resident to be repositioned. The MDS Coordinator said most residents who came into the facility would automatically be a fall risk, which would be triggered by the MDS. The MDS Coordinator said the initial care plan would have basic information to meet the resident's needs then when a change in condition occurred, the information in the care plan was updated to be more specific. The MDS Coordinator said the Interdisciplinary Team was responsible for ensuring the care plan were person-centered. During an interview on 4/14/2023 at 12:31 p.m., the Administrator said his expectation of a care plan was to be person-centered and to be about the person. The Administrator said a person should have the ability to document communications and understand the person's goals and desires. The Administrator said the care plan should contain all information about the resident to be able to properly meet that person's need and describe the resident differences from other residents. The Administrator said care plans that were not person-centered could have a negative impact on each resident's mental status. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 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 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Record review of Foursquare Healthcare Operational/Residential Care Polices, not dated, revealed the facility would develop and implement a comprehensive care plan for each resident, consistent with the resident's rights and would incorporate resident-centered goals and wishes about their care, activities, and lifestyle to include measurable short-term and long-term objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 5 of 5