Health inspection·June 27, 2025

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Warfarin 5 mg - 06/06/25, 06/09/25, and 06/13/25. Record review of Resident #1's Progress Notes dated 06/03/25 for the nurse practitioner reflected INR elevated at 3.8. Hold warfarin for 48 hours then resume at lower dose. Record review of Resident #1's Progress Notes dated 06/08/25 for the nurse practitioner reflected doing well. Repeat INR tomorrow. Record review of Resident #1's Progress notes dated 06/10/25 for the nurse practitioner reflected INR not done notified nurse, STAT INR ordered follow-up results. Record review of Resident #1's laboratory results dated [DATE] revealed a PT/INR 1.39. Record review of Resident #1's Progress Notes dated 06/15/25 at 09:00 AM reflected LVN A transferred Resident #1 to the hospital due to a change in condition. Resident#1 speech was slurred and drooping noted to left side of mouth. Record review of Resident #1's Hospital CT (medical imaging technique that uses X-rays to create detailed cross-sectional images of the body) dated 06/15/25 at 09:39 AM to 09:51AM reflected: .3. Small perfusion deficit compatible with ischemia in the left posterior frontal lobe (refers to a stroke affecting the left side of the brain, specifically within the frontal lobe, where blood flow is reduced or blocked, typically by a clot) Telephone interview on 06/20/25 at 11:13 AM with Resident #1 revealed she had history of mini strokes before, and she revealed she was on warfarin and said she has been getting her warfarin, but she was not sure at what time and what were the doses. She stated she was referred to hospital after the staff at the facility noticed her speech was slurred and dropping of one side of the face. She stated she was discharged form hospital on [DATE] to a rehabilitation hospital where she was continuing with her fractured arm therapy. She stated she still feels the speech was affected but no other part of her body. Interview on 06/20/25 at 1:13 PM with ADON B revealed she was one of Resident #1's nurses. She stated she worked on the floor on 06/06/25, 06/10/25 and 06/11/25 when LVN A who worked second shift was on vacation. ADON B stated she knew Resident#1 was supposed to get Coumadin. She said was the one that received the order for the start PTINR on 06/10/25 since the nurse practitioner wanted a repeat and on 06/11/25 she got an order to give since the INR was low. She stated she was aware she was supposed to give Coumadin on 06/06/25 and 6/10/25 and she could not recall what happened those two days whether she administered or not because the administration record was blank. She stated nurses, nurse practitioner, and doctors were responsible of putting the orders on the electronic records to resume Coumadin and also she was responsible of auditing the carts weekly. She stated failure to administer anticoagulant would cause blood clot which could lead to stroke. Interview on 06/20/25 at 3:13 PM with LVN A revealed she was one of Resident #1's charge nurses. LVN A stated she knew Resident#1 was supposed to get Coumadin (warfarin) and she was getting during her shift. She stated she was aware she was supposed to hold Coumadin on 06/03/25 and 06/04/25 and resume on 06/05/25 on a lower dose as she was instructed by the nurse practitioner. She stated she was supposed to restart her with 2.5mgs and 5 mgs but she failed to clarify with the nurse practitioner about the lower doses. She stated nurses ,nurse practitioner and doctors were responsible of putting the orders on the electronic records to resume administering after two days of hold. She stated the nurse practitioner orders were supposed to show on the facility's electronic record, and she was supposed to activate but that did not happen she thought the nurse practitioner failed to put the orders. LVN A stated she never saw Resident #1's electronic health record flag the warning of missed Coumadin dose administration. LVN A stated it was every nurse's responsibility to follow-up with doctor and Nurse Practitioner for order clarification to ensure residents had right orders for medication administration. She stated failure to administer Coumadin as prescribed by the doctor could lead to blood clots and then stroke. Telephone interview on 06/20/25 at 03:20 PM with the DON revealed she was unaware Resident #1 was not receiving her Coumadin as ordered. She stated she knew she was the only resident with Coumadin, and it was the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676422 If continuation sheet Page 2 of 6 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 676422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palomino Place 3160 Gus Thomasson Road Mesquite, TX 75150 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few doctor and Nurse practitioner to put orders in the system and nurses to activate the orders so that they can reflect on the medication administration record. The DON stated her expectation was the nurse could have clarified the orders with the doctor, and they administer medication as indicated on the MAR. She stated ADON was responsible of monitoring the labs and ensure the doctors get results and new orders were given and taken care of. She stated failure to administer anticoagulants could lead to clots. Observation on 06/20/23 of the medication cart for 400 halls with LVN A revealed two bubble packs of Coumadin 2.5 mg with 21/2 tablets remaining having received 81/2 tablets on 05/30/25 and Coumadin 5 mg with tablet remaining having received 6 tablets on 05/30/25. Interview on 06/20/25 at 4:31 PM with the Corporate Regional Director of Clinical Nurse it was revealed the nurses received an order to hold the Coumadin on 06/03/35 for two days and follow-on lower dose and as per the records the nurses did not resume administration after the hold. She stated the nurse practitioner, doctors and nurses are responsible of putting the orders in the system and nurse activate them. She stated since they were moving from one system to another she could not tell what had happened. She stated the DON who was out after an oral surgery and the ADON were responsible of monitoring the medications are being administered. Interview on 06/20/25 at 4:45 PM with the Nurse Practitioner revealed Resident #1 was on Coumadin, and she was following her INR closely. She stated on 06/03/25 after the labs results she put the Coumadin on hold for 48 hours. She stated the nurses were supposed to resume Resident #1 with 2.5 mg Tuesday, Thursday, Saturday and Sunday and 5mgs on Monday, Wednesday, and Friday on 06/05/25. She stated she then had orders a repeat of PT/INR on 06/09/25 and when she came for the rounds on 06/10/25 she ordered for STAT labs which were done and then on 06/13/25 she did labs and at that point she orders the nurse to give resident an extra 2.5 mg to make the dose to 7.5 mg and then to continue with the previous doses of 2.5 mg and 5 mg. She stated she was in the facility 3 days in a week and she was not notified the resident was not receiving Coumadin as she had ordered. She stated she was also responsible of putting orders in the system and the nurse also. The Nurse Practitioner stated failure to administer anticoagulant to Resident #1 could lead to development of blood clots and would make the resident be admitted to hospital with signs of stroke. Interview on 06/26/25 at 11:24 AM with DON she stated she had been off sick, and she only received a text message saying Resident #1 was sent to hospital due to drooping of the left face and slurred speech. She stated when she reported back on 06/23/25 she went through Resident #1's MAR, and she noticed Coumadin was supposed to be held for two days 06/3/25 and 06/04/25 and resumed on 06/05/24 at low dose. She stated the nurse and the ADON were responsible for clarifying the orders with doctor or Nurse Practitioner, and the Nurse Practitioner notes reflected they ought to have resumed the Coumadin after it had been placed on hold. She stated she suspended all the nurses that worked with Resident #1 and also the nurse that was responsible for holding the Coumadin and resuming the Coumadin at a low dose. She stated the Nurse Practitioner was responsible for putting the orders in the system, and the nurse was responsible for activatinge the orders. The DON stated it appeared that the Nurse Practitioner told the nurse about the changes regarding Coumadin administration for Resident #1; however, the nurse did not put the orders in the system. She stated the nurse also failed to clarify the Coumadin orders with the Nurse Practitioner. The DON stated she felt there was miscommunication between the nurse and the Nurse Practitioner, and nobody caught the mistake because they were changing over from one computer system to another. Record review of the facility's Anticoagulation Therapy policy, dated 01/04/16, reflected: It is the policy to monitor any patient prescribed an anticoagulant therapy for the side effects and drug interactions. Responsibility:- to test for therapeutic levels of anticoagulant therapy(Coumadin, heparin, lovenox)as prescribed by the physician. Procedures: Orders (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676422 If continuation sheet Page 3 of 6 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 676422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palomino Place 3160 Gus Thomasson Road Mesquite, TX 75150 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few for all patients on anticoagulation medications (Coumadin, Heparin, Lovenox for example) are entered into the Electronic Medical Record (EMR) system. Lab testing for monitoring is conducted weekly or as requested by physician. Side effect monitoring is completed every shift in the Electronic Medical Record system in the eTAR. This was determined to be an Immediate Jeopardy (IJ) on 06/26/25 at 3:46 PM. The Administrator was notified. The Administrator was provided the IJ template on 06/25/25 at 3:50 PM and a plan of removal was requested. The following plan of removal submitted by the facility was accepted on 06/26/25 at 7:03 PM and included the following: .Date: 06/26/25 Plan of Removal Problem: F760 Resident are free of significant med errors Interventions: The Resident is no longer in the building. The Medical Director was assigned this resident. The Ombudsmen was notified on 06/23/2025. On 06/23/2025 The RDCS in-serviced DON and IP Nurse on Coumadin monitoring and tracking and being responsible for bringing the results of monitoring and tracking to the Ad hoc QAPI committee 6/23/25. On 06/23/2025 The RDCS completed a 100% audit of all residents, and no other residents are on Coumadin at this time. On 06/23/2025 All in-house licensed and registered nurses and medication aides were re in serviced with a test to validate competency by the DON and Unit Manager on: Coumadin toxicity, lab monitoring, Lab review, Notification to Physicians, Identifying Changes in Condition and Assessments. Our Pharmacist completed an audit on all anticoagulants on 6/23/25. It identified no other residents on Coumadin or any other anticoagulants requiring therapeutic monitoring. No concerns were identified in the review. Director of Nursing & Nurse Managers immediately reviewed all residents that have anticoagulants therapy with a visual record audit as well as visual assessment completed on 6/23/25 on review the three residents on anticoagulant therapy did not require any changes. The three nurses identified as not administering the medication were suspended, pending investigation. Systematic Approach: On 06/23/2025 A QAPI meeting was held, in attendance were the Medical Director, Executive Director, DON, the Regional Director of Clinical Services and the Regional Director of Operations. A Root Cause analysis was completed by the Executive Director with the support/collaboration of Regional Director of Clinical Services, Interim Director of Nursing and Regional Director of Operations. Nursing staff was educated on, anticoagulant medications, Coumadin, and labs as well as bringing results to the QA committee. Also discussed with the Medical Director the medication administration form that is utilized in stand up daily with the plan for daily discussion with him for all high-risk medications and required monitoring. In addition, a review of present protocols and/or policies/procedures concerning Coumadin monitoring and tracking, lab monitoring, lab review, Notification to Physicians and Changes in Condition, the present Policies and Procedures were found to be sufficient, but the QAPI Team added a new protocol for pharmacy dispensing--- that each Coumadin order set will include the review of the date and result of the most present INR and New/Change/Readmit orders for Coumadin will not be given without appropriate labs and physician review before administering. On 06/23/2025 A Medication Error Report was completed by the DON Education and monitoring: DON, UM's, and IP were educated on 6/23/25 on the daily process of medication administration and discussion on follow up labs to all high-risk medications and change of status on the change of status log. The monitoring logs will be reviewed daily in morning stand-up by the facility clinical team with additional review in Monthly QA meeting. On the weekends and holidays, the Nurse Supervisor/Designee will complete the review. The DON/Designee will monitor this process. Nurse managers were educated 6/23/25 and will use the Grand Rounds process and logs (High Risk Medication and Change in status) to review all at risk patients daily for 2 weeks, Weekly for 2 weeks and then monthly. On the weekends and holidays, the Nurse Supervisor/Designee will complete the review. The DON/ Designee will monitor daily, M-F, on the weekends and holidays, the Nurse Supervisor/Designee will complete the review. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676422 If continuation sheet Page 4 of 6 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 676422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palomino Place 3160 Gus Thomasson Road Mesquite, TX 75150 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The DON/Designee will monitor this process. All nurses educated by 6/23/25 on new protocol that each Coumadin order set will include the review of the date and result of the most present INR and New/Change/Readmit orders for Coumadin will not be given without appropriate labs and physician review. The DON/ Designee will monitor daily, M-F, on the weekends and holidays, the Nurse Supervisor/Designee will complete the review. The DON/Designee will monitor this process. Charge nurses will review all new admission orders and verify with the physician on all new Coumadin and required lab orders, DON or designee will be responsible for reviewing the admission orders for Coumadin have the appropriate monitoring orders. DON and UM's in-service on 6/23/25. The DON/ Designee will monitor daily, M-F, on the weekends and holidays, the Nurse Supervisor/Designee will complete the review. The DON/Designee will monitor this process. The following plan of removal monitoring was conducted: The resident was sent to the ER on [DATE]. Record review reflected employee coaching and counselling due to failure to administer and/or document medication to be administered by licensed nurse and action taken to staff was suspension. Supervision and training was done by phone and one-on-one. Interview on 06/27/25 at 3:45 PM with DON revealed she had created a log for anticoagulants which she check daily and also document new admitted resident with anticoagulants and the ADONs also were given the forms during the morning meeting and they will be monitoring on respectful halls and report every morning during the meeting. Record review on 06/27/25 revealed monitoring started on 06/23/25 and ongoing daily. Inservice Training Topics: Documentation/Following physician orders /writing physician orders /MARS completion/Labs. A change in dose or time of medication must be highlighted and rewritten in anew space on the MAR. Only RN, LVN or MA that removes the medication from the packages may administer the medications. Orders for all patients on coagulation medications (Coumadin, Heparin, lovenox for example) are entered into the electronic medical record (EMR) system. Date Conducted 06/25/25 Instructor DON Attendees to include: RNA F, RN X, LVN A, ADON B, ADON E, LVN C, LVN G, LVN N, LVN P, LVN O, LVN D, LVN H, MA U, MA T, MA V, MA R, LVN N, LVN E, LVN J, LVN M, LVN K, LVN L, and LVN Q. Pre and posttest:1. Physician orders are to be reviewed daily. True ___ False __ _2. Any missing dose of medication has to be documented. True __ False __3. Orders discontinued or on hold must be reviewed during shift change. TRUE __ False __ _4. Nurses need to monitor residents on anticoagulants for sideeffects? True __ False __5. Labs should be monitored every daily per physician orders for anticoagulants. True ___ False __6. Nurses and medication aides need to review MARS prior to end of shift to ensure .:. medications have been signed off on or documentation shows why med was not given . True_False_ Record review reflected the facility had introduced anticoagulant logs dated 06/23/25, 06/24/25, 06/25/25, 06/26/25 and 06/27/25 that they were monitoring Coumadin and other anticoagulants on all new admits and report to morning meeting daily. Monitoring was done by the ADON and DON Monday through Friday and on weekend by the weekend supervisor. All other residents on anticoagulant medications MAR and TARS were audited by the Pharmacist and all medications were moved to nurses' cart to be administered by nurses and being monitored by the ADON and the DON daily. Interviews were conducted on 06/27/25 at 10:30AM to 4:30PM with RN F, RN X, LVN A, ADON B, ADON E, LVN C, LVN G, LVN N , LVN P, LVN O, LVN D, LVN H, MA U, CMA T, MA V, MA R, LVN N, LVN E, LVN J, LVN M, LVN K,LVN L, and LVN Q indicated they had understanding: They all knew they should review orders daily and clarify orders with the doctor. The staffs stated in case of a missing dose they should document on the MAR/TAR and notify the doctor and management. Orders that were discontinued or put on hold should be reviewed by the outgoing nurse and the incoming nurse and orders verified and documented in 24-hour report. All resident on anticoagulants should be monitored by the nurse through labs and for side effects. Labs should be checked daily as per physician orders and doctor notified and incase of new orders and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676422 If continuation sheet Page 5 of 6 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 676422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palomino Place 3160 Gus Thomasson Road Mesquite, TX 75150 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete changes it should be documented on residents MAR and TAR. Before the change of shift the nurse on duty and the medication aide need to review the MAR/TAR to ensure all medications have been signed off and if not there should be a documentation showing why medication was not signed off/given. The Administrator was informed the Immediate Jeopardy was removed on 06/27/2025 at 04:36 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Event ID: Facility ID: 676422 If continuation sheet Page 6 of 6