Health inspection·August 27, 2025

F 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few she saw LVN A go into Resident #1's room at unknown time and then leave the room. RN B said LVN A told her that he tried to give Resident #1 a medication by mouth because he did not know the resident had a feeding tube. RN B said LVN A told her that it was a speech therapist who told him not to give Resident #1 a pill by mouth. RN B said she told LVN A that it was very important to follow the rights of giving medication, including route. RN B said she saw LVN A later that shift and he was counting the medication cart with another nurse. RN B said LVN A called later and said he was not coming back to work at the facility. RN B said she saw the DON and told her to do 1:1 training with LVN A. RN B said she only passed a couple of medications to residents, and she saw LVN A documenting under her name. She said she told LVN A not to document under his name. RN B said she thought it was a speech therapist who had talked to LVN A, not the FNP.An interview on 08/26/25 at 2:30 PM with the DON revealed there were 5 residents who were NPO. She said she was not there when Resident #1 was given a pill by mouth. The DON said she was told by RN B that LVN A gave Resident #1 a pill by mouth instead of by feeding tube and the FNP removed it. The DON said she was told by RN B that the FNP counseled LVN A. The DON said she did not talk to LVN A about the incident. The DON said LVN C was placed to work with LVN A for the rest of the shift. The DON said LVN A did not know the residents at the facility but knew the system of working at the facility and was a transfer from a sister facility. The DON said she saw LVN A and LVN C talking during the shift. The DON said she did not tell LVN C about the incident. The DON said she was supposed to in-service LVN A and she attempted to call him, but he declined all calls. The DON said she did not do any in-services with the other nurses because they knew which residents had feeding tubes. The DON said to determine the route to administer medication, nurses were supposed to read the order. The DON said if a resident had NPO restrictions then they would have a picture posted in their room of a green plant. The DON said normally LVN A would have been trained and orientation for new nurses was 72 hours. The DON said in this case, he was a transfer from a sister facility, and she thought he was good to take over the medication cart until LVN C arrived at 8:00 AM. The DON said going forward, all nurses would be given a 72-hour orientation before passing medications.Review of the facility policy, Medication Administration Through a Feeding Tube, updated March 2019, reflected: PurposeTo provide a route for accurate and timely medication administration for a Patient who cannot or should not take medications orally.GuidelinesA physician's order is required for the administration of any medication via feeding tube.This was determined to be an IJ on 08/26/25. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 08/26/25 at 4:49 PM. The Plan of Removal was accepted on 08/26/25 at 9:48 AM and reflected the following:Immediate Actions1. 08/26/225-Resident #1 was assessed by the DON and was deemed to be at her normal baseline. The Medical Director gave no new orders or guidance.2. The Ombudsman was notified of the content of the immediate jeopardy via email on 08/26/25.3. On 08/26/25 The RDCS in-serviced the DON with test for competency on: Following physicians' orders The 6 Rights of Medication Administration Enteral Administration of Medications (with skill competency and test) [NAME] Foliage Picture Protocol (which identifies NPO residents, Picture above the bed) and green wrist bands4. On 08/26/25 The RDCS and DON completed a 100% audit of all residents who were NPO, who hadthe potential to be affected. The result of the audit yielded that no other residents were affected and were at their normal baseline. The audit consisted of individual review of the residents' orders, visual audit of the residents' rooms to ensure that a [NAME] Foliage Picture was above the bed and that [NAME] Wrist bands were present on the residents who were NPO. In addition, the electronic medical records were audited to ensure a specific care plan denoting NPO status and that the NPO status was also on the CNA's Plan of Care in the electronic medical record.Staff Training and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676422 If continuation sheet Page 2 of 4 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 08/27/2025 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 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few EducationMandatory Training: Starting 08/26/25 All licensed and registered nursing staff will undergo mandatory training with test for competency (must pass 100%) on: Following physicians' orders The 6 Rights of Medication Administration Enteral Administration of Medications (with skill competency and test) [NAME] Foliage Picture Protocol (which identifies NPO residents, Picture above the bed) and green wrist bandsTraining will be conducted by the DON/RDCS and Clinical Designee(s).Competency Assessment: Each licensed or registered nursing staff member will be required to demonstrate competency in Medication Administration via Enteral Feed through hands-on evaluations. Staff who fail to demonstrate competence will not be allowed to work or perform enteral medication administration-related procedures until retraining and reassessment are completed.CNA's and Medication Aides will also be trained with test competency on the: [NAME] Foliage Picture Protocol (which identifies NPO residents, Picture above the bed) and green wrist bands; in addition, a re-in-service that the NPO status is located in their Plans of Care and Care Plans.Systematic Approach1. On 08/26/25 A QAPI meeting was held to discuss the components of this Plan of Removal, in attendance were the Medical Director (via TEAMS), Executive Director, DON, and the Regional Director of Clinical Services, The Director of Clinical Education and the Director of Regulatory Compliance. Policy and Procedures on Medication Administration via Enteral Feeding, the 6 rights of Medication Administration, The [NAME] Foliage and the [NAME] Wrist Band protocols for residents who are NPO. The review deemed that the policy and procedures met state and federal regulations. The [NAME] Foliage and Wrist Bands were adequate. The QAPI Team also decided to add NPO under the picture of each resident who was NPO under their resident profile.2. The facility will incorporate NPO protocols into its annual staff training program and QAPI initiatives to ensure ongoing compliance and resident safety.Monitoringa) The DON/ Unit Manager/ Clinical Designees will review the Order Listing Report, the 24-Hour Summary and Review of All New Admits/readmits to ensure compliance and knowledge of all residents who are NPO and/or who may have had their diet status change. This will occur daily for 2 weeks, weekly for 2 weeks and then monthly x 2. On the weekends and holidays, the Nurse Supervisor/Designee will complete the audit/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.Any staff who are not present to complete the in-service by 08/26/25 will be required to complete the in-service at the start of their next shift before beginning work. New Hires, PRN and any agency staff will also be in-serviced prior to the start of their shift. The education will be conducted and monitored by the DON/Designee.Quality Assurance:Results of all monitoring by DON and Unit Manager shall be brought to the Quality Assessment and Assurance Committee for review and any committee recommendations will be acted upon. The DON will be responsible for bringing the results of the monitoring to the QA committee.Completion Date: 08/26/25This Emergency QAPI plan was reviewed and approved by the QAPI members.Monitoring of the facility's Plan of Removal included the following:Record reviews of the facility Plan of Removal In-services reflected:38 staff were in-serviced on: NPO Protocol, not dated; and The 6 Rights of Medication, not dated.Observations and interviews on 08/27/25 from 10:20 AM to 11:00 AM revealed the rooms of Residents #1, #2, and #3 had a green foliage sign above the resident's bed indicating NPO status and a green armband on their bed. The residents said they had not received medications by mouth. Record review during this time revealed 5 residents were NPO.Interviews with staff from 08/27/25 at 10:55 AM to 08/27/25 at 1:00 PM were completed. 15 staff were interviewed in person/on the phone who worked all shifts at the facility. The interviewed staff were MA D, LVN C, LVN E, CNA F, CNA G, CNA H, LVN I, LVN J, LVN K, CNA L, CNA M, CNA N, LVN O, weekend supervisor, and LVN P. The staff were able to verbalize they were in-serviced on following physicians' orders, the 6 Rights of Medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676422 If continuation sheet Page 3 of 4 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 08/27/2025 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 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Administration, Enteral Administration of Medications (with skill competency and test), and [NAME] Foliage Picture Protocol and green wrist bands. Staff were able to identify residents with NPO status. Staff were able to verbalize the procedure of how to know to administer medications through a feeding tube instead of orally.An interview with the DON on 08/27/25 at 12:23 PM revealed she had worked at the facility for 3 years. She said her role in the Plan of Removal would be to review the Order Listing Report, the 24-Hour Summary and Review of All New Admits/readmits to ensure compliance and knowledge of all residents who were NPO and/or who may have had their diet status changed. The DON said the process would occur daily for 2 weeks, weekly for 2 weeks and then monthly x 2. The DON said on weekends and holidays, the Nurse Supervisor/Designee would be completing the audit/review. The DON said new or pulled staff would be trained to pass medications by being in-serviced with 72 hours on the floor as well as a check-off for g-tube medications. The DON said if the issue occurred in the future, she would take immediate action to in-service, educate, and discipline the nurse who did the infraction. The DON said an incident report would be completed, and the resident would be assessed and notify the physician. The DON said she would be completing random observations of medication pass for residents with a feeding tube.An interview on 08/27/25 at 12:50 PM with the Administrator revealed he had worked at the facility for 3 years. The Administrator said his role in the Plan of Removal would be to overlook and ensure everything in the Plan of Removal was completed. The Administrator said a QAPI meeting was held on 08/26/25 and would continue monthly.An IJ was identified on 08/26/25. The IJ template was provided to the facility on [DATE] at 4:49 PM. While the IJ was removed on 08/27/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimum harm because all staff had not been trained on the Plan of Removal. Event ID: Facility ID: 676422 If continuation sheet Page 4 of 4