Health inspection·April 12, 2023

F 0689 Level of Harm - Actual harm Residents Affected - Few with mechanical lift and 2 staff members. Date Initiated: 03/27/2023 o I am NWB to right leg secondary to fracture tibia for 6-8 weeks per Texas Joint Institute. Date Initiated: 04/04/2023 Revision on: 04/05/2023 o Knee brace discontinued per TJI while at rest. Brace to be worn during transfers and when out of facility for the next month. Date Initiated: 04/04/2023 Revision on: 04/05/2023 o Monitor/document /report PRN x 72h to MD for s/sx: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Date Initiated: 04/03/2023 o Resident preference to have brace placed on by nurse when incontinent care provided. Date Initiated: 04/04/2023 Review of Resident #1's Physician's Order, dated 03/20/23, reflected Description: OT initial eval completed and POC established. OT clarification for 5x/wk for treatment to include treatments for therex, theract (systematic and planned performance of body movements or exercises which aim to improve and restore function), neuro re-ed (neuromuscular [relating to nerves and muscles] re-education), self care. Order Type: Therapy Orders Review of the Physical Therapy PT Evaluation & Plan of Treatment, Certification Period: 03/20/23-01/14/23 reflected, Initial Assessment, Current Referral: Reason for referral: Patient exhibits new onset of decrease in strength, decreased need for assistance from others, reduced functional activity tolerance, decrease in transfers and decrease in functional mobility indicating the need for PT to increase functional activity tolerance, increase LE ROM and strength and facilitate (I) with all functional mobility. Prior Level of Function: Transfers = CGA Short-Term Goal - Patient will safely perform functional transfers with Mod (A) for safety awareness with reduced risk for falls in order to decrease level of assistance from caregivers. (Target: 04/09/23) Prior Level of Function Baseline (prior to onset) (03/20/23) Transfers - CGA Total Dependence w/o attempts to initiate Long-Term Goal - Patient will safely perform functional transfers with Min (A) for safety awareness with reduced risk for falls in order to decrease level of assistance from caregivers. (Target: 04/14/23) Prior Level of Function Baseline (prior to onset) (03/20/23) Transfers - CGA Total Dependence w/o attempts to initiate Assessment Summary: Clinical Impressions: Pt is a 67 yo female with CVA and Rt hemiplegia referred to PT with muscle weakness, lack of coordination, balance deficits in standing resulting in increased burden of care and decreased functional mobility. Reason for Skilled Services: Patient requires skilled PT services to increase LE ROM and strength, increase functional activity tolerance and assess functional abilities in order to enhance patient's quality of life by improving ability to decrease level of assistance from caregivers and safely maneuver in/out of bed. Risk Factor: Due to the documented physical impairments and associated functional deficits, the patient is at risk for increased dependency upon caregivers, further decline in function and decreased skin integrity. Skilled Intervention Focus: Restoration Review of the Concern Log for March 2023, reflected Resident #1 filed a concern on 03/27/23, stating she was dropped during therapy. The DON was assigned to the concern on 03/27/23. The Resolution reflected the DON made self report to HHSC, in-serviced staff, and therapy. Review of an incident/accident report for Resident #1, dated 04/11/23, reflected under Fall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 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 676448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Reserve at Richardson 1610 Richardson Dr Richardson, TX 75080 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 0689 Incidents Resident #1 had a fall on 03/27/23 at 11:40 AM. This report was completed by the DON. Level of Harm - Actual harm Review of Resident #1's Risk Management, Incident #1009 notes, reflected the following: Date of Incident: 3/27/23 11:40 therapist came to this nurse and states that the resident was on the floor. therapist states that the resident was assisted to the floor due to her knees buckling. this nurse immediately went to assess the resident. Resident observed laying on the floor in the supine position (the patient is face up with their head resting on a pad positioner or pillow and their neck in a neutral position) with pillow underneath head. resident exhibits no signs of distress. upon assessment no injuries noted and the resident is at her baseline for movement in upper and lower extremities. Resident states that her knees buckled while being transferred. assessment complete Residents Affected - Few Review of Resident #1's hospital MRI results, dated 03/28/23, reflected Exam: MRI of the right knee without IV contrast Clinical history: Right knee pain status post fall Comparison: None available IMPRESSION: 1. Evidence of an acute nondisplaced lateral tibial plateau fracture. Review of the facility's in-service documentation, following Resident #1's fall, reflected the following in-services were conducted: All Staff in-service - Use Gait Belt for All Transfers-No Lifting, dated 03/27/23; Post Fall Huddle Form, 03/27/23; Residents Requiring Mechanical lift Require Two People for All Transfers, dated 03/29/23; Abuse and Neglect, 03/29/23 Review of Resident #1's Nursing Order from the Orthopedic Specialist, dated 04/03/23, reflected She (Resident #1) is clear for ROM as tolerated of her right knee, but NWB on the RLE for the next 6-8 weeks. Patient should continue PT for ROM of her knee, out of the knee brace, to prevent stiffness. I recommend she discontinue knee brace/immobilizer while at rest to prevent skin breakdown. She can wear it during transfers and when out of her facility for the next month. However, if she is more comfortable in the brace when at rest she can wear it at rest as well for the next month, as long as her skin does not breakdown. In an interview on 04/11/23 at 10:15 AM with the DON revealed the resident reported the aide dropped her on 03/27/23. She stated x-rays were ordered and completed. The x-rays did not show a fracture, however, the resident was sent to the hospital on [DATE],and an MRI was conducted. She stated the MRI showed a fracture. She stated because of the injury and how the resident described the incident, she wrote up an action plan on the aide. She stated she initiated an in-service on Abuse and Neglect. She stated she also talked to them to ensure everyone was on the same page with the proper way to transfer residents. She stated she stressed that everyone is expected to utilize gait belts, lifts, and proper techniques with every resident and at all times. She also noted, the resident is very particular of how she wants things done and she will let her wishes be known. She stated she will also let them know when she is not pleased with something. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 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 676448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Reserve at Richardson 1610 Richardson Dr Richardson, TX 75080 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 0689 Level of Harm - Actual harm Residents Affected - Few stated the resident has her cell number, as well as the Charge Nurse's numbers and the Administrator's number. She stated she calls them at any given time, no matter the time of day or night, when she is not pleased. In an interview on 04/11/23 at 12:19 PM with the OT revealed she stated at the time of the incident on 03/27/23, she was moderate assistance. She stated prior to the incident, the resident was a one-person transfer with the therapy team. She stated with nursing, the staff used a mechanical lift. She stated the resident stated she was tired, so the therapy session was not a strenuous one. She stated, after the session, they took the resident back to her room and let her sit in her wheelchair for about two hours sat her in the chair in her room. She stated the resident was to sit in the chair for a while, because it was a new chair and she needed to get used to the chair and they were trying to help her build up her tolerance for sitting up in the chair. She stated at around 11:30 AM, she returned to the resident's room to check on her. She stated at that time, she realized the sling was not under her for the nursing staff to get her back in the bed. She stated by the time the resident was pretty fatigued from sitting up and wanted to get back into bed. She stated the resident was insistent on getting back in bed. She stated at that point, she was trying to appease the resident and give her what she wanted, which was to get back in bed. She stated its easier to already have the sling in the chair, prior to her sitting in it. She stated because the resident was a one-person transfer with therapy staff and she had just transferred her by herself, the week prior, with no issues, she didn't feel it would be a problem to transfer her this time. She stated she angled the resident towards her left side so she could transfer her from the left side. She stated before she stood the resident up, she made sure the residents feet were a shoulder width apart, which is the proper position for standing. She stated she believes when she was turning the resident, that's when the right foot slide behind her. She stated typically, the resident's right foot would stay in place and the resident would be able to slide the right foot around with her as she turned. But this time, he slide behind her. She stated that's when she couldn't help the resident and the resident couldn't help her to ensure she could move her safely to the bed. She stated at that point, she told the resident she was going to help her to the ground, because there was no way out of the situation. She stated she was holding the resident from behind and the resident sat down gently, bottom first and then she laid the resident down and put a pillow under her head. She stated the resident's feet were toward the head of the bed. She stated the resident's' legs were bent a little bit because a nightstand was in the way. She stated once she got the resident to lay down, she then pushed the nightstand out of the way, so her legs could stretch out. She stated she had worked with the resident for months and never had an issue. She stated she was aware that for nursing, she had to have two people to transfer and that they used a sling and a mechanical lift, however, she was not aware that they, as therapist had to use two people to do it because they always did it with one person. She stated the reason she and the PT assistant transferred the resident that morning is because they happened to meet up at the resident's room at the same time. So they just did it together. She stated the resident has been comfortable with therapy transferring her without the mechanical lift and doing it with one person, however, she has never been comfortable with nursing staff transferring her and has always insisted they do it with the mechanical lift. She stated it has been this way for months. She stated this incident has taught her that it is important for things to be the same across the board, so the residents receive the same level and manner of care from all departments. She stated if that is not followed, it could result in injury to the resident. In an interview on 04/11/23 at 12:32 PM with Resident #1 revealed she stated last month (March 2023), the OT came to her room to check on her and she told her she was tired and wanted to get back in bed. She stated the OT helped (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 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 676448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Reserve at Richardson 1610 Richardson Dr Richardson, TX 75080 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 0689 Level of Harm - Actual harm Residents Affected - Few her up and as she was trying to turn toward the bed, the OT dropped her. She stated she was facing the head of the bed and she stated when she landed on the floor, her feet legs were bent to where her knees were up. She stated her legs could not straighten out because the nightstand was in the way. She stated her knees had not been bent that much in a very long time and she stated she feels that something must have popped because she was in pain. She stated the OT moved the nightstand out of the way so her legs could stretch out, however, the damage had been done by that point. She stated the OT went and got Nurse A and an aide. She stated they checked her out and helped her into bed. She stated she knew something was wrong because her knee was hurting. She stated she did not understand why they didn't send her to the hospital when it happened. She stated she kept telling them she was in pain and they gave her pain meds and later that evening, they had X-rays done. She stated they didn't send her to the hospital until after she talked to the Nurse Practitioner. She stated she felt like the fall could have been prevented if the OT had used the belt, like the aides do. In an interview on 04/11/23 at 1:31 PM with the DOR, revealed she stated how they handle residents is usually a case-by-case situation. She stated the Resident #1 had been minimum to moderate assist since she returned from the hospital. She stated when the resident was receiving therapy prior to her hospital stay, they had gotten her strong enough to be contact guard (ready-to-respond supervision) for transfers. She stated normally, they train nursing staff to transfer in the same manner as how therapy does it, so they could maintain continuity with the residents' progress. She stated Resident #1 would not allow it because she was very adamant about nursing staff using the Mechanical lift. Resident #1 stated she was more comfortable for nursing staff to use the lift and she was more comfortable with the therapist transferring her the way they had been. She stated nursing department consults with therapy to determine best method for transfers and mobility for MDS and Care Plans. She stated the rehab department goes off of the assessment of the evaluating therapist, to determine how they work with the resident, and they adjust based on the progress of the resident. She stated they have done things case-by-case for each resident, and it sometimes differs from nursing determinations and there has never been an issue or injury until this resident. She stated based on what happened with this resident on 03/27/23, she acknowledges that going different routes could result in harm to the resident. She stated going forward, they will reevaluate and work with nursing to be more cohesive. In an interview on 04/11/23 at 2:40 PM with Nurse A, revealed she stated she was still learning the nursing processes of the facility. She stated usually nursing staff referred to the therapy's determination when determining the functionality of the residents. She stated if residents come from the hospital, nursing staff go with the notes from the hospital. She stated she was not sure who determined how Resident #1 was to be transferred. She stated the resident had not transferred with her. She stated ever since she had worked at the facility, the resident had always been in bed when she checked on her. She stated if the resident had needed to be transferred, she would refer to the resident's Care Plan and MDS to see what method she required. She stated if therapy and nursing are not on the same page with how a resident is to be transferred, falls and/or injuries could happen, some injuries may even be major. She stated the most recent in-service on transfers on 03/29/23, included topics of gait belt use, mechanical lifts, one or two-person assist, the proper way to transfer and the importance of following what's in the system for each resident. In an interview on 04/12/23 at 2:56 PM with the DON she stated the therapy department works with the residents according to their abilities and the goal is to improve their ability to function. She stated the nursing staff refer to the system to see what level of care each resident needs, and they act accordingly. She stated with Resident Resident #1, its not always that simple because she insists on them doing what she feels (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 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 676448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Reserve at Richardson 1610 Richardson Dr Richardson, TX 75080 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 0689 Level of Harm - Actual harm Residents Affected - Few comfortable with. She stated, on 03/27/23, the OT told them she assisted the resident to the floor and went to get assistance, which is what she should have done. She stated the resident was comfortable with therapy transferring her the way they had been doing and if the resident's wishes were being followed, which is what they are supposed to do .as in honoring the resident's right to choose. She stated she did not understand how they could be at fault for following the resident's choice. She stated once she was notified of the incident, she took all of the appropriate steps to ensure it doesn't happen again. She stated the system said the resident required two-person assist, however, the resident did not require the therapist to follow that and she was comfortable with it, and there had never been any problems with it prior to this incident. She stated the risk of not following what is in the system, would be that the resident could fall, could be injured. However, they have been written up for not honoring resident's rights, so they were keeping that in mind and trying to honor her rights and wishes. In an interview on 04/11/23 at 3:14 PM with the Administrator, revealed he stated he interviewed Resident #1 on 03/27/23, and she told him that as the therapist was helping her to transfer, her knee buckled and that's how she lost balance, and the therapist told her she was going to help her to the ground. He stated the resident did not say she was in pain after being asked by several people. He stated she was talking to her family member, later that day and she told her family member what had happened. He stated after her conversation with her family member, she then started complaining of pain. He stated that's when they contacted the physician again and the physician ordered an X-ray. He stated the next day, Resident #1 was still complaining of pain and she expressed pain to the NP, who told them to send her to the hospital. He stated the staff were trying to do whatever they could to accommodate the resident. He stated therapy had been working to get the resident comfortable with ther new customized wheelchair, so she can get to the point of getting up and getting out of bed and out of her room and start socializing more and being more active. He stated therapy was transferring her in a way that enabled her to be used to getting in the wheelchair. He stated he believed both departments were doing it the right way, because it was the way the resident wanted, and it was working both ways. He stated they have in-serviced all staff, including the rehab department. He stated everyone had been working with the residents, with whatever method the residents were comfortable with. He stated they had to honor the residents' right to choose, while still working to help improve the quality of life and functionality of the resident. He would not say that there was a risk in everyone not using the same method of transferring the resident. He stated they had changed the way they operate, since the incident because, even in therapy, they had to begin to use the mechanical lift and two-person assist for all transfers. Review of the facility's gait belt policy, revision date 12/2022, and titled Use of Gait Belt Policy reflected: 3. It will be the responsibility of each employee to ensure they have it (gait belt) available for use at all times when at work. 5. Failure to use gait belt properly could result in harm to employee and resident and may result in termination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 If continuation sheet Page 6 of 6