Health inspection·January 3, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few unwitnessed fall from her low bed. The assessment of the resident was documented along with the notification of the physician and the responsible party. There were already interventions in place, the therapy department was treating the resident at the time and rescreened the resident at the time of the fall. In an interview on 12/30/23 at 9:30 a.m. with RN A revealed that she had cared for Resident #1 and was the nurse in charge on 12/25/23 but was not present when she had gone to the hospital . RN A stated resident #1 went to the hospital on [DATE] with a fractured left leg. RN A stated she had seen Resident #1 three times on 12/25/23 but had not assessed her lower legs for any injuries to her legs, because she had no idea that she had a fall previously, she had not been told the information during change of shift. RN A stated it must not have been on the 24-hour report. RN A stated that if a resident fell, we they were to assess them, call the doctor, call the reasonable party;, and if the resident has no apparent injures, we they were to continue to monitor them for the next 72 hours for any injuries that could arise after the fall,. She stated they were we are to document on the 24-hour report and tell each other between shifts. In an interview on 12/30/23 at 10:15 a.m. with ADON C revealed he had been working the day that Resident #1 was found on the floor on the mat next to her bed. ADON C said the resident was a wiggler in the bed so they had placed put a lot of interventions in place. ADON C said that the CNA had come came to get him, he assessed the resident, there were no injuries, she had full range of motion with no pain, and no skin abrasion or tears, He stated he helped place her back in bed, from there the charge nurse LVN A was told and she would follow the fall protocol. ADON C said the protocol was to call the physician and the responsible party and then fill out the forms for incident /accident and then the nurses were to monitor the resident for the next 72 hours to check for any latent injuries related to the incident/accident. ADON C stated the information should be placed on the 24-hour report to be passed on to the next shift, as part of the shift change communication. ADON C stated that on 12/25/23 around 6:30 p.m. he was working at the facility as a medication nurse and the family came and ask him to look at her Resident #1's left leg. He stated he did go and look the left leg it was swollen and painful. He stated he went and got the charge nurse (RN E) and she assessed called the physician and followed through . In an interview on 12/30/23 at 11:00 a.m. revealed the Medical Director stated he was aware of Resident #1's fall. He stated that the nursing staff was good about communicating with him about changes in residents' conditions. He stated the LVN A had contacted him on 12/24/235 about the cool left leg and the resident complaining of pain, so he had ordered doppler studies, then he was contacted about the swelling of the leg and pain on 12/25/23. He stated he, ordered x-rays and then he was contacted with the results of the fracture , and she was sent out. The physician stated during the interview that it would not be unusual for the resident to have a partial fracture that did not exhibit pain and then continue with therapy and care until the partial fracture became a full fracture and swelling with exhibited pain. The physician stated Resident #1 was very compromised and fragile. The physician stated he had reviewed the admission paperwork to the hospital and discussed with the investigator, reflecting that the surgeon at the hospital did not identify the fracture to be old, as acute at the time of the admission to the hospital, the surgeon stated he could not perform the surgery the same day, due to her sickle cell condition and the need for blood. The surgery was completed on the 12/27/23. The resident was transferred to another skilled nursing facility two days later. Review of the x-ray's of the bilateral hips and the left femur dated 12/25/23 reflected: femur (thigh bone) left leg reflecting an obliquely posteromedial displaced fracture femoral diaphysis (a fracture that requires surgery to realign the bone). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676466 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 676466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cheyenne Medical Lodge 750 Highway 352 Mesquite, TX 75149 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the progress notes dated 12/20/23 through 12/25/23 for all three disciplines physical therapy, occupational therapy, and speech therapy, reflected Resident #1 had been treated on 12/20/2, 12/21/23, 12/22,23, and 12/25/23. There documentation reflected no complaints of pain or swelling with Resident #1. In an interview on 12/30/23 at 2:45 p.m. with LVN A revealed she had been the nurse in charge for Resident #1 on 12/22/23, 12/23/23, and 12/24/23. LVN A stated she was working when Resident #1 was found on the floor mat on the right side of the bed. She assessed following the ADON C's assessment and she did not find any injuries or complaints of pain at that time. She filled out the required reports, called the physician, and informed the responsible party and documented on the 24-hour report about her fall. LVN A stated on 12/24/23, the family came to visit . LVN A stated the family told her that the left leg was tight. LVN A stated the leg was not tight (another description of swelling) and no pain affect was noted by the resident when she assessed Resident #1, until the family asked the resident about pain and she responded yes. LVN A stated since the resident expressed pain to the family and the leg was cold to the touch, she called the physician, and he ordered a doppler study arterial and venous (testing for circulation to determine if the person has a blood clot). She called the company and ordered the study and wrote it on the 24- hour report and reported it to the oncoming nurse, LVN E and she left. LVN A stated that was what we they were supposed to do with any change of condition with the resident, anything new, they document and place it on the 24-hour report, so the incoming nurse can could be told., she did not recall if she documented about the follow-up for the fall on the 24-hour report, or discussed the follow-up on the fall at change of shift on 12/22/23, but knew she was supposed to. Attempts were made on 12/30/23 to contact LVN D, with messages left with no return call by the time of exit. Review of the progress notes dated 12/22/23 reflected LVN A had documented the fall, the assessment, the notification of the physician and the notification of the responsible part, and the nursing administration. Further review of the nursing progress notes reflected LVN had documented the follow-up assessment of Resident #1. On 12/24/23 LVN A had documented the assessment of Resident #1 with her change of condition related to the left leg, calling the physician and ordering the doppler studies (circulation studies to rule out blood clots) for the left leg. In an interview on 12/30/23 at 5:13 p.m. with RN D revealed that she was the charge nurse on 12/25/23 for the next 16 hours. RN D stated she had just completed making her general rounds right after coming to work and had seen Resident #1 then, when ADON C came and told her that Resident # 1's leg was swollen and painful. RN D assessed the resident, called the doctor and got x-rays ordered and an order for Tramadol (pain medication) to be given one time. RN D stated the left leg was swollen and the resident exhibited pain while she assessed her. The results of the x-ray were positive for a fracture of the femur (thigh bone) left leg reflecting: an obliquely posteromedial displaced fracture femoral diaphysis (a fracture that requires surgery to realign the bone). The physician was made aware of the results, and he wanted her transferred to the emergency room. RN D stated that she followed those orders and sent her out. RN D stated this that was the first time she had seen this resident, since she had been off, and she had not but she had not been told by the off going nurse, RN B that the resident had a fall. Interview on 01/03/24 at 11:00 a.m. with the DON she stated the nursing staff was required to assess for any changes in the resident and then contact the physician. All information concerning falls, labs, tests, new medications, should be written on the 24-hour report and that was something all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676466 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 676466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cheyenne Medical Lodge 750 Highway 352 Mesquite, TX 75149 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nurses had been told. The nursing staff needed to have that information, so they could communicate between shifts so each nurse would know what was occurring with the resident. The DON stated concerning Resident #1 the process did not happen so the oncoming nurse had no idea the resident had a previous fall, and she did not know to assess her. The DON stated on the ins-service she had just recently given, she had made it clear to the nursing staff if they did not report on the 24-hour report or perform the fall follow-up, it could result in disciplinary action, possible termination. She was tired of some of the nurses not listening to her. In an interview on 01/03/24 at 11:25 a.m. with the Director of Therapy revealed she knew Resident # 1 and the resident was in their services from the time of evaluation on 12/202/3 until she discharged on 12/26/23. The Director of Therapy said that the resident was receiving all three disciplines when she fell out of her low bed. There was not any indication that she had pain or no swelling noted to her lower extremities, occasionally her confusion was worse than usually so we would try her therapy the next day, when she could not cooperate due to her confusion. The Director of Therapy stated the therapy department was aware she had fallen out of her low bed, and we did complete an additional fall screen, even though she was in our services at the time. There were no further actions to be completed or added at that time. Review of the in-service dated 01/02/24 reflected all nursing staff for acute charting guidelines and post fall procedures was given by the DON. Review of the undated policy and procedure Acute Charting Guidelines reflected: Acute charting must include . the families to be notified of change in resident status 10. D. all unobserved . whether or not it as a tear, bruise, or a fall, must be charted on for 72 hours . notify the family and doctor After the fall . E. the nurse will observe for delayed complications of a fall for seventy- two (72) hours after a fall Review of the undated policy and procedure Nursing Services reflected the facility will sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services, to assure resident safety and attain or maintain the resident practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments .the facility will ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, and identified through resident assessments .providing care incudes but not limited to assessing FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676466 If continuation sheet Page 4 of 4