Health inspection·July 23, 2025

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed conduct a Comprehensive Assessment within 14 calendar days after admission for 1 of 5 residents (Resident #111) reviewed for Comprehensive Assessments and timing. The facility failed to ensure a Comprehensive MDS Assessment for Resident #111 was completed within 14 days after her admission to the facility. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.Findings included: Review of Resident #111's Face Sheet, dated 07/22/25, reflected she was an [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including history of falling (past instances of falling). Review of Resident #111's electronic medical record on 07/22/25 reflected no evidence that an MDS Assessment had been completed. During an interview with the [NAME] President of Reimbursement on 07/22/25 at 12:09PM, he stated the facility did not currently have a full-time MDS Coordinator. He said the facility had a couple of remote MDS Coordinators who were assisting the facility until the vacant position could be filled. The [NAME] President of Reimbursement confirmed Resident #111's Comprehensive (Admission) MDS Assessment had not been completed within the required timeframe. He stated the risk of MDS Assessments not being completed within the required timeframe included the potential for residents not receiving necessary services. Review of the facility's Electronic Transmission of the MDS policy, undated, reflected, .All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data. Page 1 of 8 455412 455412 07/23/2025 Brookhaven Nursing and Rehabilitation Center 1855 Cheyenne Carrollton, TX 75010

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for 2 of 19 residents (Residents #7 and Resident #48) reviewed for quarterly assessments. 1. The facility did not ensure Resident #7's Quarterly MDS Assessment, dated 03/12/2025, was completed within 90 days of the previous assessment. 2. The facility did not ensure Resident #48's Quarterly MDS Assessment, dated 03/19/2025, was completed within 90 days of the previous assessment. These failures could place residents at risk of not having their assessments completed timely.Findings included:1. Record review of Resident #7's admission Record, dated 07/23/2025, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #7's annual MDS assessment dated [DATE] revealed he had diagnoses including Hypertension (a condition in which the force of the blood against the artery wall is too high), Anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), Orthostatic Hypotension (form of low blood pressure that happens when standing after sitting or lying down), Diabetes Mellitus (chronic condition that affects the way the body processes blood sugar, the body doesn't produce enough insulin or it resists insulin), Cerebral Palsy (a neurological disorder that affects movement and muscle coordination, caused by abnormal brain development or damage to the developing brain), Anxiety Disorder (disorder characterized by feelings of worry, anxiety, or fear that are enough to interfere with one's daily activities), Bipolar Disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows), Schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), and Autistic Disorder (neurological and developmental disorder that affects how people interact with others, communicate, learn and behave).Record review of Resident #7's EHR revealed quarterly MDS assessment dated [DATE] reflected the status was In-Progress and had not been completed or transmitted to the CMS system. His most recent completed assessment was a Quarterly MDS assessment completed on 12/14/2024.2. Record review of Resident #48's admission Record dated 07/23/2025 revealed she was a [AGE] year-old female admitted to the facility on [DATE].Record review of Resident #48's quarterly MDS assessment dated [DATE] revealed she had diagnoses including Multiple Sclerosis (a chronic autoimmune disease that affects the central nervous system, leading to a range of neurological symptoms due to damage to the myelin sheath that insulates nerve fibers), Anxiety Disorder (disorder characterized by feelings of worry, anxiety, or fear that are enough to interfere with one's daily activities), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Psychotic Disorder (severe mental health conditions characterized by disruptions in thought processes, perceptions, and emotional responses, often leading to a loss of touch with reality), Arthritis (the swelling and tenderness of one or more joints), Osteoporosis (causes bones to become weak and brittle), and Muscle Weakness (a symptom of many conditions, ranging from muscle injuries to fatigue).Record review of Resident #48's EHR revealed her quarterly MDS assessment dated [DATE] reflected the status was In-progress and had not been completed or transmitted to the CMS system. Her most recent completed assessment was a quarterly MDS assessment dated [DATE].During an interview on 07/23/2025 at 1:30 PM, the DON stated the VP of Reimbursement is responsible for completing MDS assessments until an MDS coordinator is hired. The DON stated the risks for late assessments included not getting the most up-to-date information needed during their IDT meetings and it could also affect their reimbursement.During an interview on 07/23/2025 at 2:43 PM, the Administrator stated the VP of Reimbursement was responsible for completing MDS assessments until an MDS coordinator is Residents Affected - Some 455412 Page 2 of 8 455412 07/23/2025 Brookhaven Nursing and Rehabilitation Center 1855 Cheyenne Carrollton, TX 75010

F 0638 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hired. The Administrator stated he was aware some of MDS assessments were late, and they were working to resolve the matter. He stated risks for late assessments included the resident's information may not be updated timely and they could miss a change in condition. He stated the facility's reimbursement could be impacted as well. In an interview on 07/23/2025 at 3:00 PM, VP of Reimbursement stated the facility had not completed Resident #31 and Resident #48's quarterly MDS assessments due to the facility not having an MDS coordinator. VP of Reimbursement stated he was responsible for completing the assessments until an MDS coordinator is hired. VP of Reimbursement stated the risk of late or missed assessments could affect the residents plan of care, continuity of care, and affect reimbursement.Record review of the facility's undated policy and procedure titled Electronic Transmission of the MDS, identified as current by the Administrator, reflected the following: All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data. MDS electronic submissions shall be conducted in accordance with current OBRA regulations governing the transmission of such data. 455412 Page 3 of 8 455412 07/23/2025 Brookhaven Nursing and Rehabilitation Center 1855 Cheyenne Carrollton, TX 75010

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care for the resident that met professional standards of care within 48 hours of the resident's admission for two (Resident #4 and Resident #111) of six residents reviewed for baseline care plans. The facility failed to complete a baseline care plan for Resident #4 and Resident #111 within 48 hours of their admissions. This failure could place newly admitted residents at risk of not receiving effective and person-centered care and services.Findings included: Review of Resident #4's Face Sheet, dated 07/23/25, reflected she was a [AGE] year-old female, who was admitted to the facility on [DATE], with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and anxiety (intense, excessive, and persistent worry and fear about everyday situations). Review of Resident #4's Baseline Care Plan, dated 05/13/25, reflected the ADON signed the document as completed on 05/13/25. Review of Resident #111's Face Sheet, dated 07/22/25, reflected she was an [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including history of falling (past instances of falling). Review of Resident #111's Baseline Care Plan, dated 07/19/25, reflected the ADON signed the document as completed on 07/19/25. During an interview with ADON B on 07/22/25 at 12:44PM, she stated she completed the Baseline Care Plans for Resident #4 and Resident #111. She stated although the IDT Meetings were held within 48 hours of admission for both residents, the Baseline Care Plans were not completed within that required timeframe. She confirmed that Resident #4's Baseline Care Plan was completed on 05/13/25, and that Resident 111's Baseline Care Plan was completed on 7/19/25. ADON B stated there were times in which Baseline Care Plans were not completed within the required 48-hour timeframe following admission. She stated there was not a specific reason for this delay. ADON B stated the risk of Baseline Care Plans not being completed within the required timeframe included direct care staff members not having basic information about their newly admitted residents. Review of the facility's Care Plans - Baseline policy, dated 12/2016, reflected, .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. 455412 Page 4 of 8 455412 07/23/2025 Brookhaven Nursing and Rehabilitation Center 1855 Cheyenne Carrollton, TX 75010

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal/oral hygiene for one (Resident #67) of five residents reviewed for Activities of Daily Living (ADLs). The facility failed to ensure Resident #67 received personal hygiene care, in respect to facial hair across her chin. This failure could place residents who were dependent on staff for ADL care at risk for not having their care and treatment needs met.Findings included: Review of Resident #67's Face Sheet, dated 07/23/25, reflected she was a [AGE] year-old female, who most recently admitted to the facility on [DATE], with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), muscle weakness (decreased strength in the muscles), and lack of coordination (uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements). Review of Resident #67's MDS Assessment, dated 05/05/25, reflected she required supervision or touching assistance for personal hygiene, including shaving. Review of Resident #67's Care Plan, dated 12/21/20, reflected Resident #67 required assistance from staff with ADLs. An associated goal was for Resident #67 to remain clean, comfortable, and well groomed. Associated interventions were for staff to encourage Resident #67 to participate in ADL care as she was able; staff were also to assist with/provide ADL care for Resident #67 as needed. During an observation of Resident #67 on 07/21/25 at 2:50PM, she was sitting up in her wheelchair. She was noted to have an excessive amount of thick, white facial hair across her chin, approximately 1/3 to 1/2 inches in length. During an interview with Resident #67 on 07/21/25 at 2:50PM, she stated she did not like the hair on her chin and wanted it removed; she could not recall if any staff members had previously asked her if she wanted her facial hair to be shaved. During an interview with LVN B on 07/21/25 at 2:58PM, she stated direct care staff were expected to check for facial hair on residents during routinely scheduled showers, several times per week. Upon observation of Resident #67's facial hair, she stated she would have expected for a staff member to have shaved her chin prior to it growing as long as it had. LVN B stated the risk of residents not being provided with proper grooming, such as shaving, included a lack of dignity. Review of the facility's Activities of Daily Living (ADLs), Supporting policy, dated 03/2018, reflected, .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care). Residents Affected - Some 455412 Page 5 of 8 455412 07/23/2025 Brookhaven Nursing and Rehabilitation Center 1855 Cheyenne Carrollton, TX 75010

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for one medication cart (200 hall) of the facility's' four medication carts reviewed for medication storage. The facility failed to ensure Residents #47 Basaglar Kwik pen 100unit/1ml, and Resident#11 Humulin 70/30 100 units/ml, were dated when opened.The facility failed to ensure that an opened bottle of Novolin 70/30 bottle was properly labeled and dated before storing in the 200-hall medication cart. This failure could affect residents by diminishing the effectiveness, and therapeutic benefits of the medications and/or result in medication error.The findings included: Review of Resident #47's Quarterly MDS Assessment, dated 03.28.2025 reflected the Resident #47 was a [AGE] year-old female and had a BIMs score of 2, indicating her cognitive function was severely impaired. The resident had diagnoses which included Diabetes Mellitus (a group of metabolic disorders characterized by high blood sugar levels, caused by either the body's inability to produce enough insulin or its inability to effectively use the insulin it produces), hypertension (high blood), Non-Alzheimer's Dementia, Renal insufficiency (a condition where the kidneys are unable to adequately filter waste and excess fluid from the blood). Review of Resident #47's Comprehensive Care Plan, dated [DATE], reflected the resident had Diabetes Mellitus and was taking Insulin at bedtime. Intervention included to give Diabetes medication as ordered by doctor.Review of Resident #47's active Physicians orders as of [DATE] basaglar Kwik pen 100unit/1ml insulin pen Inject 15 unit subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of Resident #11's Quarterly MDS Assessment, dated [DATE], reflected the Resident #11 was a [AGE] year-old male with a BIMs score of 15 indicating she is cognitive function is intact. The resident had diagnoses of diabetes mellitus, Hypertension( high blood pressure), coronary artery disease (a condition where the arteries supplying blood to the heart narrow or become blocked due to plaque buildup, hindering blood flow and potentially leading to chest pain, shortness of breath, or even a heart attack), renal insufficiency (a condition where the kidneys are unable to adequately filter waste and excess fluid from the blood). Review of Resident #11's Comprehensive Care Plan, dated [DATE], reflected the resident had Diabetes Mellitus. Intervention included to give Diabetes medication as ordered by doctor. Review of Resident #11's active Physicians orders as of [DATE] reflected Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 101 - 150 = 0; 151- 200 = 2units; 201 - 250 = 3units; 251 - 300 = 4units;301 - 350 = 6units; 351 - 400 = 9units; 401+ = 12units call MD , subcutaneously before meals and at bedtime for diabetes. Observation on [DATE] at 1:37 PM with LVN A on the 200-hallway's medication cart revealed Basaglar Kwik pen 100unit/1ml for Residents #47, Humulin 70/30 100 units/ml for Resident#11, and an open vial of Novolin 70/30 with no label and no open date. In an interview on [DATE] at 1:42 PM with LVN A she stated that she did not realize that Resident #47's Basaglar Kwik pen 100unit/1ml, and Resident #11's Humulin 70/30 100 units/ml did not have open dates. She also stated that she did not realize that the opened bottle of Novolin 70/30 bottle was missing a label and the date it was open. She stated that it was important to date opened insulins because once opened insulins expire after 28 days. LVN A stated that the risk to the resident was receiving expired insulin that could cause negative drug effects that could harm the resident. She stated that having insulin in the medication cart that did not have the proper label could result in 455412 Page 6 of 8 455412 07/23/2025 Brookhaven Nursing and Rehabilitation Center 1855 Cheyenne Carrollton, TX 75010

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some administering insulin to the wrong resident which may result in hospitalization. She stated that she knew that she was supposed to check and ensure all medications are within date before administering to the residents. LVN A stated that she had been in-serviced on medication storage and dating all opened insulins. An interview on 07.22.2025 at 1:47 PM with ADON A, revealed that all insulin pens and vials should be labeled, and they should have an open date. He stated it was the responsibility of every nurse to check the open date before the administering insulin to a resident. ADON A stated insulin was supposed to be dated because it expired 28 days after opening. He stated that failure to have open dates on insulin could result in administrating medication that was expired and could not be effective or that could have negative side effects to the resident. He stated that unit managers audited the medication carts as needed, but there was not set schedule. He stated that the pharmacist audited the medication carts monthly. In an interview on [DATE] at 10:57 AM with the DON, revealed that he was notified by LVN A of the undated insulin pens and the unlabeled insulin bottle in the 200-hall medication cart. He stated that after he was notified the facility audited all the medication carts and ensured that the undated insulins were disposed and all the insulin in the cart had open dates. The DON stated that he expected the charge nurses to check and make sure the insulin being administered had an open date and discarded after 28 days. The DON stated the pharmacist audited the carts monthly to make sure the insulins were dated. He stated that it was the responsibility of the nurses to make sure the insulins had an open date before administration of insulin. The DON stated that the unit managers completed random checks of the carts, and did not have a schedule. The DON stated that undated insulin could be expired which could decrease effectiveness of the insulin when administered to the resident. He stated that unlabeled insulin could be administered to the wrong patient resulting into adverse reaction and hospitalization. Review of the facility policy Storage of Medications revised on 01.07.2025 reflected: The facility stores all drugs and biologicals in a safe, secure, and orderly manner.Policy Interpretation and Implementation1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls.2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers.3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing.5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 455412 Page 7 of 8 455412 07/23/2025 Brookhaven Nursing and Rehabilitation Center 1855 Cheyenne Carrollton, TX 75010

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to maintain sanitary, clean, and safe medication storage and preparation.This failure placed residents at risk for healthcare associated cross contamination and blood borne infections.Findings included: An observation on 07/22/25 at 1:37PM revealed there was an unlabeled vial of insulin lispro with blood stains on the vial and box. The insulin vial and box were in the top drawer of hall 200 medication cart stored with other medications. An interview on 07/22/25 at 1:37PM with LVN A revealed that she did not realize the insulin box and vial had blood stains. She stated that nursing staff was responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. She stated that the blood on insulin bottle would put the residents and staff at risk for blood borne infections. She stated that the nurses were supposed to always check and ensure proper infection control. She stated that she had been in-serviced on infection control last month . An interview on 07.22.2025 at 1:47 PM with ADON A confirmed that the stain on the insulin box and vial were blood stains. He stated that the nurses were responsible for maintaining infection control and ensuring that the medication carts were clean and sanitary. He stated that the blood on insulin bottle would put the residents and staff at risk for cross contamination and blood borne infections. An interview on 07/23/25 at 1:41pm with DON revealed that he was notified by LVN A of the insulin vial with blood stain on the box and the vial. He stated that it was the nurses' responsibility to ensure that medications were stored and administered in clean, and sanitary environment. The DON stated that it was every staff members responsibility to always maintain infection control. He stated that after he was notified the unit managers conducted cart audits and removed and disposed the blood-stained insulin. He stated that the risk to the resident was blood borne infections. He stated that the staff was in-serviced in infection control 07.23.2025 Review of the facility policy Storage of Medications revised on 01.07.2025 reflected: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Review of the Facility Monitoring Compliance with Infection Control policy revised on 1.7.25 Reflected the infection preventionist or designee shall monitor the effectiveness of our infection prevention and control work practices and protective equipment. This includes but is not necessarily limited to: Surveillance of the workplace to ensure that established infection prevention and control practices are observed, and protective clothing and equipment are provided and properly used; Investigation of known or suspected exposures to blood/body fluids to establish the conditions [NAME]-rounding the exposures. Residents Affected - Few 455412 Page 8 of 8