Inspection·August 27, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few policy.Date Initiated: 06/29/2025 Keep call light within reach.Date Initiated: 06/29/2025 Keep environment clear of unnecessary objects. Keep bed locked and in lowest position unless otherwise ordered/indicated.Date Initiated: 06/29/2025 Nursing staff will monitor for side effects/adverse reactions to medications.Date Initiated: 06/29/2025 Refer to therapies and/or restorative, as indicated.Date Initiated: 06/29/2025 Safety training, retraining and education as needed.Date Initiated: 06/29/2025 An entry dated 08/26/2025 reflected: Focus: [Resident #1] was at risk for skin breakdown due to decreased mobility.Goal: [Resident #1] will have no skin breakdown in the next 90 days. Date Initiated: 08/26/2025 and Target Date: 07/30/2025. There were no Interventions in place. Record review of Resident #1's Skin Assessment for 07/30/25 at 5:00 AM due to an un-witnessed fall revealed, that Resident #1 had a small scrape on her upper right arm and denied pain. Record review of Resident #1's Neurological Check on 07/30/25 at 6:14 AM, revealed that she was complaining of vomiting and diarrhea. [Resident #1] denied any pain or discomfort or emotional distress. Record review of Resident #1's X-rays on 07/31/25 revealed that impressions were taken of the skull, hips, and chest and the findings revealed that there was no evidence of any fractures present in all areas. Record review of the facility's Admissions List for 02/01/25 to 08/26/25 revealed that Resident #1 was admitted to the facility from an acute care hospital on [DATE]. Record review of the facility's Incident Logs for 02/26/25 to 08/26/25 revealed on 07/30/25 at 5:00 PM, Resident #1 had an unwitnessed fall. Record review of the facility's In-service Training Log reflected that the staff's previous training on Resident Rights was conducted by Administrator on 07/23/25. The In-Service Training Logs reflected the staff were trained on the facility's policies and procedures on Resident Rights. The In-Service Training Attendance Roster reflected that the trainings were attended by all staff except RN A and CNA B. Record review of the facility's Staff Schedule for 07/29/25, revealed that RN A and CNA B were assigned to the evening shift on the 200 Hall where Resident #1 resided. Record review of the facility's In-service Training Log dated 07/30/25, reflected that the trainings were conducted by Administrator. The In-Service Training Logs reflected the staff were trained on the facility's policies and procedures on Abuse/Neglect, Resident Rights, Routine Round Checks, Call Lights, and Fall Preventions. The In-Service Training Attendance Roster reflected that the trainings were attended by all staff except RN A and CNA B. Record review of the employee files for RN A and CNA B revealed on 07/30/25 both staff members were suspended pending the facility's investigation of Resident #1's fall during the evening shift on 07/29/2025. Both staff members were terminated on 07/30/25 due to policy/procedure violation, prohibited conduct, safety violations, and unsatisfactory job performance which led to Resident #1's unwitnessed fall on 07/30/25. Both employee files did not reveal any other infractions or disciplinaries regarding resident neglect. Record review revealed on 07/30/25, the facility conducted Safe Surveys with the residents in the facility, and all stated that their needs were being met at the facility and did not have any concerns regarding abuse and neglect. Record review of the facility's Provider Investigation Report dated 08/06/25 revealed, RN A was the Charge Nurse on duty and CNA B was also on duty assigned to the 200 and 300 halls during the evening shift on 07/30/25, which was from 6 PM to 6 AM. On 07/30/25 at approximately 4:30 AM, [Resident #1] was observed by FM to have fallen and remained on the floor or an extended period of time. FM voiced concerns regarding the night shift doing routine checks during their shifts. [Resident #1] had a head-to-toe assessment which revealed a skin tear to her upper right arm. RN A and CNA B were immediately suspended and later terminated due to not following the facility's Routine Round Check Policy. The finding of Founded due to the neglect of RN A and CNA B. In a telephone interview with RN A on 08/26/25 at 4:25 PM revealed, that she was employed at the facility for 2 years as of 07/30/25. RN A stated that she worked the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455412 If continuation sheet Page 2 of 8 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 455412 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookhaven Nursing and Rehabilitation Center 1855 Cheyenne Carrollton, TX 75010 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 0600 Level of Harm - Actual harm Residents Affected - Few 6P-6A shift on 07/30/25. RN A stated that CNA B worked the 6P-6A shift on 07/30/25. RN A stated that herself and CNA B were assigned 2 hallways on 07/30/25. She stated at the beginning of her shift, she would do her rounds and check on residents to see how they were doing. RN A stated that Resident #1 was independent but needed some assistance with her ADL's due to her having some muscle weakness. RN A stated that Resident #1 appeared to be fine and did not appear to be in any distress or discomfort when she checked on her at the beginning of her shift. RN A stated that Resident #1 did not like to be awakened during the night and preferred to keep her door ajar or closed. RN A stated that if Resident #1's door was opened throughout the night, she would become disturbed in her sleep. RN A stated that during her shift on 07/30/25, Resident #1 had nausea and was vomiting due to her having some health issues. RN A stated that she did not Check-In with Resident #1 during her shift because she became busy with tasks such as assisting other residents and passing medications to residents. RN A stated that she was doing her rounds around 4:30 AM on 07/30/25, she heard some noise and observed Resident #1 on the floor beside her bed. She stated that Resident #1 stated that she had fallen on the floor after self-ambulating herself to the bathroom. RN A stated that Resident #1 did not know how long she remained on the floor after her fall. RN A stated that Resident #1 had a camera in her room that recorded the resident's fall on 07/30/25. RN A stated that after she observed Resident #1 on the floor, she contacted CNA B and told her that Resident #1 had fallen out of the bed and they picked up Resident #1 and placed her on her bed. RN A stated that Resident #1 complained of dizziness after the fall, and she was given a head-to-toe assessment. Resident #1's head-to-toe assessment revealed a small tear on Resident #1's right elbow. RN A stated that she took Resident #1's vital signs and everything looked good. RN A asked Resident #1 if she needed anything to drink and/or eat and she told her no, she wanted to go to sleep. RN A stated that after the fall, she did not observe any bruises on Resident #1. RN A stated that the x-ray technician came to the facility and gave Resident #1 an x-ray, which revealed no injuries. RN A stated that Resident #1 also received a Neurological Check, which revealed no concerns. She stated that after x-ray technician left Resident #1's room, she went to sleep. RN A stated that after Resident #1's fall, she notified the FM, physician and called the DON and she made an incident report. She stated that she called Resident #1's FM and left a voicemail message informing her about Resident #1's fall. RN A stated that prior to 07/30/25, Resident #1 did not have any history of falls. RN A stated that she could not remember the last In-Service she received on abuse, neglect, falls, and routine resident checks but she had taken the Trainings at least once or twice a week. RN A stated that neglect was when a resident has their Call Light on and the Call Light remains on for a long amount of time and no one answers the Call Light. RN A stated that she was told by the DON and Administrator that she would be suspended from working at the facility pending the facility's investigation on the incident. RN A stated that she was notified by the Administrator that her employment was terminated due to not following the facility's policy, Routine Resident Checks, which stated that Routine Resident Checks should be done on every shift at least every 2 hours. RN A stated that there was a potential risk of Resident #1 being on the floor for 4 hours without any assistance. RN A stated the Resident #1 could have been harmed by being unconscious, have serious injuries and fractures bones. Record review of CNA B's undated statement, Fall Incident Statement revealed, Upon the return from her 45-minute lunch break on 07/30/25 at approximately 4:00 AM, RN A called her to come to [Resident #1's] room because she needed assistance. CNA B stated that she entered the room and observed [Resident #1] on the floor. Resident #1 told CNA B that she went to the bathroom and became dizzy. RN A and CNA B assisted [Resident #1] by placing her into her bed. CNA B gave [Resident #1] the call light and advised her not to attempt to go to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455412 If continuation sheet Page 3 of 8 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 455412 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookhaven Nursing and Rehabilitation Center 1855 Cheyenne Carrollton, TX 75010 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 0600 Level of Harm - Actual harm Residents Affected - Few bathroom without assistance. [Resident #1] told CNA B that she called for help verbally. CNA B stated that she told [Resident #1] that no one heard her and to use the call light for assistance. CNA B stated that [Resident #1] typically walked with the assistance of her walking cane and she was unsure if [Resident #1] used her walking cane when she walked to the bathroom. CNA B stated that [Resident #1's] cane was observed near her bed rail. CNA B stated that [Resident #1] asks for her door to remain shut at all times and she had not entered [Resident #1's] room for a couple of hours during her shift and was unsure how long [Resident #1] was on the floor. [sic] During an observation of Resident #1's room on 08/26/25 at 4:01 PM, revealed that the Call Light was operable and was in reach. Resident #1's wheelchair was observed beside her bed. Resident #1 was not in her room. In a telephone interview with [Resident #1's] FM on 08/26/25 at 4:50 PM, she stated that she was [Resident #1's] RP/FM. The FM stated that Resident #1 was admitted to the facility on [DATE] for Long Term Care. The FM stated that Resident #1 had a camera in her room. The FM stated on 07/30/25 at 5:09 AM, she received a voicemail from RN A stating that she was making rounds throughout the facility and found [Resident #1] sitting on the floor. RN A stated that when she asked [Resident #1] what happened, she said that she was going to the bathroom and she felt dizzy and decided to sit down on the floor. RN A stated that [Resident #1] had some bruising on her right hand and nowhere else. The FM stated that she was asleep when RN A telephoned her and left the voicemail message. The FM stated that she got up around 8:00 on 07/30/25, listened to the voicemail message and thought that it was weird that [Resident #1] would get out of her bed and just sit on the floor because she had never done anything like that in the past. The FM stated that she decided to look at the video camera footage on the day of the incident. The FM stated that the video camera footage revealed that [Resident #1] had a fall on 07/30/25 around 12:30 AM and remained on the floor until about 4:30 AM until RN A seen her and CNA B assisted [Resident #1] with getting back into her bed. The FM stated that she felt like the facility staff were negligent due to no one checking in on her mom for 4 hours. The FM stated that [Resident #1] initially sustained a tear on her right arm near her elbow after the fall. She stated that a couple of days later, Resident #1 had a bruise to her check, left lower leg. The FM stated that Resident #1 had not had any falls prior to being admitted to the facility. The FM stated that she did not want to get anyone at the facility into any trouble, but she felt like the staff were negligent by not checking in on [Resident #1] during the evening shift on 07/30/25. An observation of video footage sent to HHSC Surveyor from Resident #1's FM on 08/26/25 at 5:22 PM revealed the following: On 07/30/25 at 00:56 (12:56 AM) Resident #1 was observed sitting on the edge of her bed upright, with both of her feet on the floor. Resident #1 was observed leaning towards her headboard and grabbing her cane. Resident #1 was observed then standing up, Resident #1 appeared to be unbalanced and attempted to regain her balance. Resident #1 was then observed to take about 10 steps forward when she falls forward and out of view of the camera. The floor was free of any obstacles. Resident #1 did not vocalize anything such as pain or for help. Resident #1 was observed in the bottom corner of the camera getting on her knees then the video ends. On 07/30/25 at 4:38 AM Resident #1 was observed sitting on her buttocks near the middle/bottom half of her bed, her legs are not able to be seen as they are out of view of the camera. Resident #1's cane was observed near her pillow propped up against the bed. Audio can be heard of [RN A] stating she needs help another lady's voice [CNA B] asks, with what and [RN A] says she's on the floor. On 07/30/25 at 4:39 AM, [RN A and CNA B] were observed entering Resident #1's room. RN A was heard stating she's never done this before she can walk and then telling Resident #1 Okay we need to get you up and asks Resident #1 How you feeling? to which Resident #1 was heard saying Good, I think. Both staff members were observed assisting Resident #1 from the floor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455412 If continuation sheet Page 4 of 8 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 455412 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookhaven Nursing and Rehabilitation Center 1855 Cheyenne Carrollton, TX 75010 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 0600 Level of Harm - Actual harm Residents Affected - Few to the bed, Resident #1 was observed telling CNA B that she was going to the bathroom. On 07/30/25 at 4:41 AM, CNA B was observed placing the call light within reach of Resident #1 and both staff [RN A and CNA B] tell Resident #1 to call and to use her call light and they will come help her and Resident #1 replied, Yes I know. On 07/30/25 at 4:42 AM RN A was observed taking Resident #1's vital signs and noted that Resident #1 was hurt on her elbow and asked Resident #1 if she got hurt to which Resident #1 stated yes and CNA B asked her if she hit her head and Resident #1 stated No and shook her head. CNA B then tells Resident #1 that she will be back to clean her elbow. On 08/26/25 at 10:28 AM, an attempted telephone call to CNA B was unsuccessful. In an interview with CNA C on 08/27/25 at 11:50 AM, he stated that he had been employed at the facility for 14 years. CNA C stated that he was not on duty when Resident #1 had a fall on 07/30/25. CNA C stated that he had taken In-Service Trainings on Abuse, Neglect, Falls, Fall Prevention and Routine Resident Checks sometime last month. CNA C stated that In-Service Trainings were conducted by the Abuse Coordinator who is the Administrator. CNA C stated that In-Service Trainings are ongoing and are done every time an incident happened at the facility, such as an allegation of abuse, neglect and resident falls, and call lights. CNA C stated that Routine Resident Checks are to be done every 2 hours or as needed depending on the resident's needs. CNA C stated that if he observed a resident on the floor, he would make sure that the resident was safe and then he would notify his Nurse and inform him/her what happened. CNA C stated that if a resident was left alone on the floor for 4 hours it was resident neglect. He stated that residents should not be on the floor and left unattended for that amount of time, which was excessive. CNA C was able to define and provide examples of resident neglect and was able to provide a detailed understanding of each. CNA C stated that the risk of a resident remaining on the floor for a long period of time can affect a resident's psychological well-being and cause harm such as injuries and fractured bones. In an interview with the CNA D on 08/27/25 at 11:57 AM, she stated that she had been employed at the facility for 5 years. CNA D stated that she was not on duty when Resident #1 had a fall on 07/30/25. CNA D stated that she had taken several In-Service Trainings on Abuse, Neglect, Falls, Fall Prevention and Routine Resident Checks during her tenure at the facility. CNA D stated that In-Service Trainings were conducted by the Abuse Coordinator who is the Administrator, and the DON. CNA D stated that In-Service Trainings are always being done with all staff every time an incident happened at the facility, such as an allegation of abuse, neglect and resident falls, and call lights. CNA D stated that Routine Resident Checks are to be done every 2 hours or as needed, such as if a resident turns on their Call Light. CNA D stated that if she observed a resident on the floor, she would talk to the resident to ensure that the resident was safe and did not need any emergency medical attention. CNA D stated that she would then notify her Charge Nurse and inform him/her what happened. CNA D stated that if a resident is left alone on the floor for 4 hours it is resident neglect. CNA D stated that she was not aware of any residents being abused or neglected at the facility. CNA D stated that if she suspected that a resident was being abused or neglected, she would notify the Abuse Coordinator/Administrator. CNA D stated that a resident should not be on the floor and left unattended for 4 hours, which was too long. CNA D was able to define and provide examples of resident neglect and was able to provide a detailed understanding of each. CNA D stated that the risk of a resident remaining on the floor for a long period of time is that the resident could be seriously hurt or injured, which meant that the resident needed emergency services. In an interview with the Administrator on 08/27/25 at 1:49 PM, he stated that the DON was not available due to being ill and out on Leave. The Administrator stated that on 07/30/25, Resident #1 had a fall during the evening shift and was found on the floor by RN A. He stated that RN A and CNA B assisted Resident #1 back to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455412 If continuation sheet Page 5 of 8 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 455412 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookhaven Nursing and Rehabilitation Center 1855 Cheyenne Carrollton, TX 75010 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 0600 Level of Harm - Actual harm Residents Affected - Few her bed. He stated that RN A asked Resident #1 what happened and how did she fall? He stated that RN A stated that Resident #1 told both staff members [RN A and CNA B] that she got out of the bed and felt dizzy and had fallen on the floor. RN A checked the resident for s/s of any injuries, bruises and marks via a head-to-toe assessment. RN A stated that Resident #1 stated that she was dizzy and the head-to-toe assessment revealed that Resident #1 had a small skin tear on her upper right arm near her elbow. The Administrator stated that Neurological Checks, X-rays, and Skin Assessments were completed on 07/30/25, which revealed that the resident did not have any serious injuries including fractures. He stated that Resident #1's RP and physician were notified after the incident. The Administrator stated that he was informed by Resident #1's FM that a voicemail was received from RN A on the early morning of 07/30/25, which stated that resident had a fall. The FM notified the Administrator and DON and provided video camera footage that revealed that Resident #1 was on the floor for an excess of 4 hours. The Administrator stated that he suspended and later terminated both RN A and CNA B due to them not abiding by the facility's policy for Routine Resident Checks, which were to be done on residents every 2 hours. The Administrator stated that both staff members [RN A and CNA B] admitted that they did not perform routine resident checks during their shift on 07/30/25, which led to Resident #1 being left on the floor unattended. He stated that himself and the DON viewed the videos and stated that both staff members were negligent for leaving the resident on the floor after her fall on 07/30/25. The Administrator stated that he immediately began In-Service Trainings with all staff on Reporting Abuse, and Neglect, Abuse and Neglect, Falls, Falls Prevention, Call Lights, and Routine Resident Checks. The Administrator stated that he also conducted Safe Surveys with residents in the facility, which revealed that the sampled residents did not have any concerns regarding their safety and the care they were receiving at the facility. The Administrator stated that all the In-Service Trainings will be ongoing for all staff monthly. The Administrator stated there was a risk when a resident is left alone unattended on the floor for 4 hours, which meant that the staff did not perform routine resident checks while Resident was on the floor. He stated that there are risks included the resident not having their medical needs and concerns taken care of. The Administrator stated that harm included psychological and mental well-being and serious injuries. On 08/27/25 at 2:47 PM attempted Telephone Calls to RN A and CNA B were unsuccessful. During an observation on 08/27/25 at 2:51 PM, Resident #1 was observed in the Dining Room, sitting alone in a chair with a walking cane beside her. She was well-dressed and groomed and was participating in an activity with other residents. The activity was being conducted by the Activity Director. During an observation and interview with Resident #1 in the dining room on 08/27/25 at 3:15 PM, Resident #1 was observed sitting at a table by herself. There were approximately six residents still sitting in the Dining Room. Resident #1 stated that she had 1 fall since she had been admitted to the facility. Resident #1 stated that on the day of the incident in the middle of the night, she had to use the restroom and attempted to get out of her bed and her legs were weak and she had a fall. Resident #1 stated that she was unable to crawl to her bed to press the call light for help. She stated that she was on the floor for a long period of time, but she was unable to provide a timeframe of how long she was on floor. Resident #1 stated that she did not remember hitting her head on anything during or after her fall from the bed. Resident #1 reported that she had a scrape on her right arm and a bruise on her left leg after she fell. She stated that after she fell onto the floor, she did not yell for help and remained on the floor. She stated that she was not in any pain or distress after she fell on the floor. She stated that she keeps her door cracked throughout the day and night. She stated that RN A saw her on the floor and then CNA B assisted RN A with placing her onto her bed. Resident #1 stated prior to her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455412 If continuation sheet Page 6 of 8 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 455412 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookhaven Nursing and Rehabilitation Center 1855 Cheyenne Carrollton, TX 75010 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 0600 Level of Harm - Actual harm Residents Affected - Few fall on 07/30/25, she had not had any issues in the past getting out of her bed and self-ambulating to the restroom. She stated that she did not recall any staff coming into her room to check on her when she was sleeping. She stated that she does not like to be awakened at night. Resident #1 stated that she feels safe at the facility, and she did not have any concerns regarding the care she was receiving at the facility. An observation of Resident #1 and interview on 08/27/25 at 4:03 PM, revealed that there was a small approximately 1-inch scrape to her upper right forearm and a pink bruise on her left calf. Resident #1 stated that she did not have any other injuries on her body, including her face and head areas after the fall on 07/30/25. Resident #1 stated that she had not had any falls prior to being admitted to the facility. Resident #1 stated that she had not had any falls at the facility since her fall on 07/30/25. Record Review of the voicemail sent to HHSC Surveyor from Resident #1's FM on 08/27/25 at 4:41 PM revealed the following:[RN A] telephoned the FM and stated, Hi [FM} this is the Nurse from [the facility] and this is about [Resident #1]. RN A stated, while making rounds, she was found on the floor in a sitting position. When resident was asked what happened, resident stated that she was going to the bathroom, she felt dizzy so she sat down on the floor and she did not get hurt or anything, just a little bruise on her right hand and nothing else, it was not bleeding just a little scratch and I gave her two medications and I just wanted to let you know, thank you. The Timestamp on the voicemail recording was 07/30/25 at 5:09 AM. On 09/02/2025 at 2:48 PM, an email was received from the Administrator which included a Statement from the DON about Resident #1's fall on 07/30/25. The DON's Statement stated, [DON} was notified by the Nurse, [RN A] that [Resident #1] had fallen in her room. [RN A] was making her rounds when she had [sic] calling for help. [DON] instructed [RN A] to do head-to-toe assessment on [Resident #1] and note any injury, any complaint of pain, any skin swelling or skin breakdown. [DON] also instructed her to inform the family, inform MD and request for x-ray to any body part, and initiate neuro-checks on [Resident #1]. All of the above instructions were carried out by the Nurse [RN A]. In the IDT meeting the next morning, we reviewed the fall and noted that the resident ambulated independently using a cane and liked for her door to be closed when she was in her room, including at nighttime. The x-rays were done and were negative for any injuries for [Resident #1]. The Nurses on each shift were advised to continue monitoring [Resident #1] for pain and emotional distress. The DON's Statement of Fall incident Report on 07/30/20245 was signed by the DON. Record review of facility's policy for Resident Rights, undated, reflected, Policy StatementEmployees shall treat all residents with kindness, respect, and dignity.Policy Interpretation and Implementation1.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity;c. be free from abuse, neglect.2. Staff will have appropriate in-service training on resident rights prior to having direct-care responsibilities for residents. Record review of facility's policy for Abuse Prevention Program, undated, reflected, Policy StatementOur residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from.involuntary seclusion, verbal, mental.Policy Interpretation and ImplementationAs part of the resident abuse prevention program, the administration will:1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff.or any other individual.3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents.4. Require staff training/orientation programs that include such topics as abuse prevention, identification andreporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.5. Implement measures to address factors that may lead to abusive situations, for example:a. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455412 If continuation sheet Page 7 of 8 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 455412 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookhaven Nursing and Rehabilitation Center 1855 Cheyenne Carrollton, TX 75010 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 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide staff with opportunities to express challenges related to their job and work environment.6. Identify and assess all possible incidents of abuse;7. Investigate and report any allegations of abuse within timeframes as required by federal requirements;8. Protect residents during abuse investigations;9. Establish and implement a QAPI [VT15] review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse; and10. Involve the resident council in monitoring and evaluating the facility's abuse prevention program. Record review of facility's policy for Routine Resident Checks, dated 2001, revised July 2013, reflected, Policy StatementStaff shall make routine resident checks to help maintain resident safety and well-being.Policy Interpretation and Implementation1.To ensure the safety and well-being of our residents, nursing staff shall make a routine check on each unit at least once every 2 hours and as needed.2.Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify and change in the resident's condition, identify if the resident has any concerns, and if the resident is sleeping, needs toileting assistance, etc.3.The person conducting the routine check shall report promptly to the Nurse Supervisor/Charge Nurse any changes in the resident's condition and medical needs.4.The Nursing Supervisor/Charge Nurse shall keep documentation related to these routine checks, including the time, identify of the person making checks, and any outcomes of each check. (Note: CNA's may also record this information and provide it to the Nurse Supervisor/Charge Nurse). Event ID: Facility ID: 455412 If continuation sheet Page 8 of 8