Inspection·October 3, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some dated 10/01/25, reflected:*Resident had episodes of verbal and physical behavioral symptoms as evidenced by poor impulse control with a diagnosis of schizophrenia.Facility interventions included: Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document.*Resident had a communication problem related to unclear speech and difficulty understanding and making self-understood.Facility interventions included: Be conscious of resident position when in groups, activities, and the dining room to promote proper communication with others. Record review of Resident #2's Notes written by RN A reflected:09/29/25 11:34 AM .Patient remain stable during this shift but continue to be non-compliant with care and verbally abusive to another resident this morning, the attention of this Nurse was called reporting patient was noted outside at the courtyard auguring with another resident and in the middle of the argument patient pull out a kitchen knife from his shoe, this Nurse immediately went outside at the courtyard and calmly assessed patient and ask patient if he have any knife on him, patient stated yes he has a knife and has taken it back to his room, this Nurse went straight to patient room and got the knife out of patient drawer in his room, this Nurse asked patient if he has any plans of hurting himself or others, patient replied NO this Nurse educate patient on safety precautions that must be observed at all time to keep him and other residents safe and that include not having any sharp object with him at any time and not getting close to any resident during an argument and to report any concerns he may have to the Nurse, supervisor or Administrator, patient verbalized understanding , patient refused his morning meds and bp check this morning, MD/DON notified, all safety and universal Precautions were observed, call light placed within patient reach, will continue to monitor patient. An observation and interview on 10/02/25 at 11:39 AM revealed Resident #2 was in the center of the main hallway. He was seated in his wheelchair with his leg extended out self-propelling in the hallway. The State Surveyor introduced self to Resident #2. Resident #2 started cursing at the State Surveyor and began wheeling himself away. The State Surveyor backed away from the resident. Resident #2 was yelling and cursing at everyone who walked by him. Resident #1 was in her electric wheelchair and propelled towards the State Surveyor. Resident #2 saw Resident #1 and started yelling, cursing and saying, calling the police and let the police come, and I will kill you. Resident #2 repeatedly screamed the sentences at Resident #1. Resident #1 yelled back at him and Resident #2 self-propelled himself towards Resident #1. There were multiple staff in the hallway observing and trying to redirect Resident #2. Resident #1 and the State Surveyor were pushed into the activity room to get away from Resident #2. There were 6 staff members who were trying to keep Resident #2 away from Resident #1. Resident #2 pulled out a lighter. Resident #1 was frantic and said she was afraid of Resident #2 and stayed in her room to get away from him. Resident #1 said Resident #2 had pulled a knife on her on 09/29/25 and she called the police. The police told her they could not do anything but would talk to Resident #2 and the staff. Resident #1 said she wanted to get out of the facility as fast as she could and she had to get her anxiety medication increased because of his behavior towards her. Resident #1 said she had reported the concerns to (unknown) facility staff, but nothing was done and that Resident #2 had the behaviors daily to others as well. Resident #1 said she did not file any grievances about Resident #2 because grievances did not work. An observation on 10/02/25 at 12:15 PM revealed Resident #2 was self-propelling himself in his wheelchair down the hall. At 12:20 PM, Resident #2 self-propelled himself into the dining room. Staff were assisting residents with their meals. Resident #2 passed by Resident #1 who was seated at a dining table. Resident #2 started yelling and cursing at Resident #1. Staff intervened and directed Resident #2 to his table to eat. 3. Record review of Resident #3's quarterly MDS assessment, dated 09/09/25 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455412 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 455412 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Some included post-traumatic stress disorder and bipolar disorder. Record review of Resident #3's care plan, revised 05/08/25, reflected:The resident had a behavior problem related to suicidal ideations and multiple claims regarding suicide attempts with both staff and other residents.Facility interventions included: Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, people involved, and situations. Document behavior and potential causes An interview on 10/02/25 at 11:15 AM with Resident #3 revealed he was awake, alert, and oriented to person, place, time, and situation. He said he did not feel safe at the facility. He said Resident #2 raised his anxiety and he wanted to move to a different facility. Resident #3 said he was not afraid of Resident #2 and could handle himself. A follow-up interview on 10/03/25 at 12:15 PM with Resident #3 revealed on 09/29/25 he was in the smoking area outside. He said Resident #2 was yelling and threatening Resident #1. Resident #2 reached into his tennis shoe and pulled out a butter knife. Resident #3 said Resident #2 threatened to kill him and Resident #1. Resident #3 said he grabbed his grabber stick and told Resident #2 it was bigger than his knife. Resident #2 said he would shoot Resident #1 and Resident #3. 4. Record review of Resident #4's quarterly MDS assessment, dated 10/01/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included schizoaffective disorder, bipolar type. Record review of Resident #4's Care Plans, dated 10/02/25, reflected:The resident had a mood problem related to history of schizoaffective disorder with bipolar and anxiety.Facility interventions reflected: monitor/record/report to medical doctor as needed for mood patterns, signs/symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols. Review of the Provider Investigative Report dated 09/09/25 reflected:The Administrator and the DON concluded that Resident #2 saw his family member coming to visit and got excited to open the door. He then proceeded to move Resident #4 (who was in her wheelchair) out of the way. Resident #4 hit Resident #2 on the hands and Resident #2 hit Resident #4 back. No injuries noted. Staff would continue to redirect and monitor closely. Resident #2 was referred to psych for evaluation and treatment. An interview on 10/02/25 at 11:30 AM with Resident #4 revealed she was awake, alert, and oriented to time and situation. She said there was an incident between her and Resident #2 on 09/09/25. She said she was sitting in her wheelchair speaking to the Activity Director. Resident #2 told her to move. The Activity Director said she told Resident #2 to go around them. Resident #2 said no and pushed Resident #4's wheelchair out of the way. Resident #4 said she hit Resident #2 and he hit her back. She said she felt safe at the facility, but Resident #2 bothered Resident #1 also. Resident #4 said Resident #2 cursed at everyone. An interview on 10/02/25 at 12:35 PM with the DON revealed on 09/09/25, Resident #2 pushed Resident #4's wheelchair and Resident #4 hit Resident #2. Resident #2 hit Resident #4. The DON said the facility sent Resident #2 to a psychiatric hospital for one week . He said the police were called but could not do anything . The DON said Resident #2 was on enhanced supervision. The DON said Resident #2 was very loud. The DON said the facility was trying to send Resident #2 to a psychiatric facility after his actions towards Resident #1 on 10/02/25. The DON said Resident #2 would become abusive and abuse everyone around him. The DON said the staff had been very good about calming Resident #2 down. An observation and interview on 10/02/25 at 12:40 PM with the ADON N revealed he was sitting inside the facility. He was watching Resident #2 who was seated by himself in the smoking area outside. The ADON N said Resident #2 was placed on 1:1 monitoring at 11:45 AM. The ADON N said he did not know how Resident #2 got a lighter on 10/02/25. An interview on 10/02/25 at 1:45 PM with the Administrator revealed he had never observed Resident #2 have the behaviors of cursing and going after residents until 10/02/25. He said he self-reported the incident that occurred between Resident #2 and Resident #4 on 09/09/25 . He said Resident #2 was sent to a psychiatric (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455412 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 455412 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Some facility and returned to the facility with medication changes. The Administrator said the resident had never threatened to kill any residents before 10/02/25. He said he had been trying to get Resident #2 admitted to a different facility following the incident on 09/09/25 and the SW had sent out many referrals. He said that Resident #2 was monitored closely, and staff would redirect him. The Administrator said he did not think Resident #2 was targeting Resident #1. He said Resident #2 had never threatened to kill Resident #1. The Administrator said he did not know of any incident that occurred on 09/29/25 of Resident #2 pulling a knife on Resident #1. He said he did not know how Resident #2 got a lighter on 10/02/25. A follow-up interview on 10/02/25 at 2:10 PM with the ADON N revealed Resident #2 had always been aggressive and some residents knew his temper and would poke the bear to get a reaction. The ADON N said Resident #2 did not threaten to kill residents prior to 10/02/25. The ADON N said to prevent Resident #2 from verbally abusing and going after residents, staff would re-direct them. He said he did not know why Resident #2 was targeting Resident #1 and said one day they would be good together and the next day they were not. He said Resident #2 had not threatened to kill Resident #1 until 10/02/25. The ADON N said on 09/29/25 he and the DON were in a meeting and were told Resident #2 had a knife in the smoking area, but they went outside and did not see a knife. He said he did not know Resident #1 called the police and he did not talk to them. He said he spoke to Resident #1 and Resident #2 about the incident on 09/29/25, but he never saw a knife. He said he did not know Resident #1 had her anxiety medication increased. The ADON N said the Administrator was notified about the incident on 09/29/25. A follow-up interview on 10/02/25 at 2:40 PM with the DON revealed he did not think Resident #2 was targeting Resident #1. The DON said he never heard Resident #2 threaten to kill residents. The DON said Resident #2 was on enhanced supervision to prevent him from verbally abusing and going after residents, but on 10/02/25 he was placed on 1:1 monitoring. The DON said on 09/29/25 Resident #1 and Resident #2 were outside smoking and talking. He said he was not aware of the police being called on 09/29/25 and the Administrator was notified about the incident. The DON said he thought RN A's documentation on 09/29/25 was incorrect because he never saw a knife. The DON said no one spoke to Resident #1 following the incident on 09/29/25. He said Resident #2 was not verbally abusing or threatening Resident #1. The DON said Resident #2 did not specifically curse at anyone. The DON said following the incident on 10/02/25, the facility was looking for another facility for Resident #2. The DON said he did not know that Resident #1 had her anxiety medications increased. An interview on 10/02/25 at 2:50 PM with RN A revealed on 09/29/25, the CNA told her that Resident #2 was in an argument with another resident and had pulled out a knife from his shoe. RN A said she took away the knife and told the DON. She said she did not know if Resident #2 threatened Resident #1. RN A said Resident #1 did call the police about the incident. RN A said all of her notes for 09/29/25 were correct. An interview on 10/02/25 at 3:55 PM with CNA B revealed Resident #2 was a bully to other residents and that the residents were not safe in the facility with him. An interview on 10/02/25 at 4:08 PM with CNA C revealed she was working on 09/29/25. She said Resident #2 had aggressive behaviors. She said the residents at the facility were not safe because there had been too many times when staff had to break up incidents between Resident #2 and other residents. She said on 09/29/25 Resident #1 and Resident #2 were outside smoking. Resident #1 and Resident #2 were bickering. CNA C said she was very scared, and she tried too re-direct him. Resident #2 said to Resident #1, I will cut you mother f***er and slice and dice you. CNA C said she searched and did not see the knife. An interview on 10/03/25 with an Anonymous person revealed Resident #2 had been threatening and going after residents since he was admitted . The Anonymous person said Resident #2 made specific threats including threatening to hit Resident #1 prior to 10/02/25. The Anonymous person (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455412 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 455412 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Some said the DON did not address the issues of Resident #2. The Anonymous person said Resident #2 was not safe to be around other residents. An interview on 10/02/25 at 2:40 PM with the SW revealed she was told on 10/02/25 to find a facility for Resident #2 to go to. She said when Resident #2 returned from the psychiatric facility on 09/09/25, residents were very upset. The SW said she was told by the Administrator not to find him a different place to live, because he was their resident and they were going to make it work. Record review of the facility policy, Abuse Prevention Program, not dated, reflected:Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This was determined to be an IJ on 10/02/25 at 4:40 PM. The Administrator and the DON were notified. The Administrator was provided the IJ template on 10/02/25 at 4:50 PM. The following Plan of Removal was submitted by the facility and was accepted on 10/03/25 at 11:20 AM and reflected the following:Resident #2 was immediately placed on 1:1. Local law enforcement were called while alternative placement is being sought. At 3:45 PM Resident #2 was sent to the hospital for further evaluation and treatment. Resident # 2 returned to the facility at 10:00 PM and was placed on 1:1. Continue effort to find alternative placement. Discharge notice will be given after discussion with family. Will remain 1:1 until placement is found.Resident #1 was removed from Resident #2, and a head to toe was completed on Resident #1. The resident was found to be at their normal baseline, in addition had a trauma informed assessment was completed by the social worker and a psych referral was made for further assessment, Resident #1 was emotionally reassured of their safety and educated on the additional support. Facility Psych services contacted with no new order.The Ombudsmen were notified via email.The attending physician/Medical Director and family /responsible parties of both Residents #1 and # 2 were notified.On 10/02/25 safe surveys were initiated on all interviewable residents, no pattern or concerns were identified nor noted.Head-to-toe assessments were initiated on all nonverbal residents with no pattern or evidence of any deviation from all of the residents' normal baseline status.Resident #1 family/representative offered police intervention/reporting.State Self Report was initiated, intake # pending.Systematic ApproachOn 10/02/2025 An ad hoc QAPI meeting was held, in attendance were the: Medical Director (via TEAMS), Executive Director, DON and the Regional [NAME] President of Operations to review appropriate interventions and to review our present Policy and Procedures on: Abuse Prevention, Timely Reporting and Documentation. Review of the present policies was found to be sufficient and met state and federal requirements.EducationOn 10/02/25 The Abuse Prevention Coordinator was in re-serviced by the Regional [NAME] President of Operations, on the Abuse Prevention Protocol, to include a questionnaire and in service on abuse and neglect.Beginning on 10/02/25 - All staff were re-inserviced by the Administrator /Director of Nursing Services and/or Manager on Abuse Prevention Protocol/Reporting and Documentation.On 10/02/25 Additional Inservice's with competency were added for all staff: In addition, each staff member began inservicing with competency on Abuse Prevention/Timely Reporting and Documentation and Managing Residents with Behaviors.Any staff who were not present to complete the in-service by 10/02/25 would be required to complete the in-services at the start of their next shift before beginning work. New hires and PRN will also be in service prior to the start of their shift. The education will be conducted and monitored by the DON/Designee.MonitoringResident safe surveys and/or head to toe assessments will be conducted weekly x 4 weeks on all patients, then monthly x 3 months with oversite from the facility DON and Administrator.Employees will complete Abuse questionnaires / and in-servicing weekly x 4 weeks then monthly x 3 months with oversite and monitoring from the facility DON and Administrator.Quality AssuranceIn-servicing on Abuse and Neglect and any associated concerns will be included in the facility's monthly QAPI meeting for 3 months to include the Medical Director with oversight from the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455412 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 455412 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Administrator and DON. Monitoring the facility's Plan of Removal included the following: Record review of Resident #1's clinical records revealed the resident was assessed by the facility on 10/02/25. No injuries were noted. The Family Nurse Practitioner was notified. Record review of Resident #2's clinical records revealed the resident was sent to the hospital on [DATE] but returned to the facility the same night. The resident was placed on 1:1 monitoring. An observation on 10/03/25 at 12:20 PM revealed Resident #2 was sitting in his wheelchair in the hallway with the Administrator and transport drivers with a stretcher in the hall talking to the resident. On 10/03/25 at 12:35 PM Resident #2 got onto the stretcher and left the facility with the transport drivers. Interviews were conducted on 10/03/25 from 1:15 PM to 4:30 PM with staff from various shifts. The staff included LVN D, LVN E, CNA F, LVN G, CNA H, CNA I, CNA J, CNA K, CNA L, and the SW.All staff were able to identify:What abuse was and the different types of abuse. The staff understood abuse had to immediately be reported to the Administrator. An interview on 10/03/25 at 3:00 PM with the DON revealed his roles in the facility plan of removal included: Resident #2 was in a psychiatric hospital and when he returned, he would be placed on 1:1 monitoring. The DON said he spoke to Resident #1 and she was doing well. He said he completed a trauma and emotional assessment, and she was not fearful. The DON said he would ensure all assessments were completed and he would monitor residents for any signs and symptoms of distress, anxiety, or disturbance and ensure residents did not make threats to other residents. An interview on 10/03/25 at 3:20 PM with Resident #1 revealed she was upset. She said she was terrified about Resident #1 returning to the facility. She said the DON spoke to her and she told him she was still afraid of Resident #2. An interview on 10/03/25 at 3:55 PM with Resident #1 and the Corporate Nurse revealed prior to the conversation, Resident #1 did not feel safe. She was afraid Resident #1 would return to the facility, and she would be threatened by him or even discharged . The Corporate Nurse reassured the resident and told her Resident #1 would not be returning to the facility and she was not going to be kicked out. Resident #1 told the State Surveyor that after speaking with the Corporate Nurse she felt safe. An interview on 10/03/25 at 4:22 PM with the Administrator revealed he wanted to find Resident #2 a new placement. He said if the resident came back, he would be placed on 1:1 monitoring. He said Resident #2 was not appropriate to stay at the facility. He said he spoke to Resident #1 on 10/02/25 and she was fine. He said he had told the nurses to check with her every 1-2 hours and if anything was concerning at all to give him a call. He said his role in the Plan of Removal would be monitoring to ensure resident safe surveys and/or head-to-toe assessments would be conducted weekly x 4 weeks on all patients, then monthly x 3 months. Employees would also complete abuse questionnaires/and in-servicing weekly x 4 weeks then monthly x 3 months. An IJ was identified on 10/02/25. The IJ template was provided to the facility on [DATE] at 4:50 PM. While the IJ was removed on 10/03/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on the Plan of Removal. Event ID: Facility ID: 455412 If continuation sheet Page 6 of 6