Health inspection·January 7, 2026

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few room, appeared calm, and was in no apparent physical or emotional distress at the time of the observation. Psyche NP B documented Resident #1 had dementia and insomnia with cognitive impairment. Chart review by NP B noted no supporting evidence to validate diagnosis of schizophrenia or schizoaffective disorder and Psyche NP B documented those diagnoses should be removed from Resident #1's medical record due to lack of evidence. Resident #1's current psychotropic medications were reflected as Seroquel (for agitation), Depakote sprinkles (for mood disorder), Trazadone (for agitation and dementia) and Remeron (for insomnia). Record review of nursing progress notes for Resident #1 reflected:-12/17/25 at 3:05 p.m.by LVN A, Resident noted with more jumpy behavior and combative during care and continues to have an outburst episodes, yelling mama, mama, and trying to kick staff, pt requires more cues to eat, redirected and educated multiple times but not effective, Pt vital signs WNL BP-106/66, P-63, R-18, T-97.7, Spo2- 97% RA, behavior reported to Psych NP. No new order.-12/24/25 at 9:05 p.m.by LVN A, Resident continues with outburst and aggressive behavior, yelling mama, mama, and trying to kick staff, pt redirected and educated several times but not effective, was reported to NP psych N/O received Xanax 0.5 mg PO every 6 hrs. PRN x 14 days r/t restlessness and agitation. Resident and family notified. MAR updated.-12/30/25 at 8:25 a.m.by LVN A, Late Entry: Note Text: Writer obtained order for prn Haldol IM inj, all orders carried. Will continue to update chart prn.-12/30/25 at 3:06 p.m.by LVN A, Resident continues with outburst and aggressive behavior, yelling mama, mama, and trying to kick staff, when brought to the dining area this AM resident started knocking down the chair and the tables, when redirecting, resident become more restless and agitated, hitting, scratching and kicking the staff members including this writer, he was quickly move out from the dining area and brought back to his room, this writer stayed with him notified DON, ADON and MD, N/O order obtained Haloperidol 5mg/ml Inject 1ml intramuscularly one time only as needed. MAR updated, resident and family informed.-12/30/25 at 3:09 p.m. by LVN A, Xanax 0.5 mg 1 tab PO was administered but not effective.-12/30/25 at 3:22 p.m. by LVN A, Late Entry: Also noted pt has a scratch to the right side of face.-12/30/25 at 3:29 p.m. by LVN A, The resident later calmed down and ate his breakfast 100% and lunch meal 100% with fluid as tolerated. Family members came visiting and later left. Plan of care continues.-12/31/25 at 9:25 a.m. by LVN A, Resident observed with disruptive behavior during care this Am. Haloperidol 5mg/ml 1ml intramuscular was administered per order. Pt. tolerated well with no adverse reaction noted. An observation and interview with Resident #1 was attempted on 01/07/26 at 1:46 p.m. and revealed he did not eat his lunch and his full plate of food was in front of him on the table. His eyes were closed and he was slightly slumped over in his wheelchair. A CNA tried to rouse him and he then jerked his body a few times in waking up and began slowly eating. Resident #1 was not responsive to questions and kept his eyes closed, including through eating his food. He was observed to be in a wheelchair, elderly and not able to particulate in an interview. He was not observed to have any visible injuries on his face, hands or arms at the time of the observation. An interview with CNA B on 01/06/25 at 1:22 p.m. revealed she worked in the secured unit on the morning shift, took care of Resident #1 for about a year and was very familiar with his behaviors and care needs. CNA B stated on the morning of 12/24/25, she was the CNA responsible for Resident #1. She said that morning, Resident #1 had stool in his brief and needed to be changed. She stated sometimes he did not want care, and when that happened, she went to the charge nurse for assistance. On that morning (12/24/25), CNA B said she notified LVN A that Resident #1 was resisting ADL care. LVN A came to assist with care and they placed Resident #1 in his wheelchair and took him to the dining room. She stated while in the dining room, Resident #1 began knocking on the table and making noise. She stated that behavior happened once in a while but not every day. CNA B stated because of the noise and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455463 If continuation sheet Page 2 of 13 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 455463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Health and Rehabilitation Center 8383 Meadow Rd Dallas, TX 75231 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reactions of the other residents, she and LVN A decided to remove Resident #1 from the dining room to prevent further problems. She stated Resident #1 was taken back to his room and placed in bed so he would calm down and would not start pulling at other residents. She stated Resident #1 did not slap or hit any other residents during the dining room incident. CNA B stated if a resident hit staff, staff were not supposed to do anything back. She stated the usual response was to remove the resident from the situation and give them time to calm down. She stated that sometimes nursing staff administered medication to calm Resident #1 when he got agitated. CNA B stated that after time in his room, Resident #1 typically calmed down. CNA B stated after the incident on 12/24/25, she did not observe any bruises or injuries on Resident #1 when showering or providing care. An interview with CNA D on 01/06/25 at 1:30 p.m. revealed she reported a concern of abuse regarding Resident #1 and alleged there were failures by the facility leadership to appropriately report, investigate and protect staff from retaliation after her concerns were raised. CNA D stated that on or around 12/30/25 the previous week, concerns were reported regarding Resident #1 following a behavioral incident in the secured dining room. She reported a staff member (confidential) contacted her and expressed fear about reporting what occurred. CNA D stated the staff member believed staff on the secured unit was aggressive with Resident #1 during redirection and harmed the resident. CNA D stated she had photos of the resident's injuries and showed them to ADON G. CNA D stated when ADON G was informed of the incident, ADON G said she already knew about it and Resident #1 was not injured but struck LVN A's nose and caused injury. CNA D stated she asked ADON G if Resident #1 was assessed for injuries and ADON G instructed her to show the photos to LVN A and wanted the nurse to document any injuries. CNA D was concerned the person she was asked to show the photos to (LVN A), could possibly be involved, but she showed them to LVN A as directed. CNA D stated she was unaware of any meaningful follow-up or reporting to HHSC as a facility incident. She said she believed the facility failed to initiate a formal abuse or injury of unknown source investigation and failed to remove alleged involved staff from Resident #1's care. CNA D said she felt that instead of focusing on the resident's safety concern, leadership focused on the fact that photographs were taken of Resident #1. CNA D believed after that, she was targeted by leadership and corporate for 1) having unauthorized photos of Resident #1, 2) not identifying where the photos originated and who took them, and 3) not notifying corporate of her concerns prior to her reporting alleged abuse to State. CNA D expressed concern that facility leadership was not truthful about events and emphasized the situation involved peoples' loved ones. Regarding leadership involvement, CNA D stated she believed the administrator, who was the A/N coordinator, was on vacation during this incident and the DON served as the manager and abuse/neglect coordinator in his absence. Record review of photos provided via email (not time stamped or dated) provided by CNA D from a confidential source on 01/06/25 of Resident #1 reflected:1) long thin dark red scratch breaking the skin down the left side of Resident #1's face/cheek,2) right side of his face, small bloody scratch on upper cheek and left eye had slight discoloration,3) right mid-forearm had a reddened area that looked like a hand wrap or finger pressure, and4) left hand had a lighter reddened area on top of his hand. An interview with LVN A on 01/06/25 at 2:13 p.m. revealed she was the charge nurse on the secured unit. LVN A stated on 12/24/25, CNA B reported Resident #1 was being kind of resistant. He had a bowel movement and CNA B was trying to provide incontinent care. LVN A said she did not observe Resident #1 being resistant, but CNA B told her that he refused to let her turn him to provide incontinent care. LVN A stated, You know, she [CNA B] asked him to roll over, but he didn't want to, he wanted to stay on his back. LVN A said when she went to his room, she talked to him and said please and Resident #1 was compliant, so they got him dressed and took him to the dining room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455463 If continuation sheet Page 3 of 13 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 455463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Health and Rehabilitation Center 8383 Meadow Rd Dallas, TX 75231 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Once in the dining room, Resident #1 was sat at a table where nobody else sat and started screaming mama mama! LVN A said Resident #1 knocked down a table and pushed a chair, so for the safety of the other residents, he was taken back to his room by herself and CNA B. LVN A stated she did not touch Resident #1 in the dining room and although he was trying to stand up, he sat back down on his own. She said Resident #1 hit her on the nose while trying to remove him from the dining room. When she got him back to his room, LVN A stated she asked Resident #1 if he was okay and he said no and kept repeating mama, mama, mama, mama. LVN A stated she then transferred him back to bed with CNA B, contacted the doctor, ADON G, and stayed with him until he calmed down. LVN A said Resident #1 calmed down through her talking to him. She said once he was calm, she administered him a PRN Xanax. LVN A stated, He was not really calmed down, but not like aggressive as before. So, I gave it to him to calm down. She said Resident #1 then ate his breakfast and went to eat lunch in the dining room later and was quiet in his demeanor. LVN A stated a couple of days later (date unknown-morning), Resident #1 was destructive and combative. She said CNA B went to get him up and he was tried to fight with her, so LVN A went to see what was going on. She stated Resident #1 was kicking at the air from his bed towards CNA B and herself. LVN A said he was combative and tried to kick her when she approached him. LVN A stated, So I said because I have an order for it (Haldol), well let me give it to him. She said he calmed down after the intramuscular medication administration. LVN A stated she did not have to restrain Resident #1 to administer the IM Haldol or hold his arm during administration because he was lying in bed. After the incident (date unknown), LVN A stated CNA D came to her with photos of Resident #1 on her phone and but LVN A did not know why and said CNA D was flipping through them so fast she could not see any specific details. She stated CNA D was concerned that Resident #1 had a scratch down the side of his right cheek, But it was self-inflicted. LVN A stated she witnessed Resident #1 scratch his own face. She stated he was wild, describing him as flailing his limbs and kicking. An interview with ADON G on 01/06/26 at 3:10 p.m. revealed she was present on 12/24/25 when Resident #1 had a behavioral escalation that involved throwing tables and chairs. ADON G said the incident occurred while an HHSC State investigator was present elsewhere in the building for a complaint investigation. She stated she received a text notification Resident #1 was throwing furniture and was returned to his room for safety. She stated she and the scheduler went to the secured unit shortly thereafter. ADON G stated Resident #1, at that time, was in his room with his breakfast tray present, standing near the bed. ADON G sated Resident #1 appeared agitated and fidgeted with paper. She stated she verbally redirected him, asking if he was hungry and encouraged him to sit and eat. She stated Resident #1 complied, sat down and began eating. She exited the room once he appeared calm. The next day, she stated CNA D approached her while she was working the floor and asked if she saw Resident #1 because he had scratches and bruising on his wrists. ADON G stated she told CNA D there was a known behavioral incident the prior day involving furniture throwing and staff injury. ADON G stated CNA D showed her photos depicting redness/scratches, which ADON G described as redness rather than broken skin. ADON G stated she did not believe the photos indicated abuse and felt any markings were a result of the known behavioral episode involving Resident #1 throwing furniture and redirected by staff. ADON G stated CNA D alleged abuse by staff, though not naming a specific staff member. ADON G stated she did not believe abuse occurred because staff actions were redirection and guidance rather than physical restraint or rough handling. ADON G stated she asked CNA D to show the photos to LVN A to ensure documentation and follow-up were completed. ADON G later spoke with LVN A in front of CNA D to confirm that documentation, body assessment and physician notification were completed. ADON G stated she advised CNA D the issue was addressed and that CNA D was not privy to internal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455463 If continuation sheet Page 4 of 13 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 455463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Health and Rehabilitation Center 8383 Meadow Rd Dallas, TX 75231 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few investigative processes. ADON G stated she notified the DON of the allegation and concern that staff were stating they intended to contact the State. ADON G said the DON asked whether a body assessment was completed and ADON G reported that she personally did not observe injuries when she assessed Resident #1 after the incident. ADON G stated no internal abuse investigation was initiated at the facility level because leadership believed the source of any markings was known and related to resident behavior. She stated corporate later became involved after State surveyors arrived at the facility on 01/03/26. ADON G also stated that CNA D's dissatisfaction with facility leadership's response to the allegation of possible abuse led to her reporting the concern to the State. ADON G stated when staff raised allegation concerns, the facility leadership should evaluate the resident's safety, complete assessments, notify the physician and family as appropriate and separate residents in resident-to-resident situations. She stated staff were encouraged to report concerns to leadership, who then would determine the next steps. ADON G stated decisions regarding facility incident reporting requirement and investigations were primarily managed by the DON and Administrator. She stated she deferred detailed reporting process questions to those roles. Record review of Resident #1's skin checks on 12/31/25 and 01/02/26 reflected no bruising or scratches noted. An interview with the DON on 01/06/26 at 4:05 PM revealed she became aware of concerns involving Resident #1 on 01/03/26. Prior to that time, she had limited awareness of staff concerns and was informed by ADON G that a CNA heard Resident #1 sustained a facial injury and wrist bruising. The DON stated nursing staff completed a full skin assessment which revealed no injuries, no bruising, no scabbing and no evidence of healing wounds. She stated Resident #1 recently exhibited significant behavioral escalation, including throwing furniture and striking a nurse and that any redness or marks reported were believed to be related to Resident #1's own agitation and movement during redirection. The DON stated she did not personally view photographs of Resident #1 from CNA D and was not aware of their existence until 01/03/26. The DON stated staff statements were requested but not all were received and interviews had occurred and a review was ongoing. She said the facility did not identify the situation as meeting criteria for a mandatory report to HHSC as no injuries were identified and Resident #1's behaviors were documented and addressed. The DON said no staff were suspended or removed as alleged perpetrators. The DON stated that internal facility investigations were not a substitute for reporting to HHSC, but reporting was not warranted based on the findings. She stated that clearer communication with staff regarding reporting requirements and decision-making could have been beneficial. She stated facility protocols were followed appropriately and that no abuse, neglect or injury of unknown source was identified. An interview with C-RN F on 01/07/25 at 10:35 a.m. revealed she first became aware of any concerns about Resident #1 on Saturday 01/03/26 when HHSC did a complaint investigation related to Resident #1. She stated no staff had brought concerns to her prior to that time about abuse or injuries for Resident #1. C-RN F stated she did not personally view photographs of Resident #1 and did not initiate an internal investigation, deferring to the state investigation that was conducted on 01/03/26. She reported ADON G told her on that date she saw photos on a CNA's phone for Resident #1, but could not verify the origin, date or accuracy of the photos. C-RN F stated the CNA in question (CNA D) declined to provide further information regarding who took or sent the photos. C-RN F stated that when she assessed Resident #1 on 01/03/26, she did not observe visible injuries. She emphasized that without observable injury or verifiable photo evidence, she could not confirm abuse. She stated that witnesses were reportedly present during the incident and framed the situation as staff attempting to keep other residents safe during a behavioral incident. C-RN F stated allegations of abuse or injuries of unknown origin should be reported when identified by staff and there were internal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455463 If continuation sheet Page 5 of 13 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 455463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Health and Rehabilitation Center 8383 Meadow Rd Dallas, TX 75231 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few discussions and application of an algorithm for abuse determinations, including injury of unknown origin. C-RN F stated if a CNA alleged abuse, management's responsibility was to notify leadership (ADON, DON, Administrator) and collectively determine next steps. She stated that in the case with Resident #1, she did not believe an allegation of abuse was made because CNA D reportedly did not use that term. C-RN F was asked whether the use of the word abuse was required to trigger reporting obligations to HHSC. She stated that proof and facts were critical, rather than belief. An interview with the ADM on 01/07/26 at 1:30 PM revealed he was the abuse/neglect coordinator and the week of 12/29/25 was not onsite at the facility. He stated he became aware of concerns involving Resident #1 on 01/03/26 when an HHSC surveyor arrived with allegations related to mistreatment of Resident #1. The ADM said corporate became involved because he was not present to assist with the situation. He said that in-services were initiated upon his return, including HIPAA and abuse/neglect education and those types of in-services were typically conducted when issues arose. The ADM stated his understanding of what occurred was photographs may have been taken or circulated in the facility, which prompted a HIPAA in-service. He stated assessments of Resident #1 conducted around that time reportedly showed no redness, bruising or visible injury. The ADM stated he was not informed of the situation while on vacation and learned of it upon returning to work. He stated that if he was unavailable, abuse and neglect concerns would typically start with the DON with corporate assisting if present. The ADM said an internal facility review was not a substitution and when staff raised abuse concerns, those concerns were investigated and documented as necessary. The ADM expressed concern regarding any unauthorized photographs of residents and stated that photographs should only be taken by appropriate personnel to include mainly a physician who was sent wound care photos by a nurse. The ADM stated he believed the photos of Resident #1 may have been used in a gotcha manner rather than through appropriate reporting protocols. An interview with CNA E on 01/07/26 at 1:55 PM revealed she was visibly emotional and tearful. She repeatedly expressed fear of retaliation and concern that speaking up could place her employment at risk. CNA E described Resident #1 as not normally aggressive and stated repeatedly, That man is not aggressive. She stated that she had worked with Resident #1 regularly since beginning her employment at the facility three weeks prior and had not observed him engaging in violent or combative behaviors. She stated that when she assisted Resident #1 with care, she was typically able to get him up, talked to him and redirected him without difficulty. On the morning of the incident (12/24/25), CNA E stated she first became concerned when she heard commotion and distress sounds coming from the dining room area. She stated she heard loud voices and raised tones and stated that the situation didn't feel right. She observed Resident #1 being brought into the dining room and he appeared upset, confused, was attempting to communicate but struggling to express himself clearly. She recalled him repeating fragments such as feel, feel, feel. CNA E stated she was able to calm Resident #1 by speaking softly and reassuring him, telling him, [NAME], it's me. She emphasized that this approach worked and helped him de-escalate. In contrast, she described the other staff, specifically CNA B and LVN A using loud, commanding voices and repeatedly telling Resident #1 to sit down, sit down! which she felt escalated the situation. She stated, Y'all didn't give him time, and explained that residents had the right to be mad and had the right to be left alone for a little while. She stated staff kept giving him commands rather than allowing him time to calm down. CNA E stated after the dining room incident, Resident #1 was taken back to his room. She stated she never saw Resident #1 flip tables or chairs and stated that while he may have pushed against furniture, he did not have the physical strength to seriously harm others. She stated she did not see him assault other residents and did not believe he posed the danger later described by staff. After Resident #1 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455463 If continuation sheet Page 6 of 13 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 455463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Health and Rehabilitation Center 8383 Meadow Rd Dallas, TX 75231 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete taken to his room, CNA E stated she observed physical injuries, including blood running down the side of his face, bruising, and swelling. She specifically noted swelling around the eye and bruising to the wrist and hand. CNA E expressed concern that following the incident, staff began characterizing Resident #1 as aggressive. She stated, That's not fair to him, and That's not fair to his family. CNA E stated she did not feel safe reporting concerns internally, explaining that trying to report through the Abuse/Neglect Coordinator's Phone number posted at the time was just the number to the facility, not the ADM. She reported hearing comments suggesting management would find out who called the state, which she perceived as threatening. She stated this reinforced her fear of retaliation and made her reluctant to report concerns. CNA E stated her main concern was that Resident #1 may have been harmed during a behavioral episode that she felt was escalated by staff actions. Record review of the facility's protocol for following reporting requirements reflected, Provider Letter PL 2024-14, Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility Must Report to the Health and Human Services Commission, dated 08/29/24. In the PL 2024-14, it reflected, .A NF must report to CII the following types of incidents, in accordance with applicable state and federal requirements: Abuse, Neglect. Suspicious injuries of unknown source. A NF is not required to report to CII: serious bodily injury or other injury that is NOT suspicious or of unknown source and that is NOT related to abuse; serious bodily injury or other injury that is NOT suspicious or of unknown source and that is NOT related to neglect, exploitation, or mistreatment; injury that is not suspicious or of unknown source;. State and federal law requires an owner or employee of a NF that has cause to believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect, or exploitation (ANE) caused by another person to report the abuse, neglect, or exploitation. NFs must report all suspected or alleged incidents involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property. A NF must report these incidents to CII. HHSC rules define abuse as: ‘The negligent or willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident'.CMS defines abuse as: ‘The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Event ID: Facility ID: 455463 If continuation sheet Page 7 of 13 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 455463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Health and Rehabilitation Center 8383 Meadow Rd Dallas, TX 75231 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for one (Resident #1) of four residents reviewed for care plans. The facility failed to develop and implement a care plan for Resident #1 that was individualized to his care needs, which included psychotropic medications, dementia and related behaviors, and acute use of PRN antipsychotic medication after a behavioral incident. This failure could place residents at risk for inappropriate responses to behavioral symptoms and inappropriate use of psychotropic medications.Findings included: Record review of Resident #1's face sheet, dated 01/07/26, reflected he was an [AGE] year-old male, admitted on [DATE]. Resident #1's diagnoses included metabolic encephalopathy (a brain dysfunction caused by systemic metabolic disturbances, leading to symptoms like confusion, memory loss and altered consciousness), vascular dementia (a type of dementia caused by reduced blood flow to the brain, leading to cognitive decline and memory issues), diabetes (a chronic condition where the body can't effectively use or produce insulin, leading to high blood sugar), schizophrenia disorder (a chronic brain disorder causing symptoms like hallucinations, delusions, disorganized thinking and reduced emotional expression), schizoaffective disorder (a serious mental illness blending symptoms of schizophrenia hallucinations, delusions with a mood disorder), and insomnia (difficulty sleeping). Record review of Resident #1's quarterly MDS assessment, dated 10/29/25, reflected a BIMS score of 06 which indicated severe cognitive impairment. Resident #1 had no signs or symptoms of delirium, no negative mood problems identified, and no verbal or physical behaviors directed towards others. Resident #1 had range of motion impairment on both sides of his lower extremities and used a walker as a mobility device. He required moderate/partial assistance for all ADLs and was frequently incontinent of bowel and bladder. Resident #1 received high-risk medications which included antipsychotic, antidepressant and hypoglycemic medication. Record review of Resident #1's current care plan, initiated 12/29/25, reflected no identified behaviors and no use of psychotropic medications. The current care plan did not discuss the acute behavioral incident on 12/24/25 and 12/31/25 and the new orders obtained for PRN medication. The previous care plan initiated in December 2024 (separate document) reflected Resident #1 took antipsychotic medication, had a diagnosis of vascular dementia and schizophrenia and required psychotropic medication for insomnia. The previous care plan did not indicate any identified behavioral issues or psychological concerns. Record review of Resident #1's physician order summary printed 01/06/25 reflected Resident #1 was prescribed the following medications: Haloperidol Lactate Injection Solution 5ml intramuscularly once time only related to restlessness and agitation for one date (Start Date: 12/30/25 4:15 PM), Xanax Oral Tablet 0.5mg give once every six hours as needed for restlessness and agitation for 14 days (Start Date 12/24/25 at 10:00 PM), Mirtazapine 7.5 mg once at bedtime for insomnia (antidepressant, start date 09/23/25), Seroquel Oral Tablet 200 mg two times a day for vascular dementia without behavioral disturbance (start date 12/03/25), Trazadone 50 mg give 0.5 tablet by mouth three times a day for depression (start date 10/01/25) and Depakote Sprinkles 125mg- give four capsules by mouth two times a day related to vascular dementia (Start date 10/23/25). Review of Resident #1's December 2025 MAR reflected he was administered prn Xanax on 12/28/25 at 8:03 a.m. The MAR also reflected he was administered prn IM Haldol on 12/31/25 at 7:20 a.m. An interview with LVN H on 01/07/26 1:17 p.m. revealed she was the MDS nurse and she was responsible for care planning residents prescribed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455463 If continuation sheet Page 8 of 13 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 455463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Health and Rehabilitation Center 8383 Meadow Rd Dallas, TX 75231 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete psychotropic medications. LVN H stated around November 2025 the facility underwent a change of ownership. At that time, the existing care plans did not transfer to the new online system. As a result, all the residents' care plans had to be recreated. LVN H said rebuilding the care plans for a large number of residents while also managing MDS responsibilities was challenging as she was the only person doing it. She stated care plan conferences continued to occur with interdisciplinary participation, but individualized care plans required extensive reconstruction. LVN H stated Resident #1 was on her list, however, during this care plan transition time frame, she had not updated his yet. LVN H was uncertain if she was the only person who could update care plans for acute and new issues. She stated licensed nurses should be capable of initiating care plan updates as well as when clinically significant changes occurred. LVN H stated the importance of individualized behavior-based care planning for residents with dementia and psychotropic medication use and stated the care plans should include specific behaviors, triggers and interventions to guide nursing care. Review of the facility's policy titled, Comprehensive Person-Centered Care Plans, revised March 2022 reflected, .7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including.10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers; 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. Event ID: Facility ID: 455463 If continuation sheet Page 9 of 13 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 455463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Health and Rehabilitation Center 8383 Meadow Rd Dallas, TX 75231 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 each resident's drug regimen was free from unnecessary drugs for one (Resident #1) of four residents who were reviewed for psychotropic medications. The facility failed to ensure Resident #1, who had a diagnosis of dementia, was administered PRN Haldol (antipsychotic) with adequate indications for its use. The facility nurse administered PRN Haldol intramuscularly when Resident #1 refused ADL care and was combative. This failure could place residents at risk for being administered unnecessary antipsychotic medication to control behaviors and could have adverse side effects including over-sedation, confusion and decreased quality of life.Findings included: Record review of Resident #1's face sheet, dated 01/07/26, reflected he was an [AGE] year old male, admitted on [DATE]. Resident #1's diagnoses included metabolic encephalopathy (a brain dysfunction caused by systemic metabolic disturbances, leading to symptoms like confusion, memory loss and altered consciousness), vascular dementia (a type of dementia caused by reduced blood flow to the brain, leading to cognitive decline and memory issues), diabetes (a chronic condition where the body can't effectively use or produce insulin, leading to high blood sugar), schizophrenia disorder (a chronic brain disorder causing symptoms like hallucinations, delusions, disorganized thinking and reduced emotional expression), schizoaffective disorder (a serious mental illness blending symptoms of schizophrenia hallucinations, delusions with a mood disorder), and insomnia (difficulty sleeping). Record review of Resident #1's quarterly MDS assessment, dated 10/29/25, reflected a BIMS score of 06 which indicated severe cognitive impairment. Resident #1 had no signs or symptoms of delirium, no negative mood problems identified and no verbal or physical behaviors directed towards others. Resident #1 had range of motion impairment on both sides of his lower extremities and used a walker as a mobility device. He required moderate/partial assistance for all ADLs and was frequently incontinent of bowel and bladder. Resident #1 received high-risk medications which included antipsychotic, antidepressant, and hypoglycemic medication. Record review of Resident #1's current care plan, initiated 12/29/25, reflected no identified behaviors and no use of psychotropic medications. The current care plan did not discuss the acute behavioral incident on 12/24/25 and 12/31/25 and the new orders obtained for PRN medication. Record review of Resident #1's previous care plan initiated in December 2024 reflected Resident #1 took antipsychotic medication, had a diagnosis of vascular dementia and schizophrenia and required psychotropic medication for insomnia. The previous care plan did not indicate any identified behavioral issues or psychological concerns. Record review of Resident #1's psychiatric follow-up evaluation, dated 12/17/25, by Psyche NP B, reflected the resident was seen for medication monitoring and management of psychotropic medications following reports of irritability, restlessness and need for redirection and cues from staff. The evaluation reflected Resident #1 was observed eating lunch in the dining room, appeared calm, and was in no apparent physical or emotional distress at the time of the observation. Psyche NP B documented Resident #1 had dementia and insomnia with cognitive impairment. Chart review by Psyche NP B noted no supporting evidence to validate diagnosis of schizophrenia or schizoaffective disorder and Psyche NP B documented those diagnoses should be removed from Resident #1's medical record due to lack of evidence. Resident #1's current psychotropic medications were reflected as Seroquel (for agitation), Depakote sprinkles (for mood disorder), Trazadone (for agitation and dementia) and Remeron (for insomnia). Record review of Resident #1's physician order summary dated 01/06/25 reflected Resident #1 was prescribed the following medications: Haloperidol Lactate Injection Solution 5ml intramuscularly once time only related to restlessness and agitation for one date (Start Date: 12/30/25 4:15 PM), Xanax Oral Tablet 0.5mg give once every six hours as Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455463 If continuation sheet Page 10 of 13 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 455463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Health and Rehabilitation Center 8383 Meadow Rd Dallas, TX 75231 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few needed for restlessness and agitation for 14 days (Start Date 12/24/25 at 10:00 PM), Mirtazapine 7.5 mg once at bedtime for insomnia (antidepressant, start date 09/23/25), Seroquel Oral Tablet 200 mg two times a day for vascular dementia without behavioral disturbance (start date 12/03/25), Trazadone 50 mg give 0.5 tablet by mouth three times a day for depression (start date 10/01/25) and Depakote Sprinkles 125mg- give four capsules by mouth two times a day related to vascular dementia (Start date 10/23/25). Review of Resident #1's December 2025 MAR reflected he was administered prn Xanax on 12/28/25 at 8:03 a.m The MAR also reflected he was administered prn IM Haldol on 12/31/25 at 7:20 a.m. The MAR did not reflect any behaviors occurring at the time of prn administration under the behavior monitoring section. Record review of nursing progress notes for Resident #1 reflected:-12/17/25 at 3:05 p.m.by LVN A, Resident noted with more jumpy behavior and combative during care and continues to have an outburst episodes, yelling mama, mama, and trying to kick staff, pt requires more cues to eat, redirected and educated multiple times but not effective, Pt vital signs WNL BP-106/66, P-63, R-18, T-97.7, Spo2- 97% RA, behavior reported to Psych NP. No new order.-12/24/25 at 9:05 p.m.by LVN A, Resident continues with outburst and aggressive behavior, yelling mama, mama, and trying to kick staff, pt redirected and educated several times but not effective, was reported to NP psych N/O received Xanax 0.5 mg PO every 6 hrs. PRN x 14 days r/t restlessness and agitation. Resident and family notified. MAR updated.-12/30/25 at 8:25 a.m. by LVN A, Late Entry: Note Text: Writer obtained order for prn Haldol IM inj, all orders carried. Will continue to update chart prn.-12/30/25 at 3:06 p.m.by LVN A, Resident continues with outburst and aggressive behavior, yelling mama, mama, and trying to kick staff, when brought to the dining area this AM resident started knocking down the chair and the tables, when redirecting, resident become more restless and agitated, hitting, scratching and kicking the staff members including this writer, he was quickly move out from the dining area and brought back to his room, this writer stayed with him notified DON, ADON and MD, N/O order obtained Haloperidol 5mg/ml Inject1ml intramuscularly one time only as needed. MAR updated, resident and family informed.-12/30/25 at 3:09 p.m. by LVN A, Xanax 0.5 mg 1 tab PO was administered but not effective. An interview with CNA B on 01/06/25 at 1:22 p.m. revealed she worked in the secured unit on the morning shift, took care of Resident #1 for about a year and was very familiar with his behaviors and care needs. CNA B stated on the morning of 12/24/25, she was the CNA responsible for Resident #1. She said that morning, Resident #1 had stool in his brief and needed to be changed. She stated sometimes he did not want care, and when that happened, she went to the charge nurse for assistance. On that morning (12/24/25), CNA B said she notified LVN A of Resident #1's resistance to ADL care. LVN A came to assist with care and they placed Resident #1 in his wheelchair and took him to the dining room. She stated while in the dining room, Resident #1 began knocking on the table and making noise. She stated that behavior happened once in a while but not every day. CNA B stated because of the noise and the reactions of the other residents, she and LVN A decided to remove Resident #1 from the dining room to prevent further problems. She stated Resident #1 was taken back to his room and placed in bed so he would calm down and would not start pulling at other residents. She stated Resident #1 did not slap or hit any other residents during the dining room incident. CNA B stated if a resident hit staff, staff were not supposed to do anything back. She stated the usual response was to remove the resident from the situation and give them time to calm down. She stated that sometimes nursing staff administered medication to calm Resident #1 when he got agitated. CNA B stated that after time in his room, Resident #1 typically calmed down. CNA B stated after the incident on 12/24/25, she did not observe any bruises or injuries on Resident #1 when showering or providing care. An interview with LVN A on 01/06/25 at 2:13 p.m. revealed she was the charge nurse on the secured unit. LVN A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455463 If continuation sheet Page 11 of 13 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 455463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Health and Rehabilitation Center 8383 Meadow Rd Dallas, TX 75231 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated on 12/24/25, CNA B reported Resident #1 was being kind of resistant. He had a bowel movement and CNA B was trying to provide incontinent care. LVN A said she did not observe Resident #1 being resistant, but CNA B told her that he refused to let her turn him to provide incontinent care. LVN A stated, You know, she [CNA B] asked him to roll over, but he didn't want to, he wanted to stay on his back. LVN A said when she went to his room, she talked to him and said please and Resident #1 was compliant, so they got him dressed and took him to the dining room. Once in the dining room, Resident #1 was sat at a table where nobody else sat and started screaming mama mama! LVN A said Resident #1 knocked down a table and pushed a chair, so for the safety of the other residents, he was taken back to his room by herself and CNA B. LVN A stated she did not touch Resident #1 in the dining room and although he was trying to stand up, he sat back down on his own. She said Resident #1 hit her on the nose while trying to remove him from the dining room. When she got him back to his room, LVN A stated she asked Resident #1 if he was okay and he said no and kept repeating mama, mama, mama, mama. LVN A stated she then transferred him back to bed with CNA B, contacted the doctor, ADON G, and stayed with him until he calmed down. LVN A said Resident #1 calmed down through her talking to him. She said once he was calm, she administered him a PRN Xanax. LVN A stated, He was not really calmed down, but not like aggressive as before. So, I gave it to him to calm down. She said Resident #1 then ate his breakfast and went to eat lunch in the dining room later and was quiet in his demeanor. LVN A stated a couple of days later (date unknown-morning), Resident #1 was destructive and combative. She said CNA B went to get him up and he was tried to fight with her, so LVN A went to see what was going on. She stated Resident #1 was kicking at the air from his bed towards CNA B and herself. LVN A said he was combative and tried to kick her when she approached him. LVN A stated, So I said because I have an order for it (Haldol), well let me give it to him. She said he calmed down after the intramuscular medication administration. LVN A stated Haldol was a one-time only medication and not ongoing. She said she already had the order for the Haldol from the day before. LVN A stated she did not give Resident #1 PRN Xanax during the behavioral incident in his room because he spit it out and that was why she administered PRN Haldol. LVN A stated she knew when it was time for a resident to be administered a PRN psychotropic medication, When the outburst becomes prolonged and you become combative. That's then it's time to administer. An interview with C-RN F on 01/07/26 at 10:30 a.m. revealed PRN IM Haldol would be appropriate for use when a resident had uncontrollable behaviors or behaviors that endangered other residents. She stated she did not know what behaviors occurred with Resident #1 that led to PRN Haldol administration. C-RN F stated there were some acknowledged errors in facility documentation, including no psychotropic medications listed on the care plan, no behaviors documented and behavior monitoring logs reflecting zeros despite medication administration for Resident #1. She stated IM antipsychotics should not be used to compel residents to get out of bed or comply with care. She stated monitoring following antipsychotic administration should occur for three days, including mood, appetite and behavior monitoring, with inclusion on the 24-hour report and emphasized that incomplete documentation undermined care delivery and regulatory compliance. She reported that an in-service on documentation was conducted with the nursing staff for those areas since the incident occurred. Interview with the ADM on 01/07/26 at 1:30 p.m. revealed IM antipsychotics such as Haldol should be used only when a resident posed a threat to themselves or others. He stated he would expect less restrictive interventions to be attempted first and then would review whether oral PRNs such as Xanax were effective. He stated that resisting care alone would not justify IM antipsychotic use and that staff should step away and return later. The ADM stated residents had the right to refuse care. For residents with dementia, he stated situations may be more complex but still (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455463 If continuation sheet Page 12 of 13 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 455463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Health and Rehabilitation Center 8383 Meadow Rd Dallas, TX 75231 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete emphasized encouragement, stepping away and physician involvement rather than immediate medication escalation. The ADM stated that oversight of PRN antipsychotic use would occur through review of orders and discussions during stand-up meetings with the management team. He stated the DON or the designee would typically review any decisions on psyche PRN use. An observation and interview with Resident #1 was attempted on 01/07/26 at 1:46 p.m. and revealed he did not eat his lunch and his full plate of food was in front of him on the table. His eyes were closed and he was slightly slumped over in his wheelchair. A CNA tried to rouse him and he then jerked his body a few times in waking up and began slowly eating. Resident #1 was not responsive to questions and kept his eyes closed, including through eating his food. He was observed to be in a wheelchair, elderly and not able to particulate in an interview. He was not observed to have any visible injuries on his face, hands or arms at the time of the observation. An interview with CNA E on 01/07/26 at 1:55 p.m. revealed Resident #1 was not normally aggressive and stated repeatedly, That man is not aggressive. She stated that she had worked with Resident #1 regularly since beginning her employment at the facility three weeks prior and had not observed him engaging in violent or combative behaviors. She stated that when she assisted Resident #1 with care, she was typically able to get him up, talked to him and redirected him without difficulty. On the morning of the incident (12/24/25), CNA E stated she first became concerned when she heard commotion and distress sounds coming from the dining room area. She described hearing loud voices and raised tones and stated the situation didn't feel right. She stated she observed Resident #1 being brought into the dining room and he appeared upset, confused, was attempting to communicate but struggling to express himself clearly. She recalled him repeating fragments such as feel, feel, feel. CNA E stated she was able to calm Resident #1 by speaking softly and reassuring him, telling him, [NAME], it's me. She emphasized that this approach worked and helped him de-escalate. In contrast, she described the other staff, specifically CNA B and LVN A using loud, commanding voices and repeatedly telling Resident #1 to sit down, sit down! which she felt escalated the situation. She stated, Y'all didn't give him time, and explained residents had the right to be mad and had the right to be left alone for a little while. She stated staff kept giving him commands rather than allowing him time to calm down. CNA E stated after the dining room incident, Resident #1 was taken back to his room. She stated she never saw Resident #1 flip tables or chairs and stated while he may have pushed against furniture, he did not have the physical strength to seriously harm others. She stated she did not see him assault other residents and did not believe he posed the danger later described by staff. Review of the facility's policy titled, Antipsychotic Medication Use, revised July 2022 reflected, Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. 9. Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: a. The behavioral symptoms present a danger to the resident or others; AND: (1) the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity); or (2) behavioral interventions have been attempted and included in the plan of care, except in an emergency. 12. Antipsychotic medications will not be used if the only symptoms are one or more of the following: .c. Restlessness; . k. Uncooperativeness; 13. Residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. Event ID: Facility ID: 455463 If continuation sheet Page 13 of 13