Health inspection·December 7, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on12/05/2023 at 2:56 PM with Resident #240 reveled the shower rooms could be cleaner for resident use. Interview on 12/06/2023 at 1:00 pm with CMA #4 reveled showers have a keypad for entry. Staff stand-by while residents are occupying the shower. Showers labeled East and [NAME] are located on Hall 100, shower area was for all residents on Hall 100. She entered shower labeled WEST; she stated it smelled like sewer. Interview on 12/07/2023 at 12:05 PM with Housekeeping Supervisor reveled, showers should be cleaned after each use by CNAs . The pile of soiled towels should not be left in resident bathroom. Interview on 12/07/2023 at 12:11 PM with DON reveled the expectation was for the bathroom to be cleaned after each use. When the bathroom was not clean the next resident does not have use of the shower. Interview on 12/07/2023 at 4:37 PM with DON revealed the risk of bathrooms not being cleaned after each use can increase the risk for falls and infections. Interview on 12/07/2023 at 5:11 PM with Administrator revealed the risk of unclean showers was infection control. Review of policy titled Resident Rights revised 8/2020 reflected the facility must treat each resident with respect and dignity and care for each resident in a manner, and in an environment, that promotes maintenance or enhancement of this or her quality of life, . Section III. Each resident is allowed to choose activities, schedules and health care that are consistent with his or her interests, assessments and plans of care, including: B. Personal care needs, such as bathing methods, grooming styles and dress; FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 2 of 11 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 455592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Side Campus of Care 1950 S Las Vegas Trail White Settlement, TX 76108 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for one (outside of kitchen) of one dumpster reviewed for garbage disposal. Residents Affected - Few 1. The facility failed to ensure the garbage storage area was maintained in a sanitary condition to prevent the harborage and feeding of pest and failed to ensure garbage receptacles were covered after being removed from the kitchen area to dumpster . This failure could place residents at risk of contracting disease by attracting pest and disease carrying rodents. Findings included: 1. During an observation on 12/6/2023, at 10:10 AM, of the garbage disposal areas by the trash dumpsters behind the facility, revealed large garbage cans containing refuse without lids. There was also food refuse, litter, and used medical gloves on the ground surrounding the trash dumpsters. 2. During an interview with the Director of Nutrition Services, on 12-6-2023, at 12:00 PM, she stated that her expectation was that there be no trash on the grounds by the trash dumpsters and all trash cans, containing refuse, should be covered with lids. The Director of Nutrition Services stated she did not know if the facility had a policy on trash disposal. 3. During an interview, on 12-6-2023, at 3:00 PM, the Administrator brought to the surveyor the policy on outside grounds being maintained in a safe manner. The policy stated it was the responsibility of the maintenance department to keep them in a safe manner. The Administrator stated that her expectation was that there be no refuse on the outside grounds and that all trash cans holding refuse, should have lids on them. 4. During an interview with the Director of Maintenance, on 12-7-2023, at 8:31 AM, it was revealed that the maintenance department was responsible for keeping the outside grounds clean and free of trash. The Director of Maintenance stated that his expectation of staff was to keep lids on trash cans that contain trash outside, and that staff put trash in the dumpsters and not on the ground. The Director of Maintenance stated that he believed some staff are too short to reach the top of the dumpster and trash gets on the ground that way. The Director of Maintenance stated that it was important to keep trash in the dumpsters and not on the ground because it will prevent potential disease carrying rodents and pest from accumulating on the property. It was also revealed that the trash compactor is not functioning and therefore all trash must be put in the dumpster bins without being compacted. Review of the facility's policy, undated, on outside maintenance of the grounds revealed : The Maintenance Department maintains all areas of the building, grounds, and equipment. Procedure I. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 3 of 11 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 455592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Side Campus of Care 1950 S Las Vegas Trail White Settlement, TX 76108 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 0814 The Maintenance Department is responsible for maintaining the buildings, grounds, and Level of Harm - Minimal harm or potential for actual harm equipment in a safe and operable manner always. II. Residents Affected - Few Functions of the Maintenance Department may include, but are not limited to: A. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. B. Maintaining the building free from hazards. C. Ensuring adequate ventilation. D. Maintaining the fire alarm system, sprinkler system, and emergency generator system in good working order. E. Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order. F. Maintaining lighting levels that are comfortable and assuring that exit lights are in good working order. G. Establishing priorities in providing repair service. H. Maintaining the paging system in good working order. I. Maintaining the grounds, sidewalks, parking lots, etc., in good order. J. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 4 of 11 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 455592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Side Campus of Care 1950 S Las Vegas Trail White Settlement, TX 76108 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 0814 Maintaining all mechanical, electrical, and patient care equipment in safe operating Level of Harm - Minimal harm or potential for actual harm condition. K. Residents Affected - Few Providing routinely scheduled maintenance service to all areas; and L. Other services that may become necessary or appropriate. III. The Director of Maintenance is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. A. The schedule should incorporate equipment manufacturers' recommended maintenance schedules. IV. As part of their duties, Maintenance Staff will comply with established infection control precautions. See Infection Control Manual. V. The Director of Maintenance is responsible for maintaining the following records/reports: A. Inspection of building. B. Work order requests. C. Maintenance schedules. D. Authorized vendor listing; and E. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 5 of 11 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 455592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Side Campus of Care 1950 S Las Vegas Trail White Settlement, TX 76108 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 0814 Warranties and guarantees. Level of Harm - Minimal harm or potential for actual harm VI. The Director of Maintenance is responsible for conducting regular inspections that may include, but are not limited to: Residents Affected - Few A. Activity Areas. B. Hallways. C. Laundry. D. Resident. Review of the U.S. Public Health Service Food Code, dated 2022, reflected : 5-501.112 Outside Storage Prohibitions. (A) Except as specified in (B) of this section, REFUSE receptacles not meeting the requirements specified under 5-501.13(A) such as receptacles that are not rodent-resistant, unprotected plastic bags and paper bags, or baled units that contain materials with FOOD residue may not be stored outside. (B) Cardboard or other packaging material that does not contain FOOD residues and that is awaiting regularly scheduled delivery to a recycling or disposal site may be stored outside without being in a covered receptacle if it is stored so that it does not create a rodent harborage problem. 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnable(s) shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT. 6-501.114 Maintaining Premises, Unnecessary Items and Litter. The PREMISES shall be free of: (A) Items that are unnecessary to the operation or maintenance of the establishment such as EQUIPMENT that is nonfunctional or no longer used; and (B) Litter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 6 of 11 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 455592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Side Campus of Care 1950 S Las Vegas Trail White Settlement, TX 76108 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Residents #2, #71) of 11 residents observed for infection control. Residents Affected - Some The facility failed to ensure RN A sanitized her hands after feeding Resident # 2, before starting to feed resident #71. The facility failed to ensure RN A washed her hands after cleaning a spill on Resident #71 table. The facility failed to ensure RN A performed standard hand hygiene after touching and pushing Resident #2 wheelchair. The facility failed to ensure RN A performed hand hygiene after she removed and discarded gloves. These failures could place residents at risk of contamination and infectious diseases. Findings included: Review of Resident #2's admission Record revealed, he was [AGE] year-old male admitted to facility 11/11/21 with diagnoses that included unspecified dementia moderate with other behavioral disturbance, Parkinson's disease (tremors, shaky motions), lack of coordination, generalized muscle weakness, need for assistance with personal care, difficulty swallowing, and difficulty communication and diabetes. Review of Resident # 2's MDS, dated [DATE], revealed a BIMS score of 3 which indicated severe cognitive impairment. His functional status indicated he was an extensive 1 assist for all- Activities of Daily Living (ADLs). His nutritional status indicated that he was at risk for protein and calorie malnutrition. Review of Resident # 2's Care Plan dated 10/17/23, revealed an Activities of Daily Living (ADL) self-care performance deficit due to weakness, Parkinson's disease, and impaired visual function. Goal was to show no decline in visual function and to remain free of further signs and symptoms of complications related to Parkinson's disease. Interventions included praise all efforts of self-care, to set up and supervise meals, encourage resident to fully participate for each interaction. Care plan also revealed potential nutritional problem indicated by body mass index (BMI) and impaired cognition. Goal was to maintain adequate nutritional status. Interventions included monitoring all intakes and recording meals, monitor/document/report to physician signs & symptoms of dysphagia (Pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing), refusing to eat, and appearance of concern during meals. Review of Resident #71's admission Record revealed, she was [AGE] year-old female admitted to facility 02/07/23 with diagnoses that included unspecified dementia severe without other behavioral disturbance, cognitive communication deficit, muscle weakness, angina pectoris (chest pain), unspecified cataract, and osteoarthritis (joint pain & swelling, bone deformation) unspecified site and essential primary hypertension. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 7 of 11 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 455592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Side Campus of Care 1950 S Las Vegas Trail White Settlement, TX 76108 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident # 71's MDS, dated [DATE], revealed a BIMS score of 3 which indicated severe cognitive impairment. Her functional status indicated she was partial/moderate assistance for ADLs. Review of Resident # 71's Care Plan dated 11/16/23, revealed an impaired cognitive function or impaired thought process due to dementia, goal was to maintain current level of cognitive function. Interventions included facing the resident when speaking and make eye contact. Reduction of any distractions- turn off TV, radio, close door. Observation of dining room on 12/07/23 at 8:26 AM revealed, RN A stood in front of Resident #71 at the first dining table wearing cream-colored gloves. RN A picked up a spoon, scooped it with oatmeal, and fed it to Resident #71. RN A took another spoonful of oatmeal and fed Resident #71. She then crossed the dining room to the second table and scooped up a spoon of what appeared to be eggs to Resident #2. Wearing the same gloves with no hand hygiene she scooped the spoon again with eggs and fed Resident #2. RN A then walked to the table with Resident # 71 and noticed that Resident #71 had spilled some food on the table. RN A pulled 3 wipes from a medication cart (med cart) and wiped the table. RN A then deposited the soiled wipes in the medication cart bin. She then removed and discarded her gloves in the med cart bin. No hand hygiene performed. RN A proceeded to Resident #71's cup to fill it with water from a water cooler. She returned with cup full of water and assisted Resident # 71 as she took a drink of the water. RN A continued to feed Resident #71 until the resident asked for something to drink. RN A assisted Resident #71 with her water. RN A then turned towards the second table and noticed that Resident #2 was trying to leave by pushing himself from the table in his wheelchair. She asked him to return so he can finish his food. RN A stopped helping Resident #71 and went to help Resident #2 back to the table by pushing Resident #2's wheelchair. RN A did not perform hand hygiene after assisting Resident #71 and before touching and after touching Resident # 2's wheelchair. RN A scoped some food from the plate and fed Resident #2 a spoon full of eggs. An observation on 12/07/23 at 08:42 AM revealed RN A asked CNA B to help Resident # 2 finish eating. CNA B performed hand hygiene with hand sanitizer, she pulled a chair and sat down and began to assist Resident # 2. RN A returned to table with Resident # 71 and helped her finish her oatmeal. No hand hygiene was performed. An observation on 12/07/23 at 08:48 AM revealed RN A was called into room [ROOM NUMBER] near the dining area by another staff member, RN A was observed closing the door. RN A returned a few minutes later and stood in the same spot in front of #71 and helped Resident #71 with her drink again. RN A did not perform hand hygiene after returning from room [ROOM NUMBER]. An observation on 12/07/23 at 09:03 AM revealed RN A retrieving keys with her left hand from her pocket. She opened med cart and took out some tissues and handed it to Resident # 71. No hand hygiene was performed by RN A after touching keys and med cart. Interview with RN A on 12/07/23 at 09:05 AM revealed RN A forgot to wash her hands. She stated that the risk of not performing hand hygiene was contamination and spreading of diseases. Interview with CNA B on 12/07/23 at 09:42 AM revealed that she always performed hand hygiene before and after resident care. She said that she pulled a chair to sit down for residents' dignity and to be at eye level with resident. She said that she was trained to be mindful and respectful when helping residents eat. She stated the risk of not performing hand hygiene was spreading infection and sharing germs to residents and self. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 8 of 11 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 455592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Side Campus of Care 1950 S Las Vegas Trail White Settlement, TX 76108 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 12/07/23 at 11:15 AM with DON revealed standard hand hygiene practice was required for all staff. She had trained and in served staff over and over about hand hygiene and Personal Protective Equipment (PPE) putting on and taking off She said risk for not performing hand hygiene was a risk of infection. Interview on 12/07/23 at 12:10 pm with ADM revealed all staff members were expected to follow the infection control protocol as indicated. She expected staff to wash hands and to prevent spread of infection. She expected staff to properly wash hands after and before care. She said the risk of staff not washing hands and following standard hand hygiene protocol can cause a spread of infection. Review of the facility policy Infection Prevention and Control Program COVID (Covid is short for Corona Virus Disease-a sever acute respiratory syndrome aka SARS-COV-2), revision date 07/23, reflected . .facility will follow Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) as well as state and local government guidance . Hand wash policy requested during survey facility did not provide it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 9 of 11 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 455592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Side Campus of Care 1950 S Las Vegas Trail White Settlement, TX 76108 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area for 1 of 8 residents (Resident #93) reviewed for physical environment. Residents Affected - Few The facility failed to ensure Resident #93's call light was functioning. This failure could place residents at risk of not having their needs met. Findings included: Record review of Resident #93's face sheet, dated 12/07/2023, reflected a [AGE] year-old male with an original admission date of 08/12/2022 and readmitted on [DATE]. Resident #93's diagnoses included Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and Vascular Dementia. Record review of Resident #93's most recent MDS assessment, dated 11/16/2023, revealed a BIMS score of 15, indicating intact cognition. Review of the MDS, dated [DATE], reflected Resident #93 required extensive one person assist for bed mobility and toilet use and was totally dependent with two-person assist for transfers. Observation and interview on 12/05/2023 at 11:50 AM revealed Resident #93 lying in bed with a hospital gown on. Resident #93 repeatedly said he had to get up because he had to use the restroom. When asked if resident could reach and push the call light, Resident #93 reached for the light and pushed the button, but the light did not turn on. The Staff Development Coordinator walked into the room and tried to reset the call light. She stated if she unplugged the light it worked. She then contacted a maintenance staff member with her phone and said Resident #93 would be on 15-minute rounds until the call light was fixed. Maintenance staff was observed to go into the room afterwards. Interview on 12/07/2023 at 9:05 AM, the Maintenance Director stated he had started working at the facility 3 weeks ago. He stated there was also 2 Maintenance Assistants, one full time and one part time. He stated since he had been there, he checked the call lights all the time. The Maintenance Director said call lights were to be checked monthly and they had been working on them because they found cord and bulb problems. He stated he checks every room and the annunciator panel at the nurse's station to see if the light works. He said documentation was completed in TELS. He stated if they found one not working, they would fix it, but that was not logged in TELS. The Maintenance Director stated if the call lights were not functioning, residents could be sitting there for hours, and nobody would know. He stated he fixed Resident #93's call light on 12/05/2023. Interview on 12/07/2023 at 4:37 PM, the DON stated if call lights were not working then staff were to inform her or the administrator. She stated she believed a department head was informed that Resident #93's call light was not working and then maintenance was notified. The DON said if a call light was not working then they move to 15-minute checks or give residents a bell. She stated if call lights did not work then residents could fall, have a medical emergency, be soiled extensively, and could miss care. Interview on 12/07/2023 at 5:20 PM, the Administrator stated they have ambassador rounds and leadership was assigned to certain rooms and the whole IDT team including CNA's, Nurses and leadership (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 10 of 11 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 455592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Side Campus of Care 1950 S Las Vegas Trail White Settlement, TX 76108 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few were responsible to see that call lights were functioning. She stated Maintenance would be responsible to fix call lights. She stated it was a safety risk if call lights were not working. Record review of maintenance logs reflected tests for nurse call system were marked pass for halls 100 through 400 on 11/01/2023, 11/08/2023, 11/15/2023, 11/20/2023, 11/29/2023 and 12/04/2023. Logbook documentation from 10/06/2023 through 11/13/2023 listed room numbers and pass next to the room numbers. Resident #93's room number was not listed. Record review of facility policy titled, Communication - Call System revised 06/2020, reflected in part: Purpose. To Provide a mechanism for residents to promptly communicate with nursing staff. The Facility will provide a call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities .Should the primary call system become inoperable for any reason, the Facility shall provide a bell for each resident room. Additionally, resident safety check rounds shall be conducted at least hourly and documented until the primary call system is operable again . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 11 of 11