Inspection·January 16, 2025

F 0554 to MUSCLE WASTING AND ATROPHY (muscle wasting and dying). Level of Harm - Minimal harm or potential for actual harm Review of Resident #118 care plan initiated 07/22/22 reflected, Focus: Resident #118 Focus: has been observed putting liquids in his g- tube. He states in writing that he is not hungry or thirsty feeling like he requires additional intake - but rather he can taste the soda he puts in there and enjoys the flavor. Mr. [NAME] was educated on compliance with g-tube enteral feedings/water, dangers and risks associated with putting additional fluids in the-tube, infection. Goal: The Resident will maintain adequate nutritional status as evidenced by maintaining weight within 10 percent of admission baseline through the review dated 01/28/25. Interventions: Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Residents Affected - Few Focus: Resident #118 has impaired visual function and was at risk of falls/injury. Goal: The Resident will show no decline in visual function through the review date. The Resident will maintain optimal quality of life within limitation imposed by visual function through the review date. Interventions: Arrange consultation with eye care practitioner as required. Identify/record factors affecting visual function including Physiological (glaucoma, Crohn's, macular degeneration, cataracts, color discrimination, light sensitivity, dry eyes); Environmental (poor lighting, monochromatic color scheme), Choice (refuses to wear glasses, use mag glass, turn on lights) etc. Monitor/document/report to MD the following s/sx of acute eye problems: Change in ability to perform ADLs, decline in mobility, Sudden visual loss, Pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision. Review medications for side effects which affect vision. Observation of g-tube medication administration on 01/15/25 at 8:35 AM, LVN B did not check Resident #118 g-tube placement. LVN B did not aspirate gastric content or listen for bowel sounds, she did not check for abdominal distention before Resident #118 administered his own medications, water, and bolus formular feeds. LVN B stated that Resident #118 had always self-administered his own medications and feeds. She stated that she had been told during training (two months ago) that the nurse would cocktail the medications and the resident would administer the medications himself. She stated the nurse would supervise until the resident was finished and then he would administer his own feedings. LVN B stated that she did not check for Resident #118's g-tube placement because she had been caught off guard by a different surveyor watching her in another room prior to her starting Resident#118's medications. LVN B stated that it was important for the nurse to check for placement of the g-tube to make sure that it was still in place, and it had not dislodged. LVN B stated that she should not have allowed Resident #118 to self-administer G-tube medication without an order. She stated the risk was the g-tube could be out of place, in the wrong place, and infection control. In an interview with the DON on 01/16/25 at 12:58 PM, the DON stated her expectation for staff was to check placement before giving medications or feedings to residents with G-tubes. She stated staff should have looked at Resident #111 and Resident #118's G-tube, aspirated and checked residual to ensure it was placed in the correct place. She stated LVN B should have administered Resident #118's medications. The DON stated she had inserviced staff on G-tubes. Review of facility policy titled Bedside medication Storage revision date 08/2020 reflected . read in part . Residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgment of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 2 of 19 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 01/16/2025 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 0554 facility's interdisciplinary resident assessment team (or equivalent) . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 3 of 19 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 01/16/2025 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 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents were treated in a respectful manner that maintained or enhanced each resident dignity for 1 of 4 residents reviewed for dignity (Resident #114). Resident #114 did not receive his personal clothing for two days (01/11/25 and 01/12/25) which caused him to remain in bed and not engage in preferred activities during the week. This failure could place the resident who required assistance with dressing at risk of feeling disrespected. Findings included: Record review of Resident #114's admission Record revealed [AGE] year-old male admitted to the facility on [DATE]. Primary diagnoses included: Enterocolitis due to clostridium difficile, recurrent (a complication of a Clostridioides difficile infection (CDI) that occurs when symptoms reappear within 8 weeks of a previous episode.) Record review of Resident #114's care plan date initiated 12/21/2024 reflected the following: -Focus-Resident #114 is dependent on staff for activities, cognitive stimulation, social interaction. GoalResident #114 will attend/participate in activities of choice 3x per week. Interventions- invite the resident to scheduled activities. Focus- Resident #114 had an ADL Self Care Performance Deficit related to weakness, impaired mobility, poor safety awareness. Goal- he will maintain current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet use and Personal Hygiene. Intervention- Dressing: Encourage resident to choose clothing. Nursing staff to ensure resident is dressed appropriately for season, activity and comfort. Record review of Resident #114's Minimum Data Set (MDS) State assessment dated [DATE] reflected Cognitive Patterns BIMS score of 15 ( indicates that a person's cognition was intact). Record Review of resident #114's Minimum Data Set Nursing Home Comprehensive dated 12/27/2024 reflected, Functional abilities-admission- F. Upper body dressing: 01 Resident was dependent- Helper does ALL of the effort. Resident does none of the effort to completed the activity. Or , the assistance of 2 or more helpers were required for the resident to complete the activity. G. Lower body dressing: 01 Resident was dependent- Helper does ALL of the effort. Resident does none of the effort to completed the activity. Or , the assistance of 2 or more helpers were required for the resident to complete the activity. H. Putting on/taking off footwear: 01 Resident was dependent- Helper does ALL of the effort. Resident does none of the effort to completed the activity. Or , the assistance of 2 or more helpers were required for the resident to complete the activity. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 4 of 19 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 01/16/2025 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 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Inventory of Personal Belongings dated 12/26/2024 reflected, Resident #114 Description of Clothes- Clothes were dirty and sent to laundry. Observation and Interview on 01/14/2025 at 10:20 am with Resident #114 reflected, resident was observed in his wheelchair wearing pants, shoes, undershirt, and top shirt. He stated that those were clothes from lost and found because his clothes have been lost for two days. He stated that he was unable to get out of bed over the weekend because staff were unable to locate his clothing. He stated that he likes to get up and participate in group activities around the facility but was unable to during the weekend (Saturday and Sunday) because he did not have clothes. Observation and Interview on 01/15/2025 at 10:07 AM of the laundry room with the Laundry Aide reflected, all facility laundry was washed and sorted in main laundry room. Residents' personal items are washed and sorted by room number. Interview with the Laundry Aide reflected she worked Monday-Friday not on the weekend (Saturday and Sunday). She stated that resident clothing was not distributed on the weekends. She stated that when she came in on Mondays the clothes be piled up and she would do the best she could to get the laundry distributed to the residents. Interview on 01/16/2025 at 1:00 pm with the Environmental Services Supervisor reflected the residents' personal belongings were washed on the weekend but not distributed because in the past there was an issue of lost clothing. The Monday-Friday laundry aide had a knowledge of the residents and their personal belongings, but the weekend laundry aide would place resident belonging in the wrong rooms. Record Review of policy Resident Rights date revised: 8/2020 reflected, All resident have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility including those specified in this policy. M .Retain and use personal possessions to the maximum extent that space and safety permit. 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 5 of 19 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 01/16/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights for 4 of 6 residents reviewed for clinical records (Resident #41, Resident #59, Resident #76, and Resident #121) in that: The facility failed to ensure that Resident #41, Resident #59, Resident #76, and Resident #121 use of bed rails/grab bars/mobility bars were documented in their care plans. The facility's failure placed residents requiring care at risk of not having their individual needs met, not receiving necessary care and services, and a failure to ensure continuity of care. Findings included: Record Review of Resident #41's Face Sheet reflected a [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #41 had relevant diagnoses of type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema (areas of swelling of the tiny blood vessels in the retina, caused by the weakening of their structure), unspecified eye; other abnormalities of gait and mobility; type 2 diabetes mellitus without complications (disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels); muscle wasting and atrophy; other lack of coordination; unspecified symptoms and signs involving cognitive functions and awareness; need for assistance with personal care; cortical age-related cataract (when protein fibers in the lens of the eye break down and clump together causing the lens to become cloudy), bilateral; systemic lupus erythematosus (a chronic autoimmune disease that causes the body's immune system to attack healthy tissue); muscle weakness (generalized); other specified arthritis (joint inflammation causing pain, stiffness, and swelling in a joint), multiple sites; and morbid (severe) obesity due to excess calories. Record Review of Resident #41's Quarterly MDS, dated [DATE], reflected a BIMS score of 15 indicating intact cognition. Resident #41's functional limitations in range of motion were listed as impairment for lower extremities on both sides of the body. Resident #41 was noted to use a wheelchair for mobility. Resident #41 was noted to be dependent (need complete assistance) for self-care categories of toileting, shower/bathing, lower body dressing, putting on/taking off footwear, and personal hygiene. Resident #23 was noted to need substantial/maximal assistance for upper body dressing, while only requiring partial/moderate assistance for personal hygiene. Resident #41 was noted to need substantial/maximal assistance in the mobility categories of roll left and right and sit to lying. Resident #41 was reflected to be dependent for chair/bed-to-chair transfer and tub/shower transfer. Record review of Resident #41's Care Plan, last updated on 01/07/2025, reflected focus areas of potential for pressure ulcer development r/t impaired mobility, requires extensive assist for bed mobility, and at risk for falls related to impaired mobility and requires total assist with any transfers. Resident #41 had a focus area of an ADL Self Care Performance Deficit r/t Limited Mobility, Arthritis, morbid obesity with interventions of BED MOBILITY: Roll left and right: Substantial/Maximal assist, Sit to Lying: Substantial/Maximal assist, Lying to sitting: Not attempted, DRESSING: Upper Body Dressing: Substantial/Maximal assistance, Lower Body Dressing: Dependent, Donning/Doffing shoes: Dependent, EATING: Set-up/Clean UP, TRANSFER: Chair/bed to chair: Dependent X 2 staff and mechanical lift, Sit to stand: does not occur. There was no mention of bed rails/grab bars as a focus area or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 6 of 19 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 01/16/2025 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 0656 intervention in the care plan. Level of Harm - Minimal harm or potential for actual harm Observation of Resident #41's room and bed on 1/14/2025 at 10:25 AM revealed grab/mobility bars on both sides of the bed in a raised position with the call light laying over one of the bars. Observation on 1/15/2025 at 8:08 AM revealed the grab/mobility bars in a raised position. Residents Affected - Some Interview with Resident #41 on 1/15/2025 at 8:05 AM revealed that resident utilized the grab/mobility bars for repositioning while in bed and to aid with positioning with personal care. Resident #41 stated she had been at the facility a very long time. Record review of Resident #59's Face Sheet reflected a [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #59 had relevant diagnoses of metabolic encephalopathy (brain disorder caused by chemical imbalance in the blood), type 1 diabetes mellitus (chronic condition where the pancreas makes little or no insulin, which causes high blood sugar levels)with unspecified diabetic retinopathy without macular edema (medical condition that affects the eyes), bipolar disorder (mental illness that causes extreme shifts in mood, energy, and activity level making it difficult to perform daily tasks), muscle weakness (generalized), other lack of coordination, other reduced mobility, chronic obstructive pulmonary disease with (acute) exacerbation (chronic lung disease that makes it difficult to breathe caused by damage that narrows airways making it harder to move air in and out of the lungs), acute respiratory failure (when lungs are unable to exchange gases properly with blood), unspecified whether with (lack of oxygen) or hypercapnia (too much carbon dioxide in the blood), morbid (severe) obesity due to excess calories, chronic pain syndrome, unspecified lack of coordination, inflammatory polyneuropathy(disease that affects peripheral nerves causing weakness, numbness and pain), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (paralysis or severe weakness on one side of the body caused by a stroke), acquired absence of left leg above knee, other cerebrovascular disease (conditions that affect blood flow and blood vessels in the brain). Record review of Resident #59's Quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated an intact cognition. The Quarterly MDS also showed that Resident #59 utilized a motorized wheelchair for mobility; was dependent for toileting hygiene, showering/bathing, upper and lower body dressing, personal hygiene, sit to lying, rolling right and left, tub/shower/toiler transfers, lying to sitting on side of bed, and chair/bed-to-chair transfers. Observation on 1/14/2025 at 9:55AM of Resident #59 room area and bed revealed that the bed had a bed grab/mobility bar raised on both sides of the bed. The resident was asleep in the bed at the time. The grab/mobility bar were observed again on 1/15/2025 at 8:10 AM in same position. Interview on 1/15/2024 at 1:25 PM with Resident #59 revealed the resident is liking being back at the facility. Resident #59 stated that she used the grab/mobility bars during personal care by aides, to help roll and for repositioning while in bed. Record review of Resident #59's Care Plan, last updated on 12/17/2024, reflected that Resident had ADL self-care performance deficit r/t decreased mobility and required interventions due to being completely dependent for toilet use, transfer, bathing, personal hygiene, upper body dressing, lower body dressing, putting on/taking off footwear and with bed mobility being substantial/maximum assist. The Care Plan had no mention of bed rails or grab bars as an intervention or focus for Resident #59. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 7 of 19 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 01/16/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #76's Face Sheet reflected a [AGE] year-old male, originally admitted to the facility on [DATE]. Resident #76 had relevant diagnoses including acute respiratory failure with hypoxia (condition where the body does not have enough oxygen), unspecified osteoarthritis (chronic disease that breaks down cartilage and bone in the joints), idiopathic aseptic necrosis of left femur (condition where blood flow to the hip joint is disrupted), morbid (severe) obesity due to excess calories, critical illness myopathy (disease that affects muscles that control voluntary movement), chronic systolic (congestive) heart failure (when the heart's left ventricle weakens and cannot pump enough blood), chronic obstructive pulmonary disease with (acute) lower respiratory infection (when lower respiratory infection worsens COPD symptoms), chronic respiratory failure with hypoxia (long term condition where the body is unable to adequately oxygen and carbon dioxide , leading to persistently low levels of oxygen in the blood), muscle weakness (generalized), difficulty in walking not elsewhere classified, other lack of coordination, abnormal posture, and personal history of pulmonary embolism (blockage in a lung artery caused by a substance that travels from another part of the body). Record review of Resident #76's Quarterly MDS, dated [DATE], reflected a BIMS score of 09, indicating moderate cognitive impairment. Resident #76's functional limitations were listed as dependent for toileting hygiene, shower/bathing self, lower body dressing, putting on/taking off footwear, roll left and right, sit to lying, lying to sitting on side of the bed, chair/bed-to-chair transfer and tub/shower transfer. Resident #76 was listed as substantial/maximal assistance for upper body dressing and personal hygiene. Record review of Resident #76's Care Plan, last updated on 01/02/2025, reflected a focus of ADL self-care performance deficit r/t morbid obesity with copd/chf and interventions of transfer: chair/bed transfer: dependent x 2 and mechanical lift; resident 76 has morbid obesity with recent fracture and requires staff assist due to weight; bed mobility: roll left to right: dependent, sit to lying: dependent, lying to sitting: dependent; bathing: shower three times a week and as needed, is dependent on staff for showering; dressing: encourage resident #76 to choose clothing that is appropriate for season, upper body: dependent, lower body: dependent, shoes: dependent; eating: independent with eating; toilet use: dependent. resident #76'scare plan does not mention bed rails/grab bars/mobility bars as a focus or intervention. Observation on 1/14/2025 at 10:20AM revealed Resident #76 in bed watching television. Resident #76 was in bed watching television; the resident has a trapeze as well as a call light on the trapeze within reach, bed was in a high position. Resident #76 stated that he has not been injured by the bars being on the bed but has noticed things get quickly entangled when cords are draped overbars. On 1/15/2025 Resident #76 was interviewed and revealed that the grab/mobility grab bars were frequently used to reposition himself in bed. Resident #76 showed how he also has a trapeze for repositioning that he also wraps the cord of his call light on to keep within reach. Resident #76 stated that he thinks the staff have spoken with him about safety with the grab/mobility bar. Record review of Resident #121's Face Sheet reflected a [AGE] year-old female originally admitted to the facility on [DATE]. Resident #121 had relevant diagnoses of acute and chronic respiratory failure with hypoxia (condition where the body does not have enough oxygen), polycythemia vera (blood cancer that causes the bone marrow to produce too many red blood cells), type 2 diabetes mellitus (disease where the body does not use insulin properly causing high blood sugar) with unspecified diabetic retinopathy (chronic eye condition that damages the retina due to high blood sugar levels from diabetes) with macular edema (when fluid builds up against the macula the central part of the retina at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 8 of 19 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 01/16/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the back of the eye), morbid (severe) obesity with alveolar hypoventilation (condition where a person does not breathe enough, resulting in too much carbon dioxide in the blood and not enough oxygen), muscle weakness (generalized), acute kidney failure, other abnormalities of gait and mobility, unspecified lack of coordination, and need for assistance with personal care. Record review of Resident #121's Quarterly MDS, dated [DATE], reflected a BIMS score of 15, indicating intact cognition. Resident #121 had identified functional limitations of substantial/maximal assistance with toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, and lying to sitting on side of bed. Resident #121 had functional limitations of dependent for chair/bed-to-chair transfer and tub/shower transfer. Record review of Resident #121's Care Plan, last updated on 01/07/2025, reflected a focus area of ADL self-care performance deficit r/t obesity and weakness with interventions of bed mobility: the ability to roll from lying on back to left and right side, and return to lying on back on the bed; upper body dressing: supervision/touching assist, lower body dressing: dependent, put on take off footwear: dependent; eating: setup/cleanup assist; oral hygiene: setup/cleanup assist; personal hygiene: setup/cleanup assist; shower/bathing: partial/mod assist, can bath with assistance from staff to wash her back and perineal areas; toilet hygiene: dependent; transfers: sit to stand: does not occur; bed to chair: dependent with mechanical lift x 2 staff, toilet transfer: does not occur-uses bed pan, tub/shower: dependent x 2 and mechanical lift; wheelchair mobility: setup assist to dependent. resident #121's care plan does not mention bed rails/grab bars/mobility bars as a focus or intervention. Observation of Resident #121's bed on 01/14/2025 at 9:45AM revealed resident in bed asleep, with both grab/mobility bars raised on the bed. Observation of Resident #121's bed on 01/15/2025 at 8:10 AM revealed resident in bed, both grab bars still raised, having breakfast. Resident declined to be interviewed and asked to be left alone; unable to interview this resident about the grab/mobility bars. Interview on 1/16/2024 at 12:02PM with the DON revealed that it was important to have grab/mobility bars documented in the care plan, so staff know how best to perform the care. The DON stated that the safety assessment and consent form also was offered for the resident or responsible party to review and sign explaining risks and benefits. The DON stated the Resident could have been at risk of harm if the evaluation had not been assessed incorrectly. Interview on 1/61/2024 at 12:11 PM with the ADM revealed the IDT will review resident needs including grab/mobility bars on beds and if resident would be safe to use. The ADM stated the nursing department representative is the one who usually enters these items as the care plan. The ADM stated the potential harm to the resident by not documenting on the care plan could be any harm up to death. Record Review of the facility's Nursing Manuals- Nursing Care policy on Bed Rails (Revised June 2020) states the purpose of the policy was to determine the appropriateness of bed rail use for individual residents while the policy was Decisions to use or to discontinue the use of a bed rail will be made in the context of an individualized resident assessment using an Interdisciplinary Team (IDT) and will take into account the resident's medical needs, comfort, and freedom of movement. The policy further states The resident's plan of care will be updated to reflect the use of bed rails. The plan of care should also include documentation of the type of specific direct monitoring and supervision provided during the use of the bed rails and the identification of how needs will be met during the use of bed rails (e.g., repositioning, hydration, etc. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 9 of 19 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 01/16/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Record Review of the facility's Nursing Manual-Nursing Administration Care Planning policy (Revised October 24, 2022) states the purpose is To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. Relevant sections include: Policy: Residents Affected - Some The facilities Interdisciplinary Team will develop a baseline and/or comprehensive Care Plan for each resident in accordance with OBRA and MDS guidelines. Procedures: VIII: A culturally competent and trauma-informed comprehensive person-centered Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. A. In the event that the Comprehensive Care Plan identified a change in the resident's goals or functioning that was not identified in the Baseline Care Plan, these changes will be incorporated into an updated summary and provided to the resident and/or resident's representative. B. Changes may be made to the Comprehensive Care Plan on an ongoing basis for the duration of the resident's stay. These subsequent changes will not need to be reflected through updates to the Baseline Care Plan IX: Each resident's Comprehensive Care Plan will describe the following: A. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; B. Any services that would be required, but are not provided due to the resident's exercise of rights, which includes the right to refuse treatment; C. Any specialized services including rehabilitative service as a result of PASARR recommendations. If the Facility disagrees with PASARR findings, rationale will be notated in the resident's medical record; FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 10 of 19 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 01/16/2025 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure enteral feeding physician orders were followed for two (Resident #111 and Resident #118) of the four residents reviewed for enteral tube feeding, in that: 1.LVN A failed to check G-tube residual to verify G-tube placement verification before administering medication and feedings for Resident #111 on 01/15/25. 2.LVN B failed to check G-tube residual to verify G-tube placement before administering medication and feedings to Resident #118 on 01/15/25. These failures could place residents with G-tubes at risk of aspiration pneumonia, discomfort, malnutrition and a decline in the resident's health. 1 Record review of Resident #111 admission record dated 1/15/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with an initial admission date of 04/15/22. Her diagnoses included gastrostomy status (this is a feeding tube that is placed through the abdominal cavity area into the stomach for nutritional purpose and medication for individual who have a difficulty swallowing), acute respiratory failure with hypoxia (difficulty breathing due to lack of oxygen), cerebral palsy (a congenital disorder of movement, muscle tone, or posture), and quadriplegia (this is a condition that causes partial or total paralysis of the arms, hands, trunk, legs and pelvic organs). Review of Resident #111 quarterly MDS dated [DATE] reflected Resident #111 had a BIMS of zero, indicating sever cognitive impairment. She had no indicators of delirium, depression, or behaviors. Resident #111 had impaired range of motion, both upper and lower body, on both sides of his body, and was completely dependent on staff for all of his ADLs and movement in bed. Resident #111 was always incontinent of bowel and bladder. The document reflected Resident #111 had a feeding tube while a resident of the facility and received 51% or more of her nutrition through the feeding tube. Review of Resident #111 Care plan reflected a care plan initiated 05/06/22, Focus: Resident #111requires gastrostomy tube feeding related to swallowing problem related to diagnoses of Cerebral Palsy. Goal: The resident will remain free of side effects or complications related to tube feeding through review date. The resident will maintain adequate nutritional and hydration status, as evidenced by weight stable, no signs and symptoms of malnutrition or dehydration through review date. Interventions: Check for tube placement and gastric contents/residual volume per facility protocol and record. Clean insertion site daily as ordered, monitoring for s/s infection or breakdown such as redness, pain, drainage, swelling, and/or ulceration and report to MD if symptoms arise. Continuous Enteral Feed: Formula: [brand name ]1.5; Rate: 40ml/hr x 22 hours (1320ml) provides 1980 kcal/84g Protein /1003ml free water); Monitor every Shift. and two times a day o every shift Water at 35ml/hr x 22 hours to run concurrently with enteral feeding (provides 660 ml total daily); o Monitor/document/report to MD PRN: Aspiration- fever, shortness of Breath, Tube dislodged (tube comes out), Infection at tube site, Self-extubating (taking tube out by herself), Tube dysfunction or malfunction, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distension, tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Dehydration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 11 of 19 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 01/16/2025 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few o Provide local care to G-Tube site as ordered and monitor for s/sx of infection. o The resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders. Record Review of Resident #111 Order summary dated 01/15/15 reflected, -Enteral Feed Order every shift Enteral Feed: Residual Volume Check residual before med administration. If residual volume is greater than 60mL, hold feeding and notify physician. Order active 10/17/24. -Enteral Feed Order every shift Continuous Enteral Nutrition: [brand name ] 1.5 at 37ml/hr x 22hrs to provide 1221kcal, 52 g protein and 619 ml water two times a day. -Enteral Feed Order every shift Flush enteral tube with 30 ml water pre/post medication administration and 5-10 mL water between each medication; -MiraLAX Powder 17 GM per SCOOP (Polyethylene Glycol 3350). Give 1 scoop via G-Tube one time a day for Constipation Hold for loose stool, mix with 4-8 oz of water; - Lasix Oral Tablet 20 MG (Furosemide) Give 1 tablet via G-Tube two times a day for Congestive Heart Failure; - Sucralfate 1 GM Tablet Give 1 tablet via PEG-Tube (other name for G-tube) three times a day for GERD (heart Burn); - Keppra Solution 100 MG/ML (levetiracetam). Give 5 ml via PEG-Tube two times a day for Seizure ;5ml = 500mg; dilute with 4-5 oz of water before administration. - Coreg Oral Tablet 3.125 MG (Carvedilol). Give 1 tablet via G-Tube two times a day for Hypertension (High blood pressure). Hold for sbp less than110 or dbp less than 60 - Baclofen Oral Tablet 10 MG (Baclofen) Give 1 tablet via G-Tube three times a day for Muscle spasms; - Famotidine Oral Tablet 20 MG (Famotidine). Give 1 tablet via G-Tube two times a day for Gerd. - Diflucan Oral Tablet 100 MG (Fluconazole). Give 1 tablet via G-Tube one time a day for Spots on tongue for 5 Days. - Bethanechol Chloride 5 MG Tablet. GIVE 1 TABLET VIA PEG-TUBE FOUR TIMES A DAY FOR URINARY RETENTION. - Potassium Chloride Oral Solution 20 MEQ/15ML (10 percent) (Potassium Chloride); Give 15 ml via G-Tube one time a day for Supplement; dilute with 4-5oz of water before giving to reduce its possible stomach-irritation or laxative effect. Observation of g-tube medication administration on 01/15/25 at 07:52 AM, LVN A did not check Resident #111 g-tube placement. LVN A did not aspirate gastric content and or listen for bowel sounds and did not check for abdominal distention before administering water, medications, and enteral feeds to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 12 of 19 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 01/16/2025 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #111. LVN A stated she got nervous being watched and she forgot to check for placement. She stated she knew how to check for placement by checking residual and by listening using a Stethoscope. LVN A stated the risk was that the tube may not be in the correct position. 2. Record review of Resident # 118 admission record dated 1/15/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included malignant neoplasm of head, face, and neck (this is malignant cancer of the head, face, and neck), gastrostomy status, dysphagia (trouble swallowing), and need for assistance with personal care, lack of coordination. Review of Resident #118 quarterly MDS dated [DATE] reflected Resident #118 had a BIMS of 12 out of 15, indicating moderate cognitive impairment. Resident #118 was independent for all ADL's and movement. The document reflected Resident #118 had a feeding tube while a resident of the facility received 51% or more of her nutrition through the feeding tube. Record Review of Resident #118 Order summary dated 01/15/15 reflected the following; - E very shift Flush enteral tube with 30 mLs water before and after medication administration and 5-10 mLs water between each medication; - Enteral Feed, give Five times a day Bolus Feeding: [brand name ] formula 1.5 at 265ml 5 x day to provide 1988 kcal, 85g Protein and 1007 ml water. - Midodrine HCl Tablet 5 MG. Give 1 tablet via G-Tube two times a day for b/p; hold for SBP> 130 If B/P Less than 90/50 notify MD; - Clopidogrel Bisulfate 75 MG Tablet. GIVE 1 TABLET VIA G-TUBE IN THE MORNING FOR HEART; - Aspirin Low Dose Tablet Chewable 81 MG (Aspirin). Give 1 tablet via G-Tube one time a day related to MUSCLE WASTING AND ATROPHY (muscle wasting and dying).; Review of Resident #118 care plan initiated 07/22/22 reflected, Focus: Resident #118 Focus: has been observed putting liquids in his g- tube. He states in writing that he is not hungry or thirsty feeling like he requires additional intake - but rather he can taste the soda he puts in there and enjoys the flavor. Mr. [NAME] was educated on compliance with g-tube enteral feedings/water, dangers and risks associated with putting additional fluids in the-tube, infection. Goal: The Resident will maintain adequate nutritional status as evidenced by maintaining weight within 10 percent of admission baseline through the review dated 01/28/25. Interventions: Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Focus: Resident #118 has impaired visual function and was at risk of falls/injury. Goal: The Resident will show no decline in visual function through the review date. The Resident will maintain optimal quality of life within limitation imposed by visual function through the review date. Interventions: Arrange consultation with eye care practitioner as required. Identify/record factors affecting visual function including Physiological (glaucoma, Crohn's, macular degeneration, cataracts, color discrimination, light sensitivity, dry eyes); Environmental (poor lighting, monochromatic color scheme), Choice (refuses to wear glasses, use mag glass, turn on lights) etc. Monitor/document/report to MD the following s/sx of acute eye problems: Change in ability to perform ADLs, decline in mobility, Sudden visual loss, Pupils dilated, gray or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 13 of 19 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 01/16/2025 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision. Review medications for side effects which affect vision. Observation of g-tube medication administration on 01/15/25 at 8:35 AM, LVN B did not check Resident #118 g-tube placement. LVN B did not aspirate gastric content or listen for bowel sounds, she did not check for abdominal distention before Resident #118 administered his own medications, water, and bolus formular feeds. LVN B stated that Resident #118 had always self-administered his own medications and feeds. She stated that she had been told during training (two months ago) that the nurse would cocktail the medications and the resident would administer the medications himself. She stated the nurse would supervise until the resident was finished and then he would administer his own feedings. LVN B stated that she did not check for Resident #118's g-tube placement because she had been caught off guard by a different surveyor watching her in another room prior to her starting Resident#118's medications. LVN B stated that it was important for the nurse to check for placement of the g-tube to make sure that it was still in place, and it had not dislodged. She stated the risk was the g-tube could be out of place, in the wrong place, and infection control. In an interview with the DON on 01/16/25 at 12:58 PM, the DON stated her expectation for staff was to check placement before giving medications or feedings to residents with G-tubes. She stated staff should have looked at Resident #111 and Resident #118's G-tube, aspirated and checked residual to ensure it was placed in the correct place. She stated LVN B should have administered Resident #118's medications. The DON stated she had inserviced staff on G-tubes. Review of facility policy titled, Gastronomy Placement revised 06/2020, reflected in part: I. Prior to the administration of feeding, hydration, and/or medication through a gastrostomy tube, the placement of the tube shall be verified. II. This verification procedure shall be completed by a licensed nurse IV. Access the resident's abdomen for bowel sounds and distention .XI. Aspirate gastric contents to be sure the tube is in the stomach FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 14 of 19 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 01/16/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access for one of eight residents (Resident #370) reviewed for storage of medication. The facility failed to ensure two medications/suppliments Complete mineral complex dietary supplement for professional use only and Advanced multivitamins were not stored on Resident #370's bedside table and failed to ensure they were secured in the medication cart or medication room. This failure could place residents at risk of medication misuse and supplements could interfere with prescribed medications. The findings included: Review of Resident #370's admission record printed on 01/16/25 reveled a [AGE] year-old female who was readmitted to the facility on [DATE] with an initial admission of 11/14/24. Her diagnoses were pedestrian on foot injured in collision with vehicle, acute post hemorrhagic anemia (low blood due to accident), multiple fractures of ribs, shoulder blade, hip, leg and pelvis. Resident #370 was her own responsible party. Review of Resident #370's admission MDS dated [DATE] did not reflect a BIMS score for cognition. Review of Resident #370's physician order dated 1/14/25 reflected the following orders: -Multi-Vitamin/Minerals Oral Tablet (Multiple Vitamins w/ Minerals) Give 1 tablet by mouth one time a day for Wound Healing -Order Date- 01/09/2025. -Orders did not reflect self-medication Administration. Review of Resident #370's physician orders dated 01/16/25 reflected the following: -Multivitamin Women's 50+ Adv Oral Tablet (Multiple Vitamins w/ Minerals). Give 2 tablet by mouth in the afternoon for Wound supplement May use personal vitamins in bottle. -Multivitamin/iron/minerals/calcium/fa/lyc /lut(complete vitamin). Give 2 capsules by mouth in the afternoon for Wound supplement May use personal supplement in bottle. Review of Resident #370's care plan revealed Resident #370 had impaired visual function. The goal was that the resident would show no decline in visual function through the review date 03/02/25. The interventions were to arrange consultation with eye care practitioner as required, to ensure appropriate visual aids prescription glasses are available to support the resident's participation in activities, Review medications for side effects which affect vision. The care plan did not reflect self-administration of medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 15 of 19 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 01/16/2025 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 0761 Observation on 01/14/25 at 9:35 AM LVN A in Resident #370's room performing wound care. Level of Harm - Minimal harm or potential for actual harm Observation and interview with Resident #370 on 01/14/25 at 10:12 AM, revealed two bottles of medication on the bedside table. Resident #370 stated the facility was aware that she had the medication at bedside. She stated she had a small lock box that only fit her wallet and that the bedside table had no key to lock the medication or any of her personal items. She stated when she left her room, she closed the door, but her room was not locked. Resident #370 stated she liked her own supplements because they did not contain poisonous mercury in them. She stated she had the Supplements since she returned to the facility on [DATE]. Residents Affected - Few Observation on 01/14/25 at 3:35 PM, ADON in Resident #370's room talking to resident. Resident #370 was in her bed with right leg brace open. Medications could be seen on the bedside table. Observation on 01/15/25 at 7:09 AM, medications were still on Resident #370's bedside table. LVN A was notified of the medication by the surveyor watching medications . LVN A went into Resident #370's room and took the medications and she stated she would notify the physician for the medications to be added to Resident# 370's orders. In an interview with LVN A on 01/15/25 at 0:17 AM, she stated she was not aware that Resident #370 had medication in her room. She stated Resident #370 had expressed to her in the past that her friend was going to bring her supplements that did not contain mercury in them for her. LVN A stated Resident #370 was educated that when her friend brought the medications, they would need to be given to the nurse. LVN A stated Resident #370 was not permitted to self-administer and to have medications at the bedside. She stated medications were to be locked in the medication cart. In an interview with MA C on 01/15/25 at 0:46 AM, she stated she was not aware that Resident #370 had medication at the bedside. She stated Resident #370 usually declined the facility multivitamins and other supplements including the house shake. She stated she had reported the issue to LVN A, ADON and DON. She stated the resident stated she had her own supplements, but CMA C had not seen them in her room. She stated the risk was access to medication. In an interview with ADON on 01/16/25 at 11:26 AM, he stated he was not aware that Resident #370 had medication at the bedside. He stated he was not paying attention to his surroundings to notice that Resident #370 had medication in her room when he went to talk to her 01/14/25. He stated he had gone to talk to Resident #370 regarding her concerns with her surgical site. ADON stated he was aware that Resident #370 was refusing supplements that were provided by the facility. He stated when Resident #370 came back from the hospital (01/09/25), Resident #370's friend came to the facility to bring her belonging and it might have been at that time that the friend brought Resident #370 medications. He stated he had educated both Resident #370 and her friend that if they brought the supplements that the resident wanted to take, they would give them to the nurses so that the doctor could approve them. He stated residents were not allowed to keep medication at the bedside unless they had an order to self-administer, they and an assessment for self-medication administration and had a care plan. He stated the risk was that anyone could have access to the medication in her room. In an interview with the DON on 01/16/25 at 3:20 PM, she stated on 01/10/25, the DON stated education was given to both resident and her friend to give the medications to the nurse. The DON stated she was not aware until 01/15/25 about the medications on Resident #370's bedside. She stated she did an in-service about medications at bedside and that they should be turned into the nurse. She stated residents were not permitted to keep medication at the bedside unless they had an order to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 16 of 19 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 01/16/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few self-administer, had an assessment to self-administer medication and had a care plan to self-administer medication. She stated the risk was that anyone could have access to the medication in her room. Review of facility policy titled Bedside medication Storage revision date 08/2020 reflected . read in part . Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team (or equivalent) . For residents who self-administer medications, the following conditions are met for bedside storage. to occur: a. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if unlocked storage is deemed inappropriate. Facility management should have a copy of the key in addition to the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 17 of 19 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 01/16/2025 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 observations, interviews, and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area for 1 of 1 (Resident # 165) residents reviewed for resident call system. Residents Affected - Few The facility failed to ensure Resident #165's bathroom call light was functioning outside the Resident's room. On 01/14/2025 when the bathroom light was activated, the call light did not turn on in the hallway above Resident #165's door. This failure could place residents at risk of not getting assistance and not having their needs met. Findings included: Record review of Resident #165's admission Record, dated 01/16/2025, revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included fracture of upper and lower end of right fibula (calf bone), Type 2 Diabetes (a disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels), and anxiety. Record review of Resident #165's most recent MDS, dated [DATE], revealed a BIMS of 14, indicating intact cognition. Further review of the MDS revealed Resident #165 required extensive one person assist with bed mobility, transfers and was totally dependent on one staff for toilet use. Observation and interview on 01/14/25 at 10:30 AM, Resident #165 was lying in bed and stated the emergency call light in the bathroom does not turn on. Surveyors went into the bathroom and activated the light, but the light did not turn on in the hallway above the door. Interview on 01/14/25 at 10:30 AM, Housekeeper D stated the light was supposed to come on outside the room. She stated she did not know it was not working. She said if she found a call light not working, she would call maintenance. Interview on 01/14/25 at 10:30 AM, LVN F stated the call light should be on outside the room and flashing. Interview on 01/14/25 at 10:56 AM, Maintenance Staff E arrived in Resident #165's room to fix the call light. He stated no one had reported it not working. He said if the call light was not functioning, residents cannot receive a response from the nurse. Maintenance Staff E stated the call light was working at the nurse's station. Interview on 01/16/25 at 01:25 PM, the DON stated her expectation was if the call light was not working staff would report to the nurse or maintenance. She stated Maintenance was responsible to ensure call lights were functioning. 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 18 of 19 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 01/16/2025 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 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 . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 19 of 19