Health inspection·September 27, 2023

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some understood by others and was sometimes understood (able to respond adequately to simple, direct communication only). Resident #1's BIMS score was an 06, which indicated severe cognitive impairment. Resident #1 had no signs/symptoms of delirium (inattention, disorganized thinking and altered level of consciousness), her mood score was a 00, which indicated no negative mood issues. Resident #1 had no potential indicators of psychosis, physical or verbal behaviors, rejection of care or wandering. She was independent in her ADLs, was continent in bowel and bladder, had unsteady balance during transitions and walking, and did not use a mobility device for ambulation. Resident #1 had no indicators of pain and had no falls since the last MDS assessment. Resident #1 wore a wander guard for elopement prevention daily. Record Review on 09/12/23 of Resident #1's care plan (not dated) reflected the following problems/issues: 1) [Resident #1] has a communication problem related to dementia, schizoaffective disorder and minimal hearing difficulty, 2) Resident #1 has impaired cognitive function or impaired thought processes related to dementia, schizoaffective disorder, 3) Resident #1 is an elopement risk/wanderer, 4) Resident #1 has delirium or an acute confusion episodes related to inattention and disorganized thinking, 5) Resident #1 requires antidepressant, antipsychotic medications for diagnoses of schizoaffective disorder bipolar type, 6) Resident #1 has schizophrenia and dementia, 8) Resident #1 is at risk for psychosocial well-being problem or alteration in mood state, and 7) Resident #1 is at risk for ADL self-care performance deficient. Record review of Resident #1's September 2023 Physician Orders reflected she was prescribed the current medications while under MD's medical care: Amlodipine Besylate Tablet 5 MG once a day for hypertensionhold for SBP<100 and DBP<60 and HR<55 (start date 04/22/21), Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization (seizure medication used off label-start date 04/21/21, increased PM dose by one tablet on 09/07/23), Trazadone 50 MG once at bedtime for depression (anti-depressant-start date 08/09/22) and Quetiapine Fumarate/Seroquel 325 MG twice a day(antipsychotic- start date 03/28/23). Record review of Resident #1's September 2023 MAR/TAR reflected she refused the following medications: -Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 documented as refused on 09/01/23, 09/03/23, 09/05/23, 09/08/23 and 09/09/23. - Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization documented as refused on 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/08/23 and 09/09/23. - Trazadone 50 MG once at bedtime for depression documented as refused on 09/01/23, 09/02/23, 09/03/23 and 09/04/23. - Quetiapine Fumarate (Seroquel) Oral Tablet 25 MG give with 300mg tab = 325mg twice a day for schizoaffective disorder, bipolar type documented as refused on 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/05/23, 09/08/23 and 09/09/23. Record Review of Resident #1's clinical record revealed only one nursing progress note related to medication refusals on 8/11/2023 at 8:20 AM. The progress note reflected, Resident refused to take AM meds x3, no reason given for the refusal when asked. Resident up ambulating. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 2 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of Resident #1's clinical record revealed no evidence through nursing documentation that MD, NP D or PA E or Resident #1's RP/family member(s) were notified or that Resident #1 was assessed for any decline in condition. An interview with Resident #1's secondary RP/family member on 09/11/23 at 6:04 PM revealed she found out on 09/11/23 that Resident #1 had been arrested on 09/09/23. The family member was concerned Resident #1 had a psychotic break while at the facility and thought she did not recognize her roommate and thought it was someone invading her privacy. The family member stated the facility reported [date unknown] Resident #1 was being rough and mean with her roommate [Resident #2] and slapped her and another man. The family member stated she was confused because the facility had notified her that Resident #1 was at the hospital on [DATE] because she had a mental break. When another family member/primary RP went to provide Resident #1 cigarettes on 09/09/23, the facility asked the RP if she would ride with Resident #1 to take her to a behavioral health hospital but did not provide her with any clinical paperwork. The RP was dropped off with Resident #1 by the police at the behavioral health hospital and they refused to accept Resident #1, so the RP called the police to transport Resident #1 back to the facility. The family member stated the facility had also reported to her during this time that Resident #1 had not been taking her medications for about a week. The family member stated once Resident #1 was supposed to be transported back to the facility by the police, she did not hear anything from the facility until two days later when they reported to her that Resident #1 was missing. The family member stated the facility told her on 09/11/23 the police dropped Resident #1 off across the street of the facility. So they called the police and they asked her if she knew where Resident #1 was and gave her the police report number from the incident on 09/09/23. The family member then went to the police department to file a missing person's report on 09/11/23. The family member stated through the facility's police report number, she was able to find out Resident #1 had been arrested for a felony charge of injury to an elderly person and was in the local county jail with a $500 bail. The family member felt the facility was trying to get rid of Resident #1, claiming they sent her to the hospital the week prior but the hospital sent her back because it was not a psychiatric emergency. The family member felt all of these facility behaviors were a tactic to get Resident #1 out of the facility. The family member stated she had not been able to see Resident #1 in jail yet and she was concerned Resident #1 was not getting any of her prescribed psychotropic medications. So if she was having a psychotic break, she would not be able to get through it. The family member felt the facility was causing her behaviors and did not know how to deal with residents with mental health issues. She stated the facility was agitating her with the transfers back and forth from the facility to the hospitals. The family member stated the facility did not provide her with any documentation about the transfers out in the past week. The family member stated, They cut me out of the loop .they should have discussed that [transfers/behaviors] with us to work with them. An interview with Resident #1's primary RP on 09/12/23 at 2:48 PM revealed on 09/08/23, she got a call from the activity director to bring Resident #1 some cigarettes. So she bought a carton and went to the facility the following day to deliver them (9/09/23). When the primary RP arrived, she was going to drop off the cigarettes because she was on her way to work and was using a rideshare service. However, the facility notified her that Resident #1 had attacked someone. The RP stated she told the facility staff that did not sound like Resident #1 and had they been messing with her medications? The RP stated, This is not the first time and we have discussed the same thing over and over, I said I am not POA and I can't make her take mediation, but let me tell you, when you mess with her medicine, she gets aggressive and she needs this medicine. The RP stated the facility had never informed her that Resident #1 had been refusing her medications for five days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 3 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some She was frustrated because she felt the facility called her and the other RP often for minor issues, but they could not call and notify them she was refusing her medications. The family member wanted to know why the facility did not intervene when Resident #1 started to refuse her medications. The family member stated RN F was at the facility and told her he was in charge and they had already called the police. The RP stated, Why? Because you know she didn't take her meds and why didn't you send her to the hospital? She said RN F stated Resident #1 did not want to be transported in an ambulance. The RP stated she felt something was not right about the situation so she decided to stay and see what was going to happen because she felt the facility was trying to arrest Resident #1 and she was scared that because of her ethnicity and having mental illness, if Resident #1 ended up in jail, it would not fare well for her. When the police arrived, the RP told them Resident #1 needed to go to the hospital because she had been there the week before. The RP stated when she saw Resident #1 that day, she was crazy acting, saying she was someone else, saying she saw a man who was not there and people were sitting on her and was delusional. The RP felt the facility had a plan to dump Resident #1 because they were supposed to facilitate the transfer to the hospital, but they began talking privately and she overheard them say one place was full and that they were going to take her to an inpatient behavioral health facility. The RP went with the police and Resident #1 in the police care because she felt that something was not right. When they got to the inpatient behavioral health facility, the police dropped her and Resident #1 off and left. The intake coordinator refused to admit Resident #1 due to her having noted aggression and said they would not be able to force her to take her medications because it was only a behavior clinic. The RP then called the facility to notify them of the refused admission and was told by the front desk receptionist that Resident #1 could not come back and was not allowed back. The RP then called the local police to come and pick up Resident #1 and they called the facility who said she could not come back; the RP told the facility they had to accept her back. The RP then left from the inpatient behavior health facility via rideshare to go to work because she was late and assumed the police had transported Resident #1 back to the facility. An interview with RN F on 09/12/23 at 3:54 PM revealed he was the weekend supervisor for the facility. He did not know if Resident #1's medications had been adjusted at the hospital for the first resident to resident altercation she had with Resident #3 on 09/05/23. RN F stated, I don't know, but even if they tweak her meds, she still refuses. He stated he had been working at the facility for one month on the weekends and Resident #1 always refused her medications. RN F stated the facility could try an intramuscular medication route for Resident #1, but with her, no one will try. They could also try a gel, but she doesn't want anyone close to her., So those are the dilemmas. RN F stated when a resident began refusing medications, the charge nurse should get the doctor and family involved in the care and make a nursing progress note and document the refusals. He stated the medication aides and nurses could not force a resident to take their medications. When that happened, the doctor was notified and the nursing staff should have followed up with the psychiatrist. RN F stated, If it is not resolved, we can send her out of the facility, we can discharge for not being able to take care of the resident's needs. An interview with ADON A on 09/12/23 at 4:29 PM revealed when a resident refused their medications, especially medications for a mood disorder, they could become unstable, become easily triggered and could become harmful to themselves or others. If a resident refused medication, the medications aides were supposed to report it to the charge nurse, then the charge nurse contacted the doctor and let them know. ADON A stated, Especially with behaviors, we have to stay on top of it, we can't force them to take them but we have to at least notify the doctor and [PMHP]], who comes in twice a week. When a medication has parameters, ADON A stated it was the same (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 4 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some protocol if the resident was refusing the vitals check, notify the doctor and document. She said the charge nurse could also attempts twice and then the ADON for that hall could try as well. ADON A stated no one had notified her Resident #1 was refusing her medications when she was placed temporarily on her hall and she just found out on 09/11/23, after the incident with Resident #2 that she had not been taking them. ADON A stated she needed to in-service the nursing staff about notifying nursing management when residents were refusing medications. ADON A stated she did not know how to run an audit of refused medications in the online e-charting system. An interview with ADON B on 09/12/23 at 5:35 PM revealed he knew Resident #1 and she had mental health issues and took medications for it. He stated Resident #1 was sometimes resistant to take her medications and be provided ADL care, and it could take multiple encouragements from different staff to get her to comply. After a resident to resident altercation with Resident #3 on 09/05/23, ADON B stated Resident #1 came back from the hospital with no new orders and was placed on his hall. The nursing staff were monitoring her for physical aggression, yelling, and cursing; ADON B said he had never known her to do that before. He stated sometimes Resident #1 would walk down the hall and laugh to herself, make noises, but never physically hit someone. ADON B stated he had never been notified that Resident #1 was refusing her medications. He stated he expected the medication aides and charges nurses to tell him when a resident refused medications. He stated they had to document the refusal and the family, doctor and/or psychiatrist had to be notified. ADON B stated he had never tried to administer medications to Resident #1 while she was recently on his floor. He had been working at the facility since January 2023, and he remembered in times past when he did have to administer medications to Resident #1 and he never had any issues and she always took them. ADON B stated when a resident refused medications, the medications could become less effective and drop below their therapeutic level and the resident could have behaviors that the medication was supposed to help them with; behaviors will rise. An interview with LVN I on 09/13/23 at 10:15 AM revealed when a resident refused medications, especially medications for a mood disorder, the medication aide should have notified the charge nurse first who could then encourage the resident on why they need the medication. LVN I stated she did a three refusal rule. For residents with dementia, LVN I stated, Your nurse techniques can be used; you have to know them. If the resident refused a third time, then the doctor needed to be notified, and the family. LVN I stated the next day in morning standup meeting with management, the charge nurse should talk about the refusal and then it should also have been documented on the 24 hour report which was reviewed by management. LVN I stated in the online e-charting system, the facility could run a report that showed what residents and what medications were refused. LVN I stated, It's simple and each nurse comes in and talks about their hall and their patients. LVN I stated MA J was her medication aide for the morning shift but she had not been notified Resident #1 refused medication when she was on her hall. An interview with MA J on 09/13/23 at 11:09 AM revealed Resident #1 was not on her hall for very long; maybe a week or two in the past 30 days. MA J stated Resident #1 refused medications. MA J stated she would walk up to Resident #1 and ask her if she was going to take her medication and Resident #1 would say no. MA J said she would tell Resident #1 okay and tell the charge nurse she tried to give it. Sometimes if MA J let Resident #1 smoke a cigarette first, she would be more amenable to taking her medications afterwards, but not always. MA J stated when Resident #1 refused medications, I would say thank you and move on. I never knew what triggered her. I would just tell the nurse I tried a couple times and she was refusing me and could you try. I have told different nurses. An interview with MA K on 09/13/23 at 11:20 AM revealed she had worked with Resident #1 before and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 5 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some she resisted medications and care a lot. When MA K went to pass medications, she stated she would ask Resident #1 if she was ready to take her meds, Sometimes she will say no or cuss me out. MA K stated when that happened, she would try to explain to Resident #1 what the medications were for, but Resident #1 would still say no, that MA K was not her doctor. MA K stated she would then wait a couple of hours and let Resident #1 know she still had not taken them and ask if was she ready. If Resident #1 continued to say no, MA K stated she would tell the charge nurse to see if the nurse could her to take them. MA K stated her nurse was RN L and she was not successful in getting Resident #1 to take her medications either. MA K stated if a resident was not taking their medications, then whatever they are taking medications for will start to happen, like mental issues getting worse or health issues worsening. An interview with RN L on 09/13/23 at 11:29 AM revealed Resident #1 was only on her hall for less than 24 hours, so she never really worked with her. RN L stated if a resident refused medications, if they were psychotropic medications, it could cause them to have behaviors. RN L stated for medication refusals, the medication aide was supposed to let the charge nurse. RN L stated, No one told me she [Resident #1] was refusing. She said the main thing the nurse could do was notify the doctor and RP, we can't force them. RN L stated the nurse would need to document what they had done related to notifications. An interview with ADON C on 09/13/23 at 11:40 AM revealed she was over the secured units and did not work with Resident #1, but in her experience, when a resident refused medications, the medication aides were supposed to tell the charge nurse and the charge nurse needed to try to administer. If the charge nurse could not administer to the resident, then the doctor and RP had to be notified and the medications possibly needed to be put on hold. ADON C stated if she was the charge nurse for Resident #1, she would ask her why she did not want to take them. She said when a resident had dementia, the nurses and med aides still tried to encourage them and if the continued to say no, then call the doctor and document in a nursing progress note. ADON C stated, Especially if it is pill form, because maybe change it [to liquid, crushed, in food]. ADON C stated I would have tried to get her medication in liquid form if Resident #1 was refusing to take pills because she drank a lot coffee and water, a lot of dementia residents are like that, they will not take a pill but will drink. An interview with the DON on 09/13/23 at 12:38 PM revealed she was unaware Resident #1 had been refusing her medications. The DON stated her expectation was the medication aide needed to report refusals to the charge nurse and the charge nurse notified the doctor. If Resident #1 refused her psychotropic medications for an extended period of time, the DON stated she would have talked to the doctor about it if she was aware of it. The DON said she also expected the med aides and charge nurses to try several attempts, be calm, maybe try a different staff in case the resident did not like that medication aide/nurse. An interview with the MD on 09/13/23 at 4:38 PM revealed the facility did not notify him about Resident #1 being in jail or that she was refusing her medications. He stated he only heard that she was hitting someone. The MD stated the facility was pretty good about handling resident to resident altercations and it was not typical to call the police on altercations with older residents with dementia with behaviors. The MD stated, Most of the time, we put it as acute psychosis. Might be an infection going on with the patient and they became unstable, electrolyte abnormalities, not taking meds. The MD stated he was a hospitalist by trade. So what he wanted was the facility to notify him for those types of incidents and he would have that resident directly admitted to the hospital, check them out, and stabilize them. The MD stated he was a physician at one hospital and had a contract with two hospitals for admission privileges. The MD stated, It is easy for me to navigate that process and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 6 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the facility knows that. He stated if a resident freaked out during a behavioral emergency and they were not thinking clearly, then he would want the charge nurse to call him and he would admit the resident for acute psychosis for admission. The MD stated, Especially with [Resident #1] because she is an older lady, I remember her face. If she was like that, I would have had her directly admitted instead of calling police. I would have had them call EMS and from there I can then stabilized her and send her back. The MD stated that was the protocol the nurses typically followed, but it all depended on who was working at the time of an incident. The MD stated, There are nurses who are really good who can catch it [behavior] and navigate that so I can do something about it and then there are nurses who freak out and call the police. I have done it so many times, I can get the patient stabilized. An interview with the MHNP on 09/13/23 at 2:47 PM revealed she was the psychiatric nurse for the facility residents and was unaware Resident #1, who was her patient, was in jail. She stated she was not contacted nor involved with the two resident to resident altercations Resident #1 had been in during the past week. She stated Resident #1 had never been physically aggressive, She's had manic episodes where she's difficult to redirect and delusional, but she's never been violent, ever. MHNP was unaware Resident #1 had been refusing her medications. An interview with NP D on 09/14/23 at 10:38 AM revealed she remembered being notified that Resident #1 was refusing her medications but could not recall when or who notified her. She stated she told the staff to keep trying, have different people try to administer, call the family, wait and try again. NP D stated, There is only so much we can do. She said if there were no behavior problems related to the medication, then after about a month, that medication could have been discontinued. An interview with LVN O on 09/14/23 at 1:46 PM revealed she was the charge nurse working on Resident #1's hall on 09/09/23 but she did not see the resident to resident altercation between her and Resident #3. LVN O stated she remembered Resident #1's family member was present at the facility and was upset stating the facility had to give Resident #1 her medications. LVN O stated she told the family member she would look at Resident #1's medications, but she did not follow through because Resident #1 was going to be sent to the hospital. LVN O stated if a resident refused medications, she expected the medication aides to report it to her. LVN O stated she had been hearing Resident #1 was refusing medications and doses through the grapevine. LVN O stated, But me, if I heard that, I would call doctor to see if anything else I could do, and I would have at least tried to put it in food or drink and watch her take it. That morning, after all this had happened [resident to resident altercation], then I start hearing she wouldn't take it [medications]. Back there on my unit, we find a way. LVN O stated if residents do not get their psychotropic medications, they were going to act out. LVN O stated when a medication refusal happened, she would document it in a progress note and let the doctor know what had transpired and see what they wanted her to do. LVN O stated, To me, if she was not taking her medication, why not call the [family member/RP] who would have a better relationship and schedule medicine administration where [family/RP] could be present, that is what I would have done. You got to show you tried. Record review of the facility's policy titled, Change of Condition Notification, revised June 2020, reflected, Purpose: To ensure residents, family, legal representatives, and physicians are informed of changed in the resident's condition in a timely manner; Policy: Definition: An acute change in condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physician, cognitive, behavioral, or functional domains; .Procedure: I. The Licensed Nurse will notify the resident's Attending Physician when there is an: A. Incident/accident involving the resident; B. An accident involving the resident which results in injury and had the potential for requiring physician (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 7 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some intervention, C. A significant change in the resident's physical, mental or psychosocial status, D. A need to alter treatment significantly .II. The Licensed nurse will assess the resident's change of condition and document the observations and symptoms. III. Notifying the Physician: A. The Attending Physician will be notified timely with a resident's change in condition; B. Notification to the Attending Physician will include a summary of the condition change and an assessment of the resident's vital signs and system review focusing on the condition and/or signs and symptoms for which the notification is required.IV. Emergency Situations: .A.(i) NOTE: If the Licensed Nurse is unable to reach the Attending Physician or the Physician on call during emergency situations, he/she will notify the Facility's Medical Director .V. Family Notification: A. The Licensed Nurse will notify the resident, the resident's responsible party, or family/surrogate decision-makers of any changes in the resident's condition as soon as possible; VI. Documentation: A. A Licensed Nurse will document the following: i. Date, time, and pertinent details of the incident and the subsequent assessment in the Nursing Notes, ii. The time the Attending Physician was contacted, the method by which he was contacted, the response time, and whether or not orders were received, iii. The time the family/responsible person was contacted, iv. Update the Care Plan to reflect the resident's current status, v. The incident and brief details in the 24-Hour Report, vi. If the resident is transferred to an acute care hospital, complete an inter-transfer form, vii. Complete an incident report per Facility policy, B. A Licensed Nurse will communicate any changed in required interventions to the members involved in the resident's care, C. A Licensed Nurse will document each shift for at least seventy-two (72) hours, D. Documentation pertaining to a change in the resident's condition will be maintained in the resident's medical record and on the 24-Hour Report. On 09/14/23 at 1:45 PM, an Immediate Jeopardy (IJ) was identified. The ADM was notified and provided with the IJ template, and a Plan of Removal (POR) was requested at that time. While the Immediate Jeopardy was removed on 09/18/23, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. The following plan of removal submitted by the facility was accepted on 09/15/23 at 4:45 PM: Date: 09/14/2023: PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it may concern, Summary of Details which lead to outcomes On 9/14/23, a complaint ad self-report survey was initiated at [Facility Name and address]. A surveyor provided an IJ Template notification that the Survey Agency has determined that a condition at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows:

F580 Notify Physician of Changes: 1. The facility failed to intervene regarding Resident #1's change of condition. Regarding refusal of medications and behavioral and or aggressive acts. The facility failed to document, assess, and notify the physician regarding change of condition. Identify residents who could be affected: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 8 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0580 All residents have the potential to be affected. Level of Harm - Immediate jeopardy to resident health or safety Identify responsible staff/ what action taken: 1. Licensed Nurses and medication aides in serviced by the DON on the facility policy and procedure regarding documentation, assess, and notify the physician regarding change of condition. 9/14/23 Residents Affected - Some 2. Certified Nursing Assistant received education on reporting changes in behavior in a resident by the DON.9/14/23 3. Initiated staff interviews and established a timeline of the sequence of events by Administrator on 9/14/2023. 4. Audit of all resident's MARs completed to assure if and care planned by licensed staff on 9/14/23. In-Service conducted. 1. Change in condition. 2. Medication administration The in-service was attended by licensed caregivers which include Registered Nurse, Licensed Vocational Nurse, Certified Nursing Assistants, Certified Medication Aide. This in-service was initiated on 9/14/23 and all staff must be in-service bef[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 9 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the resident has the right to be free from neglect for one (Resident #1) of five residents reviewed for neglect. Residents Affected - Some 1. The facility failed to provide prescribed psychotropic medications to Resident #1, who lived with dementia and mental illness, and moved her to several different rooms in a week's time which resulted in her having increased behaviors resulting in two separate unwitnessed resident to resident altercations. 2. The facility failed to notify the MD when Resident #1 refused her psychotropic medications prior to the two resident to resident altercations. An Immediate Jeopardy was identified on 09/14/23. The IJ Template was provided to the facility on [DATE] at 1:45 PM. While the Immediate Jeopardy was removed on 09/18/23, the facility remained out of compliance at the severity level of Actual harm that is not Immediate Jeopardy and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure could affect residents and place them at risk of further abuse/neglect with exit-seeking behaviors by placing them at risk for injury and/or death, including vehicular accidents, falls, missing medications, and an exacerbation of their dementia and mental illness related behaviors. Findings included: Record review of Resident #1's Face Sheet (undated) reflected she was a [AGE] year-old female admitted to the facility on [DATE] with active diagnoses including schizoaffective disorder-bipolar type (a mental illness where the person experiences psychotic symptoms, such as hallucinations or delusions with episodes of mania and sometimes depression), dementia-moderate with behavioral disturbance (the loss of cognitive functioning- thinking, remembering, and reasoning along with symptoms depression, anxiety, psychosis, agitation, aggression, disinhibition and sleep disturbances), generalized anxiety disorder (a feeling of fear, dread, and uneasiness), insomnia (trouble falling asleep, staying asleep, or getting good quality sleep), diabetes (a problem in the way the body regulates and uses sugar as a fuel), hypertension (when the pressure in your blood vessels is too high-140/90 mmHg or higher), difficulty in walking, unsteadiness on feet/lack of coordination and altered mental status (a change in mental function). Resident #1's reflected she had three emergency contacts and MD was listed as her attending physician. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was sometimes understood by others (ability is limited to making concrete requests) and was sometimes understood (able to respond adequately to simple, direct communication only). Resident #1's BIMS score was an 06, which indicated severe cognitive impairment. Resident #1 had no signs/symptoms of delirium (inattention, disorganized thinking and altered level of consciousness), her mood score was a 00, which indicated no negative mood issues. Resident #1 had no potential indicators of psychosis, physical or verbal behaviors, rejection of care or wandering. She was independent in her ADLs, was continent in bowel and bladder, had unsteady balance during transitions and walking and did not use a mobility device for ambulation. Resident #1 had no indicators of pain and had no falls since the last MDS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 10 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some assessment. Resident #1 wore a wander guard for elopement daily. Active discharge planning was not already occurring for Resident #1 to return to the community. Resident #1 wore a wander guard for elopement daily. Record Review on 09/12/23 of Resident #1's care plan (not dated) revealed the following problems/issues: 1) Resident #1 has a communication problem related to dementia, schizoaffective disorder and minimal hearing difficulty, 2) Resident #1 has impaired cognitive function or impaired thought processes related to dementia, schizoaffective disorder, 3) Resident #1 is an elopement risk/wanderer, 4) Resident #1 has delirium or an acute confusion episodes related to inattention and disorganized thinking, 5) Resident #1 requires antidepressant, antipsychotic medications for diagnoses of schizoaffective disorder bipolar type, 6) Resident #1 has schizophrenia and dementia, 8) Resident #1 is at risk for psychosocial well-being problem or alteration in mood state, and 7) Resident #1 is at risk for ADL self-care performance deficient. Record review of Resident #1's September 2023 Physician Orders reflected she was prescribed Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 (started date 04/22/21), Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization (seizure medication used off label-start date 04/21/21, increased PM dose by one tablet on 09/07/23), Trazadone 50 MG once at bedtime for depression (anti-depressant-start date 08/09/22) and Quetiapine Fumarate/Seroquel 325 MG twice a day(antipsychotic- start date 03/28/23). Record review of Resident #1's September 2023 Physician Orders reflected she was prescribed the current medications while under MD's medical care: Amlodipine Besylate Tablet 5 MG once a day for hypertensionhold for SBP<100 and DBP<60 and HR<55 (start date 04/22/21), Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization (seizure medication used off label-start date 04/21/21, increased PM dose by one tablet on 09/07/23), Trazadone 50 MG once at bedtime for depression (anti-depressant-start date 08/09/22) and Quetiapine Fumarate/Seroquel 325 MG twice a day(antipsychotic- start date 03/28/23). Record review of Resident #1's September 2023 MAR/TAR reflected she refused the following medications: -Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 documented as refused on 09/01/23, 09/03/23, 09/05/23, 09/08/23 and 09/09/23. - Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization documented as refused on 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/08/23 and 09/09/23. - Trazadone 50 MG once at bedtime for depression documented as refused on 09/01/23, 09/02/23, 09/03/23 and 09/04/23. - Quetiapine Fumarate (Seroquel) Oral Tablet 25 MG give with 300mg tab = 325mg twice a day for schizoaffective disorder, bipolar type documented as refused on 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/05/23, 09/08/23 and 09/09/23. Record Review of Resident #1's clinical record revealed only one nursing progress note related to medication refusals on 8/11/2023 at 8:20 AM. The progress note reflected, Resident refused to take AM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 11 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 meds x3 [three times], no reason given for the refusal when asked. Resident up ambulating. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's clinical record revealed no evidence through nursing documentation that MD, NP D or PA E or Resident #1's RP/family member(s) were notified or that Resident #1 was assessed for any decline in condition Residents Affected - Some Record review of pertinent facility progress notes for Resident #1 reflected: -09/05/23-Mood/Behavior: Late entry- Resident was seen slapping another resident. This writer, other aides and employees separated the two. [City] police were called due to the resident hitting another resident and unsuccessful attempts of calming the resident down. The resident was transferred to [hospital name]. Family called and notified along with MD. Spoke with rep from [behavioral health facility] about placement and notified them she is at [hospital]. -09/05/23-Social Service Note: Clinicals have been sent over to [behavioral health facility]. -09/07/23-Admit/readmit: Resident re-admitted to facility from [hospital name] via [transport non-emergency]- diagnosis mental health problem. NP D notified of resident's return and reviewed all orders. -09/09/23-General Progress Note written by RN F: This resident was physically aggressive and assaulted the roommate, hitting her on the head, chest and back. Resident was separated from roommate, [RP] in room taking to resident. 911 was notified, in room with resident, resident transferred to [hospital name] for psychological evaluation. Administrator, DON and Physician notified. Resident's [family]on site. -09/09/23-General Progress Note written by ADON A: Late entry- [City] police here and will take patient and [family]to hospital. [City] police stated they would take them to [hospital name]. About an hour later front desk received a call from [behavioral health facility] stating patient was too aggressive for admission. [RP] still with patient. Attempted to call [RP]. No answer. left message. -09/09/23 at 1:57 PM-General Progress Note written by ADON A: Late Entry- Resident was seen across the street by staff (resident standing at front entrance of the apartment). Police called for safe check on resident. Police and ambulance came to the apartments and facility. Ambulance left and police came into parking lot watching resident. Provided police officer with face sheet and med list. DON arrived while we were standing outside watching resident for safety. Patient stated [sic] walking away police officer stated she was going to follow her and pick her up. I asked did she need any help police officer stated 'no' she had it. Attempted to call [Resident #2's other RP] no answer and left message, to ask her why she drop her off at apartments or what where her intentions no answer no return call. Review of Resident #1's progress notes reflected no documentation from 09/09/23 at 1:57 PM until 09/17/23. During this time was when Resident #1 went missing and was found by family incarcerated in the local jail. Record review of Resident #1's clinical chart reflected no physician transfer order to the ER or to a behavioral health facility on 09/09/23. Record review of Resident #1's clinical chart reflected no required facility transfer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 12 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 documentation/checklist provided to the police/family member per the facility's transfer policy. Level of Harm - Immediate jeopardy to resident health or safety An interview with Resident #1's secondary RP/family member on 09/11/23 at 6:04 PM revealed she found out on 09/11/23 that Resident #1 had been arrested on 09/09/23. The family member was concerned Resident #1 had a psychotic break while at the facility and thought she did not recognize her roommate and thought it was someone invading her privacy. The family member stated the facility reported [date unknown] Resident #1 was being rough and mean with her roommate [Resident #2] and slapped her and another man. The family member stated she was confused because the facility had notified her that Resident #1 was at the hospital on [DATE] because she had a mental break. When another family member/primary RP went to provide Resident #1 cigarettes on 09/09/23, the facility asked the RP if she would ride with Resident #1 to take her to a behavioral health hospital but did not provide her with any clinical paperwork. The RP was dropped off with Resident #1 by the police at the behavioral health hospital and they refused to accept Resident #1, so the RP called the police to transport Resident #1 back to the facility. The family member stated the facility had also reported to her during this time that Resident #1 had not been taking her medications for about a week. The family member stated once Resident #1 was supposed to be transported back to the facility by the police, she did not hear anything from the facility until two days later when they reported to her that Resident #1 was missing. The family member stated the facility told her on 09/11/23 the police dropped Resident #1 off across the street of the facility so they called the police and they asked her if she knew where Resident #1 was and gave her the police report number from the incident on 09/09/23. The family member then went to the police department to file a missing person's report on 09/11/23. The family member stated through the facility's police report number, she was able to find out Resident #1 had been arrested for a felony charge of injury to an elderly person and was in the local county jail with a $500 bail. The family member felt the facility was trying to get rid of Resident #1, claiming they sent her the hospital the week prior but the hospital sent her back because it was not a psychiatric emergency. The family member felt all of these facility behaviors were a tactic to get Resident #1 out of the facility. The family member stated she had not been able to see Resident #1 in jail yet and she was concerned Resident #1 was not getting any of her prescribed psychotropic medications so if she was having a psychotic break, she would not be able to get through it. The family member felt the facility was causing her behaviors and did not know how to deal with residents with mental health issues and were agitating her with the transfers back and forth from the facility to the hospitals. The family member stated the facility did not provide her any documentation about the transfers out in the past week. The family member stated, They cut me out of the loop .they should have discussed that [transfers/behaviors] with us to work with them. Residents Affected - Some An interview with Resident #1's primary RP on 09/12/23 at 2:48 PM revealed on 09/08/23, she got a call from the activity director to bring Resident #1 some cigarettes so she bought a carton and went to the facility the following day to deliver them (9/09/23). When the primary RP arrived, she was going to drop off the cigarettes because she was on her way to work and was using a rideshare service, however, the facility notified her that Resident #1 had attacked someone. The RP stated she told the facility staff that did not sound like Resident #1 and had they been messing with her medications? The RP stated, This is not the first time and we have discussed the same thing over and over, I said I am not POA and I can't make her take mediation, but let me tell you, when you mess with her medicine, she gets aggressive and she needs this medicine. The RP stated the facility had never informed her that Resident #1 had been refusing her medications for five days. She was frustrated because she felt the facility called her and the other RP often for minor issues, but they could not call and notify them she was refusing her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 13 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some medications. The family member wanted to know why the facility did not intervene when Resident #1 started to refuse her medications. The family member stated RN F was at the facility and told her he was in charge and they had already called the police. The RP stated, Why? Because you know she didn't take her meds and why didn't you send her to the hospital? She said RN F stated Resident #1 did not want to be transported in an ambulance. The RP stated she felt something was not right about the situation so she decided to stay and see what was going to happen because she felt the facility was trying to arrest Resident #1 and she was scared that because of her ethnicity and having mental illness, if Resident #1 ended up in jail, it would not fare well for her. When the police arrived, the RP told them Resident #1 needed to go to the hospital because she had been there the week before. The RP stated when she saw Resident #1 that day, she was crazy acting, saying she was someone else, saying she saw a man who was not there and people were sitting on her and was delusional. The RP felt the facility had a plan to dump Resident #1 because they were supposed to facilitate the transfer to the hospital, but they began talking privately and she overheard them say one place was full and that they were going to take her to an inpatient behavioral health facility. The RP went with the police and Resident #1 in the police care because she felt that something was not right. When they got to the inpatient behavioral health facility, the police dropped her and Resident #1 off and left. The intake coordinator refused to admit Resident #1 due to her having noted aggression and said they would not be able to force her to take her medications because it was only a behavior clinic. The RP then called the facility to notify them of the refused admission and was told by the front desk receptionist that Resident #1 could not come back and was not allowed back. The RP then called the local police to come and pick up Resident #1 and they called the facility who said she could not come back; the RP told the facility they had to accept her back. The RP then left from the inpatient behavior health facility via rideshare to go to work because she was late and assumed the police had transported Resident #1 back to the facility. A interview was attempted via phone with CNA N on 09/14/23 at 11:11 AM with a voice mail left; CNA N did not respond to request to be interviewed. An interview with the front desk receptionist on 09/14/23 at 12:15 PM revealed she worked over the weekend, including on 09/09/23. She stated she saw Resident #2 being taken out by EMT to the hospital and knew the police had been called and Resident #1 had been asked to leave the facility due to an incident between her and Resident #2. The front desk receptionist stated she saw Resident #1 escorted out of the facility by the police and got into their SUV along with her family member. She then stated after that, the family member called the facility and was stating the police transported Resident #1 to an inpatient behavioral health facility and they would not admit her. The front desk receptionist notified the ADM, and he said no, she [Resident #1] was not to be admitted back in. She could not remember what reason the ADM gave her for refusing to let Resident #1 come back but she thought it had to do with behavior issues. The front desk receptionist stated, I know the [family member] said the reason she needed to come back was because [behavioral facility] would not allow her in and she needed the incident report, I heard the police say it behind her. I said I did not have that .I called her back and said she cannot come back in. She said she could not take her home. I said I am sorry but she cannot come back here. Later in the day [time unknown], the front desk receptionist remembered seeing Resident #1 standing across the street at the apartments walking back and forth and no one was with her. During that same time, [Resident #2] was brought back to the facility by a female police officer while Resident #1 was still across the street. She said ADON A called the police because she knew Resident #1 was standing across the street. The front desk receptionist stated the staff did not bring Resident #1 back into the facility because from her understanding, she was no longer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 14 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some allowed in and that was what ADON A understood to be true as well. Once Resident #1 was back in the building, the female police officer went over to deal with Resident #1 but she did not see what happened. She stated, I looked back up later and they were gone. The front desk receptionist left her shift at 8:00 PM, no one called to the facility inquiring about Resident #1 after she was gone. An interview with the ADM on 09/12/23 at 10:00 AM revealed Resident #1 had an incident a week prior where she was allegedly being rude to LVN I and another resident (Resident #3) told her not to be rude; she then walked over and slapped him. ADM stated LVN I witnessed it. The ADM stated there were no injuries and his [Resident #3] was more of a bruised [NAME]. The ADM stated the police were called and Resident #1 was arrested, Problem is, when she got arrested, [Resident #3] wanted to press charges but they took [Resident #1] to [hospital] who notified the facility the next day they were sending her back. The ADM stated, I put up a fight and said less than 24 hours, you are sending her back? The ADM stated due to his refusal to accept her back into the facility, the hospital notified his boss at the corporate level and the ADM was then told that he had to accept Resident #1 back into the facility because she did not have any behaviors while she was at the hospital. The ADM stated Resident #1 did not have any behaviors when she came back from 09/06/23 through 09/09/23. The ADM stated on 09/09/23, another incident took place and according to Resident #2 (new roommate of Resident #1), she said Resident #1 punched her on her head, chest, and back totally unprovoked. The ADM stated the information came from Resident #2's report to RN F, Which I am not sure how much I want to take at face value because of her dementia. The ADM stated he told RN F what to do because Resident #2 wanted to go to the hospital and came back the same day with no injuries. The police were notified for the alleged resident to resident altercation between Resident #1 and Resident #2 and they escorted Resident #1 from the facility but took her to a behavioral health facility along with her family member but that facility declined to do an admission, so the facility told the family member she would need to be taken to the hospital because she was technically discharged from our facility .Now care was left onto police to direct what happened. The ADM stated the police left the family member and Resident #1 at the behavioral health facility and he was under the impression the family member transported her back to the facility because a Resident #1 was seen by a staff member [name unknown] being dropped off across the street to the facility where there was an apartment complex. The ADM stated the facility staff called the police on Resident #1 again and they sent a unit out, but before they arrived, he tried to talk to Resident #1 and she told him she did not want to talk to him in a thousand years. The ADM stated when the fire department arrived, Resident #1 refused to talk to them so they left and stated the police were on their way. The ADM stated he had to leave the facility and go back home and ADON A called him and said the police showed up and Resident #1 started walking away, so they gave ADON A a police report number and followed Resident #1. The ADM stated Resident #1 was discharged from the facility and they had tried to prevent the discharge by getting her seen for psyche services, not to discharge. He stated Resident #1 had never been send out before these two incidents and there were no prior resident to resident altercations since her admission in 2021. He stated when she did have a behavioral episode in the facility, she would hit her head and make a grunting noise. The ADM stated the facility had not been able to find a good roommate fit for Resident #1 except for one female resident who she roomed with for a couple of days in the past two weeks before that roommate went out to the hospital. The ADM stated there was no witness for the resident to resident altercation between Resident #1 and #2 and both of them had a diagnosis of dementia. Review of Resident #2's clinical chart post-incident revealed no documentation of the facility speaking with Resident #2's family about pressing charges. An interview with LVN I on 09/13/23 at 10:15 AM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 15 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some revealed she did not witness Resident #1 slap Resident #3; she only heard them yelling at each other. She was shocked to see them verbally fighting with each other and reported none of the staff seemed to be doing anything. LVN I stated Resident #3 was alert and oriented x 4 and he was saying all of the mean things. LVN I asked Resident #3 to stop and remember that Resident #1 was a lady. An interview with RN F on 09/12/23 at 3:54 PM revealed he was the weekend supervisor on 09/09/23 from 7:00 AM until 11:00 PM and he was aware Resident #1 had been sent to the hospital the week prior due to an altercation where he thought she hit someone. He said Resident #1 had been back at the facility for two days prior to the weekend. When RN F got to work on Saturday 09/09/23, he was called to her room and told she had gone to the roommate's bed [Resident #2] and hit her on the back, chest, and head and was following her down the hall. When RN F arrived, he went into their room and tried to evaluate Resident #1, who was laying in bed. He asked Resident #1 what happened and she was agitated and said, That white woman is not my momma and I need her out of this room-she is not my roommate! RN F stated it was hard to re-orient Resident #1 in that state and she had dementia and psyche issues. He stated psyche issues for Resident #1 meant she always paced the hallways, was very untidy, her hair was not groomed, her clothes were not tidy, she talked to herself and made weird noises, declined care and scared other residents away. RN F stated after the incident, he called the police because Resident #2 wanted to file an allegation, I don't know what for, I don't know what she told the police. He stated Resident #1's family member happened to be at the facility but not present for the altercation and he explained the police had been contacted. RN F stated Resident #2 did not have any injuries but was tearful. RN F stated CNA N was the person who told him about the incident. He said he did not get into the details of what CNA N observed, but he did complete an incident report. RN F stated he knew Resident #1 was taken to a hospital in [adjacent city] somewhere and said the police or the family decided on where because he heard them talking. RN F stated he could not tell the police where to take Resident #1, but they did not end up going to [Hospital PP]. RN F stated the facility usually sent the residents to [Hospital PP] for psyche evaluations and a face sheet and medication record would be sent with the transport provider. RN F stated he did not know how Resident #1 ended up at the inpatient behavioral health facility. RN F stated he had called the doctor to get an order to transfer Resident #1 to the hospital, but the doctor could not give a specific order on where to take the resident. RN F stated, The [family member] and police decided to take her wherever they took her. RN F then clarified he spoke to NP D to notify about the transfer, not the MD. He said NP D told him to send Resident #1 out for a psyche evaluation. After that, RN F stated Resident # left the building and never came back that day or the following day. To his understanding. She went to the hospital but he had no idea where they took her, but she was not discharged from the facility. RN F stated the facility social worker normally followed up to see where a resident was placed and which hospital they were sent to, but there was no social worker over the weekend. An interview with ADON A on 09/12/23 at 4:29 PM revealed she was newly employed for about a month and had tried to intervene after an incident where Resident #1 slapped Resident #3 a week prior. ADON A stated when trying to intervene, Resident #1 was gunning for me, she does this reaction like '[NAME]' [ADON A was making hand gestures by her ears], cursing, saying random things like they attacked her and not making any sense. ADON A stated when she tried to physically separate the verbal altercation between Residents #1 and #3, Resident #1 threw ADON A up against the wall. ADON A stated the police took Resident #1 out in handcuffs to Hospital PP. ADON A stated she did not know what Hospital PP did with Resident #1 care wise, but she knew they completed a psychiatric evaluation. She did not know if the facility had a copy of it and she did not get a chance to review any discharge documentation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 16 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete because when Resident #1 re-admitted the next day, she was placed on a new hall/new room that ADON A was not over because they wanted to put distance between her and Resident #3. ADON A stated Resident #1 already had a recent room change from the upstairs hall to the downstairs hall where she got into the altercation with Resident #1. Now she was going to be placed back upstairs, but on a different hall than she had been on prior. ADON A stated when Resident #1 returned, the nursing staff were still trying to locate another psyche facility because we knew it would take longer for her to stabilize. Regarding resident transfers, ADON A stated the police or EMT decided where a resident would be transported when sent to the hospital. She stated NP D was notified at that time. ADON A stated Resident #1 was stable when she came back from Hospital PP. She did not know if psyche services came to visit her or adjust her medications after she re-admitted . On 09/09/23, ADON A stated she came to the facility around 10:30 AM and was not scheduled to work but she had gotten group texts that there was a resident to resident altercation with Residents #1 and #2. She was the closest in the vicinity and was going to check on things. When she arrived at the facility, NP F had already contacted the police and Resident #1's family member was present. ADON A stated the police were hesitant in taking Resident #1 to jail and were talking about transporting her to a hospital. ADON A went to talk to Resident #1 who was cool, calm, and collected and laying on her bed and said she was doing fine. ADON A told Resident #1 her family member was present and the police wanted to take her to Hospital PP. Resident #1 agreed to ride with the police. The police handcuffed Resident #1 and ADON A cut the wander guard off her ankle and printed out her face sheet and med sheet, gave the police and family member a copy, and told the family member to make sure Hospital PP looked over the medication list and they left. About an hour later, ADON A was trying to clock in and heard a housekeeping staff member say, hey, isn't that [Resident #1]? and was looking out the window across the street. ADON A stated no, she was at Hospital PP. Then ADON A looked out the front window and saw Resident #1 standing across the street with a bag of clothes and no one was with her. ADON A stated she went outside and stood in the parking lot, called the ADM and then contacted the police and asked them to do a welfare check because I wasn't sure if I could approach her. She said 911 asked her what did she think the police would be able to do about it? She told them that Resident #1 had just assaulted another resident and she [ADON A] did not know why the resident was not at Hospital PP. ADON A stated Resident #1 did not come back inside during that time and no staff tried to talk to her. ADON A stated, She had already attacked me once. By me not having any male backup, I didn't want to surround her with a group of people. I just kept an eye on her and called 911 for a well-check. ADON A stated fire truck arrived or ambulance, she did not talk to them and they were briefly there then left, but Resident #1 was still there. Then a police officer arrived (same officer that transported to the behavior facility an hour earlier). ADON A asked the police officer what happened and the police officer stated they took Resident #1 to a behavioral health facility with her family member present but they would not take the resident because she was too aggressive and the police left her there with her family member. ADON A then asked the police officer why did they not take Resident #2 to Hospital PP and she could not remember what the officer's response was. ADON A stated, It was so chaotic, I was trying to bring DON up to date and keep eyes on the resident. Police then were saying this is a fine line between criminal and dementia. She [officer] was on the phone with [county jail] and she doubted they would take her in [as an arrest]. At one point, Resident #1 started to walk away and the police officer said she would follow her, she could handle it, and we never heard anything else after that. ADON A could not remember if the police officer still had the face sheet and med list from earlier. ADON A stated she and the DON walked b[TRUNCATED] Event ID: Facility ID: 455653 If continuation sheet Page 17 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to develop and implement written policies and procedures that prohibit and prevent neglect for one (Resident #1) of five residents reviewed for neglect policies. Residents Affected - Some The facility failed to provide prescribed psychotropic medications to Resident #1, who lived with dementia and mental illness, and moved her to several different rooms in a week's time which resulted in her having increased behaviors resulting in two separate unwitnessed resident to resident altercations. The facility failed to notify the MD when Resident #1 refused her psychotropic medications prior to the two resident to resident altercations. The facility did not provide Resident #1 with behavioral interventions and instead, initiated an unplanned and inappropriate transfer that led to Resident #1 being left across the street from the facility and subsequently arrested and incarcerated for a week. The facility was unaware Resident #1 had been arrested for two days and did not attempt to look for her and discharged her from the facility. An Immediate Jeopardy was identified on 09/14/23. The IJ Template was provided to the facility on [DATE] at 1:45 PM. While the Immediate Jeopardy was removed on 09/18/23, the facility remained out of compliance at the severity level of Actual harm that is not Immediate Jeopardy and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure could affect residents and place them at risk of further abuse/neglect due to policy not being developed/implemented. Findings included: Record review of the facility's police titled, Abuse Prevention and Prohibition Program, revised August 2020, reflected, .Purpose: To ensure the Facility establishes, operationalizes and maintains and Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property and crime in accordance with state and federal standards .III. The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs and systems .VIII. Protection: .D. If the allegation is regarding a resident to resident altercation, the residents will be separated immediately, pending the investigation .IX. Reporting/Response: .C. Reporting Requirements .ii. If the suspected physical abuse is allegedly caused by a resident who has been diagnosed with dementia, and a Licensed Nurse reasonably determines that there is no serious bodily injury, the Administrator, and his/her designee, shall report to the local Ombudsman or law enforcement agency by telephone as practicably possible .v. The resident's physician and responsible party, if applicable, will also be notified of the allegation and outcome of the investigation. Record review of Resident #1's Face Sheet (undated) reflected she was a [AGE] year-old female admitted to the facility on [DATE] with active diagnoses including schizoaffective disorder-bipolar type (a mental illness where the person experiences psychotic symptoms, such as hallucinations or delusions with episodes of mania and sometimes depression), dementia-moderate with behavioral disturbance (the loss of cognitive functioning- thinking, remembering, and reasoning along with symptoms depression, anxiety, psychosis, agitation, aggression, disinhibition and sleep disturbances), generalized (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 18 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some anxiety disorder (a feeling of fear, dread, and uneasiness), insomnia (trouble falling asleep, staying asleep, or getting good quality sleep), diabetes (a problem in the way the body regulates and uses sugar as a fuel), hypertension (when the pressure in your blood vessels is too high-140/90 mmHg or higher), difficulty in walking, unsteadiness on feet/lack of coordination and altered mental status (a change in mental function). Resident #1's reflected she had three emergency contacts and MD was listed as her attending physician. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was sometimes understood by others (ability is limited to making concrete requests) and was sometimes understood (able to respond adequately to simple, direct communication only). Resident #1's BIMS score was an 06, which indicated severe cognitive impairment. Resident #1 had no signs/symptoms of delirium (inattention, disorganized thinking and altered level of consciousness), her mood score was a 00, which indicated no negative mood issues. Resident #1 had no potential indicators of psychosis, physical or verbal behaviors, rejection of care or wandering. She was independent in her ADLs, was continent in bowel and bladder, had unsteady balance during transitions and walking and did not use a mobility device for ambulation. Resident #1 had no indicators of pain and had no falls since the last MDS assessment. Resident #1 wore a wander guard for elopement daily. Active discharge planning was not already occurring for Resident #1 to return to the community. Resident #1 wore a wander guard for elopement daily. Record Review on 09/12/23 of Resident #1's care plan (not dated) revealed the following problems/issues: 1) Resident #1 has a communication problem related to dementia, schizoaffective disorder and minimal hearing difficulty, 2) Resident #1 has impaired cognitive function or impaired thought processes related to dementia, schizoaffective disorder, 3) Resident #1 is an elopement risk/wanderer, 4) Resident #1 has delirium or an acute confusion episodes related to inattention and disorganized thinking, 5) Resident #1 requires antidepressant, antipsychotic medications for diagnoses of schizoaffective disorder bipolar type, 6) Resident #1 has schizophrenia and dementia, 8) Resident #1 is at risk for psychosocial well-being problem or alteration in mood state, and 7) Resident #1 is at risk for ADL self-care performance deficient. Record review of Resident #1's September 2023 Physician Orders reflected she was prescribed Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 (started date 04/22/21), Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization (seizure medication used off label-start date 04/21/21, increased PM dose by one tablet on 09/07/23), Trazadone 50 MG once at bedtime for depression (anti-depressant-start date 08/09/22) and Quetiapine Fumarate/Seroquel 325 MG twice a day(antipsychotic- start date 03/28/23). Record review of Resident #1's September 2023 Physician Orders reflected she was prescribed the current medications while under MD's medical care: Amlodipine Besylate Tablet 5 MG once a day for hypertensionhold for SBP<100 and DBP<60 and HR<55 (start date 04/22/21), Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization (seizure medication used off label-start date 04/21/21, increased PM dose by one tablet on 09/07/23), Trazadone 50 MG once at bedtime for depression (anti-depressant-start date 08/09/22) and Quetiapine Fumarate/Seroquel 325 MG twice a day(antipsychotic- start date 03/28/23). Record review of Resident #1's September 2023 MAR/TAR reflected she refused the following medications: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 19 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0607 Level of Harm - Immediate jeopardy to resident health or safety -Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 documented as refused on 09/01/23, 09/03/23, 09/05/23, 09/08/23 and 09/09/23. - Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization documented as refused on 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/08/23 and 09/09/23. Residents Affected - Some - Trazadone 50 MG once at bedtime for depression documented as refused on 09/01/23, 09/02/23, 09/03/23 and 09/04/23. - Quetiapine Fumarate (Seroquel) Oral Tablet 25 MG give with 300mg tab = 325mg twice a day for schizoaffective disorder, bipolar type documented as refused on 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/05/23, 09/08/23 and 09/09/23. Record Review of Resident #1's clinical record revealed only one nursing progress note related to medication refusals on 8/11/2023 at 8:20 AM. The progress note reflected, Resident refused to take AM meds x3 [three times], no reason given for the refusal when asked. Resident up ambulating. Record review of Resident #1's clinical record revealed no evidence through nursing documentation that MD, NP D or PA E or Resident #1's RP/family member(s) were notified or that Resident #1 was assessed for any decline in condition Record review of pertinent facility progress notes for Resident #1 reflected: -09/05/23-Mood/Behavior: Late entry- Resident was seen slapping another resident. This writer, other aides and employees separated the two. [City] police were called due to the resident hitting another resident and unsuccessful attempts of calming the resident down. The resident was transferred to [hospital name]. Family called and notified along with MD. Spoke with rep from [behavioral health facility] about placement and notified them she is at [hospital]. -09/05/23-Social Service Note: Clinicals have been sent over to [behavioral health facility]. -09/07/23-Admit/readmit: Resident re-admitted to facility from [hospital name] via [transport non-emergency]- diagnosis mental health problem. NP D notified of resident's return and reviewed all orders. -09/09/23-General Progress Note written by RN F: This resident was physically aggressive and assaulted the roommate, hitting her on the head, chest and back. Resident was separated from roommate, [RP] in room taking to resident. 911 was notified, in room with resident, resident transferred to [hospital name] for psychological evaluation. Administrator, DON and Physician notified. Resident's [family]on site. -09/09/23-General Progress Note written by ADON A: Late entry- [City] police here and will take patient and [family]to hospital. [City] police stated they would take them to [hospital name]. About an hour later front desk received a call from [behavioral health facility] stating patient was too aggressive for admission. [RP] still with patient. Attempted to call [RP]. No answer. left message. -09/09/23 at 1:57 PM-General Progress Note written by ADON A: Late Entry- Resident was seen across the street by staff (resident standing at front entrance of the apartment). Police called for safe (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 20 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0607 Level of Harm - Immediate jeopardy to resident health or safety check on resident. Police and ambulance came to the apartments and facility. Ambulance left and police came into parking lot watching resident. Provided police officer with face sheet and med list. DON arrived while we were standing outside watching resident for safety. Patient stated [sic] walking away police officer stated she was going to follow her and pick her up. I asked did she need any help police officer stated 'no' she had it. Attempted to call [Resident #2's other RP] no answer and left message, to ask her why she drop her off at apartments or what where her intentions no answer no return call. Residents Affected - Some Review of Resident #1's progress notes reflected no documentation from 09/09/23 at 1:57 PM until 09/17/23. During this time was when Resident #1 went missing and was found by family incarcerated in the local jail. Record review of Resident #1's clinical chart reflected no physician transfer order to the ER or to a behavioral health facility on 09/09/23. Record review of Resident #1's clinical chart reflected no required facility transfer documentation/checklist provided to the police/family member per the facility's transfer policy. An interview with Resident #1's secondary RP/family member on 09/11/23 at 6:04 PM revealed she found out on 09/11/23 that Resident #1 had been arrested on 09/09/23. The family member was concerned Resident #1 had a psychotic break while at the facility and thought she did not recognize her roommate and thought it was someone invading her privacy. The family member stated the facility reported [date unknown] Resident #1 was being rough and mean with her roommate [Resident #2] and slapped her and another man. The family member stated she was confused because the facility had notified her that Resident #1 was at the hospital on [DATE] because she had a mental break. When another family member/primary RP went to provide Resident #1 cigarettes on 09/09/23, the facility asked the RP if she would ride with Resident #1 to take her to a behavioral health hospital but did not provide her with any clinical paperwork. The RP was dropped off with Resident #1 by the police at the behavioral health hospital and they refused to accept Resident #1, so the RP called the police to transport Resident #1 back to the facility. The family member stated the facility had also reported to her during this time that Resident #1 had not been taking her medications for about a week. The family member stated once Resident #1 was supposed to be transported back to the facility by the police, she did not hear anything from the facility until two days later when they reported to her that Resident #1 was missing. The family member stated the facility told her on 09/11/23 the police dropped Resident #1 off across the street of the facility so they called the police and they asked her if she knew where Resident #1 was and gave her the police report number from the incident on 09/09/23. The family member then went to the police department to file a missing person's report on 09/11/23. The family member stated through the facility's police report number, she was able to find out Resident #1 had been arrested for a felony charge of injury to an elderly person and was in the local county jail with a $500 bail. The family member felt the facility was trying to get rid of Resident #1, claiming they sent her the hospital the week prior but the hospital sent her back because it was not a psychiatric emergency. The family member felt all of these facility behaviors were a tactic to get Resident #1 out of the facility. The family member stated she had not been able to see Resident #1 in jail yet and she was concerned Resident #1 was not getting any of her prescribed psychotropic medications so if she was having a psychotic break, she would not be able to get through it. The family member felt the facility was causing her behaviors and did not know how to deal with residents with mental health issues and were agitating her with the transfers back and forth from the facility to the hospitals. The family member stated the facility did not provide her any documentation about the transfers out in the past week. The family member stated, They cut me out of the loop .they should have discussed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 21 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0607 that [transfers/behaviors] with us to work with them. Level of Harm - Immediate jeopardy to resident health or safety An interview with Resident #1's primary RP on 09/12/23 at 2:48 PM revealed on 09/08/23, she got a call from the activity director to bring Resident #1 some cigarettes so she bought a carton and went to the facility the following day to deliver them (9/09/23). When the primary RP arrived, she was going to drop off the cigarettes because she was on her way to work and was using a rideshare service, however, the facility notified her that Resident #1 had attacked someone. The RP stated she told the facility staff that did not sound like Resident #1 and had they been messing with her medications? The RP stated, This is not the first time and we have discussed the same thing over and over, I said I am not POA and I can't make her take mediation, but let me tell you, when you mess with her medicine, she gets aggressive and she needs this medicine. The RP stated the facility had never informed her that Resident #1 had been refusing her medications for five days. She was frustrated because she felt the facility called her and the other RP often for minor issues, but they could not call and notify them she was refusing her medications. The family member wanted to know why the facility did not intervene when Resident #1 started to refuse her medications. The family member stated RN F was at the facility and told her he was in charge and they had already called the police. The RP stated, Why? Because you know she didn't take her meds and why didn't you send her to the hospital? She said RN F stated Resident #1 did not want to be transported in an ambulance. The RP stated she felt something was not right about the situation so she decided to stay and see what was going to happen because she felt the facility was trying to arrest Resident #1 and she was scared that because of her ethnicity and having mental illness, if Resident #1 ended up in jail, it would not fare well for her. When the police arrived, the RP told them Resident #1 needed to go to the hospital because she had been there the week before. The RP stated when she saw Resident #1 that day, she was crazy acting, saying she was someone else, saying she saw a man who was not there and people were sitting on her and was delusional. The RP felt the facility had a plan to dump Resident #1 because they were supposed to facilitate the transfer to the hospital, but they began talking privately and she overheard them say one place was full and that they were going to take her to an inpatient behavioral health facility. The RP went with the police and Resident #1 in the police care because she felt that something was not right. When they got to the inpatient behavioral health facility, the police dropped her and Resident #1 off and left. The intake coordinator refused to admit Resident #1 due to her having noted aggression and said they would not be able to force her to take her medications because it was only a behavior clinic. The RP then called the facility to notify them of the refused admission and was told by the front desk receptionist that Resident #1 could not come back and was not allowed back. The RP then called the local police to come and pick up Resident #1 and they called the facility who said she could not come back; the RP told the facility they had to accept her back. The RP then left from the inpatient behavior health facility via rideshare to go to work because she was late and assumed the police had transported Resident #1 back to the facility. Residents Affected - Some A interview was attempted via phone with CNA N on 09/14/23 at 11:11 AM with a voice mail left; CNA N did not respond to request to be interviewed. An interview with the front desk receptionist on 09/14/23 at 12:15 PM revealed she worked over the weekend, including on 09/09/23. She stated she saw Resident #2 being taken out by EMT to the hospital and knew the police had been called and Resident #1 had been asked to leave the facility due to an incident between her and Resident #2. The front desk receptionist stated she saw Resident #1 escorted out of the facility by the police and got into their SUV along with her family member. She then stated after that, the family member called the facility and was stating the police transported Resident #1 to an inpatient behavioral health facility and they would not admit her. The front desk receptionist notified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 22 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the ADM, and he said no, she [Resident #1] was not to be admitted back in. She could not remember what reason the ADM gave her for refusing to let Resident #1 come back but she thought it had to do with behavior issues. The front desk receptionist stated, I know the [family member] said the reason she needed to come back was because [behavioral facility] would not allow her in and she needed the incident report, I heard the police say it behind her. I said I did not have that .I called her back and said she cannot come back in. She said she could not take her home. I said I am sorry but she cannot come back here. Later in the day [time unknown], the front desk receptionist remembered seeing Resident #1 standing across the street at the apartments walking back and forth and no one was with her. During that same time, [Resident #2] was brought back to the facility by a female police officer while Resident #1 was still across the street. She said ADON A called the police because she knew Resident #1 was standing across the street. The front desk receptionist stated the staff did not bring Resident #1 back into the facility because from her understanding, she was no longer allowed in and that was what ADON A understood to be true as well. Once Resident #1 was back in the building, the female police officer went over to deal with Resident #1 but she did not see what happened. She stated, I looked back up later and they were gone. The front desk receptionist left her shift at 8:00 PM, no one called to the facility inquiring about Resident #1 after she was gone. An interview with the ADM on 09/12/23 at 10:00 AM revealed Resident #1 had an incident a week prior where she was allegedly being rude to LVN I and another resident (Resident #3) told her not to be rude; she then walked over and slapped him. ADM stated LVN I witnessed it. The ADM stated there were no injuries and his [Resident #3] was more of a bruised [NAME]. The ADM stated the police were called and Resident #1 was arrested, Problem is, when she got arrested, [Resident #3] wanted to press charges but they took [Resident #1] to [hospital] who notified the facility the next day they were sending her back. The ADM stated, I put up a fight and said less than 24 hours, you are sending her back? The ADM stated due to his refusal to accept her back into the facility, the hospital notified his boss at the corporate level and the ADM was then told that he had to accept Resident #1 back into the facility because she did not have any behaviors while she was at the hospital. The ADM stated Resident #1 did not have any behaviors when she came back from 09/06/23 through 09/09/23. The ADM stated on 09/09/23, another incident took place and according to Resident #2 (new roommate of Resident #1), she said Resident #1 punched her on her head, chest, and back totally unprovoked. The ADM stated the information came from Resident #2's report to RN F, Which I am not sure how much I want to take at face value because of her dementia. The ADM stated he told RN F what to do because Resident #2 wanted to go to the hospital and came back the same day with no injuries. The police were notified for the alleged resident to resident altercation between Resident #1 and Resident #2 and they escorted Resident #1 from the facility but took her to a behavioral health facility along with her family member but that facility declined to do an admission, so the facility told the family member she would need to be taken to the hospital because she was technically discharged from our facility .Now care was left onto police to direct what happened. The ADM stated the police left the family member and Resident #1 at the behavioral health facility and he was under the impression the family member transported her back to the facility because a Resident #1 was seen by a staff member [name unknown] being dropped off across the street to the facility where there was an apartment complex. The ADM stated the facility staff called the police on Resident #1 again and they sent a unit out, but before they arrived, he tried to talk to Resident #1 and she told him she did not want to talk to him in a thousand years. The ADM stated when the fire department arrived, Resident #1 refused to talk to them so they left and stated the police were on their way. The ADM stated he had to leave the facility and go back home (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 23 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some and ADON A called him and said the police showed up and Resident #1 started walking away, so they gave ADON A a police report number and followed Resident #1. The ADM stated Resident #1 was discharged from the facility and they had tried to prevent the discharge by getting her seen for psyche services, not to discharge. He stated Resident #1 had never been send out before these two incidents and there were no prior resident to resident altercations since her admission in 2021. He stated when she did have a behavioral episode in the facility, she would hit her head and make a grunting noise. The ADM stated the facility had not been able to find a good roommate fit for Resident #1 except for one female resident who she roomed with for a couple of days in the past two weeks before that roommate went out to the hospital. The ADM stated there was no witness for the resident to resident altercation between Resident #1 and #2 and both of them had a diagnosis of dementia. Review of Resident #2's clinical chart post-incident revealed no documentation of the facility speaking with Resident #2's family about pressing charges. An interview with LVN I on 09/13/23 at 10:15 AM revealed she did not witness Resident #1 slap Resident #3; she only heard them yelling at each other. She was shocked to see them verbally fighting with each other and reported none of the staff seemed to be doing anything. LVN I stated Resident #3 was alert and oriented x 4 and he was saying all of the mean things. LVN I asked Resident #3 to stop and remember that Resident #1 was a lady. An interview with RN F on 09/12/23 at 3:54 PM revealed he was the weekend supervisor on 09/09/23 from 7:00 AM until 11:00 PM and he was aware Resident #1 had been sent to the hospital the week prior due to an altercation where he thought she hit someone. He said Resident #1 had been back at the facility for two days prior to the weekend. When RN F got to work on Saturday 09/09/23, he was called to her room and told she had gone to the roommate's bed [Resident #2] and hit her on the back, chest, and head and was following her down the hall. When RN F arrived, he went into their room and tried to evaluate Resident #1, who was laying in bed. He asked Resident #1 what happened and she was agitated and said, That white woman is not my momma and I need her out of this room-she is not my roommate! RN F stated it was hard to re-orient Resident #1 in that state and she had dementia and psyche issues. He stated psyche issues for Resident #1 meant she always paced the hallways, was very untidy, her hair was not groomed, her clothes were not tidy, she talked to herself and made weird noises, declined care and scared other residents away. RN F stated after the incident, he called the police because Resident #2 wanted to file an allegation, I don't know what for, I don't know what she told the police. He stated Resident #1's family member happened to be at the facility but not present for the altercation and he explained the police had been contacted. RN F stated Resident #2 did not have any injuries but was tearful. RN F stated CNA N was the person who told him about the incident. He said he did not get into the details of what CNA N observed, but he did complete an incident report. RN F stated he knew Resident #1 was taken to a hospital in [adjacent city] somewhere and said the police or the family decided on where because he heard them talking. RN F stated he could not tell the police where to take Resident #1, but they did not end up going to [Hospital PP]. RN F stated the facility usually sent the residents to [Hospital PP] for psyche evaluations and a face sheet and medication record would be sent with the transport provider. RN F stated he did not know how Resident #1 ended up at the inpatient behavioral health facility. RN F stated he had called the doctor to get an order to transfer Resident #1 to the hospital, but the doctor could not give a specific order on where to take the resident. RN F stated, The [family member] and police decided to take her wherever they took her. RN F then clarified he spoke to NP D to notify about the transfer, not the MD. He said NP D told him to send Resident #1 out for a psyche evaluation. After that, RN F stated Resident # left the building and never came back that day or the following day. To his understanding. She went to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 24 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete hospital but he had no idea where they took her, but she was not discharged from the facility. RN F stated the facility social worker normally followed up to see where a resident was placed and which hospital they were sent to, but there was no social worker over the weekend. An interview with ADON A on 09/12/23 at 4:29 PM revealed she was newly employed for about a month and had tried to intervene after an incident where Resident #1 slapped Resident #3 a week prior. ADON A stated when trying to intervene, Resident #1 was gunning for me, she does this reaction like '[NAME]' [ADON A was making hand gestures by her ears], cursing, saying random things like they attacked her and not making any sense. ADON A stated when she tried to physically separate the verbal altercation between Residents #1 and #3, Resident #1 threw ADON A up against the wall. ADON A stated the police took Resident #1 out in handcuffs to Hospital PP. ADON A stated she did not know what Hospital PP did with Resident #1 care wise, but she knew they completed a psychiatric evaluation. She did not know if the facility had a copy of it and she did not get a chance to review any discharge documentation because when Resident #1 re-admitted the next day, she was placed on a new hall/new room that ADON A was not over because they wanted to put distance between her and Resident #3. ADON A stated Resident #1 already had a recent room change from the upstairs hall to the downstairs hall where she got into the altercation with Resident #1. Now she was going to be placed back upstairs, but on a different hall than she had been on prior. ADON A stated when Resident #1 returned, the nursing staff were still trying to locate another psyche facility because we knew it would take longer for her to stabilize. Regarding resident transfers, ADON A stated the police or EMT decided where a resident would be transported when sent to the hospital. She stated NP D was notified at that time. ADON A stated Resident #1 was stable when she came back from Hospital PP. She did not know if psyche services came to visit her or adjust her medications after she re-admitted . On 09/09/23, ADON A stated she came to the facility around 10:30 AM and was not scheduled to work but she had gotten group texts that there was a resident to resident altercation with Residents #1 and #2. She was the closest in the vicinity and was going to check on things. When she arrived at the facility, NP F had already contacted the police and Resident #1's family member was present. ADON A stated the police were hesitant in taking Resident #1 to jail and were talking about transporting her to a hospital. ADON A went to talk to Resident #1 who was cool, calm, and collected and laying on her bed and said she was doing fine. ADON A told Resident #1 her family member was present and the police wanted to take her to Hospital PP. Resident #1 agreed to ride with the police. The police handcuffed Resident #1 and ADON A cut the wander guard off her ankle and printed out her face sheet and med sheet, gave the police and family member a copy, and told the family member to make sure Hospital PP looked over the medication list and they left. About an hour later, ADON A was trying to clock in and heard a housekeeping staff member say, hey, isn't that [Resident #1]? and was looking out the window across the street. ADON A stated no, she was at Hospital PP. Then ADON A looked out the front window and saw Resident #1 standing across the street with a bag of clothes and no one was with her. ADON A stated she went outside and stood in the parking lot, called the ADM and then contacted the police and asked them to do a welfare check because I wasn't sure if I could approach her. She said 911 asked her what did she think the police would be able to do about it? She told them that Resident #1 had just assaulted anoth[TRUNCATED] Event ID: Facility ID: 455653 If continuation sheet Page 25 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must have evidence that all alleged violations are thoroughly investigated and prevent further abuse, neglect, exploitation, or mistreatment while the investigation is in process for two (Residents #1 and #2) of five residents reviewed for abuse and neglect. Residents Affected - Few The facility failed to thoroughly investigate an unwitnessed resident to resident allegation with Residents #1 and #2,. The facility failed placed residents at risk of being sent out for unnecessary psychiatric and psychological evaluations, unnecessary increases in psychotropic medications, lack of knowledge of the events which could cause the wrong interventions, and lack of due diligence in investigating resident to resident altercations. Findings included: Record review of Resident #1's Face Sheet (undated) reflected she was a [AGE] year-old female admitted to the facility on [DATE] with active diagnoses including schizoaffective disorder-bipolar type (a mental illness where the person experiences psychotic symptoms, such as hallucinations or delusions with episodes of mania and sometimes depression), dementia-moderate with behavioral disturbance (the loss of cognitive functioning- thinking, remembering, and reasoning along with symptoms depression, anxiety, psychosis, agitation, aggression, disinhibition and sleep disturbances), generalized anxiety disorder (a feeling of fear, dread, and uneasiness), insomnia (trouble falling asleep, staying asleep, or getting good quality sleep), diabetes (a problem in the way the body regulates and uses sugar as a fuel), hypertension (when the pressure in your blood vessels is too high-140/90 mmHg or higher), difficulty in walking, unsteadiness on feet/lack of coordination and altered mental status (a change in mental function). Resident #1's reflected she had three emergency contacts and MD was listed as her attending physician. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was sometimes understood by others (ability is limited to making concrete requests) and was sometimes understood (able to respond adequately to simple, direct communication only). Resident #1's BIMS score was an 06, which indicated severe cognitive impairment. Resident #1 had no signs/symptoms of delirium (inattention, disorganized thinking and altered level of consciousness), her mood score was a 00, which indicated no negative mood issues. Resident #1 had no potential indicators of psychosis, physical or verbal behaviors, rejection of care or wandering. She was independent in her ADLs, was continent in bowel and bladder, had unsteady balance during transitions and walking and did not use a mobility device for ambulation. Resident #1 had no indicators of pain and had no falls since the last MDS assessment. Resident #1 wore a wander guard for elopement daily. Active discharge planning was not already occurring for Resident #1 to return to the community. Resident #1 wore a wander guard for elopement daily. Record Review on 09/12/23 of Resident #1's care plan (not dated) revealed the following problems/issues: 1) Resident #1 has a communication problem related to dementia, schizoaffective disorder and minimal hearing difficulty, 2) Resident #1 has impaired cognitive function or impaired thought processes related to dementia, schizoaffective disorder, 3) Resident #1 is an elopement risk/wanderer, 4) Resident #1 has delirium or an acute confusion episodes related to inattention and disorganized (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 26 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0610 Level of Harm - Minimal harm or potential for actual harm thinking, 5) Resident #1 requires antidepressant, antipsychotic medications for diagnoses of schizoaffective disorder bipolar type, 6) Resident #1 has schizophrenia and dementia, 8) Resident #1 is at risk for psychosocial well-being problem or alteration in mood state, and 7) Resident #1 is at risk for ADL self-care performance deficient. Residents Affected - Few Record review of pertinent facility progress notes for Resident #1 reflected: -09/05/23-Mood/Behavior: Late entry- Resident was seen slapping another resident. This writer, other aides and employees separated the two. Police were called due to the resident hitting another resident and unsuccessful attempts of calming the resident down. The resident was transferred to [hospital name]. Family called and notified along with MD. Spoke with rep from [behavioral health facility] about placement and notified them she is at [hospital name]. -09/05/23-Social Service Note: Clinicals have been sent over to [behavioral health facility]. -09/07/23-Admit/readmit: Resident re-admitted to facility from [hospital name] via [transport non-emergency]- diagnosis mental health problem. NP D notified of resident's return and reviewed all orders. -09/09/23-General Progress Note: This resident was physically aggressive and assaulted the roommate, hitting her on the head, chest and back. Resident was separated from roommate, [RP] in room taking to resident. 911 was notified, in room with resident, resident transferred to [hospital name] for psychological evaluation. Administrator, DON and Physician notified. Resident's [family member] on site. -Review of Resident #1's progress notes reflected no documentation from 09/09/23 at 1:57 PM until 09/17/23. Record review of Resident #2's Face sheet (not dated) reflected she was a [AGE] year-old female admitted to the facility on [DATE] with active diagnoses including dementia, diabetes, malnutrition, mood disturbance, muscle wasting and atrophy, cognitive communication deficient (difficulty with thinking and how someone uses language) and anxiety. Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected she had no hearing, vision or speech issues and her BIMS score was a 09, which indicated moderate cognitive impairment. Resident #2 had no symptoms of delirium, negative mood issues, behaviors, or rejection of care. Resident #2 required extensive assistance of one staff for bed mobility and eating. She was ambulatory but unsteady without staff assistance. Record review of Resident #2's care plan initiated 02/10/23 and last revised 09/11/23, reflected the following problems/issues: Moderate risk of falls related to deconditioning, [Resident #2] has diabetes, dementia, impaired visual function and potential for pressure sore development. Resident #2 is on pain management therapy, has an ADL self-care performance deficit and has a potential nutritional problem. Review of the facility's Provider Investigation Report-Form 3613-A reflected the resident to resident altercation was called into HHSC on 09/10/23 at 9:04 AM by the ADM between Residents #1 and #2. The report reflected Resident #1 had a history of aggression and a prior incident on 09/05/23 and Resident #2 had no prior incidents and had dementia. No witnesses were identified and Resident #2 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 27 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few noted to state Resident #1 hit her. Resident #2 reported shoulder, neck and upper back pain so she was sent to the ER and returned the same day with no physical or emotional injuries. Under the provider response, the ADM documented both residents were immediately separated and police were notified as well as RP, physician, ombudsman and family. The police intervened and transported Resident #1 out of the facility. The PIR reflected, During the investigation, it was determined [Resident #2] reported to staff that she was hit by [Resident #1] on her chest, head and back. She reported to the administrator when she was visited that the incident was totally unprovoked. The investigation summary further reflected when Resident #1 was brought back to the facility and left across the street after a failed transfer out, the ADM tried to talk to her and she said she did not want to talk to him in a thousand years. The investigation findings were unconfirmed. An interview with the ADM on 09/12/23 at 10:00 AM revealed he was not present for the resident to resident altercation between Residents #1 and #2 and was not in the building at the time. He stated Resident #1 had an incident a week prior where she was allegedly being rude to LVN I and a male resident told her not to be rude; she then walked over and slapped him. The ADM stated there were no injuries and his was more of a bruised [NAME]. The ADM stated the police were called and Resident #1 was arrested, Problem is, when she got arrested, wanted to press charges but they took [Resident #1] to [hospital] who notified the facility the next day they were sending her back. The ADM stated, I put up a fight and said less than 24 hours, you are sending her back? The ADM stated due to his refusal to accept her back into the facility, the hospital notified his boss at the corporate level and the ADM was then told that he had to accept Resident #1 back into the facility because she did not have any behaviors while she was at the hospital. The ADM stated Resident #1 did not have any behaviors when she came back from 09/06/23 through 09/09/23. The ADM stated on 09/09/23, another incident took place and according to Resident #2 (new roommate of Resident #1), she said Resident #1 punched her on her head, chest and back totally unprovoked. The ADM stated the information came from Resident #2's report to RN F, Which I am not sure how much I want to take at face value because of her dementia. The ADM stated he told RN F what to do because Resident #2 wanted to go to the hospital and came back the same day with no injuries. The police were notified for the alleged resident to resident altercation between Resident #1 and Resident #2 and they escorted Resident #1 from the facility but took her to a behavioral health facility along with her family member but that facility declined to do an admission, so the facility told the family member she would need to be taken to the hospital because she was technically discharged from our facility .Now care was left onto police to direct what happened. The ADM stated the police left the family member and Resident #1 at the behavioral health facility and he was under the impression the family member transported her back to the facility because a Resident #1 was seen by a staff member [name unknown] being dropped off across the street to the facility where there was an apartment complex. The ADM stated the facility staff called the police on Resident #1 again and they sent a unit out, but before they arrived, he tried to talk to Resident #1 and she told him she did not want to talk to him in a thousand years. The ADM stated when the fire department arrived, Resident #1 refused to talk to them so they left and stated the police were on their way. The ADM stated he had to leave the facility and go back home and ADON A called him and said the police showed up and Resident #1 started walking away, so they gave ADON A a police report number and followed Resident #1. The ADM stated Resident #1 was discharged from the facility and they had tried to prevent the discharge by getting her seen for psyche services, not to discharge. He stated Resident #1 never been send out before these two incidents and there were no prior resident to resident altercations since her admission in 2021. He stated when she does have a behavioral episode in the facility, she would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 28 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0610 Level of Harm - Minimal harm or potential for actual harm hit her head and make a grunting noise. The ADM stated the facility had not been able to find a good roommate fit for Resident #1 except for one female resident who she roomed with for a couple of days in the past two weeks before that roommate went out to the hospital. The ADM stated there was no witness for the resident to resident altercation between Resident #1 and #2 and both of them had a diagnosis of dementia. Residents Affected - Few An interview with RN F on 09/12/23 at 3:54 PM revealed he was the weekend supervisor on 09/09/23 from 7:00 AM until 11:00 PM and he was aware Resident #1 had been sent to the hospital the week prior due to an altercation where he thought she hit someone. He said Resident #1 had been back at the facility for two days prior to the weekend. When RN F got to work on Saturday 09/09/23, he was called to her room and told she had gone to the roommate's bed [Resident #2] and hit her on the back, chest and head and was following her down the hall. When RN F arrived, he went into their room and tried to evaluate Resident #1, who was laying in bed. He asked Resident #1 what happened and she was agitated and said, That white woman is not my momma and I need her out of this room-she is not my roommate! RN F stated it was hard to re-orient Resident #1 in that state and she had dementia and psyche issues. He stated psyche issues for Resident #1 meant she always paced the hallways, was very untidy, her hair was not groomed, her clothes were not tidy, she talked to herself and made weird noises, declined care and scared other residents away. RN F stated after the incident, he called the police because Resident #2 wanted to file and allegation, I don't know what for, I don't know what she told the police. He stated Resident #1's family member happened to be at the facility but not present for the altercation and he explained the police had been contacted. RN F stated Resident #2 did not have any injuries but was tearful. RN F stated CNA N was the person who told him about the incident. He said he did not get into the details of what CNA N observed, but he did complete an incident report. RN F stated he knew Resident #1 was taken to a hospital in [adjacent city] somewhere and said the police or the family decided on where because he heard them talking. RN F stated he could not tell the police where to take Resident #1, but they did not end up going to [Hospital PP]. RN F stated the facility usually sent the residents to [Hospital PP] for psyche evaluations and a face sheet and medication record would be sent with the transport provider. RN F stated he did not know how Resident #1 ended up at the inpatient behavioral health facility. RN F stated he had called the doctor to get an order to transfer Resident #1 to the hospital, but the doctor could not give a specific order on where to take the resident. RN F stated, The [family member] and police decided to take her wherever they took her. RN F then clarified he spoke to NP D to notify about the transfer, not the MD. He said NP D told him to send Resident #1 out for a psyche evaluation. After that, RN F stated Resident # left the building and never came back that day or the following day. To his understanding. She went to the hospital but he had no idea where they took her, but she was not discharged from the facility. A follow up interview with RN F on 09/16/23 at 5:08 PM revealed he did not write a witness statement related to the alleged resident to resident altercation between Residents #1 and #2. He stated he completed an incident report but did not actually see it happen because he was not on the hall and was downstairs working. When he went into Resident #1's room, she was laying on the bed and Resident #2 was in the dining room, there was not a CNA with either of them. He said he did not remember the CNA names who worked on the hall and said there was a nurse on the hall, but she split her time between two halls that shift [LVN S]. RN F stated when he completed an assessment on Resident #2 in the dining room, he told her she had the right to file an allegation but he wanted to know what was going on first. She told him that Resident #1 hit her and she was scared to go back into the room. With an assault, RN F stated he completed a head to toe assessment to make sure Resident #2 was not hurting anywhere. He stated the intervention that he did, especially if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 29 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few it involved assault, was call the police, as long as it was witnessed by someone, it can be either a resident or a staff. RN F stated a resident who was alert and oriented could be a valid witness. RN F stated he called 911 because they needed to come and investigate the altercation. RN F stated he told the charge nurse LVN S, to follow up with Resident #2 and send her to the hospital. A interview was attempted via phone with CNA N on 09/14/23 at 11:11 AM with a voice mail left; CNA N did not respond to request to be interviewed. An interview with the ADM on 09/15/23 at 1:07 PM revealed he did not have witness statements because there were no witnesses, only Resident #2 stating she had been hit. The ADM stated he interviewed Resident #2 and got a witness statement from her and it was documented in his provider investigation report. The ADM stated he did not interview or get a statement from RN F, LVN S or CNA N because they did not witness the resident to resident altercation. An interview with the ADM on 09/20/23 at 2:10 PM revealed the reason the facility went the route of calling the police on Resident #1 was because she already had an incident with a male resident a few days prior and the ADM did not want a situation where things were escalating. He said the police were only called on 09/09/23 because she allegedly got aggressive with Resident #2. An interview with the MD on 09/13/23 at 4:38 PM revealed the facility did not notify him about Resident #1 being in jail. He only had heard that she was hitting someone. The MD stated the facility was pretty good about handling resident to resident altercations and it was not typical to call the police on altercations with older residents with dementia with behaviors. The MD stated, Most of the time, we put it as acute psychosis. Might be an infection going on with the patient and they became unstable, electrolyte abnormalities, not taking meds. The MD stated he was a hospitalist by trade so what he wanted was the facility to notify him for those types of incidents and he would have that resident directly admitted to the hospital, check them out, and stabilize them. The MD stated he was a physician at one hospital and had a contract with two hospitals for admission privileges. The MD stated, It is easy for me to navigate that process and the facility knows that. He stated if a resident freaked out during a behavioral emergency and they were not thinking clearly, then he would want the charge nurse to call him and he would admit the resident for acute psychosis for admission. The MD stated, Especially with [Resident #1] because she is an older lady, I remember her face. If she was like that, I would have had her directly admitted instead of calling police. I would have had them call EMS and from there I can then stabilized her and send her back. The MD stated that was the protocol the nurses typically followed, but it all depended on who was working at the time of an incident. The MD stated, There are nurses who are real good who can catch it [behavior] and navigate that so I can do something about it and then there are nurses who freak out and call the police. I have done it so many times, I can get the patient stabilized. The MD stated he did not know if police should be making decisions about where to take the residents because they were not clinical and did not understand. He stated Resident #1 should not be in jail, she was not mentally stable, her BIMS was low and there was no way a lady like her should be I jail, so I would have a problem with that because that is not where she should be. The police should have taken her and gotten information, at least let me know, then kind of gone through the process and I would have had them take her to the hospital. The MD stated there needed to be a facility protocol on transferring residents out for behavioral episodes/ resident to resident altercations. The MD stated he was not contacted for his input by the abuse/neglect coordinator for Resident #1's alleged altercation with Resident #2. An interview with the MHNP on 09/13/23 at 2:47 PM revealed she was the psychiatric nurse for the facility residents and was unaware Resident #1, who was her patient, was in jail. She stated her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 30 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few impression was the facility had a policy of sending people out if they hit another resident. She stated she was not contacted nor involved with the two resident to resident altercations Resident #1 had been in during the past week. She stated Resident #1 had never been physically aggressive, She's had manic episodes where she's difficult to redirect and delusional, but she's never been violent ever. The MHNP stated she was not contacted for her input by the abuse/neglect coordinator for Resident #1's alleged altercation with Resident #2. An interview with Resident #2 on 09/14/23 at 10:00 AM revealed she did not remember anyone hitting her or that she had a roommate recently. Resident #2 stated she had a previous roommate for about two to four months and she was still somewhere in the facility, but she never hit her. Resident #2 stated, I don't remember anything, my memory is growing very short. Then Resident #2 stated maybe someone did hit her, but she could not remember who it was or the gender. Resident #2 stated she had been moved recently to her room because the facility told her they needed to block rooms out for people that were sick and she did not have a choice. When asked if she felt safe, Resident #2 replied yes and no. She stated there were too many people coming into her room at night and she did not know who they were and felt some of her items were missing in the mornings and there were not enough staff working on the weekends. Resident #2 stated, I've never complained of someone hitting me that I can remember. An interview with LVN O on 09/14/23 at 1:46 PM revealed she was the charge nurse working on Resident #1's hall on 09/09/23 but she did not see the incident between Resident #2 and Resident #1. LVN O stated she was not aware Resident #1 had come back from Hospital PP a few days prior (date unknown) and it was the morning of 09/09/23 she saw noticed she was now on her hall. She was passing medication on another hall (time unknown) when she remembered hearing some hollering and went to see what happened. CNA N stated Resident #1 hit Resident #2 in the back of the head, back and chest and had witnessed it. LVN O went to Resident #1's room and Resident #2 was taken to the dining room. Resident #1 was laying in the bed like nothing happened. Resident #1 told LVN O, I don't like that white woman. She ain't my momma and can't tell me what to do. LVN O stated CNA N told her Resident #2 reported she asked Resident #1 to pick up something in the bathroom and that was when Resident #1 told her You aint my momma and you can't tell me what to do. LVN I stated after that, as long as Resident #1 and #2 were separated, LVN O was okay. She notified RN F he was the weekend supervisor and reported what happened. He told LVN O not to worry about it, he would write the incident report. LVN O stated she went back onto her halls doing her duties. LVN O stated she was not interviewed by the abuse/neglect coordinator after the resident to resident altercation between Residents #1 and #2. Record review of the facility's police titled, Abuse Prevention and Prohibition Program, revised August 2020, reflected, .Purpose: To ensure the Facility establishes, operationalizes and maintains and Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property and crime in accordance with state and federal standards .III. The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs and systems .VIII. Protection: .D. If the allegation is regarding a resident to resident altercation, the residents will be separated immediately, pending the investigation FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 31 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0624 Prepare residents for a safe transfer or discharge from the nursing home. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one (Resident #1) of three residents reviewed for transfer and discharge rights. Residents Affected - Few The facility failed to provide or document sufficient preparation for an orderly transfer when Resident #1 allegedly got into an unwitnessed physical altercation with her new roommate. An Immediate Jeopardy was identified on 09/14/23. The IJ Template was provided to the facility on [DATE] at 1:45 PM. While the Immediate Jeopardy was removed on 09/18/23, the facility remained out of compliance at the severity level of Actual harm that is not Immediate Jeopardy and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure could place residents at risk of a disruption in their care and services and denying them and their RP a voice regarding their treatment plan, worsen physical and mental conditions, cause physical and emotional injury and potential hospitalization. Findings Included: Record review of Resident #1's Face Sheet (undated) reflected she was a [AGE] year-old female admitted to the facility on [DATE] with active diagnoses including schizoaffective disorder-bipolar type (a mental illness where the person experiences psychotic symptoms, such as hallucinations or delusions with episodes of mania and sometimes depression), dementia-moderate with behavioral disturbance (the loss of cognitive functioning- thinking, remembering, and reasoning along with symptoms depression, anxiety, psychosis, agitation, aggression, disinhibition and sleep disturbances), generalized anxiety disorder (a feeling of fear, dread, and uneasiness), insomnia (trouble falling asleep, staying asleep, or getting good quality sleep), diabetes (a problem in the way the body regulates and uses sugar as a fuel), hypertension (when the pressure in your blood vessels is too high-140/90 mmHg or higher), difficulty in walking, unsteadiness on feet/lack of coordination and altered mental status (a change in mental function). Resident #1's reflected she had three emergency contacts and MD was listed as her attending physician. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was sometimes understood by others (ability is limited to making concrete requests) and was sometimes understood (able to respond adequately to simple, direct communication only). Resident #1's BIMS score was an 06, which indicated severe cognitive impairment. Resident #1 had no signs/symptoms of delirium (inattention, disorganized thinking and altered level of consciousness), her mood score was a 00, which indicated no negative mood issues. Resident #1 had no potential indicators of psychosis, physical or verbal behaviors, rejection of care or wandering. She was independent in her ADLs, was continent in bowel and bladder, had unsteady balance during transitions and walking and did not use a mobility device for ambulation. Resident #1 had no indicators of pain and had no falls since the last MDS assessment. Resident #1 wore a wander guard for elopement daily. Active discharge planning was not already occurring for Resident #1 to return to the community. Record Review on 09/12/23 of Resident #1's care plan (not dated) revealed the following problems/issues: 1) Resident #1 has a communication problem related to dementia, schizoaffective disorder and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 32 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0624 Level of Harm - Immediate jeopardy to resident health or safety minimal hearing difficulty, 2) Resident #1 has impaired cognitive function or impaired thought processes related to dementia, schizoaffective disorder, 3) Resident #1 is an elopement risk/wanderer, 4) Resident #1 has delirium or an acute confusion episodes related to inattention and disorganized thinking, 5) Resident #1 requires antidepressant, antipsychotic medications for diagnoses of schizoaffective disorder bipolar type, 6) Resident #1 has schizophrenia and dementia, 8) Resident #1 is at risk for psychosocial well-being problem or alteration in mood state, and 7) Resident #1 is at risk for ADL self-care performance deficient. Residents Affected - Few Record review of Resident #1's September 2023 Physician Orders reflected she was prescribed Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 (started date 04/22/21), Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization (seizure medication used off label-start date 04/21/21, increased PM dose by one tablet on 09/07/23), Trazadone 50 MG once at bedtime for depression (anti-depressant-start date 08/09/22) and Quetiapine Fumarate/Seroquel 325 MG twice a day(antipsychotic- start date 03/28/23). Record review of pertinent facility progress notes for Resident #1 reflected: -09/05/23-Mood/Behavior: Late entry- Resident was seen slapping another resident. This writer, other aides and employees separated the two. Police were called due to the resident hitting another resident and unsuccessful attempts of calming the resident down. The resident was transferred to [hospital name]. Family called and notified along with MD. Spoke with rep from [behavioral health facility] about placement and notified them she is at [hospital name]. -09/05/23-Social Service Note: Clinicals have been sent over to [behavioral health facility]. -09/07/23-Admit/readmit: Resident re-admitted to facility from [hospital name] via [transport non-emergency]- diagnosis mental health problem. NP D notified of resident's return and reviewed all orders. -09/09/23-General Progress Note from RN F: This resident was physically aggressive and assaulted the roommate, hitting her on the head, chest and back. Resident was separated from roommate, [RP] in room taking to resident. 911 was notified, in room with resident, resident transferred to [hospital name] for psychological evaluation. Administrator, DON and Physician notified. Resident's [family member] on site. -09/09/23-General Progress Note from ADON A: Late entry- [City] police here and will take patient and [family member] to hospital. [City] police stated they would take them to [hospital name]. About an hour later front desk received a call from [behavioral health facility] stating patient was too aggressive for admission. [RP] still with patient. Attempted to call [RP]. No answer. left message. -09/09/23 at 1:57 PM-General Progress Note written by ADON A: Late Entry- Resident was seen across the street by staff (resident standing at front entrance of the apartment). Police called for safe check on resident. Police and ambulance came to the apartments and facility. Ambulance left and police came into parking lot watching resident. Provided police officer with face sheet and med list. DON arrived while we were standing outside watching resident for safety. Patient stated [sic] walking away police officer stated she was going to follow her and pick her up. I asked did she need any help police officer stated 'no' she had it. Attempted to call [Resident #2's other RP] no answer and left message, to ask her why she drop her off at apartments or what where her intentions no answer no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 33 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0624 return call. Level of Harm - Immediate jeopardy to resident health or safety -Review of Resident #1's progress notes reflected no documentation from 09/09/23 at 1:57 PM until 09/17/23. During this time was when Resident #1 went missing and was found by family incarcerated in the local jail. Residents Affected - Few Record review of Resident #1's clinical chart reflected no physician transfer order to the ER or to a behavioral health facility on 09/09/23. Record review of Resident #1's clinical chart reflected no required facility transfer documentation/checklist provided to the police/family member per the facility's transfer policy. An interview with Resident #1's secondary RP/family member on 09/11/23 at 6:04 PM revealed she found out on 09/11/23 that Resident #1 had been arrested on 09/09/23. The family member was concerned Resident #1 had a psychotic break while at the facility and thought she did not recognize her roommate and thought it was someone invading her privacy. The family member stated the facility reported [date unknown] Resident #1 was being rough and mean with her roommate [Resident #2] and slapped her and another man. The family member stated she was confused because the facility had notified her that Resident #1 was at the hospital on [DATE] because she had a mental break. When another family member/primary RP went to provide Resident #1 cigarettes on 09/09/23, the facility asked the RP if she would ride with Resident #1 to take her to a behavioral health hospital but did not provide her with any clinical paperwork. The RP was dropped off with Resident #1 by the police at the behavioral health hospital and they refused to accept Resident #1, so the RP called the police to transport Resident #1 back to the facility. The family member stated the facility had also reported to her during this time that Resident #1 had not been taking her medications for about a week. The family member stated once Resident #1 was supposed to be transported back to the facility by the police, she did not hear anything from the facility until two days later when they reported to her that Resident #1 was missing. The family member stated the facility told her on 09/11/23 the police dropped Resident #1 off across the street of the facility so they called the police and they asked her if she knew where Resident #1 was and gave her the police report number from the incident on 09/09/23. The family member then went to the police department to file a missing person's report on 09/11/23. The family member stated through the facility's police report number, she was able to find out Resident #1 had been arrested for a felony charge of injury to an elderly person and was in the local county jail with a $500 bail. The family member felt the facility was trying to get rid of Resident #1, claiming they sent her the hospital the week prior but the hospital sent her back because it was not a psychiatric emergency. The family member felt all of these facility behaviors were a tactic to get Resident #1 out of the facility. The family member stated she had not been able to see Resident #1 in jail yet and she was concerned Resident #1 was not getting any of her prescribed psychotropic medications so if she was having a psychotic break, she would not be able to get through it. The family member felt the facility was causing her behaviors and did not know how to deal with residents with mental health issues and were agitating her with the transfers back and forth from the facility to the hospitals. The family member stated the facility did not provide her any documentation about the transfers out in the past week. The family member stated, They cut me out of the loop .they should have discussed that [transfers/behaviors] with us to work with them. An interview with Resident #1's primary RP on 09/12/23 at 2:48 PM revealed on 09/08/23, she got a call from the activity director to bring Resident #1 some cigarettes so she bought a carton and went to the facility the following day to deliver them (9/09/23). When the primary RP arrived, she was going to drop off the cigarettes because she was on her way to work and was using a rideshare service, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 34 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0624 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few however, the facility notified her that Resident #1 had attacked someone. The RP stated she told the facility staff that did not sound like Resident #1 and had they been messing with her medications? The RP stated, This is not the first time and we have discussed the same thing over and over, I said I am not POA and I can't make her take mediation, but let me tell you, when you mess with her medicine, she gets aggressive and she needs this medicine. The RP stated the facility had never informed her that Resident #1 had been refusing her medications for five days. She was frustrated because she felt the facility called her and the other RP often for minor issues, but they could not call and notify them she was refusing her medications. The family member wanted to know why the facility did not intervene when Resident #1 started to refuse her medications. The family member stated RN F was at the facility and told her he was in charge and they had already called the police. The RP stated, Why? Because you know she didn't take her meds and why didn't you send her to the hospital? She said RN F stated Resident #1 did not want to be transported in an ambulance. The RP stated she felt something was not right about the situation so she decided to stay and see what was going to happen because she felt the facility was trying to arrest Resident #1 and she was scared that because of her ethnicity and having mental illness, if Resident #1 ended up in jail, it would not fare well for her. When the police arrived, the RP told them Resident #1 needed to go to the hospital because she had been there the week before. The RP stated when she saw Resident #1 that day, she was crazy acting, saying she was someone else, saying she saw a man who was not there and people were sitting on her and was delusional. The RP felt the facility had a plan to dump Resident #1 because they were supposed to facilitate the transfer to the hospital, but they began talking privately and she overheard them say one place was full and that they were going to take her to an inpatient behavioral health facility. The RP went with the police and Resident #1 in the police care because she felt that something was not right. When they got to the inpatient behavioral health facility, the police dropped her and Resident #1 off and left. The intake coordinator refused to admit Resident #1 due to her having noted aggression and said they would not be able to force her to take her medications because it was only a behavior clinic. The RP then called the facility to notify them of the refused admission and was told by the front desk receptionist that Resident #1 could not come back and was not allowed back. The RP then called the local police to come and pick up Resident #1 and they called the facility who said she could not come back; the RP told the facility they had to accept her back. The RP then left from the inpatient behavior health facility via rideshare to go to work because she was late and assumed the police had transported Resident #1 back to the facility. An interview with the front desk receptionist on 09/14/23 at 12:15 PM revealed she worked over the weekend, including on 09/09/23. She stated she saw Resident #2 being taken out by EMT to the hospital and knew the police had been called and Resident #1 had been asked to leave the facility due to an incident between her and Resident #2. The front desk receptionist stated she saw Resident #1 escorted out of the facility by the police and got into their SUV along with her family member. She then stated after that, the family member called the facility and was stating the police transported Resident #1 to an inpatient behavioral health facility and they would not admit her Resident #1. The front desk receptionist notified the ADM, and he said no, she [Resident #1] was not to be admitted back in. She could not remember what reason the ADM gave her for refusing to let Resident #1 come back but she thought it had to do with behavior issues. The front desk receptionist stated, I know the [family member] said the reason she needed to come back was because [behavioral facility] would not allow her in and she needed the incident report, I heard the police say it behind her. I said I did not have that .I called her back and said she cannot come back in. She said she could not take her home. I said I am sorry but (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 35 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0624 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few she cannot come back here. Later in the day [time unknown], the front desk receptionist remembered seeing Resident #1 standing across the street at the apartments walking back and forth and no one was with her. During that same time, Resident #2was brought back to the facility by a female police officer while Resident #1 was still across the street. She said ADON A called the police because she knew Resident #1 was standing across the street. The front desk receptionist stated the staff did not bring Resident #1 back into the facility because from her understanding, she was no longer allowed in and that was what ADON A understood to be true as well. Once Resident #1 was back in the building, the female police officer went over to deal with Resident #1 but she did not see what happened. She stated, I looked back up later and they were gone. The front desk receptionist left her shift at 8:00 PM, no one called to the facility inquiring about Resident #1 after she was gone. An interview with the ADM on 09/12/23 at 10:00 AM revealed Resident #1 had an incident a week prior where she was allegedly being rude to LVN I and another resident (Resident #3) told her not to be rude; she then walked over and slapped him. ADM stated LVN I witnessed it. The ADM stated there were no injuries and his [Resident #3] was more of a bruised [NAME]. The ADM stated the police were called and Resident #1 was arrested, Problem is, when she got arrested, [Resident #3] wanted to press charges but they took [Resident #1] to [hospital] who notified the facility the next day they were sending her back. The ADM stated, I put up a fight and said less than 24 hours, you are sending her back? The ADM stated due to his refusal to accept her back into the facility, the hospital notified his boss at the corporate level and the ADM was then told that he had to accept Resident #1 back into the facility because she did not have any behaviors while she was at the hospital. The ADM stated Resident #1 did not have any behaviors when she came back from 09/06/23 through 09/09/23. The ADM stated on 09/09/23, another incident took place and according to Resident #2 (new roommate of Resident #1), she said Resident #1 punched her on her head, chest and back totally unprovoked. The ADM stated the information came from Resident #2's report to RN F, Which I am not sure how much I want to take at face value because of her dementia. The ADM stated he told RN F what to do because Resident #2 wanted to go to the hospital and came back the same day with no injuries. The police were notified for the alleged resident to resident altercation between Resident #1 and Resident #2 and they escorted Resident #1 from the facility but took her to a behavioral health facility along with her family member but that facility declined to do an admission, so the facility told the family member she would need to be taken to the hospital because she was technically discharged from our facility .Now care was left onto police to direct what happened. The ADM stated the police left the family member and Resident #1 at the behavioral health facility and he was under the impression the family member transported her back to the facility because a Resident #1 was seen by a staff member [name unknown] being dropped off across the street to the facility where there was an apartment complex. The ADM stated the facility staff called the police on Resident #1 again and they sent a unit out, but before they arrived, he tried to talk to Resident #1 and she told him she did not want to talk to him in a thousand years. The ADM stated when the fire department arrived, Resident #1 refused to talk to them so they left and stated the police were on their way. The ADM stated he had to leave the facility and go back home and ADON A called him and said the police showed up and Resident #1 started walking away, so they gave ADON A a police report number and followed Resident #1. The ADM stated Resident #1 was discharged from the facility and they had tried to prevent the discharge by getting her seen for psyche services, not to discharge. He stated Resident #1 never been send out before these two incidents and there were no prior resident to resident altercations since her admission in 2021. He stated when she does have a behavioral episode in the facility, she would hit her head and make a grunting noise. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 36 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0624 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The ADM stated the facility had not been able to find a good roommate fit for Resident #1 except for one female resident who she roomed with for a couple of days in the past two weeks before that roommate went out to the hospital. The ADM stated there was no witness for the resident to resident altercation between Resident #1 and #2 and both of them had a diagnosis of dementia. An interview with LVN I on 09/13/23 at 10:15 AM revealed she did not witness Resident #1 slap Resident #3, she only heard them yelling at each other. She was shocked to see them verbally fighting with each other and reported none of the staff seemed to be doing anything. LVN I stated Resident #3 was alert and oriented x 4 and he was saying all of the mean things. LVN I asked Resident #3 to stop and remember that Resident #1 was a lady. An interview with RN F on 09/12/23 at 3:54 PM revealed he was the weekend supervisor on 09/09/23 from 7:00 AM until 11:00 PM and he was aware Resident #1 had been sent to the hospital the week prior due to an altercation where he thought she hit someone. He said Resident #1 had been back at the facility for two days prior to the weekend. When RN F got to work on Saturday 09/09/23, he was called to her room and told she had gone to the roommate's bed [Resident #2] and hit her on the back, chest and head and was following her down the hall. When RN F arrived, he went into their room and tried to evaluate Resident #1, who was laying in bed. He asked Resident #1 what happened and she was agitated and said, That white woman is not my momma and I need her out of this room-she is not my roommate! RN F stated it was hard to re-orient Resident #1 in that state and she had dementia and psyche issues. He stated psyche issues for Resident #1 meant she always paced the hallways, was very untidy, her hair was not groomed, her clothes were not tidy, she talked to herself and made weird noises, declined care and scared other residents away. RN F stated after the incident, he called the police because Resident #2 wanted to file and allegation, I don't know what for, I don't know what she told the police. He stated Resident #1's family member happened to be at the facility but not present for the altercation and he explained the police had been contacted. RN F stated Resident #2 did not have any injuries but was tearful. RN F stated CNA N was the person who told him about the incident. He said he did not get into the details of what CNA N observed, but he did complete an incident report. RN F stated he knew Resident #1 was taken to a hospital in [adjacent city] somewhere and said the police or the family decided on where because he heard them talking. RN F stated he could not tell the police where to take Resident #1, but they did not end up going to [Hospital PP]. RN F stated the facility usually sent the residents to [Hospital PP] for psyche evaluations and a face sheet and medication record would be sent with the transport provider. RN F stated he did not know how Resident #1 ended up at the inpatient behavioral health facility. RN F stated he had called the doctor to get an order to transfer Resident #1 to the hospital, but the doctor could not give a specific order on where to take the resident. RN F stated, The [family member] and police decided to take her wherever they took her. RN F then clarified he spoke to NP D to notify about the transfer, not the MD. He said NP D told him to send Resident #1 out for a psyche evaluation. After that, RN F stated Resident # left the building and never came back that day or the following day. To his understanding. She went to the hospital but he had no idea where they took her, but she was not discharged from the facility. RN F stated the facility social worker normally followed up to see where a resident was placed and which hospital they were sent to, but there was no social worker over the weekend. An interview with ADON A on 09/12/23 at 4:29 PM revealed she was newly employed for about a month and had tried to intervene after an incident where Resident #1 slapped Resident #3 a week prior. ADON A stated when trying to intervene, Resident #1 was gunning for me, she does this reaction like '[NAME]' [ADON A was making hand gestures by her ears], cursing, saying random things like they attacked her and not making any sense. ADON A stated when she tried to physically (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 37 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0624 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few separate the verbal altercation between Resident #1 and #3, Resident #1 threw ADON A up against the wall. ADON A stated the police took Resident #1 out in handcuffs to Hospital PP. ADON A stated she did not know what Hospital PP did with Resident #1 care wise, but she knew they completed a psychiatric evaluation. She did not know if the facility had a copy of it and she did not get a chance to review any discharge documentation because when Resident #1 re-admitted the next day, she was placed on a new hall/new room that ADON A was not over because they wanted to put distance between her and Resident #3. ADON A stated Resident #1 already had a recent room change from the upstairs hall to the downstairs hall where she got into the altercation with Resident #1. Now she was going to be placed back upstairs, but on a different hall than she had been on prior. ADON A stated when Resident #1 returned, the nursing staff were still trying to locate another psyche facility because we knew it would take longer for her to stabilize. Regarding resident transfers, ADON A state the police or EMT decide where a resident would be transported when sent to the hospital. She stated NP D was notified at that time. ADON A stated Resident #1 was stable when she came back from Hospital PP. She did not know if psyche services came to visit her or adjust her medications after she re-admitted . On 09/09/23, ADON A stated she came to the facility around 10:30 AM and was not scheduled to work but she had gotten group text that there was a resident to resident altercation with Resident #1 and #2. She was the closest in the vicinity and was going to check on things. When she arrived at the facility, NP F had already contacted the police and Resident #1's family member was present. ADON A stated they police were hesitant in taking Resident #1 to jail and were talking about transporting her to a hospital. ADON A went to talk to Resident #1 who was cool, calm and collected and laying on her bed and said she was doing fine. ADON A told Resident #1 her family member was present and the police wanted to take her to Hospital PP. Resident #1 agreed to ride with the police. The police handcuffed Resident #1 and ADON A cut the wander guard off her ankle and printed out her face sheet and med sheet, gave the police and family member a copy, and told the family member to make sure Hospital PP looked over the medication list and they left. About an hour later, ADON A was trying to clock in and heard a housekeeping staff member say, hey, isn't that [Resident #1]? and was looking out the window across the street. ADON A stated no, she was at Hospital PP. Then ADON A looked out the front window and saw Resident #1 standing across the street with a bag of clothes and no one was with her. ADON A stated she went outside and stood in the parking lot, called the ADM and then contacted the police and asked them to do a welfare check because I wasn't sure if I could approach her. She said 911 asked her what did she think the police would be able to do about it? She told them that Resident #1 had just assaulted another resident and she [ADON A] did not know why the resident was not at Hospital PP. ADON A stated Resident #1 did not come back inside during that time and no staff tried to talk to her. ADON A stated, She had already attacked me once. By me not having any male backup, I didn't want to surround her with a group of people. I just kept an eye on her and called 911 for a well-check. ADON A stated fire truck arrived or ambulance, she did not talk to them and they were briefly there then left, but Resident #1 was still there. Then a police officer arrived (same officer that transported to the behavior facility an hour earlier). ADON A asked the police officer what happened and the police officer stated they took Resident #1 to a behavioral health facility with her family member present but they would not take the resident because she was too aggressive and the police left her there with her family member. ADON A then asked the police officer why did they not take Resident #2 to Hospital PP and she could not remember what the officer's response was. ADON A stated, It was so chaotic, I was trying to bring DON up to date and keep eyes on the resident. Police then were saying this is a fine line between criminal and dementia. She [officer] was on the phone with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 38 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0624 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few [county jail] and she doubted they would take her in [as an arrest]. At one point, Resident #1 started to walk away and the police officer said she would follow her, she could handle it, and we never heard anything else after that. ADON A could not remember if the police officer still had the face sheet and med list from earlier. ADON A stated she and the DON walked back into the facility and she did not know what ended up happening to Resident #1. ADON A stated the facility DON and C-RN were trying to find out where Resident #1 was, but they did not consider her missing because the police were on the trail. She did not know if the police ended up picking Resident #1 on 09/09/23. ADON stated she had hoped the police officer would have come back to the facility and let them know, I should have followed them, but I didn't. ADON A stated if she could do things differently, she would have tried to go across the street and talk to Resident #1 to see what the facility could do to help her, even if it was to come back into the facility, But I was afraid to approach her, I wasn't familiar with her a whole lot. I really wish I had just talked to her. An attempt was made to contact the female police officer (name provided by ADON A) on 09/13/23 at 1:15 PM. Message was left with the station intake staff, police report number provided and HHSC investigator contact information, date and location of the incident and she stated she would look up information and send the officer an email requesting her to contact the HHSC investigator. An interview with the ADM on 09/12/23 at 5:37 PM revealed he had just found out that the police took Resident #1 to jail and had just gotten off the phone with them but could not say who he talked to or their title. The ADM stated, She is discharged at this point. An interview with the DON on 09/13/23 at 12:38 PM revealed the purpose of police coming to the facility after a resident to resident incident was just the facility protocol/ She said when the police came out, depending on the situation and what was going on, they questioned both sides and depending on how each side responds, pretty much determines if they take them or not. The DON stated the police would always leave a police report number regardless because the facility needed it for their self-report to HHSC. She said just because the police come out, did not mean they always took the resident with them to jail. The DON stated a lot of times for residents with behaviors, Hospital PP was the place of choice. The DON stated Resident #1 used to be on the 600 Hall and did not have a roommate, then was recently moved 9date unknown) to the 100 hall because there were new admissions coming in and they needed her room. They placed her with a roommate who ended up having to go out to the hospital for about a week. During that time, Resident #1 got into the altercation with Resident #3 where she slapped him and she was sent to Hospital PP for evaluation and came b[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 39 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for one (Resident #5) of ten residents reviewed for care plans. Resident #5's care plan was not individualized and did not address her wounds. This failure could place residents at risk of not receiving individualized care and services to meet their needs. Findings included: Record review of Resident #5's Face Sheet (undated) reflected she was a [AGE] year old woman admitted to the facility on [DATE]. Her active diagnoses included parastomal hernia with obstruction (a condition wherein abdominal contents, typically the bowel or greater omentum (a fold of peritoneum connecting the stomach with other abdominal organs), protrude through abdominal integuments surrounded by the hernia sac at the location of formed stoma). Record review of Resident #5's annual MDS assessment dated [DATE] reflected she rarely understood others and her BIMS score was a 03, which indicated severe cognitive impairment. Resident #5 had no behaviors, rejection of care or psychosis. Resident #5 required extensive assistance of one to two staff for her ADLs and used a wheelchair for ambulation. Resident #5 was always incontinent of bladder and bowel. Resident #5 was at risk for developing pressure ulcers/injuries but did not have a pressure ulcer/injury during the assessment period. Resident #5 did not have any other ulcers, wounds or skin problems or treatments. Record Review on 09/12/23 of Resident #5's care plan initiated 08/12/23 and last revised on 08/30/23 revealed no discussion of her wounds and interventions to be used. Review of Resident #5's Weekly Wound Progress Note dated 09/05/23 reflected she had one wound on the right side of her stoma identified on 08/29/23, with moderate red and thin exudate, no odor, with tissue granulation, surrounding skin was normal with clean and intact wound margins. The wound dimensions were 1.5cm x 1.5cm x 0.7cm and the wound had shown improvement. Physician's wound orders were to clean with normal saline, pat dry and apply calcium alginate every day and as needed. Review of Resident #5's Weekly Wound Progress Note dated 09/19/23 reflected she had an additional wound on her abdomen with moderate, thick exudate, with an odor present and granulation tissue. The dimensions of the wound were 1cm x 2cm x 0.5cm and the wound had shown improvement. The physician's wound orders were to clean with normal saline, pat dry and apply calcium alginate every day and as needed. An interview with MDS LVN P on 09/14/23 at 3:01 PM revealed she had been employed at the facility for three months. She stated she had been working by herself in the position since the middle of August 2023 and there was also some help PRN. MDS LVN P stated she was in charge of completing the new admission care plans within 14 days and then updated them with each quarterly/annual MDS assessment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 40 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few She stated a care plan was outlining how the facility planned to take care of a resident. She stated the MDS nurse or nurses could update the care plans as needed for acute issues. She stated the care plan meetings are done in part, to determine what was helping the resident, any new interventions needed or any other information between staff and resident if they had something to contribute. She stated the CNAs typically did not attend. MDS LVN P stated it was important for everyone to know what the plan of care was. MDS LVN P stated she knew what needed to be on a care plan based on what MDS CAAs triggered, as well as from her own experience. MDS LVN P stated she made sure the care planned sections were completed for resident diagnosis, CAA areas, high risk issues and medications. MDS LVN P stated she got her information for the care plans from going through the residents' hospital records, looking at the BIMS section the nurses completed and reviewing the doctor's H&P if it was available. MDS LVN P stated the nurses, social workers, dietary manager and ADONs could all go into a care plan document and update/edit it for new issues and interventions. An interview with Wound Care LVN DD on 09/21/23 at 1:35 PM revealed if a resident developed a new wound, she was the one who usually updated the care plan, but the MDS nurse would do it as well, We work together on it. Record review of the facility's policy titled, Care Planning, revised June 2020, reflected, To ensure that a comprehensive, person-centered care plan is developed for each resident based on their individual assessed needs .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 social well-being. Record review of the facility's policy titled, Wound Management, revised June 2020, reflected, .II. Wound Management .E. A Licensed Nurse will develop a care plan for the resident based on recommendations from Dietary, Rehabilitation and the Attending Physician .III. Documentation-C. IDT will document discussion and recommendations for: i. Pressure injury and wounds that do not respond to treatment, ii. Pressure injuries and wounds that worsen or increase in size, iii. Complaints of increased pain, discomfort or decrease in mobility by a resident, iv. Signs of ulcer sepsis, presence on exudates, odor or necrosis, v. Residents refusing treatment .F. Update the resident's care plan as necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 41 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter or alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist for four (Residents #1, #2, #4 and #5) of four residents reviewed for physician services. Residents Affected - Some The facility failed to ensure Residents #1, #2, #4 and #5 were seen by their attending physician at least once every 60 days. The attending physician's extenders were completing all visits for the residents, not alternating visits with the physician. The failure could place residents at an increased risk of not receiving appropriate and adequate medical care and a lack of oversight by the physician, which could place the residents at risk of harm and health decline. Findings included: 1. Record review of Resident #1's Face Sheet (undated) reflected she was a [AGE] year old female admitted to the facility on [DATE] with active diagnoses including schizoaffective disorder-bipolar type (a mental illness where the person experiences psychotic symptoms, such as hallucinations or delusions with episodes of mania and sometimes depression), dementia-moderate with behavioral disturbance (the loss of cognitive functioning- thinking, remembering, and reasoning along with symptoms depression, anxiety, psychosis, agitation, aggression, disinhibition and sleep disturbances), generalized anxiety disorder (a feeling of fear, dread, and uneasiness), insomnia (trouble falling asleep, staying asleep, or getting good quality sleep), diabetes (a problem in the way the body regulates and uses sugar as a fuel), hypertension (when the pressure in your blood vessels is too high-140/90 mmHg or higher), difficulty in walking, unsteadiness on feet/lack of coordination and altered mental status (a change in mental function). Resident #1's reflected MD was listed as her attending physician. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was sometimes understood by others (ability is limited to making concrete requests) and was sometimes understood (able to respond adequately to simple, direct communication only). Resident #1's BIMS score was an 06, which indicated severe cognitive impairment. Resident #1 had no signs/symptoms of delirium (inattention, disorganized thinking and altered level of consciousness), her mood score was a 00, which indicated no negative mood issues. Resident #1 had no potential indicators of psychosis, physical or verbal behaviors, rejection of care or wandering. She was independent in her ADLs, was continent in bowel and bladder, had unsteady balance during transitions and walking and did not use a mobility device for ambulation. Resident #1 had no indicators of pain and had no falls since the last MDS assessment. Resident #1 wore a wander guard for elopement daily. Record Review on 09/12/23 of Resident #1's care plan (not dated) reflected the following problems/issues: 1) Resident #1 has a communication problem related to dementia, schizoaffective disorder and minimal hearing difficulty, 2) Resident #1 has impaired cognitive function or impaired thought processes related to dementia, schizoaffective disorder, 3) Resident #1 is an elopement risk/wanderer, 4) Resident #1 has delirium or an acute confusion episodes related to inattention and disorganized thinking, 5) Resident #1 requires antidepressant, antipsychotic medications for diagnoses of schizoaffective disorder bipolar type, 6) Resident #1 has schizophrenia and dementia, 8) Resident #1 is at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 42 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0712 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some risk for psychosocial well-being problem or alteration in mood state, and 7) Resident #1 is at risk for ADL self-care performance deficient. Record review of Resident #1's September 2023 Physician Orders reflected she was prescribed the current medications while under MD's medical care: Amlodipine Besylate Tablet 5 MG once a day for hypertensionhold for SBP<100 and DBP<60 and HR<55 (start date 04/22/21), Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization (seizure medication used off label-start date 04/21/21, increased PM dose by one tablet on 09/07/23), Trazadone 50 MG once at bedtime for depression (anti-depressant-start date 08/09/22) and Quetiapine Fumarate/Seroquel 325 MG twice a day(antipsychotic- start date 03/28/23). Record review of Resident #1's clinical chart reflected no evidence of any visit by a physician 01/01/23. Review of Resident #1's clinical chart revealed the following physician extender visits by NP D and PA E since 01/01/23: 01/12/23, 01/23/23, 02/17/23, 03/13/23, 04/12/23, 04/28/23, 05/3/23, 06/19/23, 07/15/23, 08/14/23 and 09/4/23. 2. Record review of Resident #2's Face sheet (not dated) reflected she was a [AGE] year old female admitted to the facility on [DATE] with active diagnoses including dementia, diabetes, malnutrition, mood disturbance, muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), cognitive communication deficient and anxiety. Resident #2's Face Sheet reflected MD was listed as her attending physician. Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected she had no hearing, vision or speech issues and her BIMS score was a 09, which indicated moderate cognitive impairment. Resident #2 had no symptoms of delirium, negative mood issues, behaviors or rejection of care. Resident #2 required extensive assistance of one staff for bed mobility and eating. She was ambulatory but unsteady without staff assistance and received occupational and physical therapy. Record review of Resident #2's care plan initiated 02/10/23 and last revised 09/11/23, reflected the following problems/issues: Moderate risk of falls related to deconditioning, Resident #2 has diabetes, dementia, impaired visual function and potential for pressure sore development. Resident #2 is on pain management therapy, has an ADL self-care performance deficit and has a potential nutritional problem. Record review of Resident #2's September 2023 Physician Orders reflected she was prescribed the current medications while under MD's medical care: Vitamin D Oral Capsule 1.25 MG (50000 UT) once in the morning- Supplement (start date 03/18/23), Memantine HCl Oral Tablet 10 MG once in the morning and at bedtime for Dementia (start date 08/10/2023) and Metformin Cl Oral Tablet 500 MG twice a day for diabetes (start date 03/11/23). Record review of Resident #2's clinical chart reflected no evidence of any physician by MD visits since her admission on [DATE]. Review of Resident #s's clinical chart revealed the following physician extender visits by NP D and PA E since her admission on [DATE]: 03/13/23, 06/12/23 and 08/14/23. 3. Record review of Resident #4's Face sheet (not dated) reflected he was a [AGE] year old male (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 43 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0712 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some admitted to the facility on [DATE] with active diagnoses including metabolic encephalopathy (occurs when problems with your metabolism cause brain dysfunction ), hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in the blood) , depressive disorder (a depressed mood or loss of pleasure or interest in activities for long periods of time), anxiety (a feeling of fear, dread, and uneasiness) , insomnia (a common sleep disorder), hypertension (when the pressure in your blood vessels is too high ) GERD (occurs when stomach acid repeatedly flows back into the tube connecting the mouth and stomach), neurogenic bowel (the loss of normal bowel function), lumbar intervertebral disc degeneration (the wear and tear of lumbar disc that act as a cushion for the spine), neuralgia and neuritis (nerve inflammation) and dysphagia swallowing difficulties). Resident #4's Face Sheet reflected MD was listed as his attending physician. Review of Resident #4's quarterly MDS assessment dated [DATE] reflected he had no hearing, vision or speech issues. His BIMS score was an 08, which indicated moderate cognitive impairment. Resident #4 had no negative mood issues, no signs/symptoms of delirium, psychosis, verbal/physical behaviors or wandering. Resident #4 did have rejection of care during the MDS assessment period. Resident #4 had range of motion impairment in both his upper and lower body and both sides and used a wheelchair for ambulation. Resident #4 had pain presence frequently with a pain level at 7 during the assessment period and was on a scheduled pain management regimen. Resident #4 received antianxiety, antidepressant and opioid medications. Record review of Resident #4's care plan (not dated) reflected the following problems/issues: Resident #4 has anemia, GERD, potential for complications due to a diagnosis of hypertension, an indwelling catheter, poor oral hygiene, alteration in neurological status due to injury at C-4 level of cervical spine, bowel incontinence, lower back pain, has contractures to both bilateral hands and requires a palm protectors and is on anticoagulant therapy due to history of pulmonary embolism (A sudden blockage in your pulmonary arteries, the blood vessels that send blood to your lungs). Resident #4 has the potential for pressure ulcer development and skin integrity breakdown, is on oxygen therapy, prefers to lie in bed most of the day, has ADL self-care deficits, depression and impaired nutrition. Record review of Resident #4's September 2023 Physician Orders reflected he was prescribed the current medications while under MD's medical care: Cholestyramine Light Oral Packet 4 GM once a day (start date 06/01/23), Clonazepam Oral Tablet 0.5 MG one tablet three times a day and two tablets at bedtime for anxiety (start date 09/08/23), Escitalopram Oxalate Oral Tablet 5 MG two in the morning for depression (start date 08/29/23), Flonase Allergy Relief Nasal Suspension 50 MCG once a day in both nostrils (start date 06/01/23), Lidocaine Pain Relief 4 % Patch apply to lower back topically in the morning (start date 06/02/23), Melatonin Tablet 3 MG once at bedtime for insomnia (start date 08/12/23), Omeprazole 20 MG once in the morning for GERD (start date 06/01/23), Rivaroxaban Tablet 20 MG once in the evening for blood thinner (start date 06/01/23), Tamsulosin Oral Capsule 0.4 MG once a bedtime for enlarged prostate (start date 06/01/23), Trazadone 100 MG two tablets at bedtime for insomnia (start date 06/01/23), Vitamin C Oral Tablet 500 MG once in the morning as a supplement (start date 06/29/23), Zinc Sulfate Oral Tablet 220 MG) once a day as a supplement (start date 06/29/23), Zyrtec Allergy Oral Tablet 10 MG once a day for allergies (start date 06/01/23), Cephalexin Oral Capsule 500 MG twice a day for seven days (start date 09/15/23), Gabapentin Oral Capsule 300 MG two capsules twice a day for nerve pain (start date 06/01/23), Pro-Stat AWC Oral Liquid 30 ml by mouth two times a day for wound healing (start date 06/02/23), Creon Oral Capsule Delayed Release three capsules by mouth with meals related to dysphagia (start date 06/01/2023), Lactobacillus Oral Capsule three times a day for indigestion (start date 06/03/23), Simethicone Oral Tablet Chewable 80 MG three times a day for management of flatulence/bloating (start date 07/06/23) and Ursodiol Oral Capsule 300 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 44 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0712 MG three times a day for pancreas (start date 06/30/23). Level of Harm - Minimal harm or potential for actual harm Record review of Resident #4's clinical chart reflected no evidence of any visit by a physician since 01/01/23. Residents Affected - Some Review of Resident #4's clinical chart revealed the following physician extender visits by NP D and PA E since 01/01/23: 02/03/23, 02/06/23, 02/17/23, 02/20/23, 03/03/23, 04/07/23, 05/01/23, 05/05/23, 06/02/23, 06/11/23, 06/19/23, 06/24/23, 07/08/23 and 08/06/23. 4. Record review of Resident #5's Face sheet (not dated) reflected she was a [AGE] year old male admitted to the facility on [DATE] with active diagnoses including dementia, diabetes, cognitive communication deficit, adjustment disorder (a psychological response to an identifiable stressor, leading to emotional or behavioral symptoms), dysphagia (swallowing difficulties), parastomal hernia with obstruction (may cause the intestine to become trapped or kinked inside the hernia causing intestinal obstruction and loss of blood supply), hypothyroidism (when the thyroid gland does not make enough thyroid hormones to meet the body's needs), hypertension (when the pressure in your blood vessels is too high), muscle wasting and atrophy (the decrease in size and wasting of muscle tissue) . Resident #5's Face Sheet reflected MD was listed as her attending physician. Record review of Resident #5's annual MDS assessment dated [DATE] reflected she rarely understood others and her BIMS score was a 03, which indicated severe cognitive impairment. Resident #5 had no behaviors, rejection of care or psychosis. Resident #5 required extensive assistance of one to two staff for her ADLs and used a wheelchair for ambulation. Resident #5 was always incontinent of bladder and bowel. Resident #5 was at risk for developing pressure ulcers/injuries but did not have a pressure ulcer/injury during the assessment period. Resident #5 did not have any other ulcers, wounds or skin problems or treatments. Record review of Resident #5's care plan initiated 08/12/20 and last revised on 09/21/23 reflected she had the following problems/issues: Resident #5 tested positive for COVID on 09/21/23, has a communication problem and is rarely/ever understood, has hypothyroidism, potential nutritional problem, significant weight loss and ADL care performance deficits. Record review of Resident #5's September 2023 Physician Orders reflected she was prescribed the current medications while under MD's medical care: Donepezil 10 MG once in the evening for dementia (start date 03/14/23), Ergocalciferol Oral Capsule 1.25MG once in the morning every Wednesday (start date 03/18/23), Escitalopram 5 MG two tablets in the morning for anxiety (start date 01/27/23), Losartan Potassium 25 MG once a day for hypertension (start date 02/03/21), Memantine 7 MG once a day for dementia (start date 02/17/22), Synthroid 100 MCG once a day for hypothyroidism (start date 11/11/22), Trazadone 100 MG once at bedtime for insomnia (start date 06/19/23), Vitamin D3 Tablet 25 MCG once a day (start date 11/11/22), Meclizine 25 MG once a day for vertigo (start date 01/15/21). Record review of Resident #5's clinical chart reflected no evidence of any visits by a physician since 01/01/23. Review of Resident #5's clinical chart revealed the following physician extender visits by NP D and PA E since 01/01/23: 01/13/23, 02/10/23, 03/06/23, 03/08/23, 04/15/23, 04/20/23, 05/08/23, 05/10/23, 05/17/23, 06/11/23, 06/12/23, 07/06/23, 07/22/23 and 08/07/23. 5. An interview with RN F on 09/12/23 at 3:54 PM revealed he was the weekend supervisor for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 45 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0712 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility. RN F stated he had only seen the MD once when he was in new employee orientation about a month prior, but he had seen the MD's extenders often. He did not know who was in charge of ensuring the MD completed his visits with the residents. RN F stated the MD was not able to see all the residents in the facility, so as the CNA were the eyes for the nurses, the extenders were the eyes for the MD. An interview with ADON A on 09/12/23 at 4:29 PM revealed she saw the MD twice the week prior. She stated MD was the medical director as well as the attending physician for all the residents in the facility. ADON A stated she thought medical records staff were in charge of making sure he was completing his visits and turning in progress notes. ADON A stated the physician needed to see the residents face to face so they would know who he was and he laid eyes on them, as well as it was the appropriate thing to do. An interview with ADON B on 09/12/23 at 5:35 PM revealed she saw the MD two to three times a week and he was the medical director and attending physician for all the residents in the facility. ADON B stated the MD needed to see the residents periodically, Just to see the patient and keep up with them, do their assessments, get a clear picture of how the patient is. A confidential interview on 09/12/23 revealed when the MD was at the facility, and the nurse wanted to talk to him, he would tell the nurse to let his nurse practitioner know whatever it was, and he would walk off. The nursing staff stated they had never seen the MD go into a resident's room and talk to them. An interview with MR M on 09/13/23 at 11:57 AM revealed MD came twice a week to see the skilled residents and then he will also choose one hall to work on for his face-to-face visits. MR M stated it took about one and a half months for the MD to see all of the residents in the facility. She stated the MD was the only attending physician for the facility and was also the medical director. MR M also stated the MD had two physician extenders (NP D and PA E) who rotated their visits and came once a week as well. MR M stated she did not have physician notes for the MD's visits and it had been awhile since he sent any in. MR M stated it was important for the MD to see the residents because with the new residents, he was supposed to see them within seven days and then for the long-term care residents, every 30 days, then every 90 days, But that isn't happening. A confidential interview on 09/13/23 revealed the ADM had been asked already if another physician could be brought on board to help the MD and the resident caseload but the individual did not know if any progress was being made on that. The individual stated the MD had too much going on with the resident population at the facility and he was not doing his job. An interview with the DON on 09/13/23 at 12:38 PM revealed the MD came to the facility but did not see every resident because the census was around 180 and he had all of them, along with his physician extenders. An interview with the C-RN on 09/13/23 at 2:00 PM revealed the MD was required to visit a resident he was the attending physician for every 60 days and complete a general progress note for that visit and then complete a yearly H&P. The C-RN stated the MD did come to the facility to see residents and there had been no reports of him not turning in his progress notes. An interview with the MD on 09/13/23 at 4:38 PM revealed he did complete H&P's for the residents and it would be located in the online e-chart. The MD stated his physician extenders (NP D and PA E) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 46 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0712 Level of Harm - Minimal harm or potential for actual harm typically saw most of the residents who have Medicaid as their primary payor source, including their initial assessments, as long as they were in collaboration with him. The MD stated the extenders were required to see the residents at least once every 60 days. The MD stated, Typically I see Medicare patients and come twice a week .Per Medicare guidelines, the physician has to see the patient. So I will come in and see the Medicare patient, but not the Medicaid, I leave that to the mid-levels. Residents Affected - Some An interview with NP D on 09/14/23 at 10:38 AM revealed she did not know how often the MD saw the residents , but that he was there quite a bit. She stated herself and PA E rotated on-call each month, not the MD. NP D stated besides the MD signing death certificates and triplicate orders, We [NP D and PA E] do everything else. NP D stated there was no risk to the resident if they were not being routinely seen by the MD. She stated if there was an issue she nor PA E could take care, the MD could handle it because he was at the facility and could follow up if needed. 6. Record review of the facility policy titled, Physician Services and Visits, revised August 2020, revealed, .Procedure: I. Physician services include, but are not limited to, A. The resident's Attending Physician participation in the resident's assessment and care planning, monitoring changes in resident's medical status, and providing consultation or treatment when called by the Facility. B. The Attending Physician must: i. Evaluate the resident as needed and at least every 30 days for the first 90 days after admission, and at least once every 60 days thereafter unless there is an alternate schedule or state specific requirement. The Attending Physician will document the visits in the resident's health record; II. Patient diagnoses: A. Provide advice, treatment and determination of appropriate level of care needed for each patient, .E. Prescribing new therapy, ordering a transfer to a hospital, conducting required routine visits, delegating and supervising follow-up visits form Nurse Practitioners or Physicians Assistants, etc., to ensure the resident receives quality care and medical treatments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 47 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0742 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who displayed or is diagnosed with a mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for two (Residents #1 and #4) of five residents reviewed for psychosocial concerns. 1) The facility management and staff did not observe and intervene for manifestations related to mental and psychosocial adjustment difficulties when Resident #1, who lived with dementia with behavioral disturbance and mental illness was changed to three different rooms in a week, after she had been living in a room alone for most of 2023. When Resident #1 was moved to a new hall/floor, she slapped a male resident who lived across the hall from her on 09/05/23 and then moved to a different room on a new hall/floor and placed with an unfamiliar roommate and allegedly got into an unwitnessed physical altercation with her new roommate on 09/09/23 2) The facility management and staff failed to provide adequate person-centered behavioral interventions to ensure Resident #1's safety when they failed to bring her back into the facility after a failed hospital transfer after a resident to resident altercation and she was left outside across the street and subsequently arrested by the police. 3) The facility failed to provide Resident #1 with her psychotropic medications consistently prior to her having two resident-to-resident altercations. The facility med aides and nurses were documenting Resident #1 refused her psychotropic medications consistently (including an antipsychotic, mood stabilizer and antidepressant) without notifying the charge nurses, nursing management and physician. The med aide and nurses were not completing any documentation of the refusals and what intervention/orders were put in place to maintain the resident's medication regime. Resident #1 subsequently had two resident to resident altercations and was arrested and jailed for a week. 4) The facility staff failed to document any follow up post-discharge or put any interventions in place after Resident #4 returned to the facility after being sent to the hospital for expressing suicidal ideations 5) The facility failed to provide Resident #4 with his routine anti-anxiety medication for six days. 6) The facility staff and management did not follow their Behavior Management Policy when Residents #1 and #4 had a change in mental health condition. An Immediate Jeopardy was identified on 09/14/23. The IJ Template was provided to the facility on [DATE] at 1:45 PM. While the Immediate Jeopardy was removed on 09/18/23, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. These failures placed residents with a history of mental disorder or psychosocial concerns at risk (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 48 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0742 of not receiving appropriate interventions, experiencing emotional distress and having psychiatric episodes Level of Harm - Immediate jeopardy to resident health or safety Findings include: Residents Affected - Some 1) Record review of Resident #1's Face Sheet (undated) reflected she was a [AGE] year old female admitted to the facility on [DATE] with active diagnoses including schizoaffective disorder-bipolar type (a mental illness where the person experiences psychotic symptoms, such as hallucinations or delusions with episodes of mania and sometimes depression), dementia-moderate with behavioral disturbance (the loss of cognitive functioning- thinking, remembering, and reasoning along with symptoms depression, anxiety, psychosis, agitation, aggression, disinhibition and sleep disturbances), generalized anxiety disorder (a feeling of fear, dread, and uneasiness), insomnia (trouble falling asleep, staying asleep, or getting good quality sleep), diabetes (a problem in the way the body regulates and uses sugar as a fuel), hypertension (when the pressure in your blood vessels is too high-140/90 mmHg or higher), difficulty in walking, unsteadiness on feet/lack of coordination and altered mental status (a change in mental function). Resident #1's face sheet reflected she had three emergency contacts/RPs and MD was listed as her attending physician. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was sometimes understood by others (ability is limited to making concrete requests) and was sometimes understood (able to respond adequately to simple, direct communication only). Resident #1's BIMS score was an 06, which indicated severe cognitive impairment. Resident #1 had no signs/symptoms of delirium (inattention, disorganized thinking and altered level of consciousness), her mood score was a 00, which indicated no negative mood issues. Resident #1 had no potential indicators of psychosis, physical or verbal behaviors, rejection of care or wandering. She was independent in her ADLs, was continent in bowel and bladder, had unsteady balance during transitions and walking, and did not use a mobility device for ambulation. Resident #1 had no indicators of pain and had no falls since the last MDS assessment. Resident #1 wore a wander guard for elopement risk daily. Active discharge planning was not already occurring for Resident #1 to return to the community. Record Review on 09/12/23 of Resident #1's care plan (not dated) revealed the following problems/issues: 1) Resident #1 had a communication problem related to dementia, schizoaffective disorder and minimal hearing difficulty, 2) Resident #1 had impaired cognitive function or impaired thought processes related to dementia, schizoaffective disorder, 3) Resident #1 was an elopement risk/wanderer, 4) Resident #1 had delirium or an acute confusion episodes related to inattention and disorganized thinking, 5) Resident #1 required antidepressant, antipsychotic medications for diagnoses of schizoaffective disorder bipolar type, 6) Resident #1 had schizophrenia and dementia, 8) Resident #1 was at risk for psychosocial well-being problem or alteration in mood state, and 7) Resident #1 was at risk for ADL self-care performance deficient. Interventions included anticipate and meet needs, minimize background noise when communicating, administer medications as ordered, discuss concerns about confusion, keep routine consistent and encourage participation in activities. Record review of Resident #1's therapy notes reflected she was seen on 08/24/23 by MHNP and she was noted to have ongoing intermittent odd behavior and mild delusions, but no disruption to her care. Staff denied daytime sedation and falls. Resident #1 had no aggression or agitation reported and no reports of sleep/appetite disturbance. Resident #1 was documented to have criteria for schizoaffective disorder and had a history of bipolar disorder and also has had symptoms of psychosis that included delusions, disorganized speech for at least two weeks without mood symptoms during that time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 49 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0742 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of Resident #1's September 2023 Physician Orders reflected she was prescribed Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 (started date 04/22/21), Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization (seizure medication used off label-start date 04/21/21, increased PM dose by one tablet on 09/07/23), Trazadone 50 MG once at bedtime for depression (anti-depressant-start date 08/09/22) and Quetiapine Fumarate/Seroquel 325 MG twice a day (antipsychotic- start date 03/28/23). Record review of Resident #1's September 2023 MAR/TAR reflected she refused the following medications: -Amlodipine Besylate Tablet 5 MG once a day for hypertension- hold for SBP<100 and DBP<60 and HR<55 documented as refused on 09/01/23, 09/03/23, 09/05/23, 09/08/23 and 09/09/23. - Divalproex Sodium Tablet Delayed Release 500 MG give one a day and two tablets of 500 MG at bedtime for mood stabilization documented as refused on 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/08/23 and 09/09/23. - Trazadone 50 MG once at bedtime for depression documented as refused on 09/01/23, 09/02/23, 09/03/23 and 09/04/23. - Quetiapine Fumarate (Seroquel) Oral Tablet 25 MG give with 300mg tab = 325mg twice a day for schizoaffective disorder, bipolar type documented as refused on 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/05/23, 09/08/23 and 09/09/23. Record Review of Resident #1's clinical record revealed only one nursing progress note related to medication refusals on 8/11/2023 at 8:20 AM. The progress note reflected, Resident refused to take AM meds x3 , no reason given for the refusal when asked. Resident up ambulating. Record review of Resident #1's behavior tracking MAR for September 2023 reflected she was being monitored closely for significant behaviors including agitation, anxiety, nervousness, compulsiveness, physical/verbal aggression, combativeness, excitation/irritability, panic, hallucinations, paranoia, delusions and repetitiveness. If a new or increased behavior was noted, the physician's order and MAR reflected the nurse needed to contact the MD. Resident #1's behavior tracking MAR for September 2023 reflected she had one episode of aggression on 09/08/23 and 09/09/23. There were no other significant behaviors documented from 09/01/23 through 09/09/23. Record review of pertinent facility progress notes for Resident #1 reflected: -09/05/23-Mood/Behavior: Late entry- Resident was seen slapping another resident. This writer, other aides and employees separated the two. [City] police were called due to the resident hitting another resident and unsuccessful attempts of calming the resident down. The resident was transferred to [hospital name]. Family called and notified along with MD. Spoke with rep from [behavioral health facility] about placement and notified them she is at [hospital name]. -09/05/23-Social Service Note: Clinicals have been sent over to [behavioral health facility]. -09/07/23-Admit/readmit: Resident re-admitted to facility from [hospital name] via [transport non-emergency]- diagnosis mental health problem. NP D notified of resident's return and reviewed all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 50 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0742 orders. Level of Harm - Immediate jeopardy to resident health or safety -09/09/23-General Progress Note: This resident was physically aggressive and assaulted the roommate, hitting her on the head, chest and back. Resident was separated from roommate, [RP] in room talking to resident. 911 was notified, in room with resident, resident transferred to [hospital name] for psychological evaluation. Administrator, DON and Physician notified. Resident's [family member] on site. Residents Affected - Some -09/09/23-General Progress Note: Late entry- [City] police here and will take patient and [family member] to hospital. [City] police stated they would take them to [hospital name]. About an hour later front desk received a call from [behavioral health facility] stating patient was too aggressive for admission. [RP] still with patient. Attempted to call [RP]. No answer. left message. -09/09/23 at 1:57 PM-General Progress Note written by ADON A: Late Entry- Resident was seen across the street by staff (resident standing at front entrance of the apartment). Police called for safe check on resident. Police and ambulance came to the apartments and facility. Ambulance left and police came into parking lot watching resident. Provided police officer with face sheet and med list. DON arrived while we were standing outside watching resident for safety. Patient stated [sic] walking away police officer stated she was going to follow her and pick her up. I asked did she need any help police officer stated 'no' she had it. Attempted to call [Resident #2's other RP] no answer and left message, to ask her why she drop her off at apartments or what where her intentions no answer no return call. An interview with Resident #1's secondary RP/family member on 09/11/23 at 6:04 PM revealed she found out on 09/11/23 that Resident #1 had been arrested on 09/09/23. The family member was concerned Resident #1 had a psychotic break while at the facility and thought she did not recognize her roommate and thought it was someone invading her privacy. The family member stated the facility reported [date unknown] Resident #1 was being rough and mean with her roommate [Resident #2] and slapped her and another man. The family member stated she was confused because the facility had notified her that Resident #1 was at the hospital on [DATE] because she had a mental break. When another family member/primary RP went to provide Resident #1 cigarettes on 09/09/23, the facility asked the RP if she would ride with Resident #1 to take her to a behavioral health hospital but did not provide her with any clinical paperwork. The RP was dropped off with Resident #1 by the police at the behavioral health hospital and they refused to accept Resident #1, so the RP called the police to transport Resident #1 back to the facility. The family member stated the facility had also reported to her during this time that Resident #1 had not been taking her medications for about a week. The family member stated once Resident #1 was supposed to be transported back to the facility by the police, she did not hear anything from the facility until two days later when they reported to her that Resident #1 was missing. The family member stated the facility told her on 09/11/23 the police dropped Resident #1 off across the street of the facility so they called the police and they asked her if she knew where Resident #1 was and gave her the police report number from the incident on 09/09/23. The family member then went to the police department to file a missing person's report on 09/11/23. The family member stated through the facility's police report number, she was able to find out Resident #1 had been arrested for a felony charge of injury to an elderly person and was in the local county jail with a $500 bail. The family member felt the facility was trying to get rid of Resident #1, claiming they sent her the hospital the week prior but the hospital sent her back because it was not a psychiatric emergency. The family member felt all of these facility behaviors were a tactic to get Resident #1 out of the facility. The family member stated she had not been able to see Resident #1 in jail yet and she was concerned Resident #1 was not getting any of her prescribed psychotropic medications so if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 51 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0742 Level of Harm - Immediate jeopardy to resident health or safety she was having a psychotic break, she would not be able to get through it. The family member felt the facility was causing her behaviors and did not know how to deal with residents with mental health issues and were agitating her with the transfers back and forth from the facility to the hospitals. The family member stated the facility did not provide her any documentation about the transfers out in the past week. The family member stated, They cut me out of the loop .they should have discussed that [transfers/behaviors] with us to work with them. Residents Affected - Some An interview with Resident #1's primary RP on 09/12/23 at 2:48 PM revealed on 09/08/23, she got a call from the activity director to bring Resident #1 some cigarettes so she bought a carton and went to the facility the following day to deliver them (9/09/23). When the primary RP arrived, she was going to drop off the cigarettes because she was on her way to work and was using a rideshare service, however, the facility notified her that Resident #1 had attacked someone. The RP stated she told the facility staff that did not sound like Resident #1 and had they been messing with her medications? The RP stated, This is not the first time and we have discussed the same thing over and over, I said I am not POA and I can't make her take mediation, but let me tell you, when you mess with her medicine, she gets aggressive and she needs this medicine. The RP stated the facility had never informed her that Resident #1 had been refusing her medications for five days. She was frustrated because she felt the facility called her and the other RP often for minor issues, but they could not call and notify them she was refusing her medications. The family member wanted to know why the facility did not intervene when Resident #1 started to refuse her medications. The family member stated RN F was at the facility and told her he was in charge and they had already called the police. The RP stated, Why? Because you know she didn't take her meds and why didn't you send her to the hospital? She said RN F stated Resident #1 did not want to be transported in an ambulance. The RP stated she felt something was not right about the situation so she decided to stay and see what was going to happen because she felt the facility was trying to arrest Resident #1 and she was scared that because of her ethnicity and having mental illness, if Resident #1 ended up in jail, it would not fare well for her. When the police arrived, the RP told them Resident #1 needed to go to the hospital because she had been there the week before. The RP stated when she saw Resident #1 that day, she was crazy acting, saying she was someone else, saying she saw a man who was not there and people were sitting on her and was delusional. The RP felt the facility had a plan to dump Resident #1 because they were supposed to facilitate the transfer to the hospital, but they began talking privately and she overheard them say one place was full and that they were going to take her to an inpatient behavioral health facility. The RP went with the police and Resident #1 in the police car because she felt that something was not right. When they got to the inpatient behavioral health facility, the police dropped her and Resident #1 off and left. The intake coordinator refused to admit Resident #1 due to her having noted aggression and said they would not be able to force her to take her medications because it was only a behavior clinic. The RP then called the facility to notify them of the refused admission and was told by the front desk receptionist that Resident #1 could not come back and was not allowed back. The RP then called the local police to come and pick up Resident #1 and they called the facility who said she could not come back; the RP told the facility they had to accept her back. The RP then left from the inpatient behavior health facility via rideshare to go to work because she was late and assumed the police had transported Resident #1 back to the facility. An interview with the front desk receptionist on 09/14/23 at 12:15 PM revealed she worked over the weekend, including on 09/09/23. She stated she saw Resident #2 being taken out by EMT to the hospital and knew the police had been called and Resident #1 had been asked to leave the facility due to an incident between her and Resident #2. The front desk receptionist (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 52 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0742 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some stated she saw Resident #1 escorted out of the facility by the police and got into their vehicle along with her family member. She then stated after that, the family member called the facility and was stating the police transported Resident #1 to an inpatient behavioral health facility and they would not admit her. The front desk receptionist notified the ADM, and he said no, she [Resident #1] was not to be admitted back in. She could not remember what reason the ADM gave her for refusing to let Resident #1 come back but she thought it had to do with behavior issues. The front desk receptionist stated, I know the [family member] said the reason she needed to come back was because [behavioral facility] would not allow her in and she needed the incident report, I heard the police say it behind her. I said I did not have that .I called her back and said she cannot come back in. She said she could not take her home. I said I am sorry but she cannot come back here. Later in the day [time unknown], the front desk receptionist remembered seeing Resident #1 standing across the street at the apartments walking back and forth and no one was with her. During that same time, [Resident #2] was brought back to the facility by a female police officer while Resident #1 was still across the street. She said ADON A called the police because she knew Resident #1 was standing across the street. The front desk receptionist stated the staff did not bring Resident #1 back into the facility because from her understanding because she was no longer allowed in and that was what ADON A understood to be true as well. Once Resident #1 was back in the building, the female police officer went over to deal with Resident #1 but she did not see what happened. She stated, I looked back up later and they were gone. An interview with the ADM on 09/12/23 at 10:00 AM revealed Resident #1 had an incident a week prior where she was allegedly being rude to LVN I and another resident (Resident #3) told her not to be rude; Resident #1 then walked over and slapped him. ADM stated LVN I witnessed it. The ADM stated there were no injuries and his [Resident #3] was more of a bruised [NAME]. The ADM stated the police were called and Resident #1 was arrested, Problem is, when she got arrested, [Resident #3] wanted to press charges but they took [Resident #1] to [hospital] who notified the facility the next day they were sending her back. The ADM stated, I put up a fight and said less than 24 hours, you are sending her back? The ADM stated due to his refusal to accept her back into the facility, the hospital notified his boss at the corporate level and the ADM was then told that he had to accept Resident #1 back into the facility because she did not have any behaviors while she was at the hospital. The ADM stated Resident #1 did not have any behaviors when she came back from 09/06/23 through 09/09/23. The ADM stated on 09/09/23, another incident took place and according to Resident #2 (new roommate of Resident #1), she said Resident #1 punched her on her head, chest and back totally unprovoked. The ADM stated the information came from Resident #2's report to RN F, Which I am not sure how much I want to take at face value because of her dementia. The ADM stated he told RN F what to do because Resident #2 wanted to go to the hospital and came back the same day with no injuries. The police were notified for the alleged resident to resident altercation between Resident #1 and Resident #2 and they escorted Resident #1 from the facility. They took her to a behavioral health facility along with her family member but that facility declined to do an admission, so the facility told the family member she would need to be taken to the hospital because she was technically discharged from our facility .Now care was left onto police to direct what happened. The ADM stated the police left the family member and Resident #1 at the behavioral health facility and he was under the impression the family member transported her back to the facility because Resident #1 was seen by a staff member [name unknown] being dropped off across the street to the facility where there was an apartment complex [by unknown person]. The ADM stated the facility staff called the police on Resident #1 again and they sent a unit out, but before they arrived, he tried to talk to Resident #1 and she told (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 53 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0742 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some him she did not want to talk to him in a thousand years. The ADM stated when the fire department arrived first, Resident #1 refused to talk to them so they left and stated the police were on their way. The ADM stated he had to leave the facility and go back home. He stated ADON A called him and said the police showed up and Resident #1 started walking away, so they gave ADON A police report number and followed Resident #1. The ADM stated Resident #1 was discharged from the facility and they had tried to prevent the discharge by getting her seen for psyche services, not to discharge. He stated Resident #1 had never been sent out before the two incidents and there were no prior resident to resident altercations since her admission in 2021. He stated when she did have a behavioral episode in the facility, she would hit her head and make a grunting noise. The ADM stated the facility had not been able to find a good roommate fit for Resident #1 except for one female resident who she roomed with for a couple of days in the past two weeks before that roommate went out to the hospital. The ADM stated there was no witness for the resident to resident altercation between Resident #1 and #2 and both of them had a diagnosis of dementia. An interview with LVN I on 09/13/23 at 10:15 AM revealed she did not witness Resident #1 slap Resident #3, she only heard them yelling at each other. She was shocked to see them verbally fighting with each other and reported none of the staff seemed to be doing anything. LVN I stated Resident #3 was alert and oriented x 4 and he was saying all of the mean things. LVN I asked Resident #3 to stop and remember Resident #1 was still a lady and he said she slapped him. LVN I did not see her slap him and he was still yelling at Resident #1, cursing and saying 'hit me again knowing she was not in her right mind. LVN I stated Resident #3 had been upset prior to this incident when Resident #1 was moved down to his hall from upstairs and he had a vendetta with wanting her to move off his hall because she was not here all the way and made weird noises. LVN I stated Resident #3 did not like that the facility was moving people with mental illness issues onto his hall. LVN I stated Resident #1 was still wanting to try and hit Resident #3 but she and the other staff who arrived, including ADON A, separated them. LVN I stated she begged Resident #3 to stop egging Resident #1 on. She stated, He is known to instigate and pick at people. LVN O stated she called the police and told them there was an altercation between two residents. Resident #1 was sent out to Hospital PP after her shift was over and came back two days later and moved to the upstairs hall. Record review of Resident #1's discharge documentation from Hospital PP on 09/06/23 reflected she was seen due to aggressive behavior and had a mental health problem listed as the diagnosis. No other information was provided and no medication was changed or new treatments/recommendations ordered. Review of Resident #1's clinical record reflected no evidence the MHNP or MD were contacted when Resident #1 returned from [Hospital PP] on 09/06/23 to discuss possible behavioral interventions to prevent future aggressive episodes. An interview with RN F on 09/12/23 at 3:54 PM revealed he was the weekend supervisor on 09/09/23 from 7:00 AM until 11:00 PM and he was aware Resident #1 had been sent to the hospital the week prior due to an altercation where he thought she hit someone. RN F stated Resident #1 had been back at the facility for two days prior to the weekend on 09/09/23. When RN F got to work on Saturday 09/09/23, he was called to her room and told she had gone to the roommate's bed [Resident #2] and hit her on the back, chest and head and was following her down the hall. When RN F arrived, he went into their room and tried to evaluate Resident #1, who was laying in bed. He asked Resident #1 what happened and she was agitated and said, That white woman is not my momma and I need her out of this room-she is not my roommate! RN F stated it was hard to re-orient Resident #1 in that state and she had dementia and psyche issues. He stated psyche issues for Resident #1 meant she always paced the hallways, was very untidy, her hair was not made, her clothes were not tidy, she talked to herself and made (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 54 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0742 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some weird noises, declined care and scared other residents away. RN F stated after the incident, he called the police because Resident #2 wanted to file an allegation, I don't know what for, I don't know what she told the police. He stated Resident #1's family member happened to be at the facility but not present for the altercation and he explained the police had been contacted. RN F stated Resident #2 did not have any injuries but was tearful. RN F stated CNA N was the person who told him about the incident. He said he did not get into the details of what CNA N observed, but he did complete an incident report. RN F stated he knew Resident #1 was taken to a hospital in [adjacent city] somewhere and said the police or the family decided on where because he heard them talking. RN F stated he could not tell the police where to take Resident #1, but they did not end up going to [Hospital PP]. RN F stated the facility usually sent the residents to [Hospital PP] for psyche evaluations. RN F stated he did not know how Resident #1 ended up at the inpatient behavioral health facility. RN F stated he had called the doctor to get an order to transfer Resident #1 to the hospital, but the doctor could not give a specific order on where to take the resident. RN F stated, The [family member] and police decided to take her wherever they took her. RN F then clarified he spoke to NP D to notify about the transfer, not the MD. He said NP D told him to send Resident #1 out for a psyche evaluation. After that, RN F stated Resident #1 left the building and never came back that day or the following day. To his understanding, he stated Resident #1 went to the [Hospital PP] but he had no idea where the police took her and he did not follow up to find out. RN F stated the facility social worker normally followed up to see where a resident was placed and which hospital they were sent to, but there was no social worker over the weekend. A follow up interview with RN F on 09/16/23 at 5:08 PM revealed both Residents #1 and #2 had a diagnosis of dementia. RN F. stated Resident #2 was mellow, quiet and kept to herself. He stated Resident #1 could be loud and pace around and make scary sounds. RN F stated he was never notified on 09/09/23 that Resident #1 showed back up at the facility across the street by herself. He stated if he would have been told, he would have tried to bring her back into the facility. RN F stated, I don't want to abandon her, someone has to be responsible. No one asked me to help bring her back in. RN F stated he would have tried to talk to Resident #1 because she is still my patient and I have a responsibility to try and talk with her and see what happened. An interview with LVN O on 09/18/23 at 10:48 AM revealed she was the charge nurse on 09/09/23 when Resident #1 and Resident #2 had an alleged physical altercation but she did not see it. She stated no one saw it, but CNA N heard the commotion and what sounded like a hit/slap and some arguing and reported it to LVN O. LVN O went to their room to find Resident #1 in bed and Resident #2 was in the doorway. She and CNA N separated them and then she notified RN F who was the weekend supervisor and stated he would take care of it and write an incident report and next thing I know, the police show up. LVN O did not know where they sent Resident #1 and did not know she wound up back at the facility across the street by herself. LVN O stated no one came to get her to try and assist Resident #1 to come back in the facility. She stated, I could have taken another staff out with me and tried to get [Resident #1] to come in. But no one asked. An interview with ADON A on 09/12/23 at 4:29 PM revealed she was newly employed for about a month and had tried to intervene after an incident where Resident #1 slapped Resident #3 a week prior on 09/05/23. ADON A stated when trying to intervene, Resident #1 was gunning for me, she does this reaction like '[NAME]' (ADON A made hand motions by her ears to demonstrate), cursing, saying random things like [TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 55 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that in accordance with accepted professional standard and practices, medical records were accurately documented for one (Resident #5) of five residents reviewed for clinical records accuracy. The facility failed to document wound care orders on Resident #5's TAR. The facility failure could place residents at risk of inaccurate clinical records. Findings included: Record review of Resident #5's Face Sheet (undated) reflected she was a [AGE] year old woman admitted to the facility on [DATE]. Her active diagnoses included parastomal hernia with obstruction (a condition wherein abdominal contents, typically the bowel or greater omentum (a fold of peritoneum connecting the stomach with other abdominal organs), protrude through abdominal integuments surrounded by the hernia sac at the location of formed stoma). Record review of Resident #5's annual MDS assessment dated [DATE] reflected she rarely understood others and her BIMS score was a 03, which indicated severe cognitive impairment. Resident #5 had no behaviors, rejection of care or psychosis. Resident #5 required extensive assistance of one to two staff for her ADLs and used a wheelchair for ambulation. Resident #5 was always incontinent of bladder and bowel. Resident #5 was at risk for developing pressure ulcers/injuries but did not have a pressure ulcer/injury during the assessment period. Resident #5 did not have any other ulcers, wounds or skin problems or treatments. Record Review on 09/12/23 of Resident #5's care plan initiated 08/12/23 and last revised on 08/30/23 revealed no discussion of her wound and intervention(s) to be used. Review of Resident #5's Weekly Wound Progress Note dated 09/05/23 reflected she had one wound identified on 08/29/23 on the right side of her stoma with moderate red and thin exudate, no odor, with tissue granulation, surrounding skin was normal with clean and intact wound margins. The wound dimensions were 1.5cm x 1.5cm x 0.7cm and the wound had shown improvement. Physician's wound orders were to clean with normal saline, pat dry and apply calcium alginate every day and as needed. Review of Resident #5's Weekly Wound Progress Note dated 09/19/23 reflected she had an additional wound on her abdomen with moderate, thick exudate, with an odor present and granulation tissue. The dimensions of the wound were 1cm x 2cm x 0.5cm and the wound had shown improvement. The physician's wound orders from 08/29/23 were to clean with normal saline, pat dry and apply calcium alginate every day and as needed. Review of Resident #5's September 2023 TAR reflected no entry for wound care related to calcium alginate. There was only an order for ostomy care daily and every shift PRN. An interview with wound care LVN EE on 09/21/23 at 1:25 PM revealed wound care was typically done on her shift form 7AM-3PM when the charge nurse [LVN DD] did ostomy care. Wound Care LVN EE stated the wound was right next to Resident #5's stoma and since the resident got her ostomy bag changed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 56 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few daily, we do it at the same time. Wound Care LVN EE stated for wound care, while LVN DD emptied the ostomy bad and cleaned around the stoma, LVN EE cut a piece of calcium alginate, placed it on the wound and then they put the ostomy bag back in place. Wound Care LVN EE stated, To be honest, it is on the TAR consolidated as ostomy care, but we are going to split it [order] into two. She said the wound care was a separate order and not listed on the TAR, but she knew to do it once a day. She stated the wound doctor ordered the wound care treatment to be done daily with the ostomy care. Wound Care LVN EE stated it was important to ensure the physician's orders corresponded with the TAR because one was an order for ostomy care and one was an order for wound care. She stated if the orders were not separated and only ostomy care was on the TAR, then another nurse may not know Resident #5 needed daily wound care and the wound could get worse. LVN EE stated when the wound was first identified, the NP D was notified and gave an order to do Meta-Honey. She did not come out to see the wound but saw a photo. Then the wound started to look infected so that was when Wound Care LVN EE got the wound care doctor on board. The wound care doctor initially saw Resident #5 on 08/29/23 and that was when she discontinued the order for Meta-Honey and started Calcium Alginate which helped drain the infection from the wound. An interview with the DON on 09/21/23 at 1:46 PM revealed she did not know why the order for Resident #5's calcium alginate was not on the TAR but she was having the wound care nurse correct it and enter it on the TAR. The DON stated if other nurses were to provide any wound care to Resident #5, there would not be an order or a place on the TAR to show it was needed. She said thankfully, Resident #5's wound had not worsened. An interview with LVN DD on 09/21/23 at 3:00 PM revealed the wound care nurse was responsible for entering treatment orders from the wound care doctor into the online e-charting system. LVN DD stated she only did ostomy care where she changed the dressing once during her shift. She stated Wound Care LVN DD took care of Resident #5's wound at the same time. An interview with C-RN on 09/21/23 at 3:06 PM revealed she had just talked to the wound care nurse after investigator intervention about making sure to separate physician orders and they could not be combined with ostomy care. C-RN stated the Wound Care LVN EE told her the wound care doctor told her she could do it at the same time as the ostomy care was done. C-RN told her that was fine, but there had to be a separate order for it. C-RN stated the facility had a second wound care nurse who worked on the weekends. The C-RN felt that the weekend wound care nurse and weekday wound care nurse [LVN EE] did all the wound care treatments. C-RN stated if something happened and the two wound care nurses were not available to do the wound care, then no one would know what needed to be done since there was no orders or entry on Resident #5's TAR to show it needed to be completed. C-RN stated, We screwed up and that is a tag I will not argue with. Review of the facility policy titled, Wound Management, revised 06/2020, reflected, A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing. Procedure-I. Assessment-iii. Implement a wound treatment per physician's order. II. Wound Management .F. Per Attending Physician order, the Nursing Staff will initiate treatment and utilize interventions for pressure redistribution and wound management. Review of the facility policy titled, Completion and Correction from the facility's Medical Records Manual, revised June 2020, reflected, To ensure that medical records are complete and accurate . IV. Any person(s) making observations or rendering direct services to the resident will document in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 57 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0842 the record . XII. Documentation Content .C. Treatments, observations during treatments and effectiveness of treatments . 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: 455653 If continuation sheet Page 58 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0949 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide behavior health training consistent with the requirements and as determined by a facility assessment. Based on interview and record review, the facility failed to provide mandatory effective behavioral health training for six (ADON B, RN F, CNA Q, CNA R, LVN I, CNA U) of six facility staff hired since October 2022 for required training. The facility failed to ensure newly hired staff in the past year (since October 2022)- ADON B, RN F, CNA Q, CNA R, LVN I and CNA U completed behavioral health training upon hire as was listed as a training requirement in the facility's annual assessment. The facility failure could place residents at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being due to lack of staff training and knowledge in working with residents who have mental health issues. Findings included: Record review of the facility assessment provided by the ADM on 09/13/23 reflected it was updated and reviewed by the QAPI committee on 09/12/22 and reflected the facility would complete training upon hire, annually and PRN for Caring for Residents with Mental and Psychosocial Disorders. The facility assessment reflected they had 105 residents who required assistance with mental health/behavioral health needs. Record review of the facility's Staff Roster dated 09/12/2023 revealed the following hire dates for the staff: ADON B (hired 01/02/23), RN F (hired 07/10/23), CNA Q (hired 07/21/23), CNA R (hired 04/19/23), LVN I (hired 08/22/23) and CNA U (hired 03/17/23). Record review of the annual staff trainings from their respective hire dates through 09/18/23 reflected no evidence ADON B, RN F, CNA Q, CNA R, LVN I, CNA U completed mandatory Behavioral Health training. An interview with the DON on 09/13/23 at 12:38 PM revealed the facility completed monthly in-services that she and the ADM conducted. The DON stated the facility did not have an online educational system for the staff, it was the ADM and DON who used online information and presented it to the staff in person through in-services. The DON stated the in-service calendar of what staff needed to be trained on came from the Human Resources Department at the corporate level and different training topics were completed once a month as decided on by corporate. A follow up interview with the DON on 09/15/23 at 11:16 AM revealed she had been employed at the facility since the end of April 2023 and there was nothing she knew of that had been rolled out related mandatory behavioral health training since October 2022. The DON stated there was a behavior program training listed in their policies and procedures that was available for the staff to be trained on. When asked who would provide that training, the DON responded, Training would be done by me probably. The DON stated it was important for staff to be trained on residents with mental health/mental illness and related behaviors to know how to identify them and handle them. The DON stated in the community, people may not know how to respond to an individual with mental health issues and may think they are off their rockers and see them as a fight or flight response. The DON stated training for behavioral health helped staff know how to stay calm and respond to that person because sometimes it was the response of the staff that could escalate or de-escalate a situation. The DON stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 59 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0949 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff needed to be trained to know what to do if a behavior occurred, what medications were readily available to assist them and determining is a psyche referral would be warranted. An interview with the ADM on 09/13/23 at 3:36 PM revealed the facility did not complete behavioral health training for the staff as its own topic and it was tied into the Abuse/Neglect training and Resident to Resident Altercations trainings. He stated he in-serviced staff on the facility policies when he did Abuse/Neglect and Resident to Resident altercations. Record review of staff annual and PRN in-services and trainings from January 2023 through 09/13/23 reflected no staff training on behavioral health. A confidential interview on 09/14/23 revealed the facility completed in-services with the staff on the 25th of every month when they got paid, but there had never been in an in-service or staff training related to mental health, mental illness and behavioral health training related to their population. The individual stated no handouts were ever provided during those monthly trainings and there was no presentation of specific material. The individual stated it was basically the ADM talking about what to do and not do, then staff had to sign the signature sheet. The individual stated as far as a behavioral health training for residents with mental health issues, the facility staff needed training on it. The individual stated one of the ADONs had recently told the staff they were going to get the staff that training because the whole building was residents with behaviors. The individual stated, You got a big turnover with staff when they are not trained, there is a huge turnover. Also, the staff don't know to talk or communicate with that population and you need to know how to deal with them when a crisis occurs or else it would turn upside down. The individual stated he/she would like some training where staff sit around the table and talk about scenarios, like in nursing school. An interview with CNA R on 09/14/23 at 4:00 PM revealed she had worked at the facility for eight months and she had previous experience working with a patient with dementia, so when she interviewed, she stated that was the first thing the facility asked her. CNA R stated because of that, they didn't do much training because I had the training. An interview with CNA Q on 09/14/23 at 4:03 PM revealed she been employed at the facility for two months and she had very little training, but the facility had stated that if two residents started fighting, to pull the less aggressive person away from the aggressor. CNA Q stated when she started working at the facility, all her training experience came from prior jobs she had. A confidential interview on 09/17/23 revealed many of the nursing staff at the facility were misinformed on protocols relating to how to handle residents with behaviors and not using nursing judgment. The individual stated, This facility calls the police all the time, for everything, I have never been at a facility that uses the police so much. The staff here are not equipped to work with the population this facility takes in, I don't know why they take some of these residents, they were not equipped to deal with them. The individual stated he/she had seen some of the staff scared to interact or deal with residents who had mental health/mental illness issues and behaviors. The individual stated, I am afraid some of the staff will get hurt because they don't know what to do or intervene correctly. The individual stated the facility management was aware of the lack of training but nothing had been done about it. The individual stated, I don't think the staff here have been trained enough at all, they don't know what they are doing. The ADM was asked to provide a policy for required annual behavior health training on 09/13/23 at 3:36 PM. He stated he did not have one specific to that topic. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 60 of 61 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 455653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233 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 0949 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy In-Service Requirements (not dated) did not include a training related to behavioral health. Review of the facility's annual in-service training/checklist template for monthly trainings to be completed in 2023, reflected nothing related to behavioral health. Residents Affected - Some Review of the facility's policy titled, Behavior Management, revised June 20202, reflected, Purpose: To implement the most desirable and effective interventions to change, modify, decrease, or eliminate behaviors that are distressing to the resident and/or are decreasing or negatively impacting the resident's quality of life .The facility is responsible for providing behavioral health care and services that create an environment that promotes emotional and psychosocial well-being meet each resident's needs and include individualized approaches to care. Policy: The concept of behavior management is an interdisciplinary process. The key components of this process are: Identifying residents whose behaviors may pose a risk to self or others, Developing individual and practical care strategies based on assessed need, Implementing the behavior management program; and Ongoing assessment, monitoring, and evaluation of the effectiveness of the behavior management program including the effectiveness of the psychoactive drugs. The goal of any behavior management process is to maintain function and improve quality of life. The goal of the interdisciplinary team is to promptly identify behavior management issues and develop an effective management program. The facility must provide necessary behavioral health care and services which include Ensuring that the necessary care and services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice and safety; .Providing an environment and atmosphere that is conducive to mental and psychosocial well-being. The facility policy did not include any discussion of mandatory training that staff would have to complete upon hire, annually and PRN. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 61 of 61