Health inspection·November 16, 2023

F 0584 or concerns were then discussed during their morning meeting. Level of Harm - Minimal harm or potential for actual harm In an interview on 11/16/2023 at 7:53 PM, the Administrator was informed of the safety concerns noted in Rooms 701, 706, 709, and 711. He said he expected staff to log any maintenance concerns in the logbook for maintenance staff to repair. He said the concerns were a hazard to residents as they could fall off the toilet or hurt themselves on loose handrails and toilet paper holders. He said the ambassadors on the 700 halls were ADON B and the Housekeeping Supervisor. He said Management used a form, daily during rounding, to identify grooming, Abuse, or physical environment issues. He said the forms come to him daily and are also reviewed at morning management meetings. He said he expected all staff to identify and report any issues timely so maintenance can address them. Residents Affected - Some In an interview on 11/16/2023 at 8:53 PM, the Maintenance Supervisor stated the facility used ambassador rounds where management was assigned to halls and rounded daily then record any concerns to present to the administrator at morning meeting. He said they also used a logbook where staff were expected to record maintenance issues. He said he reviewed the book daily and throughout the day to ensure issues were fixed timely. He said he had not been aware of any of the issues observed in Rooms 701, 706, 709, or 711. In an interview on 11/16/2023 at 8:53 PM, ADON B stated she was one of the embassadors on 700 hall. She said ambassador rounds were done daily and concerns were discussed at the morning meetings. She said the rounds were meant to identify issues like call light and maintenance issues that could be a safety concern for residents. She said they also looked for room cleanliness, furniture condition, and resident hygiene. She said they were meant to ensure residents needs were met in a safe comfortable environment. When informed of the maintenance issues in Rooms 701, 706, 709, and 711, ADON B said she had not noticed them when she rounded. She stated all resindets had a right to live in a clean and save environment. She said loose toilet seats posed a safety [NAME] to the resindets as they could fall off the toilet. Record review of the Maintenance Log for October revealed and entry on 11/14/23 noting a bathroom handrail broken / loose in 711. The last entry previous to that was on 11/3/23. There were no entries related to lose toilet seats, toilet paper holders, or headboards. Record review of the Ambassador Round Worksheets, dated 11/2/23 through 11/13/23, completed for rooms on 700 Hall revealed no physical environment or safety issues on any room. Review of the facility's policy titled, Resident Rooms and Environment, dated 08, 2020, reflected, Purpose: To provide residents with a safe, clean, comfortable, and homelike environment. Policy: The Facility provides residents with a safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. This shall include ensuring that residents can receive care and services safely and that the physical layout of the Facility maximizes resident independence and does not pose a safety risk . Procedure: Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to the following: A. Cleanliness and order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 2 of 18 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 11/16/2023 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 comprehensive care plan that included measurable goals and objectives, and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #38) of 3 residents reviewed for comprehensive care plans. The facility failed to ensure Resident #38 had a person-centered care plan to include significant weight loss interventions. This failure could place resident at risk of not having needs identified and addressed. Findings included: Record review of Resident #38 MDS dated [DATE] revealed she is a 63- year-old female admitted to the facility on [DATE] with diagnosis of encephalopathy (a group of conditions that cause brain dysfunction), vascular dementia (general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain). unspecified Protein calorie malnutrition and Dysphagia of pharyngeal phase (swallowing difficulty). Resident # 38 required moderate assistance with eating and oral hygiene Resident #38 had a BIMS of 8 indicating she was moderately cognitively impaired. Record review of Resident #38 weight history revealed the following: 11/05/2023 110.6 pounds 10/05/2023 113.8 pounds 09/04/2023 118.2 pounds 08/14/2023 129.8 pounds On 08/14/2023, the resident weighed 129.8 pounds. On 09/04/2023, the resident weighed 118.2 pounds which is a -8.94 % Loss x 1 month which is categorized as severe weight loss. On 8/14/2023, the resident weighed 129.8 pounds. On 11/5/2023, the resident weight 110.6 pounds which is a - 14.7 % loss 3 months which is categorized as severe weight loss. Observation on 11/15/2023 at 1:06 PM revealed Resident #38 was in her room and Resident #38 had eaten about 50% of lunch tray. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 3 of 18 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 11/16/2023 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 Record Review of Physician order indicated that Resident #38 was started on Remeron (Mirtazapine) Oral Tablet 7.5 MG for Appetite Stimulant on 11/1/2023. Record review of Resident #38 care plan dated 9/16/2023 revealed: Focus: Resident #38 as noted significant weight loss in 30 days 09/08/2023; Goals: Resident #38 will consume ____50% ____75% ___100% two of three meals/day through the review date. Interventions: o Labs as ordered. Report results to physician and ensure dietician is aware. o Monitor and record food intake at each meal. o Notify the dietician of the weight loss upon their next visit o Notify the physician, resident, and family of the weight loss Interview with Dietitian, 11/15/2023 at 2:53 PM revealed that she received significant weight loss notification for Resident #38 in early September, after monthly weighs were done by the facility. Her interventions to mitigate the weight loss risk was to offer additional food items in addition to meals and added house supplement 4oz BID. The Dietitian reported that Resident #38 liked sandwiches. The Dietitian also revealed that Resident #38 height was 66 inches, her ideal body weight was 130 pounds, her current body weight was 110.6 pounds (11/5/2023) and her current BMI 17.8. She also stated that if dietary modification did not work for any resident; she recommended an appetite stimulant. She confirmed Resident # 38 was started on an appetite stimulant on November 1. The Dietitian also stated that she was not sure if facility policy for weekly weights for significant weight loss has changed, since they were in the process of changing the policy. She also stated a physician order was not needed for obtaining weekly weight. The Dietitian also stated that weekly weights plan for significant weight loss should be care planned, if used as a part of intervention and Nursing usually took care of Care Plans. She also revealed that weekly weight notification was sent to the Director of Rehab, ADON, DON, and MDS Coordinator. Interview with CNA D on 11/15/2023 3:12 PM reported that resident ate well, she had not seen any significant weight changes in Resident #38 for the past few months. CNA D reported she was not aware of Resident # 38's significant weight loss. Resident #38 usually only ate sandwiches for meals. She also reported Resident #38 refused staff to assist at meals. CNA D reported she was not in-charge of weighing her, usually it was done by a Restorative aid. Interview with LVN A on 11/15/2023 3:29 PM revealed that he was working in the facility since August 2023 and was familiar with Resident #38's care. LVN A had not seen any changes in Resident #38's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 4 of 18 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 11/16/2023 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 weight nor had seen any documentation for weight loss including person-specific care plan. He reported that if he had any resident with weight loss, he would offer them Supplement along with meals, as well as notify the physician and family. He also revealed that person centered care plans are important because if it was not care planned, staff will not know what interventions are put in place. He was not aware that Resident # 38 was on weekly weights and any intervention including weekly weight checks should be care planned. Interview with Restorative Aide/ CNA E on 11/15/2023 3:39 PM revealed that she was responsible for doing weekly checks and had weighed Resident #38 the morning of 11/15/2023. She had a log of weekly weights and shared the findings with the ADON and the DON. CNA E stated that she has been conducting weekly weights for Resident #38 since September 2023 and weight were documented in her weekly weight binder . CNA E stated that she was not aware if weekly weights for Resident #38 were care planned but stated that any interventions to mitigate significant weight loss should be person centered and care planned. Record Review of weight binder was not available for review. Interview with MDS RN on 11/15/2023 3:43 PM revealed that Care plan should be individualized, and person centered. Care plans are usually done after significant change in condition, change in medication, resident with new behaviors, significant weight loss or falls. The risk of not documenting care plans that are person centered can led to lapses in quality of care of the resident since resident will not receive appropriate care. Interview with MDS RN also revealed Care plan for significant weight loss was completed for Resident #38 in September 2023, however the interventions added to significant weight loss Care plan was not person centered. MDS RN revealed the Inter-Disciplinary team was responsible for developing the interventions for the residents. Interview with ADON A on 11/15/2023 3:56 PM revealed that restorative aide usually did the weekly weights. She reported that if they identified significant weight loss on any resident; as indicated on the weight log; they would inform the Dietitian, Physician, and resident's family members. She reported their interventions included: House supplement, liberalizing diets, bringing the resident to dining room, adjust food preferences, address any chewing issues, include weekly weight. She also reported that weekly weight should be care planned if that is used as intervention. She also revealed that not documenting care plans person-centered can lead to decline in quality of care for the resident since staff will not know what should be done for the resident. Interview with the DON on 11/16/23 10:28 AM revealed that there are three MDS Nurses that did care planning in the facility. Her expectation was care planned for each resident is completed on timely manner and should be resident centered. Care plan should be updated when there is a change in condition, new medication, infection, weight loss, fall, behavior. The risk of not care planning appropriately will affect Quality of care and Nursing staff will not know how to manage the resident appropriately. The DON stated that weekly weights was one of the interventions for significant weight loss as a part of facility protocol. Review of facility's policy Care Plans - Comprehensive revised December 2010 reflected, The IDT will revise the Comprehensive Care Plan as needed at the following intervals: A. as per RAI schedule B. As dictated by change in resident's condition . E. Other times as appropriate as necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 5 of 18 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 11/16/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 3 (Resident #22, Resident 162, and Resident #173) of 8 residents reviewed for ADLs. Residents Affected - Some The facility failed to ensure: 1Resident #22 had his fingernails trimmed. 2Resident #162 had his fingernails trimmed and cleaned. 3Resident #173 had his fingernails trimmed and cleaned. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1Review of Resident #22's Quarterly MDS assessment dated [DATE] reflected Resident #22 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses included quadriplegia (paralysis of all four limbs), and anxiety disorder. Resident #22 had a BIMS score of 014 which indicated Resident #22's cognition was intact. Resident#22 required extensive assistance of one-person physical assistance with dressing, and personal hygiene. Review of Resident #22's Comprehensive Care Plan, revised 05/26/23, reflected the following: Focus: Resident at risk for an ADL self-care performance deficit related to quadriplegia. Intervention: Personal hygiene: Requires one staff participation with personal hygiene and oral care. An observation and interview on 11/14/23 at 1:30 PM revealed Resident #22 was lying in his bed. The nails on both hands were approximately 0.4cm in length extending from the tip of his fingers. Resident #22 stated he did not like his nails long. He stated he did not tell anybody about his nails . 2Review of Resident 162's Quarterly MDS assessment, dated 10/03/2023, reflected Resident #162 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included dementia, lack of coordination, Parkinson's, and type 2 diabetes mellitus. Resident #162 BIMS score of 15 which indicated Resident #162's cognition was intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 6 of 18 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 11/16/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #162's Comprehensive Care Plan revised 11/10/23 reflected the following: Focus: ADL self-care performance deficit related to weakness. Interventions: Personal hygiene: Requires one staff participation with personal hygiene and oral care. Observation on 11/14/23 at 1:35 PM revealed Resident #162 was sitting in his wheelchair. The nails, on both hands, were discolored tan and the underside had dark brown colored residue. Fingernails were chipped on the left hand second and third fingers. Resident #162 stated he would ask the aide to help him clean his fingernails. 3Review of Resident #173's Comprehensive MDS assessment, dated 09/13/2023, reflected Resident #173 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included muscle weakness, lack of coordination, dementia, and diabetes mellitus. Resident #173 had a BIMS score of 08 which indicated Resident #173's cognition was moderately altered. Resident#173 required supervision assistance of one-person physical assistance with dressing, and personal hygiene. Review of Resident #173's Comprehensive Care Plan revised 09/27/23 reflected the following: Focus: resident#173 has an ADL self-care performance deficit related to weakness. Interventions: Personal hygiene: Requires one staff participation with personal hygiene and oral care. Observation and interview on 11/14/23 at 1:40 PM revealed Resident #173 was sitting on the edge of his bed. The nails on both hands were approximately 0.5cm in length extending from the tip of his fingers. The nails were discolored tan and the underside had dark brown colored residue. Resident #173 was unable to answer questions. Interview on 11/14/23 at 1:50 PM, CNA A stated CNAs were allowed to cut the residents' nails if they were not diabetic. CNA A stated she would trim Resident #22 fingernails. Interview on 11/14/23 at 1:56 PM, RN B stated CNAs were responsible to clean and trim residents' nails during the showers. RN B stated only nurses cut residents' nails if they were diabetic. RN B she had not noticed Resident #22's nails this morning. RN B stated the risk of having long nails would be potential for skin breakdown. Interview on 11/14/23 at 1:59 PM, CNA C stated CNAs were allowed to cut the residents' nails if they were not diabetic. CNA C stated she would check with the nurse if Resident #162 and Resident #173 were not diabetic. Interview on 11/14/23 at 2:02 PM, LVN D stated CNAs were responsible to clean and trim residents' nails during the showers. LVN D stated only nurses cut residents' nails if they were diabetic. LVN D stated nobody notified her about Resident #162 and Resident #173's fingernails and she had not noticed the nails herself. LVN D stated she would clean and trim their nails because both residents were diabetic. LVN D stated the risk would be potential for infection and skin integrity problem. Interview on 11/15/23 8:46 AM, the DON stated nail care should be completed as needed and every time aides wash the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated residents having long and dirty could be an infection control issue. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 7 of 18 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 11/16/2023 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 0677 The DON stated she was responsible to do routine rounds for monitoring. Level of Harm - Minimal harm or potential for actual harm On 11/16/23 ADL policy requested but it was not provided by facility administration prior to exit. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 8 of 18 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 11/16/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 1 (Resident #138) of 4 residents observed for medication administration and 3 medication cart (Nurses Cart 100/200 halls, Medication Aide Cart 400 hall, and Medication Aide Cart 600/800 halls) of 5 medication carts reviewed for pharmacy services in that: 1. The facility failed to ensure MA F administered medications for Resident #138 on time as ordered. 2. The facility failed to ensure medications in unsecure containers were immediately removed from stock. These failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving therapeutic effects from their medications as intended by the prescribing physician order. Findings Included: 1. Review of Resident #138's Face sheet, dated 11/15/23, reflected, he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Parkinson's disease, traumatic brain injury, and bipolar disorder. Review of Resident #138's MARs, dated November 2023, reflected: Lexapro 5 mg at 8:00 AM. Gabapentin 100mg at 8:00 AM. Folic Acid 1 mg at 8:00 AM. Thiamine 100 mg at 8:00 AM. Amantadine 100 mg at 9:00 AM and 6:00 PM. Ativan 1mg at 8:00 AM and 5:00 PM. Depakote 500mg at 8:00 AM and 5:00 PM. An interview with Resident #138 on 11/14/23 at 11:40 AM revealed he said he was upset because he did not receive his morning medications. He said some of the medications were seizure medications. An interview with MA F on 11/14/23 at 11:47 AM revealed she was preparing medications for Resident #138. She said his medications were late because she was asked to come in after another staff did not show up. She said medication pass should have been completed by 11:00 AM. MA F said the nurse was aware that the medications were administered late. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 9 of 18 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 11/16/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview with ADON M on 11/14/23 at 1:57 PM revealed Resident #138's morning medications were administered late on 11/14/23. He said there was a staff who called in and MA F was contacted to come in to work. He said the physician was notified and regarding the late medications. An interview on 11/16/23 at 10:54 AM with the DON revealed the morning medication pass was late on 11/14/23. She said a staff member did not show up for work. The ADONs were notified and when the DON was notified, she said she told the ADONs and treatment nurses to stop what they were doing and assist to pass medications. The DON said if there was a staff call-in, she expected administrative staff to stop and help pass medications. On 11/14/23, the medication pass did not start until 8:30 AM and medications were over an hour late. She said the morning medication pass ended sometime between 11:40 AM - 12:00 PM. She said there was a risk for residents who received their medications late based on the type of medication ordered. She said in this instance, the residents did not have any adverse effects. 2. An observation on 11/14/23 at 12:27 PM of the Nurses Cart Hall 100/200 revealed the blister pack for Resident #95's hydroco/APAP 10-325 mg (milligrams) tablet (controlled medication used for pain) had 2 blisters seal broken and the pills were still inside the broken blisters. In an interview on 11/14/23 at 12:30 PM, LVN D stated she was unaware when the blister pack seals were broken, and she was not aware of who might have damaged the blisters. She stated the risk of a damaged blister would be a potential for drug diversion. She stated the nurses and medication aides were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shift. She stated the count was done at shift change and the count was correct. She stated she did not see the broken blisters during the count. She stated when a broken seal was observed, two nurses should discard the medication. An observation on 11/14/23 at 12:37 PM of the Medication Aide Cart Hall 400 revealed the blister pack for Resident #84's tramadol 50 mg (milligrams) tablet (controlled medication used for pain) had 1 blister seal broken and the pill was still inside the broken blister. In an interview on 11/14/23 at 12:40 PM, MA E stated she was unaware when the blister pack seal was broken, and she was not aware of who might have damaged the blister. She stated the risk of a damaged blister would be a potential for drug diversion and infection control issue. She stated the nurses and medication aides were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shift. She stated the count was done at shift change and the count was correct. She stated she did not see the broken blisters during the count. She stated when a broken seal was observed, she would notify the nurse and two nurses should discard the medication. An observation on 11/14/23 at 1:01 PM of the Medication Aide Cart Hall 600/800 revealed the blister pack for Resident #57's lacosamide 100 mg (milligrams) tablet (controlled medication used for Seizures) had 1 blister seal broken and the pill was still inside the broken blister. The blister pack for Resident #138's lorazepam 1 mg tablet (controlled medication used for anxiety) had 1 blister seal broken and the pill was still inside the broken blister and taped over. In an interview on 11/14/23 at 1:05 PM, MA F stated she was unaware when the blister pack seals were broken, and she was not aware of who might have damaged the blisters. She stated the risk of a damaged blister would be a potential for drug diversion. She stated the nurses and medication aides were responsible to check the medication blister packs for broken seals during the count of narcotics (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 10 of 18 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 11/16/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some during the change of the shift. She stated the count was done at shift change and the count was correct. She stated she did not see the broken blisters during the count. She stated when a broken seal was observed, two nurses should discard the medication. Interview on 11/15/23 at 8:45 AM, the DON stated if a blister pack medication seal was broken the pill should be discarded. The DON stated it would not be acceptable to keep a pill in a blister pack that was opened. The DON stated the risk would be losing the medication because the seal was broken. She stated nurses were responsible for checking the medication blister packs for broken seals during the count on the change of shifts. The DON stated the ADON and the DON were supposed to check the carts randomly. Review of the Facility policy, Medication Administration, not dated, reflected: Medications may be administered one hour before or after the scheduled medication administration time . Record review of the facility's policy Storage of Medication, revised August 2020 reflected the following: . Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closure are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exists. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 11 of 18 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 11/16/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles on 1 medication cart (Nurses Cart Hall 900) of 5 medication carts observed for medication storage in that: Facility failed to ensure medication cart (Nurses Cart Hall 900) did not contain a bag of snack mixed with medication in the second drawer of the medication cart. This failure could place residents at risk of receiving contaminated medication. The findings include: During an observation and interview on 11/14/23 at 12:53 PM, in the medication cart in the second drawer of the cart was a snack bag (Simply Nature Raw almonds, Pecans and Pistachio Kernels), the net weight 8 ounces, the bag was halfway empty. LVN G stated she was responsible for the medication cart, she stated she was not aware of the snack bag in the medication cart, and she overlooked it this morning. LVN G stated food or drink should not be in the medication cart. She said the DON and ADON double checked the medication carts but was unsure how often. LVN G stated the risk was cross contamination of medications and supplies. During an interview on 11/15/23 at 8:45 AM, the DON stated the medication carts should be cleaned monthly and wiped down daily. She stated staff should not keep food or drinks on the medication carts. The DON stated the nurse using the cart was responsible for cleaning the medication cart. The DON stated the backup was herself and the ADON to double check the charts monthly for cleanliness. The DON stated the risk would be cross contamination for food left on the medication cart. The DON stated her expectation was for all the medication carts to be cleaned, no trash, loose pills, and no personal items including food or drinks left in the carts. Record review of facility's policy titled Storage of Medication, revised August 2020, reflected the following: . 9. Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperature and humidity FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 12 of 18 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 11/16/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation in that: 1. Facility failed to ensure missing tile floor was repaired in the dish room of kitchen. 2. Dietary Aide N and Dietary Aide O failed to practice appropriate hand hygiene when putting up clean dishes. These failures could place residents at risk for food contamination and food-borne illness. Findings included: Observation on 11/15/23 at 2:25 PM revealed the dish area of kitchen had 15 missing tiles under the sink in the dish area (left of dish machine) and 10 missing tiles on the floor to the right of the dish machine revealing water damage with yellowish/brownish stains on floor where the missing tiles were. Observation on 11/15/23 at 2:27 PM revealed Dietary Aide N touched his phone and then put up clean trays which just came out of the dish machine still dripping. He continued to stack clean wet trays with dripping water on top of trays. Dietary Aide N touched his hands on his clothes, did not wash his hands, and put up clean wet trays which were dripping with water. Observation on 11/15/23 at 2:30 PM revealed Dietary Aide O put dirty dishes into the dish machine, did not wash his hands, and grabbed the clean bowls putting them up on tray with other clean bowls. Interview on 11/15/23 at 2:36 PM with Dietary Aide N revealed he should have washed his hands before putting up the clean trays. He was not aware the trays needed to air dry before stacking them up. Interview on 11/15/23 at 2:37 PM with Dietary Aide O revealed he should have washed his hands before touching the clean dishes . Interview on 11/15/23 at 2:38 PM with Dietary Supervisor revealed dietary staff should have washed their hands when contaminated and before touching clean dishes . She stated the dietary aides N and O had not had a recent in-service on hand washing. She stated the floor tiles missing had been like this for at least a month. She stated Maintenance was aware of it but was not sure when it would be replaced. Interview on 11/15/23 at 2:39 PM with Corporate Dietitian revealed dietary staff not washing hands their hands properly could place dishes at risk for infection and cross contamination. She stated not allowing the dishes to air dry could place trays at risk of creating bacteria buildup when left wet. Interview on 11/15/23 at 3:08 PM with Maintenance Supervisor revealed he had been aware of floor tiles coming off in dish room since December and it had gotten worse. He stated the facility had not decided what to do about it. He stated when they put in new flooring it affected the drainage which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 13 of 18 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 11/16/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some caused the floor tiles to come off due to the water damage. He stated the facility had not had an estimate completed to see about replacing the floor tiles. Interview on 11/16/23 at 2:40 PM with Administrator revealed the facility would have the flooring fixed after Thanksgiving and could not get it scheduled until after the holidays. He stated the risk for the missing floor tiles in the dish area place employees at risk for falling. He stated the missing floor tiles place the kitchen at risk of infection. Review of facility's policy Hand Hygiene dated June 2020 reflected to ensure that all individuals use appropriate hand hygiene while at the facility. The Facility considers hand hygiene the primary means to prevent the spread of infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 14 of 18 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 11/16/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #86) of ten residents, six (200, 400, 500, 600, 700, and 800 Halls) of eight clean linen closets, and 2 of 4 medication carts reviewed for infection control. Residents Affected - Some 1. LVN H failed to change gloves and perform hand hygiene during wound care to Resident #86. 2. The facility failed to ensure clean linen closets were kept sanitary and free of personal care and clothing items. 3. The facility failed to ensure the Silent Night pill crushers were clean for 2 of 4 medication carts. These failures could place residents at risk of infection, slow wound healing, and or a decline in health. Findings included: 1. Review of Resident #86's Quarterly MDS assessment dated [DATE] reflected Resident #86 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included Respiratory failure (a condition when the lungs can't get enough oxygen into the blood), dementia, malnutrition, and difficulty in walking. Resident #86 had a BIMS score of 09 which indicated Resident #86's cognition was moderately impaired. Review of Resident #86's wound care orders reflected: as of 11/14/23 cleanse wound to right heel: cleanse with NS, pat dry, apply betadine gauze, and cover with dry dressing 3 times a week and as needed if soiled. Observation of wound care on 11/14/23 at 3:20 PM, LVN H placed supplies needed for wound care on a bedside table. Supplies included normal saline (NS), gauze squares, betadine, and dry dressing. The wound was located on Resident #86's right heel. LVN H donned clean gloves, she removed and discarded dirty wound dressing. Estimated size of the wound 2cm in length x 2.5 cm in width x 0.3 cm in depth, scant amount of drainage. LVN H without changing gloves, she cleaned the wound with NS. LVN H without changing gloves, she applied betadine gauze to the wound, and she covered with dry dressing. In an interview on 11/14/23 at 3:40 PM, LVN H stated she should change gloves and perform hand hygiene after she removed the old dressing and before and after she cleaned the wound with NS. LVN H stated she did not know why she was rushing. LVN H stated changing gloves and performing hand hygiene during wound care would prevent contamination of the wound which could cause the wound to get worse and cause the resident to be sick. In an interview on 11/16/2023 at 1:35 PM, the DON stated she expected, during wound care, the nurse to wash her hands and to put gloves. The DON stated the nurse, after she removed the old dressing, she should remove dirty gloves, perform hand hygiene, and don clean gloves. The DON stated the risk of not changing gloves and performing hand hygiene during the wound care would be cross (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 15 of 18 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 11/16/2023 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 0880 contamination of the wound. Level of Harm - Minimal harm or potential for actual harm 2. An observation and interview on 11/14/2023 at 11:45 AM, with Laundry Aide I at the clean linen closet on the 600 Hall revealed ceiling tiles water stained and hanging over the clean linen shelves. Linen was observed on the floor in the room. The Laundry Aide stated she was not sure why the ceiling in the room was falling down but it looked like there was a water leak. She said she had told Maintenance Assistant but did not record it in the logbook at the nurse's station. She said she did not recall when maintenance was informed. She said she usually told the maintenance staff about issues rather than log them in the maintenance log. She said the clean linen closets should be clean and linen should not be on the floor to minimize any infection control issues. Residents Affected - Some In an interview on 11/14/2023 at 11:55 PM, the Maintenance Assistant stated he knew about the water-stained ceiling tiles in the clean linen closets awhile ago but had not gotten around to repairing them. He said it looked like a water leak caused the stained tiles. Observations on 11/14/2023 at 2:00 PM of the clean linen closet on 500 Hall revealed a cardboard box of personal care items on the floor in front of the clean linen shelving. Clean linen on the shelving, in the clean linen closet, was hanging off the shelf and over the box and touching the floor. Bags of adult briefs were also observed both on the floor and on the shelves with the linens. An observation of the clean linen closet on 800 Hall revealed blankets and sheets on the floor. Adult briefs were observed on the bottom shelf along with linens. An observation and interview on 11/14/2023 at 3:04 PM, with CNA J of the clean linen closet on 700 Hall revealed the ceiling tile with brown water marks sagging over the linen shelves. A pile of used shoes was observed covering the entire floor of the room. CNA J stated she was not sure who placed the shoes in the clean linen closet or how long they had been there, but they were donated and given to residents who needed shoes. She said only clean linen should be in the closet to prevent cross-contamination and risk of infection. An observation and interview on 11/15/2023 at 8:00 AM, with RN B of the clean linen closet on the 200 Hall revealed sheets on the floor along with trash and socks. Bags of briefs were observed on the shelves with the linens. RN B said she was not sure if the socks were clean, but they should not be in the clean linen closet. She said briefs were stored in the closet for convenience. RN B stated only clean linen should be in the closet to prevent cross-contamination and ensure the clean linen was clean when used for residents. In an interview on 11/15/2023 at 8:10 AM, with ADON A and the Regional RN, they stated the clean linen closets should only have clean linen in them. All the other items found in the closets were an infection control issue and could cause cross-contamination. They said the Housekeeping Supervisor was responsible to train staff on linen processing and storage. They stated nursing staff were trainied in infection control and should know how to handle linens. An observation and interview on 11/15/2023 at 8:15 AM, with CNA K of the clean linen closet on the 400 Hall revealed socks and bags of briefs on the bottom shelf with linens. CNA K stated he usually worked on 100 Hall and often found wipes and briefs in the linen closets. He said he would remove them when he came across this because it was an infection control concern. In an interview on 11/15/2023 at 9:09 AM, when informed of the linen closet observations, the DON stated she expected only clean linen to be in the linen closets. She said she was not aware of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 16 of 18 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 11/16/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some water-stained ceilings in the linen closets, but nursing staff know to record any maintenance issues in the maintenance logbook at the nurse's station. She said any items stored in the clean linen closets posed a risk of cross-contamination and infection. In an interview on 11/15/2023 at 2:53 PM, the Housekeeping Supervisor said the linen closets were the responsibility of all staff. She said there should not be anything in the closets except clean linen to ensure infection control. She stated monitoring was not done formally but when laundry staff filled the linen closets they should check for cleanliness. She said she trained laundry staff about this but could not control what the CNAs did. In an interview on 11/16/2023 at 7:53 AM, the Administrator stated he expected that personal care supplies and clothing be stored separately from clean linens. He said only clean linens should be in the designated closets to minimize cross-contamination of the linens. He stated the facility did not have a monitoring system in place but all staff were responsible for this. 3. An observation and interview on 11/15/23 at 11:20 AM with LVN G for Medication Cart #1 revealed the Silent Knight pill crusher was rusty and dirty. LVN G said the pill crusher was supposed to be cleaned weekly, but because the pill crusher was rusted, she was going to get a replacement. An observation and interview on 11/15/23 at 11:32 AM with MA N for Medication Cart #2 revealed the Silent Knight pill crusher was dirty, stained, and rusty. MA N said the pill crusher was supposed to be cleaned once a week, but nothing she used to clean it worked. She said she would ask for a replacement and that the risk for using a dirty pill crusher was risk for infection. An interview on 11/16/23 at 11:09 AM with the DON revealed staff were supposed to clean the Silent Knight pill crushers weekly. She said her expectation was for staff to notify management if they needed a replacement pill crusher. She said the risk for using a dirty pill crusher was a risk for infection. Record review of the facility in-service, Silent Knight Pill Crusher, dated June 2020, reflected: Cleaning and Maintenance The Silent Knight is made entirely of non-rusting materials and may be cleaned regularly with a damp cloth. A facility approved disinfectant may also be used when indicated. Record review of facility's policy Dressings-Application and Technique, revised July 2020, reflected .II. Application of Dressing. A. Clean Technique . iii. [NAME] non-sterile gloves. iv. Prepare dressing items on the prepared work surface. v. Position resident for comfort. vi. Remove dressing and discard into plastic bag. viii. Remove and discard non-sterile disposable gloves in plastic bag at bedside. ix. Wash hands and reapply non-sterile gloves. Proceed with cleansing of wound. xii Remove and discard non-sterile disposable gloves in plastic bag at bedside. xiii. Wash hands and reapply non-sterile gloves. xv. Apply topical agents to wound as prescribed. xvi. Discard gloves. xvii. Affix the dressing in place. Record review of the facility's policy titled, Laundry-Supply & Storage, dated 08/2020 reflected, Purpose: To ensure that all laundry on premises is supplied and stored properly. Laundry areas should have at a minimum: A. Separate room for the storage of clean linen and soiled linen . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455653 If continuation sheet Page 17 of 18 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 11/16/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the facility's policy titled, Infection Prevention and Control Program, revised 07/2020 reflected, The ensure the Facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements. G. Linen: Transport and processing of used linen soiled with blood, body fluids, secretions, and excretions is handled in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and avoids transfer of microorganisms to other residents and environments. Event ID: Facility ID: 455653 If continuation sheet Page 18 of 18