Health inspection·July 17, 2025

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. Number of residents sampled:0Number of residents cited:0Based 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 in the facility's only kitchen reviewed for food safety. The facility failed to ensure dented cans were placed in a separate storage area. The facility failed to ensure the ice machine was cleaned and free of mildew. These failures could place residents at risk for food-borne illness and cross contamination.Findings Included:Observation of the dry storage room on 07/15/2025 at 9:05am revealed the following:-1 6lbs can of peaches dated 06/19/2025 was dented on front left.Observation of the ice machine on 07/15/2025 at 9:20am revealed the following:-The machine inner guard had black build up along the top inner guard.-The ice machine cleaning log was not filled out for June 2025 or July 2025. In an interview with the DM on 07/15/2025 at 9:22am she stated she's been in her role for three weeks. She stated she was unsure who was responsible for cleaning the ice machine but she can find out who was responsible for cleaning the ice machine. She stated she was unsure the last time the ice machine was cleaned or the last education staff had on cleaning the ice machine. She stated she could find out who was responsible for cleaning the ice machine and assign staff to clean the machine. She stated the mildew on the ice machine's inner guard could make residents sick. She stated all staff was responsible for checking for dented cans and placing the dented can in the designated area for dented cans. She stated dented cans could have bacteria and the bacteria could cause food borne illness. In an interview with [NAME] A on 07/16/2025 at 11:36am he stated whatever staff unloaded the truck was responsible for checking shipment for dented cans. He stated all dented cans were stored in a separate area and returned to the vendor. He stated dented cans could have poison which could cause sickness to residents. He stated a different kitchen staff was assigned to clean the ice machine. He stated the ice machine was cleaned once a month and once cleaned staff would fill out the cleaning log. He stated he was unsure who or when the ice machine was last cleaned. He stated he's received training on cleaning the ice machine but could not recall the last training. He stated failing to clean the ice machine could cause mold and the mold could cause residents to become sick. Record review of the facility's Food Safety Policy 2012 reflected, Policy Statement: We will ensure all food purchased shall be wholesome and manufactured, processed, and prepared in compliance with all State, Federal, and local laws and regulations. Food shall be handled in a safe manner. 7. Dented or otherwise damaged cans will not be used, unless inspected by the dietary service manager and found not to be dented on the top or seam, and not perforated. Dented cans will be stored in a separate location and returned to the food vendor for credit. Record review of the facility's Cleaning of the Machine Policy 2012 reflected, Policy Statement: The ice machine shall be cleaned and sanitized according to manufacturer's instructions to maintain sanitary conditions in order to prevent food contamination and the growth of disease producing organisms and toxins. 5. Wipe down all food/ice contact surfaces with a sanitizer solution, per manufacturer instructions, DO NOT rinse. Record review of the facility's Receiving Policy revised February 2023 reflected, Policy Statement: Safe food handling procedures for time and temperature control will be practiced in the transportation, delivery, and subsequent storage of all food items. 4. All canned goods will be appropriately inspected for dents, rust or bulges. Damaged cans will be segregated and clearly identified for return to vendor or disposal, as appropriate. 5. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. Record review of the facility's Food Storage: Dry Goods, revised February 2023 reflected, Policy Statement: All dry goods will be appropriately stored in accordance with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455823 If continuation sheet Page 2 of 6 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 455823 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treemont Healthcare and Rehabilitation Center 5550 Harvest Hill Rd Dallas, TX 75230 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 FORM CMS-2567 (02/99) Previous Versions Obsolete FDA Food Code 5. All packaged and canned food items will be kept clean, dry, and properly sealed. Record review of the U.S. FDA Food Code 2022 reflected: Record review of the U.S. FDA Food Code 2022 reflected: Chapter 3 . FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. Section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. Event ID: Facility ID: 455823 If continuation sheet Page 3 of 6 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 455823 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treemont Healthcare and Rehabilitation Center 5550 Harvest Hill Rd Dallas, TX 75230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Resident #2, #13, and #46) of four residents observed for infection control in that: MA B failed to clean the scissors prior to or after usage during Resident #13's and 4[VT2] #46's medication pass. Placing the unclean scissors back on the medication cart after using them to open medication packages and to cut medication patches (Lidocaine patch for pain) in half. MA B failed to disinfect the blood pressure cuff, pulse oximeter (to measure oxygen), and the thermometer in between vital sign checks for Resident #2, Resident #13, and Resident #46. This failure could place residents at risk for spread of infection through cross-contamination. Findings included: Review of Resident #2's assessment MDS[VT3] assessment, dated 04/22/2025, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with the following diagnoses: hypertension (high blood pressure), peripheral vascular disease (poor blood circulation), and end stage renal failure (kidneys do not work well). Resident #2 BIMs[VT4] score of 6 indicated the resident had severe cognitive impairment and required assistance from one staff for activities of daily living. Review of Resident #2's the consolidated physician orders dated July 2025 reflected: order dated 05/08/2025, amlodipine (high blood pressure) tablet 5mg one tab by mouth two times a day, and coreg oral tablet (high blood pressure) 25mg give one tab two times a day. Further review revealed physician orders to check oxygen saturation, blood pressure, and temperature every shift. Review of Resident #13's quarterly MDS assessment, dated 06/18/2025, reflected she was a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: diabetes (high blood sugar) and Alzheimer's disease (confusion and poor memory). Resident #13 BIMs score of 9 indicated the resident had moderate cognitive impairment and required assistance from one staff for activities of daily living. Review of Resident #13 consolidated physician orders dated July 2025 reflected: order dated 04/25/2025, check Oxygen saturation every shift. Review of Resident #46's annual MDS assessment, dated 05/23/2025, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with the following diagnoses: Malnutrition (poor nutrition), and Alzheimer's disease (confusion and poor memory). Resident #46 BIMs score of 7 indicated the resident had severe cognitive impairment and required assistance from one staff for activities of daily living. Review of Resident #46 consolidated physician orders dated July 2025 reflected: order dated 01/03/2025, check oxygen saturation every shift. Further review revealed order dated 01/03/2025, monitor and record vital signs twice daily on day and evening shift. Observation on 07/16/2025 at 8:00 a.m. revealed MA B during medication pass went to the medication cart and started preparing to perform medication administration for Resident #13. MA B took the pulse oximeter (to measure oxygen saturation level) to check her oxygen level. MA B did not clean the machine prior to or after using on Resident #13, with Sani Wipes. MA B did use hand gel on his hands prior to collecting supplies. The MA B took the generic Lidocaine Patch from the medication cart, took scissors out of the drawer, without cleaning the scissors cutting off the top of the package. The MA took the scissors without cleaning put on his gloves and cut the generic lidocaine patch into two pieces. MA B stated one for Resident #13's knee and the other patch for her back. MA B took the scissors placed them back into the medication cart without cleaning them. MA B gathered his patches and entered Resident #13's room. MA B placed the patches on the two different areas of Resident #13. MA B left the room went back to the cart removed his gloves, used hand sanitizer documented on the resident's clinical record and began to prepare for the next medication pass. Observation on 07/16/2025 Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455823 If continuation sheet Page 4 of 6 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 455823 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treemont Healthcare and Rehabilitation Center 5550 Harvest Hill Rd Dallas, TX 75230 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 at 8:30 a.m. revealed MA B during medication pass went to the medication cart and started preparing to perform medication administration for Resident #46. MA B took the pulse oximeter (to measure oxygen saturation level) to check her oxygen level, the blood pressure cuff to check her blood pressure and the electronic thermometer to check her temperature. MA B did not clean the machines prior to or after using on Resident #46. MA B did use hand gel on his hands prior to collecting supplies. The MA B took the generic Lidocaine Patch from the medication cart, took scissors out of the drawer, without cleaning the scissors cutting off the top of the package. The MA took the scissors without cleaning put on his gloves and cut the generic lidocaine patch into two pieces. MA B stated one for Resident #46's knee and the other patch for her back. MA B took the scissors placed them back into the medication cart without cleaning them. MA B gathered his patches and entered Resident #46's room. MA B placed the patches on the two different areas of Resident #46. MA B left the room went back to the cart removed his gloves, used hand sanitizer documented on the resident's clinical record and began to prepare for the next medication pass. Observation on 07/16/2025 at 9:15 a.m. revealed MA B during medication pass went to the medication cart and started preparing to perform medication administration for Resident #2. MA B took the pulse oximeter (to measure oxygen saturation level) to check his oxygen level, the blood pressure cuff to check his blood pressure and the skin touch electronic thermometer to check his temperature.[VT5] MA B did not clean the machines prior to or after using on Resident #46. MA B did use hand gel on his hands prior to collecting supplies. The MA B placed on gloves entered the room and took Resident #2's vital signs. MA B came out of the room with the equipment (for checking vital signs) and placed the equipment back on top of the medication cart not cleaning the equipment with any Sani-wipes. MA B left the room went back to the cart removed his gloves, used hand sanitizer documented on the resident's clinical record and begin to prepare for the resident's medications. In an interview on 07/16/2025 at 9:30 a.m., MA B stated he was to clean all equipment that was used before and after use on each resident, to prevent the spread of infection. MA B stated the scissors he thought since they were used to only open and cut the medication patch, they did not have to be cleaned after each usage. In an interview on 07/16/2025 at 11:30 a.m., the ADON C stated the expectation was for the staff to clean all equipment used prior to using on residents and after using on residents. That included all direct care equipment, which included scissors. The ADON C stated she would have to complete more infection control in-serves for equipment cleaning in between residents, she had just completed an in-service on infection control recently with MA B, because he was new. The ADON stated the risk in not cleaning the scissors would be cross contamination. In an interview on 07/16/2025 at 1:15 p.m. with interim DON revealed all direct care staff must clean equipment, including blood pressure cuffs, pulse oximeter, thermometer, and scissors after having contact with each resident. The interim DON stated they have Sani wipes available on all medication and treatment carts. The interim DON stated if the staff was not cleaning the equipment appropriately this could spread germs to themselves and the residents. Review of the in-services given in the past three months reflected an in-service dated June10th, 2025, for infection control and cleaning of equipment. MA B had attended the meeting. Review of the facility's policy Infection Control Plan dated March 2023, reflected, The facility has established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection . ensure that reusable equipment is appropriately cleaned, disinfected, or reprocessed . 6. Resident care equipment. 3. Non-invasive resident care equipment is cleaned . as need between use. all reusable items and equipment requiring special cleaning, disinfection . shall be cleaned in accordance with our current procedures governing the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455823 If continuation sheet Page 5 of 6 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 455823 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treemont Healthcare and Rehabilitation Center 5550 Harvest Hill Rd Dallas, TX 75230 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 cleaning. Facility [NAME], [NAME] (27070) - Infection Control 07/16/2025 12:59 PM During the morning medication pass this morning at 8:45 am MA Omachi did not clean the scissors after using them to open a package of Thrama care patch for Resident [NAME], MariaThen at 8:55 am MA Omachi used the same scissors after using them on Resident [NAME] took them out of the drawer and used them to open another package of Terma Care patches for Resident Elde [NAME] to place on her knee and back, he also cut the patch in half to use on the two separate areas. did not clean placing them back int he cart. during the medication pass the MA Omachi used the B/P pressure cuff the O2 pulsometer & the thermometer (touching to the face) of Residents [NAME], [NAME], & Resident [NAME] without cleaning the equipment in between usage. During an interview the MA Omachi stated that he did not think to clean all the equipment. he did know if the equipment was not clean then it could cause the spread of infection. Event ID: Facility ID: 455823 If continuation sheet Page 6 of 6