Health inspection·September 19, 2025

F 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few involve blood in the urine (hematuria). The reason for the discharge reflected an incident with another resident causing bodily harm. The discharge effective date was 8/21/2025. Brief history for Resident #1 reflected an increase in unsafe behaviors towards residents. The course of treatment for Resident #1 reflected interventions of increased activities and time in a calming environment. The condition Resident #1 discharged reflected was good. Rehabilitative Potential for Resident #1 reflected fair. The follow-up and discharge medications (instructions to resident) revealed the following medications were sent home for Resident #1: Depakote ER Oral Tablet, Seroquel Calcium Carbonate Tablet Chewable 500 MG, Maalox Regular Strength Suspension Potassium Chloride ER Lasix Oral Tablet 20 MG, Multivitamin-Minerals Oral Tablet, Tylenol Extra Strength Oral Tablet 500 MG, Vitamin B12, Ergocalciferol Capsule 50000 UNIT, Zoloft Oral Tablet, Anoro Ellipta Inhalation Aerosol Powder Breath Eucerin, External Lotion Metformin Gentamicin Sulfate External Ointment 0.1 % Albuterol Sulfate HFA Inhalation Aerosol Solution. Resident #1 was discharged home with no home health. The list of reconciled medications sent with the representative reflected yes. How was the list of reconciled medication sent reflected verbal. Digitally signed by the physician. Record review of Resident #1's quarterly MDS assessment, dated 06/04/2025, revealed Resident #1 did not perform an interview for mental status due to the resident rarely/never understood. Resident #1's behavior revealed no exhibited physical behavioral symptoms directed toward others, no exhibited verbal behavioral symptoms director toward others and no exhibited other behavioral symptoms directed toward others. Record review of Resident #1's Care Plan, dated 02/21/2025, revealed Resident #1 would remain in the facility for long term as she required 24-hour licensed nursing care. Resident #1 required anti-psychotic and anticonvulsant medications for diagnoses of schizophrenia, psychosis, and bipolar disorder could show aggressive behavior during periods of frustration or agitation. Record review of Resident #1's referral from the hospital to Five Points at Highlands, dated 7/28/2023, revealed Resident #1's RP stated she could not care for Resident #1 any longer, and would need somewhere long-term, possibly with a secured unit to prevent Resident #1 from trying to leave. Record review of the NP progress note, dated 08/21/2025, revealed when the NP arrived on the secured unit and there were two officers conversing with the ADON and SW. Resident #1 was in the dining room with the sitter. Police informed staff that they cannot arrest Resident #1 due to her mental capacity, nor could they detain her with OPC because she was in a facility where she could receive medical care. Resident #1's RP was informed that Resident #1 was a danger to others and was receiving immediate discharge notice. The SW explained to Resident #1's RP that she could take Resident #1 to psych hospital, but the officers could not take her. The NP stated Resident #1's RP wanted police to take Resident #1 because she could not force Resident #1 to do anything. The NP encouraged her to call family members to assist her, Resident #1 had an immediate family member, but RP told NP that he will make things worse. Record review of the SW progress note, dated 8/22/2025, revealed the SW notified of the altercation between Resident #1 and another resident. SW contacted Resident #1's RP to notify her of the altercation and the order for immediate discharge. Resident #1's RP came to the facility to pick up Resident #1 and take her home with medication, a rollator, instructions, and community referrals for medical PCP and discharge from the facility. Record review of Resident #1's electronic health records from 8/21/2025 to 8/28/2025 revealed no documentation of request and/or referral for psych observation for Resident #1. Record review of Resident #1's electronic health records from 8/21/2025 to 8/28/2025 revealed no documentation that Resident #1's RP declined alternate placement for Resident #1. Record review of Resident #1's electronic health records from 8/21/2025 to 8/28/2025 revealed no documentation that Resident #1's RP received the facility Ombudsman's contact information to assist discharge to the community. Record review (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455895 If continuation sheet Page 2 of 7 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 455895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Five Points at Lake Highlands Nursing and Rehab 9009 White Rock Tr Dallas, TX 75238 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 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few of Resident #1's electronic health records from 8/21/2025 to 8/28/2025 revealed no documentation of verbal or written notice of intent to leave the facility. In a confidential staff interview on an undisclosed date, it was revealed that Resident #1's was not a safe discharge, and the RP could not properly care for Resident #1 because she had dementia, the resident was obese and had mood disorders and the RP was a small petite elderly woman who Resident #1 could potentially harm. During an interview on 8/28/2025 at 9:10 a.m., with the Administrator revealed there was an unwitnessed incident on the secured unit and when he and the SW notified Resident #1's RP to inform her they were going to send Resident #1 out to the hospital for behavior observation, the RP stated she would just pick Resident #1 up and take her home. The Administrator stated they conducted the discharge process for Resident #1 and the RP was provided with all Resident #1's medications, but her belongings were still in the facility due to the RP stating she could not fit them in the car. During an interview on 08/28/2025 at 09:39 a.m., with Resident #1's RP she revealed that she had received a phone call on 08/21/2025 from the facility SW who stated she had to pick up Resident #1 from the facility immediately because Resident #1 could no longer stay at the facility due to an unwitnessed incident that happened and she was being discharge immediately. The RP told the SW that she had nowhere to take Resident #1 and asked if she could get Resident #1 sent to another facility, because Resident #1 gave up her apartment when she admitted to the facility and would be homeless. She stated the SW insisted the RP pick up Resident #1. The RP stated when she arrived at the facility, they gave her some papers as she put Resident #1 in the car. The RP stated she would never have picked up Resident #1 voluntarily because the RP could not care for Resident #1 properly as Resident #1 required round-the-clock care and the RP stated she worked two part-time jobs. RP revealed Resident #1 never went to her home the RP took her to another family members home until she was able to obtain an order of protective custody and police arrested Resident #1 and took her to a psychiatric hospital. During an interview with the SW on 8/28/2025 at 12:45 p.m., the SW stated Resident #1 discharged on 8/21/2025. The SW stated she informed Resident #1's RP that she could refer Resident #1 to another facility, but Resident #1's RP declined and picked up Resident #1 and took Resident #1 home. The SW stated it was a safe discharge because she had attempted to offer to find placement for Resident #1, but it was declined verbally, and Resident #1 went home with a family member who was provided with referrals for community resources, a walker, and medications. In an interview on 8/28/2025 at 217 pm, with the Administrator revealed Resident #1's RP came and picked up Resident #1 that it was a safe discharge as the RP was responsible for making decisions for Resident #1 care. The Administrator stated if the RP could not take care of Resident #1 the RP would have elected someone who could. The Administrator stated that if the RP couldn't find Resident #1 placement at another facility, he would have to consult with his superiors on Resident #1's return to the facility as days had passed so Resident #1 would have to go through the referral process and start the admission process again. Record review of facility Discharge or Transfer policy dated 12/2017 revised 2/12/2025 under Resident Discharge to the Community states For resident who want to be discharged o the community, this nursing home must determine if appropriate and adequate supports are in place, including capacity and capability for the resident's caregivers home. Family members, significant others or the resident's representative should be involved in this determination, with the resident's permission, unless the resident is unable to participate in the discharge process. A referral to the Local Contact Agency may be appropriate for many individuals, who could be transitioned to a community setting of their choice. The nursing home staff is responsible for making referrals to the LCA, if appropriate, under the process that the State has established. Nursing home staff should also make the resident and if applicable, the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455895 If continuation sheet Page 3 of 7 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 455895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Five Points at Lake Highlands Nursing and Rehab 9009 White Rock Tr Dallas, TX 75238 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 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few representative, aware that the local ombudsman is available to provide information and assist with and traditions from the nursing home. For residents who have been in the facility for a longer time, it is still important to inquire, as needed, whether the resident would like to talk with LCA experts about returning to the community. If the resident is unable to communicate their preference or is unable to participate in discharge planning, the information should be obtained from the resident's representative. Discharge planning must include procedures for: -Documentation of referrals to local contact agencies, the local ombudsman, or other appropriate entities made for this purpose. -Documentation of the response to referrals; and -For residents for whom discharge to the community has been determined to not be feasible, the medical record must contain information about who made that decision and rational for that decision. Discharge planning must identify the discharge destination, and ensure it meets the resident's health and safety needs, as well as preferences. If a resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the facility must treat this situation similarly to refusal of care, and must: -Discuss with the resident, (and/or his or her representative, if applicable) and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location; -Document that other, more suitable, options of locations that are equipped to meet the needs of the resident were presented and discussed; -Document that despite being offered other options that could meet the resident's needs, the resident refused those other more appropriate settings; -Determine if a referral to Adult Protective Services or other state entity charged with investigating abuse and neglect is necessary. The referral should be made at the time of discharge. An Immediate Jeopardy was identified on 9/16/25 and the Administrator was notified of the Immediate Jeopardy on 9/16/25 at 6:28 p.m. and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The facility's POR for Immediate Jeopardy was accepted on 9/18/25 at 3:11 p.m. and reflected the following: . Interventions: 1. Resident #1 currently does not reside in the facility as of 8/21/25. The SW, and Administrator reached out to the RP of Resident #1 to discuss alternative placement due to increased behaviors. Resident #1's RP came to the facility to pick up the resident and take her home with medications, rollator, community resources for medical PCP. 2. All residents discharged in the past 30 days had their charts audited by the RCN, DON, and ADONs to ensure that all residents were discharged safely to their destination. 18 residents were discharged to the hospital. 3 residents discharged home. Initiated 9/16/25 and Completion Date 9/17/25. 3. The Administrator, DON, ADONs, and SWs were in-serviced 1:1 by ADO, RCN on 9/16/25 on the following topics. Initiated 9/16/25 and Completion Date 9/17/25. A. Discharge or Transfer to Another Facility Policy: New Process: Initiated 9/16/25 and Completion Date 9/17/25. In the future, if there is an emergency discharge scenario- all listed IDT members and PCP/MD will have a meeting to plan a safe discharge with all necessary community services. The charge nurses will report to DON and ADON if any part of the discharge process is overlooked or not completed. When a resident is discharged home, the following IDT members will perform the following: DON: Collaborate with IDT in the planning and ensure residents have all necessary post discharge providers in place for continuity of care. The DON's last day is 9/19/25. ADON A will be trained to follow the DON responsibilities on 9/17/25 and will resume the responsibilities for the discharge process on 9/19/25. ADONs: Family members will be educated on the care of the residents, including medications and psychology/psychiatry services to facilitate a safe discharge to a safe destination. The resident's attending physician and psych MD will be notified for the order and approval to discharge. ADONs A, B, and C are responsible for educating the PCP and psych services on upcoming discharges home as well as the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455895 If continuation sheet Page 4 of 7 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 455895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Five Points at Lake Highlands Nursing and Rehab 9009 White Rock Tr Dallas, TX 75238 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 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few community services for continuity of care. Social Workers: Ensure location and discharge address to Home Health Care if needed, order DME if needed. The SW will get in contact with resident and/or RP/family within 48 hours to ensure the resident is doing well and adjusting well in discharge location. The SW will document in Point Click Care ( PCC) in progress notes. The Administrator will check on all 48-hour discharge follow-ups during facility morning and end of day meetings on PCC. Administrator: Will ensure that every discharge has an IDT meeting completed and all providers for care are involved, and community resources are set up for discharge. The Administrator will ensure that all medications, DME and home health services are in place prior to discharge home. The SWs will document in PCC under progress notes the discharge location, post discharge services, home health services and caregiver support as needed. The Administrator is responsible for training the IDT on the discharge process and will check for every planned/unplanned discharge to ensure the process is followed for all discharges home by reviewing the documentation in PCC under progress notes and d/c summary. The Administrator will inquire about upcoming and unplanned discharges 5 days a week during morning facility and end-of-day meetings. The Administrator will report to the ADO weekly on the Operations Call for all home discharges. The ADO will audit all home discharges on PCC and verify with the facility IDT. Resident Rights Policy: All residents have the right to safely discharge with education provided for care, services, and medication. Behavioral Management Policy: Residents with behavioral or psychology diagnosis will have the appropriate care and services during admission and upon discharge. The SW will ensure that psychology services are in place when discharging a resident home. The MD was notified of the immediate jeopardy on 9/16/25 by the Administrator. An AD HOC (as needed) QAPI meeting was completed with interdisciplinary team which included the MD, Administrator, DON, Admissions, and BOM to discuss the citations and plan of removal. Initiated 9/16/25 and Completion Date 9/17/25. The Administrator/designee will test the IDT and charge nurses on the discharge process. Return demonstration via testing will need to be 100% prior to their shift. If 100% is not achieved- re-education will be provided until 100% compliance is achieved. Initiated 9/16/25 and Completion Date 9/17/25. Residents who have increased behaviors will be monitored every shift for safety by the nurse charge and will report daily to the DON and ADONs and notify the MD. There are 3 residents that are currently be monitored for behaviors (see attached). Training: ADON A will be responsible for educating and testing PRN and staff that are on vacation during this time period. ADON A will update the Administrator on the progress with education and testing 5 days a week until completed. Initiated 9/16/25 and Completion Date 9/17/25. For all immediate discharges: the Administrator will notify the Area Director of Operations prior to discharge. The ADO will verify the discharge process was followed correctly for a safe discharge. Initiated 9/18/25 and Completion Date 9/18/25. In-services: All charge nurses were in-serviced on the following topics by the Administrator, DON, ADONs. All nurses not present and PRN staff will be in-serviced prior to their next shift. All new hires will be in-serviced during facility orientation. All agency staff will be in-serviced prior to their assigned shift. Initiated 9/16/25 and Completion Date 9/17/25. Discharge or Transfer to Another Facility Policy: New Process: The charge nurse will educate the resident RP/family on medication review, count narcotics if any, and complete the DC summary in PCC at the time of discharge. The Charge Nurses will report to the DON and ADONs if any part of the discharge process is overlooked or not completed. Monitoring of the plan of removal included:Record review of facility in-services titled Behavior Management and documentation, Discharge Planning Process and Documentation, Discharge Planning Process policy, and Resident Rights, dated 9/16/25 though 9/18/25, reflected staff were educated by the Administrator, DON, and ADONs.Record review of a one-on-one in-service titled Resident Rights, dated 9/16/25, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455895 If continuation sheet Page 5 of 7 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 455895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Five Points at Lake Highlands Nursing and Rehab 9009 White Rock Tr Dallas, TX 75238 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 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few reflected 4 (Administrator, DON, and two Social Workers) staff were educated by the ADO. Record review of a one-on-one in-service titled Discharge Plannings Process and Documentation, dated 9/16/25, reflected 4 (Administrator, DON, and two Social Workers) staff were educated by the ADO.Record review of a one-on-one in-service titled Behavior Management and Documentation, dated 9/16/25, reflected 4 (Administrator, DON, and two Social Workers) staff were educated by the ADO. Record review of a one-on-one in-service titled Notify ADO of any Immediate Discharge, dated 9/18/25, reflected 4 (Administrator, DON, and two Social Workers) staff were educated by the ADO.Record review of 30-Day Discharges identified two additional residents had discharged from the facility Resident, Resident #2 left against medical advice and resident #3 discharged back home after five days of respite care. Record review of the Administrator, DON, ADONs, SWs and Charge Nurses test on discharge process reflected they had 100% accuracy. Record review of the AD HOC QA meeting held on 9/16/25 reflected the meeting consisted of Administrator, DON, MDS, Medical Director, and Business Office Manager.Record review of ,residents identified for monitoring for behaviors, Resident #4, Resident #5 and Resident #6's electronic health records from 9/18/25 to 9/19/25 reflected they were monitored for behaviors. Interview with the ADO on 9/18/23 at 3:15 p.m. He stated he trained the Administrator and DON on the notification to ADO of any immediate discharge. Additionally, re-trained the Administrator, DON, and SWs on the discharge planning process and documentation, resident rights, Behavior management and documentation. Verified via record review signed by the Administrator, DON and both social workers. Interview with Administrator on 9/18/25 at 3:30 p.m., the Administrator stated the ADO re-educated him on the discharge planning process and documentation, resident rights, behavior management and documentation and the ADO trained him on the notification to ADO of any immediate discharge Interview with the DON, on 9/18/25 at 3:45 p.m., the Administrator was asked, what was the facility's monitoring or oversight process for ensuring residents were discharged safely. He responded his plan was for this to be a continuous quality measure; that started with the IDT team which consist of the resident and/or their resident representative, medical director, social worker, nursing, therapy, DON and Administrator which will ensure the resident is prepared, educated and discharged safely. The medical director approved the discharge, the social worker ensured medical equipment was ordered, referrals were placed and community services were set up and documented in PCC, the follow up 48 hours post discharge to make sure discharge was smooth and document response in PCC. The ADONs and/or charge nurse would review and educate resident and/or resident representative on medication and document in PCC. The Administrator would ensure all discharge process were followed. To ensure each steps where completed the Administrator would review the documentation was completed in PCC. The Administrator stated that the steps were the same for an immediate discharge except he had to contact the ADO and inform him of the immediate discharged resident. During an interview on 9/18/25 at 5:00 pm with ADON A revealed that she had been trained by the DON on her duty to sit in fill in as interim DON in the IDT planning and ensure residents have all necessary post discharge providers in place for continuity of care. Verified via record review of Resident #5 who resided on the secured unit showed increased behaviors and charge nurses documented Resident #5 increased behaviors in PCC. Charge nurse contacted ADON A, ADON A contacted the MD, the MD put in a psych evaluation order, Resident #5 RP contacted and Resident #5 discharged to the hospital. Interviews held on 9/18/25 from 3:15 p.m., to 6:00 p.m., and 09/19/25 from 6:00 a.m., to 5:40p.m., which covered staff who work morning, day, night shifts, PRN staff and double weekend staff conducted with the Administrator, DON, ADON A (1st shift/weekdays), ADON B(1st shift/weekdays), ADON C (1st shift/weekdays), RN D (weekdays), RN E (PRN), RN F (overnight/morning), RN G (overnight/morning), RN H (double weekends), LVN I (Overnight), LVN J (morning), LVN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455895 If continuation sheet Page 6 of 7 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 455895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Five Points at Lake Highlands Nursing and Rehab 9009 White Rock Tr Dallas, TX 75238 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 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete K (overnight), LVN L (second shift), LVN M (double weekends) and SW N, SW O indicated they all participated in in-services on resident rights, discharge process and documentation and proficiency test prior to starting their shifts. All staff knew their responsibilities. All staff were knowledgeable, who were a part of the IDT. All staff were able to state that the facility's discharge process to ensure all residents' discharges were safe, all know what was required to be documented and who was responsible for each task and understand that the Administrator would oversee the entire process to make sure it was complete, and he would report any immediate discharges to the ADO. The Administrator was informed that the Immediate Jeopardy was removed on 9/18/2025 at 3:11 p.m. The facility remained out of compliance at a severity level of that was not Immediate Jeopardy and a scope of isolated, due to staff needing more time to monitor the effectiveness of the plan of removal for inappropriate discharge. Event ID: Facility ID: 455895 If continuation sheet Page 7 of 7