Health inspection·January 18, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm the wheelchair belonged to. CNA A looked in 2 resident rooms near where the wheelchair was and shook his head no indicating the wheelchair did not belong to the residents in those rooms. At 8:55 AM when CNA A walked near the Maintenance Director, he stated he did not know who the wheelchair belonged to and he did not know who had placed it there. The Maintenance Director stated an unlocked wheelchair in the hallway was a risk because a resident could try to sit in it and could fall or get hurt. Residents Affected - Some In an interview and observation with CNA B on 1/18/24 at 10:49 AM she stated she was the restorative aide and helped with patient transfers. CNA B stated the Hoyer lift should be placed in the shower room after use or it could be in the hallway if it was locked. When asked of the Hoyer lift next to her was locked she stepped over and said it was not locked and proceeded to lock it with her foot. CNA B stated the risk of having unlocked equipment in the hallway was residents could trip or fall. In an interview with RN C on 1/18/24 at 11:43 AM she stated the risk of having all those items in the hallway was posing an unnecessary risk to the residents. She stated residents could run into or bump into them and get hurt. RN C stated that the Administrator said that the Hoyer lifts needed to be in the shower room and not on the halls. In an interview with the ADM on 1/18/24 at 2:17 PM she stated the Hoyer lifts needed to stay in the shower room. She stated the hallways needed to be kept clear of anything that could be a hazard or cause a potential hazard to residents. TheADM stated they started in-servicing the staff and would continue to do so. A record review of the facility's policy titled Investigation of Incidents and Accidents, dated 12/3/20, reflected, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk (s). 3. Implementing interventions to reduce hazard(s) and risk(s) 'Hazards' refers to elements of the resident environment that have the potential to cause injury or illness All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the resident environment and the risk of a resident having an avoidable accident . A record review of the facility's undated policy titled Hydraulic Lift (Hoyer Lift), reflected, .18. Return lift to designated area when not in use. A record review of the facility's policy titled, Care, Cleaning and Storage of Equipment, revised 2/13/22, reflected, It is the policy that resident equipment be cared for, cleaned and properly stored to ensure safety and infection prevention Clean equipment is stored in clean utility room, central supply, or designated location established by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455996 If continuation sheet Page 2 of 9 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 455996 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Renaissance at Kessler Park 2428 Bahama Dr Dallas, TX 75211 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice the comprehensive person-centered care plan and the resident's choices for 1 of 4 residents (Resident # 2) reviewed for quality of care. Residents Affected - Few The facility failed to follow physician orders concerning a non-pressure wound of the left, lower medial (situated in the middle) buttock for Resident # 2. This failure could place residents at risk of delayed treatment of injuries, worsening of injuries, pain and infection. Findings Included: Record review of Resident # 2's admission Record dated 1/18/24 revealed, a [AGE] year-old male who admitted to the facility on [DATE] and had diagnoses which included stage 3 pressure ulcer of the sacral (located at the base of the spine) region, chronic pain, and non-pressure chronic ulcer of skin of other sites with unspecified severity. Record review of Resident # 2's Quarterly MDS dated [DATE] revealed a BIMS score of 11 which indicated moderate cognitive impairment, he was dependent or substantial assistance was needed for transfers, received scheduled pain regimen, had unhealed pressure ulcers and was at risk for developing pressure ulcers, and received applications of ointments/medications for skin and ulcer injuries. Record review of Resident # 2's Care Plan, undated, revealed, Resident has the potential for the development of a pressure ulcer, and interventions included, Check frequently for wetness and soiling, every two hours and provide incontinence care as needed, and Provide wound care per physician's order. Keep dressing clean, dry, and intact. Replace the dressing as needed for soiling. Another intervention listed was, Weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas, and other changes in skin integrity. Report new conditions to the physician. Record review of Resident # 2's wound evaluation dated 1/4/24 written by the wound doctor revealed the resident had a non-pressure wound of the right medial knee with recommendation for collagen sheet and anasept gel, and a non-pressure wound of the left, lower, medial buttock that was >1 days in duration with recommendation for calcium alginate to be applied once daily for 30 days. Record review of Resident # 2's wound evaluation dated 1/11/24 written by the wound doctor revealed the resident's non pressure wound of the left, lower, medial buttock had, improved evidenced by decreased surface area, decreased necrotic tissue. Record review of Resident # 2's January 2024 MAR dated 1/17/24 revealed an order with a start date of 1/2/24 which reflected TAO to abrasion to left lower butt cheek daily until seen by wound care MD. The MAR reflected no documented evidence it was completed on 1/3/24, 1/4/24, 1/5/24, and 1/8/24. The MAR also revealed an order to Cleanse Lt. Lower buttocks with NS/wound cleanser pat dry apply calcium alginate cover with dry dressing daily was initiated on 1/9/24. Record review of Resident # 2's Progress Note dated 1/4/24 at 6:35 PM written by LVN E revealed, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455996 If continuation sheet Page 3 of 9 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 455996 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Renaissance at Kessler Park 2428 Bahama Dr Dallas, TX 75211 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Wound care Dr [name] visiting. New order cleanse rt. Medial knee with ns/or wound cleanser pat dry apply. Collagen sheet and Anasept gel, cover with dry dressing 3 times weekly. Resident's [family member] visiting. She spoke with wound care Dr. and wound care nurse concerning [Resident # 2's] care. She states that she understands [Resident #2's] condition and the non-complaint of his wound to the coccyx [(small triangular bone forming the lower portion of the spinal column)]. Dr [name] educated wound is a stage four and that it was very bad. However, we were doing our best treat the wound to ensure its improvement. MD notified. Will continue to monitor and treat. In an interview with LVN D on 1/18/24 at 12:29 PM she stated either she or the wound nurse completed the order for the topical antibiotic ointment for Resident # 2. When LVN D reviewed the MAR and saw the missed days of documentation for the application of the antibiotic, she stated she was not sure why it was not showing as having been done. LVN D stated they had been applying the ointment to Resident # 2's bottom. LVN D stated she would go ask her supervisor why it looked like that on the TAR because based on the documentation it appeared like the treatment was not done. LVN D stated they had been taking care of that. In an interview with LVN D on 1/18/24 at 12:49 PM she stated the wound nurse LVN E did not have the order for the antibiotic treatment on her TAR, and that it was only showing up on the nurse MAR. LVN D stated that LVN E told her to discontinue the order for the antibiotic ointment because they were not doing that for the resident. LVN D clarified her statement from earlier interview explaining that she thought that she was being asked about the barrier cream earlier and not the antibiotic ointment. LVN D stated that LVN E put the barrier cream on for Resident # 2 daily, however the antibiotic ointment was not what LNV D or LVN E had applied to Resident # 2's bottom. In an interview with LVN E on 1/18/24 at 12:55 PM she stated Resident # 2 should not have an order for topical antibiotic ointment as it was the charge nurse who put that order in and when the wound doctor came on 1/4/24 the doctor ordered calcium alginate for that area. LVN E reviewed her progress note from 1/4/24 for Resident # 2 and realized that she did not include the non-pressure wound of the left, lower medial buttock and only included and started a new order for another area the wound doctor had recommended that day as well. LVN E stated the wound doctor recommended calcium alginate for the non-pressure area on 1-4-24 but somehow she missed that. LVN E stated she did put the order in for the calcium alginate to the non-pressure area on 1-9-24 and had been doing that daily since then. In an interview with RN C and the ADM on 1/18/24 at 2:11 PM, RN C stated the expectation was for nurses to complete orders as prescribed by the physician, to document and to reconcile the orders as needed. RN C stated once orders were received from the wound care physician, they were to be transcribed into the MAR so that they could begin following it right away. RN C stated the risk of not implementing the wound doctor's orders right away was worsening, deterioration and infection. Record review of the facility policy titled Medication- Treatment Administration and Documentation Guidelines reviewed 2/10/20 revealed, 4. Administer the medication according to the physician order. 5. Document initials and/or signature for medications and treatments administered on the MAR or TAR immediately following administration. Record review of the facility policy titled, Following Physician Orders dated 9/28/21 revealed, For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: a. Document the order by entering the order and the time, date, and signature on the physician order sheet. B. Follow facility procedures for verbal or telephone orders including noting the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455996 If continuation sheet Page 4 of 9 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 455996 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Renaissance at Kessler Park 2428 Bahama Dr Dallas, TX 75211 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 0684 order, submitting to pharmacy, and transcribing to medication or treatment administration record. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455996 If continuation sheet Page 5 of 9 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 455996 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Renaissance at Kessler Park 2428 Bahama Dr Dallas, TX 75211 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 15 residents (Resident # 3 and Resident # 4) reviewed for wounds. Residents Affected - Few The facility failed to ensure treatment and documentation of pressure ulcers for Resident # 3 and # 4 and failed to ensure orders from the hospital were correct and accurate for Resident # 4's pressure ulcers upon readmission. This failure could affect the residents, who received pressure ulcer care, by placing them at risk of unnecessary infection and worsening of pressure ulcers. Findings included: 1. Record review of Resident # 3's admission Record dated 1/18/24 revealed, a [AGE] year-old male who admitted to the facility on [DATE] and had diagnoses of major depressive disorder, stage 4 pressure ulcer of sacral (located at the base of the spine) region, stage 3 pressure ulcer of left buttock, stage 4 pressure ulcer of right heel, stage 4 pressure ulcer of other site, unstageable pressure ulcer of sacral region, generalized muscle weakness and paraplegia (paralysis of the legs and lower body typically caused by spinal injury or disease). Record review of Resident # 3's Quarterly MDS dated [DATE] revealed a BIMS score of 14 which indicated intact cognition, he had unhealed pressure areas (all of which were present upon admission), was at risk for developing pressure areas, and his skin and ulcer treatments included a pressure reducing chair and bed, pressure ulcer care and applications of ointments/medications. Record review of Resident # 3's Care Plan, undated, revealed, Resident has a pressure ulcer and is at risk for infection, pain, and a decline in functional abilities, and interventions included but were not limited to Provide wound care per physician's order. Keep dressing clean, dry, and intact. Replace the dressing as needed for soiling, and Low air loss mattress. Record review of Resident # 3's January 2024 MAR dated 1/17/24 revealed an order with a start date of 8/8/23 which reflected Suprapubic [(above the pubis)] Site- Perform Site Care and dressing change to site. Every night shift for Prophylaxis [(to prevent disease)]. There was no documented evidence the order was completed on 1/13/24. Resident # 3 had an order with a start date of 11/7/23 that reflected, Scrotum [(male reproductive structure under the penis)] Pressure Wound Cleanse with NSS or Wound Cleanser; Pat Dry with gauze; Apply Collagen sheet Calcium Alginate with silver. Cover dry dressing daily. every day shift for Wound Healing and PRN. There was no documented evidence the order was completed on 1/1/24, 1/2/24, 1/3/24, 1/6/24 and 1/7/24. Record review of Resident # 3's wound evaluation dated 1/11/24 written by the wound doctor revealed the wound progress on his stage 4 pressure wound to scrotum was not at goal. In an interview with Resident # 3 on 1/17/24 at 1:15 PM he revealed the staff had not been doing his wound care consistently. Resident # 3 stated his wound care was performed the night prior however he had missed 3 days before last night. Resident # 3 said there was a day where the nurse was about (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455996 If continuation sheet Page 6 of 9 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 455996 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Renaissance at Kessler Park 2428 Bahama Dr Dallas, TX 75211 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 0686 Level of Harm - Minimal harm or potential for actual harm to do the wound care but she left at 2pm and told him the next shift nurse would do it but that person never came. He stated even prior to the bad weather, his wound care was inconsistent. He stated sometimes they did not have the supplies. He stated sometimes the doctor ordered one thing and the facility chose to do another. He stated, They know the wound is supposed to be done but if I don't say anything they will not say anything. Residents Affected - Few In a telephone interview with LVN G on 1/18/24 at 12:10 PM she stated she worked at the facility on the 6th and 7th of January which were weekend days. She stated if there was a hole on the MAR it meant the order was probably skipped, missed or wasn't clicked off. LVN G stated she was not sure why the wound treatment was not signed off on the 6th and 7th of January 2024 For Resident # 3. LVN G stated it was kind of hectic on the weekends, the wound nurse did not work on weekends so they did what they could. LVN G stated sometimes the weekend supervisor would do treatments for her and perhaps that person forgot to click it off as completed. LVN G stated maybe Resident # 3 was not in the facility on those days. LVN G could not recall. LVN G stated if it was not documented it meant it was not done. In an interview with the Wound Doctor on 1/18/24 at 12:35 PM during wound assessment and treatment she conducted for Resident # 3. She stated that his wounds were improving. 2. Record review of Resident # 4's admission Record dated 1/18/24 revealed a 48- year-old male admitted [DATE] with original admit date of 9/12/23. His diagnoses included bipolar disorder, muscle weakness and major depressive disorder. Record review of Resident #4's Discharge MDS dated [DATE] revealed he discharged to an acute hospital with an acute change in mental status and had 2 stage 4 pressure ulcers which had been present on admission. The BIMS score was not assessed on this MDS. Record review of Resident # 4's Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated intact cognition. Record review of Resident # 4's Care Plan, undated, revealed, Resident has a pressure ulcer and is at risk for infection, pain, and a decline in functional abilities. Stage 4 to Left ischium [(the curved bone forming the base of each half of the pelvis)]& lower coccyx [(small triangular bone forming the lower portion of the spinal column)]. Unstageable to scrotum. Interventions included but were not limited to, Provide wound care per physician's order. Keep dressing clean, dry, and intact. Replace the dressing as needed for soiling, Pressure relieving/reducing devices on bed/chair, and Provide incontinent care as needed. Record review of Resident # 4's January 2024 MAR dated 1/17/24 revealed an order with a start date of 1/7/24 which reflected Mupirocin External Ointment 2 % (Mupirocin) Apply to left ischium topically in the morning for wound Cleanse with N. S. pat dry, apply ointment, apply collagen powder, apply silver alginate, cover with dry dressing every day until resolved. There was no documented evidence on the MAR to indicate that the order was completed on 1/7/24, 1/8/24, 1/9/24, 1/10/24, 1/11/24, 1/12/24, 1/15/24 and 1/15624. The MAR also revealed an order to, PRESSURE WOUND LEFT ISCHIUM Cleanse with Dakins 1/4 solution pat dry apply Santyl ointment and Calcium Alginate . Cover with dry dressing Daily. every day shift for wound care with a start date of 9/23/23. There was no documented evidence on the MAR to indicate that the order was completed on 1/7/24 and 1/15/24. Record review of Resident # 4's wound evaluation dated 1/11/24 written by the Wound Doctor revealed his stage 4 pressure wound of the left ischium was not at goal, and his stage 4 pressure wound of the lower coccyx was, not at goal. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455996 If continuation sheet Page 7 of 9 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 455996 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Renaissance at Kessler Park 2428 Bahama Dr Dallas, TX 75211 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview with Resident # 4 on 1/17/24 at 1:31 PM he revealed the staff did his wound care daily. He stated his wound was trying to heal but just couldn't heal right. In an interview with LVN F on 1/18/24 at 11:51 AM she stated she typically documented wound care on the treatment MAR. She stated whatever orders they had on the MAR they could go in and click it to show it was completed. LVN F stated that if a treatment was not done it could be because they were short and they informed the next nurse to do that treatment. LVN F stated that in that situation she would not sign the MAR so that the next nurse would see that it was there and needed to be done. LVN F stated that normally on weekdays the wound nurse (LVN E) would complete wound treatments, however there was one resident (Resident #3) that did not want LVN E to do his wound, therefore the floor nurses did his wounds. LVN F stated she could see her TAR and the wound TAR so in case LVN E had already completed a treatment, she would see that it was done. LVN F stated if there was a hole on the MAR, it meant either the treatment was not done or someone forgot to sign that they did it, therefore the initials would not show. She stated that in the nursing world if it was not documented, it was not done. LVN F stated she worked the day shift Monday January 1st through Friday January 5th, 2024. When LVN F reviewed the TAR for Resident # 3, she saw that his wound treatment was not signed off from January 1st through the 4th 2024. LVN F stated that was her fault, she did not sign it out. She stated she was at the facility and did the treatments. LVN F stated she did not know how she missed documenting 4 days in a row. Additionally, LVN F reviewed the MAR/TAR for Resident # 4. LVN F stated that LVN E did the treatments for Resident # 4 and perhaps LVN E forgot to sign off on the Mupirocin order. LVN F pointed out that LVN E had signed off on a different order for the same wound that had the order for Mupirocin. Observation completed from 7:47 AM to 12:35 PM on 1/18/24 as Wound Doctor made rounds on 15 residents (Including Resident # 3 and Resident # 4) at the facility revealed infection control measures were followed and all dressings had been dated correctly. In an interview with LVN E on 1/18/24 at 12:55 PM she stated Resident # 4 went to the hospital and may have returned with the order for Mupirocin. LVN E stated the Mupirocin order was not showing on her TAR. LVN E stated if there was an order that she was responsible for the charge nurse would place it on her TAR. LVN E stated the order for Mupirocin should not exist because it was followed with Santyl. LVN E stated the charge nurse was responsible to review all orders when a resident returned from the hospital and reconcile them. LVN E sated the next level check would be the ADON to review the orders to ensure everything was good for a new admit or readmit. LVN E stated that in general it something was not documented it was not done. In an interview with RN C and the ADM on 1/18/24 at 1:57 PM, the ADM stated it was her expectation for nurses to document as they went while giving treatments. RN C stated she had the same expectation. RN C stated if the screen was green, they were good for their shift. RNC said if the wound nurse was not supposed to do a treatment it should be coded to the nurse MAR. RNC stated the situation with LVN F where documentation did not show on the MAR for 4 days straight for Resident # 3 was because the order was showing up on a different screen where the nurse could not document. RN C stated usually LVN E did the wound treatments, however since Resident # 3 did not want LVN E to do his treatments the respective hall nurses would do them. The issue was it was not showing on the TAR or MAR of the floor nurses. In reference to Resident # 4, RN C stated when a resident returned from the hospital, the nurse was to compare orders from before the hospitalization to the orders that came back from the hospital and call the doctor. The nurse was to ensure everything was reconciled or rectified before entering the orders into the electronic medical record. RN C stated the facility planned to recode things so that the expectations would be clearer between the floor nurses and the wound nurse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455996 If continuation sheet Page 8 of 9 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 455996 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Renaissance at Kessler Park 2428 Bahama Dr Dallas, TX 75211 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the facility policy titled Medication- Treatment Administration and Documentation Guidelines dated 2/10/20 revealed, 4. Administer the medication according to the physician order. 5. Document initials and/or signature for medications and treatments administered on the MAR or TAR immediately following administration. Record review of the facility policy titled Medication Reconciliation dated 9-24-22 revealed, admission Processes: a. Verify resident identifiers on the information received. b. Compare orders to hospital records, home or orders from healthcare entity, etc. Obtain clarification orders as needed. c. Transcribe orders in accordance with procedures for admission orders. D. The DON/designee reviews transcribed orders for accuracy and cosign the orders, indicating the review. E. Order medications from pharmacy in accordance with facility procedures for ordering medications. F. Verify medications received match the medication orders. Event ID: Facility ID: 455996 If continuation sheet Page 9 of 9