Health inspection·January 5, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some [AGE] year-old male admitted to the facility on [DATE] with diagnoses of quadriplegia (paralysis of all four limbs), injury at the spinal cord, and depression. He had a BIMS of 15 indicating he was cognitively intact. He required extensive assistance of two-person physical assistance with bed mobility, transfer, toilet use, and personal hygiene. Record review of Resident #65's Comprehensive Care Plan last revised 12/22/22 reflected the following: he had an ADL self-care performance deficit secondary to impaired mobility. Interventions include Bathing: needed 1 person assist. Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. Record review of Resident #18's Quarterly MDS assessment dated [DATE] reflected Resident #18 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of muscle weakness, cognitive communication deficit, and depression. He had a BIMS of 11 indicating he was cognitively moderately impaired. He required extensive assistance of two-person physical assistance with bed mobility, transfer, toilet use, and personal hygiene. Record review of Resident #18's Comprehensive Care Plan last revised 12/21/22 reflected the following: he had an ADL self-care performance deficit. Interventions include Bathing: needed 1 person assist. Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. An observation on 01/03/23 at 11:01 AM revealed Resident #41 was lying in bed. Both hands contracted. The nails on both her hands were approximately 0.5 centimeter in length extending from the tip of her finger. The nail on the pinky finger of the left hand was bent and pressing on the skin. Resident #41 could not answer questions. An observation on 1/03/23 at 11:34 AM revealed Resident #65 was lying in bed. The nails on both his hands were approximately 0.5centimeter in length extending from the tip of his fingers. The nails were discolored tan and the underside had dark brown colored residue. An observation and interview on 01/03/23 at 11:44 AM revealed Resident #35 was lying in bed. The nails on both his hands were approximately 0.5centimeter in length extending from the tip of her finger. The nails were discolored tan and the underside had dark brown colored residue. Resident stated he did not like his nails long and he cannot do it himself. An observation on 01/03/23 at 11:41 AM revealed Resident #18 was lying in bed. His right hand was contracted, the nails on right hand were approximately 0.8 cm. The nails on the resident's left hand were approximately 0.5 cm in length extending from the tip of her finger. Resident #18 could not answer questions. In an interview on 01/03/23 at 2:35 PM, CNA D said CNAs were allowed to cut the residents' nails if the residents are not diabetic. He said he will trim and clean Resident #10, #35, #65, and #18's nails right now. He said the risk would be transmission of infections from dirty nails. In an interview on 01/03/23 at 2:50 PM, LVN E said only nurses cut residents' nails if they are diabetic. LVN E said no one had notified her Resident #10, #35, #65, and #18's nails were long and dirty, and she had not noticed the nails herself. LVN E stated the risk would be skin tears from long nails and infection transmission from dirty nails. In an interview on 01/05/22 1:49 PM the DON said, nail care should be done as needed and every time (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 2 of 13 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 675057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balch Springs Nursing Home 4200 Shepherd LN Balch Springs, TX 75180 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 FORM CMS-2567 (02/99) Previous Versions Obsolete aides wash the residents' hands. The DON said nails should be observed daily. The DON said she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON said residents having long and dirty nails could be an infection control issue. Review of the facility's policy titled Activities of Daily Living Care , revised 2/11/2021, reflected . Fundamental Information . A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Event ID: Facility ID: 675057 If continuation sheet Page 3 of 13 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 675057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balch Springs Nursing Home 4200 Shepherd LN Balch Springs, TX 75180 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview, record review and policy review, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week for 5 (9/10/22, 9/17/22, 9/18/22, 9/24/22 and 9/25/22) of the 20 days reviewed for RN coverage. The facility failed to have the required RN coverage on 9/10/22, 9/17/22, 9/18/22, 9/24/22 and 9/25/22. These failures could place residents at risk of receiving inaccurate assessments, timeliness of care provided and exposure to unsupervised care staff, which could result in potential physical or mental degradation. Findings included: A record review of the facilities staffing postings for the month of September 2022 revealed that no Registered Nurse was scheduled on the following days in September 2022: 9/10/22, 9/17/22, 9/18/22, 9/24/22 and 9/25/22. A record review of the facilities time detail report for September 2022 revealed that a RN did not work 8 consecutive hours on the following days in September 2022: 9/10/22, 9/17/22, 9/18/22, 9/24/22 and 9/25/22. A record review of the CMS Payroll Business Journal (PBJ) Staffing data report 1705D 12/30/2022 revealed that no Registered Nurse hours were reported to CMS for September 2022 for the days of: 9/10/22, 9/17/22, 9/18/22, 9/24/22 and 9/25/22. A record review of the Contract with the facility entitled Third Eye Health, Inc. Contract Addendum: Replacement for Exhibit A Section 1 Scope of Work Contract Scope of Work Expansion dated 12/21/2017 revealed that there was no Registered Nursing waiver for the facility. In an interview on 1/05/2022 at 12:02 PM with Regional Nurse, the Regional Nurse revealed that they had been a Regional Nurse for the facility for 2 years and that she understood the requirement for having a Registered Nurse in the facility everyday and that the Registered nurse was required to perform assessments, consult with physicians, and correctly deal with medical emergencies. Not having a Registered Nurse in the facility could harm residents for emergencies and proper paperwork. They denied working at the facility for the days of: 9/10/22, 9/17/22, 9/18/22, 9/24/22 and 9/25/22. In an interview on 1/05/2022 at 12:09 PM with the DON, the DON revealed that they had been working at the facility for over 6 years and that they agreed that there had to be a Registered Nurse in the facility for at least 8 consecutive hours every day. They further revealed that residents could be affected by not being assessed properly, supervisory problems and physician consultancy issues. They denied working at he facility for the days of: 9/10/22, 9/17/22, 9/18/22, 9/24/22 and 9/25/22. In an interview on 1/05/2022 at 12:23 PM with the ADM, the ADM revealed that they had been working at the facility for almost a year and that she thought that having a teleconferencing company kept the facility in compliance for having a Registered Nurse at the facility for 8 consecutive hours everyday and that they were unaware of any waivers for nursing at the facility. They further revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 4 of 13 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 675057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balch Springs Nursing Home 4200 Shepherd LN Balch Springs, TX 75180 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete that there could be some scenarios for residents that a Licensed Vocational Nurse might not be able to handle and assessments. Review of the facilities policy and procedure entitled Nursing Services and Sufficient Staff dated 4/10/2022 reflected, Policy Explanation and Compliance Guidelines: .2. Except when waived, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. 3. The facility is required to provide licensed nursing staff 24 hours a day, 7 days a week. 4. The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for a residents needs as identified through resident assessments and described in the plan of care .8. Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. Event ID: Facility ID: 675057 If continuation sheet Page 5 of 13 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 675057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balch Springs Nursing Home 4200 Shepherd LN Balch Springs, TX 75180 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review of 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. 1. The facility failed to ensure staff completed hand hygiene during meal service while delivering meals to residents. 2.The facility failed to inspect, upon receipt, delivered whole milk cartons for quality and ensure proper labeling and dating. 3. The facility failed to ensure stored canned goods, had an uncompromised seal, free from dents. 4.The facility failed to ensure food items in the refrigerator, two freezers and dry storage were labeled and stored in accordance with the professional standards for food service. 5. The facility failed to discard items stored in refrigerator, freezers or dry storage that were not properly labeled or past the 'best buy', consume by or expiration dates. 6.The facility failed to ensure staff did not place personal items on prep tables and on surfaces in food preparation areas and near food items. 7. The facility failed to ensure the ice machine vent/grate and outer surface was free from dirt and dust. These failures could place residents at risk for food-borne illness and cross contamination. Findings Included: Observations of the Kitchen on 01/05/23 at 11:48 AM revealed the following: - Dietary Aide H left from the kitchen to take out a rack of lunch trays to the first hallway, she returned to the kitchen but did not wash her hands. She exited and re-entered the kitchen 5 times without first washing her hands when re-entering the kitchen. Observations of the walk-in refrigerator on 01/05/23 at 11:22 AM revealed the following: -1-8 oz. carton of whole milk from top crate on left side of the back of the refrigerator, had no label or date printed or embossed on the carton. Observations of the walk-in refrigerator on 01/03/23 at 09:44 AM revealed the following: -10-8 oz. cartons of whole milk from one crate had no dates on crate, and no best by or consume by dates printed or embossed on the cartons. (pulled from crate to show staff). -3 small clear plastic will improper fitting lids contained mixed fruit dated 12/23/22 @11:15, no use by date reflected on the label. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 6 of 13 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 675057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balch Springs Nursing Home 4200 Shepherd LN Balch Springs, TX 75180 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 -Clear medium pitcher with lid contained dark liquid, dated 12/29/22, there was no label of item description and no consume by or use by date. -1 large square clear container of strawberry jell-o covered with plastic wrap, dated 12/29/22. There was no item description and no consume by or use by date. Residents Affected - Some -1 plate with salad covered in plastic wrap, dated 12/29/22, there was no item description and no consume by or use by date. -1 plate with a sandwich cut in half, diagonally, wrapped in plastic wrap, dated 12/29/22, no item description and no consume by or use by date. -1 medium clear container of thick yellow viscous creamy substance (pureed food per staff) dated 12/29/23, there was no label of item description and no consume by or use by date. -1 medium clear container of pureed food covered with plastic wrap labeled SW Pt Puree, dated 12/26/22, no item description and no consume by or use by date. -1 medium cleat square container of fruit cocktail covered with plastic wrap, dated 12/24/22, there was no consume by or use by date reflected. - 1 medium clear pitcher with lid, had clear liquid. There was no label of item description, no date of preparation, and no consume by or use by date. -1 large bag of shredded lettuce, previously opened, dated 12/29/22, had started to turn brown throughout the bag, there was no consume by or use by date. -10 Cabbages in an extra-large open bin, dated 10/29/22, six had several leaves that were brownish-yellow in color and wilted. There was no consume by or use by date reflected label. -1 large zip top bag with a bag of 9 boiled and peeled eggs, 1 egg was split open, the yolk not inside the egg, water inside the internal bag. Internal bag dated12/29/22 then the outside zip top bag dated 1/2/23, there was no consume by or use by date. -1 Large clear plastic jar with lid of pasta sauce dated 12/8/22, there was no open date and no consume by or use by date. -3- 5lbs. bags of shredded yellow cheddar cheese, dated 12/29/22, no consume by or use by date reflected on the label. -1 previously opened 5 lbs. bag of shredded yellow cheddar cheese, dated 11/22/22, there was no open date and no consume by or use by date. Observations of the kitchen on 01/03/23 at 09:25 AM revealed the following: -Eyewash station, next to handwashing station sink is dirty. There was debris and stains in the sink and on the eyelet faucets. -Handwashing sink garbage receptacle had more than just paper towels, there was plastic lids, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 7 of 13 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 675057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balch Springs Nursing Home 4200 Shepherd LN Balch Springs, TX 75180 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 gloves and packaging from various products. Level of Harm - Minimal harm or potential for actual harm -Near the handwashing sink, there was a prep table that a bread toaster and an extra-large roll of plastic wrap, and a large stainless-steel bowl of peaches in liquid. Also on the table were a personal cell phone and charging cord, there was a folding chair at the table with a jacket thrown across the top of the chair, touching the edge of the prep table. Residents Affected - Some -Ice machine: top front surface- the vent filter/grate is dirty and had dust on it. -Ice machine: along the bottom of the top of the ice machine, just above the ice chest portion, is plastic boarder that is broken on left side, hanging down and exposing dirt and dust. -On Shelf with clean dishes, near main entrance, on the 2nd shelf from the top, left side, 1 small, scalloped edge plastic bowl with a piece of red food particle on the inside. Observations of the dry storage room [ROOM NUMBER]/13/23 at 10:15 AM revealed the following: -1 large white container of natural peanut butter dated 12/21/22, the manufacturer's expiration date was smudged off. There was no consume by or use by date. -1 extra-large clear cylindrical plastic container of 13 individually wrapped oatmeal pies, there was no label of item description, no open date and no consume by or use by date. -1 extra-large clear cylindrical plastic container of individually wrapped graham crackers, dated 12/5/22, there was no item description and no consume by or use by date. -1 large bag of gravy mix, previously opened, wrapped in plastic wrap. There was no item description, no visible received date, no open date and no consume by or use by date. -1 large zip top bag of breadcrumbs, dated 12/26/22, no consume by or use by date. -5- 5.51 lbs. can of artichoke hearts, dated 6/14/22, there was no manufacturer's expiration or best by date, 1 can of the 5 was dented. -3-8.16 lbs. can of grape jelly, dated 1/28/22, there was no manufacturer expiration date. -1-5 lbs. 13 oz can of spinach leaf, dated 12/13/22, can was dented and amongst other non-dented cans. -1-6lbs. 10 oz. can of tropical fruit salad, dated 12/5/22, can was dented and among other non-dented cans. Observations of the Reach-in Freezer #1 on 01/05/23 at 12:40 PM revealed the following: Left-side door-1 large box of roll dough, previously opened, dated 12/24/22, there was no open date. -1 large box of 4oz. individual containers of sherbets, dated 1/4/23, there was no opened date. Middle Door-1 large box of individual 2lbs. bags of vegetable blend, no dates on the individual bags or the box, no open date reflected on the box. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 8 of 13 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 675057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balch Springs Nursing Home 4200 Shepherd LN Balch Springs, TX 75180 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 -1 large box of individual 40 oz. bags of broccoli, dated 12/29/22, no open date reflected on the box. Level of Harm - Minimal harm or potential for actual harm Right-side door-1 large box of 14 sheeted oven rising pizza dough, dated 11/08/22, there was no open dated reflected on the box. Residents Affected - Some -1 large box of curly fires, previously opened, dated 12/16/22, no open date reflected on the box. Observations of the Reach-in Freezer #2 on 01/15/23 at 12:51 PM revealed the following: Right-side Door-1 extra-large box with 3-extra-large rolls of ground beef, dated 12/29/22, there was no open date reflected on the box. In an Interview on 01/03/23 at 10:14 AM, with [NAME] I, when asked about the milk cartons without the dates, she stated she was unaware they were there. She stated that she would take them out and show the Dietary Manager (not there at the time). [NAME] B stated that the potential harm to residents was that because there was no date, which meant they could not tell when the milk expires and its unknown when it was placed in the refrigerator. In an Interview on 01/05/23 at 10:14 AM with [NAME] J. When asked if she found the Cleaning Log, she stated on 01/14/23, they had; she stated she thought they had some, they use to but she could not find any in the binder where they use to keep them. In an Interview on 01/04/23 at 03:52 PM with Dietary Manager. She stated she was not the regular Dietary Manager, that she was filling in from another facility because this facility's Dietary Manager had an emergency. She stated she could look for some. She went into the office and looked around and asked [NAME] J where they would be kept. She returned and stated they did not have any cleaning logs. She denied being made aware about the milk that was found yesterday without any dates printed or embossed on the cartons. She was then informed by the surveyor about the milk cartons. The Dietary Manager stated if it was her facility and this happened, they would pull those cartons and dispose of them. She stated the potential harm to residents would be if the milk was spoiled and given to residents, it could cause illness and death. Any illness in this population (elderly residents) would be an issue. She stated that she would expect the staff to check for dates, cuts in boxes and packaging and or open packages/products when items are first delivered. She said, I encourage my staff to check the temps and to practice good hygiene. The Dietary Manager stated she would hold an in-service to ensure that everyone knows how to check food items before accepting and when to deny. In an Interview on 01/05/23 at 12:52 PM with [NAME] J. [NAME] J stated the Cooks clean the freezers, the refrigerator and stove daily and on that cook's last day, they clean the steam table. She explained that the Cook's Schedules are working 4 days on and 2 days off, that is what she meant by cook's last day, for that week. She also stated she went through the crates of milk last night before leaving and found 6 more cartons of milk that had no dates printed or embossed on them and she threw them out. [NAME] J confirmed the filter on the ice machine could be removed and cleaned. She stated that they use to do that' she believed it was on the cleaning log but not sure why they have not been using the log anymore. She stated that Dietary Aide H normally washes her hand, the presence of the surveyors in the kitchen made her nervous. In an Interview on 01/05/23 at 12:54 PM with Dietary Manager. The surveyor informed the Dietary Manager that there was one more carton of milk found today. Dietary Manager explained she had [NAME] J (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 9 of 13 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 675057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balch Springs Nursing Home 4200 Shepherd LN Balch Springs, TX 75180 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 go through the milk last night. The Dietary Manager and Regional Dietician and [NAME] J was informed that Dietary Aide H was noted 5 times of exiting and re-entering the kitchen without washing her hands and moving about in the kitchen and taking racks out and other items. The Dietary Manager stated that she would do an in-service with the staff to reiterate the importance of hand hygiene. The Dietary Manager was interviewed regarding the hand hygiene because Dietary Aide H did not speak English well and no one in the kitchen at the time could translate. The Dietary Manager stated that items in dry storage are kept until expiration dates. She stated that the cleaning log would hold staff accountable for cleaning the equipment and kitchen. She also stated she would put in a maintenance request for the front of the refrigerator for the broken boarder guard. The Dietary Manager stated canned goods with not expiration don't last long in the kitchen but would be kept for up to a year. In an Interview on 01/05/23 at 12:58 PM with Regional Dietician. She stated they would start the in-service on the staff right away regarding the hand hygiene and would later have one regarding checking in food items when they are delivered. The Regional Dietician stated that open items and leftovers in refrigerator are kept for 3 days. After looking on her phone, she stated she had just reviewed the policy and how long to keep the canned goods and the milk without expiration dates but to discard them if they are open or if expiration date is provided by manufacturer. When the policy (ies) for Dietary/ Nutrition Services were requested at the end of day on 01/04/23, the next day there was no policy for Labeling provided. Review of the Facility's Food and Nutrition Services Policy and Procedure Manual, Food Safety and Sanitation Plan, Origination Date 09/2005, Review Date 11/15/2017, Revision Date 11/2017 and 10/24/2022, reflected Policy: It is the policy of this facility to follow an effective, proactive food safety program that is based on preventing food safety hazards before they occur. The Hazard Analysis Critical Control Point (HACCP) Plan is an example of such a program. Basis of Control and Critical Control Items for HACCP review: . 1. Source . -Foods must be inspected to ensure that they are wholesome and unadulterated regardless of the source . 2. Receiving - When food, food products or beverages are delivered to the facility, staff will inspect items for . quality upon receipt and ensure . keeping track of when to discard perishable foods and covering, labeling, and dating . 11. Ready-to-Eat PHF Date Marking -Read -to-eat food will be clearly labeled using calendar date to indicate the date the product was prepared and the date the product must be used or discarded. Use the following to determine the use by date; [NAME] at 41 degrees F or below =7 days. Certain Bulk ready-to-eat foods (i.e. bulk cottage cheese, gallon milk, bulk sour cream) may go by manufacturer's use by date and do not need an additional use by date once opened. -Commercially prepared PHF/TCS food products are clearly labeled using calendar date to indicate the date the product was opened and the date by which product must be used or discarded. The use by date must not exceed the use by date established by the manufacturer. 13. Personal Hygiene Practices -Thorough hand washing is required (but not limited to) the following situations: . Procedure: .15. Food Handling: . Ice- .Keeping the ice machine clean and sanitary will help prevent contamination of the ice. Contamination risks associated with ice and water handling practices may include but are not limited to: . -Unclean equipment, including the internal components of ice machines that are not drained, cleaned and sanitized as needed according to manufacturer's specifications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 10 of 13 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 675057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balch Springs Nursing Home 4200 Shepherd LN Balch Springs, TX 75180 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 designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 (Resident #32, Resident #28, Resident #60, and Resident#7) of 8 residents reviewed for infection control. Residents Affected - Some 1. The facility failed to ensure CMA B disinfected the blood pressure cuff in between blood pressure checks for Residents #28, #60, and #7. 2. The facility failed to ensure LVN A disinfected the blood pressure cuff before or after check of blood pressure for Resident#32. These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: 1. Record review of Resident #28's Quarterly MDS assessment, dated 12/01/22, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses including elevated blood pressure, muscle weakness, elevated blood pressure in the eyes, and generalized anxiety disorder. She had a BIMS of 15 indicating she was cognitively intact. Record review of Resident #28's physician orders dated 01/04/23 reflected, losartan potassium-HCTZ tablet; 100-25 mg, give 1 tablet by mouth in the morning for elevated blood pressure - Special instruction: Hold for systolic blood pressure less than 100, diastolic blood pressure less than 60 and heart rate less than 60. Norvasc tablet 10 mg, give 1 tablet by mouth in the morning for elevated blood pressure - Special instruction: Hold for systolic blood pressure less than 100, and diastolic blood pressure less than 60. Record review of Resident #60's Quarterly MDS, dated [DATE], revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that include cerebral infarction (brain cell death), elevated blood pressure, and cognitive communication deficit. He had a BIMS of 13 indicating he was cognitively intact. Record review of Resident #60's physician orders dated 01/04/23 reflected, amlodipine besylate tablet; 10 mg, give 1 tablet by mouth, one time a day for elevated blood pressure - Special instruction: Hold for systolic blood pressure less than 110, diastolic blood pressure less than 60, and when the heart rate is less than 55. Review of Resident #7's Quarterly MDS, dated [DATE], revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that include heart failure (heart doesn't pump enough blood for the body's needs), elevated blood pressure, and cognitive communication deficit. He had a BIMS of 11 indicating he was cognitively moderately impaired. Record review of Resident #7's physician orders dated 01/04/23 reflected, amlodipine besylate tablet; 5 mg, give 1 tablet by mouth, in the morning for elevated blood pressure - Special instruction: Hold for systolic blood pressure less than 110, diastolic blood pressure less than 60, and when the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 11 of 13 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 675057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balch Springs Nursing Home 4200 Shepherd LN Balch Springs, TX 75180 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 heart rate is less than 55. Losartan potassium tablet 50 mg, give 1 tablet by mouth, in the morning for elevated blood pressure - Special instruction: Hold for systolic blood pressure less than 110 and diastolic blood pressure less than 60. Metoprolol succinate ER tablet 25 mg, give 1 tablet by mouth, in the morning for elevated blood pressure - Special instruction: Hold for systolic blood pressure less than 110, diastolic blood pressure less than 60, and when the heart rate is less than 55. Residents Affected - Some CMA B was observed checking the blood pressures on Residents #28, #60, and #7 and did not sanitize the blood pressure cuff in between each resident use. The blood pressure cuff was used, placed on top of the med cart, then used on the next resident without sanitizing between all three resident's blood pressure checks. Observation on 01/04/23 at 8:55 AM revealed CMA B performing morning medication pass, during which time she checked the blood pressures on Resident #28. CMA B did not sanitize the blood pressure cuff before or after using it on Resident #28 and continued to the next resident without sanitizing the blood pressure cuff. Observation on 01/04/23 at 9:05 AM revealed CMA B performing morning medication pass, during which time she checked the blood pressures on Resident #60. CMA B did not sanitize the blood pressure cuff before or after using it on Resident #60 and continued to the next resident without sanitizing the blood pressure cuff. Observation on 01/04/23 at 9:10 AM revealed CMA B performing morning medication pass, during which time she checked the blood pressures on Resident #7. CMA B did not sanitize the blood pressure cuff before or after using it on Resident #7 and placed on top of the cart. Interview on 01/04/23 at 9:15 AM, CMA B stated reusable equipment, like blood pressure cuffs, should be sanitized with wipes between each resident use (before and after use on each resident) in order to prevent transmitting an infection from one resident to another. She stated she forgot to wipe the cuff this time. 2. Review of Resident #32's quarterly MDS assessment, dated 12/14/2022, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with the following diagnoses: paraplegia (paralysis of the legs and lower body), elevated blood pressure, muscle weakness, and cognitive communication deficit. Review of the cognitive patterns reflected a BIMS of 03, which meant Resident #20's cognition was severely impaired. Record review of Resident #32's physician orders dated 01/04/23 reflected, propranolol HCL tablet; 10 mg, give 1 tablet via G-tube, in the morning for elevated blood pressure - Special instruction: Hold for systolic blood pressure less than 110, diastolic blood pressure less than 60, and when the heart rate is less than 55. Observation on 01/04/23 at 8:25 AM revealed LVN A performing morning medication pass, during which time she checked the blood pressures on Resident #32. LVN A did not sanitize the blood pressure cuff before or after using it on Resident #32. Interview on 01/04/23 at 9:20 AM, LVN A stated reusable equipment, like blood pressure cuffs, should be sanitized with wipes between each resident use (before and after use on each resident). LVN A stated the risk would be spread of infections from resident to resident. She stated she forgot to wipe the cuff this time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 12 of 13 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 675057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balch Springs Nursing Home 4200 Shepherd LN Balch Springs, TX 75180 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 Interview on 01/05/23 at 1:33 PM, the DON stated that her expectation was that staff would sanitize all reusable equipment between each resident use. She stated that not doing so placed residents at risk of cross contamination of infections from one resident to another. She said she was responsible for training staff on infection control. She said that she did routine rounds in the floor to ensure the nurses and med aids were following proper infection control procedures. Residents Affected - Some Record review of facility's Clinical Practice Guidelines: Cleaning and Disinfecting Portable Equipment, dated 5/4/2021, reflected . 2. Staff shall follow environmental infection control principals for cleaning and disinfection the equipment. b. Cleaning shall be performed daily and between residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 13 of 13