Health inspection·February 14, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview with housekeeper A on 02/13/2024 at 9:55 a.m. revealed she was one of three housekeepers working the facility today. Housekeeper A stated, she cleans two halls (hall 200 and hall 300). Housekeeper A stated that on Monday after the weekend it was always a mess. There were two housekeepers over the weekend and one does mostly floors. Sometimes the supervisor will show up, but not all the time. We were supposed to go down our hallways, sweep and mop the rooms and bathrooms and collect the trash. She stated sometimes it will take all day to do just that. She stated we are supposed to make two rounds a day, but I do not usually get around to that. She stated she only cleans once. She stated she has spoken to her supervisor, but she just told her to speed up. Housekeeper A stated since the state is here they have extended our hours in the facility . Housekeeper A stated if the rooms and bathroom are not cleaned it could cause the residents to get sick. In an interview on 02/13/2024 at 10:30 a.m. during a confidential group meeting revealed one of the residents in attendance stated her bathroom was dirty, ill kept, and she was unhappy with the housekeeper because they did not always empty her trash. The resident stated she had said something to the Housekeeping Supervisor and sometimes it was better and sometimes it was not better . Interview on 2/14/2024 at 10:01 a.m. with the Housekeeping Supervisor revealed if the bathrooms needed cleaning, it was her and her crew's responsibility. She stated we clean the resident's room and the bathrooms every day. The Housekeeping Supervisor stated that she had a crew even on the weekend and she worked herself to help. The Housekeeping Supervisor stated that she was a part of the stand-up meetings in the morning, and she had not been made aware of any problems with bathrooms. The Housekeeping Supervisor stated there were more staff in the facility today because we have extended our hours during the state survey . The Housekeeping Supervisor stated it was her responsibility to make sure the rooms and the bathrooms were clean. She stated the crews make a morning and afternoon rounds. Interview on 02/14/2024 at 4:15 p.m. with the Administrator revealed the floors in the bathrooms were unacceptable. The Administrator stated that the bathrooms were supposed to be cleaned daily . The Administrator stated the Housekeeping Supervisor was responsible to make sure the rooms and bathrooms were clean. He stated he had no expectations on how many rounds the cleaning crews had to make as long as they stayed in budget, and the facility was clean. Review of the Policy and Procedure Maintenance Services dated revised December 2022 reflected Maintenance service shall be provided to all areas of the building . and equipment .1. The maintenance Department is responsible for maintaining the buildings in a safe and operating manner at all times .2. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines .maintaining the building in good repair and free from hazards .establishing priorities in providing repair services .providing routinely scheduled maintenance service to all areas .3 the Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the building . are maintained in a safe and operable manner .maintenance .shall follow established safety regulations to ensure the safety and well-being of all concerned . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 2 of 16 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 02/14/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure all assistive devices and overbed tables were maintained and free of hazards for five (Residents #10, #12, #19, #35 and #44) of eighteen residents reviewed for essential equipment. The facility failed to properly maintain wheelchairs for Residents #10, #12, #35 and #44. The facility failed to properly maintain overbed tables for Resident #19. These failures could place residents at risk for equipment that was in unsafe operating condition, which could cause injury. Findings included: Review of Resident #10's admission MDS assessment, dated 12/14/2023, reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Dementia (confusion and forgetfulness), generalized weakness, and anxiety (nervousness). Resident #10 had a BIMs score of 00 indicating she was severely cognitively impaired and unable to make decisions for herself. Review of the Resident #10's plan of care dated 12/19/2023 with updates reflected goals and approaches to include wheelchair mobility for locomotion. Observation on 02/12/2024 at 10:35 a.m. revealed Resident #10 was sitting in her wheelchair in the front lobby and had no skin problems. The wheelchair's left and right armrests were cracked with exposed foam. Review of Resident #35's quarterly MDS assessment, dated 01/20/2024, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses paranoid schizophrenia (mental illness) and muscles weakness. Resident #35 had a BIMs score of 10 reflecting she was moderately cognitively impaired and able to make decisions for herself. Review of the Resident #35's plan of care dated 01/23/2023 with updates reflected goals and approaches to include wheelchair mobility for locomotion. Observation on 02/12/2024 at 10:45 a.m. revealed Resident #35 was sitting in her wheelchair in the common area and had no skin problems. The wheelchair's left and right armrests were missing. In an attempt to interview on 02/12/2024 at 10:45 a.m. Resident #35 revealed she was not interested in talking about her wheelchair. Review of Resident #12's quarterly MDS assessment, dated 01/25/2024, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses hypertension (high blood pressure), Cardiovascular accident (stroke), seizures (brain disorder), and unsteady on feet (instability). Resident #12 had a BIMs score of 9 reflecting she was moderately cognitively impaired and able to make decisions for herself. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 3 of 16 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 02/14/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the Resident #12's plan of care dated 01/05/2024 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 02/12/2024 at 10:50 a.m. revealed Resident #12 sitting in her wheelchair, in the front lobby, the wheelchair's left and right armrests were missing. Resident #12 was asked about her wheelchair, and she stated, It was needing some work, and the wheelchair had been provided to her by the facility. Resident #12 stated she had told the charge nurse but could not recall when or which nurse. There were no skin tears on the arms. Review of Resident #44's quarterly MDS assessment, dated 01/17/2024, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses of cardio-obstructive pulmonary disease (breathing problems), cancer, and muscle weakness. Resident #44 had a BIMs score of 15 reflecting he was cognitively alert and oriented and able to make decisions for himself. Review of the Resident #44's updated plan of care dated 12/30/2023 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 02/12/2024 at 11:00 p.m. revealed Resident #44 in his wheelchair at the nurse's station. Resident #44 stated that his arm rests were broken. The wheelchair's right and left armrests were cracked with exposed foam. Resident #44 stated he had told the nurses that his wheelchair arms were broken, but nothing had been done. He stated that it was about three weeks ago, he thought that he told the staff, but he could not recall which staff member he told. Review of Resident #19's quarterly MDS assessment, dated 12/22/2023, reflected he was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of dementia (confusion and forgetfulness), Alzheimer's disease (confusion and forgetfulness), abnormality of gait and mobility, and general weakness. Resident #19 had a BIMs score of 4 reflecting she was severely cognitively impaired and unable to make decisions for herself. Observation on 02/12/2024 at 11:14 a.m. revealed Resident #19 was in her room in bed, with no skin problems. The overbed table was beside the bed, with the veneer missing surrounding the edge of the entire table, and the left end of the table had broken wood splintering out of the edge of the overbed table. In an interview on 02/12/2024 at 11:15 a.m. with Resident #19 revealed she did not answer any questions concerning her overbed table. In an interview on 02/12/2024 at 12:30 p.m. LVN C stated when a resident's wheelchair needed repair the staff were to tell the Maintenance Supervisor. He kept all the parts to fix them. LVN C stated he should tell the maintenance supervisor the wheelchairs needed new armrests. LVN C stated usually he would keep up with that but recently he had been too busy. LVN C stated that if the resident's wheelchairs were not in good repair, it could cause injuries. In an interview on 02/12/2024 at 1:27 p.m. CNA B stated when a resident's wheelchair or overbed tables needed repair the staff were to tell the charge nurse or the Maintenance Supervisor. CNA B stated she had not reported anything recently, concerning wheelchairs or overbed tables . In an interview on 02/14/2024 at 2:46 p.m. the Maintenance Supervisor stated that he was responsible for the repair of wheelchairs and if the residents needed other equipment replaced. He stated he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 4 of 16 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 02/14/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm kept a maintenance logbook at the nurse's station, but the staff tell him, they do not use the book. The Maintenance Supervisor stated he had not had any staff members tell him about any wheelchairs needing repair, until yesterday. The Administrator told him that the state was looking at the wheelchairs, so he showed me and repaired them all, but I knew nothing before then . The Maintenance Supervisor stated that if the equipment was not in working ordered it could cause injuries. Residents Affected - Some In an interview on 02/14/2024 at 3:45 p.m. with the Administrator revealed the staff was supposed to report to the Maintenance Supervisor any equipment that needed repair. The Administrator stated all the armrests on the wheelchairs had been replaced, on yesterday (02/13/2024). He stated he saw the state surveyor looking at them, so he watched, and repaired all the wheelchairs that the state surveyor looked at. The Administrator stated the staff had not reported anything to the Maintenance Supervisor prior . The Administrator stated, if the equipment was not repaired appropriately then it could cause injuries. The Administrator stated the department heads were supposed to perform angel rounds every morning and this would something they should look at and then in the morning meeting it showed have been reported. The Administrator stated he would be reminding the department heads to follow-up. Record Review of the Maintenance log dated 11/01/2023 through 02/14/2024 at the nurse's station, reflected no entries for wheelchair armrest repair or overbed table replacement. A review of the facility's policy and procedure Adaptive Devices and Equipment dated December 2022 reflected Policy Statement Our facility maintains and supervises the use of assistive devices and equipment for residents . 6. The following factors and addressed to the extent possible to decrease the risk of available accidents associated with devices and equipment . c. Devices condition-devices and equipment are maintained on schedule and according to manufacturer's instructions. Defective or worn devices are discarded or repaired . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 5 of 16 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 02/14/2024 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 that residents who required dialysis received such services, consistent with professional standards of practice, for 1 (Resident #53) of 1 resident's reviewed for dialysis. Residents Affected - Few The facility failed to ensure post-dialysis assessments were completed for Resident #53 after return from dialysis treatment. This failure could place residents at risk of inadequate post dialysis care. Findings included: Record review of Resident #53's, admission MDS assessment dated [DATE] reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #53 had diagnoses which included end stage renal failure (when kidneys suddenly become unable to filter waste products from blood), Diabetes (increased blood sugar, dependence on renal dialysis, (procedure to cleanse the blood), and Hypertension (increased blood pressure). Resident #53 had a BIMs score of 15, reflecting she was cognitively alert and oriented and able to make decisions for herself. The MDS section O related to special treatments, procedures, and programs reflected Resident #53 received dialysis. Record review of Resident #53's care plan, dated 02/06/2024, reflected Resident #53 received dialysis related to renal failure and was at risk for the potential complications related to dialysis. Needed hemodialysis to rule out end stage renal failure. Resident #53 will have no signs of complication from dialysis through next review. Obtain vital signs and weight per protocol. Report significant changes in pulse, respiration, and blood pressure to the physician. Record review of Resident #53's physician's order, dated 01/30/2024, reflected Hemodialysis every Tuesday, Thursday, and Saturday at 11:00 a.m. Further review reflected no orders to assess the access area prior to dialysis or post dialysis. Record review of Resident #53's EHR reflected no nursing documentation regarding Resident #53's dialysis, monitoring of the resident's post-dialysis vital signs, or the assessment of the access area. Record review of Resident #53's dialysis communication forms reflected dialysis communication forms with no information on the resident assessment and observation post-dialysis section on 02/01/2024, 02/06/2024, 02/08/2024, 02/10/2024, 02/13/2024, and 12/14/23. Interview on 02/13/2024 at 10:30 a.m. with Resident #53 revealed when she returned from dialysis on the evening shifts, the nurses do not assess her access area. Resident #53 stated she knew they were supposed to assess the access area, but they never do. The staff were sometimes busy with dinner or their medication pass. Resident # 53 stated she has asked, but the staff forget. If my husband visits me, he will look at the area for me. Interview on 02/14/2024 at 1:10 PM with LVN A revealed she was aware she was supposed to send Resident #53 with the dialysis communication form when she left for dialysis. The nurse on the next shift would collect the form when the resident returned from dialysis. LVN A stated she knew she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 6 of 16 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 02/14/2024 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few supposed to take her vital signs before she left and check to make sure the dressing on the access area was intact. LVN A stated someone else obtained the resident's weight. LVN A stated she never removed the access dressing to look to see if the area was bleeding, red, or looked infected. She had not been told to do that. LVN A stated if the access area was not accessed there could be a negative outcome, such as bleeding or infection, for the resident. LVN A stated the responsibility should be the charge nurse, but thought that the assessment should occur after dialysis, rather than before. Interview on 02/14/2024 at 04:31 PM with the DON revealed it was the nurses' responsibility to send dialysis residents with a communication form to dialysis and get the form back when the resident returned to the facility. This was so, if there were orders from dialysis or changes, it was noted. She stated her expectation was for the nurses to perform post-dialysis assessments when the residents returned from dialysis and document on the dialysis communication forms on dialysis days. She stated failure to monitor the vital signs and access sight after dialysis, staff would not note the change of condition, bleeding, and whether the vitals were stable. She stated she had done training with the staff and the last in-service was when Resident #53 had admitted . The DON stated that if there were no orders given the nurses should call the physician and receive orders. It was basic nursing to know you must assess the access area before and after dialysis, as well as vital signs. She stated the risk for not assessing the vitals were that Resident #53 could be unstable and the permcath (special catheter used for short-term dialysis treatment) could be bleeding. She stated the facility will do another in-service and monitor. Interview on 02/14/2024 at 4:40 p.m. with LVN F revealed she was aware she was supposed to collect the dialysis communication form when the resident returned from dialysis. LVN F stated she was to monitor the dialysis access site for the bruit, thrill (a vibration caused by blood flowing through the fistula and can be felt by placing your fingers just above incision line), dressing for bleeding, and vital signs when Resident #53 came back from dialysis. She stated she was not consistent because when Resident #53 returned from dialysis in the afternoon, it would be during medication administration time, and sometimes during dinner. LVN F stated failure to monitor and assess Resident #53 post dialysis put her at risk of low blood pressure and bleeding. She stated she had done trainings, but she could not tell whether dialysis was one of them. Record review of the facility's policy, dated 12/22/2024, reflected the following, .19. Facility will monitor departures and returns from the dialysis center. The facility will document the resident's vital signs, general appearance, orientation, additional baseline data as needed. The resident clinical record will be documented wit this information. The date and time of the residents' return to the facility will be recorded by the nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 7 of 16 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 02/14/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents for 1 (one medication cart for Hall 100) of 6 medication carts. The facility failed to ensure medication supplies were all stored in locked compartments and permit only authorized personnel to have keys, when LVN A's one medication cart for Hall 100, was left unlocked and unattended by LVN A. This failure could result in resident access and ingestion of medications leading to a risk for harm and possible drug diversion. Findings included: An observation on 02/14/2024 at 8:15 a.m. revealed LVN A's one medication cart, for Hall 100, was left in the hallway outside of the main dining room entrance unlocked. MA A was in the main dining room serving breakfast and not in view of the medication cart for Hall 100. The lock on the medication cart was popped out showing the red bottom indicating the cart was unlocked. An observation on 02/14/2023 at 8:20 a.m. revealed LVN A's one medication cart, for Hall 100, was left in the hallway outside of the main dining room entrance unlocked. LVN A was in the dining room assisting with breakfast. An unknown resident rolled past the unlocked medication cart and a staff member (housekeeping) walked past the unlocked medication cart. The lock on the medication cart was popped out showing the red bottom indicating the cart was unlocked. An observation on 02/14/2024 at 8:27 a.m. revealed LVN A's medication cart, for Hall 100, was left in the hallway outside of the main dining room entrance unlocked. LVN A was in the dining room assisting with breakfast, not in view of the medication cart. The lock on the medication cart popped out showing the red bottom indicating the cart was unlocked. An observation on 02/14/23 at 8:39 a.m. revealed the Administrator standing at the unlocked medication cart. He walked into the dining room, and it was observed the Medication Cart for Hall 100 was locked. LVN A came out of the dining room with the Administrator looking at her Medication Cart for Hall 100. LVN A returned to the dining room. In an interview on 02/14/2024 at 8:45 a.m. LVN A stated she had gotten busy in the dining room and had not locked her medication cart. LVN A stated she knew that the medication cart should always be locked when not in use. LVN A stated that if the medication cart was not locked the medication in it could be taken by a confused resident and that could hurt them, a visitor, or another staff member. In an observation on 02/14/2024 at 9:19 a.m. with LVN A of the medication cart for Hall 100 revealed: for Resident #53 Insulin injection pen (diabetes), Acetaminophen 500mg (for pain), Ondansetron 4mg (nausea and vomiting), Carvedilol 25mg (blood pressure), and Hydroxyzine 25mg (hypertension). In an observation on 02/14/2024 at 9:20 a.m. with LVN A of the medication cart for Hall 100 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 8 of 16 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 02/14/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm revealed: for Resident #44 Clonidine patch 0.1mg (hypertension), Losartan Potassium 100mg (hypertension), Potassium Chloride extended release 20meq (for potassium imbalance), Hydralazine HCL 25 mg (hypertension), Doxazosin Mesylate Tablet 4 Mg (hypertension), Docusate sodium 100 mg (constipation), Multivitamin-minerals oral tablet (Supplement), Calcium-Vitamin D3 Tablet 250-125 Mg (supplement), Citalopram Hydrobromide Tablet 10 Mg (depression), and Aricept Tablet 10 Mg (dementia). Residents Affected - Few In an observation on 02/14/2024 at 9:22 a.m. with LVN A of the medication cart for Hall 100 revealed: for Resident #39 Metoprolol 25 mg (hypertension), and Transdermal patch (dizziness). In an observation on 02/14/2024 at 9:25 a.m. with LVN A of the medication cart for Hall100 revealed: stock medications for all residents if ordered: Vitamin C 500mg, multivitamin, multivitamin with iron, stool softener, and liquid drug destroyer. In an interview on 12/14/2024 at 3:45 p.m., the DON stated it was her expectation that medication carts should be locked when not in use. The DON said that the nurses were responsible to keep the medication carts locked when not in use. She stated if they were not locked, residents and unauthorized staff could get into the cart and there would be opportunities for harm and medication diversion. The DON said that the staff that was using the carts were responsible to monitor them to ensure they were locked. Review of the Policy and Procedure Security of Medication Cart revised dated December 2022, reflected, The medication cart shall be secured during medication passes and biologicals are stored properly . policy Interpretation and Implementation: 1. The nurses must secure the medication during the medication pass to prevent unauthorized entry .3.the medication cart must be locked before the nurse enters the resident's room [ROOM NUMBER]. The medication cart must be securely locked at all times when out of the nurse's view 5. When the medication cart is not being used, it must be locked . Review of the Policy and Procedure Storage of medications dated December 2022, reflected, The facility shall store all store all drugs and biologicals in a safe, secure, and orderly manner . 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes). containing drugs and biologicals shall be locked at all times . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 9 of 16 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 02/14/2024 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on interviews and record reviews, the facility failed to conduct and document a completed facility-wide assessment which included a current (EPP) Emergency Preparedness Plan to determine what resources were necessary to care for its residents competently during emergencies as necesarry and at least annually for one (facility) of one facility reviewed for Emergency service planning. The facility failed to review, revise and update their Emergency Preparedness Plan at least annually; the most current EPP was not in the EPP binder. And after inquiry on 02/14/24, the Administrator provided the surveyor a four-page EPP dated 01/17/23 by former Administrator G that was unsigned by anyone and without proof of all of the completed employee trainings and drills. This failure could place residents at risk of harm if the facility's emergency protocols were not properly implemented by the staff during an emergency, which could cause a delay in assistance, treatment and care to the residents, resulting in a decline in their health and psycho-social well-being. Findings included: Record review on 02/14/24 of the facility's Emergency Preparedness Plan with Former Administrator G's name on it was dated 01/17/23 revealed, A signature page of the department heads names were typed and dated 01/17/23 with no actual signatures from former Administrator G and other department heads, to confirm it was completed and reviewed. Record review on 02/14/24 of the facility's current undated staff roster consisted of Administrator hire date 10/11/23, Maintenance Director hire date 09/08/23 and DON hire date 08/15/23. Record review of a list of the resident's form was undated and provided by the Administrator on 02/14/24 revealed the facility currently had: One trachea resident (Resident #65) Three G-tube dependent residents (Residents #9, #39, #65) One dialysis resident (Resident #53) Four hospice residents (Residents #18, #22, #33, #39) Three contact isolation residents (Residents #16, #28 and #53) Interview on 02/14/24 at 10:38 am, Maintenance Director K stated their emergency preparedness plan was up to date. He stated when he first started working at this facility, he did an Elopement EPP and added he was not sure but maybe the facility did the whole EPP earlier in 2023 year. He stated he was not sure why it was not in their EPP binder. He stated the Administrator and DON and himself was responsible for ensuring the EPP was updated annually. He stated the EPP needed to be updated yearly for anything going on like the hiring of new staff, new policies, and procedures to deal with emergencies. He stated the EPP ensured everyone, including the residents knew what to do. He stated if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 10 of 16 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 02/14/2024 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the EPP were not updated, they would not have correct information and the residents may be misinformed. He stated he was not sure what could happen to the residents and how it could affect them if the EPP was not updated annually. Interview on 02/14/24 at 10:49 am, the DON stated the last PPE meeting was last year before she started working at this facility and she was not sure how often the EPP needed to be done but believed it was annually. She stated the EPP needed to be updated to ensure what the staff needed to do in an emergency to protect the residents from disasters such as bad weather. She stated if the staff were not prepared for emergencies, they may not know what to do and it could cause fatalities if residents were not transferred to another setting. Interview on 02/14/24 at 10:55 am, the Administrator stated the EPP was up to date and was done before he started working at this facility and added he was not sure when it was last done but would contact corporate to get the most current EPP emailed to him. He stated Maintenance Director K was responsible for ensuring the EPP was updated. He stated the EPP was important so that the facility staff and everyone knew where to go in case of an emergency. Record review of the employees disaster preparedness trainings and drills were requested from the Administrator on 02/14/24 at 11:32 am and on 02/14/24 at 2:05 pm the Administrator provided an internal missing person drill date 04/28/23 conducted by former Maintenenance Director H. There were no other trainings and drills (weather, fire, infection control, power outage, flooding) included. Record review of the facility's Emergency Preparedness policy: Training and Testing policy dated 01/27/18 revealed, Policy: Education and Training, including drills and exercises are utilized in this facility to achieve proficiency during emergency response and ensure effectiveness of our (EOP) Emergency Operation Plan. In compliance with state and federal regulations, our facility conducts initial training on EOP during the orientation of new staff and annually to all staff .Fire drills are done quarterly, and disaster drill done is held every six months under varied conditions for each individual shift of facility personnel . Record review of the Facility's Emergency Preparedness Committee policy undated revealed, The facility has established an emergency preparedness committee (EPC). The committee is comprised of management, supervisory staff from all departments, nursing staff, and support staff. The Administrator is the designated committee chairman .The Administrator is responsible for maintaining and effective and current emergency preparedness plan and implementing procedures. All facility staff members are responsible for understanding the scope of the emergency plan and the role they play in implementing its procedures FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 11 of 16 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 02/14/2024 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 3 (Residents #53, #57, and #174) of 6 residents reviewed for infection control. Residents Affected - Some 1. CNA D failed to put on PPE prior to entering three contact isolation rooms to serve the lunch trays. 2. CNA D failed to disinfect her hands while servicing food trays to the residents on Hall 100. These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Review of Resident #53's EHR on 02/14/24 revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including Diabetes (high blood sugar), End Stage Renal Failure (kidneys have stopped working), extended spectrum beta lactamase (infection bacteria in urine), and respiratory failure with chronic hypoxia (needs oxygen at times to breath). Review of Resident #53's admission MDS assessment, dated 02/04/2024, reflected a BIMs score of 15, indicating the resident was alert and oriented, able to make decisions. Her functional status indicate she needed one staff to complete her activities of daily living. Further review indicated she was incontinent of bowel and bladder (when she did produce urine). Review of Resident #53's physician orders dated 02/24/2024 reflected Resident #53 was to be placed in contact isolation due to extended spectrum beta lactamase. Review of Resident #57's EHR on 02/14/2024 revealed the resident was a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses including Diabetes (high blood sugar), Influenzas (Flu), Arterial Fibrillation (fast heart rate), and Cardiovascular accident (stroke). Review of Resident #57's quarterly MDS, dated [DATE] revealed a BIMs score of 15, indicating he was alert and oriented, able to make decisions. His functional status indicate he needed one staff to complete his activities of daily living. Review of Resident #57's physician ordered dated 02/01/2024 reflected contact isolation due to influenza (flu). Review of Resident 174's EHR her on 02/14/2024 revealed the resident was an [AGE] year-old female that was admitted to the facility on [DATE], with diagnoses including cerebral infarction (stroke), hypertension (high blood pressure), and enterocolitis due to clostridium difficile (infection of the colon). Review of Resident #174's admission MDS, dated [DATE] revealed a BIMs score of 9, indicating she was cognitively moderately impaired and unable to make decisions. Her functional status indicated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 12 of 16 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 02/14/2024 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 needed maximum assist of one staff with her ADLs. Further review indicated she was incontinent of bowel and bladder. Review of Resident #174's admission physician orders dated 02/04/2024 reflected contact isolation for enterocolitis due to clostridium difficile. Residents Affected - Some Observation on 02/12/2024 at 9:30 a.m. revealed on Hall 100 three contact isolation rooms with residents in the rooms. There were contact isolation instructions posted on the outside of the room, to place on full PPE (person Protection equipment) prior to entering the room. There was PPE bins avaible outside of each door. The bins were stocked with gowns, gloves, mask, and face protectors available for usage. Observation on 02/12/24 at 12:05 p.m., revealed CNA D delivered a lunch tray to Resident #57's contact isolation room. CNA D did not use hand sanitizer or wash her hands prior to entering the room. CNA D entered the contact isolation room without donning (putting on) PPE (mask, gown, gloves, and face shield). CNA D assisted Resident #57 in his wheelchair, pulled over his overbed table, then assisted him with set up of the lunch tray, touched him on his arm before leaving the room. Resident #57 was observed coughing when CNA D was in the room. CNA D exited the room. Observation on 02/12/2024 at 12:10 p.m., revealed CNA D delivered a lunch tray to Resident #53's contact isolation room. CNA D did not use hand sanitizer or wash her hands prior to entering the room. CNA D entered the contact isolation room without donning PPE. CNA D assisted Resident #53 with repositioning in her bed, pulling up her covers, then using the automatic bed adjustment to raise the head of the bed. CNA D then pulled the overbed table over to Resident #53 and assisted her with set up of the tray. Observation on 02/12/2024 at 12:17 p.m. revealed CNA D delivered a lunch tray to Resident #174's contact isolation room. CNA D did not use hand sanitizer or wash her hands prior to entering the room. CNA D entered the contact isolation room without donning PPE. CNA D repositioned the resident in the bed and then pulled the overbed table over to the resident's bedside, got a chair, sat down, and assisted the resident to eat her meal. CNA D assisted the resident to complete her meal, left the room approximately thirty minutes later, without washing her hands or using hand sanitizer. In an interview on 02/12/2024 at 1:00 p.m., CNA D stated she was aware she was supposed to put on PPE before going into the rooms and clean her hands between each room. CNA D stated I saw you watching me, and I got nervous. I was worried the food trays would not be served on time, so I just hurried through. I did not want Resident 174's food to get cold. CNA D stated she knew how-to put-on PPE and when she was supposed to put on PPE. She stated she had been recently in-serviced on PPE. CNA D stated if you do not use PPE, you can spread disease to other staff and residents. In an interview on 02/12/2024 at 2:00 p.m., LVN A stated that staff entering the contact isolation rooms must donn PPE. If the signs were on the door and the instructions, were outside, with the bin, the staff must place on everything in the bin. LVN A stated you can ask them a question from the doorway, but if you go beyond the doorway, you must donn PPE. LVN stated, that would include serving a meal tray. LVN A stated by not appropriately using PPE, you could spread infections to other residents and staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 13 of 16 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 02/14/2024 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 Residents Affected - Some In an interview on 02/13/2024 at 2:40 p.m., LVN B stated staff were to wear full PPE when entering the contact isolation rooms. LVN B stated the staff were in-serviced yesterday and many times before. LVN B stated the staff were to wear PPE to protect ourselves and others , from the spread of infections In an interview on 02/14/2024 at 4:00 p.m. the Administrator stated the staff had been in-serviced by the DON multiple times, since he started working at the facility in August. The staff should be aware of what to do concerning contact isolation rooms. The Administrator stated there was no excuse for not knowing what to do concerning infection control after the pandemic . The Administrator stated if the staff does not appropriately follow the rules for contact isolation, then they could spread the bacteria to other residents and they could get sick. In an interview on 02/14/2024 at 5:20 p.m., the DON stated that her expectation was that staff would sanitize their hands prior to serving meal trays to each room. The DON stated it was her expectation the staff follow all infection control guidelines, including the contact isolation room. She stated the staff were to donn PPE prior to entering the contact isolation rooms at all times, doffing prior to leaving, and washing their hands. The DON stated that the staff had been trained on infection control, including appropriately sanitizing your hands while serving trays at meals and contact isolation rooms. She stated that the instructions are posted outside all the doors, just in case they do not recall what to do. The DON stated she had only been here five months and the last in-service she gave on infection control was in January 2024. At that time, PPE and handwashing was discussed with return demonstration. The DON stated she thought she would have to do some further training . The DON stated if the staff does not follow the instructions for contact isolation, then the staff could spread the disease to other residents causing further outbreak. Review of the infection control in-services dated 10/07/2023, 01/10/2024, 02/13/2024, and 02/14/2024 reflected all staff in-services on donning PPE, doffing PPE, handwashing, and reported infection to the Administrator and the DON. Further review of the in-services reflected that CNA D had signed the in-service logs for all three in-services. Review of the facility's Policies and Procedure titled: Infection Prevention and control Program, dated October 24, 2022, reflected the following: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections as per accepted national standards and guidelines . Standard Precautions: all staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. B. Hand hygiene shall be performed . c. All staff shall use personal protective equipment (PPE) according to the established facility policy . Staff Education: a. All staff shall receive training, relevant to their specific roles and responsibilities . b. All staff are expected to provide cate consistent with infection control practices .c. Direct care staff shall demonstrate competence in resident care procedures established by our facility . Policies/Procedures 1. The objectives of our infection control policies and practices are to: a. prevent, detect, investigate, and control infections in the community . b. maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public .e. provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment Review of facility's Policy and Procedure titled: Transmission-Based-(Isolation) Precautions, dated October 24 2022, reflected the following . It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogen . modes of transmission . Standard Precautions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 14 of 16 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 02/14/2024 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 . gloves, gown, mask, eye protection and/or face shields . Contact. Gloves, gowns, mask, eye protection, and /or face shield . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 15 of 16 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 02/14/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for hall 300, entry to the dining area, and one out of four resident door knobs not repaired that was observed for environment The facility failed to ensure the floor between room [ROOM NUMBER] and 309, and the right side entryway into the dining room . and the and door handles were in good repair. These failures could place residents at risk for diminished quality of life due to the lack of a well-kept environment and equipment. Findings included: An observation on 02/13/24 at 9:30 a.m. revealed a floor tile was noticed sticking up between rooms [ROOM NUMBERS] and caught the state surveyor's shoe. After stepping on the tile, it popped back up. An observation on 02/13/24 at 11:20 a.m. revealed a floor tile was observed to be curled at the edge of the dining hall entrance. This tile was near the nurses' station on the right side. An observation on 02/13/24 at 2:07 p.m. revealed the door knob to room [ROOM NUMBER] was connected, but very loose Interview on 02/15/24 at 11:25 a.m. with the Director of Nursing revealed that she had not noticed the loose tile or the loose doorknob. She stated she understood the risk of injury for the loose /sticking up tiles and the loose doorknob . Interview on 02/15/24 at 2:23 p.m. with the Maintenance Supervisor revealed he was aware the floor tiles needed to be fixed or replaced. He stated that he has been searching for matching material and he placed an order with local hardware company. He stated he has been looking for flooring, but they were trying to get a match. He stated that he can fix the doorknobs by tightening the screws. He stated they always get loose especially in an old building like this. He agreed that these issues could be a hazard in case of an emergency. He stated he does daily walk through's and he fixes things as he sees them. He stated in the morning meetings they discuss issues. He stated they do have a book to enter the work orders in and at this time he was unaware of the loose knob on room [ROOM NUMBER]. Interview on 04/20/22 at 1:15 p.m. with the Administrator revealed that he had been made aware of the issues with the flooring and the door. He stated that the flooring was on order and the door would be fixed that day. He was aware of the tripping hazards for the floor and the risk of the broken door handle. They have daily walk through's and a maintenance work order book. There was no notification of the broken doorknob . Review of the Policy and Procedure For Maintenance Inspection dated 04/11/2022 stated It is the policy of this facility to utilize a maintenance inspection checklist in order to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 16 of 16