Health inspection·March 6, 2025

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #10's physician order dated 3/03/2025 revealed Resident #10 should be repositioned every two hours. In an observation on 3/04/2025 at 10:46 a.m., Resident #10 was observed laying flat on her back with one pillow under her head. No other pillows or wedges (foam wedge used for positioning) were observed in Resident #10's room. Resident #10 was unable to answer questions appropriately. In an observation on 3/04/2025 at 1:24 p.m., Resident #10 was observed in the same position on her back with one pillow under her head. No other pillows or wedges were observed in Resident #10's room. In an observation on 3/05/2025 at 11:05 a.m., Resident #10 was observed in the same position on her back with one pillow under her head. No other pillows or wedges were observed in Resident #10's room. In an observation on 3/05/2025 at 1:49 p.m., Resident #10 was observed in the same position on her back with one pillow under her head. No other pillows or wedges were observed in Resident #10's room. In an observation on 3/05/2025 at 3:36 p.m., Resident #10 was observed in the same position on her back with one pillow under her head. No other pillows or wedges were observed in Resident #10's room. In an observation on 3/06/2025 at 9:00 a.m., Resident #10 was observed in the same position on her back with one pillow under her head. No other pillows or wedges were observed in Resident #10's room. Record review of Resident #10's progress note dated 3/03/2025 at 1:54 p.m. by RN B, revealed an open area was noted to the coccyx (area near the top of the buttocks and the base of the spine). Measurements or wound type were not indicated. In an interview on 3/06/2025 at 2:30 p.m., ADON C stated the measurements for Resident #10's new wound was 0.5 x 0.5 cm. The doctor and hospice were notified on 3/03/2025. ADON C stated it was an open area and did not indicate the specific type of wound. 2. Record review of Resident #32's Quarterly MDS assessment dated [DATE] revealed Resident #32 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of diabetes, aphasia (inability to comprehend of formulate language), hemiplegia (partial paralysis of one side of the body) or hemiparesis (muscle weakness of one side of the body), and muscle wasting and muscle atrophy (decrease of muscle mass). Section C of the MDS assessment also revealed Resident #32 had severely impaired cognitive skills and was rarely/never understood. Section GG of Resident #32's MDS indicated Resident #32 was dependent (required assistance and was unable to help with activities) with all ADLs and was unable to roll to the left or right without assistance. Section M of Resident #32's MDS assessment indicated Resident #32 had one stage 4 pressure ulcer that was present upon admission and had not healed at the time of the assessment. Record review of Resident #32's care plan with a revision date of 2/06/2025 revealed Resident #32 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 2 of 11 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 03/06/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some had a pressure ulcer, and interventions included to reposition the resident every two hours or more often as needed or requested. Record review of Resident #32's wound evaluation and summary report dated 1/28/2025 revealed Resident #32 had a wound on her sacrum for more than 203 days with measurements of 4 x 2.5 x 1cm. Recommendations included to reposition per facility protocol and turn side to side in bed every one to two hours if able. Record review of Resident #32's wound evaluation and summary report dated 2/25/2025 revealed Resident #32 had a wound on her sacrum for more than 231 days with measurements of 4 x 2.5 x 1cm. Recommendations included to reposition per facility protocol and turn side to side in bed every one to two hours if able. In an observation on 3/04/2025 at 10:49 a.m., Resident #32 was observed lying flat on her back with two wedges observed stuck between the bed and the wall. One pillow was placed under the resident's head. Resident #32 was unable to answer questions due to a severe cognitive impairment. In an observation on 3/04/2025 at 1:26 p.m., Resident #32 was observed in the same position lying flat on her back with two wedges observed stuck between the bed and the wall. One pillow was placed under the resident's head. In an observation on 3/05/2025 at 10:58 a.m., Resident #32 was observed in the same position lying flat on her back with one wedge observed next to the resident on her right side (not under). Another wedge was observed stuck between the bed and the wall. One pillow was placed under the resident's head. In an observation on 3/05/2025 at 1:48 p.m., Resident #32 was observed in the same position lying flat on her back with one wedge observed next to the resident on her right side (not under). Another wedge was observed not placed under the resident and lying on the foot of the bed. In an observation on 3/05/2025 at 3:38 p.m., Resident #32 was observed in the same position lying flat on her back with one wedge observed next to the resident on her right side (not under). Another wedge was observed not placed under the resident and lying on the foot of the bed. In an observation on 3/06/2025 at 9:00 a.m., Resident #32 was observed in the same position lying flat on her back with one wedge observed next to the resident on her right side (not under). The other wedge was no longer in the room. In an interview on 3/05/2025 at 4:08 p.m., CNA A reported that pressure sores were prevented by rotating or turning the resident every two hours. CNA A stated some residents had extra pillows, and some residents had wedges to use for turning. CNA A stated that if a resident was not turned then sores could develop. CNA A stated Resident #32 and Resident #10 were turned every two hours to prevent sores from developing. In an interview on 3/06/2025 at 10:10 a.m., RN B reported if a resident was bedridden then they were repositioned every one to two hours. RN B reported they used pillows to help reposition residents, and the nurse was responsible for ensuring residents were repositioned. RN B stated if residents were not repositioned then it could cause skin breakdown (wounds). RN B stated Resident #10 was on an air mattress and was repositioned every one to two hours. RN B reported Resident #10 had wounds that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 3 of 11 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 03/06/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some did better some days and were worse on other days. RN B reported Resident #32 was repositioned with wedges, but she was not sure how often. RN B stated the wedges lifted Resident #32's bottom off the bed. RN B reported she was unsure if Resident #32's wounds had become worse because she had only worked at the facility for around six weeks. In an interview on 3/06/2025 at 11:16 a.m., ADON C stated Resident #10's wound was resolved, and Resident #10 had just developed a new wound. ADON C stated the wound care doctor monitored the status of wounds every Tuesday and documented any changes in the wound evaluation and summary report. ADON C stated Resident #32's wound would never heal because Resident #32 was receiving a low amount of nutrition via a tube feeding. ADON C reported Resident #32's wound was chronic and had not changed significantly. ADON C reported the dietician was monitoring Resident #32, and Resident #32 was unable to tolerate the tube feeding if it were increased. ADON C reported that Resident #32 and Resident #10 should have been repositioned every two hours and as needed. ADON C stated pillows and wedges were used for repositioning, and if residents were not repositioned then it could cause a pressure ulcer to form or reopen. ADON B reported that the nurses were responsible for monitoring if residents were turned every two hours. In an interview on 3/06/2025 at 11:55 a.m., the DON reported that dependent (requires assistance) residents should be turned everyone and a half to two hours and more frequently if they were in pain. The DON stated pillows or wedges were used for repositioning the residents. The DON stated Resident #10 was on hospice and wounds were not unexpected. The DON reported Resident #10 should still be repositioned every one to two hours. The DON reported Resident #32 had a wound and should be repositioned every one to two hours. The DON reported the nurses should monitor if residents were turned, and ADON C monitored the wound documentation to determine if wounds were progressing. Record review of facility's policy titled, Skin Management Policy, with a revision date of 2/01/2014, revealed If new skin alterations of any type are identified .physician orders are obtained. The patient is reviewed by the interdisciplinary team and a plan of care is initiated. A policy specific to repositioning residents for pressure ulcer prevention was not received at the time of exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 4 of 11 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 03/06/2025 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon for two (Residents #19 and Resident #9) out of six residents and failed to ensure the Pharmacist Consultant reported irregularities to the Physician whose medications were reviewed. 1. Resident 19's Pharmacist consultant recommendation for a gradual dose reduction of Citalopram (antidepressant medication) had no physician rationale for continued use. 2. Resident 19's Pharmacist consultant recommendation for a gradual dose reduction of Quetiapine (antipsychotic medication) had no physician rationale for continued use. 3. Resident 9's Pharmacist consultant recommendation for a gradual dose reduction of Risperidone (antipsychotic medication) had no physician rationale for continued use. 4. Resident 9's Pharmacist consultant recommendation for a gradual dose reduction of Divalproex (antipsychotic medication) had no physician rationale for continued use. These failures could place residents at risk for adverse consequences and could cause a decline in their physical, mental, and psychosocial condition. Findings included: Resident #19 Record review of Resident #19's face sheet dated 03/06/2025 reflected a [AGE] year-old male who was admitted to the facility on [DATE] and re admitted on [DATE] with diagnoses which included Alzheimer's Disease, schizoaffective disorder, and dysphagia (difficulty swallowing). Record review of Resident #19's MDS assessment dated [DATE] revealed he had a BIMS score of 14 which indicated intact cognition. Resident #19 diagnoses included anxiety disorder, psychotic disorder, and schizophrenia. Resident #19 received antipsychotic and antidepressant medications and exhibited no behavioral symptoms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 5 of 11 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 03/06/2025 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 0756 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #19's care plan dated 01/17/2025 revealed Resident #19 had a psychosocial well being problem r/t anxiety, schizophrenia, and depression. Goal: the resident will verbalize feelings related to emotional state .the resident will identify appropriate diversional activities. Interventions: give medication as ordered and monitor for side effects. Give positive reinforcement as initiative/involvement improves/attempts to solve conflict. Monitor/document resident's usual response to problems. Residents Affected - Some Record review of Consultant Pharmacist Recommendation to Physician dated 10/31/2024 reflected: Dear Physician G, Resident #19 has been taking Citalopram 10mg QAM 04/23/2024 without a GDR. Could we attempt a dose reduction at this time to verify this resident is on the lowest possible dose? If not, please indicate response below. The recommendation letter was not signed by Resident #19's Physician. There was no rationale documented for GDR of Citalopram. Record review of Consultant Pharmacist Recommendation to Physician dated 11/30/2024 reflected Dear Physician G, Resident #19 has been taking Quetiapine 50mg BID since 03/10/2024 without a GDR. Could we attempt a dose reduction at this time perhaps Quetiapine 25mg QAM and 50mg verify this resident is on the lowest possible dose? If not, please indicate response below. The recommendation letter was not signed by Resident #19's Physician. There was no rationale documented for GDR of Quetiapine. Record review of Resident #19's Physician orders dated 04/23/2024 by Physician G for Citalopram 20mg. Give one tablet by mouth in the morning for depression. Record review of Resident #19's Physician orders dated 03/10/2024 by Physician G for Quetiapine 50mg. Give one tablet by mouth two times a day related to schizophrenia. Dementia. Review of Resident #19's electronic record revealed there was no documentation a rationale for continuing the medications and not doing a GDR by the physician for Citalopram or Quetiapine. In an interview on 03/06/25 at 12:08 PM Interview with Resident #19 stated he take medication for gout, Motrin, and allergy medications. He stated he did not take any anti-depressants or any psychotropic medications. He stated he did not have any changes to his medications. Resident #9 Record review of Resident #9's face sheet dated 03/06/2025 reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE] with diagnosis of schizophrenia, and major depressive disorder. Record review of Resident #9's MDS assessment dated [DATE] revealed he had a BIMS score of 15 which indicated intact cognition. Resident #9 diagnosis included depression and schizophrenia. Resident #9 received antipsychotic medications and exhibited no behavioral symptoms. Record review of Resident #9's care plan dated revealed Resident #9 used psychotropic medications related to depression, schizophrenia. Goal: resident will maintain the highest level of function possible and not experience a decrease in functional abilities related to psychotropic drug use during the next 90 days. The resident will reduce the use of psychoactive medication over the next 90 days. Interventions: administer medications as ordered. Monitor/document for side effects and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 6 of 11 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 03/06/2025 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 0756 effectiveness. Level of Harm - Minimal harm or potential for actual harm Record review of Consultant Pharmacist Recommendation to Physician dated 01/31/2025 reflected Residents Affected - Some Dear Physician G, Resident #9 has been taking Divalproex 500mg BID since 07/03/2024 without a GDR. Could we attempt a dose reduction at this time to perhaps Divalproex 250mg QAM and 500mg to verify this resident is on the lowest possible dose? If not, please indicate response below. The recommendation letter was not signed by Resident #9's Physician. There was no rationale documented for GDR of Divalproex. Record review of Consultant Pharmacist Recommendation to Physician dated 09/30/2024 reflected Dear Physician G, Resident #9 has been taking Risperidone 2mg BID since 02/06/2024 without a GDR. Could we attempt a dose reduction at this time to perhaps Risperidone 1mg QAM and 2mg to verify this resident is on the lowest possible dose? If not, please indicate response below. The recommendation letter was not signed by Resident #9's Physician. There was no rationale documented for GDR of Risperidone. Record review of Resident #9's Physician orders dated 02/07/2024 by Physician G for Risperidone 2mg. Give one tablet by mouth twice daily for schizophrenia. Record review of Resident #9's Physician orders dated 07/04/2024 by Physician G for Divalproex 500mg. Give one tablet by mouth twice daily for schizophrenia. Review of Resident #9's electronic record revealed there was no documentation a rationale for continuing the medications and not doing a GDR by the physician for Risperidone or Divalproex. In an interview on 03/06/25 at 12:04pm with Resident #9 stated he took lisinopril and risperidone. He stated was unsure what dosage took but he took the same medication daily in the morning and evening. He stated he could not recall if he ever had a dosage reduction for any of his medications. In an interview on 03/06/2025 at 9:10am with the DON she stated she's been employed at the facility for 4 weeks. She stated she is unsure what the process was for the pharmacist recommendations. She stated since she's been in her position, she retrieved the pharmacist recommendations from the portal that she only had access to and send the recommendations to the physician. She stated she faxed the recommendations to the physician and the physician would review and sign the recommendations via fax or in person. In an interview on 03/06/2025 at 9:57am with the ADON she stated she's been employed at the facility since October 2024. She stated she was the interim DON prior to the current DON being hired. She stated when she was interim DON, she retrieved the pharmacist recommendations from the portal and send the recommendations to the physician. She stated the physician reviewed and signed the recommendations when she visited the facility once a week. She stated she tried retrieving the older pharmacist recommendations that included the physician's signature, but she was unable to retrieve the recommendations because the facility no longer had access to the prior DON's email. She stated she contacted Physician G and the physician stated she received pharmacist recommendations from the prior DON and reviewed, signed, and returned the recommendations to the facility. (The recommendations were not provided prior to exit.) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 7 of 11 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 03/06/2025 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 0756 Level of Harm - Minimal harm or potential for actual harm In an interview on 03/06/2025 at 11:11am with Physician G she stated she visited the facility weekly. She stated the facility provided her copies of the pharmacist recommendations via email or in person when she visited. She stated after she reviewed and signed the recommendations she returned the forms to the facility. She stated once she returned the forms to the facility, she was unsure what the facility did with the forms once received from her. Residents Affected - Some Record review of the facility's Unnecessary Drugs policy dated 10/24/2022 reflected, Policy Statement: It is the facility's policy that each resident's drug regiment is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being free from unnecessary drugs. 2. The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with the resident and/or representatives, other professionals, and interdisciplinary team. Each resident's drug regimen will be reviewed on an ongoing basis, taking into consideration the following elements: A. dose(including duplicate therapy) B. Duration of use C. Indications and clinical need for medication D. Adequate monitoring for efficacy and adverse consequences E. Preventing, identifying and responding to adverse consequences F. Any combination of reasons stated above. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 8 of 11 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 03/06/2025 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 - Some 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. Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles for one (200 hall medication cart) of three medication carts reviewed for medication labeling. The facility failed to ensure two insulin pens (one Aspart insulin syringe and one Tresiba insulin syringe) on the 200 hall medication cart had open dates. The facility failed to ensure two insulin pens on the 200-hall medication cart were discarded 28 days after being opened. One Lyumjev insulin pen and one Admelog insulin pen had an open date of 1/20/2025 and was found in the cart on 3/04/2025 (46 days after being opened). These failures could place residents at risk for not receiving the intended therapeutic effects of prescribed medication. Findings included: In an interview and observation on 3/04/2025 at 8:55 a.m., the 200-hall medication cart contained one Aspart insulin syringe and one Tresiba insulin pen with no open dates. RN D stated these two insulin pens were not opened, but the seals were not present on the insulin pens (indicated they were open). The 200-hall medication cart also contained one Lyumjev insulin pen and one Admelog insulin pen that had an open date of 1/20/2025 (46 days after being opened), and RN D stated these insulin pens were good until the manufacturer's expiration date because they were long-acting insulins. RN D stated there was no risks to the residents, and that the nurses using the carts monitored the dates on medications. In an interview on 3/04/2025 at 9:50 a.m., the DON stated an open date was required for all insulins including the long-acting insulins. The DON reported insulin should be discarded after 28 days. The DON reported that not having an open date or using beyond 28 days could cause the medication to not be as effective. The DON reported the nurses administering medications and the ADONs were responsible for monitoring the dates on medications. The DON stated her expectation was for all insulins to have an open date and to be discarded after 28 days. In an interview on 3/06/2025 at 11:16 a.m., ADON C reported she checked the medication carts for dates on medications every Tuesday. ADON C stated insulin had to have an open date because it was only good for 28 days and then must be discarded. ADON C stated if an insulin pen did not have an open date, then it could not be used and must be discarded. When asked what the risks would be to the residents if insulin was not dated or used past 28 days, ADON C just stated that insulin could not be used after 28 days, and staff would not know when the insulin was opened without a date. Record review of the facility's policy titled Medication Storage, with a date of 1/20/2021, revealed It is the policy of this facility to ensure all medications housed on our premises will be stored, dated and labeled according to the manufacturer's recommendations. The policy also revealed medication carts are routinely inspected for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 9 of 11 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 03/06/2025 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure food items were accurately labeled and dated with the received or expiration date. 2. The facility failed to ensure dented cans were placed in a separate storage area. 3. The facility failed to ensure opened items were sealed or resealed effectively. These failures could place residents at risk for food-borne illness and cross contamination. Findings Included: Observation of dry storage on 03/04/2025 at 9:13am revealed the following: -1, 1lbs box of cream of wheat dated 02/08/2025 opened and exposed to the air. - 6 bags of hot dog buns with no use by or expiration date. -1, 3lbs can of cream of chicken dated 01/08/2027 was dented on bottom left. In an interview with the DM on 03/04/2025 at 9:30am she stated dented cans were stored in a separate area in the dry storage closet. She stated when dented cans were identified, she notified the vendor to receive a credit. She stated when she received bread delivery, the expiration date was printed on the outside of the package. She stated if the expiration date was not printed on the packaging, she wrote a use by or expiration date on the packaging. She stated all food items should be properly sealed. She stated food not stored and labeled properly could cause cross contamination. In an interview with [NAME] F on 03/05/2025 at 11:19am she stated all food items needed to be sealed properly and dated with the use by or expiration date. She stated dented cans are stored in a separate area and returned to the vendor. She stated if items are not sealed, labeled, and stored properly could cause cross contamination and residents could become sick. Record review of the facility's Food Storage Policy revised 8/11/ 2017 reflected, Policy Statement: Dry storage may be in a room or area for the storage of dry goods, such as single service items, canned goods, and packaged or containerized bulk food that is not PHF/TCS. 6. Products which do not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675057 If continuation sheet Page 10 of 11 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 03/06/2025 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 - Many FORM CMS-2567 (02/99) Previous Versions Obsolete have an imprinted use by or expiration date on the product, will be dated when received and rotated as new inventory is purchased. 9. All opened products must be resealed effectively and properly labeled, dated and rotated use. 11. Canned goods that have a compromised seal will be removed from service and stored in a separate area, until they are picked up by the distributor of discarded. Record review of the U.S. FDA Food Code 2022 reflected: Chapter 3 . section 3-101.11. Safe, Unadulterated, and Honestly Presented: . FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. Food Labeling [* .(b) A food which is subject to the requirements of section 403(k) of the act shall bear labeling, even though such food is not in package form. (c The specific artificial color used in a food shall be identified on the labeling when so required by regulation in part 74 of this chapter to assure safe conditions of use for the color additive.], 9 CFR 317 Labeling, [*(a) When, in an official establishment, any inspected and passed product is placed in any receptacle or covering constituting an immediate container, there shall be affixed to such container a label .Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under § 3-202.18. Section 3-302.12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. Section 3-501.17 . Commercial processed food: Open and hold cold . B . 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety . C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Definitions 3 . Food Receiving and Storage - Section 3-302.11 Packaged and Unpackaged Food-Separation, Packaging, and Segregation Food shall be protected from cross contamination by: when combined as ingredients, separating raw animals' foods during storage, preparation, holding, and display. Event ID: Facility ID: 675057 If continuation sheet Page 11 of 11