Health inspection·March 13, 2025

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some training program. She completed the training on 06/24/24. She stated she tried to do the written portion of the test but the camera on her computer was not working properly to register for the test. She stated she had not taken the CNA written test and was told by the DON, she needed to take the test by 03/24/25. She stated she used to work PRN but as of this year, she worked full time taking care of the residents. She stated she was trained by a few nurses and CNA's. She was trained on how to bathe and change the residents, transferring to and from the bed, Hoyer lift transfer with a 2nd person and the nurses did everything else. She stated the DON said she exceeded her time and they wanted her to take the NA test before 03/24/25. She stated she was not sure what the timeframe was to get her CNA license but she kept having problems with her computer and she was finally able to get her paperwork to go through last month. She stated she was working on completing the written test on 03/24/25 . Interviews were attempted and messages left for NA B to return calls on 03/12/25 at 1:55 PM and 4:54 PM and 03/13/25 at 10:47 AM, but she did not call the HHSC State Surveyor. Interview on 03/13/25 at 11:51 AM, Staffing Coordinator E stated the facility had a CNA training program and they had three or four NA's in training, but they were not on the schedule yet. She stated when they worked they worked with somebody alongside another CNA. She stated the NA were not working independently. She stated she was not sure who was responsible for ensuring they got certified and the NA's had to work 120 hours as a Nurse aide then they could take the CNA test. Interview on 03/13/25 at 1:00 PM, the DON stated they had NA's who provided care to the residents but as of today NA A and NA B were not going to work until they passed the CNA test. She stated NA C was still within his 120 days and in the process of taking his CNA test this month and NA D just recently passed her certification test this week. She stated she did not have a date on when NA A and NA B were going to take their CNA test. She stated she received clarification today (03/13/25) about the timeframe the NA's needed to get certified. She stated she thought the NA's had a year to get certified. She stated she spoke to her Clinical Resource Consultant and he told her the NA's had within 120 days to take the test and get certified. She stated from the times NA A and NA B took the class, they were pushing them to take the test but they had problems with uploading the information to register. She stated the instructor had already approved their trainings and they just needed to register for the written test. She was not sure why they did not ask to use a computer at the facility. She stated NA A and NA B were PRN's initially and then they were assigned rooms and provided care to the residents. She stated they changed briefs, showers, feeding assistance, setting up meal trays, grooming and Hoyer lift transfers with a 2nd person. She stated her plan to prevent NA's from going over their 120 days was to make sure they got certified. She stated the NA's worked independently and nurse management checked the resident's Plan Of Care and the nurses assisted them with documentation and care. She stated she would be responsible for ensuring the CNA tests were completed in 120 days. Interview on 03/13/25 at 2:01 PM, the Operations Manager stated they had a few NA' and NA A had not obtained her certification because of an issue with her computer and had since taken her off the schedule until she passes her test. He stated he was not sure why NA B had not obtained her certification. He stated he found out this morning (03/13/25) from their Clinical Resource Consultant that the NA's had 120 days from the date of hire to get certified. He stated after they completed the class part, the NA's were able to work for a short period of time with CNA's to care for the residents. He stated the NA's gave their resident reports to the CNA they worked with, to document in the system. He stated NA A and NA B should have already become CNA's. He stated the HR Director G and the DON were responsible for tracking the NA's 120 days and keeping track of their certifications stayed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675111 If continuation sheet Page 2 of 4 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 675111 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Gardens Rehabilitation and Healthcare 2135 N Denton Dr Carrollton, TX 75006 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some active. He stated NA's caring for the residents may result in the residents not getting taken care of properly or may cause them frustration. He stated the NA could do anything a CNA could do, but document. He stated he was not sure why the NA's could not document and after reviewing the job descriptions for the NA and CNA, he said they were different but the CNA's were able to provide care without supervision. He stated the NA's had temporary licensures that prohibited them from being able to document but not the care they provided the residents. He stated he was not aware the NA's days were not being tracked to take their CNA testings. He stated that was why they reached out to their Corporate HR resource person to do employee audits to ensure there were no other issues with the employees certification deadlines. Interview on 03/13/25 at 3:11 PM, the Administrator stated the facility had four NA's and there was an ongoing effort to address the issue with the CNA certifications. He stated HR Director G was responsible for ensuring the NA's were certified and, he had spoken to their Corporate CNA Trainer F and they were going to do a full audit. He stated the NA's were not going to work until they were certified. He stated management needed to re-educate the DON and HR Director G on making sure the NA's were certified in 120 days. He did not want to say how it could affect a resident if a NA provided care to the residents. He stated the residents could potentially not get the care they needed. He stated they were going to have one of their Corporate HR people do an audit of all employees records to make sure there were no issues with other staff certifications. Interview by phone on 03/13/25 at 3:49 pm, the HR Director G stated the Corporate CNA Trainer F was the instructor for the training program and showed the NA's how to apply and get Certified. He stated he thought CNA trainer F was supposed to be checking to ensure the NA were certified in the 120 days. He stated the NA's were not supposed to do documentation but were able to provide care as long as a nurse or cna was watching over them. He stated he planned to get with the DON and Corporate to prevent this from happening again. Interview on 03/13/25 at 5:01 PM, Corporate CNA trainer F stated the NA's did three weeks of training with her. She stated she tracked when they started the NA trainings and that was it. She stated the facility was responsible for keeping up with getting NA's certified before the 120 days. She stated she told the NA's and the DON about the dates and timeframes to get certified. She stated telling the NA's and the DON the NA's had to choose the date and time to take the test and they needed to tell the DON and Administrator once it was scheduled. She stated the 120 days included the training, she had to call her counterpart because she was not sure. She stated once the NA's completed their training they needed to upload their information into the [State Portal] registration website so she could approve it. She stated then the NA could choose a date to take the test. She stated last year she approved NA A and NA B registrations in the [State Portal] to take the test because they went through the CNA training and was not sure why they had not taken the test yet. She stated she was going to speak to the facility management to ensure the oversight was over the NA's and to ensure the tracking of the 120 days were being done. She stated the difference between the NA and CNA was one was certified and the other was not. Interview on 03/13/25 at 5:33 PM, the DON stated after she reviewed the job descriptions for the Nurse Aides and CNA's, they were pretty much the same. She stated the NA's did what the CNA's did but the NA's could not document and needed a nurse or CNA to assist with their documentation. She stated she was not sure why the NA's could not do their own documentation and thought they should be able to. She stated she was not able to say what could happen if an uncertified NA provided care to a resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675111 If continuation sheet Page 3 of 4 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 675111 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Gardens Rehabilitation and Healthcare 2135 N Denton Dr Carrollton, TX 75006 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the facility's, undated, Human Resources Employee Handbook page 14 revealed, You are responsible for: Maintaining current/valid license and credentials Record review of the facility's Job Description for Nurse Aide policy, dated 12/17/21, revealed Position Summary: The primary purpose of your job position as a full-time staff member is to acquire the knowledge, skills and certification as a Certified Nursing Assistant by participation in the facility's planned educational program consisting of classroom instructions, clinical practice, and on the job, supervised training, and to perform certain services for which you have been trained and found to be competent during the training period. Essential Duties and Responsibilities: Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not excluded them from the position if the work is similar, related, or is an essential function of the position. Event ID: Facility ID: 675111 If continuation sheet Page 4 of 4