Health inspection·November 16, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the Resident #38's updated plan of care dated 10/27/23 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 11/13/23 at 10:25 a.m. revealed Resident #38 was in her wheelchair, and the wheelchair's right armrest and lower support area were missing. Resident #38 stated the wheelchair was nice, but it was missing the right side. She said she had told the CNA, but couldnot recall who, about a week ago, but nothing had happened. Review of Resident #11's quarterly MDS assessment, dated 09/11/23, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses with schizophrenia and lack of coordination and weakness. Review of the Resident #11's updated plan of care dated 09/12/23 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 11/13/23 at 10:30 a.m. revealed Resident #11 was in her wheelchair with no skin problems, and the wheelchair's right armrest was missing and the left armrest was cracked with the foam exposed . Resident #11 was asked about the wheelchair, and she stated for the surveyor to go away. Review of Resident #16's quarterly MDS assessment, dated 09/29/23, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses with senile degeneration of the brain, and lack of coordination and weakness. Review of the Resident #16's updated plan of care dated 09/30/23 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 11/13/23 at 10:45 a.m. revealed Resident #16 was in her wheelchair with no skin problems, and the wheelchair's left armrest was cracked with the foam exposed . Resident #11 was unable to be interviewed. Review of Resident #27's annual MDS assessment, dated 09/25/23, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses with diabetes, muscle wasting and atrophy, and lack of coordination and weakness. Review of the Resident #27's updated plan of care dated 09/30/23 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 11/13/23 at 11:00 a.m. revealed Resident #27 was in her wheelchair with skin problems, and the wheelchair's left armrest was cracked with the foam exposed. Resident #27 stated her wheelchair was fine; she did not have any problems with the wheelchair . In an interview on 11/15/23 at 12:27 p.m. CNA D stated when a resident's wheelchair needed repair the staff were to write it in the maintenance log at the nurse's station. CNA D stated she had never written anything in the log though she usually told the maintenance man . In an interview on 11/15/23 at 12:30 p.m. LVN A stated when a resident's wheelchair needed repair the staff were to write it in the maintenance log at the nurse's station, tell the maintenance man and try to find a new wheelchair that was not being used . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675352 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 675352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place Three 3505 S Buckner Blvd Bldg 4 Dallas, TX 75227 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 11/15/23 at 1:46 p.m. the Maintenance Director stated he repaired the wheelchairs when there was needed repairs. He stated staff were to place the needed repairs in the maintenance log located at the nurse's station. The Maintenance Director was informed about the residents' wheelchairs condition, and he stated if the wheelchairs had not been placed in the maintenance log,for repair he would not know. A review of the Maintenance log at the nurse's stations reflected there were no entries that indicated residents' wheelchairs needed the armrest repaired. A review of the facility's policy and procedure Maintenance Services dated December 2020 reflected maintenance services shall be provided to all areas of the building, grounds, and equipment . 1. The Maintenance Department is responsible for maintaining the .equipment in a safe and operable manner at all times .the Maintenance Director is responsible for developing and maintaining a schedule of maintenance serve to assure that the . equipment are maintained in a safe and operable manner FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675352 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 675352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place Three 3505 S Buckner Blvd Bldg 4 Dallas, TX 75227 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to review and revise the person-centered comprehensive care plan to reflect the resident's current status, for 2 of 5 residents (Resident #55 and Resident #88) reviewed for care plans. The facility did not update Resident #55's care plan to reflect specific instructions for hospitalization and antibiotics. The facility did not update Resident #88's care plan to reflect specific instructions for smoking. These failure could place residents at risk for not receiving appropriate care and interventions to meet their current needs. The findings were: 1. Review of Resident #55's MDS quarterly assessment dated [DATE], reflected he was a [AGE] year-old male admitted on [DATE]. His diagnoses included Schizophrenia (mental illness), sepsis (infection), and depression. His BIMs score of 1 reflected his cognitive status was severely impaired and he required moderate to maximum assist of one staff member for activities of daily living. Record review of physician's orders for Resident #55 dated 07/12/23 reflected an order for a transfer to the hospital for an evaluation. Record of the nursing progress notes dated 07/29/13 revealed Resident #55 returned to the facility following hospitalization for sepsis and to continue to receive and completed IV antibiotics . Record review of Resident #55's Care Plan updated on 09/03/23 reflected, there were not a care plan goals to reflect specific instructions for hospitalization and IV antibiotics. 2. Review of Resident #88's MDS annual assessment dated [DATE], reflected he was a [AGE] year-old male admitted on [DATE]. His diagnoses included: Hypertension (increased blood pressure), PTSD (mental health disease), and depression (mental health illness). His BIMs score of 9 reflected his cognitive status was moderately impaired. He required moderate assist of one staff member for activities of daily living. Record review of clinical assessments for Resient #88 reflected dated 10/26/23 reflected a safe smoking assessment . Resident #88 smoked with the other residents, supervised by staff. Record review of Resident #88's Care Plan initiated on 10/26/23 reflected, there was not a care plan goal to reflect specific instructions for smoking safety. Interview on 11/14/23 at 1:06 p.m. with the Regional MDS Consultant revealed she, the other ADON, the DON and were responsible for updating resident care plans. She further stated, We do have a difficult time updating all the care plans. There are so many changes and now that you have brought to my attention, I will see that the care plans are updated for all the needs of each resident, including smoking, antibiotics, IV therapy & interventions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675352 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 675352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place Three 3505 S Buckner Blvd Bldg 4 Dallas, TX 75227 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 0657 Level of Harm - Minimal harm or potential for actual harm Interview on 11/16/23 at 2:55 p.m. with the DON revealed the MDS Coordinator and ADONs were responsible for initiating and updating the care plan as needed. The DON stated it was a team effort to update and the care plans and should be updated when the changes occurred. The DON stated the follow-up on care plan updates should be completed by the nursing administrative team . The care plans should include all the needs of the residents, including IVs, smoking, and antibiotics. Residents Affected - Few Review of the facility's policy titled Care Plans, Comprehensive Person-Centered dated August 20, 2020, reflected the following: .include measurable objective and timeframe; Describe the services that are to be finished to attain or maintain the resident's highest practicable physical, mental, and psychosocial wee-being .include the resident's stated goals upon admission and desired outcome; changes may be made to the Comprehensive Care Plan on an ongoing basis for the duration of the residents stay. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675352 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 675352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place Three 3505 S Buckner Blvd Bldg 4 Dallas, TX 75227 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. Based on observation, interviews, and record review the facility failed to ensure all drugs and biological were secure in locked compartments and permitted only to authorized personal and inaccessible to unauthorized staff and residents for (one medication cart for Hall 500) of six medication carts reviewed for medication storage. The facility failed to ensure medication supplies were all stored in locked compartments and permit only authorized personnel to have keys, when RN B's and LVN C's one medication cart for Hall 500 was left unlocked and unattended by RN B and LVN C. 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 11/14/23 at 5:15 a.m. revealed an unidentified medication cart unlocked sitting at the entrance to Hall 500. The lock on the medication cart was popped out showing the red bottom indicating the cart was unlocked. An observation on 11/14/23 at 5:30 a.m. revealed the unidentified medication cart remained unlocked at the entrance to Hall 500. The lock on the medication cart was popped out showing the red bottom indicating the cart was unlocked. In an interview on 11/14/23 at 5:45 a.m. with RN B and LVN C revealed both nurses stated the medication cart should always be locked when not in use. Both nurses stated if the medication cart had been left unlocked residents and or staff could take medications off the cart and could result in harm. RN B stated the medication cart had not been unlocked and the surveyor must have been mistaken. When the surveyor informed both nurses the medication cart was unlocked, they both stated, That was impossible and then walked away. In an observation and interview on 11/14/23 at 8:30 a.m. with MA E of the medication cart for Hall 500 revealed: for Resident #54 Amiodarone 5mg (heart medication); ASA 81mg (Aspirin), B-complex (vitamin), Buspirone 15 (antidepressant), Duloxetine 30m (depression), Hydrocortisone 25mg (allergies), Lisinopril 40mg (blood pressure), Methadone (pain medication) propranolol 40mg (blood pressure), Senna plus (constipation), allergy relief (allergy medication). When MA E was asked if those were the resident's ordered medications (listed above), he said yes. In an interview on 11/14/23 at 8:20 a.m. with MA E revealed the medication carts should never be left unlocked, medications could be taken from the cart by the residents or the staff, which could result in harm . In an interview on 11/14/23 at 10:00 a.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. When the DON was asked who was responsible to monitor the carts to ensure they were locked she said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675352 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 675352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place Three 3505 S Buckner Blvd Bldg 4 Dallas, TX 75227 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 that would be the staff that was using the carts. Level of Harm - Minimal harm or potential for actual harm Review of the Policy and Procedure Medication Storage dated August 12, 2020, reflected, . Medications and biologicals are stored properly . the medication supply shall be accessible to only licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .medications carts should remain locked when not in use or attended by person with authorized access. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675352 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 675352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place Three 3505 S Buckner Blvd Bldg 4 Dallas, TX 75227 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, 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 the ice machine filter and vent were free from dirt and dust and disrepair. 2. The facility failed to ensure the ice machine chute guard and outer surface was clean. 3. The facility failed to ensure food items in the refrigerator (1 of 3), freezer (2) and dry storage room were labeled and stored in accordance with the professional standards for food service. 3. The facility failed to discard items stored in refrigerator, freezers and dry storage that were not properly labeled or past the 'best buy', consume by or expiration dates. 4. The facility failed to separate dented/compromised canned goods from the non-dented canned good. 5. The facility failed to ensure dietary staff washed their hands or changed gloves when they touched other surfaces while handling food or upon entering or re-entering the kitchen. 6. The facility failed to ensure multiple food items stored in an extra-large bin/container were clearly identifiable. These failures could place residents at risk for food-borne illness and cross contamination. Findings Included: Observation of the Dining Room (location of the ice machine) on 11/13/23 at 09:23 AM revealed the following: -The ice machine's plastic vent, located on the front facing part of the machine, the vent slats had dust on them, and the top left corner of the vent grate had two slats broken off. -The ice machine's filter, located behind the vent, was dirty and dusty. -The ice machine: on the right side of the machine, just above the ice chest compartment and running down the side in streaks, there was a dried white calcified/hardened substance along the bottom right side of the machine. -The ice machine: on the left side of the chute guard had a dried red stain running down the chute guard and a brownish smudge to the right lower corner. -The ice machine: door to the ice chest was very loose. Observations of the walk-in freezer #1 on 11/13/23 at 09:32 AM revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675352 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 675352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place Three 3505 S Buckner Blvd Bldg 4 Dallas, TX 75227 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 -On the left side, on the 2nd row from the top, was an extra-large clear plastic bag of chicken leg quarters. There was no label of item description, no received by date, no open date and no consume by or discard by date. - On the same row but reached almost to the top row, was an extra-large accumulation/formation of ice. Residents Affected - Some -At the bottom, in the left-hand corner was an extra-large grey bin containing various clear plastic bags of meat. The bin had 3 visible labels that reflected: pulled chicken 11/1/23-11/1/24, Chicken breast, legs, thighs 11/1/23-11/1/24, and fish patties 10/1/23-10/1/24 but there were no identifying marks on the bags of each item to know which was which. Observations of the reach-in refrigerator #1 on 11/13/23 at 09:34 AM revealed the following: -In an extra-large rectangular clear plastic container labeled lettuce, dated 10/27/23, contained several bags of shredded lettuce and salad mixes. There were 2 bags with several visible pieces of lettuces that had turned a brownish-red colored, the salad mix had the manufacturer's expiration date of 11/13/23. Observations of the Dry Storage Room on 11/13/23 at 09:36 AM revealed the following: -On the shelves with the regular/non-dented canned goods were: -2- 6 lbs. cans of butter beans dated 10/25/23 with a manufacturer's expiration date of 04/06/26, the cans were dented. -1-7 lbs. 3 oz ketchup dated 10/18/23, dented on the bottom side of the can. -1-6 lbs. 11 oz. can of sloppy joe sauce dated 11/1/23, dented on the bottom of the can. -1-6 lbs. 11 oz. pineapple chunks dated 10/18/23, dented on the bottom of the can. -1-3 lbs. 7 oz. can of ripe sliced olives dated 10/04/23, dented on the bottom of the can. -1-6.9 lbs. can of tomato paste dated 07/25/22 dented on the edge of the can. -1-6 lbs. 9 oz. can of sliced carrots dated 10/25/23, dented on side of can. -1-7 lbs. 5 oz. can of jellied cranberry sauce dated 01/21/22, with a manufacturer's best by date was 12/16/22. Observations of the reach-in freezer #2 on 11/13/23 at 10:07 AM revealed the following: -On the bottom right-hand side, was an extra-large grey bin with multiple large brown bags of food items, labeled: potato wedges, French fries and breaded squash. There were no identifying marks on the bags to be able to identify the contents without opening the bag. Observations of the Kitchen on 11/15/23 at 11:39 AM revealed the following: -In the dish room floor was dirty; there was small pieces of paper, condiment packets, an empty dirty clear 4 oz cup with a red residue inside and a long handled aqua and white scrub brush on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675352 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 675352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place Three 3505 S Buckner Blvd Bldg 4 Dallas, TX 75227 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 floor. Level of Harm - Minimal harm or potential for actual harm -On a prep. table next to the main entry door was a white 3-drawer bin with the 2nd drawer labeled coffee and the 3rd drawer labeled tea. There were no received by dates, no pulled dates and no consume by or discard by dates. Residents Affected - Some -Cook G entered the kitchen from the dining room (door was closed) to make coffee but did not wash her hands before taking the coffee carafe and putting it under the coffee machine. -Dietary Aide J entered the kitchen from the dish room and did not wash her hands or don a hair net. -During lunch service, a stack of cloches (dome shaped lids to cover food and keep it warm) fell on the floor, Dietary Aide I and [NAME] H picked up the lids. Dietary Aide I placed her stack of cloches on the prep table behind her (so not to use) and [NAME] H placed her stack back under the receiving table where Dietary Aide I was taking the cloches from to cover the lunch meals. The surveyor had to intervene. [NAME] H then took the stack of cloches she had collected and removed them from under the receiving table and placed on the prep table behind her. -Cook G re-entered the kitchen from dining room and did not wash her hands. She went into the dry storage room to get a container with some butter packets. -Cook H came back into the kitchen, had to touch the door to enter, she did not change her gloves then prepped more trays, placed butter packets and wrapped desserts on the tray and set them on the carts used to send trays to the dining room. -Cook H entered the kitchen, she brought in a cart from dining room (had to touch the kitchen door to enter), did not wash her hands or change her gloves before returning to prepping meal trays. - [NAME] G came into the kitchen through a closed door, did not wash her hands or don glove before going to the reach-in refrigerator #1 to get condiments requested by the residents. She was helping in dining room. - [NAME] G re-entered the kitchen without washing her hands, she went into the dish room. -At 02:55 PM the Dietary Manager accompanied the surveyor to the ice machine. The Dietary Manager lifted the ice chest door, and the door came off its brackets. She was able to get it back down to close it. In an interview on 11/13/23 at 09:45 AM with the Dietary Manager, she stated she had only been in the position 2 weeks and prior to that she was one of the cooks. When the cleaning assignment sheet was requested, the Dietary Manager stated she was revising it. She stated everyone was responsible for labeling. She also stated they had a Guideline Sheet they used for labeling and discarding food items. She stated when condiments, i.e., sugar, flour, items in reusable containers ran out, they washed the containers then re-labeled them and put fresh products in them. In an interview on 11/15/23 at 11:42 AM with the Dietary Manager, she stated they refer to the guideline sheet she mentioned on the first day to know when to discard an item but was unsure of how long they kept canned goods without an expiration date. When asked how many residents ate by mouth and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675352 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 675352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place Three 3505 S Buckner Blvd Bldg 4 Dallas, TX 75227 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some fed from the kitchen, she stated she would find out and get back to the surveyor. The Dietary Manager stated they had a Dietician and went to get her to make introductions. The Dietary Manager stated they would have to come up with a way to individually mark the items in the big bins so when they looked at the bags, they knew what they were. In an interview on 11/15/23 at 11:54 AM with the Dietician, she stated she was the regional dietician and was employed by the company. She stated she was over 4 other facilities. The Dietician stated the Dietary Manger was still in training and that they were working with her to get her Food Safety Manager's Certification. She stated she was confused at first regarding the issue with the multiple items in a large bin in the freezers. But after being asked to identify the item sitting on top, she could not and stated she understood what the issue was now. In an interview on 01/13/23 at 11:50 AM with [NAME] G, she stated handwashing was important, so they do not get germs on/in the food, so the residents did not get sick. In an interview on 11/15/23 at 02:50 PM with the Dietary Manager, she stated they did not have any current issues with the ice machine other than the door needed tightening. She stated any one of the kitchen staff can clean the ice machine and she would have to find out how often it is cleaned. She stated the problem with the filter being dirty was the air from the vent could blow dirt and dust out into the dining room causing the residents to get sick. The Dietary Manager stated she did not know the dented cans had to be separated from the regular cans. She stated her staff mentioned dented cans to her but did not tell her they could not be held with the regular/non-compromised cans. The Dietary Manager stated the staff knows to wash their hands and change gloves and she thinks that with all that was going on in the dining room and trying to get food out in a timely fashion the forgot but that an in-service on hand hygiene and some other areas were done. Review of the facility's Nutrition Services Food Storage Policy, Policy No.-DS-52, Version 1.0, Date Revised 12/2020, reflected Policy: Food items will be stored, thawed, and prepared in accordance with good sanitary practice. Procedure: I. B. Raw meat, poultry, and seafood should be stored in refrigerators/freezers in the following top to bottom order: i.[Top] Ready to eat food. ii. Seafood. iii. Whole cuts of beef and pork. iv. Ground meat and ground fish. v. [Bottom] Whole and ground poultry. II. Frozen Meat/Poultry and Food Guidelines. C. Storage: Store items promptly at 0° F or below. Foods should be stored in their original containers if designed for freezing. Foods to be frozen should be store in airtight containers or wrapped in heavy-duty aluminum foil or special laminated papers. i. Label and date all food items. E. Handling: Wash hands before handling food. Keep work surfaces clean and orderly. VI. Fresh Fruits Storage Guidelines A. Fresh fruit should be checked and sorted for ripeness. C. Unwashed produce should not be placed in the refrigerator with or near prepared foods. D. Fresh fruit should be ordered and delivered frequently to ensure freshness. E. Rotate fruit so that oldest produce is used first. VIII. Canned Fruit Storage Guidelines . E. Recommended use is within 12 months. IX Fres Vegetable Storage Guidelines. D. Fresh vegetables should be ordered and delivered frequently to ensure freshness. E. Rotate so that oldest produce is used first. X. Frozen Vegetable Storage Guidelines . C. Recommended use is within 6 months. XI. Canned Vegetable Storage Guidelines . C. Dented of bulging cans should be placed in separate area and returned for credit. D. Stock should be rotated with oldest cans in front. E. Recommended use is within 12 months XIII. Dry Storage Guidelines. G. Any opened products should be placed in storage containers with tight fitting lids. H. Label and date storage products. I. Rotate stock. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675352 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 675352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place Three 3505 S Buckner Blvd Bldg 4 Dallas, TX 75227 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the U.S. FDA Food Code 2022 reflected: Chapter 2 . section 2-301 Hands and Arms. 2-301.11 Clean Condition. Food Employees shall keep their hand and exposed portions of their arms clean. 2-301.12 Cleaning Procedure. (C). To avoid recontaminating their hands or surrogate prosthetic devices, food employees may use disposable paper towels or similar clean barriers when touching surfaces such as manually operated faucet handles on a Handwashing Sink or the handle of a restroom door. 2-201.14 When to Wash. Food Employees shall clean their hands and exposed portions of their arms as specified under section 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single-use articles. and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling service animals or aquatic animals as specified in 2-403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco products, eating, or drinking; (E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw food and working with ready-to-eat food; (H) Before donning gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the hands. Section 2-301.15 Where to Wash. Food Employees shall clean their hands in a Handwashing Sink or approved automatic handwashing facility and may not clean their hands in a sink used for food preparation or warewashing, or in a service sink or a curbed cleaning facility used for the disposal of mop water and similar liquid waste. Chapter 3 . section 3-201.11 Compliance and Food Law: . C. Packaged Food shall be labeled as specified in Law, including 21 CFR 101 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) A statement of artificial flavoring, artificial coloring, or chemical preservative shall be placed on the food or on its container or wrapper, or on any two or all three of these, as may be necessary to render such statement likely to be read by the ordinary person under customary conditions of purchase and use of such food. 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675352 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 675352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place Three 3505 S Buckner Blvd Bldg 4 Dallas, TX 75227 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 Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. www.fda.gov Residents Affected - Some eCFR- Code of Federal Regulations are indicating within the text by an *- www.ecfr.gov FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675352 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 675352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place Three 3505 S Buckner Blvd Bldg 4 Dallas, TX 75227 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for four (Halls 200, 400, 500, 600, nurse's station, lobby, conference room and the main dining rooms), of six halls reviewed for pest control program. Residents Affected - Some The facility had live common house flies and gnats in areas of the facility including the lobby, nurses station, halls 200, 400, 500 and 600 , conference room and the dining room. This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life. Findings Include: Observation and interview 11/13/23 at 9:30 a.m., revealed 1-5 live house flies crawling on the bed covers of Resident #52 on Hall 200 There was a fly strip hanging on the resident's wall beside the window, with three dead flies and 15 dead gnats. Resident #52 stated that the fly strip was there because he was tired of the flies and the gnats flying around in his room, so he bought the fly strip. Resident #52 was asked if he had reported the flies and gnats to anyone, and he said he had told the CNA several times. Observation on 11/13/23 at 9:45 a.m., revealed four gnats crawling on the table in the conference room. Observation on 11/13/23 at 10:45 a.m. revealed a gnat crawling on the medication cart on Hall 200 . Observation and interview on 11/13/23 at12:20 p.m., in the main dining room revealed a swarm of five gnats flying around the dining cart with drinks on it. An unknown resident was sitting at a table trying to eat his meal, while swatting at the gnats. The resident stated the gnats were bad and they were in the dining room all the time. He pointed toward the door to the smoking area, in the dining room and said the flies come from there . He said he did see the pest man at thei in the past two weeks but he did not know what he was treating. Observation on 11/13/23 at 12:27 p.m., revealed Resident #53 on hall 600, a gnat was flying around his uncovered feet, when he was in bed. Observation on 11/14/23 at 5:15 a.m., revealed a gnat was flying around at the nurse's station. Observation and interview on 11/14/23 at 6:30 a.m. on hall 400 revealed a gnat flying around Resdient #62's heads MA E was giving the resident his medications. MA E was asked if he saw the gnats or flies in the facility and he stated occasionally. When he was asked what he did when he saw the pests he stated he would tell the maintenance man. Observation and interview on 11/14/23 at 7:30 a.m., on Hall 400 revealed two gnats flying around Resident #66; there were two gnats flying around his head. LVN A was administering Resident # 66's G-tube (feeding tube) medications. Gnats were on the cuff of LVN A's 's glove and she continued to administer medications. LVN A saw the gnats and stated the gnats were bad she tried to tell the families (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675352 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 675352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place Three 3505 S Buckner Blvd Bldg 4 Dallas, TX 75227 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some not to bring food or fruit. The LVN cleansed her hands and changed her gloves. LVN A stated she would tell the maintenance man. In an interview on 11/14/23 at 9:00 a.m., the Maintenance Director for the campus revealed he would check the pest control logs, located the nurse's station for any pest . The Maintenance Director stated he checked the log daily and he was not aware there was a gnat or fly problem in the facility. He said he would contact the pest control company to come today. An interview with CNA D on 11/14/23 at 9:48 a.m., revealed common house flies and gnats had been in the facility for several weeks. She had not reported the flies and she did not know about a pest control log. CNA D stated she was not sure why she had not reported the flies. Observation on 11/14/23 at 12:21 p.m., revealed 5-7 live common house flies around the food of two residents in the dining area that required assistance for eating. The flies landed on the food of the residents. Additional observations in the dining area revealed residents using their hands to wave away gnats from landing on their food. Further observation revealed a blue light trap for flies/gnats was unplugged, and there was a sign on the side that reflected to not unplug. In a confidential group interview on 11/14/23 at 10:30 a.m., 8 residents revealed there was a fly/gnat problem. The residents stated the facility staff and Administrator had been told, but the flies/gnats continued to be a problem. The residents stated they had seen the pest control provider at the facility but whatever the pest control provider was using to treat the flies/gnats was not making a difference. The residents said that people were always going out the back door to the patio and that could be where they were coming in. Observation and interview on 11/14/23 at 12:06 p.m. on Hall 500 revealed Resident #69 had two gnats around the resident's hands and next to her face. Resident #69 stated she saw little black flies all the time and lately they seemed to be more. She stated she did not like the little flies in her room and she thought made the place feel dirty. Resident #69 stated she had not told anyone. Observation on 11/14/23 at 12:48 p.m., revealed three live gnats at the nurse's station. An interview on 11/14/23 at 2:00 p.m. with the Administrator revealed the facility had routine pest control visits during each month, if there was problem with gnats and flies, he was not aware. He stated he would make sure the pest control company came today and treated. Record review of the Facility's Pest Sighting Log revealed: dated 04/27/23 through the last entry 10/23/23 mentioned no flies or gnats. Record review of the pest control provider service information dated 11/02/23 through 11/15/23 revealed the following regarding the technician comments, There were entries for all pests including gnat and flies. On 11/15/23 was the last visit from the pest control provider, after the surveyor's intervention, checked specifically for flies and gnats for fruit flies/gnats dusted drains and sprayed Record review of the facility's policy dated 08/2020, and titled Pest control reflected to ensure the facility is free of insects, rodents, and other pests that could compromise the health, safety, and comfort of the residents, facility staff, and visitors .the facility maintains an ongoing pest control program to ensure the building and grounds are kept free of insects, rodents, and other pests .windows are screened at all times .garbage and trash is not permitted to accumulate in any part of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675352 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 675352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place Three 3505 S Buckner Blvd Bldg 4 Dallas, TX 75227 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 0925 the facility .the facility staff will report to the housekeeping supervisor any sign of rodents or insects .the housekeeping supervisor will take immediate action to remove any pests from the facility 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: 675352 If continuation sheet Page 16 of 16