Health inspection·November 12, 2024

F 0641 The resident was not observed or interviewed as he was discharged on 04/03/24. Level of Harm - Minimal harm or potential for actual harm In a record Review of Resident #1 face sheet dated 11/07/24 reflected he was a [AGE] year-old male that was admitted on [DATE] and discharged home on [DATE]. Resident's current DX: Poly Substance Abuse, Schizophrenia, Lymphedema, insomnia (trouble sleeping) Type 2 DM, Schizophrenia Residents Affected - Few In a record review of Resident #1 discharge MDS dated [DATE] completed by MDSC R reflected that the section for the BIMS score was empty. Sections D and E did not address mood or behaviors. Section GG reflected that resident #1 required supervision and touching for eating, oral hygiene, toileting, shower, dressing, and general hygiene. The resident uses a motorized wheelchair for mobility. Section I addressed his diagnosis of Schizophrenia. Section N use of antidepressant. Resident refused a referral for placement and discharge. The MDS was approved by the DON on 04/17/24. In a record review of Resident #1 (q) MDS dated [DATE], reflected he had unclear speech, communicate his needs; BIMS score of 15 indicating he was cognitively intact. the MDS did not indicate any behaviors or moods scoring 0. Resident active DX of Schizophrenia was addressed DM3; Heart failure, and HBP. Pressure reducing mattress for bed takes antidepressant. Section J did not address his diagnosis of pain. In a record review of Resident #1's revised Care plan dated 03/06/24 reflected resident has a history of making false allegations as evidenced by previously offering staff money for sexual acts .interventions investigate, if allegations are false the staff will reorient and redirect as needed with reassurance and reality orientation. The staff will investigate allegations/statements as per facility policy. The resident has a behavior problem r/t (offering staff money for inappropriate sexual behaviors. interventions discuss the resident behaviors. Explain/reinforce why behaviors are inappropriate and/or unacceptable. Monitor behaviors and attempt to determine the underlying cause. Take a second person in the room, when available. In a record review of Resident #1's MD progress note dated 03/08/24 reflected he had a history of substance abuse; VS have remained stable .complained of chronic knee pain. t Normal cognition, Psychologic Oriented X 3, Clear and Lucid (clear and understand), Normal Mood (state of mind)/affect. DX: Insomnia (trouble sleeping) poly substance abuse (illegal drug use), Schizophrenia (mental disorder hallucinations.) per records not treated, and major depressive disorder (mental disorder that includes low mood) (not being treated). MD E informed nurse to contact Pain management. Nursing denies any changes in conditions or any new issues. In an interview with MD E on 11/08/24 at 1:00 PM she stated that Resident #1 was not treated for his mental illness of MDD and Schizophrenia. She had no concerns about his behaviors. She stated that he does not appear to be using illegal substances or suspected at the time of her visits. In a record review of Resident #1's Hospital PASSR Screening Level 1 dated reflected he had a Mental Illness in Section C. The PL1 is completed with suspicion of positive PASSR eligibility and therefore submitted with the Preadmission type of admission because the LA is the submitter. In a record review of the document titled undated Active Residents with PASSR Positive PE provided by the ADM on 11/08/24, did not list Resident #1. Resident #3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675352 If continuation sheet Page 2 of 5 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 11/12/2024 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In a record review of Resident #3's face sheet dated 11/07/24 reflected he was a [AGE] year-old female that was admitted on [DATE] and she was discharged on 04/13/24 at 7:20 AM to the hospital. Resident's current DX were COPD (lung disease that damages the lungs and airway) Severe Asthma, Methicillin Resistant Staphylococcus Aureus (MRSA - Infection of skin and soft tissues). In a record review of Resident # 3's admission evaluation, completed by RN J and dated 04/11/24, reflected resident had oxygen equipment to be administered 3 LPM by nasal cannula. In a record review of Resident # 3's admission MDS assessment dated [DATE] completed by LVN R reflected she had a BIMS score of 13 indicating she was cognitively intact. Section GG addressed Resident #3's functional capabilities reflecting she used a wheelchair for mobility. Resident #3 required supervision and touching assistance for eating. She required partial staff assistance for oral hygiene, and she was dependent on staff for showers and ADL hygiene care Section I medical diagnosis did not address diagnosis for anxiety. Section N did not address Resident #3's active diagnosis. Section O special treatments did not address her Central PICC line catheter, while a resident and at discharge. In a record review of Resident # 3's discharge MDS dated [DATE] completed by LVN R reflected Resident #3 was discharged on 04/13/24 to a hospital. Section C cognitive patterns, C0500 BIMS summary score was left blank. Section E behaviors E 0800 rejection of care. did not address Resident #3's behavior of resisting care. Section I titled Active Diagnosis did not address Resident #3's diagnoses of anti-anxiety, DM 2, Section N titled Medications N0415 high risk drug classes did not address Resident #3's anti-anxiety medication use. Section O titled special treatments, procedures, and programs was left blank, and did not address Resident #3's oxygen treatment, H1. IV medications IV intravenous therapy medications (a way to administer fluids directly into a vein), O1 IV Access, O4, central (PICC Percutaneous Indwelling Central Catheter) (catheter device that enters the boy through the skin and remains for a period of time), isolation quarantine for active infections, IV medications Vasoactive medications), while a resident or at discharge. In a record review of Resident # 3's care plan dated 04/11/24 reflected Resident #3 has a DX of MRSA Colonization. Intervention contact isolation wear gowns, mask, changing contaminated linen. Give antibiotic therapy as ordered standard precautions for infection control. Resident has oxygen therapy r/t respiratory illness monitor for s/sx of distress and report to MD. Resident has impaired cognition function/dementia or impaired thought process. Administer medication as ordered, discuss concerns of confusion and disease process, consistent routine for resident. Resident is resistive to care. Allow the resident to make decisions about treatment regime. In a record review of Resident # 3's physician order dated 04/11/24 reflected respiratory evaluation before and after nebulizer (device used to administer medications into the lungs) treatments every shift. Order dated 04/12/24 for PICC Flush 5mL of NS every shift. Order dated 04/12/24 Vancomycin Intravenous Solution use 250 ml intravenously (by use of needle) every 8 hours for pneumonia. In a record review of Resident # 3's April 2024 MAR reflected resident entry on 04/11/24 and oxygen was checked every shift .SOB, order O2 at 2 liters per minute via NC every shift 04/12/24 at 12:36 AM. In a record review of Resident #3's hospital records dated 04/08/24 reflected a past medical history or severe persistent asthma and COPD on 2L NC at baseline admitted to the ICU on 3/14 for acute respiratory failure due to status asthmaticus requiring intubation. Initial concern for fungal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675352 If continuation sheet Page 3 of 5 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 11/12/2024 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few infection started on voriconazole (anti-fungal medications used to treat infections. Respiratory cultures reflected she was + (positive) MRSA on 3/20/24. She required prolonged intubation and finally extubated on 4/2/24. Post-extubating developed new pulmonary opacity with fever and repeat cultures still + (positive) MRSA. She was restarted on cefepime and vancomycin (antibiotic). Currently on 4L NC. In an interview on 11/12/24 at 12:00 PM, the MDSC H stated that the MDS for Resident #1 and Resident #3 was completed by the previous MDSC, MDSC R. MDSC H stated she was not employed at the time of Resident #1 and 3's admission or discharge. MDSC H would not answer any more questions about MDS. In an interview on 11/12/24 at 12:08 PM, the ADON revealed she was new employee. The ADON stated that the MDS Coordinator was responsible for ensuring the assessment accurately reflected the resident medical conditions, level of functioning, diagnosis, and treatment for care while at the facility. She stated that an inaccurate assessment could lead to residents decline in care. In an interview on 11/12/24 at 12:15 PM, the SW revealed she was responsible for completed the sections D Mood, E Behaviors, and C Cognitive on MDS. She stated that MDSC R completed the discharge MDS and quarterly MDS for Resident #1 and Resident #3 at the time. The SW said it would have been the responsibility of the MDS C to completed, review, and correct other sections of the MDS. The SW stated if the assessment was not accurate, the current status of the resident would not be correct, therefore, it could result in the resident not getting the appropriate care needed. In an interview on 11/12/24 at 12:30 PM, the DON, revealed she was familiar with Resident #1 and Resident #3. She stated the MDSC was responsible for completing and updating MDS assessments. She stated Resident #1 exhibited behaviors during the MDS look back and Resident #3 was admitted and discharged with orders for oxygen treatment via NC, PICC line, IV, and antibiotic use. The DON stated she updated Resident # 1's care plan on 03/28/24 to reflect his behaviors. She also completed Resident #3's care plan addressing her medical treatments for infection and oxygen. She stated that failing to accurately address the resident's care would be diminished due to incorrect documentation. In an interview with the ADM on 11/12/24 at 1:58 PM revealed he was familiar with both Residents #1 and #3. He stated confirmed proving the MDS dated [DATE] via email as the most recent assessment. The ADM stated that Resident #1 demonstrated verbal aggression with inappropriate sexually provocative language to female staff while being a resident and at the time of his discharge date [DATE]. He stated it was his expectation for the MDS to be accurate and reflect resident care and medical conditions. The ADM stated the MDS Coordinator was responsible for completing the MDS assessment. In a record review of facility policy dated 08/22/24 titled RAI Process reflected Policy: The Facility will utilize the Resident Assessment Instrument (RAI) process as the basis for the accurate assessment of each resident's functional capacity and health status, as outlined in the CMS RAI MDS 3.0 Manual. Each MDS section will be completed by the responsible individual. Each resident's assessment will be coordinated by and certified as complete by a registered nurse, and all individuals who complete a portion of the assessment will sign and certify to the accuracy of the portion of the assessment he or she completed. All information recorded within the MDS Assessment must reflect the resident's status at the time of the Assessment Reference Date (ARD) Validation: Verify that all MDS assessments in the file were transmitted. Check the Final Validation Report for critical and data integrity errors. In a record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675352 If continuation sheet Page 4 of 5 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 11/12/2024 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete version 1.17.1 dated October 2024 reflected, The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts . In addition, the assessment must represent an accurate picture of the resident's status during the observation period of the MDS. appropriate participation of health professionals must be based on the physical, mental, and psychosocial condition of each resident. This includes an appropriate level of involvement of physicians, nurses, rehabilitation therapists, activities professionals, medical social workers, dietitians, and other professionals, such as developmental disabilities specialists, in assessing the resident, and in correcting resident assessments reference SUBPART - Subpart B-Requirements for Long Term Care Facilities. Event ID: Facility ID: 675352 If continuation sheet Page 5 of 5