Health inspection·May 14, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #43 Clinical Record dated 04/28/2025 reflected no discharge summary and reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter). In an interview with the RN C on 05/14/2025 at 1:09PM, who stated that she could not locate a Discharge Summary for Resident #43. RN C stated completing the Discharge Summary for Resident #43. RN C stated that the facility has a stack of documents to be filed and was not able to locate documents. In an interview with the DON on 05/14/2025 at 2:15 PM, revealed that discharge summaries should be completed for each resident that discharges from the facility. DON stated that there was not a Discharge Summary for Resident #43. The DON stated that there were risks to residents being discharged from the facility without a Discharge Summary. DON stated that without a Discharge Summary, the discharged residents would not be able to meet with the staff to discuss their reconciliation of medications and their discharge plans such as home health and care responsibilities. DON stated that if a resident does not have a Discharge Summary, there was a potential for there being a gap of follow-up appointments for medical needs. The DON stated that if there was not a Discharge Summary for discharged residents, they would miss the opportunity for any continuous care and appointments. In an Interview with the Administrator on 05/14/2025 at 4:48 PM, revealed that discharge summaries should be completed for each resident that discharges from the facility. He stated that before a resident was discharged from the facility, there was a note done in PCC (Resident records), and if the resident was discharged home, the staff will speak with the family and a doctor to ensure that the resident was being sent home with some instructions regarding the care that will be needed at home. Administrator stated that different Nursing Staff Managers have been assigned to the task of ensuring that the Discharge Summaries for discharging or discharged residents have been completed. He stated that there was not anyone overseeing that Nursing Staff Managers ensure that the Discharge Summaries are being completed. He stated that he felt that the staff at the facility were doing their due diligence when a resident was discharged home, and the Staff would write a detailed progress note in their file on PCC. He stated that that families, including the residents (if they are alert and oriented), are talked to before they are discharged home to ensure that follow-up appointments will be done. He stated that he felt that the facility had done good with safe discharges for residents. The Administrator stated the risk of harm caused to a resident if they are discharged home without a Discharge Summary was a lapse in care. Record review of the facility's policy titled, Discharge Summary and Plan, reflected the following; Policy Statement: A) Assessing the resident's continuing care needs, including: 1. Consideration of the resident's and family/caregiver's preferences for care; 2. How services will be accessed; and 3. How care should be coordinated among multiple caregivers, as applicable; 4. Include regular re-evaluations of the resident to identify changes that require modification of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675417 If continuation sheet Page 2 of 17 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 675417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Park Health & Rehabilitation Center 2815 Martin Luther King Jr Blvd Dallas, TX 75215 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 0628 discharge plan. The discharge plan must be updated, as needed to reflect these changes. Level of Harm - Minimal harm or potential for actual harm B) Developing an interdisciplinary team discharge plan designed to ensure that the resident's needs will be met after discharge from the facility, including resident and family/caregiver education needs; Residents Affected - Few C) Initiating and maintaining collaboration between the Nursing Facility and the local contact agency to support the resident's transition to community living, as applicable, including making referrals to the LCA under the process established by the State; and D) Assisting the resident and family/caregivers in locating and coordinating post-discharge services. E) Refer to Section Q of the RAI Manual Discharge Summary must include: A) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent labs, radiology and consultation results. B) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter). C) A final summary of the resident's status medical and functional status at the time of discharge D) A Post-discharge plan of care (POC) 1. A post- discharge plan of care will be developed with the participation of the resident, and with the resident's consent, the resident representative (s). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675417 If continuation sheet Page 3 of 17 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 675417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Park Health & Rehabilitation Center 2815 Martin Luther King Jr Blvd Dallas, TX 75215 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living, received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Residents #22) reviewed for ADL care. Residents Affected - Few CNA G failed to ensure Resident #22 was provided her shower as scheduled on the 2:00 PM to 10:00 PM shift on 5/12/25. This failure could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem. Findings included: Record review of Resident #22's admission Record dated 5/12/25 reflected a [AGE] year-old female originally admitted to the facility on [DATE]. Record review of Resident #22's Quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 9 indicating moderately impaired cognition. Her diagnoses included hypertension (high blood pressure); stroke; hemiparesis (muscle weakness or partial paralysis on one side of the body often caused by a stroke); contractures (permanent shortening and stiffening of the muscles, tendons and ligaments) of the hand and elbow anxiety disorder; and pain. She required Substantial/Maximum assistance for showering and bathing. Record review of Resident #22's Care Plan Report reflected the following entries: Focus: [Resident #22] has hemiparesis r/t stroke, dated initiated on 12/6/17. Interventions: Bathing: I require Extensive x1 staff with bathing/showering . Focus: The resident has a behavior problem r/t Refusal of showers, dated revised 4/3/24. Interventions: Anticipate and meet [Resident #22's] needs .Caregivers to provide opportunity for positive interactions, attention. Stop and talk with him/her as passing by . Record review of Resident #22's ADL records dated May 2025 reflected an entry for bathing Monday, Wednesday and Friday on the 2 PM to 10 PM shift. All scheduled dates were signed as completed including one on 5/12/25 at 5:47 PM by CNA G. Record review of Resident #22's Progress Notes reflected the following entry dated 5/13/25 at 3:04 PM: . [Resident #22] mentioned that her shower was missed on yesterday evening. she was offered one now but declined, stating that she didn't want to throw her schedule off. Reassured that it wouldn't but she continued to decline. informed that she should let the staff know if she decides that she would like to take one this evening. The entry was signed by the DON. There were no other entries located in the progress notes related to Resident #22's shower which was due on 5/12/25. Record review of a shower schedule sheet dated 12/12/24 reflected the following [Station number] 2-10 showers.Notify nurse of EVERY refusal . DO Not change the schedule, if there are any issues (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675417 If continuation sheet Page 4 of 17 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 675417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Park Health & Rehabilitation Center 2815 Martin Luther King Jr Blvd Dallas, TX 75215 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 0677 report them to the DON/ADON. Level of Harm - Minimal harm or potential for actual harm The schedule was divided by sections reflecting which rooms were scheduled for showers on Monday/Wednesday/Friday and those scheduled on Tuesday/Thursday/Saturday. Resident #22's room number was reflected as scheduled on Monday/Wednesday/Friday on the 2 PM to 10 PM shift. Residents Affected - Few Observation and interview on 5/12/25 at 11:49 AM revealed Resident #22 was in her room, sitting up in her chair eating her lunch. She appeared well-dressed and groomed. Resident #22 stated she did not always get her showers as scheduled because the staff did not always get to her. She stated she was supposed to receive a shower every Monday, Wednesday, and Friday on the 2 PM to 10 PM shift. She stated, I'm due for one today but I might not get one because I'm going to want to lay down, they don't always want to get me up. She was unable to recall whether she had received her shower which would have been due on 5/9/25. During an observation and interview on 5/13/25 at 10:58 AM, Resident #22 was observed self-propelling from her room into the hall. She stated she had not received a shower as scheduled the evening before on 5/12/25. Resident #22 stated a CNA H stayed late and had cleaned her up before she went home and the following CNA, CNA G never offered her a shower. Resident #22 stated she did not wish to get anyone in trouble but just wanted to get her showers. Resident #22 declined to speak further about her showers as she was heading to an activity. During an interview and record review on 5/13/25 at 11:52 AM, RN C stated residents were scheduled for baths on certain days and shifts and presented a binder which held the Shower Schedule sheet. RN C stated the CNAs were to report any skin conditions or refusals directly to the charge nurse and document the showers and baths provided into the computer kiosk (resident records). RN C stated the nurses were responsible for checking the computer to ensure they were completed and report any refusals to the oncoming shift so another attempt could be made. During an observation and interview on 5/13/25 at 1:36 PM, Resident #22 was observed in bed and CNA H was leaving her room. CNA H stated she had just assisted her back to bed for a nap. CNA H stated she worked the 6 AM to 2 PM shift and it was her fourth day working at the facility. CNA H stated she stayed over the previous evening to help because someone had called in sick. CNA H stated she has assisted with a bed bath and a shower the previous evening, but neither was with Resident #22. CNA H stated she knew who needed a bath based on the Shower Schedule and kiosk (resident records), but it was her first time helping the 2 PM to 10 PM staff and she did what they (staff) had asked her to do. CNA H stated she had provided incontinent care to Resident #22 before leaving at 7 PM and the resident had not mentioned anything about a shower to her. CNA H stated, if Resident #22 had said anything to her about a shower, she would have told her charge nurse or the other aides before she left. During an interview on 5/13/25 at 1:40 PM, Resident #22 stated she never asked CNA G for a shower after CNA H left for the evening. Resident #22 stated CNA H changed her before she left, and Resident #22 had mentioned the shower to CNA G, but Resident #22 knew CNA G was heading home. Resident #22 stated CNA G should have known it was her night for a shower and never offered her one. Resident #22 stated she did not mention it to CNA G when she came in later to change her because Resident #22 knew it was close to the end of her shift. Resident #22 stated she never mentioned it or complained to her Charge Nurse because it had happened before, and nothing had changed. During an interview on 5/13/25 at 2:00 PM, LVN F stated he worked the 2 PM to 10 PM shift and was Resident #22's Charge Nurse. LVN F stated he knew the resident's bathing schedule by referring to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675417 If continuation sheet Page 5 of 17 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 675417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Park Health & Rehabilitation Center 2815 Martin Luther King Jr Blvd Dallas, TX 75215 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few schedule kept at the nurse's station. LVN F stated the CNAs documented the showers provided in the kiosk and report any refusals to them. He stated, if a resident refused to be bathed, they were supposed check on the resident and make another offer. If the resident continued to refuse, they documented the refusal and informed the oncoming nurse. He stated he checked the computer to determine the showers were completed based on the CNAs' documentation and stated her shower due on 5/12/25 had been documented as completed. LVN F stated he was unaware Resident #22 had missed a shower on 5/12/25. LVN F stated the risk to the residents not receiving showers included skin breakdown and loss of dignity. During an interview on 5/13/25 at 2:09 PM, CNA G stated she worked the 2 PM to 10 PM shift and rotated halls. She stated she knew which residents required bathing on her shift based on the Shower Schedule and information in the computer. She stated Resident #22 did not get a shower as scheduled on 5/12/25 because, She (Resident #22) went to bed, to be honest she likes [CNA I] to do them. CNA G stated she did not offer Resident #22 a shower because another aide was working her hall earlier in the shift and then stated, by the time I got to her Resident #22 said it was too late, I did offer. CNA G stated when showers were provided to residents and the showers were documented in the computer. When asked why she had documented Resident #22's shower as completed at 5:47 PM on 5/12/25, she replied, If I'm not mistaken, I think one of the girls said she gave it, I really can't say. She stated she had documented it because Mondays were one of Resident #22's shower days, she thought CNA H had done it and was not sure if she had access to the computer yet. She stated it was her mistake and she should not have done it. She stated she had been moving from hall to hall and should have confirmed it was done. CNA H stated, if a resident refused a shower, she was supposed to have documented the refusal in the computer and informed the Charge Nurse. CNA G stated the risk of residents missing showers included body odor, skin breakdown, dry skin and loss of dignity. During an interview on 5/13/25 at 3:45 PM, the DON stated she had been made aware of Resident #22 missing her shower and the documentation error. DON stated she had just checked in on the resident around 3:00 PM [5/13/25] and offered to provide one at that time, but she had declined. She stated CNAs were aware they were to report any missed showers to the Charge Nurse. DON stated the risk to residents for missing showers was skin breakdown and loss of dignity. Record review of the facility's undated policy titled, Bath, Tub/Shower reflected the following: Bathing by tub bath or shower is done to remove soil, dead epithelial cells, microorganisms from the skin, and body odor to promote comfort, cleanliness, circulation, and relaxation. A medicated tub bath can also be provided to treat skin conditions. The aging skin becomes dry, wrinkled, thinner and blemished with various aging spots over time and is easily affected by environmental temperature and humidity, sun exposure, soaps, and clothing fabrics. The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level. Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed. Goals: 1. The resident will experience improved comfort and cleanliness by bathing. 2. The resident will maintain intact skin integrity. 3. The resident will be free from soil, odor, dryness, and pruritus following bathing. Procedure: 1. The resident will receive assistance with bathing according to their resident centered plan of care . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675417 If continuation sheet Page 6 of 17 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 675417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Park Health & Rehabilitation Center 2815 Martin Luther King Jr Blvd Dallas, TX 75215 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one of five (Resident #22) residents reviewed for pharmacy services. The Facility failed to ensure nursing staff ordered medications in a timely manner for Resident #22 resulting in her missing a scheduled morning dose of Robaxin used to control her muscle spasms on 5/13/25. This failure placed the residents at risk of not receiving medications as ordered by the physician and a delay in treatment and worsening of their condition. Findings included: Record review of Resident #22's admission Record dated 5/12/25 reflected a [AGE] year-old female originally admitted to the facility on [DATE]. Record review of Resident #22's Quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 9 indicating moderately impaired cognition. Her diagnoses included hypertension (high blood pressure); stroke; hemiparesis (muscle weakness or partial paralysis on one side of the body often caused by a stroke); contractures (permanent shortening and stiffening of the muscles, tendons and ligaments) of the hand and elbow anxiety disorder; and pain. Record review of Resident #22's Care Plan Report reflected the following entries: Focus: [Resident #22] has hemiparesis r/t stroke dated revised on 7/26/21. Interventions: .Give medications as ordered. Monitor/document for side effects and effectiveness. Pain management as needed. See MD orders . Record review of Resident #22's Order Summary Report dated 5/12/25 reflected an order for methocarbamol (Robaxin) Oral Tablet 750 mg one tablet two times a day. The order was dated 3/31/25. Record review of Resident #22's Medication Administration Record dated 5/1/25 through 5/31/25 reflected the following entry: Methocarbamol Oral Tablet 750 mg give one tablet by mouth two times a day. The entry dated 5/13/25 AM reflected the code 9 (other/See Nurse Note) indicating the medication had not been administered. Entered by MA E. Record review of Resident #22's Progress Notes reflected the following entries: 5/13/25 2:26 PM: Contacted pts [Nurse Practitioner name] NP regarding pts missed dosage of Methocarbamol 750mg. Med has been ordered. Pt had no s/s reported. Signed by LVN D. During an observation and interview on 5/13/25 at 1:36 PM, Resident #22 was observed lying in bed. She stated they had new staff at the facility, and she did not believe they were ordering her medications correctly. Resident #22 stated she was told the evening before (05/12/2025) they were running (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675417 If continuation sheet Page 7 of 17 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 675417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Park Health & Rehabilitation Center 2815 Martin Luther King Jr Blvd Dallas, TX 75215 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few out of her Robaxin, and she received her last one at bedtime on 5/12/25. She stated, today they said I had to wait until tonight for it. Medication Aide said she had to talk to the nurse about it. I'm supposed to get it in the morning and at bedtime, I didn't get it this morning. Resident #22 stated the staff needed to order her medication sooner before they ran out, so she did not have to wait for the pharmacy. She stated she needed the medication for pain. Resident #22 stated she was doing ok with her pain at the time but they need to have meds for us. During an interview on 5/13/25 at 1:54 PM, RN C, stated MA E had asked her to reorder Resident #22's Robaxin that morning [5/13/25] and stated she was previously unaware she was low. During an interview on 5/13/25 at 2:00 PM, LVN F stated he was Resident #22's Charge Nurse on the 2 PM to 10 PM shift. LVN F stated he saw the facility had run out of her Robaxin the on 5/12/25 after administering her bedtime dose, and had reordered it from the pharmacy at that time. LVN F stated the pharmacy made deliveries on Monday through Friday in the evenings before 10:00 PM. LVN F stated medications should be reordered once the medications hit the blue line (last row area on a medication punch card highlighted blue to indicate the final doses available) and that it was best to order the medications when they were about a week away from running out. LVN F stated he had worked a double shift on 5/11/25 and had administered both her doses that day (05/11/2025). LVN F stated he should have reordered the medications then when he noticed Resident #22 was running low and could not explain why he did not. He stated the medication was not available in the facility's ekit [emergency supply of medication stocked at the facility]. LVN F stated they were very busy but it was a mistake and was overlooked. LVN F stated the risk of running out of medications depended on the type of medication and included pain, or increased behaviors. During an interview on 5/13/15 at 3:45 PM, the DON stated medications should be ordered once the doses remaining hit the 'blue line' depending on the number of doses due per day and early enough to ensure there was enough stock so that pharmacy delivery was reasonable. DON stated generally, if a medication was ordered by noon, they would be delivered the same day unless it was a weekend. The DON stated all nurses had been trained on medication ordering as part of their orientation. DON stated the risk to residents running out of medications depended on the medication type and therapeutic use. During an interview on 5/14/25 at 8:05 AM, the DON stated she had assessed Resident #22 and had spoken with Resident #22's Nurse Practitioner. DON said they had received an alternate medication-Baclofen [a muscle relaxant used for muscle spasms] which was available in the facility's ekit and had initiated the doses. During an interview on 5/14/25 at 10:15 AM, MA E stated she had informed the nurse on 5/13/25 in the morning Resident #22 was out of Robaxin. She stated she thought she or the nurse had ordered it the previous week and was not sure why it hadn't arrived. She stated, if they were running low or near the blue area on a medication card, she informed the nurse a medication needed to be reordered. She stated she was not absolutely sure whether the medication had been reordered. During an interview on 5/14/25 at 10:25 AM, Resident #22 stated she had received other medication for her muscle spasms and was pleased with the outcome. She stated her main concern was ensuring her medications were available when she needed them. During an interview on 5/14/25 at 5:06 PM, the Administrator stated he had been made aware of the concerns related to medication ordering. He stated the risk for failure to timely order a resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675417 If continuation sheet Page 8 of 17 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 675417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Park Health & Rehabilitation Center 2815 Martin Luther King Jr Blvd Dallas, TX 75215 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 0755 medication was missing doses and depended upon the type of medication missed. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/14/25 at 2:43 PM, the DON stated she was unable to locate a written policy related to ordering and re-ordering medications from the facility's contracted pharmacy. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675417 If continuation sheet Page 9 of 17 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 675417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Park Health & Rehabilitation Center 2815 Martin Luther King Jr Blvd Dallas, TX 75215 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 properly secure medications in a locked compartment for 1 of 2 medication carts (Unit 2) reviewed for drug storage. On 05/13/2025, LVN D left the Unit 2 medication cart unlocked and unattended for an unknown amount of time. These failures placed residents at risk for unauthorized access to the medication cart and consumption of harmful medications. Findings included: An observation and interview on 5/13/25 at 7:46 AM revealed an unlocked medication cart was situated in a hallway across from the Unit 2 nurses' station. There was no nurse or medication aide seen in the vicinity of the cart. RN C approached from around a corner and stated she did not know why the medication cart had been left unlocked and believed that MA E had the keys. RN C was observed locking the cart. During an observation and interview on 5/13/25 at 7:50 AM, MA E was passing medications on the 100 Hall and stated she did not have the keys to the 200 Hall at that time and believed the nurse had them. During an interview on 5/13/25 at 8:47 AM, LVN D stated she had counted the cart and received the keys from the night shift. LVN D stated she had briefly handed the keys to RN C who needed to check something in the cart but was standing with her the entire time. LVN D stated she did not know how she left the cart unlocked. LVN D stated leaving a cart unlocked placed residents at risk of theft. During an interview on 5/13/25 at 11:25 AM, RN C stated she did not know how the Unit 2 cart had been left unlocked and that medication carts should remain locked at all times when not in use. RN C stated the risk of unlocked carts was that residents could potentially take medications from the cart resulting a overdoses or other negative effects from the medications. During an interview on 5/13/25 at 1:05 PM, the DON stated she had been made aware of the medication cart found unlocked. DON stated the staff had been trained and knew better. The DON stated the risk of unlocked medication carts included medication theft and resident access to medications potentially causing harm. DON stated she had initiated additional in-service training related to medication security. During an interview on 5/14/25 at 5:06 PM, the Administrator stated the risk of unlocked and unattended medication carts was residents could access the carts and get at the medications causing potential harm. Record review of the facility's policy titled, Medication Storage in the Facility dated 2025 reflected the following: Policy Medications and biologicals are stored safely, securely, and properly following (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675417 If continuation sheet Page 10 of 17 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 675417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Park Health & Rehabilitation Center 2815 Martin Luther King Jr Blvd Dallas, TX 75215 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 FORM CMS-2567 (02/99) Previous Versions Obsolete manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedure . 2. Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications (e.g. medication aides) are allowed unsupervised access to medications. Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access . Event ID: Facility ID: 675417 If continuation sheet Page 11 of 17 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 675417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Park Health & Rehabilitation Center 2815 Martin Luther King Jr Blvd Dallas, TX 75215 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 for 1 of 1 kitchen reviewed for kitchen safety. 1. The facility failed to seal opened items in plastic bags in the dry storage pantry, refrigerator, and freezer areas on 05/12/25. 2. The facility failed to ensure an expired item in the dry storage pantry area was removed on 05/12/25. 3. The facility failed to ensure the dented cans in the dry storage area with the other canned food were removed from the shelf on 05/12/25. 4. The facility failed to clean the 6 A/C vents in the kitchen on 05/12/25. These deficient practices could affect residents who received meals and/or snacks from the facility's only kitchen by placing them at risk for cross contamination and other food-borne illnesses. Findings included: Observation of the facility's kitchen dry storage, refrigerator and freezer areas and the kitchen A/C vents on 05/12/25 at 9:10 AM, included the following food items were in unsealed packages and containers, expired, and dented cans with the other canned food: Dry pantry area: * 1 unsealed plastic bag of [NAME] Taco Seasoning Mix. The unsealed plastic bag was exposed to air. * 1 white plastic container of cream cheese icing was unsealed and exposed to air. * 1 white plastic container of chocolate fudge icing was unsealed and exposed to air. * 1 unsealed clear plastic bag labeled, noodles. The unsealed plastic container was exposed to air. *1 unsealed package of Tri-Color Pasta was unsealed. The unsealed package was open and exposed to air. * 1 can of 3 1b. [NAME] Artificially Flavored Strawberry Dessert Topping with an expiration date of April 12, 2025. * 1 dented 106 oz. can of pineapples * 1 dented 106 oz. can of mandarin oranges (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675417 If continuation sheet Page 12 of 17 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 675417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Park Health & Rehabilitation Center 2815 Martin Luther King Jr Blvd Dallas, TX 75215 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 Refrigerator area: Level of Harm - Minimal harm or potential for actual harm * 1 clear plastic container with green lid labeled Apple Sauce was unsealed and exposed to air. The white label on the container of Apple Sauce was labeled, Shelf Life 3/10/10. Residents Affected - Some * 1 unsealed plastic bag of American Cheese. The unsealed plastic zip loc bag was unsealed and exposed to air. * 1 clear plastic container with green lid labeled Ketchup was unsealed and exposed to air. The white label on the container of Apple Sauce was labeled, Shelf Life 5/5 and Use by 5/11. * 1 cup of soy milk was not labeled. The soy milk was unsealed and exposed to air. Freezer area: *1 unsealed container of vanilla ice cream labeled use by 04/03/25. *1 unsealed plastic bag of 4 fl. oz. of 13 individual chocolate ice creams were unsealed and exposed to air. *1 unsealed package of 16 oz. Wonton Strips *1 unsealed 13-gallon container or vanilla ice cream. The unsealed container was exposed to air. *1 unsealed plastic bag labeled, croissants. The white label on the outside of the plastic bag had Shelf Life 5-7-25 and there was not a Use By date on the label. A/C Vents: *6 A/C Vents in the Kitchen had a black substance on them. There were 2 A/C Vents directly above the food preparation table. In an interview with the DM on 05/12/25 at 9:48 AM, revealed she had been employed at the facility for 2 years. She stated she was unaware there were expired and unsealed items in the kitchen's dry storage, refrigerator, and freezer areas. The Dietary Manager stated she was unaware there were 2 dented cans stored on the shelves with the other canned food. She stated all kitchen staff were responsible for ensuring all food items in the kitchen's dry pantry, refrigerator, and freezer areas were sealed, labeled and checked for expiration dates. The DM stated that the dented cans in the dry pantry area should have been removed and placed in the area in the dry pantry that was designated for dented cans. She stated there should not be any food items in the kitchen's dry pantry, refrigerator, and freezer areas that were not labeled, sealed, and expired. The Dietary Manager stated she had a total of 6 staff members who she supervised, and they worked various shifts. She stated that she provided monthly reeducation and retraining via In-Service Trainings for all kitchen staff. She stated that the kitchen staff's In-Service trainings are on proper food handling, storage which included ensuring all food in the kitchen was dated, labeled, sealed, included food expiration, food handling and sanitization to prevent food-borne illness per the facility's policy. DM stated that the staff are to immediately throw away anything that had expired dates along with any unsealed items that were found in the kitchen's dry storage, refrigerator and freezer areas. The DM stated that staff are to inform her every time they throw away any items that were found in the kitchen's dry storage, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675417 If continuation sheet Page 13 of 17 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 675417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Park Health & Rehabilitation Center 2815 Martin Luther King Jr Blvd Dallas, TX 75215 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 refrigerator and freezer areas that was thrown away due to the food items being in unsealed packages or containers, including expired food items. DM stated that she was responsible for ensuring that the food items in the kitchen were labeled, dated, sealed and not expired. DM stated that she does a weekly audit of the kitchen's dry pantry, refrigerator, and freezer areas to ensure everything in the area was labeled, dated, sealed and check the expiration dates on the food items. DM stated her expectation was that if staff were to see anything in the kitchen's dry pantry, refrigerator and freezer areas that were not labeled, they were to place a label on the item, check for an expiration date and notify her after they have thrown away the food. DM stated her expectations were the same for the food items that were unsealed. The DM stated if kitchen staff found anything that was unsealed in the kitchen's dry pantry, refrigerator and freezer areas that was not sealed, her expectations were for the staff immediately throw away the item(s) and notify her. DM stated if any kitchen staff observed a dented can on the shelves where the canned items were stored in the dry pantry area, they should immediately place the can(s) in the area in the dry pantry area that was labeled, dented cans. DM stated her expectation for her staff, was that they were to use the FIFO (the principle and practice of maintaining precise production and conveyance sequence by ensuring that the first part to enter a process or storage location is also the first part to exit) procedures to ensure there were not any unsealed, and expired food items throughout the kitchen's dry panty, refrigerator and freezer areas. She stated all staff in the kitchen have received training on how to use the First In, First Out Method, which meant kitchen staff should label the food with the dates they store them, and when staff were restocking the shelves, they were to put the older foods in front or on top so they could be used first. She stated this system allowed the kitchen staff to use the older food items first to ensure that there were not any expired items in the kitchen. The DM stated the items found in the kitchen by the state surveyor was somethings that she missed in her weekly audits, and she will continue to reeducate the kitchen staff to ensure everyone knew what her expectations were the kitchen and to follow the guidelines in the facility's Food Storage Policy. She stated she would immediately retrain and reeducate all kitchen staff via in-service training on food storage, labeling, checking for expired items, proper sealing of containers, bags and packages, A/C vent checks, and utilizing the FIFO Method. DM stated the risk of someone, which included a resident eating food from the facility kitchen's dry storage, refrigerator and freezer areas, expired foods, dented cans were that they could become ill and become sick due to eating something that could cause food-borne illnesses. DM stated there were risks of food borne illness anytime someone ingested food items from the kitchen any items that had not been labeled and stored properly and from dented cans. DM stated that the A/C vents in kitchen are on a Cleaning Schedule for the Maintenance Supervisor. DM stated that she was unsure the last time the A/C vents in the kitchen were cleaned. DM stated that if she needed any maintenance repairs, she would verbally notify the Maintenance Supervisor. DM stated that the facility does not have a Maintenance Request Log for the kitchen. She stated the harm of someone, which included a resident ingesting food from the facility kitchen's dry storage, refrigerator and freezer areas, expired foods, eating something from a dented can could cause someone to have stomach aches and bowel issues. DM stated that if resident eats food from the facility's kitchen that has been prepared below the A/C vents that were unclean, dust and lint could blow from the A/C vent onto the food and can be ingested and cause someone to become sick. DM stated the harm of someone, which included a resident eating food from the facility kitchen's dry storage, refrigerator and freezer areas, expired foods, eating something from a dented can could cause bacteria to enter the areas if a container or package was unsealed. An email was sent to the Administrator on 05/12/25 at 1:37 PM, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675417 If continuation sheet Page 14 of 17 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 675417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Park Health & Rehabilitation Center 2815 Martin Luther King Jr Blvd Dallas, TX 75215 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 requesting the facilities policy regarding the cleaning of A/C vents in the kitchen. Level of Harm - Minimal harm or potential for actual harm In an interview with the Dietary [NAME] on 05/13/25 at 10:55 AM, he stated he had been employed at the facility for 5 days. He stated that he was unaware there were expired and unsealed items in the kitchen's dry storage, refrigerator and freezer areas. He stated he was unaware there were 2 dented cans on the shelves with the other canned food items. The Dietary [NAME] stated that all the staff were responsible for storing the items on the shelf and checking the expiration dates, dented cans to make sure there were not any unsealed items in the kitchen. He stated that at least every month, the Dietary Manager in-serviced the kitchen staff on food storage, labeling and dating, removing expired items from the shelves in the dry pantry, freezer, and refrigerator areas and for dented cans and the use of the FIFO method. The Dietary [NAME] stated that if items are unsealed and exposed to air, the kitchen staff are to immediately throw the items in the trash can and tell the Dietary Manager about the item(s) that were thrown away. He stated that when a new shipment of food is delivered to the kitchen, the kitchen staff are to use the FIFO method. He stated that the FIFO method means to push the items that were on the shelves previously on the shelves in the front and place the new delivered items to the back of the shelves. The Dietary [NAME] stated that if there were any dented cans in the dry pantry area, they are to immediately to be removed from the shelves with the other canned foods and stored in the area in the dry storage area labeled, dented cans. He stated that after placing the dented cans in the proper area, he would notify his DM. He stated there were risks of anyone who eats the food coming from the kitchen if they have eaten food items from the kitchen's dry pantry, refrigerator, and freezer areas any items that had not been labeled, stored, which included dented cans and expired foods. The Dietary [NAME] stated if any of the above food were to be eaten by anyone, they could or would become very sick and ill. Dietary [NAME] stated the risk of anyone ingesting any of the aforementioned items, they could have stomach aches and vomiting. Residents Affected - Some In an interview with the Dietary Aide on 05/13/25 at 11:14 AM, who stated she had been employed at the facility for 5 years. She stated she was unaware there were expired and unsealed items in the kitchen's dry storage, refrigerator and freezer areas. She stated she was unaware there were 2 dented cans on the shelves with the other canned food items. She stated all the staff were responsible for storing the items on the shelf and checking the expiration dates, dented cans to make sure there were not any unsealed items in the kitchen's dry storage, refrigerator and freezer areas. Dietary Aide stated that if she found any item(s) in the kitchen's dry storage, refrigerator and freezer areas, she would immediately throw them away and then tell the DM what she found. Dietary Aide stated that she had taken several In-Service trainings on food storage, labeling, dented cans, and ensuring that expired items are immediately thrown away. She stated that she had been trained on using the FIFO method. Dietary Aide stated that the FIFO method means that older food items are placed in the front on the shelves in the dry pantry area and the newer food items are placed behind the older food items on the shelves. She stated that dented cans are to be removed from the shelves and placed in the area labeled, dented cans in the dry pantry area. The Dietary Aide stated that expired items, if found are to be removed immediately and thrown away. She stated that the DM was to be notified anytime items are found to be expired, unsealed and not labeled in the kitchen's dry pantry, refrigerator and freezer areas. She stated that she if any food items are unsealed in the freezer, the food will be freezer burned. She stated that if anyone ingests food from the kitchen that was expired or came from unsealed packages or containers, they can become sick and vomit. Dietary Aide stated that if anyone ingests food from the kitchen that was expired or came from unsealed packages or container, they could be harmed by having some pain issues. In a telephone interview on 05/20/25 at 10:51 AM with Maintenance Supervisor, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675417 If continuation sheet Page 15 of 17 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 675417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Park Health & Rehabilitation Center 2815 Martin Luther King Jr Blvd Dallas, TX 75215 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 he stated that he had been employed at the facility for 24 years. He stated that on 05/12/25, the DM informed him that this Surveyor mentioned him that the A/C vents in the kitchen were not clean. He stated that on 05/12/25, he looked at the A/C vents and they were unclean, and they had dust, dirt and grease on them. He stated that on 05/12/25, he removed all the A/C vents from the kitchen and washed and cleaned them and painted them. He stated that the facility uses the Maintenance Care Application (a maintenance management software that was designed for facilities maintenance requests) for staff to log maintenance requests. He stated that the facility does not have a Maintenance Log. He stated that when a staff member enters information into the Maintenance Care Application, himself, the Administrator and the facility's Corporate Office will receive the work orders after they have been submitted by staff. The Maintenance Supervisor stated that a lot of times staff will see him on the floor, and they will tell him about a repair that was needed, and he or the staff member will have entered the Maintenance Request on the Maintenance Care Application. Maintenance Supervisor stated that in the future, he will make sure that all staff will log on the Maintenance Care Application to place their request maintenance requests to ensure that repairs are completed. The Maintenance Supervisor stated that if all maintenance requests are made in the Maintenance Care Application, there would be documentation of the repairs that were completed. He stated that the A/C vents in the kitchen will have a buildup of grease, dirt and dust and he will take them down and clean them. Maintenance Supervisor stated that his last time he cleaned the A/C vents in the kitchen was last month. He stated that the risk of there being unclean A/C vents in the kitchen was that particles, such as dirt and dust could fall in food while it was being prepared and if the food was ingested, it could cause someone to become sick, which can cause them pain. An email was sent to the Administrator on 05/20/25 at 12:14 PM, requested the facilities policy regarding the cleaning of A/C vents. Also, requested a copy of kitchen staff's request for the cleaning of the A/C vents in the Maintenance Care Application prior to the Survey Teams Exit Conference on 05/14/25. In an email received from the Administrator on 05/20/25 at 12:30 PM, who wrote that the facility did not have a policy that was specific to A/C vents. He stated that that the A/C vents in the kitchen are cleaned monthly, and as needed. The Administrator stated that the facility does not have a Maintenance Request Log for tracking A/C vent cleaning. Record review of the facility's policy titled, Food Storage dated 2022, reflected: Policy: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. Procedure: .3. Dry bulk foods (e.g. flour, sugar) are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled . 4. Open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened. 8. On perishable foods, microorganisms such as molds, yeasts, and bacteria can multiply and cause food to spoil. Spoiled foods will develop an off odor, flavor or texture due to naturally occurring spoilage bacteria. If a food has developed such spoilage characteristics, it should not be eaten. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675417 If continuation sheet Page 16 of 17 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 675417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Park Health & Rehabilitation Center 2815 Martin Luther King Jr Blvd Dallas, TX 75215 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 There are two types of bacteria that can be found on food: pathogenic bacteria, which cause foodborne illness, and spoilage bacteria, which causes foods to deteriorate and develop unpleasant characteristics such as an undesirable taste or odor making the food not wholesome, but do not cause illness. Perishable foods have been processed/treated and sealed to eliminate pathogenic bacteria, but spoilage bacteria can multiply and this is what causes the food to deteriorate in quality and taste. If perishable food items are not stored at the proper temperature, spoilage bacteria can grow faster than anticipated and food becomes spoiled and should not be served. Food items such as loaves of bread or dairy products with a stamped best-by or use by date do not need to be labeled when opened as this will not affect the date by which they should be used. However, if possible food spoilage is observed prior to the best by date, the product will be discarded. Record review revealed that the facility did not have a policy related to cleaning the A/C vents in the kitchen. The AC Vent cleaning policy was not provided by the Survey Teams Exit Conference on 05/14/25. Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under § 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675417 If continuation sheet Page 17 of 17