Health inspection·June 10, 2025

F 0644 Level of Harm - Minimal harm or potential for actual harm Dapagliflozin Propanediol Oral Tablet 5MG (Dapagliflozin Propanediol) Give 1 tablet by mouth one time a day related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. Buspirone HCl Tablet 5 MG Give 1 tablet by mouth three times a day related to ANXIETY DISORDER, UNSPECIFIED Residents Affected - Few Benztropine Mesylate Oral Tablet 2 MG (Benztropine Mesylate) Give 1 tablet by mouth two times a day related to NEUROLEPTIC INDUCED PARKINSONISM Record review of Resident#4's care plan reviewed on 06/10/2025 indicated, she had mental illness, Mental Disability and was PASARR positive. Resident #4's goal indicated she would have the specialized services recommended by the local authority per PASARR specialized services program as needed. Resident #4's interventions indicated the local authority would be invited annually to the care plan meeting for review of specialized services. Record review of Resident #4's most recent PASARR Level 1 Screening completed 01/03/2025 indicated she was positive for a primary diagnosis of Mental Illness and positive for Intellectual Disability. During an interview on 06/10/2025 at 11:20 AM the DON stated the MDS nurse was responsible for making sure PASARRs were done. The DON stated if they were not completed accurately, it could prevent residents from receiving services. During an interview on 06/10/2025 at 4:05 PM the MDS Coordinator said she had been the MDS coordinator for about a month. She stated she was responsible to complete the PASARRs. It is responsibility to enter the resident into SimpleLTC program for the state to where it is sent. Also, to where it is sent to the local authorities if it comes up positive. When it was positive someone usually came in and then assessed them for services. She stated if a PASARR screening was not completed correctly, residents may not receive the services to which they were entitled. She said there was a risk that the resident could miss services she was entitled to if the PASARR forms were not filled out correctly. The MDS coordinator stated, it went automatically if the PASARR unit did not contact her or the SW She stated the only communication she received was confirmation, that they received the orders. She stated someone would come in locally after they received an order to assess a resident. She stated, she does not receive any type of electronic notification of submitting, whether it was submitted properly. She stated she had not been notified by anyone from the state PASARR unit that it was not received. She said it could affect residents negatively if they do not receive the services for which they are slated. Both mentally and even physically. The MDS Coordinator stated even if they do not get the services some of the service department lend some assistance and help till, they do get those services. She stated they do not receive confirmation electronically and they usually just monitor it and go from there. During an interview on 06/10/2025 at 4:20 PM the ADMIN said the responsibility would fall on the MDS Coordinator to take care of the NFSS submission and follow up to ensure acceptance. it. The MDS Coordinator would be responsible for ensuring PASARR assessments were correct. ADMIN stated in the past we(staff) usually would be the backup. ADMIN stated in the past he would reach out to the appropriate dept and find out why it was not submitted. He stated he would follow up with MDS Coordinator to see if it were overlooked and not submitted. He was not aware of the facility receiving a denial. The usual protocol was if it were denied then an email would correspond to advise as such. He stated in this instance they did not receive an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675417 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 675417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2025 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few email. The ADMIN stated he was familiar with the incident and recalled receiving an email from the PASARR unit regarding resident #4. The ADMIN stated the facility submitted the NFSS electronically. He stated he did not recall the person at the PASARR unit. He stated they could not view it in the portal, so it appeared is the NFSS was not submitted. The ADMIN stated Resident#4 did not receive PT services. He stated it was the ADMIN responsibility to make sure this process was completed properly and in accordance with procedure for electronic submission in the SIMPLELTC portal. The ADMIN stated in the future he would ensure NFSS are submitted properly in the portal to prevent this from happening again. During an interview on 06/16/2025 at 3:10 PM Complainant advised it is the responsibility of the facility to monitor the submission of the NFSS into SIMPLELTC portal to ensure if it is accepted. If it is denied, the facility is responsible for making the necessary corrections and resubmit NFSS. The material that is submitted is time sensitive in regard to making sure everything is completed and necessary for the resident in question to get the proper care and services. There is only one method for submission of the documents and that is through the SIMPLE LTC portal, there is no other means to submit this information. Record review of the facility policy, dated Revised 03/16/2019, titled PASARR Nursing Facility Specialized Services Policy and Procedure reflected It is the policy of facility facilities to ensure NFSS Forms are submitted timely and accurately. 7. The IDT may recommend NFSS services for ID/DD and dual MI + ID/DD Residents. 8. Therapy, CMWC DME or DME is notified ASAP after the IDT meeting. (You only have 3 days to enter the PCSP Form after the PCSP meeting). 9. The facility only has 20 business days from the Date of the PCSP meeting to submit a completed and accurate NFSS Form. 10. NFSS will be inputted in SIMPLELTC within 24 hours of receipt of the Assessment/Service from therapy and the Alert section of SIMPLELTC will be monitored daily for approval/denial. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675417 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 675417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2025 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 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide specialized rehabilitative services such as but not limited to physical therapy, speech -language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability or services of a lesser intensity as required in the resident's comprehensive plan of care for 1 (Resident #4) of 5 residents reviewed for specialized rehabilitative services. Residents Affected - Few The facility failed to ensure Resident #4 received physical therapy per the PASARR Comprehensive Service Plan January 2025 to April 2025 . This failure could place residents who require specialized rehabilitative services at risk of a decline in health status and a decreased quality of life. The findings included: Record review of Resident #4's admission Record, dated 06/10/2025, reflected a 39- year-old female. She was admitted to the facility on [DATE]. Record review of Resident #4's Medical Diagnosis list, dated 06/10/2025, reflected Resident #4 was noted to have diagnoses which included acute myocardial infarction due to unspecified occlusion or stenosis of the heart muscle is damaged because of sudden blockage (a stroke caused by a blood vessel blockage) and age-related physical debility (a condition of worsening functional status such as increased muscle weakness, exhaustion, and frequent falls). Record review of Resident #4's Quarterly MDS, signed as completed on 04/22/2025 by the MDS Nurse, reflected Resident #4 had a BIMS score of 15 , which indicated her cognition was intact. She was documented as not having potential indicators of psychosis or behavioral symptoms. She was documented as having had upper extremity (shoulder, elbow, wrist, hand) impairment on one side and lower extremity (hip, knee, ankle, foot) impairment on both sides. She did use a wheelchair and was dependent (requiring a helper for all the effort) for all self-care abilities, to roll left and right, and for tub/shower transfers. She received zero (0) minutes of speech-language pathology and audiology services, occupational therapy, and respiratory therapy. She received five of seven (7) days of physical therapy. Record review of Resident #4's Order Summary Report, dated 06/10/2025, reflected Resident #4 did not have an active order, for PT/OT/ST to evaluate and treat . Record review of Resident #4's PT Evaluation and Plan of Treatment dated 01/06/2025 revealed resident #4 should have received Physical therapy daily five times a week for four weeks. Start date 01/06/2025 ending 03/06/2025. There was no Occupational therapy noted. Record review of Resident #4's MDS Rehab Data report dated 01/12/2025 revealed resident #4 should have received 187 minutes of Physical therapy beginning 01/06/2025. Further review of the clinical record did not validate physical therapy was received. Record review of Resident #4 PASARR Comprehensive Service Plan dated 04/08/2025 revealed the Resident #4 required Occupational and Physical Therapy services. Further review of the clinical record did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675417 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 675417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2025 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 0825 not validate physical and occupational services were received by resident #4. Level of Harm - Minimal harm or potential for actual harm Record review of the MDS dated [DATE] indicated Resident #4 was understood and understood others. The MDS indicated a BIMS score of 15 which indicated she was cognitively intact. The MDS indicated Resident #4 required limited assistance from staff for activities of daily living. The MDS did not indicate Resident #4 was receiving physical therapy. Residents Affected - Few Record review of Resident #4's Care Plan, dated as last review completed 05/09/2025, reflected Resident #4 had the following focuses and interventions: She required assistance with ADLs due to cognitive and physical impairment, with interventions including, Bathing: I require assistance in self-performance with 1 person assistance support. Dressing: required staff x1 for assistance. She was at risk for falls due to an unsteady gait, with interventions including, Rehab Therapy will screen me PRN, or quarterly, or per facility protocol if I am needing any rehab therapy. Record review of the PASSAR Nursing Facility Specialized Services (NFSS) (a request for therapy services) with the assessment date of 01/03/2025 for physical therapy submitted on 04/14/2025. The facility was unable to provide any previous NFSS form. During an interview on 06/10/2025 at 3:45 PM with Resident #4 regarding her therapy services. Resident #4 stated she did not know what PASARR services were. She did not understand about therapy services. During an interview on 06/10/2025 at 4:20 PM, the ADMIN stated the Director of Rehabilitation Services would have contracted out physical therapy and occupational services, to prevent the resident from going without therapy. This could have resulted in a decline of health status. The ADMIN stated following a therapy referral, the MDS Coordinator or DOR would have been notified of the referral. The ADMIN stated residents would often get enrolled into restorative care if there was a delay in therapy approval. The ADMIN stated if a resident had a detrimental effect from not having received therapy services, the facility would discuss the case individually. The ADMIN stated his expectation for residents would be that they should have received therapy or restorative care. The ADMIN stated the impact of a resident having not received therapy or restorative care over a few months would have a negative effect on a resident . Surveyor requested policies for Therapy services, upon entry of and throughout investigation, policies were not provided upon exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675417 If continuation sheet Page 5 of 5