Health inspection·September 10, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few catheter at times .Goal .resident will be/remain free from catheter-related trauma through review date .Interventions .monitor for signs and symptoms of discomfort on urination and frequency . An observaion on 09/08/2024 at 9:23 AM revealed Resident #49's catheter bag without a privacy bag covering it. The catheter bag was secured to the bottom railing of the residents' bed observable from the doorway. An observation on 09/08/2024 at 12:31 PM revealed Resident #57's catheter bag without a privacy bag on. The catheter bag was secured to the bottom railing of the residents' bed observable from the doorway. An observation on 09/08/2024 at 1:10 PM revealed Resident #49's catheter bag without a privacy bag on. The catheter bag was secured to the bottom railing of the residents' bed observable from the doorway. An observation on 09/08/2024 at 2:40 PM revealed Resident #57's catheter bag without a privacy bag on. The catheter bag was secured to the bottom railing of the residents' bed observable from the doorway. An observation on 09/09/2024 at 9:32 AM revealed Resident #49's catheter bag without a privacy bag on. The catheter bag was secured to the bottom railing of the residents' bed observable from the doorway. An observatiojn on 09/09/2024 at 9:36 AM revealed Resident #49's catheter bag without a privacy bag on. The catheter bag was secured to the bottom railing of the residents' bed observable from the doorway. In an interview on 09/09/2024 at 10:01 AM with CNA D she revealed that she knew privacy covers for resident catheter bags were important for the dignity and well being of the resident. She stated that she was unaware of any residents missing privacy covers for their catheter bags. She stated that sometime the facility might run out of catheter bags but that the facility ordered supplies weekly but that CNA's and Nursing staff should keep the nurse in charge of medical supplies informed of any shortage issues. In an interview on 09/09/2024 at 10:17 AM with CNA I she stated that privacy covers for catheter bags were important for the dignity of the resident because if they had visitors no one wanted to see their urine on the side of their bed but that CNA's and Nursing staff should keep the nurse in charge of medical supplies informed of any shortage issues. An observsation on 09/10/2024 at 10:00 AM revealed both Residents #49 and #57 now had privacy covers on their catheter bags. In an interview on 9/10/24 at 3:02 PM with LVN H she stated that it was important for the dignity of the residents to have privacy covers on their catheter bag. She stated that all residents when in bed should always have privacy covers on their catheter bags, but that CNA's and Nursing staff should keep the nurse in charge of medical supplies informed of any shortage issues. In an interview on 09/10/24 at 3:48 PM the DON stated that all residents that have catheter bags should have a privacy cover on their catheter bags. She stated that not having the privacy covers it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 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 675440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Dallas Nursing & Rehabilitation 3808 S Central Expwy 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete could affect the wellbeing and dignity of the residents that have catheters. She stated that she had been unaware that any residents did not have catheter bag privacy covers and she stated that there had been no shortage in supplies, but that CNA's and Nursing staff should keep the nurse in charge of medical supplies informed of any shortage issues. Record review of facilities policy titled, Promoting/Maintaining Resident Dignity read in part . It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity .All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights .Maintain resident privacy . Event ID: Facility ID: 675440 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 675440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Dallas Nursing & Rehabilitation 3808 S Central Expwy 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 (Resident # 8) of 5 residents' rooms and for 1 of 1 shower rooms reviewed for environment. 1. The facility failed to repair the wall in Resident #8's bathroom for at least a year. 2. The facility failed to ensure the shower room was sanitary, clean, free of foul odors, and in good repair. This failure could place 56 residents using the shower room and Resident #8 at risk of psychosocial harm and feeling uncomfortable due to living in an environment that was not homelike. Findings included: Record review of Resident #8's face sheet dated 9/09/2024 revealed Resident #8 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses of major depressive disorder, generalized anxiety disorder, post-traumatic stress disorder, and mild cognitive impairment. Record review of Resident #8's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 (suggested resident's cognition was intact) and revealed a diagnosis of depression. Record review of Resident #8's care plan dated 8/27/24 stated Resident #8 had potential for difficulty adapting to her environment in the nursing facility, and the goal for this focus was for the resident to feel safe and comfortable in her environment. Record review of maintenance logs for July 2024, August 2024, and September 2024, revealed no entries concerning any bathrooms or showers. In an interview on 9/08/24 at 11:15 a.m., Resident #8 stated she had asked the Maintenance Supervisor about her shower approximately 2 months ago, and he told her that he did not know anything about it. Resident #8 stated it looked ugly and has been that way since she was admitted to the facility.(admitted [DATE]) Observation on 9/08/24 at 11:17 a.m., Resident #8's bathroom wall had tile with holes where plumbing fixtures were missing and plumbing remained visible. The tiles on the walls had a white substance smeared across them. In an interview on 9/10/24 at 08:45 a.m., the Maintenance Supervisor stated that Resident #8 had not spoken to him concerning the bathroom, but that the old bathroom fixtures needed to be covered with sheetrock. The Maintenance Supervisor stated that the old showers were covered years ago by contractors, but Resident #8's had not been completed. The Maintenance Supervisor stated he would need (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 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 675440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Dallas Nursing & Rehabilitation 3808 S Central Expwy 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some approval for the repairs and had not been requested at this time. The Maintenance Supervisor stated that it was all of the staff's responsibility to report any maintenance concerns and the expectation was for the rooms to be as clean as possible and homelike. He did not state how this could affect the residents. Observation on 9/08/2024 at 9:22 a.m., the shower room on the 300 hall had a strong foul odor. Disposable briefs were in a small trash can next to the shower. A large barrel with bags of trash and another large barrel with dirty laundry were against the wall in the shower room. A black substance was observed around the edges of the shower. 2 missing tiles were observed near the shower drain on the floor. During Confidential Resident Interview on 09/09/24 revealed One resident stated they were only able to use one shower room and it was nasty. Another resident stated there were dirty briefs and roaches in the one shower room. Residents agreed the shower room was nasty and stunk. In an interview on 9/10/24 at 9:05 a.m., the Maintenance Supervisor stated CNAs were responsible for emptying the trash in the shower room, and all staff should be put in maintenance requests in the maintenance binder. The Maintenance Supervisor stated the binder was available 24 hours a day, and he checked it three times a day. The Maintenance Supervisor stated there has not been any requests concerning the shower room, and he was unaware that the tiles were missing, and a black substance was in the edges of the shower. The Maintenance Supervisor stated all staff were responsible for reporting maintenance concerns, and the shower room should be clean. Observation on 9/10/2024 at 12:25 p.m., revealed one yellow barrel with dirty linen and one gray trash barrel with the lid unable to close due to trash overflowing were located against the wall in the shower room. A black and brown substance was observed around the edges of the shower. A bug was observed on the shower curtain. In an interview on 9/10/2024 at 12:25 p.m., ADON A stated that only one shower room was functional and that the dirty barrels that were used for dirty linen and old briefs were stored in the shower room. ADON A stated they were trying to determine where they could move them to. ADON A stated that 5 residents out of 61 did not use the shower room because they took bed baths. In an interview on 9/10/2024 at 12:27 p.m., CNA D stated it smelled in the shower room because dirty linen and trash were stored in there. CNA D stated this was the only shower room for the residents. Record review of maintenance logs for July 2024, August 2024, and September 2024, revealed no entries concerning any bathrooms or showers. Record Review of the facility's policy titled Quality of Life - Homelike Environment with a revised date of May 2017, stated The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary, and orderly environment. Additional policy requested for environmental cleanliness on 9/10/2024 at 09:38 a.m. and not received at time of exit. Record review of the facility's policy titled Quality of Life - Homelike Environment with a revised (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 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 675440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Dallas Nursing & Rehabilitation 3808 S Central Expwy 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 0584 Level of Harm - Minimal harm or potential for actual harm date of May 2017, stated The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary, and orderly environment. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 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 675440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Dallas Nursing & Rehabilitation 3808 S Central Expwy 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one sharps container in the shower room of Hall 300 of three sharps containers reviewed for accidents and hazards. The facility failed to ensure that residents did not have unsupervised access to used razors in the shower room on Hall 300, and that the sharps container was monitored and changed out before it became overfilled. This failure could place residents at risk of lacerations and injury from used sharps. Findings included: Observation on 09/08/24 at 09:00 a.m. revealed the door to the shower room on the 300 Hall was open and no facility staff were present in the shower room or the hallway. The sharps container on the wall of the shower room was overflowing past the Fill Line and five used blue plastic disposable razors were laying unsecured on the top of the sharps container. No residents were noted wandering the hall or entering the shower room. In an interview and observation with MA B on 09/08/24 at 09:10 a.m., he reported the shower room door (300 hall) had always remained locked but that maybe someone had not pushed it all the way shut. When he was shown the unlocked door. The razors on top of the sharps container, he reported the razors should not have been left on top of the sharps container and the container should have been emptied when it had become full. He stated that it was the responsibility of the nurses to empty the sharps containers when they were full and that he did not have a key to open the sharps container. He reported if a resident had come into the shower room unattended and had tried to use one of the razors, the resident could have been cut and injured. He denied knowledge of any resident sustaining a razor injury. In an interview and observation on 09/08/24 at 09:15 a.m., LVN F reported he worked on the 300 Hallway. When he was shown the unlocked shower door, he stated the door should have remained locked. When he was shown the razors on top of the sharps container he stated, Oh my God! Some residents could kill themself. He denied knowledge of any resident sustaining a razor injury. He reported all staff were responsible for emptying the sharps containers when the fill line had been reached. He immediately went to get a key to empty the sharps container. It was observed the shower room door automatically locked when he pulled the shower room door fully shut. In an interview on 09/08/24 at 09:25 a.m., the DON reported that it had not been practice or policy that the shower room door remained shut and locked, except for when a resident was receiving a shower. She reported the used razors should have been disposed of in a sharps container and not left unsecured, the sharps container should have been emptied when it became full, and all nursing staff were responsible for that. She reported that a set of keys for the sharp's containers were always available at the facility and accessible to the staff. She stated that a resident with dementia could have gotten one of the razors and harmed themselves. She denied knowledge of any resident sustaining a razor injury. In an interview on 09/10/24 at 12:23 p.m., the ADM reported that his expectations were that razors (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 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 675440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Dallas Nursing & Rehabilitation 3808 S Central Expwy 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some were disposed of in sharps containers. He reported that if the sharps container was full, the container should have been emptied, that there was a protocol for emptying the containers, and the nurses knew how to empty the containers. He stated if razors were not disposed of appropriately, a resident could have gotten a razor and it would have been a hazard to the resident. Observation on 09/10/24 at 12:57 p.m. revealed that the contents of a sharps container on the medication cart on hall 500 had not reached the fill line and there were no unsecured sharps. The contents of a sharps container on the medication cart on hall 200 had not reached the fill line and there were no unsecured sharps. The sharps box in the 300 Hall shower room was empty. There was a sharps box holder in Hall 600, but no sharps container was in the holder, and it was not in use. In an interview on 09/10/24 at 12:57 p.m., LVN C confirmed that a total of three sharps boxes were in use at the facility. Record Review of the facility's policy Sharps Disposal, dated January 2001 (Revised January 2012), reflected: .1. Whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated containers. 2. Contaminated sharps will be discarded into containers that are: a. Closable; b. Puncture resistant; c. Leakproof on sides and bottom; d. Labeled or color-coded in accordance with our established labeling system; and e. Impermeable and capable of maintaining impermeability through final waste disposal. 3. During use, containers for contaminated sharps will be handled as follows: c. Designated individuals will be responsible for sealing and replacing containers when they are 75% to 80% full to protect employees from punctures and/or needlesticks when attempting to push sharps into the container FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 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 675440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Dallas Nursing & Rehabilitation 3808 S Central Expwy 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 - Some 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 observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that ensured drugs and biologicals were accurately acquired, received, dispensed, and administered) to meet the needs of each resident for 1 of 1 medication room reviewed for pharmacy services. The medication room contained: 1. 1 almost full opened box (quantity of 50) of IV administration sets with an expiration date of 6/05/2024. 2. 10 IV insertion cannulas with an expiration date of 02/28/2024. 3. 6 acetaminophen 650mg suppositories with a use by date of 12/11/2023 prescribed for Resident #30. This could place 1 (Resident #99) of 1 resident receiving IV medications and Resident #30 at risk for not receiving the intended therapeutic benefit of their medications and having possible adverse effects. Findings included: Record review of Resident #99's face sheet dated 9/10/2024 revealed the resident was [AGE] years old, was admitted on [DATE], and had a diagnosis of acute osteomyelitis (bone infection). Record review of Resident #99's admission MDS dated [DATE] had not been completed. Record review of Resident #99's care plan dated 9/10/24 stated the resident required IV therapy. Record review of Resident #30's Annual MDS dated [DATE] revealed the resident was [AGE] years old, was admitted on [DATE], had a diagnosis of Alzheimer's disease, and a BIMS score of 04 (suggested severe cognitive impairment) and received hospice care. Record review of Resident #30's care plan dated 8/22/2024 revealed the resident had a terminal prognosis and received hospice care. Observation on 9/09/24 at 12:18 p.m., expired medications and supplies were stored in the only medication room. Expired medication and supplies observed in the medication room included 1 almost full box of IV administration sets with an expiration date of 6/05/2024, 10 IV insertion cannulas with an expiration date of 2/28/24, and 6 acetaminophen 650mg suppositories with a use by date of 12/11/2023 prescribed for Resident #30. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 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 675440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Dallas Nursing & Rehabilitation 3808 S Central Expwy 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 - Some In an interview on 9/09/24 at 12:20 p.m., ADON A stated that the medication room was checked monthly by herself or the DON for expired medications and supplies. ADON A stated that expired medication should be placed in a locked gray trash bin in the medication room, so it can be destroyed by the pharmacist. ADON A stated there was one resident currently receiving IV medications and that staff were using the non-expired IV administration sets located on the counter in a clear bin in the medication room. ADON A did not state what the failure could cause. In an interview on 9/09/24 at 12:23 p.m., the DON stated she was unaware that the IV supplies were in the cabinet and stated the IV supplies could affect the integrity of the tubing and places the residents at risk for adverse effects. The DON did not state who was responsible for monitoring the expiration dates. In an interview on 9/10/24 at 9:48 a.m., the DON stated the expectation was for there not to be expired medications and supplies in the medication room. Record review of facility's policy titled Storage of Medications with a revision date of April 2007, stated the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 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 675440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Dallas Nursing & Rehabilitation 3808 S Central Expwy 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure they had promptly notified the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for 1 (Resident #28) of 10 residents reviewed for Keppra (antiseizure medication) lab levels and notifications. Resident #28 had abnormal Keppra lab results on 8/27/24, and the facility failed to follow up to ensure prompt notification was received by the ordering physician. This failure could result in the physician not being fully aware of the resident's clinical condition and response to Keppra for 10 residents currently prescribed Keppra. Findings included: Record review of Resident #28's Annual MDS dated [DATE], revealed the resident was [AGE] years old, admitted on [DATE], had a diagnosis of a seizure disorder, and a BIMS score of 08 (suggested moderate cognitive impairment). Record review of Resident #28's care plan dated 7/10/2024 revealed Keppra levels would be monitored monthly, lab values would be monitored, and abnormal results would be reported. Record review of Resident #28's physician order dated 11/21/2019 revealed an order to check Keppra levels every month. Record review of Resident #28's lab results with a reported date of 8/27/2024 revealed the Keppra level was out of range at 48.9ug/mL and marked high. Normal range listed on lab was 10.0-40.0 ug/mL. Record review of Resident #28's progress notes revealed the last seizure documented for Resident #28 was on 6/7/2023. In an interview on 9/09/24 at 2:10 p.m., the DON stated this lab was missed. The DON stated that lab values were flagged different colors in their electronic medical record system when they were abnormal, but the Keppra labs were not flagged. The DON stated that the staff notified the physician as soon as they get the results or during their shift and she would notify the physician of the results now. In an interview on 9/10/2024 at 9:34 a.m., ADON A stated lab and x-ray results were faxed to them from the lab, and the results were available in their electronic medical records system. ADON A stated that all nurses had access to the fax machine and to the results on their computers. ADON A stated the expectation was for the nurses to communicate in report with the next nurse that labs were pending and monitor for results. ADON A stated that if a lab result was a critical level (dangerously too high or too low) then the lab would call the facility and speak with a nurse. ADON A stated Resident #28 had not had any neurological symptoms. ADON A did not state what the failure could cause. In an interview on 9/10/24 at 9:48 a.m., the DON stated the expectation was for labs not to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 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 675440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Dallas Nursing & Rehabilitation 3808 S Central Expwy 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few missed and should be monitored by the nurses. The DON did not state how this failure could affect the residents. In an interview on 9/10/2024 at 11:02 a.m., Physician E stated that routine levels on patients receiving Keppra were not necessary unless they were symptomatic and experiencing symptoms such as somnolence, dizziness, tiredness, or any other neurological symptoms. Physician E stated that the Keppra lab was ordered by a previous physician, but she expected all labs to be reported to the current physician. Record review of the facility's policy titled Lab and Diagnostic Test Results - Clinical Protocol with a revision date of September 2012, stated If a test was obtained to monitor the blood level of a medication and the level is reported as high (above therapeutic range) or toxic, the nurse will notify the physician promptly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 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 675440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Dallas Nursing & Rehabilitation 3808 S Central Expwy 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff for 1 handwashing sink, 1 dishwashing sink and 1 dishwasher reviewed for essential equipment. 1.The facility failed to ensure the handwashing sink was in working order 2.The facility failed to ensure drainage in the dishwashing sinks was in working order. 3.The facility failed to ensure drainage in the dishwashing room was proper working order. These failures could affect all residents that eat meals from the kitchen and pose a possible risk for cross-contamination. Findings included: Observations of the Kitchen on 09/08/24 at 09:15 AM with the [NAME] G revealed the following: -Handwashing sink was non-functioning, there was no running water that comes from the faucet when the handle was turned on hot or cold side. -Dishwashing sink - water would not drain -Dishwasher - water would not drain - Near the center of the dishwasher room, there was a wet vacuum (designed to wet debris pickup), which had a long (an inch or two longer than a 12-inch ruler) black slender cylindrical tube (vacuum attachment); it extended up beyond the drain opening approximately 5 inches to soak up/suction water when it. In an Interview with the Dietary Manager on 09/09/24 at 11:30 AM, he stated the black tube protruding out of the kitchen floor (drain in center of floor) was a wet vacuum attachment. It was there to allow the staff to use a wet vac to suction up the water to prevent overflowing onto the floor when the drain beneath the dishwasher machine or the dishwasher sink started to fill up. He stated the drain under the dishwashing sink and dishwasher doesn't drain well due to a drainage problem and a plumber had already been out multiple times, but it hasn't been fixed. He stated that the sink and plumbing issues have been like this for at least a year when state was in the building for survey. He was waiting on invoice from the plumber to request funding. The Dietary Manager stated it was a risk to staff due to the possibility of injury, such as slip, and the drainage issue could pose a potential harm of unsanitary kitchen environment. In an Interview with the Administrator on 09/10/24 at 3:17 PM, he stated that he took over the facility on June 20th, 2024, and on that day, he learned about the broken sink and drainage problem in the kitchen. The Administrator stated that during turnover with the previous administrator, that the facility had plumbers come out to look at it, but there were no details on what had been done to address the problems, which had been ongoing for a year. The Administrator stated that once the new dietary manager was hired in August, they have been trying to get this fixed. They had a plumber out on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 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 675440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Dallas Nursing & Rehabilitation 3808 S Central Expwy 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 08/10/24 and he never returned. The Administrator stated that they had a different plumber come out on 08/27/24 and that plumber stated he would need $800 prior to running a camera in the drains. The Administrator told the plumber that he would need an invoice as they would have to request funding but have yet to receive an invoice. Review of the Administrator text messages on 8/27/24 between him and the plumber requesting an invoice for work to be completed. Review of the facility's Nutrition Services Policy & Procedures: Food Receiving and Storage, Version 1.3 (H5MAPL0335), Effective Date: 2001, Revised October 2017, reflected: Policy: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: 1. Food Services, or other designated staff, will maintain clean food storage areas at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 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 675440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Dallas Nursing & Rehabilitation 3808 S Central Expwy 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 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free from pests for one of one active shower rooms reviewed for pest control program. Residents Affected - Some The facility had live small flies and roaches in the only active shower room in the facility. This failure could place residents at risk for spread of infection, cross contamination, and decreased quality of life. Findings included: An observation on 09/08/24 at 9:21 AM revealed a small fly was crawling on the door frame of the shower room on the 200 hall. In an interview on 09/08/24 at 12:22 PM MA G revealed that she had seen flies in the facility and that she had heard about roaches in the facility from residents. She stated that the staff were supposed to write pest sightings in the pest control book that was somewhere in the nurse's station. In an interview on 09/08/24 at 1:02 PM with Resident #53 he revealed that the shower room was always nasty, smelly, and dim. He stated that he had seen roaches in the shower room several times and that there were always flies in the shower room. He stated that he had seen spiders, roaches, and flies in his room as well. He stated that the staff knew about the roaches and flies. In an interview on 09/08/24 at 1:30 PM with Resident #58 he revealed that he had seen small flies and roaches in the shower room. He stated that he had seen roaches in his room and that he was sure that the kitchen was full of roaches. He stated that he had told the staff at the facility about the roaches and flies many times. In an interview on 09/09/24 at 12:26 PM with Resident #29 she stated that she was legally blind so she had not seen any roaches in the facility. She stated that many of the other residents that she talked too have told her that there were roaches and flies in the facility and that makes her uncomfortable because she could not tell if they got into her food or not. Record review of the pest sighting log on 09/09/24 at 12:45 PM revealed that roaches were sighted and reported in the facility on 06/09/24 in rooms [ROOM NUMBER]. Roaches were reported again on 06/14/24 in room [ROOM NUMBER]. Roaches were reported again on 08/21/24 in room [ROOM NUMBER], no other entries were found. Record review on 09/09/24 at 1:00PM revealed that the contracted pest control company had visited the facility on 07/31/24 and treated for ants, American Cockroaches, and German Cockroaches in the kitchen, bathrooms, and entry points (no specific rooms identified). The contracted pest control company visited on 08/31/24 and treated for roaches and German Cockroaches in rooms 405, 303, and a washroom (unspecified). Further review revealed that the pest control contract was active and valid. In an observation on 09/10/24 at 12:27 PM a live roach was observed on a shower curtain of shower stall #1 in the only active shower in the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 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 675440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Dallas Nursing & Rehabilitation 3808 S Central Expwy 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 0925 Level of Harm - Minimal harm or potential for actual harm In an observation on 09/10/24 at 12:29 PM three live small flies were noted either actively flying or resting on the wall above a small full garbage can in the facility's only active shower room. In an observation 0n 09/10/24 at 12:33 PM a second live roach was observed near the ceiling above the second shower stall in the facility's only active shower room. Residents Affected - Some In an interview on 09/10/24 at 12:59 PM with the Maintenance Supervisor he revealed that the facility was only using one shower room for the last 12-18 months because the other shower room in the facility still required some repairs. He stated that the staff were supposed to write all pest sightings in the pest control log so that the pest control personnel knew where and what to spray. He stated that the pest control contractor came out to the facility every two weeks and that he could call them for extra visits. He stated that he has heard complaints about roaches in the facility and that sometimes he treats them himself for the past 6 months. He stated that having pests around could make residents feel bad about where they are living. In an interview on 09/10/24 at 3:02 PM with LVN H revealed that she knew staff were to write down all pest sightings in the pest control log located behind the nurse's station. She stated that pests like flies and roaches could cause cross contamination in food for residents and could make residents upset about living in areas with pests. She stated that she was unaware that there were roaches in the shower room. In an interview on 09/10/24 at 3:48 PM with the DON she revealed that all staff were directed to write all pest sightings in the pest control log. She stated that pests like flies and roaches could cause cross contamination and possibly cause illness in residents. She stated that pests could cause mental duress for residents if the pests persist. Review of the policy titled Policy and Procedure: Pest Control (undated) revealed that . 1) When a pest problem is encountered, the reporting person will go to the pest control log book and document accordingly . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 16 of 16