Health inspection·June 9, 2025

F 0600 current injury/illness) for the ability to go up and down a curb and/or up and down one step. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's Care Plan, dated 03/06/25, reflected a Focus: The resident has an ADL self-care Performance deficit CVA with left hemiplegia, diabetes with neuropathy(damage to nerves), dementia and muscle weakness. Bed mobility: partial assist of 1-2, Transfers: partial to substantial assist 1-2, Eating: set-up to supervision of 1, Toileting: partial assist of 1-2. Provisions are mad to care as needed. Level of assistance may vary depending on my condition. Goal: The resident will maintain or improve current level of function in bed partial to substantial assist of 1-2 by the next review date. Interventions/Tasks: Provide sponge bath when a full bath or shower cannot be tolerated .Allow sufficient time for ADL tasks .Make sure are comfortable and not slippery. Residents Affected - Some Record review of Resident #1's Active Orders, as of 06/08/25, reflected Resident #1 had 2 active orders for pain medications prior to the left humerus comminuted fracture of 02/10/25 listed as the following: 1. Orders reflected Gabapentin 400 mg. Give 1 capsule by mouth three times per day for pain. Order start date 11/27/24, End Date: Indefinite. 2. Tylenol Oral tablet 325 mg. Give 1 tablet by moth every 4 hours as needed for Pain. Order start date 11/27/24, End Date: Indefinite. Record review of Resident #1's Active orders, as of 06/08/25, reflected Resident #1 had 4 active orders for pain after the right humorous comminuted fracture of 02/10/25 listed as the following: 1. Orders reflected Gabapentin 400 mg. Give 1 capsule by mouth three times per day for pain. Order start date 11/27/24, End Date: Indefinite. 2. Tylenol Oral tablet 325 mg. Give 1 tablet by mouth every 4 hours as needed for Pain. Order start date 11/27/24, End Date: Indefinite. 3. Tramadol HCL Oral Tablet 50 mg, Give 50 mg by mouth three times a day for pain. Start Date: 02/10/25, Revision Date: 03/10/25, New orders, give 50 mg by mouth every 8 hours as needed for pain. End Date: Indefinite 4. Hydrocodone-Acetaminophen Oral tablet 5-325 mg, Give 1 tablet by mouth three times a day for pain. Start Date: 03/06/2025. End Date: Indefinite. Record review of Resident #1's weights taken at the facility found reflected Resident #1 weighed 154.4 LBS on 02/07/25. Record review of the facility's PIR, dated 02/25/25, reflected on 02/10/25 CNA A and CNA B stated Resident #1 had a slip in the shower chair while transferring from a shower chair to a wheelchair. Resident #1 stated to the facility that Resident #1 had slipped and hit his shoulder while he was in the shower. Resident #1 did not report the incident to the facility until 02/21/25. The PIR Investigation Summary reflected on 02/10/25 CNA A had taken Resident #1 to the shower room and Resident #1 started to slip out of the shower chair. CNA A then called for LVN B who helped assist the resident immediately by placing their arms (CNA A and LVN B) under Resident #1's arms (while resident was still wet) and pulled Resident #1 back up into the shower chair. LVN B reported Resident #1 did not report any injuries and subsequent skin assessments found no injuries, bruises, or skin integrity issues. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 2 of 29 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 06/09/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Both CNA A and LVN B stated there was no fall or change of plan as they prevented Resident #1 from having a fall. Record review of CNA A's witness statement, included in the PIR, dated 02/24/25, and signed by CNA A, reflected CNA A had assisted the nurse with a transfer in the shower room, shower was given to Resident #1. The nurse assisted with transferring Resident #1 back to the wheelchair from the shower chair. Residents Affected - Some Record review of LVN B's witness statement, included in the PIR, dated 02/24/25, and signed by LVN B, reflected LVN B had assisted CNA A with a transfer of Resident #1 from a wheelchair to a shower chair and then from a shower chair to wheelchair on 02/10/25. She stated Resident #1 had no complaint of pain upon transferring to the wheelchair. Record review of Resident #1's EHR for Resident #1 from 02/04/25 to 2/11/25 found no evidence of a fall being reported, no documentation of skin or pain assessments. No documentation of Resident #1 slipping from a shower chair. Two progress notes related to the incident of 02/10/25 were found (1) denoting a pain medication ordered after LVN E had been informed by Hospice RN D about a fall and need for pain medications, and (2) When the facility first found out about the incident: 1. A Progress Note was found, dated 02/10/25 at 9:17 PM written by LVN E, ordering tramadol HCL Oral tablet 50 mg, give 50 mg by mouth three times a day for pain. 2. A Progress Note, dated 02/21/25 at 9:36 AM by the DON, reflected Resident (#1's) family reported to this nurse, he (Resident #1) still had pain from the fall that happened Monday before last. Skin assessment pain assessment and stat left shoulder x-ray. Notified hospice, family present, notified MD and administrator. Record review of the facility Incident Accident Log found no evidence of Resident #1 having a fall, near fall or injury for the dates of 02/04/25 to 02/21/25. Record review of a document entitled Radiology Report for Resident #1, dated 02/21/25, reflected Left Shoulder X-ray Complete 2 or more views .Significant Findings .Multiple views of the left shoulder show a comminuted fracture (a fracture where the bone breaks into three or more pieces) to the left humeral head/neck (top part of the arm bone). Fracture of the glenoid (where the head of the arm bone connects to the shoulder) is also noted .No soft tissue swelling is seen. Record review of a document titled After Visit Summary, dated 02/22/25, found an order for an appointment to a named Orthopedic Surgeon was to be made as soon as possible. This order was put into place to address the right humorous comminuted fracture after the resident had been admitted to the hospital on [DATE], and discharged from the hospital on [DATE]. Interview on 05/28/25 at 9:45 AM with Resident #1 revealed Resident #1 was able to speak with some difficulty but was able to make his needs known. Resident #1 stated his arm was broken several months ago. He identified the CNA as the facility CNA not his hospice CNA, and he stated it was just CNA A in the shower room with him when the fall occurred. He stated he hit his shoulder when the fall occurred. He stated he went to the hospital but had not been out for any follow-up appointments. Interview on 05/28/25 at 9:58 AM with the Hospice SW C revealed she had been in the building that morning to visit with Resident #1 to discuss care plan options with the resident since he had come (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 3 of 29 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 06/09/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some under her hospice agency care on 02/04/25. She stated Resident #1 told her he was in pain and he had a fall in the shower room earlier that morning and he indicated his left shoulder where the pain was the worst. Hospice SW C stated she contacted Hospice RN D and reported to her Resident #1 was complaining of 5/10 pain in his left shoulder and Resident #1 told her he had a fall earlier that morning in the shower. Interview on 05/28/25 at 9:58 AM with Hospice RN D revealed Resident #1 reported to her he had a fall in the shower room earlier that day (02/10/25). Hospice RN D stated she did an assessment on Resident #1, and Resident #1 complained of pain in his left shoulder at 5/10 on a pain scale and Resident #1 had no swelling and no redness no bruising. Hospice RN D stated she notified the hospice physician and ordered 50 mg Tramadol three times a day. Hospice RN D stated she informed the facility nurse, LVN E about the new order, fall and pain and another Hospice RN had assessed Resident #1 on 02/13/25 and Resident #1 did not complain of pain that day. Interview on 05/29/25 at 10:58 AM with LVN E revealed she worked on Resident #1's hall on 02/10/25. She stated she remembered speaking with Hospice RN D that day and Hospice RN D told her Resident #1 had complained of 5/10 pain in his left shoulder, he reported to her that he had a fall earlier that day in the shower and she ordered Tramadol 50 mg three times a day for Resident #1. LVN E stated she was a brand-new nurse at the time and assumed LVN B, who had been at the facility much longer, told the DON about the fall in the shower room. LVN E stated she first learned of Resident #1's fracture on 02/23/25 when the DON asked if she knew anything about Resident #1's fracture. Interview on 05/28/25 at 1:58 PM with CNA A, CNA A reported CNA A and LVN B were transferring Resident #1 from a shower chair to a wheelchair in the shower room on 02/10/25. CNA A stated she and LVN B had Resident #1 up from the shower chair and were pivoting him around to sit in the wheelchair and Resident #1 was yelling that he was slipping. CNA A stated Resident #1 did not have a fall. CNA A stated he had started to slip a little out of the shower chair but she and LVN B caught him. She stated he did not complain of pain at any time even after she placed him back into bed. She stated she had not used a gait belt and she was unaware if there was a gait belt in the shower room at the time. CNA A stated that Resident #1 was still wet at the time of the transfer. Interview on 05/29/25 at 2:56 PM with LVN B revealed CNA A called her into the shower room to assist with transferring Resident #1 from a shower chair to a wheelchair. She stated Resident #1 was already unclothed and she and CNA A had their arms around Resident #1 to transfer him. She stated the resident was still a little wet and he had a towel around his private area. She stated Resident #1 did not say anything or indicate he was slipping. She stated she did not report anything because there was never any fall. She stated it was possible they could have broken his arm during the transfer but there had been no indication of it, she stated that because nothing happened and there was no indication of pain or discomfort, she did not assess Resident #1. Interview on 05/30/25 at 9:45 AM with the DON revealed she was aware of the need to make an Orthopedic appointment for Resident #1 after he returned from the hospital on [DATE]. She stated the hospice agency was contacted about the need for an appointment at that time but had not addressed the Orthopedic appointment again after that. The DON was unable to explain why the appointment for Resident #1 had never been arranged. The DON was unable to provide any documentation that the hospice agency had been contacted, who was spoken to at the hospice agency or when the conversation may have taken place. Interview on 05/30/25 at 11:09 AM with LVN Q revealed she understood follow-up appointments for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 4 of 29 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 06/09/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some residents returning from the hospital were to be handled through the Social Worker or the ADON but because the Social Worker had quit a few weeks ago it was mainly through the ADON. Interview on 05/30/25 at 11:11 AM with the ADON revealed for residents who were on hospice care and returned from the hospital to the facility with orders to have an appointment made the facility should have contacted the hospice agency about the appointment. She stated in the case of Resident #1 she did not see any in any progress notes that the hospice agency for Resident #1 had been contacted about the follow-up order for Resident #1, she stated that in the absence of the SW the ADON or the DON would be responsible for the follow up appointment and notifying the hospice agency. Interview on 05/30/25 at 11:30 AM with the ADM revealed he was not at the facility when this incident occurred. He stated his expectations were that a physical communication sheet should have been filled out showing when, who, what had been communicated to any outside agency. He stated he was not aware of any documentation that showed if Resident #1's orthopedic appointment had been made or if anyone was contacted about the appointment having to be made. Interview on 05/30/25 at 11:48 AM with facility MD, MD stated that it was acute fx, meaning the fracture was recent, around 1-2 weeks, no soft tissue swelling could indicate that there had been enough time for the swelling to have been resolved. Resident #1 might not have been as uncomfortable as someone who did not have paralysis in the affedted arm. Looking back it looks like I was informed about Resident #1 having pain in that arm on the 21st, but I had been informed that the family may have had some idea of a mechanism of injury previous to the 21st of February. I would not expect Resident #1 to have a spontaneous fracture, he did not have diagnosis that would be indicative of that. The two bones could have articulated during a lift. I would say that injury could happen in both a lift or fall scenario. She stated usually the facility will make appointments for residents. Interview on 06/02/25 at 10:26 PM with Hospice SW C revealed her hospice agency had no record of ever being contacted about a referral appointment for Resident #1. She stated she would have been the person who would have been contacted about making an appointment. She stated she had no idea Resident #1 had come back from the hospital with orders to make an appointment to an Orthopedic surgeon. Interview on 06/02/25 at 2:24 PM with the ADM revealed it was ultimately his facility nurses responsibility to make sure all orders from physicians were followed and that his nurses made sure the appointment was made and kept. He stated it was a major concern that a resident returned from the hospital on [DATE] and still had not gone to the appointment that had been ordered. Interview on 06/02/25 at 2:49 PM with the MD revealed she was aware of the referral to Orthopedics for Resident #1, but the hospice agency should have been responsible for making the appointment since they were the ones who had to pay for it. Interview on 06/06/25 at 12:00 PM with the ADON revealed she received and gave training on the new Admissions/Re-admissions binder. She stated the binder was to always be located at the main nursing station next to the permanent computer at the nursing station. She stated if she were to receive re-admission orders on a Sunday, she would have to document the information in the progress note. She stated the new binder was where staff put appointments, informed all parties, family included. Then staff would make the appointment during business hours. After the appointment was made staff would arrange for transportation and then staff would log all of the appointment information in the communication log in the Electronic Health Record to make sure all parties knew the information. She stated all nurses and CNA's had access to the Electronic Health Record communication tab/board. She stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 5 of 29 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 06/09/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the new binder ensured the resident was receiving all of the services available to them. She stated there had been updates to the Ambassador rounds, staff were more in-depth question on a new form that staff asked the residents assigned to them, she stated an email with all of the new questions was sent to all staff, identified as Ambassadors, and a paper copy was also presented at the morning meeting. Interview on 6/2/25 at 5:59 PM with the DON revealed she defined a fall as anytime a resident stumbled, lost balance or their knees touched the floor. She stated all falls, witnessed or unwitnessed should be reported to the ADON, DON, and the ADM. She stated all orders from a physician, referrals, and appointments should be scheduled, and transportation arranged to get residents to appointments, she stated all appointment/referrals should be documented in the Admission/re-admission binder and in the Electronic Health Record. She stated the family went to her on 02/21/25 because they wanted Resident #1 repositioned, and they told her he had a fall a couple of Mondays ago and he complained his left shoulder hurt. She stated Resident #1 described he had a fall in the shower and his arm hurt. The DON stated that was when she did pain/skin assessments, informed the Administrator and ordered x-rays. Interview on 6/2/25 at 6:08 PM, the ADM stated a fall was defined as anyone who lost balance or for example knees gave out and had to be lowered to the floor, would be a fall. Also, even if they lost balance of gave got and caught themselves and the staff had to assist them in any manner was considered a fall according to the policy/procedure. He stated all physician orders should be carried out by the nursing staff and all appointments made in accordance with those orders, he stated he would monitor the new Admission/re-admission binder to monitor all orders/appointments were followed/made and all corresponding documentation was present. Record review of the facility's policy titled Abuse Investigation and Reporting, dated 2001 and revised July 2017, reflected: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Policy Explanation and Compliance guidelines: The facility will develop and implement written policies and procedures that: Prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property. Established policies and procedures to investigate any such allegations; and Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, and dementia management and resident abuse prevention. Provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. Existing staff will receive annual education through planned and services and as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 6 of 29 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 06/09/2025 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 0600 Training topics will include prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation. Level of Harm - Immediate jeopardy to resident health or safety Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property. Residents Affected - Some Recognizing signs of abuse, neglect, exploitation and misappropriation of resident property, such as physical or psychosocial indicators. Reporting process for abuse, neglect exploitation and misappropriation of resident property comma including injuries of unknown sources. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as: wandering Preventative abuse, neglect and exploitation the facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: Identifying, correcting and intervening in situations in which abuse, neglect, exploitation and or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, license, and certified staff on each shift the sufficient numbers to meet the needs of the residents, and ensure that the staff assigned have knowledge of the individual residence care needs and behavioral symptoms; The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with need and behaviors which might lead to conflict or neglect. Addressing features of physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur. Record review of the facility's policy titled Accidents and Incidents-Investigating and Reporting, dated 2001 and revised July 2017, reflected: Policy Statement. All accidents or incidents involving residents, employees, visitors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Guidelines. 1. The Nurse Supervisor/Charge Nurse and or the department director or supervisor shall promptly initiate and document investigation of the accident or incident . 5. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. 6. The Director of nursing shall ensure that the Administrator receives a copy of the Report of Incident/Accident form for each occurrence. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 7 of 29 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 06/09/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review on 06/07/25 of the Admission/re-admission Binder documented Resident #11 had been entered into the binder as a new admission. All relevant paperwork for Resident #11 was found in the Admission/re-admission Binder. Subsequent review of the Electronic Health Record documented progress notes with orders for Resident #11. This was determined to be an Immediate Jeopardy (IJ) on 06/02/25 at 8:00 PM. The ADM and the DON were notified. The ADM was provided with the IJ template on 06/02/25 at 8:00 PM. The following Plan of Removal submitted by the facility was accepted on 06/05/25 at 3:00 PM: [The Facility] [address and phone number] FTAG 600- The facility failed to protect Resident # 1 and neglected Resident #1 because CNA A and LVN B failed to report a Slip/Fall on 2/10/2025 during Residents #1 shower which resulting in delay of care and X-rays for Resident #1. Facility will focus on reporting, education on safe transfers, freedom form neglect. 1. DON and ADON will in-service nursing staff on Safe Transfer. Nursing staff will be able to voice concepts of safe transfer to include residents limitations taken into account to determines how many people are required for transfer, where is the transfer taking place, is the resident dried off from a shower, are clothes donned before applying gait belt. Nursing will turn in a written test of knowledge over Safe Transfer and complete a return demonstration for DOR. Weekend staff and PRN will be provided training by DON and ADON and DOR. DON, will visually monitor each member of the nursing staff safely transfer a residents, every shift, starting on 6/4/2025, until 100% of staff have been monitored. Date initiated: 6/2/2025. A master copy of in-services/training/tests table with employee names is being used to audit. This form will be updated and turned into every day. After meeting with the survey team, additional education provided on 6/4/2025. To include place of transfer, resident ability, number of staff required, resident clothed, resident dry. Date completed: 6/9/2025 2. DON and ADON will in-service ALL staff on the definition of a FALL, AWARENESS, REPORTING, INTERVENTION AND PREVENTION. All staff will complete a written test of knowledge to be placed on file immediately. Weekend staff and PRN will be provided training by DON and ADON and DOR. This training must be completed before returning to the floor. ADON, will visually monitor each charge nurse report a fall, every shift, starting on 6/5/2025, until 100% of staff have been monitored. DON will maintain competency audit and update it daily and give to Administrator daily. Date initiated: 6/2/2025 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 8 of 29 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 06/09/2025 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 0600 Date completed: 6/5/2025 Level of Harm - Immediate jeopardy to resident health or safety Upon hire, and quarterly thereafter Residents Affected - Some DON has reviewed all of May admissions and readmissions up to current date to verify there weren't any appointments or referrals needed. No issues identified. An admission/readmission report has been ran, printed and marked with a check mark for reviewed and no issues or a question mark requiring a hospital request for additional records. 3. Date initiated: 6/2/2025 Date completed: ongoing, daily Upon hire, and quarterly thereafter 4 Skills check off will be completed for Nursing staff, in relation to their roles required for a fall, by DON/ADON. Now, Upon hire, and quarterly. Training must be completed before returning to the floor. DON and Administrator will maintain competency audit and ensure compliance. This training must be completed before returning to the floor. A staff roster containing staff member name, department and status of employment, will be utilized to keep track of competencies/training completed/required. Individual interviews will be conducted for all nursing staff by ADON. During the interview the staff member will recite respective response to a fall, according to their position. These interviews will start on 6/5/2025, every shift until 100% of nursing staff have been interviewed. A spread sheet will indicate all staff have been interviewed and will be updated and provided to the Administrator for review daily. Nurse roles in a fall Completing and documenting fall risk assessments to identify residents at risk of falling. Monitoring the resident's medical condition for any changes that could affect the resident's fall risk status. Reporting falls to the physician, DON/ADON and Administrator, and obtaining medical orders as needed. Supervising nursing aides and educating patients and their families on fall prevention measures CNA role for a fall: Report to Charge nurse immediately and do not move the resident. Date initiated: 6/5/2026 Date complete:6/9/2025 5. Starting on 6/4/2025, DON will ensure that 1st and 2nd shift CNA's have a gait belt readily available. ADON will be assigned to monitor for 3rd shift on 6/4-5/2025 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 9 of 29 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 06/09/2025 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 0600 Will have gait belts readily available for use. This ensures proper preparedness for safe transfer immediately. Level of Harm - Immediate jeopardy to resident health or safety Administrator will verify gait belts were provided on 6/4/2025 and 6/5/2025 by reviewing the gait belt audit log, daily. Residents Affected - Some Date initiated:6/4/2025 Completed by: 6/5/2025 6. DON and ADON will in-service charge nurses about Admission/ readmission Binder. It will be kept at the nurses' station. DON/ADON, will review this Binder daily, during their assigned shift, to ensure any appointments/ referrals are made according to admission paperwork. All admission paperwork will be uploaded by admitting nurse to Medical Records via front office scanner and logged into the binder log in sheet located in the front of the binder. Weekend staff and PRN will be provided training by DON. This training must be completed before returning to the floor DON and ADON will maintain competency audit and ensure compliance. This training must be completed before returning to the floor. A staff roster containing staff member name, department and status of employment, will be utilized to keep track of competencies/training completed/required. Date initiated 6/3/2025 Date completed: ongoing Monitored in real time on 6/4/2025, LVN B, notified DON, a resident had returned from the hospital with new orders. She uploaded the paperwork to medical records and placed in in the communication binder, at the nurses station. She also logged the information onto the login sheet in the front of said binder. Information included: resident name, date/time, reason for ER/visit or discharge, charge nurse initials, and yes or no boxes for needing appointments or new orders. See exhibit- A readmission paperwork login form. 7. Charge nurses will be in-serviced on reporting incidents such as falls, made by third party vendors, such as Hospice. When report of a fall is received by a third party or family, it is to be reported immediately to the DON/ADON. Weekend staff and PRN will be provided training by DON and ADON. This training must be completed before returning to the floor. DON will maintain competency audit and ensure compliance. This training must be completed before returning to the floor. A staff roster containing staff member name, department and status of employment, will be utilized to keep audit of competencies/training completed/required. Administrator will confirm education provided by interviewing staff on 6/4/2025. Inservice to begin 6/4/2023. Completed by 6/5/2025 Third party vendors will be notified via telephone, by DON/ADON, of referrals recommended, or appointments made. A progress note will be entered into PCC, by the charge nurse, naming who they spoke with, date and time and short description on the nature of the information relayed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 10 of 29 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 06/09/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety 8. Charge nurses will be in-serviced on the Appointments/ Referral Protocol immediately, intermittently, upon hire. Any appointment obtained by a charge nurse, will be reported to DON/ADON as soon as possible, but no later than the end of their shift. DON/ADON will update information pertaining to the resident's appointment in PCC on community board. Weekend staff and PRN will be provided training by DON and ADON. This training must be completed before returning to the floor. DON maintain competency audit and ensure compliance. This training must be completed before returning to the floor. Residents Affected - Some DON/ADON, will visually monitor each member of the nursing staff recite or perform the Appointments/ Referral Protocol starting on 6/4/2025, until 100% of staff have been monitored. Date initiated: 6/2/2025. A master copy of in-services/training/tests table with employee names is being used to audit. This form will be updated and turned into Administrator for review every day. Monitored in real time on 6/4/2025, LVN B, notified DON, a resident had returned from the hospital with new orders and a referral appointment. Initiated 6/4/2025 Completion: ongoing daily 9.Starting today, 6/4/2025, all department heads will conduct Ambassador rounds. The revised form has been provided to all department heads by email. This will identify any incidents or accidents that may have happened and weren't properly reported, documented or identified. These rounds consist of room conditions, meal satisfaction, needs and will address falls, abuse, neglect and feelings of safety. These will be provided to Administrator daily. A FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 11 of 29 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 06/09/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury to the administrator of the facility and to other officials which included the State Survey Agency in accordance with State law through established procedures for 1 of 8 residents (Resident #1) reviewed for reporting allegations of neglect. The facility failed to ensure a report for an allegation of neglect was submitted within 2 hours to the State Agency after Hospice RN D reported a fall with possible injury to LVN E. This failure could place residents at risk of abuse, physical harm, mental anguish and emotional distress. Findings include: Record review of Resident#1's face sheet, dated 05/28/25, revealed a [AGE] year-old male with an initial admission date of 11/27/24. Resident #1 had diagnoses which included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting the Left Non-Dominant side (paralysis of the left side of the residents body due to a stroke), Vascular Dementia (Brain damage caused by multiple strokes) and Aphasia (Language disorder caused by brain damage). Record review of Resident #1's quarterly MDS, dated [DATE], reflected Resident #1 had a BIMS of 12, which indicated mildly impaired or moderate cognitive impairment. Resident #1 had impairment to one side. Resident #1 required Substantial/maximal assistance (help of 1-2 staff members) with showers and sitting to standing and was totally dependent (help of 2 or more staff members) for toileting. Record review of Resident #1's Significant Change MDS, dated [DATE], reflected Resident #1 had a BIMS of 12, which indicated Resident #1 was mildly impaired or had moderate cognitive impairment. Resident #1 was dependent and required the assistance of 2 or more or more helpers for tub/shower transfer, toilet transfer and chair to bed transfer. Resident #1 was listed as Not applicable (due to current injury/illness) for the ability to go up and down a curb and/or up and down one step. Record review of Resident #1's Care Plan, dated 03/06/25, reflected Focus: The resident has an ADL self-care Performance deficit CVA with left hemiplegia, diabetes with neuropathy, dementia and muscle weakness. Bed mobility: partial assist of 1-2, Transfers: partial to substantial assist 1-2, Eating: set-up to supervision of 1, Toileting: partial assist of 1-2. Provisions are made to care as needed. Level of assistance may vary depending on my condition. Goal: The resident will maintain or improve current level of function in bed partial to substantial assist of 1-2 by the next review date. Interventions/Tasks: Provide sponge bath when a full bath or shower cannot be tolerated .Allow sufficient time for ADL tasks .Make sure are comfortable and not slippery. Record review of Resident #1's Active Orders as of 06/08/25 reflected Resident #1 had 2 active orders for pain medications prior to the left humerus comminuted fracture of 02/10/25 listed as the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 12 of 29 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 06/09/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm 1. Orders reflected Gabapentin 400 mg. Give 1 capsule by mouth three times per day for pain. Order start date 11/27/24, End Date: Indefinite. 2. Tylenol Oral tablet 325 mg. Give 1 tablet by moth every 4 hours as needed for Pain. Order start date 11/27/24, End Date: Indefinite. Residents Affected - Few Record review of Resident #1's Active orders as of 06/08/25 reflected Resident #1 had 4 active orders for pain after to the right humorous comminated fracture of 02/10/25 listed as the following: 1. Orders reflected Gabapentin 400 mg. Give 1 capsule by mouth three times per day for pain. Order start date 11/27/24, End Date: Indefinite. 2. Tylenol Oral tablet 325 mg. Give 1 tablet by moth every 4 hours as needed for Pain. Order start date 11/27/24, End Date: Indefinite. 3. Tramadol HCL Oral Tablet 50 mg, Give 50 mg by mouth three times a day for pain. Start Date: 02/10/25, Revision Date: 03/10/25, New orders, give 50 mg by mouth every 8 hours as needed for pain. End Date: Indefinite 4. Hydrocodone-Acetaminophen Oral tablet 5-325 mg, Give 1 tablet by mouth three times a day for pain. Start Date: 03/06/2025. End Date: Indefinite. Record review of the Facility, PIR dated 02/25/25, reflected on 02/10/25, CNA A and CNA B stated Resident #1 had a slip in the shower chair while transferring from a shower chair to a wheelchair. Resident #1 stated to the facility that Resident #1 had slipped and hit his shoulder while he was in the shower. Resident #1 did not report the incident to the facility until 02/21/25. The PIR Investigation Summary reflected on 02/10/25 CNA A had taken Resident #1 to the shower room and Resident #1 started to slip out of the shower chair. CNA A then called for LVN B who helped to assist the resident immediately by placing their arms (CNA A and LVN B) under Resident #1's arms and pulled Resident #1 back up into the shower chair. LVN B reported Resident #1 did not report any injuries and subsequent skin assessments found no injuries, bruises, or skin integrity issues. Both CNA A and LVN B stated here was no fall or change of plan as they prevented Resident #1 from having a fall. Record review of CNA A's witness statement included in the PIR, dated 02/24/25, and signed by CNA A, reflected CNA A assisted the nurse with a transfer in the shower room, shower was given to Resident #1, nurse assisted with transferring Resident #1 back to the wheelchair from the shower chair. Record review of LVN B's witness statement included in the PIR, dated 02/24/25, and signed by LVN B, reflected LVN B assisted CNA A with a transfer of Resident #1 from a wheelchair to a shower chair and then from a shower chair to wheelchair on 02/10/25. She stated Resident #1 had no complaint of pain upon transferring of Resident #1 to a wheelchair. Record review of a document entitled Radiology Report for Resident #1, dated 02/21/25, reflected Left Shoulder X-ray Complete 2 or more views .Significant Findings .Multiple views of the left shoulder show a comminuted fracture (a fracture where the bone breaks into three or more pieces) to the left humeral head/neck (top part of the arm bone). Fracture of the glenoid (where the head of the arm bone connects to the shoulder) is also noted .No soft tissue swelling is seen. Record review of Resident #1's EHR from 02/04/25 to 2/11/25 found no evidence of a fall being (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 13 of 29 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 06/09/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reported, no documentation of skin or pain assessments. No documentation of Resident #1 slipping from a shower chair. Two progress notes related to the incident of 02/10/25 were found (1) denoting a pain medication ordered and (2) When the facility first found out about the incident: 1. A Progress Note was found, dated 02/10/25 at 9:17 PM, written by LVN E, ordering tramadol HCL Oral tablet 50 mg, give 50 mg by mouth three times a day for pain. 2. A Progress Note, dated 02/21/25 at 9:36 AM, by the DON, reflected Resident (#1's) family reported to this nurse, he (Resident #1) still had pain from the fall that happened Monday before last. Skin assessment pain assessment and stat left shoulder x-ray. Notified hospice, family present, notified MD and administrator. Record review of the facility Incident Accident Log reflected no evidence of Resident #1 having a fall, near fall or injury for the dates of 02/04/25 to 02/21/25. Interview on 05/28/25 at 9:45 AM with Resident #1 revealed Resident #1 was able to speak with some difficulty but was able to make his needs known. Resident #1 stated he had his arm broken several months ago. He identified the CNA as the facility CNA not his hospice CNA, and he stated it was just CNA A in the shower room with him when the fall occurred. He stated he hit his shoulder when the fall happened and he had less movement in his left arm and hand than he did before. He indicated with his right arm and hand to his left shoulder and indicated his left hand where it was observed he could still move his pinky and ring finger. Interview on 05/28/25 at 9:58 AM with the Hospice SW C revealed she was in the building that morning to visit with Resident #1 to discuss care plan options with Resident #1 since the resident had come under her hospice agency care on 02/04/25. She stated Resident #1 told her he was in pain and he had a fall in the shower room earlier that morning and he indicated his left shoulder was where the pain was the worst. Hospice SW C stated she contacted Hospice RN D and reported to her Resident #1 was complaining of 5/10 pain in his left shoulder and Resident #1 had told her he had a fall earlier that morning in the shower. Interview on 05/28/25 at 9:58 AM with Hospice RN D revealed Resident #1 reported to her he had a fall in the shower room earlier that day (02/10/25). Hospice RN D stated she did an assessment on Resident #1, she stated Resident #1 complained of pain in his left shoulder at 5/10 on a pain scale and Resident #1 had no swelling, no redness no bruising. Hospice RN D stated she notified the hospice physician and ordered 50 mg Tramadol three times a day. Hospice RN D stated she informed facility nurse, LVN E, about the new order, fall and pain and that another Hospice RN had assessed Resident #1 on 02/13/25 and Resident #1 did not complain of pain that day. Interview on 05/29/25 at 10:58 AM with LVN E revealed she had been working on Resident #1's hall on 02/10/25. She stated she remembered speaking with Hospice RN D that day and Hospice RN D told her Resident #1 had complained of 5/10 pain in his left shoulder, that he reported to her that he had a fall earlier that day in the shower and she ordered Tramadol 50 mg three times a day for Resident #1. LVN E stated she was a brand-new nurse at the time and assumed LVN B, who was at the facility much longer, told the DON about the fall in the shower room, and assessed Resident #1. LVN E stated she first learned of Resident #1's fracture on 02/23/25 when the DON asked if she knew anything about Resident #1's fracture. Interview on 6/2/25 at 5:59 PM with the DON revealed she defined a fall as anytime a resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 14 of 29 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 06/09/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stumbled, loses balance or their knees touch the floor. She stated staff were always expected to report any accidents incidents to the DON or the ADM as soon as possible so residents could receive the services they required. Interview on 6/2/25 at 6:08 PM, the ADM stated a fall was defined as anyone who lost balance or for example knees gave out and had to be lowered to the floor would be a fall. Also, even if they lost balance of gave out and caught themselves and the staff had to assist them in any manner was considered a fall according to the policy/procedure. He stated staff were always expected to report any accidents incidents to the DON or the ADM as soon as possible so residents could receive the services they required. He stated that a former ADM had been notified of he incident on 02/21/25, and he was unsure why the original incident of 02/10/25 had not been reported properly. Record review of the facility's policy titled Accidents and Incidents-Investigating and Reporting, dated 2001 and revised July 2017, reflected: Policy Statement. All accidents or incidents involving residents, employees, visitors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Guidelines. 1. The Nurse Supervisor/Charge Nurse and or the department director or supervisor shall promptly initiate and document investigation of the accident or incident . 5. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. 6. The Director of nursing shall ensure that the Administrator receives a copy of the Report of Incident/Accident form for each occurrence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 15 of 29 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 06/09/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one of 3 residents (Resident #1) reviewed for transfers. The facility failed to ensure that CNA A and LVN B transferred Resident #1 using a gait belt as per facility protocol, and dried the resident off before transfer, which resulted in a fall and a comminuted fracture (a fracture where the bone breaks into three or more pieces) to the left humeral neck (top part of the arm bone) and fractures to the glenoid bone (where the head of the arm bone connects to the shoulder), which were discovered from X-Ray results on 02/21/25. An Immediate Jeopardy (IJ) situation was identified on 06/02/25. While the IJ was removed on 06/09/25, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risks of accidents, and could result in serious harm, injury, impairment, and death. The findings include: Record review of Resident#1's face sheet dated 05/28/25 revealed he was a [AGE] year-old male resident with an initial admission date of 11/27/24 with diagnosis that included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting the Left Non-Dominant side (paralysis of the left side of the residents body due to a stroke), Vascular Dementia (Brain damage caused by multiple strokes), and Aphasia (Language disorder caused by brain damage). Record review of Resident #1's quarterly MDS dated [DATE] reflected that Resident #1 had a BIMS (Brief Interview for Mental Status) of 12, meaning mildly impaired or moderate cognitive impairment. Resident #1 had impairment to one side. Resident #1 required Substantial/maximal assistance (help of 1-2 staff members) with showers and sitting to standing and was totally dependent (help of 2 or more staff members) for toileting. Record review of Resident #1's Significant Change MDS dated [DATE] reflected that Resident #1 had a BIMS (Brief Interview for Mental Status) of 12 meaning Resident #1 was mildly impaired or had moderate cognitive impairment. Resident #1 was dependent and required the assistance of 2 or more or more helpers for tub/shower transfer, toilet transfer and chair to bed transfer. Resident #1 was listed as Not applicable (due to current injury/illness) for the ability to go up and down a curb and/or up and down one step. Record Review of Resident #1's Care Plan dated 03/06/25 reflected that Focus: The resident has an ADL self-care Performance deficit CVA with left hemiplegia, diabetes with neuropathy, dementia and muscle weakness. Bed mobility: partial assist of 1-2, Transfers: partial to substantial assist 1-2, Eating: set-up to supervision of 1, Toileting: partial assist of 1-2. Provisions are mad to care as needed. Level of assistance may vary depending on my condition. Goal: The resident will maintain or improve current level of function in bed partial to substantial assist of 1-2 by the next review date. Interventions/Tasks: Provide sponge bath when a full bath or shower cannot be tolerated .Allow (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 16 of 29 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 06/09/2025 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 sufficient time for ADL tasks .Make sure are comfortable and not slippery. Level of Harm - Immediate jeopardy to resident health or safety Record review of the Facility PIR (Provider Investigation Report) dated 02/25/25 reflected that on 02/10/25 CNA A and CNA B stated that Resident #1 had a slip in the shower chair while transferring from a shower chair to a wheelchair. Resident #1 stated to the facility that Resident #1 had slipped and hit his shoulder while he was in the shower. Resident #1 did not report the incident to the facility until 02/21/25. The PIR Investigation Summary reflected that on 02/10/25 CNA A had taken Resident #1 to the shower room and that Resident #1 had started to slip out of the shower chair. CNA A then called for LVN B who helped to assist the resident immediately by placing their arms (CNA A and LVN B) under Resident #1's arms and pulled Resident #1 back up into the shower chair. LVN B reported that Resident #1 did not report any injuries and subsequent skin assessments found no injuries, bruises, or skin integrity issues. Both CNA A and LVN B had stated that here had been no fall or change of plan as they had prevented Resident #1 from having a fall. Residents Affected - Few Record review of CNA A's witness statement included in the PIR dated 02/24/25 and signed by CNA A, reflected that CNA A had assisted nurse with transfer in the shower room, shower was given to Resident #1, nurse assisted with transferring Resident #1 back to the wheelchair from the shower chair. Record review of LVN B's witness statement included in the PIR and dated 02/24/25 and signed by LVN B, reflected that LVN B had assisted CNA A with a transfer of Resident #1 from a wheelchair to a shower chair and then from a shower chair to wheelchair on 02/10/25. She stated Resident #1 had no complaint of pain upon transferring of Resident #1 to a wheelchair. Record review of the facility Incident Accident Log found no evidence of Resident #1 having a fall, near fall or injury for the dates of 02/04/25 to 02/21/25. Record review of a document entitled Radiology Report for Resident #1, dated 02/21/25, reflected Left Shoulder X-ray Complete 2 or more views .Significant Findings .Multiple views of the left shoulder show a comminuted fracture (a fracture where the bone breaks into three or more pieces) to the left humeral head/neck (top part of the arm bone). Fracture of the glenoid (where the head of the arm bone connects to the shoulder) is also noted .No soft tissue swelling is seen. Record review of a document titled After Visit Summary, dated 02/22/25, found an order for an appointment to a named Orthopedic Surgeon was to be made as soon as possible. This order was put into place to address the right humorous comminuted fracture after the resident had been admitted to the hospital on [DATE]. Record review of Resident #1 EHR (Electronic Health Record) for Resident #1 from 02/04/25 to 2/11/25 found no evidence of a fall being reported, no documentation of skin or pain assessments. No documentation of Resident #1 slipping from a shower chair. Two progress notes related to the incident of 02/10/25 were found (1) denoting a pain medication ordered and (2) When the facility first found out about the incident: 1. A Progress Note was found on 02/10/25 at 9:17 PM written by LVN E ordering [after being told by Hospice RN D of the fall and need for pain medications] tramadol HCL Oral tablet 50 mg, give 50 mg by mouth three times a day for pain. 2. A Progress Note on 02/21/25 at 9:36 AM by the DON reflected that Resident (#1's) family reported to this nurse, he (Resident #1) still had pain from the fall that happened Monday before last. Skin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 17 of 29 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 06/09/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few assessment pain assessment and stat left shoulder x-ray. Notified hospice, family present, notified MD and administrator. Record review of the facility Incident Accident Log found no evidence of Resident #1 having a fall, near fall or injury for the dates of 02/04/25 to 02/21/25. Record review of Resident #1's Active Orders as of 06/08/25 revealed that Resident #1 had 2 active orders for pain medications prior to the left humerus comminuted fracture of 02/10/25 listed as the following: 1. Orders reflected Gabapentin 400 mg. Give 1 capsule by mouth three times per day for pain. Order start date 11/27/24, End Date: Indefinite. 2. Tylenol Oral tablet 325 mg. Give 1 tablet by moth every 4 hours as needed for Pain. Order start date 11/27/24, End Date: Indefinite. Record review of Resident #1's Active orders as of 06/08/25 revealed that Resident #1 had 4 active orders for pain after to the right humorous comminuted fracture after 02/10/25 listed as the following: 1. Orders reflected Gabapentin 400 mg. Give 1 capsule by mouth three times per day for pain. Order start date 11/27/24, End Date: Indefinite. 2. Tylenol Oral tablet 325 mg. Give 1 tablet by moth every 4 hours as needed for Pain. Order start date 11/27/24, End Date: Indefinite. 3. Tramadol HCL Oral Tablet 50 mg, Give 50 mg by mouth three times a day for pain. Start Date: 02/10/25, Revision Date: 03/10/25, New orders, give 50 mg by mouth every 8 hours as needed for pain. End Date: Indefinite 4. Hydrocodone-Acetaminophen Oral tablet 5-325 mg, Give 1 tablet by mouth three times a day for pain. Start Date: 03/06/2025. End Date: Indefinite. Record review of Resident #1's weights taken at the facility found that Resident #1 weighed 154.4 LBS on 02/07/25. Interview on 05/28/25 at 9:45 AM with Resident #1 revealed Resident #1 was able to speak with some difficulty but was able to make his needs known. Resident #1 stated arm was broken several months ago. He identified the CNA as the facility CNA not his hospice CNA, and he stated it was just CNA A in the shower room with him when the fall occurred. He stated he hit his shoulder when the fall happened and he had less movement in his left arm and hand than he did before. He indicated with his right arm and hand to his left shoulder and indicated his left hand where it was observed he could still move his pinky and ring finger. Interview on 05/28/25 at 9:58 AM with the Hospice SW C revealed that she had been in the building that morning to visit with Resident #1 to discuss care plan options with Resident #1 since had had come under her hospice agency care on 02/04/25. She stated that Resident #1 told her that he was in pain and that he had a fall in the shower room earlier that morning and that he indicated his left shoulder where the pain was the worst. Hospice SW C stated that she contacted Hospice RN D and reported (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 18 of 29 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 06/09/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few to her that Resident #1 was complaining of 5/10 pain in his left shoulder and that Resident #1 had told her he had a fall earlier that morning in the shower. Interview on 05/28/25 at 9:58 AM with Hospice RN D revealed that Resident #1 reported to her that he had a fall in the shower room earlier that day (02/10/25). Hospice RN D stated that she did an assessment on Resident #1, she stated that Resident #1 complained of pain in his left shoulder at 5/10 on a pain scale and that Resident #1 had no swelling, no redness no bruising. Hospice RN D stated that she notified the hospice physician and ordered 50 mg Tramadol three times a day. Hospice RN D stated that she had informed facility nurse LVN E about the new order, fall and pain and that another Hospice RN had assessed Resident #1 on 02/13/25 and that Resident #1 did not complain of pain that day. Interview on 05/28/25 at 1:58 PM with CNA A, CNA A reported that CNA A and LVN B were transferring Resident #1 from a shower chair to a wheelchair in the shower room on 02/10/25. CNA A stated that she and LVN B had Resident #1 up from the shower chair and were pivoting him around to sit in the wheelchair and Resident #1 was yelling that he was slipping. CNA A stated that Resident #1 did not have a fall. CNA A stated that he had started to slip a little out of the shower chair but that she and LVN B had caught him. She stated that he did not complain of pain at any time even after she had placed him back into bed. She stated that she had not used a gait belt and she was unaware if there had been a gait belt in the shower room at the time. CNA A stated that resident #1 was still wet at the time of the transfer. Interview on 5/30/25 at 11:48 AM with the Facility Physician revealed the fracture to Resident #1's arm was acute and if the fracture occurred on 02/10/25 then by the time the x-ray was taken on 02/21/25 soft tissue swelling could have been absent. She stated looking at Resident #1's diagnosis, she would not expect Resident #1 had a spontaneous fracture, and Resident #1 might not be as uncomfortable as someone who did not have paralysis in the affected arm. Interview on 6/2/25 at 5:59 PM with the DON revealed she defined a fall as anytime a resident stumbled, loses balance or their knees touched the floor. She stated staff were always expected to use a gait belt for transfers she stated she had not been aware all CNA's did not have a gait belt and there seemed to be only a few gait belts in the facility at that time. She stated any resident being transferred from a wheelchair to a shower chair, the staff must use a gait belt, the resident should have a shirt on or a gown and once the resident was safely transferred to a shower chair the gait belt and then the shirt/gown should come off. She stated the resident should be completely dried and a gown or a shirt should be placed back on the resident and a gait belt applied to transfer the resident back to a wheelchair. Interview on 6/2/25 at 6:08 PM, the ADM stated a fall was defined as anyone who had lost balance or for example knees gave out and had to be lowered to the floor would be a fall. Also, even if they lost balance of gave out and caught themselves and the staff had to assist them in any manner was considered a fall according to the policy/procedure. Record review of the facility's policy titled Safe Lifting and Movement of Residents, dated 2001 and revised July 2017, reflected: Policy Statement: In order to protect the safety and well being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 19 of 29 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 06/09/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on and ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: a. Resident's preferences; b. Resident's mobility (degree of dependency); c. Resident's size; d. Weight-bearing ability; e. Cognitive status; f. Whether the resident is usually cooperative with staff; and g. The resident's goals for rehabilitation, including restoring or maintaining functional abilities. 4. Staff responsible for direct care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices . 12. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: a. Involves employees in identifying problem areas and implementing workplace safety and injury-prevention strategies; b. Addresses workplace injuries; c. Provides training on safety, ergonomics and proper use of equipment; and d. Continually evaluates the effectiveness of workplace safety and injury-prevention strategies. This was determined to be an Immediate Jeopardy (IJ) on 06/02/25 at 8:00 PM. The ADM and the DON were notified. The ADM was provided with the IJ template on 06/02/25 at 8:00 PM. The following Plan of Removal submitted by the facility was accepted on 06/05/25 at 3:00 PM: [The facility][address and phone number] FTAG 689- The facility failed to protect Resident #1 because CNA A and LVN B did not use proper assistive device and proper procedure drying resident/using gait belt when assisting Residents #1 during shower. Adequate supervision and assisted devices are required to prevent accidents. Focus will be safe transfers and proper supervision. 4. DON and ADON will in-service nursing staff on Safe Transfer. Nursing staff will be able to voice (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 20 of 29 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 06/09/2025 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 - Immediate jeopardy to resident health or safety concepts of safe transfer to include residents limitations taken into account to determines how many people are required for transfer, where is the transfer taking place, is the resident dried off from a shower, are clothes donned before applying gait belt. Nursing will turn in a written test of knowledge over Safe Transfer and complete a return demonstration for DOR. Weekend staff and PRN will be provided training by DON and ADON and DOR. DON, will visually monitor each member of the nursing staff safely transfer a residents, every shift, starting on 6/4/2025, until 100% of staff have been monitored. Residents Affected - Few Date initiated: 6/2/2025. A master copy of in-services/training/tests table with employee names is being used to audit. This form will be updated and turned into every day. After meeting with the survey team, additional education provided on 6/4/2025. To include place of transfer, resident ability, number of staff required, resident clothed, resident dry. Date completed: 6/9/2025 5. DON and ADON will in-service ALL staff on the definition of a FALL, AWARENESS, REPORTING, INTERVENTION AND PREVENTION. All staff will complete a written test of knowledge to be placed on file immediately. Weekend staff and PRN will be provided training by DON and ADON and DOR. This training must be completed before returning to the floor. ADON, will visually monitor each charge nurse report a fall, every shift, starting on 6/5/2025, until 100% of staff have been monitored. DON will maintain competency audit and update it daily and give to Administrator daily. Date initiated: 6/2/2025 Date completed: 6/5/2025 Upon hire, and quarterly thereafter 6. DON has reviewed all of May admissions and readmissions up to current date to verify there weren't any appointments or referrals needed. No issues identified. An admission/readmission report has been ran, printed and marked with a check mark for reviewed and no issues or a question mark requiring a hospital request for additional records. Date initiated: 6/2/2025 Date completed: ongoing, daily Upon hire, and quarterly thereafter 4 Skills check off will be completed for Nursing staff, in relation to their roles required for a fall, by DON/ADON. Now, Upon hire, and quarterly. Training must be completed before returning to the floor. DON and Administrator will maintain competency audit and ensure compliance. This training must be completed before returning to the floor. A staff roster containing staff member name, department and status of employment, will be utilized to keep track of competencies/training (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 21 of 29 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 06/09/2025 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 - Immediate jeopardy to resident health or safety completed/required. Individual interviews will be conducted for all nursing staff by ADON. During the interview the staff member will recite respective response to a fall, according to their position. These interviews will start on 6/5/2025, every shift until 100% of nursing staff have been interviewed. A spread sheet will indicate all staff have been interviewed and will be updated and provided to the Administrator for review daily. Residents Affected - Few Nurse roles in a fall Completing and documenting fall risk assessments to identify residents at risk of falling. Monitoring the resident's medical condition for any changes that could affect the resident's fall risk status. Reporting falls to the physician, DON/ADON and Administrator, and obtaining medical orders as needed. Supervising nursing aides and educating patients and their families on fall prevention measures CNA role for a fall: Report to Charge nurse immediately and do not move the resident. Date initiated: 6/5/2026 Date complete:6/9/2025 5 Starting on 6/4/2025, DON will ensure that 1st and 2nd shift CNA's have a gait belt readily available. ADON will be assigned to monitor for 3rd shift on 6/4-5/2025 Will have gait belts readily available for use. This ensures proper preparedness for safe transfer immediately. Administrator will verify gait belts were provided on 6/4/2025 and 6/5/2025 by reviewing the gait belt audit log, daily. Date initiated:6/4/2025 Completed by: 6/5/2025 6. DON and ADON will in-service charge nurses about Admission/ readmission Binder. It will be kept at the nurses' station. DON/ADON, will review this Binder daily, during their assigned shift, to ensure any appointments/ referrals are made according to admission paperwork. All admission paperwork will be uploaded by admitting nurse to Medical Records via front office scanner and logged into the binder log in sheet located in the front of the binder. Weekend staff and PRN will be provided training by DON. This training must be completed before returning to the floor DON and ADON will maintain competency audit and ensure compliance. This training must be completed before returning to the floor. A staff roster containing staff member name, department and status of employment, will be utilized to keep track of competencies/training completed/required. Date initiated 6/3/2025 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 22 of 29 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 06/09/2025 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 Date completed: ongoing Level of Harm - Immediate jeopardy to resident health or safety Monitored in real time on 6/4/2025, LVN B, notified DON, a resident had returned from the hospital with new orders. She uploaded the paperwork to medical records and placed in in the communication binder, at the nurses station. She also logged the information onto the login sheet in the front of said binder. Information included: resident name, date/time, reason for ER/visit or discharge, charge nurse initials, and yes or no boxes for needing appointments or new orders. Residents Affected - Few See exhibit- A readmission paperwork login form. 7. Charge nurses will be in-serviced on reporting incidents such as falls, made by third party vendors, such as Hospice. When report of a fall is received by a third party or family, it is to be reported immediately to the DON/ADON. Weekend staff and PRN will be provided training by DON and ADON. This training must be completed before returning to the floor. DON will maintain competency audit and ensure compliance. This training must be completed before returning to the floor. A staff roster containing staff member name, department and status of employment, will be utilized to keep audit of competencies/training completed/required. Administrator will confirm education provided by interviewing staff on 6/4/2025. Inservice to begin 6/4/2023. Completed by 6/5/2025 Third party vendors will be notified via telephone, by DON/ADON, of referrals recommended, or appointments made. A progress note will be entered into PCC, by the charge nurse, naming who they spoke with, date and time and short description on the nature of the information relayed. 8. Charge nurses will be in-serviced on the Appointments/ Referral Protocol immediately, intermittently, upon hire. Any appointment obtained by a charge nurse, will be reported to DON/ADON as soon as possible, but no later than the end of their shift. DON/ADON will update information pertaining to the resident's appointment in PCC on community board. Weekend staff and PRN will be provided training by DON and ADON. This training must be completed before returning to the floor. DON maintain competency audit and ensure compliance. This training must be completed before returning to the floor. DON/ADON, will visually monitor each member of the nursing staff recite or perform the Appointments/ Referral Protocol starting on 6/4/2025, until 100% of staff have been monitored. Date initiated: 6/2/2025. A master copy of in-services/training/tests table with employee names is being used to audit. This form will be updated and turned into Administrator for review every day. Monitored in real time on 6/4/2025, LVN B, notified DON, a resident had returned from the hospital with new orders and a referral appointment. Initiated 6/4/2025 Completion: ongoing daily 9.Starting today, 6/4/2025, all department heads will conduct Ambassador rounds. The revised form has been provided to all department heads by email. This will identify any incidents or accidents that may have happened and weren't properly reported, documented or identified. These rounds consist of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 23 of 29 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 06/09/2025 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 - Immediate jeopardy to resident health or safety room conditions, meal satisfaction, needs and will address falls, abuse, neglect and feelings of safety. These will be provided to Administrator daily. A manager on duty will be assigned to work 4 hours on Saturday and Sunday, four hours each day. Manager on Duty will be responsible for completing room rounds on all residents, turning form into administrator's mailbox and reporting incidents, accidents, fall or alleged abuse to Administrator immediately via phone. Residents Affected - Few Exhibit E. Administrator will be responsible for monitoring the plan of removal. If it is found the plan is not working or an issue is identified, a meeting amongst department heads will convene immediately to discuss and determine revisions necessary for the safety of the residents and positive outcomes. Monitoring of the POR included the following: Observation on 5/28/25 at 1:23 PM revealed CNA A transferred Resident #2 from a wheelchair to the residents bed. CNA A explained to Resident #2 they were about to perform a transfer. CNA A placed Resident #2's wheelchair next to the bed that was on a level equal to the height of the wheelchair. Wheelchair was observed to be locked. CNA A then placed a gait belt on Resident #2 and counted down with the resident to stand up, Resident #2 was successfully transferred to the bed with no issues. In an interview on 06/07/25 at 3:00 PM the DON stated that in-services had been completed on all nursing staff. Record review of all in-service rosters and written competencies revealed that all nursing staff had received all in-services and written competency tests had been conducted and completed by all nursing staff. Between the dates of 06/05/25 and 06/07/25 6 gait-belt and 2 mechanical lift transfer trainings were observed to be conducted by the DOR and re-demonstrations in front of the DOR by the following staff members: CNA A, LVN B, CNA F, CNA H, CNA M, ADON, LVN Q, LVN R, CNA T, CNA X and LVN Y. Between the dates of 06/05/25 and 06/09/25, during all shifts, twenty-seven nursing staff members out of 39 nursing staff members were asked the following questions: All: -Title/Name/Length of time at the facility? -Did you receive training on transfers? /Did you demonstrate a safe transfer? To whom? -Describe a safe transfer related to showers. -Why are safe transfers important? When would you need a nurse to assess a resident? -Did you take a test for transfers/falls after training? -What is a fall? -Did you learn anything new from your latest in-services/demonstrations? (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 24 of 29 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 06/09/2025 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 CNA's: Level of Harm - Immediate jeopardy to resident health or safety -If you see a fall, who do you report it too/What is your role? Residents Affected - Few RN's: -When do you use a gait belt? -What is your role in falls? -Where exactly is the admission/re-admission folder located? What is its purpose? -What methods can you use to report incidents to the ADON/DON? -Why is it important to make sure hospital/specialist/orders are followed/appointments made? -Admissions/re-admissions/falls this shift? ADON, DON, DOR, CNA A, LVN B, LVN E, CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, CNA N, CNA O, LVN P, LVN Q, LVN R, LVN S, CNA T, LVN U, LVN V, CNA W, CNA X, LVN Y and CNA Z representing and interviewed during the 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and the 10:00 PM to 6:00 AM shifts, were able to answer all questions in a satisfactory manner that suggested training had been conducted and understood, written competencies had been conducted and completed, and nursing staff performed transfers in front of the DOR, DON or the ADON. Between the dates of 06/05/25 and 06/09/25 during all shifts, 8 gait-belt transfers and 3 mechanical lifts were observed to be conducted in a safe and competent manner by the following nursing staff CNA A, LVN B, CNA F, CNA K, CNA M, LVN Q, LVN U, CNA W, CNA X, and CNA Z, with Residents #1, #2, #3, #4, #5, #6, #7, and #8. The ADM and the DON were informed the Immediate Jeopardy was removed on 06/09/25 at 4:00 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 25 of 29 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 06/09/2025 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the designated interdisciplinary team member was responsible for collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services and communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family for 1 (Resident #1) of 8 residents reviewed for hospice services. The facility failed to ensure a staff member was designated to communicate with a hospice agency. This deficient practice could place residents at risk of receiving substandard care due to miscommunication between their hospice and facility caregivers. The findings were: Record review of Resident#1's face sheet dated 05/28/25 revealed he was a [AGE] year-old male resident with an initial admission date of 11/27/24 with diagnosis that included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting the Left Non-Dominant side (paralysis of the left side of the residents body due to a stroke), Vascular Dementia (Brain damage caused by multiple strokes), and Aphasia (Language disorder caused by brain damage). Record review of Resident #1's quarterly MDS dated [DATE] reflected that Resident #1 had a BIMS (Brief Interview for Mental Status) of 12, meaning mildly impaired or moderate cognitive impairment. Resident #1 had impairment to one side. Resident #1 required Substantial/maximal assistance (help of 1-2 staff members) with showers and sitting to standing and was totally dependent (help of 2 or more staff members) for toileting. Record review of Resident #1's Significant Change MDS dated [DATE] reflected that Resident #1 had a BIMS (Brief Interview for Mental Status) of 12 meaning Resident #1 was mildly impaired or had moderate cognitive impairment. Resident #1 was dependent and required the assistance of 2 or more or more helpers for tub/shower transfer, toilet transfer and chair to bed transfer. Resident #1 was listed as Not applicable (due to current injury/illness) for the ability to go up and down a curb and/or up and down one step. Record Review of Resident #1's Care Plan dated 03/06/25 reflected that Focus: The resident has an ADL self-care Performance deficit CVA with left hemiplegia, diabetes with neuropathy, dementia and muscle weakness. Bed mobility: partial assist of 1-2, Transfers: partial to substantial assist 1-2, Eating: set-up to supervision of 1, Toileting: partial assist of 1-2. Provisions are mad to care as needed. Level of assistance may vary depending on my condition. Goal: The resident will maintain or improve current level of function in bed partial to substantial assist of 1-2 by the next review date. Interventions/Tasks: Provide sponge bath when a full bath or shower cannot be tolerated .Allow sufficient time for ADL tasks .Make sure are comfortable and not slippery. Record review of Resident #1's orders as of 06/02/25 revealed that Resident #1 had orders that stated Admit to Hospice, call for any change of condition .Admit to Facility under hospice custodial services. admission orders have been reviewed, verified and changes have been made. Physical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 26 of 29 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 06/09/2025 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 0849 Therapy/Occupational Therapy/Speech Therapy to screen and treat as indicated. Level of Harm - Minimal harm or potential for actual harm During an interview with the Administrator on 06/02/2025 at 5:50 p.m., the Administrator stated there was no specific person designated to communicate with hospice, but the nurse who received the resident would communicate with hospice. When a resident was received to the facility with orders, the nurse who received the resident was their responsibility to ensure the orders were carried out. The Administrator stated his expectation was if a resident came in on weekend it was the responsibility of the nurse who accepted the resident to ensure their orders were carried out and communicated with any third-party agency. Residents Affected - Some During an interview with the DON on 06/02/2025 at 6:18 p.m., the DON stated the facility did not have one person who was designated to speak with hospice, but the Social Worker, Nursing Staff to include ,the DON and the Administrator, were able to speak to hospice on behalf of the residents. During an interview with the Hospice SW on 06/4/25 at 3:23 PM, the Hospice SW stated that she had never been notified by the facility that Resident #1 had any follow up appointments. She stated that her hospice agency had never received any discharge paperwork from the facility for Resident #1's hospital visit on 02/21/25. She stated that she would have been the person that would have coordinated follow up appointment, and that she was unsure which facility staff should have contacted her but it usually the facility Social Worker that was generally responsible for communicating with the hospice agency. Record review of the facility's policy titled, Residents with Hospice Services, revised 7/2018, revealed 12. Our facility has designated Name (left blank), Title (left blank) to coordinate care provided to the resident by our facility staff and the hospice staff. (Note: this individual is a member of the IDT with clinical and assessment skills who is operating within the State scope of practice act). He or she is responsible for the following: 12Aa. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for resident receiving services; 12b. Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, relation conditions, and other conditions, to ensure quality of care for the residents and family; 12c. Ensuring that the LTC facility communicates with the hospice medical director, the resident's attending physician, FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 27 of 29 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 06/09/2025 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 observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 3 of 3 resident rooms (rooms 603, 605 and 607) and 1 of 6 hallways (600 hallway) reviewed for environment. Residents Affected - Some 1. The facility failed to ensure the main hallway was free of roaches on 06/07/25 at 1:30 PM. 2. The facility failed to ensure resident rooms 603, 605 and 607 were free of rodents on 06/05/25 at 10:04 AM. These failures could place residents at risk for insect borne illness, not having a home free of pests and a comfortable environment in which to live. Findings include: In an interview on 5/28/25 at 11:28 AM, Resident #6 stated he saw roaches in his room and around the facility many times. He stated the roaches were a lot worse a few months ago but he still saw roaches in his room. He stated he heard other residents talk about mice in the facility but he had not seen any. In an interview on 05/28/25 at 11:30 AM, Resident #9 stated he saw a roach crawling on his wall the night before. He stated he told the CNA's about it and the roach problem was a lot worse several months ago. He stated he had not seen mice in his room but he thought he heard them scratching around at night. In an interview and observation on 05/28/25 at 11:32 AM, Resident #10 stated he saw mice in his room, he stated he saw mice earlier that morning coming out from under his air conditioning unit. Small black pellets were observed under Resident #10's air conditioning unit, the pellets appeared uniform in length around 3-5 mm and all appeared to be the same color of black. Resident #10 stated he informed the CNA's and a nurse about the mice. In an interview on 05/28/25 at 11:34 AM, Resident #12 stated he saw both mice and roaches in his room on a regular basis, nearly every night. He stated he kept his room very clean, but he still saw roaches and mice in his room. He stated he saw roaches recently in the hallways. In an interview and observation on 06/05/25 at 10:16 AM revealed Resident #14 came to the State Surveyor in the hallway. Resident #14 had a large box of crackers balanced on his legs while seated in a wheelchair. He stated he had a bad mouse problem in his room, and he the mice chewed through his cracker box and ruined his crackers. The box appeared to have a ragged hole on one side of the box that was approximately 1 x 2 inches. Resident #14 then led the State Surveyor to Resident #14's room. Resident #14 stated he saw mice in his room nearly every night, he stated he saw the mice behind his refrigerator and coming out of his closet. Small black pellets of uniform length of approximately 3-5 mm were observed behind the resident's refrigerator and in Resident #14's closet. Resident #14 stated he told staff about the mice. In an observation and interview on 06/07/25 at 2:48 PM, the State Surveyor and the ADM were walking towards the conference room down the 600 hall. A live roach was observed crawling up the wall by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 28 of 29 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 06/09/2025 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 Residents Affected - Some the receptionist desk. The ADM exclaimed some surprise when the State Surveyor pointed the live roach out to him. The ADM stated he would inform the Maintenance Supervisor about the roach, and he stated it could make residents upset if they saw roaches in the facility. In an interview on 06/09/25 at 10:15 AM, the Maintenance Supervisor stated there was a very bad roach problem in the facility several months ago because the facility had not paid the pesticide company, so they did not come to treat the facility. He stated there was a mouse problem in the facility right now and he recently put out traps. He stated he was aware of the mouse problem in Resident #14's room. Record review of the Pest Management Binder found: Last sighting log on 5/30/25 reflected rodents outside of RM [ROOM NUMBER], 3/31/25 Mouse RM [ROOM NUMBER], and 3/10/25 Roaches RM [ROOM NUMBER] roaches in on dresser. No receipts for service could be found for visits to the facility between 2/01/24 to 6/30/24. No visits could be found from 01/18/24 to 07/23/24. Record review of the facility's, undated, policy and procedure titled Pest Control reflected Purpose: to provide an environment free of pests. Policy: 1. The facility will have pest control that provides frequent treatment of the environment for pests. It will allow for periodic treatment when a problem is detected. There will be emphasis on the pest control in the kitchens, cafeterias, laundries, loading docks, construction activities and other areas prone to infestation. Monitoring of the environment will be done by the facility's staff. Pest control problems will be reported promptly. Screens will be maintained in all windows that open to the outside. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 29 of 29