Health inspection·December 2, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete disease stage 4 (severe kidney damage, where the kidneys are functioning at 15-29% of their normal capacity), hypertension, anemia, cognitive communication deficit, difficulty in walking and Schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar disorder) Record review of Resident#2's MDS, dated [DATE] reflected his BIMS score was 03 which indicated serve cognitive impairment. Resident#2 had a presence and frequency of wandering daily. Record review of Resident#2 care plan, dated 10/09/25 reflected, no documentation of Resident#1 having a wander guard Record review of Resident#1's progress notes dated 10/09/25, reflected from 08/08/25 to 10/09/25 :On 08/13/25 Resident#2 actively exit seeking, not easily redirected. Record review of Resident#2 order summary, dated 10/09/25 reflected: Ensure Resident#1 wander guard was present on her left leg. Every 10 hours for wandering. Order started on 08/20/25 and was ongoing. Record review of Resident #3's face sheet, dated 10/09/25 reflected he was a [AGE] year-old male who was admitted on [DATE] and diagnosed with unspecified Dementia (decline in cognitive function that cannot be definitively attributed to a specific type of dementia), psychotic disturbance (a mental health condition characterized by a significant loss of contact with reality), mood disturbance (a persistent change in a person's emotional state, going beyond typical ups and downs to affect their ability to function) and anxiety ( common mental health condition characterized by excessive worry, fear, and nervousness), Hypothyroidism (abnormally low activity of the thyroid gland, resulting in slowing of growth and mental development), unspecified, difficulty in walking (This code is used to describe difficulty walking when the underlying cause cannot be classified into a more specific category) not elsewhere classified, generalized muscle weakness and unspecified pain. Record review of Resident #3's MDS, dated [DATE] reflected his BIMS score was 08 which indicated moderate cognitive impairment. Resident #3 did not exhibite a presence and frequency of wandering behaviors. Record review of Resident #3's care plan, dated 10/09/25 reflected no documentation of Resident #3 having a wander guard. Record review of Resident #3's progress notes dated 10/09/25, reflected from 08/09/25 to 10/09/25: No documentation of wandering. Record review of Resident #3's order summary, dated 10/09/25 reflected: Ensure Resident #3's wander guard was present on his left leg. Every 10 hours for wandering. Order started on 10/09/25 and was ongoing. In an interview and observation on 10/09/25 at 3:25 pm the ADON and surveyor reviewed the 4 residents' care plans who wore wander guards. Resident #1 did not have interventions in place documented in the care plan for exit seeking behavior. Resident #2 and Resident #3 had interventions in place for exit seeking behavior and did not have the wander guard as an intervention. The ADON stated the MDS nurse was responsible for updating the care plans. In an interview on the phone on 10/09/25 at 3:29pm the ADON called the MDS Nurse. The MDS Nurse stated she updates the care plan according to the IDT meetings and as needed. The MDS nurse and the ADON discussed Resident #1, Resident #2 and Resident #3 did not have wander guard interventions identified on the care plans. The MDS Nurse stated she would update the care plans as soon as possible. Record review of facility policy titled, care plans, comprehensive person centered reflected,4. Each resident's comprehensive person-centered care plan will be consistent with residents' rights to participate in the development and implementation of his or her plan of care, including the right to: g. Receive the services and/or items included in the plan of care. Event ID: Facility ID: 675440 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2025 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 - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations and record reviews, the facility failed to ensure 2 out of 4 residents (Resident#1 and Resident#2) received adequate supervision and assistance devices to prevent incidents. The facility failed to ensure Resident #1 and Resident #2's wander guards worked properly. These failures could place residents at risk of elopement.indings included:Record review of Resident #1's face sheet, dated 10/09/25 reflected, she was a [AGE] year-old female who was originally admitted on [DATE] and diagnosed with unspecified Dementia (decline in cognitive function that cannot be definitively attributed to a specific type of dementia), psychotic disturbance (a mental health condition characterized by a significant loss of contact with reality), mood disturbance (a persistent change in a person's emotional state, going beyond typical ups and downs to affect their ability to function) anxiety ( common mental health condition characterized by excessive worry, fear, and nervousness), hypertension (a condition where the force of blood against the artery walls is consistently too high), Hypothyroidism (abnormally low activity of the thyroid gland, resulting in slowing of growth and mental development), Edema (a condition where excess fluid accumulates in the body's tissues, causing swelling), Psychotic disorder with hallucinations due to physiological condition (a mental health condition where psychotic symptoms like hallucinations and delusions are a direct result of a medical illness) and Psychotic disorder with delusions due to known physiological condition (diagnosis characterized by the presence of delusions (false beliefs) that are directly caused by an underlying medical condition). Record review of Resident #1's MDS, dated [DATE] reflected her BIMS score was 06 which indicated serve cognitive impairment. Record review of Resident#1 MDS reflected Resident #1 did not exhibit wandering behavior at the time the MDS was completed. Record review of Resident #1's care plan, dated 10/09/25 reflected, no documentation of Resident #1 having a wander guard. Record review of Resident #1's progress notes dated 08/13/25 reflected Resident #1 actively exit seeking, not easily redirected. Record review of Resident #1's order summary, dated 10/09/25 reflected: Ensure Resident #1's wander guard was present on her left leg. Every 10 hours for wandering. Order started on 08/20/25 and was ongoing. Record review of Resident #1's TAR, dated 10/09/25 reflected: Ensure wander guard is present on her left leg every 10 hours for wandering Start date of 08/20/25 and a discontinued date of 10/09/25. Ensure wander guard is present on her left leg, check functioning placement, skin integrity every shift for wandering. Order started on 10/09/25. Record review of Resident #2's face sheet, dated 10/09/25 reflected, he was a [AGE] year-old male who was originally admitted on [DATE] and readmitted on [DATE] and diagnosed with unspecified Dementia (decline in cognitive function that cannot be definitively attributed to a specific type of dementia), psychotic disturbance (a mental health condition characterized by a significant loss of contact with reality), mood disturbance (a persistent change in a person's emotional state, going beyond typical ups and downs to affect their ability to function) and anxiety (common mental health condition characterized by excessive worry, fear, and nervousness) mother sequelae of cerebral infraction (paralysis, aphasia, and cognitive impairment), neuroleptic induced Parkinsonism (a temporary movement disorder that can occur as a side effect of taking certain medications called neuroleptics, also known as antipsychotics), chronic kidney disease stage 4 (severe kidney damage, where the kidneys are functioning at 15-29% of their normal capacity), hypertension, anemia, cognitive communication deficit, difficulty in walking and Schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar disorder) Record review of Resident #2's MDS, dated [DATE] reflected his BIMS score was 03 which indicated serve cognitive impairment. Resident#2 had a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2025 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 - Minimal harm or potential for actual harm Residents Affected - Some presence and frequency of wandering daily. Record review of Resident #2's care plan dated 10/09/25 reflected, no documentation of Resident#1 having a wander guard. Record review of Resident #2's progress notes dated 10/09/25, reflected from 08/08/25 to 10/09/25 on 08/13/25 Resident #2 was actively exit seeking, not easily redirected. Record review of Resident #2's order summary, dated 10/09/25 reflected: Ensure Resident #2's wander guard was present on his left leg. Every 10 hours for wandering. Order started on 08/20/25 and was ongoing. Record review of Resident #2's TAR, dated 10/09/25 reflected: Resident is wearing a wander guard device to left ankle every shift for wandering. Order discontinued on 10/09/25. Monitor wander guard to lower extremity every shift every shift for wander guard No order start date posted. Ensure wander guard is present on her left leg, check functioning placement, skin integrity every shift for wandering. No order start date posted. To ensure that wander guard is functioning correctly, every shift take resident to front door to ensure that alarm sounds. If alarm does not sound, please alert ADMINISTRATOR ASAP.every shift for wandering No order date posted. Record review of Resident #2's order summary, dated 10/09/25 reflected: Monitor wander guard to lower extremity every shift every shift for wander guard with a start date of 06/23/22 and ongoing. Resident is wearing a wander guard device to left ankle every shift for wandering with a start date of 05/09/23 and going. To ensure that wander guard is functioning correctly, every shift take resident to front door toensure that alarm sounds. If alarm does not sound, please alert ADMINISTRATOR ASAP.every shift for wandering with a start date of 05/30/23 and ongoing. Record review of Resident #2's progress notes, dated 10/09/25 reflected: Resident #2 had no documentation of exit seeking from 08/15/25 to 10/09/25. During an interview on 10/09/25 from 1:45 pm to 2:00 pm, LVN A and LVN B both stated Residents' wander guards were checked daily for placement and functioning before the end of shift and documented in the TAR. During an interview on 10/09/25 at 2:15 pm to 2:25pm, LVN C and LVN D both stated Residents wander guards were checked daily for placement and functioning before the end of shift. During an observation on 10/09/25 at 2:30 pm revealed Resident #1's wander guard did not have a light on and did not sound the alarm at the front door. Surveyor opened the front door and the door alarm sounded. During an observation on 10/09/25 at 2:35pm revealed Resident #2's wander guard did not have a light on and did not sound the alarm at the front door. Surveyor opened the front door and the door alarm sounded. During an interview and observation on 10/09/25 at 3:20 pm, the ADON and surveyor looked over the wander guard system. The handheld (Wander guard system-secure Tag Activator/Deactivator) showed that it was not active. The ADON stated the nurses check the residents' wander guard every shift for placement and document on the TAR. The ADON stated the wander guard has a red light that blinks. The ADON called the Business Office Manager on speaker who stated a new system had been ordered. The ADON stated no residents had eloped from the facility. During an interview on 10/08/25 at 3:30 pm the Maintenance Director stated he checked the wander guard system every Monday. During an interview on 10/09/25 at 3:38 pm the Admin stated the wander guard system had been working fine and it was checked regularly. The Admin stated of course when surveyors come into the building things sometime would go wrong. The Admin stated LRC came and checked the system recently and it worked fine. The Admin stated no residents had eloped from the facility. During an interview on 10/09/25 at 3:35 pm over the phone the Medical Director stated the Residents at the facility were safe. The Medical Director stated wander guards were put in place for extra precautions for residents who were exit seeking. The Medical Director stated as far as she knew no residents had eloped from the facility. During an interview on 10/09/25 at 3:38 pm the LRC stated they came out and serviced the front door on 08/14/25 because the alarm did not sound for the residents with TAGS (wander guard). The tech made a new jumper for the (Wander guard) system, and the tech checked the TAG and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2025 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 - Minimal harm or potential for actual harm door functioned properly. Record review of the Maintenance Director logs dated 10/08/25 reflected: Resident Monitoring systems: Check operation door monitors and patient wandering systempassed.Record review of invoice from LRC dated 08/25/25 reflected access control start kit repair. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675440 If continuation sheet Page 5 of 5