Health inspection·August 27, 2023

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (new connective tissue), and 30% necrotic (dead tissue), 30% slough (a form of dead tissue) with Tissue type 4 necrotic/eschar and serosanguineous (pink/brown) drainage. Record review of Resident #2's Care Plan dated 08/03/23 reflected she had unstageable pressure wound to the left heel and will show signs of healing by the next review date. The care plan stated, treatment as follows: clean with ns, pat dry, apply calcium alginate with AG, cover with dry dressing every Tuesday and Friday and PRN if becomes soiled/dislodged. Review of Resident #2's Physician's Orders dated 08/04/23 and 08/16/23 (respectively) revealed wound care orders for the following; 1. Start Date: 08/04/23 wound care- twice a week cleanse unstageable pressure wound to left heel with NS, pat dry, apply calcium alginate with Ag, cover with dry dressing 2 times a week on Tuesday and Friday and PRN if becomes soiled/dislodged. 2. Start Date: 08/16/23 PRN wound care- as needed cleanse unstageable pressure wound to left heel with NS, pat dry, apply calcium alginate with Ag, cover with dry dressing 2 times a week on Tuesday and Friday and PRN if becomes soiled/dislodged Review of Resident #2's electronic Treatment Administration Record (eTAR) and eTAR Notes, dated August 2023 revealed when the wound care treatment was performed the nurse would indicate this with her initials. According to the eTAR wound care start date was 08/04/23 and was provided on 08/18/23, 08/22/23, and 8/25/23 for the left heel. When the procedure was not performed an X would take the place of the nurses' initials. The as needed wound care order was not listed on the eTAR until the day of surveyor entry on 08/26/23. The eTAR revealed 08/26/23 was the only day Resident #2 had received as needed wound care. Review of nurse's notes revealed Resident #2 did not refuse wound care in August 2023. Interview on 08/26/23 at 12:18 PM with the Resident #2 family member revealed the Resident #2 only spoke Spanish. The Family member stated Resident #2 had been at the facility for 3 weeks. The Family member stated the resident was getting wound care on the left heel and there was a large blister that had been drained by the wound care doctor. She stated the resident had walked a lot which caused the heel to drain to the point of Resident #2's sheets would often get changed. The Family member stated wound care was provided only upon request. The Family member stated Initially the staff would do the resident's wound care often and the wound was getting worse because it was a open wound. The Family member stated Resident #2's left heel drained so much the facility had left a small kit in the resident's room for the family to change the dressing. The Family member stated she had changed the resident dressing last night. Record review revealed Resident #2 had muscle tissue debridement performed by surgical excision of devitalized subcutaneous muscle on 08/15/23. Observation on 08/26/23 at approximately 12:30 PM revealed Resident #2 had no date on the left heel dressing. Observation revealed the family member had removed Resident #2's dressing because the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675592 If continuation sheet Page 2 of 7 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 675592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE C C Young Memorial Home 4849 W. Lawther Dr. Dallas, TX 75214 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bottom of the dressing was saturated with pink/brown fluid. The family member had check the bag of supplies given to her by Resident #2's left heel pressure ulcers had shown the top two layers of the skin was absent and draining clear fluid towards the bottom of the heel, and black necrotic (dead) tissue on top. The pressure ulcer was approximately (L)3cm x (W)3cm x (D) 0.5cm. Interview on 08/26/23 at 1:17 PM with Wound Care Nurse revealed Resident #2 was to receive wound care for her left heel twice weekly on Tuesdays and Fridays and as needed if the dressing become dislodged. She stated she would be responsible for Resident #2's scheduled dressing changes and the floor nurses were responsible for as needed and weekend dressing changes. She stated the left heel was unstable (there may been [NAME]/ dead tissue, but you need to see the bed to accurately stage it). She stated family was not allowed to provide wound care to residents because it can delay healing and she was not aware that family was providing wound care for Resident #2. The Wound Care Nurse stated she did complete in-services on wound care in the last month. Interview on 08/26/23 at 1:56 PM with LVN A revealed Resident #2's left foot has an unstageable ulcer with the bottom edges open with drainage. He stated the family was usually good at keeping up with the wound care. He stated the family was not supposed to provide wound care because the resident would pose the risk of infection. LVN A stated he had completed in-services on wound care in the last month. Interview on 08/27/23 at 3:57 PM with the Wound Care Physician revealed Resident #2 was admitted with a left heel pressure ulcer. She stated Resident #2 was seen on 08/08/23, 08/15/23, and 08/22/23 was admitted with a deep tissue injury ulcer of the left heel and was a blood blister which meant the wound was at a muscular level. She stated the wound on the left heel was unstageable (will be at the muscular or the bone level). She stated unstageable was somewhere between stage 3 or 4. The Wound Care Physician stated the Left heel was at the 50% slough and granulation Unstageable. She stated the dressing changes was on Tuesday and Friday and prn if dislodged. She stated she was not aware that family was providing wound care and given supplies to complete the intervention. The Wound Care Physician stated Resident #2's left heel was to be always covered because it had sanguineous drainage coming from the wound. She stated the risks of the family members performing wound care for Resident #2 could cause an infection and delayed wound healing. Interview on 08/27/23 at 6:38 PM with the DON (Director of Nursing) revealed Resident #2 was being treated for wound care on the left heel. He stated the family was not allowed to provide wound care to Resident #2. He stated he was not aware that family was providing wound care to Resident #2. The DON stated, the nurses are the only employees allowed to do wound care for the residents. He stated the treatment nurse was responsible for wounds during the week and the floor nurses were responsible for wound care on the weekends. He stated the wounds were supposed to be covered all times. The DON stated the risks of allowing a family member provide dressing changes could delay healing. 2) Record review of Resident #3's MDS assessment dated [DATE], reflected she was an [AGE] year-old male, who had a current admit date to the facility on [DATE]. The resident's diagnoses included presence of left artificial hip joint, post covid-19, anemia, fall, peripheral vascular disease, cutaneous abscess of the right limb, chronic kidney disease, heart failure, presence of cardiac pacemaker, sinus syndrome, and need for assistance with personal care. The resident had a BIMS score of 15, he was cognitively intact. He required limited assistance of one person with ADL's and was incontinent of both bowel and bladder. He had limited mobility in the lower extremities and required partial/ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675592 If continuation sheet Page 3 of 7 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 675592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE C C Young Memorial Home 4849 W. Lawther Dr. Dallas, TX 75214 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 0686 moderate assistance. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #3's Care Plan dated 07/27/23 revealed he had peripheral vascular diseaseright 1st metacarpal joint and treatment should be followed per doctor orders. Residents Affected - Few Review of Resident #3's Physician's Orders dated 07/10/23 and 07/19/23 (respectively) revealed wound care orders for the following. 1. Start Date: 08/02/23 wound care- once daily cleanse right 1st metatarsal joint with normal saline, pat dry, apply Santyl, apply derma blue foam, cover with dry dressing 3 times on Monday, Wednesday, and Friday and as needed if became dislodge. 2. Start Date: 08/02/23 PRN wound care- cleanse right 1st metatarsal joint with normal saline, pat dry, apply Santyl, apply derma blue foam, cover with dry dressing 3 times on Monday, Wednesday, and Friday and as needed if became dislodge. Review of Resident #3's electronic Treatment Administration Record (eTAR) and eTAR Notes, dated August 2023 revealed when the wound care treatment was performed the nurse would indicate this with her initials. According to the eTAR wound care start date was 08/02/23 and was provided on the right 1st metatarsal joint. The eTAR revealed wound care had not been completed on 08/25/23. Review of nurse's notes revealed Resident #3 did not refuse wound care in August 2023. Observation on 08/26/23 at 9:13 PM with the Wound Care Nurse revealed Resident #3's dressing on his right 1st metatarsal joint was dated for 8/24. The wound dressing appeared to look old and the edges were pulled up. She had cleaned the wound with normal saline and had applied a dressing dated for 8/27. The wound had shown signs of healing with approximated edges, skin around the wound was yellow and pink. Interview on 08/26/23 at 1:17 PM with the Wound Care Nurse revealed Resident #3's Right toe dressing was to be changed three times a week on Monday, Wednesday, and Friday. She stated Resident #3 should have had wound care done on 08/25/23 and because the wound dressing was labeled 08/24/23 then wound care was not done on the 08/25/23 as ordered. Wound Care Nurse stated she was responsible for providing wound care Monday- Friday and floor nurses was responsible Saturday and Sunday and in her absence during the week. Wound Care Nurse did confirm she was at work on 8/25/23. She stated the risk were delayed wound healing. The Wound Care Nurse stated she had received an Inservice on medication administration in the last month. Interview on 08/27/23 at 3:57 PM with the Wound Care Physician revealed Resident #3 was seen on 08/08/23, 08/15/23, and 08/22/23. She stated, Resident #3 has a right 1st metatarsal joint wound due to peripheral vascular disease. Order for ointment Monday, Wednesday, and Friday and prn if the dressings dislodged or soiled. The Wound Care Physician stated the risks of not receiving wound care on ordered days would delay wound healing. Interview on 08/27/23 at approximately 6:38 PM with DON (Director of Nursing) revealed Resident #3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675592 If continuation sheet Page 4 of 7 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 675592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE C C Young Memorial Home 4849 W. Lawther Dr. Dallas, TX 75214 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was seen for wound care. He stated the resident was ordered to receive wound care on right 1st metatarsal joint on Mondays, Wednesdays, Friday, and as needed when dressing had become dislodged. He stated the expectation for staff was to use the correct date for dressing every time the dressing was changed. The DON stated the date was applied to a wound dressing was to ensure wound care had been provided for that day. He stated the nurses were responsible for ensuring the dressing change was completed. He stated the risks of not performing wound care for the resident as ordered could lead to delayed wound healing. The DON stated the staff had received an Inservice on wound care in the last month. Interview on 08/27/23 at approximately 6:45 PM with the Administrator revealed she had spoken with the Wound Care Nurse and 08/25/23 was a missed date on eTAR for Resident #3. Interview on 08/27/23 at approximately 6:46 PM with the DON revealed missed dates that were not documented on the eTAR would put Resident #3 at risk for delayed healing. 3) Record review of Resident #4's MDS assessment dated [DATE], reflected she was an [AGE] year-old female, who had a current admit date to the facility on [DATE]. The resident's diagnoses included benign neoplasm, history of venous thrombosis, type 2 diabetes, depression, hypothyroidism, hyperlipidemia, aortic valve stenosis, and anxiety disorder. The resident had a BIMS score of 6, indicating severe cognitive impairment. She had required extensive assistance of one person with ADL's and was incontinent of both bowel and bladder. Record review of Resident #4's Care Plan dated 07/27/23 revealed she had a potential for skin breakdown due to: cognitive deficit, urinary in continence, and bowel incontinence. Staff were to minimize exposure to moisture and assist with toileting or provide incontinence care. Review of Resident #4's Physician's Orders dated 08/22/23 revealed wound care orders for the following; 1. Start Date: 08/22/23 wound care- once daily cleanse right upper buttocks with NS, pat dry, apply collagen powder, cover with dry dressing daily and as needed if became soiled/dislodge. 2. Start Date: 08/02/23 as needed wound care- as needed cleanse right upper buttocks with NS, pat dry, apply collagen powder, cover with dry dressing daily and as needed if became soiled/dislodge. Review of Resident #4's electronic Treatment Administration Record (eTAR) and eTAR Notes, dated August 2023 revealed when the wound care treatment was performed the nurse would indicate this with her initials. According to the eTAR wound care start date was 08/22/23 and was provided on the right upper buttocks. The eTAR revealed as needed wound care had not been added or completed on 08/27/23. Review of nurse's notes revealed Resident #4 did not refuse wound care in August 2023. Interview and observation on 08/27/23 at 9:42 AM with Resident #4 stated she was in pain on her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675592 If continuation sheet Page 5 of 7 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 675592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE C C Young Memorial Home 4849 W. Lawther Dr. Dallas, TX 75214 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 0686 Level of Harm - Minimal harm or potential for actual harm bottom. The Wound Care Nurse had asked Resident #4 if she wanted pain medication. The resident had refused at that time, but as the nurse was turning the resident the resident yelled ouch, ouch and stated she was in pain on her bottom, and she could not be turned no further. The resident requested her pain medications. The Wound care nurse stopped and informed the floor nurse resident need for pain medication. Residents Affected - Few Observation on 08/27/23 at 9:53 AM of Wound Care Nurse and CNA C revealed Resident #4 tolerated the body turn but complained of pain on her bottom. Resident #4 was given pain medication. There were no dressing on the resident's right upper buttocks. The nursed had opened the brief to look for the dressing, but there were no dressing in the brief or on the resident's bed. The Wound was open and red with underlying tissue exposed at approximately (L) 2cm x (W) 3cm. The resident had asked, is that what hurt so bad and Wound Care Nurse responded by saying, you have an open sore on your bottom. The Wound Care Nurse and CNA C had proceeded to provide incontinent care to the resident because her brief was wet. Interview on 08/27/23 at 10:13 AM with LVN B revealed she must clean Resident #4 very often because of how Resident #4 would slide down in her chair and incontinent care causes dressings to become dislodged. LVN B stated the last time she had provided wound care was 08/26/23 after it had gotten dislodge, but she did not have documentation of the time. The nurse stated she did not chart the prn wound changes because she just does not. However, she said the last charted wound change was for 08/26/23 at 9:42 AM. She stated Resident #4's wound was located on her coccyx area in between the glutes at the top with redness around the open with jagged edges. She stated the resident had voiced and exhibited pain regarding her wound. She stated when she gets the wound cleaned, she voices that she is in pain and will say ouch. She stated she was not aware of the resident wound being uncovered. LVN B stated the wound was not supposed to be uncovered, it was to always remain covered. She stated the resident was to receive daily and prn when dressing dislodge. The cna will let the nurse know when the dressing dislodges. She stated if Resident #4 wound was not covered, the risk had posed infection and delay of wound healing. She stated the last skin assessment on the resident was yesterday 08/26/23 and she does not recall the last time the resident was seen by a physician. She stated the wound looks the same as it did when wound care first had begun. She stated whenever staff would inform her of an uncovered wound she would immediately to clean and cover the area. She stated the resident had not voiced that she was not receiving wound care or that her wound was not covered. She stated she had received in services on wound care in the last month. Interview on 08/27/23 at approximately 10:30 AM with CNA C revealed she was caring for Resident #4. She stated Resident #4 had wounds on the right side below the coccyx area. She stated Wound Care Nurse or LVN B provide wound care. She stated the wound was supposed to be always covered. She stated she had noticed this morning around 8 am the dressing was missing, and it was not inside the resident brief at that time. CNA C stated she did not know how long Resident #4's dressing had been uncovered. She stated she did not inform LVN B immediately about the wound being uncovered because breakfast trays were already being passed. CNA C stated she was rushing to get Resident #4 up and dressed and to the dining area. She stated she would inform LVN B once she had brought the resident to her room. She stated when Resident #4's wound was uncovered or soiled, she was supposed to notify LVN B immediately after. CNA C stated she had completed in services on wound as it related to providing incontinent care. She stated the risks for leaving a wound uncovered could cause an infection. Interview on 08/27/23 at 10:55 AM with the Wound Care Nurse revealed the wound care physician would come on Tuesday and she rounds with her. She stated Resident #4 was seen by the wound care physician. She stated Resident #4 had moisture associated skin damage. She stated it was typically diagnosed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675592 If continuation sheet Page 6 of 7 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 675592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE C C Young Memorial Home 4849 W. Lawther Dr. Dallas, TX 75214 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for residents with incontinent or residents with yeast folds. She stated the wound was located on the upper buttocks but was not a pressure wound because it was moisture associated. She stated the wound was located on the right upper buttocks. She stated the wound was painful for the resident during the time of wound care that was performed. She stated the resident had not experienced pain from her wound prior to today. She stated the resident received wound care daily. She stated the resident can verbalize needs but has moments of confusion. She stated she completes wound care during the week for Resident #4 and the floor nurses would complete wound care on the weekends. She stated the resident's wound was not covered when she went to perform wound care. She stated the resident's wound was to be covered due to daily wound care and she was supposed to have a dressing on her wound. She stated if the dressing had become dislodged a new dressing was supposed to be applied. She stated she did not know the approximate dimensions but said her wound was better. She stated if the CNA saw the residents dressing was off Resident #4 right upper buttocks, the nurse should have been notified to place a dressing on the wound. She stated there was a risk of infection because the wound was open and could deteriorate. She stated the wound had minimal redness. She stated the minimal redness could also be from her having an open wound. Interview on 08/27/23 at approximately 3:57 PM with the Wound Care Physician revealed Resident #4 was seen on 8/15/23. She stated Resident #4 wound was not a pressure ulcer because the wound was not on a bony prominence. She stated Resident #4 had an upper right buttock wound due to moisture skin damage. Right buttocks orders were daily and as needed. She stated when the dressing had dislodged the dressing needed to get replaced. Wound Care Physician stated the risk of leaving open wounds uncovered would delay wound healing. Interview on 08/27/23 at approximately 6:38 PM with the DON (Director of Nursing) revealed Resident #4 had a wound on the upper right buttocks. He stated the wound was to be covered with dry dressing. The DON stated the orders stated the resident wound was to remain covered with dry dressing daily prn or if it gets dislodged. He stated Resident #4 was at risk for delayed wound healing if the wound was not covered. He stated Wound Care Nurse was responsible for Resident #4 wound care during the week and the floor nurse was responsible for wound care on the weekend. He stated the expectation of staff was to notify the nurse immediately when they see a wound was not covered or dressed. The DON stated the staff had received an Inservice on wound care in the last month. Review of the facility's Pressure Ulcers/Skin Breakdown-Clinical Protocol policy dated April 2018 reflected, The physical will help staff characterize the likelihood of wound healing based on review of pertinent factors' for example: Healing or Prevention Likely: The resident's underlying physical condition, prognosis, personal goals, and wishes, care instructions, and ability to cooperate with the treatment plan make wound healing and subsequent wound prevention realistic . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675592 If continuation sheet Page 7 of 7