Health inspection·September 23, 2022

F 0692 with medication pass twice a day. The plan read to alert nurse if Resident #43 was not consuming on a routine basis. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #43's Consolidated Physician orders dated 08/12/2022 reflected the following dietary orders: Residents Affected - Few -Regular diet, Regular texture, thin consistency; Diet customized for individual needs dated 08/12/2022. -Double Desserts for lunch and supper. Add Frozen Nutritional Treat to lunch and supper dated 08/12/2022. -two times a day 90 ml House Supplement for additional calories/protein dated 08/22/2022. -Offer substitute if resident eats <50% dated 03/04/2022. -Resident is at risk for malnutrition related to new admission and diagnosis: Bipolar with Psychosis will weigh once weekly x 4 weeks, and monthly thereafter. Dietician to consult as needed, per orders dated 03/04/2022. Record review of Resident #43's electronic medical record revealed only monthly weights were being recorded, and the facility was not following the order for weekly weights suggested for the resident. Record review of a nursing evaluation dated 03/05/2022 revealed a nursing skilled evaluation of Resident #43's who was admitted on [DATE]. The note read, The resident began receiving Skilled Nursing Services with skilled diagnosis: bipolar disorder, mixed with severe recurrent and with psychotic's features. Skilled care being provided: Management and Evaluation of Patient Care Plan; Observation and Assessment of Patient; Vital Signs: Blood Pressure 128/82, Temperature 97.7, Respirations 18, and Weight 163.5 lbs. Scale: Standing. Record review of a Nutritional Note dated 05/13/2022, written by the Registered Dietician revealed the following, Text: Resident #43 has experienced a significant weight loss decline x 30 days (-6.0%) and the Registered Dietician notes reflected further, Resident #43's dietician' notes reflected the following: -May wt.: 157 lbs. - April wt.: 167 lbs. Further review of the Registered Dietician's notes dated 05/13/2022 5/13/22 dietician's note revealed Resident #43 was eating >75, Interventions currently in place: Regular texture diet - eating majority of the time >75% per ADL documentation. Resident prefers Korean type foods. Likes Sweets. No family to bring her familiar foods. Korean recipes for typical foods will be provided to kitchen that focus on rice and vegetables and protein. Add two desserts to lunch and supper. Record review of a Nutritional note dated 06/15/2022, written by the Registered Dietician revealed she wrote, Interventions currently in place: Regular texture diet - eating majority of the time >75% per ADL documentation. Resident prefers Korean type foods. Likes Sweets. No family to bring her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 2 of 23 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 675680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place One 3505 S Buckner Blvd Bldg 2 Dallas, TX 75227 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 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few familiar foods. Korean recipes for typical foods will be provided to kitchen that focus on rice and vegetables and protein. Add two desserts to lunch and supper. The Registered Dietician notes added the following information, significant weight loss decline x 90 days (-7.9%). June wt. 151 lbs. BMI 28.5 May wt.: 157 lbs. April wt.: 167 lbs. Further review of the Registered Dietician's 06/15/2022 notes revealed Resident #43 was eating >75% the majority of the time, still losing weight, Interventions currently in place: Regular texture diet - eating majority of the time >75% per ADL documentation. Resident prefers Korean type foods. Likes Sweets. No family to bring her familiar foods. SLP is known to bring the resident favorite dishes that contain cabbage. Korean recipes for typical foods were provided to kitchen that focus on rice and vegetables and protein. Resident does like sweets. Add two desserts to lunch and supper. Add Frozen Nutritional Treat to Lunch and Supper. Continue to monitor for signs, changes and monitor weekly weights. Record review of a nutritional note dated 07/07/2022, written by the Registered Dietician revealed, Resident #43 has experienced a significant weight loss decline x 90 days (-11.4%). -July wt.: 148 lbs. - June wt. 151 lbs. -April wt.: 167 lbs. Further review of the Registered Dietician's notes read 06/15/2022, Interventions currently in place: Regular texture diet - eating majority of the time >50% per ADL documentation. Resident prefers Korean type foods. Likes Sweets. No family to bring her familiar foods. SLP is known to bring the resident favorite dishes that contain cabbage. Korean recipes for typical foods were provided to kitchen that focus on rice and vegetables and protein. Resident does like sweets. The Registered Dietician listed the following as a plan for weight loss: -Receives two desserts to lunch and supper. -House 2.0 Supplement 90 ml BID added 6/24/22. -Resident may benefit from IV Vitamin Therapy r/t wt. loss. -Consider adding Remeron for appetite stimulation x 45 days. -Add MVI w/ Minerals daily. -Add Frozen Nutritional Treat to Lunch and Supper. -Continue to monitor for sig changes and monitor weekly weights. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 3 of 23 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 675680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place One 3505 S Buckner Blvd Bldg 2 Dallas, TX 75227 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 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of a nursing note dated 07/14/2022 read order for infusion by physician, Alert Charting, late: Resident has been cleared for IV hydration and vitamin therapy by the Facility's Physician. Current meds were reviewed, if any, and all contraindications have been found. Reviewed resident allergies. Order verified. Assessment completed. Resident prepared for IV vitamin infusion. Site prepared per protocol 22g x 1 attempt. IV site secured per protocol no redness or signs of infiltration. Infusion for wellness r/t multiple comorbidities and support immune function and promote nutrition. The physicians order read as follows, Order: 0.9% Normal Saline 250mL, and further notes revealed, Infusion started @ 250mL/hour on dial a flow. Patient in no distress, IV site without redness, edema, signs of infiltration. Patient comfortable and denies needs. 1830 Infusion complete. Resident tolerated infusion without difficulty or complication. IV discontinued and gauze applied to site. Report of infusion completion. Record review of the Registered Dietician's note dated 07/15/2022 read as follows, Nutritional Note: Resident #43 has a significant weight decline x 90 days: from 167 lbs. to 148 lbs. She is refusing to eat the food provided and all attempts to provide her cultural foods, yet the ADL documentation notes occasional >50%. Further notes revealed the recommended interventions as follows, -IV therapy for nutritional support was given 07/14/22. - It was discussed that monies needs to be obtained to get local food that perhaps the resident will eat. - Will continue to monitor and try to find foods she will eat. Record review of the Registered Dietician's note dated 8/12/2022 reads as follows, Nutritional Note Resident #43 has a significant weight loss decline x 90 days (-8.9%). -August wt.: 143 lbs. -May wt.: 157 lbs. Further review of Registered Dietician's notes revealed, She is refusing to eat the food provided and all attempts to provide her cultural foods, yet the ADL documentation notes occasional >50%. The Registered Dietician's noted that these interventions were in place: A Regular Diet was being provided, and double Desserts for lunch and supper would be provided. The Registered Dietician's notes went on to add, Disposable utensils only on meal trays. Add Frozen Nutritional Treat to lunch and supper. Record review of the Registered Dietician's note dated 09/17/2022 read as follows days Nutritional Note: Resident #43 has a significant weight decline x 90 days (-7.9%). -[DATE] lbs. Re-weigh 137 lbs. -June 151 lbs. The Registered Dietician's notes stated that she estimated nutrient needs for Resident #43 were the following: -1575-1890 kcal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 4 of 23 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 675680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place One 3505 S Buckner Blvd Bldg 2 Dallas, TX 75227 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 0692 -62-76 gm Protein Level of Harm - Immediate jeopardy to resident health or safety -575-1890 ml Residents Affected - Few The Registered Dietician continued, her notes stating, She is occasionally refusing to eat the food provided. Attempts to provide her Korean foods are being made. ADL documentation indicates some improvement in po intake. The Registered Dietician's noted that these interventions were in place: Regular Diet was being provided, and she said, Efforts are made to purchase Korean foods locally. SLP notes that she will eat this better in bowls. This has been added to tray ticket. Resident enjoys sweets -Double Desserts for lunch and supper. Disposable utensils only on meal trays. Frozen Nutritional Treat to lunch and supper. House Supplement 90 ml BID. MVI w/ Minerals daily. The Registered Dietician wrote goals for Resident #43, she said the resident would eat >50% of meals/desserts/supplements to maintain current weight of 137 lbs. The Registered dietician ordered to have Resident #43 weighed weekly for 3 weeks, and wrote further, It was discussed that monies needs to be obtained to get local food that perhaps the resident will eat. FSM will look into this. Will continue to monitor and try to find foods she will eat. Weekly weight to be monitored x 4 weeks. Review of the Registered Dieticians intervention notes contradicted the times she wanted Resident #43's weights to be checked, she first wrote to check them weekly for 3 weeks and at the end of her note, she wrote to check the residents weighed weekly for 4 weeks. Record review of Registered Dietician's email sent to Dietary Manager dated 05/14/2022 revealed she stated that the email was sent to share Korean diet suggestions. The email read, Korean Americans from South Korea: some foods include: -Rice, noodles, leafy vegetables, kimchi, small fish, grilled beef, [NAME] and vegetable fats Record review of Resident #43's Medication Administration Record dated 06/01/2021 through 06/30/2022 revealed and order: 2.0 Supplement two times a day= 90 milliliters ordered to start on 06/24/2022, the resident is recorded to have drunk the supplement on the evening of 06/24/2022, and then consecutively 06/25/2022 through 06/30/2022. Resident #43 was recorded by facility staff to have consumed the supplement for the entire month of July 2022, and then in August of 2022, Resident #43 was recorded to have not consumed the supplement for 11 days and was recorded to drink the supplement for the remainder of the month of August 2022. Resident #43's electronic records revealed there had been loggings of 100 % consumption of the supplements up until the beginning of the state survey when it was discovered by surveyor observation that the resident was not intaking the supplement as stated by nursing staff and was found to be left unopened on Resident #43's breakfast and lunch trays on 09/19/2022, 09/20/2022 and 09/23/2022. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 05/18/2022 for Resident #43's health plan read, Patient consumes 25% of meals and snacks. The SLP wrote Resident #43 was referred due to decline in functional activity tolerance during oral intake and weight loss. The SLP's clinical review for weight loss was noted for significant weight loss. The SLP continued to write Resident #43 required maximum encouragement for adequate meal intake and consumed only 25% of the meal. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 05/19/2022 for Resident #43's revealed, the resident had been assessed for meal consumption (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 5 of 23 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 675680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place One 3505 S Buckner Blvd Bldg 2 Dallas, TX 75227 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 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few during breakfast and lunch, and Resident #43 at 0% of her meals. The SLP noted that she tried to offer supplements and Resident #43 refused them. the SLP wrote that Resident #43 requested Korean food and she inquired what the resident likes, and dislikes were, and Resident #43 said she would eat salads, the SLP wrote that she would get the kitchen to provide salad, stated, Discussed likes and dislikes and patient stated she would eat salads, kitchen to provide salad tomorrow for lunch meal. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 05/20/2022 for Resident #43's read, SLP provided ice cream, coke and salad and patient consumed 50% of ice cream and hard-boiled eggs out of the salad. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 05/25/2022 for Resident #43 revealed she wrote, SLP will provide Korean meal for patient to increase meal intake on 05/26/2022 as requested by patient. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 05/26/2022 for Resident #43 revealed, the SLP wrote, SLP provided Korean food and maximum verbal cues and then wrote, Patient consumed 25% and stated she would eat the rest later but appeared to really enjoy the food. Returned to the room later and patient consumed 75% of food. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 05/31/2022 for Resident #43 revealed she wrote, Offered patient fruit and supplement and patient ate 100%. Further comments written by SLP were, the kitchen had provided Korean type foods the patient liked such as broth, hard boiled eggs, rice, and vegetables for lunch meals. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 06/06/2022 for Resident #43 read the SLP provided Korean food, Kimchi chicken, and the resident ate 50%s of the meal. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 06/08/2022 for Resident #43 revealed the SLP provided Kimchi chicken to assist with meeting nutritional needs, and the resident consumed the meal. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 06/09/2022 for Resident #43 read, Patient requested Kimchi and SLP provided a bowl of patients preference and patient consumed 100%. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 06/24/2022 for Resident #43 revealed she noted, Consumption of food provided by SLP (Korean type) accepted and 100% intake with set up only, the note meaning that the SLP provided the resident with her favorite food, and she ate all of it, and did not need coaxing. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 08/24/2022 for Resident #43 stated the resident had poor intake of meals and significant weight loss. The plan stated Resident #43 had previously receive therapy for service dated 05/18/2022 through 06/27/2022 and stated that the resident had made steady progress with stated goals and increasing her meal intake to 80 % of meals and snacks. The initial assessment for this date noted the resident had a significant weight loss. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 6 of 23 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 675680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place One 3505 S Buckner Blvd Bldg 2 Dallas, TX 75227 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 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few dated 08/24/2022 for Resident #43 read, Patient presents with 0% intake of lunch meal. Patient provided with culturally sensitive food that the patient prefers, and patient consumed 50% of food provided. The SLP commented the following, patient and caregivers educated on foods the patient prefers to increase intake and maintain weight. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 08/26/2022 for Resident #43 read the SLP attempted to coax the resident to eat the lunch tray provided by the kitchen, and Resident #43 refused to eat any of the items on the tray, the SLP brought in an alternate meal and the resident ate 25% of the items on the tray. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 08/30/2022 for Resident #43 read the resident did not eat any of her lunch tray, so the SLP brought in an alternate meal of rice and vegetables and the resident ate 75% of the meal. The SLP wrote Resident #43 requires maximum assist for feeding and intake of meals. Record review of Speech Language Pathologist (SLP) Speech Therapy Evaluation and Plan of Treatment dated 09/05/2022 for Resident #43 revealed the SLP had noted that she educated the Dietary Manager on the patient's intake of fresh fruits, and that she liked fruit and when provided with the fruit, she would eat 100% of the item. Observation on 09/19/2022 at 10:35 a.m., Resident #43 was in her room in bed, and stated not liking the food. CNA Q was removing Resident #43's breakfast tray, the only food item on the tray was a bowl of cereal and two boiled eggs, an untouched glass of milk, no other food items or supplements were observed on the tray. During an interview on 09/19/2022 at 10:40 am, CNA Q revealed that Resident #43 was a very picky eater and regularly refused meals, breakfast, lunch, and dinner. She denied trying to coax the resident to eat or offering an alternate because the resident did not ask for them. During an interview on 09/19/2022 at 1:30 PM, LVN Z revealed she was familiar of the resident and the problems with eating her meals. She said that it was important to check a Resident meal trays against meal tickets and sending back to the kitchen for correction if not matching and documenting accurate meals for each resident with weight loss problems. A staff member should be informing a charge nurse, dietician, or kitchen staff of a change in condition for residents not eating meals. Interview on 09/19/2022 at 10:45 AM, CNA R revealed she worked the 6:00 am to 2:00 PM shift and worked the 300 halls, she cared of Resident #43 and knew that she did not like the food served by the kitchen and said that SLP came to help her eat. She denied providing Resident #43 with an alternate meal, she said thought the SLP was taking care of the alternant meal because she saw her brining in foods from a Korean place. During an interview on 09/19/2022 at 11:30 AM with Registered Dietician, she was asked about the significant weight loss recorded on Resident #43's medical record and she replied that the resident was a very picky eater and did not like much of the food the kitchen would make. The Registered Dietician revealed that because the resident was Korean, she spoke to the Dietary Manager about what type of foods could be provided, Korean meals, and they had the idea to provide rice, noodles, and vegetables. The Dietician said the Dietary manager had gone to the grocery store to buy Korean frozen foods and rice and vegetables and they kept a box in kitchen specifically for Resident #43. This intervention came about after discussing Resident #43's weight loss during a weekly interdisciplinary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 7 of 23 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 675680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place One 3505 S Buckner Blvd Bldg 2 Dallas, TX 75227 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 0692 meeting for residents with significant weight loss. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 09/19/2022 at 12:00 PM with Dietary Manager, she was asked about the location of Resident #43's personal box of preferred foods, she immediately guided the surveyor to the pantry and frantically looked for the box but was unable to locate it. The Dietary Manager then turned to seek help from [NAME] G to find the foods, [NAME] G said that she had no idea where the box was. The Dietary Manager said she had been on vacation a week prior and that before she left, the box was in the pantry, and revealed the last time she bought food for Resident #43 was a month ago in August. She said the administrator gave her the facility credit card and she went to local grocery store and bought rice, noodles, and vegetables as well as frozen Korean foods. The Dietary Manager said these types of foods were not available to order trough their current food distributer, and that was the reason she had to make the trip to the grocery store to buy the special items. Residents Affected - Few Record review of receipt from Walmart dated 08/15/2022 revealed a purchase totaling $35.20 of the following items: -Bags of rice -ginger spice -and sweet chili Record review of the facility Petty Cas Reconciliation invoice dated 08/19/2022 revealed the amount of $35.20 that was paid to the grocery store was for, Food for Asian Resident that has had a weight loss. There were no other receipts provided during this investigation. During an interview on 09/20/2022 at 8:45 AM, the Director of Rehab (DOR), revealed the Restorative Aid does weights as ordered per the Registered Dietician, and that the Registered Dietician keeps up with weight loss on a weekly basis. She said that once a month, the Registered Dietician provides her with the monthly weights on residents who are flagged for weight loss, and she said, I conduct a monthly weight loss report, and get the weights off the electronic medical record where the Registered Dietician inputs the monthly percentages. She was asked why the electronic medical record only showed monthly weights, and she said the weekly weights are supposed to be in the system, but it is up to the Registered Dietician to input the weights. The DOR said that the interventions for treatment for Speech Therapy and Occupational Therapy are generated by the weights and the intervention are geared to treat for people weaknesses, to check if they need adaptive equipment, or if they have swallowing problems. She said the Registered Dietician is part of an Interdisciplinary team meeting every Thursday, and the team consist of Nursing, dietary and therapy and they come together weekly to discuss the interventions for weight loss, how to benefit the resident's intake of meals, and the interventions include new cues to initiate a person to eat, once the treatment is completed and hopefully the resident's weight increases, they are discharged from therapy. Sometimes even if the resident does not improve, they are discharged due to insurance problems. But it they do improve, the treatments are completed, and all interventions are discussed at meeting and nursing takes over after discharge to continue to monitor the resident for changes in condition. The DOR discussed Resident #43's case saying, Korean type foods were discussed with the dietary manager, Registered Dietician and the ADON, but with this particular resident, we found that her preferences changed, and it was a day-to-day task with her of finding out what she will like to eat, like today, I brought in Korean food, kimchee, hopefully she will like it. The DOR was asked how many times the therapy department was bringing in the Korean foods, she said once or twice a month, brought in by both herself and the SLP. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 8 of 23 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 675680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place One 3505 S Buckner Blvd Bldg 2 Dallas, TX 75227 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 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview on 09/22/22 at 12:07 PM, the Registered Dietician revealed she had been employed for 2 years and worked for campus. She was asked about the purpose for the interdisciplinary team meetings, she said that it was developed by her approximately in December 2022, she said because they had lost their DON, and said the team consisted of social work staff member, the ADON, the food service manager, and the minimal data set nurse. She said that the [NAME] president of nutrition gets an update on weight loss residents and the interventions discussed in the meeting. The Registered dietician said she inputs the orders for the interventions into the electronic medical record and she is in charge of notifying the physician of any new changes in condition and new interventions. The Registered Dietician said that the restorative aid is in charge of weighing people weekly, and that after the weekly weight loss meeting, she is provided with a list of residents every Monday that she must weigh weekly for 4 weeks and then monthly, a protocol the Registered Dietician said she put into place. The Registered Dietician said that the weekly weight the restorative aid records on her document goes into an Excel spread sheet that she generated and said she only inputs monthly weights into the facility electronic medical record and she was asked the purpose of not inputting the weekly weights into the facility electronic medical record, and she said, if I put in the weekly weights, the percentages would be skewed. The Registered Dietician was interviewed regarding the type of education she received after the incident was discovered, she said the [NAME] President of Nutrition discussed that she get more information from the families to find the residents likes and dislikes, and they discussed getting Resident #43 a snack when she is up getting and handing her finger foods. Also discussed was serving Resident #43 first, purchasing cultural foods, seasonings, and making out menus. The Registered Dietician said the facility was working on writing out a menu, three-day, three meals, 9 total, breakfast, lunch and dinner, the menu will not be repeated and the goal was to see which foods Resident #43 liked, and based on that the facility would continue to make menu's. The items included boiled eggs, sausage patties, sweet cakes, honey buns, and said the facility nursing and dietary departments would work closely with speech therapy to trial different foods. The Registered Dietician was asked why the interventions for weekly weights was not ordered by a physician, she said, we do not have to get orders, we just weigh them. The restorative aid weighs the resident as asked by myself and then brings me the list. During an interview on 09/20/2022 at 10:10 AM, the Speech Language Pathologist revealed that she occasionally brought in Korean type foods that Resident #1 had expressed she liked. The SLP stated that it took several attempts to coax the resident to eat some of her meals. She said the resident had a poor appetite, but when she brought in fresh foods, she would eat all of it. The SLP said that the kitchen manager was open to listening to her suggestions regarding Resident #43's likes and also her dislikes but said most times the kitchen provided the regular scheduled meals. The SLP said she was aware of the facilities weekly interdisciplinary team meetings and said that due to the residents monthly weight figures, it was decided to have speech therapy to assess the reason for the continued decline in Resident #43's weight. The SLP said that she had been bringing Korean foods at least once or twice since the resident was recommended to be assessed for weight loss in May of 2022. Interview on 09/21/2022 at 8:25 AM, Resident #43's physician, Physician BB, revealed his opinion about the residents weight loss was unanticipated, he said, my team saw her on 09/13/22 by my physician assistant, and there were no notes on her weight loss, he said that at this time the nursing staff is doing the maximum preventative methods at this time, and said he will repeat metabolic labs, and stated he knew that Resident #43 was a diabetic and that the resident may have kidney issues which can cause weight loss, he said that she had a recent UTI and was on antibiotics. He said that he leaves the weight loss recommendations to the dietician and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 9 of 23 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 675680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place One 3505 S Buckner Blvd Bldg 2 Dallas, TX 75227 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 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few expects the staff to follow the suggestions and inform him of any significant changes in health conditions. He said that the facility should accommodate the resident with local foods, offer her with preferred foods, also they could try feeding assistance. He was asked if he was aware that the dietician suggested the use of Remeron, he said that it was not brought up to his attention and could be tried but it was a method that is not proven to really work to increase appetite. He reiterated that at this time everything was being done and mentioned other more invasive methods could be discussed such as a peg tube, but he did not think it was a good Idea due to the possibility for infections. He said that due to the residents' numerous comorbidities such as the progression of her dementia, the diseases could play a big role in weight loss. He said that because he was unaware of Resident #43's significant weight loss, the resident will be on his radar and will try to get to the bottom of the problem. He was asked about the one-time order for infusion of IV vitamins and said that method could have been helpful but said again it is not a proven method and it was not a preferred method for weight loss. Interview with on 9/22/2022 at 2:00 pm with Vice-President of Nutrition revealed, she was unaware the Registered Dietician was inputting the facility residents weekly weight loss changes in a separate spread sheet and only monthly weights into the facility residents flagged for significant weight loss monthly into their perspective health care records. She said the standard protocol was for the restorative aid to weigh the residents and that the Registered Dietician input the numbers in the health records on a weekly basis. The Vice-President of Nutrition denied knowing why the Registered Dietician had a separate file with the resident's weekly weights and denied knowing why nursing or dietary had not informed the physician of Resident #43's significant weight loss, she stated that Dietary Managers have the ability to order interventions and should also call the physician with significant changes in a residents health condition. An Immediate Jeopardy (IJ) was identified on 09/21/2022 at 14:29, the administrator, corporate nurse, MDs nurse was notified, due to the above failures. The administrator was notified of the IJ and the IJ template was provided to him, he verbalized understanding and a Plan of Removal was requested. The facility's plan of removal was accepted on 09/23/2022 at 2:29 p.m., and included: PLAN OF REMOVALFOR IMMEDIATE JEOPARDY Summary of Details which lead to outcomes The notific[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 10 of 23 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 675680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place One 3505 S Buckner Blvd Bldg 2 Dallas, TX 75227 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering and securing of medications for 2 (Nurse Aid medication cart and Nurse cart) of 4 medication carts reviewed for pharmacy services. MA A did not report a damaged blister pack of Resident #1's Alprazolam 1 mg tablet. LVN B did not remove an unlabeled and undated vial of insulin belonging to Resident #3 from his medication cart. These failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medications. Findings Included: 1.An observation on [DATE] at 8:50 AM of the nurse aid medication cart in hall 400 revealed the blister pack for Resident #1's Alprazolam 1 mg tablet (anxiety medication) had 1 blister seal broken and the pill was missing inside the broken blister. In an interview on [DATE] at 8:52 AM, MA B stated she was unaware when the blister pack seal was damaged, and she was not aware of who might have broken open the blister pocket. She said the risk of the damaged blister was giving a wrong medication to the resident. She said the nurses and medication aids were responsible to check the medication blister packs for broken seals during the count of the narcotic. She said the count was done at shift change and the count was correct. The count was compared to the blister packs and the count was correct. 2.An observation on [DATE] at 8:58 AM of the nurse cart in hall 500 revealed there was a vial of insulin with no date of when it was opened belonging to Resident #3. In an interview on [DATE] at 9:00 AM LVN C stated he was unaware of the undated vial belonging to Resident #3 and said he just did not notice that there was no date because he became very busy, but agreed that there was a potential for a medication administration error if the vial was expired. He stated they would toss the current vial and replace it with a new one and make sure it was properly dated with the open date. In an interview on [DATE] at 2:10 PM with ADON E revealed she stated if a blister pack medication seal was broken the pill should be discarded. The DON said it would not be acceptable to keep a pill in a blister pack that was opened. The ADON said the risk would be giving the wrong medication and a potential for drug diversion. She said nurses and medication aids and nurses were responsible for checking the medication blister packs for broken seals during the count in the beginning of each shift and making sure all insulin vials had an open date written on them. She expressed that undated vial could cause a resident to receive expired doses. Review of facility's Pharmacy Services policies and procedures - Medication Storage, revised [DATE], reflected the following: . 12. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 11 of 23 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 675680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place One 3505 S Buckner Blvd Bldg 2 Dallas, TX 75227 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 disposed of according to procedures for medication destruction, and reordered from the Pharmacy, if replacements are needed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 12 of 23 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 675680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place One 3505 S Buckner Blvd Bldg 2 Dallas, TX 75227 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to Residents Affected - Some store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. 1.The facility failed to ensure food items in the refrigerators (3), freezers (2) and dry storage were labeled and stored in accordance with the professional standards for food service. 2. The facility failed to discard items stored in refrigerators (3) or dry storage that were not properly sealed/secure or past the 'best buy', consume by or expiration dates. 3. This facility failed to develop, implement and or provide a policy for Food Labeling and Procurement and or holding leftovers in the refrigerator. 4. The facility failed to have opened containers of potentially hazardous foods or leftovers dated or used within 7 days or according to facility policy. These failures could place residents at risk for food-borne illness and cross contamination. Findings included: Observation of the Kitchen on 09/19/22 at 10:12 AM, revealed the following: -1 Tall stainless-steel foot-pedal operated garbage can, was used for the 2nd hand-washing sink and the remainder of the kitchen's trash. The 2nd hand-washing sink sits in the middle of a prep table, there are two flat stainless-steel areas to the left and right of the attached sink. The trash receptacle sits across from the sink, up against a food prep table and adjacent to the steam table. The trash receptacle had paper towels, gloves, food, food item packaging. Observations of Reach-in Refrigerator #2 on 09/19/22 at 10:12 AM, revealed the following: -1 Large cardboard box with date of 9/16, opened 9/18, had raw bacon inside the box (the bacon's original container) and lying on top of the raw bacon, inside the box, was a large zip top bag with some raw breakfast sausage patties in it. The zip top bag was unlabeled, had no open date and the zip top bag nor the box had a consume by date reflected. -1-32 oz. carton of liquid whole eggs, fading (marker used was not dark) date of 9/9 with manufacturer's expiration of 10/23/22, no open date or consumed by date reflected. -1 large bag of thawing liquid whole eggs, dated 9/16 with no use or consume by date reflected. -1 16oz. container (of temperature-controlled) chicken base, no received by, or consume by dates reflected. -1 large container of Silver Source Salad dressing (white) dated 9/2, open date 9/19 but no consume by date reflected. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 13 of 23 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 675680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place One 3505 S Buckner Blvd Bldg 2 Dallas, TX 75227 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 0812 -1 Large container of lemon juice, open date 9/14, no received date and no consume by date reflected. Level of Harm - Minimal harm or potential for actual harm -1 medium square clear container, with lid, of grape jelly dated 9/17, no consume by date reflected. -1 Large bottle of Cattleman's BBQ sauce open date 8/25/22, no consume by date. Residents Affected - Some -1 Large container of Village Garden [NAME] Slaw Dressing, open date 9/17, no received date or consume by date reflected. -1 large container of soy sauce open date 5/01/22, no received by date and consume by date reflected. -1 Large container of Pace Picante Sauce medium opened date 9/03 and 9/17 listed on bottle but no received by or consume by date reflected. Observations of the Reach-in Freezer on 09/19/22 at 10:18 AM, revealed the following: -1 tray of 13 small grey cups with lids, had chocolate ice cream in each, dated 9/18 but no consume by date reflected. Observations of the Reach-in Refrigerator #3 on 09/19/22 at 10:25 AM, revealed the following: -1 Large bag of Coleslaw mix dated 9/7/22 but there is no consume by or discard date reflected. -1 container with no lid or covering, had red and green bell peppers with a label dated 9/16 but no consume by date reflected. -1 large zip top bag of 2 separate opened bags of shredded cheeses, one cheddar and the other mozzarella. There was an opened date of 9/16 but no label reflecting each type of cheese in bag and no dates each opened or consume by dates. -6- 1lb (16 oz) clear containers (original packaging) of fresh whole strawberries dated 9/16, there was no consume by date reflected. -3 large zip top bags with 3 whole cantaloupes in each bag, dated 9/16 without a consume by or discard date reflected. - The Fan Cover Vent slats (located at the bottom of the reach-in refrigerator) are dusty and in the corners, have dust/dirt build up. -Top of refrigerator had a greasy residue buildup across the top Observations of the Dry Storage Room on 09/91/22 at 10: 35 AM, revealed the following: -7 large bags of 30 medium Tortillas each, in a large clear container with lid Manufacturer's expiration date 08/04/22 labeled on each bag, but on the container, no consume or discard by date otherwise reflected. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 14 of 23 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 675680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place One 3505 S Buckner Blvd Bldg 2 Dallas, TX 75227 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some -1 medium cardboard box with 9 large bags of Tea, the box is open and the plastic bag inside the box is open to air there is no label on box, no received by date and no consume by or discard dates reflected. -18 small packets of Tortilla soup base #4204, in a small clear square container with lid, labeled Taco Mix but there was no received date, or consume or use by date listed on individual packets or the container they were placed in. Some of the packets mix contents had a change in color. Some bags coloring had lightened or become pale (the ones on the top) and others were a deeper orange color, a few bags with mixed pale and dark colored contents. -7 large cans of Silver Source sliced pears with no manufacturer's expiration date listed. -1 package of gravy opened and wrapped in plastic wrap, open date 9/11/22 but there is no consume by or discard date reflected. -3 packs Pioneer Pork Roast Gravy mix dated 9/9, manufacturer's PG date 06/03/22. -1 large bag of [NAME] cracker in a zip top bag dated 8/29 but there is no consume by date. Observations of the Kitchen during lunch service on 09/20/22 at 11:02 AM, revealed the following: - (11:51 AM) Fly seen in kitchen, landed on the lid of a carafe filled with tea. The lid was not completely down on the carafe. (The Dietary Aides fill carafes with juice and tea and shortly before service, ice is added, and the lid placed on and pressed down.) (12:24 PM) There was a tray of chocolate cake pieces that were unwrapped in plastic wrap and a fly landed on a piece of cake. -1 Tall Stainless-steel foot-pedal operated garbage can, filled with enough trash the lid did not close all the way down. This trash receptacle remained, sitting against a prep table and adjacent to the steam table from previous visit. - (11:35 AM) Dietary Aide I already had a short stack of prepared trays for lunch service then she stacked up more trays on the existing trays which made them tall enough to be right in front of the window unit air conditioner, that was in use. In an interview on 09/20/22 at 11:36 AM, Dietary Aide I stated the air blowing on the clean trays can get dust on them. She states that she normally puts them on the end of the sink, but the [NAME] (Cook G) is still using the sink. In an interview on 09/20/22 at 11:40 AM, the Dietary Manager stated that having the trays that tall could allow dust to blow from the window unit onto the meal trays. She stated she would try and find a better place to stack the meal trays when prepping for a meal service. In an interview on 09/20/22 at 12:25 PM, the Dietary Manger stated that they do not usually have a problem with flies. She states it is extra hot and we have the dietary doors open and the smokers go out onto the patio next door to us and that maybe how the fly came in. In an interview on 09/20/22 at 2:11 PM, with the Dietary Manager and the Dietician, the Dietary Manager stated that they had a binder with the cleaning schedule for the staff but at the time she could not produce it. When shown the vents on the bottom of Refrigerator #3, she stated that was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 15 of 23 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 675680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place One 3505 S Buckner Blvd Bldg 2 Dallas, TX 75227 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some probably from where they wiped it with a rag. She was shown the dirt gathered in the corners and she replied, oh. The Dietician stated in question form if I wanted them to throw out their container of lemon juice when they were given an example of not having received by or consume by dates on some open items in the refrigerator. The Dietary Manger stated to the Dietician, to clarify, that with no open date on the container or discard date then we do not know when it was opened so we cannot say how long it has been in there (refrigerator, freezer or storage room). The Dietary Manger nor the dietician could answer on how long they would keep a canned good if it had no manufacturer's expiration date, according to the facility's policy. The Dietary Manger could not answer how long they kept opened items in the refrigerator, according to the facility's policies. The Dietician stated she would get those policies to the surveyor. Review of the Facility's Nutrition Services Food Storage Policy, Policy No.-DS-52, Version 1.0, Date Revised 12/2020, reflected Policy: Food items will be stored, thawed, and prepared in accordance with good sanitary practice. Procedure: I. Raw Meat/Poultry/Seafood Storage Guidelines A. Raw meat is to be stored separately from cooked meats and raw foods as temperature below 41 degrees F. II. Frozen Meat/Poultry and Food Guidelines . C. i. Label and date all food items. D . Thaw meat by placing it in deep pans and setting it on lowest shelf in refrigerator. Develop guidelines detailing defrosting procedure for different types of food. i. Date meat when taken out of freezer and with date of meal service. ii. Follow meat-pull schedule on menus. VI. Fresh Fruit Storage Guidelines A. Fresh Fruit should be checked and sorted for ripeness C. Unwashed produce should not be placed in the refrigerator with or near prepared foods VIII. Canned Fruit Storage Guidelines. E. Recommended use is within 12 months XI Canned Vegetable Storage Guidelines . E. Recommended use is within 12 months XIII. Dry Storage Guidelines. G. Any opened products should be placed in storage containers with tight fitting lids. H. Label and date storage products. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 16 of 23 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 675680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place One 3505 S Buckner Blvd Bldg 2 Dallas, TX 75227 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 0880 Provide and implement an infection prevention and control program. 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 its infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents (Residents #2, #3, and #77) and 4 of 4 staff (LVN C, CNA B, CMA N and CMA A) reviewed for infection prevention, in that: Residents Affected - Few LVN C did not utilize proper hand hygiene when assisting Resident #77 with his intermittent intravenous (IV) infusion. CNA B and CMA N did not follow changing of proper PPE (Personal Protective Equipment) when providing incontinent care for Resident #3. CMA A did not follow correct procedure when assisting Resident #2 with preparation of his meal. These failures could place residents at risk for infection. The findings were: Record review of Resident #77's MDS Assessment, dated 08/18/22, revealed a [AGE] year old male admitted [DATE] with a diagnoses of Autoimmune disease, Bacteremia (bacteria in the blood stream), Discitis (infection of the disc of the vertebrae spine), Anemia, Urinary Tract Infection, and Osteomyelitis (infection within the bone). Record review of Resident #77's care plan, dated 08/31/22, revealed the resident had impaired immunity related to autoimmune disease. The goal included he would not display any complications related to immune deficiency. The interventions included he was at risk for contracting infections due to impaired immune status. Keep the environment clean and to use universal precautions to prevent infection. Another care plan focus area was Resident #77 was on anti-infective therapy related to an infection. The goal was Resident #77 will be free of any discomfort or adverse side effects of antibiotic therapy. The interventions included administer medication as ordered. Another care plan area for Resident #77 was he was on IV Medication including Vancomycin HCL related to Osteomyelitis of the Vertebra and Bacteremia. The goal was Resident #77 would not have any complications related to the IV therapy. The interventions included monitoring for signs and symptoms of infections. During an observation on 09/20/22 at 8:45 a.m., LVN C connected the IV to administer vancomycin for Resident #77. After completing the connection of the IV, LVN C removed his gloves then left Resident #77's room without washing his hands. LVN C walked down the hallway and took a clip board from another staff member, then returned the clip board. LVN C walked to the middle of the hallway and then used the hand sanitizer. In an interview on 09/20/22 at 9:20 a.m., LVN C revealed he knew how to wash his hands and when to wash his hands. When ask about the reason he did not wash his hands after he removed his gloves in Resident #77's room, LVN C stated he used hand gel in the hallway. When LVN C was informed he was observed handling other supplies before using hand gel, he said he was just covering the hallway since the other nurse was late and knew the IV had to be given. LVN C stated that it could spread germs by not cleaning his hands. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 17 of 23 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 675680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place One 3505 S Buckner Blvd Bldg 2 Dallas, TX 75227 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #3's MDS Assessment, dated 09/05/22, revealed an [AGE] year-old female admitted [DATE] with a diagnosis of Non-Alzheimer's Dementia, Hypertension, Anemia, and Malnutrition. Record review of Resident #3's care plan, dated 07/20/22, revealed she had bowel and bladder incontinence. The goals included she would remain free from skin breakdown due to incontinence and brief use. The interventions included incontinent care and to check the resident every two hours and as required for incontinence. Wash, rinse, and dry the perineum. Change clothing PRN after incontinence episodes. On 09/19/22 at 03:36 p.m., Resident #3 was observed while incontinence care was provided by CNA B and CMA N. The two staff washed hands before starting the procedure, applied gloves, and then changed their gloves after removing Resident #3's pants. Then the old gloves were removed, and new gloves were applied. CNA B and CMA N unfastened the brief in the front then replaced their gloves. CMA N then cleaned the front perineum area with a santi-cloth. With the same gloves, she assisted with moving the resident to her right side. CMA N then rolled the soiled brief and draw sheet under the resident's right buttock. CMA N then cleansed the resident's buttock with a new santi-wipe. With the same soiled gloves, CMA N then placed the clean brief under Resident #3's buttock. With the same soiled gloves, she held the resident's back and her left leg to assist with rolling the resident to her left side. CMA N then held Resident #3 in place on her left side with the same soiled gloves. Once Resident #3 was on her left side, CNA B the removed the soiled brief and placed it into a plastic bag. With the same soiled gloves, CNA B then rolled the soiled draw sheet into a ball and dropped it onto the floor. CNA B then pulled the new brief from under the resident. Then both CNA B and CMA N rolled the resident onto her back utilizing their same soiled gloves. They pulled Resident #3's legs open slightly so to reach the front of the brief to pull it up between the resident's legs. They then finished applying the brief. With the same soiled gloves, CNA B and CMA N pulled Resident #3's shirt down and lifted her up in the bed. CMA N, while using the same soiled gloves, then picked up the box of clean gloves and clean santi-wipes from the resident's bed and moved them to the over-bed table. Then CMA N adjusted Resident #3's bed linen. CNA B and CMA N then moved Resident's #3's bed back into its original position, while still using the same soiled gloves. CNA B and CMA N then removed their soiled gloves and washed their hands. In an interview immediately after the incontinent care, both CNA B and CMA N acknowledged they should have changed their gloves throughout the process to prevent infections. Record review of Resident #2's MDS Assessment, dated 07/01/22, revealed a [AGE] year-old male admitted [DATE] with a diagnosis of Alzheimer's disease, Hypertension, Malnutrition, and Dysphagia. Record review of Resident #2's care plan, dated 09/20/22, revealed the resident had potential nutritional problem. The goal was he will comply with recommended diet and interventions included he would come to the dining room for meals and be provided finger food for all meals. There was an additional care plan focus to assist him with his ADLs due to Alzheimer's disease. The goal was Resident #2 would maintain current his level of functioning which includes eating. The intervention reflected limited assistance with eating. Record review of Resident #2's physician orders dated 8/11/22, revealed finger foods diet, regular texture, with thin consistency liquids. On 09/19/22 at 12:15 p.m., during a lunch observation, Resident #2 was observed at a dining room table. CMA A was observed assisting him with his meal. She was observed cutting his sandwich in half by placing her ungloved left hand on top of the sandwich, to hold sandwich while she cut it in half. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 18 of 23 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 675680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place One 3505 S Buckner Blvd Bldg 2 Dallas, TX 75227 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Then she turned plate to cut the sandwich again into four squares while holding the sandwich with her ungloved left hand. In an interview with CMA A on 09/19/22 at 12:45 pm, she acknowledge she should have had clean gloves on if touching a resident's food. During an interview 09/20/22 at 04:11 p.m., ADON D said regarding Resident #77's IV administration with no hand hygiene afterwards she stated this was not appropriate technique when removing gloves. ADON D was also interviewed about the CNAs observed incontinent care of Resident #3. ADON D stated CMA N and CNA B using the same gloves to clean the resident's perineal area then touching the resident legs, clean brief, resident's clothes, the bed linen, the box of clean gloves, and the package of clean santi-wipes was not acceptable and was not correct perineal care. When discussing CNA B dropping the draw sheet on the floor, ADON D stated this not correct technique for soiled linen and also stated nursing staff should not be physically touching the resident's food. ADON D stated she would start in-services today with both the CNAs and Nurses related to the issues discussed. ADON D acknowledged not washing hands appropriately, utilizing soiled gloves on a resident, and touching resident's food could spread infections to residents and within the facility. Record review of the facility's Intermittent Infusion policy, dated 12/2014, reflected the following. Procedure 4. Explain procedure to resident. 5. Wash hands 7. Apply gloves .23. Dispose of used supplied per facility policy. 24. Remove gloves. 25. Wash hands; When Infusion is complete 1. Wash hands. 2. Apply gloves .6. Dispose of supplies per facility policy. 7. Remove gloves. 8. Wash hands. Record review of the facility's Perineal Care policy, dated 06/2020, reflected Procedure XII. Remove gloves. Wash hands or use alcohol-based hand sanitizer. Note: Do not touch anything with soiled gloves after procedure (i.e. curtain, side rails, clean linen, call light, etc.). XIII. Put on clean gloves XV. Place soiled linen in proper container. XVI. Remove gloves. XVII. Wash hands. In a record review of the facility's Infection Prevention and Control Program policy, dated 6/2020, reflects II. Infection Control Policies and Procedures (A) The facility's infection control policies and procedures are intended to facilitate maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 19 of 23 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 675680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place One 3505 S Buckner Blvd Bldg 2 Dallas, TX 75227 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for two (Halls 500 and 600) of six halls with rooms 504, 506 ,507, 601, 604, 607, and 608 observed for environment, in that: The facility failed to ensure furniture, floors, and bathrooms were clean and in good repair for Rooms 504, 506, 507, 601, 604, 607, and 608. These failures could place residents at risk for diminished quality of life due to the lack of a well-kept environment and equipment. Findings included: An observation on 09/20/22 at 9:15 a.m., revealed Hall 500's floors was sticky. An observation on 09/20/22 at 9:20 a.m., in room [ROOM NUMBER] there was a dried dark substance on the floor at the entrance to the room and food under both beds. An observation on 09/20/22 at 9:37 a.m., in room [ROOM NUMBER] there was a dried dark red substance on the floor at the end of bed A and food under bed B. An observation on 09/20/22 at 9:39 a.m., at the entrance to Hall 500 there was a medication cart with a dried brown stain on the top. An observation on 09/20/22 at 9:46 a.m., in resident room [ROOM NUMBER], the floor was sticky with food under both beds. An observation on 09/20/22 at 9:48 a.m., in resident room [ROOM NUMBER] the floor was sticky with food under both beds. An observation on 09/20/22 at 10:22 a.m. in resident room [ROOM NUMBER] the floor was sticky, with food under both beds. An observation on 09/20/22 at 2:17 p.m. in resident room [ROOM NUMBER] was a large puddle of a dark liquid on the floor at the end of bed B. An observation on 09/20/22 at 2:19 p.m., in resident room [ROOM NUMBER] there was food on the floor under both beds. An observation on 09/20/22 at 2:25 p.m., in resident room [ROOM NUMBER] the overbed tables was missing veneer from the edges. An observation on 09/20/22 at 4:25 p.m., in the public bathroom by the nurse's station hall 400 revealed the floor of the bathroom had grimy built-up wax in the corners, around the toilet. The floor of the bathroom had rugs on it that had dirt and food particles on them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 20 of 23 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 675680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place One 3505 S Buckner Blvd Bldg 2 Dallas, TX 75227 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 09/20/22 at 8:27 a.m., Housekeeper A revealed she was responsible to clean the rooms and bathrooms on halls 600 & 200, on the days she worked. The Housekeeper stated it was the CNAs job though to clean up after themselves when they changed a resident, and they should not leave dirty linens in the rooms and there should not be trash left in the rooms in bags. She said on somedays she feels if she gets all the bathrooms cleaned in the residents' rooms, she has done a good job. The housekeeper said there was usually only two housekeepers here we do two halls a piece and I really do not know what happens to the other hallways, I just clean the hallways I am assigned to. Interview on 09/20/22 at 4:15 p.m., with the Administrator revealed the floors in the rooms and hallways should not be sticky ,maybe it was the product that was being used. The Administrator stated that the housekeepers was not fully staffed, and the campus did not allow in the budget a separate housekeeping supervisor only the maintenance man. The Administrator stated the facility needed to kept clean and well maintained this is the resident's home and by not keeping it clean and in good repair can develop germs. An observation on 09/21/22 at 9:47 a.m., in resident room [ROOM NUMBER] revealed two bags of laundry on the floor and one large bag of trash on the floor. An observation on 09/21/22 at 10:00 a.m., in resident room [ROOM NUMBER] revealed an open window with the screen bent out at the base of the window. An observation on 9/21/22 at 10:30 a.m., in resident room [ROOM NUMBER] revealed food on the floor with a black dried substance from bed B to the door of the room. In an interview on 09/21/22 at 10:32 a.m., LVN C revealed he had a room that needed to be cleaned then he would tell the housekeeper that was working on the hallway to let them know. LVN C stated if the facility was not clean it could cause germs. Interview on 09/21/22 at 4:45 p.m., the Maintenance Director/Housekeeping revealed he did the schedules and the housekeepers cleaned, there were positions open, but he did not have responsibilities with hiring. There was no follow-up from him with the housekeepers if they were cleaning appropriately unless he was told to. He said he would tell the Administrator if there were problems with housekeeping. The Maintenance Director/housekeeping stated if the facility was not clean, it was poor representation to the visitors and it could cause germs. Review of the Policy and Procedure Resident Rooms and Environment dated 08/2020 reflected . to provide residents with a safe, functional, sanitary and comfortable environment Facility staff will provide the residents with a pleasant environment . Cleanliness and order FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 21 of 23 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 675680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place One 3505 S Buckner Blvd Bldg 2 Dallas, TX 75227 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 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 for two (Halls 500 and 600, and kitchen and the main dining rooms), of six halls reviewed for pest control program. Residents Affected - Some The facility had live common house flies in areas of the facility including the kitchen, hallways, conference room and the dining room. This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life. Findings Included: Observation 09/21/22 at 9:00 a.m., revealed 1-5 live house flies in the lobby. There was an unidentified resident that was going out the front door, swatting at the flies. Observation on 09/21/22 at 9:20 a.m., revealed a fly on the wall of Hall 500. Observation on 09/21/22 at 9:30 a.m., a fly on the fire doors to the entrance to Hall 600. Observation on 09/21/22 at 9:35 a.m. a fly crawling on the medication cart on Hall 500. Observation on 09/21/22 at 9:45 a.m., a fly was on the wall of the shower room on Hall 600. Observation on 09/21/22 at 9:55 a.m., a fly was crawling on the table in the conference room. Observation on 09/21/22 at 10:20 a.m., a fly was crawling on the top of the nurses station. Observation on 09/21/22 at 11:45 a.m., two live house flies were observed landing on the bowls used for lunch. One live house fly landed on wrapped fresh fruit. There were several foods located on the steam table that was also uncovered. Observation on 09/21/22 at 12:21 p.m., revealed 5-7 live common house flies around the food of two residents in the dining area that required assistance. The flies landed on the food of the resident. Additional observations in the dining area revealed residents using their hands to wave away flies from landing on their food. In an interview on 09/21/22 at 12:30 p.m., Resident #75 revealed he was tired of all the flies, he stated he had reported it to the Administrator, and he had seen the pest control people here, but nothing had changed there were still flies in the dining room. Resident #75 was stated he was thinking of eating his meals in his room, but he did not know if that would make a difference, he had seen flies in the hallways also. In a confidential group interview on 09/22/22 at 10:00 a.m., 10 residents revealed there was a fly problem. The residents stated the facility staff and administrator had been told, but the flies continued to be a problem. The residents stated they had seen the pest control here, but whatever the pest control was using to treat the flies was not making a difference. The resident said that people are always going out the back door to the patio and that could be where they are coming in. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 22 of 23 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 675680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place One 3505 S Buckner Blvd Bldg 2 Dallas, TX 75227 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 Observation on 09/22/22 at 12:48 p.m., revealed three live common house flies at the nurses station. Level of Harm - Minimal harm or potential for actual harm Observation on 09/22/22 at 12:52 p.m., revealed live house flies landed on the covered food trays of residents on hallway 600. Residents Affected - Some An interview with CNA P on 09/22/22 at 9:48 a.m., revealed common house flies had been in the facility for several weeks. She had not reported the flies and she did not know about a pest control log. She said she had not seen anyone come to the facility to treat for the flies. An interview with CMA N on 09/22/22 at 10:37 a.m., revealed she had seen the flies at the facility for over 2 weeks. She said she had not informed the maintenance director of the sightings of the flies. She had documented in the pest control log. An interview with DA I on 09/22/22 at 1:24 p.m., revealed she had seen flies at the dining room and kitchen recently. She said she informed the Maintenance Director on 09/01/22. She said she did not document in the pest control log. An interview with the Maintenance Director 09/22/22 at 1:36 p.m., revealed the pest control provider last treated the facility on 09/19/22. He was made aware of flies in the facility on 09/01/22. He educated the staff to close the doors. He did not contact the pest control provider to come out and treat the facility for flies. He stated the pest control provider would be at the facility soon. Record review of the pest control provider service information dated 09/01/22 revealed the following regarding the technician comments There were entries for mice and ants. There was no treatment documented for common house flies. 09/19/22 was the last visit from the pest control provider, sprayed perimeters doors . an entry for treatment of flies. Record review of the Facility's Pest Sighting Log revealed: 08/14/22 Flies in the facility, 08/27/22 Flies in facility, 09/01/22 Flies in facility. Record review of the facility's policy dated 08/2020, and titled Pest control reflected to ensure the facility is free of insects, rodents, and other pests that could compromise the health, safety, and comfort of the residents, facility staff, and visitors .the facility maintains an ongoing pest control program to ensure the building and grounds are kept free of insects, rodents, and other pests .windows are screened at all times .garbage and trash is not permitted to accumulate in any part of the facility .the facility staff will report to the housekeeping supervisor any sign of rodents or insects .the housekeeping supervisor will take immediate action to remove any pests from the facility FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 23 of 23