Health inspection·July 21, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Progress. Resident #1 had medically complex conditions and active diagnoses of malnutrition (lack of proper nutrition); psychotic disorder (other than schizophrenia); and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Other active diagnoses included paranoid (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly - delusions and hallucinations are the two symptoms that can involve paranoia) schizophrenia; unspecified osteoarthritis; muscle wasting and atrophy (waste away); cognitive communication deficit; repeated falls; and unspecified abnormalities of gait and mobility. Resident #1's BIMS score reflected 03, which indicated severe impairment. The Quarterly MDS indicated Resident #1 required supervision setup help only with ADLs. Resident #1 was occasionally incontinent of bladder and frequently incontinent of bowel. The Quarterly MDS did not indicate Resident #1 had any behavioral symptoms or rejection of care during the MDS review period. A review of Resident #1's comprehensive care plan, review start date 06/29/23, target completion date 07/06/23 indicated: FOCUS: [Resident #1] is an elopement risk/wanderer AEB Disorganized thinking and disillusion. GOAL: [Resident #1] will not leave facility unattended through the review date [Resident #1] safety will be maintained through the review date INTERVENTIONS: 11/18/20 [Resident #1] refuses to wear WanderGuard (a monitoring device) Distract resident from wandering by offering pleasant diversion, structured activities, food, conversation, television, book. Resident prefers: pampered nails, musical entertainment, and movies Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. FOCUS: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 2 of 12 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 07/21/2023 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 0600 - Level of Harm - Immediate jeopardy to resident health or safety [Resident #1] is PASRR positive and receives MHMR specialized services of service coordination through [a non-profit organization mental, physical, and emotional health services provider] and psychosocial rehabilitative services . is positive for Mental Illness Residents Affected - Few 2/10/20 IDT Meeting: psychosocial rehab to start. GOAL: [Resident #1] will receive indicated specialized services as ordered through review date. INTERVENTIONS: IDT meetings with resident, facility staff and [non-profit organization] Resident to receive psychosocial rehabilitative services per IDT meeting findings Resident to receive service coordination from [non-profit organization] Social Services to communicate with resident and [non-profit organization] as needed FOCUS: [Resident #1] has mood problem related to Schizophrenia and Psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) . has conversations with herself, as well as talks to people about aliens and living on a different planet. GOAL: [Resident #1] will have improved mood state (happier, calmer appearance, no s/sx of depression, anxiety or sadness) through the review date. INTERVENTIONS: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 3 of 12 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 07/21/2023 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 0600 - Level of Harm - Immediate jeopardy to resident health or safety Administer medications as ordered. Monitor/document for side effects and effectiveness Residents Affected - Few Behavioral health consults as needed - Monitor/record mood to determine if problems seem to be related to external causes Monitor/record/report to MD PRN acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/ eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills Monitor/record/report to MD prn mood patterns s/sx of depression, anxiety, sad mood as per facility behavior monitoring protocols Monitor/record/report to MD prn risk for harming others: increase danger, labile mood or agitation, feels threatened by others . Observe for signs and symptoms of mania (periods of over-active and high energy behavior) or hypomania (milder version of mania) racing thoughts or euphoria (extremely joyful and pleasurable); increased irritability; frequent mood changes; pressured speech; flight of ideas; marked change in need for sleep; agitation or hyperactivity (move about constantly, including in situations when it is not appropriate, or excessively fidgets, taps, or talks) Review of Resident #1 progress notes reflected: 06/16/23 at 10:04 PM: [Resident #1] constantly wanders and is exit seeking while awake . does not spend time in room and is very confused . Late Entry 7/16/2023 at 9:55 PM [Effective date: 07/15/23 at 08:15 AM], LVN A wrote: [Resident #1] left the building AMA with her red bag . said that the facility has been holding her against her will . refused to sign any paperwork . looked presentable and clean before living . [PCP] notified and said to notify the Police . called the Police. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 4 of 12 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 07/21/2023 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 0600 - Level of Harm - Immediate jeopardy to resident health or safety 07/17/23 at 10:02 AM, the SW wrote: left message for (Ombudsman), to inform of [Resident #1] elopement Residents Affected - Few 07/17/23 at 12:05 PM, the SW wrote: [Resident #1] elopement was reported to APS (a social services program that provides a support system to elderly and dependent adults who may be subject to ANE) . - Previous notes entered by SW on 07/17/23 at 10:02 AM and 07/17/23 at 12:05 PM reflected incorrect documentation and were struck through. Review of Resident #1 progress notes reflected: 07/18/23 at 9:04 AM, the SW wrote: left message for [Ombudsman] to inform of [Resident #1] decision to go AMA 07/18/23 at 9:07 AM, the SW wrote: [Resident #1] decision to go AMA was reported to APS . This information was given to the NFA. During a brief entrance conference on 07/18/23 at 8:45 AM, after informed the purpose of investigator visit, the NFA stated . the resident left AMA . the SW reported it . The investigator verbalized understanding and requested to interview the SW. During an interview on 07/18/23 at 9:18 AM, the SW indicated that she worked at SNF for less than two weeks. The SW stated that on Sunday 07/17/23 she received a message to report to the SNF. The SW stated that when she arrived to the SNF there where several other staff members were present and to her [The SW] understanding, were going to look for [Resident #1], to bring back to the SNF, to assist and offer resources to relocate and appropriately discharge from the SNF. The SW stated she drove her personal car to search for Resident #1, did not locate her and returned to the SNF. The SW indicated she stayed around the SNF for about an hour and half, went to receptionist to verify able to leave, and headed home around 3 PM. The SW stated during the drive home, she received a call from the Regional SW, and mentioned that she [SW] . had just left the facility to search for Resident #1. The SW said that the Regional SW said to Notify APS, the Ombudsman, and document. The SW said she understood the purpose of calling APS was to report Resident #1 was not in the SNF and concerned about safety. The SW said that she placed a call to report to APS and left message for Ombudsman on Monday (07/17/23) morning. The SW said she called APS back before 4:00 PM to inform that intent was to file a self-report for the facility and not a complaint against the facility. The SW defined eloped in own words as a person gone off, don't know where and [staff] did not know they [individual eloped] were leaving. The SW gave an example of [leaving] AMA that MD suggested staying at facility and the individual leaves anyway. The SW indicated she was not specifically familiar with the policy regarding a resident leaving AMA but knew where to find the policies for review. The SW stated did not file police report because facility staff filed a police report. During an interview on 07/18/23 at 3:53 PM, the BOM indicated his role/responsibility was to receive payments from guardian over [Resident #1] finances and deposit in trust account. The BOM said had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 5 of 12 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 07/21/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few a good rapport with Resident #1. The BOM said his knowledge of Resident #1 leaving the SNF was that she left AMA. The BOM indicated the procedure to follow when a resident desired to leave the SNF AMA, Monday - Friday and management is present, there is a form the resident must fill out . management was not present over the weekend, so it was to my understanding that [Resident #1] just left. The BOM said that Resident #1 verbalized from time to time, over 10 years, wanting to leave and go home, but to her knowledge had never left before. The BOM said did not recall or observed [Resident #1] present exit-seeking behavior and did not have a WanderGuard. The BOM said that he was present at the SNF on Saturday (07/15/23) afternoon we he learned that the resident had left. The BOM said he participated in the search parties on Saturday (07/15/23) and Sunday (07/16/23) coordinated by the LCA. The BOM said that Resident #1 might try to go to El Paso because she always talked about it. During an interview on 07/18/2023 at 4:49 PM, the DON stated she was a new hire and her first day was Monday (07/17/23). The DON said that she conducted in-services on Elopement Risks and Wanderguard after she learned that [Resident #1] left the SNF without supervision. The DON was not sure how Resident #1 eloped from or departed from the secured building without proper procedures being followed. The DON stated she would need to become familiar with the SNF policy and procedure but expected staff to follow proper procedure and not provide a resident access through a secured exit if not accompanied by a supervising representative, transportation personnel, or without a physician order. Review of a facility self-reported incident, dated 07/19/23 at 10:21 AM, indicated the NFA first learned of incident on 07/18/23 at 4:00 PM, the date/time incident occurred was 07/18/23 at 4:00 PM. The NFA wrote a brief narrative summary of the reportable incident that [Resident #1] left the facility and refused to sign out AMA or allow the facility to do a proper discharge. The NFA did not name an alleged perpetrator and indicated actions and notifications included police, ombudsman, APS, and doctor. The NFA indicated the incident was reported to the police, in-services were initiated on Elopement vs AMA. During an interview on 07/19/2023 at 12:03 PM, LVN A said that he was employed for with the facility about one year and worked weekend doubles as the charge nurse. LVN A stated he completed ANE training on hire and after one-year employment. LVN A stated he also participated in on-going ANE in-services. LVN A defined neglect in his own words: Is when refuse or do not give care to resident. LVN A defined elope in his own words: resident leaves the building and the nurse did not that [resident] left. LVN A described {leaving} AMA When a resident demanded to leave, but [staff] try to encourage them to stay, but [resident] keep demanding to leave. LVN A stated that the staff should try to explain to the resident the consequences of leaving AMA; then, call the NFA, MD, and the police for further recommendations. LVN A stated he was unsure of specific policy for AMA. LVN A indicated he worked Friday, 07/14/23 through Sunday, 07/16/23. LVN A said was not often assigned to the hall Resident #1 resided on. LVN A said was familiar with Resident #1 by seeing her around the SNF. LVN A described Resident #1 as ambulatory without an assistive device, ate in the dining room without assistance, required standby assistance for showering, was Independent, could verbalize wants and needs, was own responsible party. LVN A indicated was assigned to Resident #1's hall on Saturday (07/15/23) morning and observed resident during morning change of shift rounds (6 AM). LVN A indicated sometime after breakfast, Resident #1 approached [LVN] and stated she wanted to leave the facility. LVN A said that he asked Resident #1 can this wait until Monday, so that SW can assist with the discharge process? Resident #1 replied, do not have to wait . do not understand why being held against my will. LVN A said that Resident #1 would walk away but return shortly and state that she would sue the facility for holding against will. LVN A said that Resident #1 followed [LVN A] around in hallway saying I need you to let me out . you are holding me against my will . I'm a lawyer, I am going to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 6 of 12 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 07/21/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few sue this place for holding me against my will. LVN A said Resident #1 continued to repeat over and over that she wanted to leave the facility. LVN A said that he attempted to present Resident #1 with the Statement Releasing the Home from Liability when Resident leaves AMA form and Resident #1 refused to sign. LVN A said that he escorted Resident #1 to the front door, entered the code and allowed Resident #1 to exit - the external gate was propped open, did not need to buzz [Resident #1] out, and the gate closed completely after Resident #1 exited. LVN A stated he completed passing medications. LVN stated he thinks it was sometime around 9AM when he let Resident #1 out of the building. During a continued interview (07/19/2023 at 12:03 PM), LVN A said that he placed an outbound call to the PCP and informed them that Resident #1 wanted to leave and said she was being held against will. LVN A said that the PCP replied to call the police get them involved, follow the protocol for a resident who wanted to leave the SNF. LVN A stated that he attempted to verify with the PCP if the policy he was to follow was for AMA, did not get a response and the call ended. When asked if he [LVN A] followed the procedure to discharge a resident AMA and was an order given by the PCP, LVN A stated that he received a verbal order from the PCP to discharge the resident AMA but did not enter the order into PCC. LVN A said that the PCP did not speak to the resident over the telephone or came come to SNF to discuss and advise potential consequences of discharging AMA. LVN A said that he did not call immediately, but later in the afternoon, placed an outbound call to 911 to report that [Resident #1] left the SNF AMA. LVN A stated that he then placed a call to the RDO to inform that [Resident #1] left AMA and the RDO replied, Have to see about getting [Resident #1] back and do a proper discharge. LVN A said that leadership coordinated a search for Resident #1 on Saturday 07/15/23 and Sunday 07/16/23, to his knowledge Resident #1 was not located. LVN A said he received a case number when police arrived to take a report. LVN A stated that he entered a narrative note on Sunday 07/16/23 as a late entry. LVN A stated that he conducted an in-service with staff Saturday (07/15/23) on Ensure gate is closed. During a phone interview on 07/19/2023 at 4:02 PM, the PCP indicated they received a call Saturday late afternoon that [Resident #1] left the bldg. The PCP stated if [Resident #1] was present at time the call was received, they would attempt to speak with them and encourage them to stay or would have given an order to discharge the resident AMA to a receiving care provider. The PCP reiterated they received the call after the resident was no longer at the SNF. Observation of video surveillance with the RDO on 07/19/20 at 4:18 PM revealed Resident #1 approach the main gate on 07/15/23 at 8:04 AM. Resident #1 paused, reached into a bag and retrieved a piece of paper, approached and handed SG I the piece of paper. It appeared that SG I maintained courtesy toward Resident #1 when redirected and avoided touching [Resident #1]. At 8:07 AM, it was noted that Resident #1 became agitated, began pacing from left to right as SG I tried to redirect; SG C was noted approaching SG I and Resident #1. At 8:08 AM, Resident #1 pushed by SG I and was observed walking off toward the main street, crossed a busy 4 - 6 lane street to the opposite side without regard for traffic. During an interview on 07/20/23 at 12:58 PM, the NFA stated that she became the administrator about a month ago; and just returned to work from vacation on 07/17/23. The NFA described Resident #1 as very intelligent . had a BIMS of 14 . no assistance with walking . been at the facility for about sixteen years. The NFA said first learned about the incident Sunday (07/16/23) night when she reviewed messages via the SNF group text. The NFA said she believed the incident happened on Saturday (07/15/23). Upon return to work on Monday, 07/17/2023, the NFA stated she inquired about what happened (referring to the group chat) and the BOM indicated Resident #1 was very passionate about going home and left the building. The NFA said that it was her understanding that [Resident #1] wanted to go back (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 7 of 12 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 07/21/2023 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 0600 home to El Paso and left the building. Level of Harm - Immediate jeopardy to resident health or safety During a phone interview on 07/20/23 at 1:46 PM, SG C indicated that she worked Saturday, 07/15/23. SG C stated on Saturday, 07/15/23 around, 8 AM, she was posted in the [Security] booth when Resident #1 was observed approaching the main gate. SG C said as she logged incoming vehicles, SG I attempted to redirect Resident #1 back on campus. SG C said after all arriving vehicles were logged and okay to enter campus, she tried to assist SG I when Resident #1 pushed past SG I and headed toward the main street. SG C said she attempted to call the secured unit but there was no answer. SG C stated she placed an outbound call to the RDO and informed them that an unidentified resident left off campus without being unsupervised and without a pass to leave campus. SG C said that the RDO asked if the resident was in line of sight and what direction they were headed. SG C stated that she last saw Resident #1 cross to the opposite side of the street and could not see Resident #1 at that time. SG C stated shortly after she spoke with the RDO, the facility staff came out asking about and looking for Resident #1. SG C stated that for anyone walking off campus must present a pass or a badge. Residents Affected - Few Review of the Abuse Prevention and Prohibition Program policy and procedure provided by the facility, revised October 24, 2022, indicated purpose is to ensure the Facility . screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting . neglect . in accordance with federal and state requirements. Staff is instructed to report any signs of stress from family and other individuals involved with the resident that may lead to .neglect . and intervene as appropriate. Physical Neglect o f. Inadequate provision of care o g. Caregiver indifference to resident's personal care and needs o i. Leaving someone unattended who needs supervision Review of the Discharge Against Medical Advice policy and procedure provided by the facility revised 06/2020, indicated in part that a resident may discharge themselves from the Facility against the advice of his/her physician. Procedure: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 8 of 12 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 07/21/2023 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 0600 Mitigating circumstances influencing the resident's decision to leave should be evaluated and addressed in an effort to prevent the resident from leaving against medical advice (AMA). Level of Harm - Immediate jeopardy to resident health or safety - Residents Affected - Few A licensed nurse will notify the attending physician, on call physician, or medical director of the resident's desire to leave the Facility AMA. The Facility and/or physician will discuss with the resident and/or the resident's personal representative, if applicable, the reason for the AMA decision and will advise them of the potential consequences of the AMA decision. If the resident demonstrates the following risks, the charge nurse will notify the Administrator/designee, Director of Nursing Services, Attending Physician, Responsible Party, and law enforcement: o A. Resident displays impaired cognition o B. Resident is at risk of harming self or others The facility's Plan of Removal was accepted on 07/21/23 at 4:34 PM and included: All residents have the potential to be affected. 1. LVN A was removed from duty and suspended pending the investigation on July 20, 2023. 2. Training for all licensed nursing staff on Policy and Procedures of the AMA process was initiated on 7/17/2023 and completed on 7/19/23 by DON and will be ongoing until all staff have completed the training. 3. Training for all licensed nursing staff on Closing the front gate was initiated on 7/15/23 by the Maintenance Director and completed on 7/19/23 and will be ongoing until all staff have completed the training. 4. Training for all licensed nursing staff was initiated on 7/17/23, on notification of elopement assessments that trigger for moderate or higher will require DON, ADON and/or MDS notification. Training was conducted by the RNC and completed on 7/19/23 and will be ongoing until all staff have completed the training. 5. DON/ADON/MDS completed audit of all resident elopement assessments on 7/17/23. The outcome confirmed that 18 residents are at imminent risk for elopement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 9 of 12 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 07/21/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 6. DON/RNC completed audits of all residents with wanderguard on 7/17/23 and updated all elopement binders. The outcome revealed that all imminent risk residents with wandergaurds were intact and functioning. In-Service conducted. 1. Training for all staff in response to resident AMA was initiated on 7/15/23 and completed by the RDO. a. The Facility Staff member who finds that a resident wishes to leave the facility will alert the charge Nurse. The charge nurse will verbalize and document any verbal and/or physical exit seeking behaviors to the oncoming shift and 24hrs report. 2. A licensed nurse will notify the attending physician, on call physician, or medical director of the resident's desire to leave the Facility AMA Training for all licensed nursing staff on completion of accurate elopement assessments initiated on 7/17/23 and will be ongoing until all staff have completed the training. 3. The Facility and/or physician will discuss with the resident and/or the resident's personal representative, if applicable, the reason for the AMA decision and will advise them of the potential consequences of the AMA decision. 4. A licensed nurse will have the resident or the residents' personal representative sign Discharge AMA, or similar form located in the Facility's EHR. A. If the resident or personal representative refuses to sign, the licensed nurse will read the Form to the resident, make a specific notation in the progress notes of the refusal to sign, and have a witness sign the form as acknowledgement of the resident's or resident's personal representative's refusal to sign. If a resident is a has a legal Guardian or a [NAME] of the State, the nurse will notify them of the resident's desire to leave the facility despite the residents' BIMS/cognition level. This resident was not a ward of the State, she was her own responsible party. 5. Nursing staff will document in the progress notes all pertinent information concerning the residents' actions, including the resident's stated reasons for his/her desire to leave the Facility. Implementation of Changes Training for the Multidisciplinary Team was initiated on 7/17/23 on resident's leaving AMA by the Chief Nursing Officer. The changes were started by the RNC. The changes were implemented effective on 7/17/2023 and training was completed on 7/20/2023. Staff will not be allowed to work until they have been fully re-educated. All new hires will be educated on AMA protocol/response prior to working the floor. The DON will ensure competency through signing of in service, verbalization of understanding and completion of returned questionnaire. A licensed nurse will notify the attending physician, on call physician, or medical director of the resident's desire to leave the Facility AMA. Nursing staff will document in the progress notes all pertinent information concerning the resident's actions, including the resident's stated reasons for his/her desire to leave the Facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 10 of 12 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 07/21/2023 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 0600 Residents with a history of wandering or who IDT have assessed to be at risk for wandering or elopement will have a photograph maintained in their medical record and Elopement/Wandering Risk Binder. Level of Harm - Immediate jeopardy to resident health or safety Monitoring Residents Affected - Few The NFA/DON/ADON/RNC will be responsible for monitoring the implementation and effectiveness of in-service on 7/15/2023. o The NFA/DON/ADON/RNC will monitor/review all residents with wandergaurds for placement and functioning daily x4 weeks, then weekly thereafter and report any adverse finding monthly during QAPI. o DON/ADON will conduct a daily audit of wander/elopement assessment x4 weeks, then weekly thereafter and report any adverse findings monthly during QAPI. o Residents will be monitored by staff every shift for any exit seeking behaviors. Any changes will be reported to the DON and ADON immediately for appropriate action. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 7/15/2023 and conducted an Ad HOC QAPI regarding the resident who left AMA and the policy and procedure. The Medical Director was notified about the IJ on 7/20/2023, the POR was reviewed and accepted by medical director. Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, NFA, DON, and social services director to review the plan of removal on 7/20/2023. Who is responsible for implementation of process? The DON and NFA will be responsible for implementation of New Process. The New Process/ system was started on 7/17/2023. On 07/21/23 the investigator began monitoring if the facility implemented their plan or removal sufficiently to remove the IJ by: Observation of all residents (total 19) identified as an elopement risk, appropriate placement of WanderGuard to left or right lower extremity and worked appropriately as evidenced by alarm sounding when resident was within approximately 30 feet of the exit door. Interviews conducted with nursing staff scheduled 6a - 2p and 2p - 10p shift on 07/21/23 [CNA D, CNA E, CNA F, LVN B, RN K, LVN L, CMA J, CMA M, CMA N, CNA V, CNA P, CNA O, and MDS] indicated they participated in an in-service training about elopement risk residents, WanderGuards, ANE, AMA process, gate, and door security. Licensed nurses summarized the topic of discussion as policy and procedure for elopement and AMA, steps of procedure, evaluating elopement risk, and building security. identifying, assessing, and monitoring wounds clinical protocol. The CNAs, CMAs, and non-nursing staff [RECPST, MR-CS, BOM] summarized the topic of training in their own words knowing and monitoring elopement risk residents, door and gate code security, and reporting ANE if suspected. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 11 of 12 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 07/21/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of in-services conducted by the DON titled AMA and Elopement Risk Residents/WanderGuard (beginning 07/17/23); and ANE, AMA Policy & Process, and Gate Security (beginning 07/20/23) reflected staff signatures across all shifts and various departments - nursing, housekeeping, dietary, kitchen and therapy, including the RECPST, MR-CS, BOM, and SW participated in the in-service. Review of Post-tests of the AMA Process for CNAs and non-nursing AMA questionnaires dated 07/20/23 revealed passing scores by staff completed. An IJ was identified on 07/20/23. The IJ template was provided to the facility on [DATE] at 4:25 PM. The facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 12 of 12