Health inspection·November 30, 2023

F 0692 Record review of Resident #66's care plan dated 11/5/2023 for weight loss revealed: Level of Harm - Minimal harm or potential for actual harm The resident's weight will stabilize within 4 weeks. Assigned Staff to administer dietary stimulant as ordered. Residents Affected - Few Mirtazapine 7.5 MG Give Resident #66 supplements (House Shake TID with meals). as ordered. Alert nurse if not consuming on a routine basis. Mirtazapine 7.5 MG Resident# 66 has a diet order other than Regular and is at risk for unplanned weight loss or gain. (Puree texture, thin consistency) Resident #66 will maintain ideal weight and receive proper nutrition daily x 90 days. Monitor weight per facility protocol. Offer sub, if resident eats less than 50% or dislikes meal and offer supplement if resident continues to eat less than 50%. RD assess per facility protocol. ST eval and Tx per Physicians orders as condition warrants. Record Review of Dietitian's Progress Note dated 6/14/2023. Resident #66 had weight loss reported d/t decreased progression of condition. Current monthly weight 145.0 pounds, weight loss -13.2% x 90 days/-18.1% x 180 days; 81% of Ideal Body Weight, and BMI =19.13. His current diet order is Regular diet, mech. soft texture, thin liquids, and he is on House shakes. Reported oral intake 50-100% most of the time. No concerns with diet tolerance. Diet order is appropriate. Reported intake is not meeting nutrition needs. Recommend starting an appetite stimulant to enhance increased calories and protein intake. Will continue to encourage oral intake of meals and supplements, will follow up with resident's nutrition status, and nutritional needs. Record Review of Dietitian's Progress Note dated 10/12/2023. Resident #66 had weight loss reported d/t decreased progression of condition. Current monthly weight 129.0#, weight loss -11.8% x 30 days/-19.9% x 180 days; 80% of IBW, and BMI =19.32. His current diet order is Regular diet, puree texture, thin liquids, and House Shakes. Reported oral intake 75-100% most of the time, per nursing. No concerns with diet tolerance. Diet order is appropriate. Reported intake is not meeting nutrition needs. Recommend Ready Care 2.0 at 120cc with med pass TID. Will continue to encourage po intake of meals and supplements, will follow up with resident's nutrition status, and nutritional needs. In an interview with CNA C on 11/28/23 at 11:03 AM revealed that resident #66 is not verbal, he will sometimes understand what is being said but may not react to it. She stated she had not seen any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 2 of 8 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 11/30/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few weight loss on Resident #66. CNAC worked on the Resident # 66 hall since October and knew the resident well. She also reported Resident # 66 was sleepy on the day of the interview, so he was not taken to the dining room for activities and needed full assistance with transfers and ADL's. Observation on Observation 11/29/2023 at 12:40 PM revealed that Resident #66 was in the dining room and was fed by CNA A. The resident ate 100% of his meals. Meal ticket was not available for review. Observation on 11/30/2023 at 10:14 AM revealed that Restorative Aide/CNA B weighed Resident # 66 in a wheelchair and weight was 153.2 pounds. In an interview with CNA A on 11/29/2023 12:45 PM revealed that they started feeding Resident #66 recently; about 2 weeks ago since Resident #66 was spilling food and not eating most on his plate. CNA A did not observed any weight loss on Resident #66. He also stated that he was not aware if Resident #66 was on weekly weights. In an interview with LVN A 11/29/2023 at 12:55 PM revealed that Resident # 66's weight was stable. She stated that Resident # 66 messed up while eating by himself; and would not finish his meals. She had noticed that CNA's had recently started feeding Resident# 66. She also reported that if she observed any weight loss or food issues on residents, it was reported to Nursing team and Administrator at the daily morning meeting. In an interview with CNA B Restorative Aide on 11/29/2023 at 12:59 PM revealed she weighed Resident #66 every month. She also revealed that Resident #66 was not on weekly weights currently or for last few months. Resident #66 was weighed with wheelchair and then the wheelchair weight was deducted to obtain Resident# 66's weight. She stated the Nursing team would alert her if any resident was on weekly weight. She stated she was only responsible for weighing residents and notifying the nursing team if she saw any changes in weight from last month. She also stated that ADON's are responsible for documenting weights. In an interview with ADON A on 11/29/2023 at 1:20 PM revealed that he was just promoted to be the ADON A for Resident's #66 Hall. He revealed that he did not believe that Resident #66 was on weekly weights and was not sure if Resident #66 had history of weight loss. He revealed the process of weighing residents in the facility started with CNA / Restorative Aide weighed the residents and handed over the weights to ADON A. ADON A will then enter the weights in the weight log and notify DON, dietitian, physician, and family as needed. He also stated that not following facility policy of weekly weights for resident with significant weight loss will lead to failure to gauge if interventions put forth for weight loss were effective. In an interview with Speech Language Pathologist on 11/29/2023 at 1:45 PM revealed that Resident #66 was on Speech therapy from 8/9/2023-10/7/2023 for oropharyngeal dysphagia (difficulty initiating a swallow). Resident # 66 was triggered on 8/9/2023 for weight loss and dysphagia. Her goal for the Resident # 66 was to safely swallow thin liquids and return to soft and bite sized consistency. She revealed that resident was on Pureed Diet currently related to his swallowing problems. In an interview with Dietitian on 11/29/2023 at 2:25 PM revealed Resident #66 was initially triggered for weight loss in June. She recommended Resident # 66 started on Mirtazapine (appetite stimulant medication) and was implemented by the Following physician in June. She reported that in June Resident # 66 had weight loss -13.2% in 90 days and BMI =19.13. She reported Resident # 66's diet order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 3 of 8 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 11/30/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm was Mechanical soft diet with thin liquids; was on House shakes and Resident # 66's food intake was 50-100% of most meals. Dietitian was not aware if resident #66 needed any feeding assistance. Dietitian then revealed that resident was stable for a while and no Intervention were added until October 2023. Residents Affected - Few In October 2023, Resident # 66 had weight loss of weight loss -11.8% x 30 days/-19.9% x 180 days; 80% of IBW, and BMI =19.32. She revealed she recommended Recommend Ready Care 2.0 (supplement) at 120cc with medpass TID. Dietitian added she suspected there was a problem with the scale but reweights were not carried out at the time. Dietitian also stated that she did not look at weekly weights for Resident # 66 and was not sure if Resident # 66 was placed on weekly weight monitoring, although Resident # 66 had significant weight loss since June 2023. Dietitian reported that she was not trained to look at weekly weights on residents unless the resident was newly started on Enteral feedings and had to be monitored. She also stated that she was not aware of the facility policy regarding placing residents with significant weight loss on weekly weights. She also revealed that if any resident was placed on weekly weights, it was the Nursing team that handled weekly weights and she was not responsible for monitoring whether weekly weighing was carried out nor did she look at them during her clinical review. Dietitian also revealed that since she reviewed monthly weights; she based her effectiveness of interventions for residents with significant weight loss on Monthly weights alone. She also revealed that the risk for not weighing residents with significant weight loss could result in failure to determine if added interventions to mitigate weight loss were effective. In an interview with the DON on 11/29/2023 at 2:55 PM revealed that Resident #66 started declining in September of 2023 and the staff fed Resident # 66 since then. She added that Resident # 66 started spilling food while feeding himself and hence was referred to Speech language pathologist for weight loss and dysphagia. She revealed that if any resident had significant weight loss in the facility, Nursing would notify the MD and the Dietitian and follow through with their recommendations. She then revealed that weekly weight protocol would be initiated per facility policy. She also stated she was not sure if Resident # 66 was on weekly weights despite being identified with significant weight loss. She revealed it is usually the dietitian that will recommend weekly weight intervention. In another interview with the DON on 11/29/2023 at 3:30 PM revealed that she read the facility policy that stated that any resident with significant weight loss should be on weekly weights. The DON stated that she was not aware she did not need the Dietitian recommendation to implement weekly weight interventions and it was an oversight from the Nursing team. She stated Inter disciplinary team approach should be used for weight loss intervention with Dietitian recommending diet changes and Nursing team monitoring weekly weights. She also revealed that she had received in-service from the corporate Nursing team just before this interview regarding weekly weight implementation for residents with Significant weights per facility policy. She also stated that not implementing weekly weight for Resident # 66 could result in failure to determine if interventions that were added for mitigating weight loss were effective and could risk resident's physical health. Record review of Resident 66's medical record revealed there was no documentation of weekly weights in his chart and wherever else weights were documented. Review of facility's Assessment and Management of Resident Weights Policy dated 06/2020 revealed that V. (F) Residents with significant weight change will be weighed at least weekly and discussed at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 4 of 8 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 11/30/2023 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 0692 the Resident at Risk or other clinical meeting to determine possible causes of weight gain or loss including goals for care. 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 5 of 8 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 11/30/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #73) of three resident reviewed for respiratory care. Residents Affected - Few The facility failed to ensure Resident #73's nasal cannula, nebulizer mask, and oxygen tubing were dated. The facility failed to ensure Resident #73's nebulizer mask was properly stored. The facility failed to ensure Resident #73 had an order for continuous O2 administration. These failures could place the resident at risk for respiratory infection and not having their respiratory needs met. Findings included: Review of Resident #73's Face Sheet dated 11/28/2023 reflected resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included chronic obstructive pulmonary disease with acute exacerbation, shortness of breath, pulmonary hypertension due to lung diseases and hypoxia (insufficient amount of oxygen in the body), and uncomplicated unspecified asthma. Review of Resident #73's Quarterly MDS assessment dated [DATE] reflected Resident #73 was cognitively intact with a BIMS score of 15. Resident #73's primary reason for admission was debility (physical weakness due to illness) and cardiorespiratory conditions such as chronic obstructive pulmonary disease with acute exacerbation, shortness of breath, hypoxemia (low blood oxygen), and asthma. Review of Resident #73's Comprehensive Care Plan dated 11/26/2023 reflected Resident #73 had Oxygen Therapy continuous 2-4 L NC r/t Respiratory illness (COPD/SOB) or 02 sat below 94% and one of the assigned task was OXYGEN SETTINGS: (Specify: The resident has, O2 via nasal prongs/mask@ (2-4) L continuously. Review of Resident #73's Physician Order dated 12/02/2022 reflected, Oxygen @ 2-4L via N/C as needed to maintain oxygen above 94% as needed for SOB. Review of Resident #73's Physician Order dated 07/30/2023 reflected, Check O2 sat Q shift and PRN every shift. Review of Resident #73's Physician Order dated 07/30/2023 reflected, Change Respiratory Tubing, Mask, Bottled Water, clean filter q7d every night shift every Sun q 7 days. Review of Resident #73's Physician Order dated 07/30/2023 reflected, Change Respiratory Tubing, Mask, Bottled Water, clean filter q7d every night shift every Sun q 7 days. Review of Resident #73's Physician Order dated 09/28/2023 reflected, may have 02 @ 2-4L/min via NC PRN SOB/02 sat<92%. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 6 of 8 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 11/30/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #73's Physician Order dated 11/16/2023 reflected, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally every 6 hours for COPD. Review of Resident #73's Physician Order reflected no order for continuous oxygen administration. Observation and interview with Resident #73 on 11/28/2023 at 10:58 AM revealed resident was in his bed resting. Resident #73 was receiving oxygen supplement at 2 liters per minute via nasal cannula that was connected to the oxygen concentrator, the nasal cannula had no date. The humidifier bottle on the oxygen concentrator also had no date. Resident #73 had a nebulizer machine inside the drawer of the right bedside table. Resident #73 stated he had been with oxygen since he cannot remember. He said he had lung problem that was why he was in oxygen. Observation and interview with Resident #73 on 11/28/2023 at 3:05 PM revealed resident on his bed resting. The nebulizer mask was on the floor between the bed and the oxygen concentrator. The tubing of the nebulizer mask was not dated. According to Resident #73, he had a breathing treatment after lunch but he was not aware what time. He stated the nurse came in and put the mask on him. The resident said the nurse did not come back when it was done so he put the mask on the table and did not notice it fell. Resident #73 added it was hard for him to reach for the plastic bag. Interview and observation with LVN I on 11/28/2923 at 3:10 PM, LVN I stated the nebulizer mask should not be on the floor but instead stored in a plastic bag at the bedside. LVN I said she was not sure what time Resident #73 had his breathing treatment. LVN I stated she did not notice the nebulizer mask was on the floor when she did the shift change round. She said the nebulizer mask could get contaminated and increase the risk of respiratory infections. She added she was about to give him another breathing treatment and would change the nebulizer mask. LVN I pulled the tubing of the nebulizer mask from the nebulizer and said she would dispose of it and bring a new one. No date was noted from the nebulizer mask that was pulled from the nebulizer machine. Interview with DON on 11/29/2023 at 8:09 AM, the DON stated any equipment used for respiratory care must be bagged to ensure cleanliness. The DON said a nebulizer mask on the floor could cause infection and cross contamination. She also said the tubing for the nasal cannula, the tubing for the nebulizer mask, and the humidifier should be dated to ensure the residents were not using old tubings and humidifier. She explained the old tubings and nebulizer mask could lead to infection and compromised oxygen intake. The DON stated whoever was changing the tubings or the nebulizer mask should date them to indicate that the tubings and the mask were changed. According to the DON, the night nurse was responsible in changing the tubings and the mask once a week but whoever saw the mask or even the nasal cannula on the floor should change it and date it. The DON said the nurse must have missed dating the said items. The DON concluded the staff must ensure the tubings and the mask were dated. She said she would continually remind the educate the staff of the importance of a competent respiratory care. Interview with RN G on 11/29/2023 at 8:15 AM, RN G stated she was with the facility for a couple of months. RN G said she was familiar with the care of Resident #73. She added Resident #73 had respiratory problems that is why he was on oxygen and used breathing treatment. RN G said she gave the breathing treatment twice for her shift. She said she was not aware the mask for the breathing treatment was on the floor. She said the mask must be a bagged when not in use. She added the tubings and the mask should be dated to know when they were last changed and when they were supposed to be changed. RN G said she was not sure if the humidifier needed dating. RN G said a resident with oxygen had to have a physician order for oxygen supplement. She said it should be in the system so the staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 7 of 8 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 11/30/2023 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 0695 would know what to do and if the staff were giving the right treatment. Level of Harm - Minimal harm or potential for actual harm Review of Resident #73's Physician Order reflected a new order dated 11/29/2023 at 8:18 AM stating, may have 02 @ 2-4L/min via continuous NC SOB/02 sat<92%. Residents Affected - Few Interview with Resident #73 on 11/29/2023 at 8:41 AM, Resident #73 reiterated the nurse would put on the breathing treatment and when the treatment was done, he would usually put it on the table. He said sometimes it would fall l on the floor. Resident #73 said sometimes he would get something from the drawer and the mask would fall. He said the nebulizer machine and the mask should be placed on top of the table so that when he would get something from the drawer, the mask will not fall. Interview with CNA I on 11/29/2023 at 9:30 AM, CNA I stated anything that the residents used must be clean. CNA I said if the residents were using oxygen, everything used such as nasal cannula and breathing masks should be clean and bagged if not in use. She added if the mask was on the floor, it could cause an infection because the germs from the floor will be inhaled by the resident. She added if ever she saw a mask on the floor, she would tell the nurse so the nurse could replace it before the resident would use it again. CNA I further added there was no five minute rule for the mask, if the mask was on the floor even for one second, it should be changed. Interview on 11/30/2023 at 8:23 AM, the Interim Administrator stated the tubings and the mask must be dated weekly at a to minimum to make sure the staff were changing it. He said the tubings and the mask were being changed to ensure they were in good conditions. The Interim Administrator added the nasal cannula and the mask must be bagged when not in use. He continued if the tubings and the mask were not changed, it could cause respiratory infection and the oxygen intake could be compromised. The Interim Administrator stated there should be a physician order if the resident was using oxygen. He added the nurses, ADON, and the DON were responsible in ensuring the required orders were in place. He said the physician order was done to make sure the staff was following the exact prescription for oxygen administration. He further added if the physician wanted a continuous administration of oxygen, then the system must reflect continuous administration or else the resident will not get the treatment needed. The Interim Administrator specified the expectation were for the staff to make sure to place the mask in a place where it will not fall, to make sure the tubings and the mask were dated, and to make sure the system accurately reflect the physician's order. Interview with the DON at 11/30/2023 at 10:19 AM, the DON stated Resident #73 had been in and out of the facility. She continued that during the last admission, dated 11/15/2023, the nurse must had missed putting the order for continuous oxygen. She acknowledged that she overlooked Resident #73 did not have a physician order for continuous oxygen administration. Record review of facility's policy Oxygen Administration, Nursing Manual - Nursing Care rev. 6/2020 revealed Purpose: To prevent or reverse hypoxemia and provide oxygen to the tissues . I. Initiation of Oxygen: A physician's order is required to initiate oxygen therapy . The order shall include i. Oxygen flow rate ii. Method of administration (e.g. nasal cannula) iii. Usage of therapy (continuous or prn) iv. Titration instructions (if indicated) v. Indication for use . II. Infection Control . A. Will be changed weekly and when visibly soiled . date . oxygen being used . B. Oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675680 If continuation sheet Page 8 of 8