Health inspection·May 11, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some -Left side door: -2 trays with 24-8 oz cups covered with plastic wrap with red liquid inside. There was a sticker with 5/9 on both trays but no label of item description, no use by or discard date. Observations of Walk-in Refrigerator on 05/09/23 at 09:56 AM revealed the following: - 7 uncooked grilled cheese sandwiches on a plate, covered with plastic wrap, dated 05/08/23; there was no consume by or discard date. -1 large white plastic shallow pan with diced tomatoes, covered with plastic wrap, dated 05/07/23; there was no consume by or discard date. -2-32 oz. packs of smoked ham dated 02/19/23 and 02/22/23 with no manufacturer expiration date noted, there was no consume by or discard date reflected. -4-32 oz. packs of smoked ham, dated 02/22/23 with no manufacturer expiration date noted, there was no consume by or discard date reflected. -1-32 oz. pack of smoked ham, no received by date, no manufacturer expiration date noted, there was no consume by or discard date reflected. -1-30 oz. pack of smoked ham, previously opened, wrapped in plastic wrap. The manufacturer's label was obscured, there was no label of item description, no open date, no manufacturer expiration date, and no consume by or discard date reflected. -1-5 lbs. bag of Feta Cheese crumbles, previously opened, in zip top bag dated 04/20/23. There was no consume by date or visible manufacturer expiration date. -1-5 lbs. bag of shredded Mozzarella cheese in a zip top bag dated 05/05/23, there was no consume by date or discard date. -1-2 gallon bag of shredded American cheese in a zip top bag dated 05/07/23, there was no consume by or discard date. - 1-5 lbs. of Feta Cheese crumbles in a zip top bag, dated 03/25/23, there was no open date, no consume by or discard date. -1-24 oz plastic container of large curd cottage cheese, dated 05/07/23, there was a manufacturer use by date of 05/07/23. -1 large clear plastic metered container covered with plastic wrap, containing 2.5 liters of chocolate syrup, dated 05/07/23, there was no consume by or discard date. -1 large plastic package, previously opened, tied close, with 8 boiled eggs remaining. There was no open date, label of item description, no open date, no consume by or discard by date. Observations of the Dry Storage room on 05/09/23 at 10:21 AM revealed the following: -1-6 lbs. 15 oz. can of Pinto beans dated 5/3, expiration date 03/2025, can is dented and stored with regular/undented cans. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675754 If continuation sheet Page 2 of 11 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 675754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Traymore Nursing Center 4315 Hopkins Ave Dallas, TX 75209 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 -4-6 lbs. 110 oz. can of cheddar cheese sauce, dated 3/18, there was no manufacturer expiration date or no discard date reflected. -3-6 lbs. 10 oz. can of spaghetti sauce dated 05/03/23, no manufacturer expiration date, no consume by date. Residents Affected - Some -1- 7 lbs. 3 oz. can of tomato ketchup dated 10/15, no manufacturer expiration date, no consume by date reflected. The date was written 15/10 but the Dietary Manager said, the received by date was 5/10, but the date of the observation was 05/09/23 the ketchup could not have been received on 05/10/23). -2- 7 lbs. 3 oz. cans of tomato ketchup dated 03/18/23, no manufacturer expiration date or no consume by date. -3- 6 lbs. 10 oz. pizza sauce dated 03/03/23, no manufacturer expiration date or no consume by date reflected. -3- 6 lbs. 10 oz. can of Monterey [NAME] cheese sauce, dated 01/04/23, no manufacturer expiration date or no consume by date reflected. -2 6 lbs. 6 oz. can of large diced tomatoes in juice, dated 03/08/23, no manufacturer date or no consume by date reflected. -1-7 lbs. 4 oz. can of cane sweetened Cherry fruit filling/topping, dated 04/22/23, no manufacturer expiration or consume by date reflected. -1-5 lbs. bag of cornbread mix, previously opened, wrapped in plastic wrap, received by date obscured. There was no open date, no manufacturer expiration date or no consume by date. -1- 5 lbs. bag of Cherry cake mix, dated 05/03/23, previously opened but unsecured closed, manufacturer expiration date 12/27/23. There was no open date, no consume by or discard by date. -1-16 oz. bag of plain potato chips in a zip top bag, dated 04/03/23, no consume by date or discard date. -1-24 oz. bag of cherry gelatin mix previously opened, wrapped in plastic wrap with label obscured. There was no open date, no consume by date or no discard by date. -2 lbs. 3 oz. bag of Sugar Frosted Flakes cereal in a zip top bag, no received by or manufacturer expiration date. There was no open date, no consume by or discard by date. -1-2 lbs. 3 oz. bag of Toasted Oats cereal, no received by or manufacturer expiration date. (When the Dietary Manager was shown the bag not having a date, she wrote 5/9 on it). -1-1.34 oz box, previously opened oatmeal pies, there was no received by date, no opened date, no consume by or manufacturer expiration date. -1-1 lb. 1 ¾ oz. bag of hot dog buns (5) previously opened, no received by date, expiration date 05/18/23. There was no consume by date or discard by date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675754 If continuation sheet Page 3 of 11 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 675754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Traymore Nursing Center 4315 Hopkins Ave Dallas, TX 75209 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- 1 lb. 10 oz. bag of white bread previously opened, no received by date, expiration date 05/13/23. There was no opened date, no consume by date or discard date Observations of the Kitchen on 05/11/23 at 11:50 AM revealed the following: -Handwashing sink #2 was blocked by an industrial sized rolling mop bucket with dirty smelly mop water in it and a mop. - The garbage receptacle was full and had more than paper towels in it, product box packaging, cardboard pieces, paper towel wrapper, gloves and tissue paper were also noted. -At 11:43 AM: [NAME] F while standing on the line, at the steam table and taking temperatures of the food on the steam table for lunch service, with his gloves on he removed his glasses from him shirt pocket to look through them then placed them back in his shirt pocket. He did not change his gloves; he then grabbed some plates from the dish carrier to start preparing meals to go out to the dining room. -At 12:05 PM: Dietary Aide G went out to the dining room to assist residents and was observed standing by the counter wiping the perspiration from her forehead then getting a cup and going back into the kitchen. She went to the drink machine got water in the cup then reached over to the clean dish area near the line and got at lid. At no time did she wash her hands after re-entering the kitchen. In an interview on 05/09/23 at 09:58 AM with Dietary Manager. She stated for items kept in the refrigerator, if they are closed then they check the expiration date to know when to discard them but if they are processed in the kitchen then they go by the product's expiration date. If dairy is added to a product then go by the date produced to discard. She stated they keep cheese 8 weeks from when it's received. In an interview on 05/09/23 at 11:15 AM with Dietary Manager. She stated dented can are kept in her office. The Dietary Manager stated [NAME] F and [NAME] H do the inventory, she places the orders and staff does inventory on Sundays. She stated all the residents in the facility eat by mouth. She stated that can goods without an expiration date are kept up to 6 months from receipt. Dry goods are kept depending on open date and manufacturer expiration date. In an interview with Dietary Manager on 05/11/23 at 3:06 PM when showing the Dietary Manager an item open and placed in the refrigerator with an opened date but no date of consume by or discard date, she stated we put an end date on some things. The Dietary Manager stated that when food items in the kitchen are opened that the staff is expected to seal it and label the open dated and place in the refrigerator, freezer, or dry storage. She also stated open items in the refrigerator are kept for 3 days. The dietary Manager stated that if staff when preparing food/setting up for service touches surfaces other like their hair, clothes, faces, walls, etc. then they are expected to wash their hands or change their gloves. When asked how they have the received date of a Large curd cottage cheese marked at 05/07/23 and the manufacturer expiration date on one of the containers was 05/07/23, she stated that she received those cottage cheese containers from a delivery from Walmart. The Dietary Manager insisted that the staff does inspect items that are received via delivery, but she had several items in the kitchen with recent da received by dates but soon expiring. Review of the facility's Nutrition Services Policy & Procedures: Handling of Potentially Hazardous Foods: Sanitation, Policy No.: 4.42, Effective Date: Last Revision: 01/01/10, Page: 4-68, reflected: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675754 If continuation sheet Page 4 of 11 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 675754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Traymore Nursing Center 4315 Hopkins Ave Dallas, TX 75209 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 Policy: In order to prevent food borne illness, all potentially hazardous food (PHF) will be cooked and handled in a safe and sanitary manner. PHF is food that consists in part of milk or milk products, meat, poultry, fish, eggs, shellfish, or other ingredients in a form capable of supporting rapid, progressive growth of micro-organisms. Procedure: . 2. MEATS, POULTRY AND FISH . d. Avoid cross-contamination between raw and cooked foods. g. When holding foods on a serving line or buffet, keep color foods 41 degrees F or below and hot foods 135 degrees F or above. Foods should not be held for longer than 2 hours. Review of facility's Nutrition Services Policy & Procedures: Food Safety in Receiving and Storage: Sanitation, Policy No.: 4.40, Effective Date: Last Revision: 04/01/10, Page: 4-58, reflected: Policy: Food will be received and stored by methods to minimize contamination and bacterial growth. Procedure: Receiving Guidelines . 3. Compare delivery invoice against products ordered and products delivered. 4. Food is inspected when it is delivered to the facility and prior to storage for signs of contamination. Example of signs of contamination include the following: A. Cans with badly swollen sides or ends, flawed seals or seams, rust, dents, or leaks. 5. Check expiration dates and use-by-dates to assure the dates are within acceptable parameters. 6. Refuse contaminated food and return to the vendor for credit. If the food cannot e returned immediately, it is kept away from other food and supplies to prevent contamination. Dented cans are kept in a designated location (labeled Do Not Use) until the vendor can pick them up. 8. When adding newly delivered food into current inventory, the FIFP (First In, First Out) method is utilized so that old stock is rotated to the front and utilized first. General Food Storage Guidelines . 3. Food that is repackaged is placed in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight fitting lid. The container/lid is labeled with name of contents and dated with eh date it was transferred to the container. Cold Food Storage Guidelines . 11. Potentially hazardous leftover foods are properly covered, labeled, dated and refrigerated immediately. They are discarded after 3 days unless otherwise indicated. 13. Foods may remain in the shipped box as long as content and date are easily visible on the box. Any foods removed from the shipped box must be labeled and dated. Dry Storage Guidelines . 4. Open packages of food are stored in closed containers with tight covers. 5. All food products will be date upon delivery on each individual can, box, or bag. 6. Stock is rotated on a first-in, fist-out basis. 10. Clean exterior surfaces of food containers such as can of jars of visible soil before opening. Food code referennce www.fda.gov/food/fda-food--code/food-code-2017. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675754 If continuation sheet Page 5 of 11 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 675754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Traymore Nursing Center 4315 Hopkins Ave Dallas, TX 75209 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** The facility failed to establish and maintain an 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 two (Residents #56 and #210) of 8 residents reviewed for infection control. Residents Affected - Some 1) The facility failed to ensure CNA A sanitized her hands, put on a gown and gloves prior to entering Resident #56's contact isolation room to get his breakfast meal tray. 2) The facility failed to effectively ensure Resident #210 was not continuing to go outside to smoke cigarettes at the same time the other residents smoked. These failures could place all residents at risk of cross contamination of hard to treat and highly infectious diseases, which could cause residents to experience gastro-intestinal or other types of infections, decreased psycho-social well-being and physical decline. Findings Include: Observation on 05/09/23 at 11:06 am, Resident #56's room door was open, and he had a contact isolation station stocked with gowns, gloves, N-95 masks and face shields and no hand sanitizer. And there was signage on the door: Contact Precautions: Everyone must: Clean their hands, including before entering and when leaving the room .Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit .Put on gown before room entry, discard gown before room exit . Observation on 05/10/23 at 8:41 am, Resident #56's room door was open, and CNA A walked into Resident #56's room and did not put on a gown or conduct hand hygiene and once next to Resident #56 she put gloves on then grabbed his breakfast meal tray. CNA A starting walking fast and was about to walk out of his room then stopped at the entrance of Resident #56's door. CNA A then asked Resident #56 to press his call light button for staff to assist her with getting his breakfast meal tray and she and she stood there for approximately two to three minutes waiting for someone to get Resident #56' breakfast tray. LVN B walked up to CNA A and started whispering to her then she retrieved Resident #56's meal tray and placed it into the meal cart. CNA A took her gloves and threw them into the biohazard box and washed her hands in Resident #56's bathroom then walked out of his room towards another resident's room but was stopped by the HHSC Surveyor. Interview on 05/10/23 at 8:45 am, CNA A stated Resident #56 was on contact isolation for a urinary tract infection and was not sure for how long he would be on contact isolation. She stated for contact isolation precautions, the staff were to wear a gown, gloves, mask, and face shield but when she went to Resident #56's room this morning (05/10/23) to pick up his breakfast tray, she only had on gloves and did not have a gown or mask on because she did not know she had to wear a gown and mask to pick up his meal tray. She stated she grabbed a PPE gown as soon as she got inside Resident #56's room but did not put it on because she was moving fast and usually put PPE on before entering Resident #56's but did not this time. She stated she could not remember the last infection Control training (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675754 If continuation sheet Page 6 of 11 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 675754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Traymore Nursing Center 4315 Hopkins Ave Dallas, TX 75209 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 she had but thought it was last week by Staffing Development LVN that covered PPE usage and ways not to transfer bacteria. She stated she was not about to walk into Resident #56's room at first and was not sure why she did not put on PPE before entering his room. She stated if staff were not properly wearing PPE it could cause a transfer of bacteria to everyone. She stated she should have gowned up before she went into Resident #56's room. Residents Affected - Some Record review of Resident #56's Quarterly MDS assessment dated [DATE] revealed A [AGE] year old male who admitted [DATE] with a BIMS Assessment score 12 [Cognitively Intact], limited one person assist with bed mobility, transfers, toilet use and supervision with setup assist for dressing and personal hygiene, Bathing needed with physical help in part of bathing, use of manual wheelchair, occasionally incontinent with bladder and continent with bowel with diagnoses MDRO infections and ESBL Resistance . Record review of Resident #56's Order Summary Report dated 05/10/23 revealed, Diagnoses Resistance to multiple antibiotics. Absence of left below knee amputation, sepsis, retention of urine, MRSA, Acute respiratory failure, urinary tract infection, ESBL . Order start date: 05/03/23 Isolation: resident requires transmission-based precautions .because of active infection with highly transmissible or epidemiologically significant pathogen that has been acquired by physical contact .State pathogen: ESBL .Transmission Based precautions (contact) are in effect . Record review of Resident #56's Care Plan initiated 05/03/23 and revision date 05/10/23 with target date 07/12/23 revealed, I require isolation due to ESBL in his urine. I will no longer require isolation within the next 60 day .Date initiated 05/10/23 and target date: 07/31/23 - The resident has Urinary Tract Infection related to ESBL in the urine . date initiated 09/09/22 and target date: 07/31/22: Resident has bowel and bladder incontinence and occasional assist with ADL's related to weak unsteady gait/transfers, cognitive impairment . Record review of Resident #56' Lab results collected 04/24/23 and reported date 05/01/23, Urinalysis, complete w/reflex to culture .Therapy comments: Note 1. - Extended spectrum beta-lactamase (ESBL) producing organisms demonstrate decreased activity with penicillin's, cephalosporins aztreonam .Note 2. The organism has been confirmed as an ESBL producer . Record review of Resident #56's Nurse Medication Administration Record dated 05/04/23 revealed, 1 application 3 times daily right arm .injection of Imipenem-Cilastatin Intravenous Solution Reconstituted 500 mg: start date 05/04/23 and Transmission Based Precautions start date 05/03/23. Record review of Resident #56' Nurse Progress noted dated 05/10/23 at 3:37 pm revealed, HEALTH STATUS Note Text: Insufficient UA specimen per biostat. MD aware, N.O. repeat UA C&S. Resident notified . Observation on 05/09/23 at 9:05 am, Resident #210's Room door revealed he had a contact isolation station on his room door stocked with gowns, gloves, N-95 masks and face shields and no hand sanitizer. And there was signage on the door: Contact Precautions: Everyone must: Clean their hands, including before entering and when leaving the room .Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit .Put on gown before room entry, discard gown before room exit . Record review of Resident #210's admission MDS assessment dated [DATE] revealed, A [AGE] year-old male who admitted [DATE] with a BIMS Assessment score of 11 [moderate cognitive impairment], (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675754 If continuation sheet Page 7 of 11 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 675754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Traymore Nursing Center 4315 Hopkins Ave Dallas, TX 75209 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 - Some Supervision with setup assist for most ADL Care, no device assistance with walking, always continent to bowel and bladder, diagnoses septicemia, urinary tract infection, sepsis due to Methicillin Susceptible Staphylococcus Aureus . Record review of Resident #210s Order Summary Report dated 05/10/23 revealed diagnoses Methicillin Susceptible Staphylococcus Aureus infection, encounter for surgical aftercare following surgery, other seizures, left hand osteomyelitis, sepsis .order start date 04/25/23 Isolation: Resident Requires transmission-based precautions because of active infection. Record review of Resident #210's Nurse Progress Notes dated 05/10/23 at 4:37 pm revealed, HEALTHSTATUS Note Text: Resident redirected back to room and reeducated resident of isolation precautions, resident yelled back at this nurse . Record review on Resident #210's Nurse Progress Notes dated 05/06/23 at 3:28 pm revealed, HEALTHSTATUS Note Text: Resident continue on SNF care due to recent hospitalization for SEPSIS WITH MRSA, UTI, SEIZURE DISORDER, OSTEOMYELITIS TO RIGHT HAND, S/P DEBRIDEMENT . Currently receiving IV Abx (antibiotic) cefazolin TID (three time a day) for MRSA to right hand until 5/24/23. Midline to LUA (left upper arm) flushes easily, NARN (no adverse reactions noted). Resident noncompliant with isolation precautions in place, nurse educated pt. (patient) on importance of contact isolation precautions. Pt. (patient) voiced he has to go out to smoke, nurse able to take resident out when no other pt. (patient) are present . Record review of Resident #210's Care Plan dated 05/04/23 target date: 05/16/23 revealed, Cigarette Smoking and I require isolation due to an infection due to MSSA in the urine, I am non-compliant with isolation precautions . Record review of Resident #210's Lab results dated revealed, Sepsis, MSSA bacteremia and UTI, present on admission .Cefazoline through 05/24/23 .Antimicrobials: Cefazolin 2g IV Q8 (every 8 hours) .42 day (04/13/23 to 05/24/23) . In a Resident Group meeting on 05/10/23 at 11:13 AM, three of the residents stated Resident #210 had one of those contact isolation things on his door and he went outside to smoke at the same time they did and was afraid they may get sick. They stated reporting their concern to the Administrator and nurses who spoke to Resident #210, but he did not comply because he still went outside when they did at times. The resident stated they were not sure why Resident #210 was not discharged for not listening to the Administrator and nurses. Interview on 05/10/23 at 2:52 pm, Resident #56 stated he had an infection in his urine, a bladder infection and the nurses told him he had to quarantine in his room until the infection went away. He stated he was told he would have to take antibiotics for about a month and was not sure how long he had been quarantined. He stated all the nurses including the CNAs did not wear gowns and gloves when entering his room or when providing him care and some of the staff wore only gloves at times. Interview on 05/10/23 at 8:54 am, LVN B stated Resident #56 had an ESBL infection in his urine for a week and half and was currently on contact isolation and considered infectious right now until they did a Urinalysis and received his lab results to determine if he still had the infection. She stated before the staff entered Resident #56's room they were to put on a gown and gloves, but a mask was optional. She stated Resident #56 was incontinent and not sure if a mask was required during that time and was not sure of what their policy said about mask wearing for contact isolation. She stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675754 If continuation sheet Page 8 of 11 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 675754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Traymore Nursing Center 4315 Hopkins Ave Dallas, TX 75209 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 - Some this morning when she received Resident #56's meal tray, CNA A should have had on a gown, but she did not and was not sure why. She stated a PPE gown and gloves should be put on prior to entering a contact isolation room to protect the staff and residents. She stated If staff were not wearing the appropriate PPE the staff could harm themselves and spread the infection to other residents and stated Resident #56's EBSL infection was anti-resistant to many antibiotics, and he was being treated with an IV anti-medication imipenem- cilastatin. Interview on 05/10/23 at 9:13 am, the DON stated she was the Infection Preventionist, and the facility had two residents on contact isolation Residents #56 and #210, she stated Resident #56 had ESBL in his urine since 04/14/23 and was on a 30-day IV Antibiotic treatment plan and Resident #210 had MRSA in his urine since he admitted [DATE] and he was on a 33 day IV Antibiotic treatment plan. She stated the staff were good about putting on their PPE prior to entering the resident's contact isolation room, to protect the staff and residents and to minimize the risk of exposure to infections. She stated they had to constantly do infection control trainings with the staff and the last one was yesterday 05/09/23. She stated for contact isolation, the staff were to put on PPE before they entered Resident #56's room and added there was postings on his front and back door with the instructions on how to don and doff. She stated for contact isolation the staff should have a gown and gloves on but did not have to have the mask or face shield on even during his incontinent care it was optional if they wanted to wear a mask of not. She stated the facility's policy did not specify mask usage for contact precautions. and stated Resident #56's was non-complaint at times and kept his room door open. She stated Resident #56's cognitive status was very intact, and he understood the risks involved with spreading ESBL. She stated Resident #210 cognition was intact also, but he tried to find other residents to give him cigarettes and went outside to smoke and they educated him about the risk of infecting others with MRSA but Resident #210 did want he wanted to do and required a lot of re-direction. She stated she was not aware of any of the staff going into Resident #56 room without the proper PPE until the HHSC State Surveyor brought it to her attention about CNA A going into Resident #56's room today (05/10/23). She stated CNA A had not worked at this facility for a year and would educate her with return demonstration on the facility's infection control policy today 05/10/23. She stated ultimately, she was responsible for ensuring the staff properly put on PPE and for the staff to look out for each other and stop staff if they did not have on appropriate PPE. She stated her expectations for infection control was for the staff to be acknowledged and to maintain infection control compliance and for the staff to be trained weekly and as needed. Interview on 05/11/23 at 12:48 pm, CNA A stated on 05/10/23 the Staffing Educator LVN did a 1:1 training, about her not putting on proper PPE in Resident #56's room and said she was trained on wearing PPE, handwashing/sanitizing, contact precaution training. She stated once a resident was put on contact isolation. Interview on 05/11/23 at 1:24 pm, the DON said she stated she spoke to CNA A and asked her what happened yesterday, 05/10/23, why did she not remember to put on a gown and gloves prior to going into Resident #56's room. She stated CNA A responded she went into Resident #56's room because she did not have a chance to put the gown on because she saw a bug and got startled. She stated she told CNA A she should have put on PPE (gown and gloves) prior to entering Resident #56's room and the CNA A agreed. She stated Staff Development LVN trained CNA A and had her sign a 1:1 training form on infection control and complete a skills check to verify she knew what she was to do. She stated if CNA A continued to have problems following their infection control issues, disciplinary actions and termination would occur. Interview on 05/11/23 at 2:44 pm, Staff Development LVN stated on 05/10/23 she did a 1:1 Inservice (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675754 If continuation sheet Page 9 of 11 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 675754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Traymore Nursing Center 4315 Hopkins Ave Dallas, TX 75209 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 - Some with CNA A on infection control, donning and doffing, hand hygiene and skills checkoffs, because on 05/10/23 CNA A did not wear proper PPE when she went into Resident #56's room who was on contact isolation. She stated on 05/09/23 she conducted an infection control training with all staff including the nursing department and stated she knew when a resident was on contact isolation, she saw the Contact Isolation signs and PPE station on the resident's door and stated there was no communication forms or notices formally given to them about residents placed on contact isolation. She stated everyone was properly trained on infection control, but she had no tracking system to determine who was trained but kept a binder with skills checks. She stated Resident #56's ESBL bacterial infection in his urine was infectious and other residents could get infected which could result in them getting a fever, altered mental status, urinary tract infection, having a bizarre behavior or becoming septic. She stated the Infection Preventionist was the DON and ultimately responsible for ensuring all staff properly practiced appropriate infection control measures. She stated she talked to CNA A and was not sure why she went into Resident #56's room without proper PPE because the steps on how to wear PPE was on Resident #56's door if staff forgot. She stated CNA A said she had the gown in her hand when she went into Resident #56's room and was not sure why she did not put the PPE on before getting his meal tray. Interview on 05/11/23 at 3:13 pm, the DON stated all the staff were trained on infection control and was not sure why CNA A had not completed the Infection Control module in the facility's electronic training program. She stated when a resident was placed on contact isolation it was discussed in the morning meeting and clinical meetings after the standup meeting. She stated Resident #56 was ordered to take antibiotics until 05/24/22 because of his ESBL diagnoses and Resident #219 had MRSA which was a staph infection. Interview on 05/11/23 at 4:18 pm, the Administrator stated not being aware of any issues with communicating among the department heads once a resident was placed on contact isolation. He stated they did not use a communication form, but the department heads communicated by phone, standup meetings, and email encrypted messaging. He stated the administrative team communicated first in the standup meeting about any residents on contact isolation and for the department heads to notify their staff. He stated infection control trainings was an ongoing process of continuing education to ensure staff were properly donning and doffing and hand washing. He stated being told yesterday (05/10/23) CNA A did not properly don PPE before entering Resident #56's room and afterwards she had a 1:1 face to face infection control training and said would continue to monitor her for infection control compliance. He stated if CNA A did not continue to follow their infection control policy, she would be disciplined which could lead to termination. He stated the reason it was so important for the staff to wear PPE was to prevent cross contamination and the spread of contaminants from going from a resident with an infection to the other residents. He stated the nurses and two ADON's were responsible for ensuring the staff followed their infection control policy but ultimately the DON was responsible for it. He stated his expectations for infection control and PPE usage was for the staff to properly use it. He stated not all the staff needed to know the resident's diagnosis. He stated the facility's Medical Director was aware of the recent infection control issues brought to his attention yesterday (05/09/23) and would further discuss ways to address them in their QA meetings. He stated when it came to communication there was always room for improvement. He stated Resident #210 was on contact isolation precautions for MRSA and at times tried to go out with the other residents who smoked, despite having his own smoke times and added they did their best to redirect him to wait for his time to smoke. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675754 If continuation sheet Page 10 of 11 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 675754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Traymore Nursing Center 4315 Hopkins Ave Dallas, TX 75209 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 Record review the facility's Staff Roster revealed CNA A was hired 11/20/22. Level of Harm - Minimal harm or potential for actual harm Record Review of CNA A training transcript dated 05/11/23 did not reveal she had the facility's Electronic Training Infection control training since she was hired 11/20/23. Residents Affected - Some Record review of CNA A's 1:1 Inservice training dated 05/10/23 revealed, Donning/Doffing, PPE, Hand Hygiene with in-service and return demonstration was sign completed and signed by Staff Development LVN. Record review of CNA A facility's skills Checkoff sheet dated 05/10/23 revealed, PPE, Hand Hygiene Competency Validation - Return Demonstration was signed by CNA A and Staff Development LVN. Record review of Healthline ESBLs (Extended Spectrum Beta-Lactamases) updated April 14, 2017, revealed, Extended spectrum beta-lactamases (or ESBLs for short) are a type of enzyme or chemical produced by some bacteria. ESBL enzymes cause some antibiotics not to work for treating bacterial infections. Common antibiotics, such as cephalosporin and penicillin, are often used to treat bacterial infections. With ESBL infections, these antibiotics can become useless .Bacteria use ESBLs to become resistant to antibiotics .E. coli and Klebsiella infections can usually be treated with normal antibiotics like penicillin and cephalosporin. But when these bacteria produce ESBLs, they can cause infections that can no longer be treated by these antibiotics. In these cases, your doctor will find another treatment to stop the new infection that's become resistant to antibiotics .Certain infections that can also develop resistance to antibiotics can increase your risk of getting a bacterial infection with ESBLs, such as MRSA (a staph infection) .You can spread an ESBL infection simply by touching someone or leaving bacteria on a surface that someone else touches. This can include shaking hands, breathing on someone, handling an object that is then handled by someone else .Bacteria with ESBLs are especially common in hospitals. They are spread most easily by doctors, nurses, or other healthcare professionals who touch people, objects, or surfaces in facilities where the bacteria live . https://www.healthline.com/health/esbl Record review of the facility's Infection Control Policy undated revealed, Maintain an organize, effective facility wide program designed to systematically identify and reduce risk of acquiring and transmitting infections among residents, visitors and healthcare workers .Healthcare Workers and Resident/Family Education: Infection prevention and control provides education, based on surveillance findings .Policies and procedures: Contact Precautions: appropriate use of PPE . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675754 If continuation sheet Page 11 of 11