Health inspection·January 24, 2024

F 0677 Record review of Resident #1's point-of-care in EHR reflected the resident received oral care twice daily from 01/12/24-01/19/24 , once during the evening on 01/20/24, and once during the afternoon on 01/21/24. Level of Harm - Actual harm Residents Affected - Few Record review of a nursing note by LVN D, dated 01/21/24 at 05:30 AM, reflected the following: Resident [Resident #1] observed with wet sounding nonproductive at this time while checking AM BS. Temp 97.3F spo2@ 95% on room air resp 20. Paged [MD B] at this time awaiting callback. Oncoming nurse to follow up. Record review of a nursing note by RN C, dated 01/21/24 at 08:35 AM, reflected the following: Received new order from [MD B] for chest x-ray. Order placed in. RP left a voice message. Record review of a nursing note by RN C, dated 01/21/24 at 03:36 PM, reflected the following: Chest x-ray results with significant findings reviewed by [MD B] and received new order to start on Doxycycline Hyclate Tablet 100 MG Give 1 tablet via G-Tube two times a day for Pneumonia for 7 Days. Order placed in [sic] RP made aware. VA nurse left a voice msg regarding chest x-ray order, results, and new order. Record review of a nursing note by RN C, dated 01/21/24 at 06:19 PM, reflected the following: VA nurse notified via voice message of change of condition and transfer out to ER. Record review of photo from Resident #1's hospital record reflected particles removed from the resident's throat. There were three particles, each approximately 0.5-1.0 inch long, translucent light brown color, thick edges, with a ridged and flaky texture. One of the particles was rolled up. Observation on 01/23/24 at 10:45 AM, Resident #1 was observed at the local hospital. Resident #1 was lying on his back with an oxygen mask on. Resident #1's mouth remained open as he was breathing through it, and his lips were dry. Resident #1 was unable to be interviewed due to cognition and health status. In an interview on 01/23/24 at 10:48 AM, Resident #1's RP revealed the resident was admitted to the nursing facility on 01/11/24 after discharging from a local hospital where he was being treated for a stroke. The RP stated Resident #1 was unable to fully communicate needs. However, she was able to understand most of what he tried to say. The RP stated Resident #1 could say simple phrases such as Hi or How are you but was unable to ask for specific things such as food items. She stated Resident #1 was normally very calm but would sometimes become agitated and aggressive toward the staff at the nursing facility. The RP stated she visited Resident #1 on 01/20/24 and noticed that he had a cough and indicated to her that he wanted water, but she reminded him that he could not drink anything by mouth. She stated she did not think much of it and did not report it to anyone. The RP stated the following day on 01/21/24, the charge nurse called and told her Resident #1 was making a gurgling noise and that she should come to the nursing facility. The RP stated when she arrived, Resident #1 was very agitated, but she was able to calm him down. She stated she left the nursing facility briefly then returned at approximately 5:00 PM and found Resident #1's breathing had gotten worse, and he was in distress. The RP stated she was informed by RN C that Resident #1's x-ray results showed pneumonia and MD B had ordered for him to start on antibiotics. The RP stated RN C informed her that Resident #1 had not started on the antibiotics yet because she was waiting until 08:00 PM so the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675754 If continuation sheet Page 2 of 5 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 01/24/2024 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 0677 Level of Harm - Actual harm Residents Affected - Few administration times could be scheduled for 08:00 AM and 8:00 PM. The RP stated she and RN C went back and forth about whether to send Resident #1 out to the local hospital before she made the final decision to have him sent out. The RP stated when Resident #1 arrived at the ER, the ER doctor removed particles from Resident #1's throat that he stated looked like chips. The RP stated Resident #1 would not have been able to feed himself and should not have had access to any food. The RP stated Resident #1 had a roommate at the nursing facility, but the roommate had an amputated leg. She stated the roommate was unable to get out of bed without staff's assistance to her knowledge. She stated when Resident #1 first admitted to the nursing facility, the admitting nurse expressed concerns that the CNAs would not follow directions regarding the G-tube. The RP stated she was concerned that a staff member may have accidentally given Resident #1 chips to eat. She stated she had also noticed when visiting Resident #1 at the nursing facility his mouth would be extremely dry, and he would have dry skin flaking off his tongue. However, the flakes she saw did not look like the particles pulled from Resident #1's throat in the ER . In an interview on 01/23/24 at 10:57 AM, MD A stated she was Resident #1's attending physician at the local hospital. MD A stated she did not see Resident #1 in the ER, but based on the notes, he presented to the ER with SOB and required oxygen. MD A stated she was able to see a picture of the particles pulled from his throat in the charts and a computed tomography (CT) scan that showed an image of solid substances midway in Resident #1's throat, obstructing his airway, and aspiration in his lungs. MD A stated she could not determine if the particles in the picture or the solid substances on the computed tomography (CT) scan was food or dry skin; however, she stated that it was not secretions . In an interview on 01/23/24 at 04:10 PM, LVN E stated she worked at the facility since 09/2023, on the morning shift. She stated she worked with Resident #1 when he was admitted to the facility. She stated Resident #1 admitted with a G-tube and was totally NPO. LVN E stated Resident #1's family reported that he had swallowing and aspiration problems after recently having a stroke. LVN E stated she did not have concerns that the facility would not be able to properly care for Resident #1's G-tube. LVN E stated it was the nurses' responsibility to provide all care needs regarding G-tubes, and the nurses would ensure the CNAs knew which residents were NPO. LVN E stated residents who had an NPO status would wear white bracelets and have a NPO sign hung in the room . LVN E stated she only worked with Resident #1 one time, the day he admitted to the nursing facility, and did not see any dry skin flakes in or around his mouth. In an interview on 01/23/24 at 04:10 PM, RN C stated she worked at the facility for 3 years, on the morning shift. RN C stated she worked with Resident #1 during the week he was at the facility. She stated Resident #1 was aggressive towards staff and often refused care. RN C stated Resident #1 had NPO status and did not receive anything by mouth. She stated Resident #1 was not able to communicate clearly, could not express needs, or ask for food. She stated she worked with Resident #1 on 01/17/24 and 01/18/24, then again on 01/21/24 when he was sent out to the ER. RN C stated Resident #1 was fine on 01/17/24 and 01/18/24, and was not coughing, gurgling, or having a hard time breathing. However, she stated he always breathed through his mouth. RN C stated the mouth breathing caused Resident #1 to have a severe dry mouth and she would have to pick dry skin out of his mouth and off his lips. RN C stated she also used mouth swabs to keep his mouth as moist as possible on each of her shifts when Resident #1 would allow it. She stated she could not recall seeing dry skin inside of Resident #1's mouth on the day he went out to the local hospital; however, he often had dry skin in and around his mouth. RN C stated only nurses were allowed to feed Resident #1 via G-tube and provide all care regarding his G-tube. RN C stated the CNAs were aware that Resident #1 was NPO status because the nurses had to orient them to all residents. She stated the CNAs also knew to look in the chart to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675754 If continuation sheet Page 3 of 5 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 01/24/2024 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 0677 Level of Harm - Actual harm Residents Affected - Few gather additional information about residents. RN C stated the NP was at the nursing facility on 01/17/24 and she assessed Resident #1. RN C stated the NP stated Resident #1 was a good candidate for hospice. RN C also stated the NP noticed how Resident #1 breathed through his mouth and noticed the dry skin inside of his mouth. RN C stated when she returned to work on 01/21/24, she noticed Resident #1 had a cackling sound in his chest. She stated LVN D informed her that she noticed it to and had already paged MD B. RN C stated she spoke with MD B at approximately 08:00 AM and received an order for Resident #1 to have a chest x-ray. She stated the x-ray technician arrived at the nursing facility by 09:00 AM and she received the results around 02:00 PM that showed Resident #1 had pneumonia. RN C stated MD B ordered for Resident #1 to start on antibiotics. RN C stated Resident #1's condition continued to get worse, and she and the RP decided he should be sent out to the local hospital . In an interview on 01/23/24 at 04:25 PM, the DON stated Resident #1 was a new resident and had only been at the nursing facility for about a week before being sent out to the hospital. The DON stated Resident #1 was admitted to the nursing facility from a local hospital and admitted with a G-tube already placed. The DON stated Resident #1 had a decline in health on 01/21/24 due to auditory gurgling. She stated he was sent out to the local hospital after a chest x-ray revealed lung infiltration. The DON stated Resident #1 had a NPO order and she was confident that all staff knew he was NPO. She stated, it was noted in his orders, care profile, and he had a sign above his bed to alert everyone. The DON stated Resident #1's family came to retrieve his items from the nursing facility and reported the ER found chips in his throat. The DON stated chips were not available as a normal snack so staff would not have had them to provide to the residents . In an interview on 01/24/24 at 12:15 PM, the NP stated she last saw Resident #1 on 01/18/24. She stated she did not recall seeing large flakes of dry skin in his mouth. However, she did recall that Resident #1's mouth was always open, and he was a mouth breather. The NP stated the staff knew that Resident #1 was NPO as it was documented in his orders. The NP stated she did not think staff fed Resident #1 food. She stated with Resident #1 breathing though his mouth, it was possible for dry skin to form and flake off in his mouth. The NP stated it was standard for all residents who were NPO to have an order in place for oral care to help reduce the risk of dry mouth. She stated the ADONs were able to put in standard orders such as oral care, then she or the MD would later sign off . The NP stated Resident #1 should have had a standard order in place for oral care. In an interview on 01/24/24 at 12:40 PM, LVN F stated she worked at the facility for over a year on the morning shift. She stated she did not work with Resident #1. However, she did work with other residents who had G-tube's and were NPO. LVN F stated residents who were NPO wore white wrist bands and had signs above their bed to alert all the staff. She stated it was the nurses' responsibility to ensure that CNAs knew how to care for all residents, especially those who were NPO. LVN F stated residents who were NPO had orders in place for oral care. She stated only nurses could provide their oral care, so that the amount of water could be monitored, and completion of the task was documented in the EHR. LVN F stated if she found that a resident who was NPO did not have an order for oral care in place, she would notify the MD to get one. LVN F stated the importance of oral care for residents who were NPO was to keep their mouth moist, prevent infections, and breakdown in the mouth . In an interview on 01/24/24 at 12:48 PM, LVN D stated she worked at the facility for over a year on the overnight shift. LVN D stated she worked with Resident #1 the last two nights before he went out to the hospital. She stated the first night Resident #1 did not have gurgling noises or trouble breathing. She stated she returned to work on the night of 01/20/24 and noticed the gurgling noises, the morning of 01/21/24, when she checked on Resident #1 before her shift ended. She stated she called the MD to notify her and had to leave a message. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675754 If continuation sheet Page 4 of 5 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 01/24/2024 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 0677 Level of Harm - Actual harm LVN D stated she reported this to RN C. LVN D stated oral care was a part of all residents' ADL care and they did not need an order to provide it. She stated she provided oral care to Resident #1 each time she flushed his tube, and it consisted of her swabbing his mouth to moisten it . LVN D stated she checked Resident #1's mouth during oral care and did not see any dry skin flakes in or around his mouth. Residents Affected - Few In an interview on 01/24/24 at 01:30 PM, the DON stated oral care was a part of the residents' routine ADL care and their policy did not state there had to be an order in place unless it was for special circumstances. The DON stated nurses and CNAs were able to provide oral care to all residents, including residents who had a NPO order. The DON stated oral care was documented under POC in the EHR. The DON stated she had not seen any dry skin flakes in Resident #1's mouth and it had not been reported to her. However, the DON stated in her experience she had seen other residents with severe dry mouth develop thick dry skin flakes in their mouth. The DON stated the risk of a resident with dry mouth not receiving proper oral care could be developing the thick dry skin in the mouth that could be swallowed . In an interview on 01/24/24 at 01:56 PM, MD B stated she was the attending physician at the nursing facility. She stated oral care was a part of regular ADL care and the residents did not need to have an order for it, even residents who were NPO, unless it was a special circumstance. MD B stated Resident #1 did breathe through his mouth, which increased the risk of severe dry mouth that could cause dry skin to peel in his mouth. However, she did not feel this warranted a special order for oral care. She stated oral care could be provided as often as needed based on the caregiver's discretion to keep mouth clean and moistened. MD B stated she was aware that Resident #1 was sent out to the local hospital with aspiration pneumonia. MD B stated hindsight shows were there could be room for improvement . Review of the facility's policy titled Oral Hygiene, undated, revealed in part the following: Purpose: To cleanse the mouth and teeth to prevent infection and irritation, to moisten mucous membranes, to promote health of the oral cavity. . Procedure: . 8. Assist resident with a glass of water and emesis basin to rinse mouth. a. If resident is NPO (nothing by mouth, or thickened liquids) use lemon glycerin swabs or pink toothettes. 9. Inspect mouth and gums for irritation or open areas and notify the charge nurse if any problems are observed. Documentation: Document oral care on the nurse aide flow record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675754 If continuation sheet Page 5 of 5