Health inspection·June 20, 2024

F 0638 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 6/20/24 at 10:10 AM, MDS LVN A stated she had not yet completed Resident #31's quarterly MDS assessment. She stated she moved the date out in order to capture rehabilitation minutes and needed to clarify the minutes before she could enter the data. When asked about Resident #84's assessment, MDS LVN A stated she had completed her assessment on 6/19/24 and was waiting for a signature. She stated she had missed getting Resident #84's quarterly assessment completed on time. MDS LVN A stated the risk of late or missed assessments was it could affect the residents plan of care, continuity of care, and affect reimbursement. During an interview on 6/20/24 at 10:30 AM, the DON stated she was responsible for signing the MDS assessments upon completion and had noticed some were late on occasion. She stated the risks for late assessments included delays in communication among staff related to assessment components such as ADLs. She stated they risked not getting the most up-to-date information needed during their IDT meetings and it could also affect their reimbursement. During an interview on 6/20/24 at 10:43 AM, the Administrator stated his MDS team was responsible for ensuring the assessments were completed and transmitted on time. He stated he had just been made aware some were late, and they were working to resolve the matter. He stated risks for late assessments included the resident's information may not be updated timely and they could miss a change in condition. He stated the facility's reimbursement could be impacted as well. Record review of the facility's undated policy and procedure titled Resident Assessment, identified as current by the Administrator, reflected the following: It is the policy of this facility to conduct and document, initially and periodically, a comprehensive, accurate, standardized, reproducible assessment of a resident's functional capacity on all residents admitted to the facility. The facility will electronically transmit to CMS resident-entry-and -death-in-facility tracking records required by the RAI; and OBRA assessments, including admission, annual, quarterly, significant change, significant correction, and discharge assessments. This will provide the facility with the information necessary to develop a care plan and to provide appropriate care and services for each resident . Frequency of Clinical Assessments . Quarterly review assessments will be completed not less frequently than once every three months using the quarterly review instrument specified by HHSC and approved by CMS . Automated Data Processing: The facility will complete an MDS for each resident. The facility will encode the MDS data into the facility's assessment software within 7 days after completing the MDS and electronically transmit the encoded, accurate, and complete MDS data to CMS within 14 days after completing the MDS FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675754 If continuation sheet Page 2 of 4 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 06/20/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to 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 disease and infection for 1 of 5 residents (Resident #9) reviewed for infection control. Residents Affected - Few CNA D did not change her gloves or wash her hands while providing incontinent care for Resident #9. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #9's face sheet, dated 06/20/2024, revealed an [AGE] year-old female with an admission date of 03/04/2016 with diagnoses which included: lack of coordination, contracture to the right hand, cognitive communication deficit, reduced mobility, anxiety, dementia, and muscle wasting and atrophy. Record review of Resident #9's Annual MDS assessment, dated 02/14/2024, revealed Resident #9 had a BIMS score of 8, which indicated moderate cognitive impairment. Resident #9 was indicated to always being incontinent of bowel and bladder. Review of Resident #9's care plan, initiated 01/02/2019, revealed a focus of, Resident requires assist with ADLs due to weakness, right hemiplegia (one-sided paralysis or weakness), intervention, Provide 1 staff member to complete dressing, peri-care, bed mobility, re-positioning, personal hygiene, and bathing needs. Observation on 06/19/2024 at 09:43 AM revealed CNA D provided incontinent care to Resident #9. Resident #9 was in bed. CNA D informed the resident she was going to provide her with incontinent care and gathered the supplies. CNA D completed hand hygiene put on gloves and then started incontinent care. CNA D cleaned the resident with wipes, the resident was soiled with urine. After cleaning the resident, CNA D did not complete any form of hand hygiene or change gloves. She proceeded to apply the barrier cream and then applied the clean brief. After fastening the brief, CNA D then changed her gloves without any form of hand hygiene and proceeded to dress the resident. Interview on 06/19/2024 at 02:35 PM with CNA D revealed she had been in the facility for about 1 month. She stated she had worked in the facility for a short period, and she had been checked off by the lead aide on incontinent care. CNA D stated she was not aware she was supposed to change gloves or complete hand hygiene after cleaning the resident. CNA D stated she had been in-serviced on hand hygiene and infection control. CNA D stated she was supposed to complete hand hygiene and change gloves to maintain infection control. Interview on 06/20/2024 at 12:51 PM with the DON, she stated while providing incontinent care the staff was to maintain infection control. The DON stated the staff was supposed to complete hand hygiene, after cleaning the resident and before touching the clean brief. She stated infection control and hand hygiene in-service was completed with the staff and incontinent care proficiency was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675754 If continuation sheet Page 3 of 4 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 06/20/2024 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 0880 completed by the staff. Level of Harm - Minimal harm or potential for actual harm Review of the incontinent care procedure and proficiency evaluation dated 05/22/2024 reflected CNA D completed the skills check off with a female resident and competency demonstrated. It indicated, . 8. Remove old brief, rolling resident to side, check for any stool. If there no stool, remove gloves and hand sanitize. 9. Apply gloves and place clean barrier (clean towel) under resident. Residents Affected - Few Review of the facility policy undated and titled Hand Washing reflected, . Hand washing is required before and after a procedure that involves direct or indirect contact with a resident, after with any waste or contaminated materials, before handling any food, . or any time the hands are soiled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675754 If continuation sheet Page 4 of 4