Health inspection·August 23, 2024

F 0755 Hour 28 mg one capsule by mouth at bedtime. Level of Harm - Minimal harm or potential for actual harm -A revised order dated 7/17/24 reflected Memantine HCL 10 mg tablet 1 tablet by mouth twice daily for cognitive function-order source: Pharmacy. Residents Affected - Few -Order dated 7/19/24 for Memantine HCL ER Oral capsule Extended Release 24 Hour 28 mg one capsule by mouth two times a day for dementia. -Order dated 7/17/24 Carbidopa-Levodopa ER (used to treat Parkinson's disease) Oral Capsule Extended Release 48.75-195 mg Give three capsules by mouth four times daily-shown as discontinued 7/17/24. Order dated 7/18/24 for Carbidopa-Levodopa ER (used to treat Parkinson's disease) Oral Capsule Extended Release 48.75-195 mg Give three capsules by mouth four times daily. Record review of Resident #1's MAR dated 7/1/24 through 7/31/24 reflected the following entries: Memantine HCL 10 mg tablet give one tablet by mouth two times a day for cognitive function. Order start date 7/18/24. The medication was signed as administered on 7/18/24 at 9 AM and 6 PM and on 7/18/24 at 9 AM . Memantine HCL ER Oral Capsule Extended Release 24 hour 28 mg Give one capsule by mouth two times a day for dementia. Order start date 7/19/24. The medication was signed as administered on the following dates and times: 7/19/24: 5 PM 7/20/24: 9 AM and 5 PM 7/21/24: 9 AM and 5 PM 7/22/24: 9 AM and 5 PM 7/23/24: 9 AM and 5 PM 7/24/24: 9 AM and 5 PM 7/25/24: 9 AM and 5 PM 7/26/24: 9 AM and 5 PM 7/27/24: 9 AM and 5 PM 7/28/24: 9 AM and 5 PM 7/29/24: 9 AM and 5 PM Carbidopa-Levodopa ER Oral capsule Extended Release 48.75-195 MG Give 3 capsules by mouth four times a day for Parkinson Disease. Start date 7/17/24. No doses were signed as administered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675754 If continuation sheet Page 2 of 6 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 08/23/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few PENDING CONFIRMATION Carbidopa-Levodopa ER 50-200 MG Tablet extended release. Take 3 tablets by mouth four times daily. Order start date 7/17/24. No doses were signed as administered. Rytary (Carbidopa-Levodopa) Oral Capsule Extended Release 48.75-195 MG Give 3 capsule by mouth four times a day for Parkinson's Disease. The doses were signed as administered on 7/18/24 at 4 PM and 8 PM then four times daily from 7/19/24 at 7:00 AM through 7/30/24 at 7 PM. The doses were signed as administered on 7/31/24 at 7 AM, 11 AM and 3 PM. [Resident #1 discharged home on 7/31/24.] During an interview on 8/22/24 at 4:52 PM, the ADON stated Resident #1 was admitted for respite care on 7/17/24 and came with his bottles of medications. She stated she placed the orders in the computer and selected inventory on hand to indicate they already had the medications available. She stated the orders were based on what Resident #1 was taking at home. She stated, when that occurred, she typically did not get medications delivered or received a call from the pharmacy for any clarifications they needed. The ADON stated, the next day she noticed some of the medications had been changed to pending confirmation status in the computer including his Carbidopa-Levodopa. She stated she had also noticed the pharmacy had changed his Memantine order from 28 MG extended release once a day to 10 MG twice a day and sent the medications. She stated he had already received some of those doses. She stated she changed his Memantine order back to his original daily dose strength, but she had forgotten to change it back to once a day and left it as twice a day in error. The ADON stated she thought Resident #1 had arrived with a list of medications and would look for the list. She stated they were not aware of the error with his Memantine until his day of discharge when the family noticed he had fewer doses left than he should have. During an interview on 8/23/24 at 9:30 AM, the Administrator stated there were no current residents receiving respite services in the facility. In an interview on 8/23/24 at 9:50 AM, CNA A stated he typically worked the day shift and remembered Resident #1 very well. He stated he did not notice any changes in his cognition or function throughout his stay. During an interview on 8/23/24 at 10:01 AM, RN B stated she was very familiar with Resident #1 but had not been assigned as his charge nurse during his stay. She stated she did not notice any changes in his cognition or mobility during his stay and had not heard about any issues related to his medications. During an interview on 8/23/24 at 10:09 AM, LVN C stated she frequently care for Resident #1 during his stay. She stated she was unaware of any issues with his medications other than possible missing his Carbidopa-Levodopa on his first day as there were some pharmacy issues. He had also asked for his dose time to be changed so that he received it before breakfast. LVN C stated he did not notice any changes in his strength or cognition while he was there, and he would chat about his previous job while sitting with them. During an interview on 8/23/24 at 11:22 AM, the Medical Director stated she had heard from the DON and been made aware of the dosing issue with Resident #1's Memantine in that it was an extended-release dose and should have been administered only once a day. The Medical Director was unable to recall on what day she was made aware by the DON. She stated they usually gave the lower dose two times a day at the facility, and she had overlooked the transcription error as well. She stated the risk of double dosing a resident was you were not supposed to overdose anyone. The Medical Director stated, for that particular medication, she would not think it would cause significant issues for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675754 If continuation sheet Page 3 of 6 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 08/23/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few timeframe involved. She stated other medications such as anti-anxiety medications would cause more serious issues. She stated she was aware Resident #1 missed 4 doses of his Carbidopa-Levodopa. She stated, having Parkinson's and being on respite care, I really can't say there was too much risk. They usually don't do well if they miss too many doses. They might not feel great and can feel a little tight but not necessarily increased fall risks. She stated she did not believe Resident #1 missing his initial doses at the facility contributed to his falls . The Medical Director stated she had not had any other issues with pharmacy services at the facility and the staff were usually pretty good at letting her know of any concerns. She stated respite residents typically came with their own medications from home. In an interview on 8/23/24 at 12:01 PM, LVN D stated she had cared for Resident #1 during his respite stay at the facility. LVN D denied noting any decline in Resident #1's cognition or strength while he was at the facility. She stated she was not aware of any medication issues on her shifts. In an observation and interview on 8/23/24 at 12:19 PM, Resident #2 was sitting up in his room watching television. He stated he remembered Resident #1 very well and described him as a very nice guy. He stated they often talked about his previous profession, and he would chat with his family as well. Resident #2 stated he remembered him slipping out of bed on a couple of occasions. Resident #2 stated he had never had any issues with his medications while staying at the facility and felt the staff did a good job. In an interview on 8/23/24 at 12:41 PM, the facility's Pharmacy Consultant stated she had been informed about Resident #1's medication issues. She stated she performed the monthly drug regimen reviews for the facility but would not have done one for Resident #1 as he was only there two weeks. She stated the typical dose of Memantine for residents was 10 MG twice a day and she understood he had received two doses of the 28 MG extended-release doses twice a day instead due to a transcription error. The Pharmacy Consultant stated she did not believe there was any real risk to the dose he had received, or it would have been very minimal. The Pharmacy Consultant looked up Resident #1's doses of Carbidopa-Levodopa when asked about missing the 4 doses. She stated there was still minimal to no risk as the medications were long acting and had a half-life on 12-24 hours meaning there would still be medication in his system. She stated the longer a patient was on the medication, the more of it would still be in his system. She did not know how long Resident #1 had been taking the medication. She stated he may have felt some stiffness toward the end of the last dose missed but it would have been doubtful. During an interview on 8/23/24 at 1:08 PM, the ADON stated when orders were entered in the computer, the medication may move to an interchange status and pending confirmation if medications were not readily available and could be dispensed another way once confirmed with the physician. She reviewed the MAR and orders in the electronic medical record. The ADON stated the doses of Carbidopa-Levodopa were missed because when the pharmacy placed the order in pending confirmation status, the dose times on the MAR would not show up for the nurses and medication aides. She stated that should not have occurred because she had placed the status of his medications as on hand which let the pharmacy know the medications were already available. She stated, when she arrived back to the facility on 7/18/24, she noticed the interchange and pending confirmation status and called the pharmacy. She stated she questioned the pharmacy why the medications had been showing an interchange when she clearly marked them as 'on hand. The ADON stated the pharmacy contact looked at the orders and stated they had a new technician who had missed it. She stated she informed the pharmacy she was going to discontinue the interchanges made and reorder the medications the way they were supposed to be ordered. The ADON stated she believed by the time the changes were made in the orders and system, Resident #1 had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675754 If continuation sheet Page 4 of 6 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 08/23/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few missed the 4 doses of his Carbidopa-Levodopa. The ADON stated, as she was making the corrections, she corrected the strength of Resident #1's Memantine but failed to change the doses back to once a day and they remained twice a day. The ADON stated she had been unaware of the error until it came time to discharge Resident #1 from the facility and they were handing over his medications to the family. She stated his family noted the missing medications and questioned it and that was when she realized her mistake. She stated she explained what had happened to Resident #1's family. She assessed Resident #1 and there were no changes noted to his condition. The ADON stated she apologized to Resident #1's family and assured them they would replace his medication stock. She stated the family member did not express any concerns other than getting his medications returned and stated he would take care of Resident #1 and ensure other family were aware. She stated Resident #1's family returned the next day to pick up his medications and told her Resident #1 was doing fine. She stated she had explained everything to the Administrator who had investigated the issue. In an interview on 8/23/24 at 1:51 PM, the Administrator stated he was out of the country when the events involving Resident #1's medication errors were discovered. He stated he had been in contact with the outside Social Worker who had initially set hp his respite stay, had investigated the matter and discussed it with them. He stated he learned there had been errors involving the pharmacy technician communication and transcription of the orders. He stated he had interviewed the ADON about it and the ADON, DON and Medical Director had reviewed the medication errors. The Administrator stated the incident had been added to their QAPI ongoing issues and they had the pharmacy involved to ensure the situation did not occur again. The Administrator stated the risk of medication errors including overdosing and missed medications depended on the resident in terms of the medication, severity, and disease processes involved. During an interview on 8/23/24 at 2:35 PM, the DON stated she had been made aware of the medication errors from her ADON who had explained her transcription errors. She stated she had discussed it with the Medical Director. She learned more about the pharmacy details, where they had missed the on-hand portion of the order when the Administrator initiated the investigation. She stated the risk of medication errors depending on the medications and resident's condition. Missed medications and extra doses could lead to resident harm. Record review of the facility's undated policy titled, Pharmacy Services reflected the following: The facility provides routine and emergency drugs and biologicals to residents under arrangement and/or by contracted services . The facility will provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) to meet the needs of the resident. The pharmaceutical services of this facility was the responsibility and under the direction of the director of nurses and the consultant pharmacist. When pharmacy services are provided by a person or agency outside the facility, the facility assumes responsibility for obtaining services that meet professional standards, principles and timeliness of the service. Arrangements for such services specify this responsibility in writing .Consultation: A licensed pharmacist provides consultation on all aspects of the provision of pharmacy services in the facility. The pharmaceutical services consultant establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. The pharmaceutical services consultant determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. The number of hours spent in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675754 If continuation sheet Page 5 of 6 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 08/23/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm facility by the consulting pharmacist is based on the number of hours determined to be sufficient to meet the needs of the residents. A record of all consultant pharmacist services, consultations, and recommendations for pharmacy procedure is maintained at the facility. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675754 If continuation sheet Page 6 of 6