Health inspection·July 22, 2025

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete interview with the DON on 07/22/2025 at 2:15 PM, she stated she became aware of the call light concern on 07/21/2025 by a CNA. The DON stated that unless care planned otherwise, call lights were to always be within reach, whether the resident was in or out of bed. She confirmed staff were expected to round hourly and ensure the call light was within reach. She acknowledged that not having access to a call light was a safety issue and could prevent a resident from calling for help if they did fall. Record review of the facility's undated call light policy stated in Procedure #9: The call light must always be within resident's reach before you leave the room. 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 07/22/2025 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refer all Level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for a Level II resident review for one (Resident #9) of four residents reviewed for PASRR services.The facility failed to identify a discrepancy between a negative PASRR Level I evaluation and the resident's mental disorder diagnosis during admission. Due to this failure, the facility did not refer Resident #9 for a Level II PASRR Evaluation. This failure could place residents at risk of not receiving necessary care and services to attain or maintain their highest practicable physical, mental and psychosocial well-being. Findings included: Review of Resident #9's Face sheet, dated 07/22/2025, reflected she was a [AGE] year old female, who was admitted to the facility on [DATE], with diagnoses including respiratory failure unspecified with hypercapnia (a condition where the respiratory system cannot adequately remove carbon dioxide), essential hypertension (high blood pressure), Type 2 diabetes mellitus without complications (a condition where the body does not use insulin properly), chronic kidney disease, stage 4 (severely reduced kidney function), schizoaffective disorder, unspecified (symptoms of both schizophrenia and mood disorder) and muscle weakness (less strength or muscle control). Resident #9 did not have a dementia diagnosis. Review of Resident #9's MDS Assessment, dated 06/17/2025, reflected she had a documented diagnosis of Schizophrenia, and was prescribed an antipsychotic medication . Review of Resident #9's PASRR Level I Screening, dated 07/18/2024, reflected she did not have a mental illness, intellectual disability or developmental disability (negative). Review of Resident #9's electronic medical record reflected no evidence that any additional PASRR Level II Screenings or evaluations had been completed since the initial PASRR Level I Screening was conducted on 07/18/2024. Review of Resident #9's Comprehensive Care Plan, dated 06/08/2025, reflected she had a Schizoaffective Disorder focus: The resident has a communication problem r/t Schizoaffective Disorder.Goal: The resident will be able to make basic needs known on a daily basis through review date. Interventions included: Anticipate and meet needs. Be conscious of resident position when in groups, activities, dining room to promote proper communication with others. Encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense or responds to the feeling resident is trying to express.During an interview with the MDS Coordinator on 07/21/2025 at 4:30 PM, the MDS coordinator stated that based on Resident #9's diagnosis of schizoaffective disorder, the resident's Level I PASRR was incorrectly marked negative, and she should have a Level II PASRR evaluation. When asked who was responsible for identifying a discrepancy between the negative Level I PASRR and the resident's diagnosis, the MDS coordinator stated it was the responsibility of the MDS coordinator. The MDS coordinator stated she was the corporate MDS nurse and had covered this facility since May 2025. She stated there had been a lot of employee turnover in the MDS office and lack of continuity. The MDS coordinator stated she completed a form 1012 on 07/21/2025 for Resident #9. (A form 1012 is a Mental Illness/Dementia Resident Review form, used by facilities to determine whether to submit a new positive PASRR Level I screening form on the Long Term Care Portal because further evaluation is needed.) The MDS Coordinator identified the risk for the resident is that they may need mental health services and not get them. Record review of the facility's PASRR policy (not dated) stated the following: If during a resident's stay they receive a new diagnosis from their physician that could be considered a positive PASRR for MI, ID, or DD , the facility will complete a form 1012 and follow through to see if a physical or mental evaluation is needed. If the PE determines that the resident's negative PASRR for MI, ID, or DD is (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 07/22/2025 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 0644 positive then the record will reflect a positive PASRR for MI, ID, or DD. 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: 675754 If continuation sheet Page 4 of 4