Inspection·January 5, 2024

F 0655 completed within 48 hours. Level of Harm - Minimal harm or potential for actual harm Record review of facility policy titled Care Plans - Baseline, revised March 2022, reflected in part: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. 1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: Residents Affected - Few a. Initial goals based on admission orders and discussion with the resident/representative; b. Physician orders; c. Dietary orders; d. Therapy services; e. Social services; . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675934 If continuation sheet Page 2 of 13 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 675934 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Dora Nursing and Rehabilitation Center 1960 Bedford Rd Bedford, TX 76021 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 13 residents (Resident #28, Resident #30, and Resident #65) reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #30 ' s tube feeding status was documented in the care plan. 2. The facility failed to ensure Resident #65 ' s wandering and elopement risk was documented in the care plan. 3. The facility failed to ensure Resident #28 ' s PICC (Peripherally Inserted Central Catheter) was documented in care plan. These failures could place residents at risk of not receiving adequate care and not having their physical, mental, and psychosocial needs met. Findings included: 1. Record review of Resident #30 ' s admission record, dated 01/05/24, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included perforation of esophagus, dysphagia, malignant neoplasm of esophagus, and malnutrition. Record review of Resident #30 ' s MDS assessment, dated 11/27/2023, reflected a BIMS score of 14, indicating intact cognition. Section K - swallowing/Nutritional status of the MDS reflected Resident #30 had a feeding tube while a resident. Record review of Resident #30 ' s comprehensive care plan, dated 11/22/2023, did not include Resident #30 ' s feeding tube or interventions. Record review of Resident #30 ' s physician orders, dated 11/22/2023, reflected NPO diet, NPO texture, NPO consistency for g-tube only and physician orders, dated 12/8/2023, reflected Osmolite 1.5, 1 Carton (237ml) 5x daily with H20 flush 60ml before and after each bolus to provide: 1775kcal, 74gm protein, 905ml free H20 and 1505ml total H20. five times a day for Maintain weight and nutrition. Interview on 01/03/24 at 09:27 AM, Resident #30 stated he did not remember when he got to the facility, but it had been about 3-4 weeks. He stated he did not get to eat or drink anything orally. He said he had a feeding tube because when he had surgery something with his esophagus went wrong and he was restricted from receiving water orally. Interview on 01/05/24 at 11:37 AM, LVN B stated Resident #30 could not have water orally because the surgeon had not completed what he was doing and Resident #30 had a follow up appointment scheduled on 01/15/2023. She said Resident #30 had a swallow study done (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675934 If continuation sheet Page 3 of 13 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 675934 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Dora Nursing and Rehabilitation Center 1960 Bedford Rd Bedford, TX 76021 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Record review of Resident # 65 ' s admission record, dated January 5, 2024 revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included unspecified Alzheimer's disease, anemia, hypothyroidism, and unspecified mood disorder. Record review of Resident #65 ' s MDS assessment, dated 10/30/2023, revealed a BIMS of 0, indicating sever cognitive impairment. Further review of the MDS section E - Behavior, revealed wandering occured daily. Record review of Resident #65 ' s Comprehensive care plan did not indicate that resident was an elopement risk and resident needed to be placed on the secure unit. The MDS Coordinator said that it should have been updated before she got onto the unit but since it happened so fast, it looked as if it was missing. He said he will personally update the CarePlan today (1/5/24) to show the need of her being on the secure unit. Observation on 01/05/2024 at 11:00am revealed Resident #65 was seen being redirected back into her room after trying to enter the room of another resident on the secure unit. Resident #65 seemed a bit confused when staff showed her that her room was in a different direction from which she was walking. Resident #65 was observed in her room resting with no complaint or issue to report. 3. Record review of Resident #28 ' s admission record, dated 01/05/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included unspecified organism sepsis (infection in the blood or whole body), type 2 diabetes, unspecified Alzheimer ' s diseases, high blood pressure, other viral pneumonia, muscle wasting and dying multiple sites, unsteady on her feet and lack of coordination. Record review of Resident #28 ' s Physician order summary dated 01/03/2024, reflected Change dressing to PICC site one time a day every 2 day(s) using gauze dressing, order active 01/01/2024. Record Review of Resident #28 MDS dated [DATE], revealed no BIMS score and no functional assessment completed. Record review of Resident #28 ' s Comprehensive care plan did not indicate Resident # 28 had a PICC line and/or required PICC dressing changes. Interview on 01/05/24 at 01:07 PM, the DON stated the MDS Coordinator was responsible to complete the comprehensive care plan and they had 21 days to get the comprehensive going but did not mean it was going to be completed. The DON said NPO and Resident #30 ' s tube feedings should be care planned, and it would be on his meal ticket and on the top of his chart. She stated it should definitely be in his dietary care plan. The DON said if a resident was an elopement risk or wandered it should be in the care plan. She stated Resident #65 had been in the secure unit about 4 weeks, but it was enough time to get that in the care plan. Interview on 01/05/24 at 01:24 PM, the MDS Coordinator stated Resident #30 ' s tube feeding and Resident #65 ' s wandering should be on the care plan. He stated it was important to know what to do to care for the residents. He stated he usually does the comprehensive care plan after he does the MDS, within 14 days. He stated the care plan was completed after the MDS assessment so he would know their CAA ' s (Care Area Assessment). The MDS Coordinator said if a resident was receiving skilled services, he would complete the care plan within 8 to 9 days. He stated they have a clinical meeting every day and he updates acute care plans like falls or skin tears right then. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675934 If continuation sheet Page 4 of 13 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 675934 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Dora Nursing and Rehabilitation Center 1960 Bedford Rd Bedford, TX 76021 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 0656 Level of Harm - Minimal harm or potential for actual harm Interview on 01/05/24 at 02:36 PM, the Administrator stated Resident #30 ' s care plan should include the feeding tube to understand the profile of care. He stated Resident #65 was in the [name] hall when she first admitted , and the family wanted her to move to the secure unit. He stated he thought they just missed updating the care plan to include wandering. The Administrator stated if care plans were not completed staff could miss things and could cause a lot of problems with resident care. Residents Affected - Few Medication observation and interview on 01/03/2024 at 03:23 pm, revealed Resident #28 was not able to answer PICC dressing questions. Resident #28 was in the dining room playing cards, and she had intravenous (IV) medication attached to her right upper arm which revealed a PICC line. The PICC had 3 lumens/ ports/entrances, two of the ports had green caps on and one was attached to an IV tubing infusing medication. The IV medication was hung on an IV pole covered in a white pillowcase. The PICC dressing was dated 12/26/2023. The clear dressing around the PICC was loose and had come off around the edges. A white 2x2 medium sized tape was placed on the right outer side holding the dressing in place. The overlaying band-aid was not dated. The PICC line entry site was not exposed to air. The dressing looked old, and it was coming off around the edges near the arm pit and the upper right side of the arm. The PICC line entry site could not be fully seen because of the white tape overlaying on top of the dressing. RN F said that he did not change the PICC dressing because the last dose of IV medication was completed 01/03/2024. RN F said that he did not look at the PICC dressing change orders to see when it was last changed. He said not changing PICC line dressing places the resident at risk for infection. Record review of facility policy titled Care Plans, Comprehensive Person-Centered, revised March 2022, reflected in part: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical psychosocial and functional needs is developed and implemented for each resident. 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant change in status), and no more than 21 days after admission . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675934 If continuation sheet Page 5 of 13 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 675934 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Dora Nursing and Rehabilitation Center 1960 Bedford Rd Bedford, TX 76021 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders for 1 (Resident #28) of 4 residents reviewed for intravenous fluids Residents Affected - Few The facility failed to ensure Resident #28 received PICC (Peripherally Inserted Central Catheter -PICC line is a soft, flexible catheter inserted into a central vein used for prolonged antibiotic therapy) line dressing changes as ordered every 2 days. This failure places residents at risk of bacterial contamination and risk of infection. Findings included: Record review of Resident #28 ' s admission record, dated 01/05/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included unspecified organism sepsis (infection in the blood or whole body), type 2 diabetes, unspecified Alzheimer ' s diseases, high blood pressure, other viral pneumonia, muscle wasting and dying multiple sites, unsteady on her feet and lack of coordination. Record review of Resident #28 ' s Physician order summary dated 01/03/2024, reflected Change dressing to PICC site one time a day every 2 day(s) using gauze dressing, order active 01/01/2024. Record Review of Resident #28 MDS dated [DATE], revealed no BIMS score and no functional assessment completed. Record review of Resident #28 ' s Comprehensive care plan did not indicate Resident # 28 had a PICC line and no dressing changes. Review of Resident #28 ' s Administration Record dated 01/03/24, revealed dressing change checked on 01/01/24. Medication observation and interview on 01/03/2024 at 03:23 pm, revealed Resident #28 was not able to answer questions about PICC line dressing changes. Resident #28 was in the dining room playing cards, and she had intravenous (IV) medication attached to her right upper arm which revealed a PICC line. The PICC had 3 lumens/ ports/entrances, two of the ports had green caps on and one was attached to an IV tubing infusing medication. The IV medication was hung on an IV pole covered in a white pillowcase. The PICC dressing was dated 12/26/2023. The clear dressing around the PICC was loose and had come off around the edges. A white 2x2 medium sized tape was placed on the right outer side holding the dressing in place. The overlaying band-aid was not dated. The PICC line entry site was not exposed to air. The dressing looked old, and it was coming off around the edges near the arm pit and the upper right side of the arm. The PICC line entry site could not be fully seen because of the white tape overlaying on top of the dressing. RN F said that he did not change the PICC dressing because the last dose of IV medication was completed 01/03/2024. RN F said that he did not look at the PICC dressing change orders to see when it was last changed. He said not changing PICC line dressing places the resident at risk for infection. Interview with LVN B on 01/04/2024 at 02:32 PM revealed that she did not know how to perform PICC (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675934 If continuation sheet Page 6 of 13 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 675934 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Dora Nursing and Rehabilitation Center 1960 Bedford Rd Bedford, TX 76021 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dressing changes as it had been a while since she had done one. LVN B said she would have to look up PICC dressing change. She said a paper in-service was put on her desk to read and sign on PICC line care prior to Resident #28 returning from the hospital. LVN B said that she did an assessment of Resident # 28 upon arrival from the hospital on [DATE], but she did not chart PICC line in the EHR. She said that she was aware that PICC lines required dressing change per order, but she did not change Resident #28s PICC dressing. She said that she thought the dressing changes would be done on the evening shift. LVN B stated that she added some tape to the PICC because Resident #28 was pulling the dressing. She said she used some tape to reinforce the PICC dressing so it would not come off. She said not changing PICC line dressing placed the resident at risk for infection, drainage cannot be seen due to tape blocking clear dressing, and it is not healthy for the skin not to get cleaned. Interview with DON on 01/04/2024 at 10:30 AM, revealed that all nursing staff were in-serviced prior to Resident #28 ' s return from the hospital with a PICC line. She said that she in-serviced nurses on Peripheral Inserted Central Cather (PICC) and Central Venous catheter (CVC) care and management of the line. DON said that nursing staff were in serviced of complications of not caring for PICC properly such as bacterial contamination, sepsis (infection in blood), cellulitis (red blistered swelling), blood clots, hemorrhage, and self-trauma if resident attempts to interfere or remove the line. She said that regular tape could be used to reinforce dressing but should not cover the IV site. She said that it is important to clearly see through the tape, so that site of port into the vein can be accessed for infection, infiltration (swelling) and other PICC complications. Interview with the Administrator on 01/05/2024 at 2:36 PM, revealed his expectation was for staff to follow the policy on changing the dressing. He stated the risk would be infection and cross contamination if not changed. The Administrator stated the DON would be responsible for monitoring staff following the policy. Record review of the facility's policy titled Central venous Catheter care and Dressing Changes, revised March 2022, reflected: The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter infections that are associated with contaminated, loosed [SIC], soiled, or wet dressings . 3.change dressings if it becomes damp, loosened, or visibly soiled and: a. at least every 7 days with TSM dressing; b. at least every 2 days for sterile gauze dressing . c. immediately if the dressing or site appear contaminated . 5. Access central venous access devices with each infusion and at least daily . b. Check expiration dates of the infusion system (solutions, administration set and dressing); . d. Palpate [feel] and inspect the skin, dressing and securement device for signs of complications, including: dislodgement, redness, tenderness, swelling, infiltration, induration [thicker/harder], elevated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675934 If continuation sheet Page 7 of 13 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 675934 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Dora Nursing and Rehabilitation Center 1960 Bedford Rd Bedford, TX 76021 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 0694 body temperature or drainage . Level of Harm - Minimal harm or potential for actual harm .Documentation of date and time dressing was changed . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675934 If continuation sheet Page 8 of 13 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 675934 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Dora Nursing and Rehabilitation Center 1960 Bedford Rd Bedford, TX 76021 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a medication administration error rate below 5% for 2 of 24 (error rate 8.33%) opportunities for errors during medication pass. Residents Affected - Few Facility failed to ensure Intravenous (IV) Medication was administered as ordered for Resident#28. Facility failed to ensure correct medication dose was administered to Resident #48. These failures could place residents at risk for significant medication errors and jeopardize the residents ' health and safety. Findings included: Review of Resident #28 ' s admission record, dated 01/05/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included unspecified organism sepsis (infection in the blood or whole body), type 2 diabetes, unspecified Alzheimer ' s diseases, high blood pressure, other viral pneumonia, muscle wasting and dying multiple sites, unsteady on her feet and lack of coordination. Record review of Resident #28 ' s Physician order summary dated 01/03/2024, reflected antibiotic Meropenem 500 mg/ns 100 ml snap, infuse intravenously 100 ml (500mg) over 30 minutes. Rate 200 ml/hr every 12 hours need stop date 1/3/24. Review of Resident #48 ' s admission record, dated 01/05/2024, revealed a [AGE] year-old male who was admitted to facility on 02/21/23 with diagnoses of brain damage, pneumonia, malnutrition, difficulty swallowing, muscle wasting, kidney failure, anemia, and heart diseases. Record review of Resident #48 ' s Physician order summary dated 01/03/2024, reflected Valproic Acid oral solution 250/5ML, Give 7.5 ML 3 times a day per tube. Give 7.5 ml via G-Tube three times a day for Mood stabilizer. Give 7.5ml per tube 3 times a day. Medication observation and interview on 01/03/2024 at 03:23 pm, revealed Resident #28 was in the dining room playing cards, and she had intravenous (IV) medication attached to her upper right arm via a PICC line. The PICC had 3 lumens/ ports/entrances, two of the ports had green caps on and one was attached to an IV tubing infusing medication. The IV medication was hung on an IV pole covered in a white pillowcase. Medication bag read as Meropenem 500mg/ns 100 ml snap, infuse intravenously 100 ml (500mg) over 30 minutes. Rate ordered 200 ml/hr every 12 hours need stop date 1/3/24. RN F set IV rate to 80 ml/hr. RN F said that he calculated the rate according to the IV bag. Medication observation and interview on 01/03/24 at 01:41 pm, revealed LVN C measured Valproic Acid oral solution 250/5ML for Resident #48. The nurse measured approximately 5.5 ml in a graduated measuring cup. LVN C said she uses the cups to measure liquid medication and sometimes it was hard to see the numbers on it. She said that she used a flashlight at other times. She said that using a medication syringe is the most accurate way to dose liquid medication. She said that under dosing or overdosing a resident can cause adverse effects or can cause the resident not to achieve the desired outcome. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675934 If continuation sheet Page 9 of 13 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 675934 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Dora Nursing and Rehabilitation Center 1960 Bedford Rd Bedford, TX 76021 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with RN J on 01/04/24 at 03:34 pm, revealed that he received, read, and signed an in-service before resident #28 came back to facility from the hospital. He said that the best and most accurate way of measuring liquid medication is to use a syringe. He said that the facility has different sizes of syringes in the medication room. He said he uses a graduated measuring cup when a medication has a whole number like 5 ml, 10 ml, or 15 ml. He said for a medication like 7.5 ml he would use a syringe for accurate dose. He said for all medications, he follows the 6 Rights (Right patient, Right medication, Right dose, Right time, Right route, Right documentation). RN J said risk of wrong dose is overdose or underdose. RN J said that when he does not understand an order, he calls the pharmacy. He said that he can also talk to the doctor about dosage. He said the risk of running an IV rate inaccurately depending on medication can cause death. He said under dose rates can cause bacteria to grow. Interview with 01/04/24 at 10:30 AM DON revealed that she in-serviced the staff prior to the residents coming back to the facility with different medication, drains or medical equipment. She said that she expects staff to follow doctors ' orders and to ask questions when it is not clear. Interview with regional VP of clinical on 01/04/24 at 12:27 PM revealed that Resident #28 IV medication should have been run at the rate of 200 ml/hr as ordered. She said she expected the nurse to have followed the rate as ordered. She said that she expects staff to ask questions if they have some confusion. She said that staff can ask pharmacy to look at the IV bag for accuracy. She said she expects staff to double check the orders and the IV medication bag. She said she expects 2 nurses to check off IV medication. The risk is overdosing or underdosing. Interview with the Administrator on 01/05/2024 at 2:36 PM revealed his expectation was that staff be more cautious and use something that would have a more accurate way to measure. He stated residents could be underdosed or overdosed. Review of policy titled Adverse Consequences and Medication Errors, revised February 2023 reflected: .medication error is defined as the preparation or administration of drugs or biological which is not in accordance to physician orders, .wrong dose .failure to follow manufactures instructions .review the resident's medication regimen for efficacy . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675934 If continuation sheet Page 10 of 13 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 675934 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Dora Nursing and Rehabilitation Center 1960 Bedford Rd Bedford, TX 76021 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 observation, interview, 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 diseases and infections for 6 of 14 residents (Residents # 20, #38, #11, #42, #29, and #18) reviewed for infection control. Residents Affected - Some The facility failed to ensure residents with a COVID-19 positive status in the secured unit (Residents #42, #29, and #18) were not cohorted with residents with a COVID-19 negative status (Residents #20, #38, and #11) and that CNA A failed to inform the facility when she did not feel well on 12/21/23 and continued to work on the secured unit prior testing positive for COVID-19. These failures placed all residents at risk for the spread of infection through cross-contamination of pathogens and illness. Findings included: Interview on 01/02/24 at approximately 9:15 AM, the DON stated three residents (Resident #42, #29, and #18) were on transmission-based precautions in the secure unit for covid and were mostly asymptomatic. She stated PPE was available to don before entrance and to doff on the way out of the unit. Record review of facility room roster, dated 01/02/24, reflected Resident #42 (covid positive) in the same room as Resident #20 (covid negative), Resident #29 (covid positive) in the same room as Resident #38 (covid negative), and Resident #18 (covid positive) in the same room as Resident #11 (covid negative). Review of Resident # 42 ' s admission record, dated 01/05/2024, revealed an [AGE] year-old female who admitted on [DATE] with diagnoses that included aortic stenosis, and vascular dementia. Review of Resident #29 ' s admission record, dated 01/05/2024, revealed an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, and Alzheimer ' s Disease. Review of Resident #18 ' s admission record, dated 01/05/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis that included unspecified dementia. Review of Resident #28 ' s admission record, dated 01/05/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included unspecified organism sepsis (infection in the blood or whole body), type 2 diabetes, unspecified Alzheimer ' s diseases, high blood pressure, other viral pneumonia, muscle wasting and dying multiple sites, unsteady on her feet and lack of coordination. Review of Resident # 39 's admission record, dated 01/05/2024, revealed an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included Alzheimer ' s Disease, dementia, and cognitive communication deficit. Review of Resident #19 's admission record, dated 01/05/2024, revealed a [AGE] year-old female who admitted on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), dementia, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675934 If continuation sheet Page 11 of 13 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 675934 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Dora Nursing and Rehabilitation Center 1960 Bedford Rd Bedford, TX 76021 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 schizoaffective disorder. Level of Harm - Minimal harm or potential for actual harm Review of the facility's Provider Investigation Report (PIR) for self-report 472603, dated 12/31/2023, revealed incident date of 12/23/23 for COVID+ within staff and named CNA A. The PIR further reflected COVID outbreak mode initiated, contact trace testing and All staff/residents that were in contact with [Name] were contact trace tested and rule out of COVID-19 . Residents Affected - Some Observation on 01/02/24 at 9:54 AM revealed bins with PPE outside of the secure unit with signage posted on the door to don PPE. Observation on 01/02/24 at 10:03 AM in the secured unit revealed, Resident #42 observed in her room sitting close to the doorway in a wheelchair with bedside table in front of her. The resident door was open with an isolation sign on the door. Resident # 20 (Resident #42 ' s roommate) was observed in the dining room. Resident #29 was observed lying in her room and Resident #38 was also observed in the same room. Resident # 18 was observed in the dining room with 8 other residents in the room and no masks on any residents. Interview on 01/02/24 at 10:19 AM with CNA A revealed Resident #42 had been positive for COVID for about a week and the roommate (Resident #20) was negative and had been in the room since last week when they were tested. She stated Resident #29 was positive and her roommate (Resident #38) was negative, and Resident #18 was positive, and her roommate (Resident #11) was negative. CNA A stated she (CNA A) tested covid-19 positive at home on [DATE] at 2:55 PM. She said that she had a sore throat, congestion, coughing and stuffy nose and told the scheduling person. She stated she thought it was the weather, did not go home and worked the whole shift and was off for two days (12/26/23 and 12/27/23) and was back to work on 12/28/23. Interview on 01/02/24 at 10:55 AM the DON revealed she was aware that covid positive and negative residents were in the same rooms together on the secure unit. She stated they had nowhere else for the residents to go because they were flight risks and could not be in the general population. She said they had no choice and told their families that they were going to be quarantined. She stated by having to redirect residents with dementia they made the secure unit a hot zone. The DON stated Resident #28 was the first one to pop hot, so they put her and her roommate (Resident # 39) on isolation. She stated Resident #39 ' s family was upset and wanted Resident #28 to move out but after the DON explained infection control to the family member, the family was okay with her being in the same room. The DON stated with dementia and Alzheimer ' s Disease they cannot really force the residents to stay in the room so that was why they had the whole unit as a hot zone. She stated they could put 2 negative residents together but since she had already been exposed that was not going to change anything and they had zero options. The DON stated five total residents had tested positive, Resident #28 was the first and all residents were tested on days 1, 3, and 5 afterwards. She stated three residents (Resident #42, #29 and #18) tested positive on day 5 (12/28/23) and she would test all the residents again on Thursday 01/04/24.The DON stated she did not think it was a smart idea to move residents that are confused. She said the families would be upset and residents would wander to their old rooms. The DON stated they discussed it and figured it was not going to make a difference to infection control outcomes. The DON stated she goes by the CDC and state guidelines. The DON said CNA A did not test at the facility and sent a picture of her positive test from home on [DATE]. She said CNA A had worked on 12/20/23 and 12/21/23, called in on Friday 12/22/23 and called about the positive test results on Saturday 12/23/23. The last time CNA A worked at the facility was 12/21/23 at 2 PM. The DON said the facility staff had not been required to wear masks since their last outbreak in early October. The DON stated if staff had symptoms that mimic covid, like flu, then they would let them (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675934 If continuation sheet Page 12 of 13 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 675934 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Dora Nursing and Rehabilitation Center 1960 Bedford Rd Bedford, TX 76021 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 go home, but if something like allergies, then they would not be expected to test. She said if there was a positive test then time off would be given, and they could come back at 7 days with no symptoms. Interview on 01/02/24 at 11:58 AM, surveyors requested the facility covid and infection control policy related to cohorting residents, and the DON stated she was not sure if there was an actual policy, they were just following the CDC and state guidelines. Interview on 01/02/24 at 3:02 PM, the Staff Development Coordinator stated if staff were feeling sick, they were supposed to report to her, the nurse, or the DON. She said CNA A was feeling bad on 12/21/23 and called into work on 12/22/23. The Staff Development Coordinator worked for CNA A on 12/22/23 and CNA A returned to work on 12/28/23. She said if an employee was feeling sick and it appeared to be symptoms of covid, they would test them and then get them out of the building. Interview on 01/02/24 at 3:34 PM with the DON and Administrator, revealed the Administrator reported the covid cases to the county health department but did not speak to someone directly about the cohorting in the secure unit. The Administrator stated when he spoke with CNA A, she said she just had a headache. He said if residents had symptoms, they would call the MD and get orders from there. The DON stated the benefits were zero in moving positive residents together and negative residents together because residents would wander, and if they moved a positive resident room to room, she thought it would have led to an increase in positive cases. The Administrator said in the past when they moved residents, it caused confusion in the minds of residents with dementia. Review of the CDC ' s policy Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 05/08/23, revealed, . The IPC recommendations described below (e.g., patient placement, recommended PPE) also apply to patients with symptoms of COVID-19 (even before results of diagnostic testing) and asymptomatic patients who have met the criteria for empiric Transmission-Based Precautions based on close contact with someone with SARS-CoV-2 infection. However, these patients should NOT be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675934 If continuation sheet Page 13 of 13