Health inspection·November 7, 2024

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interventions: Provide the following assistance with ADLs in self-performance and staff support . J. Personal hygiene: Extensive. An observation on 11/06/24 at 2:33 PM revealed Resident #69 was observed sitting in the wheelchair. The nails on both hands were approximately 0.7 centimeter in length extending from the tip of his fingers. The nails were discolored tan and the underside had dark brown colored residue. Resident #69 was unable to answer questions. 2. A record review of Resident #86's Comprehensive MDS assessment dated [DATE] reflected Resident #86 was a [AGE] year-old male admitted to the facility initially on 08/08/2024 and readmitted on [DATE] with diagnoses included muscle weakness, lack of coordination, cognitive communication deficit, and need for assistance with personal care. Resident #86 had a BIMS score of 7 which indicated Resident #86's cognition was severely impaired. He required supervision with personal hygiene. A record review of Resident #86's Comprehensive Care Plan, revised 03/27/23, reflected the following: Focus: [Resident #86] has an ADL self-care performance deficit related to activity intolerance . Interventions: Provide the following assistance with ADLs in self-performance and staff support . J. Personal hygiene: Supervision. An observation and interview on 11/06/24 at 3:39 PM revealed Resident #86 was laying in his bed. The nails on both hands were approximately 0.3 centimeter in length extending from the tip of his fingers. Second and third nails on the left hand were chipped. Resident #86 stated he would trim his fingernails, but he did not have a finger clip. In an interview with LVN G on 11/06/24 at 3:57 PM, he stated both CNAs and LVNs were responsible for nail care. He stated if a resident has diabetes, only nurses were allowed to provide nailcare. He stated the risk for not performing nailcare was increased risk of infection. He offered to clean and trim resident#69 and #86's fingernails after the interview. 3- Record review of Resident #47's Face Sheet dated, 11/07/24, reflected a [AGE] year-old man admitted on [DATE] with diagnoses of difficulty in walking, other abnormalities of gait and mobility, muscle weakness, need for assistance with personal care, hereditary and idiopathic neuropathy (nervous system disorders that affect the peripheral nerves), cognitive communication deficit (a communication impairment caused by a disruption in cognition) and flaccid hemiplegia affecting right dominant side (a type of paralysis that occurs when the brain or spinal cord is damaged, resulting in muscle weakness and decreased control of the right side of the body). Record review of Resident #47's Annual MDS assessment dated [DATE], reflected Resident #47 had a BIMS score of 15, which indicated he was cognitively intact. Further review of MDS assessment for Resident #47's self-care revealed he required substantial to maximal assistance with showering/bathing. Record review of Resident #47's Comprehensive Care Plan, revised on 08/27/24, reflected the following: Focus: [Resident #47] has an ADL self-care performance deficit related to right sided hemiplegia. Interventions: Bathing: Extensive x1 staff. In an interview on 11/06/24 at 01:58 PM with Resident #47 he was asked if he had any concerns with his care at the facility. Resident #47 revealed that he was getting showers regularly except for on Saturday, 11/02/24. Resident #47 stated CNA L reported to LVN M that he refused his shower on 11/02/24. Resident #47 shower days are Tuesday, Thursday, and Saturdays. Resident #47 stated he did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676276 If continuation sheet Page 2 of 16 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 676276 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewest Rehabilitation and Skilled Care 2450 Bickers St Dallas, TX 75212 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 - Minimal harm or potential for actual harm refuse his shower. Resident #47 stated he asked CNA L if he had the bed linens prior to getting him ready for a shower. CNA L stated he did not. Resident #47 stated he asked CNA L to come back to get him for a shower when he had the bed linen. Resident #47 stated he did not want to have to wait for clean linen after having been showered. Resident #47 stated CNA L never returned to give him a shower. Resident #47 stated he did not like that CNA L reported he refused his shower when he did not. Residents Affected - Some In an interview on 11/07/24 at 9:55 AM with CNA L stated he went to get Resident #47 ready for a shower. CNA L stated Resident #47 refused his shower because CNA L did not have the bed linen available. CNA L stated he documented on the refusal on the shower sheet. CNA L stated Resident #47 asked him to come back to get him when CNA L had the bed linen available. CNA L stated he never went back to Resident #47 to provide him with a shower. In an interview on 11/07/24 at 5:00 PM with LVN M revealed she was working the weekend shift. LVN M stated she checked the shower sheet which revealed that Resident #47 refused his shower . LVN M stated she spoke with Resident #47 and asked him why he refused his shower. LVN M stated Resident #47 stated he did not refuse his shower. LVN M stated Resident #47 told her that he asked CNA L if he had all the linen for his bed prior to giving him a shower. LVN M stated Resident #47 said CNA L said no and that's when Resident #47 asked CNA L to come back when he had the linen. LVN M stated Resident #47 was very particular and liked to have his shower items and linen available upon showering. LVN M stated Resident #47 was given a shower the next day, Sunday 11/03/24. 4- Record review of Resident # 33's Face Sheet dated, 11/07/24, reflected a [AGE] year-old man admitted on [DATE] with diagnoses of methicillin resistant staphylococcus aureus infection (a bacteria that is resistant to many antibiotics), acute and subacute infective endocarditis (type of bacterial infections that affect the heart's lining, heart valves, and other areas), intracardiac thrombosis (serious condition that occurs when a blood clot forms in the heart). Record review of Resident #33's MDS assessment dated [DATE], reflected Resident #33 had a BIMS score of 10, which indicated she was moderately cognitive impaired. Further review of MDS assessment for Resident #33's self-care revealed he was dependent on staff for self-care. Record review of Resident #33's Comprehensive Care Plan, revised on 03/05/24, reflected the following: Focus: [Resident #33] has an ADL self-care performance deficit related to impaired balance, limited mobility, uses wheelchair. Interventions: Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. In an observation on 11/06/2024 at 02:00 PM Resident #33 was observed lying in bed. Observation of Resident #33's nails revealed a dark brown substance around the fingernail cuticles of his left hand. Observation and interview with CNA L's on 11/06/24 at 2:45 PM of Resident #33 nails, he stated the brown substance around Resident #33 fingernails on his left hand looked like bowel movement (feces). CNA L stated Resident #33 often refused patient care and wound care. CNA L stated he documented the refusal and stated he was going to make another attempt later. CNA L stated the protocol was to inform the charge nurse of the refusal. CNA L reported he did not inform the charge nurse. CNA L stated the risk to Resident #33 would be infection. In an interview with ADON H on 11/06/24 at 4:08 PM revealed her expectation was that nail care should be provided as needed, especially during shower time. She stated that CNAs were responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676276 If continuation sheet Page 3 of 16 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 676276 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewest Rehabilitation and Skilled Care 2450 Bickers St Dallas, TX 75212 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 - Minimal harm or potential for actual harm Residents Affected - Some doing nail care unless the resident had diagnosis of diabetes. She also stated that the ADONs were responsible to do routine rounds for monitoring. She stated residents having long and dirty fingernails could be an infection control issue and skin breakdown. In an interview on 11/07/24 at 5:00 PM, the ADON H stated it was the facility's expectation for residents to be provided with nailcare and showers according to schedule. She stated the expectations of the CNA's were to report any refusals to the charge nurse and that CNA's should not be charting refusals. The ADON H stated she would in service staff on ADL care and documentation. Record Review of the facility policy titled Activities of Daily Living (ADLs) revised 2, 2023 reflected, . Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676276 If continuation sheet Page 4 of 16 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 676276 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewest Rehabilitation and Skilled Care 2450 Bickers St Dallas, TX 75212 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 0687 Provide appropriate foot care. 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 that residents receive proper treatment and care to maintain good foot health for 1 (Resident #40) of 8 residents reviewed for quality of care. Residents Affected - Few The facility failed to ensure Resident #40 received foot care and treatment for her dry, flaky skin on her feet. These failures placed all residents at risk for not receiving foot care which is consistent with professional standards of practice. Findings include: Review of Resident #40's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old-female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her BIMS score was 15 out of 15 which indicated she was cognitively intact, required extensive, one-person assistance for ADLs. Her diagnoses included hypertension (high blood pressure), diabetes mellitus (elevated blood sugar), Non-Alzheimer's Dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Review of Resident #40's Care Plan dated 10/14/24 reflected Focus. ADLS: Resident has an ADL self-care performance deficit related to limited mobility Goal: Resident will maintain current level of function in all ADLs through the review date. Intervention: Provide the following Assistance with ADLs .J. Personal hygiene: Extensive one staff. Observation and Interview on 11/06/24 at 09:09 AM, revealed Resident#40 was lying in bed wearing a hospital gown. Observation revealed Resident#40's feet were dry with flaky skin at the bottom. Resident#40 stated she would like her feet cleaned. Resident#40 further stated she got bed bath three times a week, and the staff cleaned and put lotion on her feet once in a while. Observation on 11/06/24 at 09:30 AM revealed CNA K looking at Resident#40's bottom of the feet. Interview with CNA K revealed the feet needed to be cleaned and put some lotion on them. CNA A stated she would clean resident#40 feet and put lotion on them today. CNA K stated the implication on Resident#40 development of infection, and skin break down. Interview on 11/06/24 at 02:09 PM with the LVN J, she stated it was the responsibility of the CNAs to clean and put lotion on residents' feet. LVN J stated it was her responsible to make sure CNAs were doing proper care for the residents including shower, and foot care. LVN J stated the risk to resident development of infection and skin break down. LVN J further stated CNAs should report any persistent dry/flaky skin to the charge nurse who should assess the skin and call the doctor. Interview on 09/26/24 at 02:12 PM with the ADON I revealed her expectation was that foot care should be provided on shower day or as needed by the CNAs. She stated the risk to residents were infection, and skin issue. She stated that as the ADON I, either herself or the charge nurse's designee were responsible to do routine rounds for monitoring. Record Review of the facility policy titled Skin Integrity-Foot Care revised February 2023 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676276 If continuation sheet Page 5 of 16 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 676276 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewest Rehabilitation and Skilled Care 2450 Bickers St Dallas, TX 75212 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 0687 reflected, It is the policy of this facility to ensure residents receive proper treatment and care ., to maintain mobility and good foot health. This policy pertains to maintain the skin integrity of the foot . 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: 676276 If continuation sheet Page 6 of 16 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 676276 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewest Rehabilitation and Skilled Care 2450 Bickers St Dallas, TX 75212 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 0692 Provide enough food/fluids to maintain a resident's health. 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 that a resident is offered sufficient fluid intake to maintain proper hydration for one (Resident #5) of six residents reviewed for quality of care. Residents Affected - Few The facility failed to ensure Resident #5 was provided adequate hydration on 11/05/24. This failure could place residents at risk of dehydration and decline in nutritional status. Findings included: Review of Resident #5's Quarterly MDS assessment dated [DATE] reflected Resident #5 was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] to the facility with diagnoses of Hemiplegia (partial or complete paralysis or weakness) on left side, hypertension, Type 2 Diabetes, wound infection, Respiratory Failure and Dysphagia (difficulty swallowing). Resident #5 had a BIMS score of 10 indicating she was moderately cognitively impaired. Resident #5 required set-up assistance with eating. Resident #5 was on hospice services. Resident #5 had a mechanically altered diet and a swallowing disorder. Review of Resident #5's comprehensive care plan last revised 08/23/24 reflected Resident #5 was on therapeutic & Altered Consistency Diet. Fortified with puree/Level 4 texture and Honey Moderately Thick .liquid consistency. Intervention included Encourage dietary\fluids intake within dietary limits. Review of Resident #5's physician orders for November 2024 reviewed on 11/05/24 reflected the following: -Resident #5 had a physician order dated 02/15/24 with start date of 02/15/24 of Fortified diet puree level 4 texture, Honey moderately thick .consistency. -Resident #5 had a physician order dated 10/21/24 of treatment for coccyx wound on both buttocks. It did not reflect Resident #5 was on fluid restriction. Observation and Interview on 11/05/24 at 10:55 AM revealed Resident #5 was lying in bed. She stated she was dependent on staff for assistance. She stated she wanted some water because she was thirsty. She stated the facility staff had not passed any water to her this morning on the day shift. She stated she was given water with her breakfast this morning. Interview on 11/05/24 at 11:05 AM LVN F stated the CNAs had not passed water since before breakfast. She stated she would make sure Resident #5 was provided water. Follow- up interview on 11/05/24 at 1:52 PM with LVN F revealed she was not aware the CNAs had not passed water before breakfast to residents on 400 hall. She stated the CNAs passed out water right before lunch today after speaking to surveyor earlier. She stated the potential risk to residents not drinking water was dehydration and increased confusion. She stated Resident #5 was on honey thickened liquids and she received water on her meal trays. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676276 If continuation sheet Page 7 of 16 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 676276 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewest Rehabilitation and Skilled Care 2450 Bickers St Dallas, TX 75212 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 0692 Level of Harm - Minimal harm or potential for actual harm Interview on 11/05/24 at 1:41 PM CNA P stated she and CNA B did not have time to pass out water to residents on Hall 400 including Resident #5 before breakfast. She stated if they do not get water passed out before breakfast on the day shift then they pass it out later on their shift. She stated Resident #5 was on honey thickened liquids. She stated they did not pass out water to residents on Hall 400 until right before lunch. Residents Affected - Few Interview on 11/05/24 at 1:55 PM CNA B stated she did not pass water to residents on 400 hall including Resident #5 before breakfast. Interview on 11/06/24 at 3:31 PM with ADON H and ADON I revealed MAs were responsible to pass out water when they do the snacks between breakfast and lunch. They stated the CNAs pass out and refill water at beginning of their shift. They stated residents not getting water could place them at risk for Urinary Tract Infections and dehydration. Interview on 11/06/24 at 4:12 PM with MA E revealed she did give Resident #5 thickened apple juice about 9:30 AM this morning. She stated she did not offer or give her water with her snacks. She stated the CNAs were responsible to pass out water in the morning using the cooler. She stated she was only responsible for passing out snacks and drinks provided from the kitchen. She stated to fill Resident #5's ice and water she would have to get the thickened water from the kitchen. Interview on 11/07/24 at 2:00 PM with CNA P revealed she got the ice for the cooler to pass before breakfast. She stated she would need to get water honey thickened liquid for Resident #5 from the kitchen. Review of facility's policy Hydration dated February 2023 reflected The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preference to maintain proper hydration and health. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676276 If continuation sheet Page 8 of 16 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 676276 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewest Rehabilitation and Skilled Care 2450 Bickers St Dallas, TX 75212 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 - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 3 medication carts (Nurses cart hall 300, Med Aide cart hall 300/400, and Nurses cart hall 400) of 3 medication carts reviewed for pharmacy services. The facility failed to ensure: 1- LVN D, responsible for Nurses Cart Hall 300, removed medications in unsecure blister packs from the Nurses Cart. 2- MA E, responsible for Med Aide Cart Hall 300/400, removed medications in unsecure blister packs from the Med Aide Cart. 3- LVN F, responsible for Nurses Cart Hall 400, removed medications in unsecure blister packs from the Nurses Cart. These failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: 1- Record review and observation on 11/05/24 at 12:40 PM of Nurses Cart Hall 300, with LVN D revealed: - the blister pack for Resident #292's Hydroco/APAP 5-325 mg tablet (controlled medication used for pain) had 1 blister seal broken and the pill still inside the broken blister. - the blister pack for Resident #3's APAP/Codeine 300 mg tablet (controlled medication used for pain) had 1 blister seal broken and the pill still inside the broken blister. Interview on 11/05/24 at 12:40 PM, LVN D stated she was unaware when the blister pack seals were broken, and she was not aware of who might have damaged the blister. She stated the risk would be a potential for drug diversion. She stated the nurses and medication aides were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shift. She stated the count was done at shift change and the count was correct. She stated she was not sure if the blister was broken during the count. She stated she would discard the pill with another nurse. 2- Record review and observation on 11/05/24 at 12:53 PM of Med Aide Cart Hall 300/400, with MA E revealed the blister pack for Resident #35's APAP/Codeine 300-30 mg tablet (controlled medication used for pain) had 1 blister seal broken and the pill still inside the broken blister. Interview on 11/05/24 at 12:58 PM, MA E stated the count of controlled medication was done at shift change and the count was correct. She stated she did not see the broken blister during the count, she stated she was supposed to check the packs for broken blister, she did not know why she did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676276 If continuation sheet Page 9 of 16 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 676276 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewest Rehabilitation and Skilled Care 2450 Bickers St Dallas, TX 75212 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 check. MA E called another nurse and she proceeded to discard the pill. Level of Harm - Minimal harm or potential for actual harm 3- Record review and observation on 11/05/24 at 1:00 PM of Nurses Cart Hall 400, with LVN F revealed the blister pack for Resident #61's Tramadol 50 mg tablet (controlled medication used for pain) had 1 blister seal broken and the pill still inside the broken blister. Residents Affected - Some Interview on 11/05/24 at 1:00 PM, LVN F stated the nurses and med aides were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shift. She stated she counted with the ongoing nurse in the morning, the count was correct, but she did not see the damaged blister. She stated she would discard the pills with another nurse. Interview on 11/06/24 at 4:08 PM, ADON H stated she expected if a blister pack medication seal was broken the pill should be discarded. ADON H stated it would not be acceptable to keep a pill in a blister pack that was opened. She stated the risk would be potential for drug diversion and infection control issue. She stated nurses were responsible for checking the medication blister packs for broken seals during the count on the change of shifts. She stated the ADON, and the DON were supposed to check the carts weekly. Record review of the facility's policy Medication Storage dated 05/2023, reflected the following: .Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676276 If continuation sheet Page 10 of 16 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 676276 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewest Rehabilitation and Skilled Care 2450 Bickers St Dallas, TX 75212 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to provide food that was at an appetizing temperature and palatable for one (11/06/24) of one meal reviewed for food palatability and temperature. Residents Affected - Few The facility failed to serve hamburger at an appetizing temperature and vegetables at a palatable texture during the lunch meal on 11/06/24. This failure could affect residents by placing them at risk of weight loss, altered nutritional status, and a diminished quality of life. Findings included: In a confidential group interview on 11/06/24 at 10:00 AM revealed residents complained about the food not being cooked properly it can be overcooked. Observation on 11/06/24 at 1:02 PM revealed nurse was walking down 400 hall to give last meal tray down to resident on end of 400 hall. 400 hall trays were the last to be served. Observation at 11/06/24 at 1:05 PM revealed lunch test tray of vegetable medley including cauliflower and green beans were harder and undercooked. The Hamburger was cold. Interview on 11/06/24 at 12:48 PM with Dietary [NAME] Q revealed he should have temped the hamburgers, it should have been at least 165 F. He stated it was important to ensure food temperatures were taken to ensure warm foods and cold foods were at correct temperatures to serve to prevent food borne illness risk. Interview on 11/06/24 at 2:39 PM with the Dietary Manager revealed the vegetables should not be overcooked and hard. She stated vegetables being harder can make it more difficult on residents to chew, residents might not eat the vegetables, and could place residents at risk of getting sick. She stated the Dietary [NAME] should have temped the hamburgers prior to serving to ensure food temperature was at least 165 F. She stated the food temperatures should have been checked prior to serving to ensure food at right temperatures and to prevent food borne illness. She stated the hamburger should be served warm. Review of Resident Council Minutes dated 09/03/24 reflected dietary concerns of the food could be hotter. Review of facility's policy Date Marking for Food Safety dated 2023 reflected The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food .6.The Head Cook, or designee shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. 7. The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, and document accordingly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676276 If continuation sheet Page 11 of 16 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 676276 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewest Rehabilitation and Skilled Care 2450 Bickers St Dallas, TX 75212 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food items in walk-in refrigerator were sealed and produce did not show signs of expiration. 2. The facility failed to ensure food temperatures of hamburger patties, chicken nuggets, fries, ice cream and gelatin dessert were obtained prior to serving lunch on 11/06/24. 3. Dietary Aide N, LVN J and Dishwasher O wore effective hair restraints during lunch meal service on 11/06/24. These failures could place residents at risk for food contamination and food-borne illness. Findings included: 1. Observation in the facility's kitchen walk-in refrigerator on 11/05/24 at 9:32 AM revealed a stainless-steel square container labeled Burger Toppings. The container was not sealed properly, and the lettuce was turning brown. Observation in the facility's kitchen walk-in refrigerator on 11/05/24 at 9:35 AM revealed a white bin full of tomatoes. Several of the tomatoes was bruised. Observation in the facility's walk-in refrigerator revealed on 11/05/24 at 9:34 AM an open box of bacon in plastic bag not sealed. Interview on 11/05/24 at 9:37 AM with the Dietary Manager revealed the food items in the refrigerator should be sealed. She stated she will throw out the lettuce and tomatoes. She stated she will seal the bacon. 2. Observations on 11/06/24 starting 11:32 AM revealed food temperatures were taken except for hamburger patties, fries, chicken nuggets, ice cream and gelatin dessert. At 11:41 AM Dietary [NAME] Q started plating food for lunch. At 11:53 AM and 12:02 PM hamburger patties and fries were placed on resident lunch meal trays. At 12:15 PM, chicken and fries were placed a resident meal tray. Ice cream and gelatin dessert were place on resident meal trays. Interview on 11/06/24 at 12:48 PM with Dietary [NAME] Q revealed he should have temped the hamburgers should have been at least 165 F, chicken nuggets, fries, ice cream and gelatin dessert. He stated it was important to ensure food temperatures were taken to ensure warm foods and cold foods were at correct temperatures to serve He stated the ice cream and gelatin should have been at 32 F or below. Interview on 11/06/24 at 12:55 PM with Dietary [NAME] Q revealed he did not take temperature of chicken nuggets but only 1 resident was served the chicken nuggets. Dietary [NAME] Q stated he was going 100 miles an hour trying to get food out on time and forgot to take temperature. He stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676276 If continuation sheet Page 12 of 16 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 676276 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewest Rehabilitation and Skilled Care 2450 Bickers St Dallas, TX 75212 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 0812 Level of Harm - Minimal harm or potential for actual harm expectation was to take temperatures of all food prior to serving. He stated the risk to resident were they could get sick. 3. Observation on 11/06/24 at 11:45 AM revealed LVN J had about ½ inch of hair out in the front and on both sides, which was not covered by a hair restraint while she plated resident's plates. Residents Affected - Many Observation on 11/06/24 at 11:45 AM revealed the Dietary Aide N had about ¼ inch of hair out in the front and back, which was not covered by a hair restraint while she plated resident's plates. Observation on 11/06/24 at 11:45 AM revealed the Dishwasher O was filling up water and juice pitchers. The facial hair on his upper cheeks, which was about ¼ inch in length, was not covered by a hair restraint. In an interview with the Dishwasher O on 11/06/24 at 12:35 PM, he stated the expectation was for all facial hair to be covered. He stated the risk to the resident was hair could fall into the food and drinks, which could cause residents to choke. In an interview with the Dietary Aide N on 11/06/24 at 12:45 PM, she stated the expectation is for all hair to be covered. She stated the risk to resident was hair could fall into the food and drinks, which could make residents sick. In an interview with LVN J on 11/06/24 at 01:21 PM, she stated she was unaware any hair was sticking out of the hairnet. She stated the expectation was for all hair to be covered under hair restraint. She stated the risk to resident was hair could get into the food and drinks, which could cause residents to get sick. Interview on 11/06/24 at 2:39 PM with the Dietary Manager revealed the Dietary [NAME] should have temped the hamburgers, chicken nuggets, fries, ice cream and gelatin prior to serving. She stated the hamburgers and chicken nuggets should be at 165 Fahrenheit prior to serving so it can be served warm to residents. She stated the ice cream should be at 32 degrees Fahrenheit or lower. She stated employees should be wearing effective hair restraints in the kitchen to cover their hair including facial hair. She stated Dietary Aide N and Dishwasher O had not been in-serviced about effective hair restraints. She stated the risk to food temperatures not taken prior to serving were placed residents at risk of food borne illness and can make them sick. Interview on 11/07/24 at 10:48 AM with the Dietary Manager revealed employees wearing effective hair restraints was important to keep hair out of food and to prevent cross contamination. Review of facility's policy Date Marking for Food Safety dated 2023 reflected The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food .6. The Head Cook, or designee shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. 7. The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, and document accordingly. Review of facility's policy Food Safety Requirements implemented March 2023 and last revised March 2024 reflected Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety .1. Food safety practices shall be followed throughout the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676276 If continuation sheet Page 13 of 16 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 676276 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewest Rehabilitation and Skilled Care 2450 Bickers St Dallas, TX 75212 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many facility's entire food handling process .Elements of the process include the following: b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms .Employee hygienic practices .3. Facility staff shall inspect all food, food products, and beverages for .proper storage .c. Refrigerated storage .Practices to maintain safe refrigerated storage include: .v. Keeping foods covered or in tight containers .4. When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce, or eliminate potential hazards .d. Holding -staff shall monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures are maintained. Staff shall adhere to the current FDA Food Code and facility policy for food temperatures as needed .5. Foods .shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the Danger Zone .7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects .d. Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food. E. Hairnets should be worn when cooking , preparing, or assembling food Review of the FDA US Food Code 2022 reflected the following: -under section 2-3 Personal Cleanliness 2-301.11 Clean Condition Food Employees shall keep their hands and exposed portions of their arms clean. -under section 2-402.11 Effectiveness. (Hair Restraints) 1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel. (b) (6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other effective hair restraints. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676276 If continuation sheet Page 14 of 16 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 676276 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewest Rehabilitation and Skilled Care 2450 Bickers St Dallas, TX 75212 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 control program designed to prevent the development and transmission of infection for 2 residents (Resident #3 and Resident#83) of 4 residents observed for infection control. Residents Affected - Some The facility failed to ensure: 1- CNA A performed hand hygiene between change of gloves during incontinent care for Resident #3. 2- LVN C and CNA B donned the appropriate PPE during wound care for Resident #83 who was on enhanced barriers precautions. These failures could place residents at risk for infection and cross contamination of pathogens and illness. Findings included: Resident #3 Record review of Resident #3's Quarterly MDS assessment dated [DATE] reflected Resident #3 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included need for assistance with personal care, dementia, and cognitive communication deficit. Resident #3 had a BIMS score of 3, which indicated Resident #3's cognition was severely impaired. The MDS assessment indicated Resident #3 was always incontinent of bladder and bowel. Record review of Resident #3's Care Plan dated 07/6/22, reflected the following: Focus: [Resident #3] has an ADL self-care performance deficit . Goal [Resident #3] will maintain a sense of dignity by being clean, dry, odor free, and well-groomed . Interventions: .resident requires extensive assist by 1 staff with personal hygiene .Resident requires extensive to total assist by 1-2 staff for toileting . Observation on 11/5/24 at 10:39 AM revealed CNA A entered Resident #3's room to provide incontinence care. CNA A washed her hands and donned gloves, she unfastened Resident #3's brief and cleaned the front pubic area. The resident was assisted onto her side revealing she had a small bowel movement. CNA A discarded the dirty gloves, without hand hygiene she donned clean gloves. She cleaned the resident's buttocks area using several wipes. CNA A removed and discarded the dirty gloves, without hand hygiene, she donned clean gloves. She placed a clean brief under resident buttocks, she fastened the brief, and covered the resident in the bed. CNA A gathered the dirty clothes and trash, removed her gloves, washed her hands, and left the room. In an interview on 11/5/24 at 11:07 AM, CNA A stated she supposed to perform hand hygiene between change of gloves. CNA A stated she should change her gloves and perform hand hygiene when she went from dirty to clean. CNA A stated failing to provide proper care exposed the resident to infections. Resident #83 Record review of Resident #83's Comprehensive MDS, dated [DATE], revealed Resident #83 was a [AGE] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676276 If continuation sheet Page 15 of 16 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 676276 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewest Rehabilitation and Skilled Care 2450 Bickers St Dallas, TX 75212 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 year-old male admitted to the facility on [DATE] with diagnoses included pressure ulcer of sacral region, diabetes mellitus, and hemiplegia (a condition that causes paralysis or severe weakness in the muscles on one side of the body, often affecting the arm, leg, and face) affecting left side. Resident #83 had a BIMS score of 9, which indicated Resident #83's cognition was moderately impaired. Record review of physician orders dated November 2024 reflected Enhanced barrier precautions (EBP) every shift for wound with high-contact care activities. With a start date of 09/24/2024. Observation on 11/05/24 at 01:23 PM revealed Resident #83 was on Enhanced barriers precautions. There was signage on the right side of the door that informed visitors/staff he was on enhanced barriers precautions, perform hand hygiene before and after leaving room, necessary PPE to wear in room, and donning/doffing (put on/remove) information. CNA B was in Resident #83's room without gown, she was wearing gloves. LVN C entered Resident #83's room without any form of PPE, there was PPE cart at the door Resident#83's room. LVN C washed hands and donned gloves, she proceeded to do wound care with the assistance of CNA B, for Resident#83 without wearing gowns. In an interview on 11/05/24 at 01:43 PM, LVN C stated she was new, on her first week in the facility, she did not pay attention to the signage at the door, and she was focused on wound care. She stated she was in-serviced regarding different type of infection control during orientation. She stated the risk of not wearing proper PPE in enhanced barriers precautions residents' rooms was exposing herself and others to the development of infection and spreading germs. Interview with CNA B on 11/05/24 at 01:46 PM revealed she knew she supposed to wear gown to assist with wound care, but she thought the signage in front of the room was for the resident in bed A, and the resident she assisted was in bed B. She could not recall the last time she had in service on infection control related to EBP. She stated the risk would be development of infections. In an interview on 11/07/24 at 1:50 AM, ADON H stated enhanced barriers precaution (EBP) was new this year. She stated for the EBP they had signage outside the resident's room, and for any high contact activity with the resident on EBP including transfer, peri care, wound care .staff should be gowning and gloving. She stated she was responsible for training staff on infection control. She further stated training for EBP was done on hire, monthly, and as needed for infection control. ADON H stated they used EBP to prevent infection to high-risk residents. Record review of the facility's policy Enhanced Barrier Precautions dated 04/2024, reflected the following: . Enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities . 4. High-contact resident care activities include: . g. Wound care . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676276 If continuation sheet Page 16 of 16