Health inspection·August 6, 2025

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few state regulation, to make sure Resident #22 received the new wheelchair in a timely manner. She stated she checked the status of the application, and it was not initiated within the 20 days from 05/08/2025, resident had not received the new wheelchair yet. She stated the wheelchair Resident #22 used at that time was big, and that increased the risk for falls.Interview on 08/06/2025 at 12:23 PM, the Director of Rehab revealed she was working at the facility since 2024. She stated Resident #22 currently used an inappropriate size wheelchair, which increased Resident #22's risk for falls and injuries. She stated she received a recommendation for a new customized wheelchair for Resident #22 through PASRR services during the quarterly care plan meeting held on 05/08/2025, attended by the Coordinator with PASRR program, Director of Rehab, social worker and Resident #22. Director of Rehab stated she was responsible to initiate the application process within 20 days from the date PASRR service was recommended (05/08/2025) as per the state regulations, but she initiated it on 07/31/2025, because she was not able to coordinate with all parties to finish the application process. She stated resident #22 did not have any falls from her wheelchair and at that time the application was pending state approval. The Director of Rehab stated she and her employees received in services on abuse, neglect, resident rights every month and after each incident. Interview on 08/06/2025 at 12:48 PM, Certified Occupational Therapy Assistant revealed it was important to have appropriate size wheelchair for all residents to ensure their safety, not having appropriate size wheelchair increased the risk for pressure sores, fall risk, mobility issues. He stated the Director of Rehab was responsible to order customized wheelchair timely as per the PASRR recommendation. He stated Resident #22 used a bariatric wheelchair which was taller, wider, heavier and due to that she was sitting at the edge of the seat to use her legs to move the wheelchair, she was not able to properly ambulate the wheelchair. He stated he received in services on abuse, neglect, resident rights within the past month. Interview on 08/06/2025 at 01:00 PM, Physical Therapy Assistant revealed Resident #22 used an inappropriate size wheelchair, which was too high for her to sit properly, and inappropriate size wheelchairs increased the risk of impaired skin integrity- can cause pressure sores, falls among residents. She stated the Director of Rehab was responsible to order and make sure the residents received customized wheelchair as per PASRR service recommendations. She stated she received in services on abuse, neglect, resident rights every month.Interview on 08/06/2025 at 01:13 PM, the Physical Therapist revealed it was important to have appropriate size wheelchair for residents with mobility issues and Resident #22 used a wheelchair which was higher off the ground, which made it difficult for resident to sit properly. He stated not having a proper size wheelchair increased the risk for pressure sores, falls, injuries, easy ambulation and poor participation in activities among residents. He stated Resident # 22 sat at the end of the chair to ambulate using her legs because it was difficult for her to use the hands to wheel the wheelchair. He stated PASRR services recommended a new customized wheelchair for resident and the Director of Rehab was responsible to order it, he stated he did not know the time frame to start the application process once the recommendation was received from PASRR services. He stated he received in services on abuse, neglect, resident rights every month.Interview on 08/06/2025 at 01:02 PM, the MDS nurse revealed he was working at the facility for 2 months and he was not aware that Resident #22 had a recommendation from PASRR services for a new customized wheelchair. He stated the wheelchair resident #22 used was bigger than what she needed, and the use of inappropriate size wheelchairs increased the risk for pressure sores, falls and overall safety among residents. He stated the Director of Rehab was responsible to order customized wheelchair as per the PASRR recommendation, he would collaborate with the social worker to monitor the PASRR related services. He stated he received in services on abuse, neglect, resident rights every month. Interview on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676276 If continuation sheet Page 2 of 3 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 08/06/2025 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 08/06/2025 at 03:20 PM, the DON revealed she expected all residents to have appropriate mobility, independence, positioning while using a wheelchair and not having the appropriate size wheelchair increased the risk for discomfort, falls and decreased mobility. She stated she did not deal with PASRR services, and the Director of Rehab or Social Worker was responsible to order the new customized wheelchair within a timely manner, as per PASRR recommendations. She stated she did not know the time frame to initiate the application for new wheelchair as per the PASRR services recommendation. She stated all the employees received in services every month on abuse, neglect, resident rights. Interview on 08/06/2025 at 03:37 PM, the Administrator revealed she learned from Resident #22 that she was going to get a new wheelchair. The Administrator stated the Director of Rehab was responsible to order customized wheelchairs and to make sure it was ordered timely as per the PASRR recommendation. She stated she did not know the time frame to initiate the application for new wheelchair as per the PASRR service recommendation. She stated the residents who did not have the proper size wheelchair were not able to live their full potential, not able to ambulate independently, and it would increase the risk for falls. Administrator stated she will put a system in place as an intervention to ensure all the PASRR service recommendations were carried out in a timely manner: MDS nurse must notify the administrator if any services were missing/delayed related to PASRR, social services to implement a tracking system to ensure PASRR services were up to date, make sure all care plans were in compliance with regulations, discuss and make sure all the records were up to date during the IDT meetings. Review of the facility policy with revised date of 1/2025, titled Resident Assessment- Coordination with PASARR Program reflected Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: . PASARR Level II- a comprehensive evaluation by the appropriate state designated authority (cannot be determined by the facility) that determines whether the individual has MD, ID or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. Recommendations, such as any specialized services, from a PASARR level II determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning and transition of care. Event ID: Facility ID: 676276 If continuation sheet Page 3 of 3