Health inspection·October 30, 2025

F 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide and document sufficient preparation and orientation of resident to ensure safe and orderly transfer or discharge from the facility and ensure the orientation was provided in a form and manner that the resident could understand for one (Resident #1) of three residents reviewed for discharge.1. On 09/26/2025, the facility failed to ensure Resident #1's post-discharge destination and continued care provider could meet Resident #1's needs. Resident #1 required medication management and supervision with activities of daily livings, which the shelter did not provide. 2. On 09/26/2025 the facility failed to ensure Resident #1 was admitted to the shelter, as Resident #1 was left standing in line. On 10/03/2025 Resident #1 was found by a high school security guard approximately 14 miles away from the shelter where he had been dropped off to.This deficient practice could place residents at risks of accidents, and could result in serious harm, injury, impairment, and death.An Immediate Jeopardy was identified on 10/29/2025 at 2:26 p.m., while the IJ was removed on 10/30/2025 at 3:38 p.m., the facility remained out of compliance at a at a severity level of potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. Record Review of Resident #1's face sheet, dated 10/29/2025, revealed a [AGE] year-old man originally admitted on [DATE]. Resident #1 had diagnoses which included anoxic brain damage (brain does not receive enough oxygen), major depressive disorder serious mental health condition that significantly impacts a person's mood, thoughts, and behavior), anxiety disorder (excessive fear or anxiety), seizures (sudden, uncontrolled electrical discharges in the brain), lack of coordination, muscle weakness,, difficulty walking, sever protein-calorie malnutrition (does not consume enough protein and calories to meet their body's needs), chronic viral hepatitis C long-term infection of the liver caused by the hepatitis C virus), hyperlipidemia (high levels of lipids (fats) in the blood, including cholesterol and triglycerides), chronic pain syndrome, essential hypertension (high blood pressure without an identifiable underlying cause), and gastro-esophageal reflux disease without esophagitis ( condition where stomach contents flow back into the esophagus (reflux) but do not cause inflammation or damage to the esophageal lining ). Record review of Resident #1's discharge MDS assessment, dated 09/26/2025, revealed Resident #1 had a BIMS score of 7, which indicated severe impairment. Resident #1's functional abilities required supervision for all self-care needs. Record review of Resident #1's Care Plan, dated 06/19/2025, revealed Resident #1 had an ADL self-care performance deficit r/t impaired balance, required antidepressant medication for diagnosis of major depressive disorder, had potential for complications diagnosis of hypertension, was a risk for falls, had impaired cognitive function/dementia or impaired thought processes r/t anoxic brain injury, and was incontinent at times due to confusion, inability to communicate needs.Record review on 10/28/2025 of Resident #1's social services progress note revealed Resident #1 was discharged on 9/26/2025 to shelter. Record review on Page 1 of 6 676293 676293 10/30/2025 Forest Park Nursing & Rehabilitation 6825 Harry Hines Blvd Dallas, TX 75235

F 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 10/28/2025 through 10/30/2025 of Resident #1's electronic health records from revealed no documentation of referral for alternate placement for Resident #1. Record review on 10/28/2025 through 10/30/2025 Resident #1's electronic health records revealed no documentation of verbal or written notice of intent to leave the facility. Record review on 10/28/2025 through 10/30/2025 Resident #1's electronic health records revealed no documentation that Resident #1 representative refused to pick Resident #1 up from the facility. [SP3] During an interview on 10/27/2025 at 3:28 p.m., the complainant revealed that she had received a call from Resident #1's family member who stated the nursing facility allegedly dropped Resident #1 off at a shelter (date unknown) and he was found at a school 14 miles away from the alleged shelter, by security. Resident #1 was currently at his family members home and will stay there until they find him placement.During an interview on 10/27/2025 at 3:33 p.m., Resident #1's assigned case manager revealed that she was assigned to Resident #1 case on 10/06/2025. She stated that Resident #1's family member was contacted by law enforcement on 10/03/2025 and stated that Resident #1 was located at or near a school. Resident #1's family went and picked him up on 10/03/2025. The case manager stated she had spoken with Resident #1's family and was told that Resident #1 was allegedly dropped off at a shelter (date unknown) and was found on 10/03/25 by law enforcement and someone Resident #1 was able to provide his brothers phone number, Resident #1 family was contacted, and the family member went to get Resident #1. The case manager stated that the family member had contacted Resident #1 and APS was involved also. She stated that APS had assisted with clinical records on 10/25/2025 after APS went to the nursing facility to sign the release form, but the records were incomplete. The case worker stated that she needed more recent clinical documentation to place Resident #1, what she had received stopped in April 2025. During an interview on 10/27/2025 at 3:55 p.m., Resident #1's family member revealed that Resident #1 was found by a school security on 10/03/2025. The family member stated that Resident #1 stated he had walked to the school, and that he would sleep on the street. The family member stated when Resident #1 was picked up he looked like he had slept on the streets for a few days. The Family member said they called APS. The Family member stated they would take care of Resident #1 until placement was found for him as he needed assistance because he cannot cook, required help with bathing, and putting clothes on and off. During an interview on 10/27/2025 at 4:04 p.m., Resident #1 revealed that the facility had provided him with a notice of discharge because he was caught smoking in the facility. Resident #1 stated that he did not ask to go to a shelter. Resident #1 stated the nursing facility dropped him off at the shelter. He was tired of waiting for a bed at the shelter, so he started walking. Resident #1 said that he walked to the school but wasn't aware how long it took him but thought it was a couple of days. During an interview on 10/28/2025 at 9:50 a.m., with the APS worker stated she had received a report from Resident #1's Parole Officer on 10/04/2025 that Resident #1 had been picked up by his family member and needed placement. The APS worker stated that she had talked to Resident #1's family member and was told that the nursing facility dropped Resident #1 off to the shelter and he got tired of waiting on a bed and started walking and was found on 10/03/2025 by school security. The APS worker stated she worked with the case manager to find placement and she had received clinicals on or about 10/24/2025 and forwarded to the case manager but required more recent clinicals as the clinicals that were sent ended in April 2025, but to place Resident #1 they required most up to date records. During an interview on 10/28/2025 at 2:39 p.m., with the facility SW revealed Resident #1 was discharged on 09/26/2025 after Resident #1 had been provided a 30-day discharge notice on 08/26/2026 for failure to follow facility smoking policy to a shelter. The SW stated that the shelter had a nurse on staff, provided day and night shelter, so she thought it was safe for Resident #1 to discharge there. The SW 676293 Page 2 of 6 676293 10/30/2025 Forest Park Nursing & Rehabilitation 6825 Harry Hines Blvd Dallas, TX 75235

F 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few stated the ADM told her it was okay to discharge Resident #1 to the shelter. The SW stated she gave Resident #1's paperwork to the shelter security guard after she confirmed she did not have to stay with Resident #1. The security guard told her since it was his first time there should be no issues with him admitting to the shelter and she did not have to stay. The SW stated she did not do any referrals for alternate placement for the resident. The SW revealed that there was no documentation that the resident representative refused to pick him up and there was no documentation that resident intent was to leave the facility and go to a shelter. During an interview on 10/28/2025 at 4:42 p.m., with the facility Nurse Practitioner who revealed he was informed by the facility that Resident #1 had a bed at the shelter and there was nurse staff that would assist him with his medication management. The nurse practitioner stated that if the shelter could not provide the medication management that it would not be a safe discharge. During an interview on 10/29/2025 at 9:10 a.m., with the shelter intake specialist revealed that the shelter was open from 7am to 5pm daily and night shelter was available depending on availability. The shelter intake specialist stated individuals who have proof of income, birth certificate and social security cards were first priority for beds, then woman and finally men, but currently there were no beds available and that there were women who have been waiting for approximately 3 months for a bed. The shelter intake specialist stated that there were no 24-hour medical staff. The shelter intake specialist stated that there were care managers to assist individuals, but it was not a requirement for them to do so and would depend on their case load if they would be able to assist. During an interview on 10/29/2025 at 9:57 a.m., the ADM revealed that she had provided Resident #1 with a 30-day notice for a second offense of violation of facility smoking policy. The ADM stated that Resident #1 was caught smoking illegal substance on two occasions. The ADM stated on the first offense Resident #1 was placed on a behavior contract that he acknowledged and signed on 8/16/25. The ADM stated the 30-day notice was provided to Resident #1 as well as contacted Resident #1 family member to inform them that the notice was provided and what caused the 30-day notification. The ADM stated the family member understood and agreed to take Resident #1 home. The ADM stated that the IDT met and agreed that Resident #1 was safe to discharge home with family members. The ADM stated the day Resident #1 family member was supposed to pick Resident #1 up they did not show up and did not answer the phone. The ADM stated Resident #1 still wanted to leave the facility and the SW had found the shelter that provided day/night services had a nurse on staff so felt that was a safe place for Resident #1. The ADM stated she was not aware if any alternate nursing home placement referrals were made, did not believe there was any documentation that the representative refused to pick the resident up, and there was no documentation that the resident expressed his intent to leave the facility and go to a shelter. The ADM stated that she felt the shelter was a safe place to discharge Resident #1 because their website stated they offered/night shelter and that there were nurses there to provide medication management and to assist with ADLs for him. The ADM stated that she did not call the shelter to verify bed availability or if there was 24-hour nurse care at the shelter. The ADM stated that it was her responsibility to ensure that residents had a safe discharge location. During an interview on 10/29/2025 at 11:44 a.m., the Ombudsman revealed that he was notified on 8/27/2025 that Resident #1 had received a 30- day discharge but was not aware that the facility discharged Resident #1 to a shelter until 10/06/20025 when he spoke to a family member. The Ombudsman stated that they advocate homeless shelters because they cannot provide the level of care residents need. The Ombudsman stated he was not aware if the facility made any alternate nursing home referrals for Resident #1 or if Resident #1 requested to go to the shelter. During interview on 10/29/2025 at 12:37 p.m., with the SW, she revealed that the ADM made the final determination to send 676293 Page 3 of 6 676293 10/30/2025 Forest Park Nursing & Rehabilitation 6825 Harry Hines Blvd Dallas, TX 75235

F 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #1 to the shelter. Record review of the facility Discharge or Transfer policy undated stated Purpose To ensure that resident are transferred and discharges from the facility in compliance with state and federal laws and to provide complete, safe, and appropriate discharge planning and necessary information to the continuing care provider. Procedures under Documentation. A. When the facility anticipates a resident's discharge to a lower level of care (e.g., private resident, group home or board or care or assisted living) tor to another nursing care facility, the IDT with assistance of the resident and his/her personal representative, will develop a discharge summary and posit discharge plan to assist the resident to adjust to his or her new living environment. A. i. Appropriate IDT members will educate the resident or his/her personal representative regarding the discharge plan issues and will assist the resident with discharge plansG. If the resident is transferred because needs cannot be met, the facility must document attempts to [NAME] the residents needs and the services available at the receiving facility to meet the needsXV. Documentation and education provided to a resident or to his/her personal representative in preparation for transfer/discharge will be provided in a language he/she understands. This was determined to be an Immediate Jeopardy (IJ) on 10/29/25 at 2:26 p.m. The ADM, RDO and RCN were notified. The ADM was provided with the IJ template on 10/29/25 at 2:2:26 p.m. The facility's POR for Immediate Jeopardy was accepted on 10/30/25 at 3:38 p.m. and reflected the following: Date: 10/30/2025 PLAN OF REMOVAL FORIMMEDIATE JEOPARDYSummary of Details which lead to outcomes: Resident #1 had been discharged from the facility on 09/26/2025 and dropped off at a homeless shelter by the social worker but did not get checked in. On 10/29/2025 received an IJ Template notification that the Survey Agency had determined that this discharge was unsafe and constitutes immediate jeopardy. Identified areas for improvement include:- Lack of consistent IDT oversight on discharge decisions.- Inadequate documentation verifying safe placement and discharge readiness.- Facility did not verify that the resident was admitted safely to the discharged location.- Missed opportunities to seek other alternative placement prior to discharge.The notification of the alleged immediate jeopardy states as follows:F627 Transfer and discharge.The facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly discharge from the facility.Identify residents who could be affected: All residents set to discharge from the facility have the potential to be affected.Actions Taken to Prevent Serious Adverse Outcome from Occurring or Recurring1. On 10/29/2025, Resident #1's Power of Attorney was contacted by the Regional Director of Operations and offered the option to have resident #1 readmit to the facility to which she agreed. On 10/29/2025, resident #1 was picked up from his family members home and re-admitted to the facility.2. On 10/29/2025, Resident #1 was assessed by the Medical Director and was determined to be at Medically stable with prior level of functioning.3. On 10/29/2025, Regional Social Service Director initiated and completed an audit of all resident discharges from August 1, 2025, to present to ensure safe resident discharges. All audited residents were confirmed to have been safely discharged from the facility. A review by DON of residents with smoking violations did not reveal any residents with smoking violation related discharges.4. Nursing facility Administrator employment was terminated effective 10/29/2025 and the Regional Director of Operations will provide oversite until a new Administrator is appointed.5. The facility social worker was educated by the regional Director of Social Services regarding Inadequate documentation verifying safe placement and discharge readiness. Training and post test was conducted on 10/29/2025.6. Once a new Administrator is hired, they will be educated by the Regional Director of operations on resident safe discharge before being allowed to work.7. IDT team members which includes: the Administrator, DON, social service director, MDS coordinator, Therapy Director, Activity Director, Dietary services and 2 ADON's were educated 676293 Page 4 of 6 676293 10/30/2025 Forest Park Nursing & Rehabilitation 6825 Harry Hines Blvd Dallas, TX 75235

F 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few by regional Director of Operations, Regional Nurse Consultant and Regional Social Service Director on safe resident discharge process, the education was followed by a post test on 10/29/2025. All IDT members who were not present at the facility at the time of the education were educated and completed a post test over the phone. Education was initiated and completed on 10/29/2025.8. Charge nurses were educated by ADON's on safe resident discharge process; the education was followed by a post test. All nurses who were not present at the facility at the time of the education were educated ADON's and completed a post test over the phone. Education was initiated and completed on 10/29/2025.9. New staff will receive this training during onboarding and annually thereafter from the Administrator/DON or designee.10. No IDT team members or charge nurses will be allowed to work until they complete education on safe resident discharge. Training will be completed by the DON or designee. In-Services conducted: Initiated and completed 10/29/20251. Resident safe discharge process: All IDT team members and charge nurses. Training conducted by Regional Nurse Consultant, Regional Director of Operations and Regional Social service Director. Each IDT team member and charge nurse also completed post test.2. Discharge Safety Verification Checklist: All IDT team members. Training conducted by Regional Nurse Consultant, Regional Director of Operations and Regional Social service Director. Each IDT team member and charge nurse also completed post test.11. No IDT team members or charge nurses will be allowed to work until they complete this education. Training will be completed by the DON or designee.Implementation of changes:A new Discharge Safety Verification Checklist will be completed with on all resident discharges. Each IDT member will check and sign off on this verification checklist before any resident discharges from the facility.Checklist requires verification of:- Reason for discharge- Interdisciplinary Team (IDT) Involvement- Placement and safety verification- Notice and documentation- Resident Preparation- Final IDT review and Authorization.Each IDT team member or designee will document in PCC under progress notes to include information relevant to their disciplines on discharge planning. Form will be managed by the social worker in a binder stored behind the 1st floor nurses station and accessible to the IDT members. Completed discharge verification checklist form will be uploaded to PCC and verified by the Regional Director of Operations and Regional Nurse Consultant.Monitoring Effective 10/29/2025, Each resident discharge will be reviewed and a Discharge Safety Verification Checklist completed by the IDT team members daily (Monday through Friday) and by the weekend supervisor during the weekends. The discharge safety verification checklist will be emailed to the Regional Director of Operations, Regional Nurse Consultant and Regional Social Service Director for review and approval before any resident discharges.Monitoring and review for approval will continue with each scheduled discharge for two months and then periodically thereafter.Involvement of Medical Directorhe Medical Director met with the Interdisciplinary team on 10/29/2025 and conducted an Ad HOC QAPI regarding safe resident discharge process. The Medical Director was notified about the immediate Jeopardy on 10/29/2025, the Plan of removal was reviewed and accepted by the Medical Director on 10/29/2025.Who is responsible for implementation of process? The Regional Director of Operations (RDO) and Regional Nurse Worker (RNC) will be responsible for the implementation and monitoring of the new process. RDO and RNC will review scheduled discharges with social worker Daily x4 weeks, bi-weekly x4 weeks and monthly thereafter to monitor for process implementation. The New Process/system was started on 10/29/2025.Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued 10/29/2025. Monitoring of the plan of removal included:Administrator Termination effective on 10/29/2025, verified via nursing facility employee termination form.Observation of Resident #1 readmitted at the facility on 10/29/25 at 12:56pmRecord review of a one-on-one in-service titled Resident Safe Discharge, dated10/29/2025 reflected Social Worker was educated by 676293 Page 5 of 6 676293 10/30/2025 Forest Park Nursing & Rehabilitation 6825 Harry Hines Blvd Dallas, TX 75235

F 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Regional Area of DirectorRecord review of in-service titled Discharge planning process - Safe discharge, dated 10/29/25 reflected the DON and 2 ADONS were educated by the Regional Nurse Record review of in-service titled on Discharge Process - Safe Discharge Planning, dated 10/29/25 reflected the facility IDT staff members (Social Worker, Human Resources, Admissions, Director of Rehabilitation, 2 MDS coordinators, medical records, dietary Manager, staffing and central supply and 2 ADONs) were educated by Regional Nurse, Area Director and Regional Social Worker Record review of the IDT posttest on discharge process reflected they had 100% accuracy.Record review of in-service titled Discharge Instructions, Compliance, Regulations, dated 10/29/25, reflected 18 Licensed Nurses were educated by Regional NurseRecord review of 30-Day Discharges revealed no other residents were discharged to the homeless shelter. Record review of facility discharge audit dated 10/29/25, reflected no other residents were discharged to an unsafe location. Record review of the AD HOC QA meeting held on 10/29/25 reflected the meeting consisted of RDO, RCN, RSW, DON, MDS, Medical Director, and DORInterview with the DON, on 10/30/25 at 10:19 a.m., The DON stated that she was not aware that Resident #1 did not discharge home with his family member until his parole officer called a week later. The DON stated that she was a member of the IDT and was present for the meeting but did not recall a discussion for Resident #1 to go to a shelter. The DON stated that her role in the IDT was to ensure that the location for the residents was safe and that the location could provide the medical care requirements for each resident and she did not recall an IDT meeting to discuss Resident #1 going to a shelter. The DON thought Resident #1 had discharged his to his family member house planned. Interview with the RDO on 10/30/25 at 11:15 a.m., he stated he trained the SW on the discharge planning process and documentation. Additionally, the RDO stated that the RCN and RSW re-educated the IDT team on discharge process and safe discharges. This was verified via record review of social service in-service dated 10/29/25.An interview with the RCN on 10/30/25 at 11:30 a.m., she stated she had trained the DON, ADON A and ADON B on the discharge planning process and documentation. This was verified via record review of IDT training in-service dated 10/29/25. During an interview on 10/30/25 at 12:20 p.m., Resident #2's family member revealed that the discharge process at the facility went smooth, the SW has set up home health and only thing left to do was pick up Resident #2. This was verified via record review that the SW had placed order for home health.Interviews held on 10/30/25 from 1:11 p.m., to 5:45 p.m. which covered staff who work morning, day, night shifts, PRN staff and double weekend staff conducted with the DON, ADON A (Sunday through Thursday), ADON B (Tuesday through Saturday), LVN C (1st shift/weekdays), LVN D (weekdays), LVN E (PRN), LVN F (overnight/morning), LVN G (overnight/morning), LVN H (double weekends), LVN I (Overnight), LVN J (morning), LVN K (second shift), LVN L (second shift), MDS N, MDS O, and DOR indicated they all participated in in-services on Discharge Process - Safe Discharge, documentation and proficiency test prior to starting their shifts. All staff knew their responsibilities. All staff were knowledgeable, who were a part of the IDT. All staff were able to state that the facility's discharge process to ensure all residents' discharges were safe, all know what was required to be documented and who was responsible for each task and understood that the ADO and RCN would oversee the entire process to make sure it was complete.The ADM, RDO and RCN were notified that the IJ was removed on 10/29/2025 at 3:38 p.m. The facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. 676293 Page 6 of 6