Health inspection·May 15, 2025

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 establish and 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 1 of 2 (MA B) staff members and 2 of 5 residents (Residents #50 and #38) reviewed for infection control procedures. Residents Affected - Some MA B failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #50 and #38. Facility staff failed to clean up the dirty soiled linens and clothing out of the shower room on Hall 200. These failures could place residents at risk for cross contamination and infections. Findings included: Record review of Resident #50's other type of payment MDS assessment, dated 03/30/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #50 had diagnoses which included: Cardiovascular accident (stroke), and hypertension (high blood pressure). Resident #50 was moderate cognitive impaired and unable to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #50's physician orders dated 04/01/25 reflected, Aldactone tablet (high blood pressure) 50 mg give one tablet by mouth one time a day, amlodipine (high blood pressure) 10 mg one tablet by mouth one time a day, coreg (high blood pressure) 25 mg one tablet by mouth two times a day, hydralazine (high blood pressure) 100 mg one tablet by mouth three times a day, lisinopril (high blood pressure) 40 mg one tablet by mouth one time a day, and to obtain blood pressure one time a day on each shift. Record review of Resident #38's other type of payment MDS Assessment, dated 03/16/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #38 had diagnoses which included: congestive obstructive pulmonary disease (lungs do not function well), hypertension (increased blood pressure). Resident #38 was cognitively intact and able to make all decisions for herself and required one staff for assistance with activities of daily living. Record review of Resident #38s physician orders dated 04/01/2025 (open ended) reflected, amlodipine (high blood pressure) 5 mg give one tablet by mouth two times a day, carvedilol (high blood pressure) 20 mg give one tablet by mouth one time a day, and enalapril (high blood pressure) 25 mg give one tablet by mouth one time a day. Obtain blood pressure one time a day on each shift. Observation on 05/13/2025 at 10:10 a.m. revealed in the shower room on Hall 200 there were two soiled towels with brown liquids stains on both towels, and two flat sheet linens, one that was underneath the shower chair, wet and one flat sheet lying on the floor. There was a shirt with stains on the front of it and a pair of dark pants on the floor. There was a soiled brief on the floor of the shower stall. Observation on 05/13/2025 at 11:45 a.m., revealed MA B performing morning medication pass, during (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676326 If continuation sheet Page 2 of 6 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 676326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Rehabilitation and Care Center 1101 Windbell Dr Mesquite, TX 75149 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 which time she checked the blood pressure on Resident #50. MA B failed to sanitize the blood pressure cuff before or after using it on Resident #50. Observation on 05/13/2025 at 11:55 a.m., revealed MA B performing morning medication pass, during which time she checked the blood pressure, on Resident #38, using the same blood pressure cuff used on Resident #50. MA B failed to sanitize the blood pressure cuff before or after using it on Resident #38. In an interview on 05/13/2025 at 12:30 p.m., MA B stated she did not think about cleaning the blood pressure cuff between usage, and she had been in-serviced on that. MA B stated if the cuff was on the residents and then not cleaned it could spread germs to others. Observation and interview on 05/13/2025 at 10:30 a.m. revealed CNA C entered the shower room. CNA C excited the shower room and retrieved a bag, placing all the dirty linens and clothing in the bag. CNA C took the bag to the dirty linen room placing the linens and the dirty clothing in the barrel, removing her gloves then washing her hands. CNA C stated that not everyone that works there will clean up after themselves. CNA C stated that is not right and they are supposed to clean up after they have given a shower and changed the resident. CNA C stated she had no idea who had left the shower that way, but they were taught to clean up because it could cause spreading of germs. The CNA stated this is part of the infection control in-service they have one time a month. In an interview with the DON, who was the infection control preventionist on 05/15/2025 at 10:39 a.m., the DON stated that all direct care staff must clean equipment, including blood pressure cuffs after having contact with each resident. The DON stated, the staff has available the disinfectant wipes that will kill all germs. The DON stated when a staff member uses the shower rooms, they should always remove all the dirty linens and the dirty clothing when they are done. The staff should leave the shower room clean and organized after each resident they assist. The DON stated she had just had an in-service on 04/25/2025 concerning all of this, presenting step by step the cleaning of equipment and infection control. The DON stated during the in-service the staff did not ask any questions and appeared to understand and indicated they knew everything. The DON stated if they do not clean the blood pressure cuffs appropriately and clean the shower rooms after each use when they should, they could spread germs to themselves and the residents. Record review of an in-service log dated 04/25/2025 revealed entire direct care staff and MA B, had received in-service on cleaning and properly storing equipment after each use and how to prevent the spread of infection, including cleaning shower rooms and dirty linens. Record review of the Facility's Policy titled Infection Prevention and Control Policies and Procedures dated May 2023, reflected: Subject: Infection Prevention and Control Program and Plan Purpose: To establish a facility wide program that incorporates a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. The program covers all residents, staff, consultants, students . volunteers, visitors and other individuals providing services . subject: Infection Prevention and Control Program and Plan: . Staff Development 6) proper handling of linens, waste, equipment and supplies . 10) cleaning, disinfecting and sanitation procedures . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676326 If continuation sheet Page 3 of 6 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 676326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Rehabilitation and Care Center 1101 Windbell Dr Mesquite, TX 75149 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for four hallways, (halls: 100, 200, 300, and 400) of five and the activities room, outside one public bathroom of two, Assistant Director of Nursing Office, Maintenance entrance and conference room, reviewed for physical environment. 1. The facility failed to ensure the facility carpet was clean and in good repair. These failures could affect all residents. Findings included: Observation on 05/14/2025 at 1:00 p.m. revealed a large dark stain, the size of two footballs, on the carpet between the fire doors on Hall 100. Observation on 05/14/2025 at 1:02 p.m. revealed a white stain, the size of a baseball on the carpet near the doorway of room [ROOM NUMBER]. Observation on 05/14/2025 at 1:03 p.m. revealed a dark stain approximately 3 feet in length on the carpet between room [ROOM NUMBER] and room [ROOM NUMBER]. Observation on 05/14/2025 at 1:04 p.m. revealed a red stain, the size of a golf ball on the carpet outside of room [ROOM NUMBER]'s doorway. Observation on 05/14/2025 at 1:05 p.m. revealed a dark stain, the size of a baseball, on the carpet outside of room [ROOM NUMBER]'s doorway. Observation on 05/14/2025 at 1:29 p.m. revealed at the entrance to the assisted dining room the carpet was frayed at the doorway with a large dark stain the size of a football outside the doorway. Observation on 05/14/2025 at 1:35 p.m. revealed multiple dark stains, some the size of a watermelon, others the size of oranges, on the carpet throughout the entire nurse station for Halls 100 and 200. Observation on 05/14/2025 at 1:30 p.m. revealed a large dark stain on the carpet the size of a baseball to the entrance of the employee's lounge near the nurses station for halls 100 and 200. Observation on 05/14/2025 at 1:32 p.m. revealed a dark stain on the carpet the size of a football near the Assistant Director of Nurse's office window. Observation on 05/14/2025 at 1:35 p.m. revealed in the activities and television room across from the main dining room, the carpet in front of the couch had multiple white stains the size of golf balls. Further observations revealed multiple white stains in front of the chairs next to the couch and under the gaming table in the room. Observation on 05/14/2025 at 1:36 p.m. revealed a seam in the carpet, behind the couch in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676326 If continuation sheet Page 4 of 6 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 676326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Rehabilitation and Care Center 1101 Windbell Dr Mesquite, TX 75149 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 0921 activities room was frayed the entire length of the seam, running the width of the room. Level of Harm - Minimal harm or potential for actual harm Observation on 05/14/2025 at 1:38 p.m. revealed the carpet leading to the maintenance room had multiple white stains, the size of eggs on the carpet leading to the doorway. Residents Affected - Some Observation on 05/14/2025 at 1:37 p.m. revealed the carpet inside the nurse's station for halls 300 and 400 was dark with multiple stains, and the carpet was loose with rolls of carpet. The carpet was frayed at the entrance to the medication room and frayed at the door to the medication room. Observation on 05/14/2025 at 1:40 p.m. revealed in the television room on halls 300 and 400 a large brown stain, the size of a watermelon, on the carpet in the middle of the room, near the couch. Observation on 05/14/2025 at 2:00 p.m. revealed a large stain, the size of a football, on the carpet at the entrance to hall 300, near the fire doors. Observation on 05/14/2025 at 2:05 p.m. revealed a large stain on the carpet, the size of a football, to the entrance of hall 400 at the fire doors. Observation on 05/14/2025 at 2:06 p.m. revealed a long brown stain approximately 2 feet in length, on the carpet between rooms [ROOM NUMBERS]. Observation on 05/14/2025 at 2:07 p.m. revealed frayed carpet on hall 400 leading into the laminated floor area of resident doorways. Observation on 05/14/2205 at 2:39 p.m. revealed a large dark stain, the size of a football, outside of the door to the public bathroom in the foyer. Observation on 05/14/2025 at 2:40 p.m. revealed multiple large dark stains in the conference room. Stains were at the doorway and entrance to the conference room. The stains were located next to the conference room table. An interview on 05/15/2025 at 11:07 a.m. with the Administrator revealed the Maintenance Director, was responsible for cleaning the carpet and he had just cleaned the carpet last week. The Administrator stated that some of the stains were permanent and probably could not be removed. The Administrator stated he realized that the carpet was old and worn in some areas and needed to be replaced. An interview on 05/15/2025 at 11:42 a.m. with the Maintenance Director revealed he was responsible for the cleaning of the carpet. He stated he had just cleaned the carpet last week, using his carpet cleaning machine. The Maintenance Director stated he could not get some of the stains that were in the carpet out. The Maintenance Director stated he had spoken to the Administrator about the carpet and the permanent spots in the carpet. The Maintenance Director stated he knew it did not look clean in some areas, but he had done what he could for the carpet. Review of the facility policy Maintenance/Housekeeping Policies and Procedures, dated March 2006, reflected: Carpet Maintenance this guide to carpet maintenance explains the necessary system and procedures required to develop and maintain an efficient and effective carpet maintenance program . Maintenance is especially important to consider since the ultimate cost of a carpet installation is determined more by the years of service the carpet provides rather than its initial cost to the facility, and it's contribution to the appearance and ambiance of the area it is used in .Spot and Stain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676326 If continuation sheet Page 5 of 6 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 676326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Rehabilitation and Care Center 1101 Windbell Dr Mesquite, TX 75149 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 0921 Removal the rapid removal of spots and spills is essential in preventing permanent staining of carpet Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676326 If continuation sheet Page 6 of 6