Health inspection·October 12, 2023

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 10/12/23 at 03:17 pm with the DON revealed there was a miscommunication with the nurses on the process to get the baseline care plans completed and the process should be the charge nurses are the ones who should be opening them and the MDS nurse checked to makes sure they were completed and accurate. She stated the potential harm to the resident if the care plans were missing could be the plan of care could be missed and not followed. She stated the cause of them missing could be related to the transition to a new EMR system and her expectations is that the care plans are accurate and completed. Interview on 10/12/23 at 04:13 pm with the Administrator revealed the breakdown in the baseline care plans had been brought to his attention today(10/12/23).He stated another MDS nurse will start on 11/01/23 to help with the volume of resident charts that need to be reviewed. He stated his expectation is that the care plans are completed on time and accurately. Record review of facilities policy titled Care Plans- Baseline revealed a baseline plan of care is completed to meet the resident within forty-eight hours of admission. To assure that the residents immediate care needs are met and maintained, a baseline care plan will be developed within 48 hours of the resident's admission and include: initial goals based on admission orders, physician orders, dietary orders, therapy services, social services and PASARR recommendations if applicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676335 If continuation sheet Page 2 of 20 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 676335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 out of 4 residents reviewed. (Resident #133, Resident # 57, and Resident #33) The facility failed to develop person centered care plans for antibiotic use, medical management of seizure disorder, anxiety, depression and fall prevention for Resident #133. The facility failed to develop interventions/tasks within the person-centered care plans for hypothyroid disease, depression, malnutrition, and shortness of breath. They also failed to develop care plans for medical management of insomnia and allergy to penicillin for Resident # 57. The facility failed to develop person centered care plans for medical management of depression, insomnia, NPO status (nothing by mouth), fall prevention, and allergies to Droperidol, Hydralazine., Ativan, Compazine, Relpax, Topamax, Toradol, Penicillin, Sulfonamide, and wasp venom for Resident #49. The facility failed to develop person centered care plans for medical management of depression, oxygen use, specialized diet, and antibiotic use for Resident #33. This failure could place residents at risk of residents not receiving individualized care to maintain the resident's highest level of practicable physical, mental, and psychosocial wellbeing. Findings included: 1.Record review of Resident # 133's admission MDS dated [DATE] revealed she was a [AGE] year-old female admitted on [DATE]. She had a diagnosis of Diabetes Mellitus (high blood sugar), hypertension (high blood pressure), Cerebral Vascular Accident (stroke) and seizure disorder. She had a BIMS of 6 (severe cognitive impairment). She required the use of a walker and or wheelchair and moderate assistance with ADLs. Record review of Resident # 133's physician order summary dated 10/03/23 revealed the following orders: *Buspirone HCl tablet 5mg give 1 tablet by mouth three times a day for anxiety with a start date of 10/06/23. *Carbamazepine tablet 200mg give 1 tablet by mouth two times a day for seizures with a start date of 10/04/23, *Ceftriaxone sodium intravenous solution reconstituted 2gm one time a day for infection until 11/08/23 with a start date of 10/04/23. *Escitalopram 10mg tablet give 1.5 tablet by mouth one time a day for depression/anxiety 1.5 tab = 15mg with a start date of 10/12/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676335 If continuation sheet Page 3 of 20 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 676335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm *Levetiracetam 750mg tablet give 2 tabs by mouth wo times a day for seizures 2 tabs =1500mg with a start date of 10/04/23. Record review of Resident #133's care plans dated 10/11/23 revealed there was no care plans for medical management of antibiotic use, seizures, anxiety, depression or fall prevention. Residents Affected - Some 2. Record review of Resident #57's Quarterly MDS dated [DATE] revealed he was a [AGE] year old male admitted on [DATE]. He has a diagnosis of hypertension (high blood pressure), Dementia, anxiety, depression, insomnia, Obstructive sleep apnea, malnutrition, and hypothyroidism. He had a BIMS of 6 (severe cognitive impairment). He required the use of a walker and or wheelchair, a CPAP (continuous positive airway pressure) at night and limited assistance with ADLS. Record review of Resident #57's physician order summary dated 10/01/23 revealed the following orders: *Mirtazapine 15mg disintegrating tablet give 1 tablet at bedtime or appetite stimulant with a start date of 10/06/23. *Trazodone HCl 50mg give 0.5 tablet by mouth at bedtime for insomnia with a start date of 10/06/23. Record review of Resident #57s care plan dated 09/22/23 revealed a care area for hypothyroidism initiated on 09/22/23 revealed there were no goals or interventions. Further review revealed the care areas depression, malnutrition, and shortness of breath initiated on 09/22/23 revealed there were no interventions. There was no care area for the medical management of insomnia or allergy to penicillin. 3.Record review of Resident #33's Quarterly MDS dated [DATE] revealed he was a [AGE] year old male admitted on [DATE]. He had a diagnosis of coronary artery disease, hypertension (high blood pressure), pneumonia, MDRO (multidrug resistant organism), urinary tract infection, and generalized muscle weakness. He had a BIMS of 6 (severe cognitive impairment). He required the use of a wheelchair, extensive assistance, and oxygen therapy. Record review of Resident # 33's physician order summary dated 10/01/23 revealed he had the following orders: *No salt on tray, puree texture, regular/thin consistency, no straws. *May have oxygen at 2-4 liters per minute related to shortness of breath as needed with a start date of 10/03/23. *Cefuroxime Axetil oral tablet 500mg give 1 tablet by mouth two times a day for pneumonia for 10 days with a start date of 10/05/23. *Celexa oral tablet 20mg give 1 tablet by mouth one time a day for depression with a start date of 10/10/23. Record review of Resident #33's care plans dated 10/06/23 revealed there was no care plans for medical management of antibiotics use, depression, oxygen use, or specialized diet. 4. Interview on 10/11/23 at 05:53pm with CNA L revealed that they have access in their charting to see interventions on how to care for the residents. Some examples of information found were how to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676335 If continuation sheet Page 4 of 20 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 676335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some transfer the resident, if they need help eating, and any specialized care needs. She stated this information was pulled from the resident's care plans. Interview on 10/11/23 at 06:30 pm with LVN M revealed the care plans are done by the DON and or the MDS nurse. He stated the charge nurses do not do the care plans, but they do look at them to see how to care for the residents. He also stated the care plans include information on how to care for that resident specifically. If there were missing care plans, it could lead to missing the proper care of the resident. Interview on 10/12/23 at 12:04 pm with RN H revealed the MDS nurse does the comprehensive care plans during reviews and then as needed. The importance of the care plans are so all the nurses can see how to care for the resident the best way. She also stated that if there were missing care plans then the residents might not get the care they should be getting. Interview on 10/12/23 at 12:44 pm with MDS coordinator I revealed she was responsible for doing the comprehensive care plans. She stated all the care plans are in the EMR and if they were not there then they were probably missed. She stated there should be a care plan for all medical diagnosis and specialized medications so that the residents can be properly monitored and to ensure that the care plans were person centered. She stated if there were missing care plans that the potential harm to the residents could be missing interventions to protect the residents. She was unsure why Resident #133, Resident #57, and Resident 33's care plans are not complete. Interview on 10/12/23 at 03:17 pm with the DON revealed the MDS nurse was the one who was responsible for completing the comprehensive care plans. She stated the care plans should include an inclusive look at the residents care some examples were fall prevention, dietary orders, specialized medication such as antibiotics and psychotropic, allergies, and specific medical equipment use. She stated the potential harm to the resident if the care plans were missing could be the plan of care could be missed and not followed. She stated the cause of them missing could be related to the transition to a new electronic medical record system and her expectations was that the care plans are accurate and completed. Interview on 10/12/23 at 04:13 pm with the Administrator revealed the breakdown in the care plans had been [NAME] to his attention today, they have another MDS nurse starting on 11/01/23 to help with the volume of resident charts that need to be reviewed. He stated his expectation was that the care plans are completed on time and accurately. Record review of facilities policy titled Care Plans, Comprehensive Person-Centered revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive person-centered care plan is developed within seven days of the completion of the required comprehensive assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676335 If continuation sheet Page 5 of 20 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 676335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible and received adequate supervision for 3 residents (#8, #36 and #37) of 10 residents reviewed for supervision. The facility failed to have adequate staff supervision in the 300 hall Tea/Bistro room and main dining room, to ensure the pureed and mechanically soft diet residents were not at risk of getting or receiving solid foods from the snack stands. This failure could potentially place residents at risk of eating food not doctor ordered and unsafe for them to eat and drink, which could cause them to choke or aspirate, resulting in a decreased quality of life and psycho-social well-being. Findings included: Resident #8's Quarterly MDS assessment dated [DATE] revealed an [AGE] year old female who admitted on [DATE] her BIMS Score was 03 (severely impaired cognition), extensive one person assistance for eating and upper extremity impairment on one side, used a wheelchair .diagnoses of hypertension, diabetes mellites, aphasia, CVA, Non Alzheimer's Dementia, hemiplegia/hemiparesis, malnutrition and dysphagia with a swallowing disorder: coughing or choking during meals .complaints of difficulty or pain with swallowing with a mechanically altered diet . Record review of Resident #8's Diet order dated 08/29/23 revealed, Enhanced Diet: Pureed texture, regular/thin consistency. Record review of Resident #8's Care Plan dated 10/12/23 revealed the residents care areas: Difficulty making own decisions: please approach from the front in calm, unhurried manner, give verbal cues/reminders when cannot remember .Hypertension: monitor for signs/symptoms of headache, gastrointestinal distress .Hyperlipidemia: monitor for serious side effects headache, fatigue irregular heart rate .ADL assistance: give verbal cues to help prompt .Aphasia: allow a making wants/needs known, allow ample time for residents to respond to what is asked, anticipate needs .Difficulty swallowing: supervise for all oral intake, thicken all my liquids to nectar consistency, remind to tuck chin when swallowing .On pureed diet: diet as order, Monitor meal intake and right side weakness: assess for signs of decreased tissue perfusion. Resident #36's Quarterly MDS assessment dated [DATE] revealed an [AGE] year old female who admitted [DATE] and as of this assessment her BIMS score was 03 (severely impaired cognition), limited one person assistance for eating and upper extremity impairment on one side, used a wheelchair .with diagnoses hypertension, hyperlipidemia, CVA, non - Alzheimer's Dementia, hemiplegia/hemiparesis, malnutrition, depression .loss of liquids/solids from mouth when eating and drinking and coughing or choking during meals. Record review of Resident #36's Diet order dated 09/25/23 revealed, Enhanced Diet: Mechanical soft texture, regular/thin consistency Record review of Resident #36's Care Plan dated 10/12/23 revealed, Dysphagia: Supervise all of my (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676335 If continuation sheet Page 6 of 20 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 676335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few oral intake, thicken my liquids .staff assist for ADL's: Observe resident for pain .Mechanical soft diet order: Monitor food intake and document, assist in eating as needed .Hypertension: Monitor blood pressure as ordered. Resident #37's Quarterly MDS assessment dated [DATE] revealed an [AGE] year old female who admitted [DATE] and as of this assessment her BIMS score was 08 (Moderate impaired cognition) with supervision with setup assist with eating, no upper extremity impairment with use of a walker and wheelchair .diagnoses hypertension, peripheral vascular disease, hyperlipidemia, non- Alzheimer's dementia, malnutrition, dysphagia and swallowing disorder: holding food in mouth/cheek or residual food in mouth after meals. Record review of Resident #37s Diet order dated 09/25/23 revealed, Enhanced Diet: Pureed texture, honey/moderately thick consistency. May have snacks 3 x daily magic cup 3 x daily. Resident #37's Care plan dated 10/12/23 revealed, ADL self-care performance deficit related to dementia: Eating: the resident requires supervision by x1 staff to eat .Dysphagia: monitor/document circumstances surrounding mealtimes/refusals to eat .Impaired cognitive function/dementia or impaired thought processes related to dementia: cue, reorient and supervise as needed .hypertension: Monitor for and document any edema .GERD: avoid coffee, fatty foods, chocolate, citrus juices, [NAME], tomato products .Swallowing problem related to complaints of difficulty or pain with swallowing, coughing, choking during meals: all staff to be informed of resident's special dietary and safety needs, check mouth after meal for pocketed food and debris, resident to eat only with supervision. Observation on 10/10/23 at 11:09 am, in the 300 hall Tea/Bistro room, Residents #8, #36 and #37 were sitting at the tables approximately 3 to 4 feet away from the 3 tier snack stand which had bananas, apples, granola bars and cereal packs on it; and a coffee dispenser was next to it. A female Resident (who had a regular diet order) used a walker to ambulate, went to one of the tables and began to consume her food and drink in front of the other residents and no staff was present watching them. Observation on 10/10/23 at 1:20 pm, in the dining room, there was a 3 tier snack stand with bananas, apples, granola bars and cereal and a coffee dispenser was located on the countertop. Resident #37 was sitting in her wheelchair at a dining room table, by herself approximately 5 feet way from the snack stand and coffee dispenser. Resident #37 was looking around the dining room, looking at the table and chairs and there was no staff watching this resident. Observation on 10/10/23 at 4:15 pm, in the 300 hall Tea/Bistro room there were snacks on the 3-tier snack stand and a coffee dispenser was on the counter. A female resident (who had a regular diet order) was eating a banana with a drink in front of Residents #8 and #36 who were watching tv and no staff was present in the room watching them. Observation on 10/11/23 at 9:15 am, in the 300 hall Tea/Bistro room, there were snacks and a coffee dispenser, and a female resident (who had a regular thin liquid diet order) was standing at the snack stand and walked to a table with a drink in her hand and sat down and started drinking it in front of Residents #36 and #37 present and there was no staff around watching them. Observation on 10/11/23 at 10:30 am, in the 300 hall Tea/Bistro room, Residents #8, #36 and #37 was sitting 3 to 4 feet away from the snack stand with 7 apples, 3 bunches of bananas and a coffee dispenser. And a male resident (who had a regular thin liquid diet order) and ambulated with a walker, was getting a cup of coffee and started drinking it in front of the residents and there was no any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676335 If continuation sheet Page 7 of 20 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 676335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032 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 0689 Level of Harm - Minimal harm or potential for actual harm staff in the room watching the residents. The snacks were at counter height, within arms reach of the residents. Observation on 10/12/23 at 8:55 am, in the Tea/Bistro room Residents #8, #36 and #37 were sitting in their wheelchairs watching Television and they were not interviewable. Residents Affected - Few Interview on 10/11/23 at 2:37 pm, CNA A stated the dietary department filled the snack stand in the dining room and Tea/Bistro room between 6:00 am or 7:00 am and anyone could get those snacks. She stated they were good about watching the residents in the Tea/Bistro room and dining room, while they were at the nurses' station and walking down the halls, they checked on them. She stated normally the mechanical soft and pureed diet residents did not try to get to the food on the snack stand. Interview on 10/11/23 at 2:55 pm, LVN B stated the snack stands had been in the Tea/Bistro and dining rooms for the past four months she worked at this facility. She stated there was no staff in the Tea/Bistro room at all times when the residents were in there. She stated their eyes could not be everywhere all the time if they were busy they might miss something. She stated if a resident was to get a snack from the snack bar a resident could choke if they were not supposed to eat regular diet consistency food. Interview on 10/11/23 at 4:32 pm, the Dietary Director stated the snacks in the dining room and both Tea/Bistro rooms were always available, which consisted of oranges, apples, peanut butter crackers, apple sauce cups and [NAME] buddy. She stated normally the CNA's watched the residents eating the snacks. But today she was told by her boss to remove the snacks for now and put them out at the nurses station. She stated the snacks being available for anyone to get was not a good idea. She stated if a resident were to get fruit and they were on a pureed diet that would be a choking hazard. She stated she made her staff pickup all of the snack trays until they figured out what to do with them and wanted to put the snacks out the right way. She stated Dietary Aides C and D removed the snacks from the 2 tea/bistro rooms and dining room today (10/11/23) and took them to the nurses' stations to better monitor who was getting what snacks. She stated the CNA's and nurses were responsible for monitoring to ensure the residents were not getting the wrong snacks to eat. Interview on 10/11/23 at 4:56 pm, the DON stated the snack stands usually had crackers, graham crackers that were always out and available for the residents to consume. She stated there were no staff monitoring who was eating in those snack areas when snacks were put out daily and said she really did not have an answer with how they ensured the staff monitored the residents from getting the snacks they were not supposed to get. She stated as of today the snacks were removed from the snack stands in the main dining room and both Tea/Bistro rooms. She stated anybody with any diet order could choke and stated she would look at the policy and get back with the surveyor to clarify. She stated the nurses and CNAs monitored the meal services but not all the time in the tea rooms and dining room and stated now the snacks were kept at the nurses station. She stated her expectation for snack services was for it to be done accordingly. Interview on 10/12/23 at 10:37 am, CNA E stated they used to have snacks in the Tea/Bistro room like graham crackers, apples, granola bars, oatmeal, [NAME] buddies, Oreo cookies, apple sauce that was put out in the mornings for any residents could get who could walk. She stated Residents #8, #36 and #37 were on pureed diets and liked to go to the Tea/Bistro room. She stated she had not ever seen the residents that were pureed and mechanical soft diets trying to get the snacks, and she told them they could not have the snacks by redirecting them because they could choke or stop breathing if they ate the wrong types of food. She stated there were times no staff watched the residents in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676335 If continuation sheet Page 8 of 20 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 676335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032 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 0689 Tea/Bistro room but said they checked on the residents often, like Resident #8, every two hours. Level of Harm - Minimal harm or potential for actual harm Interview on 10/12/23 at 11:01 am, Dietary Aide F stated they used to put graham crackers, apples, fruits, peanut butter crackers, pudding and oranges on the snack stands. But stated as of today (10/12/23) the Dietary Director told them they could not put out snacks on the snack stands any longer. He stated the Dietary Director was concerned a pureed person would eat the wrong snacks, and choke. He stated the snacks were currently being taken to the nurses' station to give to the residents. Residents Affected - Few Interview on 10/12/23 at 11:11 am, [NAME] G stated they put snack bars, chips, [NAME] buddy bars, oatmeal pies, apple sauce, bananas, peanut butter crackers and granola bars out daily around 6:00 am and at 12:00 pm and again around 6:45 pm. He stated the nursing department should be watching the residents in the Tea/Bistro room at all times for the resident's safety. He stated if a resident with a pureed diet could choke on the food on the snack stand if they took them or was given to them. Interview on 10/12/23 at 11:22 am, LVN B stated Residents #8 and #37 were on pureed diets, and Resident #36 was on a mechanical soft diet went to the main dining room for meals with the nursing staff present. She stated in the Tea/Bistro room there was no specific person watching the residents, but they often looked in there. She stated they monitored the residents often as she was doing her nursing tasks. She stated they have snack stands in the main dining room and Tea/Bistro room and not ever seen the pureed residents eating the snacks from the snack stands but it they did they could choke or aspirate. Interview on 10/12/23 at 11:43 am, RN H stated Residents #8, #36 and #37 were on pureed diets and also went to many of the activities and in the tea for activities in the morning. She stated #37 could feed herself and Residents #8 and #36 needed staff assist with meals. She stated staff were not always in the Tea/Bistro room, but she worked by the Station #1 and kept an eye on the residents. She stated she never saw the residents with pureed and mechanical soft diets get snacks from the snack stand or residents in their right mind give them snacks. She stated if she saw that she would take the food or drink from the resident and give them something like apple sauce to eat. She stated the residents were at risk of choking if they ate the wrong type of food. She stated the residents with pureed and mechanical diets could not reach the snack bar because the countertop was high. Interview on 10/12/23 at 12:32 pm MDS Coordinator I, stated she did not see an issue with the snacks being in the Tea/Bistro room and main dining room because a nurse would see them and stop them if a resident grabbed the wrong type of food. She stated there was no staff in the actual room the entire time the residents were in the Tea/Bistro room, but the nurses watched them from the nurses' station, when they were at the nurses station. She stated she was not sure who watched the residents when the nurses left the nurses station and stated the staff was not able to watch the residents in the tea/bistro room all the time because of doing patient care in rooms. She stated if a Resident had a pureed diet and ate an apple or banana they could choke and could be harmful and the resident could choke to death. She stated the snack stands were no longer in the main dining room and Tea/Bistro rooms and was not sure why. Interview on 10/12/23 at 3:24 pm, the DON stated the CNAs and nurses monitored the residents in the Tea/Bistro room often and the CNAs knew what the residents diet orders were and if they did not, they could ask the nurse. She stated the resident's snacks were now being stored in the nutrition room for the staff to give to the residents. Interview on 10/12/23 at 3:48 pm, the Administrator stated they had three snack stands with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676335 If continuation sheet Page 9 of 20 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 676335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few variety of snacks on them, two were in the Tea/bistro rooms and one was in the main dining room and stated the snacks were no longer in those areas and added after review they planned to put them back out. He stated the Dietary Manager removed them because the HHSC Surveyor said something about them. He stated there was no concern about the residents with pureed diets getting to the snack stand and did not think anyone would give a person a banana unless it was mashed for a resident with a mechanical soft diet. He stated they did not always have staff in the tea/bistro rooms monitoring what snacks and drinks the residents were getting from the snack stand and was not sure if the residents with pureed and mechanical soft diets were even in the bistros. He stated it was a group effort among the nurses and CNA's to ensuring the residents did not get the wrong types of snacks. He stated ultimately the ADON and DON were responsible for ensuring the residents were not getting the wrong types of foods. Interview on 10/12/23 at 4:06 pm, the Dietary director stated she did an Inservice training with the dietary staff today 10/12/23 for them to put the resident's snacks behind the nurses station so the snacks would not be out for all the residents to possibly get to. She stated after they put out the snacks it was out of her hands, and they were nurses responsibility to watch what food the residents ate. Interview on 10/12/23 at 4:13 pm, Dietary Aide D stated he had an Inservice training yesterday 10/11/23 about making sure the resident's snacks were put behind the nurses' station now. He stated the snacks went behind the nurses' station now because the Residents had different diet orders. He stated what if a resident had a different order from what was on the snack stand and was not supposed to eat it, they could choke. Interview on 10/13/23 at 12:49 pm, the Facility's Ombudsman stated unattended snacks was not a good idea if the staff were not monitoring which residents was getting snacks from the snack stands in the Tea/Bistro and Dining room. She stated she saw the snack stands in the tea/bistro rooms and said typically it was nice to have available snack stands, but if the residents had dietary restrictions and somehow got snacks they should not get, could cause a problem if the resident was not to have them. She stated the nurses could see who was getting the snacks better if they were at the nurses' station to ensure the snacks were given to the right residents. She stated at most facility's they usually stored snacks in a refrigerator, and the staff passed the snacks out to the residents. She stated it was better the residents' snacks were closer to the nurses station to better monitor them, otherwise a resident could choke. Record review of the Dietary Department All staff Inservice training dated 10/11/23 revealed, Always Available Resident Snacks on both Tea/Bistro room and Dining Rooming .Presenter: Dietary Director and 8 residents signed it including the dietary director. Record review of the facility's incident/accident policy was requested on 10/12/23 at 5:30 pm but was not provided. Record review of the facility's QAPI Program Policy undated revealed, Policy Interpretation and implementation: The purpose of QAPI in our facility is to take a proactive approach to continually improve the way we care for and engage with our residents .The QAPI program provides a system for objective and systematic monitoring and evaluation of the quality, appropriateness, efficiency and effectiveness of clinical care and service delivered Record review of the facility's Assistance with meals policy dated 2001, revised 2022, Policy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676335 If continuation sheet Page 10 of 20 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 676335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032 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 0689 Level of Harm - Minimal harm or potential for actual harm Statement: Resident shall receive assistance with meals in a manner that meet the individual needs of each resident .Policy and interpretation and implementation: Dining room residents 1. All residents will be encouraged to eat in the dining room .Residents requiring full assistance: .2. Residents who cannot feed themselves will be fed with attention to safety, comfort dignity Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676335 If continuation sheet Page 11 of 20 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 676335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032 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 observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1.The facility failed to ensure food items in the refrigerator, freezer and dry storage room were labeled and stored in accordance with the professional standards for food service. 2. The facility failed to ensure the ice machine vent was free from greasy residue buildup with dust. 3. The facility failed to discard items stored in refrigerator, freezers or dry storage that were not properly labeled or past the 'best buy', consume by or expiration dates. 4. The facility failed to ensure the emergency water supply was monitored and changed out as needed 5. The facility failed to ensure handwashing sink #1 was free from debris in the sink. 6. The facility failed to ensure food items stored in the walk-in refrigerator and dry storage room were not left open to air or secured close. 7. The facility failed to ensure hazardous tools were not left out unsecured in the dry storage room. 8. The facility failed to ensure they use and open one food item first before opening another. 9. The facility failed to ensure they separated good useable canned good from dented unusable canned goods. These failures could place residents at risk for food-borne illness and cross contamination. Findings Included: Observation of the kitchen on 10/10/23 at 09:31 AM revealed the following: -Handwashing sink #1 (of 3) had a clear-ish gelatinous like lump of a material in the sink, sitting in the drain. -On the receiving side of the steam table, at the end, there was a small prep. table with plate warmers stacked. The top warmer on the first stack had a dark brown quarter sized piece of debris on it. -Ice Machine plastic vent, located on the left side of the machine, the vent slats had a greasy residue/film with dust on them. Observation of voltage closet in central supply room with the Dietary Manager on 10/10/23 at 09:38 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676335 If continuation sheet Page 12 of 20 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 676335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032 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 AM revealed the following: Level of Harm - Minimal harm or potential for actual harm -Emergency water supply in 1-gallon jugs (47). One jug in the back of the room against the wall, was half full, the cap still sealed. Residents Affected - Many -Another jug on the 2nd row from the door, had the seal broken and only approximately ¼ of the water remaining. -Several of the jugs were not full as the majority of the jugs, but seals remained intact. Observations of walk-in refrigerator on 10/10/23 at 09:49 AM revealed the following: -Left side: 2nd row from top- 1 whole medium sized watermelon no item of description, no received by date, no consume by or discard by date. -1 Large opened box labeled [NAME] leaf cabbage slaw: 1 large zip top bag dated 10/06/23, label of item description, no consume by or discard by date. -1 Large opened box dated 09/19/23 label premium lettuce has a large plastic bag with romaine lettuce inside. The bag was open to air, there was a medium brown spot not on the left side of the lettuce head. - At the bottom of the bag, there was lettuce as the bottom wilted, brown and soggy, no open date, no consume by or discard by date. -3rd row from the bottom: -1 extra-large stainless-steel bowl with 2 halves of a watermelon, there was plastic wrap on the on the bowl, but it was not completely covering the bowl or the watermelon, dated 09/27/23 after the plastic wrap was stretched to check for label and date, no consume by or discard by date. -4th row from the top: -1 large box with 4 head of cabbage in it, was open to air, dated 09/29/23. The writing was illegible, cook stated the date was 09/27 or 09/29. There was no consume by or discard by date. -Right side shelf, 2nd row from the top: -1 large zip top bag with a small amount of yellow cheese slices, dated 10/10/23 there was no label of item description, no consume by or discard by date. - 1 Large zip top bag, open to air, the bag was sealed but just under the zip top portion the bag had been torn open across the top almost tore the zip top portion off. The bag was dated 10/10/23, it contained a small amount of uncut deli meat, no label of item description, no consume by or discard by date. -1 Large zip top bag dated 10/06/23 with shredded yellow cheese, product label not visible and no written label of description, no consume by or discard by date. -1 Large zip top bag with more than 11 boiled eggs dated 10/06/23, no label of item description, no consume by or discard by date. -3rd row from the top: -1 large metal pan with potato salad dated 10/10/23 for lunch, there was no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676335 If continuation sheet Page 13 of 20 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 676335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032 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 label of item description, no consume by or discard by date. Level of Harm - Minimal harm or potential for actual harm 4th row form the top: -1 small stainless-steel pan with 5 sausage patties and a small amount of ground/crumbles sausage patties, labeled sausage and dated 10/10/23 had no consume by or discard by date. Residents Affected - Many -Left side, 2nd shelf (had condiments on tip row), 3rd row from the top: - large zip tip bag with 3 thick cut pieces of turkey lunch/deli meat dated 10/07/23, there was no label of item description, no consume by or discard by date. Observations of the walk-in freezer on 10/10/23 at 10:10 AM revealed the following: -On the right side, bottom shelf, there were 3 large bags of potato wedges, no label of item description, no received by date, no consume by or discard by date. -1 Small opened box dated 08/08/23, with a blue plastic bag inside, open to air, that contained breaded squash. The squash was freezer burned- had dried white patches on various pieces of the squash. -1 Large opened box with 2 bags of chicken parts/pieces, no received by date noted on any side of the box. -1 Large beef brisket in its original plastic packaging, no received by date. There was a dried, aged appearance to bottom middle area of the brisket, ice crystals over the middles portion of the packaging. Observations of Dry Storage Room with Dietary Manager on 10/10/23 at 10:21 AM revealed the following: -Left side of the room, near the door there were 2 (usable) canned good racks. 2nd rack, 4th row from the top: -1-6lbs. 6 oz. tomatoes 7 zucchini sliced in juice dated 10/10/23, no manufacturer expiration date, can is dented at the bottom and small dent at the top of the can. -1-6lbs. 6 oz can tomatoes & zucchini sliced in juice dated 20/10/23 no manufacturer expiration date, dented at the bottom of the can. - 3rd shelf, 2nd row from the top: -1-7 ¼ oz can of vegetable beef soup, no received by date, manufacturer expiration date 05/09/24. The can was sitting in the box of a different product (pimentos) that was dated 08/11/23. -1 small box with 8-7 oz cans of unpeeled dried pimentos, dated 08/11/23, when the can was picked up to check the can, it was stuck to bottom of the box as if something had spilled dried and made the can stick to the box. The bottom of the can had rust around it and the other 7 cans. -1-7 oz can of unpeeled dried pimentos with dented bottom. -1 large white bin with individually wrapped saltines dated 10/03/23, no consume by or discard by date. -4th row from the top, left side: 1-7 lbs. can cut yams (sweet potatoes) in syrup, dated 07/28/23, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676335 If continuation sheet Page 14 of 20 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 676335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032 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 manufacturer's expiration date 09/20/25, medium sized dent at top of can and a large dent at bottom of can. Level of Harm - Minimal harm or potential for actual harm -3- 6 lbs. 12 oz can of Texas rancheros style pinto beans dated 09/22/23, manufacturer's expiration date 06/20/25, dented on top and bottom of cans. Residents Affected - Many -5th shelf (middle of back wall), 2nd row: -when preparing to look at a 2lbs 10 oz. cannister of old-fashioned oatmeal dated 09/29/23, there was a switchblade type knife, in opened position, sitting on top of the oatmeal cannisters. -1 Large zip top bad dated 09/26/23 with 1.99 lbs. bag of potato pearls (dehydrated potato flakes) no clear visible packaging label, no written label of item description, no consume by or discard by date. -3rd row from the top: -1 large zip top bag with 1.86 lbs. bag of refried beans, dated 09/08/23, no open date, no consume by or discard by date. -4th row form the top: -1- 35 lbs. opened box of long grain parboiled rice, dated 09/22/23, in a blue plastic bag, open to air, no opened date, no consume by or discard by date. -1 35 lbs. opened box of long grain parboiled rice, dated 09/12/23, in a blue plastic bag, open to air, no opened date, no consume by or discard by date. -1-10 lbs. previously opened bag of wheat semolina pasta, dated 07/02/23, no opened date, product packaging label no visible, no written item of description, no consume by or discard by date. -1 Extra-large bag of elbow noodles, no visible received by date, previously opened, wrapped in plastic wrap, no opened date, no label of item description, no consume by or discard by date. -1-5 lbs. bag of cornbread mix in zip top bag, dated 09/02/23, no received by date, no label of item description, no consume by or discard by date. Observations of kitchen on 10/12/23 at 11:04 AM revealed the following: -Cook K was standing behind the steam stable and had finished temperatures had grabbed plates to start preparing meals, touched his forehead with the back of his hand and did not go wash his hands or put on gloves before he proceeded to prepare plates for the halls. -Cook G came back to the kitchen with a new food warmer but did not change his gloves or wash his hands when he returned to the kitchen. Cook G went to the kitchen door to answer it and took lunch tickets from a CNA but did not change gloves or wash his hands before going back to receiving side of the steam table. Observations of Dry Storage Room on 10/12/23 at 01:24 PM revealed the following: -On right side, last shelf, 3rd row from the top: -1-25 lbs. bag of non-fat milk powder dated 04/17/21, no consume by or discard by date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676335 If continuation sheet Page 15 of 20 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 676335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032 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 Observation of dining room on 10/12/23 at 01: 27 PM revealed the following: Level of Harm - Minimal harm or potential for actual harm -On the counter where juice and coffee items are held under the juice machine, in cabinet nearest the kitchen's main entrance, was a garbage receptacle that was full of trash and had a dark thick dried substance running down the sides of the garbage receptacle. Residents Affected - Many In an interview on 10/10/23 at 09:53 AM with [NAME] K, when asked about the illegible date written on the side of the box of cabbage, he stated it read either 09/27 or 09/29 then he settled on 09/29/23. He stated dating the new products received let staff know when it came into the kitchen and then you can figure out how long you can keep it as well as look or smell of the product. In an interview and observation on 1/11/23 at 11:30 AM with the Dietary Manager, she stated they keep leftovers in the refrigerator for 3 days. There were two sets of sliced cheddar cheese opened with different dates and the Dietary Manager was asked how long is opened cheese kept, the Dietary Manager stated they put an end date on the cheese. She said, it varies on how long opened items are kept in the dry storage room because they do not stay long. The Dietary Manager had entered the dry storge room while the surveyor was doing a round. She asked if there was there any concerns. She was shown the rice and how it was left open to air. She noted the switchblade knife and put it in her pocket. When asked about the open switchblade knife left open sitting on top of the oatmeal, she stated they know they are not supposed to leave that there. She stated the harm could be to staff or any person that came in the kitchen and reached for the product before seeing the knife and get cut/injured. The Dietary Manager was able to show where the dented can were but there was a non-dented can with the dented cans, she stated she did not see that regular can with the dented cans, on the bottom shelf. The Dietary Manager stated she would have to check the policy to see how long they kept canned goods with no expiration date and get back to me. The Dietary Manager stated they kept opened items in the freezer for 6 months to 1 year. She stated she does inventory and rotates the stock. She stated they use First In-First Out system. The Dietary Manager stated the kitchen served 69 residents. In an interview on 10/12/23 at12:12 PM with the Dietary Staff, [NAME] K answered and said, cross contamination was the harm to resident regarding dust on the vent of the ice machine and any other items, could lead to sickness and death of the residents. Review of the Facility's Nutrition Services Food Storage Policy and Procedure, Policy Number: 03.003; Date Approved: October 1, 2018; Date Revised: June 1, 2019; reflected that Policy: To ensure that all served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HAACCP guidelines. Procedure: 1. Dry storage rooms . e. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated G. Where possible, leave items in the original cartons placed with the date visible. Use the firs-in, first-out (FIFO) rotation method. Date packages and place new items behind existing supplies, so that the older items are used first. 2. Refrigerators . e. Use all leftover within 72 hours. Discard items that are over 72 hours old 3. Freezers . c. Store all foods on racks or shelves off the floor. d. Do not over stock the freezer and leave space between items to further improve air circulation. Review of the U.S. FDA Food Code 2022 reflected: Chapter 3 section 3-501.17 . Commercial processed food: Open and hold cold . B. 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676335 If continuation sheet Page 16 of 20 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 676335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032 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 FORM CMS-2567 (02/99) Previous Versions Obsolete date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Definitions 3. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. www.fda.gov Event ID: Facility ID: 676335 If continuation sheet Page 17 of 20 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 676335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032 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 reviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 (Hall 300) of 8 halls and 1(Nurses Station #1) of 2 nurses stations and one resident (#29) of 8 residents and one (confidential meeting) reviewed for Environment. The facility failed to repair or replace the flooring and carpet areas around the 300 hall and nurses' station #1, which was reported to the Maintenance Director months ago by staff and documented in the maintenance logbook. These failures placed residents at risk of being potentially at risk of tripping and falling which could cause injury, pain, and distress, resulting in a decrease in their quality of life and psycho-social well-being. Findings included: Record review of Resident #29's Quarterly MDS assessment dated [DATE] revealed, a [AGE] year-old female who admitted on [DATE] and as of this assessment her BIMS score was 09 (moderate cognitive impairment), supervision with setup help for locomotion off unit, no upper and lower impairment, used a walker and wheelchair,. The resident's diagnoses were CVA, hypertension, Renal Failure (kidney). Observation on 10/11/23 at 2:28 pm, Resident # 29 was having a hard time rolling her wheelchair along the 300 hall, towards Station #1, she used her arms when going down the 300 hall and was moving very, very slowly. Observation on 10/10/23 at 10:37 am, approximately 40 feet of the 300 hall flooring foundation, from rooms 308 to 320 had several ridges, bumpy, and the carpet was loose in some areas. And there was loose carpeting that was arched up in three places in front of rooms [ROOM NUMBERS] and 312. Observation on 10/12/23 at 10:00 am, the carpet around the Nurses Station #1 was torn, coming up and frayed and the white strings of fabric from the carpet was seen. Interview on 10/11/23 in a confidential group meeting, a resident stated the 300-hall carpet was bumpy and hard for him/her to move their wheelchair, most of the residents stated the flooring was uneven and went up and down as they moved along it. A resident stated they had to put more of an effort moving down this hallway and it was hard moving up and down and had to put more effort into moving along the 300 hall. One resident stated the 300 hall had been like that for a year and another resident stated the 300 hall flooring was not leveled and slowed them down. A resident stated the flooring was bumpy and dirty and wished they would fix it and it was frustrating going down that hall. They stated they complained to the staff about the carpet and the staff were aware of the issue. One resident stated the 300 hall flooring went Up a little and bump bump bump and said it would be wonderful if they fixed the flooring. He/She stated, They paid like the rich and lived like the poor and did not understand why the floor had not been fixed and cleaned and said the carpet was old but said maybe it would be too expensive to fix. Observation on 10/12/23 at 10:59 am, the Corporate Maintenance Rep. was on the 300 hall with a glue gun trying to flatten out the raised carpeted areas and placed yellow marker signs in those areas. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676335 If continuation sheet Page 18 of 20 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 676335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032 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 Observation on 10/12/23 at 11:36 am, the Dietary Aide F rolled a metal meal cart down the 300 hall, and it was vibrating and rattled very loudly as he pushed it down the hallway. Interview on 10/12/23 at 2:30pm, the Housekeeping/laundry Supervisor stated for the past 4 or 5 months she noticed the carpet on the 300 hall was worn, loose, and uneven. She stated she spoke to the nursing department and to the Administrator about it and was told they would look into it. She stated when going down the 300 hall, the housekeeping cart and broom bounce around a lot and she needed to hold on to the broom to prevent it from falling off the housekeeping cart. She stated onetime on a weekend, this past summer, she had to clean up a meal tray off of the 300 hall floor, that fell off the meal cart. Interview on 10/12/23 at 9:24 am, the Maintenance Director stated for a little over a year the carpet was coming up and he guessed it was the glue needing to be redone. He stated the adhesive probably was not sticking to the carpet and pulled in certain areas. He stated the 300 hall carpet needed to be relayed down and was not sure why the flooring under the carpet was bumpy and had not noticed it until it was brought to his attention 2 months ago by the dietary staff. He stated he went to the administrator and they both went to the 300 hall to look at it to come up with a solution and stated they were still trying to come up with repairing the flooring that was cost efficient. He stated he received five estimates that were kind of high and Corporate Maintenance Rep. was also made aware of the 300 hall flooring. He stated the dietary staff complained about having a hard time pulling the meal carts down the hallway and reported it to him and he noticed the carpet was bunched up in some areas. He stated he nor the Corporate Maintenance Representative had not tried to fix the carpet and flooring issue because they were not sure how to fix it. He stated they had not yet determined who was going to fix it and was not aware of any residents falling but knew it was a fall hazard. He stated he was responsible to ensure repairs were completed and stated he was not aware of any problems of worn carpet around Station 1 until the HHSC Surveyor showed it to him today (10/1/23). Interview on 10/12/23 at 11:01 am, Dietary Aide F stated the 300 hall flooring was a little bumpy for as long as he could remember working here and was not sure why he did not notify maintenance director. Interview o 10/12/23 at 11:11 am, the [NAME] G stated he noticed the carpet was raised up in some areas of the 300 hall. He stated he spoke to the Maintenance Director, and the Maintenance Director said he would have someone look at it. He stated he had no problems wheeling the meal carts down the 300 hall, but noticed walking down there how uneven it was. Interview on 10/12/23 at 12:32 pm, MDS Coordinator I stated not being sure when, but she felt the little bumps under the carpet on the 300 hall. She stated she told the maintenance director about it in passing down the hall a few months ago. Interview on 10/12/23 at 3:24 pm, the DON stated she never noticed any issues and had no complaints about the 300 hall flooring being bumpy or rough. She stated the staff did a good job reporting maintenance requests and the Maintenance Director was pretty good fixing things and stated this was a stable building. Interview on 10/12/23 at 3:48 pm, the Administrator stated there were no issues with the 300 hall flooring being bumpy or carpeting being loose. He stated the Corporate Maintenance Representative was using a glue dispenser gun earlier today (10/12/23) because the HHSC surveyor said something about the carpet. He stated there were no bids for the flooring to be repaired and he had not spoken to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676335 If continuation sheet Page 19 of 20 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 676335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032 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 anyone about repairing the flooring including the Maintenance Director. He stated he had no complaints from anyone about the 300 hall flooring and there had not been any residents who had tripped or fallen on the 300 hallway and stated he was responsible for ensuring maintenance repairs were done. Interview on 10//13/23 at 12:49 pm, the Facility's Ombudsman stated the residents complained to her on 10/11/23 about the 300 hall flooring being bumpy and they showed her where the bumps in the flooring was. She stated one of the residents pointed to an area of the flooring and said that area of the 300 hall they had to put more strength and effort to move their wheelchair. She stated as she walked along the 300 hall she also noticed how uneven the flooring was and could see the carpet was worn and torn in some areas and it needed to be repaired. She stated it was almost like a pipe was underneath the 300 hall that moved the flooring around and stated she tried to discuss this issue with the administrator, but he was not in his office and said she would follow-up with him later. Record or the facility's Maintenance Log sheet dated 09/21/23 by ADON J Carpet coming up Station #1 (Nurse Station #1) with no completed date and initialed - by Maintenance Director. Record review of the facility's Maintenance Service Policy dated 2002 and revised 2009 revealed, Policy Statement: Maintenance services shall be provided to all area of the building, grounds, and equipment .Policy Interpretation and Implementataion:1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times .2. Functions of maintenance personnel include but are not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines .b. Maintaining the building in good repair and free from hazards .f. Establishing priorities in providing repair services .3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings .are maintained in a safe operable manner FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676335 If continuation sheet Page 20 of 20