Health inspection·July 26, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some angry, he makes up false allegations against staff, then recants his story when interviewed for investigation status. Goals- Number of verbal incidents will be decreased over the next 90 days as on Behavior Tracking Record. Interventions- Encourage caregivers to participate in activities with Resident #1 to promote positive interactions (Disciplines- Nutrition Services Director), gently remind Resident #1 that screaming/cursing was not appropriate (Disciplines- Skilled Nursing), record behaviors on behavior tracking form, monitor pattern of behavior (time of day, precipitating factors, specific staff, or situations) (Disciplines- Skilled Nursing), respond in a calm voice, maintain eye contact, and, remove from area if Resident #1 was abusive to others (No discipline responsibility indicated) . Record Review of Resident #1's admission MDS revealed Resident #1 was dependent for the following functional mobilities: Upper body dressing (the ability to dress and undress above the waist; including fasteners, if applicable), lower body dressing (he ability to dress and undress below the waist, including fasteners; does not include, footwear), toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement) and personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face, and hands (excludes baths, showers, and oral hygiene) In an interview with Resident #1's representative on 07/25/24 at 10:41am revealed that on 06/09/24 while visiting with Resident #1, it was stated by Resident #1 that a night shift CNA threw a washcloth at his face and told him to, go back to bed. RP #1 stated that she reported the incident to LVN A. She stated that LVN A reported the allegations and concerns of RP #1 to the facility's DON, the Administrator, the ADON, and the Weekend Supervisor. RP #1 revealed the facility's Weekend Supervisor entered Resident #1's room, took statements from Resident #1 and herself. At the conclusion of the interview process by the Weekend Supervisor, RP #1 stated that she would like to proceed with filing a grievance. RP #1 stated she requested to file a grievance to ensure the facility followed up with her about the alleged communication concerns and care treatment displayed by the facility staff. RP #1 revealed in the interview the facility contacted her on 06/10/24 to alert her that the concerns reported to the facility by RP #1 on 06/09/24 was reported to the Texas Department of Health and Human Services Commission and that the facility was conducting their own internal investigation into the allegations. RP #1 revealed that she met with the facility DON, the ADON and the Wound Nurse on 06/10/24 regarding the facility's internal investigation. RP #1 revealed that in the meeting on 06/10/24 it was revealed to her that during the investigation Resident #1 recanted his statement and the investigation was concluded. RP #1 revealed that the facility administration did not acknowledge her request made previously on 06/9/24 of filing an official grievance to the facility, did not provide a resolution to RP #1's stated concerns of communication and care delivery or provide written documentation regarding her grievance filed. Interview with RP #1 revealed that her or her family were not made aware of the facility's grievance policy or procedures. Review of the document titled, [Facility Name] Grievance Log, dated for 07/25/24, did not reveal a grievance filed for RP #1 and it did not reveal a grievance filed for RP #1 being resolved. Interview with LVN A on 07/25/24 at 11:24am revealed that she was the nurse for Resident #1 on 06/09/24. LVN A revealed that RP #1 reported the allegations expressed by Resident #1 and wanted to file (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676422 If continuation sheet Page 2 of 13 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 676422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palomino Place 3160 Gus Thomasson Road Mesquite, TX 75150 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 0585 Level of Harm - Minimal harm or potential for actual harm a concern. LVN A stated that she reported the findings to the DON, the Administrator, the ADON, and the Weekend Supervisor. LVN A revealed that the Weekend Supervisor completed the interview process on 06/09/24 and revealed that she was unsure if the Weekend Supervisor filed an official grievance for RP #1. LVN A revealed that residents and their representatives were informed of the facility's grievance policies and procedures on admission. Residents Affected - Some Review of Resident #1's admission agreement revealed to be signed by RP #2 and dated for 06/06/24. Review of Resident #1's admission agreement did not outline the facility's grievance policy or the rights for residents and their representatives on filing a grievance. The facility did not produce any supplemental attestations or documents showcasing Resident #1's representatives signed that they were informed of the facility's grievance policy or procedures. Interview with RP #2 on 7/26/24 at 9:00am revealed that she was the one that signed the admission agreement on 06/6/24. Interview with RP #2 revealed that the facility did not review the facility's grievance policy and procedures with her when signing the admission agreement or at any time during their stay. RP #2 revealed that the facility staff told her if there was ever a concern, go to the nurse. Interview with the facility's interim admissions director (IAD) on 07/26/24 at 10:04am revealed that she was responsible for ensuring that the admission paperwork was completed within 48 hours of admission. IAD stated that she reviewed the admission agreement with the residents and/or their representatives which included the facility policies, procedures, and the grievance policy and procedures. Interview with IAD revealed that residents and their families can file grievances to any staff member and that a member of management will follow-up. IAD reviewed resident #1's signed admission agreement with the state surveyor which revealed no documentation related to the facility's grievance policy or procedures. IAD stated that there were attachments that were not provided by the facility administration. IAD provided four documents (Page 45, 46, 57, and 58) which revealed the following: 1. Page 45-46: Titled, Information About the Ombudsman Program for Patients and Families, Office of the State Long-Term Care Ombudsman, Texas Department of Aging, Post Office Box 12786, [NAME], Texas, 78711, Ph# [PHONE NUMBER]. Document revealed sections, what is an Ombudsman, An Ombudsman as a resource, and other resources to assist you. 2. Page 57-58: Section N, Grievances, did not outline the facility's policy on grievances, who the assigned facility grievance official is, their contact information, the right to file an anonymous grievance, and the right to receive a written statement regarding their grievance. The provided attestations (Pages 45, 46, 57, 58) were not signed by RP #2 indicating she was made aware of this information. Interview with the facility DON on 07/25/24 at 3:30pm revealed that she investigated the allegations brought to the facility's attention by RP #1. The DON revealed that she met with RP #1 on 06/10/24 where he recanted the statement and allegations made on 06/9/24. The DON revealed that she met with RP #1 on 06/10/24 along with the facility wound nurse and the ADON to provide her the outcome of the facility's internal investigation. The DON revealed that there was no mention of a grievance or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676422 If continuation sheet Page 3 of 13 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 676422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palomino Place 3160 Gus Thomasson Road Mesquite, TX 75150 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some request for a follow-up on unresolved concerns related to the grievance. The DON revealed that RP #1 did ask for a written summary of their investigation, but she denied the request stating that the state can provide that information as they cannot provide information to a family member on an internal investigation. The DON revealed that if a resident or representative requested to file a grievance, the receiving staff member should document the grievance in the facility's EMR system to alert the necessary department heads to follow-up or complete a facility grievance form . The DON revealed that the expectation was that grievances should be resolved within three business days per the facility's grievance postings. Observation of the facility receptionist desk on 07/26/24 at 8:25am revealed a binder situated behind the receptionist desk that was inaccessible for residents. To access the binder, residents would have to physically ask the receptionist for a grievance form. In an interview with the facility's receptionist on 07/25/24 at 1:07pm revealed that she had been the receptionist for one year and works the hours 8am-4pm, Monday through Friday. Interview with the Receptionist revealed that she does keep a binder behind her desk with grievance forms for the facility's residents. The Receptionist revealed that if a resident requested to file a grievance with her, she would assist the resident with filling out one of the grievance forms. During interview with the facility receptionist, the facility receptionist agreed that the posting titled, Grievances could potentially intimidate or hinder the resident from filing a grievance as there was no option outlined for residents on how to file a grievance in an anonymous way . The Receptionist did not state the expected time frame regarding grievance resolutions. The Receptionist revealed that the facility Social Worker was responsible for overseeing the grievances and the grievance binder. In an interview with the facility's ADON on 07/25/24 at 2:38pm revealed that she was contacted by LVN A on 06/09/24 regarding the allegations made by RP #1. The ADON revealed that she also alerted the DON, the Administrator, and the Weekend Supervisor who was conducting the investigation. The ADON revealed that she was unsure if RP #1 requested to file a grievance as she did not conduct the investigation. When asked about the facility policy on grievances, the ADON revealed that if a resident had a grievance or concern, they would be given a grievance form by a staff member, or their grievance would be entered into the facility's EMR system to ensure resolution and follow-up. The ADON revealed that the residents and their representatives should receive communication from the facility staff in a timely manner regarding their grievance . Interview with the facility Social Worker on 07/25/24 at 12:35pm revealed that she was alerted of RP #1's allegations and the facility's investigation by nursing. The SW revealed that she met with the resident to ensure that all his needs were met. Interview and review of the facility's document titled, [Facility Name] Grievance Log dated for 07/25/24 with the SW, revealed that the SW was unsure why the grievance log did not have a grievance for RP #1. She stated typically a grievance would be filed in relation to a facility internal investigation to showcase and ensure it was resolved. The SW revealed that it was her responsibility to ensure grievances were followed through and assigned to the proper department head for follow-up and resolution. The SW revealed that the admissions director reviewed the grievance policy on admission when they complete the admission paperwork . Review of the document titled, [Facility Name & Corporation Name] Job Description, Social Services Worker, dated for January 2017, revealed that the overall purpose of the Social Services Worker position is to enable the facility to identify medically related social and emotional needs of the patients/residents. Review of the Social Services Worker essential functions outlined in the document did not reveal functions related to grievances, resolving grievances or preforming duties related to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676422 If continuation sheet Page 4 of 13 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 676422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palomino Place 3160 Gus Thomasson Road Mesquite, TX 75150 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 0585 acting as the facility Grievance Official. Level of Harm - Minimal harm or potential for actual harm Observation of the facility on 07/25/24 at 12:15pm revealed the following: Residents Affected - Some 1.Paper sign posted at the facility [NAME] Neighborhood Nurses Station titled Grievances stated, please ask the charge nurse for grievance forms. Abuse Prevention Coordinator- Executive Director, Grievance Official- Social Services Director, Resident Council- Staff Liaison- Lifestyle Director. The Grievance Process is addressed in a timely manner; please allow up to 3 business days to resolve concerns. For further details or information please see our front receptionist. 2.Paper sign posted at the facility Palio Neighborhood Nurses Station titled Grievances stated, Abuse Prevention Coordinator- Executive Director, Grievance Official- Social Services Director, Resident CouncilStaff Liaison- Lifestyle Director. The Grievance Process is addressed in a timely manner; please allow up to 3 business days to resolve concerns. For further details or information please see our front receptionist. 3.Paper sign posted to bulletin board across from Ascot Dining Room revealed information regarding the facility's Grievance forms and grievance processes. Form stated that, for grievance forms (please ask staff for assistance), Grievance Processes: All grievances are electronically filed, Grievance investigation (s) are resolved in a timely manner, Grievance binder location(s): Palio rm and nursing stations. Grievance Official listed the facility administrators name and contact information. Observation and Review of the Palio Room Grievance Binder revealed a black dresser with a sign in a plastic covering which stated, Grievance Forms located here in drawer. Top drawer revealed a white binder with several blank forms titled, Grievance/Complaint Form, form revealed that this form shall be utilized to provide written documentation of any concern expressed by a resident or resident representative and to record the follow-up action taken and results thereof. Sections included: Receipt of Grievance/Complaint, Documentation of Grievance/ Complaint, Documentation of Facility Follow-up, and Resolution of Grievance/Complaint. Observation and Review of the facility's grievance postings revealed that both the facility Social Worker and the facility administrator were both named as the facility's grievance official on two separate postings. Review of the facility's grievance postings revealed that the facility's postings did not include information on how to anonymously file a grievance, guidance on how to properly fill out and submit the facility's grievance forms titled, Grievance/Complaint Form if the resident requested to submit a grievance in a written manner to the identified grievance official, or the ability for the facility residents to obtain a written decision regarding their grievance. In an interview with the Facility Social Worker on 07/25/24 at 12:35pm revealed that there were postings around the facility regarding grievances. During the interview with the SW revealed that the forms posted at the two nurses' stations, titled Grievances do state that residents do have to ask the charge nurse for a grievance form and do not mention the residents right to file an anonymous grievance or obtain a written decision regarding the grievance. During interview with the SW, the SW agreed that the posting titled, Grievances could potentially intimidate or hinder the resident from filing a grievance as there is no option outlined for residents on how to file a grievance in an anonymous way. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676422 If continuation sheet Page 5 of 13 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 676422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palomino Place 3160 Gus Thomasson Road Mesquite, TX 75150 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record Review of Resident #2's admission MDS with an ARD of 07/26/2024 revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #2's diagnoses included: gastroesophageal reflux disease (Condition in which the stomach acid is repeatedly flowed back up into the esophagus) depression (other than bipolar), and diabetes mellitus (Group of diseases that affects how the body uses blood sugar). The MDS revealed Resident #2 had a BIMS score (Brief Interview for Mental Status - is a mandatory tool used to screen and identifying the cognitive condition of residents upon admission into a long-term care facility) of 13 indicating no cognitive impairment. Record Review of Resident #2's admission agreement revealed that the admission agreement was signed by Resident #2 on 07/26/24 and was not sent to the resident for review until 07/26/24 at 18:01pm, 7 days after the resident admitted to the facility. The facility did not produce additional attestations or documents signed by resident #2 indicating he had been informed on the facility's grievance policies, including how to file a grievance either anonymously, orally, or in a written manner and the right to obtain a written decision regarding his grievances. In an interview with Resident #2 on 07/25/24 at 4:23pm revealed that he admitted to the facility about 8 or 9 days ago. Interview with Resident #2 revealed that he was unsure of the facility's grievance policy, or his rights related to grievances. Interview with Resident #2 revealed that he had not been educated on how to file a grievance, anonymously, orally, or in a written manner. Interview with Resident #2 revealed that he had not yet signed admission paperwork or reviewed the facility's admission agreement. Interview with Resident #2 revealed that he was unsure of who the facility grievance official was. Interview with Resident #2 revealed that if he had a concern, he was unsure of who to go to. Interview with Resident #2 revealed he was unsure of where in the facility the grievance postings were located. Record Review of Resident #3's admission MDS with an ARD of 07/29/2024 revealed a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #3' diagnoses included: Diabetes (group of diseases that affect how the body uses blood sugar), urinary tract infection (last 30 days) (infection of any part of the urinary system), cerebrovascular accident (CVA ) (condition where the supply of blood flow to the brain is stopped), transient ischemic attack (TIA) (Brief blockage of blood flow to the brain), or stroke. The MDS revealed Resident #3 had a BIMS score (Brief Interview for Mental Status- is a mandatory tool used to screen and identifying the cognitive condition of residents upon admission into a long-term care facility) of 13 indicating no cognitive impairment. The facility did not produce a signed admission agreement for Resident #3. The facility did not produce additional attestations or documents signed by Resident #3 indicating she had been informed on the facility's grievance policies, including how to file a grievance either anonymously, orally, or in a written manner, and the right to obtain a written decision regarding his grievances. In an interview with Resident #3 on 07/25/24 4:27pm revealed that she had been at the facility for about 48 hours. Resident #3 revealed that she had not signed admission paperwork. Resident #3 reports that she was unsure of the facility's grievance policy, or her rights related to grievances. When asked who she would go to if she had a grievance or concern, Resident #3 stated she would go to her family member. Interview with resident #3 revealed that she was unsure of where in the facility the grievances postings were located. Interview with resident #3 revealed that she had not been educated or informed on how to file a grievance anonymously, orally, or in a written manner or the right to obtain a written decision regarding her grievances. Interview with resident #3 revealed she was not sure who the facility's grievance official was. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676422 If continuation sheet Page 6 of 13 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 676422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palomino Place 3160 Gus Thomasson Road Mesquite, TX 75150 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record Review of Resident #4's Quarterly MDS with an ARD date of 06/10/2024 revealed an [AGE] year-old female who admitted to the facility on [DATE]. Resident #4's diagnoses included: diabetes mellitus (group of diseases that affect how the body uses blood sugar), hyperkalemia (condition of high potassium levels in the blood), and depression (other than bipolar) (mental state of low mood and aversion to activity). The MDS revealed Resident #4 had a BIMS score (Brief Interview for Mental Status- is a mandatory tool used to screen and identifying the cognitive condition of residents upon admission into a long-term care facility) of 14 indicating no cognitive impairment. In an interview with Resident #4 on 07/25/24 at 4:35pm revealed that she had been at the facility for a little over a year. Resident #4 revealed that that she was unsure of the facility's grievance policy or her rights related to grievances. Resident #4 revealed that she was unsure of who the facility grievance official was. When asked who resident #4 would go to with a concern or grievance, Resident #4 revealed she wouldn't know where to go. Interview with Resident #4 revealed that she was unsure of where in the facility the grievances postings were located. Interview with Resident #4 revealed that she had not been educated or informed on how to file a grievance anonymously, orally, or in a written manner, or the right to obtain a written decision regarding her grievances. In an interview with the facility's DON on 07/25/24 at 3:30pm revealed that there had been no concerns with residents being able to file a grievance or filing a grievance in an anonymous manner . Review of the facility's policy titled, Grievances dated November 2017 revealed that, the patient or patient representative has the right to voice grievances to the facility or other entity that hears grievances without the fear of discrimination or reprisal. Grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other patients, and other concerns regarding their LTC facility stay. The facility must make prompt efforts to resolve grievances and must make information on how to file a grievance or complaint available to the patient. When the facility is made aware of a problem or concern voiced by a Patient or on behalf of the Patient, the facility must make every effort for prompt resolution of all grievances regarding the residents' rights. The policy revealed that, The Executive Director is the designated grievance official for the facility. The policy revealed that the facility must make information on how to file a grievance or complaint available. When the facility is made aware of a problem or concern voiced by a Patient or on behalf of the Patient, the facility must make every effort for prompt resolution of all grievances regarding the resident's rights. Notify patients through postings in prominent locations through the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; The right to obtain a written decision regarding his or her grievance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676422 If continuation sheet Page 7 of 13 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 676422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palomino Place 3160 Gus Thomasson Road Mesquite, TX 75150 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 resident (Resident #6) reviewed for pharmacy services. Resident #1's narcotic pain medication was not accurately received as required. DON on 7/25/24 at 10:15am revealed the medication was delivered by a general shipping company. The medication was left unsecured as revealed by none of the staff receiving the medication and resulted in the medication not being accounted for resulting in a drug diversion. This failure could place residents at risk of misappropriation by drug diversion, and could result in increased pain, and poor quality of life. The noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 5/3/24 and ended on 5/16/24. The facility had corrected the noncompliance before the survey began. Findings included: Record review of Resident #6's face sheet dated 7/26/24 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Chronic Obstructive Pulmonary disease-a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation, pain, fibromyalgia-a medical syndrome which causes chronic widespread pain, accompanied by fatigue, waking unrefreshed, and cognitive symptoms., and restless leg syndrome. Record review of Resident #6's Care Plan dated 8/25/2023-Present revealed Resident #6 was under the care of Hospice, who ordered the medication. Record review of Resident #6's Electronic Health Record physician orders revealed an active date of 5/30/24 for oxycodone-acetaminophen 10mg-325mg (hydrocodone-acetaminophen) PRN (as needed) every 6 hours. Record review of state form 3613 Provider Investigation Report on 5/21/2024 revealed a routine audit of medications was completed and noted the Oxycodone from pharmacy was not available. Interview on 7/25/24 at 2:35pm, the Social Worker revealed that the administrator was working with the hospice company to develop a more efficient medication delivery system. Interview on 7/25/24 at 2:45pm with Resident #6 revealed the resident was currently not in pain and did not miss any pain medication administration. Interview on 7/25/24 at 2:55pm with the DON, revealed that she was familiar with the incident regarding alleged missing narcotics. DON revealed the expectation for medications was to have been received and stored properly. DON revealed the responsibility ultimately fell on the DON. The DON revealed that the resident did not miss any doses as she still was using medication, she had prior to the delivery of the medication. The DON revealed an agreement for the hospice company to order medications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676422 If continuation sheet Page 8 of 13 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 676422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palomino Place 3160 Gus Thomasson Road Mesquite, TX 75150 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few from the same pharmacy service the facility used ruling out medications not being properly received and stored. A failure could affect the resident by not having needed medication, resulting in unnecessary pain. Record Review of facility policy titled, Medication Labeling and Storage dated February 2023, revealed that medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. This noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 5/3/24 and ended 5/16/24. The facility had corrected the noncompliance before the investigation began. The facility took the following actions to correct the non-compliance: 1. 5/16/24 Hospice company began using the same pharmacy as the facility. 2. 5/17/24 Staff were in-serviced on medication management. 3. 5/17/24 The Facility self-reported the incident to Health and Human Services. 4. 5/17/24 The facility notified the resident's family. 5. 5/17/24 The facility notified the facility's medical director. 6. 5/17/24 The facility notified the hospice company. 7. 5/17/21 Performance Improvement Plan was started for Hospice medication delivery. 8. 5/17/24 staff with possible access to the medication were drug tested with negative results. 9. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676422 If continuation sheet Page 9 of 13 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 676422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palomino Place 3160 Gus Thomasson Road Mesquite, TX 75150 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 5/17/24 The facility made a police report. Level of Harm - Minimal harm or potential for actual harm 10. Going forward when narcotics are delivered two nurses will sign off as to receiving the medication. Residents Affected - Few 11. Statements were taken from staff. 12. SW conducted a psychosocial well-being assessment with Resident #6. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676422 If continuation sheet Page 10 of 13 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 676422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palomino Place 3160 Gus Thomasson Road Mesquite, TX 75150 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and record review the facility failed to ensure that drugs and biologicals were stored and labeled in accordance with accepted professional principles for 1 (800 hall Medication Aide Cart) of 3 medication carts . 1.The facility failed to ensure that medications already opened, and in-use were dated and labeled on the date they were initially opened on the 800 hall MA (Medication Aide) cart. 2. The facility failed to ensure that there were loose medications on the 800 MA (Medication Aide) cart that were unidentified. These failures could place residents at risk for adverse pharmaceutical reactions. Findings Included: Observation and audit of the facility 800 hall MA cart on 07/26/24 at 2:15pm, during 6am-2pm shift and 2pm-10pm shift change revealed the following: 1.Fish Oil 500 mg, opened, with no labeled date indicating the date first accessed or opened. 2.Ibuprofen Tab 200 mg, opened with no labeled date indicating the date first accessed or opened. 3. Three unidentified pills scattered in various drawers in the 800 hall MA cart (One oval shaped, white pill with 114 marking, one oval red colored pill with H146 marking, one oval white pill, scored with 1/25 marking) Interview with LVN B on 07/26/24 at 4:05pm revealed that it was the responsibility of the floor nurses and medication aides to ensure that when a medication was opened, it was labeled with the date initially opened. LVN B revealed that it was the responsibility of the nurses and medication aides to ensure the medications within the cart were stored in a safe and sanitary manner. LVN B revealed that if loose medications were in the cart, when noticed they should be disposed of immediately. Interview with LVN B revealed that risks associated with not labeling medications with the date initially opened could risk using medications past their expiration date or past their shelf life . Interview with the DON on 07/26/24 at 4:10pm revealed that the pharmacist was just at the building to complete medication cart audits and informed the DON that OTC (over the counter) medications were now to be labeled with the date they were opened. The DON revealed that per her understanding, this practice has just recently gone into effect . The DON revealed that she expected all nurses and medication aides to follow safe practices when it came to the handling, storing and distribution of medications. The DON revealed that loose pills should not be anywhere in the medication cart. The DON did not reveal any risks associated with not labeling medications with the date initially opened. Record Review of facility policy titled, Medication Labeling and Storage dated February 2023, revealed that medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676422 If continuation sheet Page 11 of 13 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 676422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palomino Place 3160 Gus Thomasson Road Mesquite, TX 75150 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 0761 nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676422 If continuation sheet Page 12 of 13 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 676422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palomino Place 3160 Gus Thomasson Road Mesquite, TX 75150 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to 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 2 (CMA C and LVN B) of 4 staff members reviewed for infection control practices. Residents Affected - Few 1.CMA C failed to preform hand hygiene before and after medication administration. 2.LVN B failed to follow safe infection prevention practices by placing gloves on before entering a patient's room, entering the Resident's room to provide care, failing to preform hand hygiene before and after care, and exiting the patients room with gloves on. These failures have the potential to affect all residents in the facility by exposing them to care that could lead to the spread of viral or secondary infections and communicable diseases. Findings included: Observation on 07/26/24 at 11:15am with CMA C revealed that CMA C was preparing for the 12:00pm medication rounds. CMA C revealed that she was preparing to administer medications for Resident #5. CMA C logged into the facility's EMAR system, verified Resident #5's orders within her clinical record, unlocked her cart, located Resident #5's medications (Gabapentin 600 mg and Hydrocodone 325mg), placed the medications into a plastic medication cup, and closed and locked her medication cart. CMA C along with the medications and a plastic cup of water, walked to Resident #5's room, and provided Resident #5 with the medications and water. CMA C took her gloves off, placed them in the trash can, and exited the room. Interview with CMA C on 07/26/24 at 11:45am revealed that she forgot to preform hand hygiene after completing the medication administration for Resident #5. CMA C revealed that a risk to the resident if staff does not preform hand hygiene after direct patient care or contact would be exposure to germs. Observation on 07/26/24 at 5:05pm revealed LVN B at her medication cart, placed gloves on, entered a resident's room, then exited with gloves on. Interview with LVN B on 07/26/24 at 5:20pm revealed that she was not supposed to have gloves on in the hallways after exiting a Resident's room. LVN B revealed that she should have entered the Resident's room, washed her hands, placed the gloves on, performed care, removed gloves, washed her hands, and exited the room. LVN B revealed that she was in a hurry and forgot. LVN B revealed that a risk to the residents when hand hygiene was not performed or keeping gloves on after performing care would be a risk in spreading infection. Interview with the DON on 07/26/24 at 4:15pm revealed that it was her expectation from staff to perform and maintain safe infection control practices, including hand hygiene. The DON revealed that they were providing in-services to staff today regarding hand hygiene. Record Review of the facility's policy titled, Infection Control dated for November 2017 revealed that the facility must establish an infection prevention and control program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676422 If continuation sheet Page 13 of 13