Health inspection·December 5, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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, which 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 1 of 1 resident (Resident #2), reviewed for care plan development. The facility failed to ensure Resident #2's comprehensive care plan included a plan of care for ADLs. This failure could place residents at risk of not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health.Record review of a face sheet dated 10/14/25 revealed Resident #2 was 90-years-old and was admitted on [DATE] with diagnoses including other idiopathic peripheral autonomic neuropathy (damage to the nerves that control involuntary bodily functions), depression (mental health condition), secondary hypertension (high blood pressure ), unspecified atrial fibrillation (an irregular rapid heart rate), and chronic diastolic congestive heart failure (the heart muscle is unable to relax properly). Record review of the most recent MDS dated [DATE] indicated Resident #2 was cognitively intact with a BIMS score of 15. Section GG (Functional Abilities) reflected Resident #2 required substantial/maximal assistance for toileting hygiene, shower/bathe self, partial/moderate assistance with upper body dressing and set up or clean up assistance with eating and oral hygiene. Record review of Resident #2's care plan last reviewed 09/08/25 revealed there was no plan of care that identified measurable objectives, goals, interventions and timeframes for ADLs. During an interview on 10/15/25 at 12:59 p.m., the Administrator stated the care plan told a story about the resident's care and preferences. The Administrator stated that without ADLs listed in the care plan, the staff won't know what the residents like. The Administrator stated the MDS nurse was responsible for the comprehensive care plan. During an interview on 10/15/25 at 1:53 p.m., the DON stated every resident should have a plan of care that reflected their likes, dislikes, everyday routine, and anything that affected the residents. She stated the absence of ADLs in the care plan diminished staff communication and knowledge of resident preferences. She stated she was unsure why ADLs were not included in the care plan. She stated the MDS Coordinator was responsible for writing the care plans. During an interview on 10/15/25 at 01:43 p.m., the MDS Nurse stated she was responsible for updating the care plan. She stated the care plan reflected a picture of the resident's functioning, preferences, and how much assistance was needed to meet their needs. She stated it was important to have an accurate care plan because it reflected the resident's level and any improvement. Record review of the facility Care Plan-Process policy last revised on 02/12/20 and reviewed 03/27/23 revealed: The interdisciplinary team will coordinate with the resident and their legal representative an appropriate care plan for the resident's needs or wishes based on the assessment and reassessment process within the required time frames. 4) Interdisciplinary Team meets and reviews the care plan as follows: Quarterly and annually 5) The team directs care planning toward Page 1 of 7 676453 676453 12/05/2025 Simpson Place 3922 Simpson Street Dallas, TX 75246

F 0656 attaining and maintaining the highest optimal physical, psychosocial, functional status including Advance Directives, and signs the approved plan of care. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 676453 Page 2 of 7 676453 12/05/2025 Simpson Place 3922 Simpson Street Dallas, TX 75246

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of five residents reviewed for catheter and incontinence care. The facility failed to ensure CNA G provided timely incontinence care for Resident #2 on 10/14/25. This failure could place residents at risk for not receiving appropriate care to address their incontinence and could increase the risk of urinary tract infectionRecord review of a face sheet dated 10/14/25 revealed Resident #2 was a [AGE] year-old female who was admitted on [DATE]. Resident #2 had a BIMs score of 15, which indicated she was cognitively intact. Resident #2's diagnoses included other idiopathic peripheral autonomic neuropathy (damage to the nerves that control involuntary bodily functions), depression (mental health condition), secondary hypertension (high blood pressure), unspecified atrial fibrillation (an irregular rapid heart rate), and chronic diastolic congestive heart failure (the heart muscle is unable to relax properly). Record review of Resident #2's most recent MDS dated [DATE] indicated: Section H (Bladder and Bowel): H0300-Urinary Continence reflected Frequently incontinent. H0400-Bowel Continence reflected Frequently Incontinent. An interview with Resident #2 on 10/14/25 at 10:50am revealed she had not had a diaper change all morning. Resident #2 stated her call light had not worked for 2 months but she had a bell to alert staff. An interview with CNA G on 10/14/25 at 10:58am revealed Resident #2 was not changed since her shift began at 6:00am. CNA G stated she had to get 4 to 5 residents up for breakfast when she arrived for her shift and another resident needed a shower. CNA G stated she was responsible for 16 residents this day. CNA G stated incontinent care was expected to be provided every 2 hours or when requested. CNA G stated incontinent care delay resulted in skin breakdown or rawness for the resident. An interview with LVN K on 10/14/25 at 11:59am revealed residents were expected to be changed every 2 hours or when needed. LVN K stated delayed incontinent care caused skin breakdown or depression. An interview with the DON on 10/15/25 at 1:53pm revealed the expectation for incontinence care was every two hours for residents or when the call light was pressed for care. The DON stated the risk of incontinent care delay was potential infection, UTIs, and skin breakdown. Record review of the facility's policy titled, Perineal Care/Incontinent Care effective April 2012, reflected, staff will perform perineal/incontinent care with each bath and after each incontinent episode. Residents Affected - Few 676453 Page 3 of 7 676453 12/05/2025 Simpson Place 3922 Simpson Street Dallas, TX 75246

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one resident (Resident #1) reviewed for catheter care. The facility failed to ensure CNA C maintained Resident #1's indwelling urinary catheter (a tube that drains urine from the bladder) drainage bag below the bladder level during transfer from bed to Geri-Chair (a supportive, reclining chair designed for individuals with limited mobility, offering more comfort and stability than a traditional wheelchair) on 10/15/25. This failure placed residents at risk for infection. A record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including obstructive uropathy (a condition where urine flow is blocked, leading to the accumulation of urine in the urinary tract), and cancer (a group of diseases characterized by uncontrolled cell growth and the ability to invade and spread to other parts of the body). Resident #1 had a BIMS score of 09 which indicated Resident #1's cognition was moderately impaired. He required extensive assistance of two-person physical assistance with bed mobility and transfer. Resident #1 had an indwelling catheter. Record review of Resident #1's care plan dated 06/26/25 reflected, Problem: Urinary catheter (SUPRAPUBIC) . Goal: Resident will be free of complications of indwelling catheter . Interventions: . Complications can include an increased risk of urinary tract infection, blockage of the catheter with associated bypassing of urine, expulsion of the catheter . Observation on 10/15/25 at 07:38 AM revealed CNA C, CNA E were in the process of getting Resident #1 transferred from bed to Geri chair. CNA C unhooked the catheter bag from the bed rail. CNA C put the catheter bag flat on the foot of the bed, above the resident's bladder. CNA C and CNA E hooked the transfer sling to the Mechanical left. CNA C took the foley catheter bag and hung it to the shaft of the Mechanical left. The two CNAs maneuvered the mechanical left and get Resident#1 on the Geri chair. During the procedure urine was observed flowing back toward the resident's bladder. After lowering Resident#1 to the Geri chair, CNA C hooked the catheter bag onto the Geri chair frame. In an interview with CNA C on 10/15/25 at 07:55 AM, she stated she was trained to always keep the catheter drainage bag below the bladder. She stated she put the bag on the bed to prevent it from pulling. She stated having it above the bladder could possibility cause the urine to run backwards, which could cause an infection. In an interview with the Administrator on 10/15/25 at 12:58 PM she stated her expectations were for the staff not to put the foley catheter bag on the bed because the flow could go back and cause the Resident to develop infection. In an interview with the DON on 10/15/25 at 2:13 PM she stated any resident with a foley catheter should always have the bag and tubing below the bladder. She stated not keeping the foley catheter bag below the resident's bladder, placed them at risk of urinary tract infection and cross contamination. Review of the facility's policy titled, Care and Removal of an Indwelling Catheter, revised 01/12/2020 did not address the concern. 676453 Page 4 of 7 676453 12/05/2025 Simpson Place 3922 Simpson Street Dallas, TX 75246

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to 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 two (Resident #1, and Resident#3) of two residents observed for infection control during incontinent care. 1-The facility failed to ensure LVN A, CNA C, CNA D, CNA E wear proper PPE while caring for Resident#1 in EBP Isolation. 2-The facility failed to ensure CNA F performed hand hygiene between glove changes, and LVN B did not put the dirty linen on the floor while providing incontinent care to Resident #3. These failures could place residents at risk for spread of infection through cross-contamination.1- A record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including obstructive uropathy (a condition where urine flow is blocked, leading to the accumulation of urine in the urinary tract), and cancer (a group of diseases characterized by uncontrolled cell growth and the ability to invade and spread to other parts of the body). Resident #1 had a BIMS score of 09 which indicated Resident #1's cognition was moderately impaired. He required extensive assistance of two-person physical assistance with bed mobility and transfer. Resident #1 had a supra pubis catheter (a urinary drainage tube inserted through a small incision in the lower abdomen, just above the pubic bone, into the bladder). Record review of Resident #1's care plan dated 06/26/25 reflected, Problem: Enhanced Barrier Precautions related to suprapubic catheter and wounds. Goal: Prevent/manage the likelihood of complications due to isolation over the next 90 days. Interventions: Contact Isolation Precautions are to be used during all aspects of care. handwashing Educate resident and family members on standard precautions and the importance of.Observation on 10/15/25 at 7:38 AM revealed LVN A was in the process of changing the nephrostomy (a surgical procedure that creates a temporary or permanent opening in the kidney to drain urine directly into a collection bag) exit site dressing, and supra-pubic catheter exit site dressing for Resident#1 with gloved hands and without wearing a gown. CNA C with gloved hands, and without wearing a gown was providing Resident#1 morning care and got him ready to sit in a Geri-chair (a supportive, reclining chair designed for individuals with limited mobility, offering more comfort and stability than a traditional wheelchair). CNA E entered Resident#1's room, washed hands, put on clean gloves, but she did not put on a gown. CNA E proceeded to help CNA C put resident lift sling under Resident#1. CNA D got the Geri-chair and the Mechanical lift and entered Resident#1's room.She washed her hands, put on clean gloves but did not put on a gown. The three CNAs maneuvered the Mechanical left, the Geri chair, and put Resident#1 on the Geri chair. The three CNAs removed gloves, washed hands and exited the room. There was a PPE supplies cart in front of the room, but no EBP isolation signage.In an interview on 10/15/25 at 07:45 AM, LVN A stated she was supposed to wear a gown while performing high contact procedure with Resident#1 who was in EBP isolation. She stated, she was about to go home at the end of her night shift, when she found out that Resident#1 had to get up and ready for a doctor appointment. She stated she was in rush and forgot to put on proper PPE (gloves and gown). She stated the risk spread of infection.In an interview on 10/15/25 at 07:55 AM, CNA C stated she did not know that she supposed to wear gown while performing morning care for Resident#1. She stated she saw the supplies cart in front of the room but did not know what it was for. She stated the risk spread of infection.In an interview on 10/15/25 at 08:12 AM, CNA D stated she did not know that she supposed to wear gown while helping with Resident#1's transfer. She stated she saw the supplies cart in front of the room but did not know what it was for. She stated the risk spread of infection.In an interview on 10/15/25 at Residents Affected - Some 676453 Page 5 of 7 676453 12/05/2025 Simpson Place 3922 Simpson Street Dallas, TX 75246

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 10:22 AM, CNA E stated she was supposed to wear gown while helping to get Resident#1 up in his Geri chair. When asked how she knew Resident#1 was in EBP isolation, she replied by the PPE supply cart in front of the resident's room, and the name of the resident written on blue paper vs the white paper for non-isolation residents. She stated the risk would be the spread of infection. 2-Review of Resident #3's quarterly MDS assessment, dated 07/04/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with the following diagnoses: type 2 diabetes, hypertension, morbid obesity due to excess calories. Review cognitive patterns reflected a BIMS of 15, which meant Resident #3's cognition was intact.Observation on 10/15/25 at 11:51 AM revealed CNA F with the help of LVN B entered Resident#3's room to do incontinence care. CNA F washed her hands using soap and water and donned clean gloves. LVN B washed hands and put on clean gloves. CNA F unfastened the resident's brief tabs and wiped the pubic area with a disposable wipe and discarded, she then wiped the folds of skin at left and right groin area using a new wipe. CNA F with the help of LVN B turned the resident on the left side. She cleaned the buttocks area with a disposable wipe. CNA F then removed the soiled brief and discarded it into a trash bag. CNA F rolled the linen (draw sheet and fitted sheet) and pushed it under Resident#3. CNA F changed her gloves without performing any form of hands hygiene (CNA F did not wash her hands or use had sanitizer between glove change). CNA F put a clean brief on Resident #3. Both staff turned Resident#3 to right side. LVN B removed the dirty linen and put it in a pillowcase and put it on the floor. CNA F and LVN B finished putting brief on Resident#3. LVN B removed gloves, took the dirty linen and exited the room, disposed of it in the dirty linen hamper in the Hallway, and sanitized hands. CNA F removed gloves, washed hands, and left the room. In an interview on 10/15/25 at 12:19 PM, CNA F stated she was supposed to perform hand hygiene in the beginning and at the end of the incontinent care procedure, and between change of gloves. She said she did not do it this time because she was nervous. CNA F stated the dirty linen was not supposed to be on the floor. CNA F stated the dirty linen was supposed to be in a plastic bag at the foot of the bed. She stated the risk would be the spread of infection.In an interview on 10/12/25 at 12:24 PM, LVN B stated, the staff were not allowed to bring the dirty linen hamper in front of the residents' room. LVN B stated putting the dirty linen in the pillowcase and on the floor was not an issue. LVN B stated the dirty linen will be washed anyway. She stated the risk was the spread of germs.In an interview on 10/15/25 at 12:58 PM, the administrator stated all the staff were supposed to perform hand hygiene before any contact with the residents, and between change of gloves. She stated the dirty linen was supposed to be put on a plastic bag not on the floor. She stated the risk would be the spread of infection.In an interview on 10/14/25 at 02:13 PM, the DON stated the expectation was for the staff to wear proper PPE while taking care of the residents, and for EBP isolation the staff were supposed to wear gowns, and gloves for any high contact care with the residents. When asked about some staff who did not know about EBP isolation, she replied the facility just had annual skills faire, and they talked about EBP isolation. The DON stated her expectation for the CNAs and nurses to perform hand hygiene before and after any care, and any time after removing dirty gloves. She stated if the staff hands were visibly soiled, they were to clean with soap and water, otherwise, they could use hand sanitizer. The DON stated the dirty linen was not supposed to be put on the floor. She stated the CNAs and nurses were trained to put the dirty linen on a plastic bag. The DON stated the risk could be cross-contamination. Review of the facility's policy titled Hand Hygiene for Staff and Resident reviewed January 2022 revealed, . 1. Hand hygiene is done: . After: . H. removal of medical/surgical or utility gloves.At the date and time of exit on 10/15/25 at 3:00 PM the facility did not provide the linen handling policy.Review of the facility Policy titled Enhanced barrier precaution dated 676453 Page 6 of 7 676453 12/05/2025 Simpson Place 3922 Simpson Street Dallas, TX 75246

F 0880 Level of Harm - Minimal harm or potential for actual harm April 01, 2024 revealed .This facility utilizes EBP as a strategy to decrease transmission of MDROs when Contact Precaution do not apply. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high contact care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Residents Affected - Some 676453 Page 7 of 7