Health inspection·January 15, 2026

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to conduct a comprehensive, accurate assessment within 14 days after the facility determined or should have determined there had been a significant change in the resident's physical or mental condition for 1 (Residents #1) of 2 residents reviewed for Resident Review. The facility failed to complete the significant change MDS assessment for Resident #1 was hospitalized for atypical chest pain, Hypoxia, and altered mental status, and Leukocytosis (elevated white blood cell count) on [DATE].The facility failed to complete the significant change MDS assessment for Resident #1 was hospitalized for Hypernatremia (elevated sodium in the blood) on [DATE]. These failures could prevent residents from obtaining services and equipment to improve and maintain their level of functioning and well-being. Record Review of Resident #1's face sheet dated [DATE], reflected he was a [AGE] year-old male that was admitted on [DATE]. The resident was diagnosed with: Metabolic Encephalopathy (brain disorder that mimics dementia due to memory loss), Diabetic Mellitus ( unstable blood sugar levels) type Hyperosmolality (high concentration in blood.like sodium, sugar, and urea (compound produced by the liver) and Hypernatremia (elevated sodium levels), Acute and Chronic Respiratory failure with Hypoxia (low blood oxygen) . Record Review of Resident #1's MDS, type was left empty, dated [DATE] by LVN-R reflected Section C-Cognitive Patterns the C0500 BIMS Summary score was empty.C0700 Staff assessment of Mental status.Resident short term and long-term memory indicated memory problems. Inattention. Section J- health Conditions.SOB with exertion, when sitting at rest, and when lying flat.Section K-Swallowing and nutritional status .Nutritional approaches parenteral IV feeding while not a resident. Section O for special treatments was left empty, therefore not addressing the resident oxygen and IV use. Record Review of Resident #1's Quarterly MDS dated [DATE] by LVN/MDS R, reflected Section C-cognitive patterns.C0500. BIMS score of 07, indicating he was severely impaired cognitively. Section J-Health Conditions.SOB with exertion, when sitting at rest, and when lying flat.Section K-Swallowing/Nutritional Status.Nutritional approaches.Parenteral/IV feeding. Section O-Special treatments, procedures, and programs, indicating he did not require any special treatments (IV or oxygen). Resident #1 did not have a significant change in condition assessment in his file. Record review of Resident #1's MD orders by MD-J dated [DATE] reflected Admit to skilled care, 2.0 med-pass 90 cc Cal Med Pass (nutritional supplement) 120cc TID three time a day (8:00 AM, 2:00 PM, 8:00 PM.) Order dated [DATE].PRN.Albuterol sulfate 0.63 MG/3ML solution (albuterol sulfate) 3mL inhalation every 6 hours as needed . PRN May resite [Reset] peripheral IV PRN infiltration (you stop the infusion, remove the old IV, assess the tissue damage (swelling, redness, pain), apply compresses (warm/cold depending on fluid), elevate the limb, mark the site, and then start a new IV at a different, healthy location, following facility protocol for managing the infiltrated area.), extravasation (leakage of fluids) as needed any time.Record Review of Resident #1's hospital transfer change in condition dated [DATE] by ADON reflected MD-J and NP admitting.full code CPR (may use AED device that analyzes heart Residents Affected - Few Page 1 of 5 676453 676453 01/15/2026 Simpson Place 3922 Simpson Street Dallas, TX 75246

F 0637 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few rhythm).Reason for Transfer: abnormal labs (critical labs).Usual mental status. Alert and oriented follows instructions.Specials Treatments.O2 Chronic.Risk Alerts.swallowing precautions.needs meds crushed.aspiration.VS stabilized and follow up plan can be done in NH. Record review of Resident #1 MD progress notes dated [DATE] reflected the following: [DATE] 03:08 PM Category: MD-J and NP here. Made rounds and ordered to start IV fluids: normal saline at 70 cc/hr. for 1 liter and do a stat CMP (blood test measuring in the body). The floor nurse notified Smart Lab to start CMP (blood test measuring in the body). This nurse spoke with [NP] regarding [Resident #1's] thin liquids. She stated that he understands the risk of drinking the thin fluids. This nurse went over with [Resident #1's] t drinking thin liquids. He can have aspiration (choking) pneumonia and can die from this. He understood. This nurse did BIMS, and his score is 03:29 PM. Peripheral IV initiated in the right hand using a 20G, 1-inch catheter first attempt. Skin prepped with Chlorhexidine; site clean, dry, intact with no redness/swelling. Transparent dressing applied and labeled. Line flushed with 10mL NS, positive blood return, no resistance. Patient tolerated well, denies pain. not accessible for the surveyor in the EMR, and the documents were requested from the DON. Record Review of Resident #1's MD visit dated [DATE]. Reflected History and physical examination Complexity level: High.Reason for visit.Examination and medical management of this patient who has multiple significant chronic medical issues, on multiple drugs, with significant potential side effects. Record review of Resident #1's interdisciplinary progress notes dated [DATE] by MD reflected History of Present Illness: Patient HX of chronic respiratory failure on 2L NC (A device used to provide supplemental oxygen), O2, COPD (Disease, a progressive lung condition characterized by airflow limitation, often including emphysema and chronic bronchitis, causing symptoms like shortness of breath, cough, and mucus, primarily due to smoking or long-term exposure.), DM (unstable blood sugar), CKD (loss of kidney function), mood disorder presented to ED on 10/31-11/2 for atypical chest pain and leukocytosis of uncertain etiology (high white blood cell count without an obvious cause.who presented from SNF on [DATE] for hypernatremia in the 170s on routine ELAB (electronic laboratory system) work. This was likely in setting of severe FW (pure water free of pollutes) deficit from noncompliance with thickened liquid diet. Patient stayed 12 days and was needing thickened liquids which may have limited access to free water when at SNF. Patient had NA corrected and AKI (decrease in kidney function) resolved after increased FW deficit. Patient was previously admitted for AMS (changes in awareness) found to have hypoxia to 88% with AMS. CT (Xray) chest showed small PE in segmental and subsegmental pulmonary artery branches. Patient was treated for PE (lung infection), COPD (Disease, a progressive lung condition characterized by airflow limitation, often including emphysema and chronic bronchitis, causing symptoms like shortness of breath, cough, and mucus, primarily due to smoking or long-term exposure.),and respiratory failure with heparin GTT, and then transitioned to Eliquis. Patient was weaned back down to 2L O2 NC (tube used to transport oxygen). Patient was s/p shock and treated for aspiration PNA (lung infection) with pressors, steroids and antibiotics. Patient noted to have GI bleed and treated for it. Patient had AKI (decrease in kidney function), due to shock so was treated and CR (waste product in blood) resolved back to 1.08 baseline. Patient was discharged to [name] SNF for decreasing debility and deconditioning and rehabilitation.Dysphasia c/w soft bite sized solids/honey thickened liquids PO, unable to tolerates has not yet seen patient, Patient wants to sign off on thin liquids for aspiration precautions.Record Review of Resident #1's quarterly care plan dated [DATE] completed by the SW reflected Develop and implement a comprehensive person-centered plan that is consistent with your 676453 Page 2 of 5 676453 01/15/2026 Simpson Place 3922 Simpson Street Dallas, TX 75246

F 0637 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's rights and will meet your medical, nursing, mental and psychosocial needs. Cognitive loss, Dietician referral, Provide diet as prescribed, altered nutrition status related to weight loss.has shortness of breath, at risk of dehydration, oxygen therapy r/t COPD XXX[DATE].Needs total assistance with hygiene after toilet use .NEEDS Assist of 2 staff members for all ADLS r/ bedbound status. Record review of email sent by CRN on [DATE] at 5:23 PM reflected an Admissions MDS dated [DATE] and a Quarterly MDS dated [DATE]. The facility failed to completed a change in condition assessment review for Resident #1. Record review of email sent by CRN on [DATE] at 5:23 PM reflected an Admissions MDS dated [DATE] and a Quarterly MDS dated [DATE]. The facility failed to completed a change in condition assessment review for Resident #1. During an interview on [DATE] at 10:30 AM with CRN-R he needed to check the MDS's that were updated. He stated that Resident #1 was hospitalized several times returning with clinical changes to diet approaches of thickened liquids, respiratory treatments and IV. During an interview on [DATE] at 1:10 PM the DON stated that the MDS should accurately reflect the residents' current care status and needs. She stated that Resident #1's change in diet, treatments for IV and respiratory should have been coded to reflect care and treatment. DON stated that it was ADON, MDSC, and DON's responsibility to ensure that assessments were completed timely and accurately. She said failing to complete an accurate MDS the resident at risk of clinical care and task. During an observation and interview with Resident #1 on [DATE] at 3:00 PM when asked about recent hospitalization, oxygen treatments and thickened water, he said whatever they said. Resident #1 did not provide any additional information. During an interview on [DATE] at 4:40 PM with ADM, stated that facility recently terminated the MDSC after observing a pattern of failing to complete timely and accurate assessments for the residents. ADM said the DON was responsible for monitoring and ensuring that the MDS was updated. The ADM requested staff to provide an updated copy of Resident #1's most recent MDS to reflect MDS completion for Resident #1. The ADM did not provide any additional information regarding the change in condition. During an interview on [DATE] at 4:45 PM with CRN stated that Resident #1 had updated MDS in the facilities EMR. He was informed that there was no change in condition MDS located in the EMR. CRN left to search for MDS. CRN provided no additional information about the change in condition MDS. Record review of facility policy titled: change of Condition.Clinical Operations.dated [DATE] and revised on [DATE].reflected Policy: The primary goal of identifying Acute Changes of Condition (ACOCs) is to enable staff to evaluate and manage a patient at the community and avoid transfer to a hospital or emergency room (ER). To achieve this goal, the community's staff and practitioners must recognize an ACOC and identify its nature, severity, and cause(s). Examples of circumstances of when it is appropriate to communicate information to these parties may include, but are not limited to: Diagnosis of a new condition or a significant change in diagnosis.Transfer of a patient to another healthcare community for assessment, treatment, or care.Unexpected deterioration in condition or status.Significant injury or illness.Definitions: An acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death. 676453 Page 3 of 5 676453 01/15/2026 Simpson Place 3922 Simpson Street Dallas, TX 75246

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the status for 1 (Resident #1) of 4 residents reviewed for accuracy of assessments in that: Resident #1's quarterly MDS dated [DATE], did not address his diet in Section K with changes to thickened liquids and his respiratory treatments in Section O. The failure place residents at risk for missed treatments, aspiration, and changes in health that could result in death.Record Review of Resident #1's face sheet dated 01/15/2026, reflected he was a [AGE] year-old male that was admitted on [DATE]. The resident was diagnosed with: Metabolic Encephalopathy (brain disorder that mimics dementia due to memory loss), Diabetic Mellitus ( unstable blood sugar levels) type Hyperosmolality (high concentration in blood.like sodium, sugar, and urea (compound produced by the liver) and Hypernatremia (elevated sodium levels), Acute and Chronic Respiratory failure with Hypoxia (low blood oxygen) Record Review of Resident #1's MDS, type blank dated 09/09/2025 by LVN-R reflected Section C-Cognitive Patterns the C0500 BIMS Summary score was empty.C0700 Staff assessment of Mental status.Resident short term and long-term memory indicated memory problems. Inattention. Section J- health Conditions.SOB with exertion, when sitting at rest, and when lying flat.Section K-Swallowing and nutritional status .Nutritional approaches parenteral IV feeding while not a resident. Record Review of Resident #1's Quarterly MDS dated [DATE] by LVN/MDS R, reflected Section C-cognitive patterns.C0500. BIMS score of 07, indicating he was severely impaired cognitively. Section J-Health Conditions.SOB with exertion, when sitting at rest, and when lying flat.Section K-Swallowing/Nutritional Status.Nutritional approaches.Parenteral/IV feeding. Section O-Special treatments, procedures, and programs, indicating he did not require any special treatments (IV or oxygen).Section Z-Assessment Administration.Z0500.Signed by RN-L, 12/23/2025. Resident #1's last MDS was on 09/09/2025, and the type of assessment was not documented. He was admitted to the hospital on [DATE] and 12/2/2025. Resident #1's quarterly MDS did not address the need for thickened liquids in Section K and respiratory treatments in Section O Record Review of Resident #1's quarterly care plan dated 01/14/2026 completed by the SW reflected Develop and implement a comprehensive person-centered plan that is consistent with your resident's rights and will meet your medical, nursing, mental and psychosocial needs. Cognitive loss, Dietician referral, Provide diet as prescribed, monitor weight, altered nutrition status related to weight loss, extensive assistance with 2 person support on toilet, has shortness of breath, at risk of dehydration, oxygen therapy r/t COPD 12/23/2025.Needs total assistance with hygiene after toilet use .NEEDS Assist of 2 staff members for all ADLS r/ bedbound status. Resident recently received thin liquids and is slowly trying to feed himself. Residents is progressing in speech. Record review of email sent by CRN on 01/15/2026 at 5:23 PM reflected an Admissions MDS dated [DATE] and a Quarterly MDS dated [DATE]. The facility failed to completed a change in condition assessment review for Resident #1. During an interview on 01/15/2026 at 10:30 AM with CRN-R he needed to check the MDS's that were updated. He stated that Resident #1 was hospitalized several times returning with clinical changes to diet approaches of thickened liquids, respiratory treatments and IV for enteral feeding. During an interview on 01/15/2026 at 1:10 PM the DON stated that the MDS said care clinical assessments and plan should be updated to reflect the resident's current. The DON stated that it was ADON, MDSC, and DONs to ensure that all resident records were completed timely and accurately. She said failing to complete or update MDS assessments place the resident at risk of missing individualized clinical care, treatment; and task. She stated that Resident #1 was prescribed thickened water and oxygen treatment PNA and aspirations (accidental inhalation of food, liquids in the airway). The DON was asked to provide the progress notes on changes, due to the surveyor not Residents Affected - Few 676453 Page 4 of 5 676453 01/15/2026 Simpson Place 3922 Simpson Street Dallas, TX 75246

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few having access to all areas of the EMR. During an observation and interview with Resident #1 on 01/15/2026 at 3:00 PM when asked about recent hospitalization, oxygen treatments and thickened water, he said whatever they said. Resident #1 did not provide any additional information. During an interview on 01/15/2026 at 4:40 PM with ADM, stated that facility recently terminated the MDSC after observing a pattern of failing to complete timely and accurate assessments for the residents. ADM said the DON was responsible for monitoring and ensuring that the MDS was updated. The ADM requested staff to provide an updated copy of Resident #1's most recent MDS. The ADM did not provide any additional information regarding the change in condition. During an interview on 01/15/2026 at 4:45 PM with CRN stated that Resident #1 had updated MDS in the EMR. He was informed that there was no change in condition MDS located in the EMR. CRN left to search for MDS. CRN provided no additional information about the change in condition MDS. Record review of facility policy titled: Resident assessment.clinical operations.dated 09/13/2017 and revised on 01/12/2020.MDS 3.0. reflected Purpose: To assess each residents strengths, weaknesses, and care needs.use this assessment data to develop a person-centered comprehensive Plan of Care (POC) for each resident that will assist a resident in achieving and maintaining the highest practical level of mental functioning, physical functioning, and wellbeing as possible.To enter this assessment data into a computerized format that will be transmitted to the.(CMS).Standard of Practice:.facility to conduct, initially and periodically, a comprehensive, accurate assessment of each resident's functional capacity utilizing the Minimum Data Set (MDS) according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual.Procedure: A registered nurse will coordinate each assessment.and shall sign to certify the completion of each assessment in item Z0500. Each resident will be scheduled for an assessment period. with the frequency and type of assessment being determined according to the guidelines in the RAI Manual. Comprehensive assessments will be completed not less often than once every 12 months (366 days), within 14 calendar days after admission, or within 14 days of a significant change determination. Quarterly assessments will be conducted not less often than once every 3 months (92 days). 676453 Page 5 of 5