Health inspection·September 22, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure each resident had the right to be free from neglect. For one resident (Resident #1) out of 5 residents reviewed for deprivation of goods and services. LVN A failed to follow protocol after Resident #1 had a fall. LVN A picked Resident #1 off the floor and returned her to her bed without conducting an assessment and reporting the incident to RP, DON, and Physician. This resulted in Resident #1 not being diagnosed with a fracture on her left hip and a right dislocated shoulder for 11 hours.An IJ was identified on 09/19/2025, the IJ template was provided to the facility on [DATE] at 3:35 p.m. While the IJ was removed on 9/22/2025. The facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy, because all staff had not been trained.This failure has the potential to result in serious injury or death as a result of abuse and neglect.Findings include:Record review of Resident #1's quarterly MDS, dated [DATE], reflected Resident #1 was an [AGE] year-old female with an initial admission date of 04/12/2023 with a diagnosis of muscle weakness, Alzheimer's disease, hypothyroidism (when your thyroid gland doesn't make enough thyroid hormones to meet your body's needs), unspecified lack of coordination, other abnormalities of gait and mobility, and chronic kidney disease. She had a BIMS score of 2 which indicates severe cognitive impairment. Resident #1 required supervision or touching assistance with toileting hygiene, oral hygiene, and eating and partial/moderate assistance where an employee does less than half the work showering or bathing, upper and lower body dressing, and personal hygiene. Resident #1 walked with a walker. Record review of Resident #1's quarterly MDS, dated [DATE], reflected Resident #1 had a BIMS score of 2 which indicates severe cognitive impairment. Resident #1 required substantial/maximal assistance (help of 1-2 staff members) with showers, toileting hygiene, oral hygiene and sitting to standing position. Resident #1 was listed as needing a wheelchair. New diagnosis of displaced intertrochanteric fracture of unspecified femur (a severe fracture of the upper part of the thigh bone), and pain in left hip. Record review of Resident #1's care plan dated initiated 04/14/2023 and revised on 08/13/2024 revealed a focus for Resident #1 is a high fall risk. She had a fall at home prior admitting to hospital and coming here to facility Her fall before admission facility resulted to a (right) humerus fracture. The intervention for this goal was anticipate and meet her needs, follow facility fall protocol, (and) PT evaluate and treat as ordered or PRN.Record review of facility PIR dated 08/22/2025, with an allegation of neglect, reflected that Resident #1 sustained a fall in her room on 08/16/2025 at approximately 5:00 am. When the family notified the facility staff of Resident #1's fall, staff completed an x-ray. The x-ray revealed that the resident sustained a femur fracture. Resident #1 was expected to return to the facility upon completion of hospital stay. In service was completed for falls and Social Worker completed safe survey's which showed no trend. Action taken post-investigation revealed continued fall education and monitor resident for further Page 1 of 14 676474 676474 09/22/2025 Le Reve Rehabilitation & Memory Care 3309 Dilido Road Dallas, TX 75228

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few healing during the process. LVN A's witness statement included in the PIR, not dated, or signed, revealed LVN A went into Resident #1's room and saw that she was on the floor between her bed and her roommate's bed. The resident was placed back in bed. LVN A was going to come back to assess her but became busy and forgot to assess her. The facility found the allegation to be confirmed. Safe surveys in the PIR dated 08/19/2025 indicated the residents felt safe, they knew who to report concerns to and would inform staff if they didn't feel safe. In service on ANE and falls was conducted on 08/18/2025 and 08/19/2025 and quizzes were given to staff which revealed that the staff understood the training. A witness statement included in the PIR, dated 08/18/2025 signed by the Administrator, reflected the Administrator attempted to speak to Resident #1 with her family member as a translator and she didn't remember falling or what she was doing before she fell. While reviewing the PIR there the facility did not include what they were doing to prevent this from occurring again other than in-servicing staff.Record review of Resident #1's progress notes revealed no evidence that LVN A reported a fall or completed any assessments for Resident #1. Record review of Resident #1's progress note dated 08/16/2025 at 8:18 pm written by RN B revealed at approximately 4:00 PM Resident #1's family member told RN B that Resident #1 was observed on the floor at around 5:15 am. Vital signs taken, hypotensive at 94/55, no visible signs of injury. She had limited ROM to LLE due to pain. Family at bedside and aware. The Physician was notified, and RN B was told to transfer Resident #1's to the hospital. Resident #1 transferred to the hospital at 8:04 pm. On 08/17/2025 at 10:05 am RN B documented that he called the hospital for an update on Resident #1 and was told she was admitted . (Approximately 11 hours after family said she fell.)Record review of the facility fall report dated 08/16/2025 found RN B documented an unwitnessed fall for Resident #1. Record review of hospital notes with a date of service 08/16/2025 at 10:42 pm revealed anterior shoulder dislocation.acute intertrochanteric fracture of the left femur (a break in the bone just below the hip joint).In an interview with the DON on 09/18/2025 at 12:10 pm the DON said she received a call from RN B on 08/16/2025 around 5:00 pm and he said that Resident #1's family member told him that Resident #1 had fallen around 5:00 am. RN B reported that LVN A had found Resident #1 on the floor and didn't report or assess the fall. When RN B called the DON, an in-house x-ray had been ordered and once it was determined that her femur was broken, RN B sent her to the ER. When asked what the protocol was when a resident has an unwitnessed fall, she said an assessment is completed, ask another staff member to assist with moving the resident, do a head to toe, complete an incident report, call the family, the DON, and the Physician. She said an in-service was completed for fall protocol, abuse, and neglect, but wasn't sure of the date it was completed. She said LVN A was terminated after the facility investigation.Record review of LVN A's Employee Disciplinary Action, dated 08/19/2025 reflected Nurse fail(s) to assess the resident when resident was observed by nurse on the floor got her up and place(d) her in bed. Date of violation 8/16/2025. LVN A was terminated. LVN A's comments: Will be more competent in my approach and be more mindful of my actions. LVN A signed the disciplinary action.In an interview with the Administrator on 09/18/2025 at 5:10 pm she stated that she and the DON investigated the fall for Resident A. She stated that she had discovered that LVN A worked the night of 08/16/2025 from looking at the timecards. She stated that the DON called her about Resident #1's fall. She stated the DON conducted in-services for Resident #1's fall, she stated that they covered what to do for falls and not picking up residents until assessed. She stated that the in-services had started on the weekend, possibly the 18th or the 19th. She stated the normal protocol for in-services for falls or incidents is they start as quickly as possible if not immediately. She stated that after the in-services that they try to continue the education by doing quizzes. She stated that LVN A told her directly that he had 676474 Page 2 of 14 676474 09/22/2025 Le Reve Rehabilitation & Memory Care 3309 Dilido Road Dallas, TX 75228

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few picked her up after the fall.In an interview with the DON on 09/19/2025 at 9:50 am she stated that she started her in-service training on the 08/18/2025. She said she didn't come to the facility that weekend and had instructed RN B about what to do to address the incident.In an interview with RN B, on 09/19/2025 at 10:02 am RN B said Resident #1's family member told him around 4:00 pm that Resident #1 had fallen early in the morning, he asked them how they knew, the family member said from the video in the resident's room. RN B completed an incident and accident report and immediately assessed the resident, found she had pain, notified the DON and Physician, and the Physician ordered an x-ray. RN B said the x-ray results were provided not too long afterwards which showed a fracture of the left hip. RN B said he contacted the Physician with the results of the x-ray and the Physician said to transfer Resident #1 to the hospital. RN B said Resident #1 left the facility around 8:00 pm. RN B said LVN A didn't tell him about Resident #1's fall. RN B said on 08/25/2025 he said the hospital told him about the dislocated shoulder. RN B reported he didn't notice a change in condition of Resident #1 prior to being told about her fall.In an interview with CNA J on 09/19/2025 at 4:57 pm he reported that he didn't notice a change in condition of Resident #1 prior to being told about her fall and said Resident #1 eats her breakfast and lunch in her room. He said her son takes the food tray from him and does all the set up and assists her with setting up her tray for meals.In an interview on 09/20/2025 at 9:55 am with the Activity Director she said prior to Resident #1's fall she'd come to activities but didn't participate, she'd watch but she participated in social celebrations, like birthdays. She said since her fall she hasn't participated in activities, she said she's asked if she wanted to participate but she's declined. The Activity Director said she did one-on-one activities with Resident #1 such as talking with her and discussing current events. In an interview with CNA F on 09/20/2025 at 10:45 am she reported that she didn't notice a change in condition of Resident #1 prior to being told about her fall and said Resident #1 eats her breakfast and lunch in her room, she said her son takes the food tray from her and does the set up and assists her with setting up her tray for meals.In an interview on 09/20/2025 at 12:31 pm with LVN A over the phone, he stated on 08/16/2025 that Resident #1's roommate found him between 3:00 am and 4:00 am, he said he found Resident #1 on the floor and put her back into bed. He said he left because he had been working on a trach, and he had to go back to suctioning. He said, I take full credit for leaving her, I made a mistake. He added that he didn't pass the information on to RN B about the fall. He said he knew he should have reported it to the next nurse, documented it, and made sure that the DON and Physician also knew. In an interview with CNA C on 09/20/2025 at 3:59 pm she reported that she didn't notice a change in the way Resident #1 was moving or behaving prior to being told about her fall and said Resident #1 eats her breakfast and lunch in her room, that her son takes the food tray from her and does the set up and assists her with setting up her tray for meals.Record review of the facility Falls and Fall Risk Managing policy dated 2001 Definition according to the MDS a fall is defined as unintentionally, coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. There is nothing in the Falls and Fall Risk Managing policy that explains what staff members should do when a resident is found to have fallen.This was determined to be an IJ on 09/19/2025 at 2:55 pm. The Administrator and the DON were notified, and the Administrator was provided with the IJ template on 09/19/2025 at 3:35 pm.The following Plan of Removal was submitted by the facility and accepted on 09/20/2025 at 4:50 pm:Resident #1 sustained a fall and was placed back into bed by a nurse who failed to assess her. The resident's family notified the facility later onto the next shift that the resident had 676474 Page 3 of 14 676474 09/22/2025 Le Reve Rehabilitation & Memory Care 3309 Dilido Road Dallas, TX 75228

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few fall on video camera. Resident #1 had x-rays completed, notification to appropriate parties, and sent out to the hospital at this time. Resident #1 sustained a femur fracture and shoulder dislocation on 08/16/2025. Facility monitoring was not completed immediately. The facility failed to ensure that all residents have the right to be free from abuse and neglect. Facility failed to ensure that resident #1 was assessed or reported nor documented by the nurse on shift.1. The medical director was notified of IJ on 09/19/2025 at 4:00 pm.2. The Administrator and DON contacted the RDO and vice president regarding the IJ on 09/19/2025 per the lack of monitoring practices of the fall. The RDO and VP provided re-education to the administrator and DON on 09/19/2025.3. In-service conducted by the Director of Nursing with RNs and LVNs on assessment of residents when a fall has occurred and where to document assessments initiated on 09/19/2025 and will end on 09/20/2025. The training will include not picking up residents off of the floor without assessment for injuries, vital signs, etc. Resident #1 was found on the floor in her room by the nurse without proper assessment before placing the resident back into bed. The training will also ensure nurses are aware of the proper area in the EMR system to document the fall assessments. Incident reports and the SBAR report will be shown for any changes in condition. A checklist will be created for competencies for the RNs and LVNs with the director of nursing signing off. The nurses will show demonstration of the training by showing the DON where the assessments are located in the EMR system. This training will diligently explain that the nurses are to assess all residents prior to picking them up off of the floor such as the case with Resident #1. The nurses will verify understanding by returned demonstration on a staff member during a mock training with a staff member being on the floor and showing the assessment, such as taking vital signs, etc. The nurses will also be trained on who to notify during these assessments and will be shown the area where to place notation of all parties notified, including the responsible parties, physician, Director of Nursing, administrator, etc.4. In-service initiated by the administrator with all staff regarding abuse and neglect. This will be initiated on 09/19/2025 and will end on 09/20/2025. All staff will be trained on who the abuse coordinator is, the time frame to report abuse, neglect, or exploitation, the definition of ANE, and the different types of abuse. Staff will complete a quiz to verify understanding.5. In-service all nurses (RN and LVN) on fall policies and procedures. The training will be conducted by the Director of Nursing and will start from 09/19/2025-09/20/2025. The DON will verify understanding by having the nurses complete a quiz over fall policies.6. DON and/or designee, including the registered nurse supervisor on the weekends, will round daily on all residents to ask if they have observed any falls or any evidence of falls or injuries. The DON will train the RN supervisor via checklist of how to complete rounds, what questions to ask residents, and signs or symptoms of pain to look for. This will be initiated on 09/19/2025 and end on 09/20/2025. This will include all shifts, including weekends. If there are negative findings, we will take the appropriate steps as listed on the fall policy and procedure. Residents that are unable to communicate will be given a communication board for communication. The residents that are unable to utilize a communication board will be assessed for any change in conditions, such as grimacing.7. All nursing staff to be in-serviced in the above-mentioned areas prior to working the next assigned shift by the Director of Nursing, who will verify training completion. The DON will ensure all nurses have completed the fall quizzes.8. LVN A was terminated by facility on 08/19/2025.9. Director of Nursing and/or designee will be observing fall policies and protocols daily for one week and then 3x/ week thereafter for the next 30 days. The staff will be interviewed for facility fall protocols and procedures. The administrator will monitor that the DON monitors the nursing staff by reviewing the checklist and signing off. The DON will use a monitoring tool for each resident spoken to about any physical 676474 Page 4 of 14 676474 09/22/2025 Le Reve Rehabilitation & Memory Care 3309 Dilido Road Dallas, TX 75228

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few signs, restricted movement, and/or pain that they may have.10. Summary of IJ and corrective action to be reviewed by QAPI committee weekly x4 weeks or until substantial compliance is established and continued monthly for 90 days to ensure ongoing compliance. Any deficient practice will be discussed with the medical director at the time of occurrence and will also mention during the QAPI meeting. The Monitoring checklist will be reviewed at the QAPI meeting.Monitoring of the POR included the following:In an interview on 09/20/2025 at 7:30 pm the DON stated in-services were completed on all nursing staff.Record review of all in-service rosters, checklists, policies and in-services revealed in-services and quizzes were conducted with nursing staff by the DON and completed for fall protocol and ANE. Interviews were conducted between the dates of 09/20/2025 at 7:45 pm and 09/22/25 at 3:00 pm with 26 nursing staff members out of 31 nursing staff members, were asked the following questions:All:u Title/Name/Length of time at the facility?u Did you receive training on fall protocol, abuse, and neglect?u Did you take a quiz or answer questions about your training?u What is a fall?u Did you learn anything new from your latest in-services?u If you see a fall or find a resident on the floor, what do you do?u What if you see a fall?u Who do you report incidents/accident to?u Who is the abuse coordinator?DON, RN B, CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, CNA J, LVN K, RN L, CNA M, LVN N, RN O, LVN P, CNA Q, CNA R, CNA S, LVN T, CNA U, LVN V, LVN W, LVN X, CNA Y, and CNA Z representing and interviewed during the 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and the 10:00 PM to 6:00 AM shifts, were able to answer all questions in a satisfactory manner that suggested training had been conducted and understood, written competencies had been conducted and completed.An IJ was identified on 09/19/2025, the IJ template was provided to the Administrator on 09/19/2025 at 3:35 pm. While the IJ was removed on 9/22/2025, the facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy, because all staff had not been trained. 676474 Page 5 of 14 676474 09/22/2025 Le Reve Rehabilitation & Memory Care 3309 Dilido Road Dallas, TX 75228

F 0610 Respond appropriately to all alleged violations. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in process. For one resident (Resident #1) out of 5 residents reviewed for neglect and abuse.The facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment by LVN A by allowing him to work and have direct contact with the resident while the allegations were still under investigation.An IJ was identified on 09/20/2025. The IJ template was provided to the facility on [DATE] at 8:07 pm. While the IJ was removed on 09/22/2025, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that is not immediate jeopardy, because the facility allowed the alleged perpetrator to remain in the facility and to have direct contact with other residents on 08/16/2025 and 08/17/2025.These failures could result in residents experiencing serious harm, impairment, or death due to the facility failure of protecting residents.Findings include:Record review on 09/18/2025 at 4:00 pm of LVN A's Employee Disciplinary Action, dated 08/19/2025 revealed he was discharged due to a violation on 08/16/2025. LVN A's comments: Will be more competent in my approach and be more mindful of my actions. LVN A signed the disciplinary action.Record review of facility PIR dated 08/22/2025, with an allegation of neglect, reflected that Resident #1 sustained a fall in her room on 08/16/2025 at approximately 5:00 am. When the family notified the facility staff of Resident #1's fall, staff completed an x-ray. The x-ray revealed that the resident sustained a femur fracture. Resident #1 was expected to return to the facility upon completion of hospital stay. In service was completed for falls and Social Worker completed safe survey's which showed no trend. Action taken post-investigation revealed continued fall education and monitor resident for further healing during the process. LVN A's witness statement included in the PIR, not dated, or signed, revealed LVN A went into Resident #1's room and saw that she was on the floor between her bed and her roommate's bed. The resident was placed back in bed. LVN A was going to come back to assess her but became busy and forgot to assess her. The facility found the allegation to be confirmed. Safe surveys in the PIR dated 08/19/2025 indicated the residents felt safe, they knew who to report concerns to and would inform staff if they didn't feel safe. In service on ANE and falls was conducted on 08/18/2025 and 08/19/2025 and quizzes were given to staff which revealed that the staff understood the training. A witness statement included in the PIR, dated 08/18/2025 signed by the Administrator, reflected the Administrator attempted to speak to Resident #1 with her family member as a translator and she didn't remember falling or what she was doing before she fell. While reviewing the PIR there the facility did not include what they were doing to prevent this from occurring again other than in-servicing staff.In an interview with the Administrator on 09/18/2025 at 5:10 pm she stated that she had discovered that LVN A worked the night of 08/16/2025 from looking at the timecards. In an interview with the DON on 09/18/2025 at 5:19 pm she stated that she immediately suspended LVN A but had no written documentation of his suspension.In a record review on 09/19/2025 at 1:14 pm of the nursing schedule for 08/16/2025 from 10:00 pm to 6:00 am on 08/17/2025 LVN A worked station 1.In a record review on 09/20/2025 at 1:10 pm of LVA A's timecard on 08/16/2025 revealed he clocked in at 9:56 pm and clocked out 08/17/2025 at 6:29 am.In an interview with the Administrator on 09/20/2025 at 3:13 pm she said that LVN A was to be suspended because it was alleged that he didn't assess, document or inform the oncoming nurse of Resident #1's fall and should have been suspended while he was under investigation for failure to report.In an interview with the DON on 09/20/2025 at 4:48 pm when asked what the process for suspension was, she said the employee would come in and write a statement and be Residents Affected - Few 676474 Page 6 of 14 676474 09/22/2025 Le Reve Rehabilitation & Memory Care 3309 Dilido Road Dallas, TX 75228

F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few suspended until the investigation was completed. The DON said once she is notified, she informs the Administrator. She added that staff gets suspended to protect residents.In an interview with LVN A (on the telephone) on 09/20/2025 at 4:58 pm when asked when his last day of work was, he stated he worked 08/16/2025 from 10:00 pm until 6:30 am on 08/17/2025.This was determined to be an IJ on 09/20/2025 at 8:07 pm. The Administrator, the DON and RDO were notified, and the Administrator was provided with the IJ template on 09/22/2025 at 3:35 pm.In an interview with the RDO on 09/21/2025 at 10:55 am he said that staff members are suspended for any alleged allegation of abuse or neglect, to protect the residents from any further abuse, neglect or harm. He said the guidelines for suspension are to be made in person, if not possible, by phone, but a disciplinary form should be filled out to document the disciplinary action and conclusion. He said he felt it was lack of oversight from the Administrator and DON, to ensure the suspension was enacted and followed up with the staff (member) to make sure.The following Plan of Removal was submitted by the facility and accepted on 09/21/2025 at 4:37 pm:Plan of RemovalThe facility failed when Nurse A worked an additional shift and the Administrator and DON did not ensure that any further potential abuse and neglect, exploitation or mistreatment was prevented. The facility failed to monitor the suspended Nurse A was not completed. The facility failed to ensure that all residents have the right to be free from abuse and neglect. The facility failed to ensure that the procedure for the Facility Abuse Investigation and Reporting Policy by The Administrator and Director of Nursing ensures ongoing investigation and corrective measures completed.The Administrator and DON were educated on Immediate Reporting & Follow-Up Procedure - Abuse Prevention remove the risk and ensure no further abuse occurs through prompt protective measures, leadership oversight, and staff accountability. The RDO provided re-education to the administrator and DON on 09/21/25.The RDO completed education and competencies material understanding suspensions to ensure the Administrator and Director of Nursing understand to ensure abuse neglect, reporting completed on 09/21/2025.Summary of IJ and corrective action to be reviewed by QAPI committee ongoing moving forward to ensure ongoing compliance. The Administrator, Director of Nursing and/or HR oversee notify the RDO of all suspensions. The administrator and DON will have the suspension check sheet signed and dates and sent to the RDO. HR in conjunction with all managers, as soon as she gets suspension, remove them from the system, fill out the suspension form and post suspension alert, alert all staff with our group messaging that the individual is suspended and is not allowed in the building pending the investigation. All managers and managers on duty will be alerted by HR who should be and who shouldn't be working when a suspension occurs and will revoke their access. The Administrator and DON are responsible for informing the employee clearly of the suspension and reason, providing written suspension notice to the employee document time, date, and persons present during communication, notify HR for personal records update. In conjunction with HR and the RDO, they will make sure their access is removed from the system with documentation emailed completion to the RDO. The Administrator and DON will start the investigation. The RDO will do daily calls with Human Resources on all personal items and suspensions incidents, along with weekly audits to review suspensions by monitoring time sheets, all investigations, incidents accidents and self-reports. Suspensions require suspension forms filled out signed and dated, alert all managers and staff through group messaging that the individual is suspended and not allowed in the building pending the investigation and the suspension alert forms for staff posted. The Medical Director was notified of the new IJ and plan of removal on 09/21/2025. Monitoring of the POR included the following:In an interview with the Administrator on 09/21/2025 at 4:45 pm she stated that she received training from the RDO about reporting and follow up for Abuse Prevention and she did a written quiz on ANE, and she said the facility now has a 676474 Page 7 of 14 676474 09/22/2025 Le Reve Rehabilitation & Memory Care 3309 Dilido Road Dallas, TX 75228

F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few check list to make sure that suspensions, staff education, internal facility actions are carried out in a professional fashion. She stated that her training was a good refresher.In an interview with the DON on 09/21/2025 at 4:55 am she stated that she received ANE training this morning on how to conduct the investigations, protocol and who to contact upon suspension of a staff member (The Administrator, RDO and the staff members to be suspended). She said that she had taken a written test in conjunction with training, that the training and protocols being put into place now will stop another incident like this from occurring in the future. She stated that she did not learn anything new, but it was a good refresher.In an interview with the Administrator on 09/22/2025 at 1:01 pm she stated that she is aware of the new forms, and after that the staff member is immediately suspended, the RDO and HR are notified to make sure that the identified suspended staff member is not on the premises during the course of investigation.In an interview with the DON on 09/22/2025 at 1:05 pm she said that she had also received the new training and described the new process in the same manner as the Administrator.In an interview with the RDO on 09/22/2025 at 1:15 pm he said that the suspension protocol is that the Administrator and DON notify him and HR and then they document the contacted staff member who is suspended and make sure the document is signed and dated. We, with HR, will make sure everyone is informed.Record review of Immediate Reporting and Follow-Up Procedure, revealed in-services were conducted with the Administrator and DON by the RDO and interviews with the Administrator and DON revealed they understood the training they received. An IJ was identified on 09/20/2025. The IJ template was provided to the Administrator on 09/20/2025 at 8:07 pm. While the IJ was removed on 09/22/2025, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that is not immediate jeopardy, because the facility allowed the alleged perpetrator to remain in the facility and to have direct contact with other residents on 08/16/2025 and 08/17/2025. 676474 Page 8 of 14 676474 09/22/2025 Le Reve Rehabilitation & Memory Care 3309 Dilido Road Dallas, TX 75228

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety Based on interviews and record reviews LVN A failed to assess Resident #1 which prevented her from receiving timely treatment. LVN A failed to follow protocol after Resident #1 had a fall. LVN A picked Resident #1 off the floor and returned her to her bed without conducting an assessment and reporting the incident to RP, DON, and Physician. This resulted in Resident #1 not being diagnosed with a fracture on her left hip and a right dislocated shoulder for 11 hoursFindings include:Record review of facility PIR dated 08/22/2025, with an allegation of neglect, reflected that Resident #1 sustained a fall in her room on 08/16/2025 at approximately 5:00 am. When the family notified the facility staff of Resident #1's fall, staff completed an x-ray. The x-ray revealed that the resident sustained a femur fracture. Resident #1 was expected to return to the facility upon completion of hospital stay. In service was completed for falls and Social Worker completed safe survey's which showed no trend. Action taken post-investigation revealed continued fall education and monitor resident for further healing during the process. LVN A's witness statement included in the PIR, not dated, or signed, revealed LVN A went into Resident #1's room and saw that she was on the floor between her bed and her roommate's bed. The resident was placed back in bed. LVN A was going to come back to assess her but became busy and forgot to assess her. The facility found the allegation to be confirmed. Safe surveys in the PIR dated 08/19/2025 indicated the residents felt safe, they knew who to report concerns to and would inform staff if they didn't feel safe. In service on ANE and falls was conducted on 08/18/2025 and 08/19/2025 and quizzes were given to staff which revealed that the staff understood the training. A witness statement included in the PIR, dated 08/18/2025 signed by the Administrator, reflected the Administrator attempted to speak to Resident #1 with her family member as a translator and she didn't remember falling or what she was doing before she fell. While reviewing the PIR there the facility did not include what they were doing to prevent this from occurring again other than in-servicing staff.Record review of Resident #1's progress notes revealed no evidence that LVN A reported a fall or completed any assessments for Resident #1. Record review of LVN A's Employee Disciplinary Action, dated 08/19/2025 reflected Nurse fail(s) to assess the resident when resident was observed by nurse on the floor got her up and place(d) her in bed. Date of violation 8/16/2025. LVN A was terminated. LVN A's comments: Will be more competent in my approach and be more mindful of my actions. LVN A signed the disciplinary action.In an interview with RN B, on 09/19/2025 at 10:02 am RN B said Resident #1's family member told him around 4:00 pm that Resident #1 had fallen early in the morning, he asked them how they knew, the family member said from the video in the resident's room. RN B completed an incident and accident report and immediately assessed the resident, found she had pain, notified the DON and Physician, and the Physician ordered an x-ray. RN B said the x-ray results were provided not too long afterwards which showed a fracture of the left hip. RN B said he contacted the Physician with the results of the x-ray and the Physician said to transfer Resident #1 to the hospital. RN B said Resident #1 left the facility around 8:00 pm. RN B said LVN A didn't tell him about Resident #1's fall. RN B said on 08/25/2025 he said the hospital told him about the dislocated shoulder. RN B reported that despite her injuries he didn't notice a change in condition of Resident #1 prior to being told about her fall.In an interview with CNA J on 09/19/2025 at 4:57 pm he reported that he didn't notice a change in condition of Resident #1 prior to being told about her fall and said Resident #1 eats her breakfast and lunch in her room. He said her son takes the food tray from him and does all the set up and assists her with setting up her tray for meals.In an interview with CNA F on 09/20/2025 at 10:45 am she reported that she didn't notice a change in condition of Resident #1 prior to being told about her fall and said Resident #1 eats her breakfast and lunch in her room, Residents Affected - Few 676474 Page 9 of 14 676474 09/22/2025 Le Reve Rehabilitation & Memory Care 3309 Dilido Road Dallas, TX 75228

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few she said her son takes the food tray from her and does the set up and assists her with setting up her tray for meals.In an interview with CNA C on 09/20/2025 at 3:59 pm she reported that she didn't notice a change in the way Resident #1 was moving or behaving prior to being told about her fall and said Resident #1 eats her breakfast and lunch in her room, that her son takes the food tray from her and does the set up and assists her with setting up her tray for meals.In an interview on 09/20/2025 at 12:31 pm with LVN A over the phone, he stated on 08/16/2025 that Resident #1's roommate found him between 3:00 am and 4:00 am, he said he found Resident #1 on the floor and put her back into bed. He said he left because he had been working on a trach, and he had to go back to suctioning. He said, I take full credit for leaving her, I made a mistake. He added that he didn't pass the information on to RN B about the fall. He said he knew he should have reported it to the next nurse, documented it, and made sure that the DON and Physician also knew. This was determined to be an IJ on 09/19/2025 at 2:55 pm. The Administrator and the DON were notified, and the Administrator was provided with the IJ template on 09/19/2025 at 3:35 pm.The following Plan of Removal was submitted by the facility and accepted on 09/20/2025 at 4:50 pm:Resident #1 sustained a fall and was placed back into bed by a nurse who failed to assess her. The resident's family notified the facility later onto the next shift that the resident had fall on video camera. Resident #1 had x-rays completed, notification to appropriate parties, and sent out to the hospital at this time. Resident #1 sustained a femur fracture and shoulder dislocation on 08/16/2025. Facility monitoring was not completed immediately. The facility failed to ensure that all residents have the right to be free from abuse and neglect. Facility failed to ensure that resident #1 was assessed or reported nor documented by the nurse on shift.1. The medical director was notified of IJ on 09/19/2025 at 4:00 pm.2. The Administrator and DON contacted the RDO and vice president regarding the IJ on 09/19/2025 per the lack of monitoring practices of the fall. The RDO and VP provided re-education to the administrator and DON on 09/19/2025.3. In-service conducted by the Director of Nursing with RNs and LVNs on assessment of residents when a fall has occurred and where to document assessments initiated on 09/19/2025 and will end on 09/20/2025. The training will include not picking up residents off of the floor without assessment for injuries, vital signs, etc. Resident #1 was found on the floor in her room by the nurse without proper assessment before placing the resident back into bed. The training will also ensure nurses are aware of the proper area in the EMR system to document the fall assessments. Incident reports and the SBAR report will be shown for any changes in condition. A checklist will be created for competencies for the RNs and LVNs with the director of nursing signing off. The nurses will show demonstration of the training by showing the DON where the assessments are located in the EMR system. This training will diligently explain that the nurses are to assess all residents prior to picking them up off of the floor such as the case with Resident #1. The nurses will verify understanding by returned demonstration on a staff member during a mock training with a staff member being on the floor and showing the assessment, such as taking vital signs, etc. The nurses will also be trained on who to notify during these assessments and will be shown the area where to place notation of all parties notified, including the responsible parties, physician, Director of Nursing, administrator, etc.4. In-service initiated by the administrator with all staff regarding abuse and neglect. This will be initiated on 09/19/2025 and will end on 09/20/2025. All staff will be trained on who the abuse coordinator is, the time frame to report abuse, neglect, or exploitation, the definition of ANE, and the different types of abuse. Staff will complete a quiz to verify understanding.5. In-service all nurses (RN and LVN) on fall policies and procedures. The training will be conducted by the Director of Nursing and will start from 09/19/2025-09/20/2025. The DON will verify understanding by having the nurses complete a 676474 Page 10 of 14 676474 09/22/2025 Le Reve Rehabilitation & Memory Care 3309 Dilido Road Dallas, TX 75228

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few quiz over fall policies.6. DON and/or designee, including the registered nurse supervisor on the weekends, will round daily on all residents to ask if they have observed any falls or any evidence of falls or injuries. The DON will train the RN supervisor via checklist of how to complete rounds, what questions to ask residents, and signs or symptoms of pain to look for. This will be initiated on 09/19/2025 and end on 09/20/2025. This will include all shifts, including weekends. If there are negative findings, we will take the appropriate steps as listed on the fall policy and procedure. Residents that are unable to communicate will be given a communication board for communication. The residents that are unable to utilize a communication board will be assessed for any change in conditions, such as grimacing.7. All nursing staff to be in-serviced in the above-mentioned areas prior to working the next assigned shift by the Director of Nursing, who will verify training completion. The DON will ensure all nurses have completed the fall quizzes.8. LVN A was terminated by facility on 08/19/2025.9. Director of Nursing and/or designee will be observing fall policies and protocols daily for one week and then 3x/ week thereafter for the next 30 days. The staff will be interviewed for facility fall protocols and procedures. The administrator will monitor that the DON monitors the nursing staff by reviewing the checklist and signing off. The DON will use a monitoring tool for each resident spoken to about any physical signs, restricted movement, and/or pain that they may have.10. Summary of IJ and corrective action to be reviewed by QAPI committee weekly x4 weeks or until substantial compliance is established and continued monthly for 90 days to ensure ongoing compliance. Any deficient practice will be discussed with the medical director at the time of occurrence and will also mention during the QAPI meeting. The Monitoring checklist will be reviewed at the QAPI meeting.Monitoring of the POR included the following:In an interview on 09/20/2025 at 7:30 pm the DON stated in-services were completed on all nursing staff.Record review of all in-service rosters, checklists, policies and in-services revealed in-services and quizzes were conducted with nursing staff by the DON and completed for fall protocol and ANE. Interviews were conducted between the dates of 09/20/2025 at 7:45 pm and 09/22/25 at 3:00 pm with 26 nursing staff members out of 31 nursing staff members, were asked the following questions:All:u Title/Name/Length of time at the facility?u Did you receive training on fall protocol, abuse, and neglect?u Did you take a quiz or answer questions about your training?u What is a fall?u Did you learn anything new from your latest in-services?u If you see a fall or find a resident on the floor, what do you do?u What if you see a fall?u Who do you report incidents/accident to?u Who is the abuse coordinator?DON, RN B, CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, CNA J, LVN K, RN L, CNA M, LVN N, RN O, LVN P, CNA Q, CNA R, CNA S, LVN T, CNA U, LVN V, LVN W, LVN X, CNA Y, and CNA Z representing and interviewed during the 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and the 10:00 PM to 6:00 AM shifts, were able to answer all questions in a satisfactory manner that suggested training had been conducted and understood, written competencies had been conducted and completed.An IJ was identified on 09/19/2025, the IJ template was provided to the DON on 09/19/2025 at 3:35 pm. While the IJ was removed on 9/22/2025, the facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy, because all staff had not been trained. 676474 Page 11 of 14 676474 09/22/2025 Le Reve Rehabilitation & Memory Care 3309 Dilido Road Dallas, TX 75228

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 10 days of 60 days reviewed for RN coverage.This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment.Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 10 days of 60 days reviewed for RN coverage.This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment.Findings included:The facility failed to ensure they had an RN on duty on 01/18 (SAT); 01/19 (SUN); 01/25 (SAT); 01/26 (SUN); 02/01 (SAT); 02/02 (SUN); 05/10 (SAT); 05/11 (SUN); 05/17 (SAT) and 05/18 (SUN).Review of staffing hours for January and May of 2025 reflected zero hours worked by an RN on the dates of 01/18 (SAT); 01/19 (SUN); 01/25 (SAT); 01/26 (SUN); 02/01 (SAT); 02/02 (SUN); 05/10 (SAT); 05/11 (SUN); 05/17 (SAT) and 05/18 (SUN).In an interview on 09/18/2025 at 11:17 AM the BOM revealed that he was aware of the missed days for RN hours and that the weekend charge nurse had quit and it had taken the facility some time to find a replacement. He stated that it could have been an issue because of a possible lack of supervision, and that assessments may not have been sufficient, and that interventions, care, and treatment may have been lacking in some fashion because of the absence of a registered nurse on those days.During an interview on 09/18/2025 at 11:43 AM the ADM stated that it is important to have an RN in the facility because they are licensed to do more for the residents than the LVN's can do especially assessments. We did have an RN resign earlier in the year and we did not have an RN for full coverage for some time. I know that we are supposed to have an RN every day and that not having an RN could affect the health and welfare of the residents.Record review of facility policy dated August 2023 reflected the following, Policy Statement: The nursing services department shall be under the direct supervision of a registered or licensed practical/vocational nurse at all times. Policy Interpretation and Implementation: 1. A registered or licensed practical/vocational nurse (RN/LPN/LVN) is on duty 24 hours per day, seven days per week, to supervise the nursing services activities in accordance with physician orders and facility policy. 2. A registered nurse (RN) is employed as the Director of Nursing Services. The DNS is on duty during the day shift Monday through Friday. During the absence of the DNS, a nurse supervisor/charge nurse is responsible for the supervision of all nursing department activities, including the supervision of direct care staff. 3. The nurse supervisor/charge nurses are registered nurses (RN) or licensed practical vocational nurses (LPN/LVN), and are duly licensed by the state. 4. The Director of Nursing Services and/or the nurse supervisor/charge nurse, as a minimum, is responsible for: a. making daily resident visits to observe and evaluate the residence, physical and emotional status; b. reviewing medication, cards for completeness of information, accuracy in the transcription of physician orders, and adherence to stop order policies;c. reviewing individual, resident care, plans for appropriate goals, problems, approaches, and revisions, based on nursing needs; d. Assuring that the residence plan of care is being followed; e. arranging schedule to allow time for supervision and evaluation of performance of nursing personnel, and paid feeding assistants; f. informing attending physicians and resident families of changes in the residence, medical condition; g. charting and documenting medical records as necessary; h. keeping Nursing Service Personnel, informed of status of residence, and other related matters through written reports and verbal communication; i. Assigning work schedules and staffing to meet the needs of residence; providing direct resident care as necessary or appropriate; j. and other tasks and functions, that may become necessary. 676474 Page 12 of 14 676474 09/22/2025 Le Reve Rehabilitation & Memory Care 3309 Dilido Road Dallas, TX 75228

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four of four ( Resident #46, #16, #17, and #54) and two of three (DA A and DA B) staff members reviewed for infection control procedures. Dietary Aide A failed to perform hand hygiene after direct contact with Residents #46 and #16 while serving meals in the main dining room.Dietary Aide B failed to perform hand hygiene after direct contact with Residents #17 and #54 while serving meals in the main dining room. This failure could place residents at risk for healthcare associated cross contamination and infections. Findings included:Record review of Resident #46's quarterly MDS assessment, dated 09/04/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #46 had diagnosis which included: dementia (brain confusion), hypertension (increased blood pressure), and diabetes (increased sugar levels). Resident #46 had severe cognitive impairment and required assistance of one staff for activities of daily living. Record review of Resident #16's quarterly MDS Assessment, dated 07/03/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #16 had diagnosis which included: dementia (brain disease that affects memory and behaviors), atrial fib (abnormal heart rhythm), hypertension (increased blood pressure), and depression (mood disorder). Resident #16,had moderate cognition impairment and required one staff for assistance with activities of daily living. Record review of Resident #17's annual MDS Assessment, dated 09/14/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #17 had diagnosis which included: Cardiovascular accident (stroke), heart failure, atrial flutter (irregular rhythm of the heart), and diabetes (increased sugar levels). Resident #17 was severely impaired for cognition and required one staff for assistance with activities of daily living. Record review of Resident #54's quarterly MDS Assessment, dated 07/25/25, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #54 had diagnosis which included: Hypertension (high blood pressure), depression (mental illness), and dementia (brain disease that affects memory and behavior). Resident #54 was cognitively able to make decisions and required assistance of one staff for activities of daily living. Observation on 09/17/25 beginning at 12:00 p.m. revealed DA A had adjusted her clothing, did not use hand sanitizer, and served a lunch tray to Resident #46. DA A touched the hand and shoulder of Resident #46 and prepared the meal tray for the resident to eat her lunch. DA A did not have on gloves. DA A was observed not to wash her hands or use hand sanitizer, available in the dining room. DA A walked over the serving cart that had lunch trays on the cart and took another tray off the cart serving the lunch meal to Resident #16. DA A touched Resident 16's edge of the dining table, unwrapped the eating utensils, and then took the lids off the dessert bowl. DA A left the resident's table without using hand sanitizer. Observation on 09/17/25 beginning at 12:20 p.m., DA B was observed coming out of the kitchen with a serving cart, with lunch meals on the cart. DA B was observed to serve Resident's #17's, setting up the resident's lunch tray, adjusting the chair at the table, and unwrapped the utensils removed tops off drinks, for the resident. She did not complete hand hygiene before going to the next resident. DA B served Resident #54's lunch meal, unwrapping his eating utensils and taking the lids off the drinks and the wrap off the top for the dessert. An interview on 09/17/25 at 1:45 p.m., DA A stated she did not complete hand hygiene after having direct contact with residents. DA A stated she was supposed to use the hand sanitizer in between serving each tray from the cart. She stated she washed her hands after having direct contact with the residents when she went back into the kitchen. DA A said she Residents Affected - Few 676474 Page 13 of 14 676474 09/22/2025 Le Reve Rehabilitation & Memory Care 3309 Dilido Road Dallas, TX 75228

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had been educated on completing hand hygiene, by the Dietary Manager. DA A stated the Dietary Manger had told her to always before she left the kitchen to serve the trays off the cart, she must wash her hands, she never said anything about using hand sanitizer between each tray served. DA A stated she did not sanitize her hands, because she was nervous and trying to get the lunch trays served. DA A stated if she did not wash or [NAME] her hands she could spread germs. An interview on 09/17/25 at 1:50 p.m., DA B stated she did not complete hand hygiene in the dining room after having direct contact with the residents. DA B stated she had washed her hands in the kitchen before coming out with the cart to serve the trays. After serving trays DA B stated she washes her hands when she goes back in the kitchen with the cart to get more lunch trays. DA B stated she thought before and after serving was enough, she did not realize you are supposed to use hand sanitizer or wash your hands in between each lunch tray. DA B stated the Dietary Manager had told her to always wash her hands before leaving the kitchen to serve the trays in the dining room, she never mentioned anything about cleaning your hands between each tray served. DA B stated if your hands are not clean you can spread germs to others. An interview with the DON on 09/17/25 at 2:13 p.m. revealed that all staff must complete hygiene after having contact with residents. She stated DAs were trained to use hand sanitizer between each tray that was served. The DON stated she was in the dining room with hand sanitizer available to use, but the kitchen staff did not ask to use it. The DON stated she had the hand sanitizer bottle with her; there was no other available for the dietary aides to use. The DON said the dietary aides should have known they could have gotten the hand sanitizer from me, I was standing there holding the bottle. The DON stated if the DAs do not use appropriate hygiene, they can spread germs to the residents and themselves. The DON clarified she did not have any in-services with the kitchen staff concerning handwashing, the Dietary Manager did. An interview with the Dietary Manger on 09/17/25 at 2:30 p.m., revealed the Dietary Manager had no in-services for hand sanitizing. The Dietary Manager stated, she had instructed all her staff serving meals in the dining room, to wash their hands before going out of the kitchen and when the staff returned to the kitchen. The Dietary manager stated she was unaware that you had to wash hands or use hand sanitizer between each meal tray that was served. The Dietary Manager stated if the hands were not clean the staff could spread germs to the residents and the staff. The Dietary Manager stated she knew the DON had conducted in-services on infection control, but the DON did not let her staff know when those in-services occurred. The Dietary Manger stated now that she knows she will be including this in her conversations she has with her staff, concerning infection control. Review of the facility's policy titled Infection Control dated revised October 2018 reflected, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. 1. This facility's infection control policies and practices apply to all personnel. 2 The objectives of our infection control policies and practices are to: a. prevent, detect, investigate, and control infections in the facility. b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitor, and the general public. 4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter. 676474 Page 14 of 14