Health inspection·December 7, 2025

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure they provided, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two (Residents #1 and #2) of eight residents reviewed for activities. The facility failed to ensure the residents had scheduled activities since Former AD G stopped working 10/31/25. This failure could place residents at risk of not having routine activities to stimulate their minds and prevent boredom which could result in a decrease in the residents health and psycho-social well-being. Findings included: A)Record review of Resident #2's Quarterly MDS dated [DATE] revealed a [AGE] year old male who admitted [DATE], he had a BIMS score of 04 (severe cognitive impairment). He had a primary medical condition of a stroke and diagnoses of anemia, hypertension, hyperlipidemia, CVA, Non -Alzheimer's dementia. Record review of Resident #2's Care plan revised 02/24/25 revealed, Has a communication problem related to intellectual disabilities, impaired cognitive function/dementia or impaired thought processes, oral/dental health problems poor nutrition, diet order other than regular (no salt on tray, mechanically soft diet), and is at risk for unplanned weight loss or gain. Has status related to hypertension, transient cerebral ischemic attack and hyperlipemia and osteoarthritis. And The resident has little or no activity involvement revision on: 07/25/2024 Resident #2 will participate in activities of choice as tolerated per week by review date, establish and record the resident's prior level of activity involvement and interests by talking with the resident caregivers, and family on admission and as necessary. explain to the resident the importance of social interaction, leisure activity time. Encourage the resident's participation. Interview on 12/05/25 at 1:13 pm, interview was attempted with Resident #2 but he was not interviewable. He was lying in bed watching TV in his room. Interview on 12/08/25 at 10:36 am, Resident #2's FM stated the facility had a family Thanksgiving dinner but she had not seen any activities lately. She stated she was not sure if it was because of the holidays or what. She stated she had not spoken to any of the staff about it yet. She stated Resident #2 liked to play dominoes and bingo but she had not seen him playing them in the past month or so. B)Record review of Resident #3's Quarterly MDS Quarterly assessment dated [DATE] revealed a [AGE] year old female who admitted [DATE] with a BIMS score of 15 (no cognitive impairment). She had a primary diagnosis of medically complex conditions. She had diagnoses cancer, anemia, coronary artery disease, heart failure, hypertension, peripheral artery disease, ulcerative colitis, renal insufficiency, diabetes mellitus, hyperlipidemia, malnutrition, gastro-esophageal reflux and diverticulitis of large intestine. Record review of Resident #3' Care plan revised on 11/19/25 revealed, Has potential/actual impairment to skin integrity related to edema, fragile skin, heart failure and takes diuretics as ordered, diabetes mellitus, Residents Affected - Some Page 1 of 11 745006 745006 12/07/2025 Five Points Nursing and Rehabilitation 1901 N Hampton Rd Desoto, TX 75115

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hypertension, impaired immunity related to: cancer, lupus and lymphedema, GERD, diverticulosis, and Crohn's disease, alteration in hematological status related to history of thrombosis. And Resident #3 has little or no activity involvement. Revision on: 11/19/2025 - Resident #3 will express satisfaction with type of activities and level of activity involvement when asked through the review date. Explain to resident the importance of social interaction, leisure activity time. Encourage Resident #3's participation. Interview on 12/07/25 at 8:30 a.m., Resident #3 was sitting up in bed watching TV in her room, she stated she was not sure who the AD was now and had not seen any activities going on or being offered in a while and was not sure why, so she just watched a lot of TV. Interview on 12/08/25 at 10:48 am, FM 4 of Resident #3 stated [This facility] has had activities in the past but had not seen them doing any lately. He stated he used to see the residents playing bingo and things like that and it had been about a month since seeing the residents doing activities. In a confidential interview on 12/07/25, (Anonymous) stated they had not had any activities for two months. They stated they were supposed to have $200.00 per month for activities and was not sure what that money was being used for now. They stated they complained to the staff about not having activities and was told to go to the Church activities but said they were not into church like that. They stated the therapy did have music therapy twice a week but they were not interested in that. They stated they had not had bingo, movie matinee and no monthly birthday party for the residents. They stated they watched a lot of TV and went out on pass with family and friends and talked on the phone a lot. They stated hopefully activities would be back again really soon. Interview on 12/06/25 at 12:43, the DON stated Former AD G quit working at this facility on 10/31/25 and the Therapy Department and SW H were doing activities with the residents. She stated they could not find the Resident council minutes form for November 2025 and was not sure where Former AD G put it. Interview on 12/06/25 at 1:58 pm, SW H stated they did not have an AD anymore because she stopped working here in October 2025. She stated since the AD she was not filling in as AD and doing activities with the residents. She stated some CNA's and nurses played music for the residents and the residents watched TV and had church services. Interview on 12/06/25 at 2:23 pm, PTA J stated they did not fill in for the facility not having an AD but they did group therapy for all the residents who wanted to participate. She stated usually around 15 to 20 residents participated for one hour on Wednesday and one hour on Fridays. She stated they did exercises and balloon tosses, [NAME] says and wheelchair races. Interview on 12/07/25 at 10:55 am, DOR K stated they had group therapy with the residents in the dining room on Wednesdays and Fridays at 10:30 am that was available for all residents to do. She stated usually about 15 residents participated in the dining room. She stated the therapy department did not follow the schedule on the activity's calendar board. She had not seen the residents playing bingo, live music but had seen them watching TV like family feud and western shows in the dining room. Interview on 12/07/25 at 11:55 am, Staffing Coordinator L stated they did not have an AD since the beginning of November 2025 and said the therapy department did group therapy with the residents. She stated they would put the residents in a circle and talk to them, introduce themselves and play music. She stated the residents had not had any bingo, pretty nails, birthday parties, since the Former AD G left. She stated in their standup meeting they discussed they were running an ad for a new AD. Interview on 12/07/25 at 12:46 pm, HR M stated the Former AD G stopped working at this facility 10/31/25. He stated she went to another facility paying more money. He stated they were looking for another AD and one AD he interviewed said the pay was too low at this facility. He stated other interviewees were not experienced. He stated the staff did activities at times with the residents whenever they had time and said their Transportation driver O helped with activities but was not sure when the last she did activities 745006 Page 2 of 11 745006 12/07/2025 Five Points Nursing and Rehabilitation 1901 N Hampton Rd Desoto, TX 75115

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some like bingo with them. He stated they had three potential AD's but the pay at this facility was too low. He stated one AD potential had 10 years AD experience, but told him if the payrate was below $27.00 per hour she would accept the position. She stated this facility starting rate for AD was $19.50 per hour. He stated he had spoken to Corporate and they said they were not able to increase the pay. He stated they had a potential housekeeper interested in the AD Role but would have to get her certified first. Interview on 12/07/25 at 2:05 pm, DA P stated for activities he saw the residents doing exercises last Friday 12/05/25 and said they listen to music sometimes in the dining room. He stated he had not seen the residents having activities like Bingo on a regular basis. Interview on 12/07/25 at 2:34 pm, ADON A stated they have had some changes in the staff and no longer had an AD and the facility was currently searching for another one. She stated their therapy department did some group activities with the residents twice per week. She stated last Friday 12/05/25 therapy played music with the residents and said the residents loved their activities around here. She stated she was not be able to say if therapy was doing all the activities listed on the activity calendar. She stated she had not seen SW H doing activities with the residents. She stated each department head did champion rounds to each of the residents and was not sure who did the champion rounds for the 600 hall. She stated they did there very best as a team to resolve grievances, by getting their departments heads involved and to follow/up with the complainant to see if the complaint was resolved. She stated the SW was responsible for ensuring the complaints were address and then the Administrator and DON reviewed them. Interview on 12/07/25 at 3:09 pm, DD F stated this facility did not have an AD and was not sure how long she had been gone. He stated he saw the therapy department doing workouts around 10:30 am, with a few of the residents in the dining room at times during the week. He stated he had not seen anyone doing the activities like bingo and was not sure about the residents having activities on the weekends. Interview on 12/07/25 at 4:16 pm, the DON stated Former AD G stopped working here 10/31/25 which was why they did not have a November 2025 resident council meeting. She stated they were going to have SW H do a resident council meeting this week. She stated from what she heard they were advertising online for a new AD. She stated she was aware it was a regulatory requirement to have an AD at this facility but they had been some churches came by for singing. She stated the residents also had snack activities. She stated hospice companies provided birthday cakes for the resident and [NAME] for them and called bingo. She stated therapy did some group therapy with ethe residents Monday - Friday and said she was not sure if they were doing activities on the activities calendar. She stated the van driver also helped with activities at times. She stated not having an AD could cause the residents to get bored. She stated they talked about the need for an AD in their standup meetings Interview on 12/07/25 at 5:06 pm, the Acting Administrator stated they had an AD job posting on jobsites and knew they were interviewing for a new AD. He stated as a team they were doing activities with the residents and the therapy department did activities with the residents last Friday (12/05/25). He stated therapy was playing music and said he saw one staff doing a residents nails last Wednesday. He stated he was not aware if anyone was going by the activities calendar and had not seen residents playing bingo. He stated he knew it was important for this facility to have an AD and they were doing their best to hire someone soon. Observation on 12/07/25 at a.m., the 200 hall wall revealed a large activity calendar for October 2025. Record review of the November 2025 Resident Advisory Council meeting was requested but the DON stated there was no meeting for this month because they did not have an Activity Director. Observations between 12/05/25 at 9:30 am and 12/07/25 at 5:30 pm, did not reveal the residents in daily activities, some residents were seen watching TV in the dining room or in the hallways interacting with other residents and the staff. (On Friday 745006 Page 3 of 11 745006 12/07/2025 Five Points Nursing and Rehabilitation 1901 N Hampton Rd Desoto, TX 75115

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 12/05/25 around 11:00 am several of the resident participated in a group activity with music playing in the dining room. And Sunday 12/07/25 around 11:30 am, Church services with 7 residents seen participating in the dining room. Record review of the November and December activity calendars were requested from the Acting Administrator and DON on 12/08/25 at 8:09 am, but they did not respond. Record review of the facility's Activities Director Policy dated 2011 revealed, ACTIVITY PROGRAMMING: STANDARD: The Activity Director and staff will provide for ongoing Activity programs. PRACTICE GUIDELINES: 1. Recreation programs are based on the interests and needs of the residents expressed through the Activity assessment. 2. Residents or family's expressed needs and interests are included in the development of programs. Input from residents may be done individually or discussed at Resident Advisory Council meeting. 3. Activity programs are based on resident's leisure interests and implemented to meet the needs (physical, cognitive, creative, social, spiritual, independent, and sensory) of the residents. 4. Programs will be geared to maintain functional ADL's, provide social interaction and, at the same time, protect residents from environmental over stimulation. 5. Those who cannot participate in group settings are provided individual programming. Inability to participate could include those who refuse to participate in activities, those who are in isolation, or physician ordered bed rest. 6. Programming includes large groups, small groups, individual and independent opportunities. 7. Programs may take place in mornings, afternoons and/or evenings that span throughout the entire week. 8. Programs use various areas available in and out of the health care center. 9. The resident population is cognitively assessed routinely to determine the number of functional level programs needed. 10. The opportunity is provided for regular community outings/trips. 11. Programs are developed to include community resources and involvement within, and outside, the health care center. 745006 Page 4 of 11 745006 12/07/2025 Five Points Nursing and Rehabilitation 1901 N Hampton Rd Desoto, TX 75115

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure each resident received and the facility provided with food that was palatable, attractive, and at a safe and appetizing temperatures for 3 (Residents #1, #2, and #3) of 8 residents reviewed for nutritional services. The facility failed to ensure the staff served hot meals to the residents, subsequently they had no interventions in place to address the delays in meal services. This facility could cause all residents to be at risk of not getting the nutrients needed for weight management and good health which could have led to weight loss and deteriorating health and decline resulting in decreased psychosocial well-being. Findings included: A)Record review of Resident #1's Quarterly MDS 11/20/25 revealed a [AGE] year old male who admitted [DATE]. He had a BIMS score of 08 (moderate cognitive impairment. For Eating: helper provided verbal cues and /or touching and contact guard assistance as resident completed activity, assistance may be provided throughout activity or intermittently. He had a diagnoses of coronary artery disease, hypertension, malnutrition, and protein calorie malnutrition and no checkmark for therapeutic diet and he had 7 days of insulin injections. Record review of Resident #1's Care plan dated 03/31/25, Resident has paraplegia, impaired cardiac functioning related to diagnoses of HTN and ASHD- Monitor/document/report to MD PRN any s/sx of malignant hypertension: Headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, seizure activity, difficulty breathing, diagnosis of diabetes mellitus - Diabetes medication as ordered by doctor, Resident #1 has anemia r/t abnormal lab - Encourage intake of foods high in iron, vitamin C, risk for weight fluctuations related to diagnoses of malnutrition and chronic kidney disease Monitor and document meal intake per policy, monitor resident weights per facility policy. Record review of Resident #1's Diet order dated 10/20/25 revealed, Fortified/Enhanced Diet - diet Regular texture, Regularconsistency, DOUBLE MEAT/PROTEIN PORTIONS for diet. Interview on 12/05/25 at 10:32 am, Resident #1 stated he ate in his room and he did not like the food, You mean the slop that comes out the kitchen. He stated the food was always cold and stated he had not told the management staff but told the nurses about it. He stated he had not asked the staff to warm up his food and would just eat snacks in his room. He stated this facility needed to get some older people in the kitchen to cook the food so that it would stay hot longer and taste right. He stated he ate his meals in his room all the time and his hall was always served last. He stated the last time he received his food late was his lunch yesterday at 1:45 pm. B) Record review of Resident #2's Quarterly MDS dated [DATE] revealed a [AGE] year old male who admitted [DATE], he had a BIMS score of 04 (severe cognitive impairment). Eating: Helper sets up or cleans up; resident completes activity, helper assists only prior to or following the activity. He had a primary medical condition a stroke and diagnoses of anemia, hypertension, hyperlipidemia, CVA, Non -Alzheimer's dementia. He was on a therapeutic diet. Record review of Resident 2's Care plan revised 02/24/25 revealed, Resident #2 has a communication problem related to intellectual disabilities - Anticipate and meet needs, validate resident's message by repeating aloud. And for impaired cognitive function/dementia or impaired thought processes Communicate with the resident/family/caregivers) regarding residents capabilities and needs. And for oral/dental health problems poor nutrition - coordinate arrangements for dental care, transportation as needed/as ordered, Monitor/document/report to Medical Doctor PRN s/sx of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth. And for diet order other than regular (NSOT, mechanically soft diet) - Monitor weight per facility protocol, offer substitute, if resident eats less than 50% or dislikes meal and offer supplement if resident continues to eat less than 50%, Registered Dietitian assess per Residents Affected - Some 745006 Page 5 of 11 745006 12/07/2025 Five Points Nursing and Rehabilitation 1901 N Hampton Rd Desoto, TX 75115

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility protocol, the resident has mechanically altered diet. He was at risk for unplanned weight loss or gain - Monitor weight per facility protocol, offer substitute, if resident eats less than 50% or dislikes meal and offer supplement if resident continues to eat less than 50%, Registered Dietitian assess per facility protocol, the resident has mechanically altered diet. He had statuses related to hypertension and transient cerebral ischemic attack and hyperlipemia and osteoarthritis. Record review of Resident #2's Diet order dated 11/13/25 revealed, NSOT diet Regular texture, Regular consistency. Interview on 12/05/25 at 1:13 pm, interview was attempted with Resident #2 but he was not interviewable. Interview on 12/08/25 at 10:36 am, the FM stated Resident #2 complained about his meals being late and cold ever since he admitted to the facility. She stated he did not like the mechanically softened food either. B) Record review of Resident #3's Quarterly MDS Quarterly assessment dated [DATE] revealed a [AGE] year old female who admitted [DATE] with a BIMS score of 15 (no cognitive impairment). Eating: helper sets up clean up; resident completes activity helper assists only prior to or following the activity. She had diagnoses of cancer, anemia, coronary artery disease, heart failure, hypertension, peripheral artery disease, ulcerative colitis, renal insufficiency, diabetes mellitus, hyperlipidemia, malnutrition, gastro-esophageal reflux and diverticulitis of large intestine. There was no therapeutic diet checked. Record review of Resident #3' Care plan revised on 11/19/25 revealed, Resident #3 has potential/actual impairment to skin integrity related to edema, fragile skin - Avoid scratching and keep hands and body parts from excessive moisture. encourage good nutrition and hydration in order to promote healthier skin. And for heart failure and takes diuretics as ordered Monitor/document/report to MD PRN any s/sx of Congestive Heart Failure: dependent edema of legs and feet, periorbital edema, .weight gain unrelated to intake, diabetes mellitus - Monitor/document/report to MD PRN for s/sx of hyperglycemia: increased thirst and appetite, frequent urination, weight loss And for hypertension - Monitor/document/report to MD PRN any s/sx of malignant hypertension, Headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting. And for impaired immunity related to: cancer, lupus and lymphedema - Encourage fluid intake and adequate rest to bolster the immune system, monitor /document/report to MD PRN any s/sx of infection: Fever; Redness; Drainage or swelling around wounds or catheter sites; Cough, respiratory symptoms; Dysuria, hematuria, flank pain and foul smelling urine. And for GERD, diverticulosis, and Crohn's disease- Avoid lying down for at least 1 hour after eating. Keep HOB elevated. Encourage to stand/sit upright after meals, avoid overeating. Provide small frequent meals rather than 3 large ones. Encourage the resident to take their time eating. Alternate food with sips of fluids. And for alteration in hematological status related to history of thrombosis - Obtain and monitor lab/ diagnostic work as ordered. Report results to MD and follow. Interview on 12/07/25 at 8:30 am, Resident #3 stated she preferred to eat in her room and said her food usually was too hard and spicy to eat. She stated the food was cold most of the time and she ate sandwiches at times. She stated the food was never on time and whatever she did not like they put on her tray anyway. She stated when HHSC staff was in the building she would get breakfast in the 8:00 am hour but when they were not at this facility she would usually get it at 9:30 am. She stated she received lunch around 1:00 pm or 1:15 pm. She stated she would usually get dinner at 6:00 pm and said she guessed they did not have enough dietary staff. She stated hearing they only had two dietary staff in the kitchen. She stated the last time her food was cold and late was yesterday 12/06/25 her oatmeal was normally cold and the staff would not take it back to warm up because they said it was cross contamination. She stated they used to warm up the food but they stated it was against state rules so she just ate something else. She stated she did not file a grievance because she complained to the staff about the food issues. Interview on 12/08/25 at 745006 Page 6 of 11 745006 12/07/2025 Five Points Nursing and Rehabilitation 1901 N Hampton Rd Desoto, TX 75115

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 10:48 a.m., FM 4 stated this facility changed cooks two or three times that he was aware of. He stated a few times he was a the facility for breakfast or lunch and the food was not cooked right. He stated, a few weeks ago for lunch, he did not know what was on the plate it looked like hamburger helper but it was hard to say. He stated Resident #3 complained about it and got food from the alternate menu. In a confidential interview on 12/07/25, (Anonymous) stated the food was served cold most of the time and hopefully things would get better with the new Administrator. They stated at least one to two meals had to be reheated daily because they were cold. They stated the management people were aware of the food issues and with not having enough dietary staff. They stated management needed to pay the dietary staff more money so they would stay. They stated the food was served late for two or three months and was usually an hour and 15 minutes late every day. They stated they were not sure if the dietary staff got to work late or what. They stated they had an idea how breakfast was to determine how lunch and dinner would be. They stated there was new staff working in the kitchen but the last time food was late and cold was last night 12/06/25. Interview 12/05/25 at 1:25 pm, the Ombudsman stated for the past year many residents complained about the food quality and about the food being late and cold getting to them. She stated the residents said the food was nasty, not good and there were complaints about the facility being understaffed. She stated the last time she was there was this week and it was the same complaints. She stated she had spoken to the Administrator each time visited the facility and there was still no changes. She stated she spoke to the last administrator and he said he was working on getting more dietary staff. She stated nobody like the food and she was not sure if the delay was in passing the trays out or something else. She stated over the past year up to 16 residents complained about the food. Observation on 12/05/25 of the facility's dining room services revealed: 12:40 pm, 12 residents were eating their meals in the dining room. 12:50 pm, one staff passed out meals on the 100 hall and one staff passed out meals on the 200 hall to the residents who were in their rooms. 1:10 pm, most of the meal trays were sent to the halls but not the 600 hall. 1:35 pm, one staff passed out meals on the 600 hall. Interview on 12/05/25 at 2:39 p.m., LVN B stated Residents #1 and #2 complained about their food being late and cold often. She stated she spoke to the kitchen staff about warming up their meals and hot plates were made for them. She stated she was not sure why the resident's food came out late and was not sure why she had not spoken to management about the meal issues. Interview on 12/06/25 at 10:54 am, [NAME] C stated she heard about the food complaints. She stated she and DA D usually work together on the split shift schedule. She stated they needed one more DA for their shift and said they had not had a DA for two weeks or so. She stated the DD had been coming in to help at times with meal services which helped. She stated she heard the Morning [NAME] E ran late and did not start her shift on time and was not sure why. She stated yesterday (12/05/25) breakfast and lunch was late and said that DD was starting to make changes. She stated they were good with having enough cooks just short on a DA. She stated whenever she cooked the breakfast was on time. Interview on 12/06/25 at 11:05 am, DA stated he worked the split shift. He stated they used to have a full team but when the previous DD quit, one cook and two DA's left. He stated a Corporate lady was the temporary DD over the dietary department for a few weeks. He stated the new DD F started working here two or three weeks ago and said they needed 1 more DA for his shift. He stated he helped with setting up the meal trays with silverware and cooked as needed. He stated in the mornings the meals were getting out late because the dayshift dietary staff were not prepping early enough. He stated sometimes when he came to work at 1:00 pm the dayshift dietary staff were still making lunch plates so he would help. He stated sometimes it could take up to five minutes for a nurse to check the meal trays and sometimes they had to go get a nurse. He stated 745006 Page 7 of 11 745006 12/07/2025 Five Points Nursing and Rehabilitation 1901 N Hampton Rd Desoto, TX 75115

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the morning shift had one cook and two DA's and for about a month the split shift only had one cook and himself. He stated not being sure why the Dayshift dietary staff was always running behind. He stated there was a new DA that work two times on the split shift, but she had not been back to work but still on the schedule. He stated the last time the new DA worked here was last Thursday 12/04/25 he believed. He stated [NAME] E did not have a since of urgency when food prepping and cooking but [NAME] C was great in getting the meals out on time and the food was never brought back for hot meals. He stated the split shit go the food out on time with just himself and one cook and did not understand why the Dayshift Dietary staff ran behind with more staff. Interview on 12/06/25 at 12:26 pm was attempted with [NAME] E but she did not answer and a message was left for a return call. Interview on 12/06/25 at 12:55 pm, CNA I stated she started her shift at 6:00 am. She stated almost all of the resident said their meals were late and cold. She stated Resident #1 mentioned his food came out late and cold since the end of October 2025. She stated for lunch Resident #1 complained about his breakfast and lunch being late. She stated DD F should know about these concerns. She stated 9 times out of 10 the meals came out late from the kitchen and it was not that the meal trays were sitting in the hallways that caused the meals to be late. She stated if meal trays were rolled out at 8:30 am the nursing staff could get the meals out to the residents in their rooms a lot earlier. She stated the latest time for lunch trays were served to the residents was 1:45 pm in the past month. She stated the meals were supposed to come out at 12:00 pm but the 600 hall residents did not get their meals until 1:30 pm or 1:45 pm. She stated the DON and ADON knew about the meal time issues. She stated they had Inservice trainings but had no open forum for them to discuss their concerns for getting feedback about the meal service delays. Observations on 12/06/25 revealed:*12:25 pm , there was 8 residents in the dining room watching TV and waiting for meals. *1:24 pm the meal carts rolled to the 600 hall and one staff passed out the meal trays to the room residents; the last tray was given to a resident was at 1:34 pm *1:37 pm - Test was tray given after last resident served their meal - the test tray food looked appetizing and was hot. (Chicken fried steak with gravy, baked potato with green beans and a roll). Interview on 12/06/25 at 1:58 pm, SW H stated some of the residents complained about the food being cold and one resident said he was served a burnt pancake three weeks ago. She stated the last time she received a complaint about cold food was in the past month. She stated she noticed the meal carts were served late on Saturday 11/08/25 when she was manager on duty, She stated on Sunday 11/09/25 the meal carts went out late for lunch around 1:45 pm. She stated the kitchen staff was short staff and they needed another DA and figured that was why they were late coming out of the kitchen. She stated in the last two weeks she has had to warm up a resident's food because it was cold, but did not write it down as grievances. She stated she talked in the standup/standdown meetings about the cold meals and they were told management staff would help with serving the residents their meals. She stated she was responsible for making sure the relevant department head resolved grievances then the grievance were given to the Administrator. She stated the late and cold meals was still a concern. Interview on 12/07/25 at 9:34 am was attempted with [NAME] E but she did not answer and a message was left for a return call. Interview on 12/07/25 at 10:55 am, DOR K stated sometimes get the residents food was late and cold. She stated they discussed the meal issues in their last standup meeting and how to resolve it. She stated they were not sure why the trays were not being moved fast enough and were told to tell the staff to move much faster and they were going to continue to monito the situation. She stated everyday Monday - Friday, the department heads did daily room rounds. She stated they were supposed to ask the residents how was their food before their standup meetings to be able to discuss in the meetings. Interview on 12/07/25 at 11:55 am, Staffing 745006 Page 8 of 11 745006 12/07/2025 Five Points Nursing and Rehabilitation 1901 N Hampton Rd Desoto, TX 75115

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinator L stated Resident #1 and #2 complained about their food being late and cold. She stated they were no longer about to use the microwave in the breakroom to warm them up. She stated they just ask the dietary department to make another plate and said the last time Residents #1 and #2 complained about the food and they had to get hot meals was last Friday 12/05/25. She stated HR M stated they were needing one DA the past Friday 12/05/25. Interview on 12/07/25 at 12:46 pm, HR M stated they needed one more cook and DA. He stated cook was hired was a no call not show two weeks ago. He stated DA N worked split shift who worked last Thursday 12/04/25 but she quit. He stated they had a pool of applicants about 30 something that DD F was interviewing. He stated this facility paid the cooks $14.00 per hour and DA $12.00 per hour and had asked corporate about increasing hourly pay rates they said they could not do. Observations of the dining service on 12/07/25 revealed the following: *1:00 pm - Residents were in the dining room eating and meal trays were being served to the residents in their rooms. *1:10 pm - There was six dietary staff (including DD) preparing the meal trays for the hall carts, they appeared to be moving fast. The food was being prepared from the steam table and the food appeared hot because steam was seen coming them. *1:29 pm - The 600 hall residents were not eating yet. *1:31 pm - A female staff rolled the meal cart to the 600 and started passing out meal trays. *1:36 pm - There was one female staff passing out meal trays to the 600 hall residents *1:37 pm - Resident #2 received his lunch tray and began eating his food and they said it was served hot. *1:38 pm - Resident #1 received his lunch tray and began eating his food and they said it was served hot. Interview on 12/07/25 at 1:53 pm was attempted with [NAME] E but she did not answer and a message was left for a return call. Interview on 12/07/25 at 2:05 pm, DA P stated there were still issues with dining room services. He stated sometimes once the dietary staff put the meal carts out, the nurses were not around to check them. He stated the meal carts sat for a while and sometimes he had to get a nurse to check the trays. He stated the last time there was a delay in getting a nurse to check the trays was last Wednesday 12/03/25 for breakfast. He stated they had enough dietary staff and as long as they worked together they were able to get the meals out. He states if someone was slacking they went to help that person in the kitchen. He stated to his knowledge there was no issue with the cooks not working as fast as they could or getting to work late . He stated the cooks had to be at the facility at 5:00 am and the DA had to arrive at 6:00 am. He stated there was no issues with the dietary staff arriving to work late. He stated one dietary stated was late to work due to the traffic being bad a month ago but normally that did not happen. He stated they had enough cooks but needed one DA since last month. He stated they needed another DA nightshift. Interview on 12/07/25 at 2:34 pm, ADON A stated there were no complaints about the residents' food being cold or late. She stated she may have seen meal trays going out late about two months ago. She stated they did not rewarm the residents meals per policy but would get them another hot plate of food, She stated the dining room residents meal trays were served first, then the hall trays went out. She stated never just seen the meal carts just sitting waiting for a nurse to check it. She stated the expectation was for meal to go out at 12:30 pm and if dietary had a delay they needed to let them know. She stated expectation for all of the hall room trays to be delivered around 1:00 pm or 1:15 pm. She stated she was not aware the meal trays being served to the residents at 1:40 pm or 1:45 pm. She stated if residents received their meals late and cold could cause them to get an infection, get sick, have weight loss and make them not want to eat. Interview on 12/07/25 at 3:09 pm, DD F stated on 11/05/25 one resident really pulled him in to talk to him about the food experience not being good. He stated he told that resident what he was he going to do to address the issues by working with and re-educating the staff. He stated this resident did not want his sausages being overcooked around the edges. 745006 Page 9 of 11 745006 12/07/2025 Five Points Nursing and Rehabilitation 1901 N Hampton Rd Desoto, TX 75115

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some He stated he had not checked with this resident yet and was not aware his sausage was overcooked this morning 12/07/25. He stated this resident was really good about letting him know about a meal issue. He stated he used to have enough staff but DA N did not show up for work last Friday 12/05/25. He stated DA N said she did not have a babysitter and on Saturday 12/06/25 she was a no call no show and did not work. He stated the DA position was vacate for a month but he was filling in for that position. He stated he had two staff coming in to interview for that position. He stated he was going to do a wage analysis of the DA position, maybe the facility needed to increase the pay rate. He stated he needed a PRN [NAME] for when staff called out. He stated currently he had one cook and two aides for the day and evening shifts but the DA was needed for the split shift. He stated meal services started at 7:30 am, 12:30 pm and 5:30 pm and the food came from the steam tables hot and temperature checked. He stated once the meals were ready to push out it should only take one hour to serve the whole facility. He stated he was not aware the meals were getting to the residents at 1:45 pm until he saw HHSC surveyor on the halls. He stated he noted one staff person was passing out the meal trays and knew that was slowing down that person if had to get some missing off the tray. He stated he needed to come up with a plan for more staff to help serve the meal trays to get them to the rooms faster. He stated when a resident complained about having a cold plate the staff needed to get them another hot meal tray. He stated he did not recommend warming up the residents' meal place in a microwave due to cross contamination and temperature control issues. He stated the dayshift [NAME] E needed more work on meal prep and time management because there was no time to relax in the kitchen. He stated after breakfast the cook needed to be prepping for lunch. He stated he had been trying to address the cold plate complaints and was thinking about asking for the enclosed meal enclosed carts. He stated he saw the meal cart on the hall last week and asked the aide did she need helped passing out the meal trays. He stated it looked like the CNA was answering the call lights to get condiments and he told her to ask for help. He stated meals being cold could affect the residents, they could get sick and if they did not eat and diabetic it could cause their blood sugar to drop. He stated he spoke to HR M about the DA and PRN [NAME] staff needed and preferred dependable staff. He stated [NAME] E lacked experience [NAME] he was addressing. He stated the previous Administrator said the biggest problem at this facility was getting the food out fast enough. He stated there were no problems with the morning staff coming to work late including [NAME] E. He stated [NAME] E needed to prep in advance and said he had been watching her closely. He stated [NAME] C was good with getting her tasks completed and helping the DA's. He stated he was in the process of getting [NAME] C to be the dayshift to cook for breakfast and lunch services. He stated [NAME] C needed to give other job notice before she could change shifts here. He stated he had enough of a budget to run his department. He stated he had not reviewed the November resident council minutes but the department heads went over grievances in the standup meeting and there was a few cold food complaints. He stated he was doing his best to address them. Interview on 12/07/25 at 4:16 pm, the DON stated none of the residents complained about the meal services being late, cold or that staff refused to warm food. She stated there was on occasion the meal trays were late getting the residents in their rooms. She stated they did not have that problem any longer with meal services and could say the lunch services rolled over to 1:00 pm. She stated they were good about resolving grievances. She stated the SW H was great about bringing the resident and RP complaints to the morning meetings. She stated SW _ would ask the department head did they resolves the complaints for their departments. She stated the SW received the grievances and kept a log of them and gave the grievances to the department head to resolve the issue. Interview on 12/07/25 at 5:06 pm, the Acting Administrator stated he was new to the facility and 745006 Page 10 of 11 745006 12/07/2025 Five Points Nursing and Rehabilitation 1901 N Hampton Rd Desoto, TX 75115

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was not aware of any complaints about the meals being late and cold. He stated he had not noticed the meal carts going out late causing delays with meal service. He stated he was aware of the kitchen being short a DA and cook which were both being posted on job sites. He stated he was in the process of asking for a higher wage for their cooks. he's ask for higher wage for a cook. He stated he noticed only one member of staff was passing out the hall meal trays and that he was going to make sure the department head helped pass trays to get them out faster. He stated he was currently working on getting this facility where it needed to be. Record review of the facility's Mealtimes posting revealed. Breakfast 7:30 am, Lunch 12:30 pm and Dinner 5:30 pm. If you have any question regarding meal services or times, please feel free to contact Director of food and nutrition. Record review of the 07/21/25 Resident Advisory Council minutes revealed, Want to get meals on time, dinner getting later and later. (There was no follow-up documentation to address concerns). Record review of the 08/28/25 Resident Advisory Council minutes revealed, Meal out on time. (There was no follow-up documentation to address concerns). Record review of the November 2025 Resident Advisory Council meeting was requested but the DON stated there was no meeting for this month because they did not have an Activity Director. Record review of the September 2025 Grievances revealed the following: 09/02/25 Resident #5 reported the eggs were cold, 09/03/25 Resident #6 reported the breakfast was cold , pancakes burnt doesn't like eggs so don't put on tray, 09/04/25 Resident #7 reported the breakfast was cold, and09/09/25 Resident #8 reported she didn't like her meal. Record review of the facility's October 2025 Grievances were requested from the DON and Administrator on 12/05/25 but was told they did not have it in the binder. Record review of the facility's November 2025 Grievances revealed, On 11/10/25 Resident #9 reported his breakfast meal was burnt. Observations between 12/05/25 at 12:40 pm and 12/07/25 at 5:30 pm, revealed the facility used metal frame carts that were not insulated and the last hall served meals was the 600 hall and for each hall there was only one staff person passing out the meal trays to the residents. Record review of the facility Daily Food temperature control policy dated 2012 revealed, We will assure that food is served at a safe temperature. Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature log. This is done to help ensure that food is safe and is served within the acceptable ranges. Procedure: 1. There is a thermometer available for use in the department to test the temperature of foods which is sanitized between food testing. 2. Prior to meal services, the cook shall take the temperature of all hot and cold foods. 3. Temperatures are recorded on the Temperature log form. 4. All hot foods shall be cooked and held for service at temperature of 140 degrees F or above. 5. Any hot or cold food which does not meet minimum acceptable temperature shall be heated to a temperature of 165 degrees F and held at least 15 seconds. These instances should be recorded on the HAACP form. 745006 Page 11 of 11