Health inspection·August 17, 2023

F 0689 Level of Harm - Actual harm Residents Affected - Few Observation and interview on 08/17/23 at 9:20 AM revealed Resident #2 had a wound to the top of his right hand that was round and scabbed over and measured approximately two centimeters wide. Resident #2 stated he burned himself with a cigarette about three weeks prior. The staff member monitoring them notified the nurse of his burn. Resident #2 stated the nurse, a male whose name he could not recall, put a bandage on the burn at that time. Resident #2 stated nothing else had been done to treat his burn. Review of Resident #2's EHR revealed no documentation of a wound to his right hand, no physician orders for wound treatment, and no medications for the wound. Review of the nurse 24 hour logs from 07/01/23 to 08/17/23 revealed no report of Resident #2 having a wound to his right hand. Observation and interview on 08/17/23 at 10:10 AM revealed Resident #1 in the smoking area with a pack of cigarettes and a lighter in his shirt pocket. Resident #1 stated he would come out to smoke all the time while he tended the flowers in the smoking area. Resident #1 stated it was easier to keep his cigarettes himself instead of having to wait on the staff. Resident #1 stated he was aware he was not supposed to keep his cigarettes, as staff kept confiscating them, but he would walk to the convenience store and buy more. Resident #1 was observed to be smoking prior to staff presence for monitoring. Observation on 08/17/23 at 10:30 AM revealed Resident #2 was being monitored by a staff member while smoking. Resident #2 was wearing his protective apron. Resident #2 had a noticable tremor to his hands, caused by his Parkinson's disease. Interview on 08/17/23 at 12:00 PM with the Administrator revealed he had been at the facility for three months, and the residents that smoked had always been a problem. He stated they were non-compliant with the smoking policy, he and the staff were constantly having to confiscate smoking materials from residents, and they would go out to smoke at non-scheduled times. The Administrator stated he was working with his corporate leaders to see what his options were. Interview on 08/17/23 at 3:00 PM LVN A revealed Resident #2 had never reported the wound on his hand to her. She admitted to documenting no skin issues on his skin assessment, but stated he was always hiding his hands because he usually had something he was not supposed to have. LVN A stated a head-to-toe assessment should include looking at the resident's skin from head-to-toe. LVN A stated failing to assess the residents could result in an injury or infection going unnoticed. Interview on 08/17/23 at 4:40 PM with the DON revealed skin assessments were done weekly by the nurses and any skin issue should be documented until it was resolved. She stated she had not been made aware of Resident #2's burn until around 2:00 PM. The DON stated she would make sure the physician was aware and see if any treatment was needed. Review of the facility's current, undated Smoking Policy revealed the facility had a designated smoking area, residents were not allowed to smoke outside of the designated smoking area, and residents were not allowed to retain any smoking materials. Residents would sign and date the policy when it was given to them. Review of information retrieved from https://www.healthline.com/health/burns#firstdegree-burn (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455576 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455576 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Richland Hills Rehabilitation and Healthcare Cente 3109 Kings CT Fort Worth, TX 76118 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 on 08/31/23 reflected: Level of Harm - Actual harm .First-degree burns would have dry peeling skin as burn heals. First-degree burns usually health within 7 to 10 days. Second-degree burns are more serious because the damage extends beyond the top layer of skin. This type burn causes the skin to blister and come extremely red and sore. Over time, thick, soft sab-like tissue called fibrinous exudate may develop over the wound. Due to the delicate nature of these wounds, keeping the area clean and bandaging it properly is required to prevent infection. Some second-degree burns take longer than three weeks to heal, but most heal within two to three weeks without scarring, but often with pigment changes to skin Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455576 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455576 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Richland Hills Rehabilitation and Healthcare Cente 3109 Kings CT Fort Worth, TX 76118 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0839 Employ staff that are licensed, certified, or registered in accordance with state laws. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews the facility failed to ensure they employed professional staff required to be licensed for 1 (Administrator) of 5 employees reviewed for licensure. Residents Affected - Many The facility failed to ensure the Administrator had a valid LNFA license. This failure could place the residents at risk of not receiving care regulated by CMS. Findings included: Interview on 08/17/23 at 4:45 PM the Administrator stated he had completed the Licensed Nursing Facility Administrator course but had not passed the test. He stated he was eligible to re-take the test at the end of August. He stated he did not have a current LNFA license and did not know who's license he was operating under, but thought it might be the previous administrator. He stated he was appointed to the job with the anticipation he would pass his test. Review of information retrieved from TULIP Nursing Facility Administrator Public Registry on 08/28/23 revealed the Administrator's NFA License Status was listed as Prospective. The sections for License Number, License Issue Date, and License Expiration Date were all blank. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455576 If continuation sheet Page 4 of 4