Health inspection·January 11, 2024

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide separately locked, permanently affixed compartments in the medication room refrigerator for storage for controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Acts of 1976 and other drugs subject to abuse for 1 (Resident #14) of 9 residents reviewed for pharmacy services. The facility failed to ensure safe and secure storage of Lorazepam gel (controlled drugs/medication) in the medication room's refrigerator. This failure could cause access, loss, and diversion of controlled medications/drugs. Findings Included: Observation and interview with DON on [DATE] at 01:43 PM revealed, inside medication room on second floor, a white up-right refrigerator that was unlocked. Inside it was a clear lock box that was open and unlocked. Inside the clear box were 2 dark brown plastic bags of medication in single syringes that read Lorazepam gel 1 MG per ML, Apply Topically Every 8 Hours as NEEDED, Orig:[DATE], Use by [DATE], for [Resident #14]. The total of syringes in first brown bag was qty:12 and the second bag qty:1 syringe when counted with DON. DON said the medication in the open box were controlled medications and should be in a locked box, locked up. The DON said all controlled drugs should be under 2 locks per Sate Regulations. She said the risk of not storing and securing controlled medications was a violation of State Regulations and a risk for drug diversions. Interview with LVN D on [DATE] at 10:29 AM revealed nursing staff should always make sure that control drugs was a locked box before removing medications and after removing medications. She said that every nurse has a key to lock boxes for controlled drugs. She said that prior to shift, all controlled drugs were counted, and the control book was updated. LVN D said she cannot remember when she was last in-serviced for controlled drugs storage. She said it was nursing basic practice to secure all controlled drugs and she practiced it. LVN D said the risk was diversion and cross contamination in the fridge. Interview with ADM on [DATE] at 05:24 PM, revealed she expected all nursing staff to follow State Regulations when storing and securing controlled medications and all other medications. She said she expects controlled drugs are locked up in a lock box. She said the risk for unlocked controlled drugs was diversion of drugs. Record review of facility's policy 2.2 Delivery & Storage of Medications and Supplies revised [DATE], revealed . .Controlled medications will be stored in accordance with facility policy, according to law and regulation . Record Review of facility policy Omnicare LTC Pharmacy Services and Procedures Manual, 8.2 Disposal/Destructions of Expired or Discontinued Medication revised [DATE], revealed .Facility should always secure controlled substances under double lock. Double Lock can mean a locked cabinet in a locked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455891 If continuation sheet Page 2 of 7 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 455891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Park Multi Care Center 4252 Bryant Irvin Rd Fort Worth, TX 76109 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 0761 room or a double locked cabinet. Double lock can also mean a sealed container in a locked cabinet . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455891 If continuation sheet Page 3 of 7 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 455891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Park Multi Care Center 4252 Bryant Irvin Rd Fort Worth, TX 76109 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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Tag: F812 Residents Affected - Few S/S= E Surveyor Name(s): Sunny [NAME], [NAME] Immediate Supervisor: [NAME] Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen reviewed for food and nutrition services. The facility failed to ensure canned food items were free from dents and stored away from other canned food items. This failure could place residents at risk for food-borne illness. Findings include: A brief initial observation on 01/09/2024 at 9:14 AM of the dry food storage area, as identified by the Dietary Manager revealed the following: - One dented can of tuna stored on the rack with other food items. - One dented can of apples stored on the canned foods rack. A secondary observation on 01/10/2024 at 2:07 PM of the dry storage area revealed the following: -The dented can of tuna was removed from the rack. -The dented can of apples was still stored on the canned foods rack. An interview on 01/10/2024 at 2:07 PM with the Dietitian revealed she was not aware of the dented canned food item on the shelf. She stated dented cans were removed from the food storage room and moved to the Dietary Manager's office where they can be returned to the vendor. The Dietician was observed giving the dented can to the Dietary Manager to put in her office. The Dietitian stated that inspection of canned foods and removal of dented cans from the storage area is important to prevent contamination and to protect the residents from food-borne illness. The Dietician stated that it is the responsibility of all kitchen staff to inspect and remove dented cans from the storage area. Review of the facility's Food Storage policy dated 04/26/2023 revealed, Dented, leaky, rusted and swelling cans that could affect food safety are returned to the vendor but stored in a designated area away from other food. These items will not be used. Review of the U.S. Public Health Service Food Code, dated 2022, reflected: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455891 If continuation sheet Page 4 of 7 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 455891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Park Multi Care Center 4252 Bryant Irvin Rd Fort Worth, TX 76109 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete .3-101.11 Safe, Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under § 3-601.12, honestly presented . Review of the U.S. Public Health Service Food Code, dated 2022, reflected: .3-202.15 Package Integrity. Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants . Event ID: Facility ID: 455891 If continuation sheet Page 5 of 7 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 455891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Park Multi Care Center 4252 Bryant Irvin Rd Fort Worth, TX 76109 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 4 (Residents #11, #14, #20, and #32) of 9 residents reviewed for infection control. Residents Affected - Some The facility failed to ensure Medication Aide sanitized the blood pressure cuff between uses on Residents #11, #14, #20, and #32. This failure could place residents at risk of infectious disease. The findings included: Records review of Resident # 11's admission Records dated 01/11/24 reflected a [AGE] year-old female who admitted to the facility on [DATE]. Resident # 11 was her own responsible party. Resident #11 had diagnoses which included High blood pressure with heart failure, acquired right below the knee absence, Vascular dementia without behavior disturbance, history of falling, Type 2 Diabetes Mellitus, heart irregularity (Arterial fibrillation) Records review of Resident # 14's admission Records dated 01/11/24 reflected, a [AGE] year-old female who admitted to the facility 03/11/23. Resident #14 had diagnoses which included Stroke affecting the left side, Type 2 Diabetes Mellitus, Muscle wasting, unspecified Depression, repeated falls, Pressure ulcer, unspecified Bipolar, Contracture of left arm and knee, post-traumatic stress disorder. Records review of Resident # 20's admission Records dated 01/11/24 reflected, a [AGE] year-old female who admitted to the facility on [DATE]. Resident # 20's diagnoses included Anxiety, Anemia, difficulty swallowing since Stroke, Unspecified chronic pulmonary disease, high cholesterol, history of blood clots, lack of coordination, abnormal posture, and Osteoarthritis. Records review of Resident # 32's admission Records dated 01/11/24 reflected, an [AGE] year-old male who admitted to the facility on [DATE]. Resident #32's diagnoses included unspecified dementia, muscle wasting and weakness, high cholesterol, back surgery, unspecified hearing loss, heart failure (Sick Sinus), end stage kidney failure, and pacemaker. Continuous observations on 01/10/24 between 08:29 AM and 09:00 AM revealed CMA C in hallway outside Resident #32's room. Resident #11 and Resident #32 was in their wheelchairs in the hallway by CMA C. CMA C took blue blood pressure (BP) cuff off Resident #32's upper right arm and placed it on white mobile basket on top of different sized BP cuffs stacked together. CMA C completes administering medications to Resident #32. She completed hand hygiene and went back to computer and starts on Resident 11's medications. CMA C does not sanitize the BP cuff. CMA C gets the same blue unsanitized/unclean BP cuff from the stacked pile of BP cuffs and places it on Resident # 11's left upper arm and takes her BP. Her BP reading was 121/71. CMA C takes the BP cuff off Resident #11's arm and places it back on the BP cuff pile on the white mobile basket. CMA performs hand hygiene and administers medications to Resident #11. CMA C then goes to Resident #14's room. CMA C looks at Resident #14 medications on her computer and says that Resident #14 has a blood pressure medication. CMA C takes the same unclean blue BP cuff and places it on Resident #14's right upper arm. BP reading 116/76. CMA C (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455891 If continuation sheet Page 6 of 7 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 455891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Park Multi Care Center 4252 Bryant Irvin Rd Fort Worth, TX 76109 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some places the blue BP cuff on pile again and performs hand hygiene. CMA C dispenses Resident #14 medications and administers them to the resident. CMA C performs hand hygiene after completion and goes to Resident # 20's room. CMA C does not sanitize or clean the blue BP cuff. CMA C takes the unclean BP cuff and places it on Resident #20's upper right arm and takes her blood pressure. Her BP reading was 134/57. CMA C places the unsanitized and unclean BP cuff back on the pile of BP cuffs. CMA C completes medication administrations and washes her hands. CMA C attempts to go to the next room but surveyor intervened and stopped CMA C. Interview with CMA C on 01/10/24 at 10:02 AM revealed that CMA C had forgotten to sanitize the blue BP cuff in between the residents. She said that she was supposed to wipe the BP cuff with purple top sanitizer wipes. She said that the risk of not sanitizing and cleaning equipment between residents was the spread of infection. Interview with DON on 01/10/34 at 10:58 AM, revealed after each resident, the BP cuff should be cleaned with the purple top San cloth sanitizer cloths. She said that she expected staff to sanitize the BP cuff, thermometer, and pulse oximeter before use, in between each resident and after use. DON said that all staff are in-serviced on infection control prevention every quarter and as needed. She said the risk of not cleaning equipment in-between residents is the spread of infection. Interview with the infection control preventionist (IP) on 11/11/24 at 02:53 PM, revealed the expectation was that BP cuffs and other shared equipment are sanitized in-between each resident use. She said the risk of not cleaning equipment in-between residents placed them at risk of infection and contamination. IP said that she was in the process of in-servicing for Equipment disinfection. Review of facility's policy revised06/03/23 titled Cleaning and Disinfection of Non-Critical patient Care Equipment revealed .Reusable items are cleaned and disinfected, or sanitized between residents (e.g., blood pressure cuffs, stethoscopes, wheelchairs, therapy equipment) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455891 If continuation sheet Page 7 of 7