Inspection·December 7, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Interview on 12/06/23 at 1:30 PM with the DON revealed most CNAs filled out a paper shower sheet and turned those into the nurse at the end of their shift. The DON stated she would check the shower sheets and find proof that Resident #5 had been showered or refused his showers. The DON stated the CNAs were responsible for bathing residents and the nurses are supposed to monitor if the resident was bathed as described on the shower sheet. Residents Affected - Few Review on 12/07/23 of three shower sheets provided by the DON revealed Resident #5 was showered on 11/25/23, 11/28/23, and 11/30/23. No shower sheets indicating Resident #5 had refused showers. Review of Resident #5's Nursing Progress notes and Daily Assessments for November and December 2023 revealed no documentation of resident refusing cares or showers. Review of Resident #345's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included stroke, dementia, and weakness. Review of Resident #345's quarterly MDS assessment, dated 11/14/23, revealed a BIMS score was not calculated for him. His Functional Status indicated he required substantial assistance with his ADLs, bathing required substantial assistance of staff. Review of Resident #345's care plan, dated 11/26/23, revealed he had a self-care deficit with an intervention of minimal assistance of 1 for bathing. There is no documentation of resident refusing cares or showers. Resident to be bathed three times a week. Observation and interview on 12/05/23 at 10:13 AM revealed Resident #345 could not recall when his last shower was. The resident stated he likes to shower at least twice a week and stay clean shaven. Resident #345's hair had a greasy appearance, white flakes were noted in his hair, and the resident wore a baseball cap most of the time. Interview on 12/05/23 at 10:15 AM with CNA A revealed he did not know when Resident #345 had last been bathed. He stated the resident was on a Tuesday, Thursday, Saturday schedule Review of Resident #345's Bathing Task List for November and December 2023 reflected his last documented shower was on 12/02/23; all other days are documented as Not Done. Review of one Shower Sheet provided by the DON reflected the last shower was on 12/02/23. There were no other Shower Sheets provided indicating the resident had refused showers. Review of Resident #345's Nursing notes and Daily Assessments from November and December 2023 revealed no documentation of the resident refusing cares or showers. Review of the facility's Activities of Daily Living (ADLs) policy, revised March 2018, reflected: .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675018 If continuation sheet Page 2 of 13 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 675018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Oaks Health and Rehabilitation Center 2416 NW 18th St Fort Worth, TX 76106 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #15) reviewed for dialysis. Residents Affected - Few The facility failed to ensure that Resident #15 had a current order for dialysis after readmission to the facility. This failure could place residents at risk of not receiving the appropriate care as ordered by the physician. Findings included: Record review of Resident #15's quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #15's active diagnoses included Type 2 diabetes, legal blindness, major depressive disorder, anxiety, anemia, epilepsy, muscle weakness, thrombocytopenia which is a condition that occurs when the platelet count in your blood is too low, myoclonus which is a quick jerking and uncontrollable movement, hypercholesterolemia, which is high blood pressure, hypertension, and end stage renal disease. Record review of Resident #15's quarterly MDS Assessment, dated 11/21/23, revealed a BIMS score of 15, indicating the residents' cognition was intact. Resident #15 required assistance with some ADLs, and he received dialysis. Record review of Resident #15's Care Plan, dated 04/28/23 and revised, revealed Resident #15 required dialysis three times a week due to end stage renal disease. Record review of Resident #15's Order Summary Report dated 12/06/23 at 1:25 PM revealed there was not an active physician order for Resident #15 to receive dialysis treatment. Record review of Resident #15's Telephone/Verbal Order Summary Report dated 12/06/23 at 1:42 PM revealed there was not an active physician order for Resident #15 to receive dialysis treatment. Record review of Resident #15's Telephone/Verbal Order Summary Report dated 12/07/23 at 11:18 AM revealed an active verbal physician order for Resident #15 to receive dialysis treatment out of the facility. The verbal order was signed dated 12/06/23 at 3:00 PM. Interview with the Administrator on 12/06/23 at 1:45 PM revealed there were not any physician orders for Resident #15 to receive dialysis treatment. The Administrator stated the physician orders should be in PCC in the Orders tab. The Administrator was advised the orders were not in PCC in the Orders tab, or the Telephone/Verbal Orders tab. Point Click Care, PCC is a cloud-based Healthcare Software that the staff at the facility use to input information such as resident care, resident services, and financial operations. The Administrator stated he would need to speak to the DON to inquire more information. Interview with the Administrator on 12/07/23 at 9:05 AM revealed physician orders had been entered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675018 If continuation sheet Page 3 of 13 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 675018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Oaks Health and Rehabilitation Center 2416 NW 18th St Fort Worth, TX 76106 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 0698 Level of Harm - Minimal harm or potential for actual harm in PCC for Resident #15 to receive dialysis treatment. The Administrator stated the DON was responsible for ensuring that the residents' orders were placed in their medical records in PCC. The Administrator stated Resident #15 had been going to his dialysis treatment three times each week since being admitted to the facility. The Administrator reported that Resident #15 did not receive any harm due to his physician order for dialysis not being in his medical record in PCC. Residents Affected - Few An email was sent to the Administrator on 12/07/23 at 9:11 AM requesting the policies for dialysis and physician orders. Interview with the DON on 12/08/23 at 3:02 PM revealed she had been employed at the facility for 3.5 months, and her duties include ensuring the physician/doctor orders were entered into the resident's medical records in PCC. The DON confirmed that on 12/06/23, Resident #15 did not have any physician/verbal orders in PCC. She stated that on 12/06/23, the verbal order for Resident #15 was added to Resident #15's medical record in PCC under the Telephone/Verbal Order tab. The DON stated Resident #15 was sent out to the hospital for a few weeks and had a physician's order for dialysis treatment in his medical record prior to being discharged to the hospital. The DON reported that when Resident #15 was readmitted to the facility on [DATE], she assumed his physician order for dialysis was still in his medical record. The DON stated she had a system, which included a checklist for residents who discharged or admitted /readmitted to the facility. The DON stated the checklist included checking physician orders and ensuring they were entered in PCC for each resident. The DON stated she remembered checking off the tasks on her checklist for Resident #15 when he readmitted to the facility, but she must have gotten side-tracked, or someone must have come into her office while she was completing her checklist for Resident #15 because she did not complete the checklist. The DON stated she told management that she was the reason for the physician's order for dialysis treatment for Resident #15 not being inputted into his medical record in PCC. The DON reiterated that she assumed that when Resident #15 was readmitted to the facility, his physician order would have remained in his medical record. The DON stated she was informed by the Corporate Nurse that when a resident was discharged and went to the hospital, their physician orders would fall off and would need to be re-entered into PCC. The DON stated that on 12/06/23, the Corporate Nurse reactivated the physician order for Resident #15 to receive dialysis treatment in PCC in the Verbal/Telephone Order tab in PCC. The DON reported that Resident #15 was scheduled to go to dialysis three times a week. She reported that Resident #15 did not receive any harm from the physician orders for dialysis treatment not being in his medical record in PCC. Record review of the facility's Medication and Treatment Orders policy, revised July 2016, reflected, Orders for medications and treatments will be consistent with principles of safe and effective order writing; .7. Verbal Orders must be recorded immediately in the resident's medical chart by the person receiving the order and must include the prescriber's last name, credentials, the date and the time of the order. Record review of the facility's End-Stage Renal Disease, Care of a Resident With, policy revealed the policy did not include physician orders for dialysis treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675018 If continuation sheet Page 4 of 13 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 675018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Oaks Health and Rehabilitation Center 2416 NW 18th St Fort Worth, TX 76106 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure its medication error rate was less than 5%. Residents Affected - Few MA B had two medication errors out of 39 opportunities resulting in an error rate of 5.13%. This failure could place residents at risk of not receiving the intended therapeutic effects of medications or receiving the wrong medication. Findings included: Observation on 12/06/23 at 8:30 AM revealed MA B administered Hydrocodone 7.5-325 mg orally to Resident #20. Observation on 12/06/23 at 8:49 AM revealed MA B administered Enteric Coated Aspirin 81 mg orally to Resident #24. Review of Resident #20's physician orders revealed an order for Hydrocodone 10-325 mg written on 12/15/22. Review of Resident #20's MAR for November and December revealed he was being provided Hydrocodone 7.5-325 mg Review of Resident #24's physician orders revealed an order for Aspirin 81 mg to be chewed. Interview on 12/06/23 at 11:30 AM with MA B revealed he did not have chewable aspirin on his cart, only enteric coated aspirin. MA B stated he did not know how Resident #20 had hydrocodone 7.5 mg on his cart when the order stated hydrocodone 10 mg. MA B stated he did not know how long Residents #20 and #24 had been receiving the wrong medications. MA B was able to recite the Five Rights of medication administration, and stated he violated the Right Medication portion of the Five Rights. MA B stated the medication aides were responsible for restocking their carts and making sure the right medications were on the cart. Telephone interview on 12/06/23 at 12:15 PM with the Pharmacist revealed in September of 2023 hydrocodone 10-325 mg was on national back order with no date of when it would be available again. A notice was sent out to all physicians to change their hydrocodone 10-325 mg orders to another medication. The Pharmacist stated they received a new prescription from the Doctor for Resident #20 on 9/28/23 for hydrocodone 7.5-325 mg. Resident #20 was sent the new order at that time. The Pharmacist could not say when Resident #20 started taking the lower dose because it would depend on how many of the 10 mg pills he still had. The Pharmacist stated Resident #24 taking enteric coated aspirin versus chewable aspirin was not a medication issue, just an order issue. Both forms would accomplish the intended effect. Enteric coated is designed to pass through the stomach and be absorbed by the mucosa in the intestines. Chewable aspirin was designed to be chewed and absorbed by the mucosa in the mouth. Interview on 12/06/23 at 1:00 PM with Resident #20 revealed his pain control was good, and he had no complaints about his pain medication. Interview on 12/06/23 at 1:30 PM with the DON revealed she was unaware of the change in Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675018 If continuation sheet Page 5 of 13 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 675018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Oaks Health and Rehabilitation Center 2416 NW 18th St Fort Worth, TX 76106 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #20's medication dosage or how that occurred. She stated if the resident had no pain with the lower dosage, then the only issue was why the order had not been changed in the physician orders. The DON stated the physician must have sent a new prescription directly to the pharmacy and failed to change the order when he made rounds at the facility. The DON stated she would address this with the physician immediately. The DON stated she would re-educate MA B on the Five Rights, and ensure he placed chewable aspirin on his cart. The DON stated she would check the other medication carts as well. Review of the facility's Administering Oral Medications policy, revised October 2010, reflected: .6. Check the label on the medication and confirm the medication name and dose with the MAR. 7. Check the expiration date on the medication. Return any expired medications to the pharmacy. 8. Check the medication dose. Re-check to confirm the proper dose. 9. Prepare the correct dose of medication 10. Confirm the identity of the resident FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675018 If continuation sheet Page 6 of 13 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 675018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Oaks Health and Rehabilitation Center 2416 NW 18th St Fort Worth, TX 76106 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 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. Based on observation, interview, and record reveiw, the facility failed to ensure all drugs were stored in locked compartments with access by authorized personnel only for 1 of 4 carts (South Station Nurse Cart) reviewed for storage of drugs and biologicals. RN C failed to secure her medication cart before she stepped away from it. This failure could place residents at risk of accessing medications not prescribed for them. Findings included: Observation on 12/06/23 at 1:10 PM revealed the nurse medication cart for South Hall was unlocked, all drawers were able to be opened by the surveyor. Observation on 12/06/23 at 1:15 PM revealed RN C returned to the nurses' station from another hall. She did not notice her cart was unlocked until made aware by the surveyor. Interview on 12/06/23 at 1:16 PM with RN C revealed she initially stated the cart was unlocked because she was going to medicate a resident. When the surveyor pointed out that the cart had been unlocked while she was away from it and on another hall while residents were sitting in wheelchairs nearby, RN C stated she had stepped away briefly to take a phone call and must have forgotten to lock her cart. RN C stated leaving the cart unlocked posed a risk of a resident gaining access to medications not prescribed for them and possibly having an allergic reaction to the medication. The medication cart contained both over the counter medications as well as prescription medications. Controlled substances were not available due to them being secured in a locked cabinet inside the cart. Review of the facility's Storage of Medications policy, revised November 2020, reflected: .6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675018 If continuation sheet Page 7 of 13 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 675018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Oaks Health and Rehabilitation Center 2416 NW 18th St Fort Worth, TX 76106 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 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. Residents Affected - Many 1. The facility failed to ensure the oven and stove were maintained in a clean and sanitary manner. 2. The facility failed to ensure hot dog buns that had grown mold were not kept in the panty. These failures could place residents who receive food from the kitchen, at risk for food contamination and food-borne illness. Findings included: Observation on 12/05/23 at 8:47 AM revealed the conventional oven had grease and grime that was the color of dark brown on the window of the oven. Observation on 12/05/23 at 8:48 AM revealed the side of the gas stove and the top of the stove had grease and grime that was the color of dark brown and black. Observation on 12/05/23 at 8:50 AM revealed the pantry floor was sticky, and cereal was sprinkled on the floor throughout the pantry. Observation on 12/06/23 at 11:30 AM revealed 9 packs of hot dog buns with 12 hot dog buns each with green and blue mold and 1 pack of hot dog buns with 6 hot dog buns with green mold. Interview on 12/06/23 at 11:46 AM with [NAME] Z revealed everyone was responsible for sanitizing and cleaning up the kitchen. [NAME] Z revealed she usually swept and mopped the kitchen and pantry every day. [NAME] Z revealed she had not cleaned the conventional oven in the last 3 weeks. [NAME] Z revealed the conventional oven was not used all the time because it had been broken. [NAME] Z stated the gas stove should be cleaned every day. [NAME] Z revealed everyone was responsible for cleaning the refrigerator and freezer. [NAME] Z revealed she was not sure about the harm to residents. Interview on 12/06/23 at 1:20 PM with the Dietary Manager revealed the food was covered with foil when it was in the oven and residents would not experience harm. The Dietary Manager revealed molded food should be checked for every day. The Dietary Manager stated everyone was responsible for keeping the kitchen clean, and there was a cleaning check-off list. The Dietary Manager stated cooks were responsible for cleaning the conventional oven and gas oven. Record review of kitchen's daily cleaning schedule for December 2023 documented cook and aides intitals. Interview on 12/06/23 at 11:46 AM with [NAME] Z revealed everyone was responsible for checking the bread to make sure it was not molded. [NAME] Z revealed the morning shift was responsible for putting up cold items and the evening shift was responsible for taking care of pantry items. [NAME] Z revealed the Dietary Manager ordered bread weekly. [NAME] Z revealed residents could get sick from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675018 If continuation sheet Page 8 of 13 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 675018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Oaks Health and Rehabilitation Center 2416 NW 18th St Fort Worth, TX 76106 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 eating molded bread. Level of Harm - Minimal harm or potential for actual harm Interview on 12/06/23 at 1:20 PM with the Dietary Manager revealed she would find the information about harm to residents when there was molded bread. The Dietary Manager revealed she had not experienced residents getting a hold of molded bread. Residents Affected - Many Record review of Food and Drug Administration Food Code dated 2017 Section 4-601.11 reflected: .Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675018 If continuation sheet Page 9 of 13 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 675018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Oaks Health and Rehabilitation Center 2416 NW 18th St Fort Worth, TX 76106 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 diseases and infections for 4 of 8 residents (Residents #16, #17, #20, and #24) reviewed for infection control. Residents Affected - Some MA B failed to sanitize a re-useable blood pressure cuff between blood pressure checks on Residents #16, #20, and #24. This failure could place residents at risk of contracting or spreading an infection. Findings included: Review of Resident #16's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included emphysema, high blood pressure, and history of COVID. Review of Resident #16's quarterly MDS, dated [DATE], revealed a BIMS score of 15, indicating he was cognitively intact. His Functional Status indicated he required limited assistance with his ADLs. Review of Resident #16's care plan, dated 11/28/23, revealed he was a moderate fall risk, he had just completed antibiotics for a UTI, and had an ADL self-care deficit. Review of Resident #20's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included diabetes, communication deficit, and legal blindness. Review of Resident #20's quarterly MDS, dated [DATE], revealed a BIMS score of 13 indicating he was cognitively intact. His Functional Status indicated he required minimal assistance with his ADLs. Review of Resident #20's care plan revealed he was prone to skin tears, was high fall risk, and had an ADL self-care deficit. Review of Resident #24's undated admission record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included depression with psychotic symptoms, dementia, and a history of COVID. Review of Resident #24's quarterly MDS assessment, dated 09/22/23, revealed a BIMS score of 11 indicating moderate cognitive impairment. Her Functional Status indicated she required limited assistance with her ADLs. Review of Resident #24's care plan, dated 10/12/23, revealed she was a moderate fall risk, had impaired visual function related to cataracts, and had a stroke. Observation on 12/06/23 at 8:30 AM revealed MA B used a re-useable blood pressure cuff to take Resident #20's blood pressure. The blood pressure cuff was not sanitized prior to use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675018 If continuation sheet Page 10 of 13 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 675018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Oaks Health and Rehabilitation Center 2416 NW 18th St Fort Worth, TX 76106 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 Observation on 12/06/23 at 8:49 AM revealed MA B used the same blood pressure cuff to check Resident #24's blood pressure, the cuff was not sanitized before or after use. Observation on 12/06/23 at 9:28 AM revealed MA B used the same blood pressure cuff to check Resident #16's blood pressure. The cuff was not sanitized before or after use. Residents Affected - Some Interview on 12/06/23 at 10:00 AM revealed MA B was aware he had not cleaned the blood pressure cuff between resident uses and stated he was nervous with surveyor present. He stated the risk of not sanitizing the cuff was spreading an infection from one resident to another. Interview on 12/06/23 at 1:30 PM with the DON revealed their policy required all re-useable medical equipment to be sanitized between each resident it was used on. She stated she would have to educate staff. Review of the facility's Cleaning and Disinfection of Resident-Care items and Equipment policy, revised October 2018, reflected: .Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. .3. Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. 4. Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675018 If continuation sheet Page 11 of 13 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 675018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Oaks Health and Rehabilitation Center 2416 NW 18th St Fort Worth, TX 76106 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 0914 Provide bedrooms that don't allow residents to see each other when privacy is needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to assure full visual privacy for residents in 3 (Resident #4, #5, and #35) of 6 rooms reviewed for visual privacy. Residents Affected - Some The facility failed to provide privacy curtains at the foot of B beds in 6 rooms. This failure could place residents at risk of loss of dignity and decreased feelings of self-worth. Findings included: Review of Resident #4's undated admission Record revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included seizures, diabetes, and morbid obesity. Review of Resident #4's quarterly MDS assessment, dated 10/14/23, revealed a BIMS score of 14 indicating she was cognitively intact. Her Functional Status indicated she required assistance with all of her ADLs. Review of Resident #4's care plan, dated 10/10/23, revealed she had a self-care deficit, was a high fall risk, and incontinent of urine and stool. Review of Resident #5's undated admission Record revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of stroke affecting his right side, seizures, and dementia. Review of Resident #5's quarterly MDS, dated [DATE], revealed a BIMS score of 10, indicating moderate cognitive impairment. His Functional Status indicated he required assistance with all of his ADLs. Review of Resident #5's care plan, dated 11/11/23, revealed he was a moderate fall risk with goals of no falls, and helping as needed. Resident #5 had a self-care deficit with interventions of encouraging the resident to perform tasks as he can. Review of Resident #35's undated admission Record revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included paralysis below the waist, self-care deficit, and muscle weakness. Review of Resident #35's quarterly MDS, dated [DATE], revealed a BIMS score of 15 indicating he was cognitively intact. His Functional Status indicated he required limited assistance with his ADLs. Review of Resident #35's care plan, dated 11/13/23, revealed he was a moderate fall risk, prone to skin tears, and was incontinent of bowel and bladder. Observation on 12/05/23 at 9:52 AM revealed resident #5 was receiving incontinent care, provided by CNA-A, with the privacy curtain between A and B beds pulled. Surveyor observed that Resident #5 could still be visualized via the mirror over the sink at the foot of his bed. There was no track on the ceiling to allow a privacy curtain to be hung to provide full visual privacy for Resident #5. Interview on 12/05/23 at 10:00 AM CNA-A stated there had never been a curtain at the end of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675018 If continuation sheet Page 12 of 13 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 675018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Oaks Health and Rehabilitation Center 2416 NW 18th St Fort Worth, TX 76106 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 0914 Resident #5's bed since he had been at the facility. Level of Harm - Minimal harm or potential for actual harm Interview on 12/05/23 at 10:05 AM Resident #5 stated he was unaware he could be observed via the mirror at the end of his bed. He stated he was not comfortable with that. Residents Affected - Some Interview on 12/05/23 at 12:18 PM the Maintenance Director stated he had never noticed there were no tracks on the ceiling to allow privacy curtains at the end of the bed. He stated he had been at the facility for 2 years and it had never been pointed out to him or raised as a concern. Interview on 12/05/23 at 12:30 PM Resident #4, when asked, stated she was not aware that she could be observed via the mirror at the end of her bed. Resident #4 stated it made her very uncomfortable knowing that. Interview on 12/05/23 at 12:34 PM Resident #35, when asked, stated he was not aware he could be visualized via the mirror at the foot of his bed. He stated he was uncomfortable with that and it needed to be fixed as soon as possible. Interview on 12/06/23 at 1:30 PM the DON stated she had never noticed the lack of a privacy curtain at the end of the B bed in several of the rooms, it had never been pointed out or mentioned by anyone before. She stated she would have to get with maintenance and see what could be done about it as soon as possible. Review of the facility policy Dignity, revised February 2021, reflected: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 11. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675018 If continuation sheet Page 13 of 13