Health inspection·December 4, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few [LVN C] educated [Resident #1] on the importance of keeping Dialysis appointment. Notified DON/MD/Family. Further record review of Resident #1's progress notes, from 10/04/25-10/10/25, reflected there was no documentation of Resident #1 missing dialysis treatments on 10/04/25 or 10/07/25 or attempts to send the resident to the hospital for evaluation after missing 3 dialysis treatments. Record review of Resident #1's Lab Results Report, dated 10/07/25, reflected in part the following: -Collection Date: 10/07/2025 at 6:17 AM-Received Date: 10/07/2025 at 11:36 AM-Reported Date: 10/09/2025 at 4:57 PM. CMPGlucose-298 mg/dL (range 74-100)- HighChloride- 108.3 mmol/L (range 98.0-107.0)- HighBUN46 mg/dL (range 8-26)- HighCreatinine- 4.54 mg/dL (range 0.72-1.25)- HigheGFR (Non African-American)14 ml/min/1.73 (range >60)- LowA/G ration- 0.61 % (range 0.80-2.00)- LowAlbumin- 2.00 g/dL (range 3.40-5.00)- LowTotal Protein- 5.3 g/dL (range 6.0-7.8)- LowAlkaline Phosphatase- 156 U/L (range 40-150)High. In an interview and observation on 10/10/25 at 11:00 AM, Resident #1 was lying awake in bed with no obvious odors, marks, or bruises. Resident #1 was alert and oriented and able to participate in an interview. Resident #1 stated he received dialysis 3 times a week; however, he missed his last three treatments. Resident #1 stated he missed treatments on 10/04/25 and 10/07/25 because he had a cough and he did not want to wear a mask at the dialysis center, so he refused to go. Resident #1 stated he missed treatment on 10/09/25 because his transportation was late and he did not want the technicians at the dialysis center to be upset, so again, he refused to go. Resident #1 stated he would go to his treatment on 10/11/25 if he felt okay. Resident #1 stated he felt slightly bloated from possible fluid build-up but was otherwise fine. In an interview on 10/10/25 at 11:54 AM, the SW from the dialysis center stated Resident #1 received his last treatment on 10/02/2025 and had not returned. The SW stated she tried to contact the nursing facility to see why Resident #1 had not returned to the dialysis center for treatment and she was unable to speak with anyone. The SW stated the center was concerned with the care and treatment of Resident #1. In an interview on 10/10/25 at 12:45 PM, the Regional Compliance Nurse stated the DON was over the clinical department at the facility and she was there to monitor compliance and as support due to the DON being out of the facility. She stated it was the DONs responsibility to decide protocol for residents who refused dialysis treatment; however, she would advise getting the resident to sign a NRA to show their understanding of the risks involved in refusing and missing treatments. The Regional Compliance Nurse stated after 2 refused dialysis treatments, she would attempt to send the resident out to the hospital. In an interview on 10/10/25 at 1:16 PM, the MD stated Resident #1 had a history of refusing care including dialysis treatments, and the facility would notify him. The MD stated the resident had the right to refuse treatment, but the expectation was for the nurses to educate Resident #1 on the risks involved and to continue to encourage treatment. The MD stated if Resident #1 was missing dialysis treatments for reasons related to the facility, they would arrange for him to receive treatments at a different center; however, the resident was refusing for his own personal reasons. The MD stated if they could not force Resident #1 to go to the dialysis center, they also could not force him to go to the hospital. The MD stated not receiving dialysis treatments as ordered could place residents at risk of excess fluid and toxins in the body. In an interview on 10/10/25 at 2:14 PM, the PA stated she had several conversations with Resident #1 about the risk involved with him refusing to get dialysis treatments. The PA stated she offered Resident 1 to go to the hospital, start receiving hospice services, or go to a different nursing facility if he was unhappy, and he would refuse all. The PA stated she visited Resident #1 on 10/09/25 and he did not appear to be in distress; however, she stated after a resident missed more than 2 dialysis treatments, protocol would be to get STAT labs and depending on the results they might need to be sent out to the hospital, which the resident would have to agree (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675028 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 675028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete upon. The PA stated she could not recall if she ordered labs for Resident #1, but she would. Attempted interview on 10/10/25 at 2:45 PM with the DON was unsuccessful due to no response to call. Further interview on 10/10/25 at 3:41 PM, the PA stated that Resident #1 had labs drawn on 10/07/25 that resulted on 10/09/25. The PA stated she did not review the labs when she visited Resident #1 on 10/09/25. The PA reviewed the labs while on the phone with surveyor and stated the lab results indicated that Resident #1 needed to be dialyzed, but they were not super critical in her professional opinion. The PA stated she was not super concerned due to Resident #1's potassium and sodium levels being within range. The PA stated she was going to consult with the MD about Resident #1's labs and have the facility to ask the resident to go to the hospital due to labs and him missing 3 dialysis treatments. The PA could not state why she did not check the lab results on 10/09/25 and initiated protocol. Attempted interview on 10/10/25 at 4:31 PM with the DON was unsuccessful due to no response to call. Review of the facility's policy titled Dialysis, undated, reflected in part the following:.Policy:All facilities administering dialysis to residents will be appropriately trained and medically staffed to do so. Equipment and supplies may be the property of the physician or the facility. Facilities boarding residents who are transported to outpatient dialysis will have contracts in place with the dialysis center according to standard operating practices and the preferences of the dialysis facility.21. If the resident refuses dialysis treatment, document exactly what the resident verbalizes. Notify the attending physician, the dialysis center, and the next of kin/legal representative. The resident may need to sign an AMA form for refusal of treatment.Further review of the facility's policy reflected it did not address follow-up procedures for care after a resident refused dialysis treatment. Event ID: Facility ID: 675028 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 675028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 3 of 7 residents (Resident #1, Resident #2, and Resident #3) reviewed for infection control. The facility failed to ensure Residents #1, #2 and #3, who were on Enhanced Barrier Precautions, received proper care from staff donning and doffing personal protective equipment for infection control. This failure could place residents at risk for the spread of infections and decreased quality of life. Findings included:Resident #1 Record review of Resident #1's face sheet, dated 10/10/25, reflected a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses that included: metabolic encephalopathy (change in brain function due to systemic illness), heart failure, candidiasis (fungal infection), chronic kidney disease, dependence on dialysis (treatment to remove waste and excess fluid from the body), diabetes mellitus (body's inability to control blood sugar levels), morbid obesity (body mass index of 40 or higher), COPD (lung disease), and major depressive disorder (mood disorder). Record review of Resident #1's OSA MDS assessment, dated 07/25/25, reflected the resident's BIMS score was 9, which indicated moderate cognitive impairment. The MDS Assessment under Section G-Functional Status, reflected Resident # 1 required extensive assistance with most ADLs. The MDS Assessment under Section O-Special Treatments, Procedures, and Programs, reflected Resident #1 received dialysis. The MDS Assessment under Section M-Skin Conditions, reflected Resident #1 did not have any ulcers, wounds or skin problems; however, he received the following preventative treatments: pressure reducing device for bed, turning and repositioning program, nutrition or hydration intervention, and application of ointments/medications. Record review of Resident #1's care plan, dated 09/23/25, reflected the resident had a pressure ulcer or potential for pressure ulcer development with interventions that included: heels floated with the use of pillows, incontinent care after each episode and apply moisture barrier, assisting resident with repositioning every 2 hours, a cushion in wheelchair, and using a lifting device or draw sheet to reduce friction. Further review of this document reflected Resident #1 was on enhanced barrier precautions for Candida auris (yeast that can cause severe, invasive infections) with interventions that included: gloves and gowns donned (put on) during linen change, resident hygiene, transfers, dressing, incontinent care, bed mobility, wound care, etc., performing hand sanitation before entering the room and prior to leaving, and a posting of enhanced barrier precautions is to be placed on the door of the resident's room. Record review of Resident #1's hospital records, dated 09/27/25, reflected the resident was admitted to the hospital for observation for abdominal pain. Labs reflected a skin culture that was collected was positive for Candida auris (yeast that can cause severe, invasive infections). In an observation during the initial tour of the facility, there was no enhanced barrier precaution signage on the door of Resident #1's room. In an interview on 10/10/2025 at 11:00 AM, Resident #1 stated he received poor care from the staff regarding an open wound on his bottom due to him having to remind then to put cream on it. Resident #1 did not express any concerns with infection control. In an observation on 10/10/2025 at 11:45 AM, LVN A donned personal protection equipment with improper hand sanitizing prior to donning gloves. LVN A dropped one of her clean gloves on the floor, picked it up and put it back into her scrub pocket. A trash can was next to her feet. Observation of Resident #1's skin revealed his bilateral (both) buttocks had multiple scars from healed wounds. The skin area to the left lower buttock revealed an old scar that was slightly open as a newly formed wound. Measurements were noted to be 0.2 cm x 0.2cm x Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675028 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 675028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134 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 0 cm. Redness with no drainage was observed with foul odor noted from the anal area. There was no fecal matter present. When asked how long that area had been open LVN A stated, It's NOT open. After skin examination concluded, CNA D who was assisting LVN A, was observed doffing her personal protective gown by touching the front of her gown and jerking it off without untying all ties after doffing her gloves. Neither LVN A nor CNA D properly cleaned their hands after doffing personal protective equipment Resident #2Record review of Resident #2's face sheet, dated 10/10/25, reflected a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses that included: cerebral palsy (brain damage that causes problems with movement, balance, and posture), contractures (permanent or temporary limitations in joint mobility), need for assistance with personal care, gastrostomy (surgical procedure that creates an opening in stomach for feeding and medication administration), cognitive communication deficit (difficulty with communication), and chronic pain. Record review of Resident #2's care plan, dated 09/12/25, reflected the resident had a pressure ulcer or the potential for pressure ulcer development with interventions that included: assisting the resident with repositioning, putting a cushion in wheelchair, putting bed as flat as possible to reduce shear, use of an air mattress, treating pain as ordered, and using a lifting device or draw sheet to reduce friction. Further review of the document reflected Resident #2 was on enhanced barrier precautions with interventions that included: gloves and gowns donned (put on) during linen change, resident hygiene, transfers, dressing, incontinent care, bed mobility, wound care, etc., performing hand sanitation before entering the room and prior to leaving, and a posting of enhanced barrier precautions is to be placed on the door of the resident's room. Record review of Resident #2's quarterly MDS assessment, dated 10/06/25, reflected the resident's BIMs score was not indicated due to the resident not being able to complete the interview; however, it reflected the resident was severely impaired for making decisions regarding tasks of daily life. The MDS Assessment under Section GG-Functional Abilities, reflected Resident # 2 was dependent on staff for all ADLs. The MDS Assessment under Section M-Skin Conditions, reflected Resident #2 had open lesions other than ulcers, rashes, and cuts, and he was at risk for developing pressure ulcers and injuries. Resident #2 received the following preventative treatments: pressure reducing device for bed, nutrition or hydration intervention, pressure ulcer/injury care, application of nonsurgical dressings, and application of ointments/medications. In an observation on 10/10/2025 at 2:47 PM, LVN A set up clean wound care station for Resident #2. LVN A was observed gathering supplies for treatment with dirty gloves. The clean bandage to be used for wound care was opened and placed on a dirty surface for LVN A to write the date and initials before tossing the bandage to the clean workstation. LVN A entered Resident #2's room without knocking, performed hand hygiene and donned gloves and gown. Resident #2 had a stage three pressure injury on right lateral (one side) knee. The nurse did not utilize proper hand sanitizer after each glove change during the wound care. CNA D who was assisting the LVN/wound nurse, was observed doffing her personal protective gown by touching the front of her gown and jerking it off without untying all ties after doffing her gloves and did not dispose gown properly. Resident #3Record review of Resident #3's face sheet, dated 10/10/25, reflected a [AGE] year-old male who initially admitted to the facility on [DATE]. Resident #3 had diagnoses that included: acute kidney failure, cerebral infarction (stroke), muscle weakness, cognitive communication deficit (difficulty with communication), and adult failure to thrive. Record review of Resident #3's care plan, dated 09/16/25, reflected the resident had a pressure ulcer or the potential for pressure ulcer development with interventions that included: administering medications as ordered, not massaging over bony areas, using mild cleansers for perineal care, educating the resident and family about causes of skin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675028 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 675028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134 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 breakdown, ensuring heels were floated using pillows, following facility policies and protocols for prevention and treatment of skin breakdown, incontinent care after each episode and apply moisture barrier, informing the resident, family, and caregivers of any new area of skin breakdown, and monitoring nutritional status. Further review of the document did not reflect that Resident #3 was on enhanced barrier precautions. Record review of Resident #3's admission MDS assessment, dated 09/25/25, reflected the resident's BIMs score was 99 due to the resident not being able to complete the interview; however, it reflected the resident was severely impaired for making decisions regarding tasks of daily life. The MDS Assessment under Section GG-Functional Abilities, reflected Resident # 3 was dependent on staff for all ADLs. The MDS Assessment under Section M-Skin Conditions, reflected Resident #3 had unstageable pressure ulcers, and he was at risk for developing pressure ulcers and injuries. Resident #3 received the following preventative treatments: pressure reducing device for bed, nutrition or hydration intervention, pressure ulcer/injury care, application of nonsurgical dressings, and application of ointments/medications. In an observation on 10/10/2025 at 3:15 PM, LVN A completed wound care with Resident #3 and removed a dirty draw sheet from underneath the resident with no bag to deposit the soiled linen. LVN A folded the dirty linen and laid it at the foot of Resident #3's bed, on top of the blanket. CNA D, who was assisting the LVN A, was observed doffing her personal protective gown by touching the front of her gown and jerking it off without untying all ties after doffing her gloves. CNA D went to get clean linen and came back into Resident #3's room and laid the clean linen on top of the dirty linen at the foot of the resident's bed, resulting in cross contamination. In an interview on 10/10/2025 at 9:45 AM, the Housekeeping Manager revealed she was unaware of the EPA list of cleaning chemicals per CDC cleaning guidelines for fungal infections and multi-drug-resistant organisms. She denied receiving communication from nursing staff when residents with a diagnosis of a fungal infection for cleaning and disinfection associated with infection control. The Housekeeping Manager stated the housekeepers depended on the nursing staff and signage on the residents' doors to know what precautions to take when entering the rooms. She stated the housekeepers received the same infection control training and in-services as all facility staff monthly and as needed. In an interview on 10/10/2025 at 2:15 PM, the Regional Compliance Nurse, who was acting as the nurse in charge, revealed she had no prior knowledge of Resident #1's diagnosis of Candida auris or why the hospital performed a skin culture to test. She also denied knowledge of Candida auris or how it is treated as she was not the MD. The Regional Compliance Nurse denied knowledge of how the nursing staff updated housekeeping staff regarding residents on isolation and what precautions to take when entering resident rooms to clean. She stated the DON was over the clinical department and responsible for ensuring staff were aware and followed protocol regarding infection control. She stated general protocol for wound care included knocking on the resident's door to explain treatment, assessing for pain, washing hands, putting on PPE, setting up treatment station, washing or sanitizing hands again, removing dressing and completing wound care, sanitizing hands again, applying mediation and bandage, removing PPE, and sanitizing hands. The Regional Compliance Nurse observed wound care for Residents #1, #2, and #3, and she denied seeing any concerns with infection control. She stated not following protocol for infection control could place the residents at risk of cross-contamination and the spread of infection. In an interview on 10/10/2025 at 4:10 PM, LVN A stated she worked at the facility since 4/2025. She stated the procedure for providing wound care included sanitizing and setting up the table with all the supplies needed, knocking on the resident's door and explaining her reason for being there, asking the resident if they were ready for treatment, assessing for pain, sanitizing hands, putting on PPE, and starting wound care. LVN A stated she would sanitize hands and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675028 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 675028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134 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 FORM CMS-2567 (02/99) Previous Versions Obsolete change gloves between each task. She stated when setting up supplies, she would always date and initial bandages on a clean surface and prior to placing them on the resident. LVN A stated she made mistakes with infection control during Resident #1's wound care because she was nervous; however, she denied dating Resident #2's bandage on a dirty surface during his wound care. In an interview on 10/10/2025 at 4:38 PM, CNA B stated she worked at the facility since 7/2025. She stated she had concerns with the infection control at the facility due to lack of proper training and information regarding the health of new residents. CNA B stated they were in-serviced by documentation about infection control being left at the nurses' station for staff to read and sign. She stated training would be more effective if someone went over the information with staff. CNA B also stated when the facility received new residents, the nurses did not inform the aides of any infectious diseases they had, and they would have to find out by word-of-mouth from other staff who were not nurses. CNA B stated that concerned her because she did not want to catch or spread any contagious diseases. Review of the facility's policy titled Infection Control Plan: Overview, updated 3/2024, reflected in part the following: Infection Control Plan: Overview Infection ControlThe facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.LinensPersonnel will handle, store, process and transport linens so as to prevent the spread of infection.Fundamentals of Infection Control Precautions A variety of infection control measures are used for decreasing the risk of transmission of microorganisms inthe facility. These measures make up the fundamentals of infection control precautions.1. Hand HygieneHand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene:. Before and after entering isolation precaution settings;. Before and after changing a dressing;. After handling soiled or used linens, dressings, bedpans, catheters and urinals. After removing gloves or aprons; and After completing duty.Recommended techniques for performing hand hygiene with an ABHR:Include applying product to the palm of one hand and rubbing hands together, covering all surfaces of hands and fingers, until the hands are dry. Review of the facility's policy titled Wound Treatment Management, undated, reflected it did not address infection control protocol during wound care. Event ID: Facility ID: 675028 If continuation sheet Page 7 of 7