Health inspection·August 15, 2024

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dressing today, 08/15/24 , because she noted it was coming off, but she had not checked the order on when it needed to be changed. RN A further stated she had attempted to change the dressing the day prior, 08/14/24, but the resident had told her he was not ready. RN A also said risks of not changing the PICC line dressing as ordered increased the risk of infection. Interview on 08/15/24 at 2:01 PM with the ADON revealed PICC line dressings should be changed every 7 days, and that the facility they were set to be changed every Wednesday. The ADON further stated it was important to change PICC line dressing as ordered to ensure the site remained clean and to prevent infection. Interview on 08/15/24 at 2:14 PM with the DON revealed PICC line dressings were to be changed every 7 days and as needed and at the facility, most PICC line dressings were to be changed every Wednesday. The DON said Resident #1 would pick at his dressing at times stating it was itching, causing it to lift, so the resident's needed to be changed more frequently at times. The DON also stated risks of not changing the PICC line dressings as ordered to prevent bacteria from entering the site and getting infected. Review of the facility's undated policy titled Central Venous Catheter reflected the following: .Obtain physicians order for dressing change FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 2 of 5 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 675034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104 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 1 (Resident #2) of 8 residents reviewed for infection control. Residents Affected - Few The facility failed to investigate and report to the County Health Department when Resident #2 was diagnosed with shigella. This failure placed residents at risk for infections. Findings included: Review of Resident #2's MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility 07/18/23. His diagnoses included cancer, cerebrovascular accident (stoke), and seizure disorder and Resident #1's cognition was moderately impaired. The MDS further reflected the resident used a wheelchair for mobility. Review of Resident #2's progress notes dated 07/28/24 reflected the following: Received order and sent resident out to Hospital via EMS for medical evaluation and treatment of altered mental status, diarrhea, nausea and abdominal pain. Review of Resident #2's hospital records dated 07/28/24 reflected the following: .Assessment/Plan: Sepsis (a serious condition in which the body responds improperly to an infection) Patient found to have ESBL bacteremia with shigella (intestinal infection caused by a family if bacteria and the main sign is diarrhea, which often is bloody. Shigella can also be passed infected food or by drinking or swimming in unsafe water) Further review of Resident #2's hospital records dated 08/02/24 documented by the infectious disease doctor reflected the following: .Impression ESBL bacteremia with shigella - atypical; gastroenteritis .Plan: (shigella - intestinal infection caused by a family if bacteria and the main sign is diarrhea, which often is bloody. Shigella can also be passed infected food or by drinking or swimming in unsafe water) 1. Continue meropenem (antibiotic) ordered 10 day total 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 3 of 5 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 675034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104 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 Organism may need to be reported to the [County] Level of Harm - Minimal harm or potential for actual harm Observation and interview on 08/15/24 at 8:44 AM with Resident #2 revealed he was in bed watching television. The resident said he had been to the hospital not long ago, but did not specify the date, because he was running a fever and had diarrhea. While he was at the hospital he was told he had an infection in his stomach from something he ate and the infection that then gone into his blood stream. Resident #2 further stated the hospital staff said the infection could have been caused by eating eggs that were not fully cooked. Resident #2 said he ate all of his meals at the facility and would eat scrambled eggs in the morning for breakfast. Residents Affected - Few Interview on 08/15/24 at 9:51 AM with the [NAME] revealed all of the eggs they served were pasteurized. and the scrambled eggs were delivered frozen in a bag. The bag of eggs were then put in boiling water until they formed a hard scramble, and then they were served. The [NAME] also said they were not allowed to make over easy eggs and if a resident ordered a fried egg, they had to ensure the yolk was fully cooked. The [NAME] further stated they had not had any concerns or reports of residents becoming sick after eating the meals. Observation on 08/15/24 at 11:20 AM of the facility's kitchen revealed all refrigerated dairy products were dated, and there were no expired items stored. Observation of the scrambled eggs revealed they were in single large bags, and there were no concerns regarding expiration dates. Interview on 08/15/24 at 11:27 AM with the Dietary Manager revealed all the eggs they served to the residents were pasteurized and if residents ordered a fried egg, they were not allowed to serve them over easy and made sure the yolk was fully cooked. She said the scrambled eggs came in a bag and they were precooked and had a fridge life of two years as long as they remained frozen. The Dietary Manager further stated they did not have any concerns or incidents of resident becoming sick after eating breakfast or any of the meals. Review of the facility's infection control log for July and August 2024 reflected there were no concerns of an gastrointestinal infection outbreak. Interview on 08/15/24 at 12:46 PM with the Physician revealed he had not been made aware Resident #2 had been diagnosed with shigella and had he known he would have placed the resident on contact isolation precautions. The Physician said he would have expected the facility staff to look into the origin of the infection and follow-up with other residents to see if they were also affected. Interview on 08/15/24 at 2:01 PM with the ADON revealed she had been told Resident #2 had been treated for Ecoli in the urine when he returned from the hospital so he had been put in isolation. The ADON said the DON was responsible for reading hospital records prior to residents admitting from the hospital or the hospital usually called in and gave report to the charge nurses. The ADON further stated she was not aware Resident #2 had been diagnosed with shigella but since the resident had been put in isolation, they would not have done anything different. Interview on 08/15/24 at 2:14 PM with the DON revealed there was a facility liaison group, but she did not know who they were, that reviewed resident hospital records before they were admitted to the facility. The DON said she then would get an email letting her know the resident had been approved to admit and Resident #2 had been approved and knew he required isolation. The DON further stated she was not aware Resident #2 had been diagnosed with shigella and was told he had ecoli and believed it was in the urine. She said if they would have been aware the resident had shigella, they would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 4 of 5 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 675034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104 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 have continued the same precautions and kept the resident on contact isolation. Level of Harm - Minimal harm or potential for actual harm Interview on 08/15/24 at 2:35 PM with the Administrator revealed when Resident #2 returned from the hospital, the resident said he wanted to warn her that the health department had been notified he had gotten an infection for eating eggs that had not been cooked all they way. The Administrator said at that time she spoke to the dietary staff and she was told all of their eggs were pasteurized and served fully cooked. She also said there were no other resident who were experiencing the same symptoms so there was no outbreak. The Administrator further stated she was not aware Resident #2 had been diagnosed with shigella and said they would not have done anything different because the resident had already been placed on isolation precautions when he returned. Residents Affected - Few Interview on 08/15/24 at 2:53 PM with RN B revealed she had re-admitted Resident #2 from hospital and she did not recall who told her the resident has been diagnosed with ESBL in his bowels; therefore, he was immediately put in isolation. RN B further stated she did not read the resident's admitting paperwork; therefore, she was not aware Resident #2 had been diagnosed with shigella. Interview on 08/19/24 at 2:53 PM with the County Epidemiologist revealed shigella was a disease that should be reported to the County Health Department by the nursing facilities because it was easily spread from person-to-person. The County Epidemiologist said an infected resident would require contract isolation precautions during the remainder of the antibiotic regimen. Review of the facility's policy titled Infection Prevention and Control Program revised June 2020 reflected the following: Purpose The ensure the Facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease an infection in accordance with Federal and State requirements. Policy .1. Identifies, investigates, controls, and prevents infections in the Facility FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 5 of 5