Inspection·December 15, 2023

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of Resident #1's hospital record, dated 11/27/23, revealed, .Final diagnosis as of 11/27/23 2327 .Rib fractures .Sternal fracture .Dyspnea .Pleura effusion . In an interview and observation on 12/14/23 at 10:50 a.m., Resident #1 stated [the facility staff] took her out of the car van from dialysis and they were working together to put her in the bed when they dropped her on the floor. Resident #1 was observed lying in bed and was small and frail but alert and oriented to surroundings. In an interview on 12/14/23 at 10:51 a.m. with Resident #1's family member A revealed another family member B reported it the day it happened to the nurse (RN K) when she visited Resident #1. The following Monday 11/27/23 Resident #1's blood pressure dropped during dialysis, and she was taken to the hospital. The hospital reported she had multiple fractured ribs and a fractured sternum. In an interview on 12/14/23 at 10:58 a.m. with Resident #1's family member B revealed she came to visit Resident #1 on 11/24/23. She stated she signed in around 4:10PM-4:15pm and Resident #1 had not been back for too long but realized Resident #1 was agitated. Resident #1 then told family member B that when [facility staff ] were getting her back to her bed and out of the wheelchair, they dropped her. Family member B stated Resident #1 could not sit up well, was pointing to her ribs and told family member B she was hurting. Family member B spoke to RN K and told her the resident stated she had been dropped and was hurting. Family member B asked if there was something that could be given to Resident #1 for pain. RN K told family member B that she was in the vicinity when Resident #1 was transferred in her room and that the fall probably happened at the dialysis center. Family member B then revealed RN K bringing her some Tylenol in for Resident #1 since family member B stated she was in pain. In an interview with RN K at 12/14/23 at 11:30 a.m. revealed family member B came to her and stated the resident was dropped during transfer. RN K stated she was there at the facility when the resident returned from dialysis on 11/24/23. When Resident #1 first returned to the facility, she was exhausted and that was when Resident #1 stated to RN K she was dropped by an old man and a nurse, but RN K stated she thought Resident #1 was just having a dream. RN K also stated Resident #1 was not complaining of any pain at that time. RN K then revealed that it did not occur to her that the fall could have happened. RN K stated after she was notified by family member B, RN K did not take Resident #1's clothes off to do a full body assessment. She revealed she did give Resident #1 Tylenol since family member B stated she was in pain. RN K also stated she was by Resident #1's door when the transfer occurred while she was helping pass out dinner trays, however, she did not directly see the transfer. RN K stated if something like a resident was dropped during transfer were to occur, she was supposed to report it to the doctor, the DON, and Admin, but she just assumed the fall did not occur, and she did not notify the physician. RN K also stated even the next day the resident did not complain of pain. She then revealed she had been in serviced on falls and what to do. She stated she was supposed to do a head-to-toe assessment, obtain vitals, notify the DON and the physician. In an interview with Admin on 12/14/23 at 11:50 a.m. revealed she was unaware family member B reported to RN K that the Resident #1 had fallen during transfer. The Admin revealed in RN K's witness statement all she wrote was that a fall did not occur at the facility for Resident #1. In an interview with the physician on 12/14/23 at 2:09 p.m. revealed he was not aware Resident #1 fell, but he stated he was there when she went to the hospital on [DATE]. He stated the x-rays that were taken did not specify if the rib and sternum fracture was a new or old injury. He stated she had a lot of fluid drained from her chest and that could have been why she was in pain. The physician (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675650 If continuation sheet Page 2 of 23 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 675650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few specified since this was a change of condition, he should have been notified by the nurse who was RN K at the time. An interview with Admin on 12/15/23 at 3:22 p.m. she stated staff training and ongoing training will occur with asking residents if they have any accidents of abuse or neglect that has not been reported or need to be reported. She then revealed she would be asking nursing staff questions about incidents as rounds are conducted. The admin then stated 10 residents a day for 60 days will have assessments and may be extended if any issues occur. Record review of the facility's Changes in Resident Condition or Status policy, dated 11/26/2018, revealed, .This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status. In the case of death of a resident, the resident's physician will be notified immediately by facility staff in accordance with State law . On 12/14/23 at 4:40 p.m. the Admin was informed an Immediate Jeopardy existed and a copy of the IJ template was provided. The following Plan of Removal was accepted on 12/15/23 at 11:39 a.m. Plan of Remediation: [Facility Name] Re: IJ 12/14/2023

F580 Notification of physician Failure: The facility failure resulted in a delay in resident receiving timely x-rays and treatment, which could lead to serious harm/impairment/death. Corrective Action for those found to have been affected by the deficient practice: Identified Resident remains in the facility with no adverse residual effects. The Identified Licensed Nurse will be suspended (possibly terminated with HR approval) and Nurse License will be reported to the Board of Nursing. Resident Head to toe competencies will be completed by all licensed nurses by end of day 12/15/2023. The following in-services will be completed by 12/15/2023, by the following Administrative Nursing Staff to include, MDS, [MDS Coordinator], Infection Prevention/Staff Development Coordinator, [Infection Preventionist/Staff Development Coordinator], Senior Regional Director of Clinical Services, [Senior Regional Director of Clinical Services]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675650 If continuation sheet Page 3 of 23 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 675650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132 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 0580 Head to toe assessments-How and When to complete the assessments Level of Harm - Immediate jeopardy to resident health or safety Significant Change in status-When a resident has a change who to report to Residents Affected - Few Reporting to the Physician-Reporting any significant changes or incident that occurs with a resident and in a timely manner. Incidents and Accidents and how to report and complete Reporting to the Administrative Staff-Any significant changes or incident that has been reported, observed or noted. Abuse and Neglect-Who to report to, types of Abuse, prevention strategies Fall Management-Interventions to put in place and what to do when a fall occur Identification of other residents having the potential to be affected: Fall assessments were completed on 12/14/2023 by Sr. Regional Director of Clinical Services, MDS Coordinator RN, and Infection Preventionist/Staff Development Coordinator, to determine which residents would be potentially affected. Residents who are identified to be at risk for falls will be care planned appropriately by Sr. Regional Director of Clinical Services, MDS Coordinator RN, and Infection Preventionist/Staff Development Coordinator. Current and past falls for the last 30 days reviewed for compliance to ensure that regulatory guidelines have been met. These were reviewed, by [Senior Regional Director of Clinical Services], for the last 30 days to ensure that regulatory guidelines have been met. Measures/Systemic Changes to ensure the deficient practice does not recur: Competency Assessments for completing and documenting head to toe will be completed by all licensed nursing staff prior to them working their next shift. They will not be allowed to work until these are completed. These Competencies will be conducted by Admin Nursing Staff to include, MDS, [MDS Coordinator], Infection Prevention/Staff Development Coordinator, [Infection Preventionist/Staff Development Coordinator], Senior Regional Director of Clinical Services, [Senior Regional Director of Clinical Services]. These will be completed by end of day 12/15/2023. In-services and education for all licensed nursing staff will be completed by 12/15/2023 by Admin Nursing Staff to include, MDS, [MDS Coordinator], Infection Prevention/Staff Development Coordinator, [Infection Prevention/Staff Development Coordinator], Senior Regional Director of Clinical Services, [Senior Regional Director of Clinical Services]. In-service topics will include the following: Head to toe assessments-How and When to complete the assessments Significant Change in status-When a resident has a change who to report to Incidents and Accidents and how to report and complete (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675650 If continuation sheet Page 4 of 23 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 675650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132 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 0580 Reporting to the Physician-Reporting any significant changes or incident that occurs with a resident and in a timely manner. Level of Harm - Immediate jeopardy to resident health or safety Reporting to the Administrative Staff-Any significant changes or incident that has been reported, observed or noted. Residents Affected - Few Abuse and Neglect-Who to report to, types of Abuse, prevention strategies Fall Management-Interventions to put in place and what to do when a fall occurs. Ongoing Monitoring: Interviews with staff and residents will be completed during morning grand rounds and throughout the day to identify if they have had any injuries or falls that have not been reported. This will continue weekly for 60 days. Administrative staff will make facility rounds daily, until compliance is achieved. All components of this plan of correction will be submitted to the facility QAPI committee meeting and additional recommendations will be made until substantial compliance has been achieved. The Medical Director was notified and agrees with the plan of correction. The Admin Nursing Staff to include, MDS, [MDS Coordinator], Infection Prevention/Staff Development Coordinator [Infection Prevention/Staff Development Coordinator], Senior Regional Director of Clinical Services, [Senior Regional Director of Clinical Services], DON, [DON], Executive Director, [Administrator], are responsible for the corrections and continued monitoring. Completion date: By 5pm 12/15/2023 Monitoring included: - Review of in-services dated 12/15/23 were completed and interviews with staff confirmed by verbalizing expectations. - Interviews on 12/15/2023 between 8:00am and 1:00PM with multiple staff on various shifts revealed confirmatory knowledge of in-services dated 12/15/2023 Observation on 12/15/23 at 9:41am revealed CNA G and CNA H using the Hoyer lift to transfer a resident with the wheelchair at the head of the bed. No problems or concerns with transfer 2-person transfer. During interviews on 12/15/23 from 8:00 a.m. to 1:00 p.m. with facility staff revealed they had been trained on head-to-toe assessments, significant change in status, incidents and accidents, reporting to the physician, reporting to the administration staff, abuse and neglect, fall management and suspected injury or witness fall. All staff interviewed were able to verbalize the new training instructions back. The staff interviewed consisted of the following: LVN D, LVN E, LVN F, CNA G, and CNA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675650 If continuation sheet Page 5 of 23 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 675650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132 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 0580 H. Level of Harm - Immediate jeopardy to resident health or safety While the IJ was removed on 12/15/23 the facility remained out of compliance at a severity of actual harm and scope level of isolated due to the need for the facility to monitor it corrective action for effectiveness. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675650 If continuation sheet Page 6 of 23 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 675650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had the right to be free from neglect and failed to develop and implement written policies and procedures that prohibit and prevent neglect for 1 of 37 residents (Resident # 1) reviewed for neglect. RN K failed to report and assess Resident #1's fall to the facility when the family alleged the resident was dropped during transfer. The facility was unaware the resident had fractured ribs and sternum until Resident #1 was sent to the hospital due to unrelated concern of low blood pressure, three days after the incident. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/14/23. While the IJ was removed on 12/15/23, the facility remained out of compliance at a severity of actual harm with a scope identified as isolated. The facility was continuing to monitor for safe resident transfers as well as education to staff. This failure placed residents at risk for neglect due to a delay in treatment, and a worsening of their condition or could result in death. Findings include: Record review of Resident #1's face sheet dated 12/15/23 revealed Resident #1 was an [AGE] year-old female admitted on [DATE] with the following diagnoses: Muscle weakness, end stage renal disease, acute respiratory failure (body's inability to deliver oxygen properly), heart failure(heart doesn't pump blood like it should), hypertension (high blood pressure), and difficulty in walking. Review of Resident #1's MDS Quarterly Assessment, dated 12/04/23, reflected the resident's functional status: the resident required substantial/maximal assistance to go from lying to sitting on the side of the bed, sitting to stand, and to transfer from wheelchair to bed and from bed to wheelchair. An interview on 12/14/23 at 9:40 a.m. with the Admin, revealed Resident #1 came back from the hospital with multiple fractures but never had a fall at the facility. The Administrator then stated they interviewed everyone such as dialysis, transportation, and EMS and none of them stated anything happened to the resident that resulted in fractured ribs and sternum so the investigation was inconclusive. Review of Resident #1's hospital record, dated 11/27/23, revealed, .Final diagnosis as of 11/27/23 2327 .Rib fractures .Sternal fracture .Dyspnea .Pleura effusion . In an interview and observation on 12/14/23 at 10:50 a.m., Resident #1 stated [the facility staff] took her out of the car van from dialysis and they were working together to put her in the bed when they dropped her on the floor. Resident #1 was observed lying in bed and was small and frail but alert and oriented to surroundings. In an interview on 12/14/23 at 10:51 a.m. with Resident #1's family member A revealed another family member reported it the day it happened to the nurse (RN K) when she visited Resident #1. The following Monday 11/27/23 Resident #1's blood pressure dropped during dialysis and she was taken to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675650 If continuation sheet Page 7 of 23 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 675650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132 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 0600 hospital. The hospital reported she had multiple fractured ribs and a fractured sternum. Level of Harm - Immediate jeopardy to resident health or safety In an interview on 12/14/23 at 10:58 a.m. with Resident #1's family member B revealed she came to visit Resident #1 on 11/24/23. She stated she signed in around 4:10PM-4:15pm and Resident #1 had not been back for too long but realized Resident #1 was agitated. Resident #1 then told family member B that when [facility staff] were getting her back to her bed and out of the wheelchair, they dropped her. Family member B stated Resident #1 could not sit up well, was pointing to her ribs and told family member B she was hurting. Family member B spoke to RN K and told her the resident stated she had been dropped and was hurting. Family member B asked if there was something that could be given to Resident #1 for pain. RN K told family member B that she was in the vicinity when Resident #1 was transferred in her room and that the fall probably happened at the dialysis center. Family member B then revealed RN K bringing her some Tylenol in for Resident #1 since family member B stated she was in pain. Residents Affected - Few In an interview with RN K at 12/14/23 at 11:30 a.m. revealed family member B came to her and stated the resident was dropped during transfer. RN K stated she was there at the facility when the resident returned from dialysis on 11/24/23. When Resident #1 first returned to the facility, she was exhausted and that was when Resident #1 stated to RN K she was dropped by an old man and a nurse, but RN K stated she thought Resident #1 was just having a dream. RN K also stated Resident #1 was not complaining of any pain at that time. RN K then revealed that it did not occur to her that the fall could have happened. RN K stated after she was notified by family member B, RN K did not take Resident #1's clothes off to do a full body assessment. She revealed she did give Resident #1 Tylenol since family member B stated she was in pain. RN K also stated she was by Resident #1's door when the transfer occurred while she was helping pass out dinner trays, however, she did not directly see the transfer. RN K stated if something like a resident was dropped during transfer were to occur, she was supposed to report it to the doctor, the DON, and Admin, but she just assumed the fall did not occur, and she did not notify the physician. RN K also stated even the next day the resident did not complain of pain. She then revealed she had been in serviced on falls and what to do. She stated she was supposed to do a head-to-toe assessment, obtain vitals, notify the DON and the physician. In an interview with Admin on 12/14/23 at 11:50 a.m. revealed she was unaware family member B reported to RN K that the Resident #1 had fallen during transfer. The Admin revealed in RN K's witness statement all she wrote was that a fall did not occur at the facility for Resident #1. In an interview with the physician on 12/14/23 at 2:09 p.m. revealed he was not aware Resident #1 fell, but he stated he was there when she went to the hospital on [DATE]. He stated the x-rays that were taken did not specify if the rib and sternum fracture was a new or old injury. He stated she had a lot of fluid drained from her chest and that could have been why she was in pain. The physician stated the resident was admitted for fluid overload. The physician specified since this was a change of condition, he should have been notified by the nurse who was RN K at the time. In an interview with the transportation manager on 12/14/23 at 2:26 p.m., he revealed Transportation driver R was the one who transported Resident #1 back to the facility on [DATE]. He stated once they arrived, they usually let staff know the resident is back at the facility. He stated transportation driver R told him he helped her in bed and then went to get help to reposition her into the bed by asking a facility staff member. There was no fall. On 12/24/23 at 2:29 p.m. attempted to call transportation driver R with no answer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675650 If continuation sheet Page 8 of 23 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 675650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few In an interview with CNA E on 12/14/23 at 2:40 p.m. revealed she was working that day Resident #1 came back from dialysis on 11/24/23 but she was working the opposite hall of Resident #1. The transportation Driver R called CNA E to come help him transfer her back to the bed and to let RN K know Resident #1 was back at the facility from dialysis. CNA E then revealed she usually worked nights but was helping the dayshift that day. She stated Resident #1 was in her wheelchair when CNA E walked in the room to help transfer her back to the bed with transportation driver R. She stated she was on one side and transportation driver R was on the other and they got Resident #1 out of the wheelchair and pivoted toward the bed. The resident never fell. In an interview with dialysis nurse on 12/15/23 at 12:23PM revealed she was the nurse taking care of Resident #1 on 11/27/23. Resident #1 was having a hard time breathing, her oxygen was low and she was having pain in her rib cage. That was when Resident #1 revealed to the dialysis nurse that someone dropped her from the facility. Resident #1 then stated she wanted to go to the hospital and EMS was called on 11/27/23. The dialysis nurse stated Resident #1 comes to dialysis every Monday, Wednesday and Friday. She revealed the facility called and stated the resident fell at dialysis and the dialysis nurse stated no, Resident #1 told me she fell at the facility. In an interview with Admin on 12/15/23 at 3:22p.m. she stated staff training and ongoing training will occur with asking residents if they have any accidents of abuse or neglect that has not been reported or need to be reported. She then revealed she would be asking nursing staff questions about incidents as rounds are conducted. The Admin then stated 10 residents a day for 60 days will have assessments and may be extended if any issues occur. Record review of the facility's Abuse - Inservice Training policy, dated 07/18/2023, revealed, .Facility procedures and Federal and State requirements for reporting abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources, timeframes for reporting, and to whom staff and others must report their knowledge related to any alleged violation without fear of retaliation . On 12/14/23 at 4:40 p.m. the Admin was informed of an Immediate Jeopardy existed and a copy of the IJ template was provided. The following Plan of Removal was accepted on 12/15/23 at 11:39 a.m. Plan of Remediation: [Facility Name] Re: IJ 12/14/2023

F580 Notification of physician Failure: The facility failure resulted in a delay in resident receiving timely x-rays and treatment, which could lead to serious harm/impairment/death. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675650 If continuation sheet Page 9 of 23 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 675650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132 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 0600 Corrective Action for those found to have been affected by the deficient practice: Level of Harm - Immediate jeopardy to resident health or safety Identified Resident remains in the facility with no adverse residual effects. The Identified Licensed Nurse will be suspended (possibly terminated with HR approval) and Nurse License will be reported to the Board of Nursing. Residents Affected - Few Resident Head to toe competencies will be completed by all licensed nurses by end of day 12/15/2023. The following in-services will be completed by 12/15/2023, by the following Administrative Nursing Staff to include, MDS, [MDS Coordinator], Infection Prevention/Staff Development Coordinator, [Infection Preventionist/Staff Development Coordinator], Senior Regional Director of Clinical Services, [Senior Regional Director of Clinical Services]. Head to toe assessments-How and When to complete the assessments Significant Change in status-When a resident has a change who to report to Incidents and Accidents and how to report and complete Reporting to the Physician-Reporting any significant changes or incident that occurs with a resident and in a timely manner. Reporting to the Administrative Staff-Any significant changes or incident that has been reported, observed or noted. Abuse and Neglect-Who to report to, types of Abuse, prevention strategies Fall Management-Interventions to put in place and what to do when a fall occur Identification of other residents having the potential to be affected: Fall assessments were completed on 12/14/2023 by Sr. Regional Director of Clinical Services, MDS Coordinator RN, and Infection Preventionist/Staff Development Coordinator, to determine which residents would be potentially affected. Residents who are identified to be at risk for falls will be care planned appropriately by Sr. Regional Director of Clinical Services, MDS Coordinator RN, and Infection Preventionist/Staff Development Coordinator. Current and past falls for the last 30 days reviewed for compliance to ensure that regulatory guidelines have been met. These were reviewed, by [Senior Regional Director of Clinical Services], for the last 30 days to ensure that regulatory guidelines have been met. Measures/Systemic Changes to ensure the deficient practice does not recur: Competency Assessments for completing and documenting head to toe will be completed by all licensed nursing staff prior to them working their next shift. They will not be allowed to work until these (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675650 If continuation sheet Page 10 of 23 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 675650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few are completed. These Competencies will be conducted by Admin Nursing Staff to include, MDS, [MDS Coordinator], Infection Prevention/Staff Development Coordinator, [Infection Preventionist/Staff Development Coordinator], Senior Regional Director of Clinical Services, [Senior Regional Director of Clinical Services]. These will be completed by end of day 12/15/2023. In-services and education for all licensed nursing staff will be completed by 12/15/2023 by Admin Nursing Staff to include, MDS, [MDS Coordinator], Infection Prevention/Staff Development Coordinator, [Infection Prevention/Staff Development Coordinator], Senior Regional Director of Clinical Services, [Senior Regional Director of Clinical Services]. In-service topics will include the following: Head to toe assessments-How and When to complete the assessments Significant Change in status-When a resident has a change who to report to Incidents and Accidents and how to report and complete Reporting to the Physician-Reporting any significant changes or incident that occurs with a resident and in a timely manner. Reporting to the Administrative Staff-Any significant changes or incident that has been reported, observed or noted. Abuse and Neglect-Who to report to, types of Abuse, prevention strategies Fall Management-Interventions to put in place and what to do when a fall occurs. Ongoing Monitoring: Interviews with staff and residents will be completed during morning grand rounds and throughout the day to identify if they have had any injuries or falls that have not been reported. This will continue weekly for 60 days. Administrative staff will make facility rounds daily, until compliance is achieved. All components of this plan of correction will be submitted to the facility QAPI committee meeting and additional recommendations will be made until substantial compliance has been achieved. The Medical Director was notified and agrees with the plan of correction. The Admin Nursing Staff to include, MDS, [MDS Coordinator], Infection Prevention/Staff Development Coordinator [Infection Prevention/Staff Development Coordinator], Senior Regional Director of Clinical Services, [Senior Regional Director of Clinical Services], DON, [DON], Executive Director, [Administrator], are responsible for the corrections and continued monitoring. Completion date: By 5pm 12/15/2023 - Review of in-services dated 12/15/23 were completed and interviews with staff confirmed by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675650 If continuation sheet Page 11 of 23 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 675650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132 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 0600 verbalizing expectations. Level of Harm - Immediate jeopardy to resident health or safety - Interviews on 12/15/2023 between 8:00am and 1:00PM with multiple staff on various shifts revealed confirmatory knowledge of in-services dated 12/15/2023 Residents Affected - Few Observation on 12/15/23 at 9:41am revealed CNA G and CNA H using the Hoyer lift to transfer a resident with the wheelchair at the head of the bed. No problems or concerns with transfer 2-person transfer. During interviews on from 8:00 a.m. to 1:00 p.m. with facility staff revealed they had been trained on head-to-toe assessments, significant change in status, incidents and accidents, reporting to the physician, reporting to the administration staff, abuse and neglect, fall management and suspected injury or witness fall. All staff interviewed were able to verbalize the new training instructions back. The staff interviewed consisted of the following: LVN D, LVN E, LVN F, CNA G, and CNA H. While the IJ was removed on 12/15/23, the facility remained out of compliance at a severity of actual harm with a scope of isolated due to the need for the facility to monitor it corrective action for effectiveness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675650 If continuation sheet Page 12 of 23 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 675650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the residents' environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 Resident # 1 of 37 residents (Resident#1) reviewed for adequate supervision accident and hazards. RN K failed to report Resident #1's fall to the facility and failed to assess Resident #1 when the family alleged the resident was dropped during transfer. The facility was unaware the resident had fractured ribs and sternum until Resident #1 was sent to the hospital due to unrelated concern of low blood pressure, three days after the incident. This resulted in the residents at risk for delay in assessment in treatment, placing them at risk for further harm, injury, or death. An Immediate Jeopardy (IJ) was identified on 12/14/23. The IJ template was provided to the facility on [DATE] at 4:30pm. While the IJ was removed on 12/15/23, the facility remained out of compliance at a severity of actual harm with a scope identified as isolated. The facility was continuing to monitor for safe resident transfers as well as education to staff. Findings include: Record review of Resident #1 face sheet dated 12/15/23 revealed Resident #1 was a [AGE] year old female admitted on [DATE] with the following diagnoses: Muscle weakness, end stage renal disease, acute respiratory failure (body inability to deliver oxygen properly), heart failure(heart doesn't pump blood like it should), hypertension (high blood pressure), and difficulty in walking. Review of Resident #1's MDS Quarterly Assessment, dated 12/04/23, reflected the resident's functional status: Lying to sitting on side of bed: Substantial/maximal assistance, sitting to stand: Substantial/maximal assistance, chair to bed-to chair transfer: Substantial/maximal assistance. An interview on 12/14/23 at 9:40 a.m. with the Admin, revealed Resident #1 came back from the hospital with multiple fractures but never had a fall at the facility. The Administrator then stated they interviewed everyone such as dialysis, transportation, and EMS and neither one of them stated anything happened to the resident that resulted in fractured ribs and sternum so the investigation was inconclusive. Review of Resident #1's hospital record, dated 11/27/23, revealed, .Final diagnosis as of 11/27/23 2327 .Rib fractures .Sternal fracture .Dyspnea .Pleura effusion . In an interview and observation on 12/14/23 at 10:50 a.m., Resident #1 stated [the facility staff] took her out of the car van from dialysis and they were working together to put her in the bed when they dropped her on the floor. Resident #1 was observed lying in bed and was small and frail but alert and oriented to surroundings. In an interview on 12/14/23 at 10:51 a.m. with Resident #1's family member A revealed the family member's sister-in-law reported it the day it happened to the nurse (RN K) when she visited Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675650 If continuation sheet Page 13 of 23 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 675650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few #1. The following Monday,11/27/23 Resident #1's blood pressure dropped during dialysis and she was taken to the hospital. The hospital reported she had multiple fractured ribs and a fractured sternum. In an interview on 12/14/23 at 10:58 a.m. with Resident #1's family member B revealed she came to visit Resident #1 on 11/24/23. She stated she signed in around 4:10PM-4:15pm and Resident #1 hadn't been back for too long but realized Resident #1 was agitated. Resident #1 then told family member B that when [facility staff] were getting her back to her bed and out of the wheelchair, they dropped her. Family member B stated Resident #1 couldn't sit up well, was pointing to her ribs and told family member B she was hurting. Family member B spoke to RN K and told her the resident stated she had been dropped and was hurting. Family member B asked if there was something that could be given to Resident #1 for pain. RN K told family member B that she was in the vicinity when Resident #1 was transferred in her room and that the fall probably happened at the dialysis center. Family member B then revealed RN K bringing her some Tylenol in for Resident #1 since family member B stated she was in pain. In an interview with RN K at 12/14/23 at 11:30 a.m. revealed family member B came to her and stated the resident was dropped during transfer. RN K stated she was there at the facility when the resident returned from dialysis on 11/24/23. When Resident #1 first returned to the facility, she was exhausted and that's when Resident #1 stated to RN K she was dropped by an old man and a nurse, but RN K stated she thought Resident #1 was just having a dream. RN K also stated Resident #1 wasn't complaining of any pain at that time. RN K then revealed that it didn't occur to her that the fall could have happened. RN K stated after she was notified by family member B, RN K did not take her clothes off to do a full body assessment. She revealed she did give Resident #1 Tylenol since family member B stated she was in pain. RN K also stated she was by Resident #1's door when the transfer occurred while she was helping pass out dinner trays, however, she did not directly see the transfer. RN K stated if something like a resident was dropped during transfer were to occur, she was supposed to report it to the doctor, the DON, and Admin, but she just assumed the fall didn't occur, she didn't notify. RN K also stated even the next day the resident didn't complain of pain. She then revealed she had been in serviced on falls and what to do. She stated she was supposed to do a head-to-toe assessment, obtain vitals, notify the DON and the physician. In an interview with Admin on 12/14/23 at 11:50 a.m. revealed she was unaware family member B reported to RN K that the Resident #1 had fallen during transfer. The Admin revealed in RN K's witness statement all she wrote was that a fall did not occur at the facility for Resident #1. In an interview with the physician on 12/14/23 at 2:09 p.m. revealed he was not aware Resident #1 fell, but he stated he was there when she went to the hospital on [DATE]. He stated the x-rays that were taken didn't specify if the rib and sternum fracture was a new or old injury. He stated she had a lot oof fluid drained from her chest and that could have been why she was in pain. The physician specified since this was a change of condition, he should have been notified by the nurse who was RN K at the time. In an interview with the transportation manager on 12/14/23 at 2:26 p.m., he revealed Transportation driver R was the one who transported Resident #1 back to the facility on [DATE]. He stated once they arrived, they usually let staff know the resident is back at the facility. He stated transportation driver R told him he helped her in bed and then went to get help to reposition her into the bed by asking a facility staff member. He stated transportation driver R was prn but was a really good worker and he had no issues regarding him. There was no fall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675650 If continuation sheet Page 14 of 23 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 675650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 12/24/23 at 2:29 p.m. attempted to call transportation driver R with no answer. Level of Harm - Immediate jeopardy to resident health or safety In an interview with CNA E on 12/14/23 at 2:40 p.m. revealed she was working that day Resident #1 came back from dialysis on 11/24/23, but she was working the opposite side of Resident #1. The transportation Driver R called CNA E to come help him transfer her back to the bed and to let RN K know Resident #1 was back at the facility from dialysis. CNA E then revealed she usually worked nights but was helping the dayshift that day. She stated Resident #1 was in her wheelchair when CNA E walked in the room to help transfer her back to the bed with transportation driver R. She stated she was on one side and transportation driver R was on the other and they got Resident #1 out of the wheelchair and pivoted toward the bed. The resident never fell. Residents Affected - Few In an interview with dialysis nurse on 12/15/23 at 12:23PM revealed she was the nurse taking care of Resident #1 on 11/27/23. Resident #1 was having a hard time breathing, her oxygen was low and she was having pain in her rib cage. That was when Resident #1 revealed to the dialysis nurse that someone dropped her from the facility. Resident #1 then stated she wanted to go to the hospital and EMS was called on 11/27/23. The dialysis nurse stated Resident #1 comes to dialysis every Monday, Wednesday and Friday. She revealed the facility called and stated the resident fell at dialysis and the dialysis nurse stated no, Resident #1 told me she fell at the facility. In an interview with Admin on 12/15/ at 3:22 revealed this was a IJ because protocol was not followed and potential to resident harm. She stated staff training and ongoing training will occur with asking residents if they have any accidents of abuse or neglect that has not been reported or need to be reported. She then revealed she would be asking nursing staff questions about incidents as rounds are conducted. The Admin then stated 10 residents a day for 60 days will have assessments and may be extended if any issues occur. Record review of the facility's fall management policy, dated 12/04/23, revealed, .To promote patient safety and reduce patient falls by proactively, identifying, care planning, and monitoring patients fall indicators .The facility will assess the resident upon admission/readmission, quarterly with change in condition, and with fall event for any fall risk ad will identify appropriate interventions to minimize the risk of injury to falls . On 12/14/23 at 4:40 p.m. the Admin was informed of an Immediate Jeopardy existed and a copy of the IJ template was provided. The following Plan of Removal was accepted on 12/15/23 at 11:39 a.m. Plan of Remediation: [Facility Name] Re: IJ 12/14/2023

F 689 Accidents/Hazards Failure: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675650 If continuation sheet Page 15 of 23 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 675650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety The facility failure resulted in a delay in resident receiving timely x-rays and treatment, which could lead to serious harm/impairment/death. Corrective Action for those found to have been affected by the deficient practice: Identified Resident remains in the facility with no adverse residual effects. Residents Affected - Few The Identified Licensed Nurse will be suspended (possibly terminated with HR approval) and Nurse License will be reported to the Board of Nursing. Resident Head to toe competencies will be completed by all licensed nurses by end of day 12/15/2023. The following in-services will be completed by 12/15/2023, by the following Administrative Nursing Staff to include, MDS, [MDS Coordinator], Infection Prevention/Staff Development Coordinator, [Infection Preventionist/Staff Development Coordinator], Senior Regional Director of Clinical Services, [Senior Regional Director of Clinical Services]. Head to toe assessments-How and When to complete the assessments Significant Change in status-When a resident has a change who to report to Incidents and Accidents and how to report and complete Reporting to the Physician-Reporting any significant changes or incident that occurs with a resident and in a timely manner. Reporting to the Administrative Staff-Any significant changes or incident that has been reported, observed or noted. Abuse and Neglect-Who to report to, types of Abuse, prevention strategies Fall Management-Interventions to put in place and what to do when a fall occur Identification of other residents having the potential to be affected: Fall assessments were completed on 12/14/2023 by Sr. Regional Director of Clinical Services, MDS Coordinator RN, and Infection Preventionist/Staff Development Coordinator, to determine which residents would be potentially affected. Residents who are identified to be at risk for falls will be care planned appropriately by Sr. Regional Director of Clinical Services, MDS Coordinator RN, and Infection Preventionist/Staff Development Coordinator. Current and past falls for the last 30 days reviewed for compliance to ensure that regulatory guidelines have been met. These were reviewed, by [Senior Regional Director of Clinical Services], for the last 30 days to ensure that regulatory guidelines have been met. Measures/Systemic Changes to ensure the deficient practice does not recur: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675650 If continuation sheet Page 16 of 23 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 675650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Competency Assessments for completing and documenting head to toe will be completed by all licensed nursing staff prior to them working their next shift. They will not be allowed to work until these are completed. These Competencies will be conducted by Admin Nursing Staff to include, MDS, [MDS Coordinator], Infection Prevention/Staff Development Coordinator, [Infection Preventionist/Staff Development Coordinator], Senior Regional Director of Clinical Services, [Senior Regional Director of Clinical Services]. These will be completed by end of day 12/15/2023. Residents Affected - Few In-services and education for all licensed nursing staff will be completed by 12/15/2023 by Admin Nursing Staff to include, MDS, [MDS Coordinator], Infection Prevention/Staff Development Coordinator, [Infection Prevention/Staff Development Coordinator], Senior Regional Director of Clinical Services, [Senior Regional Director of Clinical Services]. In-service topics will include the following: Head to toe assessments-How and When to complete the assessments Significant Change in status-When a resident has a change who to report to Incidents and Accidents and how to report and complete Reporting to the Physician-Reporting any significant changes or incident that occurs with a resident and in a timely manner. Reporting to the Administrative Staff-Any significant changes or incident that has been reported, observed or noted. Abuse and Neglect-Who to report to, types of Abuse, prevention strategies Fall Management-Interventions to put in place and what to do when a fall occurs. Ongoing Monitoring: Interviews with staff and residents will be completed during morning grand rounds and throughout the day to identify if they have had any injuries or falls that have not been reported. This will continue weekly for 60 days. Administrative staff will make facility rounds daily, until compliance is achieved. All components of this plan of correction will be submitted to the facility QAPI committee meeting and additional recommendations will be made until substantial compliance has been achieved. The Medical Director was notified and agrees with the plan of correction. The Admin Nursing Staff to include, MDS, [MDS Coordinator], Infection Prevention/Staff Development Coordinator [Infection Prevention/Staff Development Coordinator], Senior Regional Director of Clinical Services, [Senior Regional Director of Clinical Services], DON, [DON], Executive Director, [Administrator], are responsible for the corrections and continued monitoring. Completion date: By 5pm 12/15/2023 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675650 If continuation sheet Page 17 of 23 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 675650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few - Review of in-services dated 12/15/23 were completed and interviews with staff confirmed by verbalizing expectations. - Interviews on 12/15/2023 between 8:00am and 1:00PM with multiple staff on various shifts revealed confirmatory knowledge of in-services dated 11/15/2023 Observation on 12/15/23 at 9:20am Revealed Resident #1 sitting at the dining table in her wheelchair ready to go to dialysis. Observation on 12/15/23 at 9:41am revealed CNA G and CNA H using the Hoyer lift to transfer a resident with the wheelchair at the head of the bed. No problems or concerns with transfer 2-person transfer. During interviews on from 8:00 a.m. to 1:00 p.m. with facility staff revealed they had been trained on head-to-toe assessments, significant change in status, incidents and accidents, reporting to the physician, reporting to the administration staff, abuse and neglect, fall management and suspected injury or witness fall. All staff interviewed were able to verbalize the new training instructions back. The staff interviewed consisted of the following: LVN D, LVN E, LVN F, CNA G, and CNA H. While the IJ was removed on 12/15/23 the facility remained out of compliance at a severity of actual harm and scope of isolated due to the need for the facility to monitor it corrective action for effectiveness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675650 If continuation sheet Page 18 of 23 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 675650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 4 medication carts (Southeast nurse's cart) and 2 (Residents #2 and #7) of 8 residents reviewed for pharmacy services. 1. The facility did not ensure RN K, counted the home narcotic drugs (narcotics that were brought in from the family) every shift change. On 11/30/2023 charge nurse A and RN B counted their meds at the beginning of shift change and there was a discrepancy of 10 tablets. 2. The facility failed to ensure RN M administered the correct medication dosage to Resident #7. These failures could result in an inaccurate narcotic medication count, drug diversion, and decreased therapeutic effects from medications. Findings included: Review of the facility's Provider Investigation Report, dated 12/06/23, revealed on 11/30/23, a discrepancy was revealed during shift change, with 10 tablets of Hydromorphone 4 mg missing for Resident #2. The police were contacted. During a record review of the narcotics log, the bottle of Hydromorphone 4mg for Resident #2 on 11/28/23 was signed off as 120 tablets and on 11/30/23 during the morning count revealed 105 tablets, the narcotic sheet was 115 tablet, which revealed 10 missing tablets . RN K counted the tablets at 120 on 11/28/23. RN A and LVN B counted the tablets at 105 on 11/30/23. During an interview with the Admin on 12/14/2023 at 10:30am revealed the two nurses listed on the self-report regarding the missing narcotics were RN A and LVN B. The Admin stated they were the nurses that caught the medication error from the day before 11/30/2023. After further review of the narcotics book it was determined that RN K did not follow protocol for receiving home narcotics. The protocol was for a nurse, along with another nurse, to count the medications together and not go by what was on the bottle to ensure accuracy. During an observation on 12/15/2023 at 11:00am during medication pass with LVN C (Southeast Nurse's Cart) revealed after she verified the resident (Resident #3) she was giving medication to (Cefuroxime 500mg tablet, Dexamethasone 2mg tablet, Escitalopram Oxal 10mg Tablet, Mucinex 400mg, BP HIGH 116/70 Metoprolol Succ ER 100mg, and Nifedipine OC 30mg), LVN C pulled out the narcotics book. After she popped out the pill she signed it out in the book underneath the resident's name. She stated that was done to keep an accurate count of the narcotics. She stated that in the morning when she came to work she counted the medication with the receiving nurse. Observation of the narcotic book revealed what she counted was accurate with the amount she received. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675650 If continuation sheet Page 19 of 23 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 675650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/14/2023 at 11:25am with RN I revealed if a family member brought in medication for a resident, before receiving it, MDS Nurse L stated she would bring in another nurse in front of the family, count the medications 1 by 1, and sign off on it as well as the family member to ensure that all the counts are the same. RN I stated they were always supposed count medications brought in by the family and never take the word of what was on the bottle. She stated this failure could potentially cause a drug diversion. During a phone interview with RN K on 12/15/2023 at 9:20 am, revealed she was not aware that the medication had to be counted in front of another nurse as well as the family member. She stated when she looked at the bottle she just assumed that the count on the label was accurate and that it was a new prescription. RN K stated that if she would have known that it was to be counted and in front of another nurse and a family member she would have made sure it was done. She stated going forward she knows now because this could have been avoided. She stated this failure could potentially cause a drug diversion and it made it look bad because now they did not have an accurate count. Review of the facility's policy, Management of Controlled Substances, dated 08/29/23, revealed, .the facility will ensure that the incoming qualified individual and outgoing qualified individual count all controlled substances and other medications with a risk of abuse or diversion at the change of each shift and whenever control of the controlled substances changes from one qualified individual to another . 2. Review of Resident #7's face sheet, dated 12/14/2023, revealed that the resident was a 69- year-old female admitted into the facility on [DATE]. admission diagnosis included spinal stenosis (A condition where spinal column narrows and compresses the spinal cord), essential hypertension, lower back pain, and edema. Record Review of facility's Provider Investigation Report, dated, 12/04/23, revealed, .o Date/Time you first learned of incident: 11/27/2023 o Date/Time the incident occurred: 11/26/2023 o Brief narrative summary of the reportable incident: two Norco 10-325mg were punched by the nurse into the medication cup. The [family member] was at the resident's bedside. The nurse turned towards the resident to take the blood pressure, when she turned back around to give the medications, 1 narcotic was missing from the medication cup . During an interview on 12/14/23 at 10:30 a.m. with RN M, stated she set the medication down on the bedside table to get the resident settled in bed because she was sitting far down in the bed. The family member picked up the cover of the tray and blocked the view of the breakfast tray. She intervened by telling her to stop and she then noticed the pill was missing. At some point of time, she admitted that she lost sight of the medication due to the family member covering the medication with the cover of the breakfast tray. She then said the family member moved. RN R demonstrated what happened in the room on 11/26/2023. She stated that she was sure that there were two Narcotics in the pill cup. She stated that she did not 100% have her eye on the medication but as a nurse she was aware of her surroundings. RN M stated that the risk of having Norco unattended was the potential to be taken away by someone. All it would take is a second. Phone interview at 12:29pm on 12/14/2023 with Resident #7's family member revealed that she was in the room and the nurse, RN M, was bringing Resident #7 the medication. The nurse was checking Resident #7's blood pressure and stated that the nurse set the medication down and then turned around and said that a pill was missing. Resident #7's family member asked the RN M if she took the medication . She stated the nurse stated that her cart was short of the medication (Norco 10-325 mg). She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675650 If continuation sheet Page 20 of 23 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 675650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated that the nurse stated that she knows that she pulled it. The family member stated that the nurse only gave Resident #7 the 1 pill instead of both. Resident #7's family member stated that the pain medication was missing, and the nurse made a mistake. At that time, she stated that she came daily to visit Resident #7 and she stated that it has never been a problem. Resident #7's family member stated that there had not been any other issues in regard to her Resident #7's care. She stated that even when Resident #7 took her own medication she took it outside. She stated that there as normally a lot of pills in the cup BP, WATER, POTASSIUM, PAIN MEDS so she did not pay attention to the cup actually. Review of Resident #7's MAR for December 2023 revealed it was documented by RN M that both pills of the Norco 10-325 mg) were given instead of just one. During an interview with the Administrator on 12/14/2023 at 10:00 a.m. the Admin said that the incident happened on 11/26/23 but was not reported to the Admin until 11/27/23. The admin reported to HHSC within 2 hrs of being made aware of the incident. The Admin stated the nurse failed to report it to her within the two hour limit that the facility required. During record review of policy Medication brought to facility by the resident/family/physician/prescriber dated 01/01/2022 revealed, . 1.3. In States where the facility must use medications brought into the facility by a resident, a resident's Responsible Party, or a resident's Physician/Prescriber, facility staff should 1.3.1 Acquire an order to use the medications from the Physician/Prescriber . 1.3.2 Verify the medication and strength in the container with a pharmacist, on-line pill identifier, or by using the drug information tab on Omnicare Omniview .1.3.3 Verify the directions on the label with current orders . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675650 If continuation sheet Page 21 of 23 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 675650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one (Resident #7) of 8 residents reviewed for medication storage. The facility failed to ensure medications were monitored during medication pass, leaving medications exposed on the medication cart when RN M turned away. This failure could place all residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and drug diversion. Findings included: Review of Resident #7's face sheet, dated 12/14/2023, revealed that the resident was a 69- year-old female admitted into the facility on [DATE]. admission diagnosis included spinal stenosis (A condition where spinal column narrows and compresses the spinal cord), essential hypertension, lower back pain, and edema. Review of the facility's Provider Investigation Report, dated 12/04/23, revealed on 11/26/23, the nurse (RN M) removed two pills of Norco 10-325 mg to administer to the resident (Resident #7), placed the pill in a medication down, turned away to take the resident's blood pressure, and found that one pill was missing. The police were contacted. During an interview on 12/14/23 at 10:30 a.m. with RN M, stated she set the medication down on the bedside table to get the resident settled in bed because she was sitting far down in the bed. The family member picked up the cover of the tray and blocked the view of the breakfast tray. She intervened by telling her to stop and she then noticed the pill was missing. At some point of time, she admitted that she lost sight of the medication due to the family member covering the medication with the cover of the breakfast tray. She then said the family member moved. RN R demonstrated what happened in the room on 11/26/2023. She stated that she was sure that there were two Narcotics in the pill cup. She stated that she did not 100% have her eye on the medication but as a nurse she was aware of her surroundings. RN M stated that the risk of having Norco unattended was the potential to be taken away by someone. All it would take is a second. During an interview on 12/14/23 at 11:25 a.m. with RN I - Stated she does not take her eyes off the medication, no matter what the circumstances were even if it were regular medications, especially if someone else is in the room. Phone interview at 12:29pm on 12/14/2023 with Resident #7's family member revealed that she was in the room and the nurse, RN M, was bringing Resident #7 the medication. The nurse was checking Resident #7's blood pressure and stated that the nurse set the medication down and then turned around and said that a pill was missing. Resident #7's family member asked the RN M if she took the medication . She stated the nurse stated that her cart was short of the medication (Norco 10-325 mg). She stated that the nurse stated that she knows that she pulled it. The family member stated that the nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675650 If continuation sheet Page 22 of 23 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 675650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132 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 only gave Resident #7 the 1 pill instead of both. Resident #7's family member stated that the pain medication was missing, and the nurse made a mistake. At that time, she stated that she came daily to visit Resident #7 and she stated that it has never been a problem. Resident #7's family member stated that there had not been any other issues in regard to her Resident #7's care. She stated that even when Resident #7 took her own medication she took it outside. She stated that there as normally a lot of pills in the cup BP, WATER, POTASSIUM, PAIN MEDS so she did not pay attention to the cup actually. During an interview with the Administrator on 12/14/2023 at 10:00 a.m. the Admin said that the incident happened on 11/26/23 but was not reported to the Admin until 11/27/23. The admin reported to HHSC within 2 hrs of being made aware of the incident. The Admin stated the nurse failed to report it to her within the two hour limit that the facility required. Review of facility's Drug Diversion Prevention Program, training, undated revealed, .Nurses have a professional responsibility to store, administer, and dispose of controlled substances appropriately, guarding against abuse while ensuring that residents have medication available when needed FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675650 If continuation sheet Page 23 of 23