Health inspection·August 31, 2023

F 0693 when the bag was placed in his room. The resident refused to answer any further questions. Level of Harm - Minimal harm or potential for actual harm Interview on 09/29/23 at 4:23 PM with LVN A, an agency nurse, revealed she was the nurse for Resident #65. LVN A stated she had not been to Resident #65's room today (08/29/23). LVN A stated Resident #65's feeding started at 6:00 PM and ended at 6:00 AM. LVN A stated formula bags should be dated with the time, date and the nurse's initials. LVN A stated she was unaware Resident #65 had a formula bag in his room, she stated she worked the previous night, and she was the one who provided Resident #65 with his feeding. LVN A was informed the formula bag had no time, date and initials. She stated she placed it on a sticker. LVN A stated the bag should had been removed this morning. LVN A was asked if she could show where she placed the sticker, LVN A stated, If you did not see a label or sticker, it might not have it. LVN A stated formula bags needed to have a time and date, so other nurses knew when it needed to be thrown out. Residents Affected - Few Observation and interview on 08/29/23 at 4:30 PM with the ADON in Resident #65's room revealed the ADON observed the formula bag. The ADON stated formula bag did not have a time, date, and nurse initials. There was no observation of a sticker on the tubing. The ADON stated the formula bag should be labeled with the time and date. The ADON stated LVN A was the one, who hung it up last time (08/28/23), and it should have been discarded when the feeding was turned off. The ADON stated she would be removing the formula bag. She stated it was important to label the formula bag, so that staff knew when it needed to be discarded. 2. Record review of Resident #37's face sheet dated 08/31/23 revealed the resident was [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with a diagnoses that included dementia without behavioral disturbance, adult failure to thrive, and gastrostomy status. Record review of Resident #37's quarterly MDS dated [DATE] revealed the resident had moderate cognitive impairment with a BIMS score of 11. The assessment reflected Resident #37 required extensive assistance with eating, one-person physical assist, and the resident received nutrition via a feeding tube. Record review of Resident #37's care plan revised dated 07/29/23 revealed: Resident requires tube feeding r/t dysphagia. Resident also receives diet for pleasure feedings, regular dysphagia puree level 1. Goal: Will maintain adequate nutritional and hydration status aeb weight stable, no s/sx of malnutrition or dehydration through review date. Will remain free of side effects or complications related to tube feeding through review date. Interventions: The resident is able to tolerate tube feeding: Formula: Jevity 1.5 Rate: 65cc/hour x 20 hours down time of 4 hours (9am - 1pm). The resident is depended on staff for tube feeding and water flushes. Record review of Resident #37's physician order dated 06/12/23 revealed pump give Jevity 1.5 at 65 cc/hr per g-tube for 20 hours every shift. The orders reflected the g-tube feeding down time was from 9:00 AM-1:00 PM. The order start date was 06/12/23. Record review of Resident #37's physician order dated 06/12/23 revealed an order for the nutrition stop feeding one time a day at 9:00 AM. The order reflected a nurtition start feeding in the afternoon 1:00 PM. Record review on 08/30/23 at 1:15 PM of Resident #37's August 2023 MAR revealed Resident #37 had been connected at 1:00 PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675759 If continuation sheet Page 2 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675759 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonegate Nursing and Rehabilitation 4201 Stonegate Blvd Fort Worth, TX 76109 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 08/30/23 at 2:00 PM of Resident #37 to be in her wheelchair. Resident #37 was not connected to her g-tube. An attempt was made to interview Resident #37; however Resident #37 would not respond to questions. Observation on 08/30/23 at 2:37 PM of Resident #37 to be in her wheelchair. Resident #37 was not connected to her g-tube. Observation on 08/30/23 at 2:42 PM revealed LVN B entering Resident #37 room and was observed to hang Resident #37 formula bottle, dated 8/30 at 3:00 PM. Observed Resident #37 to be in her wheelchair, and LVN C was observed to check Resident #37 g-tube placement, aspirated and flushed g-tube with 30 cc of water. LVN C then proceed to connect Resident #37 to her g-tube feeding. Interview on 08/30/23 at 2:52 PM with LVN B revealed she was the nurse for Resident #37. LVN B reviewed Resident #37's physician orders and stated Resident #37 had an order to connect resident at 1:00 PM. LVN B stated when she started her shift today (08/30/23) she was informed Resident #37 was not connected and was informed something about her breakfast. During the interview with LVN B, the ADON intervened by stating Resident #37 could eat by mouth as well; however, the resident refused to eat breakfast. The ADON stated they did not disconnect Resident #37 until 11:00 AM. The ADON stated she notified the physician, and the physician agreed to connect Resident #37 at 3:00 PM. The ADON stated she had documented the conversation. When LVN B was asked if she had documented in the Resident #37 MAR prior to providing Resident #37's formula feeding, the ADON intervened by stating it was a mistake by LVN B. Record review of Resident #37's Progress notes dated 08/30/23 at 14:54 [2:54 PM] by ADON revealed: Resident did not feel like eating any of her breakfast so instead of taking her feeding down at 9am to 1pm. The feeding will be taken down from 11am to 3pm today. Dr is aware. Follow-up interview on 08/30/23 at 3:26 PM with LVN B revealed she started her shift at 12:30 PM. LVN B stated the ADON was the nurse for Resident #37 this morning (08/30/23). LVN B stated the ADON had told her that she had done everything, so she assumed Resident #37 was already connected to her feeding. LVN B stated she documented on Resident #37's MAR that the feeding was already provided; however, later the ADON informed her she had not connected Resident #37 yet. LVN B stated the ADON informed her that Resident #37 did not have breakfast this morning (08/30/23), and they did not disconnect Resident #37 until 11:00 AM and would need to be connected at 3:00 PM. LVN B stated the ADON informed her Resident #37 ate 100% of her lunch. LVN B stated the ADON was the one, who contacted the doctor. She stated she was not sure of the time. LVN B stated prior to documenting she should have ensured Resident #37 was connected. LVN B stated it was not the proper thing to do. LVN B stated the risk of not following physician orders was that it could cause digestive problems. Interview via phone call on 08/30/23 at 3:46 PM with Resident #37's Physician revealed she received a text from the facility regarding Resident #37. The Physician stated the text informed her Resident #37 was disconnected at 11:00 AM because she was tired, and she had eaten all her lunch. The Physician stated she agreed to start the feeding at 3:00 PM and signed the order. When asked at what time she received the text message the Physician stated, for some reason it does not show the time. The Physician then stated she might have received a call stating resident was tired. Record review of Resident #37's physician order date 08/30/23 revealed Enteral Feed Order one time only for Enteral Feeding until 08/30/2023 23:59 [11:59 PM] May Stop the enteral feeding at 11:00 a.m. Start Date 08/30/2023 1907 [7:07PM]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675759 If continuation sheet Page 3 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675759 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonegate Nursing and Rehabilitation 4201 Stonegate Blvd Fort Worth, TX 76109 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #37's physician order date 08/30/23 revealed Enteral Feed Order one time only for Enteral Feeding until 08/30/2023 23:59 [11:59 PM] May re-start the enteral feeding at 3:00 p.m. Start Date 08/30/2023 1907 [7:11PM]. Interview on 08/31/23 at 3:23 PM with the ADON revealed Resident #37 was not disconnected from her g-tube feeding until 11:00 AM due to refusing to eat breakfast on 08/30/23. She stated Resident ate 100% of her lunch and she notified the doctor in which the doctor agreed to connect Resident #37 until 3:00 PM. She stated she called the Physician at around 9:00 AM. The ADON stated LVN B documented by mistake on Resident #37's MAR, because it was rare that situations like this happened. The ADON stated it was the responsibility of the nurses, herself, and the DON to update resident's physician orders. She stated it was the responsibility of herself and the DON to monitor the documentation that was being recorded by staff. She stated the risk of not following physician orders was that it could cause a change in condition. Interview on 08/31/23 at 3:41 PM with the DON revealed her expectation was for her staff to follow physician orders. If there were any modifications, they must notify the physician. She stated she was made aware of Resident #37 refusing her breakfast; however, the resident ate all her lunch. She stated at times Resident #37 did eat and at times she did not. She stated her expectations were for the times Resident #37 refused to eat staff should continue the feedings and notify the physician. The DON was notified Resident #37's MAR indicated Resident #37 was provided with her feeding at 1:00 PM; however, the resident was not connected until 3:00 PM. The DON stated the best practice was for staff to follow physician orders and then document after the procedure was completed. The DON stated each formula bag should be labeled with the time, date and nurses initials. She stated the formula was good for 24 hours. The DON stated the risk of not following physician order would depend on the situation. Record review of the facility policy on medication orders, revised November 2014, reflected: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. Recording Orders: .4. Enteral Orders - When recording orders for enteral tube feedings, specify the type of feeding, amount, frequency of feeding and rationale if prn. The order should always specify the amount of flush following the feeding. Example: Isocal 250cc followed by H20 50 cc every 4hours via NG tube . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675759 If continuation sheet Page 4 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675759 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonegate Nursing and Rehabilitation 4201 Stonegate Blvd Fort Worth, TX 76109 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 ensure residents who need respiratory care were provided such care, consistent with professional standards of practice for 1 (Resident #37) of 7 resident reviewed for respiratory care. Residents Affected - Few The facility failed to follow the physician orders for Resident #37's oxygen. This failure placed residents who received oxygen therapy at risk of respiratory complications. Findings included: Record feview of Resident #37's face sheet dated 08/31/23, revealed the resident was [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with a diagnoses that included dementia without behavioral disturbance, adult failure to thrive, and gastrostomy status. Record review of Resident #37's quarterly MDS dated [DATE] revealed the resident had moderate cognitive impairement with a BIMS score of 11. It also revealed the resident required extensive assist with 2 to 3 staff assistance for ADL care. The MDS did not reflect the resident was on oxygen therapy. Record review of Resident #37's care plan dated 06/06/23 revealed the resident requires the use of Oxygen Therapy. Goal: Will have no s/sx of poor oxygen absorption through the review date. Interventions: Oxygen Settings: O2 via nasal cannula @ 2L continuously. Record review of Resident #37's physician order date 05/12/23 revealed an order for the resident to receive oxygen via nasal canula at 2 liters per minute continuously every shift with a start date 05/12/23. Record review of Resident #37's August 2023 MAR revealed Resident #37 was provided with her oxygen for the hours of Day, Eve, Night on 08/30/23. Record review of Resident #37's oxygen saturation levels revealed no concerns. Observation on 08/30/23 at 8:50 AM revealed Resident #37 lying in bed asleep. Resident #37 did not have her oxygen on. Observation on 08/30/23 at 2:00 PM revealed Resident #37 was in her wheelchair. Resident #37 did not have her oxygen on. An attempt was made to interview Resident #37; however, Resident #37 would not respond to questions. Record review of Resident #37's August 2023 MAR revealed Resident #37 was provided with her oxygen for the hours of Day on 08/31/23. Observation on 08/31/23 at 10:48 AM revealed Resident #37 lying in bed. Resident #37 did not have her oxygen on. Interview on 08/31/23 at 10:55 AM with LVN C revealed she was the nurse for Resident #37. LVN C stated Resident #37 received oxygen during the night. LVN C stated Resident #37's O2 stats during the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675759 If continuation sheet Page 5 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675759 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonegate Nursing and Rehabilitation 4201 Stonegate Blvd Fort Worth, TX 76109 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few day had been stable, in which Resident #37 did not need her oxygen. LVN C was asked if she had obtained new physician orders for Resident #37, since Resident #37 had an order for oxygen to be administered continuously. LVN C stated she had spoken to the physician at the end of last week about changing Resident #37's orders, and the physician agreed. LVN C stated she did not receive the orders and had not documented her conversation with the Physician. LVN C was asked regarding her documentation on the Resident #37's MAR, LVN C stated she made a mistake by documenting that Resident #37 was provided with her oxygen. Record review of Resident #37's progress notes dated 08/31/23 at 12:14 PM documented by LVN C reflected: Resident's SpO2 stable on RA. O2 sat ranging 98-100% on RA, MD notified. Order clarification for O2 to change from continuous to PRN noted. Will continue to check O2 sat routinely Q shift. Interview on 08/31/23 at 03:23 PM with the ADON revealed Resident #37's oxygen orders had not changed. The ADON stated LVN C was under the impression they wanted Resident #37 to be winged off her oxygen use. The ADON stated Resident #37 orders should have been PRN. The ADON stated LVN C made an error on Resident #37's MAR documentation. The ADON was informed Resident #37 MAR also indicated resident was provided with oxygen on 08/30/23, the ADON stated she was unaware. The ADON stated it was the responsibility of the nurses, herself, and the DON to update resident's physician orders. She stated it was the responsibility of herself and the DON to monitor the documentation that was being recorded by staff. She stated the risk of not following physician orders was that it could cause a change in condition. Interview on 08/31/23 at 3:41 PM with the DON revealed her expectation was for her staff to follow physician orders. If there were any modifications, they must notify the physician. The DON stated the best practice would be staff to follow physician orders and then document after the procedure was completed. The DON stated the risk of not following physician order would depend on the situation. A policy for oxygen administration was requested; however, it was not provided prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675759 If continuation sheet Page 6 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675759 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonegate Nursing and Rehabilitation 4201 Stonegate Blvd Fort Worth, TX 76109 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 all drugs and biologicals were stored securely for 2 (Resident #30 and Resident #73) of 18 residents observed for medication storage. 1. Resident #30 had 1 bottle of Tums pills stored at the resident's bedside table not locked in a lock box or secured in the medication cart or medication room. 2. Resident #73 had unidentified cream at her bedside table and unidentified pills in a plastic cup on her bed not locked in a lock box or secured in the mediation cart or mediation room. This failure could place residents at risk of overmedication or adverse drug reactions. Findings included: 1. Record review of Resident #30's Face Sheet, dated 08/31/23, revealed the resident was a [AGE] year-old female who was admitted on [DATE], readmitted on [DATE]. Resident #30 had diagnoses that included hyperlipidemia (cholesterol and fats in blood), atherosclerotic heart disease of native coronary artery (build-up of fats, cholesterol, and other fats), hypertension (high blood pressure), and muscle weakness. Review of Resident #30's MDS dated [DATE] revealed the resident's cognitive was intact with a BIMS score of 14. Review of Resident #30's care plan, dated 03/21/23, revealed the resident had altered cardiovascular status related to hyperlipidemia. The care plan reflected: Goal: Will be free from signs and symptoms of complications of cardiac problems through the review date. Intervention: Observe/document/report to MD PRN any signs and symptoms of Coronary Artery Disease: chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating, dependent edema, changes in cap refill, color/warmth of extremities. Record review of Resident #30's order summary report dated 08/31/23 did not reveal physician's order for Tums (over-the-counter medication used to treat symptoms caused by too much stomach acid such as heartburn, upset stomach, or indigestion). Observation on interview on 08/29/23 at 11:23 AM revealed Resident #30 with a bottle of Tums on the nightstand table. According to Resident #30, her family member brought them in for her to use when she had an upset stomach or heartburn. Resident #30 stated she just had them there in case she needed them; she was not able to say when she last used them. 2. Record review of Resident #73's face Sheet, dated 08/31/23, revealed the resident was a [AGE] year-old female who was admitted on [DATE]. Resident #73 had diagnoses that included: cellulitis of the right and left lower limb (A serious bacterial infection of the skin. Usually affects the leg and the skin appears as swollen, red, and painful), psoriasis (a chronic skin condition), urticaria (skin rash), sepsis, and candidiasis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675759 If continuation sheet Page 7 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675759 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonegate Nursing and Rehabilitation 4201 Stonegate Blvd Fort Worth, TX 76109 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #73's MDS dated [DATE] revealed the resident's cognitiion was intact with a BIMS score of 15. Review of Resident #73's care plan, dated 03/21/23, revealed the resident had limited physical mobility related to compression fracture of thoracic vertebrae and cellulitis of lower extremities. The care plan reflected: Goal: Will remain free of complications related to immobility, including skin-breakdown. Intervention: Observe/document/report to physician as needed signs and symptoms of immobility: skin-breakdown. Record review of Resident #73's order summary report dated 08/31/23 revealed she had an order for: - Acidophilus Probiotic Oral Tablet (Lactobacillus) Give1 capsule by mouth one time a day for supplement; - Magnesium Oxide Oral Tablet 400 MG (Magnesium Oxide) Give 1 tablet by mouth one time a day for supplement-Multivitamin-Minerals Oral Tablet (Multiple Vitamins w/ Minerals) Give 1 tablet by mouth one time a day for wound healing; and - Ammonium Lactate External Cream 12 % (Lactic Acid (Ammonium Lactate)) Apply to bilateral lower extremity topically every day shift for dry skin. Interview with LVN D on 08/29/23 at 12:22 PM, who was the charge nurse for Hall 100, revealed the facility did not have residents who self-administered medications. She stated residents were not allowed to have medications in their rooms, and residents' families were educated not to leave over-the-counter medications with the residents. LVN D was observed going to Resident #30's room, and she asked the resident about the Tums located on nightstand. LVN D was observed removing the Tums from the nightstand. Observation and interview on 08/30/23 at 9:00 AM of Resident #73 revealed there was a medication cup of cream on her table in her room. She revealed she had been having this prescription medication in her room for a while. Resident #73 then pointed out at the bottom of both legs and ankles dry patches of skin. Resident #73 stated she compiled a collection of this leftover medication to save to apply the cream to her legs on her own. Resident #73 was observed with a small container of pills on her bed, when asked what they were, Resident #73 stated they were supplements that she puts in a cup to administer on her own daily. Resident #73 stated the prescription cream that she applied to her legs were given to her by staff after they administered cream to her legs. Resident #73 stated the pills in the cup were supplements she removed from bottles that her sister brought to her. During observation of the room, surveyor did not observe any bottles of supplements in the room. Interview with LVN D on 08/30/23 at 2:22 PM, LVN D stated she completed a room sweep and was able to observe unidentified pills in a covered cup on Resident #73's bed and a cup of cream later identified as a prescription cream that Resident# 73 gets applied to both legs. LVN D stated Resident #73 said she placed the pills in the cup herself and like to have them in the cup so that she could administer them. LVN D stated nursing staff are responsible for administering any type of medication whether it was pills, supplements, or prescription cream to residents and ensure there are no medications left in resident rooms. If resident are able to have medications in their rooms it puts them at risk of overmedicating, possible choking, or other residents could get ahold of them. LVN D stated she had not seen Resident #73 with any pills or cream in a cup when she entered the room prior to today. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675759 If continuation sheet Page 8 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675759 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonegate Nursing and Rehabilitation 4201 Stonegate Blvd Fort Worth, TX 76109 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 08/30/23 at 9:19 AM with the ADON revealed residents should not have any medications in the room with them. The ADON stated residents would have to pass an assessment which would indicate they are capable of administrating medications on their own and none of our residents are capable of passing the assessment. The ADON stated nursing staff are responsible for ensuring resident do not have any type of medications whether over the counter or prescribed in their rooms. The ADON stated Resident #30 should not have Tums in her room because it could be a risk of Tums interacting with her medications and we need to know what she was taking at all times. The ADON stated Resident #73 should not have any loose pills or prescription medication in her room. The ADON stated Resident #73 had a prescription for her legs that nursing staff administered but was not aware of any supplements that she would take on her own. The ADON stated if she did have supplements, nursing staff should be aware so the staff could administer them to her. The nursing staff were responsible for applying any topical prescription for residents. The ADON stated she asked nursing staff to complete a sweep to ensure residents did not have any over-the-counter medications. Interview on 08/31/23 at 3:49 PM with the DON revealed residents are not supposed to have medication of any kind in their rooms. The DON stated there were no residents who were able to self-administer medications on their own. The DON stated the ADON addressed this issue with her, and the facility did a room sweep to ensure residents were without any over-the-counter or prescription medications in their rooms. The DON stated it was the responsibility of the nursing staff to remove any pills, prescriptions, or over-the-counter medications from resident rooms. The DON stated residents having medications in their rooms put them at risk of double medicating, staff not knowing what they are taking, or other residents could get ahold of them. Review of the facility's current, undated Storage of Medications policy reflected: . The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675759 If continuation sheet Page 9 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675759 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonegate Nursing and Rehabilitation 4201 Stonegate Blvd Fort Worth, TX 76109 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the clinical record were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for 1 (Resident #37) of 18 residents records reviewed for treatment documentation. 1. LVN B documented Resident #37 had been connected to her g-tube feedings at 1PM but resident was not connected to her g-tube feedings until 3PM. 2. LVN C documented Resident #37 had been receiving oxygen therapy, but observation revealed resident was not receiving oxygen therapy. These failures could affect the residents medical record not being an accurate representation of the resident's medical condition or medical needs. Findings included: 1. Record review of Resident #37's face sheet dated 08/31/23, revealed the resident was [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with a diagnoses that including dementia without behavioral disturbance, adult failure to thrive, and gastrostomy status. Record review of Resident #37's quarterly MDS dated [DATE] revealed the resident had moderately impaired cognition with a BIMS score of 11. The assessment reflected Resident #37 required extensive assistance with eating, one-person physical assist, and the resident received nutrition via feeding tube. Record review of Resident #37's care plan revised dated 07/29/23 revealed: Resident requires tube feeding r/t dysphagia. Resident also receives diet for pleasure feedings, regular dysphagia puree level 1. Goal: Will maintain adequate nutritional and hydration status aeb weight stable, no s/sx of malnutrition or dehydration through review date. Will remain free of side effects or complications related to tube feeding through review date. Interventions: The resident is able to tolerate tube feeding: Formula: Jevity 1.5 Rate: 65c/hour x 20 hours down time of 4 hours (9am - 1pm). The resident is depended on staff for tube feeding and water flushes. Record review of Resident #37's physician order dated 06/12/23 revealed pump give Jevity 1.5 @65cc/hr per GT X 20 hours every shift for G-tube feeding Down time is from 9am-1pm. Start Date: 6/12/2023. Record review of Resident #37's physician order dated 06/12/23 revealed one time a day for nutrition stop feeding at 9:00 AM and in the afternoon for nutrition start feeding at 1:00 PM. Record review on 08/30/23 at 1:15PM of Resident #37's August 2023 MAR revealed Resident #37 had been connected at 1PM. Observation on 08/30/23 at 2:00 PM of Resident #37 to be in her wheelchair. Resident #37 was not connected to her g-tube. An attempt was made to interview Resident #37; however Resident #37 would not respond to questions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675759 If continuation sheet Page 10 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675759 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonegate Nursing and Rehabilitation 4201 Stonegate Blvd Fort Worth, TX 76109 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 08/30/23 at 2:37 PM of Resident #37 to be in her wheelchair. Resident #37 was not connected to her g-tube. Observation on 08/30/23 at 2:42 PM revealed LVN B entering Resident #37 room and was observed to hang Resident #37 formula bottle, dated 8/30 at 3:00 PM. Observed Resident #37 to be in her wheelchair and LVN C was observed to check Resident #37 g-tube placement, aspirated and flushed g-tube with 30 cc of water. LVN C then proceed to connect Resident #37 to her g-tube feeding. Interview on 08/30/23 at 2:52 PM with LVN B revealed she was the nurse for Resident #37. LVN B reviewed Resident #37 physician orders and stated Resident #37 had an order to connect resident at 1:00 PM. LVN B stated when she started her shift today (08/30/23) she was informed Resident #37 was not connected and was informed something about her breakfast. While interviewing LVN B, the ADON intervened by stating Resident #37 could eat by mouth as well; however, the resident refused to eat breakfast and they did not disconnect Resident #37 until 11:00 AM. The ADON stated she notified the physician, and the physician agreed to connect Resident #37 at 3:00 M. The ADON stated she had documented the conversation. When LVN B was asked if she had documented on Resident #37's MAR prior to providing Resident #37 formula feeding, the ADON intervened by stating it was a mistake from LVN B. Record review of Resident #37's Progress Notes dated 08/30/23 at 2:54 PM by the ADON reflected: Resident did not feel like eating any of her breakfast so instead of taking her feeding down at 9am to 1pm. The feeding will be taken down from 11am to 3pm today. Dr is aware. Follow-up interview on 08/30/23 at 3:26 PM with LVN B revealed she started her shift at 12:30 PM. LVN B stated the ADON was the nurse for Resident #37 this morning (08/30/23). LVN B stated the ADON had told her that she had done everything, so she assumed Resident #37 was already connected to her feeding. LVN B stated she documented on the Resident #37 MAR that the feeding was already provided; however, later the ADON informed her she had not connected Resident #37 yet. LVN B stated the ADON informed her that Resident #37 did not have breakfast this morning (8/30/23) and they did not disconnect Resident #37 until 11:00 AM and would need to be connected at 3:00 PM. LVN B stated the ADON informed her Resident #37 ate 100% of her lunch. LVN B stated the ADON was the one who contacted the doctor, she stated she was not sure of the time. LVN B stated prior to documenting she should had ensured Resident #37 was connected, she stated it was not the proper thing to do. Interview via phone call on 08/30/23 at 3:46 PM with Resident #37's Physician revealed she received a text from the facility regarding Resident #37. She stated the text informed her the resident was disconnected at 11:00 AM because she was tired, and she had eaten all her lunch. The Physician stated she agreed to start the feeding at 3:00 PM and signed the order. When asked at what time she received the text message the Physican stated, for some reason it does not show the time. The Doctor then stated he might have received a call stating resident was tired. Record review of Resident #37's physician order date 08/30/23 reflected: Enteral Feed Order one time only for Eternal Feeding until 08/30/2023 23:59 [11:59 PM] May Stop the eternal feeding at 11:00 a.m. Start Date 08/30/2023 1907 [7:07PM]. Record review of Resident #37's physician order date 08/30/23 revealed Enteral Feed Order one time only for Eternal Feeding until 08/30/2023 23:59 [11:59 PM] May re-start the eternal feeding at 3:00 p.m. Start Date 08/30/2023 1907 [7:11PM]. 2. Record review of Resident #37's quarterly MDS dated [DATE] revealed the resident had moderately (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675759 If continuation sheet Page 11 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675759 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonegate Nursing and Rehabilitation 4201 Stonegate Blvd Fort Worth, TX 76109 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few impaired cognition with a BIMS scored of 11. It also revealed resident required extensive assist with 2 to 3 staff assistance for ADL care. The MDS did not reflect the resident was on oxygen therapy. Record review of Resident #37's care plan dated 06/06/23 revealed the resident requires the use of Oxygen Therapy. Goal: Will have no s/sx of poor oxygen absorption through the review date. Interventions: Oxygen Settings: O2 via nasal cannula @ 2L continuously. Record review of Resident #37's physician order date 05/12/23 revealed an order for oxygen to be administered at 2 liters per minute via nasal canula continuously every shift, with a start date 05/12/23. Record review of Resident #37's August 2023 MAR revealed Resident #37 was provided with her oxygen for the hours of Day, Eve, Night on 08/30/23. Record review of Resident #37's oxygen saturation levels revealed no concerns. Observation on 08/30/23 at 8:50 AM revealed Resident #37 lying in bed asleep. Resident #37 did not have her oxygen on. Observation on 08/30/23 at 2:00 PM revealed Resident #37 was in her wheelchair. Resident #37 did not have her oxygen on. An attempt was made to interview Resident #37; however, Resident #37 would not respond to questions. Record review of Resident #37's MAR for August 2023 revealed Resident #37 was provided with her oxygen for the hours of Day on 08/31/23. Observation on 08/31/23 at 10:48 AM revealed Resident #37 lying in bed. Resident #37 did not have her oxygen on. Interview on 08/31/23 at 10:55 AM with LVN C revealed she was the nurse for Resident #37. LVN C stated Resident #37 receives oxygen during the night. LVN C stated Resident #37's O2 stats during the day had been stable, in which Resident #37 does not need her oxygen. LVN C was asked if she had obtained new physician orders for Resident #37, since Resident #37 had an order for oxygen continuously, LVN C stated she had spoken to the physician the end of last week about changing Resident #37's orders and the physician agreed. LVN C stated she did not receive the orders and had not documented her conversation with the physician. LVN C was asked regarding her documentation on the Resident #37's MAR, LVN C stated she made a mistake by documenting that Resident #37 was provided with her oxygen. Record review of Resident #37's progress notes dated 08/31/23 at 12:14 PM documented by LVN C reflected: Resident's SpO2 stable on RA. O2 sat ranging 98-100% on RA, MD notified. Order clarification for O2 to change from continuous to PRN noted. Will continue to check O2 sat routinely Q shift. Interview on 08/31/23 at 3:23 PM with the ADON revealed Resident #37 was not disconnected from her g-tube feeding until 11:00 AM due to refusing to eat breakfast on 08/30/23. She stated Resident ate 100% of her lunch and she notified the doctor in which the doctor agreed to connect Resident #37 until 3:00 PM. She stated she called the doctor at around 9AM. The ADON stated LVN B documented by mistake on Resident #37 MAR, because it rare when situations like this happen. Resident #37 oxygen orders had not changed. The ADON stated LVN C was under the impression that they wanted Resident #37 to be winged off her oxygen use. The ADON stated Resident #37 orders should had been PRN. The ADON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675759 If continuation sheet Page 12 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675759 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonegate Nursing and Rehabilitation 4201 Stonegate Blvd Fort Worth, TX 76109 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated LVN C made an error on Resident #37's MAR documentation. The ADON was informed Resident #37's MAR also indicated resident was provided with oxygen on 08/30/23, the ADON stated she was unaware. The ADON stated the responsiblity of the nurses, herself, and the DON to updated the resident's physician orders. She stated it was the responsibility of herself and the DON to monitor the documentation that was being recorded by staff. She stated the risk of not following physician orders was that it could cause a change in condition. Interview on 08/31/23 at 3:41 PM with the DON revealed her expectation was for her staff to follow physician orders. If there were any modifications, they must notify the physician. The DON stated best practice would be staff to follow physician orders and then document after the procedure was completed. Record review of the facility current Charting and Documentation policy revised July 2017 revealed the following: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care 3.Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675759 If continuation sheet Page 13 of 13