Health inspection·February 5, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some oxygen in the blood due to underlying lung diseases like chronic obstructive pulmonary disease. Resident #99 also has a diagnosis of chronic obstructive pulmonary disease, which is a group of lung diseases that cause ongoing inflammation and narrowing of the airways, leading to breathing difficulties. Record review of Resident #99's MDS assessment, dated 01/14/25, revealed the resident had a BIMS score of 12 indicating moderate cognitive impairment. Record review of Resident #99's Care Plan, dated 01/10/25, revealed: Focus: COPD Date Initiated: 01/16/2025. Revision on: 01/16/2025. Goal: of poor oxygen absorption through the review date. Date Initiated: 01/16/2025. Revision on: 01/21/2025. Target Date: 04/10/2025. Interventions/Tasks: o oxygen apparatus. Date Initiated: 01/16/2025. o Give medications as ordered by physician. Monitor/document side effects and effectiveness. Date Initiated: 01/16/2025. o Prevent abdomen compression and respiratory embarrassment by routinely checking the residents position so that he or she does not slide down in bed. Date Initiated: 01/16/2025. o Promote lung expansion and improve air exchange by positioning with proper body alignment (if tolerated, head of bed at 45 degrees). Date Initiated: 01/16/2025. Focus: Resident #99 has Shortness of Breath r/t ACUTE AND CHRONIC RESPIRATORY (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675817 If continuation sheet Page 2 of 24 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 675817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FT Worth Southwest Nursing Center 5300 Alta Mesa Blvd Fort Worth, TX 76133 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 0584 Level of Harm - Minimal harm or potential for actual harm FAILURE WITH HYPOXIA 01/16/25 Resident refusing to wear Bi-Pap at this time. States No, I can't do it, I don't want it on I can't breath. Explained to her she is getting oxygen through the mask. She pulled the mask off her face and said No, I can't do it. Educated her on the risk of not wearing her bipap and that she has critical CO2 level and it is important for her to comply with MD orders. Residents Affected - Some Date Initiated: 01/16/2025. Revision on: 01/16/2025 . Goal: Resident #99 will have no complications related to SOB though the review date. Date Initiated: 01/16/2025. Revision on: 01/21/2025. Target Date: 04/10/2025. Interventions/Tasks: o Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of anti-depressant drugs. Date Initiated: 01/23/2025. Revision on: 01/23/2025. o Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness. ANTIDEPRESSANT SIDE EFFECTS: dry mouth, dry eyes, constipation, urinary retention, suicidal ideations. Date Initiated: 01/23/2025. o Monitor/document/report to MD prn ongoing s/sx of depression unaltered by CNA Focus: The resident has a terminal prognosis r/t dmit Amatus Hospice: [PHONE NUMBER] dx CHRONIC RESPIRATORY FAILURE It is expected resident will have weight loss, skin breakdown, dehydration, fecal impaction, gradual or rapid loss of ability to move, use of narcotic to control pain and anxiety, anti-anxiety, and hypnotic medications r/t terminal prognosis. Date Initiated: 01/31/2025. Revision on: 01/31/2025. Goal: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675817 If continuation sheet Page 3 of 24 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 675817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FT Worth Southwest Nursing Center 5300 Alta Mesa Blvd Fort Worth, TX 76133 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 0584 The resident's comfort will be maintained through the review date. Level of Harm - Minimal harm or potential for actual harm Date Initiated: 01/31/2025. Revision on: 01/31/2025. Residents Affected - Some Target Date: 04/10/2025. Interventions/Tasks: o Adjust provision of ADLS to compensate for resident's changing abilities. Encourage particpation to the extent the resident wishes to participate. Date Initiated: 01/31/2025. o Consult with physician and Social Services to have Hospice care for resident in the facility. Date Initiated: 01/31/2025. o Delegation of duties meeting between Magnolia hospice and facility staff to determine appropriate plan of care specific for this resident. Date Initiated: 01/31/2025. LVN o Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. Date Initiated: 01/31/2025. o Refer for Psychiatric/Psychogeriatric consult if indicated Date Initiated: 01/31/2025. o Review resident's living will and ensure it is followed. Involve family in discussion. Date Initiated: 01/31/2025. o Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Date Initiated: 01/31/2025. o Work with nursing staff to provide maximum comfort for the resident. Date Initiated: 01/31/2025. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675817 If continuation sheet Page 4 of 24 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 675817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FT Worth Southwest Nursing Center 5300 Alta Mesa Blvd Fort Worth, TX 76133 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 0584 Focus: Level of Harm - Minimal harm or potential for actual harm The resident was on Antibiotic Therapy r/t infection (PNA ). Resident started on Levaquin 750 mg daily x 7 days. Residents Affected - Some Date Initiated: 02/03/2025. Revision on: 02/03/2025. Goal: o Resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. Date Initiated: 02/03/2025. Revision on: 02/03/2025. Target Date: 04/10/2025. Interventions/Tasks: o Administer medication as ordered Date Initiated: 02/03/2025. o Any antibiotic may cause diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions. Monitor q-shift for adverse reaction. Date Initiated: 02/03/2025. o Observe for possible side effects every shift Date Initiated: 02/03/2025. During an observation and interview on 02/03/25 at 11:21 AM with Resident #99 in her room revealed the resident was alert and laying on her bed. Resident #99 was observed with a nasal cannula and an oxygen concentrator was observed on the floor at bedside. Resident #99 reported that she was currently on Hospice and has COPD. She stated that she has been at the facility for about a month. Resident #99 was advised that the A/C vents above Resident#27's bed were dusty and uncleaned. Resident #99 was observed coughing throughout her interview. She stated that she did not remember when the last time staff cleaned the A/C vents above Resident #27's bed were cleaned. Resident #99 stated that she was unaware that both A/C vents were dirty and not cleaned. She stated that with her being on oxygen, dust and dander and dirt are not good for her health. She reported that would like somebody to come clean the A/C vents in her room to ensure good air quality. Resident #99's roommate was Resident #27. 3. Review of Resident #107's face sheet, dated 02/05/25, revealed Resident #107 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #107's diagnoses included bipolar disorder (a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675817 If continuation sheet Page 5 of 24 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 675817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FT Worth Southwest Nursing Center 5300 Alta Mesa Blvd Fort Worth, TX 76133 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). Record review of Resident #107's MDS assessment, dated 09/10/24, revealed the Resident #107 had a BIMS score of 04 indicating severe cognitive impairment. Observation on 02/03/25 at 11:45 AM with Resident #107 in her room revealed the ceiling vent was dusty, and there were black marks on the ceiling around the vent opening. During an observation and interview on 02/03/25 at 11:53 AM with Resident #107 revealed that she was alert and sitting in her wheelchair and was coughing. Resident #107 stated that she had been coughing a lot lately. She reported that she did not know that there was dust in the vent above her bed and that may be the reason why she had been coughing lately. She reported that since she has been at the facility, she cannot remember if staff have cleaned the A/C vent above her bed. She stated that she wanted someone to come into her room and clean the A/C vent above her bed now that she noticed the dust on the vent but did not know who to contact to clean the A/C vent. In an interview with Maintenance Director on 02/05/25 at 9:07 AM in the 100 Hallway revealed that there were several rooms in the 100 Hallway that had dusty A/C vents. He stated that he would speak with one of his staff members in Maintenance and he would have them come to the Conference Room to discuss the dirty A/C vents in the 100 Hallway. He reported that the Maintenance and Housekeeping Departments are both responsible for ensuring that the A/C vents were clean in the residents' rooms. In an interview with Maintenance Staff L on 02/05/25 at 9:15 AM in the 100 Hallway revealed that he had been employed at the facility for almost 7 years. He stated that his supervisor notified him that it was brought to his attention by a State Surveyor that the A/C vents in the residents' rooms on the 100 Hallway were not clean. He stated that he was unaware that the A/C vents were not clean until it was brought to his attention. He stated that staff are required to complete a Maintenance Request in the Maintenance Log on issues such as dirty A/C vents. He stated that the Maintenance Request Log was located at the Nurses Station on the 100 Hallway. He stated that he has not seen any requests in the Maintenance Log regarding the A/C vents needing to be cleaned on the 100 Hallway. He reported that the Maintenance Director will give each Maintenance Staff member a sheet with their Work Orders, and he will complete the Work Orders as they are completed. Maintenance Staff L was shown the A/C vents in Resident #27, Resident #99 and Resident #107 rooms. Maintenance Staff L agreed that the A/C vents in the rooms he observed were not clean. He stated that it is the responsibility of the Nursing Staff to notify the Maintenance and Housekeeping Departments if there is something like dust in the A/C vents in a resident's room. He stated that both departments work hand in hand with each other regarding keeping the A/C vents in residents' rooms clean. He stated he would take full responsibility for making sure that the A/C vents in the 100 Hallway are cleaned, and he would be working closely with the staff to ensure they were cleansed on a regular basis. He stated the risk of the ceiling vents being unclean is that if the dust blew onto residents they could be affected, especially those allergic to dust and have breathing issues. He also stated resident's rooms should be clean and safe. Record Review of the facility's Maintenance Request Log at the 100 Hall's Nurses Station, revealed no entries regarding dusty A/C vents in the 100 Hallway. In an interview with CNA M on 02/05/25 at 1:32 PM revealed that she stated that he had been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675817 If continuation sheet Page 6 of 24 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 675817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FT Worth Southwest Nursing Center 5300 Alta Mesa Blvd Fort Worth, TX 76133 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some employed at the facility for 8 months. She stated that her primary assignment was the 100 Hallway. She reported that she has not noticed that the A/C vents covers above the beds of residents in A bed were not clean. She stated that if she was to observe the A/C vents in a resident's room not clean, she would notify Maintenance and complete the Maintenance Request in the Maintenance Log at the Nurses Station. She stated that if the A/C vents in resident's room are not cleaned on a regular basis, residents can be at risk for respiratory infection from the dust being clogged up in the vents and breathing issues and/or problems. She stated that dirty A/C vents can cause a resident to having breathing issues, which can lead or cause lung issues due to the resident or residents not being able to breath properly. In an interview with CNA N on 02/05/25 at 1:38 PM revealed that he stated that he had been employed at the facility for 2 years. He reported that he was unaware that the A/C vents covers about the beds of residents in A bed were not clean. He stated that Housekeeping was responsible for ensuring that the A/C vents in residents' rooms are cleaned. He reported that he could not recall the last time that anyone from the Housekeeping Department cleaned the A/C vents in residents' rooms. He stated that if he notices that the A/C vents are not cleaned, he will report it to Maintenance via completing the Maintenance Request Log. CNA N reported that the Maintenance Request Logs for the 100 Hallway are kept at the Nurses Station. He stated that if the A/C vents in a resident's room was not cleaned regularly, it can cause for the resident or residents in the room to have respiratory issues. He stated that the residents could be harmed by not being able to breathe, having breathing issues and can cause them to have allergies. In an interview with Housekeeping Supervisor on 02/05/25 at 2:39 PM revealed he was unaware that Resident #27, Resident #99, and Resident #107 and majority of the rooms on the 100 Hallway had unclean A/C vents. He stated that his department alongside the Maintenance Departments are responsible for the cleaning and upkeep of the air vents with help from the housekeepers. He reported that there was not a schedule of when the A/C vents are to be cleaned. He stated that the last time the A/C vents in residents' rooms on the 100 Hallway was a week ago. He reported that his Housekeepers, which include about 13 staff members should be cleaning the A/C vents, as needed when they make their daily rounds to each resident's room. He stated he did not have any reason why the vents in the residents' rooms in the 100 Hallway were dirty. He stated residents should reside in a clean and safe environment. He stated that if the A/C vents in the residents' rooms are not cleaned, there was a risk for residents to have infections caused by breathing in dust and inhaling dust can get into a person's lungs and was not good for anyone especially if they already have breathing issues and are on oxygen. In an interview with the DON on 02/05/25 at 2:52 PM revealed that he was unaware that the A/C vents covers above the beds of residents in A bed in the 100 Hallway were not dusty and unclean. He reported that his staff are to do Q2 rounds, or as needed in the 100 Hallway. He reported that his expectation was that staff notify himself, management or housekeeping if they observe something like the A/C vent covers needing to be cleaned or any repairs that need to be done. He stated that the Maintenance Log at the Nurses Station on the 100 Hallway would be used for something such as dusty A/C vents. He stated that the responsibility of the A/C vents being cleaned falls upon the Maintenance and Housekeeping departments, not his nursing staff. DON stated that the A/C vents in a resident's room were not a risk for infection and everyone's vents in their homes, including new build homes and the State Surveyors homes were probably not clean and dirty. He stated that there was a potential for harm due to the A/C vents being harmful, but dust was in everyone's vents any place you go. He stated that going forward, he would have his staff put in any work orders regarding the cleaning or the A/C vents. He stated, he will relay to his staff, if it doesn't seem right, fix it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675817 If continuation sheet Page 7 of 24 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 675817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FT Worth Southwest Nursing Center 5300 Alta Mesa Blvd Fort Worth, TX 76133 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 0584 Record review of the facility's Resident Room Cleaning policy revised August 2020 did not provide any information regarding cleaning of A/C vents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675817 If continuation sheet Page 8 of 24 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 675817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FT Worth Southwest Nursing Center 5300 Alta Mesa Blvd Fort Worth, TX 76133 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 of 2 residents (Resident #90) reviewed for PASRR Level I screenings. Residents Affected - Few The facility's PASRR Level 1 Screening dated 10/25/2023 had no indicators of dementia as a primary diagnosis or evidence of mental illness, the PASRR did not correctly identify Resident #90 as having a mental illness of bipolar disorder onset date 10/25/2023 when the facility did not complete a new PASRR Level I Screening. This failure placed residents at risk of not receiving adequate services or care related to mental illnesses. Findings included: Record review of Resident #90's admission Record dated 2/5/25 reflected a [AGE] year-old male was originally admitted to the facility on [DATE]. Record review of Resident #90's Quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 00 indicating severe cognitive impairment. His diagnoses included non-Alzheimer's dementia, anxiety disorder, depression, bipolar depression, and psychotic disorder. Record review of Resident #90's Diagnoses Report dated 2/5/25 reflected his primary diagnosis was muscle wasting and atrophy-onset date 1/30/24. His secondary diagnoses included: bipolar disorder-onset date 10/25/23; major depressive disorder-onset date 10/25/23; and unspecified dementia-onset date 10/25/23. Record review of Resident #90's PASRR Level 1 Screening dated 10/25/23 reflected there were no indicators of dementia as a primary diagnosis or evidence of mental illness. During an interview on 2/5/25 at 11:43 AM, MDS Coordinator J stated he had submitted the PASRR information for Resident #90. He stated he submitted the information as it was provided to him from Resident #90's previous facility, and he was not allowed to change it. He stated he only completed the PASRR on admission and the resident was negative due to dementia. He denied ever sending a correction form. During an interview on 2/5/25 at 12:49 PM MDS Coordinator J stated he should have submitted a correction form upon noting the resident's mental illness diagnoses. He stated he had initiated a correction and submitted it to the physician for review. MDS Coordinator K stated, if they receive a PASRR that was incorrect, they were supposed to contact the provider who sent the PASRR and request a corrected one. She stated, if the provider failed to send a corrected form, they submitted the one they were provided along with a State Form 1012 to determine if a correction was needed. During an interview on 2/5/25 at 2:56 PM, the DON stated the MDS nurses were responsible for ensuring the PASRRs were complete and accurate. He stated the risk for incorrect PASRRs was residents may not get access to services for which they qualify. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675817 If continuation sheet Page 9 of 24 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 675817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FT Worth Southwest Nursing Center 5300 Alta Mesa Blvd Fort Worth, TX 76133 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 2/5/25 at 3:48 PM, the Administrator stated she had been made aware of the PASRR concerns and would ensure they were corrected. She stated the MDS Nurses were responsible for the submission of PASRR documents. She stated the risk to residents was they may not get additional services they could use. Record review of the facility's policy titled, Pre-admission Screening Resident Review (PASRR) dated revised 06/2020 reflected: Purpose: To ensure that all facility applicants are screened for mental illness and/or intellectual disability prior to admission and to ensure this assessment effort is coordinated with the appropriate state agencies if indicated .Policy: I. The Facility, as a Medicaid certified nursing facility, that Level I of the Preadmission Screening Resident Review (PASRR) is completed prior to admission of all applicants, regardless of payor, to determine if they have a Mental Disorder (MD) or Intellectually Disables (ID) .V. A negative Level I PASRR permits admission to proceed and ends the PASARR process, unless a possible serious mental disorder or intellectual disability arises later. A positive Level I screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASARR Level II, which must be conducted prior to admission to a nursing facility . Event ID: Facility ID: 675817 If continuation sheet Page 10 of 24 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 675817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FT Worth Southwest Nursing Center 5300 Alta Mesa Blvd Fort Worth, TX 76133 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that met professional standards of care within 48 hours of the resident's admission for one (Resident #221) of five residents reviewed for baseline care plans. The facility failed to complete Resident #227's baseline care plan within 48 hours of admission that included the minimum required healthcare information including physician orders, dietary orders, therapy services, and social services. Resident #227 was admitted to the facility on [DATE] and her baseline care plan was not completed until 02/03/25. This failure placed residents at risk of not receiving effective and person-centered care. Findings included: Review of Resident #221's Face Sheet, dated 02/05/25, reflected she was a [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including acute on chronic diastolic heart failure (a sudden worsening of symptoms related to diastolic heart failure) and methicillin resistant staphylococcus aureus infection (a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections). Review of Resident #221's electronic medical record on 02/05/25 reflected Resident #221's Baseline Care Plan was not completed until 02/03/25. During an interview with ADON E on 02/05/25 at 1:35PM, she stated she was under the impression that baseline care plans were required to be completed within 72 hours of a resident's admission. She stated Resident #221 was admitted on Friday, 01/31/25, and her baseline care plan was completed on Monday, 02/03/25. She said there was not a plan in place to ensure baseline care plans were completed for new admissions over the weekend, as baseline care plans were completed by various department heads. ADON E stated she did not believe there was a risk in baseline care plans not being completed within the required 48 hours of admission. Review of the facility's Care Planning policy, dated 06/2020, reflected, .The Facility will develop a person-centered Baseline Care Plan for each resident within 48 hours of admission . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675817 If continuation sheet Page 11 of 24 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 675817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FT Worth Southwest Nursing Center 5300 Alta Mesa Blvd Fort Worth, TX 76133 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of three residents (Resident #1) reviewed for incontinence care. 1. The facility failed to ensure CNA B thoroughly cleaned Resident #1 during incontinence care. This failure could place residents at risk for not receiving care appropriate to address their incontinence and could increase the risk of urinary tract infections. Findings included: 1. Record review of Resident #1's annual MDS assessment, dated 01/14/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 5 indicating his cognitive status was severely impaired. His diagnoses included heart failure, renal failure, and diabetes. The resident was dependent on staff for toileting. The resident was always incontinent of bowel and bladder. Record review of Resident #1's care plans, dated 04/02/23 reflected: The resident had an ADL Self Care Performance Deficit related to impaired balance. Facility interventions included: The resident required 1 staff participation for toileting. There was no documentation to indicate Resident #1 did not want his penis cleaned. An observation on 02/04/25 at 1:50 PM revealed Resident #1 was lying in bed. His brief was soiled with urine and bowel movement. CNA B folded down the resident's brief and cleaned the peri-area and the inner thighs of the resident. The CNA did not clean the penis or the foreskin. CNA B rolled the resident over and cleaned his buttocks. The CNA folded the brief under the resident. The CNA did not change gloves or perform hand hygiene. The CNA grabbed a new brief and placed it under the resident. The CNA started to fasten the brief. The Surveyor asked if the CNA was going to clean the resident's penis and she said no. CNA B fastened the brief and left the room. An interview on 02/04/25 at 2:00 PM revealed CNA B said she did not clean Resident #1's penis because he did not like his penis to be cleaned. CNA B did say it was important to clean the penis to reduce infection. An interview on 02/04/25 at 2:07 PM with the Infection Preventionist revealed staff were supposed to clean the penis when performing incontinence care for a man. She said it was important to keep the penis clean to prevent infection and yeast. An interview on 02/05/25 at 12:54 PM with the DON revealed staff were supposed to clean the penis when performing incontinence care for a man. He said it was important to keep the penis clean to prevent infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675817 If continuation sheet Page 12 of 24 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 675817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FT Worth Southwest Nursing Center 5300 Alta Mesa Blvd Fort Worth, TX 76133 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 0690 Review of the facility competency, Pericare / Incontinent Care Evaluation, not dated, reflected: Level of Harm - Minimal harm or potential for actual harm Male - retract foreskin - clean head of penis in circular motion - pat dry- and replace retracted foreskin. Wash complete shaft of penis working down the shaft - pat dry. Wash scrotum top and underside and wash perineum - remember front to back. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675817 If continuation sheet Page 13 of 24 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 675817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FT Worth Southwest Nursing Center 5300 Alta Mesa Blvd Fort Worth, TX 76133 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 - Some 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 observation, interview, 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 (Resident #78) of 8 residents reviewed for pharmacy services. The facility failed to ensure Resident #78 received the correct dosage of morphine 15 mg as ordered by his physician on 11/19/2023 when the pharmacy delivered morphine ER (extended release) 15 mg tablets on 01/09/2024. The medication had been signed as administered 37 times between 1/15/25 and 2/5/25. The discrepancy had not been detected until surveyor inquiry on 02/05/2025. This failure placed the residents at risk of not receiving medications as ordered by the physician and a not receiving the intended therapeutic effect of their medications. Findings included: Record review of Resident #78's admission Record dated 2/5/25 reflected a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #78's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 15 indicating he was cognitively intact. His diagnoses included: Hypertension (high blood pressure); other fracture and dislocation of the right humerus (upper arm). He was receiving scheduled and offered PRN pain medication. Record review of Resident #78's Care Plan reflected the following entries: [Resident #78] requires pain management. Intervention included administer analgesia (pain medications) as per orders. Date initiated 12/5/23. Record review of Resident #78's physician orders reflected: Morphine Sulfate Oral Tablet 15 mg. Give one tablet two times a day for pain. Order date 11/19/23. Record review of Resident #78's Medication Administration Record dated 2/1/25- 2/28/25 reflected the following entries: Morphine Sulfate Oral Tablet 15 mg. Give one tablet two times a day for pain. Order date 11/19/23. Record review of Resident #78's Controlled Drug Administration Record dated received 1/9/24 reflected: morphine sulfate ER 15 mg tab. The medication had been signed out as administered 37 times between 1/15/25 and 2/5/25. An observation and interview during medication pass on 2/4/25 at 7:40 AM revealed LVN C was standing outside Resident #38's room He stated he had just taken the blood pressure for Resident #78 and showed a reading on the BP cuff of 112/76. He sanitized the cuff and his hands. LVN C poured the resident's medications which included morphine ER 15 mg 1 tablet. He administered the medications to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675817 If continuation sheet Page 14 of 24 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 675817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FT Worth Southwest Nursing Center 5300 Alta Mesa Blvd Fort Worth, TX 76133 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 Resident #78 who was observed sitting up in his room in his wheelchair. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 2/5/25 at 7:51 AM, LVN I stated she usually worked another hall but was helping on Resident #78's hall that day. Resident #78's morphine card and narcotic sign out sheet was reviewed along with the orders. Both the medication card and sign out sheet reflected morphine sulfate ER 15 mg and the order reflected morphine sulfate 15 mg. LVN I stated she had overlooked the discrepancy and had already administered the medication that morning. She stated the risk of administering an ER dose instead of immediate release was the medication would take longer to get in your system and would stay in your system longer than intended. Residents Affected - Some During an interview on 2/5/25 at 7:55 AM, the DON stated he was unaware of the discrepancy between Resident #78's morphine orders and the medications received. He stated he would research the issue. During an interview on 2/5/25 at 8:22 AM, the DON stated they had called Resident #78's physician and his morphine was always supposed to be extended release and had been on previous orders. He stated there had been a transcription error with a reorder of the medication and it should have been caught sooner when the medication dose received did not match the order. He stated the risk of medication errors depended upon the medication and could cause unintended consequences or side effects. The DON stated LVN C usually worked night shift and had been picking up an extra shift on 2/4/25. On 2/5/25 at 8:31 AM, an attempt to reach LVN C via telephone for an interview was unsuccessful. A voicemail message was left. During an interview on 2/5/25 at 10:10 AM, ADON E stated she had called Resident #78's pain physician about his morphine order and reported the administration of the ER doses. She stated the physician sent the order for the medication straight to the pharmacy himself and the order should have been extended release all along. She stated he told her to correct the order in the computer to reflect ER. ADON E stated the nurse should have caught the error while administering the medication because the orders are to be checked against the medication every time it was administered. She stated the Charge Nurses were responsible for ensuring the medications in their carts were correct and the risk was adverse effects and not receiving the therapeutic effect needed. On 2/5/25 at 2:47 PM, another attempt to reach LVN C via telephone for an interview was unsuccessful. A voicemail message was left. During an interview with the DON on 2/5/25 at 10:46 AM stated when medications were received from the pharmacy, the nurse checking in the medications was responsible for checking the actual medication received against the manifest provided by the pharmacy. He stated they were checking to ensure the correct amount of medication was received. The DON stated whatever nurse stocked the cart was responsible for ensuring the medications matched the orders. He stated, ultimately the Charge Nurse was responsible for ensuring the medications administered matched the order from the physician. On 2/5/25 at 2:47 PM, another attempt to reach LVN C via telephone for an interview was unsuccessful. A voicemail message was left. During an observation and interview on 2/5/25 at 3:04 PM, RN H stated she worked PRN and had worked on Resident #78's hall the previous week. She reviewed Resident #78's morphine sign-out sheet and orders and stated she had administered the dose on 2/3/25. She stated she had overlooked the discrepancy between the extended and immediate release order and should have called for a clarification. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675817 If continuation sheet Page 15 of 24 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 675817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FT Worth Southwest Nursing Center 5300 Alta Mesa Blvd Fort Worth, TX 76133 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete stated the risk of administering an extended-release medication when an immediate release medication was ordered was unintended side effects. Record review of the facility's policy titled, Oral Medication Administration, dated revised 08/2020 reflected: Policy: Medications will be administered in a safe and effective manner .Procedures .2. Review and confirm medication orders for each individual resident on the MAR prior to administering medications to each resident . Event ID: Facility ID: 675817 If continuation sheet Page 16 of 24 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 675817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FT Worth Southwest Nursing Center 5300 Alta Mesa Blvd Fort Worth, TX 76133 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that it is free of medication error rates of five percent or greater. The facility had a medication error rate of 9%, based on 3 errors out of 32 opportunities, which involved two (Resident #107 and Resident #78) of six residents reviewed for medication administration. Residents Affected - Some 1. On 2/4/25 at 7:12 AM, MA F failed to administer a medication as ordered to Resident #107 by crushing Depakote DR (an anti-seizure medication) a medication that should not be crushed and attempted to administer prior to surveyor intervention. 2. On 2/4/25 at 7:40 AM, LVN C failed to administer medications as ordered to Resident #78 when he administered Morphine extended release 15 mg instead of morphine 15 mg immediate release as ordered. LVN C administered Geri-kot (generic form of Senekot-a laxative) 8.6 mg instead of the ordered dose of Senekot Plus 8.6-50 mg (Senekot plus docusate). These failures could place residents at risk for inaccurate drug administration resulting in a decline in health and decreased quality of life. Findings included: 1. Record review of Resident #107's admission Record dated 2/5/25 reflected an [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #107's Annual MDS assessment dated [DATE] reflected she had a BIMS score of 3 indicating severe cognitive impairment. Her diagnoses included pulmonary embolism (blood clot in the lung); stroke, aphasia (speech disorder commonly caused by a stroke); and cognitive communication deficits. Record review of Resident #107's Care Plan reflected the following entry dated 5/6/24: [Resident #107] has impaired cognitive function/dementia or impaired thought processes. Interventions included review medications and record possible causes of cognitive deficit: Review medications and record possible causes of cognitive deficit: new medications or dosage increases; anticholinergics, opioids, benzodiazepines, recent discontinuation, omission or decrease in dose of benzodiazepines, drug interactions, errors or adverse drug reactions, drug toxicity. Record review of Resident #107's physician orders reflected the following orders: Depakote Oral Tablet Delayed Release 125 mg give 1 tablet by mouth two times a day .do not crush medication. Order Date 8/20/24. Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for DVT. Order date 4/12/24. Multi-Vitamin/Minerals Oral Tablet Give 1 unit by mouth one time a day. Order date 4/22/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675817 If continuation sheet Page 17 of 24 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 675817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FT Worth Southwest Nursing Center 5300 Alta Mesa Blvd Fort Worth, TX 76133 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Senna Plus Oral Tablet 8.6-50 MG (Sennosides-Docusate Sodium) Give 1 tablet by mouth two times a day. Order date 5/6/24. Lisinopril Oral Tablet 20 MG (Lisinopril) Give 1 tablet by mouth one time a day HOLD for SBP (systolic blood pressure) less than 100. Order date 10/19/24. Residents Affected - Some Magnesium Oxide -Mg Supplement Oral Tablet 250 MG Give 1 tablet by mouth one time a day. Order date 5/3/24. May crush oral medications or open capsules and mix all medications together for administration with medium of resident's choice. Record review of Resident #107's Medication Administration Record dated 2/1/25-2/28/25 reflected: Depakote Oral Tablet Delayed Release 125 mg . give 1 tablet by mouth two times a day .do not crush medication. An observation and interview during medication pass on 2/4/25 at 7:12 AM revealed MA F stated she was preparing medications for Resident #107. She sanitized her hands, donned gloves and checked the resident's blood pressure which read 132/88. MA F sanitized the BP cuff and her hands and began to pour the medications. She poured the Depakote 125 mg 1 tablet, Apixaban 5 mg 1 tablet, multivitamin with minerals 1 tablet, Senna plus 8.6/50 mg 1 tablet; lisinopril 23 mg 1 tab, and magnesium oxide 250 mg 1 tablet into the same cup. She then poured all the tablets together into a small plastic bag, crushed them together and poured them back into a medication dose cup. She retrieved a container of yogurt and stated she was going to mix the yogurt with the medications because that was how Resident #107 preferred to swallow them. She was asked to check the order for Depakote and how she determined which medications could be crushed. MA F stated, according to the nurse, the medications can be crushed if the resident can't swallow. She can't swallow pills well so it's ok to crush them. She stated if a medication can't be crushed, the pharmacy will send them in liquid form, these are OK. When the medication card was reviewed with MA F, she stated she did not know what DR meant and she had not had any guidance on it. She stated, We can crush the med unless the order says not to. She checked her MAR on her computer and stated it did not say we can't crush. Resident #107's Charge Nurse, RN G approached and was asked about crushing medications. She stated some medications cannot be crushed and they were usually noted by the pharmacy. She reviewed Resident #107's Depakote medication card with MA F and pointed out the instructions that reflected do not crush medication and DO NOT CRUSH OR CHEW printed on the label. RN G stated the medication was delayed release and should not be crushed because the dose would be given all at once and not slowly. She stated there was a risk for adverse side effects. MA F stated she had missed the notes when she poured the medication. She discarded the poured medications and repoured and crushed all the medications except for the Depakote. She administered the Depakote whole in a spoonful of yogurt to Resident #107 who swallowed the pill without difficulty (the resident was eating a regular breakfast tray at the time). She administered the crushed medications mixed with yogurt. 2. Record review of Resident #78's admission Record dated 2/5/25 reflected a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #78's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 15 indicating he was cognitively intact. His diagnoses included: Hypertension (high blood pressure); other fracture and dislocation of the right humerus (upper arm). He was receiving scheduled and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675817 If continuation sheet Page 18 of 24 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 675817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FT Worth Southwest Nursing Center 5300 Alta Mesa Blvd Fort Worth, TX 76133 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 offered PRN pain medication. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #78's Care Plan reflected the following entries: Residents Affected - Some [Resident #78] requires pain management. Intervention included administer analgesia (pain medications) as per orders. Date initiated 12/5/23. [Resident #78] is on Pain medication therapy r/t muscle pain. Interventions included, Administer medication as ordered and Monitor/document for side effects of pain medication. Observe for constipation . Date initiated 12/5/23. Record review of Resident #78's physician orders reflected the following entries: Morphine Sulfate Oral Tablet 15 mg. Give one tablet two times a day for pain. Order date 11/19/23. Senna Plus Oral tablet 8.6-50 mg (sennosides-Docusate Sodium) Give 1 tablet by mouth one time a day for constipation. Order date 5/6/24. Aspirin Low Dose Oral Tablet Chewable 81 MG. Give 1 tablet by mouth one time a day. Order date 11/19/23. Sertraline HCl Oral Tablet 25 MG Give 2 tablet by mouth one time a day. Order date 3/5/24. Finasteride Oral Tablet 5 MG Give 1 tablet by mouth one time a day. Order date 12/4/23. Gabapentin Oral Capsule 400 MG Give 1 capsule by mouth three times a day. Metoprolol Tartrate Oral Tablet 25 MG Give 1 tablet by mouth two times a day for HOLD FOR SBP <115 DBP <70 HR <55. Record review of Resident #78's Controlled Drug Administration Record dated received 1/9/24 reflected: morphine sulfate ER 15 mg tab. An observation and interview during medication pass on 2/4/25 at 7:40 AM revealed LVN C was standing outside Resident #38's room He stated he had just taken the blood pressure for Resident #78 and showed a reading on the BP cuff of 112/76. He sanitized the cuff and his hands. LVN C poured the following medications: Geri-kot 8.6 mg (generic form of Senekot) 1 tablet, Aspirin 81 mg 1 tablet, sertraline 25 mg 2 tablets, finasteride 5 mg 1 tablet, gabapentin 400 mg 1 tablet, and morphine ER 15 mg 1 tablet. LVN C stated he was holding Resident #78's metoprolol because his blood pressure was below the ordered parameters. He administered the medications to Resident #78 who was observed sitting up in his room, in his wheelchair. During an interview on 2/4/25 at 11:22 AM, the DON stated RN G had told him about MA F crushing the Depakote tablet. He stated he had conducted and in-service training with MA F and noted she was not reading her MAR correctly. He stated the medications instructions were not in an expanded view on her computer so she could not see the note. He stated she should have seen the instructions on the medication card. The DON stated he had called the physician and the pharmacy and had Resident #107's order changed to Depakote sprinkles so that the medication can be swallowed easier. He stated he was conducting in-service training for all nurses and MAs as a refresher. He stated the risk for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675817 If continuation sheet Page 19 of 24 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 675817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FT Worth Southwest Nursing Center 5300 Alta Mesa Blvd Fort Worth, TX 76133 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some crushing extended or delayed release medications is the resident would receive all the medication at once instead of over a period of time which could result in too much medication received and too short of a duration period. During an interview on 2/5/25 at 8:22 AM, the DON stated they had called Resident #78's physician and his morphine was always supposed to be extended release. He stated there had been a transcription error with a reorder of the medication and it should have been caught sooner when the medication dose did not match the order. He stated the risk of medication errors depended upon the medication and could cause unintended consequences or side effects. He stated administering Geri-kot (generic form of Senekot which only contained senna) instead of Senna plus meant the resident did not get the added docusate and had an increased risk of constipation. The DON stated LVN C usually worked night shift and had been picking up an extra shift on 2/4/25. On 2/5/25 at 8:31 AM, an attempt to reach LVN C via telephone for an interview was unsuccessful. A voicemail message was left. During an interview on 2/5/25 at 10:10 AM, ADON E stated she had called Resident #78's pain physician about his morphine order and reported the administration of the ER dose. She stated the physician sent the order for the medication straight to the pharmacy himself and the order should have been extended release all along. She stated he told her to correct the order in the computer to reflect ER. ADON E stated the nurse should have caught the error while administering the medication because the orders are to be checked against the medication every time it was administered. She stated the Charge Nurses were responsible for ensuring the medications in their carts were correct and the risk was adverse effects. ADON E stated she was aware of Resident #107's medication error where the MA crushed a delayed release tablet. She stated the risk was adverse effects of the medication, receiving too much at once and not getting the therapeutic effect of a longer acting medication. On 2/5/25 at 2:47 PM, another attempt to reach LVN C via telephone for an interview was unsuccessful. A voicemail message was left. Record review of the facility's policy titled, Oral Medication Administration, dated revised 08/2020 reflected: Policy: Medications will be administered in a safe and effective manner .Special Considerations 1. Refer to crushing guidelines prior to crushing any medication for confirmation that it can be pulverized .Procedures .2. Review and confirm medication orders for each individual resident on the MAR prior to administering medications to each resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675817 If continuation sheet Page 20 of 24 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 675817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FT Worth Southwest Nursing Center 5300 Alta Mesa Blvd Fort Worth, TX 76133 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #23 and Resident #1) of five residents, three of five pill crushers, and two of two washing machines observed for infection control. Residents Affected - Some 1. The facility failed to ensure CNA A changed gloves and performed hand hygiene during incontinence care for Resident #23. 2. The facility failed to ensure CNA B changed gloves and performed hand hygiene during incontinence care for Resident #1. 3. The facility failed to ensure the pill crushers used on Medication Carts 1, 2, and 3 were clean. 4. The facility failed to ensure the facility's two washing machines were clean. These failures placed residents at risk for healthcare associated cross contamination and infections. Findings included: 1. Record review of Resident #23's annual MDS assessment, dated 01/17/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 6 indicating his cognitive status was severely impaired. His diagnoses included diabetes, stroke, and Non-Alzheimer's dementia. The resident was dependent on staff for toileting. The resident was frequently incontinent of bowel and bladder. Record review of Resident #23's care plans, dated 05/19/21 reflected: The resident had an ADL Self Care Performance Deficit related to hemiplegia (on-sided weakness or paralysis). Facility interventions included: The resident required 1 staff participation for toileting. An observation on 02/04/25 at 12:57 PM of incontinence care for Resident #23 revealed the resident was lying in bed on his back. CNA A folded down the top of the resident's brief. CNA A grabbed cleaning wipes and cleaned the penis and scrotum of the resident. The resident was assisted to turn to his side and the CNA grabbed cleaning wipes and cleaned the resident's buttocks. CNA A pushed the used brief underneath the resident. CNA A did not change her gloves or perform hand hygiene. CNA A grabbed a clean brief and placed it under the resident. The resident was turned back, and the CNA pulled out the used brief, fastened the clean brief, and repositioned the resident. An interview on 02/04/25 at 1:10 PM with CNA A revealed she only needed to change her gloves and perform hand hygiene after completing the incontinence care. She said she was the only staff changing the resident and did not know how she was supposed to change her gloves and perform hand hygiene if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675817 If continuation sheet Page 21 of 24 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 675817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FT Worth Southwest Nursing Center 5300 Alta Mesa Blvd Fort Worth, TX 76133 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 she was by herself providing the care. Level of Harm - Minimal harm or potential for actual harm 2. Record review of Resident #1's annual MDS assessment, dated 01/14/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 5 indicating his cognitive status was severely impaired. His diagnoses included heart failure, renal failure, and diabetes. The resident was dependent on staff for toileting. The resident was always incontinent of bowel and bladder. Residents Affected - Some Record review of Resident #1's care plans, dated 04/02/23 reflected: The resident had an ADL Self Care Performance Deficit related to impaired balance. Facility interventions included: The resident required 1 staff participation for toileting. An observation on 02/04/25 at 1:50 PM revealed Resident #1 was lying in bed. His brief was soiled with urine and bowel movement. CNA B folded down the resident's brief and cleaned the peri-area and the inner thighs of the resident. The CNA did not clean the penis or the foreskin. CNA B rolled the resident over and cleaned his buttocks. The CNA folded the brief under the resident. The CNA did not change gloves or perform hand hygiene. The CNA grabbed a new brief and placed it under the resident. The CNA started to fasten the brief. The Surveyor asked if the CNA was going to clean the resident's penis and she said no. CNA B fastened the brief and left the room. An interview on 02/04/25 at 2:00 PM revealed CNA B said she did not clean Resident #1's penis because he did not like his penis to be cleaned. CNA B said it was important to clean the penis to reduce infection. CNA B said she did not know why she did not change her gloves and perform hand hygiene but had been trained to. She said failure to change gloves and perform hand hygiene could cause infection. An observation and interview on 02/04/25 at 1:27 PM of Medication Cart #1 revealed the back of the pill crusher was dirty. It had dust, rust, and a dirt-looking substance on it. LVN C said he cleaned it after use with purple wipes. He said there was a risk of infection if the pill crusher was not kept clean. An observation and interview on 02/04/25 at 1:35 PM of Medication Carts #2 and #3 revealed the back of their pill crushers was dirty. They had dust, rust, and a spilled-looking substance on them. RN D said she cleaned the side and top of her pill crusher, but she did not clean the back of it. An observation and interview on 02/05/25 at 12:45 PM revealed the laundry washers were both dirty on the inner ring of the front-loading doors. There was heavy layer of a crusty-tan substance that was wet on the inner ring of the door. The Laundry Staff said she was not able to clean the area because she could not reach them. She said the areas were not accessible. She said she cleaned the outside of the machines every day. An interview on 02/05/25 at 12:50 PM with the Maintenance Director revealed the staff did not clean the inner rings of the doors. He said he would have to contact the machine company to find out how to access the part to clean it. He said he would add it to the cleaning schedule to ensure it was kept clean. An interview on 02/04/25 at 2:07 PM with the Infection Preventionist revealed staff were supposed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675817 If continuation sheet Page 22 of 24 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 675817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FT Worth Southwest Nursing Center 5300 Alta Mesa Blvd Fort Worth, TX 76133 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to change gloves and perform hand hygiene after cleaning the resident. She said it was important to keep infection down. The Infection Preventionist said the nurses were responsible for cleaning the pill crushers after using them. She said the use of dirty pill crushers could cause infection. An interview on 02/05/25 at 12:54 PM with the DON and Administrator revealed staff were supposed to change gloves and perform hand hygiene after cleaning the resident to prevent potential infection. The DON said the nurse was responsible for cleaning the exterior portion of the pill crusher. The DON said there was no risk of infection with using dirty pill crushers because the medications were kept in strong pill crusher plastic bags. The facility Administrator and DON did not know about the washing machine door seals being dirty. The Administrator said she would have to talk with maintenance and the vendor to find out how to clean it. The DON said he would need to look at it to see if there was any risk to the resident. Review of the facility policy, Infection Prevention and Control Program, revised June 2020, reflected: Purpose: The ensure the Facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection . Review of the facility policy, Hand Hygiene, revised June 2020, reflected: Facility Staff and volunteers must perform hand hygiene procedures in the following circumstances including but not limited too . A. Wash hands with soap and water: .iii. When soiled with visible dirt or debris; iv. After unprotected (ungloved and damaged gloves) contact with blood, other body fluids, secretions, excretions, mucous membranes, non-intact skin, intact skin soiled with blood and other body fluids, wound drainage and soiled dressings; v. After contact with intact and non-intact skin, clothing and environmental surfaces of residents with active diarrhea even if gloves are worn . vii. Upon starting of the shift viii. After removing personal protective equipment PPE and before moving to another resident in the same room or exiting the room . B. Alcohol-based hand hygiene products can and should be used to decontaminate hands: i. Immediately upon entering a resident occupied area (single or multiple bed room, procedure or treatment room) regardless of glove use; ii. Immediately upon exiting a resident occupied area (e.g., before exiting into a common area such (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675817 If continuation sheet Page 23 of 24 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 675817 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FT Worth Southwest Nursing Center 5300 Alta Mesa Blvd Fort Worth, TX 76133 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 as a corridor) regardless of glove use; Level of Harm - Minimal harm or potential for actual harm iii. Before moving from one resident to another in a multiple-bed room or procedure area regardless of glove use; Residents Affected - Some VI. Hand hygiene is always the final step after removing and disposing of personal protective equipment. VII. The use of gloves does not replace hand hygiene procedures. Review of the facility document, Pill Crusher, Cleaning and Maintenance Instructions, not dated, reflected: The frequency in which the pill crusher is cleaned is dependent on a facility's cleaning and disinfection protocol. The Silent Knight Pill Crusher . may be cleaned regularly with a damp cloth. A facility approved disinfectant wipe may also be used when indicated. Review of an email received from the Administrator on 02/05/25 at 3:22 PM regarding the facility washing machines reflected: I do not have a specific policy for this. We clean the machine when it is visibly soiled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675817 If continuation sheet Page 24 of 24