Inspection·September 14, 2023

F 0686 start date of 08/29/23. Level of Harm - Minimal harm or potential for actual harm - Apply skin prep to right heel. one time a day. This order had a start date of 08/29/23. Residents Affected - Some Record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1 had no BIMS score because Resident #1 is rarely/never understood. Section M Skin Conditions of the MDS revealed Resident #1 had one Stage 3 pressure ulcer that was present upon admission or re-entry and had an unstageable deep tissue injury that was present upon admission. She needed pressure ulcer/injury care and a pressure reducing device for her bed. Record review of Resident #1's August 2023 MAR and TAR, obtained 09/13/23, revealed no documentation which indicated wound care was done for Resident #1's Stage 3 pressure ulcer to her sacrum, on 08/26/23, 08/27/23, 08/28/23 and 08/29/23, iliac crest on 08/26/23, 08/27/23 and 08/28/23 and her right heel 08/26/23 and 08/27/23 and 08/28/23. Record review of the wound specialist notes, dated 08/30/23, revealed Resident #1 had a Stage 3 pressure wound to the sacrum which was full thickness wound size (length x width x diameter): 4.0 x 7.0 x 0.2 cm. The treatment was alginate calcium apply once daily for 30 days; Santyl apply once daily for 30 days. Secondary dressing(s) gauze island with border apply once daily for 30 days. Unstageable deep tissue injury of the right heel partial thickness measuring (length x width x diameter): 4.0 x 7.0 x [diameter] not measurable; admitted to facility with wound dressing treatment plan betadine apply once daily for 30 days. Record review of Resident #1's care plan, dated 09/13/23, revealed the following problem area: [Resident #1] has pressure injury to Sacrum with potential for further skin breakdown rule out: immobility, impaired mobility, incontinence, and unstageable deep tissue injury pressure injury to right heel, with potential for further skin breakdown rule out: immobility, impaired mobility. The intervention was: Administer treatment as ordered and monitor for effectiveness. Interview on 09/14/23 at 8:13 a.m. with LVN A, who was the Treatment Nurse/Wound Care Nurse, revealed she did the initial assessment of Resident #1 with a corporate nurse who was orienting her on 08/25/23, since she was newly hired. LVN A revealed Resident #1 admitted with pressure ulcers on the sacrum, a skin tear on the iliac crest, and a deep tissue injury on the right heel. LVN A stated she cleansed the wounds and applied a clean dressing on 08/25/23. She stated she did not know what happened, the orders were omitted, and she did not document on the TAR after completion of the wound care. LVN A stated on admission after the skin assessment she wrote a wound care consult, and she did not know how they forgot to put the orders in the MAR for the other nurses to be aware the resident had wounds. LVN A stated when she was not available to do wound care, the floor (charge) nurses were responsible for wound care treatment . LVN A stated Resident #1 was admitted on a Friday and when she came back on Monday, she did not check to ensure wound care was being provided. LVN A stated Resident #1 was supposed to receive daily wound care. LVN A revealed Resident #1 received wound care on 08/29/2,3 and she did not take the measurements since the wound care doctor was scheduled to come on 08/30/23; although she was supposed to document the measurements upon admission, so that she could know when the wound worsened. She could not tell whether the wounds had worsened. She stated failure to get orders and failure to perform wound care could lead to the wound getting infected. Interview on 09/14/23 at 8:50 a.m. with the DON revealed it was the charge nurse's responsibility to admit new residents, perform skin assessments, and notify the Wound Care Nurse if a resident was admitted with wounds. The DON stated she expected the Wound Care Nurse to assess Resident #1 and put (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675930 If continuation sheet Page 2 of 8 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 675930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbrook Plaza 401 W Arbrook Blvd Arlington, TX 76014 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some treatment orders in the TAR. The DON revealed it was the responsibility of the Wound Care Nurse to ensure wound care was being done for Resident #1. The DON revealed she left early on 08/25/23, and she had not realized Resident #1's wound care was not being documented on the TAR until on 08/29/23 when the treatment orders were received, and when the the HHSC surveyor started to inquire about the resident's wound care. The DON stated she was responsible for monitoring to ensure wound care was being provided to residents by both nurses and the treatment nurse. The DON stated failure of her staff to perform wound care could lead to infection and worsening of the wounds. The DON stated she completed in-services on 08/24/23 regarding MARs, TARs, assessments, wound assessments, and notification. She stated when the Wound Care Nurse was not at the facility the charge nurses were responsible for the wound treatment for their allocated halls. Interview on 09/14/23 at 12:00 p.m. with LVN C revealed she was the one who admitted Resident #1 on 08/25/23. LVN C revealed Resident #1 had pressure ulcers on her sacrum, a skin tear on her iliac crest, and a deep tissue injury on her right heel. LVN C stated on 08/25/23 she removed the old dressing and applied a new dressing and notified the Wound Care Nurse for an assessment and got the wound care orders from the doctor as per the facility's protocol that indicated if a resident was admitted while the Treatment Nurse was in the facility it was her responsibility to assess the wounds and enter treatment orders. LVN C stated she worked with Resident #1 on 08/28/23 and 08/29/23, and she did not perform wound care for Resident #1, because the Wound Care Nurse was responsible for administering treatment. LVN C stated when the Treatment Nurse was off the charge nurses were responsible for the wound care on their halls. Interview on 09/14/23 at 12:44 p.m. with RN B revealed he worked with Resident #1 on 08/26/23 and 08/27/23, and he could not recall whether Resident #1 had wound care orders. RN B stated he only worked double weekend, and he declined to reveal whether he was responsible for performing wound care on weekends. The resident was discharged home against medical advice on 09/01/23. Record review of the facility's in-services revealed the facility offered training on MAR, TAR wound care, and assessment to their staff on 08/24/23. Record review of the facility's current Pressure Ulcer/Skin Breakdown-Clinical Protocol policy revised March 2014, reflected: Assessment and recognition 1 .nurse shall describe and document/report the following. a. Full assessment of pressure sore including location, Stage, length, width, and depth b. D. Current treatments including support surfaces .3. The staff will examine the skin of a new admission for ulceration or alterations in skin. Treatment /Management (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675930 If continuation sheet Page 3 of 8 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 675930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbrook Plaza 401 W Arbrook Blvd Arlington, TX 76014 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 0686 1.The physician will authorize pertinent orders related to wound care treatments including wound cleansing and debridement, dressing and application of topical agent if indicated for type of skin. 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: 675930 If continuation sheet Page 4 of 8 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 675930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbrook Plaza 401 W Arbrook Blvd Arlington, TX 76014 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. Residents Affected - Some 1. The facility failed to ensure food items and clean dishes were kept away from contaminants and an unsanitary environment. 2. The facility failed to ensure the ice machine was clean and sanitary. These failures could place residents at risk for food contamination and food-borne illness. Findings included: An observation of the kitchen on 09/12/23 at09:02 AM revealed three preparation tables had rust and debris that included dust and old food particles on the undershelves, where uncovered containers of clean cooking utensils and materials were stored. Observation also revealed the kitchen had one operating ice machine that was used for the residents, and it contained a buildup of black and brown substances on the interior lining of the machine, near the ice. Interview on 09/12/23 at 10:48 AM with Dietary Aide D revealed she worked at the facility for 4 years. She stated all kitchen staff were trained and in-serviced on kitchen sanitation at least once a month. She stated it was the responsibility of all kitchen staff to maintain the cleanliness and sanitation of the kitchen. She stated the daily and general cleaning of the kitchen included sweeping, mopping, washing dishes, wiping down the preparation counters, equipment, and steam tables, organizing refrigerator/freezer and dry food pantry, and wiping down the walls. She stated there were no separate deep cleaning tasks or days because they were trained to deep clean on all tasks daily. Dietary Aide D stated it was maintenance's responsibility to clean things such as the ceilings, vents, and ice machine. Dietary Aide D stated she recalled wiping down the outside of the machine about a month ago, but it was not a part of her regular cleaning tasks. She stated the rust and debris had been on the undershelves of the preparation table for months and management was aware of it. She stated the risk of having an unsanitary kitchen could place the residents at risk of getting sick from cross-contamination. Interview on 09/13/23 at 9:45 AM with the Dietary Manager revealed he had worked at the facility since December 2022 and was working on improving kitchen operations. He stated it was reported to management the preparation tables were rusted and needed to be replaced. The Dietary Manager stated he thought the tables had already been ordered about a month ago by the previous maintenance director; however, they were not. He could not state if management was following up on the order. Interview on 09/14/23 at 2:15 PM with the Dietary Manager revealed all staff were trained on kitchen sanitation monthly. He stated the dietician also did a monthly sanitation audit of the kitchen. The Dietary Manager stated kitchen staff had sign-off sheets for all completed daily cleaning tasks. He stated the daily cleaning was split between the cooks and the dietary aides, and they all had assigned tasks. The Dietary Manager stated general and deep cleaning were all the same because the kitchen staff deep cleaned daily. He stated maintenance was ultimately responsible for emptying and cleaning out the ice machine at least once a month; however, he would wipe down the outside and interior (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675930 If continuation sheet Page 5 of 8 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 675930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbrook Plaza 401 W Arbrook Blvd Arlington, TX 76014 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some parts that could be reached without completely breaking it down when he noticed it was dirty. He stated he would tell the kitchen staff to wipe down the ice machine as needed also. The Dietary Manager stated having rusty preparation tables and an unsanitary ice machine could cause cross-contamination and place the residents at risk for food-borne illness. Interview on 09/14/23 at 2:38 PM with the Administrator revealed it was her expectation for all kitchen equipment to be clean and in working order. She stated it was maintenance's responsibility to clean the ice machines and order new kitchen equipment when needed. The Administrator stated the previous maintenance director was recently terminated and before leaving he had not followed through on ordering new preparation tables for the kitchen. She was unaware of the last time the previous maintenance director had cleaned the ice machine in the kitchen. There was no cleaning log for the ice machine provided. The Administrator stated there was a second ice machine in the nourishment room that was out of order and not used but had just been replaced with a brand new one. She stated new preparation tables would be ordered for the kitchen. Interview on 09/14/23 at 3:38 PM with the Maintenance Director revealed he had only worked at the facility for one month and was still learning all his responsibilities. He stated he had just been informed it was his responsibility to deep clean the ice machines once a month, and kitchen staff were responsible for doing a weekly check to clean areas accessible to them and inform him of any major issues. He stated the Administrator informed him it was also his responsibility to order and replace kitchen equipment as needed. Record review of the facility's Clean Schedules, dated for July 2023, August 2023, and September 2023, revealed it was current and all tasks, which included cleaning worktables, were signed off. Cleaning the ice machine was not listed on the schedules. Record review of the facility's sanitation audit report, dated 07/27/23 and 08/22/23, revealed all major and minor equipment in the kitchen was clean. Record review of the facility's training reports for kitchen staff, dated for July 2023, August 2023, and September 2023, revealed all current kitchen staff had received trainings including cross-contamination, cleaning and sanitation, and infection control. Record review of the facility's current Equipment policy, revised September 2017, reflected the following: Policy Statement: All food service equipment will be clean, sanitary, and in proper working order. Procedures: 1. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. 2. All staff will be trained in the cleaning and maintenance of all equipment Record review of the Federal Drug Administration Food Code, dated 2017, section titled Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils reflected: .(A) equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675930 If continuation sheet Page 6 of 8 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 675930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbrook Plaza 401 W Arbrook Blvd Arlington, TX 76014 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 0812 Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris 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: 675930 If continuation sheet Page 7 of 8 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 675930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbrook Plaza 401 W Arbrook Blvd Arlington, TX 76014 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 Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 17 resident rooms (Resident #71's room) reviewed for infection control. Residents Affected - Few The facility failed to dispose of used push-button lancet (finger-prick needle), blood testing strips (used to obtain a fingerstick blood sugar), one used alcohol wipe, 0.09% sodium chloride injection and one IV catheter (used to provide access to administer IV fluids) in Resident #71's room. This failure could place residents at risk of exposure to communicable diseases and infections. Findings included: Observation and interview on 09/12/23 at 11:42 AM of Resident #71's room, there was a green and orange push-button lancet, one used blood testing strip, one used alcohol wipe, 0.09% sodium chloride injection and one IV catheter on the resident's dresser located next to Resident #71 bed. Resident #71 was not in the room. Resident #71 had a roommate, Resident #54, who stated Resident #71 was sent to the hospital either Saturday or Sunday evening and had not returned yet. Observation and interview on 09/12/23 at 11:49 AM, LVN E stated she was the nurse assigned to 400 Hall. She stated Resident #71 discharged to the hospital on Saturday (09/09/23) and had not returned yet. LVN E and the HHSC surveyor entered Resident #71's room, LVN E observed the blood testing strip, push button lancet, alcohol wipe, IV catheter and chloride injection. LVN E stated the facility did not use those items. She stated the paramedics might had left them behind. LVN E was observed to don gloves and dispose of the items in the sharps container located on her medication cart. LVN E stated she was not the nurse on Saturday; however, it was the responsibility of the nurses and CNAs to ensure the room was clean. LVN E stated housekeeping cleaned the rooms; however, they did not touch sharps items. LVN E stated the risk of leaving used sharps items in the rooms would be infection control. Interview on 09/14/23 at 3:19 PM, CNA F stated he worked on Saturday (09/09/23) and was assigned to 400 Hall. CNA F stated Resident #71 went out to the hospital Saturday evening. He stated he was not assigned to Resident #71's room; however, if a resident was sent out to the hospital the staff assigned to the room would go back and clean the room. He stated the nurses or med tech would dispose of any used sharp items. He stated the risk of leaving used sharp items in resident rooms may cause someone to find them and poke themselves. Interview on 09/14/23 at 3:49 PM, the DON stated LVN E informed her the paramedics left sharp items in Resident #71's room on Saturday (09/09/23). She stated her expectation was for staff to return to the room, clean, and dispose of any used sharp items. The DON stated the risk of leaving sharp items was that it could be infection control and the risk of the roommate touching the times. Record review of the facility Waste Disposal policy, revised August 2008, reflected the following: All infectious and regulated waste shall be handled and disposed of in a safe and appropriate manner. C. Immediately after use, sharps shall be disposed of in closable, puncture resistant, disposable container that are leak- proof on the sides and bottom and are labeled or color-coded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675930 If continuation sheet Page 8 of 8