Inspection·May 19, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #1's bathing was scheduled for Tuesday, Thursday, and Saturday and he preferred a time from 2-10 PM. Further review of the ADLs revealed from 04/25/23 to 05/18/23 baths were completed on 04/26/23, 05/05/23, 05/06/23, and 05/17/23. A record review of Resident #1's electronic Progress Notes, from 04/25/23 to 05/18/23, revealed no documentation which reflected the resident refused baths. Resident #2: Record review of Resident #2's electronic face sheet, dated 05/19/23, revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had diagnoses which included hemiplegia and hemiparesis (weakness on one side of your body) following cerebral infraction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply) affecting left non-dominant side, difficulty walking, muscle weakness, and falls. Record review of Resident #2's Comprehensive MDS assessment, dated 02/08/23, revealed Resident #2 had a BIMS score of 14, which indicated his cognition was intact. Further review revealed section G0120. Bathing indicated code 4 (Total Dependency), which meant full staff performance every time during entire 7-day period. Record review of Resident #2's care plan, dated 10/07/22, revealed Resident required ADL Assistance and Therapy Services needed to maintain or attain highest level of function. The intervention included Assist with mobility and ADLs as needed. The care plan did not specifically address Resident #2's bathing needs. A record review of Resident #2's bathing ADLs in his electronic clinical record revealed Resident #2's bathing was scheduled for Monday, Wednesday, and Friday and he preferred a time from 6 AM - 10 PM. Further review of the ADLs revealed from 04/21/23 to 05/18/23 a bath was completed on 04/26/23. A record review of Resident #2's electronic Progress Notes, from 04/21/23 to 05/18/23, revealed no documentation which reflected the resident refused baths. In an interview on 05/19/23 at 7:41 AM, Resident #1's Family Member (FM) stated Resident #1 was supposed to receive a baths 3 days per week and he was not getting them. The FM stated on Wednesday (05/17/23), they did complain to one of the aides (did not want to provide name) about Resident #1 not receiving a bath and was ungroomed. The FM stated Resident #1 smelled and looked unkept. The FM stated she helped the aide provide Resident #1 a bath. In an interview on 05/19/23 at 9:59 AM, Resident #1 stated he was not getting 3 baths per week, and he would like to receive them. He stated he was not sure when he received his last bath, and he believed it was last week. In an interview on 05/19/23 at 10:04 AM, LVN A stated she was the nurse for Resident #1. She stated she had not received any complaints from the resident or his family members stating Resident #1 had not bathed. She stated none of the CNAs had told her that Resident #1 was refusing baths. LVN A stated she assumed he was receiving his baths. She stated the baths schedules are posted at the nursing station. LVN A stated after the CNAs provided baths they were supposed to document in the resident's clinical record. She stated if a resident refused, then the CNAs were supposed to notify the charge nurse, the charge nurse was supposed to verify the refusal and document the resident refused in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675935 If continuation sheet Page 2 of 3 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 675935 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Haltom 2936 Markum Dr Fort Worth, TX 76117 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 0677 his clinical record. Level of Harm - Minimal harm or potential for actual harm In an interview on 05/19/23 at 10:11 AM, CNA B stated Resident #1's FM did complain either Tuesday or Wednesday about him not getting baths and being shaved. The CNA B stated she worked 6 AM- 2PM and Resident #1's baths were supposed to be during the 2-10 PM shift and did not know why they were not completing them. She stated she did not tell management because she did not want to get anyone in trouble. CNA B stated she did give Resident #1 a bath and shaved him the day his FM complained. She stated she could tell Resident #1 had not been receiving baths because he was dirty, and she knew he not been shaved in a long time because of the amount of hair on his face. Residents Affected - Some In an interview on 05/19/23 at 10:33 AM, Resident #2 stated he was supposed to receive three baths per week and had not been receiving them as he liked. He stated he believed staff were not providing baths because they were too busy. Resident #2 stated it was not enough staff. He stated it had been over a week since he last received a bath, but he was not sure the of the exact date. In an interview on 05/19/23 at 11:32 AM, LVN C stated she was the nurse on Resident #2's hall. She stated she did not receive any complaints from Resident #2 or any of the other residents on her hall that they were not receiving baths. She stated none of the CNAs had ever told her Resident #2 was refusing baths. LVN C stated after the CNAs gave resident's baths, they were supposed to document it in their electronic clinical record. She stated if a resident refused, then the CNAs were supposed to notify her, and she would verify with the resident if they refused the bath. LVN C stated if they confirmed they refused, then she would, the charge nurse was supposed to verify and document it in the resident's clinical record. In an interview on 05/19/23 at 1:40 PM, the Administrator stated he was not aware of any current issues with residents not receiving baths. The Administrator stated this was an issue before and staff reported to him they were not giving baths due to the facility had a shortage of linens. He stated he purchased thousands of dollars' worth of linens and thought everything had gotten better. The Administrator stated it was his expectation that staff were providing baths as scheduled. He stated he would put a new process in place that nurses would be required to check off that the CNAs were completing the scheduled baths. The Administrator stated he was very disappointed and would in-service all staff. A record review of the facility's policy titled Activities of Daily Living (ADLs), undated, revealed Policy . The resident will receive assistance as needed to complete activities of daily living (ADLs). Any change in the ability to perform ADLs will be documented and reported to the licensed nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675935 If continuation sheet Page 3 of 3