Health inspection·May 25, 2023

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some of the upper right extremity. There was no order to change PICC/midline dressing using sterile technique every 7 days and as needed and to monitor for infection and infiltration. Observation on 05/25/23 at 9:33 AM of Resident #2's PICC/midline revealed a dressing, not dated on her right upper extremity. The PICC/midline insertion site was not open to air; the dressing was still intact with no signs of infection and looked dirty. 3. Review of Resident #3 MDS assessment, dated 04/24/23, revealed the resident was admitted to the facility on [DATE] with other acute osteomyelitis (inflammation of the bone) of the right ankle, cellulitis (serious bacterial infection of skin) of left and right lower limb and foot and sepsis ( Body extreme response to an infection). His BIMS score was 14 indicating he was cognitively intact. Review of Resident #3's TAR/MAR revealed he was required to receive intravenous antibiotics ceftriaxone 2 gm for 37 days via his PICC line of the left upper extremity. There was no order to change PICC/midline dressing using sterile technique every 7 days and as needed and to monitor for infection and infiltration. Observation on 05/25/23 at 09:48 AM of Resident #3's PICC/midline revealed a dressing, dated 05/17/23 (8 days prior to observation) . The PICC/midline insertion site was not open to air, the dressing was still intact with no signs of infection, but it was rolled up. Interview on 05/25/23 at 2:01 PM with LVN A revealed nurses were responsible for the PICC/midline dressings. She stated the dressing change for Resident #3 was overdue. LVN A stated Resident #3 requested she change the midline dressing when she was doing his wound care because it was all rolled up. She stated midline dressings should have been changed every seven days or whenever it was necessary. LVN A stated the dressing looked old and dirty. She stated she understood if the dressing was not changed as scheduled the resident was at risk of becoming infected. She stated she knew the dressing change was supposed to be done weekly and as needed. She denied seeing the date on the dressing since it was rolled up. Interview on 05/25/23 at 2:25 PM with LVN B revealed the midline dressing change for Resident #1 was overdue. LVN B stated she was responsible for Resident# 1 only that day since the nurse for the hall called in. She stated PICC/midline dressings should have been changed every seven days or whenever it was necessary. She stated she was aware that Resident #1 had a PICC/midline, and she changed the dressing 05/25/23 because she noticed it was dirty, had an old date and was rolled up on the edges. She stated it was her first day working with Resident#1, and she did not see orders for the midline dressing change on the MAR. LVN B stated she documented dressing changes on the nurse's progress notes . She stated she understood if the dressing was not changed as scheduled the resident was at risk of becoming infected. She stated she had done training on PICC/midline dressing change. Interview on 05/25/23 at 2:38 PM with LVN C revealed the PICC/midline dressing change for Resident #2 was supposed to be changed weekly. She stated PICC/midline dressings should have been changed every seven days or whenever it was necessary. LVN C stated nurses were responsible for the PICC line dressings. She stated she never changed the PICC/CVC line dressing on Resident #2, and she could not remember seeing the date when she administered the medication in the morning. She stated she checked the dressing on the midline, and there was no date, but she did not notify the DON. LVN C stated the importance of putting the date on the dressing was to verify the date of changing the dressing to prevent infection. She stated the dressing was dirty, and she knew if the dressing was not dated as scheduled the resident was at risk of becoming infected. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675935 If continuation sheet Page 2 of 5 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 05/25/2023 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 05/25/23 at 3:23 PM with the DON revealed her expectation was for the nurses to change the PICC/midline every 7 days and as needed. She stated she was the only RN and the LVNs were the ones that administered intravenous medication and changed the dressings on PICC/midlines. She stated all staff were IV certified. She stated they had been performing the duties of IV administration and dressing changes, but she had not seen their certification. The DON stated when the nurses mentioned to her that the dressings were overdue, she checked on the MAR and realized there were no orders to change the dressing every week for Resident #1, Resident# 2, and Resident#3. She stated the admitting nurse was responsible for inputting the orders. The DON stated Resident#2's dressing was supposed to have the date it was changed, but it did not. The DON stated she did not understand how the orders were missed. She stated failure to change the dressing effectively would predispose the residents to infection. She stated whoever changes the dressing should put a date and the purpose of putting a date was to notify when the next change was due. She stated she had not done any training on PICC/midline care with staff since she did not think there was a problem. Interview on 05/25/23 at 3:30 PM with Administrator revealed he could not trace the file with the LVNs IV certification. He stated he believed during the transition of the old owner and the new facility owner, the documents were misplaced. He stated the facility was under the certifying pharmacy, but he had no documentation of the training. He stated he talked to his staff, and they stated they were all certified and the certificates were at home. Record review of the facility's current Central Vascular Access Device Dressing Changes policy, dated June 2021, reflected the following: Licensed nurses according to state law and facility policy. The nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice. Competency validation is documented in accordance with organizational policy. 1. Perform sterile dressing changes using standard antiseptic techniques:1.1.1 .Upon admission if transparent dressing is dated, clean, dry, and intact ,the admission dressing change may be omitted and scheduled for 7 days from the date on the dressing label. 1.2. At least weekly 1.3. If the integrity of the dressing has been compromised (wet,loose,or soiled). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675935 If continuation sheet Page 3 of 5 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 05/25/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 (Residents #4) of 2 residents reviewed for pharmaceutical services. The facility failed to ensure Resident #4 took her medications when they were administered, which resulted in the resident saving the medication in her room. This failure could place residents at risk of not receiving the therapy needed. Findings included: 1. Review of Resident #4's face sheet, dated 05/25/23, revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included essential hypertension (high blood pressure) and depression (mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident #4's MDS assessment, dated 03/24/23, revealed a BIMS score of 09 which indicated her cognition was moderately impaired. Record review of Resident #4's physician order, dated 03/17/23, revealed she had an order for Sertraline HCl oral tablet 50 mg one tablet by mouth daily for depression. Record review of Resident #4's May 2023 MAR revealed Resident #4 was administered Sertraline HCl oral tablet 50 mg one tablet at 8.00 AM. Observation and interview on 05/25/23 at 10:25 AM with Resident #4 revealed Resident #4 had one blue pill on her bed side table and two medication cups lying on her table labeled with Resident #4's room number. Resident #4 stated the nurses left the medication with cups, and she would take the medications when she was ready. Resident #4 stated she was good at taking her medication. She stated she did not know one pill was on the table. She did not want to disclose whether she was left with the medication in the morning during medication pass, she only stated LVN C was a good nurse. Observation and interview on 05/25/23 at 10:33 AM with LVN C revealed a blue pill on the Resident #4's bedside table. LVN C stated the resident should not have any medication in her room. LVN C stated she provided Resident #4's medication that morning, and she did not know who left the pill and the cups in Resident # 4's room. LVN C stated medication should not be left unsupervised or left in the room. She stated the risk of leaving meds was that it could lead to another resident taking it. LVN C stated she had been trained on medication administration. Interview on 05/25/23 at 1:08 PM with the DON revealed her expectation was the nurse should not leave medication in resident rooms unsupervised. The DON stated it was the nurse's responsibility to ensure residents took all the pills before they left the room. She stated the risk of leaving medication unsupervised was other residents could take them which could cause side effects. She stated she had not done any training with staff since she had not experienced the issue of medication being left in the rooms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675935 If continuation sheet Page 4 of 5 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 05/25/2023 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 0755 Record review of facility's current, undated Preparing Medication Administration policy reflected the following: .Nurse or qualified staff should stay with resident until medication have been taken. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675935 If continuation sheet Page 5 of 5