Inspection·September 14, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Head to toe assessment performed when resident returned from dialysis and not apparent injuries noted. [Resident #242] stated he wasn't hurt he wasn't hurt and he didn't hit his head Interview on 09/14/23 at 11:14 AM with the Transportation Aide revealed the day of the incident, 09/07/23, he loaded Resident #242 in the van and buckled him up making sure his wheelchair did not move. As the Transportation Aide was driving, he stated he looked in his rear view mirror and noticed he did not see Resident #242 so he pulled over. He stated he noticed the resident had slid out of his wheelchair. He stated the resident's back was against his wheelchair seat, and the resident was in a seated position. When the Transportation Aide opened the door to the van, he stated he noticed Resident #242 had been sitting on a pillow that was placed in his wheelchair. The Transportation Aide further stated the resident also had a Hoyer sling under him, and he thought the pillow Resident #242 was sitting on must have slid against the Hoyer sling making it slick, causing the resident to slide out of his chair. Interview on 09/14/23 at 2:51 PM with LVN A revealed shortly after Resident #242 was on his way to dialysis, on 09/07/23, she was called and told the resident had slid out of his wheelchair. She stated the Transportation Aide turned the van around and drove back to the facility, and Resident #242 was assisted back into his wheelchair. LVN A noticed the resident did not have a cushion in his wheelchair, and there was a pillow in the seat. LVN A said she also did not know why there was not a cushion in the resident's chair and staff should know better not to use a pillow because it could cause the resident to fall. LVN A said she worked the 2:00 PM-10:00 PM shift and the morning aide, CNA B, would have been aide that got Resident #242 ready for his dialysis appointment. Attempts to contact CNA B on 09/14/23 were unsuccessful. Interview on 09/14/23 at 3:32 PM with the DON revealed she was told Resident #242 had slid out of his wheelchair, and they believed he might not have had the appropriate cushion so they referred the resident over to therapy. The DON stated pillows should not be used in wheelchairs because it was not safe and the pillow could slide. The DON said she believed Resident #242 had put the pillow in the chair himself for comfort, that was why the resident was referred to therapy for a new cushion. The DON later stated she had asked Resident #242 about the pillow, and the resident told her he wanted it there. Interview on 09/14/23 at 12:00 PM with the Director of Therapy revealed she assisted in getting Resident #242 back into his wheelchair after he had slid out of it on his way to dialysis. At the time they were assisting, she noticed the resident had a standard pillow in the seat. The Director of Therapy stated using a pillow as a cushion was not best practice because wheelchair cushions should be used for proper weight distribution and skin issues. After the incident, the resident was given a proper wheelchair cushion so he did not slide out his chair again. Interview on 09/14/23 at 4:49 PM with the Administrator revealed Resident #242 wanted the pillow in the wheelchair, and the residents had rights to their preferences. The Administrator further stated there was no failure because his job was to advocate for the residents and honor their preferences. Interview on 09/14/23 at 5:20 PM with the Administrator revealed they did not have a wheelchair cushion policy that pertained to Resident #242's incident. 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 09/14/2023 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 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 6 (CNA G, CNA H, CNA I, CNA J, CNA K and LVN B) of 16 facility staff reviewed for trainings consistent with their expected roles. Residents Affected - Some 1. The facility failed to provide CNA G, CNA H and LVN B's annual trainings consistent with their expected roles. 2. The facility failed to provide CNA I, CNA J, CNA K's new hire trainings consistent with their expected roles. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings included: Record review of personnel records provided by the HR Manager revealed CNA G with hire date of 07/03/06 did not have any documented evidence in the facility for annual trainings taken on Residents with Dementia, HIV, Fall Prevention, Abuse and Neglect or use of Restraints which was consistent with her expected role. Record review of personnel records provided by the HR Manager revealed CNA H with hire date of 12/19/07 did not have any documented evidence in the facility for annual trainings taken on Residents with Dementia, HIV, Fall Prevention, Abuse and Neglect or use of Restraints which was consistent with her expected role. Record review of personnel records provided by the HR Manager revealed LVN B with hire date of 09/03/15 did not have any documented evidence in the facility for annual trainings taken on Residents with Dementia, HIV, Fall Prevention, Abuse and Neglect or use of Restraints which was consistent with her expected role. Record review of personnel records provided by the HR Manager revealed CNA I with hire date of 06/12/23 did not have any documented evidence in the facility for new hire trainings taken during orientation on Abuse and Dementia which was consistent with her expected role. Record review of personnel records provided by the HR Manager revealed CNA J with hire date of 08/09/23 did not have any documented evidence in the facility for new hire trainings taken during orientation on Abuse and Dementia which was consistent with her expected role. Record review of personnel records provided by the HR Manager revealed CNA K with hire date of 08/16/23 did not have any documented evidence in the facility for new hire trainings taken on Statement of Resident Rights or orientation on Abuse and Dementia which was consistent with her expected role. During an interview and record review on 09/14/23 at 10:40 AM with HR Manager revealed she was recently hired, she was still training, and working to update employee records. The Human Resources Manager stated she only knew of the training she had taken when she was first hired, which was taken on the computer system. The Human Resources Manager stated she was not familiar with how previous (continued on next page) 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 09/14/2023 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 0940 Level of Harm - Minimal harm or potential for actual harm trainings were provided. The Human Resources Manager stated she relied on corporate office to assist her employee records at this time. Human Resources Manager stated she was hired for the Account Payable/Payroll and was told to assist the Human Resources responsibilities, she was not sure who would be responsible for staff training. Human Resources Manager stated not having employee files updated caused residents to be at risk of abuse and neglect. Residents Affected - Some Interview on 09/14/23 at 11:00 AM with the Administrator revealed the facility was not able to provide evidence of annual trainings. According to the Administrator he arrived to the facility in December 2022, he finally had a person in the role of Human Resources Manager as of April 2023. The Administrator stated he was unaware employee files did not include annual trainings, he expected employee files to include annual trainings and up to date information. The Administrator stated it was the responsibility of the Human Resources Manager and education department to ensure trainings are up to date. The Administrator stated when staff are not up to date on trainings it puts residents at risks of receiving proper care. Review of the facility's Education and Training Requirements policy revised 03/28/23 reflected the following: The facility will maintain an effective in-service and orientation program for all associates. A facility must develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. A facility must determine the amount and types of training necessary based on a facility assessment. The Staff Development Coordinator or designee plans and directs an effective orientation, training, and evaluation program. Competencies and skill sets will for all new and existing staff, must be consistent with their expected roles. The facility will need to ensure staff are trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program. The following training requirements should be met prior to associates and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment . Abuse, neglect, and exploitation Activities that constitute abuse, neglect, exploitation, and misappropriation Procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation (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 09/14/2023 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 0940 Dementia management and resident abuse prevention Level of Harm - Minimal harm or potential for actual harm An individual training record is maintained for each associate to include: Date of each training class attended Residents Affected - Some Subject of the class Instructor of the class All training records will be made available to Federal and State surveyors upon request. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675935 If continuation sheet Page 5 of 5