Health inspection·July 3, 2025

F 0552 7/3/25 at 5:50 PM the Administrator was unable to supply a policy on Consents prior to exit. He stated he did not think there was a policy addressing consents specifically. 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: 676080 If continuation sheet Page 2 of 27 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Arlington, Inc. 824 W Mayfield Rd Arlington, TX 76015 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 - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and comfortable interior for 1 of 21 residents (Residents #48) reviewed for environment. The facility failed to ensure Residents #48's bed curtain was free from a dried brown substance. This failure could affect any resident and place them at risk for not having a sanitary homelike environment. Findings included: Record Review of Resident #48's Quarterly MDS, dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #48's MDS also reflected diagnoses of non-Alzheimer's dementia (a range of neurodegenerative and other disorders that cause cognitive decline, distinct from Alzheimer's disease), anxiety, and chronic kidney disease stage 2 (signifies a mild decrease in kidney function alongside evidence of kidney damage). Resident #48's MDS also reflected a BIMS of 6 (meaning severe cognitive impairment). Resident #48's MDS also reflected Resident #48 required supervision for ADL's. Observation and interview on 07/01/25 at 10:37 AM with CNA H of Resident #48's room revealed the privacy curtain had a dried brown substance on it. The substance area was approximately .5 cm x 1 cm. CNA H stated that it was her responsibility to tell maintenance when a resident's privacy curtain became dirty. CNA H said that when aides reported dirty privacy curtains to maintenance, maintenance would remove the dirty privacy curtains and take them to the laundry. CNA H revealed it was important to keep residents' privacy curtains clean to help prevent infections. CNA H stated that the facility policy was to keep privacy curtains clean and when resident's privacy curtains became dirty, staff were to report it to the maintenance director. Observation on 07/02/25 at 04:03 PM of Resident #48's room revealed the privacy curtain had a dried brown substance on it. The substance area was approximately 0.5 cm x 1 cm. Interview on 07/02/25 at 04:14 PM with LVN I revealed that dirty privacy curtains should be reported to the maintenance department who would take the curtain down and send it to the laundry. LVN I stated the importance of clean privacy curtains was to prevent infection and ensure residents' dignity. LVN I said it was all staff's responsibility to report dirty privacy curtains. Interview on 07/03/25 at 9:28 AM with the facility Director of Maintenance/Housekeeping revealed soiled privacy curtains should be reported to him. The Director of Maintenance/Housekeeping stated that when dirty privacy curtains were reported to him, he would ensure that they were removed, washed, and hung back up the same day. The Director of Maintenance/Housekeeper said that it was everyone's responsibility to report soiled curtains. He also said that if the curtains are not reported, the resident would have to continue to view the dirty curtains. The Director of Maintenance/Housekeeper revealed that no one had reported the dirty curtains to him. Interview on 07/03/25 at 9:46 AM with CNA J revealed that staff should report to their nurse if they saw a dirty privacy curtain. CNA J stated that the importance of clean curtains was for good health and avoid the spread of germs. CNA J said that when the maintenance department got the request, they should remove dirty privacy curtains, wash them, and hang them back up. CNA J stated that if the nurse would not report the dirty curtains to the maintenance department, she would notify her ADON. Interview on 07/03/25 at 10:41 AM with the Housekeeper revealed that if she saw a dirty privacy curtain, she would report it to her supervisor. Interview on 07/03/25 at 12:43 PM with Resident #48 revealed that the dirty privacy curtain did not interrupt her daily life. Resident #48 stated that she didn't see well, so she could not see the brown substance on her privacy curtain. Record Review of the facility's Use of Privacy Curtains in Resident Rooms policy, undated, reflected: .Procedures .5. Infection Control-Curtains must be laundered or replaced according to infection control guidelines (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676080 If continuation sheet Page 3 of 27 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Arlington, Inc. 824 W Mayfield Rd Arlington, TX 76015 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 or immediately if soiled 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: 676080 If continuation sheet Page 4 of 27 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Arlington, Inc. 824 W Mayfield Rd Arlington, TX 76015 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 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure there were physician orders for a resident's immediate care at the time the resident was admitted for 1 of 5 (Resident #49) reviewed for admission orders.The facility failed to obtain physician orders for Resident #49's immediate care when he admitted to the facility on [DATE] with a Stage 2 pressure ulcer on his coccyx, which resulted in the resident not receiving physician-ordered wound treatment from 06/02/25-06/24/25 and the Stage 2 pressure ulcer worsening to a Stage 4. An IJ was identified on 07/02/25. The IJ template was provided to the facility on [DATE] at 4:10 PM. While the IJ was removed on 07/03/25, the facility remained out of compliance at a scope of isolated and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems.The failure placed residents at risk for medical complications, wound deterioration, infection, and death. Record review of Resident #49's admission MDS assessment, dated 06/09/25 and signed off as completed by the DON on 06/15/25, reflected the resident was a [AGE] year-old male, who admitted to the facility from the hospital on [DATE]. The resident's active diagnoses included malnutrition, pneumonia, respiratory failure, anxiety disorder, essential hypertension (high blood pressure), and generalized muscle weakness. Resident #49 had moderate cognitive impairment with a BIMS score of 11. The resident required supervision or touching assistance with eating, and he had an admission weight of 128 pounds. The resident required substantial/maximal assistance with toileting hygiene, and he was frequently incontinent of bowel and bladder. The MDS further reflected the resident admitted to the facility with one Stage 2 pressure ulcer, and he was supposed to have pressure ulcer/injury care and a pressure reducing device for bed.Record review of Resident #49's Clinical Admission Initial Assessment, dated 06/02/25, completed by RN L reflected the following questions were answered: .24. Skin Issue - Pressure ulcer/Injury27. Pressure ulcer staging - Stage 2 Pressure Ulcer/Injury: Partial thickness skin loss with exposed dermis[BR5] [LO6] (the skin)35. Acquired - Present on admission36. Onset - Unknown46. Presence of wound pain - No53. Staged by: In-house nursing59. Length (cm) - 360. Width (cm) - 561. Depth (cm) - 0 Record review of Resident #49's Progress notes on 06/02/25 21:50 by LVN K reflected the following Skin: Skin warm & dry, skin color WNL and turgor (skin's elasticity) is normal. Skin Issue: #001: New skin Issue. Location: Coccyx (the final segment of the vertebral column). Laterality / Orientation: Medial (closer to the midline of the body). Issue type: Pressure ulcer / injury. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound was present on admission. It is unknown how long the wound has been present. Painful: No. Staged by: In-house nursing. Length (cm): 3 Width (cm): 5 Depth (cm): 0#002: New skin Issue. Location: Left antecubital space (the triangular area on the inner side of the left elbow). Additional location information: Bruises Issue type: Bruising (contusion). Wound was present on admission. It is unknown how long the wound has been present.#003: New skin Issue. Location: Right anterior (nearer the front) elbow. Laterality / Orientation: Right. Additional location information: Bruises Issue type: Bruising. Wound was present on admission. It is unknown how long the wound has been present. Record review of Resident #49's Progress notes from 06/02/25 through 06/24/25 by LVN K, RN L, LVN M, RN Z, and LVN AA reflected the following notes: Skin: Skin Issue: #001: Skin issue has not been evaluated. Location: Coccyx. Laterality / Orientation: Medial. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound was present on admission. It is unknown how long the wound has been present. Staged by: In-house nursing. #002: Skin issue has not been evaluated. Location: Left antecubital space. Additional Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676080 If continuation sheet Page 5 of 27 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Arlington, Inc. 824 W Mayfield Rd Arlington, TX 76015 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 0635 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few location information: Bruises Issue type: Bruising. Wound was present on admission. It is unknown how long the wound has been present. #003: Skin issue has not been evaluated. Location: Right anterior elbow. Laterality / Orientation: Right. Additional location information: Bruises Issue type: Bruising. Wound was present on admission. It is unknown how long the wound has been present. There was no documentation of Wound Care Physician, Nurse Practitioners were made aware of Resident #49's pressure wound. No documentation of any wound care provided to Resident #49.Record review of Resident #49's Nurse Practitioner Visit Notes dated 06/10/25 reflected: Chief complaint - Skilled care visit - Nurse reports abnormal lab results and request to review lab.Review of systems: Skin - neg for rash Objective: Physical Examination: Skin: Warm and Dry. There was no documentation in the Nurse Practitioner's notes reflecting the resident's pressure ulcer was observed. Record review of Resident #49's Initial Wound Evaluation & Management Summary dated 06/25/25 reflected the following exam completed: Stage 4 Pressure Wound Sacrum full thickness - Etiology (quality) Pressure, Stage 4, Wound Size (L x W x D): 4.0 c 4.0 x 0.8 cm. Surface Area: 16.00cm2. Infection Assessment: No sign(s) of infection. Record review of Resident #49's Physician's orders dated 06/25/25 reflected the following orders: Zinc Oral Tablet 50 MG (Zinc) Give 1 tablet by mouth in the evening for wound care for 2 Weeks until wound heals - Start date 06/25/25Wound treatment plan to the sacrum: clean with NS or wound cleanser, pat dry, apply sodium hypochlorite gel (anasept), collagen powder, cover with gauze island w/bdr once daily, every day shift for wound care. - Start Date 06/26/2025Beneprotein Oral Powder (Protein) Give 7 gram by mouth two times a day for WOUND CARE for 90 Days - Start date 06/26/2025. Resident #49 had no medication or treatment orders for his wound from 06/02/25 - 06/25/25. Record review of Resident #49's June 2025 MAR/TAR reflected wound care medication started on 06/25/25 and wound care treatment started on 06/26/25. There was no documentation of wound care treatment provided to Resident #49 from 06/02/25 - 06/25/25.Record review of Resident #49's care plan, revised on 06/27/25, reflected Focus: Resident has current Skin Concerns: Pressure Ulcer on sacral area. Goal: Areas will heal without complications over the next 90 days. Interventions: Assess skin weekly and record findings in clinical record. Perform treatments per order, if no improvement x 2 weeks-report to MD. Provide pressure relieving and positioning devices as needed. Care Plan revised on 07/01/25, reflected: Focus: Resident has a Pressure Area: Stage: 4 (characterized by full-thickness tissue loss, exposing muscle, tendon, or bone) Location: SACRUM (large, triangular bone at the base of the spine that forms the back wall of the pelvis.) TX: Sodium hypochlorite gel (anasept) apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days; Collagen powder apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Goal: Resident will have improved skin integrity as evidenced by a decrease in size and depth of pressure area during the next 90 days. Interventions: Keep family/responsible party and MD informed of resident's progress. Monitor labs and report abnormals to MD. Record review of Resident #49's Wound Evaluation & Management Summary dated 07/02/25 reflected the following exam completed: Stage 4 Pressure Wound Sacrum full thickness Etiology (quality) Pressure, Stage 4, Wound Size (L x W x D): 4.0 c 4.0 x 0.8 cm. Surface Area: 16.00cm2. Infection Assessment: No sign(s) of infection. Observation and interview on 07/02/25 at 8:51 AM revealed Resident #49 in bed and awake. Observed Resident #49 to be on a pressure relieving mattress. Resident #49 stated he had been at facility for about 2-3 weeks. Resident #49 stated he had a pressure sore on his bottom. He stated he was not sure if he admitted with the wound or if it developed at the facility. Resident #49 stated he had been seen by the wound care doctor twice since being admitted . Resident #49 stated he was seen by the wound care doctor last week unknown of exact date and today (07/02/25). He stated prior to being seen by the wound care doctor he was not receiving any treatment for his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676080 If continuation sheet Page 6 of 27 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Arlington, Inc. 824 W Mayfield Rd Arlington, TX 76015 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 0635 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few wound. Resident #49 stated he never refused any treatment. Resident #49 stated he had pain but was getting pain medication. Interview by phone on 07/02/25 at 10:51 AM, LVN K revealed Resident #49 admitted to her hall. She stated when Resident #49 admitted to the facility she completed a skin assessment and noted a wound on his bottom. She stated the facility's process of when a resident admitted to the facility was the admitting nurse was responsible for completing the skin assessment and if the resident admitted with a wound the admitting nurse must notify the ADON and the ADON would notify the Wound Care Physician. LVN K stated the Wound Care Physician visits=ed twice a week, and Resident #49 had been seen by the Wound Care Physician, unknown date. She stated she was not sure if Resident #49's treatment was completed during the morning shift or afternoon shift. She stated she could not recall if she provided any treatments during her shift. She stated she could not recall if treatment orders were obtained for his wound upon admission or if the physician was notified. Interview by phone on 07/02/25 at 10:57 AM, RN L revealed she only worked at the facility during the weekends. RN L stated she could not recall admitting Resident #49 and could not recall any wounds or what wound care Resident #49 required. Interview on 07/02/25 at 11:01 AM ADON A/Wound Care Coordinator revealed the process of when a resident admitted to the facility, the admitting nurse must complete a head-to-toe assessment. If wounds were present upon admission, the admitting nurse must complete a communication form, put it in her box and she was responsible for contacting the Wound Care Physician. ADON A stated the nurses were responsible for completing wound care treatments for residents. She stated she was responsible for contacting the Wound Care Physician and completing rounds when the Wound Care Physician visited every Wednesday. She stated every Wednesday before the Wound Care Physician visited, she completed rounds and would ask all the nurses if they had any admitting residents with wounds. She stated Resident #49 admitted to the facility with a wound on his sacrum. ADON A reviewed Resident #49's clinical records and stated Resident #49 was first seen by the Wound Care Physician on 06/25/25 and received treatment orders the same day. ADON A stated based on documentation it did not seem Resident #49 received any wound care treatment. ADON A stated there was a gap from the time Resident #49 admitted until he was seen on 06/25/25 by the Wound Care Physician. ADON A stated Resident #49 admitted to the facility on [DATE] which was a Monday, and the Wound Care Physician would have visited Wednesday, and the reason Resident #49 was not seen was because Resident #49 did not show up in the Wound Care Physician's computer system, and the nurses were told to continue standing treatment orders. ADON A stated if nurses were not able to obtain attending physician's orders for wound care the facility had in-house standing treatment order dry dressing and should be uploaded in the resident's chart. ADON A reviewed Resident #49's discontinued orders and stated in-house standing treatment orders were not put in the system. ADON A stated she was not sure if Resident #49 received any treatment prior to being seen by the Wound Care Physician. She stated she visited Resident #49, but did not document her visit. She stated she would monitor her nurses when the nurses would ask her for wound care supplies, then she would complete a supply count and the count wound be accurate. ADON A stated when nurses would ask her for wound care supply, she would not question the nurses who the supplies were used for. ADON A stated she never obtained a communication form from the admitting nurse who admitted Resident #49, and she did not follow up because she was not aware of the wound. ADON A stated nurses should not measure the wounds and should not stage the wounds because the measurements could be wrong. ADON A stated she was not aware RN L staged and measured Resident #49's pressure wound. She stated the Wound Care Physician was notified of Resident #49's pressure wound. However, she could not recall the exact date, but it was a day or two before Resident #49 was seen by the Wound Care Physician on 06/25/25.Interview on 07/02/25 at 12:35 PM, LVN M revealed she was on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676080 If continuation sheet Page 7 of 27 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Arlington, Inc. 824 W Mayfield Rd Arlington, TX 76015 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 0635 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few leave when Resident #49 admitted to the facility, and she had returned to work on 06/09/25 morning shift. She stated she could not recall the exact date, but it was the week when Resident #49 was seen by the Wound Care Physician on 06/25/25 when she was notified of the pressure wound. She stated CNA J notified her of the wound on Resident #49's sacrum area. When CNA J was providing Resident #49 incontinent care, Resident #49 dressing came off and CNA J needed her to put a new dressing on. She stated she was not aware of the pressure wound. She stated she cleaned it and put a new dressing on. She stated when she cleaned the wound it did not appeared infected, no drainage was noted and had no odor to it. She stated she immediately went and notified ADON A. She stated there should had been orders in the system but there were no treatment orders in the resident's clinical chart when she reviewed it. She stated the facility had standing treatment orders, but she could not recall if any orders were put in the system. LVN M stated she did not put any orders in the system when she cleaned the wound. She stated if it was not documented it did not happen and it was her mistake for not putting the standing treatment orders in the system. She stated the process of when a new resident admitted to the facility the admitting nurse should complete skin assessment, notify the ADON A, obtain orders and put them in the system. LVN M stated prior to CNA J notifying her of the wound, she was never told or received any report from any staff regarding the wound. She stated she never provided any wound care to Resident #49 during her shift until the day CNA J asked her to put a new dressing on. She stated she completed a skin check on Resident #49 and had not noticed the wound; however, Resident #49 would refuse to be checked. She stated it was her mistake for not documenting the refusal. She stated the potential risk of not providing wound care treatment would be infections. She stated it was not good quality of care. Interview on 07/02/25 at 1:27 PM, CNA J revealed she could not recall the exact date, but she was providing Resident #49 incontinent care when his wound dressing had come off. She stated prior to proving the incontinent care Resident #49 had the dressing on his sacrum. She stated when the dressing came off, she notified LVN M and LVN M cleaned the wound and put a new dressing on him. She stated that was the first time she was assigned to Resident #49. She stated she was not aware of the wound until she provided incontinent care. Interview on 07/02/25 at 1:39 PM, ADON B revealed she was working when Resident #49 admitted to the facility. She stated Resident #49 admitted to the facility with a wound on his sacrum and nursing staff were using the standing orders to clean and cover the wound until he was seen by the Wound Care Physician. ADON B stated the admitting nurse was responsible for putting in standing orders in the system and completing a communication form to request wound care for residents to the ADON A. She stated the admitting nurse failed to communicate to ADON A to put Resident #49 on the list to be seen by the Wound Care Physician. ADON B stated LVN M had just resumed her job duty from being on leave and was completing skin assessments on residents when she noticed Resident #49's wound. She stated LVN Y was the nurse assigned to Resident #49 before LVN M returned to work. She stated LVN Y was providing wound care treatment to Resident #49, but it was unknown if it was documented. She stated if the ADON A was not notified of Resident #49's pressure wound then the Wound Care Physician was not notified. She stated the potential risk of not providing any wound care treatment would be infection. Interview on 07/02/25 at 2:00 PM, the DON revealed her expectation for when a resident admitted to the facility was the admitting nurse should complete a skin assessment. If a resident admitted with a wound, the admitting nurse should obtain treatment orders either form the doctor, hospital records or the in-house standing orders and should be put in the system. She stated the nurses should also complete a communication form and provide it to ADON A, and ADON A would place the resident's name on the list to be seen by the Wound Care Physician. The DON stated when Resident #49 was being provided with incontinent care, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676080 If continuation sheet Page 8 of 27 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Arlington, Inc. 824 W Mayfield Rd Arlington, TX 76015 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 0635 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few resident had a dressing on the sacrum, and it fell off. She stated the nurse put a new dressing on and reported the wound to ADON A. The DON stated the admitting nurse for Resident #49 had not communicated Resident #49 had a wound. She stated she was not aware Resident #49's wound was staged and measured upon admission. She stated wound care treatment was provided to Resident #49; the nurses were using the standing orders, but the standing orders were not put in the system. She stated she was not aware there was no documentation in Resident #49's clinical chart. The DON stated she expected her nurses to put physician orders in the resident clinical chart/system. The DON stated Resident #49's wound was getting better and had no signs of infection. She stated her staff failed to put treatment orders in the system and failed to communicate to ADON A. She stated the Wound Care Physician was not notified until the ADON A was notified of the wound. She stated the potential risk would be infection. Interview on 07/02/25 at 2:06 PM with CNA N revealed she was the CNA assigned to Resident #49 when he was on the 100 Hall. She stated every time she would provide incontinent care to Resident #49, he had a dressing on his bottom. She stated Resident #49 admitted to the facility with a wound. CNA N stated during the morning shift, LVN M would change the wound dressing on Resident #49. She stated Resident #49 always had a dressing on his wound. She stated the nursing staff were aware of Resident #49's sacrum wound. An attempt was made on 07//02/25 at 2:33 PM to interview LVN Y by phone but was unsuccessful. Interview by phone on 07/02/25 at 3:00 PM, the Wound Care Physician stated if a resident admitted with a wound, he expected the Attending Physician or Nurse Practitioner to see the resident and write initial wound care orders, and to add him as an attending. If the resident had hospital orders that included wound orders, staff could follow those orders. ADON A would text him with a new resident's information prior to his next visit. He did not give any standing orders for wound care due to the liability, but he would allow ADON A to start treatment because he had worked with her for many years. He stated he was not aware of Resident #49's wound until he saw him on 6/25/25. He stated all wounds were considered colonized with a bacterium of some form, but that did not mean it was infected. If the wound was not healing, then it would be considered infected. Resident #49's wound was healing so he did not consider it to be infected. Interview on 07/02/25 at 3:13 PM, the Nurse Practitioner revealed she was not made aware of Resident #49's pressure wound when she visited the resident on 06/10/25. She stated she visited Resident #49 and completed an assessment, but she did not inspect the resident's back because she was not aware of the wound. She stated since she was not made aware of the wound no treatment orders were provided. She stated she could not recall the exact date, but she was notified by the DON that Resident #49's wound had worsened and that the Wound Care Physician had been notified and provided treatment orders. She stated when a resident admits to the facility with a wound her expectations were to be notified and for nurses to obtain orders. She stated if a resident had not been seen by the Wound Care Physician or the nurses were not able to get ahold of the Wound Care Physician, the ADON normally would notify her, and she would provide treatment orders. Interview on 07/02/25 at 3:51 PM, the Administrator revealed wound care questions were more of a clinical nursing aspect, but his expectations were for the nurses to assess the wound and notify the Wound Care Physician. The Administrator expected nursing staff to follow treatment orders and to document any care that the resident was being provided with. Record review of facility policy Significant Change in Resident's Status undated reflected the following: It is the policy of this organization that this facility immediate inform the resident, consult with the resident physician, and if knows notifies the resident's legal representative or an interested family when there is: .C. Need to alter treatment significantly (this is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment.4. Deterioration in a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676080 If continuation sheet Page 9 of 27 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Arlington, Inc. 824 W Mayfield Rd Arlington, TX 76015 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 0635 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few resident's health status, where this change: places the resident's life in danger. is associated with a serious clinical complication, e.g., initial development of stage III or stage IV pressure ulcer.When any of the above occurs the attending physician, the resident and/or responsible party and/or legal representative and/or interested family member is notified. Document is made in the Nurses Notes and the Resident Assessment Instrument, and the Comprehensive Care Plan is updated to reflect the changes This was determined to be an Immediate Threat (IT) on 07/02/25 at 4:02 PM. The Administrator and DON were notified. The Administrator was provided with the IT template on 07/02/25 at 4:10 PM. The Facility's Plan of Removal for Immediate Threat was accepted on 07/02/25 at 6:32 PM and reflected the following: Date of IJ Determination: 07/02/2025 Immediate Corrective Actions Taken Physician Notification for Identified ResidentAs of 07/02/2025, the resident identified in the IJ was immediately assessed by the Director of Nursing. The resident's attending physician and the Wound care Physician were immediately consulted, and updated treatment orders were obtained to address the resident's wound and overall plan of care. Chart Review for Timely Physician NotificationA comprehensive audit of all admissions and current residents with significant changes in physical status was completed on 07/02/2025 to ensure physician notification occurred as required. Any instances lacking documented physician notification were immediately corrected by contacting the respective physician and updating the medical records.Immediate Staff EducationOn 07/02/2025, all licensed nurses received in-service training on:- Recognizing and defining significant changes in resident condition.- The requirements for immediate physician consultation upon identification of significant changes.- Accurate and timely documentation of physician notifications and resulting orders.Staff sign-in sheets and education materials are maintained for verification. Process ChangesA Physician Notification Protocol has been implemented requiring nurses to notify the physician within 1 hour of identifying a significant change in a resident's condition, including the development or worsening of pressure ulcers.A physician notification from was created to document:-The date and time change identification.-The date and time of physician notification.-Physician response and orders.admission protocols were updated to require physician notification within 24 hours for all residents admitted with pressure ulcers or other significant health conditions. Ongoing MonitoringThe Director of Nursing or designee will conduct daily audits of residents with significant changes in condition to confirm timely physician notification and documentation.Weekly audits of 10% of resident charts will be performed for 3 months to ensure compliance with the physician notification protocol. Quality Assurance and OversightPhysician notification compliance will be a standing agenda item at the facility monthly Quality Assurance Performance Improvement (QAPI) meeting for at least 3 months. Audit results and corrective actions will be reviewed by the Administrator and Medical Director. How the Plan Removes the Immediate JeopardyImmediate assessment and physician consultation for the identified resident ensures appropriate and timely medical oversight, mitigating current risk. Staff education and protocol changes ensure future prompt physician notification for any significant changes, reducing the risk of delayed treatment. Ongoing audits and oversight confirm sustained complaint, preventing recurrence of the issue and ensuring resident rights are protected. Date IJ was Corrected:We believed the Immediate Jeopardy was removed on 07/02/2025, the date corrective actions were implemented. Ensuring Staff Not Present Received TrainingAll nursing staff who are not present on 07/02/2025 for the in-services training will receive a make-up in-service by the Staff Development Nurse within 5 calendar days of returning to work, and before providing direct resident care. Completing will be tracked on a staff education log. Implementation Date for Physician Notification Protocol:The updated Physician Notification Protocol was implemented on 07/02/2025, the same day as the initial corrective actions. Title of Staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676080 If continuation sheet Page 10 of 27 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Arlington, Inc. 824 W Mayfield Rd Arlington, TX 76015 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 0635 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Conducting Audit and In-Service:The Director of Nursing (DON) conducted the comprehensive char audit for physician notifications.The Staff Development Nurse (SDN) provided the in-service training on physician notification requirements. Electronic In-Service Distribution and Acknowledgement:Nursing staff who are not present for in-person in-services will receive the training materials electronically through the facility's secure communication platform within 5 calendar days of returning to work. Staff will be required to review the material and electronically signs and acknowledgements from confirming their understanding. Record of completion and acknowledgements will be maintained by the Staff Development Nurse and made available for surveyor review. In-Service: Recognizing Significant Changes & Physician NotificationObjective: Train nursing staff to recognize significant changes in resident condition, promptly notify the physician, and properly document the process to ensure timely treatment and protect resident rights. Agenda: Defining Significant Change - Examples: new/worsening wounds, sudden mental status changes, falls with injury, acute infections, uncontrolled pain. Timeframes for Physician Notification - Immediate vs. urgent vs. routine notification standards - Facility policy on notifying the physician within 1 hour of significant changes. Documentation of Notification - How to complete the physician notification form. - Documenting date/time of change, date/time of call, physician response. Communication Best Practices - SBAR (Situation, Background, Assessment, Recommendation) approach when calling providers. - Tips for effective and concise communication Policy & Procedure Review- Physician notification protocol - Review of facility admission protocols requiring physician notification. Q&A Session Materials: Physician notification form Updated physician notification policyCompetency Validation: Staff sign-in sheet Charting exercise: completing a sample physician notification form Electronic In-Service Distribution and Acknowledgement:Nursing staff who are not present for in-person in-services will receive the training materials electronically through the facility's secure communication platform within 5 calendar days of returning to work. Staff will be required to review the material and electronically signs and acknowledgements from confirming their understanding. Record of completion and acknowledgements will be maintained by the Staff Development Nurse and made available for surveyor review. Monitoring of the facility's Plan of Removal included the following: Record review of a facility in-service training report for facility nurses across all shifts dated 07/02/25 reflected the following: Skin Issues on Admission. Protocol: Do a thorough assessment. 1) Document. Initially nurses are not to measure unless you're a wound care certified nurse. 2) Make sure there is a treatment ordered. (Hospital order, standing order or MD/NP order) Fill up a communication form and submit it to the Wound Care Nurse (ADON) for Dr. (Name) (Wound MD) to look at on his next visit. Document everything! Do Skin assessments every week! Notification of MD for worsening wounds if it's not documented it's not done!! Record review of a facility in-service training report for facility nurses across all shifts dated 07/02/25 reflected the following: Accurate and timely wound assessment and documentation. The requirement for immediate physician notification for wounds at admission or with signs of worsening. Proper initiation for treatment orders for wounds. Staff sign-in sheets and education materials are maintained for verification. Record review of the facility QAPI meeting revealed the facility medical director was notified by the director of nurses of the immediate jeopardy via phone while in attendance with the facility administrator on 07/02/25. Record review of the facility admission Wound Assessment Checklist form reflected on 07/02/2025 the form included the name of the resident, date of admission, wound treatment, MD Notified, notes. Record review of the facility Weekly Audit tool blank form revealed it included the date, resident, treatment, and documentation in PCC. Record review of the facility Communication Form revealed it must include information pertaining the resident, new admission/readmission, indicate which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676080 If continuation sheet Page 11 of 27 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Arlington, Inc. 824 W Mayfield Rd Arlington, TX 76015 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 0635 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete department it applied to and to include message/comments. Record review of the facility Physician notification Form undated, reflected staff should provide the date and time change identification, the date and time of physician notification and Physician response and orders. Record review of the Facility SBAR (Situation, Background, Assessment, Recommendation) reflected staff should document when a change of condition occurred and when the provider was notified. Record review of Resident #49's progress noted dated 07/02/25 by the DON reflected Pressure wound on sacrum assess with wound MD. Stage 4 full thickness. Wound size (LxWxD) 4.0x3.5x0.8 cm Surface area = 14, exudate - Moderate serous (clear fluid drainage from a wound). Wound has improved since last visit as evidence by decrease surface area. No signs of infection noted. Treatment review with physician. No changes made at this time. Resident remains on air mattress. No c/o pain but instructed to call the nurse if he has pain. PRN pain medication ordered. Dietician made aware of the nutritional consult for the resident. Staff instructed to turn and reposition resident Q 2 hours. Call light within reach. Record review of Skin Assessments revealed they were completed on 07/02/25 for all 73 residents. The assessments indicated any skin concerns and the location of the skin concerns. Record review of a facility in-service training report for facility nurses across all shifts dated 07/03/25 reflected the following: On wound assessment on admission, the Admitting Nurse is required to document the following: 1. Wound measurements. 2) Notification of the physician w/in 24 Hrs. of identification. 3) Initiation of wound treatment per protocol or physician order. 4) A standing protocol has been established requiring automatic wound consult for any Stage 2 Event ID: Facility ID: 676080 If continuation sheet Page 12 of 27 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Arlington, Inc. 824 W Mayfield Rd Arlington, TX 76015 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 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for one of five residents (Resident #49) reviewed for pressure ulcers.The facility staff failed to notify the Wound Care Physician of Resident #49's Stage 2 pressure ulcer on his coccyx upon admission. Resident #49 was not provided with wound care treatment from 06/02/25 06/25/25 which resulted in resident's pressure ulcer worsening from a Stage 2 to a Stage 4. An IJ was identified on 07/02/25. The IJ template was provided to the facility on [DATE] at 4:10 PM. While the IJ was removed on 07/03/25, the facility remained out of compliance at a scope of isolated and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems.These failures could place residents at risk for new development or worsening of existing pressure injuries, pain, decreased quality of life, and hospitalization.Findings included: Record review of Resident #49's admission MDS assessment, dated 06/09/25 and signed off as completed by the DON on 06/15/25, reflected the resident was a [AGE] year-old male, who admitted to the facility from the hospital on [DATE]. The resident's active diagnoses included malnutrition, pneumonia, respiratory failure, anxiety disorder, essential hypertension (high blood pressure), and generalized muscle weakness. Resident #49 had moderate cognitive impairment with a BIMS score of 11. The resident required supervision or touching assistance with eating, and he had an admission weight of 128 pounds. The resident required substantial/maximal assistance with toileting hygiene, and he was frequently incontinent of bowel and bladder. The MDS further reflected the resident admitted to the facility with one Stage 2 pressure ulcer, and he was supposed to have pressure ulcer/injury care and a pressure reducing device for bed. Record review of Resident #49's Clinical Admission Initial Assessment, dated 06/02/25, completed by RN L reflected Resident #49 admitted to the facility with a Stage 2 pressure ulcer that measured 3.0 cm x 5.0 cm x 0.0 cm. Record review of Resident #49's Progress Notes written by LVN K, dated 06/02/25 at 9:50 PM, reflected the following: Skin: Skin warm & dry, skin color WNL and turgor (skin's elasticity) is normal. Skin Issue: #001: New skin Issue. Location: Coccyx (the final segment of the vertebral column). Laterality / Orientation: Medial (closer to the midline of the body). Issue type: Pressure ulcer / injury. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound was present on admission. It is unknown how long the wound has been present. Painful: No. Staged by: In-house nursing. Length (cm): 3 Width (cm): 5 Depth (cm): 0. Record review of Resident #49's Progress notes from 06/02/25 through 06/24/25 by LVN K, RN L, LVN M, RN Z, and LVN AA reflected they all used the same note in all their entries regarding Resident #49's pressure ulcer: Skin: Skin Issue: #001: Skin issue has not been evaluated. Location: Coccyx. Laterality / Orientation: Medial. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound was present on admission. It is unknown how long the wound has been present. Staged by: In-house nursing.There was no documentation in Resident #49's Progress Notes reflecting the Physician, Nurse Practitioner, or the Wound Care Physician had been made aware of Resident #49's pressure ulcer. There was also no documentation in the Progress Notes reflecting Resident #49 was receiving wound care nor was there documentation reflecting the resident was on a low air loss mattress. Record review of Resident #49's Nurse Practitioner Visit Notes dated 06/05/25 reflected the resident had a diagnosis of protein calorie malnutrition prior to his admission the facility in the hospital on [DATE]. Regarding the resident's skin, the Nurse Practitioner documented: .Physical Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676080 If continuation sheet Page 13 of 27 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Arlington, Inc. 824 W Mayfield Rd Arlington, TX 76015 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 - Immediate jeopardy to resident health or safety Residents Affected - Some Examination.Skin: No visible skin lesions or rashes noted in exposed BUE or BLE. There was no documentation in the Nurse Practitioner's notes reflecting the resident's pressure ulcer was observed nor was there an order for care/treatment of the pressure ulcer.Record review of Resident #49's Care Plan, initiated on 06/09/25, reflected Resident #49 was at risk for weight loss as evidenced by being a new admission and consuming less than 25% of meals with a poor appetite. Care Plans, initiated on 06/21/25, reflected: Resident #49 was at risk for skin breakdown; the resident had ADL deficits to include bed mobility, transfers, eating, toilet use, dressing, personal hygiene, and bathing; and the resident was incontinent of bowel and bladder. Record review of Resident #49's Initial Wound Evaluation & Management Summary dated 06/25/25 reflected the following exam completed: Stage 4 Pressure Wound Sacrum full thickness - Etiology (quality) Pressure, Stage 4, Wound Size (L x W x D): 4.0 c 4.0 x 0.8 cm. Surface Area: 16.00cm2. Infection Assessment: No sign(s) of infection. Record review of Resident #49's Physician's Orders dated 06/25/25 reflected the following orders were initiated to treat Resident #49's pressure ulcer as follows: Zinc Oral Tablet 50 MG (Zinc) Give 1 tablet by mouth in the evening for wound care for 2 Weeks until wound heals - Start date 06/25/25 Wound treatment plan to the sacrum: clean with NS or wound cleanser, pat dry, apply sodium hypochlorite gel (anasept), collagen powder, cover with gauze island w/bdr once daily, every day shift for wound care. - Start Date 06/26/2025 Beneprotein Oral Powder (Protein) Give 7 gram by mouth two times a day for wound care for 90 Days - Start date 06/26/2025. Resident #49 had no medication or treatment orders for his wound from 06/02/25 - 06/25/25. Record review of Resident #49's June 2025 MAR/TAR reflected wound care medication started on 06/25/25 and wound care treatment started on 06/26/25. There was no documentation of wound care treatment provided to Resident #49 from 06/02/25 - 06/25/25. The June 2025 TAR also reflected the resident was placed on a low air loss mattress starting on 06/27/25 to address wound healing for the pressure ulcer. Record review of Resident #49's care plan, revised on 06/27/25, reflected: Focus: Resident has current Skin Concerns: Pressure Ulcer on sacral area. Goal: Areas will heal without complications over the next 90 days. Interventions: Assess skin weekly and record findings in clinical record. Perform treatments per order, if no improvement x 2 weeks-report to MD. Provide pressure relieving and positioning devices as needed. Care Plan revised on 07/01/25, reflected: Focus: Resident has a Pressure Area: Stage: 4 (characterized by full-thickness tissue loss, exposing muscle, tendon, or bone) Location: SACRUM (large, triangular bone at the base of the spine that forms the back wall of the pelvis.) TX: Sodium hypochlorite gel (anasept) apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days; Collagen powder apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Goal: Resident will have improved skin integrity as evidenced by a decrease in size and depth of pressure area during the next 90 days. Interventions: Keep family/responsible party and MD informed of resident's progress. Monitor labs and report abnormals to MD. Record review of Resident #49's Wound Evaluation & Management Summary dated 07/02/25 reflected the following exam completed: Stage 4 Pressure Wound Sacrum full thickness - Etiology (quality) Pressure, Stage 4, Wound Size (L x W x D): 4.0 c 4.0 x 0.8 cm. Surface Area: 16.00cm2. Infection Assessment: No sign(s) of infection. Observation and interview on 07/02/25 at 8:51 AM revealed Resident #49 in bed and awake. Observed Resident #49 to be on a pressure relieving mattress. Resident #49 stated he had been at facility for about 2-3 weeks. Resident #49 stated he had a pressure sore on his bottom. He stated he was not sure if he admitted with the wound or if it developed at the facility. Resident #49 stated he had been seen by the wound care doctor twice since being admitted . Resident #49 stated he was seen by the wound care doctor last week unknown of exact date and today (07/02/25). He stated prior to being seen by the wound care doctor he was not receiving any treatment for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676080 If continuation sheet Page 14 of 27 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Arlington, Inc. 824 W Mayfield Rd Arlington, TX 76015 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 - Immediate jeopardy to resident health or safety Residents Affected - Some his wound. Resident #49 stated he never refused any treatment. Resident #49 stated he had pain but was getting pain medication. Interview by phone on 07/02/25 at 10:51 AM, LVN K revealed Resident #49 admitted to her hall. She stated when Resident #49 admitted to the facility she completed a skin assessment and noted a wound on his bottom. She stated the facility's process of when a resident admitted to the facility was the admitting nurse was responsible for completing the skin assessment and if the resident admitted with a wound the admitting nurse must notify the ADON and the ADON would notify the Wound Care Physician. LVN K stated the Wound Care Physician visits=ed twice a week, and Resident #49 had been seen by the Wound Care Physician, unknown date. She stated she was not sure if Resident #49's treatment was completed during the morning shift or afternoon shift. She stated she could not recall if she provided any treatments during her shift. She stated she could not recall if treatment orders were obtained for his wound upon admission or if the physician was notified. Interview by phone on 07/02/25 at 10:57 AM, RN L revealed she only worked at the facility during the weekends. RN L stated she could not recall admitting Resident #49 and could not recall any wounds or what wound care Resident #49 required. Interview on 07/02/25 at 11:01 AM ADON A/Wound Care Coordinator revealed the process of when a resident admitted to the facility, the admitting nurse must complete a head-to-toe assessment. If wounds were present upon admission, the admitting nurse must complete a communication form, put it in her box and she was responsible for contacting the Wound Care Physician. ADON A stated the nurses were responsible for completing wound care treatments for residents. She stated she was responsible for contacting the Wound Care Physician and completing rounds when the Wound Care Physician visited every Wednesday. She stated every Wednesday before the Wound Care Physician visited, she completed rounds and would ask all the nurses if they had any admitting residents with wounds. She stated Resident #49 admitted to the facility with a wound on his sacrum. ADON A reviewed Resident #49's clinical records and stated Resident #49 was first seen by the Wound Care Physician on 06/25/25 and received treatment orders the same day. ADON A stated based on documentation it did not seem Resident #49 received any wound care treatment. ADON A stated there was a gap from the time Resident #49 admitted until he was seen on 06/25/25 by the Wound Care Physician. ADON A stated Resident #49 admitted to the facility on [DATE] which was a Monday, and the Wound Care Physician would have visited Wednesday, and the reason Resident #49 was not seen was because Resident #49 did not show up in the Wound Care Physician's computer system, and the nurses were told to continue standing treatment orders. ADON A stated if nurses were not able to obtain attending physician's orders for wound care the facility had in-house standing treatment order dry dressing and should be uploaded in the resident's chart. ADON A reviewed Resident #49's discontinued orders and stated in-house standing treatment orders were not put in the system. ADON A stated she was not sure if Resident #49 received any treatment prior to being seen by the Wound Care Physician. She stated she visited Resident #49, but did not document her visit. She stated she would monitor her nurses when the nurses would ask her for wound care supplies, then she would complete a supply count and the count wound be accurate. ADON A stated when nurses would ask her for wound care supply, she would not question the nurses who the supplies were used for. ADON A stated she never obtained a communication form from the admitting nurse who admitted Resident #49, and she did not follow up because she was not aware of the wound. ADON A stated nurses should not measure the wounds and should not stage the wounds because the measurements could be wrong. ADON A stated she was not aware RN L staged and measured Resident #49's pressure wound. She stated the Wound Care Physician was notified of Resident #49's pressure wound. However, she could not recall the exact date, but it was a day or two before Resident #49 was seen by the Wound Care Physician on 06/25/25. Interview on 07/02/25 at 12:35 PM, LVN M revealed she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676080 If continuation sheet Page 15 of 27 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Arlington, Inc. 824 W Mayfield Rd Arlington, TX 76015 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 - Immediate jeopardy to resident health or safety Residents Affected - Some on leave when Resident #49 admitted to the facility, and she had returned to work on 06/09/25 morning shift. She stated she could not recall the exact date, but it was the week when Resident #49 was seen by the Wound Care Physician on 06/25/25 when she was notified of the pressure wound. She stated CNA J notified her of the wound on Resident #49's sacrum area. When CNA J was providing Resident #49 incontinent care, Resident #49 dressing came off and CNA J needed her to put a new dressing on. She stated she was not aware of the pressure wound. She stated she cleaned it and put a new dressing on. She stated when she cleaned the wound it did not appeared infected, no drainage was noted and had no odor to it. She stated she immediately went and notified ADON A. She stated there should had been orders in the system but there were no treatment orders in the resident's clinical chart when she reviewed it. She stated the facility had standing treatment orders, but she could not recall if any orders were put in the system. LVN M stated she did not put any orders in the system when she cleaned the wound. She stated if it was not documented it did not happen and it was her mistake for not putting the standing treatment orders in the system. She stated the process of when a new resident admitted to the facility the admitting nurse should complete skin assessment, notify the ADON A, obtain orders and put them in the system. LVN M stated prior to CNA J notifying her of the wound, she was never told or received any report from any staff regarding the wound. She stated she never provided any wound care to Resident #49 during her shift until the day CNA J asked her to put a new dressing on. She stated she completed a skin check on Resident #49 and had not noticed the wound; however, Resident #49 would refuse to be checked. She stated it was her mistake for not documenting the refusal. She stated the potential risk of not providing wound care treatment would be infections. She stated it was not good quality of care. Interview on 07/02/25 at 1:27 PM, CNA J revealed she could not recall the exact date, but she was providing Resident #49 incontinent care when his wound dressing had come off. She stated prior to proving the incontinent care Resident #49 had the dressing on his sacrum. She stated when the dressing came off, she notified LVN M and LVN M cleaned the wound and put a new dressing on him. She stated that was the first time she was assigned to Resident #49. She stated she was not aware of the wound until she provided incontinent care. Interview on 07/02/25 at 1:39 PM, ADON B revealed she was working when Resident #49 admitted to the facility. She stated Resident #49 admitted to the facility with a wound on his sacrum and nursing staff were using the standing orders to clean and cover the wound until he was seen by the Wound Care Physician. ADON B stated the admitting nurse was responsible for putting in standing orders in the system and completing a communication form to request wound care for residents to the ADON A. She stated the admitting nurse failed to communicate to ADON A to put Resident #49 on the list to be seen by the Wound Care Physician. ADON B stated LVN M had just resumed her job duty from being on leave and was completing skin assessments on residents when she noticed Resident #49's wound. She stated LVN Y was the nurse assigned to Resident #49 before LVN M returned to work. She stated LVN Y was providing wound care treatment to Resident #49, but it was unknown if it was documented. She stated if the ADON A was not notified of Resident #49's pressure wound then the Wound Care Physician was not notified. She stated the potential risk of not providing any wound care treatment would be infection. Interview on 07/02/25 at 2:00 PM, the DON revealed her expectation for when a resident admitted to the facility was the admitting nurse should complete a skin assessment. If a resident admitted with a wound, the admitting nurse should obtain treatment orders either form the doctor, hospital records or the in-house standing orders and should be put in the system. She stated the nurses should also complete a communication form and provide it to ADON A, and ADON A would place the resident's name on the list to be seen by the Wound Care Physician. The DON stated when Resident #49 was being provided with incontinent care, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676080 If continuation sheet Page 16 of 27 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Arlington, Inc. 824 W Mayfield Rd Arlington, TX 76015 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 - Immediate jeopardy to resident health or safety Residents Affected - Some resident had a dressing on the sacrum, and it fell off. She stated the nurse put a new dressing on and reported the wound to ADON A. The DON stated the admitting nurse for Resident #49 had not communicated Resident #49 had a wound. She stated she was not aware Resident #49's wound was staged and measured upon admission. She stated wound care treatment was provided to Resident #49; the nurses were using the standing orders, but the standing orders were not put in the system. She stated she was not aware there was no documentation in Resident #49's clinical chart. The DON stated she expected her nurses to put physician orders in the resident clinical chart/system. The DON stated Resident #49's wound was getting better and had no signs of infection. She stated her staff failed to put treatment orders in the system and failed to communicate to ADON A. She stated the Wound Care Physician was not notified until the ADON A was notified of the wound. She stated the potential risk would be infection. Interview on 07/02/25 at 2:06 PM with CNA N revealed she was the CNA assigned to Resident #49 when he was on the 100 Hall. She stated every time she would provide incontinent care to Resident #49, he had a dressing on his bottom. She stated Resident #49 admitted to the facility with a wound. CNA N stated during the morning shift, LVN M would change the wound dressing on Resident #49. She stated Resident #49 always had a dressing on his wound. She stated the nursing staff were aware of Resident #49's sacrum wound. An attempt was made on 07//02/25 at 2:33 PM to interview LVN Y by phone but was unsuccessful. Interview by phone on 07/02/25 at 3:00 PM, the Wound Care Physician stated if a resident admitted with a wound, he expected the Attending Physician or Nurse Practitioner to see the resident and write initial wound care orders, and to add him as an attending. If the resident had hospital orders that included wound orders, staff could follow those orders. ADON A would text him with a new resident's information prior to his next visit. He did not give any standing orders for wound care due to the liability, but he would allow ADON A to start treatment because he had worked with her for many years. He stated he was not aware of Resident #49's wound until he saw him on 6/25/25. He stated all wounds were considered colonized with a bacterium of some form, but that did not mean it was infected. If the wound was not healing, then it would be considered infected. Resident #49's wound was healing so he did not consider it to be infected. Interview on 07/02/25 at 3:13 PM, the Nurse Practitioner revealed she was not made aware of Resident #49's pressure wound when she visited the resident on 06/10/25. She stated she visited Resident #49 and completed an assessment, but she did not inspect the resident's back because she was not aware of the wound. She stated since she was not made aware of the wound no treatment orders were provided. She stated she could not recall the exact date, but she was notified by the DON that Resident #49's wound had worsened and that the Wound Care Physician had been notified and provided treatment orders. She stated when a resident admits to the facility with a wound her expectations were to be notified and for nurses to obtain orders. She stated if a resident had not been seen by the Wound Care Physician or the nurses were not able to get ahold of the Wound Care Physician, the ADON normally would notify her, and she would provide treatment orders. Interview on 07/02/25 at 3:51 PM, the Administrator revealed wound care questions were more of a clinical nursing aspect, but his expectations were for the nurses to assess the wound and notify the Wound Care Physician. The Administrator expected nursing staff to follow treatment orders and to document any care that the resident was being provided with. Record review of facility policy Significant Change in Resident's Status undated reflected the following: It is the policy of this organization that this facility immediate inform the resident, consult with the resident physician, and if knows notifies the resident's legal representative or an interested family when there is: . C. Need to alter treatment significantly (this is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. 4. Deterioration in a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676080 If continuation sheet Page 17 of 27 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Arlington, Inc. 824 W Mayfield Rd Arlington, TX 76015 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 - Immediate jeopardy to resident health or safety Residents Affected - Some resident's health status, where this change: places the resident's life in danger. is associated with a serious clinical complication, e.g., initial development of stage III or stage IV pressure ulcer. When any of the above occurs the attending physician, the resident and/or responsible party and/or legal representative and/or interested family member is notified. Document is made in the Nurses Notes and the Resident Assessment Instrument, and the Comprehensive Care Plan is updated to reflect the changes This was determined to be an Immediate Jeopardy (IJ) on 07/02/25 at 4:02 PM. The Administrator and DON were notified. The Administrator was provided with the IJ template on 07/02/25 at 4:10 PM. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 07/02/25 at 6:32 PM and reflected the following: Date of IJ Determination: 07/02/2025 Immediate Corrective Actions Taken Physician Notification for Identified Resident As of 07/02/2025, the resident identified in the IJ was immediately assessed by the Director of Nursing. The resident's attending physician and the Wound care Physician were immediately consulted, and updated treatment orders were obtained to address the resident's wound and overall plan of care. Chart Review for Timely Physician Notification A comprehensive audit of all admissions and current residents with significant changes in physical status was completed on 07/02/2025 to ensure physician notification occurred as required. Any instances lacking documented physician notification were immediately corrected by contacting the respective physician and updating the medical records. Immediate Staff Education On 07/02/2025, all licensed nurses received in-service training on: - Recognizing and defining significant changes in resident condition. - The requirements for immediate physician consultation upon identification of significant changes. - Accurate and timely documentation of physician notifications and resulting orders. Staff sign-in sheets and education materials are maintained for verification. Process Changes A Physician Notification Protocol has been implemented requiring nurses to notify the physician within 1 hour of identifying a significant change in a resident's condition, including the development or worsening of pressure ulcers. A physician notification from was created to document: -The date and time change identification. -The date and time of physician notification. -Physician response and orders. admission protocols were updated to require physician notification within 24 hours for all residents admitted with pressure ulcers or other significant health conditions. Ongoing Monitoring The Director of Nursing or designee will conduct daily audits of residents with significant changes in condition to confirm timely physician notification and documentation. Weekly audits of 10% of resident charts will be performed for 3 months to ensure compliance with the physician notification protocol. Quality Assurance and Oversight Physician notification compliance will be a standing agenda item at the facility monthly Quality Assurance Performance Improvement (QAPI) meeting for at least 3 months. Audit results and corrective actions will be reviewed by the Administrator and Medical Director. How the Plan Removes the Immediate Jeopardy Immediate assessment and physician consultation for the identified resident ensures appropriate and timely medical oversight, mitigating current risk. Staff education and protocol changes ensure future prompt physician notification for any significant changes, reducing the risk of delayed treatment. Ongoing audits and oversight confirm sustained complaint, preventing recurrence of the issue and ensuring resident rights are protected. Date IJ was Corrected: We believed the Immediate Jeopardy was removed on 07/02/2025, the date corrective actions were implemented. Ensuring Staff Not Present Received Training All nursing staff who are not present on 07/02/2025 for the in-services training will receive a make-up in-service by the Staff Development Nurse within 5 calendar days of returning to work, and before providing direct resident care. Completing will be tracked on a staff education log. Implementation Date for Physician Notification Protocol: The updated Physician Notification Protocol was implemented on 07/02/2025, the same day as the initial corrective (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676080 If continuation sheet Page 18 of 27 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Arlington, Inc. 824 W Mayfield Rd Arlington, TX 76015 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 - Immediate jeopardy to resident health or safety Residents Affected - Some actions. Title of Staff Conducting Audit and In-Service: The Director of Nursing (DON) conducted the comprehensive char audit for physician notifications. The Staff Development Nurse (SDN) provided the in-service training on physician notification requirements. Electronic In-Service Distribution and Acknowledgement: Nursing staff who are not present for in-person in-services will receive the training materials electronically through the facility's secure communication platform within 5 calendar days of returning to work. Staff will be required to review the material and electronically signs and acknowledgements from confirming their understanding. Record of completion and acknowledgements will be maintained by the Staff Development Nurse and made available for surveyor review. In-Service: Recognizing Significant Changes & Physician Notification Objective: Train nursing staff to recognize significant changes in resident condition, promptly notify the physician, and properly document the process to ensure timely treatment and protect resident rights. Agenda: Defining Significant Change - Examples: new/worsening wounds, sudden mental status changes, falls with injury, acute infections, uncontrolled pain. Timeframes for Physician Notification - Immediate vs. urgent vs. routine notification standards - Facility policy on notifying the physician within 1 hour of significant changes. Documentation of Notification - How to complete the physician notification form. - Documenting date/time of change, date/time of call, physician response. Communication Best Practices - SBAR (Situation, Background, Assessment, Recommendation) approach when calling providers. - Tips for effective and concise communication Policy & Procedure Review - Physician notification protocol - Review of facility admission protocols requiring physician notification. Q&A Session Materials: Physician notification form Updated physician notification policy Competency Validation: Staff sign-in sheet Charting exercise: completing a sample physician notification form Electronic In-Service Distribution and Acknowledgement: Nursing staff who are not present for in-person in-services will receive the training materials electronically through the facility's secure communication platform within 5 calendar days of returning to work. Staff will be required to review the material and electronically signs and acknowledgements from confirming their understanding. Record of completion and acknowledgements will be maintained by the Staff Development Nurse and made available for surveyor review. Monitoring of the facility's Plan of Removal included the following: Record review of a facility in-service training report for facility nurses across all shifts dated 07/02/25 reflected the following: Skin Issues on Admission. Protocol: Do a thorough assessment. 1) Document. Initially nurses are not to measure unless you're a wound care certified nurse. 2) Make sure there is a treatment ordered. (Hospital order, standing order or MD/NP order) Fill up a communication form and submit it to the Wound Care Nurse (ADON) for Dr. (Name) (Wound MD) to look at on his next visit. Document everything! Do Skin assessments every week! Notification of MD for worsening wounds if it's not documented it's not done!! Record review of a facility in-service training report for facility nurses across all shifts dated 07/02/25 reflected the following: Accurate and timely wound assessment and documentation. The requirement for immediate physician notification for wounds at admission or with signs of worsening. Proper initiation for treatment orders for wounds. Staff sign-in sheets and education materials are maintained for verification. Record review of the facility QAPI meeting revealed the facility medical director was notified by the director of nurses of the immediate jeopardy via phone while in attendance with the facility administrator on 07/02/25. Record review of the facility admission Wound Assessment Checklist form reflected on 07/02/2025 the form included the name of the resident, date of admission, wound treatment, MD Notified, notes. Record review of the facility Weekly Audit tool blank form revealed it included the date, resident, treatment, and documentation in PCC. Record review of the facility Communication Form revealed it must include information pertaining the resident, new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676080 If continuation sheet Page 19 of 27 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Arlington, Inc. 824 W Mayfield Rd Arlington, TX 76015 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 - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete admission/readmission, indicate which department it applied to and to include message/comments. Record review of the facility Physician notification Form undated, reflected staff should provide the date and time change identification, the date and time of physician notification and Physician response and orders. Record review of the Facility SBAR (Situation, Background, Assessment, Recommendation) reflected staff should document when a change of condition occurred and when the provider was notified. Record review of Resident #49's progress noted dated 07/02/25 by the DON reflected Pressure wound on sacrum assess with wound MD. Stage 4 full thickness. Wound size (LxWxD) 4.0x3.5x0.8 cm Surface area = 14, exudate Moderate serous (clear fluid drainage from a wound). Wound has improved since last visit as evidence by decrease surface area. No signs of infection noted. Treatment review with physician. No changes made at this time. Resident remains on air mattress. No c/o pain but instructed to call the nurse if he has pain. PRN pain medication ordered. Dietician made aware of the nutritional consult for the resident. Staff instructed to turn and reposition resident Q 2 hours. Call light within reach. Record review of Skin Assessments revealed they were completed on 07/02/25 for all 73 residents. The assessments indicated any skin concerns and the location of the skin concerns. Record review of a facility in-service training report for facility nurses across all shifts dated 07/03/25 reflected the following: On wound assessment on admission, the Admitting Nurse is required to document the following: 1. Wound measurements. 2) Notification of the physician w/in 24 Hrs. of identification. 3) Initiation of wound treatment per Event ID: Facility ID: 676080 If continuation sheet Page 20 of 27 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Arlington, Inc. 824 W Mayfield Rd Arlington, TX 76015 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 1 resident (Resident #61) reviewed for enteral nutrition. The facility failed to follow Resident #61's physician's orders for enteral feeding. These failures could affect residents receiving enteral nutrition/hydration and place them at risk of health complications and decline in health. Findings included:Record review of Resident #61's Quarterly MDS, dated [DATE], reflected a [AGE] year-old female with an initial admit date of 01/30/25 and re-admit date of 06/10/25. Resident #61 had diagnoses of nontraumatic intracerebral hemorrhage in hemisphere, subcortical (a type of stroke where bleeding occurs within the brain's white matter, specifically in the area beneath the cortex of the cerebral hemispheres), gastrostomy status (refers to the presence of a gastrostomy tube, an artificial opening in the stomach for feeding or medication administration), diabetes mellitus (a group of diseases that result in too much sugar in the blood), and dysphagia following cerebral infarction (a common and serious swallowing difficulty complication following a cerebral infarction(stroke)). Record review also reflected Resident #61 could rarely or never be understood so a BIMS score could not be attained. Record review also reflected that Resident #61 also received nutrition via a feeding tube. Record review of Resident #61's care plan revised dated 06/10/25 reflected:Focus: Resident at nutrition and dehydration risk related to receiving feeding via G-tube secondary to Dysphagia. Formula: Glycerna, may use Osmolite. Goal: Resident will have adequate nutrition and fluid over the next 90 days. Interventions: Administer Tube Feeding as order by the MD. Check for residual q shift or as the physician orders. Check for tube placement q shift or as ordered by physician. Flush g-tube before and after meds as ordered by physician. H2O as ordered by the physician. Record review of Resident #61's physician order dated 06/11/25 revealed every shift for g-tube every shift Glucerna 1.5 via g-tube @50 ml[BR7] [LO8] /hr, (may use Osmolite 1.5) x 22 hours (off between 12PM and 2 PM) with water flushes 100 ml every 6 hours and every shift flush g-tube with 60 ml of H2O before and after medication administration. Observation on 07/02/25 at 11:01 AM revealed Resident #61 lying in bed watching television. Observation also revealed Resident #61's feeding pump was running at a rate of 60 ml/hr. Interview on 07/02/25 at 11:08 AM with LVN C revealed Resident #61's physician's order reflected the enteral feeding pump should be set at 50 ml/hr. LVN C stated that the pump was running incorrectly at 60 ml/hr. LVN C said that the enteral feeding pump rate should match the physician's order. LVN C then revealed the incorrect rate could create a risk of fluid overload which could then lead to aspiration, (which is the inadvertent inhalation of substances like food, liquid, or other materials into the lungs), instead of being swallowed properly. LVN C stated that it was his responsibility to verify residents' enteral feeding pump rates were the same as the physician's orders when making rounds. LVN C said he should report it to the ADON if he found a resident's enteral feeding pump was running at an incorrect rate. LVN C corrected the enteral feeding pump and notified ADON A. Interview on 07/02/25 at 05:05 PM with ADON A revealed she expected nurses to review the physician's order prior to entering the rate on the resident's enteral feeding pump. ADON A stated that the nightshift nurse started the enteral feeding pumps, but she expected the dayshift and evening shift to verify the orders when making rounds. ADON A said that the facility policy stated that the enteral feeding pump rate should match the physician's orders. ADON A revealed that the risk to the resident when the rate entered was more than the rate ordered was the resident's stomach getting too full, weight gain, etc. ADON A stated that a nurse should follow (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676080 If continuation sheet Page 21 of 27 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Arlington, Inc. 824 W Mayfield Rd Arlington, TX 76015 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the chain of command and notify their ADON if they found an order entered wrong on an enteral feeding pump. ADON A stated that she was notified previously of the incorrect rate on Resident #61's enteral feeding pump. Interview on 07/02/25 at 06:14 PM with the DON revealed that she expected nurses to follow physician's orders when they set residents' enteral feeding pumps. The DON stated that it was the responsibility of all nurses to ensure their residents' orders were entered correctly on the enteral feeding pump and were checked by nurses when they made rounds. The DON said that the if a nurse found an enteral feeding pump set incorrectly, the nurse should notify their ADON. The DON revealed that residents risked fluid overload and excess calories when their enteral feeding pumps were set too at a faster rate than their physician's orders. Record review of the facility's Enteral Tube Feeding via Continuous Pump policy, revised March 2015, reflected: .General Guidelines .3. Check the enteral nutrition label against the order before administration. Check the following information: .g. Rate of administration (mL/hour) ) Event ID: Facility ID: 676080 If continuation sheet Page 22 of 27 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Arlington, Inc. 824 W Mayfield Rd Arlington, TX 76015 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 0791 Provide or obtain dental services for each resident. 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 assist residents in obtaining routine and 24-hour emergency dental care for one (Residents #5) of three residents reviewed for dental services. The facility failed to follow up and schedule an appointment for resident to be seen by dentist so that she could receive dentures. This failure could affect residents by placing them at risk for oral complications, dental pain, and diminished quality of life. Findings included: Review of Resident #5's Quarterly MDS, dated [DATE], reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (longstanding disease of the kidneys leasing to renal failure), non-Alzheimer's dementia (a group of neurodegenerative disease that cause cognitive decline, but are distinct from Alzheimer's disease, diabetes mellitus (a group of diseases that result in too much sugar in the blood), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Record review also reflected a BIMS score of 7, indicating severe cognitive impairment. Resident #5's functional status indicated she required supervision or touching assistance in her ADLs. Her Oral/Dental Status did not indicate broken or loose-fitting dentures and no pain with chewing. Review of Resident #5's care plan, dated 7/15/24, reflected resident had a mechanical soft, low concentrated sweets diet. Review of Resident #5's care plan dated 05/06/25 also reflected: Focus-Resident has dental problems AEB: Edentulous (meaning no teeth)Goal-Resident will have no adverse effects from dental problems through the next review periodInterventions-Staff will assess oral status on admission, staff will provide oral care daily, staff will refer any dental problems to social services for follow up. Review of Resident #5's Progress Notes by the Social Worker, dated 05/21/25 at 1:07 PM, reflected SW reached out JPS and left voicemail to return call for dental referral. Review of Resident #5's weights revealed that resident had no weight loss since admission. Interview and observation on 07/02/2025 at 4:26 PM with Resident #5 revealed the resident had no lower teeth or upper teeth. Resident #5 stated that she had no dentures nor teeth. Resident #5 said that it bothered her having no teeth because she had to eat chopped meats and did not like eating it that way. Resident #5 stated that she desperately wanted dentures. The resident did not say how long she had been without teeth. Interview on 07/02/25 at 3:17 PM with the Social Services Director revealed that it was her responsibility to schedule dental appointments for residents. The Social Services Director stated Resident #5 was referred to a dental company by her hospital due to her income status. The Social Services Director stated she had not gotten around to calling the referred dental company and asking what documents needed to be sent over so that the appointment could be scheduled. The Social Services Director said that it was on her to do list. The Social Services Director stated that she was aware the resident and knew the resident had no teeth and was on a mechanical soft diet due to having no upper or lower teeth. The Social Services Director revealed that when she assisted residents who need dentures, she would check financing, check resourcing, then call the referred dental company. The Social Services Director stated that in this case, she had not had time to call the referred dental company in the past five weeks. The Social Services Director stated that having no teeth didn't affect Resident #5 because she has seen Resident #5 eat what she wants to eat. Interview on 07/03/25 at 12:05 PM with the Administrator revealed that it was the Social Services Director's responsibility to follow up on dental referrals. The Administrator stated if the Social Services Director did not follow up on referrals, it was ultimately his responsibility to follow up on the referral but did not reveal this process. The Administrator said that the importance of residents' dental appointments was so residents could enjoy their food and eating. Interview on 7/3/25 at 12:35 PM with LVN C revealed if a Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676080 If continuation sheet Page 23 of 27 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Arlington, Inc. 824 W Mayfield Rd Arlington, TX 76015 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 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete resident needed to see a dentist the nurses would communicate it to the Social Services Director. LVN C then stated that the Social Services Director would then put the resident's name on the dentist's list so they could be seen by the dentist the next time they came to the facility. LVN C also revealed that he would inform the doctor. And if the resident is in pain, LVN C would request pain medication. Record Review of Timeliness of Referral to Outside Vendors policy, dated 7/3/25, reflected:The designated staff member (e.g., Social Worker, DON, or Referral Coordinator) must contact the vendor within 3 business days of referral initiation. If the service is urgent, contact must be made within 24 hours, and documentation must reflect the urgency. Residents with no source of income, may require extended processing of referrals. Event ID: Facility ID: 676080 If continuation sheet Page 24 of 27 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Arlington, Inc. 824 W Mayfield Rd Arlington, TX 76015 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 FORM CMS-2567 (02/99) Previous Versions Obsolete 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 service safety. in the facility's only kitchen. 1. The facility failed to ensure the refrigerator was maintained in a sanitary manner free from dark substances. 2. The facility failed to ensure food items stored in the freezer were properly discarded. This failure could place all residents at risk for food contamination and food borne illness. Findings included: Observation and interview on 07/01/25 at 9:01 AM with the Dietary Manager revealed a dark substance on the floor of the walk-in cooler. The dark substance was approximately 12 inches by 4 inches on the non-porous floor. The Dietary Manager stated that the substance had built up over the years and would not come off the floor. Therefore, nothing had been attempted in the past to clean the substance off the floor. The Dietary Manager said that the substance on the floor would not affect the residents' health because it was not touching anything. The Dietary Manager also revealed it was his responsibility to ensure the kitchen was clean and sanitary. Observation and interview on 07/01/25 at 9:06 AM with the Dietary Manager revealed a clear unlabeled and undated sealed plastic bag in the freezer was previously defrosted ground beef and re-frozen. The clear bag had a puddle of frozen blood from being previously thawed and re-frozen. The Dietary Manager stated that the previously defrosted ground beef should not have been in the freezer and should not have been re-frozen. The Dietary Manager said that if the ground beef was cooked and served, residents were at risk of food borne illnesses. The Dietary Manager revealed this meat had been put in the freezer by a new cook who was not aware this could be harmful to the residents. The Dietary Manager stated the new cook, who would not work the remainder of the week, had placed the thawed meat back into the freezer on the previous Sunday when he had not worked. Attempts were made to interview the staff member that placed the re-frozen meat in the freezer, but she did not work that week. The Dietary Manager stated he had not seen the meat in the freezer. The Dietary Manager stated that he in-serviced staff every Wednesday at 1:00 PM, and he would in-service his staff that afternoon regarding the issues found. The Dietary Manager said that he expected his cooks to know how to store, label, and date and regularly made rounds to ensure that items were not stored incorrectly. The Dietary Manager removed the previously defrosted ground beef from the freezer and disposed of it. Review of the facility's undated Receiving and Storage policy, reflected: Storage: All foods will be properly stored to preserve flavor, nutritive value, and appearance and to protect against foodborne illness 1. b. Do not refreeze a thawed product - cook and or use immediately . 7. Refrigeration units should be kept clean with spillage wiped up immediately and a thorough cleaning at least weekly Event ID: Facility ID: 676080 If continuation sheet Page 25 of 27 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Arlington, Inc. 824 W Mayfield Rd Arlington, TX 76015 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 observations, interviews and record reviews the facility failed to 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 resident (Resident #50) of 7 residents observed for infection control. Staff failed to use the appropriate PPE when providing care for Resident #50 who was on EBP. This failure could place resident at risk of being infected with germs from another resident. Record review of Resident #50's undated admission Record reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included fracture of the leg with surgical repair, dementia, and kidney failure. Record review of Resident #50's admission MDS, dated [DATE], reflected a BIMS score of 12, indicating she had moderate cognitive impairment. Her Functional Status assessment reflected she required some assistance with her ADLs. Record review of Resident #50's care plan, dated 6/17/25, reflected she was planned for right leg fracture, decreased ADL function, and isolation precautions related to surgical wound. Record review of the facility's Infection Control/Antibiotic Stewardship log revealed the facility had 14 residents on isolation for wounds, catheters, gastric tubes, and IV access. Resident #50 was on EBP because she had wounds as well as a urinary catheter. Observation on 7/01/25 beginning at 9:10 AM of the 100 and 200 Halls revealed seven residents with signage outside their rooms indicating they were on EBP. Observation on 7/01/25 at 9:15 AM revealed Resident #50 had signage on her door indicating she was on EBP. PPE was located in an alcove near her room. Observation on 7/02/25 at 11:21 the COTA transferred Resident #50 from her wheelchair to her bed using a slide board. The COTA was not wearing any PPE. Observation on 7/03/25 at 12:30 PM CNA-D and CNA-E transferred Resident #50 from her bed to her wheelchair, without wearing any PPE, using the mechanical lift. In an interview on 7/3/25 at 1:25 PM CNA-D stated she knew which residents were on isolation by the signage outside their room. The sign advised her what level of PPE was required to be worn when providing care to the resident. She stated she did not wear PPE while transferring Resident #50 because she did not normally work on the floor, and she was unfamiliar with the residents of that hall and she just forgot. She stated the risk of not wearing PPE was spreading infection from one resident to the other. In an interview on 7/3/25 at 1:45 PM CNA-E stated she did not notice the sign outside Resident #50's room, so she did not use any PPE. She stated she was called to that hall from where she normally works, and she was not familiar with the residents of that hall. She knew residents with the sign at the door meant she had to wear a gown and gloves. In an interview on 7/3/25 at 2:15 PM the COTA stated she did not know what it meant when a resident was on EBP. She stated she was aware of the signs on the resident rooms showing the wearing of gowns and gloves. She stated she just did not wear it as the resident was in a hurry to get back to bed. She stated the risk of not wearing the PPE was possibly spreading infections. In an interview on 7/3/25 at 2:20 PM CNA- F stated she did not know what EBP was, but she knew to wear a gown and gloves with residents who had the sign outside their room. She did not know the risk of not wearing the proper PPE. In an interview on 7/3/25 at 2:28 PM CNA-G stated EBP signs were placed outside the rooms of residents they were supposed to wear a gown and gloves when they were providing care to them. In an interview on 7/3/25 at 2:35 PM CNA-H stated she knew which residents were on EBP because the nurse would tell them, plus there was a sign outside their room. EBP required a gown and gloves to be worn. In an interview on 7/3/25 at 5:15 PM the DON stated EBP were put in place for any resident with a wound, IV, or any tube that was inserted. She stated signs were placed outside the room of those residents, and PPE was kept in an alcove on the hall. She stated the risk of not wearing the appropriate PPE was Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676080 If continuation sheet Page 26 of 27 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Arlington, Inc. 824 W Mayfield Rd Arlington, TX 76015 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 FORM CMS-2567 (02/99) Previous Versions Obsolete giving the resident an infection from another resident. The DON stated she or the Infection Preventionist perform in-services for staff on infection control and PPE usage. She stated there was no monitoring of staff to ensure PPE was being used. Record review of the facility's undated policy Infection Control reflected: Contact Precautions Use personal protective equipment (PPE) appropriately, including gown and gloves. Wear gown and gloves for all interactions that may involve contact with the resident or the resident's environment. Event ID: Facility ID: 676080 If continuation sheet Page 27 of 27