Health inspection·May 7, 2024

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some -Wednesday Dinner 5/1/2024 - Ham Salad Sandwich, Lettuce & Tomato, Potato Chips, Creamy Cucumber & Onion Salad, Seedless Watermelon Cubes, House Shake, Milk, Tea. Anonymous #2 received Seedless Watermelon Cubes and Tea. -Tuesday Dinner 4/30/2024 - [NAME] Garlic Shrimp, Steamed Rice, Broccoli Florets, Dinner Roll/Bread, Margarine, Chilled Peach Parfait, House Shake, Milk, Tea. Anonymous #2 received [NAME] Garlic Shrimp and Tea. -Monday Dinner 4/30/2024 - Homestyle Meatloaf w/Ketchup Glaze, Au Gratin Potatoes, Honey Roasted Carrots, Dinner Roll/Bread, Margarine, Chocolate Ice Cream, House Shake, Milk, Tea. Anonymous #2 received Au Gratin Potatoes and Tea. -Tuesday Dinner 5/28/2024 - Crispy Baked Chicken, Oven Browned Potatoes, Lima Beans, Dinner Roll/Bread, Margarine, Peanut Butter Cookie, House Shake, Milk, Tea. Anonymous #2 received Oven Browned Potatoes, Lima Beans, and Tea. -Tuesday Dinner 5/14/2024 - Rotisserie Chicken, Cheesy Mashed Potatoes, Lima Beans, Dinner Roll/Bread, Margarine, Banana Pudding Parfait, House Shake, Milk, Tea. Anonymous #2 received Lima Beans and Tea. Interview on 05/07/2024 at 12:59 PM, Resident #4 stated the food never matched the ticket. Interview on 05/07/2024 at 4:00 PM, the Dietary Manager stated if a resident had a food allergy, he added a note into the system and would also put it under preferences, so the resident did not get that item. He stated technically the kitchen was supposed to prepare trays, take them to the unit and before trays were passed out the nurse was supposed to check the tickets for allergies and diets. Interview on 05/07/2024 at 4:24 PM, the District Dietary Manager stated if the resident was allergic or had a preference, the system took it out so the resident would get the other item. He stated he had not received any complaints related to dietary services. He stated the kitchen was responsible for putting health shakes or fortified items on the trays and if it was Ensure or Med pass then nursing would take care of that. Record review of the facility's week 3 menu for Tuesday (05/07/2024) revealed the dinner meal consisted of Chicken Parmesan w/Spaghetti Noodles, Roasted Zucchini, Dinner Roll/Bread, Dessert Fruit Cocktail. The Alternate Dinner Menu was Parsley Pork Chop, Sugar Snap Peas, and Mashed Potatoes. Record review of menu dated 05/07/2024 posted in the dining room revealed the following: Dinner Menu Chicken Parmesan w/Spaghetti Noodles, Roasted Zucchini, Dinner Roll/Bread, and Dessert Fruit Cocktail, and the Alternate Dinner Menu reflected Parsley Pork Chop, Sugar Snap Peas, and Mashed Potatoes. Observation and record review on 05/07/2024 at 5:46 PM with Anonymous #2 revealed the dinner meal appeared to be chicken with spaghetti noodles, squash, fruit cocktail and tea. Anonymous #2 stated he did not receive a dinner roll, milk or a health shake. Review of the meal ticket revealed for Tuesday Dinner 05/07/2024 Crispy Baked Chicken, Oven Browned Potatoes, Lima Beans, Dinner Roll/Bread, Peanut Butter Cookie, House Shake, Milk, and Tea. Observation and interview on 05/07/2024 at approximately 5:50 pm, revealed Resident #4 had what (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676139 If continuation sheet Page 2 of 4 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 676139 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Oaks Nursing & Rehabilitation 3033 W Green Oaks Blvd Arlington, TX 76016 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some appeared to be chicken with spaghetti noodles, squash, and tea. Review of Resident #4's meal ticket revealed for Tuesday Dinner 05/07/2024 Ground Breaded Chicken Patty, Poultry gravy, Oven Browned Potatoes, Lima Beans, Dinner Roll/Bread, Peanut Butter Cookie, Milk, and Tea. Observation and interview on 05/07/2024 at 5:54 PM, with RN C in Resident #5's room revealed the meal appeared to be chicken with spaghetti noodles and squash. Resident #5 and RN C both stated the meal did not match the menu. Resident #5 stated the menu did not ever match but was okay with what was served. Interview on 05/07/2024 at 5:54 PM, Resident #6 stated she was okay with the food being served even though it did not match the menu. She stated it happened a lot, but she did not like the food at the facility altogether. She stated she had gotten to the point she did not care because no matter how much she complained it did not change. Interview on 05/05/2024 at 6:00 PM, the District Dietary Manager stated the meal tickets were from the old menu and he did not change it back when the Surveyor had requested the past 2 weeks of menus. He stated he was in a hurry, had to retype the menu and had to inactivate the new one and forgot to reactivate the current menu, so all the tickets printed from the previous production cycle. When asked when meal tickets were printed, he stated one day in advance. When asked why the meal tickets for dinner (05/07/2024) did not match the menu if they were printed a day ahead, he stated a dietary aide had spilled some liquid on the dinner tickets for tonight, so he had to reprint the dinner tickets. Interview on 05/05/2024 at 6:22 PM, LVN A stated there would be the wrong menu on the meal tickets and it would happen at least once a week. She stated she would have to take the cart back to the kitchen when that happened. LVN A stated after they tell the kitchen about the incorrect meal tickets, then they would tell the Administrator and the Administrator would directly handle that with the Dietary Manager. She stated the nurses were responsible to check the cart and meal tickets and then CNAs would pass the trays. LVN A stated it there was an item substitution, it was to be listed on the ticket and the Dietary Manager was supposed to inform them but lately he had not informed them of any. Interview on 05/05/2024 at 6:49 PM, LVN B stated she has received complaints from residents about the wrong meal tickets. She stated if that happened, they would take the tray back to the kitchen. She stated the nurse was supposed to verify and make sure all residents had received their supplements and if not, take the tray back to the kitchen or have one of the CNAs go to the kitchen to get the supplement. LVN B stated there could be problems for not having accurate tickets, especially with allergies. She stated residents could also be disappointed if menus and meals did not match. LVN B stated some dietary supplements could be given by the nurse and some could be given by the kitchen. She stated if the supplement was for weight loss, then they would need to monitor that it was given. Interview on 05/05/2024 at 7:26 PM, CNA D stated he never noticed the meal and tickets did not match. He stated if it did not match, he would report to the charge nurse, and if a resident refused food, he would report to the nurse so the nurse could go to the kitchen. CNA D stated the dietary staff were responsible to make sure all items were on the tray for the meal, the nurse was supposed to check the tickets and trays and, if something was missing, they were supposed to go to the kitchen to get it. Interview on 05/05/2024 at 7:42 PM, the District Dietary Manager stated everything on the meal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676139 If continuation sheet Page 3 of 4 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 676139 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Oaks Nursing & Rehabilitation 3033 W Green Oaks Blvd Arlington, TX 76016 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ticket was supposed to match. He stated kitchen staff were responsible to ensure the tray matched the ticket. He stated the nurse checked prior to serving and they were supposed to come back to the kitchen and get what was not on the tray. He stated there could be a nutritional risk and could be a dignity issue when not following what was posted. Record review of a grievance, dated 02/26/2024, revealed by Resident Council menu not accurate . Further review revealed facility follow up included, more info required for inaccurate menu. Staff will monitor food preparation process daily to ensure quality and the resolution included, Nurse will check diet ticket and staff will monitor food preparation process daily to ensure food quality. Record review of resident council minutes dated 03/11/2024, revealed issue .menu not accurate. Record review of facility policy titled Resident Food Preferences revised 2008 revealed it did not indicate how substitutions would be communicated or meal tickets matching what meal was served. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676139 If continuation sheet Page 4 of 4