Health inspection·February 24, 2025

F 0583 Record review of Resident #2's Administration Record dated January 2025 revealed an order for: Level of Harm - Minimal harm or potential for actual harm Methocarbamol Oral Tablet 500 MG (Methocarbamol) Give 0.5 tablet by mouth three times a day for spasms give half tab = 250mg dose Residents Affected - Few Record review of Resident #2's Discharge Summary reflected Resident #2 discharged home on 2/5/25 with all her medications documented accordingly. During a telephone interview on 2/20/25 at 3:50 PM with Resident #1's FM, she stated she received Resident #1's medications when Resident #1 discharged from the facility on 1/31/25. The FM also stated when she arrived home, she discovered another resident's (Resident #2) Methocarbamol medication (muscle relaxant). The FM read the Blister Pack and provided Resident #2's name, date of birth and her room number at the facility. During an interview on 2/21/25 at 1:50 pm with RN B, he stated he printed a Medication Summary and obtained the keys to both medication carts from RN A. RN B stated he collected all of Resident #1's medications, compared the Blister Packs to the printed Medication Summary and ensured everything was correct. RN B stated he went over everything with the FM and educated her on following up with Resident #1's primary care physician within 7-10 days, reminded her that she needed to pick up Resident #1's medication from the pharmacy, any treatments, and recommended diet for Resident #1. RN B stated he was unsure how Resident #2's medication was included. As it was confirmed that the FM was able to provide Resident #2's name, her date of birth and the name of the medication, RN B stated it was important to confirm all information to respect the privacy and confidentiality of all Residents. During an interview on 2/21/25 at 2:25 PM with the DON, she stated she called in Resident #1's prescriptions to [Pharmacy] for a 30-day Supply. The DON stated she believed RN B mistakenly pulled the other resident's medication due to Resident #2's medication being directly behind Resident #1's medication. The DON stated RN B informed her that he gathered the medications and went through each individual Blister Pack with the FM but he did not recall the other resident's medication being in there. The DON stated it was important to protect all residents' personal information and medication history. During an interview on 2/21/25 at 2:25 PM with the ADM, he stated the FM informed him when Resident #1 discharged home, there was one medication belonging to another resident (Resident #2). The ADM stated starting today (2/21/25), the nursing staff was re-educated on discharging medications including the importance of protecting residents' personal information and medication history by the DON. The ADM stated all staff were responsible to ensure residents' confidentiality. Record review of the facility's policy titled, Resident Rights, dated Revised December 2016 reflected the following: . 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: t. privacy and confidentiality; Record review of an undated Confidentiality and Non-Disclosure Agreement signed on 2/21/23 by RN B reflected the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676139 If continuation sheet Page 2 of 11 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 02/24/2025 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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few . Our facility information systems contain confidential records pertaining to our business operations, our residents, business associates, health care professionals, and employees. This information is vital to the operation of our facility in providing quality care and services to our residents, therefore it must be protected. As such, in accordance with current HIPAA regulations and facility policies governing the access, use, and disclosure of protected health or facility information, you have the responsibility to protect such data. As an employee of this facility, .Your signature on this document indicates that the information contained herein has been explained to you, you received a copy of this document and that you understand the rules set forth. YOU AGREE: . 3. To disclose confidential resident, business, financial or employee information ONLY to those authorized to receive it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676139 If continuation sheet Page 3 of 11 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 02/24/2025 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to complete a discharge summary that included a reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter), for 1 (Resident #1) of 5 residents reviewed for discharge planning. The facility (RN B) failed to complete the Discharge Summary Nursing Section regarding a reconciliation of Resident #1's medications when she discharged home on 1/31/25. This failure placed residents at risk for a lack of continuity of care and adequate medication administration after they are discharged home. Findings included: Record review of Resident #1's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] and discharged home on 1/31/25. Record review of Resident #1's admission MDS assessment dated [DATE] reflected a BIMS score of 13 indicating she was cognitively intact. Resident #1's diagnoses included acute kidney failure (inability to remove waste products and maintain fluid and electrolyte balance), Paroxysmal Atrial Fibrillation (heart rhythm disorder), Chronic obstructive pulmonary disease (lung diseases that cause airflow obstruction and breathing difficulties), Dysphagia (difficulty swallowing), Transient Ischemic Attack (temporary interruption of blood flow to the brain) and Cerebral Infarction (blood flow to the brain is interrupted). Record review of Resident #1's undated Care Plan reflected the following entries: Date initiated 1/21/25: [Resident #1] has potential for impairment to skin integrity related to fragile skin. Interventions included administer treatment as ordered. Assist resident with turning and repositioning during rounds. Encourage good nutrition and hydration in order to promote healthier skin. Keep skin clean and dry. Use lotion on dry skin. Do not apply on the site of injury. Date initiated 1/10/25: [Resident #1] exhibits ADL self-care performance deficits, requires assistance: limited mobility, uses a wheelchair. Interventions included provide assistance with eating, bathing, toileting and grooming as needed; provide appropriate diet; bath per schedule and praise resident for all efforts made. Record review of Resident #1's progress notes reflected the following entries: 1/8/25: [Resident] is a [AGE] year-old female, new admit to the facility from [hospital name], arrived via wheelchair accompanied by the driver and [family] . AAOx4, able to communicate all needs . Signed by LVN A 1/31/25: Medications called into pharmacy of choice: [pharmacy] [phone number], per MD 30-day supply with no refills. Signed by DON Record review of Resident #1's Physician's Discharge Order dated 1/31/25 reflected: May discharge (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676139 If continuation sheet Page 4 of 11 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 02/24/2025 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few home with home health services of choice. Skilled nursing, meds and disease education, wound care per wound care orders, PT/OT to home evaluate and medical social worker if needed. Record review of Resident #1's Discharge Summary reflected Resident #1 discharged home on 1/31/25 with her FM. Resident #1's Discharge Summary revealed all sections were completed and signed, except Section 4 Nursing - A. Medications. During a telephone interview on 2/20/25 at 3:50 PM with Resident #1's FM, she stated she received Resident #1's medications when Resident #1 discharged from the facility. The FM also stated when she arrived home, she discovered another resident's (Resident #2) Methocarbamol medication (muscle relaxant). The FM stated she had not contacted the facility immediately afterward. The FM stated Resident #1 was supposed to discharge on Monday, 2/3/25, but she decided to pick her up instead on Friday, 1/31/25. The FM stated she did not speak with the ADM until 2/17/25 whereas she voiced her concerns and that she received one medication that belonged to a different resident. The FM stated the ADM informed her that they would look into it and that himself, or someone else would call her back. The FM stated after not hearing from anyone in three days, she called in the report to HHS. The FM confirmed she received a printout of Resident #1's discharge summary and a separate list with her medications. During an interview on 2/21/25 at 1:25 PM with RN A, she stated she was the assigned nurse for Resident #1's hall. RN A stated she was completing rounds with the MD, so RN B handled Resident #1's discharge. RN A stated she gave RN B the keys to the medication carts and she assumed RN B went over the medications because he was in the room with Resident #1 and the FM. RN A stated the nurse completing the discharge was responsible for completing Section 4 (Medications) of the Discharge Summary and reconciling the medications with the resident/family. RN A stated during a discharge, the nurse went over the entire Discharge Summary with the resident/family. RN A stated due to the incident, she was in-serviced by ADON A on Friday, 2/21/25. RN A stated they went over that they no longer provided Blister Packs at discharge and all medications needed to be called into the pharmacy. RN A stated you made sure all sections of the Discharge Summary was completed, signed, and had the family sign it. RN A stated moving forward, if existing medications were being sent home with the family, you must obtain approval from an ADON or the DON. RN A stated she should had followed up with RN B since Resident #1 was one of her residents. During an interview on 2/21/25 at 1:50 pm with RN B, he stated he assisted RN A with Resident #1's discharge. RN B stated he printed a Medication Summary and RN A gave him the keys to the medication carts. RN B stated he collected all of Resident #1's medications, compared them to the Medication Summary and ensured everything was correct. RN B stated he went over everything with the FM and educated her. RN B stated while he went over the medications, he had the printed paper and the Blister Packs to ensure everything matched. RN B stated he was unsure how Resident #2's medication was included. RN B stated he checked the list and medications several times. RN B stated the FM was engaged and had a firm understanding of the medications as well as Resident #1's upcoming appointments. RN B stated he did not recall the FM handling the Blister Packs. RN B stated the discharge process was to confirm the resident being discharged and make sure the family was aware. RN B stated you made sure there was a Physician's Discharge Order and that all medications were listed on the Discharge Summary. RN B stated normally you do not send medications home with the residents, you called the orders into the pharmacy. RN B stated once the resident discharged , you document who they left with and their status. RN B stated he was in-serviced by the DON today (2/21/25) and he learned to be more mindful and if he is not clear about something, to ask questions to prevent errors. RN B stated they were no longer sending medications home and to ensure the family is aware that all medications were called (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676139 If continuation sheet Page 5 of 11 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 02/24/2025 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few into the pharmacy of their choice. RN B stated he was also in-serviced on making sure all sections of the Discharge Summary was completed fully. During an interview on 2/21/25 at 2:25 PM with the DON, she stated she called in Resident #1's prescriptions to [Pharmacy] for a 30-day Supply. The DON stated when time permitted, they requested all medications from their pharmacy to be delivered to the facility. The DON stated medications arrived from the pharmacy in a bundle inside of a large envelope. The DON stated if there was not enough time, the facility would call the orders into the pharmacy of the family's choice. The DON stated when pharmacies sent over medications, they sent more than one Blister Pack. The DON stated RN B must had pulled the other resident's medication out by mistake due to it being directly behind Resident #1's medication. The DON stated she was informed by RN B that RN A was discharging Resident #1 and RN A asked him to assist. The DON stated RN B informed her that he gathered Resident #1's medications and went through each one with the FM but he did not recall the other resident's Blister Pack. The DON stated she was unsure how the medication was overlooked. The DON stated the only time they discharged residents with medications was if it was a specialty medication. The DON stated it was not against their policy to discharge with medications, they just preferred the orders were called in to ensure residents had enough medication once they arrived home. During an interview on 2/21/25 at 2:25 PM with the ADM, he stated he had not received a call from the FM until 2/17/25, almost three weeks after Resident #1 discharged home. The ADM stated the FM informed him that Resident #1 received all her medications, but there was one medication included that did not belong to Resident #1. The ADM stated starting today (2/21/25), the DON re-educated the nursing staff on discharges and sending medications home. The ADM stated the normal process was the nurse assigned to the hall would pull the medications and send the medications home with the resident. The ADM stated in this situation, RN A asked for assistance and RN B stepped in to assist. During an interview on 2/24/25 at 10:05 AM with ADON A, she stated a Discharge Order was obtained from the MD. ADON A stated the assigned nurse went over all medications with the family and followed up with the MD if needed. ADON A stated Resident #1's allotted discharge time was scheduled for Monday (2/3/25), but the FM arrived on Friday (1/31/25). ADON A stated due to this they allowed the FM to take the Blister Packs home and the DON called the Orders into the family's preferred pharmacy. ADON A stated all medications should had been listed on the Discharge Summary along with the details of the discharge. ADON A stated if the FM had waited until the scheduled day of discharge, the pharmacy would have sent the medications to the facility. ADON A stated normally Blister Packs were not sent home because the facility paid for the medications for Skilled Residents. ADON A stated what went wrong was two different nurses working on the discharge and normally, only the floor nurse completed the discharge. ADON A stated RN A should had handled the discharge and not RN B even though he was an RN. ADON A stated RN A should had double-checked the Blister Packs and ensured there were no extra Blister Packs. ADON A stated the DON in-serviced her on the discharge policy moving forward. ADON A stated the only thing new is if Blister Packs were being released with the Resident, an ADON or the DON must sign off. ADON A stated she assisted with in-servicing the nurses. ADON A stated the worst that could had happened was Resident #1 could had taken medication not prescribed to her. During an interview on 2/24/25 at 10:30 AM with LVN A, she stated the nurses completed the Nursing Section of the Discharge Summary. LVN A stated you printed the Discharge Summary, confirmed the information with the family and had the family or resident sign it. LVN A stated the pharmacy normally delivered a discharge package of medications to the facility prior to discharge. LVN A stated if the discharge packet were not ready at discharge, the facility would call in the orders to the family's preferred pharmacy. LVN A stated they normally do not discharge residents with the Blister Packs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676139 If continuation sheet Page 6 of 11 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 02/24/2025 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few LVN A stated RN B may have gone through the printed list of medications, but not the actual Blister Packs. LVN A stated she was in-serviced this morning (2/24/25) by ADON A on Discharges. LVN A stated now before you could discharge a Resident with Blister Packs you must obtain approval from an ADON or the DON. LVN A stated they must double-check everything regardless of how busy it may be. LVN A stated the worse that could had happened was if the family had not noticed the name on the Blister Pack, Resident #1 could have had a bad reaction. During an interview on 2/24/25 at 11:10 AM with ADON B, she stated once they were aware a resident would be discharged , they completed assessments, went over scheduled medications, and the DON called in orders to the pharmacy. ADON B stated time-permitting, the pharmacy delivered a Medication Package for the resident to the facility. ADON B stated the package from the pharmacy would contain a list of all medications and all the Medication Packs inside of the envelope. ADON B stated all pertinent departments completed their portion of the Discharge Summary and signed off on it. ADON B stated the nurse would go over all the medications with the resident and family and have one of them sign it. ADON B stated when RN B grabbed the Medication Packs out of the cart, one of the other resident's Medication Packs was grabbed mistakenly due to human error. ADON B stated she was in-serviced on Discharges by the DON on Friday (2/21/25). ADON B stated she then assisted with in-servicing the remaining nurses. ADON B stated the worse that could had happened was Resident #1 could had been harmed if she had taken the incorrect medication. During a follow-up interview on 2/24/25 at 11:55 AM with the DON, she stated she completed in-services on Discharges and completing the Discharge Summary in its entirety. The DON stated her expectations moving forward was for the nursing staff to follow procedures. The DON stated if a resident was discharging, the social worker would setup the discharge. The DON stated the facility would request the pharmacy to send over a 30-day supply of medications to the facility. The DON stated if there were not enough time, they would call the Orders into the family's pharmacy of choice. The DON stated they would only discharge with in-house medications if the pharmacy was unable to get the medication delivered to the facility in a timely manner. The DON stated the worse that could had happened was the resident having access to someone else's medication and personal information. The DON stated the resident could had been administered the incorrect medication by her family. During a follow-up interview on 2/24/25 at 1:45 PM with the ADM, he stated the nursing staff had been educated on the discharge process by the DON and the ADONs. The ADM stated they would discuss the incident this week at their QAPI meeting on Wednesday (2/26/25). The ADM stated they would start auditing the Discharge Summaries at a minimum, monthly or whatever is decided during the meeting. The ADM stated his expectations moving forward was that the facility would call all medications into the pharmacy. The ADM stated if the facility must send medications home with the residents, all requests must be approved by an ADON or the DON. The ADM stated the worse that could had happened was Resident #1 could had taken a medication not prescribed to her and had a potential reaction. Review of in-service documentation, titled, Discharging, dated 2/21/25, reflected the following: . -Skilled Discharge Resident must have discharge package or medications called into pharmacy prior to leaving. -Do not send pharmacy blister pack home with residents without ADON or DON's knowledge. -Discharge Summary must be completed, printed, and signed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676139 If continuation sheet Page 7 of 11 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 02/24/2025 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the facility's policy titled, Discharge Summary and Plan, dated Revised December 2016 reflected the following: . 2. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. 3. As part of the discharge summary, the nurse will reconcile all pre-discharge medication with the resident's post-discharge medications. The medication reconciliation will be documented. Record review of the facility's policy titled, Discharge Medications, dated Revised December 2016 reflected the following: . 2. The Charge Nurse shall verify that the medications are labeled consistent with current physician orders including instructions for use. 6. The nurse shall complete the medication disposition record . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676139 If continuation sheet Page 8 of 11 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 02/24/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #1) of 5 residents reviewed for pharmacy services. The facility (LVN B) failed to follow the facility's policy for reconciling unused medications when Resident #1 discharged home on 1/31/25, which resulted in an inaccurate reconciliation of Resident #1's medications. LVN B sent Resident #2's Methocarbamol Blister Pack (pain medication) home with Resident #1 and Resident#1's FM. This failure could place residents at risk for loss of prescribed medications, resident's safety, and drug diversions. Findings included: Record review of Resident #1's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] and was discharged home on 1/31/25. Resident #1 diagnoses included acute kidney failure (inability to remove waste products and maintain fluid and electrolyte balance), Paroxysmal Atrial Fibrillation (heart rhythm disorder), Chronic obstructive pulmonary disease (lung diseases that cause airflow obstruction and breathing difficulties), Dysphagia (difficulty swallowing), Transient Ischemic Attack (temporary interruption of blood flow to the brain) and Cerebral Infarction (blood flow to the brain is interrupted). Record review of Resident #1's Physician's Discharge Order dated 1/31/25 reflected: May discharge home with home health services of choice. Skilled nursing, meds and disease education, wound care per wound care orders, PT/OT to home evaluate and medical social worker if needed. Record review of Resident #1's Discharge Summary reflected Resident #1 discharged home on 1/31/25 with her FM. Resident #1's Discharge Summary revealed all sections were completed and signed, except Section 4 Nursing - A. Medications. Record review of Resident #2's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] and discharged home on 2/5/25. Resident #2 diagnoses included type 2 diabetes (body doesn't use insulin properly), hypo-osmolality (levels of electrolytes, proteins, and nutrients in the blood are lower than normal), hyponatremia (sodium level in the blood is lower than normal), major depressive disorder (persistent low mood, loss of interest, and other symptoms that significantly interfere with daily life). Record review of Resident #2's Care Plan reflected the following entry: Date initiated 1/7/25: [Resident #2] has acute/chronic pain. Interventions included Monitor/record pain characteristics . Observe and report changes in usual routine . [Resident #2] prefers to have pain controlled by medication, treatment). Record review of Resident #2's Administration Record dated January 2025 revealed an order for: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676139 If continuation sheet Page 9 of 11 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 02/24/2025 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 0755 Methocarbamol Oral Tablet 500 MG (Methocarbamol) Level of Harm - Minimal harm or potential for actual harm Give 0.5 tablet by mouth three times a day for spasms give half tab = 250mg dose Residents Affected - Few Record review of Resident #2's Discharge Summary reflected Resident #2 discharged home on 2/5/25 with all her medications documented accordingly. During a telephone interview on 2/20/25 at 3:50 PM with Resident #1's FM, she stated she received Resident #1's medications when Resident #1 discharged from the facility on 1/31/25. The FM also stated when she arrived home, she discovered another resident's (Resident #2) Methocarbamol medication (muscle relaxant). The FM read the Blister Pack and provided Resident #2's name, date of birth and her room number at the facility. During an interview on 2/21/25 at 1:50 pm with RN B, he stated he printed a Medication Summary and obtained the keys to both medication carts from RN A. RN B stated he collected all of Resident #1's medications, compared the Blister Packs to the printed Medication Summary and ensured everything was correct. RN B stated he went over everything with the FM and educated her on following up with Resident #1's primary care physician within 7-10 days, reminded her that she needed to pick up Resident #1's medication from the pharmacy, any treatments, and recommended diet for Resident #1. RN B stated he was unsure how Resident #2's medication was included. As it was confirmed that the FM was able to provide Resident #2's name, her date of birth and the name of the medication, RN B stated it was important to confirm all information to respect the privacy and confidentiality of all Residents. During an interview on 2/21/25 at 2:25 PM with the DON, she stated she called in Resident #1's prescriptions to [Pharmacy] for a 30-day Supply. The DON stated when time permitted, they requested all medications from their pharmacy to be delivered to the facility. The DON stated RN B must had pulled Resident #2's medication out by mistake due to it being directly behind Resident #1's medication. The DON stated RN B informed her that he gathered Resident #1's medications and went through each one with the FM but he did not recall the other resident's Blister Pack. The DON stated she was unsure how the medication was overlooked. The DON stated it was not against their policy to discharge with medications, they just preferred the orders were called in to ensure residents had enough medication once they arrived home. During an interview on 2/21/25 at 2:25 PM with the ADM, he stated he had not received a call from the FM until 2/17/25, almost three weeks after Resident #1 discharged home. The ADM stated the FM informed him that Resident #1 received all her medications, but there was one medication included that did not belong to Resident #1. The ADM stated starting today (2/21/25), the DON re-educated the nursing staff on discharges and sending medications home. The ADM stated the normal process was the nurse assigned to the hall would pull the medications and send the medications home with the resident. The ADM stated in this situation, RN A asked for assistance and RN B stepped in to assist. During a follow-up interview on 2/24/25 at 11:55 AM with the DON, she stated she completed in-services on Discharges and completing the Discharge Summary in its entirety. The DON stated her expectations moving forward was for the nursing staff to follow procedures. The DON stated if a resident was discharging, the social worker would setup the discharge. The DON stated the facility would request the pharmacy to send over a 30-day supply of medications to the facility. The DON stated if there were not enough time, they would call the Orders into the family's pharmacy of choice. The DON stated they would only discharge with in-house medications if the pharmacy was unable to get the medication delivered to the facility in a timely manner. The DON stated the worse that could had happened was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676139 If continuation sheet Page 10 of 11 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 02/24/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the resident having access to someone else's medication and personal information. The DON stated the resident could had been administered the incorrect medication by her family. During a follow-up interview on 2/24/25 at 1:45 PM with the ADM, he stated his expectations moving forward was that the facility would call all medications into the pharmacy. The ADM stated if the facility must send medications home with the residents, all requests must be approved by an ADON or the DON. The ADM stated the worse that could had happened was Resident #1 could had taken a medication not prescribed to her and had a potential reaction. Record review of the facility's policy titled, Discharge Medications, dated Revised December 2016 reflected the following: . 2. The Charge Nurse shall verify that the medications are labeled consistent with current physician orders including instructions for use. 4. The nurse will reconcile pre-discharge medications with the resident's post-discharge medications. The medication reconciliation will be documented. 6. The nurse shall complete the medication disposition record . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676139 If continuation sheet Page 11 of 11