Health inspection·October 10, 2024

F 0580 following intervention: Encourage support system of family and friends. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's lab results report dated 10/03/2024 reflected an ammonia, plasma level of 181 ug/dL (micrograms of lead per deciliter of blood) (Reference Range 34-178). Residents Affected - Few Record review of Resident #1's Order Summary reflected an effective date of 10/01/2024 an order for Lactulose Oral Solution 10 gm/15mL - 45 mL by mouth four times a day for hyperammonemia (metabolic condition characterized by the raised levels of ammonia). Record review of Resident #1's October 2024 MAR reflected the resident was scheduled to receive Lactulose Oral Solution 10 gm/15mL by mouth four times a day for hyperammonemia (metabolic condition characterized by the raised levels of ammonia). The MAR further reflected Resident #1 missed three doses over a two-day period documented as the following: - Saturday, 10/05/2024 (12:00 PM); and - Sunday, 10/06/2024 (12:00 PM and 5:00 PM) Record review of Resident #1's nurses notes dated 09/7/2024 to 10/08/2024 did not reflect any documentation by LVN A, for Resident #1's refusal to take her Lactulose medication on 10/05/2024 nor 10/06/2024. Record review of Resident #1's nurses notes dated 09/07/2024 to 10/08/2024 did not reflect communication between the facility and physician regarding notification of Resident #1's change in condition. Record review of Resident #1's nurses notes dated 10/06/2024 at 7:42 PM by LVN A reflected: [Family] at bedside this evening concerned that [Resident #1] is more sleepy and slow to answer questions as well as decreased oral intake today than they saw her yesterday. [Family] is concerned that this might be due to [Resident #1]'s issues with elevated ammonia levels. Patient is on Lactulose 45 mL four times daily and the last ammonia level on 10/2 was 181. [Resident #1] is responsive and able to follow simple commands at this time, her baseline is unknown to me. VS stable. [Family] wants [Resident #1] sent out to ER for evaluation. [MD] notified and is agreeable. DON also notified. [Resident #1] is being transported to the [hospital] via non-emergency 911. Record review of Resident #1's Transfer/Discharge Report reflected her vital signs as Blood Pressure (114/67 mmHg), Pulse (77 bpm), Temperature (97.8 F) and Respirations (16 rr). Record review of Resident #1's hospital paperwork reflected Resident #1's hospital diagnosis was the same current diagnosis of Hepatic Encephalopathy with an ammonia level of 151 umol/L and her condition listed as fair (conscious, has stable vital signs, and is expected to have a favorable outcome). Observation and interview on 10/08/2024 at 4:30 PM revealed Resident #1 was at the hospital lying in bed watching television. Resident #1 said she refused her Lactulose medication because it made her have more incontinence episodes. Resident #1 stated she had no complaints regarding her stay at the facility. Resident #1 stated she was now ready to go back to her own home. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676141 If continuation sheet Page 2 of 6 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 676141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matlock Place Health & Rehabilitation Center 7100 Matlock Rd Arlington, TX 76002 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 10/07/2024 at 1:57 PM with Family Member A revealed Resident #1 was diagnosed with cirrhosis of the liver, diabetes, and hepatic encephalopathy. She stated Resident #1 was placed on Hospice prior to admitting to the facility, but she took the resident off hospice services because she was not satisfied due to needing to sign a DNR. Family Member A stated at the hospital, the doctors gave Resident #1 the same medication (Lactulose), but as a suppository. She stated she requested Resident #1 be sent out to the hospital because she noticed Resident #1 was not as responsive as she was the day prior on Saturday, 10/05/2024. Interview with on 10/08/2024 at 1:00 PM with the NP revealed he was not made aware that Resident #1 refused her Lactulose Oral Solution 10 gm/15mL on 10/05/2024 and 10/06/2024. He stated Resident #1 was on hospice and her ammonia levels were only 151 ug/dL when admitted to the hospital. He stated he was unsure of the family member's expectations as to why Resident #1 had been put her on hospice, if the family believed she would get better. The NP stated everyone's body was different and missing one or two doses of Lactulose could cause the ammonia levels to go up. He stated staff did not have to call the physician every time a resident refused unless the levels were too high. He stated they did not want Resident #1 to refuse any of the doses. He stated to be sent out was not based on the level of the ammonia level, it would be associated with other symptoms such as drowsiness and mental status changes. The NP stated Resident #1 did not have to be sent out for 150 ug/dL. The NP stated there were no issues with her ammonia levels to warrant her being sent out, and it was her family member's choice. Interview on 10/8/2024 at 1:25 PM with the Hospice Nurse revealed Resident #1's hospice services was revoked on Thursday, 10/02/2024. He stated Resident #1 was admitted to hospice for cirrhosis of the liver. He stated Resident #1 was not compliant with her Lactulose medication because it caused her to have diarrhea. The Hospice Nurse stated if the medication was taken, then the ammonia levels would stay down. He stated if the medication was not taken, then the ammonia levels would go up. He stated he educated Resident #1 that she needed to remain compliant with her medications. He stated due to Resident #1's terminal diagnosis, she was not going to get better and refusing her Lactulose medication exacerbated her condition. Interview on 10/08/2024 at 2:30 PM with the DON revealed if a resident refused a dose of medication, it should be coded on the MAR as a refusal. She stated best practice was to notify the family and the physician if a dose was refused. She stated if it was not a regular occurrence and a nurse could get the resident to take the medication later, the physician would not be contacted. The DON stated per policy, the physician and the family should had been notified. She stated Resident #1's ammonia levels were last checked on 10/02/2024, and the level had decreased to 181 ug/dL. The DON stated when Resident #1 was sent out to the hospital, the resident's ammonia levels had decreased even more to 151 ug/dL; therefore, the three missed doses did not affect the resident. The DON stated on 10/01/2024, the physician had increased the frequency of Resident #1's Lactulose medication from 3 times a day to 4 times a day. Interview on 10/08/2024 at 4:00 PM with the Hospital RN revealed Resident #1 was admitted to the hospital due to altered mental status and elevated ammonia levels. She stated Resident #1 had been prescribed Lactulose several times a day at the facility. She stated at the hospital, Resident #1 was given Lactulose 20 gms three times a day, and Resident #1 had multiple bowel movements which caused her ammonia levels to decrease to 37 ug/dL. She stated Resident #1 refused her Lactulose medication this morning (10/08/2024) and again this afternoon. The Hospital RN stated she explained to Resident #1 the importance of her medication and tried to bargain with her if she took it. She stated Resident #1 would not say why she would not take the Lactulose medication and would turn her head away when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676141 If continuation sheet Page 3 of 6 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 676141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matlock Place Health & Rehabilitation Center 7100 Matlock Rd Arlington, TX 76002 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 0580 Level of Harm - Minimal harm or potential for actual harm she tried to administer it to her. She stated Resident #1's ammonia levels were now back to a high normal. She stated around 2:00 PM, due to already having three bowel movements, she held Resident #1's 3:00 PM dose of Lactulose. She stated sometimes Resident #1 would talk and sometimes she would just look at you. She stated Resident #1 had been eating good and consumed 75% of each meal. She stated Resident #1's weight was 182 pounds and her BMI was good. Residents Affected - Few Telephone interview on 10/10/2024 at 8:29 AM with the Hospital Physician revealed Resident #1 had a prior diagnosis of cirrhosis of the liver and hepatic encephalopathy. He stated one missed dose of Resident #1's Lactulose medication would cause her ammonia levels to build up. HE stated Resident #1 was admitted to the hospital due to altered mental status. He stated when Resident #1 arrived at the ER, her ammonia levels were at 151 ug/dL, which was high. He stated Resident #1 was already receiving Lactulose orally; however, in the ER they initially administered it rectally and now she was back to oral doses. Telephone interview on 10/10/2024 at 9:45 AM with MA A revealed Resident #1 did not like taking her Lactulose medication. She stated on Saturday (10/05/2024), Resident #1 refused one dose (12:00 PM) and on Sunday (10/06/2024), Resident #1 refused two doses (12:00 PM and 5:00 PM). MA A stated she told LVN A and later LVN A said Resident #1 took her medication. MA A stated she did not go into the room with LVN A when she administered the medications. She stated if a rrefused their medications, she would tell the nurse and the nurse would re-attempt. She stated if the Resident still refused, the Nurse would document the refusal and report it to the MD. She stated policy further stated the nurse is supposed to document the refusal in PCC and report any refusals to the MD. MA A stated Resident #1 could had continued to get worse and possibly be in serious condition. Telephone interview on 10/10/2024 at 10:25 AM with LVN A revealed if a resident refused a medication, the MA would tell the nurse. She stated MA A informed her about Resident #1 refusing her medications but MA A did not tell her about the refusal of the Lactulose. LVN A stated at first, she could not get Resident #1 to take her pills, so she crushed the pills and put them in a syringe and Resident #1 then took them. LVN A stated due to the Lactulose not being in a pill form, she would had put the Lactulose in the syringe first, but MA A did not tell her about the Lactulose. LVN A stated on Saturday (10/05/2024), she was not aware that Resident #1 refused one of her Lactulose doses. LVN A stated Resident #1 was up and out of the bed on this day and came out of the room for the housekeeper due to dropping the glass of pickles her family had purchased. LVN A stated on Sunday (10/06/2024), it was harder to wake Resident #1. LVN A stated she got a towel and wiped Resident #1's face and Resident #1 swatted the towel away. LVN A stated she checked Resident #1's vitals which were stable and administered her insulin. LVN A stated she was successful administering Resident #1's medications again via the syringe. LVN A stated Resident #1 kept swatting at them, but she still took her medications. LVN A stated neither day was she informed about or given Resident #1's Lactulose medication by MA A to administer to Resident #1. LVN A stated she would had entered a progress note into PCC about the refusal of Resident #1's Lactulose medication because it helped with her liver. LVN A stated all MA A had to do was hand her Resident #1's Lactulose medication and she would had attempted to administer it to Resident #1. LVN A stated due to the medication being in a liquid form, she would had put the Lactulose medication into the syringe first. LVN A stated per policy, if a resident refused their medication, you entered the refusal into the progress notes as to why and you always let the physician know (via phone, voicemail, etc.). LVN A stated if it was a critical medication, you most definitely would inform the physician. LVN A stated a resident had the right to refuse but you still documented the refusal and informed the physician. LVN A stated the worse that could had happened was that Resident #1's ammonia levels would increase which was not good. LVN A stated Resident #1 was diagnosed with cirrhosis of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676141 If continuation sheet Page 4 of 6 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 676141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matlock Place Health & Rehabilitation Center 7100 Matlock Rd Arlington, TX 76002 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few liver and it does not help to miss any doses of her Lactulose medication. LVN A stated if it had been a critical medication, the medication would be on the Nurse's cart, not the Med Aide's cart. LVN A stated she would recommend transferring the Lactulose medications to the nurse's cart, unless it is PRN. Interview on 10/10/24 at 11:15 AM with LVN B revealed Resident #1 normally took her Lactulose medication for her. LVN B stated when a resident refused their medication, you documented the refusal in the progress notes, and informed the family and the physician. LVN B stated if a resident missed a dose of Lactulose, their ammonia levels would increase resulting in an abnormal level. LVN B stated the resident would have had a change in condition (altered mental status). LVN B stated any change in condition must be reported to the physician immediately. LVN B stated the worse that could had happened is Resident #1 could have had a change in mental status and increased ammonia levels. LVN B stated per policy, if a resident refused a medication by the medication aide, the nurse must try. LVN B stated if the resident still refused, you must report it to the DON to try and if the Resident still refused, the refusal was reported to the family and physician immediately. Interview on 10/10/2024 at 11:40 AM with the ADON revealed he was not made aware of Resident #1's missed doses over the weekend. He stated if a resident refused a medication multiple times, the physician should be notified. He stated the Med Aide should be going to the nurse to attempt again in case they are more responsive and if the Resident continued to refuse, the physician should be notified. He stated the ammonia levels going up could cause confusion and altered mental status. The ADON stated that is why it is important to document because if a Resident refused, which they had the right to do, it would be noted. He stated per policy the Nurse should had notified the family and the physician of the refusal. He stated policy was not followed and that is why they are re-educating the staff. Interview on 10/10/2024 at 3:15 PM with the Administrator revealed Resident #1 admitted to the facility on [DATE], already on hospice for cirrhosis of the liver. He stated prior to and after admission, the family had Resident #1 sent out for increased levels of ammonia. He stated hospice allowed Resident #1 to go out to the hospital once for high ammonia levels and informed the family that if the family had Resident #1 sent out again, she would be taken off hospice. He stated when Resident #1 refused her Lactulose medication, staff did not inform the family, nor the physician per policy. He stated they started two in-services detailed as followed: - The NP and MD must be notified of medication refusals, especially medications that are life-sustaining. Families are to also be notified of medication refusals. This includes treatments as well. - If a resident is refusing medications, then the MD and the family must be notified, and it must be documented. Any changes in a resident must be documented. If on antibiotics, you should be documenting. The Administrator stated the family and the physician should had been notified and documentation should had been entered into PCC. He stated what could had been done differently was definitely the prompt notification to the family and the physician. Record review of the facility's Notification of Changes policy, revised 09/18/2024, reflected: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676141 If continuation sheet Page 5 of 6 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 676141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matlock Place Health & Rehabilitation Center 7100 Matlock Rd Arlington, TX 76002 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 0580 representative when there is a change requiring notification. Level of Harm - Minimal harm or potential for actual harm Clinical Complications: Examples-Development of stage 2 pressure injury, recurrent episodes of delirium, recurrent UTIs or onset of depression. Residents Affected - Few .2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications Record review of the facility's Medication Administration policy, revised 09/28/2024, reflected: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . .22. Report and document any adverse side effects or refusals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676141 If continuation sheet Page 6 of 6