Health inspection·October 31, 2023

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few pressure injury on the right inner ankle. The wound was identified on 8/2/2023 and measured as 3.0cm x 0.5cm with 80 % of the wound bed appearing red (new tissue) and 20% of the tissue described as slough (non-viable yellowish/tan) tissue. Record review of Resident #3's Wound-Weekly Observation tool dated 9/28/2023 revealed a new stage 3 pressure injury to the right heel. The wound was identified on 9/28/2023, measurements were documented as 2.0cm x 1.5cm with 80% of the wound bed appeared pink, 10% red and 10% slough. Record review of Resident #3's progress note dated 10/10/2023 at 9:19 PM, LVN S wrote, antibiotic to be started 10/11/2023 after collection of right foot wound culture. Record review of Resident #3's Wound-Weekly Observation tool dated 10/12/2023 revealed the stage 3 pressure injury on the right inner ankle had increased in size and measured 7cm x 4cm. No change in appearance of the wound bed. Overall impression of the wound by the WCN was documented as worsening. Record review of Resident #3's Wound-Weekly Observation tool dated 10/19/2023 revealed the stage 3 pressure injury on the right inner ankle had increased in size and measured 12cm x 3cm. No change documented regarding the appearance of the wound bed. Overall impression of the wound by the WCN was documented as worsening. Record review of Resident #3's Wound-Weekly Observation tool dated 10/19/2023 revealed the stage 3 pressure injury to the right heel had increased in size and measured 6cm x 6cm. The appearance of the wound bed was unchanged and described as 80% pink tissue, 10% red and 10% slough. Overall impression of the wound by the WCN was documented as worsening. Record review of Resident #3's culture results revealed, the specimen was collected on 10/18/2023 at 3:10 PM and resulted 10/22/2023 at 11:34 AM. The culture was scheduled for collection 10/11/2023 prior to the start of the antibiotic Keflex. Record review of Resident #3's Progress note dated 10/22/2023 at 6:26 PM, LVN wrote Received wound culture results .antibiotic changed to Linezolid 400mg BID x10 days. Record review of Resident #3's Progress note dated 10/23/2023 09:48 AM, LVN O wrote, Linezolid 400mg was not available in the Emergency kit and was on order from the pharmacy. At 10:02 AM, LVN O called the NP for Resident #3 to obtain a new order for Linezolid 600mg because the prescribed dose of 400mg was not available. Record review of Residents # 3's Order Summary Report dated 10/26/2023 reflected: as of 10/22/2023 Cleanse stage 3 (involves the layers of skin and fat, not muscle) pressure wound to right heel with NS, pat dry, apply Medihoney (medicated wound dressing) and optifoam (waterproof foam) dressing every other day. Every day shift every other day. As of 10/23/2023 Cleanse rt inner ankle stage 3 pressure injury with N/S pat dry apply therahoney (medicated wound dressing) cover with foam dressing change 3x weekly and PRN as needed for soiled or if dislodged. Review of Resident #3's, Departmental Notes/progress notes revealed the absence of progress notes and physician orders indicative of communication to the physician and RP regarding an increase in size of the wound on the right heel, the right inner ankle or the new wound on the inner edge of the right foot. No documentation was found informing the physician of the delay in obtaining the wound (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676161 If continuation sheet Page 2 of 14 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 676161 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Valley Healthcare and Rehabilitation Center 6850 Rufe Snow Dr Fort Worth, TX 76148 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 culture. Level of Harm - Immediate jeopardy to resident health or safety In an interview on 10/26/2023 at 10:03 AM, WCN stated that she took photos of wounds when they deteriorated to document the changes. Reviewed three photo taken by WCN of Resident #3's right foot. Photo number 1, taken 09/28/2023 revealed redness from the inner aspect of the ankle extending upwards towards the great toe, stopped mid foot. Photo #2 taken 10/10/2023 revealed a large open wound near the ankle with a strip of black tissue extending from the right ankle, up the side of the foot to just below the bunion area of the right great toe. Photo #3, taken 10/18/2023, revealed that the black strip of tissue along the inner aspect of the right foot had come off revealing open tissue with areas of redness and slough. The open area extends from the wound on the inner right ankle to the base of the bunion region of the great toe. Residents Affected - Few In an interview on 10/26/2023 at 11:24 AM, RP stated she was not informed of the wound the hospital found on the inner edge of the right foot. RP stated that she was not aware that the wound on the rt heel had gotten bigger. In an interview on 10/26/2023 at 1:45 PM WCN stated that when completing the Wound-Weekly Observation Tool Section D - Communication was used to identify who would be contacted for changes with the wound. Once contacted a progress note would be written with the information. WCN does not recall calling the physician or the RP on 10/19/2023 when she identified an increase in size in the wound on the Rt heel. WCN stated she did not call the physician or RP on 10/12/2023 reporting the appearance of a new wound on the inner edge of the right foot. WCN provided no explanation of why the physician or RP were not informed of the changes. WCN stated she was responsible for making the notifications to the physician, family and obtaining treatment orders from the physician. In an interview on 10/26/2023 at 3:16 PM, DON stated that the physician and the RP were to be notified when a wound changes or when a new wound was identified. When completing the wound observation tool, the communication section reflects who was notified. The progress note would contain a brief summary of what was told and if new orders were received. This notification was expected weekly as the wound observation tool was completed every 7 days. In an interview on 10/30/2023 at 10:15 AM, PCP stated she last saw Resident #3 on 10/12/2023 and observed the open wound on Resident #3's right heel and redness along inner right side of the foot. Resident was started on Keflex (antibiotic) on 10/10/2023, PCP expected that a wound culture was sent before starting the Keflex. After evaluation of the right foot, PCP discontinued the Keflex and ordered Levaquin oral tabs 500 mgs BID for wound infection. PCP said, this order may change once the culture results come back. PCP stated she was not made aware that on 10/19/2023 the wound on Resident #3's right heel had increased in size. PCP stated she was not notified of the development of a black strip of tissue that extended from the rt inner ankle to the base of the bunion region of the right foot. PCP was not notified of the delay in obtaining a wound culture of the wound on the right heel. Record review of facility policy, reviewed 1/2023, and titled, Change of Condition and Physician/Family Notification: Examples of Significant changes - development of wounds, rashes or bruises. Record review of facility policy, reviewed 1/2023, and titled, Skin Integrity Prevention and Treatment Program. Section Weekly Wound Assessment - d. physician updated; e. RP/or family if they are RP or Resident has directed family to be updated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676161 If continuation sheet Page 3 of 14 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 676161 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Valley Healthcare and Rehabilitation Center 6850 Rufe Snow Dr Fort Worth, TX 76148 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 On 10/26/2023 at 3:40 PM requested policy or reference material regarding the completion of the Wound Weekly Observation tool. DON reported on 10/23/2023 facility has no policy. Level of Harm - Immediate jeopardy to resident health or safety This was determined to be an Immediate Jeopardy (IJ) on 10/30/2023 at 1:07 PM. The Administrator was notified. The Administrator was provided with a copy of the IJ Template on 10/30/2023 at 1:12 PM Residents Affected - Few The following Plan of Removal was submitted by the facility was accepted on 10/31/2023 at 09:25 AM. Immediately on 10/26/2023 treatment nurse was suspended. Immediately on 10/26/2023 medical director was notified. Immediately on 10/26/2023 reassessment of current wounds was completed by CCS/DON/Designee, and an audit was completed to ensure correct physician orders were in place with notification of physicians. Inservice for nursing administration will be completed by CCS on 10/26/2023 on the following Skin policy and protocol to include reporting protocol of all skin changes, process of assessment and documentation of all skin concerns, how to conduct a skin assessment, notification of MD/family, and carrying out physician orders. Competency was validated for DON by CCS on 10/26/2023. On 10/26/2023 the DON/Designee completed in-servicing of nurses on the skin policy and protocol to include: reporting of all skin changes to nursing administration, process of assessment and documentation of all skin concerns, how to conduct a skin assessment, notification of MD/family and carrying out of physician orders. On 10/26/2023 an inservice for certified nursing assistants will be completed by DON/Designee on immediate notification to their licensed nurse of any skin concerns that they observe. Inservice will be completed on 10/26/2023. No CNAs will be allowed to their scheduled shift until they complete the inservice. Employees will receive education prior to being allowed to work. Staff will receive a quiz to ensure competency of all education provided. The above information will be included in new hire orientation effective October 26, 2023. In order to monitor current residents for potential risk, DON/Designee will conduct skin sweeps weekly x4weeks. After 4 weeks, the DON/Designee will follow the above process twice a month for 8 weeks, then monthly thereafter. CCS will monitor DON Compliance weekly. The facility QA Committed will meet weekly starting October 26, 2023 for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA committee. In-servicing will be completed on October 30, 2023. Monitoring for the implementation of the POR, initiated on 10/30/2023: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676161 If continuation sheet Page 4 of 14 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 676161 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Valley Healthcare and Rehabilitation Center 6850 Rufe Snow Dr Fort Worth, TX 76148 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Interview on 10/30/2023 at 3:25 PM, CNA B (6:00 AM - 2:00 PM) had been in-serviced regarding reporting skin issues. Interview on 10/30/2023 at 3:47 PM, CNA C (6:00 AM - 2:00 PM) had been in-serviced regarding reporting skin issues. Interview on 10/30/2023 at 3:52 PM, CNA D (2:00 PM - 10:00 PM) had been in-serviced regarding reporting skin issues. Interview on 10/30/2023 at 3:58 PM, CNA E (floater) had been in-serviced regarding reporting skin issues. Interview on 10/30/2023 at 3:52 PM, LVN F (2:00 PM - 10:00 PM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/30/2023 at 4:10 PM, LVN G (2:00 PM - 10:00 PM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/30/2023 at 4:19 PM, ADON A had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/30/2023 at 10:24 PM, RN H (10:00 PM - 6:00 AM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/30/2023 at 10:31 PM, RN I (10:00 PM - 6:00 AM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/30/2023 at 10:40 PM, CNA J (10:00 PM - 06:00 AM) had been in-serviced regarding reporting skin issues. Interview on 10/31/2023 at 09:30 AM, CNA K (6:00 AM - 2:00 PM) had been in-serviced regarding reporting skin issues. Interview on 10/31/2023 at 09:39 AM, CNA L (6:00 AM - 2:00 PM) had been in-serviced regarding reporting skin issues. Interview on 10/31/2023 at 09:44 AM, CNA M (6:00 AM - 2:00 PM) had been in-serviced regarding reporting skin issues. Interview on 10/31/2023 at 9:49 AM, LVN N (6:00 AM - 2:00 PM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/31/2023 at 10:07 AM, LVN O (6:00 AM - 2:00 PM) had been in-serviced regarding, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676161 If continuation sheet Page 5 of 14 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 676161 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Valley Healthcare and Rehabilitation Center 6850 Rufe Snow Dr Fort Worth, TX 76148 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 - Immediate jeopardy to resident health or safety expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/31/2023 at 10:19 AM, RN P (6:00 AM - 2:00 PM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Residents Affected - Few Interview on 10/31/2023 at 10:41 AM, ADON Q had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. The administrator was notified that the IJ was removed on 10/31/2023, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676161 If continuation sheet Page 6 of 14 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 676161 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Valley Healthcare and Rehabilitation Center 6850 Rufe Snow Dr Fort Worth, TX 76148 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 a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #3) of 3 residents reviewed for pressure ulcers. Residents Affected - Few The facility failed to ensure Resident #3 did not experience a worsening of an existing pressure ulcer and did not develop a new pressure ulcer. The pressure ulcer on the rt heel increased in size and a new pressure injury (inner edge of the right foot) was identified on 10/12/2023. The facility failed to ensure there was documentation in the clinical record in the form of the wound weekly observation tool documenting the occurrence of the new wound on the inner edge of the right foot. The facility failed to ensure Resident #3 was provided with individual treatment orders for the pressure injury that was identified on 10/12/2023. Resident #3 was discharged to the emergency room [DATE] r/t to elevated temperature and weakness. An immediate Jeopardy (IJ) situation was identified on 10/30/2023. While the IJ was removed on 10/31/2023, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These deficient practices could place residents at risk for pressure sores being unidentified and untreated. Findings included: Record review of Resident #3's hospital records revealed that on 10/23/2023 at 7:38 PM Resident #3 arrived in the emergency room and then admitted to the hospital diagnosed with sepsis r/t pneumonia and right foot wound. Review of the Nurses admission assessment to the unit dated 10/24/2023 at 00:40 AM revealed - PU right heel and right foot. Red granulation (new) tissue, stage 3 (involving all layers of skin to the fat) w purulent drainage, medial rt foot stage 3 beefy red with moderate purulent drainage. As of 10/31/2023, Resident #3 remains in the hospital. Record review of Resident # 3's face sheet dated 10/26/2023 revealed a 43/F admitted to the facility 12/3/2018 with a readmission on [DATE]. Her diagnoses included: cerebral palsy (lack of muscle control r/t brain dysfunction), muscle weakness and muscle wasting, aphasia (inability to speak). Record review of Resident # 3's quarterly MDS dated [DATE] revealed Resident #3 had severe cognitive impairment by a BIMS score of 00. Resident # 3 was dependent on staff for all ADL care and bathing and required the assistance of 2 staff members for bed mobility and transfers. Record review of Resident #3's Wound-Weekly Observation tool dated 9/20/2023 revealed a stage 3 pressure injury on the right inner ankle. The wound was identified on 8/2/2023 and measured as 3.0cm x 0.5cm with 80 % of the wound bed appearing red (new tissue) and 20% of the tissue described as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676161 If continuation sheet Page 7 of 14 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 676161 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Valley Healthcare and Rehabilitation Center 6850 Rufe Snow Dr Fort Worth, TX 76148 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 slough (non-viable yellowish/tan) tissue. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #3's Wound-Weekly Observation tool dated 9/27/2023 revealed the stage 3 pressure injury on the right ankle had no change in size. The wound bed was described as 95% red and 5% slough. Residents Affected - Few Record review of Resident #3's Wound-Weekly Observation tool dated 9/28/2023 revealed a new stage 3 pressure injury to the right heel. The wound was identified on 9/28/2023, measurements were documented as 2.0cm x 1.5cm with 80% of the wound bed appeared pink, 10% red and 10% slough. Record review of Resident #3's dietary consultation dated 9/30/2023 revealed, recommendations to continue prostat and decubivite (supplements used for wound healing). Record review of Resident #3's Wound-Weekly Observation tool dated 10/5/2023 revealed the stage 3 pressure injury on the right ankle had no changes in size or appearance since the last evaluation completed on 9/27/2023. Record review of Resident #3's Wound-Weekly Observation tool dated 10/5/2023 revealed the stage 3 pressure injury to the right heel had no changes in size or appearance since the initial evaluation completed on 9/28/2023. Record review of Resident #3's Wound-Weekly Observation tool dated 10/12/2023 revealed the stage 3 pressure injury on the right inner ankle had increased in size and measured 7cm x 4cm. No evidence found in the record indicative of a therapeutic treatment causing the change in size. The wound bed was described as 95% appeared red and 5% slough which was unchanged from the previous evaluation. Overall impression of the wound by the WCN was documented as worsening. Record review of Resident #3's Wound-Weekly Observation tool dated 10/12/2023 revealed the stage 3 pressure injury to the right heel had no changes in size or appearance since the last evaluation. Record review of Resident #3's Wound-Weekly Observation tool dated 10/19/2023 revealed the stage 3 pressure injury on the right inner ankle had increased in size and measured 12cm x 3cm. No evidence found in the record indicative of a therapeutic treatment causing the change in size. The wound bed was described as 95% with red tissue and 5% slough unchanged from the previous evaluation. Overall impression of the wound by the WCN was documented as worsening. Record review of Resident #3's Wound-Weekly Observation tool dated 10/19/2023 revealed the stage 3 pressure injury to the right heel had increased in size and measured 6cm x 6cm. The appearance of the wound bed was unchanged and described as 80% pink tissue, 10% red tissue and 10% slough. Overall impression of the wound by the WCN was documented as worsening. Record review of the October 2023 Wound-Weekly Observation tools revealed the absence of a tool addressing the new pressure injury identified on the inner edge of the rt foot. Record review of Residents # 3's Order Summary Report dated 10/26/2023 reflected as of 10/22/2023 Cleanse stage 3 (involves the layers of skin and fat, not muscle) pressure wound to right heel with NS, pat dry, apply Medihoney (medicated wound dressing) and optifoam (waterproof foam) dressing every other day. Every day shift every other day. As of 10/23/2023 Cleanse rt inner ankle stage 3 pressure injury with N/S pat dry apply therahoney (medicated wound dressing) cover with foam dressing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676161 If continuation sheet Page 8 of 14 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 676161 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Valley Healthcare and Rehabilitation Center 6850 Rufe Snow Dr Fort Worth, TX 76148 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 change 3xweekly and PRN as needed for soiled or if dislodged. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #3's Care plan printed 10/26/2023 revealed as of 9/29/2023 Resident #3 had a stage 3 pressure ulcer to the right medial foot and right heel. Interventions included repositioning every 2 hours, a protective boot on the right foot, administration of medications as ordered; administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Residents Affected - Few Record review of Resident #3's physician orders revealed the absence of physician orders regarding instructions for treatment of a new strip of black tissue identified on 10/12/2023 and measured at 7cm x 4cm on the inner edge of the right foot extending to the bunion region of the right foot. Review of Resident #3's, Departmental Notes/progress notes dated 10/10/2023 - 10/19/2023 revealed the absence of progress notes regarding the identification of a new pressure injury located on the inner edge of the right foot or the deterioration of the existing wound on the rt heel. In an interview on 10/26/2023 at 10:03 AM, WCN stated that she took photos of wounds when they deteriorated to document the changes. Reviewed three photos taken by WCN of Resident #3's right foot. Photo number 1, taken 09/28/2023 revealed redness from the inner aspect of the ankle extending upwards towards the great toe, stopped mid foot. Photo #2 taken 10/10/2023 revealed a large open wound near the ankle with a strip of black tissue extending from the right ankle, up the side of the foot to just below the bunion area of the right great toe. Photo #3, taken 10/18/2023, revealed that the black strip of tissue along the inner aspect of the right foot had come off revealing open tissue with areas of redness and slough. The open area extends from the wound on the inner right ankle to the base of the bunion region of the great toe. In an interview on 10/26/2023 at 1:45 PM WCN stated that she considered the new wound on the inner edge of the right foot to be an extension of the wound identified on the rt inner ankle. On 10/12/2023 she measured the wound on the rt ankle as 7cm x 4 cm. WCN nurse applied the treatment written for the wound on the rt inner ankle to the black strip of tissue found on the inner edge of the rt foot extending upwards towards the bunion region of the rt foot. WCN did not notify the physician or obtain orders for treatment of the new wound. In an interview on 10/26/2023 at 3:16 PM, DON stated that the Wound-Weekly Observation tool was completed for each wound identified on a resident. DON expects that each wound had a treatment order specific for the wound. DON expects that when a wound changes in appearance notification to the physician and family was completed timely. In an interview on 10/30/2023 at 10:15 AM, PCP stated she last saw Resident #3 on 10/12/2023 and observed the open wound on Resident #3's right heel and redness along inner right side of the foot. PCP stated she was not made aware that on 10/19/2023 the wound on Resident #3's right heel now measured 6cm x 6cm. PCP stated she was not notified of the development of a black strip of tissue that extended from the rt inner ankle to the base of the bunion region of the right foot which was measured at 12cm x 3cm. PCP stated that had she known about the deterioration of the heel wound and the development of a new wound she may have discharged the resident to the hospital for evaluation of the wounds. Record review of facility policy, reviewed 1/2023, and titled, Change of Condition and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676161 If continuation sheet Page 9 of 14 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 676161 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Valley Healthcare and Rehabilitation Center 6850 Rufe Snow Dr Fort Worth, TX 76148 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 Physician/Family Notification: Examples of Significant changes - development of wounds, rashes or bruises. Level of Harm - Immediate jeopardy to resident health or safety Record review of facility policy, reviewed 1/2023, and titled, Skin Integrity Prevention and Treatment Program. Section Weekly Wound Assessment - d. physician updated; e. RP/or family if they are RP or Resident has directed family to be updated. Residents Affected - Few This was determined to be an Immediate Jeopardy (IJ) on 10/30/2023 at 1:07 PM. The Administrator was notified. The Administrator was provided with a copy of the IJ Template on 10/30/2023 at 1:12 PM The following Plan of Removal was submitted by the facility was accepted on 10/31/2023 at 09:25 AM. Immediately on 10/26/2023 treatment nurse was suspended. Immediately on 10/26/2023 medical director was notified. Immediately a complete head to toe skin sweep was initiated on 10/26/2023 and completed by CCS, DON, ADONs to include updated assessments which includes pressure and non pressure assessments; appropriate documentation, treatment orders if indicated, notification of MD/family, care plan update. Immediately on 10/26/2023 reassessment of current wounds was completed by CCS/DON/Designee, to include current measurements and staging as well as any required treatment changes. Immediately an audit was completed of Braden Scales, current treatment/wound orders and care plans to ensure accuracy. Audit was completed by CCS/DON/Designee on 10/26/2023. Inservice for nursing administration will be completed by CCS on 10/26/2023 on the following Skin policy and protocol to include reporting protocol of all skin changes, process of assessment and documentation of all skin concerns, how to conduct a skin assessment, notification of MD/family, and carrying out physician orders. Competency was validated for DON by CCS on 10/26/2023. On 10/26/2023 the DON/Designee completed in-servicing of nurses on the skin policy and protocol to include: reporting of all skin changes to nursing administration, process of assessment and documentation of all skin concerns, how to conduct a skin assessment, notification of MD/family and carrying out of physician orders. On 10/26/2023 an inservice for certified nursing assistants will be completed by DON/Designee on immediate notification to their licensed nurse of any skin concerns that they observe. Inservice will be completed on 10/26/2023. No CNAs will be allowed to their scheduled shift until they complete the inservice. Employees will receive education prior to being allowed to work. Staff will receive a quiz to ensure competency of all education provided. The above information will be included in new hire orientation effective October 26, 2023. In order to monitor current residents for potential risk, DON/Designee will conduct a skin sweep weekly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676161 If continuation sheet Page 10 of 14 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 676161 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Valley Healthcare and Rehabilitation Center 6850 Rufe Snow Dr Fort Worth, TX 76148 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 x4weeks. After 4 weeks, the DON/Designee will follow the above process twice a month for 8 weeks, then monthly thereafter. CCS will monitor DON compliance weekly. The facility QA Committed will meet weekly starting October 26, 2023 for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA committee. In-servicing will be completed on October 30, 2023. Residents Affected - Few Monitoring for the implementation of the POR, initiated on 10/30/2023: Interview on 10/30/2023 at 3:25 PM, CNA B (6:00 AM - 2:00 PM) had been in-serviced regarding reporting skin issues. Interview on 10/30/2023 at 3:47 PM, CNA C (6:00 AM - 2:00 PM) had been in-serviced regarding reporting skin issues. Interview on 10/30/2023 at 3:52 PM, CNA D (2:00 PM - 10:00 PM) had been in-serviced regarding reporting skin issues. Interview on 10/30/2023 at 3:58 PM, CNA E (floater) had been in-serviced regarding reporting skin issues. Interview on 10/30/2023 at 3:52 PM, LVN F (2:00 PM - 10:00 PM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/30/2023 at 4:10 PM, LVN G (2:00 PM - 10:00 PM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/30/2023 at 4:19 PM, ADON A had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/30/2023 at 10:24 PM, RN H (10:00 PM - 6:00 AM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/30/2023 at 10:31 PM, RN I (10:00 PM - 6:00 AM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/30/2023 at 10:40 PM, CNA J (10:00 PM - 06:00 AM) had been in-serviced regarding reporting skin issues. Interview on 10/31/2023 at 09:30 AM, CNA K (6:00 AM - 2:00 PM) had been in-serviced regarding reporting skin issues. Interview on 10/31/2023 at 09:39 AM, CNA L (6:00 AM - 2:00 PM) had been in-serviced regarding (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676161 If continuation sheet Page 11 of 14 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 676161 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Valley Healthcare and Rehabilitation Center 6850 Rufe Snow Dr Fort Worth, TX 76148 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 reporting skin issues. Level of Harm - Immediate jeopardy to resident health or safety Interview on 10/31/2023 at 09:44 AM, CNA M (6:00 AM - 2:00 PM) had been in-serviced regarding reporting skin issues. Residents Affected - Few Interview on 10/31/2023 at 9:49 AM, LVN N (6:00 AM - 2:00 PM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/31/2023 at 10:07 AM, LVN O (6:00 AM - 2:00 PM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/31/2023 at 10:19 AM, RN P (6:00 AM - 2:00 PM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/31/2023 at 10:41 AM, ADON Q had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. The Administrator was notified that the IJ was removed on 10/31/2023. The facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility continuing to monitor the implemtation and effectiveness of their plan of removal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676161 If continuation sheet Page 12 of 14 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 676161 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Valley Healthcare and Rehabilitation Center 6850 Rufe Snow Dr Fort Worth, TX 76148 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 observation, interview, and record review, 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 #4) of 5 residents observed for infection control. Residents Affected - Few WCN failed to sanitize the surface of the dresser where the wound care supplies were first placed upon entry into Resident #4's room. WCN failed to perform hand hygiene after each glove change during wound care. WCN failed to change gloves after completing the treatment on one wound before beginning treatment on another wound. WCN failed to place a clean barrier between the open wound on Resident #4's right heel and the bed sheet after removal of the old dressing. These failures could place residents at risk for infection, cross contamination, and illness. Findings include: Review of Resident #4's face sheet dated 10/26/2023 revealed an [AGE] year-old male admitted to the facility 06/19/2023. His diagnosis included Alzheimer's disease, non-pressure chronic ulcer off the left lower leg, muscle weakness and muscle wasting. Review of Resident #4's quarterly MDS assessment dated [DATE] revealed Resident #4 had severe cognitive impairment with a BIMS score of 3. Section M - skin conditions revealed other skin problems skin tears which required the application of ointments/medications and nonsurgical dressings. Record review of the facility's Undated Wound report revealed Resident #4 had a wound to the Rt heel that measured 3.5cm x 2.0. Resident #4 also had a wound on the back of the left arm. Review of Resident #4's physician's orders reflected: as of 10/22/2023 clean right heel wound with NS (Normal saline), pat dry, apply Santyl (used to remove dead tissue from a wound bed) and cover with optifoam (waterproof foam dressing) dressing and kerlex (rolled gauze) daily. As of 10/22/2023 clean skin tear to outer upper left arm with NS, pat dry, apply dry dressing every other day and PRN every 1 hour as needed. As of 10/22/2023 clean skin tear to lower right leg with NS, pat dry, apply dry dressing daily and PRN every day shift every other day. Observation on 10/26/2023 at 10:28 PM, WCN was observed placing items (sterile gauze, saline bullets, the cover dressing) intended for use during wound care on the dresser in Residents #4's room. The top of the dresser contained 1 stuffed animal, an open box of gloves and a helium balloon tied to the drawer handle with the ribbon moving side to side near the open container of santyl. After sanitizing Resident #4's bedside table, the wound care items were removed from the dresser and placed on the sanitized bedside table. No barrier was placed between the treatment supplies and the bedside table. While removing the dressing on the right leg, WCN was observed removing scissors from her pocket and used them to cut off the old dressing. After removal of the old dressing, Resident #4's right foot with an open wound on the heel was placed directly on the sheet on the bed. No barrier was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676161 If continuation sheet Page 13 of 14 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 676161 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Valley Healthcare and Rehabilitation Center 6850 Rufe Snow Dr Fort Worth, TX 76148 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 - Few placed between the exposed wound and the sheets. The wound was cleaned with gauze soaked with NS and patted dry. WCN removed her gloves, applied clean gloves without performing hand hygiene and applied santyl using a no touch technique. The cover dressing was applied and without changing gloves, WCN was observed removing a dressing from the shin of Resident #4's right leg. The wound was a skin tear on which a medicated strip of gauze was noted. The strip of medicated gauze was removed, wound was cleaned with saline and patted dry. WCN removed her gloves and applied clean gloves without performing hand hygiene. A medicated gauze strip was applied to the wound and secured with a cover dressing. Without changing gloves WCN removed the dressing on Resident #4's left lower leg. The wound bed was pink and dry in appearance without drainage. Sterile gauze was moistened with saline for cleaning of the wound. After the wound was cleaned WCN removed her gloves and applied clean gloves without performing hand hygiene. A cover dressing applied, without changing gloves WCN removed the dressing on Resident #4's left upper arm. Sterile gauzed was moistened with saline and used to clean the wound on Resident #4's upper arm. Dry gauze was used to pat the wound dry, WCN removed her gloves and applied clean gloves without performing hand hygiene. WCN applied the cover dressing, collected the garbage and sanitized the bedside table. Prior to leaving the room WCN was observed removing her gloves and washing her hands. In an interview on 10/26/2023 at 2:15 PM WCN stated that she washes her hands before starting wound care and would sanitize on completion. When asked about placing Resident #4's right heel directly on the sheet after removal of the old dressing. WCN said she did not have anything she could use as a barrier. WCN verbalized that she put Resident #4 at risk for cross-contamination by not changing her gloves after completing the treatment of one wound and beginning the treatment on another wound. WCN confirmed that she was provided with training specific to wound care April 2023. In an interview on 10/26/2023 at 3:16 PM, DON stated that before beginning wound care, the nurse was expected to set up a clean workspace by sanitizing a hard surface and placing a barrier between the surface and the supplies. DON, expects that hands were washed prior to the start of wound care and with each glove change staff were expected to perform hand hygiene (wash or sanitize). DON stated that hands were to be washed at the completion of the treatment prior to leaving the room. When working with residents with multiple wounds gloves should be changed after completing one dressing before moving to the next one. In an interview on 10/27/2023 at 2:47 PM, ADON A stated training for the WCN was on the job training. It included self paced computer based learning, review of policies and procedures, reading physician orders and demonstration with return demonstration. Review of facility policy, revised 10/2020, and titled Handwashing-Hand Hygiene Policy and Procedures reflected: Section: Policy Interpretation and Implementation section 7, letter G. Use an alcohol - based hand rub containing at least 62% alcohol or soap and water before handling clean or soiled dressings, gauze pads etc. Letter K. After handling used dressings, contaminated equipment etc; Letter M. After removing gloves. Treatment/Admin Nurse Skills Validation Checklist revised 2023, was signed by WCN and ADON Q on 4/12/2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676161 If continuation sheet Page 14 of 14