Health inspection·February 28, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Review of Resident #49's quarterly MDS, dated [DATE], reflected she was dependent for toileting hygiene, bathing and lower body dressing. Resident #49 needed Substantial/maximal assistance for transfers, upper body dressing and personal hygiene. Resident #49 needed supervision for oral hygiene and Setup assistance for eating. The MDS reflected Resident # 49 had a BIMS score of eleven, indicating possible moderate cognitive impairment. Residents Affected - Few Review of Resident #81's admission Record, dated 2/28/24, reflected a [AGE] year-old male, admitted [DATE] with diagnoses which included Parkinson's Disease (a disorder of the central nervous system that affects movement), Constipation and Difficulty in walking. Review of Resident #81's Care plan, undated, reflected the resident was a high risk for falls related to confusion, gait/balance problems and being unaware of safety needs. One intervention reflected, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Review of Resident #81's admission MDS, dated [DATE], reflected he needed Substantial/maximal assistance for transfers, toileting hygiene, bathing and lower body dressing. Resident # 81 needed partial assistance for oral hygiene, upper body dressing and personal hygiene, and needed Setup help for eating. The MDS reflected Resident #81 had a BIMS score of fifteen, indicating intact cognition. Observation on 2/26/24 at 10:54 AM revealed the call light was on the floor and was not within reach for Resident #27. Observation on 2/26/24 at 11:05 AM revealed Resident #49 was in bed asleep; bed was in low position and fall mat was on the floor. Her call light was wrapped around her walker and not within her reach. Observation and interview on 2/26/24 at 11:49 AM revealed Resident #81 attempting to reach for his call light unsuccessfully and water was on the floor from his water cup that had apparently spilled. Resident # 81 stated the aide who was helping him earlier left quickly and did not say what she was going to do. In an interview and observation on 2/26/24 at 11:51 AM with LVN A stated Resident #49's call light should have been left within his reach. LVN A refilled Resident #81's water cup and left to get someone to clean up the floor. In an interview on 2/26/24 at 12:03 PM with CNA D she stated she had helped the resident earlier. CNA D stated the nurse asked her to transfer the resident from his wheelchair into the bed and that is what she helped him with. CNA D stated the water cup had not spilled in her presence. She stated when she finished, she placed the call light across from him. CNA D stated this was her first time working with this resident as his usual aide was on break when the nurse asked her to help him, therefore she did not know if he had a clip for his call light. CNA D stated some of the other residents she worked with regularly had clips for their call lights . In an interview on 2/26/24 at 12:27 PM with LVN A stated some residents had clips for their call lights and some did not. She stated Resident #81 needed one, so she was going to get him one. Observation and interview on 2/26/24 at 12:31 with DON revealed the call light for Resident #49 was not within reach. The DON stated Resident #49 did not use her call light but could use it. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676161 If continuation sheet Page 2 of 10 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 02/28/2024 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated staff were still supposed to ensure call lights were within reach for Resident # 49. The DON stated there was no way to determine who got a clip and who did not with their call light. The DON stated some residents requested clips. Observation and interview on 2/26/24 at 12:39 PM with the DON revealed the call light for Resident #27 was on the floor as Resident #27 was eating her lunch. The DON stated Resident #27 was able to use her call light and that her call light should be kept within reach. The DON stated the risk of not having a call light within reach was Resident #27 would have to yell for help which could disturb other residents. The DON stated the risk for Resident # 49 was that she would attempt to get out of bed by herself and possibly fall. In an interview on 2/26/24 at 2:27 PM Resident #49 stated she was able to use the call light if she needed to and the staff usually kept it close to her . In an interview on 2/26/24 at 2:42 PM with the DON she stated the risk for Resident #81 not having his call light within reach is he could have slipped in the water that was on the floor. She stated she would get a clip for Resident # 81. In an interview on 02/28/24 at 3:38 PM with the ADM he stated his expectation was for call lights to be reachable to the residents. If it was not within reach, the risk to the resident was they may not be able to get help as quickly as they would otherwise. The ADM stated Resident #81 could use the call light while Residents #27 and #81 cognitively may not be able to use the call light. The ADM stated there was not a way to determine who got a clip. He stated if a resident had a turn bar, they would have the call light there instead of clipped to the bed so they could see it more easily. Record review of facility policy titled Answering the Call light, dated September 2022, revealed, Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676161 If continuation sheet Page 3 of 10 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 02/28/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (200 hall) of four halls reviewed for environment. The facility failed to ensure equipment stored on 200 hall was locked. This failure could place residents at risk for falls and/or injury. Findings included: An observation on 02/26/24 at 11:02 AM on the 200 hall revealed two unlocked wheelchairs against the wall in between the entrance to rooms [ROOM NUMBERS]. An observation and interview with the DON on 2/26/24 at 12:33 PM revealed a locked mechanical lift (assistive device used to transfer residents between a bed and chair) that still moved when it was pushed and two unlocked wheelchairs against the wall between the entrance to rooms [ROOM NUMBERS]. The DON stated it was okay for the Hoyer lift to be on the hall and stated that she would have maintenance investigate why the mechanical lift was still moving while locked . The DON stated wheelchairs were kept on the hall if a resident could use the restroom independently to ensure adequate space in their room for movement. The DON stated the wheelchairs on the hallway were supposed to be locked. She stated the risk of having unlocked wheelchairs on the hall was someone could grab one and move and could cause a fall. In an interview with the Administrator on 02/28/24 at 2:35 PM he stated the facility did not have a policy that covered wheelchairs that were not in current use. In an interview with the ADM on 02/28/24 at 3:43 PM he stated the issue with the Hoyer lift was possibly a faulty brake. He stated the Hoyer lifts were inspected and checked often. The ADM stated if equipment was causing clutter in a resident's room it was okay to keep it in the hallway. He said the Hoyer lift was okay to be on the hallway if it was on the same side as other items on the hall, and there was an uninterrupted path along the handrail. The ADM stated he preferred the wheelchairs on the hall be locked. He stated the risk of having an unlocked chair on the hall was a resident could try to sit in it and if it moved, they could fall to the floor. The ADM stated the facility did not have a policy that specified wheelchairs were to be locked if on the hall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676161 If continuation sheet Page 4 of 10 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 02/28/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for two (Resident #7 and Resident #8) of seventeen residents reviewed for respiratory care. Residents Affected - Some The facility failed to ensure Resident #7 received a physician order for isolation precautions. The facility failed to ensure Resident #8 had physician orders for oxygen. These failures could place residents at risk of not receiving the appropriate care and treatment. Findings included: Review of Resident #7 admission Record dated 02/26/24, revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: Organism unspecified pneumonia, acute respiratory failure with hypoxia (a breathing issue due to not getting enough oxygen), atrial fibrillation (an irregular heartbeat), malignant neoplasm of prostate (prostate cancer), chronic obstructive pulmonary diseases, lack of coordination, Rib fracture, and muscle weakness. Review of Resident #7 Order summary dated 02/26/24 did not reflect Resident #7 isolation orders. Record Review of Resident #7 Care plan on 02/26/24 at 12:15 pm did not reflect isolation precautions. Review of Resident #7 nurses' notes reelected that Resident #7 discharged to the ER on [DATE] for respiratory distress (trouble breathing and low Oxygen) Record review of Resident #8's admission Record, dated 2/28/24, reflected a [AGE] year-old female was admitted on [DATE] and re-admitted on [DATE] with diagnoses which included: Acute and Chronic Respiratory Failure (injury or disease that affects breathing) with Hypercapnia (high levels of carbon dioxide in the body), Other specified symptoms, signs involving the circulatory and respiratory systems, and Legal Blindness. Record review of Resident #8's Care plan, undated, reflected the resident was a high risk for falls related to gait/balance problems. Resident #8 had confusion, incontinence, was unaware of safety needs and had hearing and vision problems. Record review of Resident #8's quarterly MDS, dated [DATE], reflected a BIMS score of 9, which indicated moderate cognitive impairment and disorganized thinking. Resident #8 is dependent on assistance for toileting hygiene, shower/baths, lower body dressing and putting on/taking off footwear. Resident #8 needed substantial/maximal assistance for upper body dressing and Partial/moderate assistance for eating and oral personal hygiene. Observation on 02/26/24 at 10:04 AM of Resident #8 revealed the resident's oxygen bag and tubing did not have a date on them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676161 If continuation sheet Page 5 of 10 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 02/28/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm In an interview 02/27/24 at 08:55 AM with RN E, she stated Resident #8's oxygen bag was supposed to have a date on it. Record review of Resident #8's Orders on 02/27/24 at 11:37 AM revealed no physician orders listed for oxygen for Resident #8. Residents Affected - Some In an interview on 02/28/24 at 01:24 PM with CNA C she stated she had been at the facility for 7 months. CNA C stated Resident #8 had been on oxygen since she had worked at the facility. In an interview and observation on 02/28/24 at 01:25 PM LVN B stated Resident #8 was on continuous oxygen. LVN B stated she checked Resident #8 oxygen level to make sure it is at 90% and documented the levels on the vital signs daily. LVN B stated the tubing was changed once a week and documented in Resident #8's orders. LVN B stated she changed Resident #8's tubing on Monday, 02/26/24, because the tubing did not have a date. LVN B stated she documented the change in the orders. LVN B stated the tubing is changed every Saturday and Resident #8 received 2 liters. LVN B reviewed MAR for Resident #8 and could not find Resident #8 orders or where she documented the changing and dating of the oxygen tubing and bag. LVN B stated normally there should be an oxygen order specifying the amount Resident #8 should be given. LVN B stated orders are placed by ADON and the nurse. LVN B stated the risk of not having orders would result in Resident #8 not getting what the physician ordered, as well as not knowing how often to change the tubing. In an interview and observation on 02/28/24 at 01:39 PM with the DON and Corporate Nurse, the DON reviewed the MAR and stated, looks like there is no order. The DON stated Resident #8 was recently in the hospital and the order was probably missing. The DON stated the bag and tubing were supposed to be changed once a week by the nurse on the floor. The DON stated she had no idea what was supposed to be on the order the risk was not knowing how much oxygen is in the order and how often the bag and tubing is changed. DON stated the nurse on the floor was responsible for making sure the orders were in the system. The DON stated she was responsible for auditing the residents' charts to ensure the nurse puts the orders in. The DON stated she audited residents charts a couple of days after admission. When asked what was the risk to Resident #8?, the DON responded, that's a trick question and did not answer the question. In an interview on 02/28/24 at 04:32 PM with the ADM stated that there should be orders in the MAR. The ADM stated Resident #8 had previous orders, so he was glad staff continued with the oxygen. The ADM stated he expected staff to document all orders. The ADM stated the risk of not having orders in the MAR was the nurse could forget to give oxygen. The ADM stated the risk to Resident #8 could have a drop in oxygen levels. Observation and interview on 02/26/24 at 10:48 AM, revealed Resident #7 door signage read STOP Droplet /Contact Precautions, SEE NURSE BEFORE ENTERING. An isolation cart with gowns, masks, gloves, and face shields was placed outside Resident #7 door and required to be worn per signage. Resident #7 said that all staff members wore the PPE when they entered. Resident #7 could not be interviewed further due to his shortness of breath. Observation and Interview with LVN G on 02/26/24 at 03:06 PM, revealed LVN G got out of Resident #7 room. LVN G performed hand hygiene upon exit. LVN G said it was her third day working at the facility. She said she wore a gown, mask, eye shield, and gloves before she went into Resident #7 room. She said she was required to wear PPE because Resident #7 had tested positive for bacteria (ESBL) in his sputum. She said she did not know if the resident had orders for isolation or when he was placed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676161 If continuation sheet Page 6 of 10 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 02/28/2024 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 0695 in isolation. Level of Harm - Minimal harm or potential for actual harm Interview with LVN F on 02/26/24 at 03:12 PM, revealed that Resident #7 was in isolation since he was re-admitted to facility on 2/19/24. She said that whoever admitted Resident #7 should have put the isolation orders in the EMR/MAR. She said that when the admission nurse got report from the hospital, they were notified that Resident#7 required isolation precautions and what type of isolation. She said it was just a matter of making sure orders were put in the computer. She said that she did not see the risk of no orders because the staff were aware and wore PPE before they went into Resident #7 room. Residents Affected - Some In an interview with ADM on 02/28/24 at 04:32 PM, he stated that there should be orders in MAR. He said he expected staff to document all orders. Record review of facility policy titled Oxygen Administration, dated February 2023, revealed, Verify that there is a physician's order for this procedure. Documentation After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed. 2. The name and title of the individual who performed the procedure. 3. The rate of oxygen flow, route, and rationale. 4. The frequency and duration of the treatment. Record review of facility policy titled Medication Orders, revised November 2014, revealed, Supervision by a Physician . Each resident must be under the care of a Licensed Physician authorized to practice medicine in this stated and must be seen by the Physician at least every sixty (60) days. 1. A current list of orders must be maintained in the clinical record of each resident. 2. Orders must be written and maintained in chronological order. 3. Physician Orders/Progress Notes must be signed and dated every thirty (30) days. (Note: This may be changed to every sixty (60) days after the first ninety (90) days of the resident's admission, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676161 If continuation sheet Page 7 of 10 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 02/28/2024 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 0695 provided it is approved by the Attending Physician and the Utilization Review Committee.) Level of Harm - Minimal harm or potential for actual harm Recording Orders Oxygen Orders- When recording orders for oxygen, specify the rate of flow, route, and rationale. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676161 If continuation sheet Page 8 of 10 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 02/28/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 of 5 residents (Resident #247) reviewed for medical records. The facility failed to ensure Resident #247 's diagnosis documented in the clinical records were accurately transcribed to match her hospital discharge diagnoses. Facility recorded Resident #247 had a diagnosis of Parkinson's Disease (A disorder of the central nervous system that affects movement, often including tremors). This failure could place resident at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information and could cause confusion about the resident's care and place residents at risk for harm due to inaccurate records. The findings include: Review of Resident #247 admission Record dated 02/26/24 revealed a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included Acute cholecystitis with chronic cholecystitis (a condition of inflammation of the gallbladder) onset 2/23/24, anxiety disorder onset 2/23/24, major depressive disorder onset 2/23/24, High blood pressure onset 2/23/24, hyperlipidemia (high cholesterol) onset 2/23/24, restless leg syndrome onset 2/23/24, and Parkinsonism unspecified onset 2/23/24. Review of Resident #247 orders summary on 02/26/24, reflected Mirapex Oral Tablet 0.5 MG (Pramipexole Dihydrochloride) Give 1 tablet by mouth one time a day related to Parkinsonism, unspecified. Review of Resident #247 MDS dated [DATE] did not reflect a BIMS nor did it indicate any memory issues. Review of Resident #247 progress note dated 02/23/24, reflected a telemedicine session with a medical provider on a virtual call with Resident #247. Provider stated in his notes Virtual rounding Objective: Was asked to evaluate the patient by the medical staff Assessment: Clinically stable per staff Plan: Continue current treatment plan .- Parkinson's disease- Established patient, level 1visit. Interview and observation with Resident #247 on 02/26/24 at 12:17 PM, revealed she was concerned that she was getting too many medications in her medication cup. She said that she was not sure what medications she was getting and LVN F was frustrated with her when she asked her to tell her what was in her medication cup. Resident #247 said she wanted someone to tell her why she was getting Parkinson diseases medication. She asked surveyor if I have a new diagnosis of Parkinson would the doctor not tell me?. Social worker came in at 12:32 PM and told Resident #247 that she was there to do new admission screening and to complete her MDS. Interview with RN E on 02/26/27 at 12:45 pm revealed that Resident #247 was a new admission that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676161 If continuation sheet Page 9 of 10 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 02/28/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had come in over the weekend (02/23/24). She said that she would go over all the medication with the resident. She said that she would make changes to the medication after doing a medication reconciliation with Resident #247 and the DON. She said that the hospital may have added new medications at discharge and she was going to make sure that she talked with Resident #247 so she had clarity. Interview with LVN F could not be completed due to suspension regarding a self-report intake for reminder of survey 2/27/24 and 2/28/24. Medical Provider from telemedicine provider did not return call for interview on 02/28/24 or during duration of this tag writing regarding the new diagnoses for Resident #247 of Parkinsonism unspecified onset 2/23/24. Interview with the DON on 02/28/24 at 01:39 pm revealed that she had entered Resident #247 medication into the MAR. She said that when she entered the medication name one of the options selections in the system was Parkinson's diseases. She said it was her responsibility to audit charts and ensure the medications reconciliations and diagnoses were accurate in the MAR. She did not say what the risk was to Resident #247. She stated, that's a tricky question. Interview with the ADMN on 02/28/24 at 03:39 PM, revealed the new admission process was to review all orders with resident and responsible party. He said the Initial orders would be done by admitting nurse. He said he expected the nurses to correct input diagnoses in the MAR. He said that he was not aware if Resident #247 had a new diagnosis of Parkinson's diseases. He said that the resident was at no risk because she was taking medication for restless leg syndrome. He said it did not cause a threat or danger but a clarification. He said he would verify the orders. He said he expected all staff to follow the facility policies. Review of facility policy titled Reconciliation of Medication on Admission revision date July 2017 reflected . gather all the information needed to reconcile the medication list. Approved medications reconciliation form, discharge summary from referring facility, admission order sheet, all prescription and supplement information obtained from resident/family during the medication history .medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications .reason for taking each medication .ask resident to list all physicians and pharmacies from which he or she has obtained medications . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676161 If continuation sheet Page 10 of 10