Health inspection·September 5, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few order for [Resident #1] to go to hospital for evaluation. [Ambulance] took her to ER for evaluation. Record review of Resident #1's progress notes, dated 08/12/25 at 06:18PM by LVN C reflected the following: [Resident #1's] [RP] called to say that [Resident #1] was likely to spend the [night] at the hospital because she had a broken bone. She said they were waiting for an X-ray on the arm. Notified DON. Record review of Resident #1's hospital records, dated 08/13/25, reflected in part the following: admit date and Time: 08/12/2025 at 03:19 PM History of present illness: [Resident #1] is a 75 y.o. female that has a past medical history of Chronic pain disorder, Hemiparesis affecting right side as late effect of stroke, Neuromuscular disorder, Right-sided muscle weakness, Shortness of breath, Splenic artery aneurysm, Stroke, and Wheelchair dependent who presents with acute right arm pain after being repositioned in her chair today when her caretaker felt a pop near her shoulder. [Resident #1] is willing in pain, when asked where it hurts she points specifically to her arm. [Resident#1] has chronically dislocated right shoulder. Complaint: Per NH staff, concerned for right shoulder dislocation. Heard a pop while moving [Resident #1] from WC to bed.Impression at 04:30PM:1. Anterior dislocation [{upper bone moves forward out of its socket)] of the right shoulder. Right humeral neck fracture.2. Pleural effusion and infiltrates in the visualized right chest. Recommend a dedicated chest x-ray. Final Result: Limited axillary view with the persistent anterior glenohumeral dislocation.XR humerus right 2 views:1. Humeral neck fracture with mild displacement.2. Anterior glenohumeral dislocation of the shoulder.3. Vascular stent in the axillary region. XR shoulder right view:1. Anterior dislocation of the right shoulder. Right humeral neck fracture.2. Pleural effusion [(excess buildup of fluid)] and infiltrates in the visualized right chest. Recommend a dedicated chest x-ray. In an interview on 09/04/25 at 11:26AM, Resident #1's RP stated on 08/12/25 while Resident #1 was being transferred by facility staff and was injured. Resident #1's RP stated an aide was manually transferring Resident #1 from her wheelchair to the bed. RP stated while an aide was moving Resident #1 from the wheelchair, a family member who was visiting noticed that the resident needed to be changed, so the aide held Resident #1 up while the family member pulled down her pants, and that was when they heard a pop in the resident's arm. Resident #1's RP stated the aide was doing the transfer alone and without the mechanical lift, which was an improper transfer. RP stated Resident #1 complained of pain afterwards, so the EMTs were called, and the resident was transported to the local hospital. Resident #1's RP stated after further examination, it had been determined Resident #1 had a humerus fracture. In an interview on 09/04/25 at 12:04 PM, LVN A stated she worked with Resident #1, and she was only at the facility for about two weeks. LVN A stated she worked 1st shift on 08/12/25 when the incident occurred. She stated it was reported to her by CNA B that Resident #1 had been injured during a transfer. LVN A stated CNA B reported while moving the resident there was a pop in Resident #1's arm. LVN A stated CNA B should not have moved Resident #1 without assistance. LVN A also stated Resident #1's was a two-person transfer with a mechanical lift. LVN A stated Resident #1's family was in the room at the time and did not want CNA B to use the mechanical lift. LVN A stated after the incident was reported, she assessed Resident #1, and she complained of pain. LVN A stated she offered Resident #1 PRN medication for pain, but the resident refused. LVN A stated after some encouragement, Resident #1 took Tylenol. LVN A stated she asked Resident #1 if the facility could take an x-ray, but she also refused. LVN A stated Resident #1's RP insisted she be transported to the hospital, so LVN A stated she called an ambulance and notified the MD. LVN A stated according to the facility's policy, CNA B should have followed the MD orders regarding the transfer instead of listening to the family. She stated not following MD orders for transfers could place residents at risk of falling and sustaining injuries. In an interview on 09/04/25 at 12:22PM, CNA B stated she worked with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676161 If continuation sheet Page 2 of 5 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 09/05/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #1 on 08/12/25. She stated she was called into Resident #1's room to transfer her from the wheelchair to the bed. CNA B stated when she moved Resident #1, the family told her that Resident #1 needed to be changed. CNA B stated she asked Resident #1's family to assist by taking her pants off. CNA B stated she bear-hugged Resident #1 around her back, and while holding the resident up, her arms slid underneath Resident #1's arms and that was when she heard the resident's shoulder pop. CNA B stated Resident #1 groaned and expressed extreme pain. CNA B stated she placed Resident #1 back in her wheelchair and called LVN A to come assist. CNA B stated Resident #1 was assessed by LVN A then transported to the hospital. CNA B stated she knew that Resident #1 required a 2-person transfer using a mechanical lift; however, she worked with her previously and was always able to transfer her manually with no problems. CNA B stated Resident #1's family would also tell her not to use the mechanical lift, or they would transfer the resident manually themselves. In an interview on 09/04/25 at 12:58PM, the DON stated she worked on 08/12/25. The DON stated she was at the facility at the time of the incident with Resident #1. The DON stated it was reported that while CNA B was moving Resident #1 there was a pop in her arm. The DON stated the CNA did not follow protocol when she moved Resident #1. She stated CNA B should have gotten another staff to assist in moving the resident and used a mechanical lift for the transfer. The DON stated Resident #1 required total assistance with ADLs. She stated based on MD orders; Resident #1 was a two staff transfer with a mechanical lift. The DON stated she completed one on one training regarding transfers with all staff immediately after the incident occurred. The DON stated the facility's policy on mechanical lifts was to follow the MD orders. She stated Resident #1 had a MD order for two staff persons to transfer with the mechanical lift. The DON stated residents are assessed by a physical therapist and gives a recommendation for transfers to the MD, who writes the order. The DON stated not following the MD orders for transfers could place residents at risk for serious injuries. In an interview on 09/05/25 at 01:51 PM, the DOR stated she managed all PT staff and also provided therapy to the residents. The DOR stated she trained facility staff on properly using the mechanical lift and transfers. The DOR stated she was not familiar with Resident #1. She stated the facility provided in-services to staff about proper transfers with the mechanical lift. She stated she has educated residents on mechanical lifts and why it was the safest way to transfer. The DOR stated when a resident did not want to use the mechanical lift, either her or staff would educate the residents and family about safety. She stated the use of a mechanical lifts helped to reduce possible injury to the resident or staff during transfers. She stated the facility's policy on mechanical lifts was to always follow the MD orders on transfers, even if the resident does not want it used. In an interview on 09/05/25 at 03:45 PM, Administrator stated the expectations for staff was to follow MD orders for transfers. He stated there should be two staff to transfer a resident with a mechanical lift. He also stated if resident or family refused, staff are to educate on safety a mechanical lift to transfer. He also stated risks of not following MD orders to use a mechanical lift could result in the resident or staff getting injured. Record review of the facility's policy, revised on 07/18/18, titled Safe Patient Handling and Moving Protocol, reflected in part the following: The Q.A. Committee will ensure implementation of this policy to identify, assess, and develop strategies to control risk of injury to residents and nursing staff associated with the lifting, transferring, repositioning or movement of a resident. Two Person Transfer:Mechanical or Electric LiftTo be utilized when transferring residents who are non-weight bearing and unable/unsafe to be transferred by alternate methods. At no time will a staff member attempt to use a mechanical or electric lift without being in-serviced on equipment specific procedures. Mechanical and electric lift transfers must always be done with 2 staff members present.? All staff shall adhere to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676161 If continuation sheet Page 3 of 5 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 09/05/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few each lift's specific manufacturer guidelines for safe handling and operation. Each facility shall determine the number and types of devices needed. Devices should be located so that they are easily accessible to employees. The facility should develop and assign routine maintenance schedules to ensure equipment is in good working order. This was determined to be an Immediate Jeopardy IJ on 09/04/25 at 04:00 PM. The DON was notified. The DON was provided with the IJ template on 09/04/25 at 04:41 PM. The following Plan of Removal submitted by the facility was accepted on 09/05/25 at 12:32 PM: [Nursing Facility]Plan of RemovalSeptember 4, 2025F689 Free of Accident Hazards/Supervision The facility allegedly failed to ensure Resident #1 was free of an accident hazard when she was transferred by one CNA without a mechanical lift, and it resulted in a significant injury. Facility Medical Director was notified of the Immediate Jeopardy by DON on 9/4/25. Immediately on September 4, 2025 CCS in serviced DON on transfer policy to include utilization of a mechanical lift. Corporate Clinical Specialist (CCS) has demonstrated hands-on expertise in resident care practices, clinical compliance and evidence-based protocols, including the [corporate] transfer policy to include utilization of a mechanical lift. Training included following MD orders and what to do in the event the resident/family/RP has concerns or refusals regarding the transfer status. Compliance was verified through competency check off and quiz. On September 4, 2025 DON/MDS Coordinator completed an audit of all transfer statuses and updated care plans accordingly. On September 4, 2025 DON initiated in servicing with nursing staff on transfer policy to include utilization of a mechanical lift. Training included following MD orders and what to do in the event the resident/family/RP has concerns or refusals regarding the transfer status. Training will be completed on 9/5/2025. Competency checks on transfers were initiated with nursing staff by DON/Designee on September 4, 2025. Compliance was verified through competency check off and quiz. In servicing and competency checks will be completed on 9/5/2025. Staff will not be allowed to work until in servicing has been completed. Compliance will be monitored by DON. The above training material will be incorporated into the new hire orientation by DON effective September 4, 2025 and ongoing. Checkoff includes transfers to include utilization of a mechanical lift. In order to monitor current residents for potential risk, DON/ADON will complete daily audits of transfer procedures for all residents requiring mechanical lifts for the next 30 days, starting on September 5, 2025. Thereafter, the DON/ADON will complete weekly audits for 3 months. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action, starting September 5, 2025. The QA Committee will monitor quarterly up to a year to monitor Facility QA Committee for compliance. If no further concerns noted, will continue to monitor as per routine facility QA Committee. Monitoring of the POR included the following: Interviews on 09/05/25, 12:48-02:47 PM, conducted with the Administrator, DON, nurses, CNAs, and Med Aides: LVN A (1st shift), CNA B (1st shift), LVN C (2nd shift), LVN D (1st shift), LVN E (prn), LVN F (1st shift), LVN G (1st shift), Med Aide H (1st shift), CNA I (1st shift), CNA J (1st shift), CNA K (1st shift), CNA L (1st shift), RN M(1st shift), CNA N (2nd shift), RN O (2nd shift), CNA P (2nd shift), CNA Q (2nd shift), CNA R (2nd shift), CNA S (2nd shift), RN T (new trainee), RN U (weekends), Med Aide V (weekends), CNA W (weekends), CNA X (1st shift), CNA Y (3rd shift), LPN Z (1st shift/weekends), CNA AA (nights) indicated they all participated in in-service trainings regarding the facility's transfer policy and how to use a mechanical lift starting on 09/04/25. All staff were able to state if resident was unable to bear weight staff must follow MD's orders/care plan and use mechanical lift transfer using two staff. Staff was able to state that residents that can bear weight and require manual assistance they must use a gait belt. Staff were also able to state that what to do in the event the resident, RP or family had refusal regarding the use of the mechanical lifts. The Administrator and DON understood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676161 If continuation sheet Page 4 of 5 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 09/05/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete it was their responsibility to implement and monitor the effectiveness of all interventions put in place. Observation on 09/05/25 of Resident #2 revealed staff followed the facility's policy while transferring the resident using a mechanical lift. Interviews on 09/05/25 from 12:35-3:30 PM with RPs and Residents #3, #4, #5, #6, #7, #8, and #9 revealed there were no concerns for safety or quality of care regarding transfers at the facility. Record Reviews of Residents #2, #3, #4, #5, #6, #7, #8, and #9 care plans revealed they were all updated and included appropriate transfer procedures and interventions. Record review of a 1:1 in-service titled Utilization of Mechanical Lift, dated 09/04/25, reflected DON was educated on transfer policy to include the utilization of a mechanical lift. DON was also educated on following MD order and what to do if resident, family or RP had concerns or refusal regarding the transfer. Record review of an in-service titled Utilization of Mechanical Lift, dated 09/04/25, reflected all nursing staff were educated on the facility's mechanical lift policy, following MD orders and what to do in the event the resident, family or RP has concerns or refusals regarding the transfer status. Record review of an in-service titled Transfer Residents Properly, dated 09/04/25, reflected all nursing staff were educated on properly transferring residents according to MD orders. Staff were also educated on using two staff with mechanical lift transfers and educating resident, family, or RP on safety and following the care plan. Record review of a document provided by the Administrator titled Audit Attestation, dated 09/04/25, reflected all residents who required transfer assistance were audited to ensure proper transfer procedures were care planned and being implemented. Record review of a document provided by the Administrator titled QIPP QAPI Worksheet, dated 09/05/25, reflected a QAPI meeting was held regarding the correction plan for the facility's deficiency. In a follow-up interview on 09/05/25 at 02:47 PM, DON stated she ensured nursing staff were trained on transfers. She stated staff are to follow MD orders to ensure the safety of resident. She also stated if there was refusal from the resident, family or RP staff are to educate, document and inform a supervisor.An Immediate Jeopardy (IJ) was identified on 09/04/25 at 04:00 PM and an IJ Template was provided to the DON at 04:41PM. While the IJ was removed on 09/05/25, the facility remained out of compliance at a scope of isolated with the severity level of potential for more than minimal harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems. Event ID: Facility ID: 676161 If continuation sheet Page 5 of 5