Health inspection·October 3, 2024

F 0623 send anything in writing with the resident or to the responsible party regarding the reason for discharge or information for the ombudsman because they were anticipating Resident #74 to return to the facility. Level of Harm - Minimal harm or potential for actual harm Review of the facility's Transfer or Discharge Notice policy revised November 2016 reflected the following: Residents Affected - Few .2. The Patient/Resident's representative will be provided with the following information The reason for the transfer or discharge; .h. The effective date of the transfer or discharge; i. The location to which the Patient/Resident is being transferred or discharged ; j. A statement of the Patient/Resident's appeal rights, including the name, address, (mailing and e-mail), and telephone number of the entity which received such requests: and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. k. The name, address, and telephone number of the state long-term care ombudsman .n. The facility must send a copy of the notice to a representative of the Office of the State Long term Care Ombudsman FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676249 If continuation sheet Page 2 of 8 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 676249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Carlyle at Stonebridge Park 170 Stonebridge Lane Southlake, TX 76092 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #15) reviewed for comprehensive care plans. The facility failed to ensure Resident #15's care plan addressed pain management and behaviors. This failure could place residents at risk of not having their individual needs met, not receiving necessary care and services, and a decreased quality of life. Findings included: Record review of Resident #15's Face Sheet, dated 10/03/24, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Record review of Resident #16's quarterly MDS assessment, dated 06/19/24, reflected her diagnoses included Type 2 diabetes mellitus with foot ulcer, anxiety disorder, depression, and schizophrenia. Resident #15's had BIMS score of 09, which indicates moderate cognitive impairment. The MDS further revealed Section J - Pain Management indicated resident received scheduled pain medication regimen. Record review of Resident #13's October 2024 physician order sheet, reflected: Morphine 15 mg immediate release tablet (1) TABLET Oral, As Needed Every Six Hours Starting 06/20/2023. For Pain. Gabapentin 300 mg capsule (1) Capsule Oral, Two Times Daily Starting 10/02/2024. For Chronic Pain Syndrome. Record review of Resident #15's care plan, undated, reflected: Problems: Enhanced Barrier Precautions implemented r/t: Pressure ulcer, diabetic foot ulcers, unhealed surgical wounds, venous stasis ulcers. Goals: The spread of an MDRO will be reduced over the next 90 days. Interventions: Monitors for signs and symptoms of infections. Care plan does not address pain management or behaviors. Observation and interview on 10/01/24 at 11:40 AM with Resident #15 revealed he had concerns regarding his pain medications. Resident #15 stated he was not receiving his pain medication as scheduled. He also stated staff would not provide him with the pain medication when he requested it. Resident #15's toes had some redness around them and scabbing. Resident #15 stated he had some wounds on his toes, and he was receiving wound care. He stated he removed the scabs once the wounds healed. Resident #15 stated he liked to pick at his scabs and remove them which would caused the wounds to reopen. Record review of Resident #15's September and October 2024 MAR reflected the resident received his pain medications as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676249 If continuation sheet Page 3 of 8 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 676249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Carlyle at Stonebridge Park 170 Stonebridge Lane Southlake, TX 76092 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 10/02/24 at 3:22 PM with LVN C revealed Resident #15 was on scheduled pain medications. She stated Resident #15 had a history of making allegations of not receiving his pain medications. She stated Resident #15 would ask for more or stronger pain medications. LVN C stated Resident #15 had wounds around his legs and feet, and he was being seen by the Wound Care Nurse. She stated Resident #15 had a behavior of picking at the scabs once the wounds healed. LVN C stated since it was a recurring problem for the resident to pick at his skin and allege he was not receiving his pain medication, and it should be care planned. LVN C reviewed Resident #15's care plan and stated pain management and behaviors were not care planned. She stated the ADON and MDS Coordinator were responsible for care plans. Interview on 10/03/24 at 3:11 PM with the MDS Coordinator revealed all nursing staff were responsible for updating care plans. She stated anything in the MDS assessments should be care planned. The MDS Coordinator stated pain management and behaviors should be cared planned. She stated the Wound Care Nurse was responsible for care planning skin/wound care concerns. She stated the potential risk of not care planning pain management and behaviors was that the resident might receive improper care. Interview on 10/03/24 at 3:16 PM with the Wound Care Nurse revealed Resident #15 was receiving wound care for the wounds on his feet, and the wounds healed. She stated due to trauma or the resident picking at the scabs, the wounds reopened. She stated Resident #15 had a history of picking at his scabs after the wounds healed. She stated the resident's wounds and behaviors should be care planned. The Wound Care Nurse reviewed Resident #15's care plan and stated the resident's wounds were not care planned. She stated she thought the wounds were care planned. The Wound Care Nurse stated there was no potential risk to the resident if his wounds were not care planned since the resident was receiving wound care. Interview on 10/03/24 at 3:36 PM with the ADON revealed the MDS Coordinators were responsible for care plans. She stated almost everything should be care planned to include pain management and behaviors. She stated she was not aware Resident #15's care plan was not updated to address pain management or behaviors regarding the resident's wounds. She stated it was her responsibility to ensure care plans were updated. She stated care plans were important because the care plans let all staff know how to care for the patient, goals, and address any issues they had. Record review of the facility's Care Plans - Comprehensive policy, dated September 2010, reflected the following: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. .8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition changes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676249 If continuation sheet Page 4 of 8 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 676249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Carlyle at Stonebridge Park 170 Stonebridge Lane Southlake, TX 76092 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. Residents Affected - Some The facility failed to ensure various foods stored in the pantry were sealed, dated, and labeled. This failure could place all residents at risk for food contamination and food borne illness. Findings included: Observation and interview with the Dietary Manager on 10/01/24 beginning at 9:20 AM of the dry pantry revealed an unsealed and unlabeled 10-pound cardboard box dated 11/30/24 containing enriched macaroni product sitting on the bottom shelf of the dry pantry in the kitchen. There was also a 10-pound box of linguine opened, unsealed, and undated. The Dietary Manager observed the boxes and stated she was unaware the two boxes of opened, unsealed, undated, and unlabeled noodles were in the dry panty. The Dietary Manager then said it was the Cook's responsibility to store food in sealed, dated, and labeled containers. The Dietary Manager revealed the facility policy reflected all opened items were supposed to be sealed, dated, and labeled. The Dietary Manager then said she would trash both opened boxes of noodles because there was a risk that the residents could get sick if they ate the noodles. Interview on 10/01/24 at 9:49 AM with [NAME] A revealed the policy reflected all items in the dry pantry should be in sealed containers, labeled, and dated. [NAME] A stated if food was found not in a sealed container, it should be thrown away. [NAME] A was also unaware who placed the items in the pantry. [NAME] A concluded by stating if the facility policy was not followed, then residents could get sick. Interview on 10/01/24 at 9:42 AM with [NAME] B revealed the facility policy reflected if something was opened, it should be wrapped up, dated, and placed in a sealed container. [NAME] B stated if the facility policy was not followed, the residents could become sick if they were to eat those items. [NAME] B concluded by stating the Dietary Manager was responsible for ensuring all items were placed in sealed containers and properly labeled and dated. Interview on 10/03/24 at 2:38 PM with the Administrator revealed opened packages should be sealed, labeled, and dated. The Administrator stated the Dietary Manager was responsible for ensuring foods were stored safely. The Administrator declined to answer the risk to the resident if food items were not sealed, labeled and undated. Record review of the facility's Food Storage policy, dated March 2009, reflected: .Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. All containers must [sic] legible and accurately labeled, including the date the package was opened. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676249 If continuation sheet Page 5 of 8 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 676249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Carlyle at Stonebridge Park 170 Stonebridge Lane Southlake, TX 76092 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 effective pest control program for 1 of 22 residents (Resident #20) reviewed for pest control. Residents Affected - Few The facility failed to ensure Resident #20's room was free of ants, and the resident sustained ant bites on his arms, legs, and stomach on 08/06/24, which were treated with hydrocortisone cream. The noncompliance was identified as PNC. The noncompliance began on 08/06/24 and ended on 08/08/24. The facility corrected the noncompliance before the survey began. This failure could place residents at risk of a decreased quality of life. Findings included: Record review of Resident #20, quarterly MDS dated [DATE] reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #20 had diagnoses which included non-traumatic brain disfunction, cancer, coronary artery disease, and renal insufficiency. Record review also reflected Resident #20 had a BIMS of 11, which meant a moderate cognitive impairment. Record review of Resident #20 nursing notes written by LVN D, dated08/06/24, indicated Patient reported that he has ant bites, head to toe assessment done, ant bites noted on his hands and legs, denies pain complains of itching on the bite areas, states that he saw amts [ants] in his room, ant noted in patients room on the carpet and across the wall, MD notified new order hydrocortisone cream, cream applied on the affected areas, RP notified, ADON and ED notified, patient moved to room [ROOM NUMBER], will continue monitoring. Record review of Resident #20 nursing notes written by LVN E, dated 08/07/24, indicated New orders received from Dr [NAME] for Benadryl cream to areas of ant bites BID x 5 days. Apply to areas on both hands and knees. Review of the facility's provider investigation report dated 08/13/24 revealed the following: Head to Toe Skin Assessment & Pain Assessment completed. Resident has what appears to be ant bite marks on his arm and back. Resident stated reported [sic] that he has some itching but that he was pain free. Resident's MPOA and Facility Medical Director were immediately notified. Resident immediately relocated to a different room that is free of ants. In-services on identifying insect bites on residents and reporting insect sightings to Maintenance Director via Pest Control Log. Maintenance Director inspected resident's room. There were sightings of ants near the area where resident usually eats in his room. Skin assessment from nurse confirmed that resident had been bitten by ants on his arms and legs. 100% of residents room were inspecting for ants. There were no sightings of ants in any of the residents' room. Skins assessment completed on 100% of residents. No bite mark found on any of the residents. None of the residents reported having any bite marks or itching when asked during the skin assessment. Pest Control treated resident's room on 8/7. Pest Control treated each room in the facility, all public areas, dining room, and outside of the facility. Resident's room inspected and cleaned by Housekeeping Director, ensuring it is free of food with open containers. Maintenance Director inspected resident's room after Pest Control treatment to ensure it is free of ants. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676249 If continuation sheet Page 6 of 8 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 676249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Carlyle at Stonebridge Park 170 Stonebridge Lane Southlake, TX 76092 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 0925 Resident monitored for by nurse, reporting no pain and itching as stopped. Level of Harm - Minimal harm or potential for actual harm Interview and observation on 10/01/24 at 2:57 PM with Resident #20 revealed he woke to find about 25 bites covering on his both arms, both legs, and his stomach. Resident #20 said that the bites itched, so he went to the nurses' station to report the bites. Resident #20 stated that he went back to his room and discovered that ants crawling on the baseboard, under his bed, on his bed, and in his trash can. The facility treated his room, and he has not seen ants in his room since then. Resident #20 observed to have no visible bite marks. Residents Affected - Few Interview on 10/01/24 at 2:00 PM with LVN C revealed that she came to work on 08/06/24 and was instructed to go from room to room inspecting form ants. LVN C stated that Resident #20 had large quantities of prepackaged snacks in his room. LVN C said that she assessed Resident #20 and saw 3-4 bites on both arms and both legs. LVN C revealed that the resident complained of itching. LVN C stated that she had not seen ants in the resident's room since that day. LVN C also said that at each nurses' station, there was a book that nurses document anything they need maintenance to address such as ants or pests. LVN C concluded by stating that when pests are seen and documented, then maintenance would contact the pest control company. Interview on 10/01/24 at 4:01 PM with Maintenance Director revealed he was called after hours on 08/06/24 about ants. The Maintenance Director said that he entered and inspected Resident #20's room. The Maintenance Director revealed he saw ants near the resident's window. The Maintenance Director stated he moved Resident #20 to another room that night, and then he checked the residents' rooms next to Resident #20's room. The Maintenance Director stated he saw ants in one other room, so he moved that resident that night as well so that his room could be treated for ants as well. The Maintenance Director revealed he called the after-hours pest control person on call so that he could schedule them to come out the following morning. The Maintenance Director stated the pest control company arrived about 7:00 AM on 08/07/24 and both rooms were treated. The Maintenance Director gave the staff all clear to move the residents back into their room. The Maintenance revealed that the pest control company came back out to the facility a week later and retreated the whole hallway, the two room that had active ants, and outside the facility as well. The Maintenance Director stated that he followed up weekly for three weeks by inspecting Resident #20's room for food in the waste basket. The Maintenance Director also said that he has not seen any ants since that time nor has the pest control company. The Maintenance Director revealed that until this incident with ants in the residents' rooms, no one had reported ants. The Maintenance Director also stated that he walked the grounds daily to look for things like ant piles. The Maintenance Director stated that his process was to notify the pest control company if something is reported to him, or he observed pests during his daily rounds. The Maintenance Director said the pest control company will come out the same day or the following day to treat, depending on availability when he calls them for treatment. The Maintenance Director concluded by stating that the risk to the resident for not having an effective pest control program was that a resident could get bit by a pest to which they are allergic. Interview on 10/03/24 at 2:06 PM with the Administrator revealed the pest control company came monthly and came additionally as needed to address anything that was urgent during the month as well. Administrator also said that management did angel rounds Monday through Friday while the manager on duty walked the premises on Saturday and Sunday to ensure that there were no pests or insects. Administrator also stated that direct care staff check the residents' rooms daily during their shifts as well as housekeeping. Administrator stated that it was all the staff's responsibility to check rooms for pests and report it in the maintenance logbook or the pest control book if pests are seen. Administrator stated the pest control book was at the front desk. Administrator revealed that a resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676249 If continuation sheet Page 7 of 8 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 676249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Carlyle at Stonebridge Park 170 Stonebridge Lane Southlake, TX 76092 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few can be injured by bites from ants. Administrator stated that when Resident #20 reported the bites, he was given a head-to-toe assessment and moved to a different room so that he was not at risk for further injury. Administrator reported that his room was treated by pest control the following day and continued to be assessed for pain. Administrator stated that he maintenance director walks the grounds daily and inspects rooms as well. Administrator concluded by stating that all staff were in-serviced on looking for insects and pests and reporting insects and pests. This was completed on 08/06/24. Record review of the facility's pest control logs for 07/04/23 through 07/26/24 reflect the facility was treated for ants and pests once per month. Record review of the facility's pest control logs reflected the facility was treated for ants on 08/07/24. Observation on 10/02/24 at 10:25 AM revealed the exterior of the building including the interior courtyard and the windowsills had no ants. The porches of the facility were also observed with no ants sighted. There were no ant hills seen in the grass around the facility outside as well. There also were no ants observed in the residents' rooms or in the public areas of the facility during the investigation throughout the week. Record review of the facility's undated Pest Control Policy reflected, .1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Review of the facility's In-service Training Report dated 08/06/24 provided by the Administrator revealed the following: Topic: If you notice any type of bug/insect infestation or you see suspected bug bites on a resident, you MUST complete the following: Complete skin assessment Move resident to a different room Complete incident report Notify maintenance and place in maintenance /pest control log Notify management, MD and RP Maintenance book-located @ each nurses' station Pest Control log-Located at Receptionist desk in front Action to be Taken Employees must follow state/company policies and procedures. Employees educated on reporting insects and pests. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676249 If continuation sheet Page 8 of 8