Health inspection·August 10, 2023

F 0693 Level of Harm - Minimal harm or potential for actual harm no date and time. The DON stated that going forward these would be added to the daily rounds and would keep on reminding the staff to adhere to the policies. Interview with the Administrator on 08/10/2023 at 11:10 AM administrator stated that all staff must observe and follow the best practice for the residents to have a high quality of care. Residents Affected - Few Record review of the facility policy, Enteral Feedings - Safety Precautions, rev. May 2014 revealed Preparation 1. All personnel responsible for preparing, storing, and administering enteral nutrition formula will be trained, qualified and competent in his or her responsibilities . Preventing errors in administration 1. Check enteral nutrition label . Check the following information: . c. Date and time formula was prepared . 2. On the formula label document initials, date, and time the formula was hung/administered, and initial that the label was checked against the order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 2 of 9 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 676305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Stayton at Museum Way 2501 Museum Way Fort Worth, TX 76107 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, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 2 residents (Resident #4 and Resident #23) reviewed for respiratory care. Residents Affected - Some The facility failed to ensure Resident #4's (two tubings) and Resident #23's (one tubing) nasal cannula tubing were dated. This failure could place residents at risk of not having their respiratory needs met. Findings included: Review of Resident #4's Face Sheet, dated 08/10/23, revealed she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included Unspecified Moderate Dementia, Acute Chronic Systolic (Congestive) Heart Failure, Unspecified Anemia, and Shortness of Breath. Review of Resident #4's Physician's Order dated 7/24/2023 reflected, O2 at _3_L/Min via nasal cannula as needed for SOB. Review of Resident #4's admission MDS, dated [DATE] reflected she was cognitively impaired with a BIMS score of 04. She required supervision for eating and extensive assistance of two staff for bed mobility, transfer, locomotion on unit, dressing, toilet use, and personal hygiene. Record review of Resident #4's Comprehensive Care Plan, dated 07/21/2023 revealed that she had a Congestive Heart Failure and interventions were . monitor/document for labored breathing . monitor/document/report PRN any s/sx of Congestive Heart Failure . SOB upon exertion . Review of Resident #23's Face Sheet, dated 08/10/23, revealed a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified systolic (Congestive) heart failure, chronic respiratory failure, unspecified chronic obstructive pulmonary disease (COPD), and unspecified anemia. Review of Resident #23's Physician's Order dated 07/28/2023 reflected, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML, 3 milliliter inhale orally every 4 hours as needed for SOB or Wheezing via nebulizer. Review of Resident #23's Physician's Order dated 7/26/2023 reflected, O2 at _3_L/Min via nasal cannula every shift. Review of Resident #23's Physician's Order dated 7/30/2023 reflected, Change Oxygen Tubing & Bubblers every night shift every Sunday. Review of Resident #23's admission MDS, dated [DATE] reflected resident was moderately impaired cognitively with a BIMS score of 09. She required supervision for eating, limited assistance for locomotion on unit and extensive assistance of two staff for bed mobility, transfer, locomotion off unit, dressing, toilet use, and personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 3 of 9 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 676305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Stayton at Museum Way 2501 Museum Way Fort Worth, TX 76107 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 Record review of Resident #23's Comprehensive Care Plan, dated 07/21/2023 revealed that resident has COPD and chronic respiratory failure with hypoxia (low level of oxygen in body tissues) and interventions were Give aerosol or bronchodilators as ordered . Monitor for difficulty breathing (Dyspnea) on exertion .Monitor for s/sx of acute respiratory insufficiency .Monitor/document/report PRN any s/sx of respiratory infection .OXYGEN SETTINGS: O2 via NC@3L /m Residents Affected - Some Observation on 08/08/2023 at 11:09 AM revealed Resident #4 was on her bed resting with O2 at 3 liters per minute via nasal cannula. The tubing the resident was using was attached to the oxygen concentrator. It was also observed that she had an oxygen tank at the back of her wheelchair with a nasal cannula attached. Both tubings of the nasal cannula connected to the oxygen concentrator and the tubing attached to the oxygen tank at the back of the wheelchair had no dates of when the tubings were last changed. Observation on 08/08/2023 at 10:49 AM revealed Resident #23 was on wheelchair talking to her family member, on O2 at 3 liters per minute via nasal cannula. The nasal cannula was connected to an oxygen concentrator. The tubing had no date of when it was last changed. Interview with Resident #23 on 08/08/2023 at 10:49 AM, resident #23 stated that the nasal cannula was not changed on a weekly basis. Resident #23 added that she seldom saw the nasal cannula being changed. Interview with LVN O on 08/09/2023 at 9:21 AM, LVN O stated that the tubing should be changed routinely because it was made of plastic and was prone to cracking and leaking thus reducing the amount of oxygen being delivered. LVN O also added that old tubings could be a breeding ground for bacterial growth. LVN O stated that any nurse could change the nasal cannula as scheduled or as needed and put the date on it. LVN O stated that he did not notice that the tubing has no date. Interview with the ADON on 08/09/2023 at 11:08 AM, ADON stated that her expectation would be that the nasal cannula should be changed weekly. The ADON stated that not changing the tubing could lead to infection. Bacteria could remain on the tube and could cause the resident to be sicker. Interview with the DON on 08/10/2023 at 9:16 AM, DON stated that she was made aware by the ADON about the tubings not dated. The DON verbalized that it was important to change the tubings so there won't be a buildup of bacteria that could lead to infection. It should be dated to show that the tubing was changed and to know when it should be changed again. The DON said that the staff should follow the policy and the best standard. Record review of facility policy, Oxygen Administration, rev. October 2010 revealed The purpose of this procedure is to provide guidelines for safe oxygen administration . After completing the oxygen set-up . The date and time that procedure was performed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 4 of 9 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 676305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Stayton at Museum Way 2501 Museum Way Fort Worth, TX 76107 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 Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure foods in the facility's dry storage area, refrigerator, and freezer were stored and dated according to guidelines. The facility failed to ensure that staff was wearing the proper head and face coverings when serving food. The facility failed to ensure proper discarding of expired food stored in the refrigerator and freezer storage area. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observation on 08/08/23 at 09:20 AM included: One Pitcher of juice (Unknown) unlabeled and undated in the refrigerator. One package of six English Muffins with expiration date of 05/06/23 in the refrigerator. One large fruit platter of grapes, pineapples, strawberries, cantaloupes, and berries was unlabeled and undated in the refrigerator. One quart pitcher of Caesar dressing was undated in the refrigerator. One quart pitcher of Balsamic Vinaigrette dressing was undated in the refrigerator. One quart pitcher of Ranch dressing was undated in the refrigerator One quart pitcher of Blue Cheese dressing was undated in the refrigerator One quart pitcher of Italian dressing was undated in the refrigerator One quart pitcher of Raspberry Vinaigrette dressing was undated in the refrigerator One quart pitcher of Honey Mustard dressing was undated in the refrigerator One 5lb. bag of fries was unlabeled and undated in the refrigerator One 5lb. bag of fries was unsealed, unlabeled and undated in the refrigerator Two large trays of cookies or biscuits was exposed, unlabeled, and undated Five large boxes of potatoes were stored under a cooking preparation table located in the main (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 5 of 9 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 676305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Stayton at Museum Way 2501 Museum Way Fort Worth, TX 76107 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 kitchen of the facility. Level of Harm - Minimal harm or potential for actual harm One large box of bananas was stored under a cooking preparation table and near a cleaning bucket located in the main kitchen of the facility. Residents Affected - Some One tray of bread located in the dry storage room was unsealed. One large container of sugar appeared to have two small dark in color bugs observed laying on the top surface located in the dry storage room. One large container of gluten free flour located in the dry storage room, observed with a lid that had a lot of dirt particles all over it. One large container of Buffalo Sauce was observed to have a Good Thru Date of 08/02/23 Interview and observation with Executive Chef B on 08/08/23 at 09:15 AM revealed he was observed working in the Main kitchen of the facility on the 11th floor with no head cover on. Executive Chef B had hair on his head that measured approximately an inch in length that was uncovered. He advised that he was aware he should have had a head cover on, but stated he was not wearing one because he was not preparing food. He was advised that he was observed preparing for lunch and he did not reply. He stated the risk of not wearing a head covering could result in food contamination and residents getting sick. Interview with Sous Chef P on 08/08/23 at 09:20 AM in the main kitchen of the facility revealed he was shown the concerns observed in the kitchen. He stated that he would have them corrected immediately. He advised the risk of these concerns being present could result in food borne illnesses. He advised that Executive Chef B was responsible for managing the kitchen. Interview and observation with Culinary Server L on 08/08/23 at 11:30 AM revealed he was observed working in the Sub kitchen of the third floor, plating food for residents, with no beard cover on. Culinary Server L had a beard of about an inch in length that was uncovered. He advised that he was aware he should have had a beard cover on, but forgot to put one on. He stated the risk of not wearing a beard covering could result in hair falling in the food and residents getting sick. Interview and Observation with Culinary Lead V on 08/10/23 at 10:30 AM revealed, she was observed entering and exiting the facility's main kitchen, while food was being prepared with no head cover on. Culinary Lead V had long braids going down her back that was exposed. She stated she should have had her hair covered but was only in the kitchen briefly. She stated the risk of not covering her hair could be hair transferring to food and residents getting sick. Interview with Executive Chef B on 08/10/23 at 10:45 AM. he was shown pictures of the concerns discovered during the initial walk through of the facility's main kitchen on the 11th floor. He stated that he was made aware of the findings by Sous Chef P, and had corrected all of them. He stated that he was overall responsible for ensuring proper dating and labeling of foods and he was also overall responsible for ensuring food was covered appropriately and expired food was discarded. He stated he thought the head covering were being worn appropriately and thought staff complied. He stated he would ensure staff covered their entire hair and facial hair. He stated that all of these concerns were a threat to the residents because they could get sick. He stated that they were contracted and often follow Assisted Living Guideline but understand that they also had to follow guidelines for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 6 of 9 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 676305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Stayton at Museum Way 2501 Museum Way Fort Worth, TX 76107 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 Skilled Nursing. Level of Harm - Minimal harm or potential for actual harm Interview with the Administrator on 08/10/23 at 10:55 AM, he was shown the pictures of the concerns discovered in the main kitchen of the facility, on the 11th floor, and he was advised of the concerns of some kitchen staff members not wearing the appropriate hair and beard coverings. He advised that the Kitchen staff were contracted, and he would communicate the concerns to the contracted company's department leadership. He advised the risk of the concerns identified could result in food contamination and residents getting ill. Residents Affected - Some Review of the Facility policy and Procedure on Safety and Sanitation dated 02/2018, referencing Hair Restraints/Beard Guards revealed, Hair nets must be worn by all who are in the kitchen production areas. As an alternative, team members may wear an approved Unidine hat. Beards are not recommended for any team members who handles food; however, if a team member had a beard/Facial Hair ¼ growth or more, then a beard guard must be worn at all times while in the kitchen and/or handling food. The product should not be consumed after the date on the package due to the product's perishable nature and the product should be disposed of. Foods that have been opened or prepared must be covered. Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. Processed reduced oxygen foods that exceed the use-by date or manufacturer's pull date cannot be sold in any form and must be disposed of in a proper manner. All equipment and utensils must be cleaned and sanitized. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 7 of 9 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 676305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Stayton at Museum Way 2501 Museum Way Fort Worth, TX 76107 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 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 3 residents observed for infection control. Residents Affected - Few The facility failed to ensure that the two prongs of Resident #4's nasal cannula (a device used to deliver supplemental oxygen to an individual. It consists of a lightweight tube on which one is connected to the oxygen source and the other end splits into two prongs and are placed in the nostrils) was off the floor and not touching any surface when not in use. This failure could place the residents at risk of cross-contamination and infections. Findings included: Review of Resident #4's Face Sheet, dated 08/10/23, revealed she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified moderate Dementia, acute chronic systolic (Congestive) heart failure, unspecified anemia, and shortness of breath. Review of Resident #4's Physician's Order dated 7/24/2023 reflected, O2 at _3_L/Min via nasal cannula as needed for SOB. Review of Resident #4's admission MDS, dated [DATE] reflected resident had a severe cognitive impairment with a BIMS score of 04. She required supervision for eating and extensive assistance of two staff for bed mobility, transfer, locomotion on unit, dressing, toilet use, and personal hygiene. Record review of Resident #4's Comprehensive Care Plan, dated 07/21/2023 revealed that she had a Congestive Heart Failure and interventions were . monitor/document for labored breathing . monitor/document/report PRN any s/sx of Congestive Heart Failure . SOB upon exertion . Observation on 08/08/2023 at 11:09 AM revealed Resident #4 was on her bed resting with O2 at 3 liters per minute via nasal cannula attached to an oxygen concentrator. It was also observed that she had an oxygen tank at the back of her wheelchair with a nasal cannula attached. The prongs of the nasal cannula on the wheelchair was hanging on the backrest of the wheelchair with the prongs touching the surface of the backrest. Observation on 08/09/2023 at 08:34 AM revealed Resident #4 was eating breakfast. Oxygen tank was still at the back of the wheelchair with a nasal cannula attached. The prongs of the nasal cannula were touching the floor. Interview with LVN O on 08/09/2023 at 9:21 AM, LVN O stated that the cannula should not be touching the floor. LVN O further stated that the cannula should be changed immediately before the resident uses it. This could result to infection to residents that did not have any infection or more medical issues for residents that were already sick. LVN O has been with the facility for almost five years and also stated that he works on the weekend. LVN O said that all staff should ensure that the nasal cannula is free from contaminations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 8 of 9 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 676305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Stayton at Museum Way 2501 Museum Way Fort Worth, TX 76107 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 Interview with CNA D on 08/09/2023 at 10:03 AM, CNA D stated the CNAs put on the nasal cannula when a resident was transferred to the wheelchair. If the nasal cannula was not clean or seen touching the floor, it should be reported to the nurse so it could be changed. CNA D added that nasal cannula on the floor could cause infection and particles from the floor could enter the opening and could cause blockage. Interview with the ADON on 08/09/2023 at 11:08 AM, ADON stated that the nasal cannula should not be touching any surface or be on the floor when not in use. ADON stated that it could cause infection and pulmonary issues, and other medical issues. Interview with CNA R on 08/10/2023 at 9:04 AM, she stated that before transferring a resident that uses O2, the staff should ensure that an Oxygen tank and nasal cannula were on the wheelchair. CNA R stated that the nasal cannula should be clean and kept clean because it would cause a lot of medical issues. If the nasal cannula was seen on the floor, it should be changed. Interview with the DON on 08/10/2023 at 9:16 AM, DON stated that using contaminated cannula could develop infection. It should not be touching any surface and should be bagged when not in use. Her expectation was that all the staff would follow Infection Prevention Protocol. Record review of facility policy, Equipment, Cleaning, rev. 05/2007, Policy It is the policy of this facility to implement the follow procedures to ensure equipment is cleaned and cared for appropriately. Procedures: 1. Reusable resident items are cleaned and disinfected for residents . 4 . disinfectants will be utilized for non-critical items. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 9 of 9