Health inspection·January 10, 2024

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 01/10/24 at 12:37 PM with CNA A revealed she had tested positive for COVID on 12/29/23. CNA A stated the last time she worked was Tuesday (12/26/23), she stated she was assigned to A-Tower. She stated she had close contact with residents on A-Tower. CNA A stated on 12/25/23 she felt congested, she stated she thought it was allergies. She stated she wore a surgical mask on 12/25/23 and 12/26/23. CNA A stated she was not on vacation. CNA A stated on 12/29/23 she notified the facility of her positive results. CNA A stated she returned to work on 01/03/24. She stated she did not and was not tested on [DATE] when she returned to work. CNA A stated she was not sure if the facility tested the residents who reside on A-tower who she had close contact with on 12/25/23 and 12/26/23. Interview on 01/10/24 at 1:18 PM with the ADON revealed she was the infection preventionist and was responsible for infection control for the facility. The ADON said the residents and staff were only tested for COVID if they showed signs and symptoms of COVID. She stated CNA A tested positive for COVID on 12/29/23, and only 1 additional staff was tested for COVID because she was roommates with CNA A. She stated they had not tested any residents since 12/19/23. The ADON stated they were only testing residents who were symptomatic per facility policy and CDC guidelines. She stated the facility corporate office reviews the CDC guidelines and would update the facility policies and would notify them of any updates. She stated she had not received any updates to their polices. The ADON stated she was not sure what the CDC recommended at the time, but the facility would follow the recommendations of the CDC. The ADON and Surveyor reviewed the CDC guidelines and the ADON stated she was not aware that the recommendations were to test on the 1st, 3rd, 5th day. The ADON stated the potential risk would all be there due to residents always having visitors; however, she stated the potential risk would be an outbreak if residents were exposed to COVID. Interview on 01/10/24 at 2:15 PM with the DON revealed corporate office and ADON were responsible for reviewing the CDC guidelines and any updates regarding COVID-19. She stated after reviewing the nursing schedules for 12/25/23 and 12/26/23, CNA A's last day of work was on 12/26/23. She stated CNA A was not on vacation. She stated until this day (1/10/24) she had not seen can A's positive test. The DON said she did not test CNA A prior to returning to work and she did not test residents who had close contact with CNA A on 12/25/23 and 12/26/23. She stated she was unaware of the CDC guidelines regarding testing staff and residents who were exposed to COVID-19. The DON stated they were only following the facility policy to only test residents who were showing signs and symptoms of COVID. The DON stated there would always be a potential risk of an outbreak of any illness; however, if they had someone that became symptomatic, the facility would have tested. Interview on 01/10/24 at 2:20PM with the Administrator revealed it was the responsibility of corporate office and the facility staff to review the CDC guidelines and any updates. The Administrator stated they follow facility policy regarding symptomatic residents. He stated the facility monitors all residents for signs and symptoms of COVID. He stated the CDC guidelines are just recommendations and they follow facility policy. Review of facility's The Sign-In Sheet dated 12/25/23 and 12/26/23 revealed CNA A worked on 12/25/23, 12/26/23 and was assigned to A- Tower middle section. Review of facility line list COVID positive Residents/Staff List revealed CNA A was positive for COVID-19 on 12/29/23. Review of facility's Pandemic Policy (COVID-19), revised date 02/27/23 reflected the following: It is the policy of this community to minimize exposures to respiratory pathogens and promptly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 2 of 4 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 01/10/2024 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 - Some identify residents, visitors and team members with clinical features and an epidemiologic risk for the COVID-19. We will adhere to federal and state/local recommendations that protect our residents and team members from the spread of infectious disease, including COVID-19 and COVID-19 variants . Skilled follow CDC guidance for Health care Settings: Quarantine will apply to residents who are not up to date with all recommended COVID-19 vaccine dose and who have had close contact with someone with SARS-CoV-2 infection should be placed in quarantine after their exposure even if viral testing is negative. Team members caring for confirmed or suspected COVID-19 residents should use full PPE. Residents can be removed from Transmission-Based Precautions after day ten following the exposure (day 0) if they do not develop symptoms. Although the residual risk of infection is low, healthcare providers could consider testing for SARS-CoV-2 within 48 hours before the time of planned discontinuation of Transmission-Based Precautions. Team Members are required to immediately report symptoms of infectious/contagious illness or possibility of exposure to COVID-19 to his or her direct supervisor and the community director of human resources. The Infection Preventionist or Director of Nursing will collaborate with the team member to identify individuals, equipment, and locations the team member encountered. Review of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last updated on 05/08/23, accessed on 01/10/24 on the CDC website reflected: .Nursing Homes .Stay connected with the healthcare-associated infection program in your state health department, as well as your local health department, and their notification requirements. Report SARS-CoV-2 infection data to National Healthcare Safety Network (NHSN) Long-term Care Facility (LTCF) COVID-19 Module. See Centers for Medicare & Medicaid Services (CMS) COVID-19 reporting requirements. Section 2. Placement of residents with suspected or confirmed SARS-CoV-2 infection Ideally, residents should be placed in a single-person room as described in Section If limited single rooms are available, or if numerous residents are simultaneously identified to have known SARS-CoV-2 exposures or symptoms concerning for COVID-19, residents should remain in their current location. Responding to a newly identified SARS-CoV-2-infected HCP or resident When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 3 of 4 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 01/10/2024 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 contact tracing fails to halt transmission. Level of Harm - Minimal harm or potential for actual harm Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Residents Affected - Some Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Due to challenges in interpreting the result, testing is generally not recommended for asymptomatic people who have recovered from SARS-CoV-2 infection in the prior 30 days. Testing should be considered for those who have recovered in the prior 31-90 days; however, an antigen test instead of a nucleic acid amplification test (NAAT) is recommended. This is because some people may remain NAAT positive but not be infectious during this period. Empiric use of Transmission-Based Precautions for residents and work restriction for HCP are not generally necessary unless residents meet the criteria described in Section 2 or HCP meet criteria in the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively. However, source control should be worn by all individuals being tested. In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration should be given to use of Empiric use of Transmission-Based Precautions for residents and work restriction of HCP with higher-risk exposures. In addition, there might be other circumstances for which the jurisdiction's public authority recommends these and additional precautions. If no additional cases are identified during contact tracing or the broad-based testing, no further testing is indicated. Empiric use of Transmission-Based Precautions for residents and work restriction for HCP who met criteria can be discontinued as described in Section 2 and the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively. If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue on affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. If antigen testing is used, more frequent testing (every 3 days), should be considered FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 4 of 4