Health inspection·September 6, 2024

F 0550 privacy bag and contents were seen from the doorway of the resident's room. Level of Harm - Minimal harm or potential for actual harm Resident #24 Residents Affected - Few Review of Resident #24's face sheet, dated 08/15/24, reflected Resident #24 was a [AGE] year-old male admitted on [DATE]. Resident #24 was diagnosed with obstructive uropathy (blockage of urine flow). Review of Resident #24's Comprehensive Care Plan, dated 08/16/24, reflected Resident #24 had an indwelling catheter related to obstructive uropathy (blockage of urine flow) and one of the interventions was position catheter bag and tubing below the level of the bladder and away from entrance room door. Put bag in privacy cover. Review of Resident #24's MDS Comprehensive Assessment, dated 08/23/24, reflected Resident #24 had intact cognition with a BIMS score of 14. The MDS Comprehensive Assessment indicated Resident #24 had an indwelling catheter. Review of Resident #24's Physician's Orders, dated 08/15/24, reflected a 16 French (French: unit used to indicate the size of the catheter) suprapubic catheter (device inserted into bladder to drain urine). Change catheter drainage bag and tubing every 14 days and as needed. Observation on 09/04/24 at 10:22 AM revealed Resident #24 was sitting in the recliner in his room. Resident #24's catheter bag was hanging on the side of the bed that did not face the doorway. It was not touching the floor. The catheter bag was not seen from the doorway but was visible when standing in front of the resident. The catheter bag was not in a privacy bag and the contents were seen. Observation on 09/05/24 at 11:00 AM revealed Resident #24's catheter bag was still not in a privacy bag. Resident #24 was sitting in his recliner. The catheter bag was not visible from the doorway, but the contents of the bag were seen when standing in front of the resident. During an interview with CNA D on 09/05/24 at 11:22 AM, she stated that every resident with a catheter bag was supposed to have it covered with a privacy bag, even when the resident was in his or her room. During an interview with the Nurse Manager on 09/05/24 at 11:30 AM, she stated the resident's catheter bag should have been covered when in public view and using a privacy bag was a discreet way to do that. The Nurse Manager stated she did not know the facility policy for covering a catheter bag when the resident was in his or her room. During an interview with the ADON on 09/05/24 at 11:36 AM, she stated she did not know the facility policy, but that the catheter bag was normally in a privacy bag. The ADON stated she previously worked in hospitals and we didn't use privacy bags there. During an interview with LVN A on 09/05/24 at 01:15 PM, he stated all residents' catheter bag should be covered whether the resident was outside or inside the room. LVN A stated that was for the resident's dignity and so other people did not see what was in the catheter bag. LVN A said that the best practice was for the catheter bag to be in a privacy bag. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 2 of 25 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 09/06/2024 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 0550 Level of Harm - Minimal harm or potential for actual harm During an interview with RN D 09/06/24 at 09:14 AM, she stated it was standard to have the resident's catheter bag in a privacy bag whether the resident was in or out of their room. Review of the facility policy Resident Rights, revised 04/16/2024, reflected Residents have the right to be treated with respect and dignity. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 3 of 25 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 09/06/2024 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #8, Resident #21, and Resident #143) of thirteen residents reviewed for reasonable accommodation of needs. Residents Affected - Some The facility failed to ensure the call light system in Resident #8, Resident #21, and Resident #143's rooms were in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Resident #8 Review of Resident #8's Face Sheet, dated 09//06/2024, reflected that the resident was an [AGE] year-old male admitted on [DATE]. Resident #8 was diagnosed with generalized muscle weakness, unsteadiness on feet, and difficulty in walking. Review of Resident #8's Comprehensive MDS Assessment, dated 08/16/2024, reflected that Resident #8 had a moderate impairment in cognition with a BIMS score of 08. Resident #8 required substantial assistance in toileting, shower, and dressing. Review of Resident #8's Comprehensive Care Plan, dated 08/29/2024, reflected that Resident #8 was high risk for falls related to deconditioning and one of the interventions was to be sure the resident's call light was within reach. Observation and interview on 09/04/2024 at 10:20 AM revealed Resident #8 was in his wheelchair beside his bed. Resident #8 was putting on his t-shirt and said he just had a shower. He said CNA C showered him and then made his bed. Resident #8 then said CNA C went out of the room to get a pair of new socks for him. He said CNA C haven't come back since after the shower and he was planning to call her to know where his socks were. He said he cannot call CNA C because his call light was on the floor, and it was hard for him to pick it up. It was observed that the resident's call light was on the floor behind his wheelchair. He said the CNA who made his bed did not make sure his call light was secured. Observation and interview with CNA C on 09/04/2024 at 10:43 AM revealed CNA C went inside Resident #8's room and put on the resident's socks. Resident #8 said CNA C was the aide that made his bed. After putting on the socks, CNA C then went out of the room and still did not notice that the resident's call light was on the floor. When prompted to check the resident's call light, CNA C looked up and said the call light was not on. When prompted to check on the call light's placement, CNA C went back inside the room, saw the call light on the floor, picked it up, and put it on top of the resident's bed. CNA C stated she gave the resident his shower and made his bed. She said she did not notice the call light was on the floor when she left the room. She said she should have made sure the call light was accessible to Resident #8 in case he needed something. She said the call lights were important because the resident use them to let the staff know that they needed something. Without the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 4 of 25 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 09/06/2024 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 0558 call light, the needs of the resident will not be known. Level of Harm - Minimal harm or potential for actual harm Resident #21 Residents Affected - Some Review of Resident #21's Face Sheet, dated 09/06/2024, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #21 was diagnosed with generalized muscle weakness, unsteadiness on feet, and difficulty in walking. Review of Resident #21's Comprehensive MDS Assessment, dated 08/09/2024, reflected that Resident #21 had a moderate cognitive impairment with a BIMS score of 11. Resident #21 required substantial assistance in toileting, shower, and dressing. Review of Resident #21's Comprehensive Care Plan, dated 07/29/2024, reflected that Resident #21 was at risk for falls related to gait balance problems and one of the interventions was to ensure/provide a safe environment. Observation and interview on 09/04/2024 at 8:54 AM revealed Resident #21 was in her wheelchair, awake. The resident's call light was observed on the floor beside the bed. She said she just came back from breakfast. She said she saw the call light on the floor when she was ushered inside the room after breakfast but the one who pushed her wheelchair did not notice the call light was on the floor. Observation and interview on 09/04/2024 at 10:28 AM revealed Resident #21 was still sitting in her wheelchair, awake. She said her call light was still on the floor. She said she frequently used it, but it should be where she could reach it in case she needed something. Observation on 09/04/2024 at 10:48 AM revealed after leaving Resident #8's room, CNA C proceeded to Resident #21's room, saw the call light on the floor, picked it up, and placed it on the bed. CNA C told Resident #21 that her call light was on the bed. Resident #143 Review of Resident #143's Face Sheet, dated 09/06/2024, reflected that the resident was a [AGE] year-old male admitted on [DATE]. Resident #143 was diagnosed with weakness, reduced mobility, and unsteadiness on feet. Review of Resident #143's Comprehensive MDS Assessment, dated 08/27/2024, reflected Resident #143 required substantial assistance in toileting, shower, and dressing. Review of Resident #143's Comprehensive Care Plan, dated 08/28/2024, reflected that Resident #143 had an ADL self-care performance deficit related to fatigue and impaired balance and one of the interventions was to encourage the resident to use bell for assistance. Observation and interview with Resident #143 on 09/04/2024 at 8:46 AM revealed resident was in his bed, awake. It was observed that Resident #143's call light was on the floor under the bed. Resident #143 stated he was trying to look for his call light because he wanted to get up but cannot find it. He said he cannot even find the cord of his call light. He said several staff already went inside the room and did not notice his call light was on the floor. Observation and interview with RN D on 09/04/2024 at 8:55 AM, RN D stated call lights should be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 5 of 25 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 09/06/2024 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with the residents all the times, because they use the call lights to call for help or assistance if needed. She said the residents used the call lights to communicate to the staff that they needed something. She added that if the call lights were not with the residents, the residents might fall trying to do things by themselves or get frustrated because they could not call the staff. She said all the staff were responsible in making sure the call lights were within reach of the residents. RN D went inside Resident #143's room, picked up the call light, and handed it to Resident #143. In an interview with the DON on 09/06/2024 at 8:26 AM, the DON stated call lights were important for the residents and they should be placed where the residents could access them without difficulty. The DON said the call lights were the residents' mode of communication so they could tell the staff they needed something. She said even if the residents seldom use them, the call lights should still be placed somewhere accessible. She said all the staff, from nurses, CNAs, therapy, housekeeping, and management, were responsible in ensuring that the call lights were within reach. The DON said the expectation was for the staff would be mindful that every time they leave the residents' room, the call lights were within reach. The DON said she would conduct an in-service and check-off about the call lights. She said she would personally monitor that all the residents' call lights were within reach. In an interview with the ADON on 09/06/2024 at 8:39 AM, the ADON stated the call lights should not be on the floor or in a place not accessible to the residents because the residents needed them to call the staff. The ADON said if the call lights were not within reach, the residents would not be able to call the staff and their needs would not be met. The ADON said the expectation was for all the staff to make sure the call lights were within the reach of the residents. The ADON said they would do an in-service about call lights being accessible to the residents. In an interview with the Administrator on 09/06/2024 at 8:51 AM, the Administrator stated the call lights should not be on the floor because the residents needed them to call the staff. The Administrator said the residents might be having an emergency and staff would not know. The Administrator said the staff should be make sure the call lights were within reach. The Administrator said he would coordinate with the DON regarding call lights and would constantly remind them that before leaving the room, make sure the call lights were with the resident. Record review of facility's policy Accommodations For Residents Who Cannot Use the Call light Operations and Service Standards Manual revised July 16, 2024 revealed . goal is to have a call light available and within reach of all residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 6 of 25 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 09/06/2024 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that assessments accurately reflected the resident's status for one (Resident #142) of seven residents reviewed for Accuracy of Assessments. Residents Affected - Few The facility failed to ensure Resident #142's Comprehensive MDS Assessment accurately reflected that Resident #142 was using a CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open). This failure could place residents at risk for not receiving care and services to meet their needs, for diminished function of health, and for regressions in their overall health. Findings included: Review of Resident #142's Face Sheet, dated 09/06/2024, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #142 was diagnosed with sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep). Review of Resident #142's Comprehensive MDS Assessment, dated 08/30/2024, reflected Resident #142 had moderate impairment in cognition with a BIMS score of 08. Resident #142's Quarterly MDS Assessment did not indicate that the resident was using a CPAP. Review of Resident #142's Comprehensive Care Plan on 09/04/2024 reflected no care plan for CPAP. Review of Resident #142's Physician Order on 09/04/2024 reflected no order for CPAP. Observation on 09/04/2024 at 9:09 AM revealed Resident #142 was in her wheelchair, sleeping. It was observed that a CPAP machine was on top of the resident's right side table. A nasal pillow mask (a small, soft, cushioned inserts that rests at the entrance of the nose) was attached to the CPAP machine. Observation and interview with Resident #142 on 09/04/2024 at 10:56 AM revealed resident was in her wheelchair, awake. It was observed that the nasal pillow mask for was still on top of the resident's side table. Resident #142 said she used the CPAP even before she was admitted to the facility. She said she could put it on and take it off but sometimes a staff would put it on and take it off. She said the staff were reminding her the benefits of using the CPAP. In an interview with LVN A on 09/04/2024 at 1:46 PM, LVN A stated the residents should be properly assessed everyday so that the staff could provide the best care possible. He said assessment was done during, admission, when there was a fall, or there was a change in condition. In an interview with the DON on 09/06/2024 at 8:26 AM, the DON stated an accurate assessment was important so that the staff would know how to take care of the residents. She said the care plan of the residents would be based on the assessment of the resident. She said if a resident was using a CPAP, it should be reflected on the medical diagnosis, physician orders, the MDS, and the care plan. She said if the residents were not properly assessed, the proper care and needs would not be met. The DON checked the resident's profile and confirmed that Resident #142 was triggered for care plan. The DON said the expectation was that the residents were properly assessed not only during admission (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 7 of 25 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 09/06/2024 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few but every day to see if there were changes in condition, any refusal of care, or a resident acting different than usual. She said she would collaborate with the MDS Nurse to audit the MDS Assessments and make the appropriate changes. She said she would do an in-service about accurate assessment and to document the assessment. In an interview with the ADON on 09/06/2024 at 8:39 AM, the ADON stated if a resident was using a CPAP, it should be reflected on the system to make sure the effectiveness of the resident's use of the CPAP. She added there should be an accurate assessment to know how to care for the residents. The ADON said if there was no accurate assessment, there could be a misunderstanding about the care needed by the resident and the resident might not be able to get the treatment needed. In an interview with the Administrator on 09/06/2024 at 8:51 AM, the Administrator stated the current condition of the resident should be reflected in the system to address the current needs of the resident. He said she would coordinate with the DON to evaluate the situation. Observation and interview with MDS Nurse on 09/06/2024 at 9:02 AM, the MDS Nurse stated she was responsible for doing the MDS Assessment. She said the CPAP would be triggered once it was on the physician order. The MDS Nurse logged on to her computer, checked the resident's profile, and confirmed that Resident #142 was not triggered for CPAP in the MDS assessment. She then checked the physician order and saw the physician order for CPAP that was just transcribed by LVN A on 09/06/2024 at 8:46 AM. She said since the CPAP already had a physician order, she would trigger it on the MDS. She said the medical diagnosis, physician order, the MDS, and the care plan should be all in synched to provide a clear overview of the resident's current condition. She said she would make an audit to make sure the MDS would reflect the current condition of the residents. Record review of facility policy, New admission Assessment Operations and Service Standards Manual revised April 16, 2024 revealed Service Standard: Each new resident should be assessed in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 8 of 25 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 09/06/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one (Resident #142) of seven residents reviewed for Care Plans. The facility failed to ensure Resident #142 was care planned for CPAP. This failure could place the residents at risk of not receiving the necessary care and services. Findings included: Review of Resident #142's Face Sheet, dated 09/06/2024, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #142 was diagnosed with sleep apnea. Review of Resident #142's Quarterly MDS Assessment, dated 08/30/2024, reflected Resident #142 had moderate impairment in cognition with a BIMS score of 08. Resident #142's Quarterly MDS Assessment did not indicate that the resident was using a CPAP. Review of Resident #142's Comprehensive Care Plan on 09/04/2024 reflected no care plan for CPAP. Review of Resident #142's Physician Order on 09/04/2024 reflected no order for CPAP. Observation on 09/04/2024 at 9:09 AM revealed Resident #142 was in her wheelchair, sleeping. It was observed that Resident #142 had a CPAP machine with a nasal pillow mask (a small, soft, cushioned inserts that rests at the entrance of the nose) was on top of the resident's right-side table. Observation and interview with Resident #142 on 09/04/2024 at 10:56 AM revealed the resident was in her wheelchair, awake. It was observed that the nasal pillow mask for CPAP was still on top of the table. Resident #142 said she used the CPAP at night, and it helped her sleep better. In an interview with the DON on 09/06/2024 at 8:26 AM, the DON stated every resident needed a comprehensive care plan to make sure the residents received the applicable and appropriate care needed. The DON said the care plan should be in place so that the staff providing care would be on the same page. The DON stated the care plan was important because it reflected the resident's problem lists, goals, and intervention. She said the care plan should be resident-centered and should show what specific care the resident needed. She said the expectation was for all residents to have a complete and detailed care plan. She said she would coordinate with the MDS Nurse to audit the care plans of the resident. In an interview with the ADON on 09/06/2024 at 8:39 AM, the ADON stated it was important that residents have a care plan to fully provide the care and services the residents needed. She said without the care plan, the staff would not be synched on the care of the residents and their needs would not be addressed. She said the expectation was all the issue of the residents were care planned. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 9 of 25 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 09/06/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm In an interview with the Administrator on 09/06/2024 at 8:51 AM, the Administrator stated all the residents should have a care plan appropriate to their needs. He said without the care plan, the staff would not know the goals and the interventions needed by the residents. The Administrator concluded that the expectation was for the staff to ensure that the residents were care planned accordingly. He said he would coordinate with the DON to make sure all the residents were care planned. Residents Affected - Few Observation and interview with MDS Nurse on 09/06/2024 at 9:02 AM, the MDS Nurse stated she was responsible in making the care plan. She said since the CPAP was not triggered in the MDS, Resident #142 did not have a care plan. She said after triggering it in the MDS, she would do the care plan to reflect the goals and the interventions. The MDS Nurse stated care plans were important to ensure the residents were getting the care needed. She said care plans served as guides on how the staff would take care of the residents. The MDS Nurse added that without the care plans, the staff might overlook the interventions needed by the residents. Record review of facility's policy, Resident Plan Of Care Operations and Service Standards Manual revised April 16, 2024 revealed Service Standard . develop a plan of care for each resident . Utilizing the assessment . team will develop a plan of care for each resident . 4. The care plan will identify problem areas and interventions needed to meet the needs of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 10 of 25 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 09/06/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to review and revise the comprehensive person-centered care plan for each resident, consistent with the resident right that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #23) of 6 residents reviewed for Care Plan reassessment and revisions. The facility failed to ensure Resident #23's care plan included the resident receiving a dietary supplement (Ensure), twice daily based on a comprehensive nutritional assessment completed by the dietician on 08/16/24. This failure could place the resident at risk for excessive weight loss. Findings included: Record review of Resident #23's Face Sheet, dated 09/06/2024, revealed she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included Alzheimer's Disease with late onset and malnutrition. Record review of Resident #23's MDS dated [DATE] revealed, she had a Brief Interview for BIMS score of 05 (severely cognitively impaired) and for ADL care it stated, for transfers, toileting, and bathing, the resident required total assistance. Section K of the MDS indicated the resident had no weight loss of 5% or more in the last month or 10% loss or more in the last 6 months. Record review of Resident #23's Comprehensive care plan dated 08/12/24 revealed the resident's intervention for her care regarding potential nutritional problem was Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, > 5% in 1 month, > 7.5% in 3 months, > 10% in 6 months. There was no intervention indicating the nutritional supplement of Ensure to be included in the resident's assessment. Record review of Resident #23's Comprehensive Nutritional assessment dated [DATE] revealed the resident was not meeting nutritional needs with average intake of 25%-51% and provide Ensure BID to aid in meeting nutritional needs. Record review of Resident #23's orders dated 09/04/24 revealed no physician orders for the Ensure shakes. Record review of Resident #23's weight in the facility's system of record revealed the resident weighed 133.9 pounds on 08/12/24 and was weighed again on 08/22/24 at 127 pounds, which was a 5.15% weigh loss. . In an interview on 09/05/24 at 10:40 AM, the Dietitian stated that she had documented in Resident #23's Dietary Nutritional Assessment on 08/16/24, which stated the following, provide resident with Ensure BId to aid in meeting nutritional needs until PO intake improves to >50%. She stated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 11 of 25 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 09/06/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the resident was forecasted to have weight loss but to attempt to slow down the weight loss by providing the resident an Ensure two times a day. She stated the nursing staff should have requested the orders for the Ensure from the physician. she stated she was not scheduled to review the resident's weight plan until 09/16/24. She stated she did not know why the resident did not have orders for the Ensure and that she would follow up with nursing to see why. She stated the risk of the resident not receiving the Ensure could result in her having possible preventable weight loss. She stated that she had submitted physician orders for the resident to receive Ensure twice daily but it somehow got rejected. She stated that she also should have added it to the resident's care plan, which would ensure that the resident received the dietary aide. She stated she was overall responsible for following up to ensure the resident had the physician orders for the Ensure shake. She stated she also added it to the resident's care plan. In an interview on 09/05/24 at 10:40 AM, the DON was made aware of Resident #23 not having a weight loss of 5.15% in less than two weeks and she stated the resident had refused the Ensure shakes, but she was advised that there were no progress notes indicating the resident refusing the Ensure shake and she also did not have any orders for the Ensure Shake. The DON stated the resident was receiving some other type of nutritional assistance, but she was advised that there were no orders observed for any else. She stated the resident should have had orders for the Ensure shake and she should have had it care, planned by the dietician, which she will ensure that the Dietician had completed. She stated the risk of not providing the resident the Ensure shake could result in unintended weigh loss. Record Review of the Facility's policy on Resident Care Plan dated 04/16/2024, revealed The plan of care will identify problems areas and interventions needed to meet the needs of the resident. The interdisciplinary team is responsible for updating the care plan when there is significant change in the resident's condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 12 of 25 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 09/06/2024 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure that residents received additional nutrition resources, based on comprehensive assessments reviewed for 1 (Resident #23) of 4 residents reviewed for assisted nutrition. Residents Affected - Few The facility failed to ensure Resident #23 received her Ensure shake twice daily, based on a dietary comprehensive assessment completed by the Dietitian on 08/16/24. This failure placed the resident at risk of unnecessary weight loss or slowing a diagnosis that causes weight loss. Findings included: Record review of Resident #23's Face Sheet, dated 09/06/2024, revealed she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included Alzheimer's Disease with late onset and malnutrition. Record review of Resident #23's Quarterly MDS dated [DATE] revealed, she had a BIMS score of 05 (severely cognitively impaired) and for ADL care it stated, for transfers, toileting, and bathing, the resident required total assistance. Section K of the MDS indicated the resident had no weight loss of 5% or more in the last month or 10% loss or more in the last 6 months. Record review of Resident #23's Comprehensive care plan dated 08/12/24 revealed the resident's intervention for her care regarding potential nutritional problem was Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, > 5% in 1 month, > 7.5% in 3 months, > 10% in 6 months. Record review of Resident #23's Comprehensive Nutritional assessment dated [DATE] revealed the resident was not meeting nutritional needs with average intake of 25%-51% and provide Ensure BID to aid in meeting nutritional needs. Record review of Resident #23's orders dated 09/04/24 revealed no physician orders for the Ensure shakes. Record review of Resident #23's weight in the facility's system of record revealed the resident weighed 133.9 pounds on 08/12/24, which was her first weigh-in since being admitted on [DATE]. and was weighed again on 08/22/24 at 127 pounds, which was a 5.15% weigh loss. . In an interview on 09/05/24 at 10:40 AM, the Dietitian stated that she had documented in Resident #23's Dietary Nutritional Assessment on 08/16/24, which stated the following, provide resident with Ensure BId to aid in meeting nutritional needs until PO intake improves to >50%. She stated that the resident was forecasted to have weight loss but to attempt to slow down the weight loss by providing the resident an Ensure two times a day. She stated the nursing staff should have requested the orders for the Ensure from the physician. She stated she was not scheduled to review the resident's weight plan until 09/16/24. She stated she did not know why the resident did not have orders for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 13 of 25 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 09/06/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure and that she would follow up with nursing to see why. She stated the risk of the resident not receiving the Ensure could result in her having possible preventable weight loss. She stated that she had submitted physician orders for the resident to receive Ensure twice daily but it somehow got rejected, she stated she was not sure if she had completed the submission process. She stated that she also should have added it to the resident's care plan, which would ensure that the resident received the dietary aide. She stated she was overall responsible for following up to ensure the resident had the physician orders for the Ensure shake. She stated she also added it to the resident's care plan. In an interview on 09/05/24 at 10:40 AM, the DON was made aware of Resident #23 having a weight loss of 5.15% in less than two weeks and she stated the resident had refused the Ensure shakes. She was advised that there were no progress notes indicating the resident refusing the Ensure shake and she was advised that the resident did not have any orders for the Ensure Shake. The DON stated she meets with her Dietician to discuss residents with weight loss concerns monthly. The DON stated the resident was receiving some other type of nutritional assistance, but she was advised that there were no orders observed for any other nutritional supplement else. She stated the resident should have had orders for the Ensure shake and she should have had it care planned. She stated the risk of not providing the resident the Ensure shake could result in unintended weigh loss. Record Review of the Facility's policy on Monitoring Weight Loss dated 04/16/2024, revealed The dietician will work with the nursing staff and other members of the interdisciplinary team to determine an appropriate plan of action which will be presented to the primary physician for review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 14 of 25 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 09/06/2024 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 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 observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three (Resident #29, Resident #142, and Resident #144) of eight residents reviewed for Respiratory Care. Residents Affected - Some 1. The facility failed to ensure that Resident #29's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored. 2. The facility failed to ensure that Resident #142 had an order for CPAP and her nasal pillow mask (a small, soft, cushioned inserts that rests at the entrance of the nose) for CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) was stored properly. 3. The facility failed to ensure Resident #144's nasal cannula was properly stored. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Review of Resident #29's Face Sheet, dated 09/06/2024, reflected that the resident was an [AGE] year-old female admitted on [DATE]. Resident #29 was diagnosed with chronic respiratory failure with hypoxia (insufficient amount of oxygen in the body), emphysema (a lung disease that damages the air sacs in the lung causing shortness of breath), and chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of Resident #29's Quarterly MDS Assessment, dated 08/26/2024, reflected that Resident #29 had moderate impairment in cognition with a BIMS score of 12. Resident #29's Quarterly MDS Assessment indicated that the resident was on oxygen therapy. Review of Resident #29's Comprehensive Care Plan, dated 08/20/2024, reflected that the resident had emphysema/COPD with chronic respiratory failure related to smoking and one of the interventions was O2 via nasal prongs at 2 L/min. Review of Resident #29's Physician Order, dated 08/19/2024, reflected O2 at 2L/Min Via (through) NC. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 15 of 25 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 09/06/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation and interview with Resident #29 on 09/04/2024 at 8:41 AM revealed that Resident #29 was in her wheelchair, awake. It was observed that she had a portable oxygen tank behind her wheelchair. A nasal cannula was attached to the portable oxygen tank. It was observed that the nasal cannula was coiled on the right hand grip of the wheelchair. The nasal cannula was not bagged and there was no bag hanging at the back of the wheelchair. Resident #29 stated she was on oxygen because of her respiratory problems. Said she would use the nasal cannula on her wheelchair when she needed to go out of her room. She said she never saw a plastic bag for her nasal cannula at the back of her wheelchair and for the nasal cannula connected on the oxygen concentrator. 2. Review of Resident #142's Face Sheet, dated 09/06/2024, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #142 was diagnosed with sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep). Review of Resident #142's Comprehensive MDS Assessment, dated 08/30/2024, reflected Resident #142 had moderate impairment in cognition with a BIMS score of 08. Resident #142's Comprehensive MDS Assessment did not indicate that the resident was using a CPAP. Review of Resident #142's Comprehensive Care Plan on 09/04/2024 reflected no care plan for CPAP. Review of Resident #142's Physician Order on 09/04/2024 reflected no order for CPAP. Observation on 09/04/2024 at 9:09 AM revealed Resident #142 was in her wheelchair, sleeping. It was observed that a CPAP machine was on top of the resident's right-side table. A nasal pillow mask was attached to the CPAP machine. The nasal pillow mask for CPAP was not bagged. Observation and interview with Resident #142 on 09/04/2024 at 10:56 AM revealed resident was in her wheelchair, awake. It was observed that the nasal pillow mask for CPAP was not bagged. Resident #142 said she used the CPAP even before she was admitted to the facility. She said she could put it on and take it off but sometimes a staff would put it on and take it off. She said did not know if the staff would put it on a plastic bag and said nobody told her to not just put the CPAP mask on the table. 3. Review of Resident #144's Face Sheet, dated 09/06/2024, reflected that the resident was an [AGE] year-old female admitted on [DATE]. Resident #144 was diagnosed with chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. Review of Resident #144's Comprehensive MDS Assessment, dated 08/26/2024, reflected that Resident #144 was cognitively intact with a BIMS score of 13. Resident #144's Quarterly MDS Assessment indicated that the resident was on oxygen therapy. Review of Resident #144's Comprehensive Care Plan, dated 08/23/2024, reflected that the resident had chronic respiratory failure and COPD r/t smoking and one of the interventions was O2 via nasal prongs at 4 L/min. Review of Resident #144's Physician Order, dated 08/22/2024, reflected O2 at 4 L/Min Via NC. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 16 of 25 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 09/06/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 09/04/2024 at 10:51 AM revealed Resident #144 was in her bed, sleeping. Resident #144 was on oxygen administration at 4 liters per minute via nasal cannula. The nasal cannula was connected to an oxygen concentrator. Resident #144 also had a nasal cannula at the back of her wheelchair connected to a portable oxygen tank. The nasal cannula was coiled on the left-hand grip of the wheelchair with the prongs of the nasal cannula hanging and was touching the left rear wheel of the wheelchair. The nasal cannula was not bagged and there was no bag at the back of the wheelchair. Observation and interview with LVN A on 09/04/2024 at 11:08 AM, LVN A stated the CPAP nasal pillow, and the nasal cannula should not be exposed nor touching anything because it could cause cross contamination and infection. He said the things mentioned should be bagged when not in use. LVN A went inside Resident #144's room and confirmed the resident's nasal cannula was not bagged and was touching the rear wheel of the wheelchair. LVN A disconnected the nasal cannula attached to the oxygen tank and threw it on the trash can. He said he was going to change it and put it on a bag. LVN A then went to Resident #29's room and confirmed the nasal cannula at the back of the wheelchair was not bagged. LVN A disconnected the nasal cannula, threw it, and said he was going to change it. LVN A went to Resident #142's room and saw the nasal pillow mask for CPAP on the table. LVN A placed the nasal pillow mask for CPAP inside the plastic bag. He said he noticed the nasal pillow mask for CPAP on the table when he checked on Resident #142 but forgot to put it in the plastic bag. Observation and interview with LVN A on 09/04/2024 at 1:46 PM, LVN A stated there should be an order for CPAP because it was a treatment being done to the resident. LVN A checked Resident #142's physician order and said the resident did not have an order for CPAP. He said he saw the CPAP and the suction machine but did not check if there was an order for it. He said the physician orders were important so the staff would know the medications or treatments needed by the resident. He said without the orders, the care needed by the residents would not be addressed. He said he will put the order on the system. In an interview with the DON on 09/06/2024 at 8:26 AM, the DON stated the nasal cannula and the CPAP mask should be bagged when not in use to keep it clean. She said if those breathing apparatus were not bagged, were exposed, or touching surfaces that were not clean, there could be cross contamination, respiratory infection, and oxygen administration could be compromised. The DON said the staff, including her, were responsible in monitoring if the nasal cannula and CPAP mask were bagged when not in use. She said there should be an order for the use of the CPAP. She said that through the physician orders, the staff would know what medications or treatments were needed by the residents on the daily basis. She said without the orders, the staff would not know what to do. She opened Resident #142's profile and confirmed there was no order done for the CPAP. She continued that even though the staff knew what to do and what to give, there should still be an order before executing any treatment or administering any medication. She said the expectation was for the staff to be mindful in making sure that the nasal cannula and the CPAP mask of the residents would be bagged when not in use. She said another expectation was for all the treatment and medications of the residents had orders. The DON said she would conduct an in-service and check-off about the respiratory care. She said she would personally monitor if the staff were bagging the nasal cannula and CPAP mask. She said she would also include the breathing mask used for nebulization. In an interview with the ADON on 09/06/2024 at 8:39 AM, the ADON stated she was the Infection Preventionist of the facility. She said the nasal cannula and the CPAP mask should be bagged when not in use. She said if the nasal cannula and the CPAP mask were exposed and touching surfaces that were dirty, cross contamination and possible respiratory infections could occur. She said the expectation was for the staff to bag the nasal cannula and the CPAP mask when not in use. She said she would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 17 of 25 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 09/06/2024 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 0695 coordinate with the DON pertaining respiratory care. Level of Harm - Minimal harm or potential for actual harm In an interview with the Administrator on 09/06/2024 at 8:51 AM, the Administrator stated everything that the residents were using should be kept clean to prevent infection and all the orders would be in the system. He said since he was not a clinician, he would coordinate with the DON on how to go forward about the issue of respiratory care. Residents Affected - Some Policy for Respiratory Care and Oxygen Administration requested on 09/05/2024 at 12:04 PM but was not provided. The Administrator stated on an email dated 09/05/2024 at 1:32 PM that they do not have specific policies for Respiratory Care, Oxygen Therapy, and Physician Order . The email stated, In the Implementation of services and procedures each facility will utilize the appropriate resources such as [NAME] manual, CDC control and prevention . The resources mentioned were also not provided prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 18 of 25 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 09/06/2024 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 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 food storage, labeling, dating, and kitchen sanitation. 1. The facility failed to ensure expired foods in the facility's refrigerator and freezer were discarded according to guidelines. 2. The facility failed to ensure foods in the refrigerator and freezer were properly sealed from air-borne contaminations. 3. The Executive Chef, Cook, and Culinary Aide failed to properly wear a hair and beard covering while breakfast was being prepared and served, in the kitchen area. 4. The facility failed to clean the food storage bins in the dry food storage area. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on 09/04/24 from 08:50 AM to 09:05 AM in the facility's main kitchen reflected: The Executive Chef was observed in the kitchen area during breakfast service, not wearing a beard covering. His beard was approximately ¼ inch in length. Cook V was observed in the kitchen area during breakfast service, wearing a baseball cap style hat and she had a large rolled up ponytail sticking out of the back of the cap with no hairnet, and she also had about at least two inches of hair sticking out of the bottom of the cap. Culinary Aide S was observed in the kitchen area during breakfast service, wearing a chef skull cap, and he also had at least an inch of hair sticking out of the bottom of the cap. The findings in the kitchen refrigerator included the following: One large tin tray containing a tin container of shredded cheese, a tincontainer of shredded carrots, a tin container of sliced cucumbers, and a tin container containing cherry tomatoes did not have stored date. One tin tray containing 6 tin containers of butter, sour cream, shredded cheese, and bacon bits did not have stored date. One large tin tray of asparagus did not have stored date. One large tin tray of broccoli did not have stored date. One large tin tray of sliced carrots did not have stored date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 19 of 25 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 09/06/2024 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 0812 One large tin tray of stringed beans did not have stored date. Level of Harm - Minimal harm or potential for actual harm One opened bag of spinach was unlabeled and did not have stored date. Residents Affected - Some One large bowl of soup had a hole in the clear cover, exposing it to air contaminants, and it was unlabeled and did not have stored date. One large tin tray of greens did not have stored date. One large tin tray of sauce did not have stored date. One small tin container marked salsa, did not have stored date. One small tin container of gravy was unlabeled and did not have stored date. One large tray of raw lobster tails was unlabeled and did not have stored date. One tin tray of raw shrimp was unlabeled and did not have stored date. One large bag of peperoni did not have stored date. One large bag of meat was unlabeled did not have stored date. One bag of franks was sitting in a tin tray unlabeled and did not have stored date. One large tin tray of cooked pasta was unlabeled and did not have stored date. The findings in the kitchen freezer included the following: One large bag of frozen beef patties, in a zip locked bag, unsealed and open to air contaminants. One large bag of frozen yellow fruit, in a zip locked bag, unsealed and opem to air contaminants. Two large trays of frozen croissants were uncovered and open to air contaminants. Two large trays of muffins were uncovered and open to air contaminants. The findings in the dry food storage area included the following: Two large white bins containing sugar and flour had brownish and blackish dirt stains all over the outer portion of the bins and the inside openings of the bins. One large container of beans (unknown type) was uncovered and open to air contaminants. One large bag of sliced almonds was unsealed and open to air contaminants. In an interview on 09/06/24 at 11:28 AM, the Executive Chef and the Director of Culinary Services was advised of the concerns observed in the kitchen area. The EC stated everyone was responsible for labeling and dating the foods in the kitchen. He stated he had a utility person that was responsible (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 20 of 25 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 09/06/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for labeling and dating the food when it arrived from the trucks, and the cooks were responsible for dating the food cooked at the end of the day, before storing it. They were shown pictures of the concerns and the EC stated he had made the corrections observed. The EC stated that everyone was responsible for checking the foods in the storage areas to ensure that it was sealed properly. The EC stated they had deep cleaned the kitchen every Sunday after brunch. The EC stated they cleaned the dry storage area, including the storage bins daily. The EC was advised of himself and the two staff members being observed not wearing the proper head and face coverings, and he stated he had corrected the issue by ensuing everyone was wearing a hairnet. The EC the concerns observed in the kitchen could contaminate foods and make the residents sick. In an interview on 09/06/24 at 11:28 AM, the Administrator was advised that there were concerns observed in the kitchen. He mentioned that he had spoken with the EC. He advised that the issues could cause food contamination and would be resolved. Record Review of the Facility's policy on Food Storage dated 04/16/2024, revealed Buckner strives to prepare, distribute, and served food under sanitary conditions. Food and supplied will be stored according to the current standards of practice. 1. Dry food storage should be maintained in a clean and dry area free of contaminants. 2. Refrigerator storage Safe practices include: d. Labeling, dating, and monitoring food. All food handling and safety must comply with the Texas Food Establishment Rules (TFER) and the CMS and Texas Health and Human Services Commission (HHSC) Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under § 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. Review of TITLE 21--FOOD AND DRUGS CHAPTER I--FOOD AND DRUG ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES SUBCHAPTER B - FOOD FOR HUMAN CONSUMPTION PART 110 -- CURRENT GOOD MANUFACTURING PRACTICE IN MANUFACTURING, PACKING, OR HOLDING HUMAN FOOD (6) Wearing, where appropriate, in an effective manner, hair nets, headbands, caps, beard covers, or other effective hair restraints. TITLE 21--FOOD AND DRUGS CHAPTER I--FOOD AND DRUG ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES SUBCHAPTER B - FOOD FOR HUMAN CONSUMPTION PART 110 -- CURRENT GOOD MANUFACTURING PRACTICE IN MANUFACTURING, PACKING, OR HOLDING HUMAN FOOD Subpart B - Buildings and Facilities (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 21 of 25 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 09/06/2024 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 0812 Sec. 110.35 Sanitary operations. Level of Harm - Minimal harm or potential for actual harm 5) Sanitizing agents shall be adequate and safe under conditions of use. Any facility, procedure, or machine is acceptable for cleaning and sanitizing equipment and utensils if it is established that the facility, procedure, or machine will routinely render equipment and utensils clean and provide adequate cleaning and sanitizing treatment. Residents Affected - Some (e) Storage and handling of cleaned portable equipment and utensils. Cleaned and sanitized portable equipment with food-contact surfaces and utensils should be stored in a location and manner that protects food-contact surfaces from contamination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 22 of 25 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 09/06/2024 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 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 observations, interviews, 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 two (Resident #7 and Resident #145) of eight residents observed for Infection Control. Residents Affected - Few 1. The facility failed to ensure that CNA C changed her gloves and performed hand hygiene while providing incontinent care to Resident #7. 2. The facility failed to ensure that CNA B changed her gloves and performed hand hygiene while providing incontinent care to Resident #145. These failures could place the residents at risk of cross-contamination and development of infections. Findings included: 1. Review of Resident #7's Face Sheet, dated 09/06/2024, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #7 was diagnosed with reduced mobility and need for assistance with personal care. Review of Resident #7's Quarterly MDS Assessment, dated 06/11/2024, reflected that Resident #7 was cognitively intact with a BIMS score of 14. Resident #7's Quarterly MDS Assessment indicated that the resident was incontinent for bowel and bladder. Review of Resident #7's Comprehensive Care Plan, dated 07/17/2024, reflected that Resident #7 was incontinent for bladder and one of the interventions was clean peri-area with each incontinent care. Observation on 09/04/24 at 11:18 AM revealed CNA C was about to transfer Resident #7 to her recliner using a sit-to-stand lift (a mechanical device designed to assist individuals in moving from a sitting position to a standing position and vice versa). CNA C entered the room with the sit-to-stand. CNA C put on a pair of gloves, she did not do hand hygiene before putting on the pair of gloves. CNA C assisted the resident into a sitting position at the side of the bed. CNA C then placed the protective strap around the resident's chest and hooked it on the sit-to-stand lift. CNA C raised Resident #7 into a standing position. Before transferring the resident to the recliner, CNA C pushed the sit-to-stand lift to the bathroom because the resident said she wanted to relieve herself. Before lowering the resident down to the toilet seat, CNA C pulled the resident's brief down and then lowered the resident onto the toilet seat. While the resident was relieving herself, the brief fell on the floor. CNA C took off the brief, threw it on the trash can, and then tied the plastic bag where she threw the brief. CNA C took off her gloves and put on a new pair of gloves, she did not sanitize her hands before putting on the new pair of gloves. CNA C then took a new brief from the sink that was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 23 of 25 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 09/06/2024 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 - Few just behind her, opened it, and placed it on the side of the sink. When the resident said that she was done, CNA C raised the resident up, pulled some wipes, and cleaned the resident's bottom. After cleaning the resident's bottom, CNA C took the opened brief that she placed at the side of the sink that was behind her and put it on the resident. CNA C did not change her gloves after cleaning the resident's bottom. After putting on the brief, CNA C rolled the sit-to-stand lift and lowered the resident to her recliner. CNA C took off her gloves, threw it, and left the room. She did not wash her hands after incontinent care and the transfer. In an interview with CNA C on 09/05/2024 at 1:13 PM, CNA C stated hands should be washed or sanitized before and after doing incontinent care. She said the hands should also be sanitized before putting on clean gloves. CNA C said hand hygiene was important to prevent the spread of germs. She said she should have done hand hygiene and changed her gloves after touching the soiled brief, after cleaning the resident's bottom, and before touching the new brief. She said she was in a hurry and forgot to change her gloves before getting the new brief. 2. Review of Resident #145's Face Sheet, dated 09/06/2024, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #145 was diagnosed with weakness and malaise (a general feeling of discomfort, illness, or uneasiness). Review of Resident #145's Comprehensive MDS Assessment, dated 08/20/2024, reflected Resident #145 had a severe impairment in cognition with a BIMS score of 03. The Quarterly MDS Assessment indicated that the resident was incontinent for bladder and bowel. Review of Resident #145's Comprehensive Care Plan, dated 08/21/2024, reflected Resident #145 was incontinent for bladder and one of the interventions was clean peri-area with each incontinent care. Observation on 09/05/2024 at 12:43 PM revealed CNA B was called by Resident #145's family member because the resident wanted to go to the bathroom. Resident #145 was already inside the bathroom and was waiting for CNA B. CNA B put on pair of gloves and assisted the resident to stand up from the wheelchair. CNA B did not do hand hygiene before putting on the gloves. CNA B instructed the resident to pivot, lowered the resident's pull-up, and then assisted the resident to sit down on the toilet seat. The pull-up was observed to be soiled. When the resident was done relieving herself, she told CNA B that she was done. CNA B assisted the resident to stand up, pulled some wipes, and cleaned the resident's bottom from middle to back. CNA B instructed the resident to sit down again so she could change the soiled pull-up. CNA B took off the resident's shoes followed by the resident's pants. CNA B then pulled the soiled pull-up and threw it on the trash can. CNA B then reached out to the sink and took a new pull-up from the side of the sink. She did not change her gloves after cleaning the resident's bottom, taking off the resident's shoes and soiled pull-up. CNA B then put on the new pull-up, followed by the resident's pants, and then the resident's shoes. In an interview with CNA B on 09/05/2024 at 12:56 PM, CNA B stated she should do hand hygiene before doing any care for a resident. She confirmed that she did not wash her hands nor sanitized her hands before putting on her gloves. She said, during incontinent care, the gloves should have been changed after touching the shoes and the soiled pull-up. She added that after touching anything that was dirty or soiled and before touching the clean items, hand hygiene should be done. She said hand hygiene should also be done in between changing of gloves. She said if hand hygiene and changing of gloves were not done, cross contamination and infection could happen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 24 of 25 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 09/06/2024 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 - Few In an interview with LVN A 09/05/2024 at 1:47 PM, LVN A stated hand hygiene was the basic component in the prevention of cross contamination and development of infection. LVN said hand hygiene should be a part of the staff's routine, especially those that were providing direct care. He said staff should do hand hygiene before and after any care. He continued that the gloves should be changed after touching anything that was dirty or soiled and before touching the clean items. He said hands should also be sanitized in between changing of gloves. In an interview with the DON on 09/06/2024 at 8:26 AM, the DON stated that hand hygiene was the most effective way to prevent cross contamination and infection. She said, first, it should be done before and after every care. She continued that secondly, the gloves should be changed after touching any soiled items. She said for this case, the gloves should have been changed after touching the shoes and the soiled brief and pull-up. She said lastly, every time staff change their gloves, they should do hand hygiene before putting on a new pair of gloves. She said the expectation was for the staff to do hand hygiene before and after any care, to change their gloves from dirty to clean, and to do hand hygiene when changing the gloves. She said he will do an in-service and check-off about infection control and would monitor the issue personally. In an interview with the ADON on 09/06/2024 at 8:39 AM, the ADON stated she was the Infection preventionist of the facility. She said hand hygiene was included in all the procedures of any care. She said the staff should do hand hygiene before and after any care. She said gloves should be changed when transitioning from dirty to clean. She said not doing hand hygiene could cause of cross contamination and probable infections. She said the expectation was for the staff to do hand hygiene before and after every care, after changing their gloves, and when transitioning from a dirty area to a clean area. The ADON said they would do in-service about infection control. In an interview with the Administrator on 09/06/2024 at 8:39 AM the Administrator stated not doing hand hygiene before and after any care, not changing the gloves after touching soiled items, and not sanitizing the hands in between changing of gloves could contribute to cross contamination and probable infection. He said the expectation was for the staff to follow the policy and procedures pertaining to infection control. He said he would collaborate with the DON to in-service the staff about infection control. Review of facility policy, Hand Hygiene Operations and Service Standards Manual revised April 16, 2024 revealed Service Standard: Handwashing is the most important procedure to follow to prevent the spread of infection . can use alcohol-based hand sanitizer . hand hygiene should be performed . before and after client contact . after removing gloves . after touching contaminated items. Policy for Incontinent Care requested on 09/05/2024 at 12:04 PM and on 09/06/2024 at 10:22 PM but was not provided prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676305 If continuation sheet Page 25 of 25