Inspection·December 20, 2023

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/21/2023 at 11:23 AM with the RD, she stated upon admission, she went to evaluate each resident. She stated that she talked to them about their preference about food as well as did the Dietary Manager. Whatever the resident listed for food preference, she would put it on the recommendation as well as an email preference to not confuse the nursing staff. She stated although she spoke with Resident #301, she had not had time to update preference to the Dietary Manager and was planning on sending it out that day 12/21/2023. During an interview with the RD on 12/21/2023 at 3:00pm, she stated that the order read the menu was not selective , it did not mean couldn't choose her own menu . She stated it just meant that she would get mainly what was served. She stated the Ensure , which the resident originally had ordered, was discontinued, because the facility did not provide it. She stated that was why the health shake was ordered instead but that she just hadn't gotten a chance to update the order to add the health shake three times a day which was the same order as the ensure. During an interview with the Dietary Manager on 12/21/2023 4:00 pm, he stated that he had not had a chance yet to get to all residents to ask about their food preferences and stated he would check with Resident #301 to see how to best help her. He stated that he was new to the facility and had only been here for two weeks. So now that he was aware Resident #301 had not had her food preferences honored, he would add Resident #301 to the top of the list to update her preferences. He stated the risk to residents not having their food preferences was it could make the resident conditions worse. Record review of facility policy labeled Resident Rights revised 12/2016 revealed: Federal and state laws guarantee certain basic rights to all residents of this facility Residents are entitled to exercise their rights and privileges to the fullest extent possible. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676405 If continuation sheet Page 2 of 21 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 676405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forum Parkway Health & Rehabilitation 2112 Forum Parkway Bedford, TX 76021 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 observation, interview, and record review, the facility failed to develoop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #355) of 8 residents reviewed for comprehensive care plans. Facility failed to complete a care plan for an implanted continuous blood sugar monitoring medical device for Resident# 355. This failure could place residents at risk for inadequate care, inaccurate blood sugar results, infection at device site, and or bleeding. Findings included: Review of resident # 355 admission Recorded dated 12/19/23, reflected he was an [AGE] year-old male admitted to facility 12/07/23 with diagnoses of Congestive heart failure, chronic obstructive pulmonary disease with (acute) exacerbation, type 2 diabetes mellitus with diabetic chronic kidney disease, type 2 diabetes mellitus with hyperglycemia, type 2 diabetes mellitus with diabetic neuropathy, unspecified, adult failure to thrive, and contagious coronavirus diseases caused by SARS-CoV-2 (COVID-19). Review of resident # 355 MDS assessment dated [DATE], revealed a Brief Interview for mental Status (BIMS) score of 15, which indicated the resident was mentally intact, was understood and could understand others. Review of Resident #355 baseline care plan dated 12/12/23, reflected Resident # 355 had a potential for high and low blood sugars (hypo/hyperglycemia) related to diabetes mellitus. The goal was to have no complications related to diabetes. Interventions were to administer medication as per physician order. Record review of resident # 355's care plan dated 12/12/23, revealed no care plan for his implanted continuous blood sugar monitoring device. Observation and interview with RN L on 12/19/23 at 11:21 AM, revealed Resident #355 had an implanted continuous blood sugar monitoring device. RN L said Resident #355 did not like his fingers pricked for blood sugar (fresh capillary whole blood from pricked fingertip, get blood on a test trip and put in a blood sugar machine). She said he refused to get finger sticks pricks and said to just to use his implanted continuous blood sugar monitoring medical device. RN L stated the protocol was that if a resident was admitted to a facility with any medical device/devices, Physician or Nurse practitioner would be notified and the device would be charted on Electronic Medical Records (EMR) where it was located and name of device. Interview with admitting nurse LVN K on 12/20/23 at 03:56 PM, revealed he did admissions from 2 pm to 10 pm shift. He stated upon admission to facility, he did vitals (BP (Blood Pressure), temperature, oxygen, heart rate) weights, complete skin assessment (starting from feet to head), the whole-body system was looked over. He stated if a resident had any medical device i.e., Oxygen, intravenous (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676405 If continuation sheet Page 3 of 21 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 676405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forum Parkway Health & Rehabilitation 2112 Forum Parkway Bedford, TX 76021 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 (IV) access for antibiotics or any findings, he would assess the device, note location, how long resident has had it, what it is used for. He stated he would ask the residents if they could answer, or he would ask the family about the device. LVN K said that he would record findings on the resident's progress notes in the Electronic Medical Records (EMR) and notify the physician and DON. Interview with the DON on 12/19/23 at 03:32 PM, revealed he was not aware that Resident #355 had an implanted continuous blood sugar monitoring medical device. He said it was the responsibility of the admitting nurse to let him know and/or make a note in the residents' chart. He said he expected his nurses to notify the physician and him about any medical devices. He said that he expected the nurses to monitor Resident #355's blood sugar with the accu-check glucometer machine (fresh capillary whole blood from pricked fingertip, get blood on a test trip and put in a blood sugar machine). He said that some residents prefer that implanted continuous blood sugar monitoring medical device to be used, and in those cases, the physician would be notified, and an order would be obtained , an assessment would be done every shift of the device site, and device would be care planned. He said the risk of not monitoring the implanted continuous blood sugar monitoring medical device is that it could malfunction and give an inaccurate reading if dislodged. Skin assessment was not done in the device area therefore, skin breakdown or infection could occur Interview with the ADM on 12/20/23 at 02:37 PM, revealed he saw a newly admitted resident within 48-72 hours (about 3 days). He expected nursing staff to carry out care plan as expected. He said he expected nursing staff to do full body assessment weekly and new admission must have a full body assessment on admission. He said he did not recommend the use of residents own glucose monitoring device because no clinical personnel can access the device if readings are on residents' phone, and they crush. He expected nursing staff to use basic protocol of checking blood sugar. Potential risk for resident is accurate results. Review of Policy titled Care Plans, Comprehensive Person-Centered, revision December 2016 read in part: . The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS) . The Interdisciplinary Team must review and update the care plan: When there has been a significant change in the resident's condition; When the desired outcome is not met; When the resident has been readmitted to the facility from a hospital stay; and At least quarterly, in conjunction with the required quarterly MDS assessment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676405 If continuation sheet Page 4 of 21 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 676405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forum Parkway Health & Rehabilitation 2112 Forum Parkway Bedford, TX 76021 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who are unable to carry out the activities of daily living received the necessary services to maintain personal hygiene for 3 of 6 residents (Resident #205, Resident #206, and Resident #209) reviewed for ADL care. Residents Affected - Some The facility failed to ensure Resident #205 and #206 were provided regular showers. The facility failed to ensure Resident #209 was provided regular showers and personal hygiene based on the resident's preference. These failures could place residents at risk of not receiving personal care services and a decreased quality of life. Findings included: Resident #205 Record review of Resident #205's admission record, dated 12/20/2023, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, and depression. Record review of Resident #205's admission MDS assessment, dated 12/10/2023 revealed a BIMS score of 13, indicating intact cognition. Record review of Resident #205's admission assessment, dated 12/06/2023, revealed Resident #205 was totally dependent for bathing. Record review of Resident #205's care plan and nursing progress notes from 12/06/2023 through 12/18/2023 did not indicate resident refused showers. Record review of Resident #205's December 2023 ADL sheet reflected a bed bath given on 12/13/23, 12/15/23 and 12/18/23. No paper shower sheets were provided for Resident's #205 for days marked No on the ADL sheets. Interview on 12/18/2023 at 10:12 AM, Resident #205's family member stated he was at the facility over a week before he got a bath. Interview on 12/20/2023 at 12:43 PM, RN L stated Resident #205's shower was on 2-10 shift and the family would say they wanted him to sleep, or he was in therapy. She said the family would ask for the resident to have a shower the next day. RN L stated CNAs completed paper shower sheets and the nurse signed off. Resident #206 Record review of Resident #206's admission record, dated 12/20/2023, revealed an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, cellulitis of right and left lower limbs, sepsis, and muscle weakness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676405 If continuation sheet Page 5 of 21 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 676405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forum Parkway Health & Rehabilitation 2112 Forum Parkway Bedford, TX 76021 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 0677 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #206's admission MDS, dated [DATE], revealed a BIMS score of 13, indicating intact cognition. Record review of Resident #206's care plan and nursing progress notes from 11/30/2023 through 12/19/2023 did not indicate resident refused showers. Residents Affected - Some Record review of Resident #206's functional abilities and goals, dated 11/30/2023, revealed Resident #206 was dependent for bathing. Record review of Resident #206's December 2023 ADL sheet reflected a bed bath given on 12/05/23, 12/07/23 and 12/19/23. No paper shower sheets were provided for Resident's #206 for days marked No on the ADL sheets. Observation and interview on 12/18/2023 at 11:48 AM, revealed Resident #206 was sitting on a chair in the middle of the room watching tv, wearing a hospital gown. Resident #206's hair was in a ponytail and appeared matted. Resident #206 stated she had not had a shower since she admitted , and staff had not offered. Interview on 12/20/2023 at 12:56 PM, LVN B stated CNA D gave Resident #206 a shower yesterday and that she would try to wash her hair because it was awful. She stated Resident #206 refused to have her hair washed yesterday and CNA D would try again today. Interview on 12/20/2023 at 1:03 PM, CNA D stated she gave Resident #206 a bed bath because there was an issue with the water yesterday. She stated Resident #206 was sensitive to care and touching on her and the water was getting cold quickly, so she just gave her a bed bath. CNA D stated she needed to get her in the shower to wash her hair because it was very bad. It looked like she was lying on it, but she sits up, and her hair was all matted up. CNA D stated if residents did not get bathed regularly they could have sores, skin break down, tangles in hair, could be smelly and overall general appearance would not be good. She stated they document in the chart and complete paper shower sheets for every shower, not just for refusals. Resident #209 Record review of Resident #209's admission record revealed an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included unspecified fracture of sternum, pulmonary fibrosis, muscle weakness and chronic kidney disease. Record review of Resident #209's admission MDS, dated [DATE] revealed a BIMS score of 4, indicating severe cognitive impairment. Record review of Resident #209's December 2023 ADL sheet reflected no shower/bed bath given on 12/16/2023 and 12/19/2023. No paper shower sheets were provided for Resident's #209 for days marked No on the ADL sheets. Observation and interview on 12/19/2023 at 11:12 AM, revealed Resident #209 lying in bed in a hospital gown. Small crumbs were observed on the front of the hospital gown and Resident #209's face appeared unshaved. Resident #209 stated staff have not asked if he wanted a shower, but he did get a bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676405 If continuation sheet Page 6 of 21 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 676405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forum Parkway Health & Rehabilitation 2112 Forum Parkway Bedford, TX 76021 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bath. When asked if he wanted a shower, Resident #209 stated he was not getting that dirty. Resident #209 stated he would not mind if someone cut his beard, but if he could not find anyone that wants to, he would just live with it. Resident #209 stated he did not remember any staff member asking if he wanted his beard shaved. Interview on 12/20/2023 at 12:56 PM, LVN B stated Resident #209 did get a shower on Saturday (12/16/2023) and yesterday (12/19/2023). She said the one that gave them was a new CNA. LVN B was not able to provide documentation that a shower or bed bath was given. Interview on 12/20/2023 at 4:48 PM, the DON stated his expectation was that residents were bathed per their schedule and prn if they asked. He stated the process was for the CNA to ask the resident, and if there was a refusal, then the nurse would follow up. The DON stated CNAs document on paper shower sheets and in the [NAME] and hand the paper shower sheets to the ADON. He said if residents were not bathed, there could be skin breakdown, would feel uncomfortable, and all the things associated with good hygiene. The DON stated sometimes if the aides do not document in the [NAME], they would complete the paper shower sheet. Record review of the facility policy titled, Shower/Tub Bath, revised October 2010, reflected the procedure in providing a shower. The policy further reflected The following information should be recorded on the resident's ADL record and/or in the resident's medical record: 1. The date and time the shower/tub bath was performed .5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676405 If continuation sheet Page 7 of 21 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 676405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forum Parkway Health & Rehabilitation 2112 Forum Parkway Bedford, TX 76021 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 8 residents (Resident #355), reviewed for quality of care. Residents Affected - Some 1. Facility failed to ensure an active order was followed for blood sugar monitoring for Resident # 355 from 12/12/23 to 12/19/23 as ordered by provider. 2. Facility failed to notify physician of an implanted continuous blood sugar monitoring medical device for Resident# 355. These failures could place residents at risk for inadequate care, inaccurate blood sugar results, infection at device site, and or bleeding. Findings included: Review of resident # 355 admission Recorded dated 12/19/23, reflected he was an [AGE] year-old man admitted to facility 12/07/23 with diagnoses of Congestive heart failure, chronic obstructive pulmonary disease with (acute) exacerbation, type 2 diabetes mellitus with diabetic chronic kidney disease, type 2 diabetes mellitus with hyperglycemia, type 2 diabetes mellitus with diabetic neuropathy, unspecified, adult failure to thrive, and contagious coronavirus diseases caused by SARS-CoV-2 (COVID-19). Review of resident # 355 MDS dated [DATE], revealed a Brief Interview for mental Status (BIMS) of 15, mentally intact, was understood and could understand others. Review of Resident #355 baseline care plan dated 12/12/23, reflected he was on an antiplatelet therapy which decreased the ability of blood clots (blood thinner). The goal was for Resident # 355 to be free from complications of anticoagulant complications: blood-tinged urine, skin abnormalities, bruising, dark or bright blood in stools, vital signs changes. Interventions included observation, documentation, and reporting to physician of anticoagulant complications. Furthermore, the Care plan revealed Resident # 355 had a potential for high and low blood sugars (hypo/hyperglycemia) related to diabetes mellitus. The goal was to have no complications related to diabetes. Interventions were to administer medication as per physician order. Record review of resident # 355's active physician orders dated 12/19/23, revealed there was no order for blood sugar monitoring using an implanted continuous blood sugar monitoring device. Review of Residents # 355 blood sugar results from 12/14/23 to 12/19/23 revealed, blood sugars as follows. 12/14/23 at 11:32 AM 99 mg/dl 12/14/23 at 04:55 PM 80 mg/dl 12/14/23 at 07:35 PM 104 mg/dl (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676405 If continuation sheet Page 8 of 21 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 676405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forum Parkway Health & Rehabilitation 2112 Forum Parkway Bedford, TX 76021 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 0684 12/15/23 at 06:18 AM 74 mg/dl Level of Harm - Minimal harm or potential for actual harm 12/15/23 at 11:59 AM 140 mg/dl 12/15/23 at 04:47 PM 104 mg/dl Residents Affected - Some 12/15/23 at 08:50 PM 112 mg/dl 12/16/23 at 08:23 AM 83 mg/dl 12/16/23 at 10:58 AM 96 mg/dl 12/16/23 at 04:39 PM 126 mg/dl 12/16/23 at 08:51 PM 112 mg/dl 12/17/23 at 05:55 AM 86 mg/dl 12/17/23 at 07:20 AM 98 mg/dl 12/17/23 at 11:15 AM 112 mg/dl 12/17/23 at 04:42 PM 117 mg/dl 12/17/23 at 08:16 PM 113 mg/dl 12/18/23 at 07:25 AM 88 mg/dl 12/18/23 at 11:29 AM 104 mg/dl 12/18/23 at 11:34 AM 104 mg/dl 12/18/23 at 04:01 PM 143 mg/dl 12/18/23 at 08:11 PM 126 mg/dl 12/19/23 at 07:15 AM 76 mg/dl 12/19/23 at 11:59 AM 112 mg/dl Observation and interview on 12/19/23 at 11:21AM, revealed RN L entering Resident #355 room wearing proper Personal Protective Equipment (PPE). She asked Resident #355 what his blood sugar was. Resident #355 scanned an implanted continuous blood sugar monitoring device on his upper left arm and told RN L that his blood sugar was 112. RN L then told Resident #355 that he did not need insulin coverage and exited the room after taking off PPE and performing hand hygiene. RN L did not access Resident #355 site of implanted continuous blood sugar monitoring device. RN L stated that they usually just asked Resident #355 for his blood sugar, and he told them. She stated Resident #355 did not like his fingers pricked for blood sugar (fresh capillary whole blood from pricked fingertip, get blood on a test trip and put in a blood sugar machine). She stated he refused to get finger stick pricks (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676405 If continuation sheet Page 9 of 21 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 676405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forum Parkway Health & Rehabilitation 2112 Forum Parkway Bedford, TX 76021 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and stated just to use his implanted continuous blood sugar monitoring medical device. RN L stated the protocol was that if a resident were admitted to a facility with any medical device/devices, Physician or Nurse practitioner would be notified and device would be charted on Electronic Medical Records (EMR) were it is located and name of device. Interview with Resident #355 on 12/20/23 at 10:15 AM, revealed that facility came and asked him about his blood sugar device yesterday 12/19/23. He stated that the facility did not check the site prior to yesterday. He stated that replaced the continuous blood sugar monitoring medical device on 12/12/23. He stated before changed the device, he got his finger pricked. He stated that he hoped to be home by 12/23/23 and he could change the device and site himself. Interview with admitting nurse LVN K on 12/20/23 at 03:56 PM, revealed he did admissions from 2pm to 10 pm shift. He said upon admission to facility, he did vitals (BP, temperature, oxygen, heart rate) weights, complete skin assessment (starting from feet to head), the whole-body system was looked over. He stated if a resident had any medical device i.e., Oxygen, intravenous (IV) access for antibiotics or any findings, he would assess the device, note location, how long resident has had it, what it was used for. He stated he would ask the residents if they could answer, or he would ask the family about the device. LVN K stated that he would record findings on the resident's progress notes in the Electronic Medical Records (EMR) and notify the physician and DON. Interview with the DON on 12/19/23 at 03:32 PM, revealed he was not aware that Resident #355 had an implanted continuous blood sugar monitoring medical device. He said it was the responsibility of the admitting nurse to let him know and/or make a note in the residents' chart. He stated he expected his nurses to notify the physician about any medical devices the resident had. He stated that he expected the nurses to monitor Resident #355's blood sugar with the accu-check glucometer machine (fresh capillary whole blood from pricked fingertip, get blood on a test trip and put in a blood sugar machine). He stated that some residents prefer that implanted continuous blood sugar monitoring medical device to be used, in those cases, physician will be notified, and an order would be obtained, an assessment would be done every shift of the device site, and device would be care planned. He said the risk of not monitoring the implanted continuous blood sugar monitoring medical device is that it could malfunction and give an inaccurate reading if dislodged., Skin assessment was not done in the device area therefore, skin breakdown or infection could occur. Interview with Medical Director on 12/20/23 at 04:21 PM, revealed she would refer any resident with implanted continuous blood sugar monitoring medical device to an endocrinologist. She said the facility would notify her of any residents admitted with medical devices. She said she would expect facility to carry out an order placed by a physician. She said accu-checks need to be checked as ordered. Review of Policy titled Blood sampling- Capillary, revised September 2014 read in part: .Residents may use a continuous blood glucose monitor per their preference but must manage changes of device per resident and must visually share monitoring results with nurse. If resident not able to monitor blood sugar through continuous blood glucose monitoring device for any reason, or if values are questionable, then a capillary finger stick will be performed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676405 If continuation sheet Page 10 of 21 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 676405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forum Parkway Health & Rehabilitation 2112 Forum Parkway Bedford, TX 76021 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 interview and record review, the facility failed to ensure residents were able to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that it was not possible, or the resident preferences indicated otherwise for 2 of 10 residents (Resident #205 and Resident #301) reviewed for quality of care. Residents Affected - Some 1. The facility failed to weigh Resident #205 and #301 at admission per facility policy and physician's orders. 2. The facility failed to ensure Resident #301 did not have an unplanned significant weight loss. 3. The facility failed to ensure the Dietitian assessed Resident #205 upon admission. These failures could place residents at risk for decrease nutritional and weight status and a decline in health. Findings included: 1. Record review of Resident #205's admission record, dated 12/20/2023, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, depression, and dysphagia. Record review of Resident #205's admission MDS assessment, dated 12/10/2023 revealed a BIMS score of 13, indicating intact cognition. Record review of Resident #205's care plan, initiated on 12/11/2023, revealed Resident #205 required a therapeutic regular, dysphagia advanced diet with regular consistency, with interventions that included RD to evaluate and make recommendations as indicated. Record review of Resident #205's admission assessment, dated 12/06/2023, revealed no weight was documented. Record review of Resident #205's physician orders, start date 12/08/2023, revealed obtain admission weight x3 days and then weekly x4 weeks. Record review of weights in Resident #205's EHR revealed a weight of 118.5 pounds completed on 12/10/2023. No other weights were listed. Record review of Resident #205's MAR for December 2023 revealed no weight documented. Record review of Resident #205's hospital history and physical, dated 12/01/2023, revealed a weight of 120 pounds. Record review of Resident #205's EHR revealed no assessment or progress notes by the Dietitian. 2. Record review of Resident #301's Face sheet dated 12/04/23 revealed a [AGE] year-old female that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676405 If continuation sheet Page 11 of 21 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 676405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forum Parkway Health & Rehabilitation 2112 Forum Parkway Bedford, TX 76021 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 admitted to the facility on [DATE] with diagnoses that included Scoliosis, COVID-19, and hypertension. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #301's MDS dated [DATE] revealed a BIMS of 12 me which indicated moderate cognitive decline. Residents Affected - Some Record review of Resident #301's Care plan last revised 12/11/23 did not address Resident #301's food preferences. Record review of resident #301's EHR revealed no assessment or progress notes by the dietitian. Record review of Resident #301's hospital history and physical dated 12/1/2023 revealed a weight of 165 pounds. Record review of Resident #301's MAR dated 12/15/2023 revealed a weight of 121 pounds. Interview on 12/20/2023 at 9:17 AM, the Business Office Director stated the restorative aide was out of the county and another aide was filling in for tasks. Interview on 12/20/2023 at 9:35 AM, LVN E stated they did not have a true restorative program and when the restorative aide was there, he would get weights, and if he was not able to, then the CNA's on the hall would get them. When asked what the weight policy was, LVN E stated she thought the policy changed, but if a resident had an order to weigh for 4 weeks, then it would show on the nurse's MAR. She stated the only way she could say why weights were not done was if the resident refused. LVN E stated if the CNA's weighed the residents, they would give that to the nurse and the nurse documented it in the medical record. LVN E stated there was not really a risk of not getting a resident's weight, unless they had a diagnosis like CHF, the weight was just to have a baseline. LVN E stated the Dietitian comes in once a week and was informed of new admissions. She said the Dietitian would email the DON if there were no weights and the DON would send an email out of who needed to be weighed. LVN E stated the wound care nurse (LVN F) was responsible for monitoring the weights. Interview on 12/20/2023 at 10:29 AM, LVN F stated she had worked at the facility since the end of October. She stated residents were supposed to be weighed upon admission. LVN F said since the restorative aide was out she typically tried to cover his spot and CNA's would be responsible for getting weights. When asked what the risk was for not obtaining a weight at admission, LVN F stated unless they had fluid overload, CHF, or a dialysis patient they weigh them on admission for a baseline. LVN F said not catching the weight loss for Resident #301 and not having an accurate baseline for both Resident #205 and Resident #301 would be the risk. LVN F stated she monitored weights by checking monthly if the nurses were inputting the weekly and daily weights. She stated she did not know why the admission weights were not completed. Interview on 12/20/2023 at 11:25 AM, the Dietitian stated shewent to the facility once or twice a week. She stated she identifies new admissions that need assessments by the admission and discharge report and enters them into a schedule to be seen. She stated assessments should be completed for new admissions within 14 days, but with a lot of admissions at one time, it goes a little beyond. The Dietitian stated she was informed Resident #205 was going to discharge the day she was at the facility and did not prioritize seeing him. She stated every resident that comes in was supposed to have a nutrition assessment. She stated if she was completing a nutrition assessment and a resident had not been weighed, she would ask for a weight, and convey that to the DON. She stated there was a weight (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676405 If continuation sheet Page 12 of 21 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 676405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forum Parkway Health & Rehabilitation 2112 Forum Parkway Bedford, TX 76021 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 person and sometimes the weight was on paper and not entered, so she would check with him. The Dietitian stated when she assessed Resident #301, she did appear malnourished. She stated she does look at hospital records for weights and saw Resident #301 weighed 121 pounds and compared that to the weight the facility got at 112 pounds. She said a lot of times the hospital weight was not immediate and the weight could be from a year ago so she would just use the hospital weight as a reference. Residents Affected - Some Interview on 12/20/2023 at 2:45 PM, the Administrator stated he would have to review the policy on nutrition assessments, but the expectation would be to get it done as quick as possible. He stated the expectation was to get an admit weight and use that as a baseline. He stated the hospital weight could be used if they could not take the residents out of the room, if residents were on isolation, they would use the Hoyer but they cannot take the scale into the room. The Administrator stated they did notify the Dietitian and Management about Resident #305's weight loss. Interview on 12/20/2023 at 4:52 PM, The DON stated his expectation was for residents to be weighed on admission and to use that weight as a baseline for the patient. He stated it depends on skilled or if they are in long term care, typically long-term care residents get weighed monthly unless there was a weight loss issue and skilled residents not that frequently unless CHF or another comorbidity. He stated he did not know the Dietitian's schedule and would like for all residents to be seen but sometimes that does not happen because some residents stay only 7 or 10 days. He stated the Dietitian reaches out to him if there are weight concerns and sends recommendations and the nurse implements those recommendations. The DON said if the Dietitian sees any kind of weight trigger, then they would go re-weight that patient. He said it could be a data entry error because those do occur. Record review of facility policy titled Nutritional Assessment, revised September 2011, reflected in part: 1. The Dietitian in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (with current initial assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition . Record review of facility policy titled Weight Assessment and Intervention, revised September 2008, reflected in part: 1. The nursing staff will measure resident weights on admission and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter .3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676405 If continuation sheet Page 13 of 21 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 676405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forum Parkway Health & Rehabilitation 2112 Forum Parkway Bedford, TX 76021 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one of ten residents (Resident #55) reviewed for pharmacy services. The facility failed to ensure Resident #55 did not have unsecured medication in her room on 12/18/23 and 12/19/23. This deficient practice could place residents at risk of not being monitored for their medications, adverse reactions, and drug diversion. Findings included: Record review of Resident #55's admission Record dated 12/20/23 reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #55 was not her own responsible party. Resident had diagnoses which included cerebral infarction (stroke), major depressive disorder, bipolar disorder, cognitive communication deficit and need for assistance with personal care. Record review of Resident #55's annual MDS assessment, dated 11/10/23, reflected she had a BIMS of 13 which indicated little to no cognitive impairment. Resident #55 required supervision or touching assistance for eating and oral hygiene, partial/moderate assistance for toileting hygiene, upper body dressing, and personal hygiene, substantial/maximal assistance for shower and lower body dressing and was dependent for putting on/taking off footwear. Record review of Resident #55's Care Plan, last revised on 12/5/23, did not reflect Resident #55 could self-administer her medications and keep medications in her room. Record review of Resident #55's Clinical Physician Orders for 12/18/23-12/19/23 did not reflect an order for nasal spray or any order indicating resident could have medications at bedside. Record review of Resident #55's Clinical Physician Orders for 12/20/2023 reflected the following order Oxymetazoline Hydrochloride 0.05% 2-3 sprays to each nasal q10-12 hrs as needed for nasal congestion. Medication kept at bedside. Pt will administer, family will provide medication. An observation and interview with Resident #55 on 12/18/23 at 10:13 AM revealed Resident #55 was in bed with 2 bottles of nasal spray on her bedside table. Resident #55 stated her son just brought the nasal spray for her that morning. She stated she had to have the nasal spray to open up her nose. An observation and interview with Resident #55 on 12/19/23 at 10:39 AM revealed 2 nasal spray bottles on her bedside table. Resident #55 stated she had been using her nasal spray. In an interview with the ADM on 12/20/23 at 8:52 AM, he stated the DON was the person to speak with concerning if a resident had been assessed to take their own meds since it was a clinical area. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676405 If continuation sheet Page 14 of 21 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 676405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forum Parkway Health & Rehabilitation 2112 Forum Parkway Bedford, TX 76021 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #55's Assessment for Self-Administration of Medications completed on 12/20/23 at 9:49 AM reflected the resident was granted approval to self-administer. This assessment was completed after surveyor intervention. Record review of Resident #55's Progress Note dated 12/20/23 at 9:32 AM reflected, Pt noted to have Afrin nasal spray at bedside pt refuse to give to nursing staff, per Pt medication was brought in by daughter, pt daughter/resp party called and made aware and ask to pick up nasal spray. NP [name] made aware and for request for order for nasal spray. Record review of Resident #55's Progress Note dated 12/20/23 at 9:54 AM reflected Received call back from NP [name] n/o noted and carried out RP made aware. In an interview with the DON on 12/20/23 at 4:31 PM he stated typically the facility would pull medication from bedside and call the family to come pick it up. The DON stated his expectation was for medication to be secured in the facility. The DON stated his preference was that residents did not have medication at bedside, and he stated this issue had been ongoing with Resident # 55. He stated the family would bring the nasal spray and the facility would give it back to them and then they would bring it back again. The DON stated the reason the facility did not pursue a doctor's order for the nasal spray for Resident #55 prior to this date (12/20/23) was that he preferred her not to have the medication at all. He stated he believed it was not safe. DON stated Resident #55 now had an order that she could have the nasal spray in her room. The DON stated it was his expectation that staff paid attention to what was at bedside when they entered the Resident's rooms. The DON stated that the way Resident # 55's new order read, the facility had no ability to monitor the frequency at which she was self-administering. The DON stated Resident # 55 did not allow them to lock her nasal spray at the med cart nor would she allow them to give her a lock box in her room. When asked how the facility would ensure no other residents had access to the nasal spray, the DON stated they would monitor or have a care plan to discuss how this was not a solution. The DON stated he was not involved in the discussion with the doctor when this order was given. He said the nurse called the nurse practitioner and got the order. The DON stated he had never had a situation in the facility where a resident had the opportunity to have an unlocked medication, even if it was an over-the-counter medication. The DON stated he did not know a situation where this could be monitored safely unless they provided 1 to 1 care. When asked about the risk to other residents, the DON stated he did not know the side effects if it was consumed by another resident but with that being said it was still a medication. The DON stated he wanted to have a Care conference with Resident #55's family to discuss appropriateness of the level of care. He stated perhaps an Assisted Living would be more appropriate. The DON stated a fall back to that option would be for the facility to keep the nasal spray locked in the nurse's cart. The DON stated that this was a medication that should be used temporarily, and the resident wanted to use it long term. The DON stated there should be a stop date for the medication. Record review of the facility's policy Self-Administration of Medications, revised December 2016, revealed, 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the unopened medication to the resident when the resident requests them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676405 If continuation sheet Page 15 of 21 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 676405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forum Parkway Health & Rehabilitation 2112 Forum Parkway Bedford, TX 76021 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, interview, and record review, the facility failed to store, distribute and served food in accordance with professional standards for food safety in the facility's only kitchen reviewed for food and nutrition services. The facility failed to dispose of food items 72 hours after opening date in the walk-in refrigerator of the facility's kitchen. These failures affected residents by placing them at risk for contamination and food-borne illness. Findings included: An observation of the walk-in refrigerator on 12/18/23 at 8:35 AM revealed: A pan dated 12/2 with 3 cucumbers open to air and one onion in a zip lock bag. One of the cucumbers was busted open and rotting with juice oozing out of it. A container with left over cranberry sauce was dated 12/2. A Ziploc back with tomato sauce was dated 12/6. In an interview on 12/18/23 at 8:38 AM the Dietary Manager stated they had just opened a new can of cranberry sauce three days prior, but they did not change the date on the container they were storing it in. He stated items were to be thrown out 72 hours after opening. He stated the staff should be updating the dates. The Dietary Manager stated the cucumbers were not as old as 12/2/23. He stated he checked the fridge daily and it was his fault that this was missed. In an interview on 12/28/23 at 8:42 AM the Dietary Manager stated the Zip lock bag with the tomato sauce should have been thrown out since it was dated 12/06. In an interview on 12/18/23 at 9:53 AM the ADM stated the facility did not have a policy that specified that bags were needed to line the trash. In an interview on 12/20/23 at 8:42 AM the ADM stated his expectation was that if the policy was for food to be thrown out after 72 hours that it was the responsibility of the Dietary Manager to ensure that occurred. He stated the risk of having outdated items in the fridge was bacteria getting on other food and running the risk of having mold spread and things like that. The ADM reported it was his expectation that once someone took out the trash, that a liner was placed there immediately. The ADM stated that risk of not lining the trash container was items could get stuck in the trash container and create mold. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676405 If continuation sheet Page 16 of 21 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 676405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forum Parkway Health & Rehabilitation 2112 Forum Parkway Bedford, TX 76021 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 Review of the facility's policy, Food Preparation and Service, revised July 2014, revealed, Food service employees shall prepare and serve food in a manner that complies with safe food handling practices .Food served once may not be served again. This policy did not have specifics on dating and labeling. Residents Affected - Some Review of the Food and Drug Administration Food Code, dated 2022, reflected: 3-501.16(A)(2) and (B) Time/Temperature Control for Safety Food, Hot and Cold Holding (P) 23. Proper date marking and disposition FDA Food Code 2022 Annex 7: Model Forms, Guides, and Other Aids Annex 7 -38 IN/OUT This item should be marked IN or OUT of compliance. This item would be IN compliance when there is a system in place for date marking all foods that are required to be date marked and is verified through observation. If date marking applies to the establishment, the PIC should be asked to describe the methods used to identify product shelf-life or consume-by dating. The regulatory authority must be aware of food products that are listed as exempt from date marking. For disposition, mark IN when foods are all within date marked time limits or food is observed being discarded within date marked time limits or OUT of compliance, such as when date marked food exceeds the time limit or date-marking is not done. N.A. This item may be marked N.A. when there is no ready-to-eat, TCS food prepared on-premise and held, or commercial containers of ready-to-eat, TCS food opened and held, over 24 hours in the establishment. N.O. This item may be marked N.O. when the establishment does handle foods requiring date marking, but there are no foods requiring date marking in the facility at the time of inspection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676405 If continuation sheet Page 17 of 21 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 676405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forum Parkway Health & Rehabilitation 2112 Forum Parkway Bedford, TX 76021 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 on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 4 (Residents #10, #47, #94, #355) of 8 residents reviewed for infection control. Residents Affected - Some 1. Facility failed to ensure the Dietary Manager wore proper Personal Protective Equipment (PPE) (gown, face shield, gloves, and N-95/KN95 respirator mask) before entering Resident #94 and Resident # 355's room that was on Transmission Based Precaution (isolation due to communicable infectious disease). 2. Facility failed to ensure LVN A, and CNA I wore proper Personal Protective Equipment (PPE) face shield while providing care in Resident's #10, #47, #48, #61 Transmission based precaution isolation (isolation due to communicable infectious disease) rooms. 3. Facility failed to ensure that MA G, and LVN J wore N-95/KN95 respirator mask with top strap over the crown of head and the bottom strap at the back of the neck for required mask seal for Transmission Based Precautions. These failures could place residents and staff at risk of transmission of communicable infectious diseases. Findings Included: Resident # 10 Review of Resident #10's admission Record dated 12/20/23 revealed, an [AGE] year-old female admitted to facility 11/18/16 with diagnoses of unspecified dementia moderate without other behavioral disturbance, Parkinson's disease (tremors, shaky motions), lack of coordination, generalized muscle weakness, need for assistance with personal care, difficulty swallowing, difficulty communication, and diabetes type 2 without complications. Review of Resident # 10's MDS assessment, dated 11/25/23, revealed, Brief Interview for mental Status (BIMS) score 99, indicating the resident was unable to complete the interview. Her functional status indicated that she was a partial/moderate assistant with eating and substantial/maximal assistance with activities of daily living (ADLs (Activities of Daily Living)). Review of Resident #10's orders dated 12/20/23, revealed on Contact and Droplet isolation precautions related to contagious coronavirus diseases caused by SARS-CoV-2 (COVID-19) positive status from 12/12/23 to 12/23/23 every shift for 11 days (about 1 and a half weeks). Resident # 47 Review of Resident #47's admission Record dated 12/20/23, revealed a [AGE] year-old female admitted to facility on 09/26/23 with diagnoses of fracture of shaft of right tibia, chronic obstructive pulmonary disease, unspecified (COPD), Acute and chronic respiratory failure lack of oxygen (hypoxia), stroke, age related osteoporosis without current pathological fractures, bone density and structure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676405 If continuation sheet Page 18 of 21 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 676405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forum Parkway Health & Rehabilitation 2112 Forum Parkway Bedford, TX 76021 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 disorder. Level of Harm - Minimal harm or potential for actual harm Review of Resident #47 orders dated 12/20/23, revealed on Contact and Droplet isolation precautions related to COVID-19 positive status from 12/12/23 to 12/23/23 every shift for 11 days (about 1 and a half weeks). Residents Affected - Some Resident #48 Record review of Resident #48's admission Record dated 12/20/23 reflected an [AGE] year-old female who was admitted on [DATE]. Resident #48 had diagnoses which included dementia, covid-19 (with onset date of 12/12/23), and weakness. Record review of Resident #48's Clinical Physician Orders dated 12/20/23 reflected she had an order for, Contact and Droplet Isolation Precautions for prophylactic measures due to recent COVID-19 tested positive. Start date of this order was 12/13/23 with an end date of 12/23/23. Resident #61 Record review of Resident #61's admission Record dated 12/20/23 reflected an [AGE] year-old female who was admitted on [DATE]. Resident #61 had diagnoses which included dementia, covid-19 (with onset date of 12/12/23) and generalized muscle weakness. Record review of Resident #61's Clinical Physician Orders dated 12/20/23 reflected she had an order for, Contact and Droplet Isolation Precautions for prophylactic measures due to recent COVID-19 tested positive. Start date of this order was 12/13/23 and an end date of 12/23/23. Resident #94 Review of Resident #94's admission Record dated 12/20/23, revealed an [AGE] year-old male, admitted to facility on 11/06/23 with diagnoses of urinary tract infection, acute kidney failure, type 2 diabetes mellitus without complications, Heart irregular rhythm (Atypical atrial flutter), weakness, unspecified lack of coordination and contagious coronavirus diseases caused by SARS-CoV-2 (COVID-19). Resident #355 Review of resident # 355 admission Recorded dated 12/19/23, reflected he was an [AGE] year-old man admitted to facility 12/07/23 with diagnoses of chronic obstructive pulmonary disease with (acute) exacerbation, type 2 diabetes mellitus with diabetic chronic kidney disease, type 2 diabetes mellitus with hyperglycemia, type 2 diabetes mellitus with diabetic neuropathy, unspecified, adult failure to thrive, and contagious coronavirus diseases caused by SARS-CoV-2 (COVID-19). Observation and interview on 12/18/23 at 12:34 PM, CNA I entered a Contact and Droplet isolation rooms with two COVID-19 positive residents, Resident #10 and Resident #47 wearing a yellow gown, 1 pair of gloves, an N-95 respirator mask, and eyeglasses. It was recommended that a face shield was worn to protect the eyes as well as the front and sides of the face. Resident #10 was asleep, and Resident #47 was eating her lunch in her bed. CNA I stood on the left side of Resident #10 and woke her to eat. He stood beside her and fed her a few spoonful and then Resident #10 refused to eat. CNA I covered Resident #10 back up and took off his gown, and gloves and took the tray out of the room. He performed hand hygiene with hand sanitizer upon exit. CNA I said that he did not wear the face shield (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676405 If continuation sheet Page 19 of 21 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 676405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forum Parkway Health & Rehabilitation 2112 Forum Parkway Bedford, TX 76021 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 because he did not see it. When he was told to open the PPE cart drawer, it revealed numerous full-face shields in it outside the isolation room. CNA I said that he had been trained and in-service about the proper PPE to use for COVID-19 isolation rooms. He said that the infection control preventionist trained him to carry the tray from the isolation room without any gloves on. He said that she told him not to wear gloves in the hallway. CNA I said he risked himself and other residents with infection. He said the best way to prevent the spread of COVID-19 infection was to wear the proper PPE; gown, gloves, face shield and N-95 mask. Observation on 12/18/23 at 1:07 PM revealed LVN A donned PPE and entered the shared room of Resident#61 and Resident#48 with medication in a cup and a cup of water. LVN A had an N95, a gown, and gloves on to enter the room. He was not wearing a face shield. LVN A doffed PPE inside the room prior to exit and performed hand hygiene with hand sanitizer. The donning station that was right outside of the room had all required PPE available including the face shield. In an interview on 12/18/23 at 1:08 PM LVN A stated he just gave Resident #61 her tramadol. He stated Resident #61 was coughing while he was inside her room. He stated he was supposed to wear N95 mask, gown and gloves to enter the room. LVN A stated he forgot to use his face shield. LVN A stated the use of the face shield was important to prevent droplets from contaminating like when Resident #61 coughed. Observation on 12/18/23 at 02:30 PM, revealed the Dietary Manager entered a Contact and Droplet isolation room with two COVID-19 positive residents, Resident #94 and Resident #355 wearing an incorrect fitting KN95 mask. After seeing the surveyor in the room wearing PPE, the Dietary Manger went back into open doorway and put on a non-fitting small gown, a KN95 mask that barely covered his nose and mouth, and walked into the room while trying to put on a clear glove on his left hand and no glove on right hand as he walked inside the resident's room. He looked at the surveyor and said, I did not see the sign on the door. Two signs on door to Residents #94 & #355 room, first sign in orange color read Contact Precautions: perform hand hygiene before entering and before leaving room, wear gloves when entering room or cubicle and when touching patients' intact skin, surfaces, or articles in close proximity, wear gown when entering room . Second sign in black and white size paper read STOP Droplet Precautions, everyone must: clean their hands, including before and when leaving the room, make sure their eyes, nose and mouth are fully covered before room entry, remove face protection before room exit. Interview with the Dietary Manager on 12/20/23 at 01:31 PM, revealed he was told that Resident #355 wanted to talk with him about food preference and he just picked up the mask close to door in the kitchen. He said that he had done a fit mask test at his former company for the correct size of mask for him to wear. He said he did not know how to perform a seal test to test if the mask sealed well. He said that everyone in dietary had been in-serviced on PPE use. He said he was aware that the facility required all staff to wear a respirator mask. He said the risk of wearing improper PPE was spreading infection. Observation and interview on 12/19/23 at 09:25 AM, LVN J wore N-95 respirator mask with top and bottom straps in her neck. It was required per Center for Diseases (CDC (Centers for Disease Control)) and per manufacture 3M instructions that top strap on N-95/KN95 mask go over the crown of head and the bottom strap at the back of the neck for a tight seal for Transmission Based Precautions. LVN J said that she had been in-serviced at hire by the ADON and DON, and received ongoing training with infection control preventionist as the COVID-19 cases increase about the correct way to wear an N-95 mask and use of PPE. She said the risk of not wearing PPE correctly was the spread of infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676405 If continuation sheet Page 20 of 21 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 676405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forum Parkway Health & Rehabilitation 2112 Forum Parkway Bedford, TX 76021 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 Observation and interview on 12/19/23 at 02:10 PM, revealed MA G wearing a loose fitted KN95 mask. MA G kept touching the [NAME] to push it in up towards her nose. Both top and bottom yellow straps to mask were observed behind her neck. MA G said that she had not been trained or in-serviced on how to wear the KN95 mask. She said she pushed and touched her mask often to cover her nose because it kept falling off her face. MA G looked at how surveyor had her mask on and adjusted her own and she responded, it fits better now and is not falling off. She said the risk of wearing improper non-fitting KN95 respirator mask was spreading infection to herself, to residents and coworkers. Interview with the Infection Control Preventionist on 12/18/23 at 01:02 PM revealed that all staff were in-serviced on PPE use, mask, hand washing since first COVID-19 case 11/25/23 and on 12/7/23. She said that all direct care staff members were required to wear N-95 or KN95, gown, gloves, and face shield or googles. She said since more residents were in isolation for COVID-19 all staff were required to wear N-95 or KN95 while in the facility. She said that all staff members are being tested 2 times a week on Mondays and Thursdays and residents are tested on Tuesday and Fridays or depending on signs and symptoms. She said that last week she in-serviced staff on taking off PPE inside the rooms putting PPE in trash bags, taking bags to biohazard room and hand washing. She said that she has not trained staff to barehand carry out trays from isolation rooms. She said she expects all direct staff to wear face shields and other PPE. She said the risk of not following transmission base precaution is spread of infection. She expected all staff to practice standard hand hygiene practices of hand washing with soap and water and using alcohol-based hand rub and wearing their PPE per requirements. Interview with the DON on 12/19/23 at 03:32 PM, revealed that infection control preventionist completed all PPE training and infection tracking. He said all departments were in-serviced on the use of PPE, cross contamination, risk of infection, hand washing. He said every shift was monitored for PPE use. He expected all staff to practice standard hand hygiene practices of hand washing with soap and water and using alcohol-based hand rub and wearing their PPE. He said the risk of not following transmission base precaution was spread of infection. Review of policy Policies and Practices-Infection Control, revised July 2014 revealed the following: .all personnel will be trained on our infection control policies and practices upon hire and periodically thereafter . Review of policy COVID-19 Policy, revised on May 11, 2023, revealed the following: . NIOSH approved particulate respirators with N95 filters or higher will be used .facilities with higher levels of SARS-CoV-2 transmission may consider implementing universal use of NIOSH approved particulate respirators with n95 filters or higher for HCP during all patient care encounters or in specific units or areas of facility at higher risk of SARS-CoV-2 Eye protection (i.e., googles or face shield that covers the front and sides of face) worn during all patient care encounters .HCP who enter the room of patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precaution and use a NISOH approved particulate respirator with N95 filter or higher, gown, gloves, and eye protection . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676405 If continuation sheet Page 21 of 21