Inspection·July 29, 2025

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few progress notes, dated 07/26/25 at 04:29 PM by RN B, reflected the following: Patient noted alert with episodes of confusion. x 1 Persian assisted with Adls, transfer and mobility. Incontinent of bowel and bladder. Uses wheelchair for ambulation. No pork, no beef. Record Review of Resident #1's progress notes, dated 07/27/25 at 02:49 PM by RN B, reflected the following: AAO X2, Incontinent of bowel and bladder, x1 person assist with Adls, transfer and mobility. Resident #1's family members reported to writer @ 1:55 p.m. that she feels patient passed out. assessment done by writer, resident understood verbal commands, vitals BP 124/61, 97.2, 64, 16, 96%, bs 139. patient is stable at this time, no dizziness noted. Upon assessment, patient family member stated that Resident #1 is having pains in her head, and stomach. writer administer prn Tylenol and Zofran. No distress noted. Record Review of Resident #1's progress notes, dated 07/28/25 at 02:20 PM by RN A, reflected the following: Pt's family member placed Call light and when this nurse reached to the room to see the pt., the family member was C/O of the pt. is not eating and her BP also low. This nurse monitored BP and found 121/57 HR:55 and the c/o lower Diastolic pressure but this nurse educated well to the family member but still wanted to call EMS and the EMS came in and monitored V/S and was stable. As per family's request pt. was taken to the hospital. An interview on 07/29/25 at 07:26 AM was attempted with Resident #1's RP but there was no answer. The operator stated the mailbox of Resident #1's RP was full and could not accept messages at the time. A text message on 07/29/25 at 07:28 AM was sent to Resident #'1's RP with no response. In an interview on 07/29/25 at 08:28 AM, the Administrator stated he was not at the facility with the issue of Resident #1 eating a hotdog. He stated he was told by his staff that Resident #1's RP complained that the resident had an upset stomach and had vomited. The Administrator stated his staff assessed Resident #1 and the resident's vitals were stable. He stated Resident #1's RP wanted staff to send the resident to the hospital after she was assessed by staff with stable vitals. He also stated his staff informed Resident #1's RP the hospital would not do anything different than the facility. He stated Resident #1 called 911 and EMTs were called out. He stated the EMTs had spoken with Resident #1's RP and did not deem it necessary for the resident to go to the hospital because the resident's vitals were good. He stated risks if the wrong food was received included choking and allergic reaction. In an interview on 07/29/25 at 08:36 AM, the DON stated he was DON at the facility for almost four years. He stated he was not at the facility when Resident #1 went to the hospital. The DON stated his charge nurse, RN A was at the facility at the time of the incident. He stated, Resident #1's RP was concerned the resident was not eating and wanted her to be sent to the hospital. He stated Resident #1 was assessed and her vitals were stable so, the facility did not deem it necessary for Resident #1 to be sent to the hospital. He stated that the Resident #1's RP did not agree, and she called 911. The DON stated he was told the EMTs spoke with the resident's RP and told her there were no critical issues for Resident #1 to go to the hospital, but she insisted. The DON stated Resident #1 went to the hospital and the facility had not received an update. The DON stated Resident #1 was being discharged and then the alleged sickness came about. He stated he felt that the family was not ready to care for the resident. The DON stated resident eating incorrect food risked the possibility of choking, not being able to swallow, or allergic reaction. In an interview on 07/29/25 at 08:55 AM, RN A stated she was the charge nurse for the 100 hall. RN A stated she worked Monday-Friday from 6:00 AM-2:00 PM. RN A stated she worked with Resident #1 on 07/25/25 and there were no concerns. RN A stated when she returned to work on 07/28/25 she was informed Resident #1 had eaten pork on Friday, 07/25/25 and got sick. RN A stated all nurses were responsible for checking residents' trays. RN A stated on 07/28/25 she worked with the resident and Resident #1 refused her breakfast. RN A also stated she was informed by Resident #1's RP that Resident #1 was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676405 If continuation sheet Page 2 of 6 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 07/29/2025 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few eating, and her blood pressure was low. RN A stated that she then checked Resident #1's blood pressure and it read at 121/57 and communicated to Resident #1's RP the low number for diastolic was normal for Resident #1. RN A stated that the RP then insisted that Resident #1 went to the hospital. RN A stated she assessed Resident #1 and did not have any clinical concerns at that time. She also stated she did not deem it necessary for Resident #1 to be transported to the hospital and told Resident #1's RP to call 911. RN A stated Resident #1's RP called 911 and the EMTs came out. She stated that Resident #1's RP spoke to the EMTs and the EMTs told the RP Resident #1's vitals were good. RN A stated although Resident #1's vitals were good, RP still insisted on the resident going to the hospital and resident was transported. RN A stated she was responsible to look at food trays and meal tickets before residents received the food. RN A stated the risks from resident eating the wrong food were choking hazard or allergic reaction. In an interview on 07/29/25 at 11:00 AM, RN B stated she worked doubles on the weekends and worked with Resident #1 on 07/26/25 and 07/27/25. RN B stated Resident #1 could not talk and was unable to express her needs. RN B stated on 7/26/25, Resident #1's RP reported to her that the resident had been nauseous, not eating, in pain and needed some medication. RN B stated Resident #1's RP had concerns that the resident was not well because she ate pork hotdog and vomited. RN B stated Resident #1 had not vomited during her day shift on 07/25/25, but the night nurse gave her report the next day that Resident #1 had vomited during the evening of 7/25/25. RN B stated she assessed Resident #1 and could tell that she did not feel. RN B stated she determine Resident #1 head hurt based on her facial expression of not smiling, resident's hand on her head, resident's eyes were closed, and she pulled away when RN B tried to grab her hand. RN B stated she touched Resident #1's stomach, and it was not hard, but soft. RN B stated she administered Resident #1 a Tylenol (for pain) and Zofran (for nausea). She stated Resident #1 seemed to feel better afterward, and she was able to eat a few bites of a salad. RN B did not report any concerns for Resident #1 on 7/27/25. RN B stated the staff were aware of residents on special diets based on a meal sheet. She also stated nurses were responsible to check the meal trays and meal sheet before residents were served. RN B stated Resident #1's RP was always by the resident's bedside and would check the resident's food. She stated she did not know how Resident #1 ate a pork hotdog if the RP fed her. RN B also stated one time RP had mistaken a turkey sandwich for beef sandwich, but it was turkey. RN B stated she had not observed Resident #1 eating pork or beef. RN B stated per the facility's policy, it was the nurses' responsibility to check the food trays before the meals were distributed to the residents. In an interview on 07/29/25 at 12:47 PM, the Dietary Manager stated she was employed at the facility for one year. The Dietary Manager stated she worked on 07/25/25 but was not at work for dinnertime. The Dietary Manager stated dinner on 07/25/25 was hot dogs. She stated she received a report that Resident #1 was served a hotdog, had eaten it, and was sick from eating a pork hotdog. The Dietary Manager stated Resident #1's RP did not like the resident eating bread, so she did not understand the RP feeding the resident the hot dog. The Dietary Manager also stated she knew Resident #1 was not supposed to consume pork, and she ensured she had that information with no pork or beef on the meal ticket. The Dietary Manager stated if a resident had dietary restrictions, she made sure it was on the meal ticket and put it in her computer. She stated she did not know how three different staff checked Resident #1's tray and the resident still ended up being served a pork hotdog. She stated after the incident, she ensured her staff took pictures of Resident #1 food tray before the food left the kitchen. The Dietary Manager stated she did not know how Resident #2 received beef tacos on 07/29/25. She stated Resident #2 was supposed to get chicken tacos. She also stated she thought maybe the mistake happened when her food server mixed Resident #2 and another resident's trays. The Dietary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676405 If continuation sheet Page 3 of 6 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 07/29/2025 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Manager stated the cook and server was supposed the check the meal ticket and tray before leaving the kitchen, then the nurse checked before it was delivered. She stated there were supposed to be at least three staff that checked before the resident received the tray. She stated the risks of eating the wrong meal preference was allergic reaction or choking. An email on 07/29/25 at 01:57 PM was sent to Resident #1's RP with no response prior to exit. In an interview on 07/29/25 at 02:19 PM, CNA D stated she was employed at the facility for over seven years. She stated she worked 02:00 PM-10:00 PM on 07/25/25 and worked the 100 hall although she usually worked the long-term hall. She stated this was her first time working the hall. She also stated she had worked with Resident #1 during her shift and was the person with a new employee that delivered Resident #1's food tray. CNA D also stated she remembered dinner was a sausage that appeared to be a pork hotdog. CNA D stated once Resident #1's food tray was delivered, the RP grabbed the hotdog sausage, tasted it, and told staff it was pork. CNA D stated staff asked Resident #1's RP if they could get the resident something else to eat and was told no by the Resident's RP. CNA D stated instead Resident #1's RP told them to bring her to the kitchen. CNA D stated they went to the kitchen and was given two plates of salad. She stated Resident #1 ate the salad. CNA D stated the risk of resident eating the wrong food was an allergic reaction or resident choking. In an interview on 07/29/25 at 02:41 PM, LVN E stated she was employed at the facility for almost eight years. She stated she had been working as the admissions nurse. LVN E stated she did Resident #'s admission and the resident did not have a clinical allergy to pork, it was her preference to not eat it. LVN E stated that she had worked the 2:00 PM-10:00 PM shift on 07/25/25. LVN E stated dinner on 07/25/25 was hotdogs, beans, and coleslaw. She also stated she wrote on Resident #1's meal ticket no pork. LVN E stated while she was at room [ROOM NUMBER], Resident #1's tray was delivered, and the RP stopped staff at the door and checked the tray. LVN E also stated after Resident #1's RP touched the food and noticed it was a hotdog, she told them to bring her to the kitchen. LVN E stated she ensured to write that Resident #1 could not eat pork, but the kitchen had given them problems. She stated it was protocol for nurses to check the tray before they gave to the resident. She stated the resident risked an allergic reason or choking. In an interview on 07/31/25 at 04:01 PM, Resident #1's RP stated the facility was informed of Resident #1 pork allergy when Resident #1 was admitted to the facility on [DATE]. Resident #1's RP stated the facility was also reminded of the resident's pork allergy on the second day. The RP stated on 07/25/25 while the RP was in the restroom one of the facility staff dropped of Resident #1's food tray and it was opened. The RP stated she had immediately picked up the food and figured it was a hotdog. Resident #1's RP stated after they sniffed the food it smelled like a pork hotdog. The RP stated they immediately left the resident's room to get staff. The RP also stated they had staff escort them to the kitchen to get some other food. The RP stated someone in the kitchen asked what could be done about the mistake. The RP also stated the kitchen staff then gave them chicken, salad, and coleslaw for Resident #1. The RP also stated when they returned to the room, there was about two bites from the hotdog that Resident #1 ate. The RP stated at that time, they did not think much of the small piece eaten by Resident #1. Resident #1's RP stated a little while later, Resident #1 head and stomach hurt. Resident #1's RP stated after a few hours, Resident #1 vomited. The RP stated Resident #1 felt bad on 07/28/25, so the RP called 911. The RP stated that EMS went to the facility and Resident #1's RP informed the EMTs Resident #1 was not eating and vomited. The RP stated the EMTs took Resident #1's vitals and informed them the vitals were good. Resident #1's RP stated the EMTs understood the concern and left the choice to the RP to transport Resident #1. Resident #1's RP stated the resident was transported to the hospital. Resident #1's RP stated the resident was admitted and discharged on 07/28/25. The RP (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676405 If continuation sheet Page 4 of 6 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 07/29/2025 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few also stated Resident #1 did not return to the facility and was at home. Record review of Resident #2's face sheet, dated 07/29/25, reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. Resident #2's diagnoses included Pulmonary Embolism (blood clots), Dysphagia (difficulty swallowing), Type 2 Diabetes Mellitus (body does not produce enough insulin (help regulate blood sugar levels) leading to high blood sugar levels), Hyperlipidemia (high levels of fats in blood), Hypertension (force of blood pushing against artery walls consistently too high), Atherosclerotic Heart Disease (buildup of fats, cholesterol in the artery walls), Cardiomyopathy (heart muscle that makes it harder for heart to pump blood), Congestive Heart Failure (heart unable to pump enough blood for the body's needs), Sequelae of Cerebral Infarction (stroke), Peripheral Vascular Disease (circulation disorder that affects vessels outside of brain and heart), Acute Respiratory Failure with Hypoxia (lungs are unable to supply the blood and maintain normal carbon dioxide levels), Muscle Weakness (reduced ability of muscles to give force), Obstructive and Reflux Uropathy (blockage of urine flow), Chronic Kidney Disease (kidneys cannot filter blood effectively), Benign Prostatic Hyperplasia (enlarged prostate (gland in male reproductive system) that causes lower urinary tract symptoms in men), Lack of Coordination (muscles not moving smoothly), Cognitive Communication Deficit (difficulty communicating), Transient Ischemic Attack (temporary disruption of blood flow to the brain). Record review of Resident #2's MDS, dated [DATE], reflected BIMS score of 03, which indicated severe cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #2 was dependent on staff for most ADLs, and required setup assistance with eating. The MDS Assessment under Section K-Swallowing/Nutritional Status, reflected Resident #2 had difficulty or pain with swallowing. Further review of the section reflected Resident #2 was on a mechanically altered diet. Record review of Resident #2's care plan, dated 07/02/25, reflected the resident's allergies were pork and red meat. In an interview on 07/29/25 at 07:56 AM, Resident #2 stated that he had cereal and toast for breakfast. Resident #2 stated that he did not eat beef or pork. He stated he had never eaten any beef or pork at the facility. He also stated that the facility had not ever mistakenly given him any beef or pork. Resident #2 stated he had no concerns. An observation on 07/29/25 at 08:14 AM, reflected the printed lunch menu. The menu consisted of beef soft tacos with flour tortilla, lettuce, tomato, and cheese, Mexican corn, peppers and onion. The dessert was fresh pineapple. The alternate lunch consisted of garlic pork chop, parsley carrots, and mashed potatoes. An interview on 07/29/25 at 11:23 AM was attempted with RN F but there was no answer. A message was left on RN F's voicemail. An observation on 07/29/25 at 12:10 PM, reflected Resident #2's food tray and meal ticket for lunch. Resident #2's printed meal ticket had dietary restrictions of no added salt, no pork, and no beef with pork as an allergy. Resident #2's meal ticket stated Resident #2 had ground baked chicken breast, poultry gravy, sauteed peppers and onions, cream style corn, dinner roll/bread, margarine, ground pineapple tidbits, and tea of choice. Resident #2's food tray was observed with two soft tortilla tacos with only ground beef. Resident #2's food tray also was observed with green and red sauteed peppers on the side of the tacos and creamed corn on the side in a bowl. Resident #2's tray also consisted of tea and pineapples in a cup. In an interview on 07/29/25 at 12:24 PM, CNA C, stated she was employed at the facility for almost two years. She stated that she was the Restorative Aide but on 07/29/25 she worked as the CNA. She also stated she worked as the CNA for Resident #2 on 07/29/25. CNA C stated she was not aware she had delivered Resident #2 beef tacos because she had not checked the tray. She stated she assumed another staff already checked Resident #2's tray. She also stated protocol was a nurse checked all residents food trays before any nursing staff delivered it to the resident. She stated it was her fault to assume the tray had already been checked. CNA C stated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676405 If continuation sheet Page 5 of 6 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 07/29/2025 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the risk of resident eating restricted food was possible allergic reaction or choking. In a follow-up interview on 07/29/25, the Administrator stated he was made aware by staff that Resident #2 received beef tacos for lunch. He stated he was not sure how his staff gave the incorrect food to Resident #1 and Resident #2. He also stated there would be more in-service training with his staff for the food issues. Review of the facility's policy, revised July 2017, titled Resident Nutrition Services reflected in part the following: Policy Statement: Each resident is provided with nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.Policy Interpretation and Implementation:4. Nursing personnel or feeding assistants will inspect food trays as they are delivered to ensure that the correct meal has been delivered, that the food appears palatable and attractive, and it is served at a safe and appetizing temperature.a. If an incorrect meal has been delivered, or a meal does not appear palatable, nursing staff will report it to the Food Service Manager so that a new food tray can be issued.b. Foods that are left without a source of heat (for hot foods) or refrigeration (for cold foods) longer than 2 hours will be discarded. Event ID: Facility ID: 676405 If continuation sheet Page 6 of 6