Health inspection·April 20, 2023

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her the cell phone back. He was concerned about her well-being because the facility was preventing Resident #30 from having contact with him and other family members. Interview on 04/19/2023 at 2:15 PM with Resident #30 revealed she was in a relationship with a former resident who was not good for her. Resident #30 stated he continued to contact her on her personal cell phone after he discharged from the facility, so to end the relationship she asked the Social Worker to hold her cell phone for a while. Resident #30 stated the Social Worker told her that he would also order her a new Medicaid phone so that she would have a different number and not have to receive unwanted calls anymore. Resident #30 stated that was two months ago, and she still had not received the new cell phone. She stated she asked for her old cell phone back after waiting for about a month, and the Social Worker told her it had been disconnected and did not return it. Resident #30 stated she was still waiting to receive a cell phone and had not received any follow-up from the Social Worker. She stated she was frustrated about not having a cell phone because it was hard to contact her family when she wanted. Interview on 04/19/23 at 2:46 PM with the Social Worker revealed Resident #30 was known to lose valuable items such as her cell phone, dentures, and eyeglasses. The Social Worker stated it was common for Resident #30 to consent to him (Social Worker) holding items for her (Resident #30). He stated she (Resident #30) had asked him to hold her cell phone not only to keep her from losing it but also because she was receiving calls from a former resident who she had been in a relationship, which was affecting her mental health. The Social Worker stated he felt it was in Resident #30's best interest to not have any contact with her ex-boyfriend/former resident. The Social Worker stated the cell phone was eventually disconnected, and he agreed to order Resident #30 a Medicaid cell phone. The Social Worker recalled Resident #30 asking about getting her cell phone back, and he told her that it was no longer working and that she had a new phone coming. The Social Worker stated Resident #30 was fine with waiting for her new cell phone, and he was unaware she was upset about not getting her old cell phone back since it was not working. The Social Worker agreed that it was Resident #30's property and that she should have been able to get it back when she asked for it, even if it was not working. Interview on 04/19/23 at 4:12 PM with the Administrator revealed she had only been at the facility for about a month and was not completely aware of the situation regarding Resident #30's personal cell phone. The Administrator stated it was against policy and residents' rights to hold on to their personal property without consent; however, it was her understanding that Resident #30 had given the Social Worker consent to hold the cell phone for her. The administrator denied knowing that Resident #30 had asked for her cell phone back and if she had done so, the Social Worker should have given it back. The Administrator stated the Social Worker spoke with Resident #30 on this date (04/19/23) and she denied wanting the cell phone back. Interview on 04/19/23 at 4:45 PM with Resident #30 revealed she no longer wanted the cell phone back. She stated the Social Worker and another staff member had come into her room questioning her about it, and she decided to just wait for the new phone to come. Record review of the facility's policy titled, Resident Rights-Personal Property, revised August 2020, revealed in part the following: Purpose: To ensure the quality of life of all residents by allowing residents to create a home-like environment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 2 of 19 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 455457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Worth Wellness & Rehabilitation 2129 Skyline Dr Fort Worth, TX 76114 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 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Policy: Residents are permitted to retain personal property (e.g., personal possessions and clothing) at the facility, as space permits. Procedure: .The facility promptly investigates any complaint of misappropriation, theft or mistreatment of resident property Event ID: Facility ID: 455457 If continuation sheet Page 3 of 19 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 455457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Worth Wellness & Rehabilitation 2129 Skyline Dr Fort Worth, TX 76114 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 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to provide a private meeting space for residents' monthly council meetings for 14 of 14 reviewed for resident council. Residents Affected - Some The facility failed to provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy. Findings included: Observation and interview on 04/19/23 beginning at 2:00 PM, during a confidential resident group meeting with 14 residents, revealed the meeting was held in an open dining room, near the facility's central nurses' station. There were no doors that could be closed to ensure the residents' privacy during the meeting. Staff were observed walking through the area while the meeting was in progress. During the confidential group meeting, all fourteen residents revealed they always met in the open dining room area, and sometimes in a different area of the open dining area that was even closer to the nurses' station. Three residents stated residents were uncomfortable expressing their concerns because they were afraid that staff would overhear and that would only make matters worse. The residents denied expressing their concern about the location to anyone because they did not feel it would do any good. Interview on 04/19/23 at 3:45 PM with the Administrator revealed he had worked at the facility for about a month and during that time resident council had always met in the open dining room. She stated the meetings should be held in a private space to ensure residents were able to voice any concerns without fear of staff hearing them. Interview on 04/20/23 at 3:38 PM with the Activity Director revealed the last three resident council meetings were held in the open dining room. She stated she had worked at the facility for a year and during that time most resident council meetings were held in the open dining room area. She stated she would rope off the area to alert staff not to enter, and all staff knew what the rope meant. She stated the meeting had been held in the rehabilitation office a few times when the dining room was being occupied. The Activity Director stated the resident council meetings were not normally held in the rehabilitation office because it was often used but moving forward, she would coordinate with the therapists to reserve a time for the meetings to be held there. She stated based on her previous experience, she knew that the residents had a right to hold meetings in a private area, but she had been told that the facility did not have a large enough private space. She denied that any residents had ever complained to her about having the meetings in the open dining area. The Activity Director stated the risk of holding resident council meetings in an open area was that the residents would not express their concerns out of fear of being overheard by staff which might lead to retaliation. Record review of the resident council minutes for January 2023, February 2023, and March 2023 revealed no requests for a private area. Record review of the facility's current, undated policy titled Resident Council revealed in part the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 4 of 19 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 455457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Worth Wellness & Rehabilitation 2129 Skyline Dr Fort Worth, TX 76114 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 0565 Purpose: To promote the exercise of a resident's right to organize and participate in resident groups at the facility. Level of Harm - Minimal harm or potential for actual harm Policy: Residents Affected - Some .The facility must provide a resident council with a private space to meet FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 5 of 19 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 455457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Worth Wellness & Rehabilitation 2129 Skyline Dr Fort Worth, TX 76114 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 observations, interviews, and record reviews, the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for three (Residents #40, #55, and #58) of 24 residents reviewed for hygiene. Residents Affected - Some The facility failed to bathe and groom Residents #40, #55, and #58 on a consistent basis. This failure placed all residents at risk of discomfort and developing skin breakdown. Findings included: Review of Resident #40's admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included respiratory failure requiring the placement of a tracheostomy, brain damage from loss of oxygen, reduced mobility, contractures, and heart failure. Review of Resident #40's quarterly MDS, dated [DATE], revealed a BIMS score was not performed based on the resident's medical conditions. Her Functional Status indicated she was completely reliant on staff for all of her ADLs. Review of Resident #40's care plan, dated 09/28/22, revealed she was at risk for oral and dental health problems, skin breakdown related to immobility, and an ADL self-care deficit related to Alzheimer's disease. Review of Resident #55's admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included morbid obesity, cauda equina syndrome (dysfunction of sacral and lumbar nerves), bladder dysfunction, and paraplegia (paralysis of lower body). Review of Resident #55's quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated she was cognitively intact. Her Functional Status indicated she was completely reliant on staff for all of her ADLs. Review of Resident #55's care plan, dated 02/16/23, revealed she was at risk for oral and dental health problems, skin breakdown related to immobility, and an ADL self-care deficit related to disease process-infection. The care plan also revealed that Resident #55 had a behavior of refusing ADL care with interventions for staff to assist her with developing more appropriate methods of coping and interacting. Review of Resident #58's admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included unspecified hemiplegia (paralysis on one side), Type 2 diabetes, obesity, recurrent depressive disorder (mood disorder), heart failure, need for assistance with personal care. Review of Resident #58's quarterly MDS, dated [DATE], revealed a BIMS score of 12, which indicated moderately impaired cognition. Her Functional Status indicated she was completely reliant on staff for all of her ADLs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 6 of 19 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 455457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Worth Wellness & Rehabilitation 2129 Skyline Dr Fort Worth, TX 76114 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 Review of Resident #58's care plan, undated, revealed she had an ADL self-care deficit related to stroke, left hemiplegia, weakness, impaired mobility, and impaired cognition with interventions that resident required at least one staff for assistance with ADLs, including personal hygiene. Observation on 04/18/23 at 11:38 AM Resident #40 was in bed, positioned on her back. The resident was non-responsive to questions. The skin on Resident #40's arms and legs was flaky. Resident #40's hair on the front of her scalp appeared to have been combed, the hair on the back of her head appeared to be severely matted. Observation on 04/19/23 at 9:27 AM, Resident #40 is positioned on her back, appearance was unchanged from previous observation. Observation on 04/20/23 at 9:33 AM of skin assessment, performed by Wound Care Nurse, revealed flaky skin on resident's feet as well as her arms and legs. Resident's hair to the back of her head is very matted. The resident had healed sores to her buttocks and coccyx. Observation and interview on 04/18/23 at 11:12 AM with Resident #55 revealed she was lying awake in bed with visible scratches to left hand. Resident #55's hair was oily and disheveled and there was a strong, sour odor coming from her body. Resident #55 stated she only got a shower about every 2-3 weeks due to her larger size. She stated staff did not like to deal with her in a shower, so they would offer more bed baths. Resident #55 stated she did not mind getting bed baths sometimes because it was hard to get up, but she would prefer a shower at least once a week. Observation on 04/20/23 at 9:40 AM of Resident #55 revealed her hair was still stringy and oily and did not appear to have been washed recently. The resident had scratches on her left hand from scratching at herself. Observation and interview on 04/18/23 at 11:56 AM with Resident #58 revealed she was lying awake in bed no visible marks or bruises; however, her nails were approximately 18-20 mm long with dirt underneath. Resident #58 stated she did not like her nails long and wanted them cut. She stated she asked staff to cut them for her a while ago and they never did. Interview on 04/19/23 at 2:20 PM with CNA L revealed she had not given Resident #55 a shower although her initials were signed on the Bathing Task Log on 04/18/23 at 5:00 PM. CNA L stated the agency staff sometimes used her credentials to sign off on tasks, and she could not confirm who completed the tasks or if it was completed at that time. She stated Resident #55 received wound care on 04/18/23 so she likely received a bed bath at that time. Interview on 04/20/23 at 9:40 AM with the Wound Care Nurse revealed Resident #40's hair was matted after she returned from the hospital, and staff had been working on detangling it. She did not know if the resident's hair had been matted prior to the hospital visit. Interview on 04/20/23 at 10:15 AM with CNA L and the Administrator revealed CNA L wanted to recant her last interview. CNA L stated she was overwhelmed and did not recall correctly during the last interview. She denied sharing her credentials with agency staff and stated she did give Resident #55 a bed bath on 04/18/23. Review of Resident #40's EHR revealed the resident had been admitted to the hospital for three days (04/14/23-04/17/23) to have her clogged gastric tube replaced. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 7 of 19 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 455457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Worth Wellness & Rehabilitation 2129 Skyline Dr Fort Worth, TX 76114 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 Interview on 04/20/23 at 11:23 AM with CNA C revealed Resident #40 did not move on her own, she stayed in whatever position she was placed in until she was repositioned. CNA C stated she had not seen Resident #40 move or respond to any stimuli other than to open her eyes. CNA C stated she did not know when the resident's last bath was, but residents were bathed 2-3 times a week based on staffing and resident preference. Residents Affected - Some Review of Resident #40's Bathing Task Log for April 2023 revealed the resident was bathed on 04/07/23, 04/11/23, and 04/14/23. Review of Resident #55's Bathing Task Log for April 2023 revealed the resident was bathed on 04/13/23, 04/17/23, and 04/18/23. Interview on 04/20/23 at 3:10 PM, the DON stated her expectation was that residents were bathed and groomed, including nail care, on a consistent basis based on resident preferences and needs. She stated she was unaware of Resident #40's hair being matted as she (the DON) had only been at the facility for about a week. The DON also stated she was unaware of Resident #55 not receiving showers as scheduled or Resident #58 needing her nails clipped. Review of the facility policy Grooming, dated June 2020, revealed the purpose was to promote hygiene, comfort, and self-esteem. The policy promoted resident self-care but did not address residents unable to assist in their care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 8 of 19 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 455457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Worth Wellness & Rehabilitation 2129 Skyline Dr Fort Worth, TX 76114 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #55) of four residents reviewed for wound care. Residents Affected - Few The facility failed to ensure that Resident #55's pressure ulcer dressing was replaced after being removed during ADL care. This failure placed the resident at risk of developing an infection in her wound. Findings included: Review of Resident #55's admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Stage 4 pressure ulcer, morbid obesity, muscle weakness, paralysis, and hospice care. Review of Resident #55's admission MDS, dated [DATE], revealed a BIMS score of 15, indicating she was cognitively intact. Her Functional Status revealed she required extensive assistance with all of her ADLs. Review of Resident #55's care plan revealed she was at risk for further decline in skin integrity due to immobility, and a current Stage IV pressure ulcer related to paralysis and immobility. Observation on 04/20/23 at 9:40 AM of wound care, performed by Wound Care Nurse, revealed when Resident #55's brief was removed there was no dressing covering her pressure ulcer. Resident #55's brief was soaked with red watery drainage from her pressure ulcer. Wound care was completed appropriately with no complaint of pain or discomfort from Resident #55. Interview on 04/20/23 at 9:45 AM the Wound Care Nurse stated Resident #55's dressing must have been removed overnight, possibly during ADL care. Wound Care Nurse stated the CNA that removed the dressing should have notified the nurse immediately so the dressing could be replaced right away. The Wound Care Nurse stated there was an order in place to guide the nurses on how to perform wound care and dressing changes in this type of situation so the wound is not left open until she was available to do wound care. Review of Resident #55's physician orders revealed an order updated on 04/18/23: Wound Care for Pressure injury to the sacrum: Cleanse with normal saline/wound cleanser, pat dry; Apply calcium alginate, cover with a dry dressing; every day and PRN Interview on 04/20/23 at 9:50 AM, CNA B stated he had not provided any cares to Resident #55 on his shift yet, he stated he had not been told by the night shift that Resident #55's dressing had been removed during the night. Interview on 04/20/23 at 3:10 PM the DON stated her expectation was any open wound found by a CNA should be reported to the nurse immediately so the nurse could assess it and dressing it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 9 of 19 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 455457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Worth Wellness & Rehabilitation 2129 Skyline Dr Fort Worth, TX 76114 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 0686 appropriately. The DON stated there were protocols in place to guide staff on wound care if there was not a physician order in place. The DON stated there was no excuse for Resident #55's wound being left open. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 10 of 19 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 455457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Worth Wellness & Rehabilitation 2129 Skyline Dr Fort Worth, TX 76114 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 observation, interview, and record review, the facility failed to offer sufficient fluid intake to maintain proper hydration and health for 1 (Resident #68) of eighteen residents reviewed for hydration, in that: Residents Affected - Few The facility failed provide/offer any means of hydration in between breakfast and lunch meals between 04/18/23-04/20/23 for Resident #68. This deficient practice placed residents at risk of dehydration, dry skin, Urinary Tract Infection's, and a decreased quality of life. Findings included: Review of Resident #68's face sheet dated 04/20/23 reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including dementia, Aphasia (inability to comprehend) and facial weakness following cerebral infarction, hemiplegia (complete loss of strength on one side of the body) and hemiparesis (difficulty standing or walking) following cerebrovascular disease affecting left dominant side, dysphagia oropharyngeal phase (difficulty swallowing). Review of Resident #68's MDS dated [DATE] reflected he had a BIMS of 12 indicating his cognition was moderately impaired. The MDS indicated Resident #68 required supervision and set up for eating, resident was considered independent once food or liquid was placed in front of him. The MDS did not indicate Resident #68 did not have a swallow disorder or signs of a swallowing disorder, and the resident required a mechanically altered diet (pureed food, thickened liquids). Review of Resident #68's current, undated Care Plan revealed Resident #68 had an alteration in neurological status related to disease process - hemiplegia and hemiparesis following cerebral infarction affecting the left side, facial weakness, cerebral infarction. The care plan gooal reflected: [Resident #68] will maintain optimal status and quality of life within limitations imposed by neurological deficits through the next 90 days. Interventions: Adjust diet to accommodate chewing, swallowing, or eating issues in order to maximize independence and nutritional intake. Cueing, reorientation as needed. Obtain and monitor lab/diagnostic work as ordered. [Resident #68] has a Urinary Tract Infection and was receiving antibiotic therapy. Goal: [Resident #68's] urinary tract infection will resolve without complications by the review date. Intervention: Encourage adequate fluid intake, Resident #68 has ADL self-care performance deficit. Goal: resident will improve current level of function with eating. Intervention: resident requires supervision assist, 1 staff participation to eat. [Resident #68] has a swallowing problem related to swallowing assessment results Regular diet, mechanical soft with chopped meat, mildly thick consistency, Goal: resident will have clear lungs, no signs of aspiration. Intervention: monitor/document/report to nurse/dietitian and Medical Doctor for difficulty swallowing. Review of Resident #68's lab work dated 04/12/23 reflected a resident change of condition evaluation, start Cipro 500 mg two times a day for 7 days for urinary tract infection. Review of Resident #68's orders reflected: Augmentin oral Tablet 875-125 mg (Amoxicillin & Pot Clavulanate) Give 1 tablet by mouth two times a day for Upper Respiratory Infection for 7 days. 04/14/23-04/21/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 11 of 19 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 455457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Worth Wellness & Rehabilitation 2129 Skyline Dr Fort Worth, TX 76114 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 Review of Resident #68's progress notes dated 04/14/23 reflected a change of condition follow-up and the primary care provider responded with the following feedback: Recommendations: Start resident on Cipro 500 milligram two times a day for 7 days for Urinary Tract Infection Residents Affected - Few New Testing orders: Urinalysis or culture X-ray New Intervention orders: new or change in medications increase oral fluids DUONEB Every 6 hours X 7 days; AUGEMENTIN 875/125 milligram two times a day for 7 days; VITAMIN C 500 milligram two times a day for 7 days. Observation on 04/18/23 from 9:30 AM - 3:30 PM revealed Resident #68 was observed for most of the day at the nursing station and out in the lobby area. Interview on 04/19/23 at 11:51 AM with Resident #68's family member revealed the family member had been frequently asking that staff supply Resident #68 with water due to him having a recent hospital visit with findings of dehydration. The family member stated Resident #68 was currently on urinary tract infection medication. The family member stated they visited yesterday, and Resident #68 was very thirsty and most of the time did not have water or drinks available in his room. The family member stated Resident #68 had a stroke that affected his dominate side (left), which left him attempting to use the right hand for drinking and eating. The family member stated that because he was using his right hand, he required assistance from staff to ensure he was eating and drinking adequately. Observation and interview on 04/19/23 at 9:17 AM revealed Resident #68 was sitting in his room, in wheelchair, asking for a snack. CNA entered the room speaking with Resident #68 and stated Oh, I know what you want. The CNA went to the corner nightstand to bring out a bite-sized candy. Resident #68 started coughing, which prompted her to ask if he needed some water to drink. Observation revealed there was no water in the room. The CNA looked around the room and stated she would have to go to the kitchen to get him a cup of water. When asked about the resident having a cup at the bedside, the CNA stated she did not know where the resident's cup was. The CNA stated she provided water to Resident #68 when he needed some and during her rounds every two hours. When asked if she could provide documentation of how much fluids were provided during the shift, she stated she would not be able to provide documentation. The CNA stated Resident #68 has come a long way, held up his left arm and stated, due to his hand being contracted he is limited assist with his right-hand use. Observation on 04/19/23 at 4:34 PM revealed in Resident #68 room there was no cup of water or form of hydration at Resident #68 bedside table. During an interview on 04/19/23 at 5:00 PM the Administrator stated staff should be providing water from the water stations during their rounds and upon request. The Administrator stated the kitchen provides water stations in the dining area and on the halls with water, ice, and cups. The Administrator stated not making hydration rounds could cause residents to become dehydrated and have other health concerns. The Administrator stated she expects staff to ensure residents maintain adequate levels of hydration. Review of the facility's undated policy titled Nutrition/Hydration Management reflected the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 12 of 19 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 455457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Worth Wellness & Rehabilitation 2129 Skyline Dr Fort Worth, TX 76114 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 .The goal of any hydration management process is to improve quality of life. A resident is assessed for hydration by nursing staff upon admission, quarterly and as needed based on clinical presentation and clinical judgement. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 13 of 19 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 455457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Worth Wellness & Rehabilitation 2129 Skyline Dr Fort Worth, TX 76114 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. 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 provide medically-related social services to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident for two (Residents #41 and #186) of two residents reviewed for activities of daily living. Residents Affected - Some The facility failed to assess Resident #41's and Resident #186's need for communication assistance to effectively communicate with staff. This failure could put residents at risk of having a loss of dignity and decreased quality of life. Findings included: Record review of Resident 41's face sheet dated 04/20/23 revealed the resident was a [AGE] year-old female admitted the facility on 03/15/23 with diagnosis of Type 2 diabetes mellitus, hypertension (high blood pressure), depressive disorders, acute and chronic respiratory failure with hypoxia (oxygen and carbon dioxide cannot be kept at normal levels), congestive heart failure, end stage renal disease, acquired absence of right leg below knee, dependence on renal dialysis and supplemental oxygen. The primary language listed was Spanish. Record review of Resident 41's MDS assessment dated [DATE] reflected the resident was cognitively intact with a BIMS score of 13. The MDS did not indicate a need for an interpreter to communicate with a doctor or health care staff. The MDS assessment revealed Resident #41 made herself understood, and she was able to understand others. Record review of Resident 41's updated care plan printed 04/20/23 reflected Resident #41 was bilingual with English as her secondary language. The care plan reflected at times Resident #41 preferred to communicate in Spanish. The care plan goal reflected: The resident will maintain current level of communication function by expressing herself in language of preference through review date. Intervention: Be conscious of resident position when in groups, activities, dining room to promote proper communication with others. Discuss with resident/family concerns or feelings regarding communication difficulty. Ensure availability of adaptive communication board/interpreter line for resident's use as desired. Use communication tools as needed, such as communication book/board/interpreter line. During an interview and observation on 04/18/23 at 11:05 AM with Resident #41, the resident stated she had concerns with the language barrier between her and staff. Resident #41 stated she would like to communicate in Spanish when speaking with staff. Resident #41 stated it made her feel like a child, and it was uncomfortable trying to recall how to speak words in English. Resident #41 stated she would prefer to speak in Spanish to make her concerns and request known to the nursing staff. Resident #41 was observed pausing, taking a minute to speak, saying she was not sure how to communicate certain words or express what she was trying to say. Resident #41 stated she did express her preference to communicate in Spanish as it was her primary language and way to communicate. Resident #41 stated the facility never had a translator to assist her with care or communication. Resident #41 apologized for not being clear and allowing her time to speak. During interview on 04/19/23 at 1:29 PM with CNA B, he stated Resident #41's accent was very heavy, and the resident had expressed that she did not know a lot of words in English. CNA B stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 14 of 19 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 455457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Worth Wellness & Rehabilitation 2129 Skyline Dr Fort Worth, TX 76114 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 0745 Level of Harm - Minimal harm or potential for actual harm Resident #41 had never expressed wanting to speak with a Spanish speaking person; however, she had communicated some words in Spanish that she did not know how to say in English. When providing care, CNA B stated she tried to keep it very basic because there was a language barrier. CNA B stated he felt like they understand what the other person was trying to say. CNA B stated he was not aware of a communication board, or an interpreter line used to translate from English to Spanish. Residents Affected - Some During interview on 04/20/23 at 1:30 PM with RN K, she stated she was aware that Resident #41 was Spanish speaking but not aware Spanish was her primary language. RN K stated she could tell that Resident #41 did not speak English very clearly. RN K stated Resident #41 never asked her to communicate in Spanish. RN K stated Resident #41 never asked for a translator or communication board. RN K stated the aides on her hall had never expressed there was a communication problem between staff and residents. RN K stated she would expect to be notified of any language barrier concerns. RN K stated she was responsible for doing rounds to ensure residents were receiving proper care, which she found no concerns during her rounds. RN K stated not being able to communicate with residents could put them at risk of not receiving proper care and being able to express their needs and wants. Record review of Resident #186's face sheet dated 04/20/23 revealed the resident was a [AGE] year-old male admitted the facility on 04/13/23 with diagnosis of Type 2 diabetes mellitus, liver disease, hypertension (high blood pressure), anxiety disorder, thrombocytopenia (deficiency of platelets in the blood), fracture of the left femur. The primary language listed was English. Record review of Resident #186's 5-day MDS assessment dated [DATE] reflected the resident had moderate cognitive impairment with a BIMS score of 09. The MDS did not indicate a need for an interpreter to communicate with a doctor or health care staff. The MDS assessment revealed Resident #186 usually made himself understood and was usually able to understand others. Record review of Resident #186's updated care plan printed 04/20/23 reflected Resident #186 had a communication problem related to a language barrier, and the resident was Spanish speaking. The care plan goal reflected: The resident will maintain current level of communication function by using communication board or interpreter line through the review date. Intervention: Be conscious of resident position when in groups, activities, dining room to promote proper communication with others. Discuss with resident/family concerns or feelings regarding communication difficulty. Use communication techniques which enhance interaction: use alternative communication tools as needed, such as communication board/interpreter line. During interview on 04/18/23 at 12:52 PM with Resident #186 stated he communicated in Spanish. Resident #186 asked if surveyor was Spanish speaking. During interview on 04/19/23 at 1:39 PM with CNA B , CNA B stated Resident #186 was Spanish speaking, CNA B stated Resident #186 had expressed wanting to speak in Spanish. CNA B stated when providing care, I try to keep it very basic because there is a language barrier. CNA B stated he had never needed to get someone to translate because he was usually providing care with the nurse or another aide. CNA B stated he was not aware of a communication board, or an interpreter line used to translate from English to Spanish. Interview on 04/20/23 at 1:26 PM with RN K revealed she was aware Resident #186 was Spanish speaking and that Spanish was his primary language. RN K stated Resident #186 frequently asked her if she was Spanish speaking. RN K stated she did attempt to communicate with Resident #186 in Spanish (stated her own language was similar to Spanish) but could tell there was a language barrier. RN K stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 15 of 19 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 455457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Worth Wellness & Rehabilitation 2129 Skyline Dr Fort Worth, TX 76114 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 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some she had never asked for a translator or communication board. RN K stated the aides on her hall had never expressed there was a communication problem between staff and residents. RN K stated she would expect to be notified of any language barrier concerns. RN K stated she was responsible for doing rounds to ensure residents were receiving proper care, which she found no concerns during her rounds. RN K stated not being able to communicate with residents can put them at risk of not receiving proper care and being able to express their needs and wants. During an interview on 04/19/23 at 5:00 PM with the Administrator, the Administrator stated she was not aware there was concerns with Spanish speaking residents in the facility. The Administrator stated the facility has several methods to communicate in Spanish if that was the preferred language. The Administrator stated there were Spanish speaking staff, translation hotline, communication boards, and the use of family to have adequate communication between residents and staff. The Administrator stated there was nothing noted in Resident #41 or #186's care plan which would express residents are uncomfortable speaking English or would prefer using Spanish language. The Administrator stated not using these options for communicating could violate residents' rights to speak freely and could affect the care they are needing. Record review of the facility's policy titled Resident Rights revised August 2020, reflected: All residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Resident will be treated with respect and dignity and care for each resident in a manner that promotes or enhanced his or her quality of life To ensure non-English-speaking residents an opportunity to convey their needs and preferences, facility staff with second language ability will be identified and utilized as interpreters on an as needed basis FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 16 of 19 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 455457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Worth Wellness & Rehabilitation 2129 Skyline Dr Fort Worth, TX 76114 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for four (Residents #29, #40, # 56, and #75) of five residents reviewed for accurate documentation. The facility failed to ensure documentation of cares provided by the CNAs was complete and accurate for Residents #29, #40, #56, and #75. This failure placed residents at risk of not receiving the proper level of care and services needed to maintain their health status. Findings included: Review of Resident #29's admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included cerebral palsy, contractures, inability to swallow requiring placement of a gastric tube, inability to speak, and profound intellectual disabilities. Review of Resident #29's care plan, dated 04/12/23, revealed he was at risk for falls related to contractures and inability to move himself, skin integrity related to impaired mobility, and cognitive impairment related to cerebral palsy. Review of Resident #29's quarterly MDS, dated [DATE], revealed a BIMS score not calculated based on his medical conditions. His Functional Status indicated he was completely reliant on staff for all of his ADLs. Review of Resident # 29's EHR revealed CNAs documented their tasks for April 2023 as below: Walking in Room Task - CNA C documented on 04/17/23 that he provided Limited Assistance: Resident Highly Involved. Eating Task - CNA-D documented on 04/17/23 that he provided Limited Assistance: Resident Highly Involved. CNA-A documented on 04/14/23 that she provided Limited Assistance: Resident Highly Involved. Review of Resident #40's admission Record revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included respiratory failure requiring the placement of a tracheostomy, brain damage from loss of oxygen, reduced mobility, contractures, and heart failure. Review of Resident #40's care plan, dated 9/28/22, revealed she was at risk for oral and dental health problems, skin breakdown related to immobility, and an ADL self-care deficit related to Alzheimer's. Review of Resident #40's quarterly MDS, dated [DATE], revealed a BIMS score was not performed based on the resident's medical conditions. Her Functional Status indicated she was completely reliant on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 17 of 19 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 455457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Worth Wellness & Rehabilitation 2129 Skyline Dr Fort Worth, TX 76114 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 0842 staff for all of her ADLs. Level of Harm - Minimal harm or potential for actual harm Review of Resident #40's EHR revealed CNAs documented their tasks for April 2023 as below: Walking in Room Task- CNA-D documented on 04/17/23 that he provided Supervision: Oversight only Residents Affected - Some Eating Task- CNA-A documented on 04/13/23 that she provided Limited Assistance: Resident highly involved CNA D documented on 04/17/23 that he provided Supervision: Oversight only CNA E documented on 04/18/23-04/20/23 that she provided Extensive Assistance Resident involved in activity. Review of Resident #56's admission Record revealed the reident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included brain injury caused by loss of oxygen, contractures of muscles, liver disease, placement of tracheostomy for breathing, and chronic respiratory failure. Review of Resident #56's care plan, dated 03/29/23, revealed he was at risk for respiratory failure requiring a tracheostomy, nutritional deficit related to requiring a feeding tube due to brain injury and altered musculoskeletal status related to contractures. Review of Resident #56's quarterly MDS, dated [DATE], revealed a BIMS score not calculated related to his medical condition. His Functional Status indicted he was totally reliant on staff for all of his ADLs. Review of Resident #56's EHR revealed CNAs documented their tasks for April 2023 as below: Eating Task: CNA F documented on 04/09/23 she provided Limited Assistance: Resident highly involved CNA G documented on 04/17/23 she provided Supervision: Oversight only Personal Hygiene Task- CNA-F documented on 04/09/23 she provided Limited Assistance: Resident highly involved CNA H documented on 04/15/23 she provided Limited Assistance: Resident highly involved Review of Resident #75's admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included stroke affecting the right side of his body, muscle weakness, difficulty walking, and a cognitive communication deficit. Review of Resident #75's care plan, dated 02/22/23, revealed he was at risk of nutritional deficit related to requiring a feeding tube, falls related to poor balance, and impaired cognitive processes. Review of Resident #75's admission MDS, dated [DATE], revealed a BIMS score of 6 indicating severe cognitive impairment. His Functional Status indicated he required extensive or total assistance from staff for all of his ADLs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 18 of 19 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 455457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Worth Wellness & Rehabilitation 2129 Skyline Dr Fort Worth, TX 76114 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 0842 Review of Resident #75's EHR revealed CNAs documented their tasks for April 2023 as below: Level of Harm - Minimal harm or potential for actual harm Walking in Room Task: CNA D documented on 04/12/23 and 04/16/23 he provided Supervision: Oversight only Residents Affected - Some Eating Task: CNA I documented on 04/08/23 and 04/12/23 the resident was Independent No Help required CNA J documented on 04/16/23 the resident was Independent No Help required CNA B documented on 04/18/23 and 04/19/23 the resident was Independent No Help required Personal Hygiene Task: CNA I documented on 04/08/23 the resident was Independent No Help required CNA D documented on 04/12/23 he provided Supervision Oversight only CNA B documented on 04/19/23 the resident was Independent No Help required Interview on 04/20/23 at 2:18 PM, CNA B stated he did not know how he documented that Resident #75 was independent in eating when he is fed via feeding tube and pump. CNA B stated he must have clicked on the wrong button as Independent and Activity did not occur are right next to each other. Interview on 4/20/23 at 2:49 PM, CNA-I stated she did not know how she documented that Resident #75 was independent in eating when he is fed via feeding tube and feeding pump. CNA-I stated she may have just been clicking too fast when documenting the care she provided, she soul have documented Activity did not occur as she is not involved with his feeding pump. Interview on 4/20/23 at 3:10 PM the DON stated she expected all staff, including CNAs, to document everything they do for the residents accurately. The DON stated most of the CNAs involved were staffing agency CNAs, but they are oriented to charting as part of their two day on-boarding process. Interview on 4/20/23 at 3:20 PM the Interim DON stated the facility had the CNAs document all of their care on the computer under the Tasks tab. Under Tasks, each care is listed and the CNA is expected to document if they provided that care, what level of help they proved, or if they did not provide that care. Residents that were considered total care would have the majority of their cares documented under Total care. Review of the facility's policy Documentation, dated June 2020, revealed the purpose was to ensure documentation of resident status and care provided. The policy reflected: .III. ADL Documentation A. The CNA will document the care provided on the facility's method of documentation. B. The CNA will sign each entry on the ADL flow sheet C. Documentation will be completed by the end of the assigned shift FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 19 of 19