Inspection·May 30, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wall. She stated the floor had been like that for a few days. She stated the vent and fan damage happen when the staff lowered her bed. She stated staff had been in the room since the incident happen and they did not say anything about repairing the damage. An interview on 05/28/2024 at 3:04 PM with the Maintenance Director revealed he was not informed of the damage in Resident #131's room until that day. He stated maintenance issues should be documented in the online system. He stated he checked the system daily for items in the facility that needed repaired. An interview on 05/3/2024 at 3:28 PM with the DON revealed the expectation was for staff to report the maintenance concerns immediately. The risk to the resident was injury, improper flow of air, and fall hazards for the floor tiles. An interview on 05/30/2024 at 3:35 PM with the Social Worker revealed she was the room ambassador for Resident #131. She stated about a week ago she noticed one of the floor tiles was loose and one of the floor tiles was missing. She stated after the morning meeting she told the maintenance director about the missing tiles. She stated she did not document the maintenance issues in the online maintenance system because she forgot. She stated the risk to the resident was she could fall or trip on the floor tile and she could get injured with the fan. Review of the facility Policy titled Resident Rooms and Environment, revised date 08/2020 reflected; The facility provides residents with a safe, clean, comfortable, and homelike environment. This shall include ensuring that residents can receive care and services safely and that the physical layout of the Facility maximizes resident independence and does not pose a safety risk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 2 of 12 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 05/30/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one(Resident #73) of eight residents reviewed for respiratory care. Residents Affected - Few The facility failed to ensure Resident #73's nasal pillow mask (a small, soft, cushioned inserts that rests at the entrance of the nose) for CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) was stored properly. This failure could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Review of Resident #73's Face Sheet, dated 05/29/2024, reflected that resident was a [AGE] year-old male admitted on [DATE] he had a diagnosis of sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep). Review of Resident #73's Comprehensive MDS Assessment, dated 05/13/2024, reflected that Resident #73 was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment also indicated that the resident was on non-invasive mechanical ventilator. Review of Resident #73's Comprehensive Care Plan, dated 05/13/2024, reflected resident was on CPAP therapy for obstructive sleep apnea and the goal was the resident will adhere to CPAP/BiPAP (Bilevel Positive Airway Pressure) regimen. Review of Resident #73's Physician Order, dated 05/09/2024, reflected May use personal CPAP with per setting from home use at bedtime and PRN every evening and night shift related to OBSTRUCTIVE SLEEP APNEA (ADULT). Observation and interview with LVN A on 05/29/2024 at 9:57 AM, LVN A said she would get some distilled water to put on the humidifier tub of the CPAP machine. LVN A then took off the CPAP nasal pillow mask off of the resident and put it on top of the side table behind the CPAP machine. LVN A went out of the room and came back with a bottle of distilled water. LVN A stated the CPAP mask should have been bagged to prevent contamination and potential infection. She said she would get a bag for the CPAP mask, clean the mask, and then put it on a plastic bag. In an interview with the DON on 05/29/2024 at 1:25 PM, the DON stated CPAP mask should be bagged when not in use to prevent contact with dirty surfaces. She added the CPAP mask should be cleaned before putting it inside the plastic bag. She said the expectation was for the staff to bag the CPAP mask when not in use. She said they would do an in-service about respiratory care. In an interview with the Administrator on 05/30/2024 at 8:00 AM, the Administrator stated the CPAP mask should be bagged so it will not be contaminated. She said the expectation was for the staff to be mindful in doing respiratory care and bag the CPAP mask. She concluded that they would do an in-service about respiratory care to remind them to bag not just the CPAP mask but also the nasal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 3 of 12 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 05/30/2024 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 0695 cannula, and the breathing mask. Level of Harm - Minimal harm or potential for actual harm Record review of facility's policy, Oxygen Administration Nursing manual - Nursing Care rev. 06/2020 revealed Purpose: To prevent or reverse hypoxemia and provide oxygen to the tissues . III. Infection Control . A. All oxygen tubing, humidifiers, masks, and cannulas . B. Oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 4 of 12 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 05/30/2024 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 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 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 diseases and infections for five (Resident #28, Resident #2, Resident #18, Resident #47, and Resident #60) of twelve residents observed for infection control. Residents Affected - Some 1. The facility failed to ensure that CNA C and CNA D changed their gloves, perform hand hygiene, and perform proper direction of wiping while providing incontinent care to Resident #28. 2. The facility failed to ensure MA B sanitized the blood pressure cuff between Resident #2, Resident #18, Resident #47, and Resident #60. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: 1. Review of Resident #28's Face Sheet dated 05/28/2024 reflected resident was a [AGE] year-old female admitted on [DATE]. Resident #28 had a diagnosis of chronic kidney disease. Review of Resident #28's Comprehensive MDS assessment dated [DATE] reflected Resident #28 had a severe impairment in cognition with a BIMS score of 06. The Comprehensive MDS Assessment indicated Resident #28 had urinary incontinence. Review of Resident #28's Care Plan dated 05/16/2024 reflected resident had an ADL self-care performance deficit and the goal was for the resident to be clean. Observation and interview on 05/28/2024 at 1:32 PM, CNA C stated they would transfer Resident #28 to bed and then would do incontinent care. CNA C and CNA D both washed their hands, put on gloves, and transferred Resident #28 from wheelchair to bed using a stand pivot transfer. CNA C and CNA D then assisted the resident to a lie down position. CNA C took off the resident's shoes and then proceeded to prepare the wipes he would use for incontinent care. CNA C did not change his gloves nor sanitized his hands before touching the wipes. CNA C unfastened the tape on both sides of the brief, rolled the front half of the brief and then pushed it between the resident's thighs. CNA C took a wipes and cleaned the front part of the resident using a front to back technique. CNA C threw the wipes. CNA C then took another wipe and cleaned the resident from back to front. CNA C took off his gloves, sanitized his hands, and put on new pair of gloves. CNA C instructed the resident to roll to her left side. CNA D assisted the resident to change her position. CNA C took the new brief, opened it, and put it parallel to the resident's thigh. CNA C and CNA D then took turns in cleaning the resident's bottom. After cleaning the resident's bottom, CNA C pulled the soiled brief, threw it on the trash can, took the new brief that was placed parallel to the resident's thigh, and then put it at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 5 of 12 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 05/30/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm bottom of the resident. They instructed the resident to roll back and both CNAs fixed the new brief. Both CNAs did not change their gloves after cleaning the resident's bottom and before fastening he new brief. They pulled the resident's blanket up and put the resident's call light within reach. CNA C and CNA D discarded their gloves, threw them in the trash can and went out of the room. Both CNAs did not wash their hands after the incontinent care. Residents Affected - Some In an interview with CNA C on 05/28/2024 at 2:01 PM, CNA C said he washed his hands before doing incontinent care but stated he did not wash his hands after cleaning the resident. CNA C stated he changed his gloves and sanitized before getting the new brief, putting it beside the resident, and cleaning the resident's bottom. CNA C continued that he should had changed his gloves again after cleaning the resident's bottom and before touching the new brief again. CNA C said gloves should be changed and hands should be sanitized after cleaning the resident and before touching the new brief to prevent contamination of the new brief. CNA C also said it was important to wash their hands at the end of the procedure to ensure that the hands were clean before touching other residents. CNA C stated that the proper way of cleaning a female resident was from front to back. CNA C continued that cleaning a female resident from back to front could cause infections such as urinary tract infection. CNA C also said he should had changed his gloves after taking off the resident's shoes because the dirt from the shoes would transfer to the things used during incontinent. In an interview with CNA D on 05/28/2024 at 2:12 PM, CNA D stated she did not change her gloves after assisting in cleaning the residents bottom and before fixing the resident's new brief. CNA D stated she should had removed her gloves, washed or sanitized her hand and then put on new gloves after cleaning the resident and before touching the new brief. She added this could cause cross contamination and infection because the dirt from the soiled gloves could transfer to the things touched after incontinent care. CNA D said it was important to wash the hands after every care to prevent transfer of infection. 2. Review of Resident #2's Face Sheet, dated 05/30/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. The resident's diagnosis was essential (primary) hypertension (blood pressure is consistently high). Review of Resident 2's Quarterly MDS Assessment, dated 05/03/2024, reflected resident was cognitively intact with a BIMS score of 14. The Quarterly MDS Assessment also indicated that hypertension was one of Resident #2's active diagnoses. Review of Resident #2's Comprehensive Care Plan, dated 05/03/2024, reflected the resident had hypertension and one of the interventions was give anti-hypertensive medications as ordered. Review of Resident #2's Physician's Order for lisinopril, dated 03/02/2024, reflected Lisinopril Oral Tablet 5 MG (Lisinopril). Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) HOLD if SBP <110, DBP <60 or HR < 60. Review of Resident #2's Physician's Order for Toprol dated 03/02/2024, reflected Toprol Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate). Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) HOLD if SBP <110, DBP <60 or HR <60. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 6 of 12 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 05/30/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3.Review of Resident #18's Face Sheet, dated 05/27/2024, reflected that resident was an [AGE] year-old female admitted on [DATE]. The resident's diagnosis was essential (primary) hypertension (blood pressure is consistently high). Review of Resident 18's Quarterly MDS Assessment, dated 05/03/2024, reflected resident was cognitively intact with a BIMS score of 14. The Quarterly MDS Assessment also indicated that hypertension was one of Resident #18's active diagnoses. Review of Resident #18's Physician's Order for losartan, dated 01/23/2024, reflected Losartan Potassium-HCTZ Oral Tablet 100-12.5 MG (Losartan Potassium & Hydrochlorothiazide). Give 1 tablet by mouth one time a day for HTN HOLD if SBP <110, DBP < 60 or HR <60. 4.Review of Resident #47's Face Sheet, dated 05/29/2024, reflected resident was an [AGE] year-old male admitted on [DATE]. The resident's diagnosis was essential (primary) hypertension (blood pressure is consistently high). Review of Resident 47's Quarterly MDS Assessment, dated 04/20/2024, reflected resident had a moderate impairment with a BIMS score of 08. The Quarterly MDS Assessment also indicated that hypertension was one of Resident #47's active diagnoses. Review of Resident #47's Comprehensive Care Plan, dated 04/20/2024 reflected resident had cerebral vascular accident and one of the interventions was to be free from signs and symptoms of CVA. Review of Resident #47's Physician's order for metoprolol dated 01/12/2024 reflected Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate). Give 1 tablet by mouth two times a day for Heart Failure HOLD if pulse < 60 & DO NOT CRUSH. Review of Resident #47's Physician's order for nifedipine, dated 01/12/2024 reflected Tablet Extended Release 24 Hour 30 MG (Nifedipine). Give 1 tablet by mouth two times a day for HTN HOLD if SBP < 110, DBP < 60 or HR < 60 & DO NOT CRUSH. 5.Review of Resident #60's Face Sheet, dated 05/29/2024, reflected that resident was a [AGE] year-old male admitted on [DATE]. The resident's diagnoses was essential (primary) hypertension (blood pressure is consistently high). Review of Resident 60's Quarterly MDS Assessment, dated 05/03/2024, reflected resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment also indicated that hypertension was one of Resident #60's active diagnoses. Review of Resident #60's Comprehensive Care Plan dated 05/02/2024 reflected resident had hypertension and one of the interventions was give anti-hypertensive medications as ordered. Review of Resident #60's Physician's Order for amlodipine, dated 06/24/2023, reflected Amlodipine Besylate Oral Tablet 10 MG (Amlodipine Besylate). Give 1 tablet by mouth one time a day for HTN HOLD if SBP <100 or DBP <60. Review of Resident #60's Physician's Order for hydralazine, dated 06/24/2023, reflected Hydralazine HCl Oral Tablet 10 MG (Hydralazine HCl). Give 1 tablet by mouth every 24 hours as needed for HTN if SBP >160 or DBP > 90. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 7 of 12 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 05/30/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 05/29/2024 at 8:02 AM revealed MA B was about to prepare Resident #2's medication. MA B said she would take his blood pressure first before preparing the medications. MA B picked up the blood pressure cuff from the top of the medication cart and went inside the resident's room and placed the blood pressure cuff on Resident #2 's. After the blood pressure reading was completed, MA B placed the blood pressure cuff on top of the medication cart, prepared the medications, went inside the resident's room, and gave the medications. She did not sanitize the blood pressure cuff. Observation on 05/29/2024 at 8:18 AM revealed MA B was about to prepare Resident #18's medication. MA B said she would take the resident's blood pressure. MA B picked up the blood pressure cuff from the top of the medication cart and went inside the resident's room and placed the blood pressure cuff on Resident #18's arm. MA B did not sanitize the blood pressure cuff. After the blood pressure reading was completed, MA B placed the blood pressure cuff on top of the medication cart, prepared the medications, went inside the room, and gave the medications. MA B did not sanitize the blood pressure cuff. Observation on 05/29/2024 at 8:37AM revealed MA B said she would next prepare Resident #47's medication. MA B picked up the blood pressure cuff from the top of the medication cart and went inside the resident's room and placed the blood pressure cuff on Resident #47's arm. MB A did not sanitize the blood pressure cuff. After the blood pressure reading was completed, MA B placed the blood pressure cuff on top of the medication cart, prepared the medications, went inside Resident - room, and gave the medications. She did not sanitize the blood pressure cuff. Observation on 05/29/2024 at 8:49 AM revealed MA B said she would next prepare Resident #60's medication. MA B picked up the blood pressure cuff from the top of the medication cart, went inside the resident's room, and placed the blood pressure cuff on the resident's arm. MB A did not sanitize the blood pressure cuff. After the blood pressure reading was completed, MA B placed the blood pressure cuff on top of the medication cart, prepared the medications, went inside Resident - room, and gave the medications. She did not sanitize the blood pressure cuff. In an interview with MA B on 12/06/2023 at 1:34 PM, MA B stated she obtained the blood pressure of the residents before giving the medication for hypertension to know if the medication needed to be held or not. MA B said the first thing to do was to wash or sanitize hands before and after giving medications. MA B also said the blood pressure cuff should be sanitized after using it and before using it on another resident. MA B stated she forgot to sanitize the blood pressure cuff in between residents when he passed medications that morning(5/29/2024). MA B said the blood pressure cuff should be sanitized to prevent cross contamination and spread of infection. Interview with the ADON on 05/29/2024 at 9:16 AM, the ADON stated hands should be washed before and after any care done for the residents. The ADON said gloves should be changed and hands should be sanitized after touching soiled items such as the shoes and the soiled briefs. The ADON added that the proper way to clean a female resident was from front to back. She said not washing the hands, not changing the gloves after touching a soiled brief, and wiping a female resident from back to front could cause probable infection. The ADON stated the blood pressure cuff should have been sanitized after every use or after every resident. The ADON said if the blood pressure cuff was not sanitized, it could also cause cross contamination and infection could spread. The ADON said the expectation was for the staff to wash their hands and change their gloves during incontinent care and the blood pressure cuff to be sanitized in between residents. She said she would start an in-service to address the infection control issue. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 8 of 12 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 05/30/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview with the DON on 05/29/2024 at 1:25 PM, the DON said the gloves should have been changed and the hands should be sanitized after touching the resident's shoes, after cleaning the resident's buttocks, and before touching the new briefs. The DON said the staff should wash their hands before and after every care. She said not washing the hands and not changing the gloves from a dirty area to a clean area could result to cross contamination and infection. The DON added the proper way to clean the front of the female resident was the back to front technique to avoid infections. The DON stated the blood pressure cuff should have been sanitized every after use. She said not sanitizing the blood pressure cuff could also cause cross contamination or development of new infections. The DON added this could clearly cause a lot of medical issues. The DON said the expectation was for the staff to remember to wash their hands before and after every care, change their gloves when transitioning from a dirty area to a clean area, clean a female resident using the front to back technique, and sanitize the blood pressure cuff after using it. The DON said she already did a one-on-one in-service with CNA C and CNA D but would do an infection control in-service for all the staff. She concluded that she would continually remind the staff to be attentive to the procedures for incontinent care. In an interview with the Administrator on 05/30/2024 at 8:00 AM, the Administrator stated hand washing before and after every care was important to prevent cross contamination and infection. She said changing the gloves was also important for the same reason. The Administrator said all reusable medical items, such as the blood pressure cuff, should be sanitized before using to another resident to prevent possible infection. She stated the expectation was for the staff to make sure all items and equipment used by the residents were sanitized, that the staff would wash their hands before and after every care, and proper technique in cleaning a female resident would be executed. She said he would remind the staff during staff meetings to be mindful about the procedures followed pertaining to infection control. Record review of facility's policy, Hand Hygiene - Infection Control revised 6/2020, revealed Policy: The Facility considers hand hygiene the primary means to prevent the spread of infections . V. Facility Staff and volunteers must perform hand hygiene procedures . i. Immediately upon entering a resident occupied area . ii. Immediately upon exiting a resident occupied area. Review of facility policy, Cleaning & Disinfection of Environmental Surfaces and Equipment Infection Control Manual rev. 6/2020 revealed Purpose: To ensure that the cleaning and disinfection of environmental surfaces . Procedure: Non-critical . iii. Non-critical equipment items include bed pans, blood pressure cuffs . II . disinfected with an EPA-registered intermediate or low-level disinfectant. Record review of facility's policy Perineal Care Nursing Manual - Nursing Care revised 6/2020 revealed Purpose: To maintain cleanliness of the genital area, to reduce odor, and to prevent infection . A. For female residents . moving from front to back. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 9 of 12 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 05/30/2024 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 effective pest control program for one (hallway 100) of four hallways, one of one dining areas, and one of one kitchen observed for pest control. Residents Affected - Some The facility did not maintain an effective pest control program to ensure the facility was free of gnats and flies in a hallway, kitchen, and dining room. This could place residents at risk for an unsanitary environment. Findings included: In an observation and interview on 5-28-2024 at 10:55 AM, revealed 2 flies landed on Resident #229 while he was being interviewed. Resident #229 said he has seen flies in his room since he admitted to the facility. Resident #229 stated having flies in his room made him feel like he was sleeping outside by cow manure. In an observation and interview on 5-28-2024 at 10:57 AM, the Resident #49 stated he has seen flies in his room and wishes they were gone. Resident #49 did not state how having flies in his room made him feel. In an observation and interview on 5-28-2024 at 10:58 AM, Resident #48 stated he has been dealing with flies in his room. Resident #48 stated that dealing with flies, in his room, caused him to feel irritation and there is nothing nastier to deal with. In an observation and interview on 5-28-2024 at 11:05 AM revealed Resident #232 has been dealing with gnats and flies in his bedroom and they have been landing on him causing him to get irritated and feel nasty. In an observation on 5-28-2024 at 11:10 AM 2 flies were observed on hallway 100. In an interview on 5-28-2024 at 11:13 AM Resident #27 stated he had a problem with flies in his room and other places in the facility. Resident #27 stated flies have been bad, for about a week and the nurses are aware of the problem. Resident #27 did not state how it made him feel. In an interview on 5-28-2024 at 11:20 AM Resident #19 stated he had seen flies in his bedroom for the past two weeks. Resident #19 stated he has been swatting flies away from him, for the past two weeks. He stated it bums the hell out of him and makes him think the facility isn't clean. In an observation and interview on 5-28-2024, at 11:42 AM 2 flies were observed in Resident #42's room. Resident #42 stated he has been dealing with flies, in his room, and it makes him feel dirty. In an observation in Hall 100 on 5-29-2024 at 1:00 PM, 3 flies were observed flying in the hallway. In an observation and interview on 5-28-2024 at 2:07 PM Resident #22 stated he had a problem with flies and mosquitoes in his room and wished they were gone. Resident #22 did not state how that made him feel. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 10 of 12 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 05/30/2024 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 0925 In an observation of room [ROOM NUMBER], on 5-29-2024, at 10:30AM a fly was flying around the room. Level of Harm - Minimal harm or potential for actual harm In an observation on 5-29-2024 at 11:50 AM, while doing food temperature checks, in the kitchen area, one fly was flying in the food preparation area. Residents Affected - Some In an interview with on 5-30-2024 at 3:40 PM, CNA-A had witnessed flies in the facility for over a week. CNA-A stated that the facility had the same problem with flies last summer. In an interview on 5-30-2024, at 3:50 PM, LVN-B had witnessed flies flying around in Hall 100 and in resident's rooms. LVN-B stated that having flies in a nursing facility was an infection control problem. LVN-B stated he has worked at the facility for 2 years and has never seen a pest control company on the property. In an interview on 5-30-2024, at 4:55 PM, the DON stated the problem with having insects in the facility, was it caused the facility to be deficient in cleanliness. The DON stated her expectation was for the facility to be free from gnats and flies. In an interview on 5-30-2024, at 5:00 PM, the Administrator stated the facility contracts with a pest control company. The Administrator stated the facility did not have a problem with flying insects until earlier in the week. The Administrator stated as soon as the facility saw flies in the facility, they contacted the pest control company, and the pest control company came out to the facility and treated it for flies. The Administrator stated she does not want flying insects to be around the food and her expectation was to not have them in the facility at all. The Administrator stated no one had complained about the flying insects to her. Record review of the facility's pest control log indicated the following: *5-22-2024 -there was a bi-monthly treatment agreement for the facility. Inspected & treated areas in the kitchen, dining area, offices, hallways, room [ROOM NUMBER], and a meeting room. *5-15-2024 - There was a treatment for ants in room [ROOM NUMBER] including the exterior of the room. *The log also showed the pest control company was onsite on 5-7-2024 & 4-27-2024. Record review of the facility's pest control policy, dated 8-2020, stated: Purpose: To ensure the Facility is free of insects, rodents, and other pests that could compromise the health, safety, and comfort of residents, Facility Staff, and visitors. Policy: The Facility maintains an ongoing pest control program to ensure the building and grounds are kept free of insects, rodents, and other pests. Procedure: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 11 of 12 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 05/30/2024 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 0925 Facility Staff will report to the Housekeeping Supervisor any sign of rodents or insects, Level of Harm - Minimal harm or potential for actual harm including ants, in the Facility. i. The Housekeeping Supervisor takes immediate action to remove the pests from Residents Affected - Some the Facility. ii. If necessary, after informing the Administrator, the Housekeeping Supervisor will call the extermination company for assistance. I. General Practices - D. The Maintenance Department assists, when appropriate and necessary, with pest control services. II. Pest Control Service Provider . v. As authorized by the Administrator, the Company will carry out any pest control actions needed to rid the Facility and its grounds of any environmental pests. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455457 If continuation sheet Page 12 of 12