Health inspection·July 17, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm while assisting them to eat. Administrator stated another risk could cause the resident and aide not to be at eye level while assisting the resident to eat. On 07/16/25 at 3:30 PM, a policy was requested for feeding residents. At 4:15 PM, a policy for Assistive Feeding Devices was given, but the policy for feeding residents was not submitted. Residents Affected - Few 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 07/17/2025 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 of 9 residents (Resident #33, #42, and #83) reviewed for pain management. 1. The facility failed to provide effective pain medication for Resident #33 who admitted to the facility on [DATE] and received Hydrocodone-Acetaminophen 1 oral tablet 325 mg. per order, on all three shifts, for 7-15-2025 and 7-16-2025. Resident #33's pain levels remained high without physician notification or effective intervention. 2. The facility failed to provide effective pain medication for Resident #83 who re-admitted to the facility on [DATE] and received Acetaminophen-Codeine 1 300-30 mg. oral tablet on 7-15-2025 three times a day per order. Resident #83's pain levels stayed above a level 5 without effective relief or physician notification or effective intervention. 3. The facility failed to provide effective pain medication for Resident #42 who admitted to the facility on [DATE] and received Norco 1 Oral Tablet 325 mg. from 7-1-2025 through 7-16-2025 every 6 hours per order. Resident #42's pain levels stayed elevated at a level 10 from 7-15-2025 thru 7-16-2025 without physician notification or intervention. An Immediate Jeopardy (IJ) was identified on 7-17-2025 at 12:46 PM. The IJ template was provided to the facility on 7-17-2025 at 12:52 PM. While the IJ was removed on 7-17-2025 at 5:50 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm, that was not immediate jeopardy, and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents, who are on controlled pain medication, at risk of not receiving appropriate pain management - resulting in pain. Findings included: 1. Record review of Resident #33's face sheet, dated 7-15-2025 indicated the resident was a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of disruption of external operation (surgical) wound, not elsewhere classified, subsequent encounter (a surgical wound that has reopened after the initial surgery, and it's being addressed in a follow-up visit), and secondary diagnoses of anemia (blood isn't carrying as much oxygen as it should), type 2 diabetes (a condition where one's body doesn't use insulin properly , a hormone that regulates blood sugar), obstructive and reflux uropathy (a blockage in the body to carry out proper urination), and pain, unspecified. Record review of Resident #33's MDS dated [DATE] revealed Resident #33 was verbal, and had a BIMS score of 13 which indicated Resident #33 was cognitively intact. Resident #33's pain assessment interview indicated she was at a level 10 for pain. Record review of Resident #33's care plan with an initiation date of 6-25-2025 revealed Resident #33 was care planned for acute and chronic pain and required pain management. Resident #33's care planned directed staff to Monitor/record/report to Nurse resident complaints of pain or requests for pain relief and Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Record review of Resident #33's physician's orders, initiated on 6-25-2025 indicated the facilities' medical director agreed with Resident #33's care plan. The physician's orders stated for Resident #33 to receive Hydrocodone-Acetaminophen 2 Oral Tablets 10-325 mg. every 4 hours as needed. On 7-15-2025 at 9:15 AM, Resident #33 was heard groaning in her bedroom. Upon entry into Resident #33's bedroom, it was revealed Resident #33 was in pain at a level 10. Resident #33 stated she had been in severe pain for 3 days. Resident #33 said she told the nurse on duty 3 hours ago she was in a high level of pain but only received a muscle relaxer and it did not relieve her pain. In an observation and interview with Resident #33, on 7-15-2025 at 3:00 PM, Resident #33 was lying in bed and said her pain level was at Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete 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 07/17/2025 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some a level 9, and the facility had not provided adequate pain relief. Resident #33 said it made her feel like just giving up. In an observation and interview with Resident #33 on 7-16-2025 at 1:45 PM, it was learned that Resident #33 was at a pain level of 9 and lying in bed. In an observation and interview on 7-16-2025 at 1:49 PM, LVN D was informed that Resident #33 was at a pain level of 9. LVN D was told by Resident #33 that she was at a pain level of 9 at 1:50 PM. LVN D gave Resident #33 PRN pain medication. Record review of Resident #33's Medication Administration Note, dated 7-16-2025 at 1:54 PM, and entered by LVN D, stated Resident #33 received 2 Acetaminophen Oral Tablets 325 mg. Record review of Resident #33's MAR, for 7-15-2025 and 7-16-2025, revealed Resident #33 received her regularly scheduled pain medication of Hydrocodone-Acetaminophen Oral Tablet 10-325 mg. 1 tablet every 4 hours on all three shifts. Record review on 7-16-2025 of the MAR, for Resident #33, revealed the 6:00 AM - 2:00 PM shift (LVN D) had entered a pain rating of 0 in the Pain Assessment Section. In an observation and interview with Resident #33, on 7-16-2025 at 3:21 PM, it was revealed that Resident #33 was lying in bed and was at a pain level of 7-8 since she received the PRN pain medicine at 1:49 PM. Record review on 7-16-2025, of the MAR for Resident #33, for the 2:00 PM-10:00 PM shift, revealed LVN E had entered a pain rating for Resident #33 at a 0. In an interview on 7-16-2025 at 3:40 PM, LVN E said she had worked at the facility for about 1 year, worked the 2:00 PM-10:00 PM shift, and was assigned to Resident #33. LVN E said her process for pain management was, when she comes to work, on her evening shift, she makes rounds with the daytime 6:00AM-2:00 PM nurse and asked the residents if they are in pain. If a resident has been given regular pain medication, and they are still in pain, she will give them their PRN pain medication. LVN E said if the PRN pain medication does not work, she will contact the doctor to get a new order. LVN E said, when she came on her shift today, Resident #33 was at a level 0 for pain. Record review of Resident #33's nurse progress notes and MAR failed to indicate staff contacted the physician because of the facility's ineffective pain management. 2. Record review of Resident #83's face sheet, dated 7-15-2025, indicated a [AGE] year-old female readmitted to the facility, from the hospital, on 7-14-2025, with a primary diagnosis of unspecified dementia without behavioral disturbance (cognitive decline but cannot pinpoint the specific type of dementia or the severity of the condition), and had secondary diagnoses of chronic pain (persistent pain that lasts for three months or longer), end stage renal disease (the final stage of chronic kidney disease, where the kidneys have lost most of their function and can no longer adequately filter waste products from the blood), anemia (a low level of red blood cells carrying oxygen in the blood), and type 2 diabetes (a chronic metabolic disorder where the body either doesn't produce enough insulin or the cells become resistant to its effects, leading to high blood sugar levels). Record review of Resident #83's Quarterly MDS dated [DATE], indicated Resident #83 was verbal, and had a BIMS score of 12, which revealed she had a mild cognitive impairment. In the pain assessment portion, of Resident #83's MDS, indicated she had pain, and the intensity level was a level 7. Record review of Resident #83's care plan initiated on 12-3-2024 and revised on 5-13-2025 stated Resident #83 was care planned for pain r/t osteoarthritis, pressure wound, muscle wasting, and atrophy.staff were to Monitor/record/report to Nurse any signs of non-verbal pain. Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment.Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Discuss and record preferences [of pain management options]. Record review of physician orders dated 7-15-2025 indicated the doctor agreed with Resident #83's care plan. Resident #83's care plan stated pain assessments should be done before and after PRN medications are administered using the 0-10 pain scale or Pain AD (Pain Assessment/Documentation area) .and should be done every shift using Pain AD. (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 07/17/2025 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Resident #83's orders included pain medication of Acetaminophen 2 oral tablets by by mouth every 6 hours and Tramadol 50 mg. 2 oral tablets by mouth every 6 hours as needed for pain. In an observation and interview, on 7-15-2025 at 9:33 AM, it was revealed that Resident #83 was in pain all the time and currently was at a pain level 7 and the facility had done nothing for her pain. Resident #83 stated she tells the staff she is in pain and staff tell her they will see if they can give her another dose of pain medication, but they don't. On 7-15-2025 at 3:13 PM, Resident #83 was observed lying on her bed and stated she was at a pain level of 6. In an observation and interview on 7-16-2025 at 9:50 AM, Resident #83 was observed in her Wheelchair about to leave for her dialysis appointment. Resident #83 stated she was at a pain level 6 and was at a pain level 6 all night long. Resident #83 said rarely was she ever below a level 5 pain level at the facility. Resident #83 was observed yelling out in pain when LVN B attempted to put a sock on Resident #83's right foot. In an interview, on 7-16-2025 at 11:19 AM, it was revealed LVN B had worked at the facility for 1.5 month, worked the 6:00 AM-2:00 PM shift, and was assigned to Resident #83. LVN B said her process for pain management was for the CMAs to give out the regularly scheduled pain medication and if a resident was still in pain, she would give the PRN pain medication. LVN B said she always asked residents for their pain scale rating and documented what level of pain they are at in the MAR. LVN B said if the PRN pain medication did not work and the resident was still at a pain level of 5 or higher, she would contact the doctor. In an interview on 7-16-2025 at 11:26 AM, LVN C said she had worked at the facility for 1.5 years and worked the 6:00 AM - 2:00 PM shift. LVN C said her process for pain management was if a resident was still in pain, after his regular pain medication was given, she would look to see if they had a breakthrough (PRN) pain medication and see if they can give it to the resident. If the resident did not have a PRN medication on file, she would contact the doctor about getting one. LVN C said it was a nursing industry standard to ask a resident what pain level they were at, using the 0-10 pain scale, to determine if a resident was getting the right medication. In an interview, on 7-16-2025 at 1:19 PM, RN F said Resident #83 had been in pain, at a level 8 since 6-9-2025, every time Resident #83 came into the dialysis office for treatment. Record review of Resident #42's face sheet dated 7-16-2025, revealed a [AGE] year-old male who admitted to the facility on [DATE]. His primary diagnosis was sequelae of cerebral infarction (the long-term consequences or complications that arise after the initial brain damage caused by a stroke), and secondary diagnoses were Chronic pain, pain in the right shoulder, and muscle wasting and atrophy (the decrease in muscle mass and strength due to the breakdown or loss of muscle tissue). Record review of Resident #42's Comprehensive MDS, dated [DATE], revealed Resident #42 had a BIMS score of 8, indicating he was mildly cognitively impaired. Record review of Resident #42's care plan dated 5-6-2025 and revised on 5-12-2025 indicated he required pain management d/t chronic pain instructing staff to monitor/record/report to nurse complaints of pain and request for pain treatment.and to notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Record review of Resident #42's physician orders dated 5-5-2025 stated Resident #42 was to be assessed for pain before and after PRN pain medication was given using the 0-10 pain scale or PainAD, and document results. The physician agreed with Resident #42's care plan.Physician order date of 5-6-2025 stated Resident #42 receive Acetaminophen-Codeine Oral Tablet 300-30 MG (Acetaminophen w/ Codeine) Give 1 tablet by mouth every 6 hours as needed for Pain.Physician order date 5-14-2025 stated Resident #42 receive Norco Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hoursfor Pain related to pain in right shoulder. Record review of Resident #42's MAR revealed he received 1 Norco Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) every 6 hours for the entire month of July (continued on next page) 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 07/17/2025 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some through 7-16-2025, received 1 Acetaminophen-Codeine Oral Tablet 300-30 MG (Acetaminophen w/ Codeine) on 7-8-2025 and 7-10-2025. The Pain assessment using the PainAD/Verbal Scale 0-10, for every shift on Resident #42's MAR, indicated he was at a zero-pain rating from 7-1-2025 through 7-16-2025. In an interview and observation on 7-15-2025 at 9:08 AM, it was learned that Resident #42's pain level was at a 10. Resident #42 was observed to be swollen, and he wanted to know if his pain medication could be increased pain in his left hand. Resident #42 said his pain levels were high at night, and it was keeping him from sleeping. Resident #42 said he had to keep his left hand elevated to prevent throbbing pain. In an observation and interview, on 7-15-2025 at 2:51 PM, Resident #42 said his pain was at a level 10. In an observation and interview on 7-16-2025 at 9:16 AM, Resident #42 said his pain level was at a level 10 and has stayed at a level 10 for days. In an observation and interview on 7-16-2025 at 1:21 PM, LVN B was observed attending to Resident #42. LVN B stated Resident #42 was in pain all the time. LVN B said Resident #42 had a diagnosis which caused pain but did not know what it was. LVN B said she was not aware of Resident #42 being in pain at a level 10. LVN B said she asked Resident #42 his pain level every time she gives him pain medication, and Resident #42 has never told her he was in pain at a level 10. LVN B said she did not know what pain level Resident #42 was on 7-15-2025, even though she was working and assigned to Resident #42. In an interview on 7-16-2025 at 1:30 PM, the Medical Director revealed the facility had not contacted him about high pain levels in the last two days. The Medical Director said the facility should contact him if a resident has received their PRN pain medication, are still at a level 5 pain or higher, and the PRN pain medication did not bring the pain level below a level 5. The Medical Director said the facility did not have a pain management doctor, but it might be a good alternative to non-narcotic pain management. Record review of the facility's policy titled Pain Management, dated 6-2020 stated: To ensure accurate assessment and management of the resident's pain. A Licensed Nurse will assess residents for pain on admission and routinely as indicated by the resident's health and functional status. Facility staff is responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain.if the Licensed Nurse is unable to determine if the resident's facial expression is related to pain, the nurse will advise the attending physician and Interdisciplinary Team committee, so that the attending physician can consider ordering a pain medication.A Licensed Nurse will reassess the resident for pain quarterly and eventfully.If there is a new onset of pain, if the pain has changed in nature, or the pain has not been relieved with current medication, the Licensed Nurse will notify the Attending Physician for review of medications.Nursing staff will implement timely interventions to reduce the increase in severity of pain. An Immediate Jeopardy (IJ) was identified on 7-17-2025, at 12:46 PM. The Administrator and ADON were notified. The IJ template was provided to the Administrator via email on 7-17-2025 at 12:46 PM and a Plan of Removal (POR) was requested. The following POR was submitted by the facility and accepted on 7-17-2025 at 3:31 PM. Summary of Details which lead to outcomes.F697 - Pain Management On 7/17/2025 during annual survey at [Nursing Facility]. [State] surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The facility allegedly failed to ensure that 3 residents' chronic pain were managed to bearable levels. The notification of the alleged immediate jeopardy states as follows: The facility failed to ensure residents 83, #33 and #42's chronic pain were managed to bearable levels. Residents remained at pain levels of 6 or higher consistently even when pian medication was administered. Identify residents who could be affected. All residents with chronic pain have the potential to be affected. Identify responsible staff and what action taken. 1. Resident # 83, #33, and # 42, new pain (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 07/17/2025 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some assessment completed. MD (Medical Director) notification to clarify orders and any changes in pain management/interventions. Completed by assistant director of nursing on 7/17/25. 2. All residents with chronic pain will have a new pain assessment completed, any assessment with pain level of 4 or greater, MD will be notified to clarify orders and any changes in pain management/interventions. Completed by Nurse managers on 7/17/25. 3. All nurse managers educated by regional nurse consultant on pain management/pain assessments, change in condition/MD notification, PRN pain medication administration. Completion of 7/17/25. 4. Director of Nursing/assistant director of nursing/nurse managers in-serviced all licensed staff pain management/pain assessments, change in condition/MD notification, PRN pain medication administration. Completion of 7/17/25. 5. Regional MDS/MDS Nurse: All residents with chronic pain care plans audited to ensure appropriate pain interventions in place. Completion of 7/17/25. 6. All patients with chronic pain, assessments will be monitored daily to ensure patients' pain is managed to comfortable levels and the residents are not experiencing adverse outcome. DON/ADON Nurse managers. Ongoing daily. 7. Pain levels documented 4 or above in pain assessment by licensed Nurse will be placed in pain monitoring log to be reviewed daily by DON/ADON/Nurse manager to ensure follow up and interventions in place. In-Service conducted. 1. All nurse managers educated by regional nurse consultant on pain management/pain assessments, change in condition/MD notification, PRN pain medication administration. Completion of 7/17/25. 2. Director of Nursing/assistant director of nursing/nurse managers in-serviced all licensed staff pain management/pain assessments, change in condition/MD notification, PRN pain medication administration. Completion of 7/17/25. Implementation of Changes Resident # 83, #33, and # 42, new pain assessment completed. MD notification to clarify orders and any changes in pain management/interventions. Completed by assistant director of nursing on 7/17/25. All residents with chronic pain will have a new pain assessment completed, any assessment with pain level of 4 or greater, MD will be notified to clarify orders and any changes in pain management/interventions. Completed by Nurse managers on 7/17/25. All nurse managers educated by regional nurse consultant on pain management/pain assessments, change in condition/MD notification, PRN pain medication administration. Completion of 7/17/25. Director of Nursing/assistant director of nursing/nurse managers in-serviced all licensed staff pain management/pain assessments, change in condition/MD notification, PRN pain medication administration. Completion of 7/17/25. Regional MDS/MDS Nurse: All residents with chronic pain care plans audited to ensure appropriate pain interventions in place. Completion of 7/17/25. All patients with chronic pain, assessments will be monitored daily to ensure patients' pain is managed to comfortable levels and the residents are not experiencing adverse outcome. DON/ADON Nurse managers. Ongoing daily.Pain levels documented 4 or above in pain assessment by licensed Nurse will be placed in pain monitoring log to be reviewed daily by DON/ADON/Nurse manager to ensure follow up and interventions in place. The changes were started by the Regional Nurse Consultant. The changes were implemented effective on 7/17/2025 and training was completed on 7/17/2025. Staff will not be allowed to work until they have been fully re-educated. All new hires will be educated pain management/pain assessments, change in condition/MD notification, PRN pain medication administration. The Director of Nursing/Assistant director of nursing will ensure competency through signing of Inservice, and verbalization. Monitoring The Administrator/Director of Nursing/Assistant Director of Nursing/Regional Nurse Consultant will be responsible for monitoring the implementation and effectiveness of in-service on 7/17/25. The Director of Nursing/Assistant Director of Nursing/Regional Nurse Consultant will monitor/review abnormal pain assessments daily in stand-up. Weekend supervisor will review on Saturday/Sunday, x 4 weeks to ensure residents' pain is managed at comfortable levels and the residents are not experiencing adverse outcomes. Any adverse findings will be (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 07/17/2025 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some reviewed during QAPI. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 7/17/2025 and conducted an Ad HOC QAPI regarding ensuring chronic pain is managed to bearable levels and that residents are comfortable and not experiencing adverse outcomes. The Medical Director was notified about the immediate Jeopardy on 7/17/2025, the Plan of removal was reviewed and accepted by Medical Director. Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, to review the plan of removal on 7/17/2025. Who is responsible for the implementation of the process? The Director of Nursing and Administrator will be responsible for the implementation of New Processes. The New Process/ system was started on 7/17/2025. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy verbally issued on 7/17/2025. The facility was monitored for compliance with the POR (Plan of Removal) on 7-17-2025 as follows: In an interview on 7-17-2025 at 3:24 PM, LVN G stated he was in-serviced on pain management today and informed that the facility received an IJ for not providing effective pain management. LVN G said a new policy that had been implemented was to complete a change in condition on a resident if they were at a pain level of 4 or higher. The facility can give Tylenol if the resident has a PRN pain medication, and their pain level is from 1-5. If the resident's pain level is above a level 5, they will give them something stronger. If the resident does not have anything stronger on their chart and they are above a pain level of 5, they notify the doctor. LVN G said in the in-service for pain, he was instructed to put a pain level number in the MAR, in (PCC) and there are not prompts to put the number in. LVN G said the nurse assigned to the resident on shift, was responsible to monitor the resident's pain levels. In an interview on 7-17-2025 at 3:45 AM, LVN E said she had been in-serviced on pain management after the IJ was called. LVN E said she was instructed when a resident's pain level is a 4 or above, call the doctor for a stronger pain medication. She was told to put in the progress notes the level of pain the resident was at and what was given to them to relief it. LVN E said the changes the facility implemented was to complete a change of condition when the resident reaches a pain level of 4 or higher. Record review on 7-17-2025 at 4:20 PM, confirmed the facility had completed in-service training, by the ADON, on Medication Administration and PRN Medication Administration to ensure residents were assessed for pain after PRN medication has been given, Pain Management to ensure residents don't rise higher than a level 5, and Change in Condition and Physician notification. In an interview on 7-17-2025, at 4:25 PM, the ADON stated the DON was on vacation and she was the ADON for the entire facility. The ADON said this IJ occurred because the State identified the nurse's documentation on pain management was inconsistent. The ADON said she will complete all in-services on how to monitor, document, and perform effective pain management. The ADON said she will make sure the managers are trained on this as well as the weekend supervisors. The ADON said the nurses on duty will notify management (ADON/DON) whenever the pain levels are greater than a 4, and they will have a discussion as to what needs to be done next. The ADON said the physician will also be called when pain levels rise above a 4. After that, the ADON said a follow-up with the patient will occur and a review of proper documentation by the nursing staff. The ADON said a new process was the facility now has a Pain Management Log, where pain levels that are greater than 4 are entered into it. In an interview, on 7-17-2025 at 4:42 PM, LVN C revealed that she was provided an in-service on 07/17/2025. LVN C said the in-service stated there will be a pink binder at the nurse's station containing pain assessment forms on each resident. The nurses were to document pain findings in the binder. LVN C stated that when a resident was in pain, we were to document the pain level, give them their routine pain medication, wait for a while, then note what their pain level was after the medication was given. If pain was at a level 4, we were to call the physician (continued on next page) 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 07/17/2025 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some for possible additional medication. LVN C said we then continue to monitor resident's pain level, and if pain continues, contact the physician to send the resident to hospital.In an interview, on 7-17-2025 at 4:45 PM, LVN D revealed that she was provided an in-service regarding pain management on 07/17/2025. LVN D said that nurses are to monitor resident's pain levels regularly and provide residents with routine pain medication. If a resident's pain level rose to a level 4, nurses are to call the physician to see if the physician will order another pain medication. If the resident's pain level is still high, contact the Physician, with change in condition filled out, and the physician will send the resident out to hospital for uncontrollable pain. In an interview, on 7-17-2025 at 4:59 PM, LVN B revealed that she was provided an in-service on pain management on 07/17/2025. LVN B said that the in-service training stated we were to document resident's pain levels, on the Pain Assessment form, when a resident asked for pain medication. LVN B said after a resident has received their regularly scheduled pain medication, wait a while, check their pain level again, and document the pain level. LVN B said if a resident's pain level was at a level 4 or above, the nurse was to call the physician for another medication. The nurse was to continue to assess the resident for pain. If a resident's pain continues to be at a level 4 or greater, contact the physician so the resident can be sent out to the hospital to be treated. In an interview, on 7-17-2025 at 5:00 PM, LVN H stated that he was not in-serviced on pain management, as of today, but was in-serviced on pain management on 7-14-2025. LVN H said he was trained to document the pain medication given to the resident that was prescribed by the doctor. LVN H said the facility has narcotics in stock. LVN H stated that he will follow-up with the resident and document the resident's pain level. LVN H said he will let the doctor know if a resident's pain persists. LVN H said if the doctor has initiated a narcotic, and he has given the resident the narcotic, he will follow up with the doctor to let him know how the resident is doing. The ADON and nurses are responsible for managing resident's pain levels and monitoring what the nurses are doing. On 7-17-2025, at 6:02 PM, LVN H said he was in-serviced on pain management, pain levels, and when to notify the doctor. LVN H said he was told to notify the doctor if a resident's pain level reached a level 5. LVN H said the in-service stated once a nurse gives a resident pain medication, the nurse was to follow up with the resident to see how effective the pain medication was. The nurses were to document, in the progress notes, what level the resident's pain was. If the pain level has not dropped, contact the doctor. In an observation, on 7-17-2025 at 5:20 PM, Resident #83 was observed to be sleeping peacefully. In an interview, on 7-17-2025 at 5:45 PM, the Medical Director stated the risk to residents not receiving proper pain management could be it could cause other problems. The Medical Director said pain management can be tricky, and everyone is different. The Medical Director said the nursing staff need to make sure they document pain management correctly in the electronic medical records. In an observation, on 7-17-2025 at 5:50 PM, Resident #42 and Resident #33 were observed being transported to the hospital due to high pain levels. On 7-22-2025 at 12:20 PM, the Administrator said the IJ occurred because the State found a concern with the way the facility was handling pain management. The Administrator said the way the facility will monitor the ensure compliance with the POR was to have daily management meetings with the nursing department and for management to stay in communication with the weekend shift with residents who have pain concerns. The facility will bring those concerns to the QAPI monthly meetings. The Administrator said the DON and the Administrator were responsible to monitor and oversee the processes of pain management. An Immediate Jeopardy (IJ) was identified on 7-17-2025 at 12:46 PM. The IJ template was provided to the facility on 7-17-2025 at 12:52 PM. While the IJ was removed on 7-17-2025 at 5:50 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal (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 07/17/2025 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 0697 harm, that was not immediate jeopardy, and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 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 07/17/2025 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that resident who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 4 residents (Resident #67) reviews for dialysis documentation. The facility failed to ensure Nurses documented ongoing assessments of Resident #67's condition and monitoring complications before and after dialysis treatments received at a certified dialysis facility. This deficient practice could place residents at risk of complications from dialysis due to the lack of documentation between the facility and dialysis center in the event of a medical event. Findings include: Record review of Resident #67's face sheet, dated 07/17/2025, revealed resident was a [AGE] year-old female admitted to the facility on [DATE] with a readmission on [DATE]. Resident #67's admitting diagnoses included Type 2 Diabetes Mellitus with Diabetic Neuropathy (caused by high levels of sugar in blood damaging the tiny blood vessels that supplied to nerves); Acute on Chronic Diastolic (Congestive) Heart Failure (a worsening of diastolic heart failure, a condition where the heart muscle doesn't relax properly during its filling phase, leading to congestion in the lungs and body); and End Stage Renal Disease (a condition in which the kidneys lose the ability to remove waste and balance fluids). Record review of Resident #67's quarterly MDS, dated [DATE], revealed her BIMS Score was 15/15, which indicated the residents' memory was intact. Resident #67's cognitive abilities were within a normal range. Resident #67 could make independent decisions regarding her care. Record review of Resident #67's care plan, dated 03/28/2023 and revised 01/13/2025, revealed in part Resident #67 needed hemodialysis r/t renal failure every Monday, Wednesday, and Friday. Resident #67 would have no complications from dialysis through the review date. Monitor, document, and report to MD any symptoms and side effects of infection to access site: Redness, swelling, warmth or drainage. Monitor, document and report to MD PRN for symptoms and side effects of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Record review of Resident #67's Dialysis Communication Forms revealed, dates 05/02/2025 through 05/30/2025, were fully completed from 14 dialysis treatments out of 14 dialysis treatments. Dialysis Communication Forms revealed dates 06/02/2025 through 07/16/2025, 9 forms were fully completed out of 20 dialysis treatments. Date 06/13/2025 had no form on file for that day. The remaining forms in Resident #67's file was not fully completed with the required information from the facility and/or the dialysis center. In an interview on 07/17/2025 at 10:00 AM with the ADON revealed each nurse was responsible for completing the Dialysis Communication Form for the resident before the resident left for their dialysis treatment. When the resident returned from their dialysis treatment, the dialysis center was to have documented the dialysis information r/t the resident on the form and return with the resident to the facility. The nurse was to document a note in the progress notes and add the information to the Dialysis Communication Form in the resident's file. The form was usually shredded when it was inputted into a resident's file. Resident #67's information should have been documented on the Dialysis Communication Form upon her return from each dialysis treatment. The ADON stated the forms may be in a book at the nurse's station or in medical records. The ADON stated if forms were unable to be located, the dialysis center would be contacted for the documentation to be sent from the previous dialysis treatments so the nurse could document them in Resident #67's file. The nurses are trained to complete the Dialysis Communication Form prior to a resident's dialysis treatment to provide the dialysis center with communication pertinent to resident. The dialysis center is to return the Dialysis Communication Form with resident with communication r/t resident during dialysis Residents Affected - Few (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 07/17/2025 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete treatment. The nurse would be able to monitor the resident for any changes that may have occurred at the dialysis center during their treatment and to be able to continue to monitor the resident upon return to the facility. If a resident had any medical changes at the dialysis center or at the facility, the resident would be sent to the hospital for a change in condition. Resident #67 has not had change in condition noted on the Dialysis Communication forms reviewed. Record review of the facility's Dialysis Care Nursing Care policy (revised 06/2020) - revealed in part, The Nursing Staff, Dialysis Provider Staff, and Attending Physician ( Dialysis Staff) will collaborate on a regular basis concerning the resident's care as follows: I. Nursing Staff will communicate pertinent information in writing to the Dialysis Staff which may include: a. Any medication changes; b. Any recent changes in condition; c. The resident's tolerance of dialysis procedures. II. The Dialysis Provider will communicate in writing to the Facility: a. The resident's current vital signs; b. Pre and post dialysis weight; and c. Any problems encountered while the resident was at the dialysis provider. 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 07/17/2025 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly. 1. The facility failed to ensure the garbage storage area was maintained in a sanitary condition to prevent the harborage and feeding of pest by failing to ensure garbage was kept off the ground, surrounding the facilities two outside trash dumpsters, and failed to keep the facility's grease trap dumpster closed. These failures could place residents at risk of contracting disease by attracting pest and disease carrying rodents. Findings included: 1. During an observation on 7-15-2025 at 8:00 AM, it was revealed that trash (used latex gloves, paper plates, used plastic wrappers, and various other trash) were on the ground surrounding the facility's two trash dumpsters. The facilities' only grease-trap-dumpster was observed to be open with greasy residue on top. These areas were observed to not have any borders or fencing around them and accessible to facility residents. The dumpster with the sliding door, was observed to be open and half full of trash. 2. During an interview with the Director of Maintenance on 7-15-2025 at 8:05 AM, it was learned that the Director of Maintenance was responsible to ensure the grounds of the facility stayed clean of trash and debris. The Director of Maintenance stated he did not know what potential risk or effect, having trash on the grounds by the trash dumpsters, could have on facility residents. The Director of Maintenance stated he believed a trash truck came and emptied the dumpster's contents and scattered the trash around the dumpsters. 3. During an interview with the Dietary Manager on 7-16-2025 at 4:30 PM, it was stated that the Director of Maintenance was responsible to keep trash off the facility's grounds and keep the trash dumpster doors closed when not in use. The Dietary Manager said it was the Dietary Manager's responsibility to keep the grease-trap-dumpster's door closed when not in use. The Dietary Manager stated it was her expectation that the trash dumpsters doors stay closed when not in use, trash stay picked up off the outside grounds, and the grease-trap-dumpster lid stay closed when not in use. The Dietary Manager stated having trash on grounds of the facility could attract rodents and pest. The Dietary Manager stated the potential harm to resident by not keeping the grease-trap-dumpster closed could be that residents could get grease on them because the area where the grease-trap-dumpster was housed was not fenced in. 4. During an interview with the Administrator, on 7-17-2025 at 5:00 PM, it was learned that the expectations of the Administrator were for the trash dumpster doors to remain closed when not in use, trash to remain off the facility's grounds, and the grease-trap-dumpster lid to remain closed when not in use. The Administrator stated not maintaining these areas properly could attract unwanted pest. The Administrator said the facility did not have a trash disposal policy. Record review of the facilities' Maintenance Services Policy dated 8-2020, stated: The Maintenance Department maintains all areas of the building, grounds, and equipment in a safe and operable manner at all times.the Director of Maintenance is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.The Director of Maintenance is responsible for conducting regular inspections. Review of the U.S. Public Health Service Food Code, dated 2022, reflected: 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled; and (B) With tight- fitting lids or doors if kept outside the FOOD ESTABLISHMENT. Review of The Occupational Safety and Health Act (OSHA) safety bulletin titled Grease Trap Hazards dated 2/2020 stated: Grease traps can generate flammable and toxic gases over time. These gases can include methane (natural gas), hydrogen sulfide, carbon monoxide, carbon dioxide, and/or other gases depending on the greases, oils, and fats found in the grease traps.to prevent such hazards grease traps Residents Affected - Many (continued on next page) 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 07/17/2025 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 0814 [should be] properly covered [securely]. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 07/17/2025 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 on observation, interview and record review the facility failed to establish and 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 1 of 4 residents (Resident #70) reviewed for infection control. CNA A failed to put on Personal Protective Equipment (PPE) while providing toileting care for Resident #70, who was on Enhanced Barrier Precaution (EBP). This deficient practice could place residents at risk of transmission of communicable diseases and infections. Findings include: Record review of Resident #70's face sheet, dated 7/15/2025, revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #70 had diagnoses which included stroke, chronic pain and muscle weakness. Record review of Resident #70's physician orders, dated 7/15/2025, revealed there was an order placed on 05/13/2025 which stated, Enhanced Barrier Precautions r/t (wound): Staff members will wear a clean gown and gloves while performing high contact resident care activities to include. changing briefs or toileting assistance. Record review of Resident #70's care plan, dated 5/7/2025, revealed Resident #70 had a stage 4 pressure ulcer on the sacrum. Record review of Resident #70's care plan, dated 4/5/2024, revealed Resident #70 was put on Enhanced Barrier Precautions. In an observation on 7/15/2025 at 10:30 AM, CNA A provided toileting care for Resident #70 without putting on PPE. Resident #70 had a stage 4 pressure ulcer on his sacrum. The Enhanced Barrier Precaution sign was posted on Resident #70's door. In an interview on 7/15/2025 at 10:45 AM, CNA A stated she forgot to put on PPE before providing care to Resident #70. She stated she was aware the resident had a wound and he was on Enhanced Barrier Precaution. She stated the risk of not wearing PPE was transmission of infection. In an interview on 7/17/2025 at 9:00 AM, the ADON stated her expectation of her nursing staff was they followed through with infection control policy. She stated she provided in-services on infection control frequently and on 7/15/2025, CNA A reported to her and a 1:1 in-service was done with CNA A and all nursing staff were in-serviced on infection control and Enhanced Barrier Precaution. She stated the risk to residents and staff if EBP was not practiced was the spread of infection. Record review on 7/17/2025 at 9:40 AM revealed CNA A completed the Corrective Action form and in-service training record indicated EBP in-service was provided to all nursing staff on 7/15/2025. Record review of the facility's Standard and Enhanced Precautions policy, dated 4/1/2024, revealed for residents whom EBP are indicated, EBP should be used when performing. bathing/showering, providing hygiene, changing briefs or assisting with toileting. Residents Affected - Few 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 07/17/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 4 halls reviewed (Hall 400) for environment. The facility failed to maintain Hall 400 in a safe and sanitary condition free from air conditioning condensation leaks from the ceiling onto the hallway floor. This failure could place residents at risk for injury and a decreased quality of life. Findings include: Observation on 07/15/2025 at 11:00 AM revealed water dripping from the ceiling between a fluorescent ceiling light and air vent onto the floor where a small puddle had formed and stained the floor tiles between rooms [ROOM NUMBERS] on the 400 hall. Observation on 7/15/2025 at 11:46 AM of the 400 hall between rooms [ROOM NUMBERS] revealed a wet floor sign was placed by the Administrator after she exited room [ROOM NUMBER] and noticed the water accumulation on the floor in the middle of the hallway. Observation on 7/17/2025 at 8:15 AM revealed a caution sign on the 400 hall between rooms [ROOM NUMBERS] where the water leak from the ceiling was previously identified. The floor tiles under the ceiling water leak revealed areas of staining. Interview on 7/15/2025 at 11:05 AM with Housekeeper J revealed the dripping water was noticed on 7/14/2025 and was reported to the facility Maintenance Director. Housekeeper J stated the water accumulation on the floor was monitored between cleaning resident rooms and mopped when accumulation was seen. Housekeeper J stated there was a bucket or trash can under the leak to catch the water yesterday, but the housekeeper was not sure where it went. Housekeeper J stated a wet floor sign was placed in the area yesterday but had not noticed it was removed. Interview on 7/16/2025 at 5:10 PM with the Administrator informed a discussion with the Maintenance Director revealed there had been condensation buildups in the building related to air conditioning units operating during the high temperatures and temperature adjustments made between hallways for resident comfort. The Administrator stated she had not thought there was any significant water accumulation on the floor on the 400 hall, however, saw some water on the floor in the 400 hallway the prior day and placed a caution sign in the area until it could be wiped up. Interview on 7/17/2025 at 4:34 PM with the Administrator revealed she was not informed on 7/14/2025 by housekeeping staff about the dripping water in the back of the 400 hall. The Administrator stated that was not an area known to have condensation drip issues, however there was an area at the front of the 400 hall that had issues previously that were addressed. The Administrator stated the risk of water dripping from the ceiling could be a resident or other person having a fall, the water could cause an accidental trip or slip hazard. The Administrator stated the expectation of staff who encountered a water leak was for the staff member to not leave the area, place a caution sign in that area, alert housekeeping for the area to be cleaned, then notify the Administrator or Maintenance Director immediately as well as place a work order. Interview on 7/17/2025 at 5:10 PM with the Maintenance Director revealed he was notified yesterday of the water leak from the ceiling at the end of the 400 hall. The Maintenance Director stated a call was placed to the contracted air conditioning company who came to the building for a repair call. The Maintenance Director informed the identified cause of the ceiling leak was an air conditioning duct that was sweating condensate due to a winterization bag covering a turbine on the roof above the area of the leak that was still in place. The Maintenance Director informed the risk of water leaks onto a hallway floor was the possibility of a slip and fall or other accident which could result in a person being hurt. The Maintenance Director stated he expected any staff member who encountered a water leak or other maintenance issue to let him know immediately so the issue could be addressed right away. The Maintenance Director stated when he was notified of an issue that (continued on next page) 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 07/17/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete required immediate attention, like a water leak, it was important to find the root of problem and remedy it properly to avoid an accident. The Maintenance Director stated if he was not on the facility property when an issue was identified, his telephone number was posted along with other department heads at the nurse's station. Record review of the facility grievance log did not reveal any grievances filed for maintenance repairs in the prior 60 days. Record review of the facility Maintenance Services policy, revised 08/2020, stated: Purpose: To protect the health and safety of residents, visitors, and Facility Staff.Policy: The Maintenance Department maintains all areas of the buildings, grounds, and equipment.Procedure:I. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.II. Functions of the Maintenance Department may include, but are not limited to: a. Maintain building in compliance with current local, state, and federal laws, regulations, and guidelines; b. Maintain the building free from hazards. e. Maintaining heating/cooling system, plumbing fixtures, wiring, etc., in good working order. g. Establishing priorities in providing repair service.VI. The Director of Maintenance is responsible for conducting regular inspections that may include, but are not limited to.: c. Hallways.IX. Maintenance staff follow established safety regulations to ensure the safety and well-being of all concerned. Record review of the facility Maintenance - Work Order policy, revised on 08/2020, stated: Purpose: To protect the health and safety of residents, visitors, and facility staff.Policy: Maintenance work orders shall be completed in an effort to sustain maintenance services as a priority.Procedure:I. To enable the Maintenance Department to prioritize tasks, Work Order Form will be filled out and forwarded to the Maintenance Director. A. Department directors/supervisors are responsible for completing such work orders and forwarding them to the Director of Maintenance B. The nurses stations will have work order forms available for use.II. Emergency work orders are given priority. A. Emergency requests should be delivered directly to the Director of Maintenance. 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 07/17/2025 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 Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for one of one resident (Resident #25) room and in two public areas reviewed for pest control. The facility failed to ensure the facility was free of roaches in common areas and the dining room.The facility failed to ensure the facility was free of flies in Resident #25 room. This failure could place residents at risk of living in an unsanitary environment.Findings include: Observation on 07/15/25 at 7:30 AM one roach crawling across the floor by the receptionist's desk. Observation on 7/15/2025 at 11:15 AM of Resident #25's room revealed 7 flies; 5 of the flies were on her body/blanket/pillow. Observation on 07/15/25 at 12:33 PM revealed a roach crawling on a wall close to the trash can in the dining room. An attempted interview was made on 07/15/2025 at 11:15 AM with Resident #25. She was hard of hearing and was unable to understand questions asked. Interview on 7/15/2025 at 11:21AM with Housekeeper J revealed the 400 hall was where she usually worked. Housekeeper J stated her assigned job duties included cleaning the restrooms, dust vents, and cleaning the bed of the resident rooms and hallway. Housekeeper J indicated pests were noticed, mainly small roaches. Housekeeper J stated the pests have not gone away despite cleaning. Housekeeper J stated she would inform the Administration if she saw pests. Housekeeper J stated she noticed the flies on Resident #25 since Saturday and thought it was due to the resident having a colostomy bag and the smell was attracting the flies. Housekeeper J said she hadn't heard the resident say anything about the flies. Interview on 7/15/2025 at 11:28 AM, the Maintenance Director stated pest control came regularly every month and they just had them come last Monday (7/07/2025). The Maintenance Director was brought to Resident #25's room and was shown the flies. The Maintenance Director stated this was the first time he was aware of the flies and stated he could request pest control service to come more often than just once a month and some rooms may have been more susceptible to pests than others due to residents having opened the windows where flies came in or had left food in the room for 3 days, etc. The Maintenance Director stated nursing staff and all other staff could notify him if there was a pest problem. Interview on 7/15/2025 at 12:18 PM with CNA I revealed she observed no flies were observed on Resident #25 or pests in general but would report to Maintenance Director if seen. Interview on 7/16/2025 at 8:30 AM with the Administrator who stated the fly problem was something the facility was aware of and it had been a problem at the facility for weeks, not just in Resident #25's room. Resident #25 liked to open the window and it did have a protective screen, but flies still came in. Pest control came in last week and over the last couple of weeks with the result of a decrease in fly activity. The Administrator revealed the fly pest issue had already begun being addressed through their Ad Hoc meeting. Interview on 7/17/2025 at 9:10 AM with the Administrator who stated the risk of pests was infection control and discomfort to the residents. Record Review on 7/16/2025 of Pest Control Log revealed:07/10/2025 - treated breakroom, conference, dining, kitchen. Flies in hallway.07/01/2025 Rebated rodent, treated for flies inside and outside06/13/2025 - Treated for flies06/04/2025 - Treated kitchen and hallway05/29/2025 - Changed glueboards05/06/2025 - rebaited for rodents Record review on 7/17/2025 of document Service Inspection Report, dated 07/01/2025, provided by Administrator was an amended pest control report indicating Resident #25 room was treated specifically. Record review on 7/17/2025 of Grievance Report revealed on 07/01/2025 Resident #25's family member reported flies in the resident's room. The facility had pest control come out to treat it. Record review of the facility's Pest Control Policy, revised 08/2020, reviewed: Purpose: To ensure the Facility is free from insects, rodents, and other pests that could compromise the health, safety, and comfort of residents, Facility Staff, and visitors.Policy: The Residents Affected - Few (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 07/17/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Facility maintains an ongoing pest control program to ensure the building and grounds are free from insects, rodents, and other pests.Procedure:I. General PracticesD.The Maintenance Department assists, when appropriate and necessary, with pest control services.II, Pest Control Service ProviderB. The Company will perform the following services: . 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.III. Staff RoleA. Facility Staff will report to the Housekeeping Supervisor any sign of rodents or insects,including ants, in the Facility.i. The Housekeeping Supervisor takes immediate action to remove the pests fromthe Facility.ii. If necessary, after informing the Administrator, the Housekeeping Supervisor will call the extermination company for assistance. Event ID: Facility ID: 455457 If continuation sheet Page 19 of 19