Inspection·September 5, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few left cheek and 1cm to bottom lip. Observation on 09/04/25 at 11:30 AM of Resident #2 revealed she was walking up and down the hallway alone. Resident #2 was not able to answer any questions and just kept walking past the surveyor. Record review of Resident #3's Quarterly MDS Assessment, dated 07/10/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. She had a BIMS score of 01, indicating severe cognitive impairment. Her noted behaviors indicated she had physical behaviors towards other that occurred for 1 to 3 days. Her active diagnoses included non-Alzheimer's disease (a general term for any form of dementia that is not classified as Alzheimer's disease), anxiety disorder (a range of conditions that cause significant and uncontrollable feelings of anxiety and fear), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), and psychotic disorder (a severe mental health condition characterized by a loss of contact with reality, often manifesting as delusions and hallucinations). Record review of Resident #3's Care Plan, revised on 07/17/25, reflected the following: Focus: [Resident #3] has potential to demonstrate physical behaviors.Interventions: When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.Empty room at the end of the hall has been locked to prevent residents wandering in and out of the room. Record review of Resident #3's Progress Notes reflected the following entry: LVN D wrote on 07/17/25 at 9:21 AM: Event- Other.4 residents were walking the hallways peacefully, per CNA two residents went into an empty room at the end of the hall and closed the door in [Resident #3's] face, [Resident #3] became agitated and pushed hard on the door, one resident opened the door and [Resident #3] grabbed her hair and pulled her out of the room. other [sic] resident started screaming and punching [Resident #3] while [Resident #3] pushed and pulled on other residents [sic] hair. nurse [sic] and CNAs ran to other end of the hall to separate residents and deescalate.Resident Statement: [Resident #3] is mostly nonverbal but was able to say ‘i [sic] was just trying'. Observation and attempted interview on 09/04/25 at 12:31 PM with Resident #3 revealed she had just come back from being out on pass with her family and had a fast-food bag of food in her hands. Resident #3 was being guided to sit down in the dining room at a table to eat her food. Resident #3 was not able to answer any questions and instead just smiled at the surveyor. Record review of the facility's Provider Investigation Report, dated 07/23/25, reflected the following: Investigative Summary: [Resident #2] and [Resident #4] entered room [ROOM NUMBER], closed the door, and [Resident #3] was walking toward the room as well. [Resident #3] pushed the door twice, met resistance, and forced the door open. [Resident #2] was behind the door, [Resident #3] grabbed [Resident #2] by the hair and started hitting each other. Staff saw the altercation and ran to separate the residents. Both residents were assessed for pain, skin, and trauma informed assessment. [Resident #2] sustained a scratch in the lower left eye. [Resident #3] was placed 1:1.Staff were interviewed. Social/psych consult for both residents. Secure care consult for [Resident #3]. No resident shows signs of anxiousness or being scared.Facility investigation Findings: Confirmed. Record review of a Witness Statement, dated 07/17/25, completed by CNA W reflected the following: [Residents #2, #4, #3, and #5] was [sic] walking towards the end of the hall; [Residents #4 and #2] went inside room [ROOM NUMBER] and closed the door. [Resident #3] walked up to the door and pushed it twice and grabbed [Resident #2] by her hair. I yelled ‘They fighting' [sic] [LVN D, CNA G], & myself ran down the hall; while [Resident #3] was punching [Resident #2] in the face, they were leaning against the wall in the corner still fighting. We broke the fight up and called [the Administrator], took [Resident #3] down the hall & sat inside an empty room and [Resident #2] at the nurse's desk. Interview on 09/04/25 at 11:53 AM with CNA E revealed he was not here when Residents #2 and #3 had an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455819 If continuation sheet Page 2 of 11 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 455819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arlington Heights Health and Rehabilitation Center 4825 Wellesley St Fort Worth, TX 76107 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few altercation on 07/17/25. CNA E said he was aware of both residents' triggers and signs they were beginning to get agitated. CNA E said Resident #2 walked up and down the hallway all day long and Resident #3 liked to walk around as well and would try to help others since she used to be a CNA herself. CNA E said staff assured Resident #3 that she did not need to help them with the other residents and distracted her with music. CNA E said he had never known or seen either Resident #2 or #3 have any physical behaviors towards another resident. CNA E said he knew to immediately intervene when two residents had an altercation with each other. CNA E said he was in-serviced after the incident to ensure he knew the facility's abuse policy and procedures as well. Interview on 09/04/25 at 12:20 PM with CNA F revealed she was not here when Residents #2 and #3 had an altercation on 07/17/25. CNA F said she had never seen or known Residents #2 or #3 to have any physical behaviors towards other residents. CNA F said Resident #3 was very caring and loving towards other residents and since she was a CNA in her past life she liked to try to help other residents. CNA F said Resident #2 was known to get upset at times but was easily calmed down through redirection and talking to her. CNA F said she was aware of both Residents #2 and #3 signs of agitation and knew how to calm them down. CNA F said she was in-serviced after the incident to ensure she knew the facility's abuse policy and procedures as well. Interview on 09/04/25 at 12:26 PM with LVN D revealed she saw Residents #2 and #3 trying to get into the last room at the end of the hallway. LVN D said Resident #2 went into the room first and when Resident #3 tried to go in it upset Resident #2. LVN D said she saw Resident #2 close the door to the room in Resident #3's face which made her upset. LVN D said Resident #3 went to push the door open again and Resident #2 slammed it shut on her. LVN D said Resident #3 opened the door again and grabbed Resident #2's hair and Resident #2 started punching Resident #3. LVN D said she saw Resident #3 stumble back into the wall behind them in the hall and by then staff were there separating the two residents. LVN D said Resident #2 ended up having scratches to her face and lip. LVN D said Resident #2 was hysterically crying and upset initially but afterwards she calmed down. LVN D said after about 15 minutes, neither resident remembered what had happened. LVN D said Resident #3 was placed on 1:1 monitoring and Resident #2 was on every 15 minute checks. LVN D said she had never seen either resident have physically aggressive behaviors towards any other resident before this incident occurred. LVN D said she was aware of both Residents #2 and #3 signs of agitation and knew how to calm them down. LVN D said she was in-serviced after the incident to ensure she knew the facility's abuse policy and procedures as well. Attempted phone interview on 09/04/25 at 1:05 PM with CNA G, who worked with Residents #2 and #3 on 07/17/25, was unsuccessful as she did not answer or call back prior to exit. Record review of a witness statement, dated 07/17/25, completed by CNA G reflected the following: I didn't see the beginning of what happened was [sic] at the nurses station when I heard someone say [Resident #2] and [Resident #3] were fighting ran [sic] down the hall to pull them apart. Phone interview on 09/04/25 at 1:11 PM with CNA H. who worked with Residents #2 and #3, revealed she had never seen either resident have physically aggressive behaviors towards any other resident before this incident occurred. CNA H said she was aware of both Residents #2 and #3 signs of agitation and knew how to calm them down. CNA H said she was in-serviced after the incident to ensure she knew the facility's abuse policy and procedures as well. Interview on 09/04/25 at 2:34 PM with Housekeeper I revealed she did not see how the situation started between Residents #2 and #3 on 07/17/25. Housekeeper I said she did see Resident #3 pulling Resident #2 by her hair out of a room, which was odd because they were just seen holding hands in the hallway. Housekeeper I said she saw staff intervening and separating the residents immediately but that was all she knew or saw. Interview on 09/04/25 at 3:50 PM with the Administrator revealed both Residents #2 and #3 had a habit of walking up (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455819 If continuation sheet Page 3 of 11 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 455819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arlington Heights Health and Rehabilitation Center 4825 Wellesley St Fort Worth, TX 76107 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete and down the hallway. The Administrator said that Resident #2 liked to go into the last room on the right side of the hallway. The Administrator said Resident #2 walked into the room and Resident #3 walked in behind her. The Administrator said when Resident #3 walked in, Resident #2 closed the door on her and then Resident #3 pushed on the door harder. The Administrator said when the door opened, Resident #3 grabbed Resident #2 and they both started hitting each other. The Administrator said Resident #2 had a scratch under her eye that was superficial and did not require any further treatment. The Administrator said Resident #3 was placed on 1:1 monitoring since she initiated the first contact with Resident #2. The Administrator said staff were in-serviced on abuse, resident-to-resident altercations, and behaviors. The Administrator said the door to the room they tried going into was also now locked so that they could not go in there anymore. The Administrator said all residents had the right to be free from abuse, even from each other. The Administrator said all staff were responsible for ensuring that any resident in the facility was free from abuse. The Administrator said the incident that occurred between Residents #2 and #3 was considered physical abuse. The Administrator said if residents were not free from abuse they could suffer physical or mental anguish from the situation. The Administrator said he expected all staff to ensure residents were free from abuse. Record review of an in-service dated 07/17/25 and titled Approaching and calming residents with Dementia, revealed 90 staff had been in-serviced. Record review of an in-service dated 07/17/25 and titled Resident to Resident Abuse, revealed 90 staff had been in-serviced. Record review of the facility's Abuse/Neglect policy, dated 03/29/18, reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in the subpart.Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. Event ID: Facility ID: 455819 If continuation sheet Page 4 of 11 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 455819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arlington Heights Health and Rehabilitation Center 4825 Wellesley St Fort Worth, TX 76107 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1, who had dementia, was provided with adequate supervision to prevent her from eloping from the facility on 08/08/25. The resident was found half a block away from the facility. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 08/08/25 and ended on 08/08/25. The facility had corrected the noncompliance before the investigation began. This failure could place residents who require supervision at risk of harm, severe injury, and possible death. Findings included:Record review of Resident #1's admission Record, dated 09/04/25, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included cerebral infarction unspecified (when the blood supply to part of the brain is blocked or reduced which prevents brain tissue from getting oxygen and nutrients and brain tissue begins to die), unspecified dementia (a group of symptoms affecting memory, thinking and social abilities), with unspecified severity and without behavioral disturbance; psychotic disturbance (a severe mental health condition characterized by a disconnection from reality); mood disturbance (mental health conditions that primarily affect a person's emotional state); and anxiety (an abnormal and overwhelming sense of apprehension and fear often marked by physical signs). Record review of Resident #1's Optional State Assessment MDS Assessment, dated 07/13/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. The resident had severe cognitive impairment with a BIMS (cognitive screening tool) score of 6. The MDS reflected the resident did not have wandering behaviors. Record review of Resident #1's Elopement Risk Evaluation, dated 07/17/25, which is used to assess the likelihood of a resident leaving a facility without the facility's knowledge and supervision, reflected the resident was at a moderate risk of elopement with a score of 6. Record review of Resident #1's Consent for Secured Unit, dated 08/08/25 reflected Resident #1 gave consent to be placed on the Secured Unit. Record review of Resident #1's Progress Notes from 07/10/25-08/07/25 reflected no documented evidence that she was exit-seeking or had made any elopement attempts. Record review of Resident #1's Progress Notes written by LVN K on 08/08/25 at 6:34 PM reflected: Today around 1500 [3:00 PM] [Resident #1] was found outside down the street by staff members after she escaped our facility by following an unknown someone who was exiting the building after they used the passcode that only staff knows. She was found with her walker outside and was brought back to the facility. We looked through the sign-out binder to see if anyone signed her out today and no one had signed her out. When I asked her roommate if she had any knowledge or warning from [Resident #1] that she was going to try and escape her roommate said ‘Yes. [Resident #1] said she was getting out of here.' When I asked [Resident #1] why and how she escaped outside today she said, ‘I don't want to be here anymore people are mean to me and call me names.' And when describing how she got out she said, ‘Someone got out of a car, went to open the door, as that person was entering, another person exiting, and I followed that person out the door.' I called her Responsible Party to alert her to this elopement, she didn't answer my call, I left a voicemail. Record review of Resident #1's Care Plan, dated 09/05/25, reflected: Focus: [Resident #1] resides in secure unit related to High Risk for Elopement-8/8/25: Actual Elopement.Goal: Resident will not have feelings of isolation and will feel safe and secure in the care received while on the secured unit.Interventions: Admit to secure unit per DR orders. Assist and monitor resident for off unit activities if able.Involve resident in daily activities designed for secured unit. Monitor for s/s of depression, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455819 If continuation sheet Page 5 of 11 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 455819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arlington Heights Health and Rehabilitation Center 4825 Wellesley St Fort Worth, TX 76107 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few withdrawal from usual activities.Notify MD and family of any changes.Psych services per DR orders. Record review of the facility's Provider Investigation Report, completed by the Administrator on 08/15/25, reflected the following under the Investigation Summary section: On 8/8/2025 at 2:55pm.housekeeper saw what she thought was a resident outside the facility. She came to the administrator's office and wanted to report what looked like a resident outside. Admin started running down towards the exit door. Housekeeper used her car to go down the road. [Housekeeper M] located the resident halfway down the block. [Housekeeper M] placed resident in her car and picked up the admin as well. Admin asked resident, why she left the facility, and she stated she got kicked out. She would not elaborate on anything else. Resident was brought back to the facility around 2:59pm. Resident was placed on the secure unit after being interviewed by the DON. Admin reviewed cameras and resident left from the 300-hall main exit. Video shows the resident walking to the door, an outside transport company was delivering a new resident, opened the door, and let the resident out without asking the resident any questions or stopping the resident. The transport staff did not let anyone know of the resident walking out. Admin called transport company to inform them of the incident. We are still waiting for staff in servicing information. Codes to exit doors were changed. All doors were checked for proper functioning with no issues. Elopement drill was conducted. Elopement assessment on all residents conducted. Verified signage is still placed on exit doors. Sent a message to all employees on change of code to the door. Sent a message to all families about not letting any resident out of the facility and to make sure the door closes behind them. Further record review of the facility's Provider Investigation Report reflected the following: Provider Action Taken Post-Investigation: In service on Elopement response.In service on Elopement prevention.In service on Abuse/Neglect.In service on door alarms. Interview on 09/04/24 at 10:22 AM, with LVN K revealed that Resident #1 had not eloped previously or attempted eloping previously. LVN K stated that she was unaware that Resident #1 had eloped until she was notified by the ADON that she had gone. LVN K stated that she had not previously noticed Resident #1 watching the front door or exit seeking. Interview on 09/04/25 at 11:47 AM, 12:18 PM, and on 09/05/25 at 9:38 AM with Resident #1 was attempted, but the resident did not awaken from her sleep. Interview on 09/04/25 at 10:43 AM with Housekeeper M revealed at about 2:50 PM on 08/08/25 she had clocked out and exited the facility. Housekeeper M stated immediately after she left, she saw an elder with a walker walking in the middle of the street. Housekeeper M said the resident said she had been kicked out of where she lived, and so the Pope told her to leave. Housekeeper M asked the resident her name, but she was not familiar with the individual's name. Housekeeper M returned to the facility and went directly to the Administrator. Housekeeper M stated she told the Administrator the name given, but he did not recognize the name (he later learned that was not her first name). However, the Administrator immediately began walking down the street toward the resident while Housekeeper M drove her car to the resident. Housekeeper M asked the resident to get in the car, and she did. The Administrator arrived to them and recognized the resident and got into the car as well. They brought Resident #1 back to the facility where she was placed on the secured unit and notified the nurse. Housekeeper M stated she received messages on her phone regarding the elopement and was in-serviced on elopement response and elopement prevention. Housekeeper M also said that the facility codes were changed on the doors. Interview on 09/04/25 at 4:03 PM with the Administrator revealed he was in his office when a housekeeper came to him and said it looked like someone who may be a resident is on the corner outside. The Administrator stated he walked to the resident, and Housekeeper M took her car and together they found Resident #1 halfway down the block from the facility. The Administrator explained that a transportation driver did not ask questions, and he let her out the door (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455819 If continuation sheet Page 6 of 11 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 455819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arlington Heights Health and Rehabilitation Center 4825 Wellesley St Fort Worth, TX 76107 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few when he entered the building. The alarm did not sound because the transportation driver used the code when entering the building. The Administrator stated he discovered Resident #1 was gone about five minutes after reviewing facility video footage. The Administrator also stated he did not have a copy of the video footage because the camera footage only saved nine days at any given time. The Administrator revealed when she was brought back to the facility, a nurse completed a skin assessment and pain assessment with no injuries found. The Administrator stated they completed an elopement assessment on Resident #1 and then placed her on the secured unit. The Administrator also said elopement assessments were completed on all residents with no residents triggering for elopement. The Administrator stated when a resident eloped, they could be injured by falling. The Administrator also revealed it was all staff's responsibility to monitor the facility's exit doors. The Administrator revealed that staff were in-serviced on Door Alarms, Elopement Prevention, Elopement Response, and Abuse/Neglect. The Administrator stated the facility sent a cover message to all staff on elopement prevention as well as a change in the code to the door alarms. The Administrator said the Maintenance Director checked all doors to ensure they were working. The Administrator stated all the door alarms were working correctly. The Administrator then revealed he started elopement drills which he continued five times per week for four weeks. The Administrator stated a QAPI was completed which revealed that the facility medical director was notified of the resident elopement. A review of the witness statements for the facility revealed no other staff had knowledge of Resident #1's elopement. Interview on 09/04/25 at 3:01 PM with the ADON revealed she was told by the Administrator that Resident #1 eloped through an exit door. The ADON said she collected the witness statements and gave them to the Administrator. The ADON also revealed the staff were in-serviced on listening for the door alarms, elopement prevention, elopement response, and abuse and neglect as well. The ADON stated everyone was supposed to be listening for the door alarms, and respond, and re-direct residents if needed to prevent residents from eloping from the facility. Then staff should notify the Administrator and the DON immediately, so the resident could be assisted back into the facility. Interview on 09/04/25 at 12:14 PM with CNA L revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior), Elopement Response ( call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/04/25 at 1:05 PM with CNA N revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior)Elopement Response (get the census and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found ), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/04/25 at 1:32 PM with CNA O revealed he had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior), Elopement Response ( call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455819 If continuation sheet Page 7 of 11 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 455819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arlington Heights Health and Rehabilitation Center 4825 Wellesley St Fort Worth, TX 76107 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/04/25 at 1:44 PM with CNA P revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior), Elopement Response (call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/04/25 at 2:05 PM with CNA Q revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior), Elopement Response (call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/04/25 at 2:28 PM with LVN R revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior), Elopement Response (call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/05/25 at 9:49 AM with MA S revealed he had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior), Elopement Response (call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/05/25 at 9:59 AM with CNA T revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior), Elopement Response ( call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/05/25 at 10:10 AM with CNA U revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention(observe residents for agitation, exit seeking, anxious behavior), Elopement Response ( call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/05/25 at 10:26 AM with LVN V revealed she had been trained on the door alarms (new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455819 If continuation sheet Page 8 of 11 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 455819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arlington Heights Health and Rehabilitation Center 4825 Wellesley St Fort Worth, TX 76107 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior), Elopement Response ( call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/05/25 at 10:33 AM with CNA W revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention(observe residents for agitation, exit seeking, anxious behavior), Elopement Response ( call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/05/25 at 10:53 AM with Social Services revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention(observe residents for agitation, exit seeking, anxious behavior), Elopement Response ( call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect(physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). The Administrator was notified on 09/05/25 at 12:35 PM, that a past non-compliance IJ had been identified related to the facility's failure to provide adequate supervision to prevent an elopement. It was determined this failure placed Resident #1 in an IJ situation on 08/08/25. Observation on 09/05/25 at 12:40 PM of the facility's exit doors and secured unit doors revealed they were locked and the keypads next to them had their green lights on indicating they were working properly. An attempt to push on the doors to open were unsuccessful. The doors stayed closed and never opened. There were signs posted on the doors which reflected the following: Reminder/Families If Resident is leaving the facility.Did you notify the Nurse? You must sign out in the Sign out book at the nurses' station prior to leaving the facility. Thank you, Management Attention!!! Staff and Visitors When Entering/Leaving Please Ensure the Door Fully Closes Behind You.Do Not Let Residents Out of the Door Without First Checking with the Nurse Thank you, Management . The facility implemented the following interventions: Record review of an Elopement Drill/Actual Event Participation Log reflected a date of 08/08/25. Record review of an Elopement Drill/Actual Event Participation Log reflected a date of 08/13/25. Record review of an Elopement Drill/Actual Event Participation Log reflected a date of 08/21/25. Record review of an Elopement Drill/Actual Event Participation Log reflected a date of 08/25/25. Record review of the facility's Elopement Prevention QA Check List reflected a date of 08/08/25 and the following items reviewed/monitored:1. Doors 1-10 maglocks were secured and armed2. Doors with keypads codes have codes that are changed monthly3. All exit doors have alarms that are loud enough to be heard when opened4. All Door lock/alarm functions validated weekly in maintenance care5. Elopement policy in place6. Elopement policy reviewed in facility general orientation7. Elopement policy in-service at least annually8. Elopement risk assessments are completed upon admission/significant change/new behavior or elopement attempt9. Care plans with elopement risk interventions in place10. Secure Unit Windows have a device that allow them to open only six inches11. Secure unit present, exit doors must not have a delayed egress function. Instead do they release when any of the following occur:a. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455819 If continuation sheet Page 9 of 11 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 455819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arlington Heights Health and Rehabilitation Center 4825 Wellesley St Fort Worth, TX 76107 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The fire alarm or sprinkler system activatesb. The facility loses powerc. A switch or button at the main nurses' station and at the monitoring station is activated. 12. Secure unit, courtyard doors have alarm/lock for going outside and NO alarm for coming inside13. Secure unit present, is there a manual fire alarm pull station located within five feet of each exit door with a sign indicating Pull to release door in emergency. Record review of the facility's Post Elopement Drill or Actual Elopement QAPI Evaluation Checklist reflected a date of 08/08/25. The QAPI evaluation checklist reflected that the facility followed its elopement response protocol, notified the family, notified the physician, notified the Administrator, and followed the procedure correctly. Record review of the facility's Elopement Risk Assessment Completed reflected a date of 08/11/25 and that Resident #1 had attempted to elope one or more times in the last week, was restless, ambulated independently, and lived on the secured unit Record review of facility's Monitoring Tool reflected staff were signing off that they had monitored all doors functioning, including the dining room door and alarms 5 times per week beginning 08/11/25 through 09/05/25. Record review of an in-service titled Elopement Response dated 08/08/25 reflected staff had been trained on the facility's policy and procedures by being provided the policy and procedure as well as being explained the policy and procedure. The policy stated that the nurses were to use the census and divide the staff on the halls into assignments. The facility will call a code orange. The facility will look for the resident both inside and outside until the resident is found. Administration is to be notified immediately. Record review of an in-service titled Elopement Prevention dated 08/08/25 reflected staff had been trained on the facility's policy and procedures by being provided the policy and procedure as well as being explained the policy and procedure. Staff are to monitor for anxiousness or exit seeking behaviors and alert their nurse to the behavior. The resident is to be re-directed until the behaviors change. Notify administration. Record review of an in-service titled Abuse and neglect dated 08/08/25 reflected staff had been trained on the facility's policy and procedures by being provided the policy and procedure as well as being explained the policy and procedure. Staff is to monitor for the types of abuse/neglect and notify the abuse coordinator immediately if signs or symptoms are observed. Record review of an in-service titled Door exits/alarms ringing dated 08/08/25 reflected staff had been trained on the facility's policy and procedures by being provided the policy and procedure as well as being explained the policy and procedure. If a door alarm sounds, staff are to check the exits for residents that may have eloped. Staff are not to ignore the alarms. The door codes are not to be given out to visitors or family members. Record review of the facility's Elopement Response policy, revised January 2023, reflected: .1. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical. 2. Determination of missing resident either by routine nursing rounds or door alarms: A. Note: A resident is determined to be missing when he/she leaves the facility without the staff's knowledge.3. Should an employee observe a resident leaving the premises, he/she should A. Attempt to prevent the departure: B. Obtain assistance from other staff members in the immediate vicinity, but do not leave the resident alone, if necessary: C. Instruct another staff member to inform the charge nurse or Director of Nursing that a resident has left the premises; and D. Be courteous in preventing the departure and in returning the resident to the facility. 4. Should an employee discover the resident is missing from the facility (Code Orange) he/she should: A. Report to the charge nurse B. Determine if the resident is out on an authorized leave or pass. If not; C. Make a thorough search of the building(s) and premises. If not located; D. Notify the Administrator and the Director of Nursing; E. Notify the resident's responsible party. J. Make an extensive search of the surrounding area.Every effort will be made to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455819 If continuation sheet Page 10 of 11 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 455819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arlington Heights Health and Rehabilitation Center 4825 Wellesley St Fort Worth, TX 76107 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. 1. The Elopement Risk Assessment will be completed upon admission. The Elopement Risk Assessment is to be completed at least quarterly, after an elopement attempt, upon new exit seeking behavior, and upon change of condition. 2. All residents who are at risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team. 6. Should an elopement episode occur, the contributing factors, as well as the interventions tried, will be documented in the nurses' notes. Director of Nursing Services should be notified of elopement. 7. If a resident is discovered to be missing, a search shall begin immediately. Record review of the facility's Abuse/Neglect policy, revised 03/29/18, reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart.Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Event ID: Facility ID: 455819 If continuation sheet Page 11 of 11