Inspection·August 1, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete and paper towels were not available and she would have to ask. She stated sometimes she brings her own soap. CNA D said resident restrooms should have soap and paper towels so the residents could use it and for infection control. CNA D stated sometimes residents hoard supplies and that was part of the reason some people do not have them. She stated in other areas staff have access to have soap and paper towels. Interview on 08/01/2025 at 8:33 am, CNA E stated if repairs were needed for a resident room, she would write down the repair and time in the book at the nurse's station. She stated if repairs were needed and not done residents could get hurt. CNA E stated she did notice no soap or paper towels in resident restrooms, and it had been like that for months. She stated there were other bathrooms like the staff bathroom where she could wash her hands. She stated the risk to residents would be infection control if soap and paper towels were not available. Interview on 08/01/2025 at 9:17 am, LVN P stated there was a maintenance book at the nurse's station to write down repairs. He stated if repairs were not done the residents would not be comfortable or safe. LVN P stated not having soap or paper towels available would be infection risk and could be failing to provide proper care. Interview on 08/01/2025 at 10:12 am, the Housekeeping Manager stated if any repairs were needed in rooms, staff were supposed to put it in the maintenance book. She said there was no risk to residents if rooms were not repaired. She stated housekeeping was responsible to clean and fill soap and paper towels in resident rooms. She said she makes 3 rounds in the facility and staff or residents would tell her if they needed some and she would take care of it. She said there was soap and paper towels available for staff in everyone's office, the break room and multiple restrooms. She said there was no risk to residents not having soap and paper towels in their restrooms. Interview on 08/01/2025 at 1:37 pm, the DON stated her expectation for staff was they report to maintenance or housekeeping any repairs or cleaning that needed to be done. She said it was not homelike, the building was old, and they were working on repairs. She said the risk for not having soap or paper towels was infection, illness, feeling not clean and could be embarrassing. Record review of the facility policy titled, Resident Rights, Revised December 2016, revealed in part, the following: Employees shall treat all residents with kindness, respect and dignity.1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity. Event ID: Facility ID: 455881 If continuation sheet Page 2 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the resident's right to be free from abuse for one (Resident #65) of 5 residents reviewed for abuse, in that: On 7/27/25 the facility failed to ensure that Resident #65 was not slapped in the face by Resident #21 resulting in a bruise to the area of the right eye. This failure could result in resident abuse and injuries.Findings include: Review of Resident #65's Face Sheet reflected he is a [AGE] year-old male admitted to the facility on [DATE]. Review of Resident #65's Quarterly MDS dated [DATE] reflected in part diagnoses including seizure disorder, traumatic brain injury, depression, and bipolar disorder (mental health condition causing extreme mood swings). A BIMS score of 11 indicated moderate cognitive impairment. Review of Resident #65's Care Plan dated 7/12/25 reflected Resident #65 was at risk for bleeding and bruising due to taking aspirin. Review of Resident #21's Face Sheet reflected he is a [AGE] year-old male resident admitted to the facility on [DATE]. Review of Resident #21's admission MDS dated [DATE] reflected in part diagnoses including Chronic Obstructive Pulmonary Disease (disease of the lungs causing restricted airflow and breathing problems), Hypertension (high blood pressure), Chronic Renal Disease (progressive loss of kidney function), Down Syndrome (genetic condition causing developmental and physical disabilities), Morbid Obesity (severely overweight), Impulse Disorder (condition making it difficult to control ones actions and reactions), and Unspecified Intellectual Disabilities. A BIMS score of 8 indicated moderate cognitive impairment. Review of Resident #21's Care Plan dated 7/07/25 reflected Resident #21 was at risk for socially disruptive behavior due to impulse control disorder and had thrown a water jug on his roommate on 6/22/25. Interventions in part included psychiatric services as needed. In an interview on 7/31/25 at 03:45 pm, the ADM stated that Resident #65 reported that Resident #21, a resident with Down Syndrome, had been upset because he (Resident #21) didn't have any cigarettes and had hit Resident #65 in the eye. He stated the staff was trying to stop him, but Resident #21 had reached around the staff and hit Resident #65. He stated that Resident #65 had been saying the N word to Resident #21. He stated that there had been no prior incidents between these two residents and there has been no conflicts or issues since that time. The ADM reported he had contacted the facility marketer since the incident, and they are seeking alternate placement for Resident #21. He stated Resident #21 had a history of becoming agitated when he ran out of cigarettes and that the family did not always bring enough. He stated that the facility would separate and watch Resident #21 when he was agitated. The ADM stated that Resident #65 had a bruise on the right side of his eye because of being hit but no other injuries were noted or reported, and he required no treatment. In an observation and interview on 7/31/25 at 4:05 pm, Resident #21 was noted sitting calmly in the smoking area. When asked about hitting Resident #65 he stated he hit Resident #65 twice and, I called him a Bitch, and he flipped me off. He reported this happened in the smoking area. It was unclear which resident and altercation he was referring to and this could not be clarified. He was a poor historian. He was unable to state what had started the verbal altercation. He was difficult to understand verbally with grunting, gesturing, and difficulty with speech. He stated he had not been upset about not having cigarettes. He was not able to further clarify any of the incidents of aggression. In an interview on 7/31/25 at 5:00 pm, LVN Q reported that on 7/27/25 he heard yelling between Resident #65 and Resident #21 in the hallway and was trying to intervene when Resident #21 slapped Resident #65 in the face. He reported he was able to redirect Resident #21 to his room following the incident. He reported he assessed Resident #65 and he had no obvious injury at that time but later had a bruise near his eye. He reported the two residents had no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 3 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 prior incidents and he was not aware of any incidents since that time. A review of a progress note dated 7/27/25 completed by LVN Q reflected that following Resident #21 slapping Resident #65 in the face on 7/27/25, LVN Q had assessed Resident #65 and noted no injuries. In an interview and observation on 08/01/25 at 08:42 am, Resident #65 reported that on 7/27/25 in the morning between 7am and 9am that he had to use the bathroom, and he was talking to someone at the front desk and Resident #21 came out of his room and started yelling at him to shut his mouth. He stated that LVN Q had got in-between him and Resident #21, but Resident #21 reached around and hit him in the left eye. He reported that after he was hit, LVN Q had been able to redirect Resident #21 to his room. He stated the hit resulted in a bruise around his eye. No bruise was observed on Resident #65's face at the time of the interview and Resident #65 stated, it's been a few days. He denied any other injuries. He denied any psychological symptoms. Resident #65 stated he had no prior issues with Resident #21 and had none since. Review of Resident #21's orders reflected a psychiatric referral was ordered on 6/18/25 by the Medical Director. The physician order indicated the reason for referral as, evaluation. Review of Resident #21's progress notes reflected the psychiatric referral was entered on 7/14/25 by the Social Worker, and the psychiatric evaluation was completed on 7/23/25. Review of Resident #21's psychiatric evaluation completed 7/23/25 reflected facility staff had reported recent aggression by Resident #21. The psychiatric evaluation concluded with the plan to draw Resident #21's blood for a valproic acid level as valproic acid was the medication Resident #21 was receiving for mood disorder and impulse disorder. In an interview on 8/1/25 at 09:10 am, the DON confirmed that the psychiatric referral was ordered on 6/18/25 but that the referral had not been placed until 7/14/25. She confirmed that the initial psychiatric evaluation was completed on 7/23/25. She stated the social worker was kind of new and this may have been an oversight. She stated that the Social Worker was currently on a cruise and could not be reached for interview. She reported a risk to the resident of not placing a timely referral would be a delay in care. The DON stated the abuse coordinator was the ADM. The DON reported the ADM handled the investigation of the incident between Resident #21 and Resident #65 and she was not familiar with any details of the incident. She reported that all staff had received training on abuse and neglect as well as the management of residents with difficult behaviors. She reported in the event of an altercation between residents; staff were to immediately separate residents for their safety and notify the nurse. In an interview on 08/01/25 08:56 am CNA S stated she was here on 7/27/25 and had heard Resident #65 cursing at everyone including near Resident #21's door. She reported she did not witness the altercation between Resident #21 and Resident #65. She reported in the event of a resident altercation staff would intervene immediately to separate the residents and report it to the supervisor. She reported she had received training on resident altercations about a month ago including the need to separate the residents and report it. She denied witnessing any other aggression by Resident #21. In an Interview on 8/01/25 at 10:25 am, the ADM stated the social worker was responsible for handling referrals, and he expected that referrals would be placed immediately once ordered. He reported that failing to place a referral could result in the same behaviors continuing without improvement. He reported that the investigation of the incident was ongoing as he was within the five-day window for providing the completed investigation to the state. The facility abuse and neglect policy titled, Abuse Prevention Program dated 2001 and revised December 2016 stated, Our residents have the right to be free from abuse. and implementation included to, implement changes to prevent future occurrences of abuse. Event ID: Facility ID: 455881 If continuation sheet Page 4 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure that an allegation of abuse was reported immediately to Health and Human Services for one (Resident #30) of three residents reviewed for abuse and neglect reporting. The facility failed to make a timely report of Resident #30's allegation that a staff member kicked a shoe at her, hurting her leg, on 07/19/25. This failure could place residents at risk of being abuse and lack of oversight by a state agency. Findings included: Review of Resident #30's face sheet, dated 07/31/25, reflected she was a [AGE] year-old female, admitted on [DATE], and having diagnoses of Alzheimer's disease, dementia in other disease (dementia associated with another health condition) with behavioral disturbance, bipolar II (a less severe form of bi-polar than bi-polar I), major depressive disorder, and an anxiety disorder. Review of Resident #30's quarterly MDS assessment, dated 06/05/25, reflected Resident #30 had adequate hearing and clear speech, and was usually able to understand others and be understood by others. Her vision was impaired, and she wore glasses. Her BIMS score was eight (out of a high score of 15), indicating possible moderate cognitive impairment. She displayed fluctuating inattention and disorganized thinking, but no behavioral symptoms. She had no impairment in her range of motion and ambulated with a walker. Resident #30 required only set-up or clean-up assistance for eating, and supervision or touching assistance for hygiene and dressing. Review of Resident #30's care plans reflected the following care plans:- h/o chronic pain, initiated 05/01/25- risk of complications r/t use of psychotropic medications (drugs that act on brain chemistry and can affect mood, behavior, and perception) / antidepressant, initiated on 05/01/2025, revised on 07/29/2025- risk of complications r/t use of psychotropic medications (drugs that act on brain chemistry and can affect mood, behavior, and perception) / anti-psychotic medication, initiated on 05/01/2025, revised on 07/29/2025- risk of experiencing symptoms of depression, initiated on 05/01/25- impaired cognitive function r/t Alzheimer's, initiated on 05/01/25- h/o falls with actual falls, initiated on 05/01/25, revised 07/10/25- impaired vision, initiated on 05/09/25- periods of forgetfulness, initiated on 05/09/25- impaired comprehension, initiated on 05/09/25- psychosocial well-being problem (actual or potential) r/t dependent attention-seeking behavior, initiated on 07/23/25. This care plan listed two relevant incidents which included 7/19/25--lifted a heavy lock box causing shoulder pain, insisted on going to ER and 7/22/25--alleged that CNA caused hematoma to foot by accident- risk for side-effects/ complications from anti-anxiety medication, initiated on 07/22/25, revised on 07/29/25 Review of Resident #30's skin assessment, dated 07/23/25, reflected no new skin issues were noted. Review of a change-in-condition note by LVN I for Resident #30, dated 07/19/25 at 3:58 PM reflected the resident had uncontrolled pain. Her vitals were within normal range, and she had no change in functional or mental status. The note reflects the resident approached the nurses station and said she tried to lift a lock box in her room, heard a pop in her left shoulder. PRN pain medication was provided, and the resident was assessed for visual injuries, with none noted. The resident then went to her room, laid down on her bed, and started crying and yelling that she was in pain, and hurt all over, and wanted to go to the hospital. Her primary care provider responded with an order to send her to the hospital. Review of a nursing progress note by LVN I, dated 7/19/25 at 4:08 PM, reflected that in addition to the information in the change-in-condition note above, Resident #30's skin was intact, and normal in color. The note reflected that the Administrator, DON, and MD were notified, and the resident was picked up by EMS and sent to a nearby hospital. Review of a nursing progress note by RN G, dated 07/19/25 at 6:29 PM, reflected EMS brought Resident #30 back to the facility. The resident made a phone call at the nursing station (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 5 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and was overheard by the RN. The note reflected the resident was saying The nurse threatened to call the police, if she didn't get dressed and out of her pj's. She also said a CNA threw a shoe at her leg and caused a hematoma. shen [sic] she began sobbing and saying go ahead and call the police because she was going to kill herself. The note reflected the nurse notified the DON, Administrator, and the MD. An order was received for Ativan. Resident #30 was noted to have said the devil made her do it and she asked to call staff to her room before she urinated, so they could collect urine for a urinalysis (testing urine to detect infection.) Review of a nursing progress note, by RN J, dated 07/20/25 at 6:01 AM, reflected the resident slept well, and had no further complaints of pain or signs of distress, and monitoring was continued. Review of a nursing progress note by RN J, dated 07/20/25 at 6:04 AM, reflected her urinalysis was negative for a urinary tract infection, and the MD was notified. Review of a nursing progress note by LVN I, dated 07/20/25 at 4:36 PM reflected the resident was on hourly monitoring, and had no further pain or distress, or behaviors. The resident had a cast, provided at the hospital. The MD was notified and education provided. Review of a note by Nurse Practitioner K, dated 07/22/25 at 8:00 AM, reflected Unspecified sprain of left shoulder joint, initial encounter*: Patient seen today for follow-up post hospitalization at (hospital name) with pain in left hand after lifting a box at bedside. Per hospital records, patient had a shoulder sprain to left upper extremities. Patient noted with a sling toleft [sic] hand and complained of pain with movement to left upper arm. Pain is reasonably controlled with current pain regimen. Patient declined x-ray to left upper extremities. Will continue with current pain management. PT/OT to evaluate and treat as indicated. The note also reflected an x-ray was ordered to evaluated the cause of pain in the resident's right, lower extremity, and that the resident had hip pain, and had been seen on an earlier date due to a fall. Review of a nursing progress note by LVN L, dated 07/22/25 at 2:06 PM, reflected the Nurse Practitioner had seen Resident #30 due to her complaint of pain in her right ankle, and an x-ray had been ordered. Review of a nursing progress note by the DON, dated 07/23/25, reflected Resident #30 told the DON and the Administrator that she sustained a hematoma to her right foot when a staff member kicked a heavy shoe at her. The DON assessed her foot, and observed no bruising, swelling, bleeding, or limitation in range-of-motion. The note reflected the resident stated the staff member did not do it (kick the shoe at her) on purpose. The resident informed the DON and Administrator that the hospital said they would call APS and if they came to the facility, she did not want to talk to them, and stated she hoped nobody was in trouble. The note reflected the DON reassured her that the hospital staff did the right thing if the resident felt threatened in any way, and they were doing their job. The resident showed the DON and Administrator the shoe which she believed caused a hematoma, and it was a very light-weight, soft foam walking shoe. The note reflected the Nurse Practitioner had seen Resident #30 and ordered an x-ray on her foot, and the resident complained of shoulder pain, but refused an x-ray on her shoulder. Review of Resident #30's note from a visit by a Psychiatric Mental Health Nurse Practitioner (PMHNP) on 07/23/25 reflected the resident was oriented to person, place, day, month, year and situation. The document included: The resident mentioned verbalizing Im gonna kill myself this past weekend due to frustration after hurting her arm. The resident denied any intent or desire to follow through with ideations. Today, the resident reported feeling safe and denied any suicidal ideationI [sic]/intent/plan. Depression: Patient denies symptoms of sad moods, loss of interest, fatigue and suicidal ideation/intent/plan. Anxiety: Patient denies symptoms of excessive worry and anticipatory worry/impending doom. Cognitive Impairment: Patient endorses current symptoms of forgetfulness. Severity is level 5 (Moderate). Psychosis: Staff reports current symptoms of delusions. Severity is level 5 (Moderate). The document also reflected Resident #30 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 6 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had a history of schizoaffective disorder (a disorder which can include symptoms of hallucinations and delusions, with significant mood fluctuations) from a previous facility, and the PMHNP confirmed the diagnosis in the document, based on the resident's symptoms and other health conditions. Review of an Investigation Follow-up document, dated 07/23/25, reflected A. INVESTIGATION 1. Date of Incident 07/19/2025 2. Date of Investigation 07/23/2025; B. INSTRUCTIONS a. Review criteria below before answering any questions. Provide as much factual information as possible. Do not include hearsay or personal opinions. C. DESCRIPTION Answer the Questions as applicable to the incident and as is necessary to come to a reasonable conclusion. b. WHO: - may have contributed to the occurrence of the resident? - is the alleged victim? - spoke to the alleged victim regarding the incident? - witnessed the incident? - may have information related to the incident? WHAT: - is the incident? - is the chronological order of events leading up to the alleged incident? - are teh [sic]injuries? - information does the alleged victim have regarding the incident? - did the the discovering person/witness see, hear, or smell? - did these people do in relation to first discovering the incident? - information do the other relevant [sic] staff members have of the incident or factors leading up to the incident? - was the functional, mental and cognitive status of the alleged victim before and after the incident? - is known about the alleged suspect or person who may have contributed to the occurrence of the incident? WHEN: - did the incident occur? WHERE: - did the incident occur? C. DESCRIPTION 1. Description of Situation: Resident stated that she picked up her lockbox forgetting that it has sodas in it, and pulled her arm/shoulder Resident requested to go to ER, refused in-house interventions offered by MD, i.e. pain medication and X-rays. D. SUMMARY 1. Resident returned from hospital with a sling to her right shoulder, no fracture or acute injury noted, nor documented on hospital paperwork (.) F. RECOMMENDATIONS 1. Resident encouraged to ask for assistance when lifting heavy things or ask staff to lift for her. The document was marked with Follow-up Needed by the resident's Agent/Caregiver/Emergency Contact, with that person's name and phone number. The document indicated follow-up with family on revisions to the careplan, reflecting facility MD to see resident on next visit, NP saw resident on 7/22; ordered foot x-ray as resident stated that she has a hematoma' to her left foot, from someone accidently kicking a shoe that hit her foot causing the hematoma, no acute injuries noted. An interview and observation on 07/29/25 at 11:15 AM with Resident #30 revealed her to be at the facility, lying on her bed, alert, and able to remember hurting her arm, and her complaint about the staff member kicking a shoe. She said overall, the staff treated her very well, and she was not afraid of anyone there. She said on a Saturday she reached for her lockbox (she pointed out a box on the floor next to her bed), and it was heavier than she expected. She said at first she did not think she needed to go to the hospital, but then her arm really began to hurt, and she wanted to go to the hospital. She said she asked a CNA if she would help her get ready, and the CNA said she could do it herself. She said the nurse also said no. Resident #30 said she told the CNA she had a bad hip, and the CNA responded that her hips were fine. Resident #30 explained she had a fractured vertebra which caused her pain in her hip, and they could not operate on it without risking her being crippled. She said the CNA did finally help her. She recognized the CNA and the nurse, but did not know their names. She said she did see them sometimes, but she was never scared of them. She just felt like there had been no reason for them to be so rude that day. When asked if she remembered a CNA kicking her shoes at her, she said it was the same CNA, and she did not get the feeling she did it on purpose, but she was rude. The resident said she could not get some things from underneath her bed, which was where the shoes were, and she needed the aide to get them out. She said that CNA treated her OK normally and nothing like that had happened since that day. She said the Administrator and DON did come (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 7 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few talk to her, and she told them about it. She reiterated that they never made her feel unsafe, and she felt very safe in the facility. She said she was able to get help by using her call button, and they kept her pain managed well, but she still did need help sometimes, and those ladies were rude when she asked for help. She said she had a sling for her arm from the emergency room, and some medicine for it, and she was not having any pain in her foot or her arm. When asked if the shoe hurt her foot when the staff member kicked it, did not answer. She was wearing shoes at the time of the interview, and no bruising, redness, or swelling was observed on her ankles. An interview on 07/31/25 with the Administrator about the allegation from Resident #30 taking place on 07/19/25, and the self-report to HHSC not being sent until 07/22/25 (date of incident was 07/19/2025), revealed he had been notified of the resident wanting to go to the hospital because her arm hurt at about 3:21 PM on 07/19/25, but there was nothing about the allegation of a staff member doing anything to her leg. He said he told the nurse to send her to the hospital. He said once he learned about the allegation, he talked with Resident #30 and she had given him an estimate of what time the allegation on the 19th took place. He said ne neglected to document the time she gave him, which was around 10:30 (AM/PM not specified), on the form he filled out. He said he watched a lot of video, covering the time she said, and a lot around it, and nobody went into her room. He said he was not able to find any evidence that someone abused her. An interview on 07/31/25 at 12:03 PM with RN G revealed that she remembered Resident #30's breakdown on 07/19/25 very well, because the resident was normally very sweet. She said she was very worried about her, because of her unusual behavior that day. She said the resident told her she hurt her arm trying to lift something and insisted on going to the hospital. She said when the resident came back, she wanted to use the phone, and she could overhear what she was saying on the phone. She was agitated and crying on the phone call, and she said the nurse (at the hospital) was going to call APS because she was still in her pajamas. She said to ahead and call the police because she was going to kill herself, and that a CNA had thrown a shoe at her leg. RN G said she notified the DON, and the Administrator and the MD, and she was pretty sure she told the Administrator about the resident's allegation about the shoe over the phone. She said the resident did not have a plan (for suicide) and was not able to describe anyone who threw a shoe. She said after that the resident was crying, and saying she was sorry, and the devil made her say those things (about the staff member throwing a shoe, and her killing herself). RN A said they put the resident on monitoring and the did 15-minute checks on her, and the MD ordered Ativan, which calmed her down a lot. She said when the resident said someone threw a shoe at her leg, she allowed RN G to assess it, and there was no redness, swelling, or bruising and she said she was not in pain at the time of the assessment. She never complained about pain to her leg or foot. RN G said she always reported concerns to the DON, Administrator, and MD immediately. She said Resident #30 calmed down immediately and did not have any more problems. An interview on 07/31/25 at 12:32 PM with the Administrator revealed he had some frustration and confusing about the reporting process, in that in some stated the two hours to report began as soon as the Administrator learned of the allegation, and he did not learn about the allegation until 07/22/25, and that is when he reported it. He said the risk of not doing an investigation soon enough, or thoroughly enough, was that the resident could be abused again, or continue to be abused. The Administrator said that when he did talk to the resident about the shoe, her story was different from what he was told, and she said she was not sure if it had happened in the facility or at the hospital. An interview on 07/31/25 at 1:26 PM with RN C said she had talked with the DON, and she had showed her a text message from RN G sent on 07/19/25, and it was only about the resident's arm. There was no mention of her leg, or allegation. An interview on 08/01/25 at 12:11 PM with CNA H (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 8 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed she had been the CNA working with Resident #30 on 07/19/25. She said when she went into the resident's room, she was crying, and the resident said her shoulder hurt, and she asked her how it happened. She said Resident #30 said she had tried to pick up her locker on the floor, with her drinks in it. CNA H said she told her to wait just a minute, and not pick anything up, and she got the nurse to go to the resident, and she continued to work, so she did not know what took place with the nurse and the resident. CNA H said later, when she was picking up trays, the resident was in her room crying, again, and she went to get the nurse, who was watching the smoking break at the time, but went to Resident 30 as soon as she was done. CNA H said the nurse then called for the resident to go to the ER. When Resident #30 came back from the hospital, the nurse said she told the hospital people that someone at the facility came in and kicked her and this and that. CNA H denied kicking the resident, and said she just helped her get ready to go to the hospital. When CNA H went into Resident #30's room after she had returned form the hospital, the resident told her the devil talked to her and told to say things, and she said some things that did not make sense to CNA H. She said Resident #30 kept crying and apologizing to her, and said the devil told her to do things, and to tell stories on the staff, and she was sorry. She said Resident #30 even asked her for a hug, and she was crying and apologizing a lot. CNA H said the resident's shoes were at the edge of the bed and she pushed them toward her feet to help her get ready to go to the hospital, but she denied kicking them or being rough about it. She said the Administrator never talked to her about the incident. An interview on 08/01/25 at 1:19 PM with the DON revealed Resident #30 had some manipulative behaviors prior to the incident on 07/19/25. On 07/19/25 Resident #30 lifted her lock-box and said her shoulder was hurt, but refused any interventions they could try here, and later was yelling and screaming. They tried to get her an x-ray, and some pain medication, but she refused everything they had, and continued to yell and scream and wanted to go to the hospital. On 08/01/25 she went to Resident #30's room because the call light was on. She said the nurse was right there, and the resident said she was dizzy and was pretending to faint, and insisted on going to the hospital. The DON said this was not new behavior for Resident #30. RN G was on duty the evening of 07/19/25 and notified her that Resident #30 said that the hospital staff were going to call the police because she was still in her pajamas, and that she was going to kill herself. She said she was also calling the Administrator. The DON copied and pasted the text of the message sent to her from RN G about Resident #30.The DON said she and the Administrator talked to Resident #30 on Tuesday (07/22/25) and she just said a black woman with curly hair to describe who allegedly hurt her with a shoe. She could not describe the shoe, she just said a heavy shoe and she showed them what shoe it was, and it was a light-weight, soft, foam shoe. The DON said that Resident #30 also said she thought it (the aide kicking the shoe at her) was an accident. She and the Administrator did do an investigation of her allegation. She said Resident #30's story kept changing. The DON said the Nurse Practitioner was also there on 07/22/25 and the resident told her it was her ankle, and the Nurse Practitioner ordered an x-ray. The DON said it was important for allegations of abuse to be reported, in order to protect the residents. Review of the text sent to the surveyor by the DON during the interview on 08/01/25, copied and pasted from a text message from RN G to her on 07/19/25, reflected (DON) and (Administrator). (Resident #30) is back from the hospital. I'll document how she said the nurse threatened to call the police because she was still wearing her pj's. And a CNA kicked a shoe at her causing a hem atoma. [sic] Review of the facility policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, reflected Policy Statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 9 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation: Reporting Allegations to the Administrator and Authorities: 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility (.) 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. (.) 6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. (.) Follow-up Report: (.) 2. The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. 3. The follow-up investigation report will provide as much information as possible at the time of submission of the report. Event ID: Facility ID: 455881 If continuation sheet Page 10 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide evidence that all an allegation of abuse was thoroughly investigated for three residents (Resident #30, Resident #15, and Resident #81) of three residents reviewed for abuse and neglect reporting. 1. The facility administrator failed to provide evidence of a thorough investigation of an allegation of abuse by Resident #30 on 07/19/25, in which she alleged a staff member kicked a shoe at her and hurt her foot.2. The facility administrator failed to provide evidence of a thorough investigation of an allegation of abuse between Resident #15 and Resident #81 where there was a physical altercation between the both of them. This failure could place residents at risk of being abused and lack of oversight by a state agency. Findings included: Residents Affected - Few 1. Review of Resident #30's face sheet, dated 07/31/25, reflected she was a [AGE] year-old female, admitted on [DATE], and having diagnoses of Alzheimer's disease, dementia in other disease (dementia associated with another health condition) with behavioral disturbance, bipolar II (a less severe form of bi-polar than bi-polar I), major depressive disorder, and an anxiety disorder. Review of Resident #30's quarterly MDS assessment, dated 06/05/25, reflected Resident #30 had adequate hearing and clear speech, and was usually able to understand others and be understood by others. Her vision was impaired and she wore glasses. Her BIMS score was eight (out of a high score of 15), indicating possible moderate cognitive impairment. She displayed fluctuating inattention and disorganized thinking, but no behavioral symptoms. She had no impairment in her range of motion, and ambulated with a walker. Resident #30 required only set-up or clean-up assistance for eating, and supervision or touching assistance for hygiene and dressing. Review of Resident #30's care plans reflected the following: - h/o chronic pain, initiated 05/01/25 - risk of complications r/t use of psychotropic medications (drugs that act on brain chemistry and can affect mood, behavior, and perception) / antidepressant, initiated on 05/01/2025, revised on 07/29/2025 - risk of complications r/t use of psychotropic medications (drugs that act on brain chemistry and can affect mood, behavior, and perception) / anti-psychotic medication, initiated on 05/01/2025, revised on 07/29/2025 - risk of experiencing symptoms of depression, initiated on 05/01/25 - impaired cognitive function r/t Alzheimer's, initiated on 05/01/25 - h/o falls with actual falls, initiated on 05/01/25, revised 07/10/25 - impaired vision, initiated on 05/09/25 - periods of forgetfulness, initiated on 05/09/25 - impaired comprehension, initiated on 05/09/25 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 11 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0610 Level of Harm - Minimal harm or potential for actual harm - psychosocial well-being problem (actual or potential) r/t dependent attention-seeking behavior, initiated on 07/23/25. This care plan listed two relevant incidents which included 7/19/25--lifted a heavy lock box causing shoulder pain, insisted on going to ER and 7/22/25--alleged that CNA caused hematoma to foot by accident Residents Affected - Few - risk for side-effects/ complications from anti-anxiety medication, initiated on 07/22/25, revised on 07/29/25 Review of an HHSC Provider Investigation Report, dated 07/28/25, reflected an allegation of abuse was made by Resident #30. Under Alleged Perpetrator it said unable to say. It was noted on the form that Resident #30 was interviewable. Under description of allegation was (Resident #30 asked for assistance with her shoe, and the CNA kicked it at her. Description of Injury said (Resident #30) was sent to the hospital for a different issue, then came back to the facility stating that this issue happened. The investigation summary said When interviewed about the incident, resident changed her story from the incident being an accident, to maybe not, to not quite sure. Provider Action Taken Post Investigation said continue to have follow-up with (Resident #30) on this issue. At the bottom of the form was written Investigation not completed. The packet of materials submitted for the investigation included the following: - A Complaint and Incident Intake (CII) Email Self-Report Template which was submitted on 07/22/25 with the original self-report. - An Administrator's Report, dated 07/24/25, which had blanks for Who, What, When, Where, and Why. The form said the resident complained that a CNA kicked a shoe at her, giving her a hematoma, and that it happened on Saturday, in her room, but she could not remember the time. Under Reportable, yes was circled, with a reason that the resident was claiming injury. The synopsis said Resident stated that staff member kicked a shoe at her and that it hit her foot, causing a hematoma. When asked what that was, the resident stated a blood clot. When asked if she [illegible] was on purpose resident stated it was probably an accident. When video was reviewed, there was no staff that went in there at the time. Resident also stated that she did not know if it was on accident or on purpose. The document was signed by the Administrator on 07/24/25. - Face sheet - Result of x-rays to Resident #30's ankle on 07/22/25, with no acute findings. - The packet did not contain, in-services, staff statements, resident safe-surveys, progress notes, skin assessments, or any other documentation relevant to the incident. Review of Resident #30's skin assessment, dated 07/23/25, reflected no new skin issues were noted. Review of a change-in-condition note by LVN I for Resident #30, dated 07/19/25 at 3:58 PM reflected the resident had uncontrolled pain. Her vitals were within normal range, and she had no change in functional or mental status. The note reflected the resident approached the nurses station and said she tried to lift a lock box in her room, and heard a pop in her left shoulder. PRN pain medication was provided, and the resident was assessed for visual injuries, with none noted. The resident then went to her room, laid down on her bed, and started crying and yelling that she was in pain, and hurt all over, and wanted to go to the hospital. Her primary care provider responded with an order to send her to the hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 12 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a nursing progress note by LVN I, dated 7/19/25 at 4:08 PM, reflected that in addition to the information in the change-in-condition note above, Resident #30's skin was intact, and normal in color. The note reflected that the Administrator, DON, and MD were notified, and the resident was picked up by EMS and sent to a nearby hospital. Review of a nursing progress note by RN G, dated 07/19/25 at 6:29 PM, reflected EMS brought Resident #30 back to the facility. The resident asked to make a phone call at the nursing station, and was overheard by the RN. The note reflected the resident was saying The nurse threatened to call the police, if she didn't get dressed and out of her pj's. She also said a cna threw a shoe at her leg and caused a hematoma. shen [sic] she began sobbing and saying go ahead and call the police because she was going to kill herself. The note reflected the nurse notified the DON, Administrator, and the MD. An order was received for Ativan. Resident #30 was noted to have said the devil made her do it and RN G asked the resident to call staff to her room before she urinated, so they could collect urine for a urinalysis (testing urine to detect infection.) Review of a nursing progress note, by RN J, dated 07/20/25 at 6:01 AM, reflected the resident slept well, and had no further complaints of pain or signs of distress, and monitoring was continued. Review of a nursing progress note by RN J, dated 07/20/25 at 6:04 AM, reflected her urinalysis was negative for a urinary tract infection, and the MD was notified. Review of a nursing progress note by LVN I, dated 07/20/25 at 4:36 PM reflected the resident was on hourly monitoring, and had no further pain or distress, or behaviors. The resident had a cast, provided at the hospital. The MD was notified and education provided. Review of a note by Nurse Practitioner K, dated 07/22/25 at 8:00 AM, reflected Unspecified sprain of left shoulder joint, initial encounter*: Patient seen today for follow-up post hospitalization at (hospital name) with pain in left hand after lifting a box at bedside. Per hospital records, patient had a shoulder sprain to left upper extremities. Patient noted with a sling toleft [sic] hand and complained of pain with movement to left upper arm. Pain is reasonably controlled with current pain regimen. Patient declined x-ray to left upper extremities. Will continue with current pain management. PT/OT to evaluate and treat as indicated. The note also reflected an x-ray was ordered to evaluate the cause of pain in the resident's right, lower extremity, and that the resident had hip pain, and had been seen on an earlier date due to a fall. Review of a nursing progress note by LVN L, dated 07/22/25 at 2:06 PM, reflected the Nurse Practitioner had seen Resident #30 due to her complaint of pain in her right ankle, and an x-ray had been ordered. Review of a nursing progress note by the DON, dated 07/23/25, reflected Resident #30 told the DON and the Administrator that she sustained a hematoma to her right foot when a staff member kicked a heavy shoe at her. The DON assessed her foot, and observed no bruising, swelling, bleeding, or limitation in range-of-motion. The note reflected the resident stated the staff member did not do it (kick the shoe at her) on purpose. The resident informed the DON and Administrator that the hospital said they would call APS and if they came to the facility, she did not want to talk to them, and stated she hoped nobody was in trouble. The note reflected the DON reassured her that the hospital staff did the right thing if the resident felt threatened in any way, and they were doing their job. The resident showed the DON and Administrator the shoe which she believed caused a hematoma, and it was a very light-weight, soft foam walking shoe. The note reflected the Nurse Practitioner had seen Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 13 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #30 and ordered an x-ray on her foot, and the resident complained of shoulder pain, but refused an x-ray on her shoulder. Review of an Investigation Follow-up document, dated 07/23/25, reflected A. INVESTIGATION 1. Date of Incident 07/19/2025 2. Date of Investigation 07/23/2025; B. INSTRUCTIONS a. Review criteria below before answering any questions. Provide as much factual information as possible. Do not include hearsay or personal opinions. C. DESCRIPTION Answer the Questions as applicable to the incident and as is necessary to come to a reasonable conclusion. b. WHO: - may have contributed to the occurrence of the resident? - is the alleged victim? - spoke to the alleged victim regarding the incident? - witnessed the incident? - may have information related to the incident? WHAT: - is the incident? - is the chronological order of events leading up to the alleged incident? - are teh [sic]injuries? - information does the alleged victim have regarding the incident? - did the discovering person/witness see, hear, or smell? - did these people do in relation to first discovering the incident? - information do the other relevant [sic] staff members have of the incident or factors leading up to the incident? - was the functional, mental and cognitive status of the alleged victim before and after the incident? - is known about the alleged suspect or person who may have contributed to the occurrence of the incident? WHEN: - did the incident occur? WHERE: - did the incident occur? C. DESCRIPTION 1. Description of Situation: Resident stated that she picked up her lockbox forgetting that it has sodas in it, and pulled her arm/shoulder Resident requested to go to ER, refused in-house interventions offered by MD, i.e. pain medication and X-rays. D. SUMMARY 1. Resident returned from hospital with a sling to her right shoulder, no fracture or acute injury noted, nor documented on hospital paperwork (.) F. RECOMMENDATIONS 1. Resident encouraged to ask for assistance when lifting heavy things or ask staff to lift for her. The document was marked with Follow-up Needed by the resident's Agent/Caregiver/Emergency Contact, with that person's name and phone number. The document indicated follow-up with family on revisions to the careplan, reflecting facility MD to see resident on next visit, NP saw resident on 7/22; ordered foot x-ray as resident stated that she has a hematoma' to her left foot, from someone accidently kicking a shoe that hit her foot causing the hematoma, no acute injuries noted. An interview and observation on 07/29/25 at 11:15 AM with Resident #30 revealed her to be at the facility, lying on her bed, alert, and able to remember hurting her arm, and her complaint about the staff member kicking a shoe. She said overall, the staff treated her very well, and she was not afraid of anyone there. She said on a Saturday she reached for her lockbox (she pointed out a box on the floor next to her bed), and it was heavier than she expected. She said at first she did not think she needed to go to the hospital, but then her arm really began to hurt, and she wanted to go to the hospital. She said she asked a CNA if she would help her get ready, and the CNA said she could do it herself. She said the nurse also said no. Resident #30 said she told the CNA she had a bad hip, and the CNA responded that her hips were fine. Resident #30 explained she had a fractured vertebra which caused her pain in her hip, and they could not operate on it without risking her being crippled. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 14 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few She said the CNA did finally help her. She recognized the CNA and the nurse, but did not know their names. She said she did see them working sometimes, but she was never scared of them, she just felt like there had been no reason for them to be so rude that day. She said it had not happened again. When asked if she remembered a CNA kicking her shoes at her, she said it was the same CNA, and she did not get the feeling she did it on purpose, but she was rude. The resident said she could not get some things from underneath her bed, which was where the shoes were, and she needed the aide to get them out. She said that CNA treated her OK normally, and nothing like that had happened that day. She said the Administrator and DON did come talk to her, and she told them about it. She reiterated that they never made her feel unsafe, and she felt very safe in the facility. She said she was able to get help by using her call button, and they kept her pain managed well, but she still did need help sometimes, and those ladies were rude when she asked for help. She said she had a sling for her arm from the emergency room, and some medicine for it, and she was not having any pain in her foot or her arm. When asked if the shoe hurt her foot when the staff member kicked it, she did not answer. She was wearing shoes at the time of the interview, and no bruising, redness, or swelling was observed on her ankles. An interview on 07/31/25 at 9:48 AM, an interview with CNA B revealed she was familiar with Resident #30. She said the resident was sweet, but could be a little out there but she presented well, so a person might not realize it until they had talked with her a lot. She said Resident #30 was able to ask for things when she needed them, and she thought she had never complained to her about anything having to do with staff treating her badly. An interview on 07/31/25 with the Administrator about the allegation from Resident #30 taking place on 07/19/25, and the self-report to HHSC not being sent until 07/22/25, revealed he had been notified of the resident wanting to go to the hospital because her arm hurt at about 3:21 PM on 07/19/25, but there was nothing about the allegation of a staff member doing anything to her leg. He said he told the nurse to send her to the hospital. He said once he learned about the allegation, he talked with Resident #30 and she had given him an estimate of what time the allegation on the 19th took place. He said he watched a lot of video, covering the time she said, and a lot around it, and nobody went into her room. He said he was not able to find any evidence that someone abused her. An interview on 07/31/25 at 12:03 PM with RN G revealed that she remembered Resident #30's breakdown on 07/19/25 very well, because the resident was normally very sweet. She said she was very worried about her, because of her unusual behavior that day. She said the resident told her she hurt her arm trying to lift something and insisted on going to the hospital. She said when the resident came back from the ER, she wanted to use the phone, and RN G could overhear what she was saying on the phone. She was agitated and crying on the phone call, and said the nurse (at the hospital) was going to call APS because she was still in her pajamas. She said to ahead and call the police because she was going to kill herself, and that a CNA had thrown a shoe at her leg. RN G said she notified the DON, and the Administrator and the MD, and she was pretty sure she told the Administrator about the resident's allegation about the shoe over the phone. She said the resident did not have a plan (for suicide), and was not able to describe anyone who threw a shoe. She said after that the resident was crying, and saying she was sorry, and the devil made her say those things (about the staff member throwing a shoe, and her killing herself). RN A said they put the resident on monitoring and the did 15-minute checks on her, and the MD ordered Ativan, which calmed her down a lot. She said when the resident said someone threw a shoe at her leg, she allowed RN G to assess it, and there was no redness, swelling, or bruising and she said she was not in pain at the time of the assessment. She never complained about pain to her leg or foot. RN G said she always reported concerns to the DON, Administrator, and MD immediately. She said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 15 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0610 Resident #30 calmed down immediately and did not have any more problems. Level of Harm - Minimal harm or potential for actual harm An interview on 07/31/25 at 12:32 PM with the Administrator revealed he did turn in the 5-day report for Resident #30's allegation, but he did not feel he had done the complete investigation he usually did for allegations. He said he normally interviewed staff, did safe surveys with residents, and got a more complete picture about what was going on with a resident. He said that the description of the alleged perpetrator fit ¾ of his staff, and he could not send them all home. He said he normally looked at the schedule, and looked to see who was going in and out of the room on camera footage, but he did not follow his normal process on this investigation. When asked why he did not, he just stated that he did not, and offered no additional explanation. He said the risk of not following the investigation process was if they did not do an investigation soon enough, or thoroughly enough, the resident could be abused again, or continue to be abused. He said the investigation could keep it from happening again. He said he had a law enforcement background, and had done HHSC's training on investigations. He said he did not feel like he finished this one, and he was apologetic about that, and about not submitting the information timely. When he did talk to the resident about the shoe, her story was different from what he was told, and she said she was not sure if it had happened in the facility or at the hospital. Residents Affected - Few An interview on 07/31/25 at 1:26 PM with RN C said she had talked with the DON, and she had showed her a text message from RN G sent on 07/19/25, and it was only about the resident's arm. There was no mention of her leg allegation. An interview on 08/01/25 at 12:11 PM with CNA H revealed she had been the CNA working with Resident #30 on 07/19/25. She said when she went into the resident's room, she was crying, and the resident said her shoulder hurt, and she asked her how it happened. She said Resident #30 said she had tried to pick up her locker on the floor, with her drinks in it. CNA H said she told her to wait just a minute, and not pick anything up, and she got the nurse to go to the resident, and she continued to work, so she did not know what took place with the nurse and the resident. CNA H said later, when she was picking up trays, the resident was in her room crying, again, and she went to get the nurse, who was watching the smoking break at the time, but went to Resident 30 as soon as she was done. CNA H said the nurse then called for the resident to go to the ER. When Resident #30 came back from the hospital, the nurse said she told the hospital people that someone at the facility came in and kicked her and this and that. CNA H denied kicking the resident, and said she just helped her get ready to go to the hospital. When CNA H went into Resident #30's room after she had returned form the hospital, the resident told her the devil talked to her and told to say things, and she said some things that did not make sense to CNA H. She said Resident #30 kept crying and apologizing to her, and said the devil told her to do things, and to tell stories on the staff, and she was sorry. She said Resident #30 even asked her for a hug, and she was crying and apologizing a lot. CNA H said the resident's shoes were at the edge of the bed and she pushed them toward her feet to help her get ready to go to the hospital, but she denied kicking them or being rough about it. She said the Administrator never talked to her about the incident. An interview on 08/01/25 at 1:19 PM with the DON revealed Resident #30 had some manipulative behaviors prior to the incident on 07/19/25. On 07/19/25 Resident #30 lifted her lock-box and said her shoulder was hurt, but refused any interventions they could try here, and later was yelling and screaming. They tried to get her an x-ray, and some pain medication, but she refused everything they had, and continued to yell and scream and wanted to go to the hospital. On 08/01/25 she went to Resident #30's room because the call light was on. She said the nurse was right there, and the resident said she was dizzy and was pretending to faint, and insisted on going to the hospital. The DON said this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 16 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was not new behavior for Resident #30. RN G was on duty the evening of 07/19/25 and notified her that Resident #30 said that the hospital staff were going to call the police because she was still in her pajamas, and that she was going to kill herself. She said she was also calling the Administrator. The DON copied and pasted the text of the message sent to her from RN G about Resident #30.The DON said she and the Administrator talked to Resident #30 on Tuesday (07/22/25) and she just said a black woman with curly hair to describe who allegedly hurt her with a shoe. She could not describe the shoe, she just said a heavy shoe and she showed them what shoe it was, and it was a light-weight, soft, foam shoe. The DON said that Resident #30 also said she thought it (the aide kicking the shoe at her) was an accident. She and the Administrator did do an investigation of her allegation. She said Resident #30's story kept changing. The DON said the Nurse Practitioner was also there on 07/22/25 and the resident told her it was her ankle, and the Nurse Practitioner ordered an x-ray. The DON said it was important for allegations of abuse to be reported, in order to protect the residents. Review of the text sent to the surveyor by the DON during the interview on 08/01/25, copied and pasted from a text message from RN G to her on 07/19/25, reflected (DON) and (Administrator). (Resident #30) is back from the hospital. I'll document how she said the nurse threatened to call the police because she was still wearing her pj's. And a CNA kicked a shoe at her causing a hem atoma. [sic] 2. Review of Resident #15's admission Record, dated 08/01/2025, revealed a [AGE] year-old male, with an original admission date of 04/26/2022 and readmission date of 01/09/2024 with diagnoses that included schizoaffective disorder (a mental illness that combines symptoms of schizophrenia and a mood disorder), major depressive disorder, generalized anxiety disorder, glaucoma (damage to optic nerve), and legal blindness. Review of Resident #15's Quarterly MDS assessment, dated 05/29/2025, revealed a BIMS score of 10, indicating moderate cognitive impairment. Review of Resident #15's skin assessment, dated 06/13/2025, revealed skin intact. Review of Resident 81's admission Record dated 08/01/2025, revealed a [AGE] year-old male, with an original admission date of 01/04/2024 and readmission date of 06/24/2025 with diagnoses that included multiple sclerosis (autoimmune disease that affects the central nervous system), Bipolar II disorder (chronic mood disorder), major depressive disorder, and legal blindness. Review of Resident 81's admission MDS, dated [DATE], revealed a BIMS of 11, indicating moderate cognitive impairment. Review of Resident 81's Discharge summary, dated [DATE], revealed Resident #81 discharged to another facility on 06/27/2025. Record Review of facility Provider Investigation Report (Form 3613), dated 06/11/2025, revealed an allegation of abuse was made by Resident #15 on 06/06/2025, with an incident date and time of 06/06/2025 at 2:55 pm. Resident #81 was listed as the alleged perpetrator and the description of the allegation revealed the following: These two residents were in the smoke yard waiting for the 3:00 Smoke break, when these two started a slight verbal altercation. No injuries or adverse effects were noted. Provider response included review information and statement and view video footage. The investigation summary revealed After interview of residents, this administrator stayed with the residents through smoke break to ensure that there were no further altercations. Residents stayed away from each other and staff was advised to monitor so no issues would happen again. The facility's investigation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 17 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few findings were confirmed. Additional documents attached with the PIR included the following:- Initial incident reporting form - Administrators report, dated 06/06/25, revealed No was circled next to video. It further said Resident #15 and Resident #18 got into an argument regarding a place to sit during smoke break on 06/06/25 at 2:55pm on the smoking patio. Both wanted to sit under the awning during smoke break. Yes was circled next to Reportable with the reason This issue started with arguing then they were pushing each other in the wheelchair have hit each other on the arm. The synopsis revealed Resident got into a verbal argument then it had a little physical altercation. Residents were separated, no injuries but did have physical contact with each other.- Resident #15 and Resident #81's admission record.- Resident safe surveys for five residents.- No witness statements, staff inservices or resident assessments were included. Interview on 07/31/2025 at 8:04 am, Resident #15 stated he had short term memory loss. Surveyor asked about incident on the smoking patio and Resident #15 stated Resident #81 slapped him and he hit Resident #81 back. Resident #15 stated Resident #81 hit him in the eye. He stated there was one staff member and no other residents present during the incident. Resident #15 stated he did not know the staff member's name. Resident #15 stated he felt safe. Interview with Resident #81 was not completed because he was discharged from the facility on 06/27/2025. Interview on 07/30/2025 at 4:55 pm, the Administrator stated there was a camera on the smoking patio. He stated he looked at the footage and the incident was not physical, Resident #81 rolled up and locked the chair in front of Resident #15 but there was no contact. The Administrator stated there was no staff present during the incident and Resident #81 was pushing Resident #15 back and they were facing each other. When asked who the staff was that separated the residents, the Administrator stated he did not know, it was during shift change and was direct floor staff like CNAs. Interview on 07/31/2025 at 2:27 pm, CNA D stated she did not witness the incident. She stated if she did, she would separate residents, report to the DON and Administrator. Interview on 07/31/2025 at 3:22 pm, LVN O stated he did not witness the incident. Interview on 08/01/2025 at 8:33 am, CNA E stated she did not witness the incident. Interview on 08/01/2025 at 9:17 am, LVN P state he did not witness the incident. He stated if he did, he would separate residents, assess for injuries, report to the Abuse Coordinator, and monitor for 3 days. Interview on 08/01/2025 at 10:32 am, the Administrator stated he thought this incident was investigated thoroughly. He stated if not, the risk to residents would be the abuse could continue and somebody could be hurt without saying they were hurt. Review of the facility policy Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, revised September 2022, reflected Policy Statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation: (.) 6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 18 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete administrator is responsible for determining what actions (if any) are needed for the protection of residents. Investigating Allegations: 1. All allegations are thoroughly investigated. The administrator initiates investigations. 2. Investigations may be assigned to an individual trained in reviewing, investigating and reporting such allegations. 3. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. (.) 4. The administrator is responsible for keeping the resident and his/her representative (sponsor) informed of the progress of the investigation. 5. The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. 6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. 7. The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's p Event ID: Facility ID: 455881 If continuation sheet Page 19 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs in order attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one resident (Resident #30) of 24 residents reviewed for care plans. The facility failed to create a care plan addressing Resident #30's trauma history on 05/07/25, when her trauma screening assessment reflected her history of trauma. This failure could affect residents by placing them at risk for not receiving care and services to meet their needs.Findings included: Review of Resident #30's face sheet, dated 07/31/25, reflected she was a [AGE] year-old female, admitted on [DATE], and having diagnoses of Alzheimer's disease, dementia in other disease (dementia associated with another health condition) with behavioral disturbance, bipolar II (a less severe form of bi-polar than bi-polar I), major depressive disorder, and an anxiety disorder. Review of Resident #30's quarterly MDS assessment, dated 06/05/25, reflected Resident #30 had adequate hearing and clear speech, and was usually able to understand others and be understood by others. Her vision was impaired and she wore glasses. Her BIMS score was eight (out of a high score of 15), indicating possible moderate cognitive impairment. She displayed fluctuating inattention and disorganized thinking, but no behavioral symptoms. She had no impairment in her range of motion, and ambulated with a walker. Resident #30 required only set-up or clean-up assistance for eating, and supervision or touching assistance for hygiene and dressing. Review of Resident #30's Trauma Informed Screening Tool, dated 05/07/25, reflected Trauma is something that happens to a person that is unusually frightening, horrible or traumatic. 1 B. Examples are serious accident or fire, physical sexual assault or abuse, earthquake, flood, war, loved one die homicide or suicide, infectious disease, seeing someone seriously injured or killed 2. Have you ever experienced this kind of event? Resident #30's answer was yes. Resident #30 also answered yes to the following questions:- 4. In the past month, have you tried hard not to think about the event or went out of your way to avoid situations that remind you of event?- 5. In the past month, have you been constantly guarded, watchful, or easily startled?The document said Careplan: 1. If any question in 3-7 is yes please proceed to care plan. Review of Resident #30's care plans reflected the following care plans:- h/o chronic pain, initiated 05/01/25- risk of complications r/t use of psychotropic medications (drugs that act on brain chemistry and can affect mood, behavior, and perception) / antidepressant, initiated on 05/01/2025, revised on 07/29/2025- risk of complications r/t use of psychotropic medications (drugs that act on brain chemistry and can affect mood, behavior, and perception) / anti-psychotic medication, initiated on 05/01/2025, revised on 07/29/2025- risk of experiencing symptoms of depression, initiated on 05/01/25- impaired cognitive function r/t Alzheimer's, initiated on 05/01/25- h/o falls with actual falls, initiated on 05/01/25, revised 07/10/25- impaired vision, initiated on 05/09/25- periods of forgetfulness, initiated on 05/09/25- impaired comprehension, initiated on 05/09/25- psychosocial well-being problem (actual or potential) r/t dependent attention-seeking behavior, initiated on 07/23/25. This care plan listed two relevant incidents which included 7/19/25--lifted a heavy lock box causing shoulder pain, insisted on going to ER and 7/22/25--alleged that CNA caused hematoma to foot by accident- risk for side-effects/ complications from anti-anxiety medication, initiated on 07/22/25, revised on 07/29/25 Review of Resident #30's Careplans reflected no careplans regarding her history of trauma. Review of Resident #30's Psychological Services Progress Note, dated 07/29/25, reflected Trauma screening: Positive but denies current symptoms. An interview on 07/29/25 at 11:15 AM revealed Resident #30 to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 20 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete lying on her bed, dressed, and able to answer questions for the surveyor. No mention of trauma was made during this interview. An interview on 07/30/25 at 9:32 AM with the Administrator revealed the Social Worker was on vacation during the survey period and was not where she could be reached. An interview on 08/01/2025 at 8:51 AM with the MDS Coordinator revealed he had done MDS at the facility for about seven years. He said he updated them with each MDS, but for new orders and such it was a collaborative effort between him, the DON, and the ADON. He said the Social Worker was responsible for the careplans related to trauma, and he did not know why Resident #30's was not done. He said that if the careplans were done properly, the resident's needs and behaviors should not come as a surprise to a new person providing care, if they were to read them. He said if that careplans could help the staff be better educated about the resident, so they might not be as reactionary if something happened, because they would know more what to expect from that resident. An interview on 08/01/25 at 1:19 PM with the DON revealed she was not aware of Resident #30's trauma or triggers. Review of the facility policy Care Plans, Comprehensive Person-Centered, revised December 2016, reflected A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the infom1ation gathered as part of the comprehensive assessment. (.) 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that arc to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; (.) g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; 1. Build on the resident's strengths; J. Reflect the resident's expressed wishes regarding care and treatment goals; k. Reflect treatment goals, timetables and objectives in measurable outcomes; I. Identify the professional services that are responsible for each element of care; (.) o. Reflect currently recognized standards of practice for problem areas and conditions. (.) 10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. a. No single discipline can manage an approach in isolation. (.) 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. a. When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers. Event ID: Facility ID: 455881 If continuation sheet Page 21 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the facility's only registered dietitian carried out the functions of food and nutrition services dietitian, according to the facility's Consultant Dietitian: Retainer Agreement. The facility failed to ensure that the registered dietitian worked a minimum of 16 hours a month and/or adjusted hours based on the facility's census. This failure could result in residents not maintaining or achieving optimal nutrition status. Findings included: An interview on 08/01/2025 at 9:19AM with the registered dietitian revealed that she had been working at the facility for 22 years and worked 12 hours a month. She explained it always had been 12 hours a month; if the census was around 60 residents, she would be expected to work at least 8 hours, if the census is 61-90 residents, she'd work 12 hours. She further stated she usually does more than 12 hours a month. Record review of the Consultant Dietitian: Retainer Agreement, dated 1/1/2026 reflected: This agreement is being entered on the 1ST day of [DATE]. Consultant ResponsibilitiesCoordinate the overall functions of the facility's consultant services in that the dietitian shall: .10. Provide a minimum of 16 hours in the facility, based on census.(Approx. 8 hours (+/based on resident acuity) for every 30 patients) .Financial Arrangements1. The consultant agrees that he/she shall devote a sufficient number of hours based upon the census of the facility, to carry out the responsibilities outlined in this agreement.The agreement was signed by the owner of the consultant group and the facility administrator on 1/1/2016. Record review of the facility's census on 08/01/2025 was 75 residents, with a licensed capacity for 98 residents. An interview on 08/01/2025 at 10:47AM with the ADM, he had thought the agreement was for the registered dietitian to work a minimum of 12 hours a month. He said the contract between the facility and the consultant group the registered dietitian worked for was signed by the consultant group owner. Event ID: Facility ID: 455881 If continuation sheet Page 22 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to develop, prepare, and periodically update menu items to meet residents needs and preferences. The facility failed to utilize and follow dietitian approved recipes for pureed food items.The facility failed to prepare an alternate menu in advance. The facility failed to ensure alternate menus were reviewed and approved to ensure it met the residents nutritional needs by the facility's dietitian.The facility failed to make reasonable efforts to develop a menu based on resident complaints about the lack of variety in food options. These failures could result in an adverse effect to resident's physical and psychosocial well-being.Findings included: During an observation on 07/29/2025 at 9:30AM, this surveyor asked the dietary assistant for a regular and alternate menu for the next 3 days. The dietary assistant was able to provide a regular menu of the meal being served that day, but not an alternate menu. She explained the alternate menu item was chosen the day of and there was not an official alternate menu. An interview on 07/29/25 at 11:58 AM with Resident #41 revealed he thought the food sucked. He said they had chicken 4-5 times a week, and it was overkill on the chicken. He said he had things listed on his slip that he could not eat, and they continually brought them to him. He said sandwiches were always their go-to alternative; if you were allergic, or did not like the main meal, you were stuck with a sandwich. He said the sandwiches were not good, either. He said their grilled cheese sandwich was so dry it was hard. He said when the residents made suggestions, the dietary staff would tell them there were set guidelines about what they could serve and they could not change it. He said they served terrible chicken patties often, and one time they had a different kind that was really good, and they never saw it again after the single time they served it. An observation on 07/30/2025 at 12:27PM revealed [NAME] F preparing pureed shrimp. [NAME] F added bread slices as thickener. [NAME] F asked the dietary assistant to get hot water to add into the pureed shrimp. At that time, this surveyor intervened before hot water was added in as the liquid ingredient. [NAME] F revealed that she was told to use bread slices as thickener and water for the liquid consistency. She stated she had seen broth and food thickener used in other kitchens outside of the facility, but that she had been doing what she was told to, and that the facility did not have food thickener or broth. When asked what the recipe instructs, the cook discussed that she used her knowledge when determining pureed food consistency. [NAME] F proceeded to pour the pureed shrimp onto pre-divided plates. When asked why she didn't use a scoop, she stated doesn't use a scoop to fill a portion of the plate. She said she was told to fill a portion of the plate with the pureed food. At that time, the dietary assistant asked if milk was acceptable to use in place of the water. This surveyor responded by asking what the recipe for pureed shrimp instructed, the dietary assistant looked for the pureed shrimp recipe in the kitchen's recipe book and was not able to provide one. The dietary assistant and [NAME] F decided to use the liquid the cooked shrimp were in. An interview on 07/29/25 at 12:57 PM with Resident #11 revealed he was unhappy with the food in the facility. He said he had not eaten pork since he was very small (young), but the facility kept serving him pork. He said some days the lunch meal, and the dinner meal would be pork, and if the alternate was also something he did not eat, they would give him a sandwich. He said he had lost weight in the facility because the food was so bad. He said pork was listed on his meal ticket as a dislike and they were not supposed to bring it to him, but they had it on the menu all the time, and they brought it to him a lot. He said he knew of a few other residents who did not eat pork in the facility, and they also continued to be served pork. He said they also just made-up names for things that did not describe what the food was. He said they served something they called turkey (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 23 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some tetrazzini, but it was just a pasta dish with hot dogs cut up in it, and it was disgusting. An interview on 07/31/2025 at 12:42PM with Resident #80 revealed that she had resided at the facility for a few years and had issues with meal variety. Resident #80 stated that she sometimes received food items that she does not want. She explained that CNAs inform her of the alternative menu item of the day about an hour before the meal being served, and residents could only choose the regular or alternative menu item for each meal. She stated she wished she knew of the alternative options sooner than an hour before the meal was served. She further discussed sometimes they (the kitchen) don't have enough of what residents want, the menus need more variety, and the menus were too repetitive. When asked what alternative options were, she stated it may be a sandwich and chips or soup, it maybe last nights dinner as next day alternative meal item. As an example, the resident stated Salisbury steak will be given for lunch as the regular menu item and then as the alternate menu option the same day. Resident #80 said there was a lot of repetition of same old food items. She explained the turkey tetrazzini was on the regular menu item and had been used over the previous years and it was an item she did not enjoy. Resident #80 stated she had expressed these issues with the food service manager, but had been told someone else makes the menu, not the dietary staff. She stated the food service manager does not follow up with the resident regarding her concerns. During an interview on 8/01/2025 at 9:19AM with facility's registered dietitian, she explained that cycle menus (menu changes every day but eventually repeats itself in the same order) were utilized at the facility and she signs off on recipes and menus that come from a food vendor. If there was an issue, a substitution would be made to the menu, and she would approve of it. She further discussed the alternate menu option was chosen the day of, and that had always been done the day of. She stated that an official alternate menu would be beneficial for the dietary staff. The registered dietitian stated she did not sign off on the alternate menu items. She stated anything on the regular menu was okay, the alternates typically a balanced meal. When asked if a deli sandwich with chips was a balanced alternate meal, she stated residents should get a salad or vegetable and would offer fruit with it. When asked if the regular menu item for lunch was acceptable for the dinner's alternate menu item, she stated that the dietary staff try to do different meats for regular and alternate menus. The registered dietitian explained the dietary staff had pureed recipes from the vendor. She further discussed bread was being used as thickener and milk was typically used as the liquid for the pureed foods, to add calories. She expected staff to not pour pureed foods onto plates and use scoops to have correct portion size. During an interview with the food service manager on 08/01/2025 at 10:55AM, she stated that alternate menus were not planned ahead of time. Dietary staff plan the alternate menu the day of, and sandwiches or leftovers were the alternate most of the time. She further explained leftovers would be the alternate for the next day or next evening depending on what the kitchen had in stock. The food service manager stated she normally did not serve the same meats for the regular and alternate menu items, if pork was on the regular menu, she would try to serve beef or chicken as the alternate option. She said she had told her staff to do that during in-services. The food service manager stated residents occasionally complained of meals being repetitive and if residents continue to complain about a specific meal, they dietary staff try to address the complaints by doing an alternate for that meal. The food service manager stated the alternate menu was something she needed to work on. She explained that in the past, she had hot dogs and burgers as an alternate all the time, but the residents were wanting the alternate instead of the regular menu item. The food service manager did not find it to be a concern that the residents preferred the hot dogs and hamburgers over the regular menu items. The food service manager said she expected staff to use scoops when serving food items and did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 24 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete know why a scoop was not used for pureed food items. She expected staff to utilize recipes that had been signed off by the dietitian and can be found in the recipe book in the kitchen. She stated there were recipes for pureed foods. The food service manager stated she would put milk in pureed food instead of hot water, and broth could be an option. She stated that using recipes make the cooking process easier. Record review of the facility's regular menu Sysco Acadiana 2025 Spring Summer Menus revealed the menus were approved by the facility's registered dietitian. The menus were shown to have a start date of April 6 and end date of October 25 (29 weeks), and to be cycled every 4 weeks. Week 1's menu was shown to be repetitively used for 8 weeks, Week 2's, 3's, and 4's menu were shown to be repetitively used for 7 weeks each. The breakfast menu item for every day of every week reflected: Egg Choice, Juice, Cereal of Choice, Breakfast Meat of Choice, Breakfast Bread, Coffee, Milk/Water. Record review of the facility's Menus policy revised October 2017 reflected: Policy - Menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy.Policy and Interpretation and Implementation1. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board (National Research Council and National Academy of Sciences).2. Menus for regular and therapeutic diets are written at least two (2) weeks in advance and are dated and posted in the kitchen at least one (1) week in advance.3. Menu items and available snacks reflect the religious, cultural and ethnic preferences of the residents, whenever reasonable.4. The Dietitian reviews and approves all menus.5. Input from the resident is considered in menu planning.8. Menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal.9. If a food group is missing from a resident's daily diet (e.g., dairy products), the resident is provided an alternate means of meeting his or her nutritional needs (e.g., calcium supplementation or fortified non-dairy alternatives). 10. Menus are updated periodically. Event ID: Facility ID: 455881 If continuation sheet Page 25 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.The facility failed to ensure the stand-by refrigerator were dated and labeled.The facility failed to ensure the refrigerator food items were dated, labeled and securely stored.The facility failed to ensure the dry storage food items were dated and labeled.The facility failed to ensure that the steam tray table was cleaned daily.The facility failed to ensure that canned good food items were free of dents.The facility failed to ensure that dishwashing protocol was followed.The facility failed to ensure pureed food temperatures were logged.The facility failed to ensure dietary staff had an adequate amount of safe and functional essential kitchen equipment, including cutting boards, stock pots, and metal sheet pans. These failures could place residents at risk for foodborne illness and foodborne intoxication.Findings included: Observation on 07/29/2025 beginning at 8:43AM of 1 of 2 refrigerators revealed:- A metal pan of a pasta dish, covered with saran wrap, with no label or use by date.- Hamburger patties wrapped in foil, and labeled, in a metal pan of gravy. The wrapped hamburger patties were separated from the gravy by a layer of saran wrap that was not sealing the gravy.- A metal pan of food with no date or label of the food item.- An unsealed bag of fully cooked pork sausage patties, in the manufacturer's box dated 7-25-25, with no use by date.- An unsealed bag of fully cooked chicken breast chunks, in the manufacturers box dated 7-25-25, with no use by date. Observation on 07/29/2025 at 8:49AM of 2 of 2 refrigerators revealed:- 4 deli sandwiches in a large Ziploc bag, with no label or use by date.- A Styrofoam plate with a deli sandwich and potato chips, covered with saran wrap, and with no label or use by date.At that time, an interview with the dietary assistant revealed the pasta dish was turkey tetrazzini and made the day before, and the metal pan of food with no date or label was chicken sausage gumbo made a few days before. The dietary assistant stated that the procedure for dating items was to label the boxes when delivered to the facility. She explained the boxes of fully cooked pork sausage patties and fully cooked chicken breast chunks had been delivered on 07/26/2025 and the date was written incorrectly but would be corrected to match the date of the delivery. She further stated the importance of labeling and dating was to not give resident's something that the kitchen had for over extended (period of) time and the risk of not properly sealing food items can cause bacteria to get in it and it's harmful to residents. The dietary assistant stated that refrigerated foods items were kept 7 days after opening. When asked why there were multiple boxes of fully cooked pork sausage patties in the refrigerator and not kept in the freezer, she explained the residents liked the pork sausage patties and they would be eaten before they were no longer appropriate for the residents to consume. Observation on 07/29/2025 at 8:52AM of the standby refrigerator revealed- An open carton of Med Plus 2.0, with no use by date. Observation on 07/29/2025 at 8:58AM of the 3-compartment sink revealed large metal pans in the 1st compartment, a serving spoon in the 2nd compartment, and a large stockpot and metal pan lids in the 3rd compartment, and a drying rack with various kitchen utensils and metal pan lids next to the 3rd compartment. No water, soap, or sanitizing solutions were in the sink. There were no sanitizing solution test strips by the sink. An interview on 07/29/2025 at that time with the dietary assistant revealed that degreaser and a bottle of soap are used on the dishes to wash them. When this surveyor asked where the sanitizer solution test strip and log were kept, the dietary assistant showed test strips by the automatic dishwashing machine and no test strip log was provided. This surveyor asked the dietary assistant what the test strip should read when the sanitizing solution was tested, she stated 32, this surveyor asked what color the test strip (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 26 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many should read, she stated purple, light purple. The dietary assistant did not know what sanitizer was used for the 3-compartment sink. This surveyor asked the dietary assistant the importance of testing the sanitizing solution, she stated too much, or too little sanitizer can result in residents getting sick. Observation on 07/29/2025 at 9:07AM of the steam tray table revealed a brown like substance built up on the heating elements, food particles including rice in the water used to steam foods. Interview on 07/29/2025 at that time with the dietary assistant revealed that steam tray table was supposed to be cleaned daily by dietary staff, and the rice seen in the water was from the lunch meal served the day before. An observation on 07/29/2025 at 9:08AM revealed 4 large cooking sheet pans with carbonized grease (black substance that forms on cookware when oils, fats, and food particles are repeatedly exposed to high heat) build-up.At that time, an interview with the dietary assistant and the diet aide revealed that they would not want to eat foods that are cooked on sheet pans with carbonized grease build up. The dietary assistant stated that the kitchen needs new sheet pans. Observation on 07/29/2025 at 9:19AM of the dry storage closet revealed - A dented caned good of diced pears dated 7/18- 2 dented cans of tomato soup dated 7/15/25- A dented can diced tropical fruit salad dated 7/18 - A saran wrapped package of dry pasta noodles, with no date or label. An interview on 07/29/2025 at that time with the dietary assistant revealed dented canned good items were a risk because they can have hole that compromises the seal. She said there is a separate spot for dented cans and they can be returned to the food vendor. An observation on 07/30/2025 11:38AM revealed the kitchen's one cutting board had deep scratching and scoring; the cutting board was had gray discoloration on the outer edges and was light yellow/white in the middle. During an observation on 07/30/2025 at 11:45AM, this surveyor intervened when the diet aide began to pour hot steaming water onto frozen plastic juice cups. An interview at that time revealed the diet aide stated that she knew cool running water should be used when thawing frozen food items, but due to the short time frame before serving the juice cups at lunch, she was going to use hot water to melt the frozen juice. Record reviews on 07/30/2025 at 11:47AM of the Daily Food Temperature Log dated July 29, 2025 and July 30, 2025, reflected temperature recorded for food items on the regular menu. No record of temperature checks for pureed food items. An observation on 07/30/2025 at 11:50AM of the facility's kitchen revealed a large cooking stock pot with tan and brown build-up on the inner sides of the pot.At that time, an interview with [NAME] F revealed she only used the large stock pot for cooking scrambled eggs; she explained liquid eggs come in a bag that can be put into water for cooking and the eggs were not exposed to the pot. She further stated the pot had been in it's condition since she began working at the facility 3 months ago. [NAME] F further stated there was only one cutting board in the kitchen. She stated she had worked in other kitchens that had different coloring cutting boards for different food items. An interview on 07/30/2025 at 1:53PM with the dietary assistant revealed the kitchen only had one cutting board. When asked the importance of having appropriate kitchen equipment, she stated for the health and safety of staff and residents, maintain proper food policy, and prevent food contamination. An interview on 07/31/2025 at 1:53PM with [NAME] F revealed that she utilizes the 3-compartment sink to pre-wash cookware she used but will then wash all cookware in the automatic dishware. She does not know if the 3-compartment sink was being used to wash dishes thoroughly; she explained incorrect water temperatures and sanitizer solutions results in unclean dishes and can lead to residents getting sick. She explained she temperature checks all food items before serving to residents but does not keep record of temperatures for pureed food items because she did not have a temperature log sheet to record the pureed foods temperatures on. She only had a temperature log sheet for regular food items. When asked what can be done until she had a separate temperature log sheet for pureed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 27 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many foods, she stated she could create a separate row on the regular food temperature log for the pureed foods and showed the surveyor a separate row for the pureed foods temperatures. An observation on 07/31/2025 at 1:57PM of 1 of 2 refrigerators revealed:- Boxes of fully cooked pork sausage, dated 7-25-25 were still in the refrigerator, and the dates had not been updated to reflect the delivery date of 7-26-25- A box of frozen ground beef tubes on top of a box of frozen chickenAn interview at that time with the dietary assistant revealed that updating the delivery dates was being worked on. When asked what can be done to make sure food items were being dated correctly, she stated she constantly had to tell the dietary staff to make sure they date and label all food items. When asked why the frozen ground beef stacked on top of the frozen chicken was an issue, she stated the ground beef could leak onto the chicken while thawing. She proceeded to place the box of frozen ground beef tubes into a large pan to prevent dripping. On 07/31/2025 at 2:45PM, this surveyor intervened and asked the dietary assistant to discard all the boxes of fully cooked pork sausage patties, dated 7-25-25. The dietary assistant proceeded to discard all the boxes. When asked why it had to be thrown away, she stated it was because the food was out of the timeframe of what would be safe to eat. She further stated the timeframe (food can be kept after opening) was 3-5 days. An interview on 08/01/2025 at 9:19AM with the facility's registered dietitian revealed she somewhat works with the dietary staff and checks the kitchen every time she's at the facility and notified the food service manager of any issues. She explained the food service managers over the kitchen but had been out of the facility recently. The registered dietitian had done in-services with the dietary staff in the past, but the food service manager would do in-services and sometimes they would do them together. When asked if dietary staff used the 3-compartment sink, she said staff used it for pot washing and other dishware was washed using the automatic dishwasher. The registered dietitian she stated the kitchen should have 2 cutting boards for vegetables and 2 cutting boards for meats, and 1 cutting board was a problem because of cross contamination of food items. When asked the expectations of dating and labeling food items, the registered dietitian stated it depends on the food item. For items in boxes, staff were encouraged to leave items like dry pasta in the manufacturer boxes and to date them when they were delivered. Once food items were opened, staff should take the food item out of the box and write an opened on date. She further stated food items only stay in the refrigerator for 3 days after opening. This surveyor asked why the dietary assistant had to throw away the fully cooked sausage patties on 07/31/2025, she explained keeping the patties in the refrigerator past the 3 days could result in bacteria growth and make resident extremely ill if they consumed the patties. The registered dietitian discussed dented canned good items can lead to a broken seal, and further lead to botulism (illness caused by toxin produced by the bacteria Clostridium botulinum, which grows when exposed to oxygen). An interview on 08/01/2025 at 10:55AM with the food service manager revealed dietary staff had been using the 3-compartment sink but then began to pre-wash dishes in the sink and fully wash all dishes in the automatic dishwasher. The food service manager thinks this was done because dietary staff do not think dishes were sanitized in the 3-compartmen sink. The food service manager plans to start having dietary staff use the 3-comaprtment sink for pot washing. She further discussed she had planned to order new sheet pans and cutting boards prior to being out of the facility. The food service manager stated she expected staff to temperatures for regular and pureed food items. She expected staff to date and label all boxed food items, for items to be in first in and first out order. She said prior to being out of the facility, she checked the refrigerator every morning to see how long food items had been in the refrigerator. She explained if food items were not dated or labeled, they were not considered good (safe for consumption). She expected staff to seal all opened food items (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 28 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many and explained rolling up (a bag) was not enough to seal food items. The food server manger discussed how long food items can stay in the refrigerator depends on the food item; left over food items can be kept in the refrigerator for 24-48 hours. She stated keeping the fully cooked sausage patties longer than 3 days can make residents sick if they were consumed. She stated dented canned food items were expected to be taken off shelves because they can cause residents to get sick. The food service manager stated she always expected frozen meats to be placed in a pan when thawing in a refrigerator, and she expected the steam tray table to be cleaned daily. The food service manager stated she had done in-services with her staff in the past but needs to do more. Record review of a letter of a kitchen equipment order, dated Jul-29-2025, reflected 5 full size sheet pans ordered. The order stated the items would arrive no later than 8-7-25. Record review of the facility's Food Receiving and Storage policy, revised October 2017, reflected: Policy Statement Foods shall be received and stored in a manner that complies with safe food handling practices.Policy Interpretation and Implementation.2. When food is delivered to the facility it will be inspected for safe transport and quality before being accepted.8. All foods stored in the refrigerator or freezer will be covered, label and dated ( use by date).13. Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables and other ready-to-eat foods. Record review of the facility's Sanitation policy, revised October 2008, reflected: Policy Statement The food service area shall be maintained in a clean and sanitary manner.Policy Interpretation and Implementation.1. All kitchens, kitchen areas and dining areas shall be kept clean.2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning.3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions.9. Manual washing and sanitizing will employ a three-step process for washing, rinsing and sanitizing. 17. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Record review of the U.S. FDA Food Code 2022 reflected: 3-302.12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. Section 3-501.17 . Commercial processed food: Open and hold cold . B . 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety . C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Definitions 3 . Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 29 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete indicated .3-501.13 Thawing. TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed. (B) Completely submerged under running water: (1) At a water temperature of 21 C (70 F) or below.3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above. (2) At 5 C (41 F) or less .3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 Food labeling, and 9 CFR 317 Labeling, marking devices, and containers .4-501.12 Cutting Surfaces. Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and SANITIZED, or discarded if they are not capable of being resurfaced.4-501.19 Manual Warewashing Equipment, Wash Solution Temperature - The temperature of the wash solution in manual WAREWASHING EQUIPMENT shall be maintained at not less than 43 C (110 F) or the temperature specified on the cleaning agent manufacturer's label instructions.4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization - Temperature, pH, Concentration, and Hardness .A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under 7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, and shall be used as follows: (A) A chlorine solution shall have a minimum temperature based on the concentration and pH of the solution as listed in the following chart.(B) An iodine solution shall have a: (1) Minimum temperature of 20 C (68 F), (2) pH of 5.0 or less or a pH no higher than the level for which the manufacturer specifies the solution is effective, and (3) Concentration between 12.5 MG/L and 25 MG/L; (C) A quaternary ammonium compound solution shall: (1) Have a minimum temperature of 24 F C (75 F), P (2) Have a concentration as specified under S 7-204.11 and as indicated by the manufacturer's use directions included in the labeling.4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. Record review of the U.S Department of Agriculture's publication Leftovers and Food Safety, last updated July 31, 2020, reflected: Store Leftovers Safely - Leftovers can be kept in the refrigerator for 3 to 4 days. Event ID: Facility ID: 455881 If continuation sheet Page 30 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 Based on interviews, 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 in this facility (one of one) reviewed for water management. The facility failed to implement a water management program/plan including: 1.) An assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread; and2.) to implement measures to prevent the growth of opportunistic waterborne pathogens (control measures), and how to monitor them. This failure could place all residents at risk of water borne illness.Findings included: In an interview on 7/31/25 at 12:00 pm, RN C stated that the facility had a legionella policy and plan, but that there was no documentation of the implementation of the water management program. She stated a water management binder had been started but that the plan was never designed or implemented . She stated she had spoken with the maintenance director today (7/31/25) and he had reported to her that he had done some water monitoring activities such as temperature checks, but that he did not have any documentation. In an interview on 7/31/25 at 1:12 pm, the Operations Manager reported that he was not aware of any water management plan at the facility. Regarding the responsibility for the water management plan he stated, I thought it was an administration thing. I know they just started it a couple of years ago. I've never been asked about this before. Regarding the assessment of the facility to identify areas of potential concern for Legionella he stated, You want to make sure the showers are clean and standing water areas. He denied any knowledge or involvement or documentation of a water management plan or control measures at this facility. He reported the risk of Legionella is, it is a very dangerous flesh-eating bacteria. In an interview on 8/01/25 at 9:10 am, the DON stated she was not aware that there was not a water management plan at the facility but that she was aware that monthly water temperatures are checked by maintenance. She reported the risk of not having a water management plan would be the risk of Legionnaires disease. She reported she had assumed that the plan would be implemented by maintenance and any issues would be reported to the Administrator. The DON stated no residents had been identified with Legionella's disease at the facility. In an interview on 7/31/25 at 1:05 pm, the ADM stated when he was previously the administrator at this facility in 2023, they had just begun initiating a water management plan. He stated that he had not followed up on this since he was rehired to the facility in January 2025, and he was not sure if the plan had ever been implemented. He reported the maintenance director was responsible for this. He stated the risk to residents of not having a water management plan it could risk a lot of people getting sick of waterborne illness. He denied any residents had been identified with Legionella's disease. The facility water management binder was reviewed and contained only the Health and Human Services publication titled, Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings dated June 24, 2021. There was no facility assessment, developed plan, or implementation of prevention measures present. The facility policy titled, Legionella Surveillance and Detection dated 2001 and revised July 2017 stated, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. Legionnaire's disease will be included as part of our infection surveillance activities. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 31 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain safe and functional essential kitchen equipment in the facility's only kitchen. The facility failed to ensure the gas stove top oven had all turn knobs, did not leak grease, and was safe to touch when operating.The facility failed to assure the wall plug sockets were free of food and grease particles, and in safe operating condition. The facility failed to ensure the toaster oven was in safe operating condition. These failures could place residents at a risk for facility essential equipment not being maintained in working order. Findings included: An observation on 07/29/2025 at 8:52AM of the gas stove top oven revealed a small pile of white cloth towels with grease on them under the left front corner of the oven.An observation on 07/30/2025 beginning at 11:50AM of the facility's kitchen revealed:- A toaster over with electrical tape around its power cord- 2 wall sockets with black burn-like appearance- 2 wall sockets covered with food particles and grease- Food particles and grease build up on the wall behind the 3-compartment sink - Power strip on the counter next to the 3-compartment sink, covered with food particles and grease- [NAME] grease like stains lining the top of the left oven door on the gas stove top oven.- 2 turn knobs missing from the stove topAt that time, an interview with [NAME] F revealed the toaster oven had electrical tape on the power cord since she began working at the facility 3 months ago. [NAME] F further discussed issues with the kitchen's stove top oven. She stated the oven had a problem with dripping grease and it had been like this since she began working at the facility. [NAME] F said the kitchen staff drain the grease from the grease tray after using the grill top on the stove, but it continued to leak. The towels were placed under the oven to catch the grease drips. She stated the turn knobs were hot to the touch and turn knob to turn on the oven does not have labeling to indicate the temperature the ovens turned onto. This surveyor touched the oven's turn knobs and was able to confirm the cook's concern of the hot turn knobs on the oven. During an interview on 07/30/2025 at 1:53PM with the dietary assistant she stated the kitchen staff had tried to have maintenance work on the oven due to the leaking grease and hot turn knobs. An interview on 07/31/2025 at 1:20PM with the maintenance director revealed that he had been planning to paint and repair imperfections in the kitchen. He further discussed that the gas stove top oven must be worked on by the vendor, and that it had been recalibrated earlier in the year. During an interview on 8/01/2025 at 9:19AM with facility's registered dietitian, she stated kitchen equipment like the steam tray table had to be fixed. The registered dietitian stated condition of the kitchen equipment matters because its good practice to have not well used equipment that's going to be serviceable. She further discussed that when the food service manager was at the facility, the kitchens operating, but it had been a challenge since the food service manager had been out. She explained the kitchen was old and the problems were ongoing. During an interview on 08/01/2025 at 10:55AM with the food service manager, she stated after discussing the oven issues with the maintenance manager, the vendor came and recalibrated the oven. She further discussed that she needed to order new turn knob, but she did not know why grease leaked from the oven. The food service manager stated she was not sure why electrical tape was on the toaster oven power cord because the toaster oven was purchased about a year ago. Record review of the U.S. FDA Food Code 2022 reflected: 4-1 Materials for Construction and Repair.4-101.11 Characteristics. Materials that are used in the construction of UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT may not allow the migration of deleterious substances or impart colors, odors, or tastes to FOOD and under normal use conditions shall be: (A) Safe; (B) Durable, CORROSION-RESISTANT, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated WAREWASHING; (D) Finished to have a SMOOTH, EASILY CLEANABLE surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and Residents Affected - Many (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 32 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete decomposition.4-2 Design and Construction 4-201 Durability and Strength 4-201.11 Equipment and Utensils. EQUIPMENT and UTENSILS shall be designed and constructed to be durable and to retain their characteristic qualities under normal use conditions. 4-201.12 Food Temperature Measuring Devices. FOOD TEMPERATURE MEASURING DEVICES may not have sensors or stems constructed of glass, except that thermometers with glass sensors or stems that are encased in a shatterproof coating such as candy thermometers may be used.4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. Event ID: Facility ID: 455881 If continuation sheet Page 33 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for two of the three hallways reviewed for pest control and the facility's only kitchen. The facility failed to ensure Resident #36 and Resident #28's room was free of flies on 7/29/25 and 7/30/25.The facility failed to ensure Resident #56 and Resident #28's room was free of flies on 7/30/25. This failure could lead to pest infestation and place residents at risk of insect transmitted diseases.Findings included: Review of Resident #36's face sheet reflected he is a [AGE] year-old male admitted on [DATE]. Review of Resident #28s face sheet reflected he is a [AGE] year-old male admitted on [DATE]. Review of Resident #56's face sheet reflected he is a [AGE] year-old male admitted on [DATE]. Review of Resident #29's face sheet reflected he is a [AGE] year-old male admitted on [DATE]. Review of Resident #36's Quarterly MDS dated [DATE] reflected a BIMs score was not done as resident was rarely/never understood. Review of Resident #28's Quarterly MDS dated [DATE] reflected a BIMs score of 4 indicating severely impaired cognition. Review of Resident #56's Quarterly MDS dated [DATE] reflected a BIMs score of 10 indicating moderately impaired cognition. Review of Resident #29's Annual MDS dated [DATE] reflected a BIMs score of 3 indicating severely impaired cognition. In an observation and interview on 7/29/2025 at 11:00 a.m., Resident #36 was observed asleep in his bed in his room. Two flies were observed on the resident's window. A third fly was observed on the resident's upper lip walking towards his nostril. Resident eventually aroused and waved the fly away. Resident # 36 was not interviewable. In an observation and interview on 7/29/25 at 11:00 a.m., Resident #29, the roommate of Resident #36, was observed laying in his bed. There were three flies observed in his bedroom, including two on the window and one on his roommate. Resident # 29 reported that flies had been in his room for months and that, they bother me. In an observation on 7/30/25 at 2:35 two flies were observed landing on the bedspread covering Resident #36 in his room. In an observation and interview on 7/31/25 at 8:30 a.m., Resident #56 was sitting at his bedside, and a fly was observed landing on his bedside table next to the coffee cup he had been drinking from. Resident #56 stated that there had been some flies in his room for about a week. He stated he had not discussed the flies with staff and was not aware if anything was being done about them. He stated the flies make him feel, bad. In an observation and interview on 7/31/25 at 8:35 a.m., Resident #28 was noted sitting on the side of his bed and a fly was sitting on the top of his bald head. Resident #28 stated flies have been a problem in his room, forever and they are, always bothering me. He stated he eats in his room and the flies are, always getting in your food and pestering you. He stated he had not notified staff of the flies indicating they were obvious. He reported the flies made him feel, not good. In an interview on 07/30/25 at 4:30 p.m., LVN A reported that she had worked at the facility for one year and four months, and that the facility had a problem with flies, since summer began this year (2025). She stated that flies were, everywhere. She reported that, the flies are terrible in the dining room at dinner time. She stated that the facility had placed electronic fly traps in the hallway but that it had not been helpful. She stated that she was aware that maintenance had been notified of the fly problem, and they were responsible for contacting pest control. She denied having received any complaints from residents about the flies. She stated that she would have expected residents to have been, aggravated and annoyed by the flies and that the flies were a risk to residents related to, germs. In an interview on 07/31/25 at 9:50, CNA B stated she had seen flies in residents' rooms, sometimes. She stated she had noted that the facility had pest control out in the past (dates unknown). She reported that when staff noted insects, they were to report it to maintenance or tell the nurses. She stated she had Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 34 of 35 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 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete previously told a nurse about flies in a resident's room, months before but not lately. In an interview on 7/31/25 at 1:05 pm, the ADM stated that flies at the facility were a problem that had occurred in the last week or less. He reported that, We need to get the pest control company back out here. He stated that the facility had installed some electronic fly traps. He reported there was a pest control log at the nurse's station for staff to report any pest sightings. He stated he believed the pest control program was working, he didn't get a lot of complaints, and it was an old building. He reported that pest control was scheduled and came every month and that he notified them as needed in addition to the scheduled visits. He reported that the last time he requested an additional visit was for bed bugs several months ago. He reported he had not had any complaints related to the flies from residents or staff. He reported that if flies were on residents' food or faces that, that is not good but did not identify a specific risk. In an interview on 8/01/25 at 9:10 am, the DON stated that a pest control company came to the facility perhaps twice a month, and the facility had a pest log, and in addition they let maintenance know when there was an excessive problem. She stated that the current pest control program worked but that the flies were very bad everywhere right now and the pest control company must continue to come out. She stated the risk to residents would be spreading infections that flies carry. She stated that the maintenance director was responsible for pest control and that this was monitored by the ADM.In an interview on 7/31/25 at 1:12 pm, the Operations Manager (maintenance director) stated that the pest control company came to the facility every month but that it is summertime, and he can't control the arrival of the flies. He reported they do have the zappers out for flies but that the frequencies of the doors being opened contributed to flies getting in. In a review of the facility pest control log from April 2025 through June 2025, invoices reflected a pest control company provided pest treatment at the facility on 4/08/25, 5/10/25, 5/29/25, and 6/06/25. The invoices dated 4/08/25 and 6/06/25 noted a target pest of flies. The facility policy titled, Pest Control dated 2001 and revised May 2008 was reviewed and stated, Our facility shall maintain an effective pest control program and This facility maintains an on-going pest control program to ensure the building is kept free of insects and rodents. Event ID: Facility ID: 455881 If continuation sheet Page 35 of 35