Inspection·October 14, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some for appropriate channeling of anger, talk in calm voice when behavior is disruptive, Social Services to evaluate and visit routinely, and monitor and document behavior. Focus of at risk of being taken advantage of r/t impaired cognition updated on 10/03/2025 when Resident #3 slapped Resident #2 after she took his cup with interventions and tasks of allow Resident #2 to express concerns about safety, anticipate Resident #2's needs, encourage Resident #2 to sit in common areas that are well populated, observe Resident #2 frequently throughout the day, psych services are available as needed, and on 10/03/2025 added intervention of place Resident #2 on 1:1 monitoring until alternate placement is found.Record Review of Resident #3's undated admission Record revealed Resident #3 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had the admitting diagnoses of Bipolar Disorder, Unspecified (psychological condition that causes dramatic changes in a person's mood, ability to think clearly, and energy; involves periods of mania and depression; unspecified is diagnosed when symptoms do not meet the criteria for other types), Depression, Unspecified (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), Anxiety Disorder, Unspecified (repeated episodes of sudden feelings of intense anxiety, and fear or terror that reach a peak within minutes), Impulse Disorder, Unspecified (group of behavioral conditions that make it difficult to control your actions or reactions), Mild Intellectual Disabilities (neurodevelopment disorder characterized by significant limitations in intellectual and adaptive functioning), Cerebral Infarction, Unspecified (a stroke where the exact cause and location of the brain damage are unknown), Other Specified Disorders Of Brain (group of conditions that do not fall into specific diagnostic categories that can affect various aspects of brain function including cognitive abilities, movement, and consciousness) and Epileptic Seizures Related to External Causes, not Intractable, without Status Epilepticus (epileptic seizures caused by external factors, such as head trauma or substance abuse, that are not difficult to treat and are considered provoked by a single external factor meaning there are clear, identifiable causes).Record review of Resident #3's annual MDS, dated [DATE], revealed a BIMS score of 03 indicating severe cognitive impairment. Signs and Symptoms of Delerium was ranked at 2 for both Inattention (difficulty focusing attention, being easily distracted, or having difficulty keeping track of what was said) and Disorganized Thinking (thinking was disorganized or incoherent, rambling or irrelevant conversation, unclear or illogical flow of ideas, startled easily to any sound or touch). Behavioral Symptoms for Resident #3 were listed at zero (Behavior not exhibited) for Physical Behavioral Symptoms directed towards others (e.g. hitting, pushing, kicking, scratching, grabbing other than sexually and zero for Verbal behavioral symptoms directed towards others (e.g. threatening others, screaming at others, cursing at others). Resident #3 was documented to have had no functional limitation in range of motion and did not utilize any assistive devices for mobility.Record review of Resident #3's care plan, dated 09/05/2025, revealed a focus area of at risk for behaviors due to impulse control disorder listing the following incidents: 05/24/2025-- resident noted with aggressive behavior, hit another resident (Resident #2), swung chair at nurse, swung chair at meal cart tipping it over, 06/15/2025 Resident increased behaviors, and 10/03/2025-- slapped a resident (Resident #2), after she took his cup. Interventions and tasks included contact to transfer resident to hospital (Geri-Psych) when explosive psychosis is exhibited, Discuss options for appropriate channeling of anger, give all meds as ordered, Give PRN anti-anxiety medication, Notify Psych NP whenever such behaviors are exhibited, psych services as needed, and Seek alternate placement that has less stimuli which could contribute to aggressive, impulsive behavior. Focus area of Potential for complications/side effects r/t use of psychotropic medications, use of antipsychotic medications added on 01/07/2024, with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 2 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Some interventions and tasks of Administer medication as ordered observing for effectiveness &/or side effects. Notify physician as needed; Monitor mood and behaviors every shift; Observe for s/s side effects/adverse reactions from use of antipsychotic medication: dry mouth, constipation, blurred vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, N/V, lethargy, drooling, EPS symptoms (tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue). Notify physician if noted. On 01/12/2024 the focus area of has signs of disorganized thinking was added for Resident #3 with interventions and tasks of Administer medications as ordered, Allow ample time to answer questions, introduce changes slowly, and Reality orientation daily during routine care. Resident #3 had the focus area of the potential for injury r/t side effects of antipsychotic medication use related to Medical dx Mental Disorder added on 05/08/2024 with interventions and tasks of Assess/record/report to physician gait disturbances, poor balance, dizziness, vertigo, unsteady gait, Consultant pharmacist to monitor drug regimen monthly and prn and contact physician for drug reduction as needed, Monitor for drug related cognitive/behavioral impairment of ADL functioning and report to physician if noted, Monitor for s/s changes in mood/behavior and report to physician if noted &/or as needed, and Monitor for side effects q shift. Notify physician if noted. On 01/21/2025 the focus area of Resident #3 has a h/o wandering into unsafe situations, Resident packs all belongings and states I'm moving as well as on 10/01/2025 Resident #3 removed his wander guard, and refuses to allow it to be put back on with interventions and tasks of alert staff to wandering behavior, Approach positively and in a calm manner, Check that wander guard is properly working every shift by taking to the door if not properly working notify DON and replace the wander guard, Resident on hourly safety checks, and Monitor and document behavior.Record Review of resident-to-resident assault on 05/24/2025 revealed that when Resident #2 passed Resident #3 in the hallway, Resident #3 hit her on the back of the head with his fist. Resident #2 expressed pain and was sent to the local hospital for evaluation and later returned with no injury diagnosis. Resident #3 was placed on 1:1 monitoring by staff for the remainder of that weekend and both residents were to be kept in eyesight when the other resident was around.Record review of resident-to-resident assault on 8/17/2025 revealed that as Resident #2 walked down a hallway, Resident #3 hit her. Resident #2 was reported to hit Resident #3 back and Resident #2 then fell to the ground after being hit a second time by Resident #3 where he then kicked Resident #3 before staff were able to intervene. Resident #2 did not indicate she was in pain, neither resident was sent to the hospital for evaluation. Resident #3 was placed on 1:1 monitoring for that weekend and referrals began for discharge to new facility for Resident #3.Record review of resident-to-resident assault on 10/03/2025 revealed that Resident #3 quickly charged through the door onto the smoking patio and hit Resident #3 with an open fist. Resident #2 was noted to have bruising, redness, and swelling around her left eye in facility photograph documentation. The facility ordered a facial x-ray which was unremarkable for any fracture. Both Resident #2 and #3 were placed on 1:1 monitoring from staff. Local law enforcement was contacted twice about the assault before arriving to the facility to remove from the facility and transfer Resident #3 to the local hospital for evaluation for his behaviors. Resident #2 remained on 1:1 monitoring for safety.Record review showed a SW letter Re: Discharge in Resident #3's miscellaneous area of the electronic health record. The discharge letter, dated 10/03/2025, was to a Payee and next of kin for Resident #3 to advise that an immediate discharge notice was given to the resident on 10/01/2025 and that another incident with Resident #3 had occurred. The payee and next of kin was advised that Resident #3 had been escorted to the hospital for treatment after the altercation with another resident and he would not be allowed to return to the facility. The Payee and next of kin was informed of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 3 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Some Resident #3's placement desires and the financial responsibilities as the Payee.Record review of the facility Investigation Follow-Up, dated effective 10/05/2025, revealed that the incident on 10/03/2025 happened at approximately 11:15am when Resident #3 came out the door like a ranging [sic] bull and hit Resident #2 upside her head. When asked why, Resident #3 stated because she (Resident #2) took my cup. Resident #3 was put on 1:1 with staff, then checked every hour. The facility also placed Resident #2 on 1:1 with staff for safety. Notification was made to the QA committee, Medical Director, Resident #2's responsible party, DON, and police. Follow-up with Resident #2's family on revisions to the Care Plan included information that the police has taken Resident #3 to the hospital and he will not be returning to the facility, the medical director had ordered facial bone x-ray to left eye, and that Resident #2 was also put on 1:1 with staff for safety.Observation and interview with Resident #2 on 10/14/2025 at 11:22 AM revealed the resident was still on 1:1 monitoring by staff. Resident #2 was seen in the dining room after observing her during the 11:00 smoke break on the patio. Resident #2 stated that was doing fine and that her face was doing better now. Resident #2 could not be engaged in a detailed conversation. Observation of Resident #2 revealed any bruising or redness to her face from being hit by Resident #3 on 10/03/2025 had resolved.Interview on 10/14/2025 at 11:30 AM with CNA A revealed that she began 1:1 with Resident #2 at the start of that shift however the 1:1 was ongoing since the incident with another resident (Resident #3) on 10/03/2025. CNA A stated that Resident #2 seemed to be at her baseline and appeared to be doing fine. CNA A stated that she did not witness the incidents of assault by Resident #3 against Resident #2 on 05/24/2025, 08/17/2025, and 10/03/2025 however was informed of them during beginning of shift huddles by the charge nurses.Interview on 10/14/2025 at 2:35 PM with SW revealed that the incident on 10/03/2025 between Residents #2 and #3 was the third altercation between the two, with Resident #3 being the aggressor in all three instances. SW stated she had not noticed any effects from the resident-to-resident assaults as Resident #2 has no real short-term memory from the dementia and that when EMT came in to assess she acted like she did not know what happened but was able to tell a family member in detail a few hours later when she called her.Interview on 10/14/2025 at 4:26 PM with the DON revealed that Resident #2 was immediately placed on 1:1 after the assault on 10/03/2025 with a staff member so that someone was always with her. The DON shared that even though Resident #3 was the aggressor on all three instances, the facility felt this should be done as Resident #2 walks the building constantly. The DON indicated that even though Resident #2 may have been targeted by Resident #3, they wanted to keep eyes on her for her safety since she has had history of taking things from other residents however has not seen or heard of any negative response from Resident #2 with having the 1:1 monitoring by staff. The DON stated that staff had been informed if Resident #2 asked why she was being followed around they were to inform her it was to keep her company. The DON stated that on 10/01/2025 an immediate discharge notice was given to Resident #3 and that a group home was going to take him then his family member called and stopped the transfer. Resident #3 was on hourly checks at that time related to the incident that happened on 08/17/2025 and between the checks he acted impulsively and attacked Resident #2 again hitting her as she walked past in the hallway; Resident #2 had no injury from this assault. The DON confirmed Resident #3 was being seen by psychiatry and psychology services, and he was not having issues with any other residents; the DON reported he had said I didn't want to marry you anyway in reference to Resident #2 and may have confused her with someone else.Interview on 10/14/2025 at 5:05PM with the Administrator revealed he had been at the facility since 9/10/2025. The Administrator stated when the resident-to-resident altercation between Residents #2 and #3 happened on 10/03/2025, he determined that Resident #3 would be placed on 1:1 monitoring and had SW begin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 4 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete looking for a safe discharge location; he reports he had to contact local police and had to have them come out twice before the police would take Resident #3 to the local hospital for evaluation and remove him from the property. The Administrator stated that he felt Resident #2 did not remember the altercation, however, a few hours later she was able to call a family member and give details.Confidential interview with family member #1 revealed Resident #2 became more withdrawn after the incidents of abuse but returned to baseline shortly after. The resident was confused and the family member was frustrated and concerned for Resident #2's safety in the facility. Family member #1 stated they were focused on finding a suitable facility for the resident to relocate to.Review of facility policy Abuse Prevention Program, revised December 2016, revealed residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation revealed as part of the resident abuse prevention, the administration will:l. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, otherresidents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends,visitors, or any other individual.3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, ormistreatment of our residents.4. Require staff training/orientation programs that include such topics as abuse prevention, identification andreporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. Review of facility policy Resident Rights, revised December 2016 revealed; Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to;C. be free from abuse, neglect, misappropriation of property, and exploitation. A past Immediate Jeopardy (IJ) was found on 08/17/25 and the immediacy was removed on 10/05/25. While the IJ was removed on 10/025/25, the facility remained out of compliance at a severity of actual harm due to the facility's need to monitor the effectiveness of their corrective systems. Event ID: Facility ID: 455881 If continuation sheet Page 5 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to notify the ombudsman of the transfer or discharge before transferring or discharging the resident for 1 of 1 resident (Resident #1) reviewed for Discharge Rights.The facility failed to notify the ombudsman in writing of the transfer/ discharge of Resident #1 to a behavioral hospital, the reason for the transfer/discharge, and the right to appeal. This failure could affect the residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes. Findings included: Record review of Resident #1's face sheet dated 10/14/2025 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 was discharged to hospital for a behavioral evaluation on 09/28/2025. Resident's diagnosis included Schizophrenia, Unspecified (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania ); Unspecified Psychosis Not Due to a Substance or Known Psychological Condition (used when psychotic symptoms are present but a specific cause, like drugs, other mental disorders, or a medical condition hasn't been identified or confirmed yet); and Major Depressive Disorder, Recurrent, Unspecified (used when a person has significant symptoms of depression that cause distress or impairment, but they do not meet the full diagnostic criteria for a more specific depressive disorder, or there is not enough information to provide one).Record review of Resident #1's MDS assessment dated [DATE], noted his BIMS Score to be 12 which reflected moderate cognitive impairment. Resident #1 Review of Resident #1's progress notes reflected that on 09/28/2025, the facility initiated a referral to transfer the resident to the hospital for a psychological evaluation due to the resident having an increase in his verbal, physical, and violent behavior towards the staff. Family member notified by phone concerning Resident #1's transfer. Resident #1 was his own responsible party. Record review on 09/29/2025 of social services notes revealed that SW spoke with Resident #1's family member about how his behavior had not gotten better since giving him the 30-day notice before. SW informed family member about Resident #1 threatening staff. Family member stated she has never known Resident #1 threaten to kill anyone and that the staff are triggering him. DSS said this was done after staff redirected him while breaking rules. Resident #1 was contacted by SW that he was being provided an immediate discharge from the facility r/t his violent behavior towards the staff and other residents in the facility. Resident #1 refused to give verbal consent by phone. SW planned for Resident #1 to move to a residential group home in the community upon discharge from hospital. Resident #1 was transferred to a group home and has adjusted well to the move. On 10/13/2025 at 1:12 p.m., an interview with the family member revealed that Resident #1 had not been at the facility for some time. Family member could not give the specific time he was discharged to hospital for a psychological evaluation. Family member stated that Resident #1 is now in another place but cannot remember the name of the group home he moved to. Resident #1 has his own room, is stable, and happy. Family member stated Resident #1 had schizophrenia and did not understand he could not smoke anytime he wanted when he was at the facility. When he acted up at the facility, the staff would contact the family member to come to the facility to calm him down. Family member stated she told the staff it was their job to take care of him. Family member stated that Resident #1 is glad he is no longer at that facility because the staff stated he was threatening to kill others and kill himself. Family member did not believe what they told her. Family member did not state if she was aware of the 30-day notice. On 10/14/2025 at 2:32 p.m., an interview with SW revealed that she contacted the Ombudsman (person who acts (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 6 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete as an independent and neutral intermediary to help resolve complaints and disputes fairly between individuals and an organization or government agency) and left a message concerning Resident #1's immediate discharge. SW did not document that a message was left on Ombudsman's voicemail and could not provide a date when she left the message. SW could not provide a copy of the first 30-day notice that was given to Resident #1 and could not provide the date. SW provided a copy of the immediate discharge notice given to Resident #1. Record review of an email conversation with the Ombudsman on 10/14/2025 at 4:33 p.m. revealed she did not receive a phone call or email r/t a notification before or after Resident #1's discharge on [DATE]. On 10/14/2025 at 4:17 p.m., an interview with DON revealed that Resident #1 exhibited behaviors that placed residents' and staff's safety at risk. He was non-compliant with facility smoking rules, would go out to the laundry, take staff's food from the employee breakroom, and verbally threaten to harm the employees. Resident #1 threatened to kill other staff and himself. Resident #1's family member was informed of his behavior, but she thought the staff were not telling the truth. The family member was verbally aggressive towards staff when she was informed by phone of Resident #1's behaviors. DON stated she was not aware the Ombudsman was not notified of Resident #1's discharge. On 10/14/2025 at 4:55 p.m., an interview with the ADM revealed that Resident #1 had to be given an immediate discharge for the safety of the other residents and staff. Resident #1 was non-compliant with the smoking rules and verbally aggressive towards other residents and staff. Resident #1 was discharged to the hospital for a psychiatric evaluation and SW planned for transfer to a group home. Resident #1's family member came into the facility to pick up his belongings and began cursing staff. The ADM was not aware that the Ombudsman had not been notified by SW r/t Resident #1's immediate discharge. The ADM expectations are for the SW to contact the Ombudsman concerning all discharges from the building and document in SS notes of notification.Record review of the facility's admission and Discharge including AMA, Against Medical Advice Policy dated March 2017, reflected, It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility, except in limited circumstances. a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. c. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident. Event ID: Facility ID: 455881 If continuation sheet Page 7 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2025 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 0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide behavioral health services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (Resident #2) of five residents reviewed for behavioral health services. The facility failed to ensure Resident #2 received a psychology consultation or assessment after three incidents (5/24/2025, 08/17/2025, 10/03/2025) of resident-to-resident abuse where Resident #2 was the victim. This failure could place residents at risk for not receiving behavioral health services and a decline in quality of life. Findings included:Record review of an undated admission Record revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had the admitting diagnoses of Alzheimer's Disease, Unspecified (a progressive neurodegenerative disorder that affects memory, thinking, and behavior), Type 2 Diabetes Mellitus without Complications (chronic condition where persistently high blood sugar levels are caused by the pancreas not being able to make enough insulin), Dementia in other Diseases Classified Elsewhere, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety (dementia where the specific cause is unknown and the person does not exhibit behavioral issues like agitation or aggression), Major Depressive Disorder, Recurrent, Unspecified (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), Cerebral Infarction, Unspecified (a stroke where the exact cause and location of the brain damage are unknown), Chronic Obstructive Pulmonary Disease, Unspecified (a group of lung diseases that cause airflow obstruction and breathlessness), Chronic Respiratory Failure, Unspecified (condition where there is not enough oxygen or too much carbon dioxide is in the body), and Presence of Cerebrospinal Fluid Drainage Device (long term device, or shunt, that allows excess fluid from the brain to drain to another part of the body relieving pressure). Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 03 indicating Severe Cognitive Impairment. Resident #2 was documented as having no (zero) behavioral symptoms. Resident #2 showed to be independently ambulatory with no functional limitations in range of motion. Record Review of Resident #2's Care Plan, dated 08/30/2025, revealed a focus added on 03/15/2023 of resident having a history of intruding on others privacy with interventions and tasks of place in area where frequent observation was possible, redirect when wandering into other resident rooms, and monitor and document behavior. Focus added on 01/14/2024 of displays socially inappropriate/ disruptive behavior due to known for taking personal items from her roommate and other peers that do not belong to her. When she is called out on this disruptive behavior, she curses at staff and peers, calls everyone names and refuses to listen to staff due to her cognitive status, Psych. diagnosis with interventions and tasks of administer medication as ordered, discuss options for appropriate channeling of anger, talk in calm voice when behavior is disruptive, Social Services to evaluate and visit routinely, and monitor and document behavior. Focus of at risk of being taken advantage of r/t impaired cognition updated on 10/03/2025 when Resident #3 slapped Resident #2 after she took his cup with interventions and tasks of allow Resident #2 to express concerns about safety, anticipate Resident #2's needs, encourage Resident #2 to sit in common areas that are well populated, observe Resident #2 frequently throughout the day, psych services are available as needed, and on 10/03/2025 added intervention of place Resident #2 on 1:1 monitoring until alternate placement is found. Record Review of Resident #3's undated admission Record revealed Resident #3 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had the admitting diagnoses of Bipolar Disorder, Unspecified (psychological condition that causes dramatic changes in a person's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 8 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2025 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 0740 Level of Harm - Actual harm Residents Affected - Few mood, ability to think clearly, and energy; involves periods of mania and depression; unspecified is diagnosed when symptoms do not meet the criteria for other types), Depression, Unspecified (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), Anxiety Disorder, Unspecified (repeated episodes of sudden feelings of intense anxiety, and fear or terror that reach a peak within minutes), Impulse Disorder, Unspecified (group of behavioral conditions that make it difficult to control your actions or reactions), Mild Intellectual Disabilities (neurodevelopment disorder characterized by significant limitations in intellectual and adaptive functioning), Cerebral Infarction, Unspecified (a stroke where the exact cause and location of the brain damage are unknown), Other Specified Disorders Of Brain (group of conditions that do not fall into specific diagnostic categories that can affect various aspects of brain function including cognitive abilities, movement, and consciousness) and Epileptic Seizures Related to External Causes, not Intractable, without Status Epilepticus (epileptic seizures caused by external factors, such as head trauma or substance abuse, that are not difficult to treat and are considered provoked by a single external factor meaning there are clear, identifiable causes). Record review of Resident #3's annual MDS, dated [DATE], revealed a BIMS score of 03 indicating severe cognitive impairment. Signs and Symptoms of Delerium was ranked at a 2 for both Inattention (difficulty focusing attention, being easily distracted, or having difficulty keeping track of what was said) and Disorganized Thinking (thinking was disorganized or incoherent, rambling or irrelevant conversation, unclear or illogical flow of ideas, startled easily to any sound or touch). Behavioral Symptoms for Resident #3 were listed at zero (Behavior not exhibited) for Physical Behavioral Symptoms directed towards others (e.g. hitting, pushing, kicking, scratching, grabbing other than sexually and zero for Verbal behavioral symptoms directed towards others (e.g. threatening others, screaming at others, cursing at others). Resident #3 was documented to have had no functional limitation in range of motion and did not utilize any assistive devices for mobility. Record review of Resident #3's care plan, dated 09/05/2025, revealed a focus area of at risk for behaviors due to impulse control disorder listing the following incidents: 05/24/2025-- resident noted with aggressive behavior, hit another resident (Resident #2), swung chair at nurse, swung chair at meal cart tipping it over, 06/15/2025 Resident increased behaviors, and 10/03/2025-slapped a resident (Resident #2), after she took his cup. Interventions and tasks included contact to transfer resident to hospital (Geri-Psych) when explosive psychosis is exhibited, Discuss options for appropriate channeling of anger, give all meds as ordered, Give PRN anti-anxiety medication, Notify Psych NP whenever such behaviors are exhibited, psych services as needed, and Seek alternate placement that has less stimuli which could contribute to aggressive, impulsive behavior. On 01/21/2025 the focus area of Resident #3 has a h/o wandering into unsafe situations, Resident packs all belongings and states I'm moving as well as on 10/01/2025 Resident #3 removed his wander guard, and refuses to allow it to be put back on with interventions and tasks of alert staff to wandering behavior, Approach positively and in a calm manner, Check that wander guard is properly working every shift by taking to the door if not properly working notify DON and replace the wander guard, Resident on hourly safety checks, and Monitor and document behavior.Record Review of resident-to-resident assault on 05/24/2025 revealed that when Resident #2 passed Resident #3 in the hallway, Resident #3 hit her on the back of the head with his fist. Resident #2 expressed pain and was sent to the local hospital for evaluation and later returned with no injury diagnosis. Resident #3 was placed on 1:1 monitoring by staff for the remainder of that weekend and both residents were to be kept in eyesight when the other resident was around. Record review of resident-to-resident assault on 8/17/2025 revealed that as Resident #2 walked down a hallway, Resident #3 hit her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 9 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2025 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 0740 Level of Harm - Actual harm Residents Affected - Few Resident #2 was reported to hit Resident #3 back and Resident #2 then fell to the ground after being hit a second time by Resident #3 where he then kicked Resident #3 before staff were able to intervene. Resident #2 did not indicate she was in pain, neither resident was sent to the hospital for evaluation. Resident #3 was placed on 1:1 monitoring for that weekend and referrals began for discharge to new facility for Resident #3. Record review of resident-to-resident assault on 10/03/2025 revealed that Resident #3 quickly charged through the door onto the smoking patio and hit Resident #3 with an open fist. Resident #2 was noted to have bruising, redness, and swelling around her left eye in facility photograph documentation. The facility ordered a facial x-ray which was unremarkable for any fracture. Both Resident #2 and #3 were placed on 1:1 monitoring from staff. Local law enforcement was contacted twice about the assault before arriving to the facility to remove from the facility and transfer Resident #3 to the local hospital for evaluation for his behaviors. Resident #2 remained on 1:1 monitoring for safety.Record review of the facility Investigation Follow-Up, dated effective 10/05/2025, revealed that the incident on 10/03/2025 happened at approximately 11:15am when Resident #3 came out the door like a ranging (raging [sic]) bull and hit Resident #2 upside her head as witnessed by a CNA. When asked why, Resident #3 stated because she (Resident #2) took my cup. Resident #3 was put on 1:1 with staff, then checked every hour. The facility also placed Resident #2 on 1:1 with staff for safety. Notification was made to the QA committee, Medical Director, Resident #2's responsible party, DON, and police. Follow-up with Resident #2's family on revisions to the Care Plan included information that the police has taken Resident #3 to the hospital and he will not be returning to the facility, the medical director had ordered facial bone x-ray to left eye, and that Resident #2 was also put on 1:1 with staff for safety. Record review of Resident #2's Trauma Informed Screening Tool, administered by SW dated 09/09/2025, that the resident, family, and staff participated in revealed positive (yes) responses on questions: Have you ever experienced this kind of event (assault by another resident)? In the past month have you had nightmares about the event when you did not want to? 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? In the past month, have you been constantly guarded, watchful, or easily startled? Record review of Resident #2's Trauma Informed Screening Tool, administered by SW and dated 08/13/2025 and 10/06/2025, indicated that the resident and staff participated; a positive (yes) response on question Have you ever experienced this kind of event? only was given when asked about being assaulted by another resident. Interview on 10/14/2025 at 11:21 AM with LPC A revealed that Resident #2 was not currently being followed by psychological services and had never had a referral for evaluation or services. LPC A verified these findings in their system using Resident #2's name and date of birth searching for all psychology related providers. Observation and interview with Resident #2 on 10/14/2025 at 11:22 AM revealed the resident was still on 1:1 monitoring by staff. Resident #2 was seen in the dining room after observing her during the 11:00 smoke break on the patio. Resident #2 stated that was doing fine and that her face was doing better now. Resident #2 could not be engaged in a detailed conversation. Resident #2 was observed to be calm and kept to herself while smoking and in the dining room. Resident #2 was polite but reserved in her interactions with others. Interview on 10/14/2025 at 11:30 AM with CNA B revealed that she began 1: with Resident #2 at the start of that shift, however the 1:1 was ongoing since the incident with another resident on 10/03/2025. CNA B stated that Resident #2 was at her baseline and appeared to be doing fine from what she could tell. Interview on 10/14/2025 at 2:35 PM with SW revealed that the incident of physical assault on 10/03/2025 between Residents #2 and #3 was the third altercation between the two, with Resident #3 being the aggressor in all three instances. SW stated she had not noticed any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 10 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2025 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 0740 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete effects from incidents of assault as Resident #2 has no real short-term memory from the dementia and that when EMT came in to assess she acted like she did not know what happened but was able to tell her family member in detail a few hours later when Resident #2 called her. The SW stated that the facility has conducted trauma assessments with Resident #2 but no further actions had been taken with that information. When asked about referral for psychological assessment or therapy due to the positive responses on the trauma assessments, the SW responded that she had not made any referrals as Resident #2 was known to refuse services in the past such as dental and vision however family were able to easily get Resident #2 to participate with care from outside providers. SW stated that she had not noticed any change in Resident #2's behaviors since Resident #3 was discharged .Interview on 10/14/2025 at 4:26 PM with the DON revealed that psychology services were offered in facility multiple times a week, however due to Resident #2's advanced dementia they had not referred for an evaluation or services. The DON stated that the SW has done trauma screenings, but no referrals were sent as Resident #2 was difficult to assess. The DON stated that Resident #2 was placed on 1:1 with a staff member so that someone was always with her. The DON indicated that even though Resident #2 may have been targeted by Resident #3, they wanted to keep eye on her for her safety since she has had history of taking things from other residents however has not seen or heard of any negative response from Resident #2 with having the 1:1 monitoring by staff. The DON stated that staff had been informed if Resident #2 asked why she was being followed around they were to inform her it was to keep her company. Interview on 10/14/2025 at 5:05PM with the Administrator revealed he had been employed at the facility since 9/10/2025. The Administrator stated that he felt Resident #2 did not remember the altercation on 10/03/2025, however, a few hours later she was able to call her family member and give details. The Administrator stated he would expect behavioral health services to be offered to residents after they were assaulted by another resident and for staff to follow what was recommended by the mental health providers as they are in the building on Wednesdays every week. The Administrator stated he also expected staff to call on these contracted mental health providers as needed, to alert them to situations that had happened in the facility since their last visit, and to do what was needed or recommended by those providers. Confidential interview with family member #1 revealed Resident #2 became more withdrawn after the incidents of abuse but returned to baseline shortly after. The resident was confused and the family member was frustrated and concerned for Resident #2's safety in the facility. Family member #1 stated they were focused on finding a suitable facility for the resident to relocate to. Resident #2 did not receive any behavioral services after each incident and Resident #3 continued to abuse Resident #2.Review of facility policy Unmanageable Residents, revised April 2010 revealed; Each resident will be provided I. Should a resident's behavior become abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others, the Nurse Supervisor/Charge Nurse must immediately:a. Provide for the safety of all concerned (i.e., move resident, equipment, etc.);b. Notify the resident's Attending Physician for instructions; Review of facility policy Resident Rights, revised December 2016 revealed; 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;c. be free from abuse, neglect, misappropriation of property, and exploitation;f. communication with and access to people and services, both inside and outside the facility;h. be supported by the facility in exercising his or her rights; Event ID: Facility ID: 455881 If continuation sheet Page 11 of 11