Health inspection·November 20, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few Resident #2 sat down outside and Resident #1 stood over Resident #2 fussing at him and grabbing on his pants to provoke a fight. Receptionist A stated they decided to hold off on smoke break and her and Housekeeper B separated the residents. Receptionist A stated that Housekeeper B and Resident #1 went back into the building and Resident #1 was taken to her room. Receptionists A stated Resident #1 was in her room still fussing and yelling. Receptionist A stated that she was at her desk, and she heard a loud commotion, and she ran outside to the smoking area. Receptionists A stated she did not see what happened when Resident #2 went back outside but before she was able to get out the door, she observed blood on Resident #1. Receptionist A stated that Resident #2 was trying to get away from Resident #1, but Resident #2 was pulling on Resident #1's pants still trying to fight. Receptionist A stated LVN C called 911 immediately. Receptionist A stated she tried her best to calm down Resident #2 until the police came, but she was still trying to fight Resident #1. Receptionist A stated that Resident #1 was in shock, and he was observed shaking. In an interview on 11/20/25 10:27 AM, LVN D stated he did not see the whole altercation, but what he observed was Resident #1 and #2 were arguing in the smoking area. LVN D stated that Resident #1 was standing over Resident #2 and hit him and that's when Resident #2 put his cane up to keep Resident #1 from hitting him. LVN D stated that he then told Resident #2 to go to her room so that he could assess her. LVN D stated 5 minutes later Resident #1 was back outside in the smoking area, but he didn't see anything else from that point. LVN D stated that he heard Resident #1 calling Resident #2 the ( N word) and calling him cripple. LVN D stated that someone called 911, and he assessed Resident #1 he said she had a cut on her forearm, and she was bleeding. In an interview on 11/20/25 at 12:19 PM, Housekeeper B stated from what she observed Resident #1 was coming out of the cafeteria door and she was walking through the courtyard to go back into the building. Housekeeper B stated when Resident #1 was going in the building and Resident #2 was coming out of the building, but Resident #1 was standing in the doorway and Resident #2 asked Resident #1, are you coming in or out? Housekeeper B stated Resident #1 told Resident #2, oh, you could have said that better. Housekeeper B stated LVN C told her to go and get LVN D since they were his patients. Housekeeper B stated that she observed Resident #1 calling Resident #2 the N word and the B word. Housekeeper B stated that she did not witness the physical fight, but she witnessed Resident #1 walk into the building with blood all over her face. In an observation and interview on 11/20/25 at 1:24 PM, Resident #2 was noted sitting on his bed and ending a phone call. When asked about the fight with Resident #1 he stated he was outside on a cigarette break and Resident #1 called him the N word and the B word and told him that she was going to kick his ass. Resident #2 stated that Resident #1 hit him, and he fell into the chair. Resident #2 stated he hit Resident #1 on the head with his cane because she was trying to give him a black eye. Resident #2 stated a caregiver ended up getting in between them and he was taken to jail. In an interview on 11/20/25 at 2:08 PM, LVN C stated that Resident #1 was coming from the smoking patio and Resident #2 was going out to the smoking patio and Resident #1 was standing in the doorway. LVN C stated Resident #2 asked Resident #1 are you coming in or out. LVN C stated Resident #1 then called Resident #2 a stupid black man and in return Resident #2 called Resident #1 a stupid B word. LVN C stated that's when Resident #1 turned around and went outside and walked up to Resident #2 and told him that she was not a B word. LVN C stated Resident #1 proceeded to grip Resident #1's cane and repeated she wasn't a B word. LVN C stated that she told Resident #1 to let go of Resident #2's cane and that's when the recoil on the cane hit Resident #1 in the nose. LVN C stated that Resident #2 did not hit Resident #1 with the cane but as they tussled back and forth with the cane when Resident #1 snatched the cane back and the recoil on the cane hit Resident #1 in the nose and Resident #1 let go of the cane immediately. LVN C (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 2 of 9 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 11/20/2025 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete stated that's when she told Resident #1 to go into the building because her nose was bleeding. LVN C stated Resident #1 then stated, look what he (F word) did, LVN C stated she told Resident #1 that Resident #2 did not do that, and she was hit in the nose due to recoil on the cane when she grabbed it. LVN C stated Resident #2 was still outside sitting down and his back was turned, and Resident #1 went back outside and swiped Resident # 2 on his head. LVN C stated that's when Resident #2 hit her with the cane causing Resident #1 to stumble off. LVN C stated that she was trying to calm Resident #2 down because he was shaking. LVN C stated she told LVN D that he needed to do something because Resident #1 was really looking for a fight with Resident #2. In an interview on 11/20/25 at 5:11 PM, DON stated she was not at the facility during the day Residents #1 and #2 got into a fight due to it happening on the weekend. The DON stated that she was told the recoil on the cane hit in the eye. The DON stated that LVN D said he took the cane. The DON stated that Resident #1 was taken to [Hospital Name] and Resident #2 was taken to jail. The DON stated Resident #1 had to get stitches above her eye. The DON stated Resident #1 was placed 1 on 1 with a caregiver until she was discharged from the facility. The DON stated that all the fighting couldn't be tolerated. The DON stated Resident #2 was referred for psych services, and Resident #2 was taken to jail. The DON stated they reeducated staff on resident-to-resident altercations and being proactive in separating residents. The DON stated that she expects staff to intervene, deescalate, separate the residents, report the incident, assess the residents, make sure all residents are safe, and do not argue with the residents. She stated the risk is that a resident could end up hurt or injured. In an interview on 11/20/25 at 6:36 PM, The ADM stated staff are expected to separate the residents as soon as possible, de-escalate the situation, and report to him and the DON. The ADM stated he encourages the staff to find out what's going on and try and solve the situation. The ADM stated it's a lot of situations he has de-escalated just by talking to the residents. The ADM stated the risk of residents getting into a fight is that someone can get hurt or staff could get hurt, or medical emergencies could happen that's why it's important to break it up as soon as you can. Record Review of the facility's Abuse Policy in part indicated - All reports of resident abuse (including injuries of unknown origin) .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 -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. Event ID: Facility ID: 455881 If continuation sheet Page 3 of 9 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 11/20/2025 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 interviews and record review the facility failed to ensure allegations of abuse were thoroughly investigated, prevent further potential abuse and mistreatment while the investigation was in process, and report the results of all investigations to the administrator or his or her designated representative and other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for 1 (Resident #4) of 3 reviewed for abuse. The facility failed to immediately investigate, protect the residents, and report allegations of abuse on 08/29/25 when Resident #4 reported a nurse hit her while in the shower, and the facility did not investigate or implement measures to protect the residents from further abuse. This failure could place residents residing in the facility at risk of abuse. Findings included: Record review of Resident #4's face sheet dated 11/21/25 reflected [AGE] year-old woman admitted to the facility on [DATE] with an initial admission date of 08/20/24 with a primary diagnosis of major depressive order, anxiety disorder, mood disorder and schizophrenia (mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). Record Review of Resident #4's care plan dated 10/14/25 reflected on 08/29/25 Resident #4 has a habit of calling 911 and stating, I am on drugs Resident #4 was observed on the floor and crawling to the hallway refusing to allow staff to help her up, insisting on going to the hospital. Interventions included instruct resident when behavior is inappropriate or unacceptable in a calm manner, Access Resident #4 for injuries when putting herself in unsafe situations and carefully explain procedures to resident, do not argue with the resident, drug test as needed, Psych services as needed. Record Review of Resident #4's MDS dated [DATE] reflected a BIMS score of 7, indicating severely impaired cognition. PIR was requested from the DON on 11/19/25 at 10:15 AM, and the wrong PIR was given to surveyor from the DON. Record Review of a progress note dated 08/29/25 reflected Resident #4 requested a shower even though she normally gets her shower on the 2-10 shift. Staff went on to assist resident #4 with her shower. Resident started calling staff names and throwing things at staff as they were assisting her with her shower. Staff assisted Resident #4 back to her room and wanted to assist her dressing, but resident would not let staff assist her and she laid down on the floor naked, saying I want to go to [Hospital Name 2], I want to go to [Hospital Name 2], don't touch me. Record Review of another progress note dated 08/29/25 reflected Incident Description- Resident #4 requested a shower even though she normally gets her shower on the 2-10 shift. Staff went on to assist resident #4 with her shower. Resident started calling staff names and throwing things at staff as they were assisting her with her shower. Staff assisted resident back to her room and wanted to assist her with her dressing, but resident would not let staff assist her and she laid down on the floor naked, saying, I want to go to [Hospital Name 2], I want to go to [Hospital Name 2], don't touch me. Nurse informed medical director who ordered resident to be sent out to the hospital. Resident #4 was transported out to [Hospital Name 2] for further evaluation. Resident #4 unable to give description. Immediate Action Taken - Nurse couldn't examine resident for injuries or get vital signs because resident would not let staff members touch her. Nurse informed medical director who ordered resident #4 be sent to the hospital. Nurse called the ambulance to get resident to the hospital. Residents were transported out to [Hospital Name 2] for further evaluation. Resident #4 is her own responsible party. Record Review of intake 1034343 dated 09/03/25 indicated the allegation of the incident was abuse. On 11/20/25 at 10:15 AM, surveyor requested PIR for intake 1034343. At 11:17 AM, the DON stated that she was looking for the PIR. Surveyor requested all information that was done for the investigation. At 11:45 AM, the DON Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 4 of 9 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 11/20/2025 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 presented a progress note from the incident and stated that's all she could find from the investigation. Resident #4 was unable to be interviewed due to being in the hospital at the time of the visit. In an interview on 11/20/25 at 11:46 AM, Med Tech F stated Resident #4 was given a shower and Resident #4 seemed agitated already and the aid that assisted Resident #4 could not get her dressed in the showers, so the aid brought her back to the resident's room to get her dressed. Med Tech F stated she couldn't remember the name of the aid that was assisting Resident #4 at the time. Med Tech F stated when the aid went to try and get Resident #4 dressed Resident #4 laid down on the floor and kept stating she did not want to get dressed and she just wanted to go to [Hospital Name 2]. Med Tech F stated [Hospital Name 2] is Resident #4's hospital of choice whenever she wants to be sent out to the hospital. Med Tech F stated Resident #4 did not fall and she willingly got on the floor. Med Tech F stated Resident #4 was not injured at all. Med Tech F stated Resident #4 always gets on the floor when she doesn't get her way. In an interview on 11/20/25 at 5:11 PM, the DON stated she could not find the PIR for intake 1034343. The DON stated the previous administrator would have had the missing PIR due to the incident happening when he was the active administrator, the DON stated that they couldn't find any information the old administrator had but she does remember what happened. The DON stated that during the incident with Resident #4 that the resident got on the floor while she was naked and kept saying she wanted to go to the hospital. The DON stated that they couldn't pick the resident up off the floor and the resident wouldn't get up by herself, and they couldn't drag her, so they called 911 to pick up the resident. The DON stated that Resident #4 was not hit by any of the staff. The DON stated that they are expected to keep all PIR's to have them for future references. She stated the risk of not having the PIR's can cause investigations to not be thoroughly done, poor patient care, and fines. In an interview on 11/20/25 at 6:36 PM, the ADM stated that the old administrator was disgruntled when he was fired. The ADM stated that the old administrator told him that he was going to make sure he gave him all the paperwork from the previous incidents, but he didn't leave any paperwork at all. The ADM stated that typically it's the administrator's job to keep up with PIR's. The ADM stated that due to him not being the administrator at the time of the incident and with no PIR to reference he can't speak about what happened during the incident. The ADM stated the risk of not having the PIR's is that the facility can be fined for not having that information for surveyors to reference. Record Review of the facility's Abuse Policy in part indicated - All reports of resident abuse (including injuries of unknown origin).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 -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.Investigating Allegations- 1. All allegations are thoroughly investigated. The administrator initiates investigations.Follow-Up Report 1. Within 5 business days of the incident, the administrator will provide a follow-up investigation 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. 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 5 of 9 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 11/20/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized for 1 (Resident #3) for accuracy of records. The facility failed to accurately transcribe the admitting diagnoses for Resident #3. This failure can affect residents by putting them at risk for inaccurate and incomplete records. Findings include:Record review of Resident #3's face sheet dated 11/19/25 reflected a [AGE] year-old man admitted to the facility on [DATE] with a primary diagnosis of HIV (a virus that attacks cells that help the body fight infection), severe protein-calorie malnutrition (inadequate intake of protein and calories), seizures, hypertension (pressure in your blood vessels is too high), atrial fibrillation (irregular and often very rapid heart rhythm), congestive heart failure (heart can't pump enough blood), cerebral infarction (reduces blood flow to a region of the brain), end stage renal disease (kidneys no longer work as they should to meet your body's needs), and anemia. Record Review of Resident #3's face sheet reflected a diagnosis of Dementia. Record review of Resident #3's MDS dated [DATE] reflected a BIMS score of 11, indicating moderately impaired. In an interview on 11/19/25 at 12:32 PM, an Anonymous family member stated the day of the incident with Resident #3 they received a call from a nurse at [Hospital Name 1]. They stated they hung up the phone because they thought someone had the wrong number and they didn't have any children at [Hospital Name 1]. Anonymous family member stated that he received another phone call from a nurse and police from [Hospital Name 1] and informed them that Resident #3 had been at [Hospital Name 1] for two hours and he couldn't find his way back to [Facility Name]. Anonymous family member stated that he immediately called [Facility Name] and asked the receptionist how Resident #3 was doing today, and the receptionist replied that Resident #3 was doing fine. Anonymous family member stated he then asked the receptionist how he is fine, and he is not in the building. Anonymous family member stated the receptionist left the phone and never came back. Anonymous family member stated when they arrived at the facility later that day, he kept asking the staff how does someone with dementia sign themselves out, they said no one was able to answer that question. Surveyor informed Anonymous family member that they were unable to find a diagnosis of Dementia for Resident #3 in the medical records the [Facility Name] has for Resident #3. Anonymous family member stated that they would send an email of a document from Resident #3's doctor with evidence Resident #3 had Dementia. In an email on 11/19/25 at 3:34 PM, Anonymous family member sent a clinical record from [Hospital/Clinic Name] that reflected a diagnosis of HIV/AIDS with HIV Dementia and Vascular Dementia with alcoholic neurological disease component. In an interview on 11/19/25 3:51 PM with the DON, she stated that diagnosis for the residents is transcribed in the database by charge nurses, the MDS coordinators, the ADON, and her. Record Review of Resident # 3's clinical record dated 09/03/25 from [Hospital Name 2] reflected a diagnosis of Dementia. Record Review of the list of Residents Who cannot leave the building or Must be supervised reflected resident #3, resident #5, resident 6, resident #7, resident #8, resident #9, resident #10 and resident #11. Record Review of Resident #3's Wander Assessment, not dated indicated a score of 9. A score of 0-8 indicates low risk, a score of 9-10 indicates a risk to wander, and 11 and above indicates high risk to wander. In an interview on 11/20/25 at 12:45 PM, the ADON stated she wouldn't say Resident #3 has Dementia, but his cognitive status can be deceiving because when he is asked his name, he knows it, but if you continue to talk to him, you can tell he is not aware and he doesn't always know where he is at. The ADON stated Resident #3 doesn't wander but he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 6 of 9 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 11/20/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few will walk up to the front of the building and say he wants to sign out and go somewhere and he would usually come back. The ADON stated she recommends that he can sign out but only with supervision. There is a book at the receptionist's desk titled Residents Who cannot leave the building or Must be supervised, receptionists will look in the book before letting a resident sign out to determine if the resident is listed in the binder. The ADON stated that she was not at work the day of the incident, but she stated Resident #3 asked to sign out the very next day on Sunday and Resident #3 asked to sign out again and she informed him that it's not safe for him to go out on his own. The ADON stated when Resident #3 was admitted and she did his assessment his BIMS score was okay for him to sign out, but when she reassessed him on 11/15/25, she stated that's when she noticed he was not safe to go out on his own any longer[JM4] . The ADON stated since the incident Resident #3 has been placed in the Residents Who cannot leave the building or Must be supervised list, and a wander guard has been placed on the resident. In an interview on 11/20/25 at 1:16 PM, with the Medical Director he stated that he did not see a diagnosis of a mental deficiency from the facility's database. The Medical Director stated that all he saw from the facility's database for Resident #3 is that he had moderate cognitive deficiency. The Medical Director stated since Resident #3 was his own responsible party he could sign out by himself but from what we know now he shouldn't be able to sign out by himself moving forward. The Medical Director stated he was going to make some changes to Resident #3's orders to be placed on the list of residents who cannot sign out. In an interview on 11/20/25 at 3:28 PM, the MDS coordinator stated that diagnosis for residents is put in the database by the charge nurses but sometimes he may take out some diagnosis if they have been discontinued. The MDS coordinator stated that when residents are admitted it's usually a team effort when transcribing all diagnosis into the database, but he stated that if he was not given a resident's clinical paperwork or if the facility was not given that information it is possible that the information was not entered. The MDS coordinator stated that he was looking into Resident #3 and that it is correct that Dementia is not listed in Resident #3's diagnosis. The MDS coordinator stated that it is possible that Resident #3 may have had paperwork showing he had a diagnosis of Dementia and that information was not entered. The MDS coordinator stated that he noticed when he looked in the Miscellaneous tab that there was a clinical record that was uploaded on 11/19/25 that indicated Resident #3 had Dementia. According to the EHR the medical record was uploaded by Staff E. The MDS coordinator admitted that the information was not in there before 11/19/25. The MDS coordinator stated that he would have loved to have had that information before. On 11/20/25 at 3:45 PM, Surveyor requested all clinical records for Resident #3 from DON. In an interview on 11/20/25 at 5:11 PM, the DON stated Resident #3 has signed out a few other times, but he usually just stands in the front of the building and then comes back in. The DON stated residents who are listed on the Residents Who cannot leave the building or Must be supervised list is determined by their BIMS score, talking to them, and are given a wander assessment. The DON said if they score high on the wander assessment then they are given a wander guard and placed on the Residents Who cannot Leave the building or must be supervised list. When asked why the diagnosis of Dementia was not transcribed into the database for Resident #3 the DON said if he has a true diagnosis of Dementia then that information should have been uploaded. She stated the risk of them not accurately transcribing the admitting diagnoses for Resident #3 is not properly care planning him or properly knowing how to care for him. The DON stated they have 48-72 hours to complete the residents baseline care plan at admission, she said it is important to make sure that information is properly uploaded in the system so they can properly know how to take care of residents. In an interview on 11/20/25 at 6:36 PM, the ADM stated just because a resident has a diagnosis of Dementia doesn't (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455881 If continuation sheet Page 7 of 9 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 11/20/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete mean they can't sign themselves out. The ADM stated they assess the residents and decide by their Wander assessments. The ADM stated when residents are admitted he expects staff to transfer all information from medical records into the system right away that day, he said he was unsure of the timeframe in which that information should be transcribed. The ADM stated they shouldn't be waiting 2-3 days to put in admitting diagnoses information he said because they need to know how to be properly care planned. The ADM stated that he fired the social worker they had because she wasn't putting in important information in the system and he has since then been looking to hire a new social worker. The ADM stated the risk of not accurately transcribing records into the database is that it could cause staff to miss something important. Record Review of the facility's Charting and Documentation Policy indicated in partAll services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Event ID: Facility ID: 455881 If continuation sheet Page 8 of 9 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 11/20/2025 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the QA committee developed and implemented appropriate plans of action to correct identified quality deficiencies. The facility failed to provide the plan of correction (POC) for a deficiency of F610 cited at D and F842 cited at D on 11/20/2025. This failure could place residents at risk of abuse and not having abuse allegations investigated and inaccurate [NAME] records. Findings included:Record review of the 2567 Provider's POC exit date 11/20/2025 for F610 revealed the following: Resident #4 was sent to hospital on 8/9/2025 and returned with no injury. Resident was assessed for injury on 12/10/2025 no injury. DON/designee attempted an investigation incident on 12/10/2025 resident does not remember episode and gives incoherent rambling answers.All residents have the potential to be affected. Education with all staff was completed by DON/designee on 12/11/2025 for reporting abuse/neglect timely. The Director of Nursing Services, or designee, will conduct a random audit of five (5) residents weekly for four (4) consecutive weeks. These residents will be assessed and interviewed to ensure that any injuries are identified, properly investigated, and reported to the appropriate people. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met. Date of compliance is 12/11/2025.Record review of the 2567 Provider's POC exit date 11/20/2025 for F842 revealed the following: Resident #3 diagnosis of dementia added on 12/10/2025 per hospital paperwork by MDS.All residents have the potential to be affected. Inservice's were completed by Corporate consultant on 12/11/2025 for accurate transcription of medical records. The DON/designee will monitor 3 residents weekly for 4 weeks to ensure diagnosis are entered into resident charts. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.Date of compliance is 12/11/2025.On 12/30/2025 at 8:49 am, Surveyor requested all evidence including inservices, policies, and monitoring for POC from the Administrator and DON. Review of the POC binder provided by the DON did not include any monitoring and had a blank audit form titled F-610 Investigate/Prevent/Correct Alleged Violations.Interview on 12/30/2025 at 11:29 am, Surveyor requested the full POC and the DON stated she would have to find the monitoring parts of the POC. Interview on 12/30/2025 at 12:51 pm, Surveyor requested the full POC and the DON stated she has gotten with the Administrator for the monitoring. Interview on 12/30/2025 at 1:58 pm, the DON stated she was responsible for completing the POC. She stated she in-serviced staff on abuse. No answer was given when Surveyor asked why the POC monitoring was not completed. The DON stated the Administrator was responsible to investigate allegations of abuse and she had been learning how to do the self-reports. She said she has been reporting and keeps the records in her office. The DON stated the risk of not completing the POC was more of the same behaviors and resident needs not being met. Interview on 12/30/2025 at 2:19 pm, the Administrator stated the DON in-serviced staff on abuse. He stated he was responsible for abuse investigations and because the DON had not done them before, she had been completing the reports and keeping copies of the investigations in her office. He stated he was responsible to ensure the POC was completed, and no answer was given when asked why the monitoring was not done. He stated the risk of the POC being completed was monetary and could be a risk to residents by not monitoring the things they said they were going to do. Event ID: Facility ID: 455881 If continuation sheet Page 9 of 9