Inspection·March 11, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few at the facility. She said the money was in her bedside table drawer [pointed to the side table by her bed]. She said it happened a month ago. She stated she had $60 first stolen then a few days later $30 was also stolen. She stated a total of $90 was stolen from her. Resident #1 said she could not remember the exact dates. Resident #1 said she did not have a lock box and that she did not ask for one. Resident #1 stated that she did not report the incident but everyone in the facility knew that there was someone going around robbing residents. Resident #1 said a CNA told her that information about the robberies, but she declined to name the staff members name, stating I don't want her to get in trouble. In an interview with the Housekeeper on 03/11/25 at 11:35 AM, revealed she was aware of Resident #1's missing money. She stated Resident #1 informed her a few weeks ago about the stolen money. The Housekeeper stated she had found some money ($30) laying around in Resident #1's room and Resident #1 asked her to help her secure it, so the Housekeeper went to the business office, got an envelope and placed the money inside the envelope then placed the sealed envelope inside a [book name] in Resident #1's drawer. She stated she could not remember the exact dates, a few weeks ago. The Housekeeper stated Resident #1 told her that she had reported the missing money and so she did not report it herself because it was already reported. The Housekeeper stated she did not even think of helping Resident #1 get a lock box for her money. She said Resident #1 was a holder and liked to carry her belongings with her, therefore she would not have agreed to a lock box. The Housekeeper stated she knew what misappropriation and exploitation meant in regard to Abuse and Neglect. She stated misappropriation and exploitation was not just money but any residents' personal belongings being taken or befriending the residents so that they can trust you with personal information and you misuse it. She stated misappropriation and exploitation should be reported to the administrator immediately. Interview with CNA A and CNA B on 03/11/25 at 11:40 AM revealed they did not know nor had heard of any robberies in the facility, and they did not know anything about any resident's money being stolen. Both CNA A and CNA B stated they had done in-services on ANE in the past month. They stated they would report missing money or any resident's property to the DON and Administrator immediately. In an interview with the Business Office on 03/11/25 at 1:46 PM she stated Resident #1 withdraw $30 on 1/14/25, $30 on 1/22/25, $30 on 02/10/25 and $30 on 02/25/25. The Business office said that no one had reported to her that Resident #1 was missing money. She stated Resident #1 wanted two small fridges for her drinks and butter and it was likely that Resident #1 had spent the money on the items. She stated if she had known about the money missing, she would have reported to the abuse coordinator right away. She stated misappropriation and exploitation are to be reported to the abuse coordinator, the administrator. Interview with ADM on 03/11/25 at 2:33 PM, revealed she was not aware of Resident #1 missing money. She stated she reported the incident after finding out today 3/11/25. She stated the expectation was that the housekeeper should have reported the incident to her. She said the risk was misappropriation and exploitation. In an interview with DON on 03/11/25 at 2:52 PM, revealed she was not aware of Resident #1's missing money until the ADM told her today. She stated the expectation was that the incident was reported immediately. DON stated the facility had lock boxes and the residents were aware and one could be provided if they wanted one. She stated she would rather have 11 people report the same incident than for them to say, someone already reported the incident. The DON stated she had in-served on ANE, and the expectation was that all staff follow the ANE policy and report incidents immediately. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455903 If continuation sheet Page 2 of 3 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 455903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Lodge Nursing & Rehabilitation 3800 Marina Dr Lake Worth, TX 76135 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 Review of Resident #1's statement titled Resident Statement Landscape reflected Resident #1 withdraw a cash on the following dates: Level of Harm - Minimal harm or potential for actual harm $30 cash on 01/14/25, Residents Affected - Few $30 cash on 01/22/25, $30 cash on 02/10/25, $30 cash on 02/25/25. Review of facility In-Service training attendance roster titled Abuse and Neglect lead by DON dated 02/28/25 was signed by Housekeeper, CNA A, CNA B, and 36 other staff members from nursing and other departments. Record review intake [number] reported on 03/11/25 by ADM allegation Exploitation/Misappropriation. Review of facility policy titled Abuse and Neglect, dated 09/09/24, reflected: The facility Reportable Incident Protocol, Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 2024-14 dated 8/29/24. a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. b. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455903 If continuation sheet Page 3 of 3