Health inspection·September 10, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some circumstances, triggers, and what deescalates behaviors and document. Assess and address for contributing sensory deficits. Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain. If resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately. Resident to be 1:1 for 24 hours, every 15minutes for 24 hours, every 30 minutes for 24 hours, every 1 hour for 24 hours, every 8 hours for 24 hours. When resident becomes agitated: intervene before agitation escalates; Guide away from the source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away; and approach later. - Resident #8 resided in the Secure Care Unit, related to diagnosis of dementia and risk for elopement. Disease Process, Disoriented to place, Memory loss. Goal: Resident will not have feelings of isolation and will feel safe and secure in the care received while on the Secure Care Unit. Interventions included: Admit to Secure Care unit per physician orders, Engage resident in group activities and provide them with individualized meaningful projects that they will accomplish throughout the day, Involve resident in daily activities designed for Secure Care Unit, Monitor for S/S of depression, withdrawal from usual activities, Notify MD of any changes, Psych services per MD orders. Record review of Resident #8's progress notes written by RN K on 06/17/25 at 12:00 PM reflected: Writer heard yelling, saw patients Resident #8 and Resident #9 hitting one another and rolling on the dry floor. RN K went out and grabbed Resident #8's arm to prevent him from hitting and telling him to let go of Resident #9's shirt. After he let go then I pulled him away. Resident #9 then sat on the couch. Resident #8 laid on the floor. Vitals were taken. Neuros taken. All withing normal limits. Resident #8 complaint of face hurting. Resident #9 complaint of right-hand hurting. RN K notified ADON C. RN K placed ice pack on Resident #8's left side of face and assisted him to chair. Record review of Resident #8's progress note Initial Skin Assessment written by ADON C on 06/17/25 at 12:30 PM revealed Skin Color: Normal; Temperature of skin: Warm; Bruise present: Yes. Location, measurements of bruising: left facial abrasion; Skin Tear Present: No; Abrasion present: Yes. Location, measurements of abrasion: left side facial abrasion; Laceration present: No; Surgical incision present: No; Rash present: No; Moisture Associated Skin Damage present: No; Pressure, venous, arterial, or diabetic ulcer present: No; Other skin findings: Left facial abrasion / swollen. Record review of Resident #8 progress note Transfer Notification written by ADON C on 06/17/25 at 1:00 PM revealed Resident #8 was transferred to a hospital on [DATE] 1:00 PM related to Unresponsive. This is intended to serve as notice of an emergency transfer. Record review of Resident #8's progress note Activity Note written by LVN L on 06/17/25 at 8:32 PM revealed resident returned from emergency room with no new orders. Resident remains alert and confused, resident at baseline. resident neuros restarted as per facility protocol. Resident assessed, resident noted with left facial swelling with bruising noted, abrasion to left lower leg. Physician notified of return new order to increase tramadol 50mg one po daily to bid. Resident's Responsible Party made aware of return, made aware of resident overall condition and any new findings and new orders. Responsible Party had no questions or concerns at this time. Record review of Resident #9's most recent Quarterly MDS (Minimum Data Set) Assessment, dated 05/22/25, reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #6 had BIMS of 06 indicating moderate cognitive impairment. Diagnosis included Unspecified Dementia (various types of dementia), Unspecified severity, without behavioral/psychotic/mood/anxiety disturbances (general decline in cognitive abilities that affect a person's ability to perform everyday activities). Depression (persistent feeling of sadness and loss of interest), and high blood pressure. Resident #'s MDS indicated he had shown mood signs of little interest or pleasure in doing things and feeling down, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675028 If continuation sheet Page 2 of 20 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 675028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134 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 depressed, or hopeless with no signs of behaviors. Record review of Resident #9's care plan last revised 06/17/25 revealed Resident #9 had been identified as having Resident at risk to exhibit physical aggression. Goal: Resident to not have any episodes of physical aggression. Intervention include resident to remain 1:1 related to physical aggression. Care Plan revealed: Resident #9 has potential to demonstrate physical behaviors Anger, Dementia, Poor impulse control was put on by another resident and responded by pushing leading to altercation. Goal: The resident will demonstrate effective coping skills. Interventions included: 1:1 supervision prn physical aggression or other aggressive behavior. Analyze [sic] of key times, places, circumstances, triggers, and what de-escalates. Assess and address for contributing sensory deficits. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately. Secure care consult for behavior management. Send to emergency room for psychiatric evaluation as needed. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Care Plan revealed: Resident #9 resides in the Secure Care Unit, related to diagnosis of dementia (or related diagnosis) and risk for elopement. Goal: Resident will not have feelings of isolation and will feel safe and secure in the care received while on the Secure Care Unit. Interventions include: Admit to Secure Care unit per physician orders. Engage resident in group activities and provide them with individualized meaningful projects that they will accomplish throughout the day. Involve resident in daily activities designed for Secure Care Unit. Monitor for signs and symptoms of depression, withdrawal from usual activities. Notify physician of any changes. Psych services as doctor orders. Record review of Resident #'s progress note Neuro Assessment written by ADON C on 06/17/25 at 12:02 PM revealed the physician was notified of a negative change. Comments and/or new orders: Transfer to the hospital. Record review of Resident #9's progress note written by RN K on 06/17/25 at 12:11 PM revealed Writer heard yelling and saw Resident #8 and Resident #9 on the dry floor rolling and hitting one another. I held Resident #8 arm and told him to let go of Resident #9's shirt. After several minutes he let go and Resident #9 got up and sat on the couch. Resident #9 then went to his room and changed his shirt. Vital signs, neuros, blood sugar done. Resident #9 to be transferred to hospital. Record review of Resident #9's progress note written by Social Services Director on 0617/25 at 3:06 PM reflected: Social Services Director met with the resident to assess any trauma after an incident between he and another resident. Resident denies any trauma. Social Services Director did not observe any trauma symptoms or behaviors. Resident continues to state he feels safe in the facility and not fearful of the other resident. Resident will be transported to the hospital for further assessment. Observation of the facility's surveillance video dated 06/17/25 at 11:42 AM revealed the nurse office door was closed and both Resident #8 and Resident #9 were in the television room within feet of each other, Resident #8 stood between a female resident in her wheelchair sitting next to the exit door and a credenza in front the television wall. As Resident #9 headed towards the exit he passed Resident #8 and pushed him in the back. As Resident #8 stumbled a couple of feet he went after Resident #9 almost tripping over the wheelchair. Both residents stepped out of the camera, within seconds they returned back in the frame tussling at each other. Resident #9 began punching Resident #8 eight times in the face. This continued until they both (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675028 If continuation sheet Page 3 of 20 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 675028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134 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 fell onto the floor holding onto each other's shirts. At 11:43.25 the door opened, however, RN K did not exit the office to assist until 11:43.51, at this time she walked over to Resident #8 and placed her hand on his wrist. The video ended. Record review of the provider investigator report revealed on 06/17/25 at 11:45 AM Residents were in the secure unit living area when they began to have a verbal altercation. Resident #9 pushed Resident #8 in the back and then proceeded to punch Resident #8 in the face several times before both residents went to the ground and continued to hold each other by the clothing before Charge Nurse, RN K, separated residents. Resident #8 was sent to the emergency room for further evaluation due to facial swelling - no further injuries noted. Immediate discharge notice delivered to Resident #9 at hospital due to aggression and unable to be redirected during altercation. Staff interviews completed. In-services regarding abuse/neglect, resident rights, how to deal with residents aggressive behavior, behavior management. Record review of hospital records for Resident #8 reflected on 06/17/25 Resident #8 presented with a fall after an assault at the nursing home. The resident was punched in the face at least 10 times per Emergency Medical Service. It reflected the resident was assaulted at 11:00 AM. The resident then walked to the dining room on his own, had lunch, fell, and was then unresponsive. Emergency Medical Service stated the resident was found down supine, no blood thinners, and the resident's blood sugar was 375. The hospital findings reflected Resident #8 had no fractures, no acute intracranial abnormality (no immediate or urgent issues detected in the brain), no acute osseous cervical spine abnormality (no severe bone issues). Record review of facility log 15 Minute Monitoring revealed Resident #9 was placed on 15-minute monitoring starting at 12:30 PM until he exited the building to hospital for further evaluation at 2:30 PM . Record review of RN K statement dated 06/17/25 I [RN K] was sitting in the office when [Resident #8 and Resident #9] were heard making a lot of commotion. I had the door partially open. As I began to open the door to see what was going on the I noticed the two residents were rolling on the floor. I felt I was in shock at what I was seeing and thinking to myself what was going on and what was I going to do? I then thought of separating the two of them. I tried to separate them, but it was hard. I did not think to yell for help. Record review of Employee Disciplinary Report dated 06/17/25 revealed Investigation Suspension: [RN K] will be placed on an investigatory suspension pending an investigation into allegations of failing to meet their job duty/responsibility expectations. Corrective plan of Action: Due to the allegations, [RN K] will be placed on unpaid investigatory suspension. [RN K] will remain on investigatory suspension until the investigation is completed into the above allegation. [RN K] will be notified when the investigation is completed. [RN K] may provide a written statement. Employee comments: I think I tried to remain calm during the action of the residents. Interview on 09/09/25 on 11:28 AM with CNA I revealed during the time of the incident she was in the shower room with another resident leaving RN on the floor and charting in the nurse office. CNA I stated when she finished in the shower she was informed there had been an altercation between Resident #8 and Resident #9. CNA I stated she saw Resident #8 after the fight and observed swelling on Resident #8's face while in the dining room, he ate well, however soon after lunch he became nonresponsive and was sent out to the hospital. Resident #9 was also sent to the hospital for evaluation and had not returned. According to CNA I, she was inserviced over resident-to-resident altercations, resident confrontations, ensure to separate residents immediately and report. CNA I stated not monitoring residents and separating immediately during an altercation placed residents at risk for injuries or hospitalization. Attempted interview on 09/09/25 at 1:30 PM with RN K was unsuccessful. Attempted interview on 09/09/25 at 1:32 PM with LVN L was unsuccessful. Interview on 09/09/25 at 2:25 PM with ADON C revealed on video, Resident #9 was offering Resident #8 a chair to sit but Resident #8 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675028 If continuation sheet Page 4 of 20 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 675028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134 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 spitting on Resident #9, as they passed each other Resident #9 pushed Resident #8. Resident #8 then turned and started hitting Resident #9, both residents ended up on the floor. ADON C stated RN K was in the office when she heard commotion and stepped out. ADON C stated RN K was slow to react to the commotion and in separating the residents. ADON C stated emergency services was called, Resident #9 was placed on one-on-one monitoring until he was sent to the hospital for evaluation due to his aggressive behavior, punching Resident #8 causing a scratch and swelling to the left side of Resident #8's face. According to ADON C Resident #8 was also placed on one-to-one monitoring, assessed and injuries cleaned, and started neuro checks. ADON C further stated after the altercation there were no further signs or symptoms of injury, after lunch RN K called her to say Resident #8 was unresponsive, emergency services was called to send him to the hospital. ADON C stated in-service trainings were completed over abuse and neglect and staff surveys to ensure staff were knowledgeable about what to do during resident-to-resident altercations. ADON C stated all staff including CNAs and Nurses were responsible for monitoring and engaging with residents, not reacting quickly to altercations placed residents at risk of harm. Interview on 09/10/25 at 11:32 AM with the DON revealed she was not in the facility during the time of the incident however when she returned she followed up on the incident. The DON stated she reviewed the video revealing both residents ended up on the floor hitting each other. The DON stated the video also revealed RN K in the nurse office with the door closed and her slow to respond to the altercation. The DON stated RN K was suspended immediately and terminated due to the evolvement of the incident. The DON stated she expected staff on the secure unit to be out in the open and engaged with residents, not behind closed doors. The DON stated resident safety is top priority, so getting residents separated during altercations are immediate and to follow up with assessments. The DON stated Resident #8 was placed one on one, and Resident #9 was sent to the hospital with an immediate discharge. The DON stated staff were provided in-service training on abuse, neglect, resident rights, residents with dementia and aggressive behavior, separate during altercations, and one to one and behavior management. The DON stated nurses were responsible for always having eyes on residents especially on the secure unit, along with the one or two aides on duty. The DON further stated not doing so placed residents at risk of their safety, someone could fall and hit their head and possibly die. Interview on 09/10/25 at 11:56 AM with the Administrator revealed she was notified by ADON C of resident-to-resident altercation on the memory care unit, upon return she was able to review the video which showed the altercation between Resident #8 and Resident #9. The Administrator stated Resident #9 was sent to the hospital for further evaluation and immediate discharge. The Administrator stated Resident #8 was placed on one-on-one monitoring and neuro checks, he had lunch with no further signs of injury or distress, until he started showing signs of being non-responsive and altered status. The Administrator stated Resident #8 was sent to the hospital by emergency medical services and returned with no findings or new orders. The Administrator stated upon review of the video it showed RN K was slow to respond to the altercation between the two residents, RN K was in the office behind closed door allowing residents altercation to last close to 2 minutes before she slowly exited the office to separate them. The Administrator stated the nurses should be out of the office as much as possible; both nurses and aides were responsible for always having eyes on residents. The Administrator further stated not having a clear sightline of residents placed them at risk of abuse and harm. The facility took the following actions to correct the non-compliance prior to the investigation: Record review of an in-service, dated 06/17/25, reflected 29 staff including nurses, CNAs, housekeepers, medication aide, Business Office Manager, dietary aides were provided with training on resident-to-resident altercations. The in-service training covered: abuse and neglect; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675028 If continuation sheet Page 5 of 20 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 675028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134 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 rights; how to deal with residents with dementia and aggressive behaviors; immediately separating residents from physical or verbal altercations; placing the aggressor on one-to-one supervision for resident safety; and behavior management Record review of an in-service, dated 06/17/25, reflected 29 staff that included nurses, nurse's aides, housekeeping, medication aide, Business Office Manager, dietary aides were in-serviced regarding: Abuse/Neglect Policy Record review of Resident #8's 15 minute checks dated 06/17/25 revealed monitoring from 12:30 PM until 06/19/25. Record review of Resident #9's 15 minute checks dated 06/17/25 revealed monitoring on 06/17/25 12:30 PM until 06/17/25 12:30 PM. Record review of Resident #9's clinical records revealed Resident #9 was placed one-on-one supervision on 06/17/25 12:30 PM until 06/17/25 2:30 PM until he was sent to the hospital for further evaluation and issued immediate discharge . Record review of Resident #8 and Resident #9's care plans were updated. Record review of Resident #8's clinical records revealed Resident #8 was assessed and transported to the emergency room for further evaluation with no findings or new orders. Record review of Resident #8's clinical records revealed Resident #8 was being monitored for behaviors throughout each shift upon his return from the hospital on [DATE] 8:30 PM until 06/19/25 at 6:00 PM until with no further signs of aggression or agitation. Record review of Staff Surveys were conducted on 06/17/25 - 06/18/25 by 24 staff over what signs and symptoms to look for when resident had a change in condition, how to respond when witnessed a resident-to-resident altercation, who do you report abuse/neglect allegations to? All with the understanding to immediately separate residents during resident-to-resident altercation and report to the nurse and the abuse coordinator which was the Administrator. Observation on 09/09/25 10:00 AM 09/10/25 4:00 PM throughout investigation revealed the door to the office on the memory care unit has been removed. Both nurse and aide were making constant rounds to visibly check on each resident on the unit. Staff were engaging with residents and not seen in the nurse's office. Interviews on 09/09/25 from 11:22 AM through 09/10/25 3:30 PM with MDS Coordinator, CNA A, LVN B, ADON C, ADON D, LVN E, MA F, LVN G, LVN H, CNA I, CNA J, Social Services Director, Director of Rehabilitation, DON, and the Administrator, Activity Director, Housekeeping Supervisor, The facility staff were able to verify education was provided to them. Facility staff were able to accurately summarize abuse and neglect, how to work with residents with behaviors, immediately separate residents in altercations and report. Facility staff stated they monitor residents throughout the shifts, if behaviors were identified staff stated they were trained to redirect residents or placed them on 1:1 or q15 checks depending on the behavior. Staff stated for residents who have had altercations or incidents they monitor closely, keep them separated to prevent any further incidents. Staff stated they provide activities to keep them engaged and provide snacks throughout the day. Staff stated upon shift change they will notify the incoming staff of any incidents or behaviors. 2. Record review of Resident #1's Annual MDS, dated [DATE], reflected the resident was a [AGE] year-old male, who admitted to the facility on [DATE]. Th resident was cognitively intact with a BIMS (mental status assessment) score of 15. His diagnoses included Type 2 diabetes mellitus (metabolic disorder marked my insulin resistance and impaired insulin secretion); chronic pain syndrome (multifactorial condition characterized by persistent pain lasting longer than 3-6 months, often accompanied by psychological and functional impairment); and cognitive communication deficit (impaired communication due to deficits in attention, memory, or executive function). The MDS reflected Resident #1 did not have any physical or verbal behaviors towards others. The MDS also reflected Resident #1 was dependent upon staff for assistance with ADLs. Record review of Resident #1's Care Plan, initiated on 11/15/24 and revised on 09/05/25, reflected: Focus: Resident has a history of making false accusations, related to but not limited to: the staff, showers, activities of daily living, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675028 If continuation sheet Page 6 of 20 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 675028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134 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 preferences. Resident instigates staff by cursing at them and calling them derogatory names. Goal: Reductions or absence or false accusation. Interventions: Anticipate and meet the resident's needs. Assist the resident to develop more appropriate methods of coping and interacting with staff. Encourage the resident to express feelings appropriately. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Interview on 09/09/25 at 9:48 AM with Resident #1 revealed on 09/04/25, his roommate called CNA A to his room. Resident #1 said CNA A walked into the room asked who had called her, to which he responded with none ya. Resident #1 said he heard CNA A say fuck you to him, and she immediately walked out of the room. Resident #1 said CNA A saying that made him cry, feel put down, and made him feel uncomfortable. Resident #1 said right after it happened, he told his nurse (LVN B). Resident #1 revealed LVN B switched aides, so CNA A no longer cared for him.? Interview on 09/09/25 at 10:17 AM with Resident #4 revealed he was Resident #1's roommate. Resident #4 reported on 09/04/25 CNA A came into the room and was helping Resident #1 get ready for bed. Resident #4 said Resident #1 was cussing and fighting with CNA A when CNA A told Resident #1, Fuck you. Resident #4 stated after it was said, CNA A walked out of the room and another aide came to help Resident #1 finish getting ready. Resident #4 stated CNA A appeared calm when she cussed at Resident #1. Resident #4 revealed he had no issues with CNA A or any other staff members. Interview on 09/09/25 at 2:23 PM with LVN B revealed Resident #1 came to her after the incident with CNA A on 09/04/25. LVN B stated Resident #1 and CNA A used the F word to each other. LVN B said when Resident #1 reported it to her, he appeared visibly upset by it. LVN B said she switched the aides out, so CNA A was no longer caring for Resident #1. LVN B stated she had to calm Resident #1 down, and she went to the Administrator because it was verbal abuse to Resident #1.? Interview on 09/09/25 at 2:38 PM with CNA A revealed she was called into Resident#1's room. CNA A asked Resident #1 to turn the call light off twice, and he replied to CNA A by saying, Fuck you. CNA A stated she said Fuck you back to Resident #1. CNA A stated she knew it was not right to say that to any resident, but it slipped out. CNA A confirmed it was verbal abuse. Interview on 09/10/25 at 3:10 PM with the Social Worker revealed on 09/05/25, Resident #1 came and told her that a CNA last night had cussed him out by saying fuck you. The Social Worker reported that Resident #1 was visibly upset when he described what had happened. The Social Worker stated she immediately reported it to the Administrator who was the Abuse Coordinator due to it being verbal abuse. Interview on 09/10/25 at 11:31 AM with the DON revealed she was told about the incident between Resident #1 and CNA A on 09/05/25 by the Social Worker right after he reported it to her. The DON stated it was reported to her that Resident #1 was baiting CNA A by saying, Fuck you first, but then CNA A said it back. The DON stated CNA A admitted it was wrong to say that to a resident. The DON revealed they suspended and then terminated CNA on 09/05/25. The DON stated telling a resident Fuck you was considered verbal abuse which was why CNA A had to be terminated. The DON stated her expectation was for staff to keep all residents safe and free from abuse. Interview on 09/10/25 at 11:56 AM with the Administrator revealed CNA A told Resident #1 Fuck you the previous night (09/04/25) around 6:00 PM. During her interview with Resident #1, he told her that CNA A cursed at him unprovoked. Resident #1's roommate also confirmed that CNA A did say that to Resident #1. The Administrator stated this was considered verbal abuse, and CNA A was terminated after admitting to the allegation. The Administrator reported that verbal abuse could put residents at risk of psychological harm. The Administrator stated she expected her staff to treat residents with respect and to report any abuse immediately. The Administrator stated her number was posted throughout the building, and she wants to be notified at any time if abuse occurs or is suspected. Observation on 09/10/25 at 3:15 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675028 If continuation sheet Page 7 of 20 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 675028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134 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 PM revealed the Administrator's phone number was posted in multiple locations, including at the nurses' station and in the hallway. Record review of CNA A's personnel file reflected CNA A was suspended and terminated on 09/05/25. Record review of facility's current, undated Abuse/Neglect Policy reflected the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility . Verbal abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend or disability . Prior to the HHSC investigation, the facility took the following actions to correct the noncompliance: Record review of Resident #1's Trauma Informed PRN Assessment had been completed on 09/05/25 with no concerns identified. Record review of the facility's Skin Monitoring: Comprehensive CNA Shower Record review had been completed on seven residents on 09/05/25. Record review of safe surveys completed on 09/05/25 showed that nine residents had been interviewed by the facility with no issues noted. Record review of In-Service Training record reflected 41 staff had been provided in-service training on abuse/neglect, resident rights, and behavior management on 09/05/25. Interviews between 09/09/25 from 9:30 AM through 09/10/25 3:15 PM with the Social Worker, LVN B, LVN E, ADON C, ADON D, Housekeeper M, MA F, LVN G, Speech and Language Therapist, LVN H, CNA I, and CNA J revealed the facility staff were able to verify education was provided to them. The staff stated they were educated on different types of abuse and neglect. Staff stated they would intervene if they witnessed any type of abuse and immediately report to the Abuse Coordinator. 3. Record review of Resident #2's Annual MDS, dated [DATE], reflected the resident was a [AGE] year-old male, who admitted to the facility on [DATE]. The resident's diagnoses included hemi[TRUNCATED] Event ID: Facility ID: 675028 If continuation sheet Page 8 of 20 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 675028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134 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 observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately to the Administrator of the facility for 1 of 3 residents (Resident #1) reviewed for reporting abuse and neglect. LVN B failed to report an allegation of verbal abuse to the Administrator, on 09/05/25 when CNA used profanity towards Resident #1. This failure could have resulted in psychological harm to residents. Findings included: Record review of resident #1's face sheet dated 09/09/25, revealed the resident was a [AGE] year-old male with an admission date of 09/04/21 and readmitted on [DATE]. Record review of Resident #1's Annual MDS, dated [DATE], reflected he had a BIMS score of 15, indicating no cognitive impairment. His diagnoses included Type 2 Diabetes Mellitus (A long-term condition in which the body has trouble controlling blood sugar), Chronic Pain Syndrome (Condition characterized by persistent pain lasting longer than 3-6 months, often accompanied by psychological and functional impairment), and Cognitive Communication Deficit (Impaired communication due to deficits in attention, memory, or executive function). The MDS reflected Resident #1 did not have any physical or verbal behaviors towards others. The MDS also reflected Resident #1 was dependent on staff to assist with ADLs. Record review of Resident #1's Care Plan Initiated 11/15/24 and revised on 09/05/25, reflected, Focus: Resident has a history of making false accusations, related to but not limited to: the staff, showers, activities of daily living, and preferences. Resident instigates staff by cursing at them and calling them derogatory names. Goal: Reductions or absence or false accusation. Interventions: Anticipate and meet the resident's needs. Assist the resident to develop more appropriate methods of coping and interacting with staff. Encourage the resident to express feelings appropriately. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Interview on 09/09/25 at 9:48 AM with Resident #1 revealed on 09/04/25, his roommate called CNA A to his room. Resident #1 said CNA A walked into the room asked who had called her, to which he responded with none ya. Resident #1 said he heard CNA A say fuck you to him and then immediately walk out of the room. Resident #1 said that CNA A saying that made him cry, feel put down, and uncomfortable. Resident #1 said that right after it happened, he told his nurse (LVN B). Resident #1 revealed LVN B removed CNA A from his hallway and provided Resident #1 with a different aide, so CNA A no longer cared for him.? Interview on 09/09/25 at 2:23 PM with LVN B revealed Resident #1 came to her after the incident with CNA A on 09/04/25. LVN B stated that Resident #1 and CNA A used the F word to each other. LVN B said when Resident #1 reported it to her, he appeared visibly upset by it. LVN B said she switched the aides out, so CNA A was no longer caring for Resident #1. LVN B reported that she had to calm Resident #1 down and reported it to the administrator and DON because it was verbal abuse to Resident #1.? Interview on 09/10/25 at 1:06 PM with LVN B revealed while she originally did say yesterday, she had reported the abuse allegation to the Administrator and DON, she remembered that she might not have because she thought CNA A had done that. LVN B stated she was expected to report the abuse immediately to the Administrator who was the Abuse Coordinator Interview on 09/10/25 at 11:31 AM with the DON revealed she was told about the incident between Resident #1 and CNA A on 09/05/25 by the Social Worker right after he reported it to her. The DON stated that it was reported to her that Resident #1 was bating CNA A and said Fuck you first, but then CNA A said it back. The DON stated that CNA A admitted it was wrong to say that to a resident. The DON revealed they suspended and terminated CNA A on 09/05/25. The DON reported that telling a resident Fuck you was considered verbal abuse. The DON stated she was unaware of LVN B being told about the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675028 If continuation sheet Page 9 of 20 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 675028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134 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 situation on 09/04/25. The DON reported that all staff were expected to notify the Administrator immediately after the allegation was reported. The DON reported that residents have the right to be free from abuse and that if abuse is not reported immediately, problem resolution may be delayed, and residents may be harmed further. The DON stated her expectations were for staff to keep all residents safe and free from abuse. Interview on 09/10/25 at 11:56 AM with the Administrator revealed CNA A told Resident #1 Fuck you the previous night (09/04/25) around 6 pm. The Administrator said during her interview with Resident #1, he told her that CNA A cursing at him was unprovoked. The Administrator said Resident #1's roommate also confirmed that CNA A did say fuck you to Resident #1 on the night of 09/04/25. The Administrator stated that the Social Worker notified the Administrator on 09/05/25 of the abuse allegation after Resident #1 notified the Social Worker. The Administrator stated on 09/05/25 is when the facility had begun their investigation. The Administrator reported being unaware that LVN B was aware of the situation the previous night on 09/04/25. The Administrator revealed she expected her staff to treat residents with respect and to report any abuse immediately. The Administrator reported that verbal abuse can put residents at risk of psychological harm and not notifying the Administrator immediately can delay interventions and may cause the abuse to continue happening. The Administrator revealed her number is posted throughout the building, and she wants to be notified at any time if abuse occurs or is suspected. Observation on 09/10/25 at 3:15 PM revealed the Administrator's phone number was posted in multiple locations, including at the nurses' station and in the hallway. Record review of the facility's current, undated Abuse/Neglect policy reflected: .E. Reporting. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of an employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist or designee will be called. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property of injury of unknown source to the facility administrator. Event ID: Facility ID: 675028 If continuation sheet Page 10 of 20 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 675028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to incorporate the recommendations from the PASRR Level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for 2 of 4 residents reviewed (Residents #2 and #5) for PASRR assessments.1.The facility failed to submit a NFSS form, used to request specialized services for residents, request within 20 from interdisciplinary team meeting dated 03/18/25 for Resident #2. 2. The facility failed to submit a completed a NFSS in the LTC Online Portal within 20 business days of Resident #5's IDT meeting. This failure could place residents at risk of not receiving or benefiting from recommendations for services they may require. Findings included:1. Record review of Resident #2's most recent Quarterly MDS, dated [DATE], reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had moderate cognitive impairment with a BIMS score of 8. The resident's diagnoses included anxiety disorder (condition that cause significant and uncontrollable feelings of anxiety and fear), depression (persistent feeling of sadness and loss of interest), and schizophrenia (severe mental disorder), bipolar disorder (mental health condition with extreme mood swings), unspecified intellectual disabilities (condition that limits intelligence and disrupts abilities necessary for living independently). Resident #2's MDS indicated he received Speech Therapy 3 days beginning 12/22/24, Occupational Therapy 2 days beginning 12/10/24, and Physical Therapy 3 days beginning 12/09/24. Resident #2 had impairment on both side of his lower extremities and utilized a wheelchair. Supervision or touching assistance with lower body dressing, partial/moderate assistance with showers, oral, personal, and toileting hygiene, with set up assistance with eating. Record review of Resident #2's care plan, undated revealed he has been identified as having PASRR positive status related to Mental Illness and Intellectual Disabilities. Goal: Resident #2 will have the specialized services recommended by local authority according to PASRR Specialized Services program as needed. Interventions included the Local Authority would be invited annually to the care plan meeting for review of Specialized Services. Record review of Active Residents with PASRR Positive PE reflected Resident #2 on the list. The list indicated Resident #2 status date was 12/14/24 due to mental illness and developmental disabilities and had special services. Record review of Resident #2's PASRR Level 1 Screening completed 12/05/24 indicated Yes to Mental Illness and Intellectual Disability. Record review of Resident #2's PASRR Evaluation completed 12/13/24 indicated Yes to Intellectual Disability and Development Disability. Record review of Resident #2's PASRR Comprehensive Service Plan Form dated 03/18/25 revealed recommended Nursing Facility Specialized Services included new: Customized Manual Wheelchair, Specialized Assessment Occupational Therapy, Specialized Assessment Physical Therapy, Specialized Assessment Speech Therapy, Specialized Occupational Therapy, Specialized Physical Therapy, Specialized Speech Therapy, Day Habilitation, Habilitation Coordination, Independent Living Skills Training. The above services have been accepted by Resident #2. Record review of Resident #2's PASRR Comprehensive Service Plan Form dated 06/19/25 reflected the recommended Nursing Facility Specialized Services included ongoing: Customized Manual Wheelchair, Specialized Assessment Occupational Therapy, Specialized Assessment Physical Therapy, Specialized Assessment Speech Therapy, Specialized Occupational Therapy, Specialized Physical Therapy, Specialized Speech Therapy, Habilitation Coordination. The above services have been accepted by Resident #2 except CMWC. Interview on 09/09/25 at 9:30 AM with Resident #2 revealed he had a wheelchair which he used daily. Resident #2 stated he received physical therapy, but he did not know if he received occupational or speech therapy. Interview on 09/09/25 at 12:00 PM with PASRR representative revealed there was an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675028 If continuation sheet Page 11 of 20 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 675028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some interdisciplinary team meeting on 03/18/25. The facility was required to have uploaded documentation from the meeting into the portal within 20 business days from the meeting. According to the PASRR representative, she saw Resident #2 during his Occupational Therapy and he was doing fine, however when she looked in the portal for the documents, they had not been uploaded from the 03/18/25 meeting. The PASRR representative stated she spoke with the Social Worker about the missing documents in the hopes of having the documents uploaded. Interview on 09/09/25 at 3:32 PM with the Social Services Director revealed she was not an employee during the 03/18/25 visit and was not aware of missing documents for Resident #2 until she spoke with PASRR representative on 09/08/25. The Social Services Director stated she just recently started getting the invite to PASRR meetings, and would pass the invitation to the Director of Rehabilitation along with letting the Director of Rehabilitation. Interview on 09/09/25 at 3:45 PM with the Director of Rehabilitation revealed she began working in the facility in November 2024 as the Director of Rehabilitation and coming to the nursing home the system was different from where she was before. The Director of Rehabilitation stated she only knew of two residents that were PASRR positive until recently when she began getting invites to the interdisciplinary team meetings. The Director of Rehabilitation stated she also recently started being notified by the MDS Coordinators that there were 8 PASRR positive residents in the facility . The Director of Rehabilitation stated all PASRR residents were receiving services, but she needed to upload all the documents such as the signature pages from the physician. The Director of Rehabilitation stated over time she had uploaded the required PASRR documents into the portal, but they were disappearing, so she reached out to her regional help. According to the Director of Rehabilitation, she and her regional help contacted the help line of the portal and were told there was a glitch in the system which would not allow them up successfully upload into the portal . The Director of Rehabilitation stated the incident was not documented, and further stated eventually the glitch was fixed and she was able to upload. The Director of Rehabilitation stated at this time there was such a back log due to her having to get new physician signature pages to upload. The Director of Rehabilitation revealed for Resident #2 she was currently waiting on the physician to sign off on the services so that she could upload the form. The Director of Rehabilitation stated she was responsible for ensuring the NFSS form and other documents were uploaded in a timely manner. According to the Director of Rehabilitation, PASRR positive residents were not at risk because residents were provided services once they admit to the facility, if they were not covered by their insurance or PASRR the facility will pay to ensure services are continued, so there was never a gap in services. Record review of Resident #2's NFSS forms for Occupational, Physical and Speech therapies revealed as of 09/10/25 - NFSS Form from interdisciplinary meeting completed on 03/18/25 was not submitted within 30 calendar days of the IDT meeting. Interview on 09/10/25 at 11:25 AM with the Administrator revealed she could not recall the exact date she was notified by the PASRR Coordinator resident's NFSS document had not been uploaded within 20 business days of their last interdisciplinary team meetings. The Administrator stated she was told by the Director of Rehabilitation there was glitch in the system which would not allow documents to be uploaded in the portal. The Administrator stated there were several people involved to ensure the issues were resolved. According to the Administrator the Director of Rehabilitation was responsible for ensuring all required documents were uploaded to the portal within an adequate time frame, not doing so placed residents at risk of delay in services. 2. Record review of Resident #5's Nursing Home Comprehensive MDS, dated , 09/07/25, reflected he was a [AGE] year-old male with an original admission date of 04/12/23 and re-admission date of 03/26/25. Record review of the MDS also reflected diagnoses that included cerebral palsy (a group of conditions that affect movement and posture (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675028 If continuation sheet Page 12 of 20 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 675028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some caused by damage that occurs to the developing brain, most often before birth), scoliosis (side to side curve of the spine), and benign prostatic hyperplasia (nonmalignant growth of prostate tissue). Record review of Resident #5's Care Plan, dated 09/09/25, reflected: Focus: Resident has Mental Illness , ID, or DD and is PASRR positive Date initiated: 02/12/25 Goal: Resident will have the specialized services recommended by local authority per PASRR Specialized Services program as needed. Date initiated: 02/12/25 Revision 08/31/25 Target Date 08/31/25. Interventions: The LA will be invited Annually to the care plan meeting for review of Specialized Services. Date initiated: 02/12/25.Record review of Resident #5's initial IDT meeting revealed it was held on 04/23/25, and a customized wheelchair was recommended by the Habilitation Coordinator.Record review of Resident #5's PASRR evaluation on 04/23/25 revealed the resident was PASRR level II positive related to his diagnoses of development disability other than an intellectual disability that manifested before the age on 22. Interview with Resident #5 on 09/09/25 at 11:22 AM revealed interview was attempted. However, Resident #5 was unable to communicate verbally. Interview on 09/09/25 at 3:57 PM with the facility Social Services Director revealed she gets a calendar invite from the resident's case manager. The Social Services Director said that she could not recall if Resident #5 was eligible for specialized services. The Social Services Director stated that she made referrals for ancillary services for vision, dental, and podiatry. The Social Services Director said that she was not involved in any other part of the resident's PASRR or referral services. Interview on 09/10/25 at 10:30 AM with the MDS Coordinator revealed she was responsible for uploading the meeting notes into Simple. The MDS Coordinator stated there was a meeting on 04/24/25 that determined Resident #5 would be placed on physical and occupational therapy serviced as well as receive a customized wheelchair. The MDS Coordinator said that the Director of Rehabilitation was responsible for submitting the nursing facility specialized services forms after the meetings. Interview on 09/10/25 at 11:00 AM with the Director of Rehabilitation revealed she was responsible for submitting the nursing facility specialized services forms for Resident #5 for physical and occupational therapy as well as the customized wheelchair after the meeting on 04/23/25. The Director of Rehabilitation stated there was a period in which the forms in Simple would disappear after they were input. The Director of Rehabilitation said that she reached out to her regional leadership and asked for assistance with the issue, and they eventually reached out to the Simple information technology department to resolve the issue. The Director of Rehabilitation stated that Resident #5 still received physical and occupational services. The Director of Rehabilitation said that they attempted to set up an appointment with the third-party company for the customized wheelchair, but he did not state the date this was attempted. However, the company did not show up for the appointment, so they had to start the process over again. The Director of Rehabilitation revealed they are now waiting for another company to come and assess the resident for a customized wheelchair. The Director of Rehabilitation stated that after the 07/10/25 meeting, she submitted and received approval for the nursing facility specialized services form approved on 07/25/25 and on 08/01/25. The Director of Rehabilitation said that Resident #1 was only waiting on his customized wheelchair that would be molded to his contractures. The Director of Rehabilitation stated that the resident has a regular wheelchair. The Director of Rehabilitation said that she knew the nursing facility specialized services forms were supposed to be submitted within 20 days after the meeting date and that she was responsible for submitting them. The Director of Rehabilitation revealed if she did not submit the forms timely then the facility would be responsible for paying for the services. Interview on 09/10/25 at 12:05 PM with the Administrator revealed the facility had an issue with forms disappearing on the Simple website. The Administrator stated she was notified by the state that the form had not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675028 If continuation sheet Page 13 of 20 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 675028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete been uploaded into the state's system, so they attempted that same day on 06/20/25. The Administrator also stated that the Director of Rehabilitation's regional director assisted the Director of Rehabilitation by uploading the Simple forms and resolved the technical issue. The Administrator revealed it was the Director of Rehabilitation's responsibility to upload the forms in a timely manner because it created a risk of delay in care to residents when forms were not uploaded time. Record review of facility's PASRR Nursing Specialized Services Policy and Procedure, revised 03/06/19, reflected: Policy: It is the policy of Creative solutions in Healthcare facilities to ensure NFSS Forms are submitted timely and accurately. Procedure: .8. Therapy, CMWC DME or DME is notified ASAP after the IDT meeting. (You only have 3 days to enter PCSP Form after the PCSP meeting). 9. The facility only has 20 business days from the Date of the PCSP meeting to submit a completed and accurate NFSS Form. Event ID: Facility ID: 675028 If continuation sheet Page 14 of 20 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 675028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 2 of 5 residents (Resident #8 and Resident #9) reviewed for supervision. The facility failed to ensure adequate supervision was provided to prevent a physical altercation between Residents #8 and #9 on the facility's memory care unit on 06/17/25 and failed to ensure the nurse on the unit, RN K, had visual access to the residents to be able to intervene timely. Resident #9 punched Resident #8 approximately eight times in the face/head resulting in Resident #8 having an abrasion and swelling on the left side of his face. The noncompliance was identified as a past non-compliance. The Immediate Jeopardy (IJ) began on 06/17/25 and ended on 06/19/25. The facility had corrected the noncompliance before the abbreviated survey began. This failure placed residents at risk of harm and/or serious injury. Findings included: Record review of Resident #8's most recent Quarterly MDS Assessment, dated 04/06/25, reflected the resident was a [AGE] year-old male, who admitted to the facility on [DATE]. Resident #8's cognition was moderately impaired with a BIMS score of 6. The resident's diagnoses included: non-Alzheimer's dementia (various types of dementia), unspecified dementia, unspecified severity, with other behavioral disturbances, coronary artery disease (general decline in cognitive abilities that affect a person's ability to perform everyday activities) and high blood pressure. Resident #8's MDS indicated he had shown no signs of behavior or mood swings. Record review of Resident #8's undated care plan reflected the following care plans that had been developed:- Resident #8 had a history of trauma that may have a negative impact related to physical aggression from another resident. The care plan goals included: maintain resident's safety and integrity during post trauma episode, using appropriate interventions. The care plan interventions included consult with family regarding the resident's condition as appropriate. Identify situation/event/images that trigger recollections of the traumatic event and limit the resident's exposure to these as much as possible. These triggers could include physical aggression from others. - Resident #8 had delirium or an acute confusional episode related to change in condition. The care plan goal reflected: Resident will be free of signs and symptoms of delirium (changes in behavior, mood, cognitive function, communication, level of consciousness, restlessness. The care plan interventions included to consult with family and interdisciplinary team, review chart to establish baseline level of functioning. Educate resident/family/caregivers to observe for and report any signs or symptoms of delirium. Ensure fluid intake of at least 1500 cc /24 hours. - Resident #8's had potential to demonstrate physical behaviors Dementia, History of harm to other, poor impulse control. The care plan goals included: The resident will demonstrate effective coping skills. The care plan interventions included: analyze [sic] of key times, places, circumstances, triggers, and what deescalates behaviors and document. Assess and address for contributing sensory deficits. Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain. If resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately. Resident to be 1:1 for 24 hours, every 15minutes for 24 hours, every 30 minutes for 24 hours, every 1 hour for 24 hours, every 8 hours for 24 hours. When resident becomes agitated: intervene before agitation escalates; Guide away from the source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away; and approach later. - Resident #8 resided in the Secure Care Unit, related to diagnosis of dementia and risk for elopement. Disease Process, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675028 If continuation sheet Page 15 of 20 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 675028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Disoriented to place, Memory loss. Goal: Resident will not have feelings of isolation and will feel safe and secure in the care received while on the Secure Care Unit. Interventions included: Admit to Secure Care unit per physician orders, Engage resident in group activities and provide them with individualized meaningful projects that they will accomplish throughout the day, Involve resident in daily activities designed for Secure Care Unit, Monitor for S/S of depression, withdrawal from usual activities, Notify MD of any changes, Psych services per MD orders.Record review of Resident #8's progress notes written by RN K on 06/17/25 at 12:00 PM revealed Writer heard yelling, saw patients Resident #8 and Resident #9 hitting one another and rolling on the dry floor. RN K went out and grabbed Resident #8's arm to prevent him from hitting and telling him to let go of Resident #9's shirt. After he let go then I pulled him away. Resident #9 then sat on the couch. Resident #8 laid on the floor. Vitals were taken. Neuros taken. All withing normal limits. Resident #8 complaint of face hurting. Resident #9 complaint of right-hand hurting. RN K notified ADON C. RN K placed ice pack on Resident #8's left side of face and assisted him to chair. Record review of Resident #8's progress note Initial Skin Assessment written by ADON C on 06/17/25 at 12:30 PM revealed Skin Color: Normal; Temperature of skin: Warm; Bruise present: Yes. Location, measurements of bruising: left facial abrasion; Skin Tear Present: No; Abrasion present: Yes. Location, measurements of abrasion: left side facial abrasion; Laceration present: No; Surgical incision present: No; Rash present: No; Moisture Associated Skin Damage present: No; Pressure, venous, arterial, or diabetic ulcer present: No; Other skin findings: Left facial abrasion / swollen. Record review of Resident #8 progress note Transfer Notification written by ADON C on 06/17/25 at 1:00 PM revealed Resident #8 was transferred to a hospital on [DATE] 1:00 PM related to Unresponsive. This is intended to serve as notice of an emergency transfer. Record review of Resident #8's progress note Activity Note written by LVN L on 06/17/25 at 8:32 PM revealed resident returned from emergency room with no new orders. Resident remains alert and confused, resident at baseline. resident neuros restarted as per facility protocol. Resident assessed, resident noted with left facial swelling with bruising noted, abrasion to left lower leg. Physician notified of return new order to increase tramadol 50mg one po daily to bid. Resident's Responsible Party made aware of return, made aware of resident overall condition and any new findings and new orders. Responsible Party had no questions or concerns at this time. Record review of Resident #9's most recent Quarterly MDS (Minimum Data Set) Assessment, dated 05/22/25, reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #6 had BIMS of 06 indicating moderate cognitive impairment. Diagnosis included Unspecified Dementia (various types of dementia), Unspecified severity, without behavioral/psychotic/mood/anxiety disturbances (general decline in cognitive abilities that affect a person's ability to perform everyday activities). Depression (persistent feeling of sadness and loss of interest), and high blood pressure. Resident #'s MDS indicated he had shown mood signs of little interest or pleasure in doing things and feeling down, depressed, or hopeless with no signs of behaviors. Record review of Resident #9's care plan last revised 06/17/25 revealed Resident #9 had been identified as having Resident at risk to exhibit physical aggression. Goal: Resident to not have any episodes of physical aggression. Intervention include resident to remain 1:1 related to physical aggression. Care Plan revealed: Resident #9 has potential to demonstrate physical behaviors Anger, Dementia, Poor impulse control was put on by another resident and responded by pushing leading to altercation. Goal: The resident will demonstrate effective coping skills. Interventions included: 1:1 supervision prn physical aggression or other aggressive behavior. Analyze [sic] of key times, places, circumstances, triggers, and what de-escalates. Assess and address for contributing sensory deficits. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675028 If continuation sheet Page 16 of 20 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 675028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few positioning, pain etc. COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately. Secure care consult for behavior management. Send to emergency room for psychiatric evaluation as needed. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Care Plan revealed: Resident #9 resides in the Secure Care Unit, related to diagnosis of dementia (or related diagnosis) and risk for elopement. Goal: Resident will not have feelings of isolation and will feel safe and secure in the care received while on the Secure Care Unit. Interventions include: Admit to Secure Care unit per physician orders. Engage resident in group activities and provide them with individualized meaningful projects that they will accomplish throughout the day. Involve resident in daily activities designed for Secure Care Unit. Monitor for signs and symptoms of depression, withdrawal from usual activities. Notify physician of any changes. Psych services as doctor orders. Record review of Resident #'s progress note Neuro Assessment written by ADON C on 06/17/25 at 12:02 PM revealed the physician was notified of a negative change. Comments and/or new orders: Transfer to the hospital. Record review of Resident #9's progress note written by RN K on 06/17/25 at 12:11 PM revealed Writer heard yelling and saw Resident #8 and Resident #9 on the dry floor rolling and hitting one another. I held Resident #8 arm and told him to let go of Resident #9's shirt. After several minutes he let go and Resident #9 got up and sat on the couch. Resident #9 then went to his room and changed his shirt. Vital signs, neuros, blood sugar done. Resident #9 to be transferred to hospital. Record review of Resident #9's progress note written by Social Services Director on 0617/25 at 3:06 PM reflected: Social Services Director met with the resident to assess any trauma after an incident between he and another resident. Resident denies any trauma. Social Services Director did not observe any trauma symptoms or behaviors. Resident continues to state he feels safe in the facility and not fearful of the other resident. Resident will be transported to the hospital for further assessment. Observation of the facility's surveillance video dated 06/17/25 at 11:42 AM revealed the nurse office door was closed and both Resident #8 and Resident #9 were in the television room within feet of each other, Resident #8 stood between a female resident in her wheelchair sitting next to the exit door and a credenza in front the television wall. As Resident #9 headed towards the exit he passed Resident #8 and pushed him in the back. As Resident #8 stumbled a couple of feet he went after Resident #9 almost tripping over the wheelchair. Both residents stepped out of the camera, within seconds they returned back in the frame tussling at each other. Resident #9 began punching Resident #8 eight times in the face. This continued until they both fell onto the floor holding onto each other's shirts. At 11:43.25 the door opened, however, RN K did not exit the office to assist until 11:43.51, at this time she walked over to Resident #8 and placed her hand on his wrist. The video ended. Record review of the provider investigator report revealed on 06/17/25 at 11:45 AM Residents were in the secure unit living area when they began to have a verbal altercation. Resident #9 pushed Resident #8 in the back and then proceeded to punch Resident #8 in the face several times before both residents went to the ground and continued to hold each other by the clothing before Charge Nurse, RN K, separated residents. Resident #8 was sent to the emergency room for further evaluation due to facial swelling - no further injuries noted. Immediate discharge notice delivered to Resident #9 at hospital due to aggression and unable to be redirected during altercation. Staff interviews (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675028 If continuation sheet Page 17 of 20 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 675028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few completed. In-services regarding abuse/neglect, resident rights, how to deal with residents aggressive behavior, behavior management. Record review of hospital records for Resident #8 reflected on 06/17/25 Resident #8 presented with a fall after an assault at the nursing home. The resident was punched in the face at least 10 times per Emergency Medical Service. It reflected the resident was assaulted at 11:00 AM. The resident then walked to the dining room on his own, had lunch, fell, and was then unresponsive. Emergency Medical Service stated the resident was found down supine, no blood thinners, and the resident's blood sugar was 375. The hospital findings reflected Resident #8 had no fractures, no acute intracranial abnormality (no immediate or urgent issues detected in the brain), no acute osseous cervical spine abnormality (no severe bone issues). Record review of facility log 15 Minute Monitoring revealed Resident #9 was placed on 15-minute monitoring starting at 12:30 PM until he exited the building to hospital for further evaluation at 2:30 PM . Record review of RN K statement dated 06/17/25 I [RN K] was sitting in the office when [Resident #8 and Resident #9] were heard making a lot of commotion. I had the door partially open. As I began to open the door to see what was going on the I noticed the two residents were rolling on the floor. I felt I was in shock at what I was seeing and thinking to myself what was going on and what was I going to do? I then thought of separating the two of them. I tried to separate them, but it was hard. I did not think to yell for help. Record review of Employee Disciplinary Report dated 06/17/25 revealed Investigation Suspension: [RN K] will be placed on an investigatory suspension pending an investigation into allegations of failing to meet their job duty/responsibility expectations. Corrective plan of Action: Due to the allegations, [RN K] will be placed on unpaid investigatory suspension. [RN K] will remain on investigatory suspension until the investigation is completed into the above allegation. [RN K] will be notified when the investigation is completed. [RN K] may provide a written statement. Employee comments: I think I tried to remain calm during the action of the residents. Interview on 09/09/25 on 11:28 AM with CNA I revealed during the time of the incident she was in the shower room with another resident leaving RN on the floor and charting in the nurse office. CNA I stated when she finished in the shower she was informed there had been an altercation between Resident #8 and Resident #9. CNA I stated she saw Resident #8 after the fight and observed swelling on Resident #8's face while in the dining room, he ate well, however soon after lunch he became nonresponsive and was sent out to the hospital. Resident #9 was also sent to the hospital for evaluation and had not returned. According to CNA I, she was inserviced over resident-to-resident altercations, resident confrontations, ensure to separate residents immediately and report. CNA I stated not monitoring residents and separating immediately during an altercation placed residents at risk for injuries or hospitalization. Attempted interview on 09/09/25 at 1:30 PM with RN K was unsuccessful. Attempted interview on 09/09/25 at 1:32 PM with LVN L was unsuccessful. Interview on 09/09/25 at 2:25 PM with ADON C revealed on video, Resident #9 was offering Resident #8 a chair to sit but Resident #8 was spitting on Resident #9, as they passed each other Resident #9 pushed Resident #8. Resident #8 then turned and started hitting Resident #9, both residents ended up on the floor. ADON C stated RN K was in the office when she heard commotion and stepped out. ADON C stated RN K was slow to react to the commotion and in separating the residents. ADON C stated emergency serivces was called, Resident #9 was placed on one-on-one monitoring until he was sent to the hospital for evaluation due to his aggressive behavior, punching Resident #8 causing a scratch and swelling to the left side of Resident #8's face. According to ADON C Resident #8 was also placed on one-to-one monitoring, assessed and injuries cleaned, and started neuro checks. ADON C further stated after the altercation there were no further signs or symptoms of injury, after lunch RN K called her to say Resident #8 was unresponsive, emergency services was called to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675028 If continuation sheet Page 18 of 20 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 675028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few send him to the hospital. ADON C stated in-service trainings were completed over abuse and neglect and staff surveys to ensure staff were knowledgeable about what to do during resident-to-resident altercations. ADON C stated all staff including CNAs and Nurses were responsible for monitoring and engaging with residents, not reacting quickly to altercations placed residents at risk of harm. Interview on 09/10/25 at 11:32 AM with the DON revealed she was not in the facility during the time of the incident however when she returned she followed up on the incident. The DON stated she reviewed the video revealing both residents ended up on the floor hitting each other. The DON stated the video also revealed RN K in the nurse office with the door closed and her slow to respond to the altercation. The DON stated RN K was suspended immediately and terminated due to the evolvement of the incident. The DON stated she expected staff on the secure unit to be out in the open and engaged with residents, not behind closed doors. The DON stated resident safety is top priority, so getting residents separated during altercations are immediate and to follow up with assessments. The DON stated Resident #8 was placed one on one, and Resident #9 was sent to the hospital with an immediate discharge. The DON stated staff were provided in-service training on abuse, neglect, resident rights, residents with dementia and aggressive behavior, separate during altercations, and one to one and behavior management. The DON stated nurses were responsible for always having eyes on residents especially on the secure unit, along with the one or two aides on duty. The DON further stated not doing so placed residents at risk of their safety, someone could fall and hit their head and possibly die. Interview on 09/10/25 at 11:56 AM with the Administrator revealed she was notified by ADON C of resident-to-resident altercation on the memory care unit, upon return she was able to review the video which showed the altercation between Resident #8 and Resident #9. The Administrator stated Resident #9 was sent to the hospital for further evaluation and immediate discharge. The Administrator stated Resident #8 was placed on one-on-one monitoring and neuro checks, he had lunch with no further signs of injury or distress, until he started showing signs of being non-responsive and altered status. The Administrator stated Resident #8 was sent to the hospital by emergency medical services and returned with no findings or new orders. The Administrator stated upon review of the video it showed RN K was slow to respond to the altercation between the two residents, RN K was in the office behind closed door allowing residents altercation to last close to 2 minutes before she slowly exited the office to separate them. The Administrator stated the nurses should be out of the office as much as possible; both nurses and aides were responsible for always having eyes on residents. The Administrator further stated not having a clear sightline of residents placed them at risk of abuse and harm. The facility took the following actions to correct the non-compliance prior to the investigation: Record review of an in-service, dated 06/17/25, reflected 29 staff including nurses, CNAs, housekeepers, medication aide, Business Office Manager, dietary aides were provided with training on resident-to-resident altercations. The in-service training covered: abuse and neglect; resident rights; how to deal with residents with dementia and aggressive behaviors; immediately separating residents from physical or verbal altercations; placing the aggressor on one-to-one supervision for resident safety; and behavior management Record review of an in-service, dated 06/17/25, reflected 29 staff that included nurses, nurse's aides, housekeeping, medication aide, Business Office Manager, dietary aides were in-serviced regarding: Abuse/Neglect Policy Record review of Resident #8's 15 minute checks dated 06/17/25 revealed monitoring from 12:30 PM until 06/19/25. Record review of Resident #9's 15 minute checks dated 06/17/25 revealed monitoring on 06/17/25 12:30 PM until 06/17/25 12:30 PM. Record review of Resident #9's clinical records revealed Resident #9 was placed one-on-one supervision on 06/17/25 12:30 PM until 06/17/25 2:30 PM until he was sent to the hospital for further evaluation and issued (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675028 If continuation sheet Page 19 of 20 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 675028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete immediate discharge . Record review of Resident #8 and Resident #9's care plans were updated. Record review of Resident #8's clinical records revealed Resident #8 was assessed and transported to the emergency room for further evaluation with no findings or new orders. Record review of Resident #8's clinical records revealed Resident #8 was being monitored for behaviors throughout each shift upon his return from the hospital on [DATE] 8:30 PM until 06/19/25 at 6:00 PM until with no further signs of aggression or agitation. Record review of Staff Surveys were conducted on 06/17/25 - 06/18/25 by 24 staff over what signs and symptoms to look for when resident had a change in condition, how to respond when witnessed a resident-to-resident altercation, who do you report abuse/neglect allegations to? All with the understanding to immediately separate residents during resident-to-resident altercation and report to the nurse and the abuse coordinator which was the Administrator. Observation on 09/09/25 10:00 AM 09/10/25 4:00 PM throughout investigation revealed the door to the office on the memory care unit has been removed. Both nurse and aide were making constant rounds to visibly check on each resident on the unit. Staff were engaging with residents and not seen in the nurse's office. Interviews on 09/09/25 from 11:22 AM through 09/10/25 3:30 PM with MDS Coordinator, CNA A, LVN B, ADON C, ADON D, LVN E, MA F, LVN G, LVN H, CNA I, CNA J, Social Services Director, Director of Rehabilitation, DON, and the Administrator, Activity Director, Housekeeping Supervisor, The facility staff were able to verify education was provided to them. Facility staff were able to accurately summarize abuse and neglect, how to work with residents with behaviors, immediately separate residents in altercations and report. Facility staff stated they monitor residents throughout the shifts, if behaviors were identified staff stated they were trained to redirect residents or placed them on 1:1 or q15 checks depending on the behavior. Staff stated for residents who have had altercations or incidents they monitor closely, keep them separated to prevent any further incidents. Staff stated they provide activities to keep them engaged and provide snacks throughout the day. Staff stated upon shift change they will notify the incoming staff of any incidents or behaviors. On 09/10/25 at 3:30 PM, the Administrator and DON stated they were working with corporate to locate a policy on accident and hazards, supervision or quality of care; however, the policies were not provided prior to exit. The noncompliance was identified as PNC. The IJ began on 06/17/25 and ended on 06/19/25. The facility had corrected the noncompliance before the abbreviated survey began. Event ID: Facility ID: 675028 If continuation sheet Page 20 of 20