Health inspection·April 15, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she was trying to get her charger into the plug on the wall when she was shocked. Resident #1 said she took pictures immediately after it happened. Resident #1 said she was scared and thought she was going to catch on fire, and it was painful when she was shocked. Resident #1 said she had a burn on her thumb and finger that blistered up and was white. Resident #1 said she showed the SW and the nurse who came to her room that night her hand. Resident #1 said the SW saw the black mark and blisters on her finger and thumb. Resident #1 said the nurse who came to her room was mostly concerned about getting her to a different room so that she would be safe. Resident #1 said she was very anxious and when the nurse asked her if she wanted to go to the hospital she said no, she wanted to stay there at the facility. Resident #1 said she tried to show her hand to the nurse, but he just wanted to take her out of the room. Resident #1 said she asked for an incident report and was told there was not one completed. Resident #1 said she did talk to the Administrator about replacing her phone charger. Resident #1 said when the shocks came out of the plug she screamed, and CNA F came to the room and tried to turn the lights on but they did not work so she left to get the nurse. Resident #1 said she immediately took pictures right after it happened of her fingers that showed they were black. Resident #1 said later that day she took pictures of her thumb and finger that showed the white blisters. Interview on the phone on 04/09/25 at 1:40 PM with LVN A revealed he was called to Resident #1's room because she had no power to her bed. LVN A said he checked the plug to see if the bed was plugged in and he noted part of it was burnt. LVN A said he asked Resident #1 if she had touched the plug, and she told him she had. LVN A said he then checked Resident #1 for any injury. LVN A said Resident #1 did not have any injuries, had no complaints of pain, and she had declined to go to the hospital. Follow-up interview on the phone on 04/14/25 at 10:08 AM with LVN A revealed he only reported the electrical issue to the Administrator on 03/16/25. LVN A said since Resident #1 had no injuries, there was nothing else to report to the Administrator at that time. Interview on 04/14/25 at 1:21 PM with the previous Maintenance Director revealed he was in Resident #1's room on Friday (03/14/25) fixing her overbed lightbulbs and he saw that her plug cover behind her bed was fine and did not have any burn marks or anything on it. The previous Maintenance Director said he got a call on either the Saturday or Sunday afterwards from staff saying that there was a loss of power to a few of the rooms. The previous Maintenance Director said he took the plugs out and tested the wires but found no electricity, so he put it all back together and called the Electrician. The previous Maintenance Director said the Electrician came out on Monday (03/17/25) and replaced the plugs in the room and fixed the circuit breaker in the breaker box. The previous Maintenance Director said when he arrived to the facility on Sunday (03/16/25), he saw the plug cover on the floor and he was not sure how it got there. The previous Maintenance Director said from what he assumed, the plug was messed with in between Friday and Sunday or somehow the plug cover was taken off. The previous Maintenance Director said if the cover was taken off and exposed the inside of the plugs a little buzz or spark could happen. The previous Maintenance Director said he did not talk to Resident #1 or her nurse to see if the resident was affected. The previous Maintenance Director said before everything could be fixed, Resident #1 was moved to a different room. Interview on 04/14/25 at 12:28 PM with the Administrator revealed the previous Maintenance Director called her the day the incident happened with Resident #1 although she could not remember what day that was. The Administrator said the previous Maintenance Director told her that the plug was not working, and he was going to the facility, so she sent him the Electrician's number. The Administrator said Resident #1 was moved to a different room and nothing else was reported to her by the staff or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 2 of 18 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 675034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the resident. The Administrator said she did not know that any sparks occurred, she found that information out last week when an HHSC surveyor asked her about that. The Administrator said LVN A told them there was only an electrical malfunction and that Resident #1 heard something coming from the plug and there was no power to the outlet. The Administrator said she never knew Resident #1 had alleged she was electrocuted or sparked, and the resident did not tell anyone about what happened to her hand. The Administrator said she would have to look at the Provider Letter first to determine if a resident coming in contact with an electrical current was considered reportable or not. The Administrator said even if a resident sustained burns/marks/blisters she was still unsure if that was a reportable incident or not. The Administrator said all injuries to a resident should be reported to her. The Administrator said she would be responsible for reporting and if Resident #1 had said she was shocked or electrocuted by a plug in the facility, that should have been reported to her. The Administrator said all staff have been trained on what and when to report things to her. The Administrator said she expected all staff to follow their abuse/neglect policy. The Administrator said the purpose of reporting any allegation of abuse/neglect was to ensure a resident's safety and keep them safe from harm. The Administrator said any staff who had knowledge of an allegation of abuse/neglect should report it. The Administrator said she monitored the building 24/7 to ensure all instances or allegations of abuse/neglect were reported to her. The Administrator did not want to answer how a resident could be affected by an allegation not being reported to her immediately. Record review of the facility's policy revised 10/24/22, and titled Abuse Prevention and Prohibition Program reflected: IX. Reporting/Response .A. Facility Staff are Mandatory Reporters .B. Administrator, or his/her designee, as Abuse Coordinator .ii. Facility Staff will report known or suspected instances of abuse to the Administrator or his/her designee .D. The Facility will report allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of property, or other incidents that qualify as a crime . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 3 of 18 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 675034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 4 residents (Resident #1) reviewed for quality of care. Residents Affected - Few The facility failed to ensure Resident #1 received treatment after she sustained blisters to her fingers on 03/16/25 after coming into contact with an electrical outlet in her room that sparked and caused scorching on the outlet and surrounding wall area. The failure placed residents at risk of delay treatment. Findings included: Record review of Resident #1's admission Record, dated 04/14/2025, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and discharged on 03/18/25. Record review of Resident #1's admission MDS Assessment, dated 03/04/25, reflected she had a BIMS score of 15, indicating no cognitive impairment. Her active diagnoses included cerebrovascular accident (CVA), transient ischemic attack (TIA), or stroke, seizure disorder or epilepsy (a chronic brain condition characterized by recurrent seizures caused by abnormal electrical activity in the brain), anxiety disorder (a group of mental health conditions characterized by fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities once enjoyed). Record review of Resident #1's progress notes reflected: - On 03/16/25 at 3:50 AM, LVN A wrote: Resident reported to have had an electrical malfunction of her bed connection cable that plugs the bed to wall socket.Resident [sic] said she felt some spackling sounds from the cables as she placed her hand to plug the bed into the wall.This [sic] nurse and a cna in the facility noted that the socket plug on her bed was loose without any electrical power on bed to wall socket.Resident [sic] denied pain or discomfort at this time.Head [sic] to toe assessment on resident noted no skin tear or bruising at this time.vS [sic] 118/72,82,20,97.7.o2 sat 86% on room air.Resident [sic] prefered [sic] not to go for any evaluation at the hospital at this time.[Physician Z] [sic] call placed.Resident [sic] transferred to a different room on a different bed.Facility [sic] administrator and DON notified.Will [sic] continue to monitor. Record review of a picture provided by Resident #1, dated 03/16/25, and timed 3:45 AM reflected Resident #1's index finger with a black charred mark on the side of it. Record review of a picture provided by Resident #1, dated 03/16/25, and timed 3:33 AM reflected a bed frame against the wall, behind it was a plug on the wall that had a black cord plugged in to it and a metal cover was loose and hanging on the cord; there was a charred/burned mark to the top left of the cover and on the wall as well. Record review of a picture provided by Resident #1, dated 03/16/25, and timed 8:18 AM reflected Resident #1's hand; her thumb and finger were in view and had white blisters on them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 4 of 18 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 675034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of a picture provided by Resident #1, dated 03/16/25, and timed 8:40 AM reflected a bed frame against the wall, behind it was a plug on the wall that was exposed and did not have a plate covering it; the top portion of the top plug was black and charred as well as the wall right above the top plug on the left side. Record review of the incident/accident log from 01/14/25 to 04/14/25 revealed no incidents had occurred related to a resident being burned or shocked during this timeframe. There was also not an incident report for Resident #1 on 03/16/25 listed. Interview on the phone on 04/09/25 at 1:40 PM with LVN A revealed he was called to Resident #1's room because she had no power to her bed. LVN A said he checked the plug to see if the bed was plugged in and he noted part of it was burnt. LVN A said he asked Resident #1 if she had touched the plug, and she told him she had. LVN A said he then checked Resident #1 for any injury. LVN A said Resident #1 did not have any injuries, had no complaints of pain, and she had declined to go to the hospital. Interview on the phone on 04/11/25 at 4:54 PM with Resident #1 revealed around 3:33 AM on 03/16/25, she was trying to get her charger into the plug on the wall when she was shocked. Resident #1 said she took pictures immediately after it happened. Resident #1 said she was scared and thought she was going to catch on fire and it was painful when she was shocked. Resident #1 said she had a burn on her thumb and finger that blistered up and was white and now her hand was numb. Resident #1 said she showed the SW and the nurse who came to her room that night her hand. Resident #1 said the SW saw the black mark and blisters on her finger and thumb. Resident #1 said the nurse who came to her room was mostly concerned about getting her to a different room so that she would be safe. Resident #1 said she was very anxious and when the nurse asked her if she wanted to go to the hospital she said not, she wanted to stay there at the facility. Resident #1 said she tried to show her hand to the nurse, but he just wanted to take her out of the room. Resident #1 said she asked for an incident report and was told there was not one completed. Resident #1 said she did talk to the Administrator about replacing her phone charger. Resident #1 said when the shocks came out of the plug she screamed, and CNA F came to the room and tried to turn the lights on but they did not work so she left to get the nurse. Resident #1 said she immediately took pictures right after it happened of her fingers that showed they were black. Resident #1 said later that day she took pictures of her thumb and finger that showed the white blisters. Observations on 04/14/25 at 9:00 AM made on the 100 hallway of resident rooms, specifically looking at their plugs and sockets in their rooms revealed there were not any concerns noted. Record review of Resident #7's admission Record, dated 04/14/25, reflected she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #7's Annual MDS Assessment, dated 01/13/25, reflected she had a BIMS score of 15, indicating no cognitive impairment. Interview on 04/14/25 at 9:51 AM with Resident #7 revealed she was in the dining room sitting at a table waiting to play dominoes. Resident #7 wanted to stay where she was to talk and explained that she was friends with Resident #1 while she was at the facility. Resident #7 said she knew about Resident #1's burns because she told her about it. Resident #7 said Resident #1 told her she was plugging in her phone charger, and it electrocuted her. Resident #7 said Resident #1 told her that there were sparks that came out of the plug and burned her hand. Resident #7 said she saw Resident #1's hand (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 5 of 18 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 675034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few where there were blisters on the inside and outside of her hands, like on the top and bottom of it. Resident #7 said Resident #1's finger and thumb area looked raw, red, and pink which was strange because the resident had a darker skin complexion. Resident #7 said she also saw dots on her hand and thumb areas and one big dot on her thumb on Resident #1's hand. Resident #7 said Resident #1 told her she was also in a lot of pain. Resident #7 said she did not know she was supposed to talk to anyone about what happened but knew that Resident #1 had told staff, but they did not want to do anything about it. Record review of Resident #6's admission Record, dated 04/14/25, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #6's Quarterly MDS Assessment, dated 03/23/25, 03/23/25, reflected she had a BIMS score of 15, indicating no cognitive impairment. Interview on 04/14/25 at 1:38 PM with Resident #6 revealed she was in her bed scrolling on her phone. Resident #6 said she was roommates with Resident #1 before she left the facility. Resident #6 said one Sunday a few weeks ago at about 4:00 AM, she heard a big bang out in the hallway. Resident #6 said she had a TV in front of her and one to the side of her and both were still working but the light behind her had turned off. Resident #6 said the previous Maintenance Director was called that night to come and fix the issue. Resident #6 said she was partially blind so could not see anything in the room even if she wanted to if there were sparks or anything like that. Record review of Resident #2's admission Record, dated 04/14/25, reflected he was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #2's Annual MDS Assessment, dated 01/13/25, reflected he had a BIMS score of 14, indicating no cognitive impairment. Interview on 04/14/25 at 1:44 PM with Resident #2 revealed he was in his room laying in his bed. Resident #2 said he had plugs in his room that failed all the time because they were worn out. Resident #2 said he also saw a lot of sparks sometimes if a plug was loaded too much, for instance if he plugged in his refrigerator and TV to the same plug. Resident #2 said he saw the burns to Resident #1's hands and took pictures of her hand for her to have. Resident #2 said Resident #7 also saw the injuries to Resident #1's hands. Resident #2 said he saw a charred mark on the top of Resident #1's hand that was black. Resident #2 said he was not sure if Resident #1 had blisters or not but she told him that she plugged her phone charger in to the wall and got electrocuted. Attempted interview on the phone on 04/14/25 at 10:15 AM with CNA F was unsuccessful as there was no answer or call back prior to exit. Interview on 04/14/25 at 10:51 AM with the SW revealed he spoke with Resident #1 one day and she told him that there was a malfunction to the outlet on her wall. The SW said Resident #1 told him either her laptop or charger got messed up and she was shocked by the plug. The SW said Resident #1 showed her hand to him and said look what happened but he did not see anything and was not sure what date this was. Interview on 04/14/25 at 11:14 AM with the RN Supervisor revealed she heard about what happened to Resident #1. The RN Supervisor said she talked to Resident #1 who told her that when she plugged something in to her wall the plug sparked or something like that. The RN Supervisor said the previous (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 6 of 18 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 675034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Maintenance Director had been called to come to the building to fix the issue. The RN Supervisor said she looked at Resident #1's hands and did not see anything but was not sure what day this was. Interview on 04/14/25 at 11:28 AM with the ADON revealed she heard that Resident #1 had something going on and she checked with the nurse to make sure a full body assessment was done . The ADON said Resident #1 did not have any injuries that she was told about so there was no follow-up required. Interview on 04/14/25 at 11:33 AM with the DON revealed she was told on Monday morning (03/17/25) that there was an electrical issue in Resident #1's room and her bed was not working because of it. The DON said Resident #1 was moved to a different room where the bed did work in the meantime. The DON said Resident #1 was allegedly sparked by the electricity in the plug but was not injured. The DON said the nurse on duty (LVN A) completed a head-to-toe assessment on Resident #1 which had no findings. The DON said that plugs spark sometimes if a person pulls a plug out or jerks a plug out sometimes it will spark. The DON said she did not follow-up on Resident #1 to see if there was a delayed injury after the nurse did the initial assessment. The DON said if Resident #1 had been shocked or burned it would have shown an injury immediately, not hours later. The DON said if LVN A did an appropriate assessment on Resident #1 immediately after it happened and saw nothing then there was no need to follow-up. The DON said if an incident occurs that results in an injury, the nursing staff usually follow-up for at least three days. The DON said even with the allegation that sparks came from the plug/outlet that was not enough for nursing staff to follow-up for delayed injury after the initial assessment. Interview on the phone on 04/14/25 at 11:55 AM with the Electrician revealed it was not impossible that a person could have been shocked by the plug in the facility. The Electrician said typically in nursing facilities, the outlet receptacles are really worn out and need to be replaced because overtime they get worn out so when a resident goes to plug something into it, it's loose and not making a good connection. The Electrician said if the plug is loose and not making good contact, it's going to heat up and get hot. The Electrician said if someone were being careless when plugging something in and did not keep their fingers back and their fingers touched the prongs, they could get shocked in that circumstance. The Electrician said this could happen because there is a load being drawn to that plug from something else, meaning there is a current already there at the plug site. The Electrician said if the receptacle was worn out and the current was also there then the electricity would arch and if someone's fingers were too close to the metal prongs on the plug it could cause a spark or shock to that person. The Electrician compared it to unplugging a turned-on appliance, there will be a spark once it's trying to be removed from the plug in the wall. Interview on 04/14/25 at 12:28 PM with the Administrator revealed the previous Maintenance Director called her the day the incident happened with Resident #1 although she could not remember what day that was. The Administrator said the previous Maintenance Director told her that the plug was not working, and he was going to the facility so she sent him the Electrician's number. The Administrator said Resident #1 was moved to a different room and nothing else was reported to her by the staff or the resident. The Administrator said she did not know that any sparks occurred, she found that information out last week when an HHSC surveyor asked her about that. The Administrator said LVN A told them there was only an electrical malfunction and that Resident #1 heard something coming from the plug and there was no power to the outlet. The Administrator said she never knew Resident #1 had alleged she was electrocuted or sparked, and the resident did not tell anyone about what happened to her hand. The Administrator said, when staff completed a head-to-toe assessment on Resident #1 and saw nothing on her, what are they to do at that point?. The Administrator said, if the nurse who completed the assessment reported there were no injuries, and that there were no injuries to her hands, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 7 of 18 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 675034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 outlet was fixed, then there was no need for a follow-up and no reason to do anything else. Level of Harm - Minimal harm or potential for actual harm Interview on 04/14/25 at 1:21 PM with the previous Maintenance Director revealed he was in Resident #1's room on Friday (03/14/25) fixing her overbed lightbulbs and he saw that her plug cover behind her bed was fine and did not have any burn marks or anything on it. The previous Maintenance Director said he got a call on either the Saturday or Sunday afterwards from staff saying that there was a loss of power to a few of the rooms. The previous Maintenance Director said he took the plugs out and tested the wires but found no electricity, so he put it all back together and called the Electrician. The previous Maintenance Director said the Electrician came out on Monday (03/17/25) and replaced the plugs in the room and fixed the circuit breaker in the breaker box. The previous Maintenance Director said when he arrived to the facility on Sunday (03/16/25), he saw the plug cover on the floor and he was not sure how it got there. The previous Maintenance Director said from what he assumed, the plug was messed with in between Friday and Sunday or somehow the plug cover was taken off. The previous Maintenance Director said if the cover was taken off and exposed the inside of the plugs a little buzz or spark could happen. The previous Maintenance Director said he did not talk to Resident #1 or her nurse to see if the resident was affected. The previous Maintenance Director said before everything could be fixed, Resident #1 was moved to a different room. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 8 of 18 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 675034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety 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 observations, interviews, and record reviews the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 3 residents (Resident #1) reviewed for accidents. Residents Affected - Few The facility failed to ensure Resident #1 was free from accidents/hazards on 03/16/25 when she was shocked after plugging in her phone charger to the wall socket, that resulted in burns to her fingers and hand. An IJ was identified on 04/14/25. The IJ template was provided to the facility on [DATE] at 4:03 PM. While the IJ was removed on 04/15/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could expose residents to risk of injury or death from electrical shock. Findings included: Record review of Resident #1's admission Record, dated 04/14/2025, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and discharged on 03/18/25. Record review of Resident #1's admission MDS Assessment, dated 03/04/25, reflected she had a BIMS score of 15, indicating no cognitive impairment. Her active diagnoses included cerebrovascular accident (CVA), transient ischemic attack (TIA), or stroke, seizure disorder or epilepsy (a chronic brain condition characterized by recurrent seizures caused by abnormal electrical activity in the brain), anxiety disorder (a group of mental health conditions characterized by fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities once enjoyed). Record review of Resident #1's progress notes reflected: -On 03/16/25 at 3:50 AM, LVN A wrote: Resident reported to have had an electrical malfunction of her bed connection cable that plugs the bed to wall socket.Resident [sic] said she felt some spackling sounds from the cables as she placed her hand to plug the bed into the wall.This [sic] nurse and a cna in the facility noted that the socket plug on her bed was loose without any electrical power on bed to wall socket.Resident [sic] denied pain or discomfort at this time.Head [sic] to toe assessment on resident noted no skin tear or bruising at this time.vS [sic] 118/72,82,20,97.7.o2 sat 86% on room air.Resident [sic] prefered [sic] not to go for any evaluation at the hospital at this time.[Physician Z] [sic] call placed.Resident [sic] transferred to a different room on a different bed.Facility [sic] administrator and DON notified.Will [sic] continue to monitor. Record review of a picture provided by Resident #1, dated 03/16/25, and timed 3:45 AM reflected Resident #1's index finger with a black charred mark on the side of it. Record review of a picture provided by Resident #1, dated 03/16/25, and timed 3:33 AM reflected a bed frame against the wall, behind it was a plug on the wall that had a black cord plugged in to it and a metal cover was loose and hanging on the cord; there was a charred/burned mark to the top left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 9 of 18 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 675034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 of the cover and on the wall as well. Level of Harm - Immediate jeopardy to resident health or safety Record review of a picture provided by Resident #1, dated 03/16/25, and timed 8:18 AM reflected Resident #1's hand; her thumb and finger were in view and had white blisters on them. Residents Affected - Few Record review of a picture provided by Resident #1, dated 03/16/25, and timed 8:40 AM reflected a bed frame against the wall, behind it was a plug on the wall that was exposed and did not have a plate covering it; the top portion of the top plug was black and charred as well as the wall right above the top plug on the left side. Record review of the incident/accident log from 01/14/25 to 04/14/25 revealed no incidents had occurred related to a resident being burned or shocked during this timeframe. There was also not an incident report for Resident #1 on 03/16/25 listed. Record review of a Work Order , created 03/16/25 at 11:05 AM reflected the following: Plug in [Resident #1's room number] behind bed not working .Notes: Replaced plugs and breaker .Priority: Critical Category: Electrical .Comments: Resident removed plate cover when plugging phone in to receptacle it popped the breaker I have replaced the plug but still no power coming to any of the outlets or next room over. [sic]. Record review of an invoice from the Electrician, dated 03/17/25, reflected the following description: .Trouble Shoot Loss of Power To Three Resident Rooms. Found Severed Hot Wire At Outlet Box. Found Defective Circuit Breaker in Panel. Repaired Wire At Outlet Box. Replaced Defective Circuit Breaker With Spare Circuit Breaker Not Being Used. Replaced 20A Duplex Receptacles and Plates . Interview on the phone on 04/09/25 at 1:40 PM with LVN A revealed he was called to Resident #1's room because she had no power to her bed. LVN A said he checked the plug to see if the bed was plugged in and he noted part of it was burnt. LVN A said he asked Resident #1 if she had touched th e plug, and she told him she had. LVN A said he then checked Resident #1 for any injury. LVN A said Resident #1 did not have any injuries, had no complaints of pain, and she had declined to go to the hospital. Interview on the phone on 04/11/25 at 4:54 PM with Resident #1 revealed around 3:33 AM on 03/16/25, she was trying to get her charger into the plug on the wall when she was shocked. Resident #1 said she took pictures immediately after it happened. Resident #1 said she was scared and thought she was going to catch on fire, and it was painful when she was shocked. Resident #1 said she had a burn on her thumb and finger that blistered up and was white. Resident #1 said she showed the SW and the nurse who came to her room that night her hand. Resident #1 said the SW saw the black mark and blisters on her finger and thumb. Resident #1 said the nurse who came to her room was mostly concerned about getting her to a different room so that she would be safe. Resident #1 said she was very anxious and when the nurse asked her if she wanted to go to the hospital she said no, she wanted to stay there at the facility. Resident #1 said she tried to show her hand to the nurse, but he just wanted to take her out of the room. Resident #1 said she asked for an incident report and was told there was not one completed. Resident #1 said she did talk to the Administrator about replacing her phone charger. Resident #1 said when the shocks came out of the plug she screamed, and CNA F came to the room and tried to turn the lights on but they did not work so she left to get the nurse. Resident #1 said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 10 of 18 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 675034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few she immediately took pictures right after it happened of her fingers that showed they were black. Resident #1 said later that day she took pictures of her thumb and finger that showed the white blisters. Observations on 04/14/25 at 9:00 AM made on the 100 hallway of resident rooms, specifically looking at their plugs and sockets in their rooms revealed there were not any concerns noted. Record review of Resident #7's admission Record, dated 04/14/25, reflected she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #7's Annual MDS Assessment, dated 01/13/25, reflected she had a BIMS score of 15, indicating no cognitive impairment. Interview on 04/14/25 at 9:51 AM with Resident #7 revealed she was in the dining room sitting at a table waiting to play dominoes. Resident #7 wanted to stay where she was to talk and explained that she was friends with Resident #1 while she was at the facility. Resident #7 said she knew about Resident #1's burns because she told her about it. Resident #7 said Resident #1 told her she was plugging in her phone charger, and it electrocuted her. Resident #7 said Resident #1 told her that there were sparks that came out of the plug and burned her hand. Resident #7 said she saw Resident #1's hand where there were blisters on the inside and outside of her hands, like on the top and bottom of it. Resident #7 said Resident #1's finger and thumb area looked raw, red, and pink which was strange because the resident had a darker skin complexion. Resident #7 said she also saw dots on her hand and thumb areas and one big dot on her thumb on Resident #1's hand. Resident #7 said Resident #1 told her she was also in a lot of pain. Resident #7 said she did not know she was supposed to talk to anyone about what happened but knew that Resident #1 had told staff but they did not want to do anything about it. Record review of Resident #6's admission Record, dated 04/14/25, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #6's Quarterly MDS Assessment, dated 03/23/25, 03/23/25, reflected she had a BIMS score of 15, indicating no cognitive impairment. Interview on 04/14/25 at 1:38 PM with Resident #6 she said she was roommates with Resident #1 before she left the facility. Resident #6 said one Sunday a few weeks ago at about 4:00 AM, she heard a big bang out in the hallway. Resident #6 said she had a TV in front of her and one to the side of her and both were still working but the light behind her had turned off. Resident #6 said the previous Maintenance Director was called that night to come and fix the issue. Resident #6 said she was partially blind so could not see anything in the room even if she wanted to if there were sparks or anything like that. Record review of Resident #2's admission Record, dated 04/14/25, reflected he was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #2's Annual MDS Assessment, dated 01/13/25, reflected he had a BIMS score of 14, indicating no cognitive impairment. Interview on 04/14/25 at 1:44 PM with Resident #2 he said he had plugs in his room that failed all the time because they were worn out. Resident #2 said he also saw a lot of sparks sometimes if a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 11 of 18 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 675034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few plug was loaded too much, for instance if he plugged in his refrigerator and TV to the same plug. Resident #2 said he saw the burns to Resident #1's hands and took pictures of her hand for her to have. Resident #2 said Resident #7 also saw the injuries to Resident #1's hands. Resident #2 said he saw a charred mark on the top of Resident #1's hand that was black. Resident #2 said he was not sure if Resident #1 had blisters or not but she told him that she plugged her phone charger in to the wall and got electrocuted. Attempted interview on the phone on 04/14/25 at 10:15 AM with CNA F was unsuccessful as there was no answer or call back prior to exit. Interview on 04/14/25 at 10:51 AM with the SW revealed he spoke with Resident #1 one day and she told him that there was a malfunction to the outlet on her wall. The SW said Resident #1 told him either her laptop or charger got messed up and she was shocked by the plug. The SW said Resident #1 showed her hand to him and said look what happened but he did not see anything. Interview on 04/14/25 at 11:00 AM with the Maintenance Director revealed he had only been in the building for three days now. The Maintenance Director said he was not aware of any issues with any electrical outlets in any of the rooms. Interview on 04/14/25 at 11:14 AM with the RN Supervisor revealed she heard about what happened to Resident #1. The RN Supervisor said she talked to Resident #1 who told her that when she plugged something into her wall the plug sparked or something like that. The RN Supervisor said the previous Maintenance Director had been called to come to the building to fix the issue. The RN Supervisor said she looked at Resident #1's hands and did not see anything but was not sure what day this was. The RN Supervisor said this happened a few weeks ago but could not give a specific date. Interview on 04/14/25 at 11:33 AM with the DON revealed she was told on Monday morning (03/17/25) that there was an electrical issue in Resident #1's room and her bed was not working because of it. The DON said Resident #1 was moved to a different room where the bed did work in the meantime. The DON said Resident #1 was allegedly sparked by the electricity in the plug but was not injured. The DON said the nurse on duty (LVN A) completed a head-to-toe assessment on Resident #1 which had no findings. The DON said that plugs spark sometimes if a person pulls a plug out or jerks a plug out sometimes it will spark. Interview on the phone on 04/14/25 at 11:55 AM with the Electrician revealed it was not impossible that a person could have been shocked by the plug in the facility. The Electrician said typically in nursing facilities, the outlet receptacles were really worn out and need to be replaced because overtime they get worn out so when a resident goes to plug something in to it, it's loose and not making a good connection. The Electrician said if the plug was loose and not making good contact, it's going to heat up and get hot. The Electrician said if someone were being careless when plugging something in and did not keep their fingers back and their fingers touched the prongs, they could get shocked in that circumstance. The Electrician said this could happen because there was a load being drawn to that plug from something else, meaning there was a current already there at the plug site. The Electrician said if the receptacle was worn out and the current was also there then the electricity would arch and if someone's fingers were too close to the metal prongs on the plug it could cause a spark or shock to that person. The Electrician compared it to unplugging a turned-on appliance, there will be a spark once it's trying to be removed from the plug in the wall. Interview on 04/14/25 at 12:28 PM with the Administrator revealed the previous Maintenance Director (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 12 of 18 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 675034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few called her the day the incident happened with Resident #1 although she could not remember what day that was. The Administrator said the previous Maintenance Director told her that the plug was not working, and he was going to the facility, so she sent him the Electrician's number. The Administrator said Resident #1 was moved to a different room and nothing else was reported to her by the staff or the resident. The Administrator said she did not know that any sparks occurred, she found that information out last week when an HHSC surveyor asked her about that. The Administrator said LVN A told them there was only an electrical malfunction and that Resident #1 heard something coming from the plug and there was no power to the outlet. The Administrator said she never knew Resident #1 had alleged she was electrocuted or sparked, and the resident did not tell anyone about what happened to her hand. The Administrator said she also knew that Resident #1's phone charger stopped working and she wanted a new one but she discharged before the facility could replace it. The Administrator said the facility did not provide any in-services to the staff after the incident occurred because it was simply a maintenance issue. The Administrator said the facility was not monitoring the plugs in resident's rooms because there was not a reason to do so. The Administrator said the Maintenance Director just started a few days ago and was brand new so he did not know anything about Resident #1 or the incident. The Administrator said her expectation was that all residents were kept safe and free from any accident or hazard in the facility. Interview on 04/14/25 at 1:21 PM with the previous Maintenance Director revealed he was in Resident #1's room on Friday (03/14/25) fixing her overbed lightbulbs and he saw that her plug cover behind her bed was fine and did not have any burn marks or anything on it. The previous Maintenance Director said he got a call on either the Saturday or Sunday afterwards from staff saying that there was a loss of power to a few of the rooms. The previous Maintenance Director said he took the plugs out and tested the wires but found no electricity, so he put it all back together and called the Electrician. The previous Maintenance Director said the Electrician came out on Monday (03/17/25) and replaced the plugs in the room and fixed the circuit breaker in the breaker box. The previous Maintenance Director said when he arrived to the facility on Sunday (03/16/25), he saw the plug cover on the floor and he was not sure how it got there. The previous Maintenance Director said from what he assumed, the plug was messed with in between Friday and Sunday or somehow the plug cover was taken off. The previous Maintenance Director said if the cover was taken off and exposed the inside of the plugs a little buzz or spark could happen. The previous Maintenance Director said he did not talk to Resident #1 or her nurse to see if the resident was affected. The previous Maintenance Director said before everything could be fixed, Resident #1 was moved to a different room. Interview on 04/14/25 at 2:00 PM with the Administrator revealed the facility has not had any other electrical issues in the building since 03/01/25, except for what happened on 03/16/25. Interview on 04/14/25 at 3:20 PM with the Administrator revealed the facility did not have a policy that addressed incidents or accidents specifically. An IJ was identified on 04/14/25. The IJ template was provided to the the Administrator on 04/14/25 at 4:03 PM. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 04/15/25 at 7:30 AM and reflected the following: Date: 04/14/2025 PLAN OF REMOVAL (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 13 of 18 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 675034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 FOR Level of Harm - Immediate jeopardy to resident health or safety IMMEDIATE JEOPARDY Residents Affected - Few Summary of Details which lead to outcomes. To Whom it may concern,

F689 On 4/14/2025 during a P1re- survey [sic] at [Facility Name] at [Facility Address], HHSC surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The facility allegedly failed to ensure Resident #1 was free from accidents/ hazards. The notification of the alleged immediate jeopardy states as follows: The facility failed to keep all residents safe from accidents/hazards when resident # 1 [sic] was allegedly shocked after plugging in her phone charger to the wall outlet on 3/16/25 in her room. Resident #1 sustained a burn mark and blister from the incident. Identify residents who could be affected. All residents have the potential to be affected. Identify responsible staff/ what action taken. All Staff in serviced on the event of any electrical issue or any other hazard, they will immediately place the issue in the maintenance log and follow with phone call to administrator. With completion date of 4/14/25. All outlets in resident rooms checked by maintenance director to ensure that they are in working order and do not present a hazard. Completion date of 4/14/25. All staff in-service [sic] on prevention of accidents, incidents and hazards. Completion date of 4/14/2025. In-Service conducted. All Staff in serviced on the event of any electrical issue or any other hazard, they will immediately place the issue in the maintenance log and follow with phone call to administrator. With completion date of 4/14/25. All staff in-service [sic] on prevention of accidents, incidents and hazards. Completion date of 4/14/2025. Implementation of Changes All Staff in serviced on the event of any electrical issue or any other hazard, they will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 14 of 18 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 675034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 immediately place the issue in the maintenance log and follow with phone call to administrator. With completion date of 4/14/25. Level of Harm - Immediate jeopardy to resident health or safety All outlets in resident rooms checked by maintenance director to ensure that they are in working order and do not present a hazard. Completion date of 4/14/25. Residents Affected - Few All staff in-service [sic] on prevention of accidents, incidents and hazards. Completion date of 4/14/2025. 6 resident rooms per week x 4 weeks will be randomly audited to ensure electrical outlets are in working order. The changes were started by the Administrator. The changes were implemented effective on 4/142025 [sic] and training was completed on 4/142025. [sic] Staff will not be allowed to work until they have been fully re-educated. All new hires will be educated on completing maintenance log to report any electrical issues or any other hazard with follow up call to administrator. Prevention of accident and incidents and hazards. [sic] Monitoring The Administrator/Designee will be responsible for monitoring the implementation and effectiveness of in-service on 4/14/25. The Administrator/Regional director of Operations [sic]/Maintenance director/designee will check 6 rooms weekly to ensure outlets are in working order weekly x4 weeks, then monthly thereafter and report any adverse finding during QAPI. The Administrator/Maintenance director/designee will check maintenance log daily to check for any new risk/ electoral issues and report any adverse findings during QAPI. [sic] Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 4/14/2025 and conducted an Ad HOC QAPI regarding ensuring all resident room outlets were checked to ensure working and not a hazard and all staff educated on accident/incident/hazard prevention, and all staff educated on reporting any electrical issues or other hazards. The Medical Director was notified about the immediate Jeopardy on 4/14/2025, the Plan of removal was reviewed and accepted by Medical Director. Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, to review the plan of removal on 4/14/2025. Who is responsible for the implementation of the process? The Administrator will be responsible for the implementation of New Process. The New Process/ system was started on 4/14/2025. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 15 of 18 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 675034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Please accept this letter as our plan of removal for the determination of Immediate Jeopardy verbally issued on 4/14/2025. Monitoring of the facility's Plan of Removal included the following: Interviews with the following staff from 04/15/25 at 9:00 AM to 3:01 PM, both in person and by phone, who worked all shifts and days of the week revealed they had been in-serviced to immediately report any electrical issues to the Administrator by phone, log the information into the Maintenance Logbook, and knew to report any accident/hazard/incident to the Administrator immediately: RN G, CNA H, CNA I, the Maintenance Director, LVN C, the ADON, RN J, CNA B, CNA D, CNA K, CNA L, the Dish Washer, LVN M, the Dietary Aide, the COTA, CNA N, LVN O, CNA P, MA Q, MA R, LVN S, CNA T, CNA U, CNA V, CNA W, CNA X, LVN Y, CNA BB, CNA CC, LVN AA, CNA DD, MA EE, the DON, and the Administrator. Record review of an in-service sign in sheet, dated 04/14/25, revealed 62 total staff had been in-serviced regarding Hazard/Electrical Issues. Record review of an in-service sign-in sheet, dated 04/14/25, revealed 63 total staff had been in-serviced regarding Prevention of Accidents and Incidents and Hazards. Record review of an in-service sign-in sheet, dated 04/14/25, revealed the ADON and DON had been in-serviced regarding Accident and Incident Follow-up and care x72 hrs. Record review of an AD Hoc Quality Assurance and Performance Improvement Plan was held on 04/14/25. Record review of a census sheet, dated 04/14/25, reflected the Maintenance Director's initials next to each room acknowledging that he had checked each room's electrical plugs to ensure they were working and there were no hazards to the residents. An IJ was identified on 04/14/25. The IJ template was provided to the facility on [DATE] at 4:03 PM. While the IJ was removed on 04/15/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 16 of 18 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 675034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pests for 1 of 8 residents (Resident #1) reviewed for pest control. Residents Affected - Few The facility failed to prevent pests from entering the facility. On 05/28/25, Resident #1 was found in bed with ants (breed/type unknown) on his body, and he had been bitten multiple times on his torso, arms, and legs. This failure placed residents at risk of physical harm from ant or other pest bites. Findings included: Record review of Resident #1's MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility 04/09/25. His diagnoses included stroke, hemiplegia (paralysis of one side of the body), anoxic brain damage (when the brain is deprived of oxygen, leading to damage brain cells) and bell's palsy (a condition that causes temporary weakness or paralysis of the muscles on one side of the face). Resident #1 had a BIMS of 0 indicating his cognition was severely impaired. The MDS further reflected the resident required substantial/maximal assistance (helper does more than half of the effort) for all ADLs. Record review of Resident #1's care plan revised on 05/19/25 reflected the resident had an ADLs self-care performance deficit related to confusion, limited mobility, and anoxic brain damage. Interventions included the resident would require assistance with ADLs. Record review of Resident #1's progress notes dated 05/28/25 at 6:23 AM documented by RN A reflected the following: Summoned by the nurse aide that there's ants in the resident bed, arrived at the resident room noted ants on the bed and on resident's gown, resident denies being in pain at this time. Moved the resident to his recliner, head to toe assessment noted, no ant bites noted at this time, denies being in pain, no sign of discomfort noted, bath given and transferred temporarily to [Room], Management and RP notified, closely monitoring for any changes. Further progress notes reflected the following: - 05/28/25 at 8:18 AM - Resident noted to have ant bites to left shoulder and upper back, [Doctor] notified with order received to hydrocortisone cream each shift. - 05/29/25 - Redness remains on shoulder and upper back, denies any pain or itching, No signs or symptoms of infection noted . - 05/30/25 - Resident's area of possible bites from ants are fading, redness less, denies any itching at this time. Record review of Resident #1's physician orders for May 2025 reflected Hydrocortisone External Cream 2.5% was orders and instructed to apply to left shoulder topically every shift for ant bites for 7 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 17 of 18 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 675034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Record review of the pest control log for the following dates reflected: Level of Harm - Minimal harm or potential for actual harm - 05/28/25 - inspected and treated room [ROOM NUMBER] and 309 for ants - 06/02/25 - replaced and treated facility for roaches and ants on the exterior Residents Affected - Few - 06/09/25 - treated for ants inside and out. Attempts to contact RN A, CNA D, and CNA E, who worked at the time of the incident, on 06/10/25 were unsuccessful. Observation and interview on 06/10/25 at 1:01 PM revealed Resident #1 was in bed awake. The resident denied pain and was unable to answer if he had been bitten by any ants. Resident #1's skin was observed with CNA F, and there were no signs of ant bites on the residents' shoulders and/or upper back. Observation on 06/10/25 from 12:56 PM through 1:27 PM of Resident #1's room and six other rooms on that hall revealed there was no evidence of ants in the rooms of the hallway. Interview on 06/10/25 at 2:12 PM, LVN B revealed she worked with Resident #1 on the 2:00 PM-10:00 PM shift the day of the incident (05/28/25). She stated she observed a few ants bites on the resident's shoulder only, and they were gone within a couple of days after that. LVN B said that during those two days, they were treating the ant bites with cream. Interview on 06/10/25 at 2:20 PM, LVN C revealed she worked with Resident #1 on the morning shift, a few hours after the incident (05/28/25) with the ant bite. She stated she had only noted a small rash on the resident's upper shoulder. LVN C said the resident was not complaining of any discomfort and once they started to treat the ant bites with cream, the ant bites quickly faded. Interview on 06/10/25 at 2:58 PM, the ADON revealed she was aware a resident had been bitten by ants, but she was not aware if had been Resident #1; therefore, she did not know the details of the incident. Interview on 06/10/25 at 3:22 PM, the DON revealed she had been told there were ants in Resident #1's room but was not told he had been bitten. The DON said the resident was moved to another room, bathed, and pest control had been called to treat the room/facility. Record review of the facility's Pest Control policy, revised on August 2020, reflected the following: Purpose To ensure the Facility if free of insects, rodents, and other pests that could compromise the health, safety, and comfort of residents, Facility Staff, and visitors. Policy The Facility maintains an ongoing pest control program to ensure the building and grounds are kept free of insects, rodents, and other pests FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 18 of 18