Inspection·May 24, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm consequences of that behavior, explain to the resident the acceptable expressions of sexuality based on the cognitive evaluation, listen/talk to the resident - see if they will tell you why they do the behavior, Psychiatric Services consult as needed, reinforce with staff that clear, firm limits are healthy and required when resident makes inappropriate gestures or statements, and report incidents of target behavior to charge nurse. Residents Affected - Few Record review of Resident #1's Transfer/Discharge Report dated 5/24/25 did not indicate a reason for discharge. Record review of Incidents by Incident Type log with a date range of 02/23/2025 - 05/23/2025, dated 05/23/2025 revealed no incidents that involved Resident #1. Interview with Administrator on 5/24/25 at 12 p.m. revealed she discharged Resident #1 because he was a registered sex offender and was getting too friendly in the dining room. The Administrator reported the friendliness was not directed toward any certain resident. She reported she never received any reports by other residents regarding Resident #1 being inappropriate toward other residents. When asked to explain what too friendly meant, the Administrator stated Resident #1 would say he wanted a girlfriend and he wanted to sit by females in the dining room. The Administrator stated Resident #1 was not given a 30-day notice. The Administrator stated she discharged planned the day prior with the social worker and family member over the phone. An attempt to interview the Social Worker was made on 5/24/25 at 10:23 a.m. and was unsuccessful. Interview with Director of Nursing on 5/24/25 at 11:40 a.m. revealed Resident #1 was discharged due to making comments about wanting a girlfriend and because of his history of being a sex offender. When asked if there was discharge planning completed, the Director of Nursing stated the discharge was discussed with the social worker a couple of days prior to the discharge date between the Administrator and Social Worker. She spoke to the family member the day he was discharged and shared their concerns about Resident #1 and that another facility had accepted Resident #1. The Director of Nursing stated the family member told her that facility was too far and agreed to take him home. The Director of Nursing stated a 30-day notice was not provided to Resident #1 or his family member. Interview with Resident #1's family member on 5/24/25 at 10:34 a.m. revealed he was called on 4/16/25 by the facility and was told to come pick up Resident #1 or the cops would be called to remove him. The family member stated he was told the reason for discharge was inappropriate behavior but was not told what the behavior was. The family member stated that was the only time he spoke to anyone at the facility. The family member stated the facility offered another facility, but it was too far. He stated he brought Resident #1 home and then Resident #1 went to another facility. Interview with Weekend Supervisor on 5/24/25 at 11:29 a.m. revealed she was not aware of why Resident #1 was discharged . She reported that she completed Resident #1's Recapitulation of Stay. She stated you need to know why the resident went home when completing the form; she stated she documented that why the resident was discharged on the form. The Weekend Supervisor stated she never saw Resident #1 being inappropriate toward other residents. Interview with RN A on 5/24/25 at 10:39 a.m. revealed she did not know why Resident #1 was discharged . She reported she never had concerns about his behavior. She stated Resident #1 usually stayed to himself in his room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2025 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 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with RN B on 5/24/25 at 11:18 a.m. revealed she did not know why Resident #1 was discharged . She reported she was not aware of any inappropriate behaviors by Resident #1. Interview with CNA A on 5/24/25 at 10:54 a.m. revealed she did not know why Resident #1 was discharged . She stated Resident #1 stayed mostly in his room and never saw him act inappropriately toward other residents. CNA A stated Resident #1 would sit at a table with all men at lunch. Interview with CNA B on 5/24/25 at 11:08 a.m. revealed she did not know why Resident #1 was discharged . She reported she never saw him being too friendly with other residents. She stated Resident #1 barely spoke. She stated she never saw him hanging out with other residents. Interview with Dietary Aide A on 5/24/25 at 10:59 a.m. revealed Resident #1 was a nice man and never saw him doing anything wrong to other residents. Interview with Dietary Aide B on 5/24/25 at 11:02 a.m. revealed he never saw Resident #1 being inappropriate toward other residents. Interview with Human Resources on 5/24/25 at 10:24 a.m. revealed she was familiar with Resident #1 and was not aware of any incidents of him being inappropriate toward other residents. She reported she was not aware of the reason for his discharge. Interview with 14 Residents selected for sample on 5/24/25 between 8:15 a.m. and 9:23 a.m. revealed no concerns for safety or inappropriate behaviors from other residents. Record review of the facility transfer and discharge policy on 5/24/25 was dated and revised on 6/2020. The policy stated To ensure that residents are transferred and discharged from the facility in compliance with state and federal laws and to provide complete, safe, and appropriate discharge planning and necessary information to the continuing provider. The Facility may transfer or discharge a resident for the following reasons. A. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility, B. The transfer or discharge is appropriate because the resident's health has improved sufficiently so that the resident no longer needs the services provided by the facility, C. The safety of individual in the facility is endangered by the resident's presence, D. The health of individuals in the facility would otherwise be endangered by the resident's presence, E. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid, or F. The facility ceases to operate. IV. Facility staff will provide the resident with reasonable advance notice of the transfer or discharge before it occurs. Unless exigent circumstances exist, the notice should be provided 30 days prior to the proposed date of transfer/discharge. Situations that may prevent 30 days' notice include: A. The resident poses a threat to the health or safety of other individuals at the facility, B. The resident's health improves sufficiently to allow for more immediate transfer/discharge, C. The resident is experiencing urgent medical needs, or D. The resident has not resided in the facility for 30 days. III. Prior to transfer/discharge, Social Services Staff or designee will provide the resident or responsible party with reasonable notice that the resident is going to be transferred or discharged . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 3 of 3