Inspection·July 25, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some non-Alzheimer's dementia (a range of neurodegenerative and other disorders that cause cognitive decline, distinct from Alzheimer's disease), anxiety disorder, and depression. Resident #13's MDS also reflected a BIMS score of 4 (meaning severe cognitive impairment). Resident #13's MDS also reflected Resident #13 required assistance and supervision for ADLs. Record review of Resident #13's Care Plan dated 02/20/25 revealed Resident #13 was dependent on staff for activities, cognitive stimulation, social interaction. Goal included Resident #13 will maintain involvement in cognitive stimulation, social activities as desired. Interventions included Assure that the activities Resident #13 was attending are: Compatible with physical and mental capabilities; Compatible with known interests and preferences; Adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation), compatible with individual needs and abilities and age appropriate. Resident #13 had adjustment issues to admission. Goal included to maintain the ability to seek social contact and stimulation. Interventions included encourage ongoing family involvement. Invite Resident #13's family to attend special events, activities, and meals. Encourage Resident #13 to participate in conversation with staff, other residents daily. Introduce Resident #13 to residents with similar background, interests, and encourage/facilitate interaction. Observation and interview on 07/22/25 at 11:53 AM with Resident #13 revealed he was in the small television room with other residents watching television. Resident #13 stated that he was doing ok, he liked to watch television, and that he felt safe to live in the facility. Resident #13 then got up and walked into another resident's room and shut the door.Interview on 07/22/25 at 1:16 PM with Resident #13's Responsible Party revealed that Resident #13 enjoyed watching television. The Responsible Party stated the family brought a television to the facility 5 months ago for Resident #13's room, however it was currently sitting behind the nursing station. The Responsible Party stated, Maintenance would not let me hang it up, but they have not either, they don't do anything that you ask. Observation on 07/22/25 at 1:30 PM revealed Resident #13 did not have a television in his room. Interview on 07/24/2025 11:23 AM with CNA F revealed she noted a television behind the nursing station. However, it had been there for so long, she did not recall who it belonged to or why it was back there. CNA F stated Resident #13 did wander but was easily redirected to the television room or with a snack. CNA F stated when there was a maintenance issue, she reported to the nurse, and the nurse would report to the maintenance department. CNA F reported that there was no risk to Resident #13 for not having his television in his room because there was a television in the living area. Observation and interview on 07/24/2025 11:33 AM with LVN G revealed she was aware of the television behind the nurse station. Observed a box pulled out from nursing station. LVN G indicated the box was the television. LVN G stated the box had been back there so long, she had forgotten it was there. LVN G stated the family brought in the television several months ago and asked the Maintenance Department to hang the television in Resident #13's room. LVN G stated she reminded the Maintenance Director several times and his response would be I got it, I will be back to do it, or No Problem but it was never done. LVN G stated the facility now had a new Maintenance Director, and she could not recall if she had requested with the new Maintenance Director to have the television hung. LVN G stated she was responsible for requesting for the television to be hung in Resident #13's room. LVN G stated she had not reported to anyone other than the previous the Maintenance Director. LVN G stated not having the television hung for Resident #13 placed him at risk of not being comfortable in his room, wandering, and his personal property being lost or stolen. Interview on 07/24/25 at 3:28 PM with the DON revealed if there was something the Maintenance Department needed to handle the nurse or aide should report that need to the Maintenance Department. The DON stated she had only worked in the facility for two weeks, and was not completely sure how the requests (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 2 of 13 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 07/25/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete were done or tracked. The DON stated if a request was made to hang up a television, she would expect it to be hung within a reasonable amount of time, by the Maintenance Department. The DON stated not hanging up the television within a reasonable amount of time, or at all, placed Resident #13 at risk for lack of activity or entertainment in the comfort of his own room. Interview on 07/24/25 at 3:55 PM with the Maintenance Director revealed he was new on staff to the facility (2 months). The Maintenance Director stated the facility used a phone app to enter maintenance requests or they would verbally inform him of any maintenance concerns. The Maintenance Director stated he was not able to review any past requests, and when he was hired, he just started working on current request. The Maintenance Director stated he had not been informed about Resident #13's television, and hanging a television was an easy task and he could complete that quickly. The Maintenance Director stated not being able to use a television that had been brought in for Resident #13, five months ago, could place Resident #13 at risk of feeling not heard or respected, this could be upsetting for Resident #13. Interview on 07/25/2025 10:25 AM with the Administrator revealed he had only been in the facility for a week, however, he had been working with the Maintenance Director to complete some tasks. The Administrator stated the staff on the floor were responsible for reporting to the Maintenance Department when there was a need. The Administrator stated no one had reported to him that a television needed to be hung, and he was not able to review any past maintenance request. The Administrator stated his expectations were for the Maintenance Director to fulfill all maintenance requests in a timely manner. The Administrator stated not fulfilling maintenance requests, like hanging a television in a resident's room, could place residents at risk of not having a safe homelike environment.Record review of the facility's Resident Rooms and Environment policy, dated 08/2020, reflected: Purpose: To provide residents with a safe, clean, comfortable and homelike environment. Policy: The facility provides resident with safe, clean, comfortable, and homelike environment. Facility staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. This shall include ensure that residents can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. To this end, the facility encourages residents to use their personal belongings to the extent possible. Event ID: Facility ID: 675034 If continuation sheet Page 3 of 13 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 07/25/2025 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 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse for 1 of 6 residents (Resident #33) reviewed for abuse. The facility failed to ensure residents were free resident-to-resident abuse when Resident #33 entered Resident #21's room, and Resident #21 pushed Resident #33 down. Resident #33 sustained abrasions on his nose and right knee. The failure placed residents at risk for abuse. Findings included:Record review of Resident #33's Quarterly MDS, dated [DATE], reflected Resident #33 was a [AGE] year-old male, who admitted to the facility on [DATE]. The resident's diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), non-Alzheimer's dementia (encompasses a variety of progressive neurological disorders that cause cognitive decline, but are distinct from Alzheimer's disease), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder (a disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). The MDS reflected resident had severe cognitive impairment with a BIMS score of 3, and he was independent with transfers and mobility. The MDS further reflected Resident #33 did not have any behaviors.Record review of Resident #33's Care Plan, dated 07/24/25, reflected: Focus: Resident #33. wandered into another resident's room and was pushed causing him to fall back, abrasion to bridge of nose and right knee on 06/24/25 . Goal: Resident #33 will be free of falls through the review date. Interventions: When resident is wandering redirect as needed to prevent as much as possible him infringing on the rights of others.Further review of Resident #33's Care Plans reflected there were no documented care plans specifically addressing the resident's wandering behavior nor were there person-centered interventions care planned to address the resident's wandering behaviors. Record review of Resident #33's Progress Notes by LVN A, dated 06/24/25 at 8:30 PM, reflected, Resident was found in [Resident #21's room] sitting on the floor holding on his face, nose skin abrasion noted, swelling and pain = 5/10, PRN Tylenol 100mg was given, ice was applied to nose for swelling and was helpful abrasion noted on right knee, [Resident #21] was standing in front of him and denied any confrontation but later [Resident #21] claimed that Resident #33 fell down while being chased out [Resident #21's room], assessment done, neuros done and are in range, facial series called in as ordered by Doctor. Record review of Resident #33's facial series results, dated 06/25/25 at 1:50 AM, reflected, Findings: The visual skull and facial bones demonstrate no acute fracture. No joint dislocation. Unremarkable soft tissues. The nasal bone is not visualized due to overpenetration. Conclusion: 1. No obvious or acutely displaced fracture. 2. A CT is recommended for better sensitivity if symptoms persist or worsen. Record review of Resident #33's psychiatric assessment, dated 06/30/25, reflected, CN reports an incident between the resident and another male resident. CN reported the resident was hit on the face by another male resident. Pt is seen sitting in bed with his wife. Pt could not explain to the provider what happened but reported another resident hit him on the face. Some minor bruised noted on patient's face. Pt denies any pain or reoccurring thought trauma.The provider encouraged the nurse to ensure residents are separated from each other to prevent any reoccurrence of altercations. Record review of Resident #21's Quarterly MDS, dated [DATE], reflected Resident #21 was a [AGE] year-old male who was originally admitted on [DATE] and re-admitted on [DATE]. The resident's diagnoses included: cerebral infarction (a condition where blood flow to the brain is blocked, causing brain tissue damage due to lack of oxygen and nutrients), bipolar disorder (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 4 of 13 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 07/25/2025 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 0600 Level of Harm - Actual harm Residents Affected - Few (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder (a disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and antisocial personality disorder (a mental health disorder characterized by disorganized for other people). The MDS reflected the resident was cognitively intact, had no behaviors, had upper extremity impairment on one side, and he was independent with transfers and mobility.Record review of Resident #21's Care Plan Report, initiated on 03/01/23 and revised 01/04/24, reflected Resident #21 had impaired cognitive function/dementia or impaired thought processes. Record review of Resident #21's Care Plan Report, initiated on 08/02/23, reflected Resident #21 was an elopement risk related to his elopement risk evaluation score being high at 15.Record review of Resident #21's Care Plan Report, initiated on 11/12/23, reflected Resident #21 was a high risk for elopement, and he was admitted to the secure unit due to his diagnosis of schizoaffective disorder and having an elopement risk score of 15. Observation on 07/23/25 at 2:25 PM revealed Resident #33 wandering down Resident #21's hall in the secured unit. Staff re-directed after Resident #33 began to speak loudly to Resident #21. Resident #33 was redirected to his hall and then to his room. Interview on 07/23/25 at 2:19 PM with LVN A revealed Resident #33 often wandered after dinner. LVN A stated on 06/24/25 after dinner, she heard screaming and found Resident #33 sitting on the floor crying with this hand on his face with Resident #21 standing in the middle of the room laughing. She stated that Resident #21 said Resident #33 attempted to wake him and then Resident #21 shoved Resident #33 causing him to bump into the dresser and fall. LVN A said that she had sat down at the nurses' station and did not see Resident #33 wander into Resident #21's room. LVN A stated that she watched the mirrors on the hall to attempt to watch the residents that wander on the unit. LVN A said she was unsure where the aide was at the time of the incident. LVN A stated that dementia residents had to be watched to ensure that they did not wander into other residents' areas. LVN A stated that she reported the incident to the Administrator and the DON when the incident occurred. The LVN could not recall the last in-service on dementia related care that the facility provided. Interview on 07/23/25 at 6:03 PM with CNA B revealed Resident #33 went into residents' rooms in the secured unit. CNA B stated that he responded that evening to Resident #33 yelling in Resident #21' room. CNA B stated that he did not see Resident #33 go into Resident #21's room that evening. CNA B said that Resident #21 usually was not physically aggressive toward residents, but that he was usually verbally aggressive toward other residents only. CNA B revealed that he attempted to keep the two residents apart in the sitting area during his shifts. CNA B said that he understood that Resident #33 had dementia and did not understand whose room he was in that night. CNA B stated that he would notify his nurse if he observed an incident between residents on the secured unit because residents could be hurt if they got into an altercation. CNA B also said that he had recently been in-serviced on resident-to-resident abuse and handling residents with behaviors. Interview on 07/24/25 at 8:34 AM with the ADON revealed she had been employed at the facility about a month. The ADON stated her first day at the facility was the day after the incident. The ADON explained that she only knew the facility policy and was not aware of any details about the altercation between Resident #33 and Resident #21. The ADON said if dementia residents were seen wandering, they should be redirected to their room. The ADON revealed that staff attempt to keep all the residents seated around the nurses' station so that they can be watched for behaviors and wandering. The ADON stated that the staff keep the residents in line of site to prevent incidents. Interview on 07/24/25 at 3:22 PM with the DON revealed that she had been employed at the facility for two approximately two weeks. The DON stated that she was not aware of the altercation between Resident #33 and Resident #21. The DON said that increased (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 5 of 13 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 07/25/2025 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 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete supervision should have occurred since the altercation. The DON said it is the staff's responsibility on the secured unit to monitor all residents that wonder. The DON also stated that residents who wander could go into other residents' rooms and get into their belonging which could lead to conflicts between residents. Interview on 07/24/25 at 3:51 PM with the facility Psychiatric Provider revealed he had previously asked the staff to keep eyes on Resident #33 and to redirect the resident if he was seen wandering. The facility Psychiatric Provider also stated that he has seen the staff redirect residents when they were in the tv room. The facility Psychiatric Provider revealed that he has directed the staff in the unit to not allow confused residents to wander into other resident's room because an incident could occur. The facility Psychiatric Provider stated that all staff in the secured unit are responsible for watching the residents who wander. Record review of the facility's current, undated Secure Care Training policy reflected: . Residents are in the secure environment because they are exit seeking and are unable to make safe decisions or feel more secure in a more structured environment. In order to provide a safe environment, the staff should practice the following: o On coming shift will make rounds with the off going shift to ensure all residents are accounted for and safe.o The staff will make a safety round before going on a lunch break and will ensure that there is sufficient staff in the secure area to provide a safe environment while they are on break. o Upon returning to the secure area, staff will make a walking round to ensure all residents are accounted for and safe. Event ID: Facility ID: 675034 If continuation sheet Page 6 of 13 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 07/25/2025 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 5 residents (Resident #19 and Resident #59) reviewed for ADL care.The facility failed to provide Resident #19 and Resident #59 assistance with grooming and nail care. Resident #19 and Resident #59's nails were observed to be about half inch long with black debris under nails on both hands. Both resident's appearance was disheveled with their clothing and uncleaned hair. This failure could place the residents at risk for decreased feelings of self-worth and infection. 1.Record review of Resident #19's face sheet, dated 07/25/25, revealed Resident #19 was a [AGE] year-old male originally admitted to the facility on [DATE], readmitted [DATE] and current admission date of 01/14/25.Record review of Resident #19's Quarterly MDS assessment, dated 04/14/25, revealed Resident #19 had cognition intact with a BIMS score of 9 (indicating cognitive impairment). Resident #19 required substantial/maximal assistance with shower/bathe self, and personal hygiene. Active diagnosis included Stroke, Dementia (memory loss), Heart Disease, anxiety disorder (uncontrollable feelings of fear), bipolar disorder (mood swings of emotional highs and lows), psychotic disorder (thought process leading to loss of touch with reality), Schizophrenia (having hallucinations and delusions) and lack of coordination and other abnormalities of gait and mobility. Review of Resident #19's care plan, undated, revealed Resident #19 had Self Care Deficit related to age and disease processes. Goal: Resident #19 will maintain current level of function in (.toilet use and personal hygiene). Interventions included Resident #19 required minimal to moderate assist of one staff member for bathing, transfer and had to reach areas and supervision for other areas. Resident #19 required set up and minimal assist and supervision of one staff member for personal hygiene/oral care. Observation on 07/22/2025 at 11:14 AM of Resident #19 in his room revealed he was sitting on the side of his bed. His hair was greasy and disheveled. His nails were at least half inch long with black debris underneath and around the nail bed. Resident #19 stated he was unsure of the last time staff assisted with showers, hair shampooing, or his nails cleaned. 2. Record review of Resident #59's face sheet, dated 07/25/25, revealed Resident #59 was an [AGE] year-old male originally admitted to the facility on [DATE].Record review of Resident #59's Quarterly MDS assessment, dated 05/14/25, revealed Resident #59 had cognition intact with a BIMS score of 99 (indicating Resident was not able to complete assessment). Resident #59 required partial/moderate assistance with shower/bathe self, and personal hygiene. Active diagnosis included Traumatic Brain Injury (external force that disrupts normal brain function), Dementia (memory loss), High Blood Pressure, anxiety disorder (uncontrollable feelings of fear), depression (persistent feeling of sadness) and lack of coordination and other abnormalities of gait and mobility.Review of Resident #59's care plan, undated, revealed Resident #59 had Self Care Deficit related to Dementia. Goal: Resident #59 will maintain current level of function in (.toilet use and personal hygiene). Interventions included Resident #59 required extensive assist of one staff member for bathing, and personal hygiene/oral care.Observation on 07/22/2025 at 11:57 AM with Resident #59 revealed Resident #59 had long nails at least half inch and longer on some with black debris underneath his nails. Resident #59 had on socks with holes in the toe area. Resident #59's hair was not combed and his clothing with colored stains. Interview on 07/23/25 at 2:02 PM with CNA F revealed Resident #19 was scheduled for showers on 2:00 PM - 10:00 PM shift on Monday, Wednesday, and Fridays. According to CNA F it was hard to say if he had a shower last night because he will mess with his hair, it does not look like he recently had a shower but would have one today on 07/23/25. Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 7 of 13 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 07/25/2025 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 07/24/25 at 11:18 AM with CNA F revealed nail care, shaving and hair grooming should be completed on resident shower days. CNA F stated it did not appear that Resident #19 or Resident #59 completed a shower or any grooming on 07/23/25 . Shower sheet for Resident #19 revealed showers were done 7/22/25, 07/21/25, 07/17/25, 07/15/25, 07/14/25, 07/11/25, 07/10/25, sheet for Resident #59 revealed showers were completed on 07/22/25, 07/21/25, 07/20/25, 07/19/25, 07/18/25, 07/17/25. CNA F stated it was the responsibility of the aides to complete nail care and grooming for residents, not doing so placed residents at risk of infections, and becoming ill. Interview on 07/24/25 at 3:26 PM with LVN G revealed some residents were showered on Monday, Wednesday, and Fridays depending on which bed letter they had, (A, B or C beds). LVN G stated both Resident #19 and Resident #59 needed assistance with nail care and grooming and it should be completed on their shower days by the CNAs (Monday, Wednesday, and Fridays). LVN G stated if there was an issue with completing nail care or grooming, the CNA was responsible for notifying the nurse, so that further attempts could be made. LVN G stated not completing nail care with cleaning and cutting nails or grooming placed residents at risks of infections. Interview on 07/24/25 at 3:25 PM with the DON revealed CNAs were responsible for all grooming which included nails to be cleaned and cut, shampooing and combing hair, shaving, skin care, and clean clothing needed to be done on residents' shower days. The DON stated nurses were responsible for following up with resident observations to ensure residents were properly groomed. The DON stated not completing total body care and grooming with residents placed them at risk of infections. Review of the facility's undated Grooming Care of the Fingernails and Toenails policy reflected: Nail care is given to clean and keep the nails trimmed. Fingernails are trimmed by Certified Nursing Assistants except for residents with the following conditions: Diabetes or circulatory impairment of the hands. Ingrown infected, or painful nails. Nails that are too hard, thick, or difficult to cut easily. Review of the facility's undated Resident Rights-Quality of Life policy revealed the facility must ensure all residents are treated with the level of dignity they are entitled to while residing at the facility. Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, and individuality. Event ID: Facility ID: 675034 If continuation sheet Page 8 of 13 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 07/25/2025 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who displays or was diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #33) reviewed for dementia services. The facility failed to ensure Resident #33 was provided with treatment and services to address his wandering behaviors related to his diagnosis of dementia which resulted in the resident entering Resident #21's room and being pushed by Resident #1. Upon being pushed, Resident #33's face/head bumped Resident #21's dresser, and Resident #33 sustained abrasions on his nose and right knee. This failure puts residents with dementia at increased risk of not having their dementia-related needs met. Findings included: Record review of Resident #33's Quarterly MDS, dated [DATE], reflected Resident #33 was a [AGE] year-old male, who admitted to the facility on [DATE]. The resident's diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), non-Alzheimer's dementia (encompasses a variety of progressive neurological disorders that cause cognitive decline, but are distinct from Alzheimer's disease), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder (a disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). The MDS reflected resident had severe cognitive impairment with a BIMS score of 3, and he was independent with transfers and mobility. The MDS further reflected Resident #33 did not have any behaviors.Record review of Resident #33's Care Plan Report, dated 07/24/25, reflected: Focus: Resident #33. wandered into another resident's room and was pushed causing him to fall back, abrasion to bridge of nose and right knee on 06/24/25 .Goal: Resident #33 will be free of falls through the review date.Interventions: When resident is wandering redirect as needed to prevent as much as possible him infringing on the rights of others. Further review of Resident #33's Care Plan Reports reflected there were no documented care plans specifically addressing the resident's wandering behavior nor were there person-centered interventions care planned to address the resident's wandering behaviors. Record review of Resident #33's Progress Notes by LVN A, dated 06/24/25 at 8:30 PM, reflected, Resident was found in [Resident #21's room] sitting on the floor holding on his face, nose skin abrasion noted, swelling and pain = 5/10, PRN Tylenol 100mg was given, ice was applied to nose for swelling and was helpful abrasion noted on right knee, [Resident #21] was standing in front of him and denied any confrontation but later [Resident #21] claimed that Resident #33 fell down while being chased out [Resident #21's room], assessment done, neuros done and are in range, facial series called in as ordered by Doctor. Record review of Resident #33's facial series results, dated 06/25/25 at 1:50 AM, reflected, Findings: The visual skull and facial bones demonstrate no acute fracture. No joint dislocation. Unremarkable soft tissues. The nasal bone is not visualized due to overpenetration. Conclusion: 1. No obvious or acutely displaced fracture. 2. A CT is recommended for better sensitivity if symptoms persist or worsen. Record review of Resident #33's psychiatric assessment, dated 06/30/25, reflected, CN reports an incident between the resident and another male resident. CN reported the resident was hit on the face by another male resident. Pt is seen sitting in bed with his wife. Pt could not explain to the provider what happened but reported another resident hit him on the face. Some minor bruised noted on patient's face. Pt denies any pain or reoccurring thought trauma.The provider encouraged the nurse to ensure residents are separated from each other to prevent any reoccurrence of Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 9 of 13 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 07/25/2025 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 0744 Level of Harm - Actual harm Residents Affected - Few altercations. Record review of Resident #21's Quarterly MDS, dated [DATE], reflected Resident #21 was a [AGE] year-old male who was originally admitted on [DATE] and re-admitted on [DATE]. The resident's diagnoses included: cerebral infarction (a condition where blood flow to the brain is blocked, causing brain tissue damage due to lack of oxygen and nutrients), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder (a disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and antisocial personality disorder (a mental health disorder characterized by disorganized for other people). The MDS reflected the resident was cognitively intact, had no behaviors, had upper extremity impairment on one side, and he was independent with transfers and mobility.Record review of Resident #21's Care Plan Report, initiated on 03/01/23 and revised 01/04/24, reflected Resident #21 had impaired cognitive function/dementia or impaired thought processes. Record review of Resident #21's Care Plan Report, initiated on 08/02/23, reflected Resident #21 was an elopement risk related to his elopement risk evaluation score being high at 15.Record review of Resident #21's Care Plan Report, initiated on 11/12/23, reflected Resident #21 was a high risk for elopement, and he was admitted to the secure unit due to his diagnosis of schizoaffective disorder and having an elopement risk score of 15. Observation on 07/23/25 at 2:25 PM revealed Resident #33 wandering down Resident #21's hall in the secured unit. Staff re-directed after Resident #33 began to speak loudly to Resident #21. Resident #33 was redirected to his hall and then to his room. Interview on 07/23/25 at 2:19 PM with LVN A revealed Resident #33 often wandered after dinner. LVN A stated on 06/24/25 after dinner, she heard screaming and found Resident #33 sitting on the floor crying with this hand on his face with Resident #21 standing in the middle of the room laughing. She stated that Resident #21 said Resident #33 attempted to wake him and then Resident #21 shoved Resident #33 causing him to bump into the dresser and fall. LVN A said that she had sat down at the nurses' station and did not see Resident #33 wander into Resident #21's room. LVN A stated that she watched the mirrors on the hall to attempt to watch the residents that wander on the unit. LVN A said she was unsure where the aide was at the time of the incident. LVN A stated that dementia residents had to be watched to ensure that they did not wander into other residents' areas. LVN A stated that she reported the incident to the Administrator and the DON when the incident occurred. The LVN could not recall the last in-service on dementia related care that the facility provided. Interview on 07/23/25 at 6:03 PM with CNA B revealed Resident #33 went into residents' rooms in the secured unit. CNA B stated that he responded that evening to Resident #33 yelling in Resident #21' room. CNA B stated that he did not see Resident #33 go into Resident #21's room that evening. CNA B said that Resident #21 usually was not physically aggressive toward residents, but that he was usually verbally aggressive toward other residents only. CNA B revealed that he attempted to keep the two residents apart in the sitting area during his shifts. CNA B said that he understood that Resident #33 had dementia and did not understand whose room he was in that night. CNA B stated that he would notify his nurse if he observed an incident between residents on the secured unit because residents could be hurt if they got into an altercation. CNA B also said that he had recently been in-serviced on resident-to-resident abuse and handling residents with behaviors. Interview on 07/24/25 at 8:34 AM with the ADON revealed she had been employed at the facility about a month. The ADON stated her first day at the facility was the day after the incident. The ADON explained that she only knew the facility policy and was not aware of any details about the altercation between Resident #33 and Resident #21. The ADON said if dementia residents were seen wandering, they should be redirected to their room. The ADON revealed that staff attempt to keep all the residents seated around the nurses' station so that they can be watched (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 10 of 13 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 07/25/2025 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 0744 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete for behaviors and wandering. The ADON stated that the staff keep the residents in line of site to prevent incidents. Interview on 07/24/25 at 3:22 PM with the DON revealed that she had been employed at the facility for two approximately two weeks. The DON stated that she was not aware of the altercation between Resident #33 and Resident #21. The DON said that increased supervision should have occurred since the altercation. The DON said it is the staff's responsibility on the secured unit to monitor all residents that wonder. The DON also stated that residents who wander could go into other residents' rooms and get into their belonging which could lead to conflicts between residents. Interview on 07/24/25 at 3:51 PM with the facility Psychiatric Provider revealed he had previously asked the staff to keep eyes on Resident #33 and to redirect the resident if he was seen wandering. The facility Psychiatric Provider also stated that he has seen the staff redirect residents when they were in the tv room. The facility Psychiatric Provider revealed that he has directed the staff in the unit to not allow confused residents to wander into other resident's room because an incident could occur. The facility Psychiatric Provider stated that all staff in the secured unit are responsible for watching the residents who wander. Record review of the facility's current, undated Secure Care Training policy reflected: . Residents are in the secure environment because they are exit seeking and are unable to make safe decisions or feel more secure in a more structured environment. In order to provide a safe environment, the staff should practice the following: o On coming shift will make rounds with the off going shift to ensure all residents are accounted for and safe.o The staff will make a safety round before going on a lunch break and will ensure that there is sufficient staff in the secure area to provide a safe environment while they are on break. o Upon returning to the secure area, staff will make a walking round to ensure all residents are accounted for and safe. Event ID: Facility ID: 675034 If continuation sheet Page 11 of 13 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 07/25/2025 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 0880 Provide and implement an infection prevention and control program. 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 infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 (Resident #76 and #96) of 3 residents reviewed for infection control during medication administration.The facility failed to ensure MA E disinfected the blood pressure cuff in between blood pressure checks for Resident #98 and Resident #76. RN D failed to wear a gown while providing care for Resident #96, who was on enhanced barrier precautions for Gastronomy tube. These failures could place residents at-risk of cross contamination which could result in infections or illness.Findings included:1.Review of Resident #76's MDS assessment dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. Resident #76 had diagnoses which included hypertension (high blood pressure) and heart failure (a serious condition but not the same as a heart attack, where blood flow to the heart is suddenly blocked). He had a BIMS score of 09 which indicated his cognition was moderately impaired. Observation on 07/23/25 at 07:29 AM revealed MA E did not disinfect the blood pressure cuff after she checked the blood pressure for Resident #98. She went directly from Resident #98's room to Resident #76's room and checked Resident #76's blood pressure without disinfecting the blood pressure cuff. Interview with MA E on 07/23/25 at 07:40 AM revealed she did not disinfect the blood pressure cuff between Residents #98 and #76. She stated she knew she should disinfect between 2 residents. She stated she had been told here in the facility she should disinfect between resident, and she forgot. She stated she was supposed to disinfect between residents to prevent cross contamination, but she had developed a habit of disinfecting after 2 residents. She stated she had done trainings on infection control two months ago. 2. Record review of Resident #96's Quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male, who admitted to the facility on [DATE] and readmission on [DATE]. The resident had severe cognitive impairment with a BIMS score of 00, and his diagnoses included gastronomy status (presence of a gastrostomy tube, an artificial opening into the stomach used for feeding) and dysphagia (swallowing difficulties), and the MDS reflected he had a feeding tube for nutrition. Record review of Resident #96's care plan dated 06/01/25 reflected: Focus: [Resident #96] has infection of the G tube site. Goal: [Resident #96] will be free from complications related to infection through the review date. Interventions: Maintain universal precautions when providing resident care. Observation on 07/23/25 08:20AM revealed RN D prepared all the medications, and she entered to Resident #96's room. RN D washed her hands, put on gloves, and performed blood pressure check. She removed her gloves, washed her hands, and put on new gloves. She administered Resident #96's medications through his gastronomy tube without wearing a gown. The gloves were the only PPE that RN D wore while administering medication through gastronomy tube. Resident #96 was observed to have a gastronomy tube with a dressing dated 07/23/25. Interview on 07/23/25 at 08:41 AM with RN D revealed she knew she was supposed to wear gloves and a gown when caring for residents on enhanced barrier precautions, but she forgot to wear a gown before entering the room. She stated she had done in-services on infection control, but she could not recall the date. Interview on 07/24/25 at 01:00 PM with the ADON revealed, her expectation was for staff to disinfect blood pressure cuffs between each Resident. She stated she noticed MA E did not disinfect the blood pressure cuff after she left Resident #98 room and she used the same cuff on Resident #76. She also stated she expected for all residents on EBP, for staff to wear a gown and gloves when having direct contact with the resident. The ADON stated the EBP were in place to protect the resident from exposure to infectious agents and disinfecting blood pressure cuff between Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 12 of 13 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 07/25/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete residents was to prevent cross contamination. She stated the facility had done training on enhanced barrier precautions, and disinfection of equipment, but she was not sure whether the staff were in attendance since some were new to the facility. Interview with the DON on 07/24/25 at 03:32PM revealed, her expectation was for staff to disinfect blood pressure cuffs between each resident due to risk of cross contamination. She stated when it came to contact, staff should use gown and gloves on residents who are on enhanced barrier precautions. She stated the facility had done in-services on infection control and enhanced barrier precautions. She stated the facility's management was supposed to be doing spot check on staff for equipment disinfection and the use of enhanced barrier precautions, but she had not done one since she was new to the facility. Record review of the facility's training records for EBP, dated 05/13/25, reflected RN D, was in attendance. Record review of the facility's training records for equipment cleaning, dated 04/13/25, reflected MA E and RN D, were in attendance. Record review of the facility's Enhanced Barrier Precautions policy, dated April 2024, reflected:Enhanced Barrier Precautions is an infection control intervention to reduce transmission of multi-drug-resistant organisms that employs targeted gown, and gloves use during high contact resident care activities.B. For resident whom EBP are indicated EBP should be used when performing the following high contact resident care activities should be used for any is indicated for residents with any of the following:vii. Device care or use: Central line, urinary catheter, feeding tube tracheostomy/ventilator. Review of the facility's policy for Cleaning & Disinfection of Environmental surface and Equipment, dated June 2020, reflected, The following categories are used to distinguish the level of sterilization/disinfection necessary for items used in the Resident environment. c. Noncritical items are those that come in contact with intact skin but not mucous membranes.ii. non-critical equipment items include bed pans, blood pressure cuffs, crutches, computers including those that are used for mobile charting, monitoring equipment. Event ID: Facility ID: 675034 If continuation sheet Page 13 of 13