Health inspection·September 8, 2025

F 0567 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that affects the central nervous system), cognitive communication deficit and dysphagia. Resident #3 did not have a medical or durable power of attorney listed and had a family member listed as an emergency contact. Resident #3 was listed as her own responsible party. Record review of Resident #3's quarterly MDS assessment dated [DATE] reflected no hearing or speech issues and was sometimes able to make herself understood. Her BIMS score was a 06, which indicated severe cognitive impairment. Record review of Resident #3's Trust Fund Statement dated 09/08/25 reflected her current balance was $5,536.98. On 08/01/25 her balance was $7,348.84, on 07/01/25 it was $5,366.84 and on 06/02/25 it was $3,976.82. There was no evidence the facility completed a spend down for her over the past quarter. Debits from Resident #3's account for the past three months included monthly care cost payment to the facility for $504.56 and two advanced cash payments of $75 and $60. There were no other debits from her trust fund account to assist in spending down her excess finances. 4. Record review of Resident #4's Face Sheet dated 09/08/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #1's active diagnoses included COPD (a long-term lung disease), abnormalities of gait and mobility and cirrhosis of liver (scar tissue on liver that interferes with functioning). Resident #4 did not have a MPOA/DPOA or any emergency contacts listed. Resident #4 was listed as his own responsible party. Record review of Resident #4's quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 15, which indicated no cognitive impairment. Record review of Resident #4's Trust Fund Statement dated 09/08/25 reflected his current balance was $4,270.20. Resident #4's balance remained over $4,000 since 06/02/25 and was increasing each month. There were no care costs paid to the facility. The only debits from her account for the past three months were resident cash advances totaling $270. There was no evidence the facility completed a spend down for her over the past quarter for her excess funds. An interview with Resident #4 on 09/08/25 at 2:05 PM revealed he was aware that he was over-resourced and at risk for being ineligible for Medicaid. He stated that he did not know what he was supposed to spend his money on. He said most of the money came from a large back pay from Social Security. Resident #4 continued to state that he did not know what kinds of things he should buy or needed since he was living in a nursing facility. 5. Record review of Resident #5's Face Sheet dated 09/08/25 reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #5's active diagnoses included metabolic encephalopathy (altered brain function), dementia, repeated falls, hemiplegia (complete paralysis on one side) and hemiparesis (muscle weakness on one side of the body), dysphagia and psychotic disorder with delusions (distorted perceptions, thoughts and behaviors). Resident #5 had a family member listed as her responsible party/emergency contact, but no MPOA/DPOA was listed. Review of Resident #5's 06/16/25 quarterly MDS assessment reflected she had a BIMS score of 04, which indicated severe cognitive impairment. Record review of Resident #5's Trust Fund Statement dated 09/08/25 reflected her current balance was $3,590.57 and had remained over $3,000 for the past three months and was increasing each month. There were no withdrawals or debits to assist her to spend down her excess funds for the past quarter. She received monthly payments from the state comptroller and Social Security totaling $75 a month as her income.6. Record review of Resident #6's Face Sheet dated 09/08/25 reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #6's active diagnoses vascular dementia (problems with memory, thinking and behavior). Resident #6 had a family member listed as her legal guardian. Record review of Resident #6's quarterly MDS assessment dated [DATE] reflected she had unclear speech and was sometimes understood by others. Resident #6 had a BIMS score of 00, which indicated severe cognitive impairment. Record review of Resident #6's Trust Fund Statement dated 09/08/25 reflected her current balance was $3,208.80 and was increasing over the past quarter: 06/02/25=$2,979.56, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 2 of 5 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 09/08/2025 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 0567 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 07/01/25=$3,055.98. There were no withdrawals or debits to assist her to spend down her excess funds for the past quarter. She received monthly payments from the state comptroller and Social Security totaling $75 a month as her income. An observation of Resident #6's room on 09/08/25 at 1:34 PM revealed she was not in her room. Her room smelled strong of urine and had an older electric recliner, one artificial plant and a mini fridge on the floor in the corner. She did not have any bedding other than what the facility provided. There were no pictures on the wall, no artwork and no decorations and minimal to no personal affects. 7. Record review of Resident #7's quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 02, which indicated severe cognitive impairment. Record review of Resident #7's Trust Fund Statement dated 09/08/25 reflected his current balance was $3,129.61 and had been increasing over the past quarter: 06/02/25=$2,832.33, 07/01/25=$2,905.75. His care cost payments to the facility were $1,306 monthly. He had $15 of allowance withdrawals over the past three months, partly to include payment for a haircut. There were no other withdrawals or debits to assist him to spend down his excess funds for the past quarter.An observation of Resident #7's room on 09/08/25 at 1:52 PM revealed he was not present. His television was cracked across the whole screen, was not functionable and did not work per his roommate. There were no decorations, personal items, nothing to make the room look homelike. His dresser drawers did not have anything in them except a pack of markers and a page that was colored. He had no shoes in his closet. 8. Record review of Resident #8's Face Sheet dated 09/08/25 reflected he was an [AGE] year-old male who admitted to the facility on [DATE]. Resident #8's active diagnoses included Alzheimer's disease, reduced mobility, lack of coordination and cognitive communication deficit. Resident #8 had a family member listed as his financial and emergency contact. Record review of Resident #8's quarterly MDS assessment dated [DATE] reflected a BIMS score of 08, which indicated moderate cognitive impairment. An observation of Resident #8's room on 09/08/25 at 1:40 PM revealed he was not in his room. His side of the room had no visible decorations, was not home-like and had no personal belongings except for a small alarm clock and a water bottle. He had no television to watch on his side of the room. Record review of Resident #8's Trust Fund Statement dated 09/08/25 reflected his current balance was $3,276.41. He paid no care costs to the facility and there were multiple cash allowance withdrawals totaling $475 over the past quarter and an income from Social Security and State Comptroller for $75 each month. There were no other withdrawals or debits to assist him to spend down his excess funds this past quarter. 9. Record review of Resident #9's Face Sheet dated 09/08/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. His active diagnoses included alcohol-induced persisting dementia, mood disorder and dysphagia. Resident #9 had a family member listed as his MPOA/DPOA/Emergency Contact. Record review of Resident #9's annual MDS assessment dated [DATE] reflected moderate difficulty hearing and use of a hearing aid, sometimes was understood and had a BIMS score of 03, which indicated severe cognitive impairment. Record review of Resident #9's Trust Fund Statement dated 09/08/25 reflected his current balance was $3,116.46. His monthly balance stayed over $3,000 for the past three months: 06/02/25=$3,096.47, 07/01/25=$3,068.47, and 08/01/25=$3,092.33, . Even though he had multiple debits from his trust fund for tobacco products and allowance, there were no other withdrawals or debits to assist him to spend down his excess funds this past quarter. An observation of Resident #9's room on 09/08/25 at 1:55 PM revealed he was not in his room. His room was observed to have blank walls, no decor, no pictures, nothing to make it look homelike. He had no shoes in his closet. He had no observed personal affects other than 14 articles of clothing and a mini radio. 10. Record review the most recent Resident Fund Balance Notifications dated two months ago on 07/03/25, reflected Residents #1, #2, #3, #4, #7, #8 and #9 were notified of their balances being within $200 or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 3 of 5 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 09/08/2025 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 0567 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some exceeding what was allowed under the Medical Assistance. The notification letter stated, Please contact your Social Worker within the next 7 days to discuss ways to assure continuance of Medicaid benefits. There was no evidence the RPs or MPOA/DPOA were notified as the only signatures on the forms were of the residents' signature scribbles and facility's representative. Residents #5 and #6 did not have any documentation provided to show they were notified of the trust funds being over-resourced.11. An interview with the AD on 09/08/25 at 11:20 AM revealed she was not involved in any resident trust funds or the spend down process. She stated only once in the past three years she had spent resident's funds in that way. The AD stated if a resident wanted to make some purchases, she encouraged them to come out in the community to the local stores she took residents to and make purchases themselves, instead of having her buy them for the resident. She stated the only exception was that she would periodically purchase cigarettes for residents with their trust fund money. An interview with the BOM on 09/08/25 at 11:30 AM revealed she had been out on leave for the past six weeks and the admissions coordinator had been covering for her while out. She stated a resident's excess funds could be spent down by reimbursing a DPOA/RP if they purchased items for a resident and brought in the receipts. The BOM stated the activity director did not usually help with spending down a resident's excess funds unless it was under special circumstances and then they would have to get consent, sign the money out, and return with receipts. The BOM said being over-resourced meant having any funds in the residents' accounts over $2,000. She stated she knew Residents #1, # 2, #3, #4, #5, #6, #7, #8 and #9 were over-resourced and it was something she was working on. The BOM stated when a resident was over-resourced, she could talk to the family or the resident to assist in making purchasing decisions such as burial plans if needed. She also stated if there was no family involvement or the resident was not alert/oriented, she would then talk to the staff to see what items the resident may be needing that the facility could purchase on their behalf. She stated she had two magazines that were specific vendor approved items that could be purchased for the long-term care population, and she made purchases from it in the past when she needed to spend down resident funds. A follow up interview with the BOM on 09/08/25 at 2:20 PM revealed when a residents' trust fund balance was approaching being within $200 of the limit of $2,000, she could use the facility's online accounting system to track it and see who all was within that range. Then the system would generate a letter called a Resident Fund Balance Notification that would be mailed to the RP or given to the resident if they had no RP. Then the resident or RP had to return the notification letter signed. She stated the SW was listed as the only contact person on that letter, but he was not a part of buying any items for residents or part of the spend down process. The BOM stated, That is just me. I can help them. She said there were a lot of residents in the facility who did not request any allowance withdraws from their trust fund accounts, so their balance was increasing. The BOM stated Resident #1 just received a large back payment from Social Security a month prior while the BOM was out on leave. She said Resident #2 got money out as cash, and the facility did purchase him a television and clothes in the past. For Resident #3, she stated she needed to contact her family and see if they wanted to purchase a burial plot. She stated Resident #4, knows it is in there, but he spends what he wants to spend. The BOM stated Resident #5's family member usually brought receipts for purchases and would get reimbursed and the family was interested in a custom wheelchair. The BOM stated she left that issue with the previous social worker, but there had been a new one hired while she was on leave so she did not know if anything had been done about it. With Resident #6, the BOM stated she talked to the family member who lived out of state and had reimbursed the RP for online purchases, but the purchase amounts were not enough to bring the balance under $2,000. The BOM stated Resident #8's balance had been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675034 If continuation sheet Page 4 of 5 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 09/08/2025 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 0567 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete going down and he got money out as cash. For Resident #9, she stated she could purchase him some clothes and he had family that was not involved. The BOM stated that she could not release any more than $75 cash to an A/O resident monthly, so if they needed to spend down, then she would have to write them a check to cash, which came with its own issues if they had no identification or a way to cash the money. She stated that usually she would have the resident just take out $75 cash each month until they spend down. She stated, They get upset about it, but I can't just give them cash if over-resourced. She stated online purchases by the facility from a resident's trust fund was not allowed with the exception being two company-approved catalogs she had to purchase from online. The BOM stated Medicaid usually gave nursing facilities a six-month grace period after a large back pay was given to a resident to spend it down. She stated Medicaid renewals were annually, so the main goal would be to make sure the residents' balances were under $2,000 sixty days before the renewal date. An interview with the SW on 09/08/25 at 11:55 AM revealed he did not handle anything related to resident trust funds or the spend down process. He was unaware of the notification letter that was being sent to RPs that stated he was the contact for any spend down process related to Medicaid eligibility. The SW stated he was new to his position at the facility but would be happy to help with the spend down process if needed. He said he knew if a resident had over $2,000 in their account, they could lose their Medicaid coverage.An interview with the ADM on 09/08/25 at 2:30 PM revealed he was one week new to the facility and he was not aware of the nine residents who were over-resourced related to trust fund management. He stated the residents could lose their Medicaid eligibility if they had over $2,000 in their account. The ADM said he wanted to make sure going forward, that he sat down with the BOM each week to review trust fund accounts to see how they could spend down residents who had excessive funds. An interview with C-RN A on 09/08/25 at 2:32 PM revealed the BOM was responsible to help with the spend down process and there were certain things they were allowed to purchase. She stated the AD was great for shopping trips in the community and would let the family members know and get involved when a resident's funds needed to be spent down. C-RN A stated she knew there had been a couple of residents who received a large back pay of money from Social Security and knew the nine residents were at risk for losing their eligibility if they over $2,000. C-RN A stated she would speak with the Corporate BOM over trust funds to see what could be done. 12. Review of the facility's, Resident Trust Fund (not dated) reflected, To establish uniform guidelines in the protection of personal funds managed by our facilities on behalf of its residents and to maintain a complete and accurate accounting for patient monies.The Administrator is responsible for ensuring the establishment and accurate maintenance of the Resident Trust Fund and the related Resident trust Fund Petty Cash Account. Event ID: Facility ID: 675034 If continuation sheet Page 5 of 5