Health inspection·July 10, 2025

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete assistance and could fall or have an accident. In an interview on 07/10/25 at 2:35 PM, the DON stated call light cords should always be left within reach of the resident. She preferred the cord was secured to the bedding or the bed rail so it would not slide off. She stated the biggest risk to the residents was not being able to call for assistance. She stated it could cause the resident to try to get up and help themselves and fall in the process. Record review of the facility's Call Lights: Accessibility and Timely Response policy, dated 10/13/22, reflected: The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance 5. Staff will ensure the call light is within reach of resident and secured as needed Event ID: Facility ID: 675622 If continuation sheet Page 2 of 8 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 675622 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cityview Nursing and Rehabilitation Center 5801 Bryant Irvin Rd Fort Worth, TX 76132 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents had the right to be free of abuse for 3 of 5 residents (Residents #6, #7 and #8) reviewed for abuse. The facility failed to ensure Residents #7 and #8 had the right to be free from abuse when Resident #6 hit Resident #7 in the face on 06/26/25 and put his hands around Resident #8's neck on 07/02/25. An IJ was identified on 07/10/25. The IJ began on 06/26/25 and was removed on 07/06/25. The facility took action to remove the IJ before the abbreviated survey began. While the IJ was removed on 07/06/25, the facility remained out of compliance with a scope of pattern and severity level of no actual harm with potential for more than minimal harm . The failure placed residents at risk for abuse. Findings included:Record review of Resident #6's admission MDS, dated [DATE] and signed as complete by the DON on 06/25/25, reflected the resident was a [AGE] year-old male. The resident admitted from home to the facility on [DATE], and his diagnoses included Alzheimer's disease, non-Alzheimer's dementia, anxiety disorder, and depression. The resident had severe cognitive impairment with a BIMS score of zero, and he displayed disorganized thinking and intention continuously. The resident was assessed to have physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, disruptive sounds), and wandering, which all occurred 1 to 3 days during the assessment period. These behaviors were assessed to significantly intrude on the privacy or activity of others. The MDS also reflected the resident rejected evaluation or care that was necessary to achieve the resident's goals for health and well-being, which occurred 1 to 3 days during the assessment period. The MDS further reflected the resident was able to transfer and walk independently. Record review of Resident #6's Care Plan, initiated on 06/13/25, reflected Resident #6 had the potential to be verbally and physically aggressive related to poor impulse control. The Care Plan included the following: Problem: 6/12/25 angry look in his face, threw coloring book across the table Problem: 6/14/25 climbed into bed with peer combative, hitting/swinging at staff during redirection. Intervention: 6/14/25 attempted to remove from peer's bed, left alone [due to] agitation Date Initiated: 06/16/2025 Problem: 6/21/25 entered female peer's room and began hitting and grabbing at the CNA's clothes when she attempted to redirect him out of room, attempted to hit female peer Intervention: 6/21/25 attempted to redirect from room, CNA used her body to shield female resident from both men, [Resident #6] left room [status post] incident with male peer, refused skin assessment and VS, NP notified with N.O. anxiolytic topically Q 6hrs, RP/DON/ADON/weekend supervisor notified, placed on 1:1 supervision; 6/22/25.NP N.O. anxiolytic PO Q6hrs PRN, RP notified - Date Initiated: 06/23/2025. Problem: 6/24/25 agitated, striking out at staff. Intervention: 6/24/25 PRN anxiolytic administered - Date Initiated: 06/25/2025. Problem: 6/26/25 hit peer in the face with closed fist. Intervention: 6/26/25 separated from peer and escorted to room, encouraged to sit on bed and provided with books to color, MD/NP/RP/DON/ADON/Administrator notified, unable to obtain VS d/t agitation, SW completed updated BIMS assessment with BIMS 1. Date Initiated: 06/27/2025 Problem: 6/27/25 combative with sitter and peers. Intervention: 6/27/25 staff attempted to redirect, once calmed down he walked to his room, PRN medication administered, DON notified, taken out on patio x approximately 15 minutes. Date Initiated: 06/30/2025. Problem: 6/30/25 verbal/physical aggression towards staff: swinging/kicking/hitting, throwing items in room, swinging pencil. Intervention: 6/29/25 verbally redirected, assisted to bed, covered with blanket, assessed as able without waking [Resident #6] up, continued monitoring. Date Initiated: 06/30/2025. Intervention: 6/30/25 topical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675622 If continuation sheet Page 3 of 8 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 675622 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cityview Nursing and Rehabilitation Center 5801 Bryant Irvin Rd Fort Worth, TX 76132 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some anxiolytic applied with assistance, pencils removed and placed in med room, NP witnessed episode, continues 1:1 monitoring. Date Initiated: 07/01/2025 Problem: 7/1/25 threw chair at sitter, then charged sitter and fell, stood up and charged at sitter again, pacing. Intervention: 7/1/25 assessed, area treated, DON/ADON/MD/RP notified with N.O. transfer to hospital r/t injury, unable to obtain VS, patio door opened, and [Resident #1] came in facility, RP arrived at facility, transferred to.hospital Problem: 7/2/25 kicked the table, entered peer's room and placed his hands around peer's neck. Intervention: 7/2/25 kicked table: assessed with trauma noted to R great toe, area cleansed and treated. 7/2/25 placed hands around peer's neck: separated from peer immediately, [head-to-toe assessment] completed, VS obtained, redirected, MD/RP notified; SWA sending clinicals to [Behavioral Health Hospitals]. Date Initiated:07/02/2025. The Care Plan also reflected the following additional interventions to address Resident #6's verbal and physical behavioral symptoms: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 06/13/2025Analyze times of day, places, circumstances, triggers, and what de-escalatesbehavior and document. Date Initiated: 06/13/2025Assess and address for contributing sensory deficits. Date Initiated: 06/13/2025. Assess [Resident #6's] needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. Date Initiated: 06/13/2025COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Date Initiated: 06/13/2025 Give [Resident #6] as many choices as possible about care and activities. Date Initiated: 06/13/2025 Modify environment adjust room temperature to comfortable level, reduce noise, dim lights, place familiar objects in room, keep door closed, etc. Record review of Resident #6's progress notes, dated 06/26/25, documented by LVN E reflected the following: This resident was observed standing in dining area talking with another resident who was sitting in a wheelchair. This resident hit the other resident in his face/cheek with his fist causing a reddened area to the other resident's cheek. The residents were separated and this resident was escorted to his room by the nurse and encouraged to sit on his bed and was given his crayon box and coloring book which he pushed away and then laid down on the bed.Review of Resident #6's progress notes dated 07/01/25, reflected the following: Resident on patio with 1/1 pacing and suddenly he picked up a chair and threw it and started running at Sitter and he fell on rt shoulder. Resident quickly got off ground charging at sitter. This nurse was passing window and saw resident chasing sitter. Resident pacing and holding rt arm, small skin tear noted to rt wrist Orders to transfer resident to hospital for injury Record review of Resident #6's progress notes, dated 07/02/25, documented by LVN F reflected the following: Resident observed going into another resident's room and placed his hands around his neck. Staff immediately separated [Resident #6] and was re-directed. Record review of the facility's Provider Investigation Report, completed by the DON on 07/03/25, reflected the following: The facility initiated an investigation on 06/26/2025 after two residents were involved in an altercation. [Resident #6] is a [AGE] year-old male who resides on the dementia unit. He was admitted on [DATE] with the diagnosis of Alzheimer's, HLD, depression, anxiety, hearing loss, HTN, and TIA's. He can walk ad lib and is dependent on staff for assistance with ADL's. He has a BIMS score of 0.[Resident #7] is a [AGE] year-old male who resides on the dementia unit. He admitted on [DATE] with the diagnosis of dementia, dysphagia, hypothyroidism, HLD, depression, HTN, DM, AFIB, CHF, COPD, cellulitis and anxiety. He uses a wheelchair for mobility and is dependent on staff for ADL's. He has a BIMS score of 1.On 06/26/2025 both residents were in the common area in front of the nurse's station. Both residents were calm and suddenly [Resident #6] struck [Resident #7] on the left cheek. The residents were separated immediately and assessed by the nurse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675622 If continuation sheet Page 4 of 8 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 675622 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cityview Nursing and Rehabilitation Center 5801 Bryant Irvin Rd Fort Worth, TX 76132 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some [Resident #7] had a reddened area to the cheek, v/s 106/64,76,97.8,18. The reddened area dissipated without bruising although there is discoloration to both cheeks that is permanent. [Resident #6] refused vital signs at the time due to his agitation. There have been no further incidents between these two residents. Neither resident could recall the incident when interviewed by the DON. There was no root cause identified as the event was unprovoked.Both families were notified. [Psychological Services], MD, Regional support team and HHSC were all notified. Both residents were seen by the Social [NAME] and [Psychiatric] N.P. [Resident #6] continues to have behaviors during one-on-one observation and remains on one-on-one with the facility seeking alternate placement. His medications were reviewed and adjusted without being effective in modifying his behaviors. Incident reports were completed, skin assessments and pain assessments were completed. Care plans were updated. Education was initiated on Abuse and Neglect and managing difficult behaviors. After through [sic] investigation, the incident did occur but due to the residents' lack of cognition, it was not an intentional act of abuse. Both residents have be monitored by administrative staff frequently. [Resident #7] remains in the facility with no distress or concerns noted. We are seeking a more appropriate placement for [Resident #6]. Record review of the facility's Provider Investigation Report, completed by the DON on 07/09/25, reflected the following: The facility initiated an investigation on 07/02/2025 after two residents were involved in an incident.[Resident #6] is a [AGE] year-old male who resides on the dementia unit. He was admitted on [DATE] with the diagnosis of Alzheimer's, HLD, depression, anxiety, hearing loss, HTN, and TIA's. He can walk ad lib and is dependent on staff for assistance with ADL's. He has a BIMS score of o.[Resident #8] is an [AGE] year-old male who resides on the dementia unit. He admitted on [DATE] with the diagnosis of dementia, dysphagia, CKD, COPD, DM, dysphagia, depression, HTN, and behavior disturbance with dementia. He uses a wheelchair for mobility and is dependent on staff for ADL's. He has a BIMS score of 01.On 07/02/2025 [Resident #6] entered [Resident #8['s room and placed his hands around his neck. The CNA was directly behind him and redirected him away from the resident immediately. [Resident #8[ was assessed and there was no redness, irritation, or bruising noted. He denied feeling anything. There was no injury.[Resident #8] was interviewed by Social Services and could not recall the incident. Neither resident could recall the incident when interviewed by the DON.Both families were notified. The police, [Psychological Services], MD, Regional support team and HHSC were all notified.Both residents were seen by the Social Services and [Resident #6] continues to be seen by the [Psychiatric] N.P. [Resident #6] continued to have behaviors during one-on-one observation and remained on one-on-one with the facility seeking alternate placement. His medications were reviewed and adjusted without being effective in modifying his behaviors. He was sent to [Hospital] on 07/06/2025 due to his agitation and aggression. He remains there currently.Incident reports were completed, skin assessments and pain assessments were completed. Care plans were updated. Education was initiated on Abuse and Neglect and managing difficult behaviors.Based on the investigation, there is no evidence of abuse.Both residents have be monitored by administrative staff frequently. [Resident #8[ remains in the facility with no distress or concerns noted. [Resident #6] is still at [Hospital], but we continue to look for a more appropriate placement for him. 2. Record review of Resident #7's quarterly MDS, dated [DATE], reflected the a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included stroke, non-Alzheimer's dementia and depression. Resident #7's BIM's was a 1, which indicated his cognition was severely impaired. The MDS further reflected Resident #7 used a wheelchair for mobility. 3. Record review of Resident #8's significant change MDS, dated [DATE], reflected an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included non-Alzheimer's dementia, depression and vascular dementia, mild with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675622 If continuation sheet Page 5 of 8 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 675622 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cityview Nursing and Rehabilitation Center 5801 Bryant Irvin Rd Fort Worth, TX 76132 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some other behavioral disturbance. The resident had a BIM's of 1, which indicated his cognition was severely impaired. The MDS further reflected Resident #8 used a wheelchair for mobility. Observation and interview on 07/10/25 at 9:39 AM revealed Resident #7 was in the secure unit television/dining room area across from the nurses' station sitting in his wheelchair pleasantly talking to other residents. He was alert and oriented and able to answer simple/basic questions. The resident was asked about the incident where he was struck by Resident #6, but he was not able to recall the incident. Observation on 07/10/25 at 9:44 AM revealed Resident #8 was in a high back wheelchair in the television/dining area. The resident was able to answer simple basic questions but was not able to recall the incident between him and Resident #6. Interview on 07/10/25 at 10:26 AM with LVN E revealed she was at the nurse's station getting a weight on another resident and Resident #7 was sitting at the doorway of where the other resident's weight was being obtained. At that time Resident #6 approached Resident #7 and both residents began to have a normal conversation and there was not aggression when all of sudden Resident #6 struck Resident #7 on the cheek with a closed fist and Resident #7 yelled out he hit me. Both residents were separated immediately, and Resident #7 was assessed, and he denied any pain but his check was slightly reddened from where he had been struck and the following day the redness was gone. LVN F said Resident #6 was admitted with extreme behaviors and wandered in and out of other resident rooms and would become very physical throwing things and trying to hit at staff as they redirected. LVN F stated Resident #6 was unpredictable and at first the resident was easily redirected to his coloring books. LVN F further stated Resident #6 was put on 1:1 supervision due to his unpredictable physical behaviors but did not recall date. Interview on 07/10/25 at 10:37 AM with CNA G revealed she had just taken Resident #7 to the bathroom and pushed him into the TV area and Resident #6 was standing in front of the nurse's station and both residents began to talk to each other in a normal tone and then, suddenly, Resident #6 struck Resident #7 in the face with a closed fist. CNA G said she immediately removed Resident #7 from the area and LVN F assisted in separating the residents. CNA G said Resident #7 had some redness to his check where he was struck but said it had not lasted very long. CNA G stated she believed Resident #6 was put on 1:1 after the incident and she described Resident #6 as very unpredictable with his mood swings. They were told if they noticed Resident #6 becoming upset, they were to remove the other residents away from him and let him calm down because Resident #6 would become very physical when he was redirected. Interview on 07/10/25 with CNA H revealed Resident #6 was very quiet but they had to pay very close attention to him because the resident would quickly strike out at anyone that was around him including the staff who were watching him 1:1. CNA H said Resident #6 would become very physical when they tried to redirect him, and the behavior would come out of nowhere and described him as very unpredictable. Interview on 07/10/25 at 11:12 AM with CNA I revealed Resident #6 appeared to be relaxed and then, all of a sudden, he would throw things around his room and became physical with others. CNA I said the staff were instructed to keep other residents away from Resident #6 and kept their distance until the resident calmed down. Interview on 07/10/25 at 1:40 PM with CNA J revealed the night of the incident with Resident #8, 07/02/25, Resident #6 had been out to the hospital and his family had taken him out AMA and took him back to the facility around 2:00 AM or 3:00 AM. She said Resident #6 was already on 1:1 supervision and when he arrived, he appeared agitated and soon after the resident's family left. CNA J said Resident #6 left his room and he was trying to go into other resident's rooms and she kept redirecting him out. During one of times, she was redirecting the resident out of a room, as she was shutting the other resident's door, Resident #6 immediately ran into the room across the hall (Resident #8's room) and CNA J said she followed him and before she could redirect him, Resident #6 was seen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675622 If continuation sheet Page 6 of 8 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 675622 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cityview Nursing and Rehabilitation Center 5801 Bryant Irvin Rd Fort Worth, TX 76132 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some bending over Resident #8 and put his hands around his neck. CNA J said she immediately got to Resident #6 before he could squeeze his neck and yelled for LVN F to assist. CNA J stated Resident #8 woke up at that time and yelled at the staff to get Resident #6 out of his room. She said as they were trying to redirect Resident #6, he kept trying to swing at them and they finally got the resident back to his room where he finally laid down. CNA J further stated that was the first time she experienced Resident #6's aggression during the night shift and the incident was all unprovoked. Attempts to interview LVN F on 07/10/25 were unsuccessful. Interview on 07/16/25 at 10:53 AM with the ADON revealed she was told about the incidents with Residents #6, #7, and #8. The ADON said Resident #6 was transferred from another facility and there was no documentation of his aggressive behaviors but once he got to their facility, the resident was very unpredictable with his physical behaviors. The ADON stated Resident #6 was put on 1:1 supervision after the first incident with Resident #7 and never came off that supervision. Interview on 07/10/25 at 2:13 PM with the DON revealed Resident #6 was admitted from another facility and they were not aware of any of his physical behaviors, or he would never have been accepted. The DON said as soon as Resident #6 was admitted he began to have aggressive behaviors, and they tried to adjust his medications and also tried diversional activities, but nothing seemed to work. The resident was immediately put on 1:1 when he began to show aggression towards staff. Resident #6 was on 1:1 supervision from 06/21/25 to 06/24/25 and had been taken off for a while due to some decreasing behaviors and was put back on 1:1 after the incident with Resident #7 on 06/26/25 and was on it until the remainder of his stay. The DON stated there was nothing that triggered his behavior and it was difficult to tell when he was about to escalate and that was why they decided to keep him on 1:1 until they could find alternate placement. The DON said the resident had been sent to the hospital (07/01/25) after he became physically aggressive with the 1:1 sitter and he had fallen back. The resident was sent to the hospital for an evaluation because he had fallen on his arm from his physical behaviors and the Resident's Family had taken him out of the hospital AMA stating she had gotten tired of waiting for Resident #6 to be seen. Finally Resident #6 was sent to the hospital again (07/06/25) because she wanted them to do a psychological evaluation where he remained as they had Resident #6 on a 4- point restraint due to his aggressive behaviors and would not be accepted back due to his aggressive behaviors. Monitoring for compliance included the following: Observation on 07/10/25 of Resident #9, who was on 1:1 supervision, revealed staff were providing the resident with 1:1 supervision. The resident was on 1:1 supervision due to behaviors exhibited towards staff and for exit-seeking. Record review of the incident/accident log reflected there were no resident-to-resident incidents/altercations in the facility following Resident #6's last incident on 07/02/25. Record review of in-services, dated 06/26/25 and 07/02/25, reflected staff were in-serviced on the types of abuse/neglect prior to the HHSC investigation. The staff were also in-serviced on what to do when resident behaviors escalated, notify the abuse prevention coordinator of the behaviors, and who to notify of any behavior/incidents. The staff were also in-serviced on tips of dealing with aggressive behaviors in residents with dementia,. 81 staff members participated in the in-service on 06/26/25 and 74 staff participated in the in-service on 07/02/25. The staff were from various titles and shifts. Interview with staff on 07/10/25 from 10:26 AM to 3:52 PM from various shifts (6:00 AM-2:00 PM; 2:00 PM-10:00 PM; and 10:00 PM-6:00 AM) included LVN E, LVN F, CNA G, CNA H, CNA I, CNA J, CNA K, LVN L, CNA M, CNA N, LVN O, CNA P and the ADON. All the staff were able identify the different types of abuse, identify when a resident was escalating, try to identify a trigger, use gently tone or try to calm the resident, move them to a calm environment, shift their attention to a different activity, remove themselves from the room or leave the resident for a while until they calm (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675622 If continuation sheet Page 7 of 8 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 675622 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cityview Nursing and Rehabilitation Center 5801 Bryant Irvin Rd Fort Worth, TX 76132 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete down and make sure other residents were safe from aggressive residents , and notify upper management if a resident behavior escalated for further instruction. Observation of the residents on the secured unit on 07/10/25 from 9:39 AM to 11:24 PM revealed none displayed verbal or physical aggression towards other residents. Facility staff on the secured unit were observed to provide adequate supervision, assistance, and redirection as needed to meet the residents' needs. Interview on 07/10/25 at 2:13 PM with the DON revealed they screened residents prior to admission, and they did not accept any residents with aggressive behaviors. Record review of the facility's Abuse, Neglect, and Exploitation policy, implemented on 08/15/22, reflected the following: PolicyIt is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures and prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. An IJ was identified on 07/10/25. The IJ began on 06/26/25 and was removed on 07/06/25. The facility took action to remove the IJ before the abbreviated survey began. While the IJ was removed on 07/06/25, the facility remained out of compliance with a scope of pattern and severity level of no actual harm with potential for more than minimal harm. Event ID: Facility ID: 675622 If continuation sheet Page 8 of 8