Inspection·August 9, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few locked unit. She stated she immediately started looking for the resident after notifying LVN B. She stated she and other staff had been driving around the community looking for Resident #1. She reported she next saw Resident #1 walking up to the front of the building escorted by CNA A and was told that Resident #1 was found next door at an auto parts store. She stated that Resident #1 had not appeared to have any injuries. She reported that the ADM came to the facility about thirty minutes later but did not speak to her. She denied she was threatened or told not to say anything about the incident. She stated that when she worked the day shift the following day, she was told in report that Resident #1 had tried to elope, and she thought this was strange because Resident #1 had actually eloped. In an interview on 8/05/25 at 1:40 PM CNA D stated she was told by a CNA (name unknown) the day following the incident (date unknown) that Resident #1 had eloped and been found at an auto parts store on the prior evening shift and had been escorted back to the facility. She declined to state if her job had been threatened or she had been told not to say anything about the incident stating, I don't want to lose my job. They will retaliate against you and I don't want you writing anything that will cost me my job. In an interview and observation on 8/05/25 at 3:07 pm, Resident #1 stated she had left the facility through a window she had pushed through, maybe the start of last week (exact date unknown). She stated she went next door to an auto parts store and borrowed a lighter from a staff at the store because she wanted to smoke. She stated a female facility staff (name unknown) rolled up approximately twenty minutes later and escorted her back to the facility. She stated she left the facility because she missed her belongings and her apartment. She stated she did not think she spoke to the ADM that day. She denied she experienced any injury or adverse effects from leaving the facility. Resident #1 was observed with no obvious sign of injury. In an interview on 8/5/25 at 4:17 pm, the DON stated that Resident #1, sometimes gets on a rant about wanting to leave but that she had not heard anything about her going out a window or being over at an auto parts store. She reported that residents' windows have screws that prevent them from being raised enough for a resident to elope. She reported that preventing elopement for Resident #1 has included that Resident #1 was accommodated to go out for activities, she was on a secure unit, she was seeing psychiatric services, and she was placed on Q15 minute checks for behaviors as needed including aggression and elopement. She stated that staff were free to report any incidents without fear of retaliation and she had not received any complaints of staff being fearful of retaliation. The DON stated that all staff had received training on elopement and actions to take. She reported that part of the training included that the staff would notify the Administrator of an elopement incident. She stated in the event of a missing resident, all staff were to immediately search indoors and if not found would expand the search to the outdoor property, the Administrator would be notified, and a decision would be made if authorities needed to be notified. She stated she was not aware of any staff having been told not to document an incident and that they will do it instead. In an interview on 8/05/25 at 3:20 PM the ADM stated he was not informed of Resident #1 going out a window. He reported to his knowledge Resident #1 had never exited or tried to exit the facility. He stated Resident #1 had called a ride service and friends to come pick her up in the past. He stated there had not been any windows repaired in the past month except one window on the male unit. He stated he was not aware that Resident #1 was placed on Q15 minute checks but that this can be done for excessive wandering as well as aggressive or other behaviors. He reported that if a resident exited the facility, he expected staff to count all residents, search the facility, call a code silver, search the exterior property, and then the surrounding properties, and notify the DON, himself, the MD, and the family. He reported that he was not aware of Resident #1 having any injuries in the past three weeks. He reported that staff have received (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675906 If continuation sheet Page 2 of 12 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 675906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Benbrook Nursing & Rehabilitation Center 1000 McKinley St Benbrook, TX 76126 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm training on handling and reporting elopements/code silver training. He stated that if staff had informed him, he would have notified the police if the Resident was not immediately found. He stated he would have notified the state if a resident had eloped. He denied he ever threatened staff with their jobs if they said anything about the incident. He stated that he would be beginning an investigation now, and if he finds that Resident #1 did in fact elope, he will report it to the state. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675906 If continuation sheet Page 3 of 12 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 675906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Benbrook Nursing & Rehabilitation Center 1000 McKinley St Benbrook, TX 76126 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 0610 Respond appropriately to all alleged violations. 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, in response to allegations of abuse or neglect, have evidence that all alleged violations were thoroughly investigated, prevent further potential abuse and neglect while the investigation was in progress, report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and take appropriate corrective action if the alleged violation was verified one (Resident #1) of five residents reviewed for reporting of abuse. The facility failed to investigate and report to the State Survey Agency the results of the investigation of the elopement of Resident #1 during July of 2025. This failure could place residents at risk for unresolved or future abuse or neglect.Findings included: Review of Resident #1's Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Review of Resident #1's Quarterly MDS dated [DATE] reflected diagnoses including Chronic Obstructive Pulmonary Disease (condition caused by damage to the lungs), coronary artery disease (disease caused by buildup of plaque in the arteries of the heart), Anxiety Disorder, and Depression. A BIMS score of 10 was reflected, indicating moderate cognitive impairment. Resident #1 scored 0 on wandering behaviors, which indicated the behavior was not exhibited. Review of Resident #1's Care Plan with start date 6/13/25 reflected Resident #1 had a focus of elopement risk r/t history of attempts to leave the facility unattended, and with impaired safety awareness with date initiated 9/09/24 and revised solely on 12/24/24. In an interview on 8/05/25 at 12:41 pm, CNA A stated that approximately two weeks prior (exact date unknown), Resident #1 had climbed out of a window on the female locked unit. She stated that she saw Resident #1's wheelchair sitting empty by an open window and had notified LVN B. She reported staff searched the unit and then the property, but that Resident #1 was not located, and staff began using their vehicles to search the community. She stated she found Resident #1 coming out of an auto parts store, the property adjacent to the facility, and escorted her back to the facility. She stated that the ADM arrived a short while later and threatened the jobs of staff if they were to say anything about the incident to anyone. She reported she had received elopement training within the past six months. In a telephone interview on 8/05/25 at 4:00 pm, LVN B stated about two weeks ago (exact date unknown), she was notified by CNA A that Resident #1 had gone out a window on the female locked unit. She stated that Resident #1 was not found at the facility but that she was returned to the facility by CNA A who reported that Resident #1 had been found at a nearby auto parts store. She stated she assessed Resident #1 upon her return to the facility and that she did not have any injuries. She stated that she called and notified the ADM and that he arrived approximately thirty minutes later and fixed the window that Resident #1 had kicked out. She stated she did not chart the elopement or her injury assessment because she was told by the ADM that he had to do an investigation, and he would take care of it. She stated she was not aware of any prior elopement attempts by Resident #1. She reported she had received elopement training within the past six months. In an interview on 8/05/25 at 1:30 PM LVN C stated while working the evening shift approximately two weeks ago (exact date unknown) she was notified by CNA A that Resident #1 had gone out of a window on the female locked unit. She stated she immediately started looking for the resident after notifying LVN B. She stated she and other staff had been driving around the community looking for Resident #1. She reported she next saw Resident #1 walking up to the front of the building escorted by CNA A and was told that Resident #1 was found next door at an auto parts store. She stated that Resident #1 did not appear to have any injuries. She stated she was not aware of any prior elopement attempts by Resident #1. She reported that the ADM Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675906 If continuation sheet Page 4 of 12 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 675906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Benbrook Nursing & Rehabilitation Center 1000 McKinley St Benbrook, TX 76126 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few came to the facility about thirty minutes later but did not speak to her. She denied she was threatened or told not to say anything about the incident. She stated that when she worked the day shift the following day, she was told in report that Resident #1 had tried to elope, and she thought this was strange because Resident #1 had actually eloped. She stated that Resident #1 was placed on Q15 minute checks for elopement risks. She stated she had thought the windows were secured but that she noted someone working on the window the day following the incident. She reported she had received elopement training within the past six months. In an interview on 8/05/25 at 1:40 PM CNA D stated she was told by a CNA (name unknown) the day following the incident (date unknown) that Resident #1 had eloped and been found at an auto parts store on the prior evening shift and had been escorted back to the facility. She stated she was not aware of Resident #1 having eloped or attempting to elope prior to this incident. She declined to state if her job had been threatened or she had been told not to say anything about the incident stating, I don't want to lose my job. They will retaliate against you and I don't want you writing anything that will cost me my job. She reported she had received elopement training within the past six months. In an interview and observation on 8/05/25 at 3:07 pm, Resident #1 stated she had left the facility through a window she had pushed through, maybe the start of last week (exact date unknown). She stated she went next door to an auto parts store and borrowed a lighter from a staff at the store because she wanted to smoke. She stated a female facility staff (name unknown) rolled up approximately twenty minutes later and escorted her back to the facility. She stated she left the facility because she missed her belongings and her apartment. She stated she did not think she spoke to the ADM that day. She denied she experienced any injury or adverse effects from leaving the facility. Resident #1 was observed with no obvious sign of injury. A bolt and nail were observed preventing Resident #1's window from opening more than a few inches. In an interview on 8/5/25 at 4:17 pm, the DON stated that Resident #1, sometimes gets on a rant about wanting to leave but that she had not heard anything about her going out a window or being over at an auto parts store. She reported that residents' windows have screws that prevent them from being raised enough for a resident to elope. She reported that preventing elopement for Resident #1 has included that Resident #1 was accommodated to go out for activities, she was on a secure unit, she was seeing psychiatric services, and she was placed on Q15 minute checks for behaviors as needed including aggression and elopement. She stated that staff were free to report any incidents without fear of retaliation and she had not received any complaints of staff being fearful of retaliation. The DON stated that all staff had received training on elopement and actions to take. She reported that part of the training included that the staff would notify the Administrator of elopement incidents. She stated in the event of a missing resident, all staff were to immediately search indoors and if not found would expand the search to the outdoor property, the Administrator would be notified, and a decision would be made if authorities needed to be notified. She stated she was not aware of any staff having been told not to document an incident and that they will do it instead. In an interview on 8/05/25 at 3:20 PM the ADM stated he was not informed of Resident #1 going out a window. He reported to his knowledge Resident #1 had never exited or tried to exit the facility. He stated Resident #1 had called a ride service and friends to come pick her up in the past. He stated there had not been any windows repaired in the past month except one window on the male unit. He stated he was not aware that Resident #1 was placed on Q15 minute checks but that this can be done for excessive wandering as well as aggressive or other behaviors. He reported that if a resident exited the facility, he expected staff to count all residents, search the facility, call a code silver, search the exterior property, and then the surrounding properties, and notify the DON, himself, the MD, and the family. He reported (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675906 If continuation sheet Page 5 of 12 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 675906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Benbrook Nursing & Rehabilitation Center 1000 McKinley St Benbrook, TX 76126 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 0610 Level of Harm - Minimal harm or potential for actual harm that he was not aware of Resident #1 having any injuries in the past three weeks. He reported that staff have received training on handling and reporting elopements/code silver training. He denied he ever threatened staff with their jobs if they said anything about the incident. He stated that he would be beginning an investigation now. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675906 If continuation sheet Page 6 of 12 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 675906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Benbrook Nursing & Rehabilitation Center 1000 McKinley St Benbrook, TX 76126 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of five residents reviewed for elopement. The facility failed to prevent Resident #1 from eloping from the facility on an unknown date in July 2025. The failure could place residents at risk for possible elopement, serious injuries, and harm. An Immediate Jeopardy (IJ) was identified on 08/08/25. The IJ template was provided to the facility on [DATE] at 3:32 pm. While the IJ was removed on 08/09/25, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm, and a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems.Findings include: Review of Resident #1's Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Review of Resident #1's Quarterly MDS dated [DATE] reflected diagnoses including Chronic Obstructive Pulmonary Disease (condition caused by damage to the lungs), coronary artery disease (disease caused by buildup of plaque in the arteries of the heart), anxiety disorder, and Depression. A BIMS score of 10 was reflected, indicating moderate cognitive impairment. Resident #1 scored 0 on wandering behaviors, which indicated the behavior was not exhibited. Review of Resident #1's Care Plan with start date 6/13/25 reflected Resident #1 had a focus of elopement risk r/t history of attempts to leave the facility unattended, and with impaired safety awareness with date initiated 9/09/24 and revised solely on 12/24/24. In an interview on 8/05/25 at 12:41 pm, CNA A stated that approximately two weeks prior (exact date unknown), Resident #1 had climbed out of a window on the female locked unit. She stated that she saw Resident #1's wheelchair sitting empty by an open window and had notified LVN B. She reported staff searched the unit and then the property, but that Resident #1 was not located, and staff began using their vehicles to search the community. She stated she found Resident #1 coming out of [an auto parts store], the property adjacent to the facility, and escorted her back to the facility. She stated that the ADM arrived a short while later and threatened the jobs of staff if they were to say anything about the incident to anyone. In a telephone interview on 8/05/25 at 4:00 pm, LVN B stated about two weeks ago (exact date unknown), she was notified by CNA A that Resident #1 had gone out a window on the female locked unit. She stated that Resident #1 was not found at the facility but that she was returned to the facility by CNA A who reported that Resident #1 had been found at a nearby auto parts store. She stated she assessed Resident #1 upon her return to the facility and that she did not have any injuries. She stated that she called and notified the ADM and that he arrived approximately thirty minutes later and fixed the window that Resident #1 had kicked out. She stated she did not chart the elopement or her injury assessment because she was told by the ADM that he had to do an investigation, and he would take care of it. She stated she was not aware of any prior elopement attempts by Resident #1. Review of Resident #1's June 2025, July 2025, and August 2025 progress notes did not reflect any documentation to indicate an elopement or elopement attempt. A few progress notes reflected Resident #1 was on Q15 minute checks and had exhibited no exit seeking behaviors during a shift but did not indicate the reason for these checks and observations. The facility incident report log was reviewed for May 2025, June 2025, and July 2025 and no elopement incidents were reflected. The facility in-service training attendance roster titled, Elopement Drill and dated 6/13/25 was reviewed with 53 staff signatures noted present. In an interview on 8/05/25 at 1:30 PM LVN C stated while working the evening shift approximately two weeks ago (exact date unknown) she was notified by CNA A that Resident #1 had gone out of a window on the female locked unit. She stated she immediately started looking for the resident after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675906 If continuation sheet Page 7 of 12 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 675906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Benbrook Nursing & Rehabilitation Center 1000 McKinley St Benbrook, TX 76126 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few notifying LVN B. She stated she and other staff had driven around the community looking for Resident #1. She reported she next saw Resident #1 walking up to the front of the building escorted by CNA A and was told that Resident #1 was found next door at an auto parts store. She stated that Resident #1 had not appeared to have any injuries. She stated she was not aware of any prior elopement attempts by Resident #1. She reported that the ADM came to the facility about thirty minutes later but did not speak to her. She denied she was threatened or told not to say anything about the incident. She stated that when she worked the day shift the following day, she was told in report that Resident #1 had tried to elope, and she thought this was strange because Resident #1 had actually eloped. She stated that Resident #1 was placed on Q15 minute checks for elopement risks. She stated she had thought the windows were secured but that she noted someone working on the window the day following the incident. In an interview on 8/05/25 at 1:40 PM CNA D stated she was told by a CNA (name unknown) the day following the incident (date unknown) that Resident #1 had eloped and been found at an auto parts store on the prior evening shift and had been escorted back to the facility. She stated she was not aware of Resident #1 having eloped or attempting to elope prior to this incident. She declined to state if her job had been threatened or she had been told not to say anything about the incident stating, I don't want to lose my job. They will retaliate against you and I don't want you writing anything that will cost me my job. In an interview and observation on 8/05/25 at 3:07 pm, Resident #1 stated she had left the facility through a window she had pushed through, maybe the start of last week (exact date unknown). She stated she went next door to an auto parts store and borrowed a lighter from a staff at the store because she wanted to smoke. She stated a female facility staff (name unknown) rolled up approximately twenty minutes later and escorted her back to the facility. She stated she left the facility because she missed her belongings and her apartment. She stated she did not think she spoke to the ADM that day. She denied she experienced any injury or adverse effects from leaving the facility. Resident #1 was observed with no obvious sign of injury. A bolt and nail were observed preventing Resident #1's window from opening more than a few inches. In an interview on 8/5/25 at 4:17 pm, the DON stated that Resident #1, sometimes gets on a rant about wanting to leave but that she had not heard anything about her going out a window or being over at an auto parts store. She reported that residents' windows have screws that prevent them from being raised enough for a resident to elope. She reported that preventing elopement for Resident #1 had included that Resident #1 was accommodated to go out for activities, she was on a secure unit, she was seeing psychiatric services, and she was placed on Q15 minute checks for behaviors as needed including aggression and elopement. She stated that staff were free to report any incidents without fear of retaliation and she had not received any complaints of staff being fearful of retaliation. The DON stated that all staff had received training on elopement and actions to take. She reported that part of the training included that the staff would notify the Administrator of an elopement incident. She stated in the event of a missing resident, all staff were to immediately search indoors and if not found would expand the search to the outdoor property, the Administrator would be notified, and a decision would be made if authorities needed to be notified. She stated she was not aware of any staff having been told not to document an incident and that a facility supervisor would do it instead. In an interview on 8/05/25 at 3:20 pm, the ADM stated he was not informed of Resident #1 going out a window. He reported to his knowledge Resident #1 had never exited or tried to exit the facility. He stated Resident #1 had called a ride service and friends to come pick her up in the past. He stated there had not been any windows repaired in the past month except one window on the male unit. He stated he was not aware that Resident #1 was placed on Q15 minute checks but that this can be done for excessive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675906 If continuation sheet Page 8 of 12 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 675906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Benbrook Nursing & Rehabilitation Center 1000 McKinley St Benbrook, TX 76126 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few wandering as well as aggressive or other behaviors. He reported that if a resident exited the facility, he expected staff to count all residents, search the facility, call a code silver, search the exterior property, and then the surrounding properties, and notify the DON, himself, the MD, and the family. He reported that he was not aware of Resident #1 having any injuries in the past three weeks. He reported that staff had received training on handling and reporting elopements/code silver training. He stated that if staff had informed him, he would have notified the police if the Resident was not immediately found. He stated he would have notified the state if a resident had eloped. He denied he ever threatened staff with their jobs if they said anything about the incident. He stated that he would be beginning an investigation now, and if he finds that Resident #1 did in fact elope, he will report it to the state. Review of the facility policy titled, Wandering and Elopements dated 2001 and revised March 2019 stated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The policy stated that, when a resident returns to the facility, the director of nursing services or charge nurse shall a.) examine the resident for injuries, b.) contact the attending physician and report findings and conditions of the resident; c.) notify the resident's legal representative (sponsor); d.) notify search teams that the resident has been located; e.) complete and file an incident report; and f.) document relevant information in the resident's medical record. In an interview on 8/08/25 at 11:05 am, an auto parts store Employee was interviewed at the store located adjacent to the facility. The employee stated that about two weeks ago (exact date unknown) an elderly white female came into the store and asked for a cigarette lighter and to call a taxi. He stated this occurred sometime between 2 pm and 4 pm. He reported about 30 minutes later a black male staff and black female staff member from the nursing home across the street came and got the resident. He reported the taxi called back after the resident left and he told them she had been taken back to the nursing home. He reported the elderly resident was walking steadily but that he had noted her hands were shaky. He stated the resident had not appeared to have any injuries. He confirmed by the picture of the facility face sheet that the resident he saw was Resident #1. He did not remember the exact date this occurred or what other employees might have been present. In an interview on 8/08/25 at 1:00 pm, the DON stated that Resident #1 was on the locked unit because she had fluctuations in her cognition that could cause her safety issues due to confusion at times. She reported that Resident #1'samily member had tried to take her home for a trial placement in the past (date unknown) but that Resident #1's family member noted she was unsafe. She was not sure what occurred that her family member felt like it was unsafe for Resident #1 to be home. The DON stated that Resident #1 had become agitated one day this week and had screamed, get me the fuck out of here. She reported that Resident #1 has always been on the locked unit since her admission to the facility. In an interview on 8/08/25 at 2:42 PM, Resident #1's family member revealed the facility had notified her when Resident #1 had behaviors, and that when Resident #1 was first admitted to the facility staff had informed her that the resident had broken a window. She said that on 8/05/25 the ADM had called and informed her Resident #1 had said she had escaped through a window at the facility, but not that she had actually done it. She stated the ADM informed her there was an investigation about Resident #1 escaping through a window and he asked if she knew anything about that and she told him she did not. She said Resident #1 had a history of drug addiction, definitely has some behavioral problems, and sometimes she acted out to get attention. She said Resident #1 had been in nursing facilities closer to their home, but they would not keep her, because of her behaviors. She said the family had been trying to work with a program that could give the resident the help she needed in her home, but when people from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675906 If continuation sheet Page 9 of 12 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 675906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Benbrook Nursing & Rehabilitation Center 1000 McKinley St Benbrook, TX 76126 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few program went to interview her, all Resident #1 had talked about was how she was leaving and was not going to stay at the facility for another minute (date unknown). The Administrator was notified on 8/08/25 at 3:26 pm that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 08/08/25 at 3:32 pm. The facility's Plan of Removal was accepted on 8/09/25 at 10:31 am and included: Corrective Actions: On 8/6/2025, the DON and the ADM in-serviced direct care staff on Code Silver Policy and Procedure (Code Silver is the code called in the facility if a resident is missing), and notification. On 8/6/2025, all windows on locked units were permanently secured so that they could only open 4-6 inches for safety and security by maintenance to ensure they did not open fully, and no residents were able to exit via the window.On 8/6/2025 all residents wandering assessments were updated by the DON, the ADON, and the MDS Coordinator. Any resident who were designated at risk as determined by the DON, the ADON, and the MDS Coordinator were placed on the secure unit with an order from the physician. All residents who were determined to be at risk of wandering had their care plan updated by the MDS Coordinator.On 8/6/2025 it was verified by the DON that all residents on the secure unit had a physician order for appropriate placement.By 8/6/2025, Ad hoc QAPI (Quality Assurance and Performance Improvement) committee meeting was conducted with the Interdisciplinary Team and the Medical Director to review the elopement policy for effectiveness, and this will be reviewed quarterly going forward for effectiveness.By 8/6/2025 all staff had been educated by the DON, the ADON and the MDS Coordinator on the definition of elopement and that if an employee observed a resident leaving the premises, he/she should:- Attempt to prevent the residents from leaving in a courteous manner.- Get help from other staff members in the immediate vicinity if necessary.- Always stay with the patient.- Instruct another staff member to inform the charge nurse or Director of Nursing services that a resident is attempting to leave or has left the premises. Call if necessary.If the door alarm sounds, but no resident is found outside the premises all staff members will conduct a thorough search for the resident in the facility, including areas such as kitchen, closets, and bathroom to ensure all residents are accounted for.If a resident is missing, initiate the elopement/missing resident emergency procedure.- Determine if the resident is out on an authorized Leave or Pass.- If the resident was not authorized to leave, initiate a search of the building and premises.- If the resident is not located, notify the Administrator and Director of Nursing services, the legal representative, the attending physician, law enforcement officials, and if needed volunteer agencies.When the resident returns to the facility the DON and/or charge nurse shall- Examine the resident for injuries.- Contact the physician, report finding and condition of resident.- Notify resident's legal representative (RP)- Notify everyone in search that the resident has been located.- Complete incident report- Document relevant information in [Electronic Medical Record]Any PRN staff member or newly hired employee who had not received in-service by end of business on 8/6/2025 would not work the floor until in-service had been received.On 8/6/2025 the DON, the ADON, and the ADM educated all staff in the event a resident had exit seeking behaviors on the secure unit, the charge nurse is to be notified, and he/she will be care planned. On 8/8/2025 the LNFA COO educated the ADM and the DON on reportable guidelines and investigation. All reportable events will be reported immediately to COO for investigation oversight. If the COO is out of office, the CEO shall be notified in her stead. Documentation:On 8/8/2025 the DON and the ADON in-serviced all licensed nurses on the importance of documentation, assessment, notification and follow up after an elopement.Monitoring:As of 8/8/2025 going forward the DON will question licensed staff regarding elopements during clinical meetings.As of 8/6/2025 window inspections will be conducted 3x week for 30 days then weekly ongoing by the Maintenance Director, a Weekend Supervisor, or the ADM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675906 If continuation sheet Page 10 of 12 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 675906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Benbrook Nursing & Rehabilitation Center 1000 McKinley St Benbrook, TX 76126 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Monitoring the plan of removal: Interviews with the following staff between 3:00 PM on 08/08/25, and 2:00 PM on 08/09/25: MDS Coordinator, CNA E (6:00 AM to 2:00 PM shift), LVN F (all shifts), CNA G (6:00 AM to 2:00 PM shift), LVN H (6:00 AM to 2:00 PM and 10:00 PM to 6:00 AM shifts), LVN I (6:00 AM to 2:00 and 2:00 PM to 10:00 PM shifts), Med Aide J (all shifts), CNA K (all shifts), LVN L (6:00 AM to 2:00 and 2:00 PM to 10:00 PM shifts), and CNA M (6:00 AM to 2:00 PM and 2:00 PM to 10:00 PM shifts), revealed staff had been in-serviced on the definition of elopement, Code Silver procedures (the code called in the facility if a resident was missing), interventions for exit-seeking behaviors, and what to do if a resident was found to be missing, notifications, documentation, assessment, follow up, reporting of exit seeking behaviors and elopements/elopement attempts. They also were knowledgeable about contacting their corporate number if they were not comfortable reporting to administration, were aware of the HHSC number for Abuse and Neglect reporting and denied having any discomfort reporting to Administration. In observations on 8/9/25 at 12:42 pm, the windows on the male and female locked units were observed to have been changed to be openable from 4-6 inches only. Review of clinical records for Residents #2, #3, #4 and #5 included progress notes, care plans, and wandering assessments done prior to 8/08/25, and wandering assessments updated on 8/08/25 as part of the facility's plan of removal. No concerns were noted, and there were no significant changes in assessments. In a review of records, Resident #1's care plan reflected interventions for elopement were updated on 8/08/2025 and included the following: activities will take Resident #1 on out of facility activities on one to one, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, Resident #1 prefers going outdoors to smoke and sit in the sun, one on one with the Activity Director including out to eat, Walmart trips, watching movies, reading books, outings with family, medication adjustment made on 8/06/25 to risperidone, monitor for fatigue and weight loss, provide structured activities- regular toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes, and resident will reside on secure unit for safety. A review of Resident #1's progress note dated 8/6/25 and created by LVN B reflected Resident #1's Risperidone was increased to one milligram twice daily and resident was placed on Q15 minute checks for exit seeking behaviors. In an interview on 8/09/25 at 10:24 am the DON reported that based on the assessments of the DON, the ADM, and the MDS Coordinator, no residents were deemed at risk requiring a move to a secure unit. A record review of the facility Order Listing Report reflected physician orders were present for residents on the locked units. A record review of the facility QAPI minutes dated 8/6/25 reflected elopement was reviewed by the facility, and 7 signatures were observed including the ADM and Medical Director as well as others. A record review of the facility in-service training record dated8/8/25 and titled, COC (Change of Condition) Charting, I/A (Incidents and Accidents) reports, Abuse/Neglect Reporting, Corporate Reporting was reviewed and included the signatures of 11 nurses and one CNA. A record review of the facility in-service training record dated 8/6/25 and titled, Elopement/Code Silver, Policy and Procedure, Documentation/Charting was reviewed and noted with 54 signatures including LVN, dietary manager, CNA, Social services, PT, dietary aide, laundry, staffing, BOM, housekeeping, and other staff. The ADM provided a list of employees who had not signed the training documenting and they were called and provided with verbal training. A review of a word document provided by the ADM dated 8/08/25 documented education was provided to the ADM and the DON on reportable guidelines and investigations by the LNFA COO and included signatures of the ADM, the DON, and the LNFA COO. In a review of records, a word document provided by the facility reflected the initial window inspection was completed on 8/6/25 and signed by the Maintenance Director with a statement noting that all windows in the female and male secure units (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675906 If continuation sheet Page 11 of 12 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 675906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Benbrook Nursing & Rehabilitation Center 1000 McKinley St Benbrook, TX 76126 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete had been verified as fixed. In an interview on 8/09/25 at 2:26 pm, the ADM reported that he and the DON received training on 8/09/25 by the regional LNFA COO who went over all the trainings that they were to provide to staff, the plan of removal, and reportable guidelines and investigation. The ADM reported he will report all reportable events immediately to the LNFA COO for investigation oversight, and if the COO is out of office, he will notify the CEO. He reported that as an Administrator he plans to talk to the staff more thoroughly and watch how he is talking to staff as something that was meant as a precautionary statement had been taken as a threat. He stated he intended to make sure that documentation is thorough. The ADM reported that this was IJ as the resident was at risk due to possible elopement that wasn't reported in a correct or timely manner and there was an allegation that the Administrator threatened retaliation against staff for documenting and reporting. In an interview on 8/09/25 at 4:17 PM the DON stated that she and the ADM had received training from corporate on all training involved in the plan of care and all the in-service trainings that they were to provide to the staff. She stated that she feels the reeducation of staff on all the topics will make a difference and that now the corporate number has been made available to staff. The DON stated that this situation was an IJ because there was an allegation of an elopement that was not processed or addressed, and it was an IJ because the situation presented a risk. She reported she will be questioning staff regarding elopements during clinical meetings going forward and will be monitoring to ensure that any PRN staff who have not received the appropriate training are not allowed to work. On 8/09/25 at 2:46 pm the ADM was notified the IJ was removed. However, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate their corrective actions. Event ID: Facility ID: 675906 If continuation sheet Page 12 of 12