Inspection·August 7, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a new roommate because he like it peaceful. Observation and interview on 08/07/25 at 12:47 PM with Resident #2 revealed he was in his recliner and appeared to be hard of hearing. The resident was asked about the incident with Resident #1 (03/18/25), and Resident #2 said it has occurred a long time ago. Resident #2 said he and Resident #1 argued about the room temperature and Resident #1 had threatened him, but he did not recall what was said. Resident #2 said he was not scared at the time because he knew Resident #1 was just talking to talk and he knew how to defend himself if he needed to. Resident #2 stated he was moved to another room, and he did not have any concerns and felt safe at the facility. Interview on 08/06/25 at 1:26 PM with LVN B revealed Resident #1 did not like to have roommates and he had been moved a couple of times due having issues with prior residents. LVN B said she was making rounds, did not recall how long ago, when she heard Residents #1 and #2 argue and when she entered the room Resident #2 wanted to turn the AC up because he was cold, and Resident #1 did not want that. LVN B said she told both residents to calm down and Resident #2 said he was going to punch the shit out of him. LVN B said she separated both residents and took Resident #2 to another room and also said Resident #2 did not appear to be afraid with the threat. LVN B stated she had never seen Resident #1 have any behaviors towards others and he only bickered with roommates because he wanted a room to himself. Interview on 08/06/25 at 1:17 PM with LVN D revealed Resident #1 was pleasant and socialized with others, staff and residents. LVN D stated she had never heard Resident #1 be verbally abusive towards other and the resident normally stayed in his room on his computer. Interview on 08/06/25 at 1:44 PM with the ADON revealed she recalled the incident Resident #1 and #2 but she did not recall the details or what words were exchanged between both residents. Interview on 08/06/25 at 3:32 PM with the Previous DON revealed she recalled there had been an incident between Resident #1 and #2, but did not recall how long ago, where the residents had argued about the room temperature. The Previous DON stated she did not recall Resident #1 had threatened to punch Resident #2. 2. Record review of Resident #3's admission MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included non-Alzheimer's dementia, Parkinson's disease, anxiety disorder and depression. Resident #3 had a BIMS of 15 which indicated his cognition was intact. The MDS further reflected Resident #3 did not exhibit physical or verbal behaviors. Record review of Resident #3's undated current care plan did not reflect any physical or verbal behaviors. Record review of the facility's Provider Investigation Report dated 07/09/25 reflected the following: [Resident #1] did stand over [Resident #3] and yelled at him because he was snoring. [Resident #3] does have a history of snoring. Safe surveys were completed and no concerns were noted by other residents.Record review of Resident #1's progress notes dated 06/28/25 documented by LVN C reflected the following: This unit nurse was called to the patient's room to address threats made by the patient towards his roommate regarding the roommate's loud snoring. The threats included the statement that if the roommate did not stop snoring loudly, [Resident #1] would ‘knock the snore out of him.' The patient expressed significant frustration and irritation, stating he had been unable to sleep for four consecutive nights and had reached his limit. The patient was transferred to [another hall] to an empty room to be by himself.Observation and interview on 08/06/25 at 10:25 AM with Resident #1 revealed he was in his room sitting on his rolling walker and did not have a roommate at the time. The resident said he had trouble with a previous roommate, and he stated Resident #3 snored very loudly, and he told Resident #3 to hush, but the Resident #3 kept snoring. Resident #1 denied threatening Resident #3 or telling him he would plug his nose up. Resident #1 further stated he now had a room to himself, and he stated he hoped he would not get a new roommate because he liked it peaceful.Observation and interview on 08/06/25 at 9:53 AM of Resident #3 revealed he was in his room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675935 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 675935 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Haltom 2936 Markum Dr Fort Worth, TX 76117 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 - Minimal harm or potential for actual harm Residents Affected - Some sitting in his wheelchair and appeared to be pleasant. Resident #3 was asked about the incident, 06/26/25, with Resident #1 and he said the end of June his roommate (Resident #1) woke him up and told him he was snoring like a pig. Resident #3 said he told Resident #1 he could not stop, and he did not recall the exact words but Resident #1 told Resident #3 he was going to plug his nose to shut him up and he was going to kick his ass. Resident #3 said he did not feel safe at the time and reported the incident to the charge nurse. Resident #3 said he was moved to another room and did not see Resident #1 anymore. Resident #3 further stated he currently felt safe at the facility and was not scared of Resident #1. Interview on 08/06/25 at 3:42 PM with LVN C revealed she recalled Resident #1 was upset with Resident #3 and stated if Resident #3 did not quiet his snoring, he was going to do something physical to him but did not recall what his exact words were. Resident #3 told LVN C he could not control his snoring and did not feel safe in the room with Resident #1 at that time. Resident #3 was then transferred to another hall. LVN C said she believed Resident #3 had made false threats as he was usually pleasant when he was around other residents. Interview on 08/06/25 at 3:23 PM with the ADON revealed she was told Resident #1 had said something to Resident #3 about his loud snoring, but she did not recall what was said between both residents. The ADON said Resident #3 was in a room alone and there were no current behavioral issues with the resident. Interview on 08/07/25 at 1:48 PM with the Administrator revealed Resident #1 had some past verbal behaviors. The Administrator said he knew Resident #1 and Resident #2 has argued about the room temperature back in March, but he was not aware #1 had threatened Resident #2. The Administrator further stated there had been an incident where Resident #1 had become upset at Resident #3's snoring. The residents were separated, and Resident #1 did better with no roommates. 3.Record review of Resident #4's quarterly MDS assessment reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, non-Alzheimer's anxiety disorder, and depression. Resident #4 had a BIMS of 4 which indicated her cognition was severely impaired. The MDS also reflected Resident #4 usually understood others. The MDS further reflected the resident had physical behaviors 4 to 6 days a week and verbal behaviors towards others 1 to 3 days a week. Resident #4. The resident also required substantial/maximal assistance for bathing/showers. Record review of Resident #4's care plan revised on 05/24/23 reflected the resident was resistive to care, refused to take showers, and became very angry yelling at staff that she cannot take a shower because she is going to fall. Interventions included to allow the resident to make decision about treatment regime and assist or offer the resident a bed bath when she refused showers. If the resident resist ADL's reassure the resident, leave for 5-10 minutes and try again later. Record review of the facility's Provider Investigation Report dated 06/06/25 reflected the following: CNA was providing a shower to resident and was being hit by resident. CNA was overheard stating ‘You are not going to hit me. I am not the person you want to do that. If you hit me again, I will not give you [soda] or candy bar'.Observation and interview on 08/06/25 at 9:50 AM of Resident #4 revealed she was in bed with her eyes open. She was asked how he was doing and she responded with good and did not answer any follow-up questions and appeared confused as she pulled her covers over her face. Interview on 08/06/25 at 2:19 PM with the Housekeeping Supervisor revealed she was making round around 3:00 PM (06/06/25) when she overheard commotion and when she walked past the shower room she heard an aide (CNA A) yell at Resident #4 don't hit me, I'm not the one and I will hit you back and also said he she did not behave the resident would not get a [candy bar] or soda. Resident #4 was heard repeatedly saying no, no, no. At that time the Housekeeping Supervisor went to get the DON, and the DON went to the shower room where she stood for a moment to listen to what was being said and the CNA continued to yell at the resident, but the Housekeeping (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675935 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 675935 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Haltom 2936 Markum Dr Fort Worth, TX 76117 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 - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Supervisor was not able to make out what was said. The DON then opened the door, asked the Housekeeping Supervisor to stay as a witness and the aide was told to get her things and leave the facility. The Housekeeping Supervisor stated Resident#4 usually yelled out stating she wanted candy and soda and had never heard any other staff yell at the resident. Interview on 08/06/25 at 3:32 PM with the Previous DON revealed the Housekeeping Supervisor reported she heard what she thought was verbal abuse. The DON said she then went to the shower room and when she entered CNA A was assisting the resident with her shower and there was BM on the resident. The DON said she did not hear verbal abuse when she stood at the door but only heard CNA A say she could not have something until the resident was nice. The DON said CNA A was not yelling but felt like the acoustics in the shower room made it appear as thought she was yelling. The DON said the resident was yelling out someone's name which she said was her baseline and did not appear distressed. The DON stated she had CNA A sent home and had another staff member finish Resident #4's shower. The DON further stated CNA A has recently been hired and did not have previous complaints about her and said she did not get to talk to the CNA A as she had to leave out of town shortly after and the Administrator had taken over the investigation. Interview on 08/06/25 at 3:23 PM with the ADON revealed she was made aware by the Previous DON of the incident between Resident #4 and CNA A. The ADON said she had only conducted staff interview as part of the investigation. The ADON stated Resident #4 had severe dementia and was combative during care and at times there were periods when the resident would become very confused. The ADON said CNA A was new to the facility and had only been out of training for about two weeks and no staff nor resident has complained about her. Interview on 08/07/25 at 1:48 PM with Administrator revealed the Housekeeping Supervisor overhead and aide (CNA A) speak to Resident #4 in an abusive manner so the Housekeeping Supervisor reported the incident to the Previous DON. The Previous DON then suspended CNA A pending the investigation and the CNA A did not return to work. The Administrator said he spoke to CNA A about the incident and the aide had denied the allegation. The Administrator further stated CNA A had not worked at the facility long and he did not have any issues or concerns with CNA prior to the incident. Record review of the facility's policy titled Abuse-Prevention Record reviewed on 05/06/25 reflected the following: PolicyIt is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation or resident property, and exploitation.The resident has the right to be free from abuse, neglect, misappropriation of resident property. Event ID: Facility ID: 675935 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 675935 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Haltom 2936 Markum Dr Fort Worth, TX 76117 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 Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin source and misappropriation of resident property are reported immediately but not later than 2 hours after the allegation is made to the administrator of the facility and to other officials (including to the State Survey Agency) for 1 of 5 residents (Resident #2) Record reviewed for reporting. The facility failed to report to the Administrator when Resident #1 verbally threatened Resident #2 on 03/18/25. This failure places residents at risk for further abuse. Findings included:Record review of Resident #1's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included non-Alzheimer's dementia, anxiety disorder, and depression. Resident #1 had a BIMS of 15 which indicated his cognition was intact. The MDS further reflected the resident did not exhibit physical or verbal behaviors. Record review of Resident #1's care plan initiated on 06/28/25 reflected the resident was at risk for behaviors related to history of initiating verbal aggression toward previous roommate. Interventions included to educate the resident on boundaries related to appropriate communication techniques, problem solving, techniques, and who to discuss with, without becoming verbally aggressive with people. Other interventions included to take resident triggers into consideration with considering roommate placement. Record review of Resident #2's annual MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] and his diagnoses included non-Alzheimer's dementia. Resident #2 had a BIMS of 9 which indicated his cognition was moderately impaired. The MDS further reflected the resident did not exhibit physical or verbal behaviors. Record review of Resident #2's undated current care plan did not reflect any physical or verbal behaviors. Record review of Resident #2's progress noted dated 03/18/25 documented by LVN B reflected the following: This nurse went to picked [sic] up morning trays after resident ate breakfast from [hall] and heard both resident were exchanging words. This nurse went to resident's room and asked both of them to stop. [Resident #1] was verbally abusing his roommate and stated he will knock him out. This nurse told him to moved [sic] back to his space and to stopped [sic] verbally abusing and threatening his roommate. This nurse moved the other resident out of the room an brought him to the nursing station.Observation and interview on 08/06/25 at 10:25 AM with Resident #1 revealed he was in his room sitting on his rolling walker and did not have a roommate at the time. The resident said he had trouble with previous and stated Resident #2 alleged Resident #1 had threatened to kill him but that never happened. Resident #1 further stated he now had a room to himself and hope he would not get a new roommate because he like it peaceful. Observation and interview on 08/07/25 at 12:47 PM with Resident #2 revealed he was in his recliner and appeared to be hard of hearing. The resident was asked about the incident with Resident #1 (03/18/25), and Resident #2 said it has occurred a long time ago. Resident #2 said he and Resident #1 argued about the room temperature and Resident #1 had threatened him, but he did not recall what was said. Resident #2 said he was not scared at the time because he knew Resident #1 was just talking to talk and he knew how to defend himself if he needed to. Resident #2 stated he was moved to another room, and he did not have any concerns and felt safe at the facility. Interview on 08/06/25 at 1:26 PM with LVN B revealed Resident #1 did not like to have roommates and he had been moved a couple of times due having issues with prior residents. LVN B said she was making rounds, did not recall how long ago, when she heard Residents #1 and #2 argue and when she entered the room Resident #2 wanted to turn the AC up because he was cold, and Resident #1 did not want that. LVN B said she told both (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675935 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 675935 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Haltom 2936 Markum Dr Fort Worth, TX 76117 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete residents to calm down and Resident #2 said he was going to punch the shit out of him. LVN B said she separated both residents and took Resident #2 to another room and also said Resident #2 did not appear to be afraid with the threat. LVN B stated she had never seen Resident #1 have any behaviors towards others and he only bickered with roommates because he wanted a room to himself. Interview on 08/06/25 at 1:17 PM with LVN D revealed Resident #1 was pleasant and socialized with others, staff and residents. LVN D stated she had never heard Resident #1 be verbally abusive towards other and the resident normally stayed in his room on his computer. Interview on 08/06/25 at 1:44 PM with the ADON revealed she heard both residents had to be separated because they were not getting along but did not recall the details. The ADON said she did not report the incident to the Administrator but assumed he had been told about the incident by the Previous DON.Interview on 08/06/25 at 3:32 PM with the Previous DON revealed she recalled there had been an incident between Resident #1 and #2, but did not recall how long ago, where the residents had argued about the room temperature. The Previous DON stated she did not recall Resident #1 had threatened to punch Resident #2 and she believed the Administrator has been made aware. Interview on 08/07/25 at 1:48 PM with the Administrator revealed he was made aware Resident #1 and Resident #2 did not get along and at one time Resident #1 was upset about the temperature in the room he shared with Resident #2. The Administrator said he was not aware Resident #1 had verbally threatened Resident #2 during the room temperature incident. The Administrator stated he was the abuse coordinator, and the verbal threat should have been reported to him and all allegations of abuse should be reported to state office. Record review of the facility's Abuse-Conducting an Investigation policy, dated May 2025, reflected the following: PolicyIt is the policy of this facility that allegations of abuse (abuse, neglect, mistreatment, including injuries of unknown origin, exploitation, and misappropriation of property) are promptly and thoroughly investigated.Complaints and grievances will be investigated as outlined in the.and will be reported immediately if the investigation reveals any alleged violation involving neglect, abuse, (including injuries of unknown source), and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State Law.3. When an incident or suspected incident of resident abuse and/or neglect, injury of unknown source, exploitation, or misappropriation of resident property is reported, the administrator/designee will investigate the occurrence. Event ID: Facility ID: 675935 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 675935 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Haltom 2936 Markum Dr Fort Worth, TX 76117 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 have evidence that all alleged violations in response to allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 of 5 residents (Resident #5) Record reviewed for abuse.The facility failed to thoroughly investigate and an incident when CNA A asked Resident #5 for $0.50 to buy a soda on 07/23/2025. This failure places the residents at risk for misappropriation and exploitation. Findings included:Record review of Resident #5's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included non-Alzheimer's dementia, anxiety disorder, and depression. The resident had a BIMS of 14 which indicated her cognition was intact. Record review of Resident #5's care plan dated 05/06/25 reflected the resident was noted to be making false accusations against staff, stating staff are not answering her call light or attending to her needs, states they make her stay in wet brief for hours when staff are in the room every time she puts call light on and at least every hour to attend to her needs. Interventions included anticipate and meet the resident's needs and if reasonable, discuss the resident's behaviors and reinforce why behavior is inappropriate and/or acceptable to the resident. Record review of the facility's Provider Investigation Report dated 07/30/25 reflected the following: When was the allegation made?07/23/25Investigation SummaryCNA stated she did request $.50 for drink from resident. CNA provided ED with $.50 and the money was returned to resident. CNA was terminated.Action to prevent recurrence CNA was suspended pending outcome of investigation and safety rounds were completed on residents on D Hall.Agency Action Post-Investigation Associate was terminated and education was completed regarding ANE prevention and reporting.Further review of the provider investigation report revealed there was no evidence of staff education and/or interviews and there was no evidence and other resident interviews were submitted during the time of the incident. Observation and interview on 08/06/25 at 10:07 AM with Resident #5 revealed she was in bed watching TV and when asked if staff has asked her for money recently, she said aide (CNA E) asked her for $.50 and she (Resident #5) did not know what to do so she just gave it to her. Resident #5 said she did not want to give her the money but felt like she had to so after that Resident #5 said she reported it to the Administrator. Resident #5 said that was the first time CNA E has asked her for money and no one else has done so since. Resident #5 said the Administrator took care of the issue and she felt safe at the facility. Interview on 08/06/25 at 10:07 AM with the Administrator revealed Resident #5 called him (07/23/25) and said CNA E asked to borrow $.50 and it sounded like the resident did not want to but felt forced. The Administrator said he spoke with CNA E who admitted asking Resident #5 for the money and also said she knew it was wrong. CNA E was suspended pending the investigation and later terminated for the incident. Interview on 08/07/25 at 2:03 PM with CNA E revealed she did not ask Resident #5 for $.50 (07/23/25) but it was the resident who wanted to give her $1 for a soda. CNA E said that she already had $.50 on her and only accepted $.50 from the resident so she could buy her soda but had planned to pay the resident back. CNA E admitted knowing it was wrong to accept the money from Resident #5 but because she knew she was going to pay her back CNA E did not think much about it. The following day after the incident, the Administrator approached her (CNA E) to ask about the money and she told him she had taken the money and also said she had the money in her pocket to pay Resident #5 back so the Administrator took the money from her and said he would give it back to the resident. Interview on 08/07/25 at 2:09 PM with the Interim Social Worker revealed she only did 2 safe surveys with residents and was told to stop by the Administrator because she had new admissions to work on. Further interview on 08/07/25 at 1:48 PM with the Administrator revealed his investigation Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675935 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 675935 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Haltom 2936 Markum Dr Fort Worth, TX 76117 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 FORM CMS-2567 (02/99) Previous Versions Obsolete with Resident #5 and CNA E was complete because the aide had admitted to asking and taking money from Resident #5 and there was nothing else to complete. The Administrator said the facility held fire drills around the same time as the incident so during the fire drill staff were talked to about taking money from residents. Record review of documentation provided by the Administrator on 08/06/25 reflected there was a fire drill completed on 07/31/25. Record review of an email sent by the Administrator on 08/11/25 reflected there 8 resident safe surveys conducted on 07/29/25 in which one of the questions included: Has an associate asked to borrow your personal belongings including money for their own use? with no concerns. Record review of the facility's Abuse-Conducting an Investigation policy, dated May 2025, reflected the following: PolicyIt is the policy of this facility that allegations of abuse (abuse, neglect, mistreatment, including injuries of unknown origin, exploitation, and misappropriation of property) are promptly and thoroughly investigated. Event ID: Facility ID: 675935 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 675935 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Haltom 2936 Markum Dr Fort Worth, TX 76117 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 5 residents (Resident #5) reviewed for wound care . The facility failed to ensure Resident #5's stage 4 pressure ulcer wound her sacrum was covered with a dressing.This failure could place residents at risk of severe pain, and lead to systemic infections causing harm for residents.Record review of Resident #5's entry MDS assessment dated [DATE] reflected the resident was a [AGE] year-old female, who admitted to the facility on [DATE] and readmitted on [DATE]. The resident had moderate cognitive impairment with a BIMS score of 11, and her diagnoses included diabetes mellitus, and the MDS reflected she had a Stage 4 pressure ulcers.Record review of Resident #5's care plan dated 06/26/25 reflected: Focus: Resident#5 has actual impairment to skin integrity. admitted with Stage 4 pressure ulcer to sacrum. Goal: [Resident #5] Risk for developingnew pressure ulcers will be minimal with nursing interventions through the Record review date. Interventions: Assess location, size and treatment of skin injury. Report abnormalities, failure to heal, sign and symptoms of infection and maceration. Treatment as ordered.Record review of Resident #5's physician order dated 07/23/25 reflected: Cleanse Sacrum with NS, pat dry, apply Santyl, and cover with gauze island with border dressing everyday shift AND as needed if soiled or dislodged.Observation and interview on 08/07/24 at 9:12 AM with the Wound Care Nurse of Resident #5's Stage 4 pressure ulcer on her sacrum revealed the pressure ulcer did not have a wound care dressing. The Wound Care Nurse asked Resident #5 what happened to the wound dressing, and the Wound Care Nurse told the resident to let somebody know when the dressing fell off. The Wound Care Nurse stated she was not aware Resident #5 did not have a dressing on. Observation of the pressure ulcer revealed there were no signs of infection noted. Interview on 08/07/25 at 9:32 AM revealed Resident #5 was lying in bed. Resident #5 stated she was doing well. Resident #5 stated she admitted to the facility with wounds on her sacrum. Resident #5 stated she was not aware the dressing was off. She stated CNA K performed incontinence care on her around 8:00 AM to 8:30 AM. Interview on 08/07/25 at 9:39 AM with CNA K revealed she was the CNA assigned to Resident #5. She stated she had provided incontinence care to Resident #5. She stated she noticed the resident's dressing was peeling off, and it had fecal matter on it, so she removed the dressing. She did not recall the time when she provided Resident #5 with incontinence care. She stated she knew she was supposed to notify the nurse or the treatment nurse about the soiled dressing, but she did not. She stated it had slipped her mind, and she forgot to notify the nurse. She stated she was in a hurry to finish giving another resident a shower on another hall because that resident had an early pick up of around 8:30 AM for appointment. She stated she was aware she was not allowed to remove dressings, and she knew she was supposed to call the nurse to come and replace the soiled peeling dressing with a clean dressing but not for her to remove it. She stated Resident #5 did not complain of pain. CNA K stated she should have notified the nurse. She stated the risk of not having a dressing on would be infection and wound getting bigger. She stated she had done training on calling the nurse if a dressing had become soiled and not to removing the dressing. Interview on 08/07/25 at 9:48 AM with the Wound Care Nurse revealed Resident #5 had a physician's order to cleanse and cover the wound daily and an order for as needed in case the dressing get soiled or dislodged. She stated she was not made aware that Resident #5's dressing had come off. She stated when she completed wound care yesterday (08/06/25) on Resident #5, she had applied a dressing over it. She stated her expectations were for the nurses to monitor the dressing every shift and if the Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675935 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 675935 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Haltom 2936 Markum Dr Fort Worth, TX 76117 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete dressing came off, they had as needed treatment orders to follow. She stated C N A's were not supposed to touch or remove the dressing. She stated her expectation was for CNA K to call her or the nurse to replace the soiled dressing. She stated the potential risk if the dressing comes off would be a decline in the wound status and infections. She stated she prefer the C N As to notify the nurses because they could leave the wound open and the resident happen to have a bowel movement and that also predisposes Resident#5 to the risk of infection. She stated she had provided staff with training regarding turning and repositioning. She provided a training record dated 02/21/25, which reflected CNA K was not in attendance as she was newly hired to the facility in April.Interview on 08/07/25 at 9:54 AM with the RN J, who was the charge nurse, revealed she was not made aware that Resident #5's dressing had come off. She stated her expectation was for CNA K to report to her so that she could replace the soiled dressing with a clean dressing when she was performing incontinent care on Resident #5. She stated the risk of removing dressing and not replacing with a clean one was infection. She stated she had done training on dressing change.Interview on 08/07/25 at 1:12 PM with the ADON revealed her expectations were for her staff to follow orders and as needed orders. If the dressing came off or it was soiled when completing peri care, she expected CNA K to stop care and notify the nurse, and the nurses were to apply a new dressing. The ADON stated CNAs were not supposed to remove the soiled dressing and if it fall off they should also notify the nurse. She stated the risk of not notifying the nurse and of not having a dressing could lead to, an infection and wound margins increasing. She stated wound care nurse had completed in-services on wound care with staffs.Record review of training on turning and repositioning, dated 02/21/25, reflected CNA K was not in attendance.The training addressed resident not having dressing or dressing are soiled they should notify nurse immediately so that a new dressing may be applied. CNAs are not to touch /remove dressings.Record review of facility policy wound care management, long term care revised June 2025, Did not address soiled and fall off dressings. Event ID: Facility ID: 675935 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 675935 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Haltom 2936 Markum Dr Fort Worth, TX 76117 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Residents #5 and #7) reviewed for infection control.1. CNA G failed to wear a PPE when she provided Resident #5, who was on enhanced barrier precautions, with incontinence care on 08/06/2025 with a physician order for PPE dated 07/16/2025. 2. CNA H failed to perform proper hand hygiene practices to include changing her gloves and washing/sanitizing her hands when she provided Resident #7 incontinence care on 08/07/2025.These failures placed residents at risk of cross contamination and the spread of infection.1.Record review of Resident #5's entry MDS assessment dated [DATE] reflected the resident was a [AGE] year-old female, who admitted to the facility on [DATE] and readmitted on [DATE]. The resident had moderate cognitive impairment with a BIMS score of 11, and her diagnoses included diabetes mellitus, and the MDS reflected she had a Stage 4 pressure ulcers.Record review of Resident #5's care plan dated 06/26/25 reflected: Focus: Resident#5 has actual impairment to skin integrity. admitted with Stage 4 pressure ulcer to sacrum Goal: [Resident #5] Risk for developing new pressure ulcers will be minimal with nursing interventions through the Record review date. Interventions: Enhanced barrier precaution.Record review of Resident #5's physician order dated 07/16/25 reflected: Enhanced barrier precautions for wound requiring dressing.Observation on 08/06/25 at 03:29 PM revealed CNA G was preparing to provide Resident #5 with incontinent care. Resident #5's door had the following sign: enhanced barrier precautions -providers and staff must also wear Gown and Gloves. There was PPE hanged on the door. CNA G performed hand hygiene and donned a pair of gloves. She put all the supplies together and without putting on a PPE gown, CNA G then provided Resident #5 with incontinent care. Interview via phone on 08/07/25 at 11:32 AM, CNA G stated she did not know whether Resident #5 was on enhanced barrier precautions. She stated she was aware that PPE was supposed to be worn during care for residents on precautions. She stated she knew she did wear a gown while providing the resident incontinence care, but she did not explain why she did not wear a gown. She stated she was aware Resident #5 had wounds. She stated the risk of not putting on PPE was that it could lead to the spread of infection. She stated she had done training on enhanced barrier precautions for residents with wounds, gastronomy tubes, and Foley catheters.2. Record review of Resident #7's comprehensive MDS assessment dated [DATE] reflected the resident was [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. The resident's cognition was severely impaired with a BIMS score of 0. The resident's diagnoses included hypertension (high blood pressure) and aphasia (a language disorder that affects a person's ability to communicate). Record review of Resident #7's care plan dated 05/10/2025 reflected: Focus: Resident#7 was incontinent of bladder and bowel rule out dementia. Goal: Resident will be clean, dry and odor free with no occurrence of skin impairment through next Record review date Interventions: Observe for non-verbal cues resident may need to use the toilet.Observation on 08/07/25 at 10:03 AM revealed CNA H providing Resident #7 with incontinence care after the resident had had a bowel movement. CNA H cleansed the resident's abdominal folds and the perineal area inside out. She helped the resident to turn using the draw sheet. She cleansed the resident's buttocks while still using one hand to hold the resident in place. She did not change her gloves after cleansing bowel movement on Resident #7. She went directly to applying a clean brief without changing her gloves or performing hand hygiene. She left resident comfortable and then removed her gloves and washed her hands.Interview on 08/07/25 at 10:15 AM with CNA H revealed she was supposed to change her gloves and Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675935 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 675935 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Haltom 2936 Markum Dr Fort Worth, TX 76117 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete perform hand hygiene after cleansing the bowel movement and before applying a clean brief, but she did not. She stated she forgot, and she knew she was supposed to remove her soiled gloves and wash her hands while moving from a dirty to clean environment. She stated changing gloves and performing hand hygiene during incontinence care would prevent contamination which could cause infection. She stated she had done training on infection control, to include changing gloves and hand washing.Interview on 08/07/25 at 1:04 PM, the ADON stated she expected staff to wear a gown and gloves while providing care to a resident, who was on enhanced barrier precautions. She stated she was not sure of what the facility policy reflected regarding when providing incontinence care on resident with wounds. She stated she expected when staff saw the PPE by a resident's door they should wear the PPE. She stated wearing PPE would prevent cross contamination and infection. She also revealed her expectation was for the staff to remove their gloves and perform hand hygiene with contamination. The ADON stated the staff was supposed to remove her gloves and wash her hands after cleansing bowel movement and before putting a clean brief on Resident #7. The ADON stated the risk of not changing gloves and performing hand hygiene during the incontinence care was that it could lead to cross contamination and then infection. She stated she had provided training on enhanced barrier precautions, perineal care, and infection control; however, no record of the training was provided. Record review of training on enhanced barrier precautions, dated 07/18/25, reflected CNA G was not in attendance.Record review of training on donning(put on) and doffing (remove) of PPE, dated 07/18/25, reflected CNA H was not in attendance.Record review of the facility's Enhanced Barrier Precautions in Nursing Homes policy, dated March 2024, reflected: Enhanced barrier precautions (EBP) are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following:Infection or colonization with CDC targeted MDRP when contact precautions do not otherwise apply or;Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO.For residents for whom EBP are indicated is employed when performing the following high contact resident activities: Changing briefs or assisting with toileting.Record review of the facility's Infection Control policy, revised August 2024, reflected: . perform hand hygiene. after contact with blood, body fluids, or contaminated surfaces; when you are moving your hands from a contaminated body site to a clean body site during resident care. Event ID: Facility ID: 675935 If continuation sheet Page 12 of 12