Inspection·October 12, 2023

F 0557 was compromised. The bag should immediately be covered. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy titled Quality of Life dated 10/4/2022 revealed the following: Dignity: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality 11. a Helping the residents to keep urinary catheter bags contained and private . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676101 If continuation sheet Page 2 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgmar Medical Lodge 6600 Lands End Court Fort Worth, TX 76116 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the prompt resolution of all grievances to include ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued for 1 of 2 residents (Resident #23) reviewed for grievances. The facility failed to ensure Resident #23's grievance was documented and resolved when she reported her cell phone was misplaced or lost. These failures could place residents at risk for grievances not being addressed or resolved promptly in turn leading to residents' lost properties not being replaced. Findings included: Review of Resident #23's admission MDS dated [DATE] revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, asthma and essential hypertension. The resident had moderate cognitive impairment with a BIMS score of 10 out of 15. Interview with Resident #23 on 10/10/23 at 12:20 PM revealed she was missing her cell phone and had reported it to the Administrator. Resident #23 stated the Administrator told her he would replace the cell phone, but he did not. Record review of the facility's grievances did not reveal a grievance for Resident #23's missing cell phone. Interview with the Administrator on 10/12/23 at 1:50 PM revealed Resident #23 reported to the Administrator that she had a cell phone missing. The Administrator stated Resident #23 felt like the cell phone fell into the trash can while she was sleeping. The Administrator said this was approximately the third time she had items go missing since her stay at the facility began. The Administrator stated Resident #23 told him it would cost about fifty dollars to replace the phone. The Administrator revealed he did not feel it was the facility's responsibility to replace it at the time if she lost the phone. On 10/12/23, the Administrator went back to Resident #23 to discuss the missing phone. After their conversation, the Administrator stated that he would replace Resident #23's phone and document the grievance. Interview with the Social Services Director on 10/12/23 at 2:23 PM revealed there were no grievances filed by Resident #23. The Social Services Director stated the Administrator came to her on 10/12/23 and told her no grievance was written for this allegation because the resident said that she lost the phone. The Social Services Director revealed a grievance should be written for all allegations. She stated the grievance policy said that missing items will be reimbursed. The Social Services Director stated the Administrator will reimburse Resident #23 per conversation 10/12/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676101 If continuation sheet Page 3 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgmar Medical Lodge 6600 Lands End Court Fort Worth, TX 76116 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 0585 Level of Harm - Minimal harm or potential for actual harm Interview on 10/12/23 at 04/10/23 with the Administrator revealed he completed the grievance form on 10/12/23. The Administrator also stated that he would be reimbursing fifty dollars to Resident #23 to cover the cost to purchase her new phone. Record review of the facility's grievance policy, dated April 2017, reflected the following: Residents Affected - Few .All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievances. The Administrator has assigned the responsibility of investigating grievances and complaints to the grievances officer. .The Grievance Officer will record and maintain all grievances and complaints on the resident grievance complaint Log FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676101 If continuation sheet Page 4 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgmar Medical Lodge 6600 Lands End Court Fort Worth, TX 76116 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of 5 of 33 residents reviewed for activities. Residents Affected - Some The facility failed to ensure resident received activities during the weekdays and weekends. The failure placed residents at risk for a diminished quality of life, isolation, lack of stimulation, and a decline in mental status. Findings included: Observation on 10/12/23 from 9:00 AM-4:00 PM revealed that facility activities were called out over the loudspeaker. However, the announcement specifics were difficult to hear over the loudspeaker. When Residents #64 and #23 were interviewed regarding the daily activities, both residents (roommates) stated they had not heard the announcement about the daily activities. Interview on 10/10/23 at 12:16 PM with Resident #64 revealed the Activity Director was also a CNA. The resident stated the Activity Director did not get to do her job as scheduled because she often worked the floor. Interview on 10/10/23 at 12:27 PM with Resident #23 revealed the Activity Director picked up shifts to work the floor as needed, as a CNA, and did not get to devote herself singularly to her role as an Activity Director. Review of facility's current October 2023 Activities Calendar, revealed the weekend activities scheduled were repetitive for every weekend in the month and included the following: Saturday - Weekend Packets, 2:30 Bingo, Residents Choice Sunday - Rise & Shine, 1:30 Church, Resident Choice Movie. Review of the facility's current October 2023 Activities Calendar, revealed the weekday activities scheduled were repetitive for the month and included the following: Mondays - activities of workout, bingo, tv time, and Bible Study. Tuesdays - Beauty shop, table games, and crafts, and tv time. Wednesdays - workout, fall packet, popcorn, and tv time. Thursdays - workout, ice cream, movie day, and tv time. Fridays - workout, nail care, mystery, and Wii games. During a confidential resident group interview, on 10/10/23 at 2:30 PM, 11 of the 13 residents in attendance revealed the Activities Director had been constantly working the floor and had been too busy to complete activities as she used to. The residents stated they were having to find activities (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676101 If continuation sheet Page 5 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgmar Medical Lodge 6600 Lands End Court Fort Worth, TX 76116 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for themselves and others to do, such as dominoes or card games. The residents also revealed the activity calendar indicated activities such as ice cream or movie day, but they had not had ice cream in very long time and the movie day had not happened in about three weeks. The residents stated playing bingo was an option if there would be someone to volunteer to call it. The resident revealed there used to be a good activities program but as of lately having an Activity Director who would provide a selection of quality activities had not been done in a long while. The residents stated when the Activity Director was asked about activities, the response was, I'm too busy for Activities. Interview on 10/11/23 at 4:49 PM with Resident #10 revealed he had given up on structured activities and following the activity calendar. Resident #10 stated the Activity Director had been too busy working the floor to care about activities with residents. Resident #10 stated he recently began calling out bingo over the weekends to assist residents with having something to do since the calendar activities had not been initiated by the Activity Director. Resident #10 stated things were just not the same anymore. Interview on 10/11/23 at 4:56 PM with the Activities Director revealed she sometimes was needed to work the floor. She stated when she worked the floor, she asked other residents or volunteers to assist her with the scheduled activities. She said she often asked them to call bingo, start a movie, or pass out prepared popcorn. The Activity Director stated when prioritizing her time and schedule, she would always pick care (CNA role) over activities. Interview on 10/12/23 at 7:02 PM with the Administrator revealed the residents had stated the activities had occurred, but by a volunteer or another resident. He explained to the residents that he wanted to get agency out of the building, so he hired directors who could also work the floor when needed. He had reviewed the schedule and time sheet, and the Activity Director had worked more the last two weeks. He asked Residents #1 and #64 what activities were missed, but they could not remember. The Administrator stated he thought that some activities did not need to have to have a certain skill set. He stated he had been making rounds in the building to ensure that activities were occurring. The facility was asked to provide the facility's activities policy; however, the facility did not provide the policy prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676101 If continuation sheet Page 6 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgmar Medical Lodge 6600 Lands End Court Fort Worth, TX 76116 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 1 resident (Resident #18) reviewed for enteral nutrition. The facility failed to follow Resident #18's physician orders for enteral feeding. These failures could affect residents receiving enteral nutrition/hydration and place them at risk of health complications and decline in health. Findings included: Record review of Resident #18's face sheet dated 10/12/23 revealed the resident was [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with a diagnoses that included cerebral palsy (a group of disorders that affect movement, muscle tone, and posture), mild protein-calorie malnutrition, dysphagia (difficulty in swallowing), severe intellectual disabilities. Record review of Resident #18's admission MDS dated [DATE] revealed the resident had severe cognitive impairment with a BIMS score of 3. The assessment reflected Resident #18 required total dependence with eating, one-person physical assist, and the resident received nutrition via a feeding tube. Record review of Resident #18's undated care plan revealed the following: Potential for weight loss, Malnutrition, and Ped tube feedings. I am on Isosource 1.5 Follow physician orders for times of administration. Goal: Resident will maintain ideal body weight through next review. Approaches: Dietician to evaluate and follow up as needed. Weigh resident and notify physician, speech therapy, nurse, and dietician as needed. Observe and document resident nutritional status as needed and per doctor orders. Report any negative trends to physician. Resident requires a PEG tube (feeding tube) for adequate nutritional intake. Goal: Resident will maintain current weight through next review. Approach: Dietician to evaluate current nutritional status, weigh monthly, site care of tube daily, check for placement before initiating feedings, check for residual before initiating feeding, monitor for changes in condition and notify physician. Record review of Resident #18's previous physician order dated 10/03/23 revealed in the morning Enteral: Enteral Nutrition Isosource 1.5 at 70 ml per hour for 16 hours via pump. Start infusion at 0800 and continue until 16 hours. 1680 kcal , 71 grams protein, 1280 free water and in the afternoon at 1600 turn on and every night shift check feeding to ensure proper function and as needed change feeding/supplies if needed. Record review of Resident #18's new physician order dated 10/12/23 revealed enteral Feed Order every shift Enteral: Enteral Nutrition Isosource 1.5 at 70 ml per hour for 16 hours via pump. Start infusion at 4pm and continue until 8:00 AM. 1680 kcal, 71 grams protein, 851 free water. Record review of Resident #18's October 2023 MAR revealed resident had been disconnected at 8:00 AM on 10/12/23 by RN E. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676101 If continuation sheet Page 7 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgmar Medical Lodge 6600 Lands End Court Fort Worth, TX 76116 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 10/11/23 at 4:00 PM of Resident #18 revealed staff pushing Resident #18 down the hall to his room, Staff stopped mid hall to assist another resident with Resident #18 was left in the middle of the hall. Resident #18 was not connected to his feeding machine. Observation on 10/11/23 at 4:24 PM of Resident #18 entered his room by staff with Hoyer lift, staff then completed transfer from wheelchair to his bed, staff then completed brief change and left him in bed. Interview and record review on 10/11/23 at 5:24 PM with RN E revealed she was an agency nurse; however, she had worked with Resident #18 before and was aware of his feeding time to begin at 4:00 PM. RN E stated she was working according to the Medication Administration Registrationwhich alerted her to medication and feedings that were required at this time. RN E pointed out that Resident #18 was past due therefore it was showing up on the Medication Administration Registration as a red color signifying it was pass due for him to have his feedings. RN E stated she knew staff were bringing him down the hall and would complete incontinent care, he did not have to be connected during incontinent care, so she did have some time to complete blood sugar checks. RN E stated she did have an hour window before after his start time to have Resident #18 connected for feeding. RN E stated since he would be connected after his window, which would require him 2.5 hours past his scheduled shut down time, she would alert the oncoming staff to leave him connected to ensure he completed his 16-hour feeding according to his orders. RN E stated since she worked the facility as needed and was new to the transitioning program if she saw anything off with the prescriptions or noted any changes to the schedule she would also alert the DON or ADON. RN E stated she was responsible to provide Resident #18 feedings according to the physician orders. RN E stated not having him connected at this time would not cause him to become malnourished, RN E did not have any risk associated to him not being connected at his scheduled time. Interview and record review on 10/11/23 at 5:35 PM the DON stated , after reading the physician order, the order did not read properly. The DON stated Resident #18 was to begin his feeding at 4:00 PM and disconnect at 8:00 AM the next morning. The DON stated Resident #18 would more than likely continue feeding past his cut off at 8:00 AM to ensure he received his full 16-hour shift of feeding. The DON stated she needed to contact the physician to verify the order and inform them that Resident #18 had not started his feeding as of this time. Observation on 10/11/23 at 6:24 PM of Resident #18 lying in bed, a feeding pump was next to Resident #18s bed infusing. A bag of enteral feeding was hanging from the pole of the feeding pump with a date of 10/11/23, time 6:29 PM, rate of 70 ml/hr. x 16 hours. Observation on 10/12/23 at 9:44 AM of Resident #18 laying in bed, revealed his feeding machine was disconnected, leaving him without continued feeding. Interview on 10/12/23 at 10:47 AM with the DON revealed Resident #18 was disconnected at 8:00 AM per his order. When asked if the resident received his 16-hour feeding per order, the DON stated she would contact the physician. The DON stated she spoke with Nurse Practitioner, Resident #18 feeding schedule was to remain to start at 4:00 PM daily, run for 16 hours and to shut off at 8:00 AM, to continue Resident #18 with normal feedings. Interview on 10/12/23 at 11:50 AM with LVN D stated the order initiated by herself was in error. LVN D stated her order indicated feeding start time (8:00 AM) and feeding shut off time (8:00 AM) as the same. LVN D stated documentation could be a problem and there must be a glitch in the system (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676101 If continuation sheet Page 8 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgmar Medical Lodge 6600 Lands End Court Fort Worth, TX 76116 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few because the order was automatically initiated. She stated when an order was automatically entered the order still must be reviewed and signed by the originating nurse for verification. LVN D stated not having an accurate order could place Resident #18 at risk of effects of malnutrition, which he had been previously diagnosed. Interview on 10/12/23 at 12:00 PM with RN E revealed she did not receive report at shift change of Resident #18's feeding held for 2.5 hours. The RN E stated she would expect to have received a report of any orders held or initiated late, which she did not. The RN E stated failure to deliver enteral feeding for specified amount of time could cause malnutrition; RN E confirmed Resident #18's enteral feeding was stopped at 8:00 AM per orders. Interview on 10/17/23 at 4:29 PM with the Nurse Practitioner revealed she was contacted on Thursday (10/12/23) about Resident #18 not being connected to begin his 4:00 PM feeding on Wednesday (10/11/23). The Nurse Practitioner stated her expectations were to contact her about the feedings being delayed and to continue the feedings after the phone call. Nurse Practitioner stated the right thing to do would have been to continue his feedings for an additional 2.5 hours to ensure he completed 16 hours of feeding time per the physician orders. Nurse Practitioner stated she was aware of his fluctuation of weight which was why she wanted the resident to have his full feedings. The Nurse Practitioner stated it was the nursing staff at the facility's responsibility to inform her when the feeding schedule was off so that she can provide proper information. The Nurse Practitioner stated she was not aware he was taken off the machine prior to completing 16 hours of feeding time. The Nurse Practitioner stated not receiving a full schedule of feeding could lead to weight loss, and malnourishment. Record review of the facility's Enteral Nutrition policy, revised November 2018, reflected: .Adequate nutritional support through enteral feeding will be provided to residents as ordered. Some examples of potential benefits of using a feeding tube include: a. Addressing malnutrition and dehydration FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676101 If continuation sheet Page 9 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgmar Medical Lodge 6600 Lands End Court Fort Worth, TX 76116 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, disposition, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #14) of 2 residents reviewed for insulin administration. The facility failed to ensure LVN C did not administer Humalog Insulin after the physician order dated 10/03/23 indicated to discontinue Humalog Insulin. This failure placed one resident, who had a physician's order to discontinue Humalog Insulin, at risk for Hypoglycemia (low blood sugar) altered mental status and falls. Findings included: Review of Resident #14's Face Sheet dated 10/12/23, revealed the resident was an [AGE] year-old female who admitted to the facility on [DATE]. Review of Resident #14's MDS, dated [DATE] revealed had moderate cognitive impairment with a BIMS score of 12 of 15. The MDS also revealed the resident had diagnoses of anemia, congestive heart failure, hypertension, end-stage renal disease, pneumonia, diabetes, fracture, anxiety, depression and chronic obstructive pulmonary disease. Review of Resident #14's Physician Orders dated 10/12/23 revealed no order for insulin. Review of Resident #14's October 2023 MAR revealed Humalog Insulin Kwikpen was discontinued 10/03/23. Further review revealed Resident #14 was administered 4 Units of Humalog on 10/10/23 by LVN C. Interview on 10/12/23 at 4:20 pm with LVN A stated Resident #14 returned from an Orthopedic appointment 10/03/23 with a new order to discontinue Humalog Insulin. LVN A stated she notified the physician of the new orders for Resident #14. LVN A stated the physician reviewed Resident #14's most recent blood glucose levels and approved discontinuation of Humalog Insulin. LVN A stated the order for Humalog Insulin was discontinued on 10/03/23. LVN A stated giving any medication without a doctor's order placed residents at risk of serious injury. During an interview on 10/12/23 at 4:33 PM the DON stated most new orders were discussed in morning meeting but stated this order was not discussed because of everyone trying to ensure the new electronic system was operating to meet resident/staff needs. The DON stated any discontinuation of medication, especially insulin, would require more investigation. The DON stated Resident #14 received insulin 10/08/23. The DON stated the insulin was given by LVN B on 10/08/2023 using an insulin pen prescribed for Resident #14. The DON stated she could not locate the insulin pen and the insulin pen may have been removed by the facility pharmacy consultant on 10/09/23. Record review of the facility's Administering Medications policy, revised April 2019, reflected: .Policy Statement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676101 If continuation sheet Page 10 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgmar Medical Lodge 6600 Lands End Court Fort Worth, TX 76116 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 0755 Medications are administered in a safe and timely manner, and as prescribed Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676101 If continuation sheet Page 11 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgmar Medical Lodge 6600 Lands End Court Fort Worth, TX 76116 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen observed for kitchen sanitation. The facility failed to ensure food items were properly labeled, dated, and thawed in accordance with professional standards. These failures could place all residents, who receive food from the kitchen, at risk for food contamination and food-borne illness. Findings included: An observation of the kitchen on 10/10/23 at 9:10 AM revealed the following: refrigerator: - Biscuits in a sealed package unlabeled and undated - Shredded cheese in a clear plastic bag unsealed Freezer: - Churros in an unsealed clear plastic bag Pantry: - Cake mix in an unsealed clear plastic bag - Refried beans in an unsealed clear plastic bag Interview on 10/11/23 at 10:57 AM with [NAME] I revealed foods had to be labeled, dated, and sealed. [NAME] I said she did not know why the items were not labeled and sealed per the facility's policy. [NAME] I stated it was the responsibility of all kitchen staff to store food items correctly. [NAME] I revealed the risk of not storing and thawing food items properly could be cross-contamination which could cause the residents to become ill. The [NAME] also said that if she finds items more than three days old in the facility's refrigerator, she will throw it in the trash. Interview on 10/10/23 at 09:26 AM with the Dietary Manager revealed she had access to the facilities dietary policies and procedures. She stated the facility's policy indicated items should be kept in the facility's refrigerators for three days and should be in a sealed container, labeled, and dated. The Dietary Manager stated it was her responsibility to ensure staff knew the facility's policies and procedures on food storage and ensure it was done correctly. She stated she was unaware the food items were not stored properly. She revealed all staff knew the proper policies and procedures of food storage at the time of inspection. She said the risk of not properly storing and thawing food items could be cross-contamination and food spoiling, which could lead to residents getting food-borne illnesses. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676101 If continuation sheet Page 12 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgmar Medical Lodge 6600 Lands End Court Fort Worth, TX 76116 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 0812 Record review of the facility's Food storage policy, dated 2018, reflected: Level of Harm - Minimal harm or potential for actual harm Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Residents Affected - Some Procedures: .Refrigerators - Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. -Use all leftovers within 72 hours. Discard items that are over 72 hours old. . Dry Storage - To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. . Freezers -Store frozen foods in moisture-proof wrap or containers that are labeled and dated. Record review of the Food and Drug Administration's Food Code dated 2017 reflected: .Section 3-305.11 Food Storage. (A) Except as specified in (B) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and . Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676101 If continuation sheet Page 13 of 13