Inspection·August 14, 2025

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some extended sitting periods or have difficulty with mobility) in the common area. Resident #2 was not able to answer questions due to his condition. The resident did not appear to be in distress or discomfort.Record review of Resident #3's quarterly MDS assessment, dated 06/25/25, reflected the resident was a [AGE] year-old male, who admitted to the facility on [DATE]. The resident's diagnoses included progressive neurological conditions (any disorder of the nervous system), cerebral palsy (a group of disorders that affect movement and muscle tone or posture), cerebrovascular accident (sudden loss of blood flow to the brain, causing brain tissue damage) and seizure disorder or epilepsy (a chronic brain disorder in which groups of nerve cells, or neurons, in the brain sometimes send the wrong signals and cause seizures). Resident #3's BIMS score of 09 indicated moderate cognitive impairment. Resident #3 had no impairment to his upper and lower extremities and did not use any of the mobility devices listed. Resident #3 was independent (meaning resident completes the activity by themself with no assistance from a helper). Record review of Resident #3's care plan, revised 04/16/25, reflected Focus: PASRR positive R/T pt identified as having PASRR positive status related to an intellectual disability, Cerebral Palsy. (The following meetings completed, and services reviewed) PCSP update 8/15/24. Services pending MCD eligibility. meeting 120/24/24. PCSP: 1/22/25 PT/OT/ST/ILST/HC. 4/16/2025 New pscp pt/ot/st/ilst/hc. Goal: will maintain highest level of practice wellbeing for the next 90 days. Interventions: /invite LIDDA representative and RP to attend careplan meeting. Report any need to evaluate for services and/or durable medical equip to maintain currently level of function. Record review of Resident #3's HSP dated 07/15/25 reflected the following: NF Specialized Services to be Monitored by the SPT .Name of Service: Physical Therapy. Occupational Therapy. Speech Therapy Outcome/Goal: Pending assessment. signed by the Habilitation Coordinator.Record review of Resident #3's PCSP Form, dated 07/15/25, reflected under the section Nursing Facility Specialized Services, a number 3 was marked next to Specialized Assessment Occupational Therapy (OT), Specialized Assessment Physical Therapy (PT), Specialized Assessment Speech Therapy (ST) which indicated it was ongoing. Under the comments section next to LA-IDD Specialized Services Comments reflected: On 4/15/2025, PE recommended services included CMWC, DME, PT, OT, ST, ILST, HC, BS, and DH. LAR and [Resident #3] would like ongoing HC, ILST, PT, OT, ST with assessments. [Resident #3] wants to focus on therapy.Observation and interview on 08/13/25 at 10:46 AM, revealed Resident #3 was sitting in the common area with other residents. Resident #3 stated he was doing well; however, when asked further questions resident would respond with I do not know. Interview by phone on 08/13/25 at 10:14 AM with Resident #2 and Resident #3's Habilitation Coordinator revealed Resident #2 and Resident #3 last PASRR meeting was on 07/15/25. The HC stated Resident #2's CMWC assessment was completed and approved but was still missing a portion of the NFSS form to be completed. She stated Resident #2's CMWC had been an ongoing concern. She stated Resident #3 had not had any therapy services provided. The HC stated NFSS forms needed to be submitted 20 days after the PASRR meeting on 07/15/25.Interview on 08/14/25 at 9:50 AM, with the MDS Coordinator revealed she had been employed since June 23rd, 2025. She stated Resident #2's NFSS CMWC/DME Assessment was completed and approved on 06/03/25; however, the application was not fully completed and was still pending submission. She stated on 07/15/25 a PCSP meeting was completed, and the facility had 20 days from the meeting to complete another assessment, but it had not been done yet. She stated Therapy had to complete another evaluation because the evaluation in the system was too old. The MDS Coordinator stated it was in the process of being completed. The MDS Coordinator stated the Treatment Nurse used to be the MDS Coordinator prior to her being employed. She stated she was not sure why there was a delay on Resident #2's NFSS CMWC assessment. The MDS Coordinator stated Resident #3 was PASRR positive, and the PCSP meeting was completed on 07/15/25 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676101 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2025 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete the prior meeting was on 04/16/25. She stated the NFSS form should have been submitted 20 days after the meeting but was not. She stated the NFSS form was for rehab therapy. She stated she did not know why it had not been submitted. The MDS Coordinator stated it was her responsibility to ensure all forms were submitted in a timely manner. She stated the potential risk if PASRR paperwork was not submitted through the database timely could be a delay in therapy services.Interview on 08/14/25 at 10:36 AM, with the Director of Rehab revealed Resident #2 was evaluated for a custom wheelchair based on a referral that was made. The Director of Rehab stated from there he sent over the forms to the previous MDS Coordinator to be uploaded in the database and sent to the PASSR unit for approval. The Director of Rehab stated the CMWC was signed 08/23/24 and the vendor came out a few days before that. The Director of Rehab stated he never received any follow-up or heard anything more about Resident #2's wheelchair. The Director of Rehab stated once the CMWC was signed it would usually take about a month or two to receive the wheelchair. He stated waiting a year for a wheelchair was too long. Interview on 08/14/25 at 11:21 AM, with the Treatment Nurse revealed she was the MDS Coordinator from October 2024 to June 2025. She stated she was involved in the PCSP meetings of Resident #2 and Resident #3. She stated she had submitted the NFSS forms for Resident #2 and Resident #3 back in April 2025 but could not recall the exact dates. However, there was a miscommunication with the residents' Habilitation Coordinator. She stated she had a conversation with the Habilitation Coordinator, and she was made aware that she needed to resubmit the NFSS forms and evaluation needed to be completed to prove that services were being covered. She stated sometime in May 2025 she was made aware that the facility was out of compliance with the NFSS forms, and they were given the opportunity to correct the issue. She stated the corporate MDS Coordinator was assisting at the time and informed her that the NFSS needed to be submitted but by that time she was already out of that position. She stated after she changed positions, she never followed up to ensure the NFSS were submitted. The Treatment Nurse stated there was no potential risk to the resident if the NFSS forms were not submitted timely, residents would still be seen by therapy, and it was more of a payment issue. Interview on 08/14/25 at 1:58 PM, with the Administrator revealed he was not aware Resident #2 and Resident #3's NFSS forms were still pending. He stated he was aware of the request for Resident #2's customized wheelchair, but he stated he was under the impression the forms and assessments were all completed. He stated the previous MDS Coordinator moved positions to be the Treatment Nurse, and they had a corporate MDS Coordinator assisting until the position was filled. He stated he was under the impression all the forms had been submitted for all residents. Record review of the facility's Preadmission and Screening Resident Record review (PASRR) Rules policy, dated 03/15/23, reflected the following: It is the intent of [Management Group] to meet and abide by all State and Federal regulations that pertain to resident Preadmission and Screening Resident Record review (PASRR) Rules .Post IDT Meeting Responsibilities .2. The facility will initiate the request for specialized services within 20 business day of the IDT/PCSP meeting, implement Specialized Services therapy within 3 business days after receiving approval from HHSC in the online portal and order CMWC and/or DME within 5 business days of receiving approval from HHSC in the online portal. Event ID: Facility ID: 676101 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2025 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 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, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 8 residents (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1, who had a history of wandering for which he wore a WanderGuard device, was provided with adequate supervision to prevent him from exiting the building on 07/23/25. The resident was observed outside the facility by a staff member, and he was found on the sidewalk near a street sign outside the facility.The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on 07/23/25 and ended on 07/24/25. The facility had corrected the noncompliance before the survey began.This failure placed residents at risk of harm and/or serious injury. Findings included:Record review of Resident #1's annual MDS assessment, dated 06/16/25, reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's diagnoses included senile degeneration of brain (progressive deterioration of brain tissue and function), unspecified dementia (a condition where the specific type of dementia cannot be identified despite the presence of cognitive decline and memory loss), Type 2 diabetes mellitus (a chronic disease characterized by high level of sugar in the blood), muscle weakness (a condition where your muscles cannot work with the expected amount of force), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), and anxiety disorder (a mood disorder characterized by excessive, persistent, and uncontrollable fear and worry about everyday situations). The MDS reflected Resident #1 had severe cognitive impairment with a BIMS score of 1. The MDS further reflected Resident #1 did not exhibit wandering behaviors. Record review of Resident #1's care plan, dated 06/24/25, reflected Focus: [Resident #1] is an elopement risk/wanderer r/t Impaired safety awareness. Risk for Wandering/Elopement Identified Wanderguard (bracelet detected near a sensor, the system triggers an alert) to right leg. Goal: The resident will not leave facility unattended. Interventions: Identify if there are triggers for wandering / eloping. Identify wandering / elopement de-escalation behaviors. One on one with resident. Wanderguard to right leg-check placement Q shift. Focus: [Resident #1] is an elopement risk/wanderer r/t Impaired safety awareness 7/23/25. Goal: The resident's safety will be maintained through the review date. Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. WANDER Guard to right ankle and check placement Q shift. Record review of Resident #1's Elopement Risk Evaluation, dated 06/20/25, reflected Resident #1 was at risk for elopement. The evaluation indicated Resident #1 had a history of attempting to leave the facility without informing staff, resident verbally expressed the desire to go home, packed belongings to go home, stayed near an exit door, and resident had wandering behavior. Record review of Resident #1's progress notes dated 07/23/25 at 14:01 [2:01 PM] by LVN C reflected: Writer was in room with a resident when loud voices were heard in the hallway. Writer waked out and saw [CNA D] in the hallway. Writer asked [CNA D] what was wrong? [CNA D] stated [Resident #1] is outside [CNA D] and I went out the back door on 200 hall and observed resident sitting in his wheelchair on the sidewalk smiling and giggling. Resident chair was facing south. Resident was brought back in the building and a head-to-toe assessment was performed which revealed no injuries. Resident was not hot or sweaty, respirations were even and unlabored, temperature was normal and vs stable. DON notified of elopement as well as Dr [Name], NP [Name] and Resident RP [Name]. Record review of Resident #1's Incident Report, dated 07/23/25 at 07:10 AM, reflected Incident location: Outside Incident Description: Nursing Description: Writer was in room with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676101 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few resident when loud voices were heard in the hallway. Writer waked out and saw [CNA D] in the hallway. Writer asked [CNA D] what was wrong? [CNA D] stated [Resident #1] is outside [CNA D] and I went out the back door on 200 hall and observed resident sitting in his wheelchair on the sidewalk smiling and giggling. Resident chair was facing south. Resident was brought back in the building and a head-to-toe assessment was performed which revealed no injuries. Resident was not hot or sweaty, respirations were even and unlabored, temperature was normal and vs stable. DON notified of elopement as well as Dr [Name], NP [Name] and Resident RP [Name]. Resident Description: I'm going to my wedding. Immediate Action Taken: Description: Resident brought inside facility, full head to toe assessment completed, resident started on 1 on 1 supervision, DON [Name] notified of elopement as well as Dr [Name], NP [Name] and Resident RP [Name]. Injury Type: No injuries observed at time of incident. Level of Pain: 0 Level of Consciousness: AlertMobility: Wheelchair bound Mental Status: Oriented Person; Oriented to SituationNotes: Resident is able to tell staff what he was doing. Predisposing Physiological Factors: Impaired Memory Predisposing Situation Factors: Wanderer Other Info: Resident was a hx of wandering around the facility, resident propels self in his wc and has a wander guard in place. Record review of the facility's Provider Investigation Report, completed by the Administrator on 07/31/25, reflected the following: Incident date: 07/23/2025, Time of Incident: 07:45 AMWhile a CNA was walking down 200 Hall she saw the resident outside on the sidewalk. She got the nurse and they brought the resident back in the facility. Assessment Date 07/23/25; Time: 7:10 AM; Resident was brought back inside the facility, and completed a full head to toe assessment was completed and skin was intact. Investigation Summary: To the best of my knowledge here is the sequence of events on 7/23 for the allegation of the incident. 7:00 am resident was seen at the end of 300 hall 7:05 am resident was seen outside at the end of 200 hall still on facility property and staff went to get resident from outside. It has been learned by the resident that he was able to go out the end of 300 hall exit door and wheel himself toward the new apartment on the sidewalk until he was seen by CNA on 200 Hall. The employees on the 300 Hall stated that they never heard a door alarm sound at the end of 300 hall. The resident has had head to toe done and no injuries noted. Things facility has done: Resident placed on 1:1Started in servicing employees on elopement and wondering All residents are being wander guard assessment completedOrdered additional door alarmsDoing door checks every shift until [Door Alarm company] comes look at the doors.Spoke to family about looking for alternate placement for resident Started Elopement Drills. Provider Action Taken Post-Investigation: Resident remained on 1:1 supervision until he discharged from the facility on 7/24/25. [Door Alarm company] checked all exit door to ensure they are in working as order and alarming as intended. In-services and drills for staff training will continued. Interview on 08/13/25 at 12:25 PM, with CNA D revealed she was not the CNA assigned to Resident #1; however, at around 7:00 AM she was rounding up residents for breakfast. She stated she was coming out of 300 Hall and entering the 200 Hall when she observed Resident #1 going down the 300 Hall towards the dining area. She stated she could not recall the exact time she last observed Resident #1, but she observed Resident #1 in the dining area for breakfast. CNA D stated within 5 minutes she was in the middle of 200 Hall, outside room [ROOM NUMBER] when she looked outside the window located at the end of the hall, and she saw Resident #1 outside on the sidewalk. She stated Resident #1 was on the sidewalk on facility grounds near the street pole sign. She stated she called for help and LVN C assisted her with bringing Resident #1 immediately inside. CNA D stated when they went outside Resident #1 was laughing the entire time. She stated they asked Resident #1 how he got out, and Resident #1 stated I got out of that door. CNA D stated Resident #1 pointed at the 300 Hall exit door, which also had a ramp. She stated she did not hear the door alarm. She stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676101 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #1 was fast in his wheelchair. She stated Resident #1 had a history of wandering the halls but was not sure about exit seeking. CNA D stated Resident #1 had a WanderGuard due to the resident wandering the halls, always packing his belongings, and saying he wanted to go home. She stated Resident #1 would always say I am making a plan to get out of here. She stated Resident #1 was assessed, and he had no injuries. She stated Resident #1 was wearing the WanderGuard when he eloped. CNA D stated she was in-serviced on abuse and neglect, elopement/code pink, and what to do when a resident eloped. She stated the staff had also completed elopement drills, extra alarms had been added to the doors, and elopement binders could be located at the nurse's station. Interview on 08/13/25 at 1:05 PM, with LVN C revealed she was the nurse assigned to Resident #1 on 07/23/25. She stated she could not recall the last time she observed Resident #1; however, according to staff the resident was last observed by the dining room located down the 300 Hall. She stated she was doing her morning rounds; other staff were rounding residents for breakfast. She stated she was in a resident room in the 200 Hall when she heard yelling coming out of the hallway He is outside. She stated CNA D and herself went outside and got Resident #1. LVN C stated Resident #1 was found on the sidewalk of the back of the 200 Hall. LVN C stated Resident #1 was laughing the entire time. She stated one of the CNAs took Resident #1 back to the dining room and Resident #1 pointed at the exit door at the end of the 300 Hall when asked which door he exited. LVN C stated no alarms were heard. She stated Resident #1 was assessed and no injuries were noted, and he was placed on 1:1 for elopement behaviors. She stated Resident #1 had a WanderGuard on and the WanderGuard was working because it was flashing red when she assessed him. She stated prior to Resident #1's elopement, the resident had a history of wandering the halls. LVN C stated she personally never observed Resident #1 exit seek but the resident would always say he wanted to leave. She stated Resident #1 would always pack his belongings, hold on to them, go down the 200 Hall and sit there looking outside. LVN C stated all facility staff were in-serviced on abuse and neglect, elopement/code pink, and what to do when a resident eloped. She stated the staff had also completed elopement drills, extra alarms were added to the doors, elopement assessments had been reviewed and updated. She stated the elopement binders were also reviewed and could be located at the nurse's station. LVN C stated she conducted a census head count before the start of her shift. Interview on 08/13/25 at 1:26 PM, with Resident #1's POA revealed she was made aware of Resident #1 exiting the facility. She stated Resident #1 had a WanderGuard on and when she was told by the Administrator that the resident exited the facility the Administrator told her that the WanderGuard sometimes don't work. Resident #1's POA stated she did not know how Resident #1 was able to exit the facility. Resident #1's POA stated Resident #1 was discharged home and then admitted to a secure unit at another facility. Interview on 08/13/25 at 1:36 PM, with MA E revealed she was working when Resident #1 eloped from the facility. She stated it was between 7:00 AM 7:30 AM when she observed Resident #1 ambulating through the dining room. She stated Resident #1 did not stay in the dining room, he continued to ambulate in his wheelchair to the 300 Hall. She stated she could not recall what time Resident #1 was found. MA E stated no alarms were heard. She stated when she asked Resident #1 which door he exited Resident #1 stated right over there and pointed at the door located at the end of 300 Hall. She stated Resident #1 was known for wandering the halls but never exit seeking. She stated everyday Resident #1 would mention he wanted to go home and would pack his items. MA E stated she was in-serviced on abuse, neglect, and elopement. She stated extra alarms were added on the exit doors, staff must check exit doors on every shift, elopement assessments were completed, and the elopement book was updated. She stated staff were also in-serviced on checking WanderGuards and ensuring they were working properly. She stated if the WanderGuards were not flashing they were no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676101 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few good. Interview on 08/13/25 at 2:33 PM, with the Maintenance Director revealed he was notified of the elopement after Resident #1 was found. He stated he could not recall the exact time. He stated he checked all the facility exit doors to ensure the alarms were working properly. He stated the 200 Hall and 300 Hall exit doors were not equipped with the WanderGuard alarm. The Maintenance Director stated when he checked the 300 Hall exit door the alarm was not working properly. He stated the PCO of the alarm was low and only buzzing. The Maintenance Director stated he had an extra PCO in his office and he changed it. He stated the PCO was like the battery of the alarm. He stated he completed door safety and alarm checks monthly and the last time he checked the facility doors was on 07/02/25. The Maintenance Director stated they had [Door Alarm company] come out and check on all the doors to ensure the alarms were working properly. He stated after the elopement the facility added extra alarms on the 200 and 300 Hall exit doors. He stated the entrance door and the exit door on 400 Hall had the WanderGuard alarms. He stated the door codes were also changed. The Maintenance Director stated all doors were checked throughout the shift and must be documented/signed off on Shift Exit Door Check. He stated after all the staff were in-serviced on elopement/code pink, he had completed elopement drills with all three shifts. Interview on 08/13/25 at 3:06 PM, with the DON revealed she received a call in the morning regarding Resident #1. She stated the nurse informed her that a staff member was on the 200 Hall and observed Resident #1 through the window sitting outside the 200 Hall. She stated Resident #1 exited through the 300 Hall door and stated he was going to a wedding. The DON stated according to the staff Resident #1 was last seen in the dining room for breakfast. She stated based on the timeline it all happened within 5 minutes, from the time the resident was seen in the dining room and then seen outside. The DON stated no alarms were heard. She stated Resident #1 was assessed, no injuries were noted and he was placed on 1:1 supervision until the resident discharged home with family. She stated they in-serviced all the staff on abuse, neglect, and elopement. She stated they also added new alarms on the doors, they completed assessments on all residents with WanderGuards, risk assessments were completed, reviewed, and they updated the elopement binders. She stated elopement drills had been completed on all shifts. Interview on 08/13/25 at 3:26 PM, with the Administrator revealed he was notified around 7:10 AM - 7:15 AM regarding Resident #1 being outside. He stated from what he gathered, Resident #1 was last seen in the 300 Hall around 7 AM, and at 7:05 AM he was noticed outside the window from the 200 Hall. The Administrator stated Resident #1 was a pretty fast mover and he could have been outside within 5 minutes. He stated according to staff no alarms were heard. He stated Resident #1 had a WanderGuard but the door he went out was not equipped with a WanderGuard alarm. The Administrator stated the two main entrance doors were the doors equipped with the WanderGuard alarms. He stated the door on the 300 Hall was not an exit door. He stated when Resident #1 was brought back inside the resident stated he was going to a wedding. He stated Resident #1 was confused, had dementia, was an active wanderer and would wheel himself around the facility. He stated Resident #1 never tried to open any exit door. The Administrator stated Resident #1 was placed on 1:1 until they could find an appropriate placement. He stated all staff were in-serviced on elopement, they had completed elopement drills and code pink drills with staff. He stated a second alarm was placed for the 200 and 300 Hall doors, they added stop signs on the doors and door codes were changed. The Administrator stated the elopement binder was updated, and assessments were also reviewed and updated. Record review of facility Wandering and Elopements policy, revised November 15, 2023, reflected the following: The facility will identify residents who are at risk of unsafe wandering and implement appropriate protective measure to help guard against a resident wandering from the facility. The facility strives to prevent harm while maintaining the least restrictive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676101 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete environment for residents. This was determined to be a Past Non-Compliance Immediate Jeopardy on 08/13/25 at 4:25 PM. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 08/13/25 at 4:38 PM. The facility took the following actions to correct the non-compliance prior to the survey: Record review of Elopement assessment/Evaluations reflected they were reviewed and completed on Resident #4, Resident #5, Resident #6, and Resident #7 on 07/23/25 and 07/24/25. Record review of facility invoice from [Door Alarm company] dated 07/24/25 reflected all door alarms were checked. Record review of facility Elopement binders located on both nurse's stations and reception reflected pictures of residents who were at elopement risk and contained information regarding the residents. Record review of the facility Elopement Drill/Code Pink Drills reflected drills were completed on the following dates: 07/24/25 - 5:30AM - 5:40AM, 2:45PM 3:05PM 07/30/25 - 6:00AM - 2:00PM, 2:00 PM - 10:00PM, and 10PM - 6:00AM (Facility continued to complete random code pink drills). Record review of facility Shift Exit Door Check forms for all exit doors from July 24 - August 8 reflected door checks were being completed for all three shifts (6AM-2PM, 2PM-10PM, 10PM-6AM). Record review of facility Door Safety and Alarm Check forms from January 2025 - August 2025 reflected they were completed monthly. Record review of Resident #4, Resident #5, Resident #6, and Resident #7 July and August 2025 MARs revealed Wanderguards were being monitored/checked placement and documenting behaviors. Observation on 08/13/25 from 11:00AM through 11:20 AM of Resident #4, Resident #5, Resident #6, and Resident #7 revealed WanderGuards were flashing a red light which indicated the WanderGuards were working properly. Observation on 08/13/25 from 2:36 PM through 2:50 PM revealed the doors on 200 and 300 Halls had two alarms. Alarms were loud enough to be heard from the nurse's station. Wander Guard doors were also checked, and no concerns noted. Record review of in-services dated 07/23/25 reflected all facility staff were in-serviced on Door Alarms, Wander guard, Wandering and Elopement, and Code pink. Objectives of the In-service: Elopement - Identified changes in behaviors of all resident's - notify management of wandering/risk of elopement behaviors. Be watchful of residents at risk and listen for door alarms. Elopement binders for at risk residents can be found at each nurses' station. Elopement Binders include current list of Residents high Risk for wandering. Wander guard - what your orders mean. Check skin around WanderGuard- Means just to make sure band or monitor is not causing pressure or injury. Check placement means to make sure band is not too loose or too tight and make sure is on the body part that the order says it is. Ex. R leg. Check Function - If red light is blinking - Battery is good condition. If the light is SOLID RED, GREEN, half red - cut WG off and replace with new WanderGuard spare will be locked in Medication carts. CALL DON, Code PINK - Missing Resident. The in-services were conducted and signed by all facility staff.Interviews on 08/13/25 from 12:25 PM through 08/14/25 at 1:49PM with CNA D, LVN C, ADON A, ADON B, MA E, CNA F, LVN G, MA H, MA I, MA J, CNA K, Treatment Nurse, Therapy L, Therapy M, Therapy N, CNA O, Dietary Aide, Kitchen Supervisor, Central Supply, LVN P, CNA Q, LVN R, CNA S, MA T, Social Worker, LVN U, CNA V, CNA W, Housekeeping Supervisor, and Housekeeping who worked the shifts of 6:00 AM-2:00 PM, 2:00 PM-10:00 PM and 10:00 PM-6:00AM revealed the facility staff were able to verify education was provided to them. Facility staff were able to accurately summarize the elopement/code pink in-service, abuse, and neglect, completing head counts before shift change, elopement assessment were reviewed/competed (an evaluation to determine any resident at risk of elopement) , where to locate elopement binders, nurses ensure WanderGuards were checked daily to ensure they were working properly and document on the MAR, alarms added to the 200 and 300 Hall doors, door codes changed and door checks completed on all three shifts. Event ID: Facility ID: 676101 If continuation sheet Page 8 of 8