Health inspection·December 10, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few reapproach, provide quiet environment, avoid crowds, noise cancelling headphones, play favorite music, talk to him about his daughters, use do you need to call family? Meds as ordered. [Resident #1] to be sent for eval and treatment at In-patient psychiatric unit if approaches unsuccessful and agitation/aggression continues. Notify MD as needed. Observe and document behavior as needed. Provide 1:1 sessions as needed. Provide for safety of resident during periods of combativeness. Provide quiet spaces when agitated as loud noise can be a trigger. Psych eval as needed. Triggers: echoes, sudden noises, loud noises, paranoia of personal space/items, others entering his space/room.The Care Plan revealed: [Resident #1] was at risk for psychosocial changes related to resident-to-resident incident. Goal: [Resident #1] he will have no psychosocial changes. Interventions included Medication as ordered. Notify physician as needed. Provide diversional activities if behaviors occur. Psychological consult as needed.The Care Plan revealed: [Resident #1] had a history of trauma that affects them negatively related to the military. Triggers include: echoes, sudden noises, loud noises, paranoia of personal space/items, others entering his space/room. He may display: suspicions, hiding items, fears things being taken away, verbal, and physical aggression, agitation, self-isolation, paranoia, refuse care or meds, collects/hides gait belts, makes false claims, throwing items, restlessness. Goal: Triggers that may cause re-traumatization will be minimized daily. Interventions included encourage relationships with family and friends that are supportive. Encourage resident to express feelings, concerns, thoughts in a safe space. Observe for signs and symptoms of depression, anxiety, sleep disturbances. Provide a quiet, non-threatening environment with decreased stimulation as needed. Triggers: echoes, sudden noises, loud noises, paranoia of personal space/items, others entering his space/room, redirect, reapproach, provide quiet environment, avoid crowds, noise cancelling headphones, play favorite music, talk to him about his daughters, use do we need to/can we call family?The Care Plan revealed: [Resident #1] has potential to be physically aggressive behavior r/t Poor impulse control. Goal: [Resident #1] will demonstrate effective coping skills through the review date. Interventions included [Resident #1] triggers for physical aggression. Staff to Monitor signs of aggression like Picking teeth with toothpick. Administer medications as ordered. Monitor/document for side effects and effectiveness. COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated.Record review of Resident #1's progress notes written by LVN A on 11/27/25 at 10:08 AM revealed [Resident #1] was the aggressor. He was sitting having breakfast and he suddenly got up from the table. I asked him to come back and take meds. He said, I will be back to you in a minute. He walked over to [Resident #2] punch him in the face and he hit the floor and hurt his left hip and leg. We spoke with outside provider; she saw him last week but will re-evaluate and inform us if any changes and will notify the family about the worsening behaviors. Family Member came in the mist of the issue and notified Resident Representative by phone. [Resident #1] is out of the building at this time due to Thanksgiving but will return this evening.Record review of Resident #1's progress note written by Social Worker B on 11/27/25 at 10:23 AM revealed Social Worker observed incident from nurses station that occurred this morning with resident to resident. Social Worker went to observe that matter and nursing staff redirected resident to this room and Social Worker assisted as needed to help redirect resident to room. Social Worker met with resident in room to check status and continue to diffuse his emotional state that caused him to hit another resident, as he was placed 1:1. Resident voiced it was the laughing he heard that made him hit the other resident. Social Worker educated and diffused resident on safety and resident was essentially receptive. Social Worker met with resident's Family Member who came to pick up Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745057 If continuation sheet Page 2 of 16 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 745057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuskegee Airmen Texas State Veterans Home 2200 Joe B Rushing Road Fort Worth, TX 76119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to go out on pass for Thanksgiving today. Social Worker informed the Family Member as to what occurred today and then the Family Member requested the Social Worker speak with another Family Member; Social Worker informed her what occurred as well. Family Members voiced understanding as to what happened today and will return resident today after Thanksgiving celebration. Care team update and Administrator updated. Record review of Resident #1 progress note written by Social Worker B on 11/27/25 at 10:41 AM revealed ADON contacted outside provider 24/7 on-call number and was able to speak with Nurse Practitioner regarding resident incident. ADON and Nurse Practitioner discussed medications that need reviewed, and Nurse Practitioner will adjust resident's medication and call the resident's family members regarding behaviors today. Care team updated.Record review of Resident #1 progress note written by LVN A on 11/27/25 at 6:24 PM revealed [Resident #1] was out with family all shiftRecord review of Resident #1 progress note written by RN C on 11/27/25 at 8:00 PM revealed [Resident #1] is 1:1 while sitting in the day room watching tv with. is pleasant and shows no sign of aggression. No Concerns at this time.Record review of Resident #1 progress note written by RN C on 11/27/25 at 9:00 PM revealed [Resident #1] is in room sleeping, with call light in reach, No Concerns at this time.Record review of Resident #1 progress note written by RN C on 11/27/25 at 10:00 PM revealed [Resident #1] sleeping on bed in room with door closed, call light in reach. No concerns at this time.Record review of Resident #1 progress note written by RN C on 11/27/25 at 11:00 PM revealed [Resident #1] sleeping on bed in room with door closed. Call light within reach. No concerns at this time.Record review of Resident #1 progress note written by LVN D on 11/27/25 at 12:37 AM revealed [Resident #1] back from pass with Family. Took meds and stayed in room until 10:30 PM and came out jumped on another Resident verbally in common area. Separated residents. [Resident #1] went back to room and went to bed. Record review of Resident 2#'s most recent Quarterly MDS (Minimum Data Set) Assessment, dated 11/17/25, reflected an [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had BIMS of 05 indicating moderate cognitive impairment. Diagnoses included Alzheimer's Disease (neurodegenerative disorder that leads to the gradual decline of cognitive functions), Non-Alzheimer's Dementia (various types of dementia). Resident #2's MDS indicated he had no signs of behavioral symptoms. Record review of Resident #1's undated care plan revealed [Resident #2] had had impaired skin integrity related to 11/27/25- Laceration to right side chin area. Goal: Resident will remain free from skin impairments related to pressure. Interventions include Braden scale risk assessment quarterly and as needed. Encourage adequate hydration and nutrition. Notify responsible party and discuss skin status as needed. Treatment as ordered.The Care plan revealed: Resident #2 has had an actual fall with (minor injury) Poor Balance, Unsteady gait. 11/27/25-fall with injury. Goal: He will resume usual activities without further incident. Interventions included: Staff to monitor more frequently. Check range of motion times daily. Continue interventions on the at-risk plan. Resident #2 sent to ER for eval and treat, pain meds administered. Provide activities that promote exercise and strength building where possible. Provide 1:1 activities if bedbound. Staff to keep Resident #2 in line of site, monitor as needed.Record review of Resident #2's progress note written by RN E on 11/27/25 at 9:02 AM revealed Outcomes of Physical Assessment: Functional Status: Fall. Nursing observations, evaluation and recommendations are: Patient status post fall, Patient noted with cut to the right-side facial area. Pain to the left hip and left rib cage. Patient sent out to the hospital for further evaluation to the left hip. Primary Care Provider Feedback patient sent out to hospital for further evaluation. Record review of Resident #2's progress note written by RN E on 11/27/25 at 9:31 AM revealed [Resident #2] was medicated for pain prior to hospital transfer. Power of Attorney, MD, DON, and Administrator notified of incident.Record review of Resident #2's progress note written by Social Worker B (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745057 If continuation sheet Page 3 of 16 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 745057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuskegee Airmen Texas State Veterans Home 2200 Joe B Rushing Road Fort Worth, TX 76119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 11/27/25 at 10:24 AM revealed Social Worker met with resident to check status as nursing staff and Director of Rehabilitation was with resident to monitor until Emergency Medical Services to arrive to go to hospital for assessment. Social Worker inquired with resident on his psychosocial well-being after incident to check if he felt safe and comfortable and resident voiced he was okay and was hurting on left side of body as care team was assessing him and assisting him with care. Social Worker contacted resident's Family Member and left voicemail to return call. Social Worker did receive a call back from resident's Family Member and Social Worker informed them of the matter that occurred and that Emergency Medical Services was currently there to pick up resident to take to hospital and they voiced understanding of the matter. Care team updated.Record review of Resident #2's progress note written by LVN A on 11/27/25 at 10:37 AM revealed [Resident #2] was walking through the common area. [Resident #1] got up from eating breakfast and went over to him and punched him in the face. [Resident #2] fell to the ground in shock. [Resident #1] stood over him and told him to say it again. CNA ran over remove [Resident #1] from the area and took him to his room. First aide was rendered immediately. Laceration was cleaned and covered. When Evaluated by Physical Therapy he could not bear weight on the left side and stated, Man, I am hurt. What happened? [Resident #2] remained seated until Emergency Medical Services arrived to transport him to the hospital.Record review of Resident #2's progress note written by LVN A on 11/27/25 at 1:52 PM revealed [LVN A] called hospital to check on [Resident #2]. emergency room Nurse, informed [Resident #2] will be admitted to the surgical floor. RN Supervisor notified.Record review of Resident #2's progress note written by LVN A on 11/27/25 at 6:24 PM revealed Hospital Admit. Record review of Resident #2's hospital record dated 12/01/25 11:16 AM revealed Chief Complaint: Fall. History of present illness: [Resident #2] is an [AGE] year-old male with history of dementia, Alzheimer's disease, alcoholic cirrhosis (advanced form of liver disease related to drinking alcohol), hypertension (high blood pressure), and prostate cancer (cancer that start in the prostate) who presented after an unwitnessed fall at his memory care facility, resulting in left hip pain and inability to ambulate. On arrival, he was noted to have left leg pain, external rotation and shortening of the left lower extremity, and an abrasion to the face, but no evidence of head trauma or loss of consciousness was reported. Imaging, including left femur (thigh bone, longest and strongest bone in the human body) and hip radiographs, confirmed an acute comminuted, displaced transcervical left femoral neck fracture (a type of hip fracture where the bone connecting the ball of the hip joint to the thigh bone breaks), additional trauma imaging showed no acute intracranial (bony part of the skull that holds the brain) or spinal injury, and no acute facial fractures. Record review of the provider investigator report revealed on 11/17/25 at 7:45 AM Resident #1 was eating breakfast talking to staff when he got up from the table, a few feet away and hit Resident #2 on the right side of his face. Resident #2 lost his balance and fell backwards into wall/window seal and then to the ground. Resident #2 had laceration below his right eye, facility cleansed area. Initially denied pain, was able to move extremities. Physical Therapy and Nursing lifted Resident #2 to a chair to finish the assessment, and he then complained of pain, stating something was wrong. Emergency Medical Services was called immediately. The provider response revealed: Residents were separated and assessed. The facility initiated protocol to include: Resident #1 being placed on 1:1 until family arrived to take Resident #1 out on pass for Thanksgiving - Resident #1 remained on 1:1 until the facility sent out to the hospital for evaluation and treatment; and proper notifications completed to family, physician, DON, Administrator, and Regional Support Team. Resident #2 complained of pain to his left side. The facility sent him out via Emergency Medical Services. The facility continued protocol to include: quality of life rounds, in-servicing, staff interviews, as needed Trauma (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745057 If continuation sheet Page 4 of 16 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 745057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuskegee Airmen Texas State Veterans Home 2200 Joe B Rushing Road Fort Worth, TX 76119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Assessment, Social Service follow-up for psychosocial assessment, and updated the plan of care. The investigation revealed: the Administrator received a phone call at 7:45 AM from the Director of Nursing notifying the Administrator of the incident. It was reported that the nurse was getting ready to give medication and Resident #1 went over and hit Resident #2 in the face, he lost balance and fell into the wall and then to the ground. Resident #2 was assessed and noted to have a laceration to the right side of the face. Nursing cleaned the laceration. Initial assessment of Resident #2 revealed he was able to move his leg. Resident #2 was lifted by staff and placed in a chair. At that time Resident #2 stated something was wrong. The Rehabilitation Director and Nursing assessed his leg and Resident #2 was noted to have pain in his left leg and unable to move. Emergency Medical Services was contacted, and Resident #2 was sent to local hospital for evaluation and treatment. Resident #1 was placed on 1:1 and required redirection multiple times. The Social Worker met with Resident #1 and when asked what happened he mentioned he was hearing laughing and thought it was Resident #2 and was hyper focused on the laughing. Family arrived shortly after the incident and wanted to take Resident #1 out on pass for Thanksgiving. The facility decided to allow Resident #1 go and upon return would be placed 1:1 and then work on an in-patient hospital stay for further evaluation and treatment. The facility did contact psych services to review incident and provider to complete a medication review. Resident #1 had a BIMS of 6, resided in a Memory Care Unit due to poor safety awareness and exit seeking tendencies. He was actively seen by both psychiatry and psychology services. Triggers identified were loud noises, people going into room, and being in his space. Resident #1 currently admitted to hospital for mood stabilization.The facility conducted care plan meeting to discuss re-admission and Resident #1 to be placed on 1:1 to see how new medications were working but facility would like to look at potential alternate placements, with family in agreement. The Administrator completed quality of life rounds, incident review, facility rounds, and staff interviews. No additional concerns identified at this time. In-services were initiated on Behavior in Dementia with de-escalation and dementia. The facility updated Ad Hoc (when necessary or needed) QAPI meeting to include: additional education for memory care unit, updating admission criteria for unit along with admission process, and evaluation of unit staff for compatibility with incident tracking and trending. Investigation Findings revealed: Unsubstantiated willful intent to harm due to Alzheimer's Diagnosis. Resident #1 was placed on 1:1 monitoring starting immediately after the incident on 11/27/25 until he exited the building with family. Resident #1 returned to the facility on [DATE] with continued 1:1 monitoring until he was sent to the hospital for further evaluation. Observation on 12/10/25 at 10:20 AM of Resident #1 in the Memory Care Unit sitting with a staff member putting together a puzzle and listening to music. Resident #1 appeared to enjoy putting the puzzle together, interacting with staff and was without distress. Interview on 12/10/25 at 11:15 AM with CNA F revealed during the time of the incident she was passing breakfast trays when Resident #1 was sitting in a chair in the dining room. CNA F stated she saw Resident #1 smile at Resident #2 as he was walking towards him and said I got something for you so Resident #2 stopped at the table, and within five minutes there was a loud noise and Resident #2 was on the floor. CNA F stated she heard Resident #1 talking to Resident #2 but did not think anything of it because he would joke from time to time. CNA F reported that she was aware of Resident #1's behaviors, therefore when he was around other residents, she often kept an eye on him to de-escalate any potential incidents. CNA F stated Resident #1 was near LVN A and other staff members were in the dining room passing breakfast trays and felt like all residents were adequately supervised. CNA F stated she observed Resident #2 with blood coming from his face, and she and the Rehabilitation Director attempted to help Resident #2 off the floor however he indicated that he was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745057 If continuation sheet Page 5 of 16 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 745057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuskegee Airmen Texas State Veterans Home 2200 Joe B Rushing Road Fort Worth, TX 76119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few in pain at his hip area. Resident #2 was immediately sent to the hospital and Resident #1 escorted to his room and placed 1:1. According to CNA F she was inserviced on abuse and neglect, separate and deescalate resident altercations and recognized that residents had the right to be free from abuse and neglect, not being able to do so placed residents at risk of harm. Observation on 12/10/25 at 12:45 PM of Resident #2 revealed Resident #1 in bed resting. Resident #2 had just finished lunch, no observations of pain or distress. Resident #2 did not respond to verbal communication at the time. Interview on 12/10/25 at 1:14 PM with the Administrator revealed both Resident #1 and Resident #2 resided in the Memory Care Unit. The Administrator stated she was notified immediately that Resident #1 was sitting at a table next to LVN A while she was talking with him and administering his medication. The Administrator stated she was told Resident #1 got up from the table and hit Resident #2. Resident #2 lost his balance by the window seal and fell. Residents were separated; Resident #1 was placed 1:1 and Resident #2 was sent out to the hospital for further evaluation due to complaints of pain. According to the Administrator she was aware of Resident #1's history of behaviors. The Administrator reported Resident #1 had been working with psych services and had not been physical towards other residents in a while. The Administrator stated while at the time of the incident #1 was not on 1:1 monitoring all staff were responsible for keeping an eye on Resident #1 for any outburst or triggers due to his history. The Administrator stated Resident #1 liked to be in his room alone most of the time, however he enjoyed listening to music and staff led activities. According to the Administrator all staff were inserviced on abuse and neglect and whom to report to all allegations of abuse. Interview on 12/10/25 at 1:55 PM with CNA G revealed during the incident she was in the kitchen when she heard a bump, and she stepped out and saw Resident #2 on the floor. CNA G stated Resident #1 was close to her, so she separated him by taking him to his room. According to CNA G during the morning hours she, Resident #2 and CNA F were looking at an old picture of Resident #2 and there was laughing during the conversation. CNA G said LVN A reported that Resident #1 hit Resident #2 because he thought Resident #2 was laughing at him. According to CNA G she was aware that Resident #1 had a history of triggers and behaviors. CNA G stated she engaged with Resident #1 a lot when he was out of his room, therefore she had never seen him get physical with other residents. CNA G stated she was responsible for monitoring all residents, CNA G stated residents reacted to triggering things that happened in the past so you have to redirect often while working on the memory care unit. CNA G stated she was inserviced on abuse and neglect, separate residents during an altercation immediately, understood signs and symptoms of abuse and neglect, who to report allegation to and not doing so placed residents at risk of harm. Interview on 12/10/25 at 3:25 PM the Rehabilitation Director revealed he was in the Memory Care Unit at the nursing station speaking with Social Worker B when he heard a disturbance behind him. The Rehabilitation Director stated when he turned around, he saw Resident #2 on the floor and Resident #1 being redirected by staff. The Rehabilitation Director stated he advised to get Resident #2 off the floor due to him being in an awkward position on the wall. The Rehabilitation Director stated once Resident #2 was in the chair he voiced that something didn't feel right. The Rehabilitation Director stated he observed Resident #2 leaning to the right side. The Rehabilitation Director stated at that point emergency services was called. The Rehabilitation Director stated the facility was inserviced on abuse and neglect, he was aware of whom to report allegations to, along with signs and symptoms of abuse. Interview on 12/10/25 at 4:07 PM with Social Worker B revealed she was at the nursing station when the staff were around Resident #1 and Resident #2 in the dining room. Social Worker B stated that she observed staff assisting residents and passing trays, she stated she did not see or hear anything prior to the incident, it was a very calm environment. Social (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745057 If continuation sheet Page 6 of 16 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 745057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuskegee Airmen Texas State Veterans Home 2200 Joe B Rushing Road Fort Worth, TX 76119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Worker B stated after the incident she went to assist with redirecting Resident #1 in his room. Social Worker B stated while with Resident #1 in his room trying to calm him down, he expressed to her that he heard laughing which got him upset. According to Social Worker B, she did not usually work with Resident #1 but was aware of his behaviors. Social Worker B stated the facility was inserviced on abuse and neglect, she was aware to separate residents during altercations immediately, and to report to the Administrator which was the Abuse Coordinator. Interview on 12/10/25 at 4:37 PM with the DON revealed she was notified by the Rehabilitation Director that the team had witnessed Resident #1 punch Resident #2. The DON stated she was told that Resident #2 was approaching the table for medication when he was intercepted with a punch by Resident #1. Resident #2 went backwards and hit his hip on the window sill, then hit the floor. The DON stated upon assessment Resident #2 reported something was wrong with his leg therefore resident #2 was sent out to the hospital. The DON stated Resident #1 was immediately separated and remained 1:1 until family came to take him home for the holiday celebration. The DON stated upon Resident #1's return to the facility he remained 1:1 until he was sent out for evaluation on 11/28/25. The DON stated she was fairly new to the facility however was aware of Resident #1's behaviors. The DON stated at the time of the incident Resident #1 was not on 1:1 monitoring however, staff were aware to keep a close eye on him and to de-escalate any situations where he was involved. According to the DON all staff were responsible for observing residents on the Memory Care Unit, and not doing so placed residents at risk of injury and harm. The DON stated residents on the Memory care Unit had past trauma and were easily triggered, things could happen quickly, making it hard to tell when something was going to occur. The DON stated education was going with staff so they could be aware of resident's triggers and aggressions. The DON stated staff were inserviced on abuse and neglect and was educated to separate residents during resident to resident conflict immediately and report to the Abuse Coordinator. Interview on 12/10/25 at 5:40 PM with the Administrator revealed she was aware of Resident #1's behaviors of having aggressions towards others, however there had not been any issues recently that required him to constantly be monitored 1:1. According to the Administrator all staff working on the memory care unit were responsible for all residents' safety, and not doing so placed residents at risk of injury and harm. The Administrator further stated since Resident #1's return to the facility; interventions had been put in place such as 1:1 monitoring, psychiatric evaluation, monitoring his behaviors, identifying his triggers, the [NAME] machine (interactive game table), participating in activities that he liked, coordinating services with family, music, and care plan meetings to identify alternate living arrangements . The Administrator stated there had not been any further incidents between Resident #1 and Resident #2, Resident #2 had been relocated to reside outside of the Memory Care Unit due to his inability to ambulate. The Administrator stated there had been inservices with staff that covered working with residents with diagnosis of dementia, abuse and neglect, along with inservices provided by the social services department educating staff of each resident's triggers and person centered needs, (Resident #1 was in the first group to train on his triggers and behaviors).The Administrator was notified on 12/10/25 at 5:45 PM that a Past Non-Compliance Immediate Jeopardy situation had been identified due to the above failures. The Administrator was provided with the Immediate Jeopardy template for her signature.Record review of facility policy titled Abuse dated October 2022 revealed to identity, prohibit, and prevent resident abuse. 1. Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion2. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, resident representatives, friends, and other individuals. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745057 If continuation sheet Page 7 of 16 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 745057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuskegee Airmen Texas State Veterans Home 2200 Joe B Rushing Road Fort Worth, TX 76119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete resident(s) will be protected from any identified offender during the course of the investigation by removing the alleged perpetrator from the facility.3. Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, of goods or services necessary to attain or maintain physical, mental, and psychosocial well-being. Willful: The individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Mental Abuse: includes but is not limited to: humiliation, harassment, threats of punishment, deprivation, or taking unauthorized pictures or videos of a resident that are demeaningPhysical Abuse: includes but is not limited to: hitting, slapping, pinching, biting and kicking. It also includes controlling behavior through corporal punishment.Serious bodily injury: an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization, or physical rehabilitation; or an injury resulting in criminal sexual abuse.Any allegation of abuse will be immediately reported to the facility Administrator. The facility will designate an Abuse Prevention Coordinator who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency, law enforcement, and other officials in accordance with state law.The facility took the following actions to correct the non-compliance prior to the investigation:Record review of an in-service, dated 11/28/25 and 12/01/25, reflected 93 staff including nurses, CNAs, housekeepers, medication aides, activity assistant, activity director, Business Office Manager, medical records, dietary assistant manager, dietary aides and social workers were provided with training on Behavior Management and De-escalation, Abuse, Neglect and Exploitation. Record review of an in-service, dated 11/28/25 and 12/01/25, reflected 93 staff including nurses, CNAs, housekeepers, medication aides, activity assistant, activity director, Business Office Manager, medical records, dietary assistant manager, dietary aides, and social workers: Fundamentals of Dementia Care for Health Facility Personnel. Record review of an in-service, dated 12/02/25, reflected 21 staff that included nurses, nurse's aides, housekeeping, medication aides, activity assistant, dietary aides were in-serviced regarding: Communication book for Staff Documentation of Behaviors or Triggers of Residents and 5 Residents review of Triggers and Intervention. Record review of Resident #1's clinical records revealed Resident #1 was placed one-on-one supervision until he was sent to the hospital for fu Event ID: Facility ID: 745057 If continuation sheet Page 8 of 16 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 745057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuskegee Airmen Texas State Veterans Home 2200 Joe B Rushing Road Fort Worth, TX 76119 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 5 residents (Resident #2) reviewed for supervision. The facility failed to provide adequate supervision to prevent a physical altercation when Resident #1, who was sitting at the dining room table eating and talking with LVN A, got up from the table. LVN A asked him where he was going and to have a seat, Resident #1 stated, I will be right back with you. He then walked up to Resident #2 and punched him in the face causing Resident #2 to fall against the wall and then to the ground, which resulted in Resident #2 sustaining facial bleeding and a fractured hip on 11/27/25. The noncompliance was identified as a past non-compliance. The Immediate Jeopardy (IJ) began on 11/27/25 and ended on 12/02/25 the facility had corrected the noncompliance before the investigation began. This failure placed residents at risk of harm and/or severe injury. Findings included:Record review of Resident #1's most recent Quarterly MDS Assessment, dated 09/25/25, reflected an [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had BIMS of 06 indicating moderate cognitive impairment. Diagnoses included Alzheimer's Disease (neurodegenerative disorder that leads to the gradual decline of cognitive functions), Non-Alzheimer's Dementia (various types of dementia). Resident #1's MDS indicated he had signs of verbal behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing) along with other behavioral symptoms not directed towards others (threatening others, screaming at others, cursing at others). Record review of Resident #1's undated care plan revealed [Resident #1] had Impaired thought processes related to Alzheimer's, Dementia. Goal: He will be able to answer simple questions with a yes/no response. Interventions included Approach calmly and warmly, Ask simple questions that require a yes or no answer, Call resident by name, Do not rush resident, explain all procedures to resident, Introduce yourself when approaching resident, Meds as ordered, Provide choices when possible, Provide consistent routine of care as much as possible. The Care Plan revealed: [Resident #1] was at risk for difficulty in psychosocial adjustment related to admission to facility. Veteran gets easily agitated. Goal: Resident #1 will not exhibit signs and symptoms of difficulties in psychosocial adjustment. Interventions included to encourage resident to read name tags if applicable. Introduce self upon each visit with resident. Introduce others who may have similar interests. Notify physician as needed. Observe for sign and symptoms of difficulties in psychosocial adjustment (decreased socialization, sad mood, verbalizes wants to go home). Orientate to facility. Provide 1:1 assistance with emotional adjustment. The Care plan revealed: [Resident #1] was at risk for exhibiting behavior problems- physical aggression towards peers/staff, agitated with staff/peers, hiding things due to fear of things being taken from him. Risk for selfisolating and paranoid behavior noted behavior refusing meds, agitation. Veteran had resident to resident incident 11/27/25, 11/28/25. Goal: he will accept reassurance and respond to interactions during periods of abnormal behaviors. Interventions included Approach resident warmly and positively at all times, Attempt to keep environment free of stress (loud noise, TV,) Consult with family as needed. Encourage family to limit the number of visitors who come to the facility at one time to decrease stimulation Interventions: redirect, reapproach, provide quiet environment, avoid crowds, noise cancelling headphones, play favorite music, talk to him about his daughters, use do you need to call family? Meds as ordered. [Resident #1] to be sent for eval and treatment at In-patient psychiatric unit if approaches unsuccessful and agitation/aggression continues. Notify MD as needed. Observe and document behavior as needed. Provide 1:1 sessions as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745057 If continuation sheet Page 9 of 16 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 745057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuskegee Airmen Texas State Veterans Home 2200 Joe B Rushing Road Fort Worth, TX 76119 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 Provide for safety of resident during periods of combativeness. Provide quiet spaces when agitated as loud noise can be a trigger. Psych eval as needed. Triggers: echoes, sudden noises, loud noises, paranoia of personal space/items, others entering his space/room. The Care Plan revealed: [Resident #1] was at risk for psychosocial changes related to resident-to-resident incident. Goal: [Resident #1] he will have no psychosocial changes. Interventions included Medication as ordered. Notify physician as needed. Provide diversional activities if behaviors occur. Psychological consult as needed. The Care Plan revealed: [Resident #1] had a history of trauma that affects them negatively related to the military. Triggers include: echoes, sudden noises, loud noises, paranoia of personal space/items, others entering his space/room. He may display: suspicions, hiding items, fears things being taken away, verbal, and physical aggression, agitation, self-isolation, paranoia, refuse care or meds, collects/hides gait belts, makes false claims, throwing items, restlessness. Goal: Triggers that may cause re-traumatization will be minimized daily. Interventions included encourage relationships with family and friends that are supportive. Encourage resident to express feelings, concerns, thoughts in a safe space. Observe for signs and symptoms of depression, anxiety, sleep disturbances. Provide a quiet, non-threatening environment with decreased stimulation as needed. Triggers: echoes, sudden noises, loud noises, paranoia of personal space/items, others entering his space/room, redirect, reapproach, provide quiet environment, avoid crowds, noise cancelling headphones, play favorite music, talk to him about his daughters, use do we need to/can we call family? The Care Plan revealed: [Resident #1] has potential to be physically aggressive behavior r/t Poor impulse control. Goal: [Resident #1] will demonstrate effective coping skills through the review date. Interventions included [Resident #1] triggers for physical aggression. Staff to Monitor signs of aggression like Picking teeth with toothpick. Administer medications as ordered. Monitor/document for side effects and effectiveness. COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Record review of Resident #1's progress notes written by LVN A on 11/27/25 at 10:08 AM revealed [Resident #1] was the aggressor. He was sitting having breakfast and he suddenly got up from the table. I asked him to come back and take meds. He said, I will be back to you in a minute. He walked over to [Resident #2] punch him in the face and he hit the floor and hurt his left hip and leg. We spoke with outside provider; she saw him last week but will re-evaluate and inform us if any changes and will notify the family about the worsening behaviors. Family Member came in the mist of the issue and notified Resident Representative by phone. [Resident #1] is out of the building at this time due to Thanksgiving but will return this evening. Record review of Resident #1's progress note written by Social Worker B on 11/27/25 at 10:23 AM revealed Social Worker observed incident from nurses station that occurred this morning with resident to resident. Social Worker went to observe that matter and nursing staff redirected resident to this room and Social Worker assisted as needed to help redirect resident to room. Social Worker met with resident in room to check status and continue to diffuse his emotional state that caused him to hit another resident, as he was placed 1:1. Resident voiced it was the laughing he heard that made him hit the other resident. Social Worker educated and diffused resident on safety and resident was essentially receptive. Social Worker met with resident's Family Member who came to pick up Resident to go out on pass for Thanksgiving today. Social Worker informed the Family Member as to what occurred today and then the Family Member requested the Social Worker speak with another Family Member; Social Worker informed her what occurred as well. Family Members voiced understanding as to what happened today and will return resident today after Thanksgiving celebration. Care team update and Administrator updated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745057 If continuation sheet Page 10 of 16 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 745057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuskegee Airmen Texas State Veterans Home 2200 Joe B Rushing Road Fort Worth, TX 76119 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 Record review of Resident #1 progress note written by Social Worker B on 11/27/25 at 10:41 AM revealed ADON contacted outside provider 24/7 on-call number and was able to speak with Nurse Practitioner regarding resident incident. ADON and Nurse Practitioner discussed medications that need reviewed, and Nurse Practitioner will adjust resident's medication and call the resident's family members regarding behaviors today. Care team updated. Record review of Resident #1 progress note written by LVN A on 11/27/25 at 6:24 PM revealed [Resident #1] was out with family all shift Record review of Resident #1 progress note written by RN C on 11/27/25 at 8:00 PM revealed [Resident #1] is 1:1 while sitting in the day room watching tv with. is pleasant and shows no sign of aggression. No Concerns at this time. Record review of Resident #1 progress note written by RN C on 11/27/25 at 9:00 PM revealed [Resident #1] is in room sleeping, with call light in reach, No Concerns at this time. Record review of Resident #1 progress note written by RN C on 11/27/25 at 10:00 PM revealed [Resident #1] sleeping on bed in room with door closed, call light in reach. No concerns at this time. Record review of Resident #1 progress note written by RN C on 11/27/25 at 11:00 PM revealed [Resident #1] sleeping on bed in room with door closed. Call light within reach. No concerns at this time. Record review of Resident #1 progress note written by LVN D on 11/27/25 at 12:37 AM revealed [Resident #1] back from pass with Family. Took meds and stayed in room until 10:30 PM and came out jumped on another Resident verbally in common area. Separated residents. [Resident #1] went back to room and went to bed. Record review of Resident 2#'s most recent Quarterly MDS Assessment, dated 11/17/25, reflected an [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had BIMS of 05 indicating moderate cognitive impairment. Diagnoses included Alzheimer's Disease (neurodegenerative disorder that leads to the gradual decline of cognitive functions), Non-Alzheimer's Dementia (various types of dementia). Resident #2's MDS indicated he had no signs of behavioral symptoms. Record review of Resident #1's undated care plan revealed [Resident #2] had had impaired skin integrity related to 11/27/25- Laceration to right side chin area. Goal: Resident will remain free from skin impairments related to pressure. Interventions include Braden scale risk assessment quarterly and as needed. Encourage adequate hydration and nutrition. Notify responsible party and discuss skin status as needed. Treatment as ordered. The Care plan revealed: Resident #2 has had an actual fall with (minor injury) Poor Balance, Unsteady gait. 11/27/25-fall with injury. Goal: He will resume usual activities without further incident. Interventions included: Staff to monitor more frequently. Check range of motion times daily. Continue interventions on the at-risk plan. Resident #2 sent to ER for eval and treat, pain meds administered. Provide activities that promote exercise and strength building where possible. Provide 1:1 activities if bedbound. Staff to keep Resident #2 in line of site, monitor as needed. Record review of Resident #2's progress note written by RN E on 11/27/25 at 9:02 AM revealed Outcomes of Physical Assessment: Functional Status: Fall. Nursing observations, evaluation and recommendations are: Patient status post fall, Patient noted with cut to the right-side facial area. Pain to the left hip and left rib cage. Patient sent out to the hospital for further evaluation to the left hip. Primary Care Provider Feedback patient sent out to hospital for further evaluation. Record review of Resident #2's progress note written by RN E on 11/27/25 at 9:31 AM revealed [Resident #2] was medicated for pain prior to hospital transfer. Power of Attorney, MD, DON, and Administrator notified of incident. Record review of Resident #2's progress note written by Social Worker B 11/27/25 at 10:24 AM revealed Social Worker met with resident to check status as nursing staff and Director of Rehabilitation was with resident to monitor until Emergency Medical Services to arrive to go to hospital for assessment. Social Worker inquired with resident on his psychosocial well-being after incident to check if he felt safe and comfortable and resident voiced he was okay and was hurting on left side of body as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745057 If continuation sheet Page 11 of 16 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 745057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuskegee Airmen Texas State Veterans Home 2200 Joe B Rushing Road Fort Worth, TX 76119 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 care team was assessing him and assisting him with care. Social Worker contacted resident's Family Member and left voicemail to return call. Social Worker did receive a call back from resident's Family Member and Social Worker informed them of the matter that occurred and that Emergency Medical Services was currently there to pick up resident to take to hospital and they voiced understanding of the matter. Care team updated. Record review of Resident #2's progress note written by LVN A on 11/27/25 at 10:37 AM revealed [Resident #2] was walking through the common area. [Resident #1] got up from eating breakfast and went over to him and punched him in the face. [Resident #2] fell to the ground in shock. [Resident #1] stood over him and told him to say it again. CNA ran over remove [Resident #1] from the area and took him to his room. First aide was rendered immediately. Laceration was cleaned and covered. When Evaluated by Physical Therapy he could not bear weight on the left side and stated, Man, I am hurt. What happened? [Resident #2] remained seated until Emergency Medical Services arrived to transport him to the hospital. Record review of Resident #2's progress note written by LVN A on 11/27/25 at 1:52 PM revealed [LVN A] called hospital to check on [Resident #2]. emergency room Nurse, informed [Resident #2] will be admitted to the surgical floor. RN Supervisor notified. Record review of Resident #2's progress note written by LVN A on 11/27/25 at 6:24 PM revealed Hospital Admit. Record review of Resident #2's hospital record dated 12/01/25 11:16 AM revealed Chief Complaint: Fall. History of present illness: [Resident #2] is an [AGE] year-old male with history of dementia, Alzheimer's disease, alcoholic cirrhosis (advanced form of liver disease related to drinking alcohol), hypertension (high blood pressure), and prostate cancer (cancer that start in the prostate) who presented after an unwitnessed fall at his memory care facility, resulting in left hip pain and inability to ambulate. On arrival, he was noted to have left leg pain, external rotation and shortening of the left lower extremity, and an abrasion to the face, but no evidence of head trauma or loss of consciousness was reported. Imaging, including left femur (thigh bone, longest and strongest bone in the human body) and hip radiographs, confirmed an acute comminuted, displaced transcervical left femoral neck fracture (a type of hip fracture where the bone connecting the ball of the hip joint to the thigh bone breaks), additional trauma imaging showed no acute intracranial (bony part of the skull that holds the brain) or spinal injury, and no acute facial fractures. Record review of the provider investigator report revealed on 11/17/25 at 7:45 AM Resident #1 was eating breakfast talking to staff when he got up from the table, a few feet away and hit Resident #2 on the right side of his face. Resident #2 lost his balance and fell backwards into wall/window seal and then to the ground. Resident #2 had laceration below his right eye, facility cleansed area. Initially denied pain, was able to move extremities. Physical Therapy and Nursing lifted Resident #2 to a chair to finish the assessment, and he then complained of pain, stating something was wrong. Emergency Medical Services was called immediately. The provider response revealed: Residents were separated and assessed. The facility initiated protocol to include: Resident #1 being placed on 1:1 until family arrived to take Resident #1 out on pass for Thanksgiving - Resident #1 remained on 1:1 until the facility sent out to the hospital for evaluation and treatment; and proper notifications completed to family, physician, DON, Administrator, and Regional Support Team. Resident #2 complained of pain to his left side. The facility sent him out via Emergency Medical Services. The facility continued protocol to include: quality of life rounds, in-servicing, staff interviews, as needed Trauma Assessment, Social Service follow-up for psychosocial assessment, and updated the plan of care. The investigation revealed: the Administrator received a phone call at 7:45 AM from the Director of Nursing notifying the Administrator of the incident. It was reported that the nurse was getting ready to give medication and Resident #1 went over and hit Resident #2 in the face, he lost balance and fell into the wall and then (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745057 If continuation sheet Page 12 of 16 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 745057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuskegee Airmen Texas State Veterans Home 2200 Joe B Rushing Road Fort Worth, TX 76119 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 to the ground. Resident #2 was assessed and noted to have a laceration to the right side of the face. Nursing cleaned the laceration. Initial assessment of Resident #2 revealed he was able to move his leg. Resident #2 was lifted by staff and placed in a chair. At that time Resident #2 stated something was wrong. The Rehabilitation Director and Nursing assessed his leg and Resident #2 was noted to have pain in his left leg and unable to move. Emergency Medical Services was contacted, and Resident #2 was sent to local hospital for evaluation and treatment. Resident #1 was placed on 1:1 and required redirection multiple times. The Social Worker met with Resident #1 and when asked what happened he mentioned he was hearing laughing and thought it was Resident #2 and was hyper focused on the laughing. Family arrived shortly after the incident and wanted to take Resident #1 out on pass for Thanksgiving. The facility decided to allow Resident #1 go and upon return would be placed 1:1 and then work on an in-patient hospital stay for further evaluation and treatment. The facility did contact psych services to review incident and provider to complete a medication review. Resident #1 had a BIMS of 6, resided in a Memory Care Unit due to poor safety awareness and exit seeking tendencies. He was actively seen by both psychiatry and psychology services. Triggers identified were loud noises, people going into room, and being in his space. Resident #1 currently admitted to hospital for mood stabilization.The facility conducted care plan meeting to discuss re-admission and Resident #1 to be placed on 1:1 to see how new medications were working but facility would like to look at potential alternate placements, with family in agreement. The Administrator completed quality of life rounds, incident review, facility rounds, and staff interviews. No additional concerns identified at this time. In-services were initiated on Behavior in Dementia with de-escalation and dementia. The facility updated Ad Hoc (when necessary or needed) QAPI meeting to include: additional education for memory care unit, updating admission criteria for unit along with admission process, and evaluation of unit staff for compatibility with incident tracking and trending. Investigation Findings revealed: Unsubstantiated willful intent to harm due to Alzheimer's Diagnosis. Resident #1 was placed on 1:1 monitoring starting immediately after the incident on 11/27/25 until he exited the building with family. Resident #1 returned to the facility on [DATE] with continued 1:1 monitoring until he was sent to the hospital for further evaluation. Observation on 12/10/25 at 10:20 AM of Resident #1 in the Memory Care Unit sitting with a staff member putting together a puzzle and listening to music. Resident #1 appeared to enjoy putting the puzzle together, interacting with staff and was without distress. Interview on 12/10/25 at 11:15 AM with CNA F revealed during the time of the incident she was passing breakfast trays when Resident #1 was sitting in a chair in the dining room. CNA F stated she saw Resident #1 smile at Resident #2 as he was walking towards him and said I got something for you so Resident #2 stopped at the table, and within five minutes there was a loud noise and Resident #2 was on the floor. CNA F stated she heard Resident #1 talking to Resident #2 but did not think anything of it because he would joke from time to time. CNA F reported that she was aware of Resident #1's behaviors, therefore when he was around other residents, she often kept an eye on him to de-escalate any potential incidents. CNA F stated Resident #1 was near LVN A and other staff members were in the dining room passing breakfast trays and felt like all residents were adequately supervised. CNA F stated she observed Resident #2 with blood coming from his face, and she and the Rehabilitation Director attempted to help Resident #2 off the floor however he indicated that he was in pain at his hip area. Resident #2 was immediately sent to the hospital and Resident #1 escorted to his room and placed 1:1. Observation on 12/10/25 at 12:45 PM of Resident #2 revealed Resident #1 in bed resting. Resident #2 had just finished lunch, no observations of pain or distress. Resident #2 did not respond to verbal communication at the time. Interview on 12/10/25 at 1:14 PM with the Administrator revealed both (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745057 If continuation sheet Page 13 of 16 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 745057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuskegee Airmen Texas State Veterans Home 2200 Joe B Rushing Road Fort Worth, TX 76119 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 and Resident #2 resided in the Memory Care Unit. The Administrator stated she was notified immediately that Resident #1 was sitting at a table next to LVN A while she was talking with him and administering his medication. The Administrator stated she was told Resident #1 got up from the table and hit Resident #2. Resident #2 lost his balance by the window seal and fell. Residents were separated; Resident #1 was placed 1:1 and Resident #2 was sent out to the hospital for further evaluation due to complaints of pain. According to the Administrator she was aware of Resident #1's history of behaviors. The Administrator reported Resident #1 had been working with psych services and had not been physical towards other residents in a while. The Administrator stated while at the time of the incident #1 was not on 1:1 monitoring all staff were responsible for keeping an eye on Resident #1 for any outburst or triggers due to his history. The Administrator stated Resident #1 liked to be in his room alone most of the time, however he enjoyed listening to music and staff led activities. Interview on 12/10/25 at 1:55 PM with CNA G revealed during the incident she was in the kitchen when she heard a bump, and she stepped out and saw Resident #2 on the floor. CNA G stated Resident #1 was close to her, so she separated him by taking him to his room. According to CNA G during the morning hours she, Resident #2 and CNA F were looking at an old picture of Resident #2 and there was laughing during the conversation. CNA G said LVN A reported that Resident #1 hit Resident #2 because he thought Resident #2 was laughing at him. According to CNA G she was aware that Resident #1 had a history of triggers and behaviors. CNA G stated she engaged with Resident #1 a lot when he was out of his room, therefore she had never seen him get physical with other residents. CNA G stated she was responsible for monitoring all residents, CNA G stated residents reacted to triggering things that happened in the past so you have to redirect often while working on the memory care unit. Interview on 12/10/25 at 3:25 PM the Rehabilitation Director revealed he was in the Memory Care Unit at the nursing station speaking with Social Worker B when he heard a disturbance behind him. The Rehabilitation Director stated when he turned around, he saw Resident #2 on the floor and Resident #1 being redirected by staff. The Rehabilitation Director stated he advised to get Resident #2 off the floor due to him being in an awkward position on the wall. The Rehabilitation Director stated once Resident #2 was in the chair he voiced that something didn't feel right. The Rehabilitation Director stated he observed Resident #2 leaning to the right side. The Rehabilitation Director stated at that point emergency services was called. Interview on 12/10/25 at 4:07 PM with Social Worker B revealed she was at the nursing station when the staff were around Resident #1 and Resident #2 in the dining room. Social Worker B stated that she observed staff assisting residents and passing trays, she stated she did not see or hear anything prior to the incident, it was a very calm environment. Social Worker B stated after the incident she went to assist with redirecting Resident #1 in his room. Social Worker B stated while with Resident #1 in his room trying to calm him down, he expressed to her that he heard laughing which got him upset. According to Social Worker B, she did not usually work with Resident #1 but was aware of his behaviors. Interview on 12/10/25 at 4:37 PM with the DON revealed she was notified by the Rehabilitation Director that the team had witnessed Resident #1 punch Resident #2. The DON stated she was told that Resident #2 was approaching the table for medication when he was intercepted with a punch by Resident #1. Resident #2 went backwards and hit his hip on the window sill, then hit the floor. The DON stated upon assessment Resident #2 reported something was wrong with his leg therefore resident #2 was sent out to the hospital. The DON stated Resident #1 was immediately separated and remained 1:1 until family came to take him home for the holiday celebration. The DON stated upon Resident #1's return to the facility he remained 1:1 until he was sent out for evaluation on 11/28/25. The DON stated she was fairly new to the facility however was aware of Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745057 If continuation sheet Page 14 of 16 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 745057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuskegee Airmen Texas State Veterans Home 2200 Joe B Rushing Road Fort Worth, TX 76119 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 #1's behaviors. The DON stated at the time of the incident Resident #1 was not on 1:1 monitoring however, staff were aware to keep a close eye on him and to de-escalate any situations where he was involved. According to the DON all staff were responsible for observing residents on the Memory Care Unit, and not doing so placed residents at risk of injury and harm. The DON stated residents on the Memory care Unit had past trauma and were easily triggered, things could happen quickly, making it hard to tell when something was going to occur. The DON stated education was going with staff so they could be aware of resident's triggers and aggressions. Interview on 12/10/25 at 5:40 PM with the Administrator revealed she was aware of Resident #1's behaviors of having aggressions towards others, however there had not been any issues recently that required him to constantly be monitored 1:1. According to the Administrator all staff working on the memory care unit were responsible for all residents' safety, and not doing so placed residents at risk of injury and harm. The Administrator further stated since Resident #1's return to the facility; interventions had been put in place such as 1:1 monitoring, psychiatric evaluation, monitoring his behaviors, identifying his triggers, the [NAME] machine (interactive game table), participating in activities that he liked, coordinating services with family, music, and care plan meetings to identify alternate living arrangements . The Administrator stated there had not been any further incidents between Resident #1 and Resident #2, Resident #2 had been relocated to reside outside of the Memory Care Unit due to his inability to ambulate. The Administrator stated there had been inservices with staff that covered working with residents with diagnosis of dementia, abuse and neglect, along with inservices provided by the social services department educating staff of each resident's triggers and person centered needs, (Resident #1 was in the first group to train on his triggers and behaviors).The Administrator was notified on 12/10/25 at 5:45 PM that a Past Non-Compliance Immediate Jeopardy situation had been identified due to the above failures. The Administrator was provided with the Immediate Jeopardy template for her signature. Record review of facility policy titled Accidents and Incidents dated October 2012 revealed to respond - provide medical attention and investigate an accident or incident. Report Accidents/Incidents the charge nurse must be informed of accidents or incidents in order to provide medical attention. Assisting Accident/Incident Victims: render immediate assistance do not move until he/she has been examined for possible injuries. Medical Attention: Examine and notify the attending physician, and responsible party of the incident and investigate the accident or incident. Record review of facility policy titled Behavioral Health Services dated October 2022 revealed The facility will ensure residents receive necessary behavioral health care and services to assist him or her to reach and maintain the highest level of mental and psychosocial functioning. Behavioral health will encompass the resident's emotional and mental well-being which include, but not limited, the prevention and treatment of mental and substance us disorders, psychosocial adjustment difficulty, and trauma or post-traumatic stress disorders. The facility will utilize the comprehensive assessment process to identify and assess a resident's mental and psychosocial status, response to stressors, trauma triggers, and provide person centered care. The process include: obtain history from medical records, the family, and resident regarding mental, psychological, and emotional health as available, MDS and care area assessments, ongoing monitoring of mood and behavior, care plan development, and implementation. The care plan should have interventions that are person-centered, evidence-based, culturally competent, trauma-informed, and in accordance with professional standards of practice, provide meaningful activities to meet the needs of the resident. Attempt to maximize the resident's dignity, autonomy, privacy, socialization, independence, and safety. Facility staff will receive training during orientation and annually related to behavioral health services. The facility took the following actions to correct (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745057 If continuation sheet Page 15 of 16 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 745057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuskegee Airmen Texas State Veterans Home 2200 Joe B Rushing Road Fort Worth, TX 76119 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 the non-compliance prior to the investigation:Record review of an in-service, dated 11/28/25 and 12/01/25, reflected 93 staff including nurses, CNAs, housekeepers, medication aides, activity assistant, activity director, Business Office Manager, medical records, dietary assistant manager, dietary aides and social workers were provided with training on Behavior Management and De-escalation, Abuse, Neglect and Exploitation. Record review of an in-service, dated 11/28/25 and 12/01/25, reflected 93 staff including nurses, CNAs, housekeepers, medication aides, activity assistant, activity director, Business Office Manager, medical records, dietary assistant manager, dietary aides, and social workers: Fundamentals of Dementia Care for Health Facility Personnel. Record review of an in-service, dated 12/02/25, reflected 21 staff that included nurses, nurse's aides, housekeeping, medication aides, activity assistant, dietary aides were in-serviced regarding: Communication book for Staff Documentation of Behaviors or Triggers of Residents and 5 Residents review of Triggers and Intervention. Record review of Resident #1's clinical records revealed Resident #1 was placed one-on-one supervision until he was sent to the hospital for further evaluation on 11/28/25. Record review of Resident #2's clinical records revealed Resident #2 was assessed and transported to the emergency room for further evaluation with findings of a fractured hip. Record review of the Resident observation Surveys conducted on 11/30/25 - 12/10/25 by staff over what signs and symptoms to look for when resident had a change in condition, how to respond when witnessed a resident-to-resident altercation, who do you report abuse/neglect allegations to. All with the understanding to immediately separate residents during resident-to-resident altercation and report to the nurse and the abuse coordinator which was the Administrator. Observation on 12/10/25 from 9:00 AM - 5:00 PM revealed Resident #1 on 1:1 monitoring, staff engaged with residents as they participated in activities, and staff mad Event ID: Facility ID: 745057 If continuation sheet Page 16 of 16