Health inspection·April 23, 2025

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in place, and she remembered that Resident #1's next of kin said the resident had no estate, and sent documents to show kinship. She said Resident #1's Power of Attorney requested the records, but they could not release them because the resident had passed away, so the Power of Attorney documents were no longer in play. She said she did not think the legal department took very long to send records normally, because she did all of the leg work to prepare the records in the facility. The DMR said she did not like to make anyone wait, and she had assumed legal had taken care of sending the records. She said it was a right for people to receive medical records for themselves, for someone they had Power of Attorney over if that resident was still alive, or for the Next-of-Kin. She said they could not send some of the things Resident #1's Next-of-Kin was asking for, like the staff records, but all of Resident #1's medical records should have been available. She said they had 30 days to get the records to the requestor. An interview on [DATE] at 1:57 PM with the DMR and Administrator revealed they had learned that the attorney who was handling the request for Resident #1's clinical records was no longer working for the company, and the current attorney had not been made aware of any pending requests, so the request had not been fulfilled. The Administrator said it had been addressed at the time of this interview, and the records would be sent out within a day or so. The DMR said she had been doing her job for a long time, and had never had a problem like this with their corporate, but now knew she needed to keep checking on the records, until she knew they had been sent. Review of documentation provided by Resident #1's Next-of-Kin reflected the following: - Resident #1's death certificate, certified [DATE], showing the date of death to be [DATE]. - Resident #1's Next-of-Kin's driver's license, and birth certificate. - An email, dated [DATE], from the Admissions Director to Resident #1's Next-of-Kin, providing the Next-of-Kin with the Authorization for Release of Medical Information form, in response to an emailed request from Resident #1's medical records from his Next-of-Kin. - An email, dated [DATE], from Resident #1's Next-of-Kin to the Admissions Director and the DMR (Director of Medical Records) with the Authorization for Release of Medical Information form attached. - A letter, dated [DATE], from Resident #1's Next-of-Kin requesting records related to Resident #1. - An Authorization for Release of Medical Information signed by resident #1's Next-of-Kin on [DATE] for the request of Resident #1's entire medical record, and additional information including incident reports, emergency response records related to [DATE], policies and procedures related to emergency response, and staffing records for [DATE] through [DATE]. - An email dated [DATE] from Resident #1's Next-of-Kin to the Admissions Director and the DMR requesting a time frame for the records to be delivered. - An email dated [DATE] from the DMR to Resident #1's next-of kin requesting a document showing the executor of Resident #1's estate. - An email, dated [DATE], from Resident #1's Next-of-Kin to the DMR replying to explain the resident did not have to go through probate, and being Next-of-Kin had been appropriate when requesting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455891 If continuation sheet Page 2 of 4 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 455891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Park Multi Care Center 4252 Bryant Irvin Rd Fort Worth, TX 76109 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 0573 other medical records. Level of Harm - Minimal harm or potential for actual harm - An email, dated [DATE], from Resident #1's Next-of-Kin to the DMR inquiring about the status of the medical records request. The email reflected the initial request was made on [DATE], and the last correspondence received was on [DATE]. The email refers to the birth certificate attached to prove status as Next-of-Kin, and expresses frustration over the facility's lack of communication and failure to follow HIPAA regulation requiring the provision of records within 30 days. The letter states a request for a formal response with a definitive timeline on receiving the records, and delivery of the records by the close of business on [DATE]. The letter stated failure to comply would be reported to US DHHS, TX HHSC, and the Attorney General's Office (enforcer of state consumer protection laws.) Residents Affected - Few - An email, dated [DATE], from the DMR to Resident #1's Next-of-Kin requesting a copy of who was the executor of Resident #1's estate. - An email, dated [DATE], from Resident #1's Next-of-Kin to the DMR which reflected there was no executor to Resident #1's estate, and the Next-of-Kin had a right to the medical records. - An email, dated [DATE], from Resident #1's Next-of-Kin to the DMR requesting an update on the release of records. - An email, dated [DATE], from Resident #1's Next-of-Kin to the DMR again requesting an update on the release of records, and a reminder of non-compliance with regulations. - An email, dated [DATE], from the DMR to Resident #1's Next-of-Kin apologizing for the length of time, and stating there should be information from the legal department on that day ([DATE].) - A final email, dated [DATE], from Resident #1's Next-of-Kin to the DMR requesting corporate contact information, and stating that unless the records were received by close of business on [DATE] complaints would be filed. Review of the facility policy, dated [DATE], for Disclosure of Protected Health Information (PHI)- Release of Information reflected Policy: ( .) Each resident has the right to access his or her protected health information contained in the medical record. The resident is assured confidential treatment of his or her medical records and may approve or refuse their release to any individual outside the facility, except in the case of his or her transfer to another health care institution, or as required by law or third-party contract. If there is a state-specific law with more stringent requirements, the facility must comply with the state statute(s). ( .) Procedure: 2. When a request is made by a current resident or another party to view or copy the medical record, those requests should be directed to the Health Information Management Director/Privacy Official. ( .) Handling a Request for Copies of Medical Records: All requests for copies should be handled by the HIMD to· ensure uniform application of the facility policy and adherence to applicable laws and practice to standards. The request for copies should be put in writing on an Authorization for Release of Information form and signed by the resident or personal representative. The request should specifically state which records are to be copied. In accordance with 42 CFR §483.10(b)(2), a request may be made orally by the resident/ legal representative. ( .) Note: The maximum turnaround time to respond to a valid request for a discharged or expired resident's information is 30 days from the date of request unless otherwise required by state law. ( .) In general, the resident is incompetent or cannot authorize the disclosure, the following individuals may serve as the resident's personal representative (in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455891 If continuation sheet Page 3 of 4 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 455891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Park Multi Care Center 4252 Bryant Irvin Rd Fort Worth, TX 76109 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 0573 Level of Harm - Minimal harm or potential for actual harm order of priority). a. Legal guardian or attorney b. Agent named in a directive, durable power of attorney for health care, other durable power of attorney c. Next of kin (in the following order): a. Spouse from a marriage recognized by law b. Adult son or daughter c. Father or mother d. Adult brother and sister. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455891 If continuation sheet Page 4 of 4