Health inspection·March 12, 2024

F 0689 AOL as needed. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's Fall Risk assessment dated [DATE], reflected Resident #1 was alert (oriented x 3), no history of falls in the previous 3 months, ambulatory/incontinent, adequate vision (with or without glasses), balance problem while walking, decreased muscular coordination, and required use of assistive devices (i.e. walker). Residents Affected - Few Record review of Resident #1's Initial Care Plan, dated 01/14/2024 at 10:43 AM, reflected, Patient presents with functional impairment and recent progressive decline in overall function, requiring increased assistance from staff to manage mobility and ADL needs. Pt demonstrates generalized weakness, fatigue, poor endurance, and decline in mobility affecting QOL and ADL performance. Referred to therapy services to improve the physical decline and decrease patient's dependence on staff and caregivers for basic daily functional needs and to improve patient's QOL. Pt requires skilled PT services in order to increase LE ROM and strength, increase functional activity tolerance, improve dynamic balance, requires skilled OT services to maximize ADLs, increase safety awareness, facilitate increased participation with functional daily activities. Safety, fall, aspiration precautions as appropriate .encourage nursing staff to increase oob activity during the day as much as possible and as patient tolerate. Pain management as appropriate to improve ability to participate in therapy activities; Monitoring and management of pain with Rx per IM/Physiatry collaboration as appropriate . Safety Precautions/ Fall Prevention: Weightbearing as tolerated. Activity as tolerated with assistance. Interdisciplinary falls prevention strategies per facility and individualized to reduce risk of falls and injuries. Record review of Resident #1's Nurse's Note dated 01/16/2024 signed by RN C reflected [Resident #1] had an unwitnessed fall in her room. Resident #1 said, I tried to get up, but my feet slid on the floor. [Resident #1] did not sustain any injuries after the fall on 01/16/2024. [Resident #1] was noted to have redness to her left knee. Resident #1 appeared or stated to be in pain, yes. [Resident #1's] physician and family were notified, and the interventions were floor mat, low bed, and interval monitoring. Record review of Resident #1's Fall Risk Assessment, dated 01/16/2024 at 4:45 AM and signed by RN C, reflected, Resident #1 had a fall with no injury on 01/16/2024 with a score of 8. Resident #1 had intermittent confusion, no falls in the past 3 months, ambulation was chair bound and requires assist with the elimination, adequate vision (with or without glasses) and resident was unable to stand. Record review of Resident #1's Progress Note dated 01/16/2024 reflected, Resident stated R hip is a little bit aching offered pain medication but refused. Record review of Resident #1's nurse Progress Note dated 01/16/2024, reflected, that Resident #1 stated that her right hip was hurting. Resident #1's physician was notified and ordered a prescription. Resident #1 was offered pain medication but refused. Record review of the Order Summary Report dated, 01/16/2024 reflected an active telephone order from MD B for Resident #1 to receive Right hip X-ray unilateral 2-3 views with pelvis due to pain S/p Fall, Pt is non ambulatory wheelchair bound. X-ray results on 1/16/24 at 1:30pm right hip and the pelvis - showed evidence of bilateral sacroiliac osteoid arthritis but no fracture. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676052 If continuation sheet Page 2 of 6 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 676052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Immanuel's Healthcare 4515 Village Creek Rd 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 - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's Progress Note dated, 01/16/2024, signed by RN C reflected, Neurocheck in progress, WNL, bed in lowest position, call light within reach, instructed to use call light at all times and not to get OOB unassisted. Record review of Resident #1's comprehensive care plan dated 01/16/2024, (completed after Resident #1's fall) reflected a focus on her history of falls. The care plan stated, Resident #1 has had an actual fall with no injury r/t Poor Balance, Poor communication/comprehension, and unsteady gait. Resident #1 is non-compliant with calling for assistance, attempts to transfer per self without assistance. Resident #1's goals reflected, the resident will resume usual activities without further incidents through the review date. Interventions included, continue interventions on the at-risk plan, encouragement for resident to ask for assistance when needed, floor mat on floor when in bed Resident #1's Care Plan did not include information regarding, interventions for falls, ADL care or toileting. Record review of Resident #1's Progress Note dated, 01/17/2024 reflected, F/U fall day 1. Alert and confused. Neuro checks WNL. C/O lower back discomfort. No visible injury noted to back. Results of unilateral 2-3 views of Rt. hip and 1 view of pelvic revealed no fx. or dislocation. Floor mat next to bed on floor. Bed in lowest position. Call light in reach. Continues to attempt to get OOB without assistance .follow-up pain scale was 0. Record review of Resident #1's Progress Note dated, 01/17/2024 at 3:46 PM, reflected, IDT team conducted care plan for resident which reflected, Resident was admitted to facility 01/13/2024. Resident has goals to remain in facility long term. Resident has a family member who speaks for resident. Resident is A&O*2 with confusion. Resident #1's family member stated resident will attempt to get out of bed and walk on her own. Resident #1's family member would like for resident to have one on one, but nursing department advised her she can have her own sitter for Resident #1, but facility does not provide sitter for family. Resident will continue to be monitored for falls and also floor mats were placed in resident's rooms for fall interventions. Record review of Resident #1's Progress Note, dated 01/17/2024 at 11:22 PM, reflected, Resident observed laying on the floor mat beside her bed, resident reported that she was going to the bathroom, head to toe assessment done, no skin injuries noted .transferred to bed x 2 staff members, resident reminded to use the call right for help . Record review of Resident #1's Fall Risk Assessment, dated 01/17/2024, reflected Resident #1 had a fall with no injury on 01/17/2024 with a high risk category and score of 14. Resident #1 was alert (oriented x 3), history of 3 or more falls in the past 3 months, ambulation was chair bound and requires assist with the elimination, adequate vision (with or without glasses) and resident was able to stand with normal gait/balance, balance problem while standing, balance problem while balance problem while walking, decreased muscular coordination, change in gait pattern when walking through doorway. Record review of Resident #1's Progress Note, dated 01/18/2024 at 5:19 AM, reflected, F/U fall day 1. Confused, neuro checks WNL. Bed in lowest position. Fall mat on floor next. Medicated x1 for back discomfort. Record review of Resident #1's Progress Note, dated 01/18/2024 at 5:23 AM, reflected, F/U fall day 1. Confused, neuro checks WNL. Continues to c/o discomfort to back. Bed in lowest position, fall mat on floor next to bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676052 If continuation sheet Page 3 of 6 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 676052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Immanuel's Healthcare 4515 Village Creek Rd 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 - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's Progress Note on 01/18/2024 at 3:09 PM, reflected, resident was observed with syncope episode, 911 called, arrived in 5 minutes, at this time resident regained some consciousness, daughter by bed side, requested to be transferred to ER for further evaluation and treatment. Record review of the Order Review Report dated 01/18/2024 revealed an active order for Resident #1 to be transferred to the hospital for an evaluation and treatment r/t syncope episode. Record review of the Provider Investigation Report reflected, Resident #1 was found on the floor on her knees near her bed, when she fell of a bedside commode on 01/16/2024. CNA A transfered Resident #1 to the commode then left the room to assist another resindet. On 01/17/2024, Redsident #1 had an unwitnessed fall and was found lying beside her bed on the fall mat. On 01/18/2024, Resident #1 had a witnessed syncope event (fainting or passing out) and was transferred to a hospital. At the hospital, Resident #1 complained of generalized back pain and lower abdominal pain. A CT was positive for acute mildly displaced inferior sacral fraction (sacrum is a large triangular bone at the bottom of the spine. It fits like a wedge between the two hip bones). The facility's investigation was confirmed in relation to CNA A leaving Resident #1 unsupervised on the commode on 01/16/2024. In interviews on 02/12/2024 at 11:03 AM and 03/12/2024 at 2:26 PM, the DON stated that Resident #1 had an fall from a bedside commode, when CNA A left the room to assit another resident, on 01/16/2024. She said Resident #1 had a second fall that was unwitnessed on 01/17/2024. Resident #1 said she was going to the bathroom. The DON stated Resident #1's fall on 01/16/2024 did not result in any injury, X-rays confirmed no fracture and pain medication was ordered. She said when acetaminophen was not effective, the physician ordered for Neproxen on 01/17/2024 at 5:24 PM which was effective. She said on 01/16/2024, Resident #1 was on the bedside commode and CNA A was assisting her with toileting. She stated that CNA A left Resident #1 on the bedside commode in the bathroom for approximately 2-3 minutes to assist another resident in another room. She stated that Resident #1 fell from the commode, and she was found on her knees on the floor beside her bed by CNA A. She stated that staff provided a head-to-toe assessment on Resident #1 and a fall risk assessment was completed. She stated that Resident #1 later complained of hip pain and X-rays were ordered of the right hip and pelvis. She said they revealed evidence of bilateral sacroiliac osteoid arthritis but no fracture. The DON stated that CNA A should not have left Resident #1 alone while on the commode on 01/16/2024. She said CNA A should have finished assisting her with toileting prior to assisting another resident in another room. She said she verbally inserviced CNA A on 01/16/2024, focusing on abuse, neglect and not leaving any residents alone during toileting. She said CNA A was suspended pending the facility's investigation of the incident on 01/17/2024. The DON said CNA A and all staff were retrained on falls, accidents, answering call lights, not leaving residents alone, and Abuse and Neglect on 01/19/2024. She stated there was no indication [NAME] the hospital or family that Resident #1 needed constant supervision due to her behavior of getting out of bed unassisted. She stated residents unsupervised while on the commode posed a risk of fall or injury. She stated her expectation was for staff to remain with residents when assisting them during toileting. She stated Resident #1 had a second unwitnessed fall on 01/17/2024 and was again assessed with no injuries, Resident #1 made no indication of pain, the physician was consulted and directed continuation of Neproxen, neuros, and fall precautions. She stated on 01/18/2024, Resident #1 was sent to hospital after a syncope incident in the bathroom, with her family present. In interviews on 02/12/2024 at 12:34 PM and 03/12/2024 at 3:20 PM, MD B said the facility notified him after Resident #1's fall on 01/16/2024 and again on 01/17/2024. He said he was informed the resident had no bruising on 01/16/2024 but did have pain. He said he ordered X-rays of the right hip and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676052 If continuation sheet Page 4 of 6 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 676052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Immanuel's Healthcare 4515 Village Creek Rd 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 - Minimal harm or potential for actual harm Residents Affected - Few the pelvis which showed evidence of bilateral sacroiliac osteoid arthritis but no fracture. He ordered neuro checks and vital checks for the resident for 8 hours after the fall and directed staff to continue to monitor the resident for pain or changes in condition. He said he ordered pain medication as well. He said on 01/17/2024, staff informed him of Resident #1's second fall and there were no injuries noted and no initial pain. He said he did not feel X-rays needed to be ordered for this reason. He said he instructed staff to continue neuro checks and monitor for pain. He said the acute mildly displaced inferior sacral fraction found on the CT scan, at the hospital, may not have shown up on the X-rays ordered on 01/16/2024. He said it could also have developed in transport to the hospital on [DATE]. He said he felt Resident #1 was assessed appropriately after falls on 01/16/2024 and 01/17/2024. In interviews on 02/12/2024 at 3:43 PM and 03/12/2024 at 2:26 PM, facility's Corporate Compliance Nurse said Resident #1 had a fall from the bedside commode, on 01/16/2024, when CNA A left the room briefly to assist another resident. He stated CNA A returned to the room and found Resident #1 on her knees beside the commode. He said he was not sure how long Resident #1 was left alone on the commode. He stated the facility did not have a policy that stated a resident should not be left alone while toileting. He said the admission assessment of Resident #1 was a one person assist with toileting. He said Resident #1's Initial Care Plan did note Resident #1 required increased assistance from staff to manage mobility and ADL needs, generalized weakness, fatigue, poor endurance, and decline in mobility affecting QOL and ADL performance. He said they had general fall risk procautions in place but had not information from the hospital or family that Resident #1 needed constant supervision or would get up on her own, without assistance. He said the facility could not admit a resident who needed 1:1 supervision. He stated he expected staff to ensure residents were safe based on the information we have. He said the facility developed and updated care plans as they see resident's behavior. He said after Residnet #1's inital fall, they updated the fall assessment, developed an updated care plan for Resident #1 and retrained staff in appropraite supervion. He said CNA A should have supervised Resident #1 while she was on the commode and did place Resident #1 at risk of injury or fall. In an interview on 03/12/2024 at 11:15 AM, LVN E stated he did the initial assessment on 01/13/2024, for Resident #1 when she came from the hospital. He said she did not get up on her own and needed one person assistance with transferring, while toileting. Several attempts on 02/12/2024 and 03/12/2024 at 3:19 PM, to contact CNA A via telephone were unsuccessful. Several attempts on 02/12/2024 and 03/12/2024 at 1:05 PM, to contact RN C, via telephone were unsuccessful. RN C was the nurse on duty during Resident #1's first fall. In an interview on 03/12/2024 at 3:20 PM, LVN D stated she was not present when Resident #1 fell on [DATE]. She said did followed up with pain assessment, neuros, and fall precautions. She said Resident #1 did not get up on her own when she first came to the facility. She said after her fall on 01/16/2024, she started to get up without assistance and staff repeatedly checked on her to ensure she did not get up on her own. A telephone call on 03/12/2024 at 9:56 AM, to Resident #1's family member revealed no response. Record review of the facility's In-Service Training Attendance Roster revealed, dated 01/19/2024, the DON had In-Serviced the all staff on Abuse and Neglect in relation to these incidents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676052 If continuation sheet Page 5 of 6 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 676052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Immanuel's Healthcare 4515 Village Creek Rd 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 - Minimal harm or potential for actual harm Residents Affected - Few Record review of facility's policy titled, Safety and Security of Residents, revised July 2017 reflected, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The section, Systems Approach to Safety, states: . 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. 3. The type and frequency of resident supervision may vary among residents and over time for the same resident . Record review of facility's policy titled, Falls and Fall Risk, Managing, revised March 2018 reflected, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676052 If continuation sheet Page 6 of 6