Health inspection·May 9, 2024

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few beat chaotically and irregularly); Pulmonary Hypertension, Unspecified (A condition that affects the blood vessels in the lungs). Record Review of Resident #33's quarterly MDS (Minimum Data Set) dated 04/16/2024 revealed his BIMS Score (Brief Interview for Mental status) was 15/15 which indicted no memory problems. Resident was independent in making consistent and reasonably decisions regarding tasks of daily life. Observation and interview on 05/07/2024 at 10:56 a.m. revealed Resident #33 laying in his bed. Resident #33 revealed that he had a shower last week but had not received one this week. Observed resident with unkept beard, flakey skin, long dirty fingernails, and toenails. Resident revealed he had requested Nurses to have his toenails and fingernails cut two weeks ago, with no follow through from staff. Resident revealed that he felt very uncomfortable with long fingernails and his toenails hurt. In an interview on 05/09/24 at 1:14 p.m. with the ADON, revealed that the Nurses were to cut the fingernails. He admitted when he first began working at the facility, he observed problems with the nails not being clipped. The ADON could not give a specific time residents' nails have been cut. ADON revealed that a schedule needed to be set up for the nails to be cut on a regular basis. The ADON would like to have assigned staff for each hall to be responsible for residents' nail care. In an interview on 05/09/2024 at 3:10 p.m. with CNA H revealed that the CNAs could trim some of resident's fingernails only after asking the nurses if the resident was diabetic or not. If the resident was diabetic, the nurse must cut the fingernails. CNA H had not noticed male resident nails being long. In an interview on 05/09/24 at 4:32 p.m. with the DON revealed that on the shower sheets there was a place to document the fingernail care. There were nail days for each resident. The DON revealed that some of the residents would not let their nails be filed or cut. The DON stated that if the nails were dirty with feces, dirt, or whatever under the nails could cause infection control issues. In an interview on 05/09/24 at 5:23 p.m. with the Administrator revealed the policy of the facility relating to long fingernails was, if a resident constantly refused, the facility would get family involved. The Administrator stated infection control problems could happen due to nails not being cut or cleaned. Review of the facility policy and procedure on care of fingernails/toenails dated revised February 2018 revealed that the purpose of the procedure is to clean the nail bed, to keep nails trimmed, and to prevent infection. Under General Guidelines, nail care includes daily cleaning and regular trimming. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676052 If continuation sheet Page 2 of 12 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 05/09/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to implement procedures that address and monitor a safe storage and handling of medication that can be altered by exposure to improper temperatures, light, or humidity for 2 of 2 medication rooms reviewed for storage of drugs and Biologicals. Facility failed to maintain a safe working refrigerator in Medication room [ROOM NUMBER]. Refrigerator temperature in Medication room [ROOM NUMBER] was 56 degrees Fahrenheit inside the refrigerator. Facility failed to ensure 2 of the 3 ceiling lights in Medication room [ROOM NUMBER] worked and 3 of the 4 ceiling lights in Medication room [ROOM NUMBER] worked to provide sufficient lighting. These failures could cause medications not to be stored at proper temperatures and other appropriate environmental controls to preserve their integrity. Findings included: Observation and interview with RN E in Medication room [ROOM NUMBER] on [DATE] at 4:40 PM, revealed dim lighting with 2 of the 3 ceiling lights not on. RN E said that she did not even notice that the medication room lights did not work. She said she would notify maintenance to fix the lighting. Medication room [ROOM NUMBER] also revealed 2 refrigerators a white one and a black. The black refrigerator had a lock on it. Upon RN E opening the black refrigerator, temperature in the refrigerator read 56 degrees. Upon inspection of medications, there were unopened and unexpired insulin vials in boxes and insulin pens, vaccines, suppository medications in a dark brown bag, and cold packs were in the refrigerator. Refrigerator door insulation was partially torn off from the middle of the door exposing a grey background. Refrigerator thermometer reading in Fahrenheit reflected the following: Freezer safe Zone -40, -30, -20, -10 and 0 (blue in color); refrigerator Safe Zone 20, 30, 40 (blue in color); danger Zone 50-80+ in red color. Temperature in the refrigerator read 56 degrees Fahrenheit in red danger zone area of the thermometer . RN E said that the night shift monitored and recorded the refrigerator temperature logs. She said she did not know what the reading should be. She said if temperature was not in correct range, it could affect the effectiveness of the medication. Interview and observation with the ADON in Medication room [ROOM NUMBER] on [DATE] at 08:23 AM, revealed 3 of the 4 lights did not work and 2 of the light covers were missing. The ADON said he replaced the refrigerator in Medication room [ROOM NUMBER] after RN E notified him. He said that he also replaced the light bulbs in Medication room [ROOM NUMBER] however, he discovered that one of the 3 lights could not work due to an electrical problem. He said the facility had an electrician on their way to facility to fix the lights. He said he would change the bulb lights in Medication room [ROOM NUMBER] as well. The ADON said he was not sure on the range of the refrigerator temperature, and he would consult the DON. He said that the night shift staff monitored the medication rooms refrigerators and documented the temperatures on a log. He said that he expected nursing staff to notify him or the DON if the refrigerator was broken or out of range. He said the risk of higher temperature in the refrigerator can cause alteration to the medication that requires to be refrigerated. He did not state the risk of dim lighting in medication room. Interview with Maintenance Director on [DATE] at 03:33 PM, revealed he was not aware of the status (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676052 If continuation sheet Page 3 of 12 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 05/09/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm of medication Rooms and the refrigerator. He said he did not know who was responsible for maintaining and monitoring the temperatures in the refrigerators. He said if it had been reported to him that a refrigerator seal or something was broken or door did not shut properly, he would have fixed it, but he did not know anything going on in the medication rooms. He did not state the risk. He said that he has only been employed at the facility for 2 months. Residents Affected - Few Interview with the DON on [DATE] at 04:27 PM, revealed the night shift nursing staff was responsible for monitoring Medication room refrigerator temperature and documenting it on a log . She said she expected them to report temperatures that were outside the range to the ADON, DON or herself. She said the higher end of the refrigerator temperature range was 46 degrees (Fahrenheit). She said that the temperatures are entered in a logbook. She said 56 degrees would be outside the range. She said she would have to look at the medications temperature to determine risk cause and effects of temperatures without looking at the medications, she could not see the risk to the residents. She said certain medications requires certain temperatures otherwise higher temperature can make them less potent. The DON said there was no risk with lighting because the nursing staff did not use the medication room to prepare any medications. Interview with Administrator on [DATE] at 05:21 PM, revealed that she expected nursing staff to monitor the medication rooms refrigerators and to report when they were out of range. She expected all staff to follow policy and procedure of the facility. She said not following the correct policy and procedure can cause the spread of infection. Record review of facility policy titled Medication Labeling and Storage revised in February 2023, reflected . the nursing staff is responsible for maintain medication storage and preparation areas in a clean, safe, and sanitary manner . No facility policy for lighting in the medication room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676052 If continuation sheet Page 4 of 12 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 05/09/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 4 (Residents #21, #35, #38, #48) of 8 residents reviewed for infection control and 2 of 2 medication rooms reviewed for infection control. Residents Affected - Some Facility failed to ensure CMA F performed hand hygiene before and after checking Resident #21 blood pressure before touching pitcher of water and administering medication to Resident #21. Facility failed to ensure CNA A followed an infection control and prevention procedure during an incontinent care for Resident #35 who was on contact isolation for C-diff by putting her dirty gloved hand into her pocket to obtain barrier cream and applied it to Resident #35 buttocks and bilateral inner thighs. Facility failed to ensure LVN D performed hand hygiene and changed gloves after adjusting Resident #38's bed before administering medication via g-tube to Resident #38. Facility failed to ensure LVN C performed hand hygiene and changed gloves after touching the door and computer before checking Resident #48's blood sugar. Facility failed to ensure Medication room [ROOM NUMBER] and Medication room [ROOM NUMBER] were free of personal belongs and Medication room [ROOM NUMBER] had a clean sink, clean counter surface, free of brown substance on the left side of the wall and ceiling. These failures could place residents at risk of infectious diseases, cross contamination, and hospitalization. The finding included: Resident #21 Record review of Resident #21 face sheet dated 05/08/24 reflected an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included stroke with left side weakness, high blood pressure, difficulty walking, type 2 diabetes, stage 4 kidney diseases, kidney stones, and urinary tract problems. Review of Resident #21 MDS dated [DATE] reflected BIMS of 10 indicating moderate cognitive impairment. Resident #21 could feed himself with staff set up, he needed dependent on staff for ADL's. Record review of Resident #21's order summary on 05/08/24 reflected the following medications: Lisinopril 10 mg, give 2 tablets by mouth one time a day for hypertension hold for sbp less than 110, dbp less than 60, or hr less than 60. Nifedipine ER 60 mg tablet, give 1 tablet by mouth daily - hold for sbp less than 110, dbp less than 60, pulse less than 60 - do not crush or chew. Observation and interview with CMA F on 05/07/24 at 08:45 AM, revealed Resident #21 lying in bed. CMA F measured Resident #21 BP. Reading 107/52, pulse 42. CMA F then came back to medication cart and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676052 If continuation sheet Page 5 of 12 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 05/09/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some placed the BP cuff on the top of cart no hand hygiene performed. She unlocked the computer on the medication cart and reviewed the MAR stated that she would not add the two blood pressure medications lisinopril and Nifedipine to Resident #21's medications because of the BP reading and she would alert the nurse of reading. CMA F then took the other medications in the cup without hand hygiene and gave it to Resident #21. CMA F said that she forgot to perform hand hygiene and she stated the risk for the resident was spread of infection. Resident #35 Record review of Resident #35's face sheet dated 05/08/24 reflected a [AGE] year-old man admitted to the facility on [DATE]. His diagnoses included complete traumatic amputation at knee level of right and left legs, uncontrolled blood sugar type 2 diabetic, depression, heart failure, cognitive decline (dementia), a general feeling of discomfort and illness, and diarrhea due to c-diff. Review of Resident #35 MDS dated [DATE] reflected BIMS of 7 indicating severe cognitive impairment. Resident #35 needed assistance with planning regular tasks. He could feed himself with staff set up, Resident #35 was dependent on staff for ADL's. Observation and interview on 05/08/24 at 11:23 AM revealed 2 CNA's, CNA and CNA B putting on PPE (gown, gloves and mask) before entering Residents #35's room. On the exterior of the door is a sign that read Contact Isolation; gown, mask, goggle, and gloves required. Resident #35 gave verbal consent for nurse surveyor to observe his incontinent care. CNA A on left side and CNA B on right side of bed. CNA A started by wiping the front peri area, then got more wipes and Resident #35 was turned to right side and CNA A wiped the buttocks area. CNA A did not change her gloves or perform hand hygiene. CNA B then stated that Resident #35 had some redness between his thighs and buttocks area. CNA A then stated she was aware and with her dirty gloves retrieve the barrier cream from her right uniform pocket and stated I have this showing the barrier cream. She opened the barrier cream packet and applied the content to Resident #35's buttocks and inner thighs without changing her gloves. CNA A then rolled the soiled brief from under Resident #35 and then took off her soiled gloves off. Without hand sanitizing her hands she put her left hand into her left uniform pocket and took out a pair of black gloves and put them on. CNA A then put a clean brief on under Resident #35 and rolled him to the left side of the bed while CNA B pulled the brief on the right side. Resident #35 was then adjusted in the bed. CNA A adjusted Resident #35 bed with a remote and closed the wipes container. Both CNA A and CNA B disposed of their PPE and went in the bathroom to wash their hands with soap and water. Interview with CNA A on 05/08/24 at 01:48 pm revealed she had been employed at facility for 3 months. She said she was aware that Resident #35 was on isolation for c-diff . She said that she forgot to change her gloves before going in her pocket and got her clothes dirty after cleaning the resident. She said the reason for PPE was to prevent the spread of infection. She said that she contaminated herself and smeared the infection back to resident when she applied the barrier cream with dirty gloves. She said that she carried gloves in her uniform pocket because the ones in the residents' rooms did not fit her well. CNA A said that she was aware that the risk to Resident #35 and herself was contaminated and spread of infection. Interview with CNA B on 05/08/24 at 02:00 PM, revealed she was employed at the facility for 4 days and she was aware that Resident #35 was on c-diff contact isolation. She said that she had an in-service on c-diff and the putting on PPE and removing PPE. She said c-diff was a contagious infection and the germs were only killed by washing hands with soap and water does not kill by hand sanitizer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676052 If continuation sheet Page 6 of 12 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 05/09/2024 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 0880 Resident #38 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #38 's face sheet dated 05/09/24 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included stroke, muscle wasting, lack of coordination, depression, difficult talking, difficult swallowing, low blood pressure, seizures, and has a g-tube. Residents Affected - Some Review of Resident #38 MDS dated [DATE] reflected BIMS of 0 indicating severe cognitive impairment. Resident #38 was totally dependent on staff for eating, bed mobility and ADL's. Review of Resident #38 order summary on 05/08/24 reflected Enteral Feed Order via g-tube every 4 hours Water flush 200ml every hour. Enteral feed orders every shift flush with 10ml of water between each medication every shift. Enteral Feed Order every shift jevity 1.5 at 65 ml / hr for 22 hours. Midodrine HCl Tablet 5 MG Give 1 tablet via G-Tube three times a day related to HYPOTENSION, hold if sbp greater than 120. Robitussin Mucus and Chest Congest Oral Liquid (Guaifenesin) Give 10 ml via G-Tube every 4 hours as needed for cough. Observation and interview with LVN D on 05/08/24 at 01:19 PM, revealed Resident # 38 lying in bed watching television. LVN D explained to Resident #38 that he was there to do his afternoon medication. Resident #38 refused the cough medication but agreed to getting the blood pressure medication. LVN D put on PPE for EBP. He measured Resident #38 BP on left hand, reading 99/63, pulse 66. He wiped bedside table and BP cuff off then placed it the cart. He took his PPE off and performed hand hygiene. He opened his computer and stated that it was ok to administer midodrine medication. He placed medication in cup after crushing it and secured computer and medication cart. He put on PPE and entered Resident #38 bathroom, filled cup with water placed it in cleaned bedside table next to g-tube syringe. He then took the bed remote and informed Resident #38 that he was raising the bed up. No hand hygiene or change of gloves before disconnecting Resident #38 feeding tube from G-tube. He then took the g-tube syringe checked the feeding residue in the g-tube and checked for g-tube placement. He gave the water, then medication and then water again via the syringe. When he was done LVN D reconnected Resident #38 back to the feeding pump and started the eternal feed. He covered Residents #38 back up and went to clean the g-tube syringe in the bathroom sink. LVN D then placed syringe back in bag and lowered the bed back down to Resident #38's liking thumbs up. LVN D then removed the PPE and washed his hands with soap and water. LVN D said that he forgot to change his gloves before disconnecting Resident #38 feeding tube. He said that he risked resident getting an infection. Resident #48 Record review of Resident #48's face sheet dated 05/08/24 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included anxiety, heart diseases, uncontrolled blood sugar type 2 diabetic, liver damage, major depression, cognitive decline (dementia), irregular heartbeat, blood clots, heart diseases, and heart attack. Review of Resident #48 MDS dated [DATE] reflected BIMS 10 indicating moderate cognitive impairment. Resident #48 required set-up assist but could eat independently, he needed set up assist for ADLs. Resident #48 walked with a walker, Observation and interview with LVN C on 05/08/24 at 11:13 AM, revealed Resident #48 seated up in his chair. LVN C performed hand hygiene, put on gloves, and cleaned bedside table with cleaning wipes. She washed her hands with soap and water then took the supplies to do blood sugar and placed then on wax paper on the clean table. She performed hand hygiene and put on gloves. She asked Resident #48 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676052 If continuation sheet Page 7 of 12 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 05/09/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some his name and birthday, which he stated. LVN C opened the door wider with her gloved right hand and then reached for her laptop with the left gloved hand took laptop off the medication cart and placed it on the cleaned bedside table next to wax paper with the blood sugar supplies on it. She opened laptop and entered her login then checked the MAR for verification of Resident #48's birthday. Without changing gloves or hand hygiene after handling the door and computer, LVN C picked up the blood sugar machine, the lancet to poke his finger, and the alcohol pad and checked Resident #48 blood sugar. Reading of blood sugar was 126. LVN C then took her computer placed it on the medication cart and then took the wax paper, used gauze and alcohol pad, and disposed the lancet in the sharp's container. She removed gloves and washed her hands. LVN C then put on new gloves and wiped the blood sugar machine and set it to dry on the medication cart. She opened her laptop and stated Resident #48 would not need insulin before lunch. LVN C said that she was nervous and forgot to change her gloves and perform hand hygiene after handling the laptop before checking Resident #48's blood sugar. She said the risk to resident was contamination and risk of infection. She said that she had been trained and in-served about hand washing, hand hygiene, and infection control when she started working at the facility a month ago. Interview with ADON on 05/09/24 at 08:23 AM revealed he, the DON and infection control preventionist were responsible for completing in services on infection control. He said that he did in-service for EBP for residents with g-tubes, wounds, and catheters. He said that he expected nurses to perform hand hygiene and change gloves and maintain PPE when handling g-tube to prevent infection. He said he expected nursing staff to follow policy for any type of isolation. He said that CNAs are trained about the different isolations, and he expected them to follow protocol for c-diff precautions to prevent the spread of infection. He said that touching your clothing with dirty hands will contaminate self and other residents. He said the facility does PPE training and periodic 1 on 1 training with staff that need to be refreshed on their training. Interview with the DON on 05/09/24 at 04:27 PM, revealed nursing department, DON, ADON, and nurses can train the CNA, seasoned CNA's can train other CNAs about different procedures including infection control, enhanced barrier, how to don and doff PPE. She said staff should not keep gloves in their pockets because they get contaminated, and she expected staff to use the gloves provided in each resident's room. She said CNAs are expected to follow facility policy and procedure for contact isolation on residents with c-diff. She said the risk of not following facility policy was risk of infection. The DON said LVN D informed her of the g-tube medication observation, and she did a 1 on 1 with him. She said there was a potential risk on any surface touched can have germs and being that G-tube is in the body, they can have infection introduced to the body. She said the risk to the resident was risk of contamination and infection. She said she expected all nursing staff to perform hand hygiene before and after care even during medication administration. She said she just did a hand hygiene in-serve in February due to COVID-19 outbreak. She said not changing gloves before checking blood sugar was a risk of contamination and she expected all staff to follow policy of hand hygiene and infection control. Observation and interview with RN E in Medication room [ROOM NUMBER] on 05/08/24 at 4:40 PM, revealed a sink with white, brown, and green colored substance inside the sink and around the faucets. [NAME] and black colored substance on the left side of celling running down to middle of left wall of medication room. A lunch bag was on the counter, a broken clear cup with water and some empty candy wrappers were observed in Medication room [ROOM NUMBER]. RN E said that it was the responsibility for the nursing staff to keep the medication rooms clean. She said the lunch bag in the medication room belonged to CMA G. She stated she was unaware of when housekeeping cleaned Medication room [ROOM NUMBER]. She said that staff members should not store their personal belongs in the medication rooms (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676052 If continuation sheet Page 8 of 12 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 05/09/2024 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 0880 because of risk of contamination. Level of Harm - Minimal harm or potential for actual harm Interview with CMA G on 05/08/24 at 05:15 PM, revealed he has been working at the facility for 2 years and no one has ever told him that he could not put his personal belongs in the medication room. He said that he was in a hurry to get report and just placed his lunch bag in Medication room [ROOM NUMBER]. He said with all medication there was a risk for contamination. He said the proper place he could have placed his lunch bag was in the break room or in his car. Residents Affected - Some Observation and interview with ADON in Medication room [ROOM NUMBER] on 05/09/24 at 08:23AM, reveled a black backpack on the counter in medication room. ADON said that staff should not store their personal belong in the medication room. He said taking backpacks in medication room can lead to risk of diversion of drugs, contamination, and risk of infection. ADON did not state when/how staff are informed that personal items are not allowed in the medication room. Interview with the DON on 05/09/24 at 04:27 PM, revealed nurses, med aides and house keepers are responsible for keeping the medication rooms clean. She said that personal belonging should not be in the medication if they impede in the medication prep areas. She said she did not see the risk to residents because they did not use the medication rooms to prepare or compound any resident medications. Interview with Administrator on 05/09/24 at 05:21 PM, revealed that she expected nursing staff to monitor the medication rooms refrigerators and to report when they were out of range. She expected all staff to follow policy and procedure of the facility. She said not following the correct policy and procedure can cause the spread of infection. Review of the facility's policy titled Infection Prevention and Control revealed .Standard precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status .hand hygiene is performed with soap (anti-microbial or non-antimicrobial) or alcohol-based hand rub before and after contact with the resident . Review of facility's policy titled, Handwashing/Hand Hygiene, revised October 2023, reflected the following: Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: before and after entering isolation precaution settings .Upon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident); After removing gloves or aprons . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676052 If continuation sheet Page 9 of 12 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 05/09/2024 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for two (hallways F and H) of two hallways reviewed for pest control,. Residents Affected - Some The facility did not maintain an effective pest control program to ensure the facility was free of flies. This could place residents at risk for an unsanitary environment. Findings included: Review of Resident #4's face sheet dated 05/09/2024 revealed resident originally admitted to the facility on [DATE] and readmitted to facility on 04/29/2024 with diagnoses Acute Osteomyelitis of left Ankle and Foot (a bone infection caused by a soft tissue infection that spreads to the bone); Atherosclerotic Heart Disease of Native Coronary Artery without Secondary Angina (narrowing of the arteries near the heart that can lead to a heart attack); Essential Primary Hypertension (a type of high blood pressure that doesn't have an identifiable cause). Review of Resident #2's quarterly MDS (Minimum Data Set) dated 05/02/2024 revealed his BIMS Score (Brief Interview for Mental status) was 11/15 which indicated moderate cognitive impairment. Resident #2 required some modified independence making decisions regarding tasks of daily life. In an observation/interview with Resident #4, on 05/07/2024, at 10:20 a.m., revealed four flies in Resident #4's room. Resident #4 complained about the flies in her room. She had her own fly swatter to keep the flies off her. The flies would land on her gown and her skin. Resident revealed the facility has had flies for as long as she could remember. Resident #4 stated the flies have always been a problem. She stated the flies drove her crazy. Observed flies in the following rooms; Hall F - RM [ROOM NUMBER]A and Hall H - RM [ROOM NUMBER]A and RM [ROOM NUMBER]A. An interview and observation on 05/07/24 at 2:04 PM with Resident #48 and his RP revealed a fly buzzing in room, and three times the RP swiped it away from her face. She said the flies were a real issue and they were in the room, and bad in the dining room. She said she had never seen any of the staff do anything about them. She said that she felt the facility was overall cleaner than some places, but there were always flies. An interview and observation on 05/07/24 at 3:30 PM with Resident #3 revealed he was in the courtyard across the hall from the activity room by himself. During the interview numerous flies landed on the resident's clothing and body. After speaking with the surveyor, the resident asked to go back inside to get away from the flies, and while the surveyor held the door open, the resident and surveyor attempted to wave the flies away from him before he went through the door. Two flies continued to land on the resident, and went into the building with him, along with one fly observed to fly in over his head. An interview and observation on 05/08/24 at 12:20 PM with Resident #8 revealed she was in bed drinking a soda with three houseflies flying around and repeatedly landing on her skin, hair, clothing, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676052 If continuation sheet Page 10 of 12 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 05/09/2024 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 0925 Level of Harm - Minimal harm or potential for actual harm table cup, rim of soda can, and bedding, and she continued to brush them away from her body, table, and soda can with her hands while we talked. She said they had flies a lot, and they bothered her. She thought they came in because her window was open, but she did not know. Her windows were open, but there were intact window screens over both. She said sometimes the staff came in and killed them, but not always and she had not complained to anyone about them. Residents Affected - Some An interview on 05/08/24 at 12:26 PM with CNA A and CNA B while they passed trays in the hall revealed they did see flies a lot, and believed it was because some residents kept juice and fruit in their rooms. They said they had to go in, and clean things up, and remove the fruit, so the flies would go away. On 05/08/2024 at 1:30 p.m. a confidential Resident Council Meeting was held. During the meeting different required topics discussed with the group in general that are required topics. All the residents in attendance addressed the issues with the fly problem in the building. The residents had repeatedly stressed their concerns with the Administrator and Maintenance Supervisor with no solutions. The residents were afraid of the diseases these flies could carry. Some residents indicated they were bitten by these flies. They were frustrated when eating in the dining room and the flies were constantly flying and landing on their food. The residents want a solution and the problem solved with pest control. Interview on 05/09/2024 at 3:10 p.m. with CNA H revealed that she felt like the flies came in the summertime and never in the other seasons. When the weather got warm, the facility would start seeing them. CNA H stated the Administrator does not talk to them about what to do about them. CNA H stated there was a flyswatter at the nurse's station but was not able to find it today. The residents have not asked for help with the flies, and nobody has complained to her. CNA H stated nobody wanted flies and that they could probably spread bacteria. She stated it was hard to get rid of them. The residents who were confused or required heavy care, come in contact with them, even if they just lay there. Interview on 05/09/2024 at 3:34 p.m., with the Maintenance Director revealed that pest control comes the 8th of every month, and just in the last week or so, they have been noticing flies. There were horse stables right by them, and they get flies from that. They had another pest company come two days ago and gave them an estimate and are working on the treatment for the flies. They had their pest control treat, and he did not know the specific chemical, but they have the sprays and bait traps for some pests. The residents have not complained personally to them. They have discussed the flies and were trying to find the correct way to do it. The facility didn't just want to hang fly traps. They have the blue light traps in each hall and when LSC came in he asked them if there were more places that they could put them that would help and not make code issues. The Maintenance Director stated he parked in the back and as soon as he parks and gets out of his car, it's like the flies are waiting. Everything on the side where he parked were horses. He was aware there were a lot of them outside. They are trying to get it resolved as soon as possible. The Maintenanece Director stated he was new, and had only been here two months, so he was not sure about the weather changes, but they do need to resolve it. They were trying to do it the right way, so they don't get in trouble. He checked his maintenance log every morning before the meeting. He stated the flies were not sanitary and an annoyance. Interview on 05/09/24 at 5:23 p.m. with the the Administrator revealed that the residents kept their windows open, which allowed flies to come into the facility. The Administrator did not mention any complaints r/t flies from the residents. The Administrator revealed that another cause would be the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676052 If continuation sheet Page 11 of 12 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 05/09/2024 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some horses that are across the street that bring in flies. The Administrator stated that flies could cause infection and discomfort. Record review of the facility's Pest Control Policy, undated, revealed: .The facility will maintain an effective pest control program that provides frequent treatment of the environment for pest so that the facility is free of pest and rodents. It will allow for additional visits when a problem is detected. Included protocols for: Fly Protocol: Technicians will be doing an assortment of things on a regular basis, including but not limited to spraying dumpsters and treating with fly baits, and offering fly lights or blowers to areas they may needed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676052 If continuation sheet Page 12 of 12