Health inspection·September 5, 2025

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some filtering ability.) Record review of Resident#2's MDS, dated [DATE] reflected his BIMS score was 12 which indicated moderate cognitive impairment. Review of Resident#2 MDS reflected under Section O - special treatments, procedures and programs reflected, dialysis while a resident. Record review of Resident#2 care plan, dated 07/31/25 reflected, date initiated 04/14/22 that Resident #2 goes to dialysis M/W/F.left arm shut.enhanced barrier precautions. Goals reflected, Resident #2 will go to appointments and return to facility without incident. Interventions reflected, educate [Resident #2] on help CNA can assist with, if needed, by accompanying him on dialysis transports, Educate [Resident#2] on reporting any incidents while out on dialysis appointments ensure enhanced barrier protection.ensure [Resident#2] leaves at scheduled time for dialysis. Record review of Resident#2's order summary, dated 09/04/25 reflected, Carvedilol Tablet 6.25 MG Give 1 tablet by mouth two times a day for Hypertension Take with meals, hold on dialysis days, hold for SBP (Top number) <110, DBP (bottom number) <60, or HR<60. Record review of Resident#2 active orders revealed, there were no active orders for dialysis/renal treatment and care and no active orders for care treatment to dialysis access site. Record review of Resident#2's vitals dated 06/25/25 to 09/04/25 in the EHR reflected no post dialysis weights. Record review of Resident#2 EHR reflected Resident#2 did not have dialysis communication documentation uploaded for 06/20/25 to 09/04/25. Record review of Resident #2 TMAR dated August 2025 to September 2025 reflected no active dialysis/ renal care treatment orders. Record review of Resident #3's face sheet, dated 09/04/25 reflected [AGE] year-old male who was admitted on [DATE] and diagnosed with but not limited to: Type 1 Diabetes mellitus with diabetic neuropathy (nerve damage caused by high blood sugar levels in people with diabetes), unspecified, type 1 diabetes mellitus without complications, and essential hypertension (high blood pressure). Record review of Resident #3's MDS, dated [DATE] reflected his reflected his BIMS score was 15 which indicated cognitive intact. Review of Resident#3 MDS reflected under Section O - special treatments, procedures and programs reflected, dialysis while a resident Record review of Resident #3 care plan dated 09/04/25 reflected, Resident#3 had chronic renal failure related to end stage disease. Resident #3 focus reflected he had chronic renal failure related to end stage disease. Resident #3 goals reflected he will be free from infection, the resident will have no s/sx of complications r/t fluid deficit, the resident will have no s/sx of complications related to fluid overload. Resident#3 interventions included but not limited to: dialysis weekly M/W/F and monitor vital signs. Notify MD of significant abnormalities. Record review of Resident #3's order summary, dated 09/04/25 reflected, date initiated 08/16/25, other diet: Regular texture, regular consistency, renal diet. There was no active order for dialysis/ treatment center and no active order for care and treatment to dialysis access site. Record review of Resident#3 vitals in the EHR dated 08/16/25 to 09/04/25 reflected, no post dialysis weights. Record review of EHR reflected Resident#3 did not have dialysis communication documentation uploaded from 08/16/25 to 09/04/25. Record review ofResident#3 the TMAR dated August 2025 to September 2025 reflected no active dialysis/ renal care treatment orders. During an observation and interview on 09/04/ 25 at 11:00 am Resident #1 stated he did not have any concerns. Resident#1 stated that he rode the bus to the dialysis center M/W/F. Resident#1 stated that the staff cleaned his dressing to his dialysis site, and he did not have any concerns. Resident#1 stated he had lost his dialysis form in the past. The Surveyor observed Resident #1's chest sit was covered, and no concerns were noted. During an observation and interview on 09/04/ 25 at 11:10 am Resident #2 stated he goes rode the bus to the dialysis center M/W/F. Resident#2 stated that the staff at the facility cleaned his dressing to his dialysis access site. Resident#2 stated was not sure about a communication form and what happened to it. The Surveyor observed a fistula (surgically made passage between a hollow or tubular organ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676052 If continuation sheet Page 2 of 3 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 09/05/2025 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete and the body surface)in his right arm and no concerns were noted. During an observation and interview on 09/04/ 25 at 11:15 am Resident #3 stated he went to dialysis every time and he did not miss any appointments. Resident #3 stated the dialysis center took the form and did not give him one back. Resident#3 stated he did not have any concerns. The Surveyor observed the fistula was covered in the right arm and no concerns were noted. During an interview and observation on 09/04/25 at 11:25 am LVN A stated the facility did not keep a book of the communications from the dialysis center. LVN A stated when residents returned from the dialysis center the forms were placed either in the purple binder or medical records drop box. The Surveyor and LVN A observed no outstanding dialysis forms. LVN A stated Resident# 1, Resident #2 and Resident #3 were on her hall and they all went to dialysis M/W/F. LVN A stated she would have Resident #1 and Resident #3 prepped and ready to go with breakfast and snacks for morning transportation to dialysis. LVN A stated residents were transported by the local- city bus on a set schedule. LVN A stated Resident #2 was transported to dialysis before lunch. LVN A stated she checked and monitored their port entry and none of the residents hadany concerns or issues with their ports. LVN A stated she had not experienced any of the three residents refuse to go to dialysis. LVN A stated if a resident refused or missed dialysis it would be documented in the progress notes. LVN A stated post dialysis vitals were supposed to be documented in the vitals section and progress notes in the EHR when residents returned. LVN A stated she would document the information if the resident vitals were abnormal in the resident's chart and report to the DON and MD. During an interview on 09/04/25 at 11:50 am the DON stated she could not make the dialysis center send the communication forms back. The DON stated if an issue or concern happened at dialysis the dialysis center could call; email and fax and the information would be received. The DON stated they would call to get the form faxed to them. The DON stated she was also over medical records and did not have any medical dialysis communication forms pending to be uploaded. The DON stated the dialysis residents were in and out the hospital a lot. The DON stated the orders were not reactivated when the residents returned to the facility. The DON stated the admitting nurse would be responsible for making sure the orders were activated. The DON stated no resident had missed dialysis because the transportation times were set, and the local bus picked up Resident #1 and Resident #3 together at the same time and Resident #2 was picked up before lunch. The DON stated the dialysis residents' entry sites were checked on every shift and any concerns would be noted in the progress notes and the DON, the MD and RP would be notified.During an interview on 09/04/25 at 1:08 pm the CNA/Central Supply stated she was responsible for doing the residents' pre/post dialysis weights and weekly weights when she was there. The CNA/Central Supply stated she was not always in the facility when Resident #2 returned from dialysis treatment. The CNA/Central Supply stated her schedule was not always the same. During an interview on 09/04/25 at 1:45pm LVN B stated that she checked Resident# 1, Resident #2 and Resident #3's vitals when they returned from dialysis. LVN B stated any abnormalities she would document in the progress notes which was in the resident's chart. and notify the DON, and the MD. LVN B stated the residents were very serious about their dialysis treatments and they did not miss their appointments. LVN B stated she checked the residents' entry sites and monitored the residents for any concerns. During an interview on 09/05/25 at 11:00 am the MD stated he was not responsible for dialysis orders and that was done by the nephrologist at the dialysis center. The MD stated he had too many residents on dialysis and he knew the facility provided care and treatment as ordered. During an interview on 09/05/25 at 3:00 pm with the Admin and the DON, the DON stated the facility had a policy related to the dialysis resident care and treatment to the access site. The DON stated the dialysis residents had not missed treatment or care. Event ID: Facility ID: 676052 If continuation sheet Page 3 of 3