Health inspection·April 12, 2023

F 0552 Record review of Resident #44's medication profile dated 01/27/23 indicated in part: Level of Harm - Minimal harm or potential for actual harm Bupropion Sustained Release Tablet Extended Release, every 12 Hour, 200 MG, Give 1 tablet by mouth two times a day for Depression. Residents Affected - Some Duloxetine Hydrochloride capsule Delayed Release Particles, 60 MG, Give 1 capsule by mouth two times a day for Depression. Record review of Resident #44's clinical records, revealed the consent on file was signed by Family Nurse Practitioner, but not signed by resident or representative prior to the facility administering Bupropion SR Tablet Extended Release for depression with a start date of 01/27/23 and Duloxetine HCl Capsule Delayed Release Particles for depression with start date of 01/27/23. Record review of Record review of Resident #148's face sheet revealed admission date of 3/15/22 with diagnoses of major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life), Type 2 Diabetes Mellitus, dysphagia (impairment of speech), dementia (progressive loss of intellectual functioning, memory, and abstract thinking), generalized anxiety disorder (severe ,ongoing anxiety that interferes with daily activities), psychotic disorder with delusions (unshakeable belief in something implausible). He was [AGE] years of age. Record review of Resident #148's admission MDS, dated [DATE], indicated he had a BIMS score of 08, which indicated he was cognitively moderately impaired. The MDS also indicated Resident #148 was diagnosed with major depressive disorder, psychotic disorder with delusions. Record review of Resident #148's care plan indicated, in part: Focus: resident requires antipsychotic and anticonvulsant medications for diagnosis of psychotic disorder with delusions due to known physiological condition. Goal: resident will be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through the review date. Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate. Discuss with MD, family regarding ongoing need for use of medication. Record review of Resident #148's medication profile dated 03/20/23 indicated in part: Seroquel Tablet, Give 100 mg via PEG-Tube two times a day related to psychotic disorder with delusions. Record review of Resident #148's clinical records, revealed the consent on file was not signed by prescribing provider, by resident, or by resident representative prior to the facility administering Seroquel Tablet related to psychotic disorder with delusions with start date of 03/20/23. Interview on 04/12/2023 at 1:00pm, the DON stated that the ADON and DON are in charge of obtaining consents for medications from residents or resident representatives. She stated that she was aware medication should not be administered without obtaining consents first. Record review of the facility's policy revised 02/01/2007, titled Resident Rights and Consent to Receive Psychotropic Medications indicated, in part: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455737 If continuation sheet Page 2 of 15 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 455737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concho Health & Rehabilitation Center 613 Eaker St Eden, TX 76837 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 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Consent must be obtained before the medication may be started. The attempt to receive this consent must be documented. Consent may be obtained by residents or their legal representatives giving the facility consent as indicated by signing the psychotropic consent form or, The person who prescribes the medication or his/her designee, including facility nursing staff, obtains consent from the resident or legal representative, documents in the chart that the required information was discussed with the resident or legal representative and the circumstances under which consent was given. Telephone consent will be acceptable. The facility staff will fill out the Psychotropic Permission Form which will be kept as permanent document to be kept in chart. Event ID: Facility ID: 455737 If continuation sheet Page 3 of 15 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 455737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concho Health & Rehabilitation Center 613 Eaker St Eden, TX 76837 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 12 residents (Residents #5, #20, and #32) reviewed for care plans in that: Resident #5 did not have a care plan to address her pain. Resident #20 did not have a care plan to address her pain. Resident #32 did not have a care plan to address her Alzheimer's/Dementia or pain. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included the following: Review of Resident #5's admission Record dated 4/12/23, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included arthritis. Record review of Resident #5's Annual MDS Assessment, dated 3/27/23, revealed: She scored a 9 of 15 on her mental status exam (indicating moderate cognitive impairment). She received scheduled and as-needed pain medications. She reported she frequently experienced pain at a level of 6 of 10. She received opiate medications for 7 of 7 days prior to the assessment Resident #5's MDS CAA documented pain as a triggered area that needed to be care planned. Record review of Resident #5's Order Summary Report, dated 4/12/23, revealed orders: Fentanyl Transdermal Patch 72 hours 12 mcg/hour - apply 1 patch transdermally one time a day every 72 hours (3 days) for pain and remover per schedule beginning 3/3/23 (no diagnosis) Meloxicam Tablet 15 mg, give 1 tablet by mouth one time a day related to arthritis. beginning 7/4/22 Oxycodone-acetaminophen 7.5mg/325 mg 1 tablet by mouth every 6 hours as needed for pain beginning 1/26/23. Tizanidine 2 mg 1 capsule every 8 hours as needed for pain and muscle spasms. beginning 2/7/23 Review of Resident #5's care plan, last updated 3/30/23, revealed no care plan for pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455737 If continuation sheet Page 4 of 15 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 455737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concho Health & Rehabilitation Center 613 Eaker St Eden, TX 76837 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 4/12/23 at 4:23 PM the MDS Coordinator stated there was no care plan for Resident #5's pain or pain medication. The MDS Coordinator stated she did not know why pain medication interventions were getting missed. She said any time there was a medication change the DON or whoever could do a care plan. She said new orders were reviewed every morning in the morning meetings and were on the 24-hour report and in the nurse's notes which she had access too. The MDS Coordinator stated the facility did not have a stable DON or ADON in she did not know how long so the Compliance RN had been reviewing the care plans on Monday - Wednesday - Friday . She said usually medications were added when they reviewed new orders in the morning meetings. Review of Resident #20's admission Record, dated 4/12/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and restless leg syndrome (uncontrollable, painful urge to move legs). Review of Resident #20's Initial MDS Assessment, dated 12/13/22, revealed: She scored a 15 of 15 on her mental status exam and showed no signs of delirium (indicating she was cognitively intact). She received as needed pain medication but reported frequently experiencing pain at an intensity of 8 of 10. Review of Resident #20's Quarterly MDS Assessment, dated 3/22/23, revealed: She scored a 15 of 15 on her mental status exam and showed no signs of delirium (indicating she was cognitively intact). She received as needed pain medication but reported frequently experiencing pain at an intensity of 8 of 10. Her CAA Summary documented Pain was a triggered item and was addressed in the care plan . Review of Resident #20's Order Summary Report, dated 4/12/23, revealed orders for: Gabapentin 300 mg twice a day for Neuropathic pain dated 12/2/22. Meloxicam 15 mg for pain dated 3/25/23 Methadone 5 mg every 8 hours as needed for pain dated 12/2/22 Morphine Sulfate 15 mg twice a day for pain dated 1/25/23 Hydrocodone-Acetaminophen every 6 hours as needed for pain dated 12/2/22 Tizanidine 4 mg every 8 hours as needed for muscle relaxant. Review of Resident #20's Care Plan, last updated 1/18/23, revealed no care plan for pain. In an interview on 04/12/23 at 2:40 PM the MDS nurse stated that the comprehensive plan of care was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455737 If continuation sheet Page 5 of 15 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 455737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concho Health & Rehabilitation Center 613 Eaker St Eden, TX 76837 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some created based upon the MDS assessment and initial baseline care plan by herself (the MDS nurse). She stated the comprehensive care plan for Resident #20 was created on 12/5/22, and although pain was triggered on the MDS assessment, it was not addressed in the comprehensive care plan on 12/5/22. The MDS nurse stated, it was an oversight on my part and I should have caught this. She also stated that changes to the care plans were done upon identified issues such as when a resident started an antibiotic or had a change in condition. She stated that she was made aware of changes to resident status during the morning meetings that occurred at 9:00AM each weekday since all department heads were present (Administrator, DON, ADON, Director of Rehab, Dietary, Maintenance, Medical Records), and each party present reported issues regarding the residents related to their discipline. Review of Resident #32's admission Record, dated 4/12/23, revealed she was an [AGE] year old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia with psychotic disturbance and anxiety, Alzheimer's Disease, and Seizures (abnormal brain activity that causes abnormalities in muscles, movement and consciousness needing specialized medication/ monitoring to control and/or other interventions to prevent injury during a seizure). Review of Resident #32's Initial MDS Assessment, dated 3/24/23, revealed: She scored a 2 of 15 on her mental status exam with no signs of delirium (indicating she was severely cognitively impaired). Identified diagnoses included: Alzheimer's Disease, Dementia, and Anxiety. (Seizures were not indicated) Review of the CAA Summary revealed Cognitive status was a triggered care area and was addressed in the care plan Review of Resident #32's Order Summary Report, dated 4/12/23, revealed orders: Gabapentin 300 mg three times a day for mild pain Memantine HCL 10mg twice a day related to Alzheimer's Disease Review of Resident #32's care plan, last updated 3/20/23 revealed no care plan for dementia/Alzheimer's disease or pain. Interview on 4/12/23 at 3:10 PM the DON stated she went and reviewed the MDS assessments to make sure the CAA Areas were triggered. In an interview on 04/12/23 at 3:20 PM the Administrator and the Director of Nurses, confirmed that plans of care were reviewed and or implemented by the Director of Nurses or Assistant Director of Nurses. The Administrator stated that the corporate Program Compliance nurse conducted audits on assessments and for Risk Management for the facility, ensured assessments matched orders and care plans, and then shared her findings with the Director of Nurses and Administrator as well as the Assistant Director of Operations. Review of the facility's policy and procedure on Comprehensive Care Planning, undated, revealed: The facility will develop and implement a comprehensive care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455737 If continuation sheet Page 6 of 15 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 455737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concho Health & Rehabilitation Center 613 Eaker St Eden, TX 76837 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 0656 nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Level of Harm - Minimal harm or potential for actual harm The comprehensive care plan will describe the following: Residents Affected - Some The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and the right to refuse treatment. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. Through the care planning process, facility staff will work with the resident and his/her representative, if applicable to understand and meet the resident's preferences, choices and goals during their stay at the facility. The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintain his or her highest practicable quality of life. Care planning drives the type of care and services that a resident receives. The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. When developing the comprehensive care plan, facility staff will, at a minimum, used the Minimum Data Set to assess the resident's clinical condition, cognitive and functional status, and use of services. If a Care Area Assessment is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing or currently has a a weakness or need associated with that CAA, and how the risk, weakness or need affects the resident. Documentation regarding these assessments and the facility's rationale for deciding whether or not to proceed with care planning for each area triggered will be recorded in the medical record. There may be times when a resident risk, weakness or need is identified within the context of the MDS assessment but may not cause a CAA to trigger. The facility will address these areas and will document the assessment of these risks, weakness or needs in the medical record and determine whether or not to develop a care plan and interventions to address the area. If the decision to proceed to care planning is made, the interdisciplinary team, in conjunction with the resident and/or resident's representative, if applicable, will develop and implement the comprehensive care plan and describe how the facility will address the resident's goals, preferences, strengths, weaknesses, and needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455737 If continuation sheet Page 7 of 15 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 455737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concho Health & Rehabilitation Center 613 Eaker St Eden, TX 76837 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 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 each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 resident reviewed for accidents hazards/supervision/devices, in that: (Resident #42). CNA A failed to complete an appropriate one-person gait belt transfer. This failure could place residents at risk of inadequate supervision and preventable injuries. Findings included: Review of Resident #42's admission Record dated 4/11/23 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included anorexia (lack of appetite causing abnormal weight loss), dementia with behavioral disturbance , muscle weakness, lack of coordination, and stroke. Resident #42 was on hospice services. Review of Resident #42's Significant Change MDS, dated [DATE], revealed: He scored a 6 of 15 on his mental status exam (indicating severe cognitive impairment) He needed stand by assistance of two staff for transfers. Review of Resident #42's Care Plan, updated 1/21/23, revealed a Focus: Resident has a terminal prognosis and/or is receiving hospice services. The Goal was the resident's comfort will be maintained through review. Interventions included: adjust provision of ADLs to compensate for resident's changing abilities. Review of Resident #42's Care plan, updated 10/21/22, revealed a focus of: Resident has an ADL self- care performance Deficit. The Goal was: the resident will maintain or improve current level of function through the revies date. Identified interventions included: Transferring: requires staff x2 for assistance and the resident requires total assistance with transfers, initiated 1/21/23. Observation on 04/10/23 at 12:55 PM revealed CNA A took Resident #42 to his room. CNA A rolled Resident #42 to his and checked his dresser for a gait belt; when she was unable to find the gait belt she left the room to find one. Resident #42 was observed to have tremors on his left said. LVN B came into the room with CNA A stating she had a gait belt. CNA A put the gait belt around Resident #42, scooted the resident to the end of the wheelchair and locked the brakes. CNA A tried to lift Resident #42. Resident #42 was not cooperative (did not participate in the process) and the gait belt slid up to his arm pits. CNA A let Resident #42 sit again and tightened the gait belt. CNA A put one hand on either side of Resident #42 and assisted him to stand, when the gait belt started sliding up his ribs, CNA A slightly pushed in to lift him with her hands on the sides. LVN B reached over the wheelchair and grabbed Resident #42 by the waistband. Resident #42 was not able to straighten his legs or bear weight. CNA A lifted Resident #42 into the bed where he laid back with his knees in the air like he was still sitting. CNA A took off the belt, straightened Resident #42's legs and covered him with a blanket. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455737 If continuation sheet Page 8 of 15 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 455737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concho Health & Rehabilitation Center 613 Eaker St Eden, TX 76837 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 Interview on 4/11/23 at 6:01 PM CNA stated she worked at the facility for about a month. CNA A said she worked at the facility for about a month but had received in-service on how to transfer residents. CNA A said to complete a one-person gait belt transfer the aide was to wash her hands, put on the gait belt tight enough to fit two-fingers under it, put their feet on either side of the resident, put the aide's hands on either side of the resident, lift with the knees and transfer. CNA A said the 4/10/23 transfer did not go that way because she had not worked on Resident #42's hall and did not know the residents and what they were capable of doing . CNA A said Resident #42 had a bad day and was not bearing weight on 4/10/23. She stated a mechanical lift would have been more appropriate, but she did not think to get it. Interview on 4/12/23 at 9:45 AM the DON, ADON, and Corporate RN stated the expectation for a one-person gait belt transfer was to make sure the bed was at the same level as the wheelchair, make sure the gait belt was tight enough, explain what the person was doing with the resident, make sure the wheelchair was locked, put a hand on either side of the resident and lift with the knees. They stated if a resident was not weight-bearing they were not appropriate for a gait belt transfer and the aides did have the ability to say if a resident needed to use a mechanical lift. They said all the aides needed to do was to go to the ADON or DON and let them know . They were informed of the observation and stated the aide should have asked for help with the transfer. Interview on 4/12/23 at 10:09 AM the Administrator was informed of the improperly completed transfer. Review of the computerized in-services revealed CNA A was in-serviced on safely moving residents - lifting and transferring on 1/2/23. Review of the in-service Transfer from Bed to Wheelchair using a Transfer Belt Inservice, completed 1/10/23, revealed: Procedure guidelines for transferring from a bed to a wheelchair using a transfer belt. Lock the bed brakes and wheelchair wheels. Adjust the height of the bed to the level of the wheelchair seat. Place the wheelchair facing toward the foot of the bed, midway between the head and the foot of the bed. Position the wheelchair at a 45-degree angle to the bed on the same side of the patient's stronger side. Secure the wheels by pushing handles forward on the locks above the wheel rims. Place the transfer belt on the waist of the patient over the gown (clothes) With the tag of the belt touching the patient's gown, slide the metal trimmed end of the gait belt through the teeth on the other end. Pull the metal trimmed end away from the teeth. Tighten the belt until snug on the patient's center of gravity. The belt should be tight enough for 2 fingers to slide into the belt. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455737 If continuation sheet Page 9 of 15 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 455737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concho Health & Rehabilitation Center 613 Eaker St Eden, TX 76837 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 Spread your feet, flex you r hips and knees and align your knees with those of the patient. Level of Harm - Minimal harm or potential for actual harm Grasp the transfer belt along the patient's sides. Position yourself slightly in front of the patient, to guard and protect him or her throughout the transfer. Residents Affected - Few Safety points Determine if the patient can fully assist or partially assist. Do not start the procedure until all required care givers are at the bedside. Properly apply the transfer belt. Review of the facility's policy and procedure on Moving a Resident, Bed to Chair /Chair to Bed, undated, revealed: Purpose: The purpose of this procedure is to allow the resident to be out of his or her bed as much as possible and to provide for safe transferring of the resident. Steps in the Procedure: Lower the height of the bed to the lowest position. If moving a Resident from chair to bed: Place the chair so it touches the side of the bed and faces the foot of the bed (Note: have the chair on the resident's strong side) Position a gait belt around the resident's waist and clasp it. Make sure it is tight enough that only a slight hand movement will guide the patient, but not so tight that you cannot firmly grasp the belt without making the patient uncomfortable. If the resident requires, two persons (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or the edge of the bed. If the resident can assist in the procedure, stand on the resident's weak side (Note: encourage the resident to use his or her strong side and to assist in the procedure as much as possible.) Support the resident by placing a gait belt around the resident's waist for you to hold and steady the resident. Instruct the resident to place his or her hands on the arms of the chair for support. Instruct the resident to stand and turn with his or her back to the bed and sit on the edge of the bed. Move with the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455737 If continuation sheet Page 10 of 15 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 455737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concho Health & Rehabilitation Center 613 Eaker St Eden, TX 76837 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 Should the resident become weak, pale, begin to perspire, complain of chest pain, feel dizzy or any other symptoms of acute distress, cease the procedure and summon the charge nurse. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455737 If continuation sheet Page 11 of 15 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 455737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concho Health & Rehabilitation Center 613 Eaker St Eden, TX 76837 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of residents for 1 of 3 medication carts and 1 of 1 surplus-stocked medication cart reviewed for medication storage. Medication Cart #1 had seven (7) expired medications. Medication Surplus Cart had one (1) expired controlled medication of ten (10) capsules in the med storage room, available for use. This failure could place residents at risk for not receiving the therapeutic effects of the medications ordered. The findings included: Observation on 04/12/23 at 08:30 AM, of surplus-stocked medication cart, revealed: Temazepam 7.5mg (10 capsules) expiration date 3/11/23 Interview on 04/12/23 at 09:00 AM , the ADON stated that the Consulting Pharmacist checked the locked medication cart in the medication storage room. She stated the Consulting Pharmacist rotated a review of medication in the medication storage room followed by medication carts on the floor one month and the next month conducted a review of medication carts on the floor only. He does not review all med carts and storage area each month. The ADON said the Pharmacist reviewed the medication in the medication storage area in February 2023. The ADON said the nurses look for expiration dates on medication packages prior to administration. Observation of medication cart #1 on 04/12/23 beginning at 09:30 AM, revealed : Three foil packages of Hemorrhoidal Suppositories expiration date 3/23 One 16 oz bottle Isopropyl Alcohol expiration date 03/23 One package Ipratropium Bromide 0.5mg and Albuterol Sulfate 3mg/ml expiration date 2/10/23 Two Povidone Iodine Swab sticks single-use package expiration date 08/22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455737 If continuation sheet Page 12 of 15 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 455737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concho Health & Rehabilitation Center 613 Eaker St Eden, TX 76837 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 0755 One 4 oz bottle Tincture of Benzoin Prep Spray expiration date 07/22 Level of Harm - Minimal harm or potential for actual harm One 30 oz bottle of ProStat Sugar free expiration date 6/6/22 Residents Affected - Few One 16 oz bottle Ultra Tuss Dextromethorphan Cough Suppressant expiration date 5/22 One Povidone Iodine Swab sticks single-use package expiration date 01/21 The expired medications were stored with non-expired medications, not separated and could be inadvertently dispensed Record review of the facility policy titled Recommended Medication Storage (PA 03-3.02h) Revised date 7/2012. There is no mention of an audit process for removal of expired medications nor a responsible party who would remove the medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455737 If continuation sheet Page 13 of 15 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 455737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concho Health & Rehabilitation Center 613 Eaker St Eden, TX 76837 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure all patient care equipment was in safe operating condition for 10 of 41 residents (Residents #6, #10, #11, #13, #14, #17, #18, #25, #28, #32) reviewed for safe, functional equipment, in that: Residents Affected - Some Residents #6, #10, #11, #13, #14, #17, #18, #25, #28 and #32 wheelchairs, to include the brakes, were not in safe working order. These failures could place residents at risk for skin issues, discomfort, and falls. Findings included: Observation, interview and record review on 4/11/23 at 3:40 PM during resident council meeting Resident #18 complained the brakes on her wheelchair were loose and that she was concerned because she knew most of the other wheelchairs in the building had similar issues. Resident #11 stated that her wheelchair brakes were also loose and had wobbly wheels but, she stated she had not reported it to anyone. On Inspection, the wheelchair brakes did not properly engage on either wheel of the wheelchair for Resident #18, #11, #10, #25 and #32. The brakes would lock but were not tight and the wheels would continue to roll even with the brake in the locked position. Resident #18 stated she had reported her brakes to a CNA but could not remember their name . No other resident had reported the brakes not working correctly to any facility staff. Record review of resident council meeting minutes book revealed no reports of any issues related to wheelchairs. Observation on 4/11/23 at 6:00 PM revealed Resident #28's right wheelchair brake not engaged. The brake would lock, but the wheel would still roll. Observation on 4/12/23 at 2:05 PM of residents gathered in the dayroom, revealed Resident #14's right wheelchair brake did not properly engage when in the locked position, Resident #6 and Resident #17's wheelchair brakes on both sides did not properly engage when in the locked position, and Resident #13's left wheelchair brake did not properly engage when in the locked position. All of the brakes locked, but the wheels continued to roll. Interview on 4/12/23 at 2:15 PM the DON, ADON, and Corporate RN stated wheelchair safety monitoring included determining which wheels roll and if the brakes worked. The ADON added they checked if brakes engaged would the wheelchair actually stop. The Corporate RN stated there was no set schedule of wheelchair monitoring. The DON stated the staff would come and tell them if there were problems with a wheelchair. The DON said if it was a weekday, the aides would come and tell the management and if it was a weekend, they would text. The Corporate RN stated there was a maintenance log and there were QR codes they could scan into their phones to access the maintenance log . They all stated loose brakes would not wait because if the resident transferred the wheelchair could move out from under them. The Corporate RN stated fixing brakes on the wheelchair was usually a quick fix completed by the Maintenance Director. Once informed of the observation the ADON stated there needed to be a sweep of the building. The DON stated the aides washed wheelchair and should check then Interview on 4/12/23 at 2:30 PM the Administrator was informed of the wheelchair brake observations. She said they don't lock?! I'll get maintenance on it right now. The Administrator stated anyone who found wheelchair brakes not working could report the issue. The Administrator said the risk to the residents was an increased risk of falls during transfers. She stated anytime there was anything (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455737 If continuation sheet Page 14 of 15 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 455737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concho Health & Rehabilitation Center 613 Eaker St Eden, TX 76837 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 0908 Level of Harm - Minimal harm or potential for actual harm wrong with equipment it should go into the maintenance book. The Administrator added if the Maintenance Director could not fix it they would order a new wheelchair. Interview on 4/12/23 at 6:34 PM the DON and Corporate RN stated there was no policy for wheelchair maintenance or resident equipment. Residents Affected - Some Record review on 4/12/23 of maintenance Status Task List for date range 3/12/23 through 4/12/23 revealed no requests regarding wheelchair brake repairs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455737 If continuation sheet Page 15 of 15