Health inspection·July 11, 2023

F 0622 Level of Harm - Minimal harm or potential for actual harm score of 08, which reflected the resident was moderately impaired. Section BO300 indicated highly impaired hearing. Resident #1 required extensive assistance with two persons for bed mobility, transfer, and toilet use, dressing, and locomotion on and off unit. Extensive assistance with one person for personal hygiene and eating. The resident required total assistance in bathing activity. Resident #1 had an impairment on both sides of upper and lower upper extremities (paralysis). Residents Affected - Few Review of Resident #1's care plan dated 06/06/23 reflected care area problems with potential for uncontrollable pain, use of anti-anxiety medication and hearing deficit. However, there was no care plan for behavioral issues as reflected on the interviews with staffs and administration. During interview with SWH on 07/11/23 at 12:37pm, she said she was the Social Worker at the hospital where Resident #1 was transferred for evaluation and treatment of suicidal ideation. SWH explained Resident #1 was hard of hearing and communicated with her through a white board. SWH noted Resident#1 said she was being abuse by a staff member in the facility which made her say she didn't want to live any longer. SWH stated they treated Resident #1 and was ready to discharge the resident to the facility. She contacted ADM of the facility who said they are not taking Resident #1 back because they cannot meet her psychological needs. SWH informed the Administrator (ADM) the hospital was not a place to keep the resident and should take her back and initiate a proper discharge. She said ADM refused to take back the Resident #1. Meanwhile, Resident #1 said she did not want to go back to the facility because she did not feel safe in the facility. During interview with SWG on 07/11/23 at 1:32p.m, he said he was the Social Worker of the facility. SWG explained he was not involved in the discharge of Resident #1. He found out in the Morning meeting after Resident #1 was discharged . He said he did not know the facility did not want Resident #1 back after her discharge from the hospital. SWG explained Resident #1 has been trying to leave the facility to move to Abilene close to his brother. He called the brother who stated no facility will take her because of behavioral issues. SWG said he made several calls to different facility and none will take the resident. He explained Resident #1 constantly calls for assistance and gets very angry if the facility did not respond fast enough. SWG noted the DON and Administrator were involved with the discharge of Resident #1. He normally calls discharge residents to ensure they were getting services at home. However, Resident #1went to another facility and he did not call her. During interview with ADM on 07/10/2023 at 3:15p.m, she said she was the Administrator and responsible for the discharge of Resident #1. ADM explained Resident #1 was transferred to the hospital for suicidal ideation and did not return to the facility. The ADM was asked to provide information about the discharge of Resident #1. She said did not have documentation because she was not planning on discharging Resident #1 when she went to hospital. She stated she did not have the following: 1) Resident/Representative verbal or written notice of intent to leave the facility. 2) Comprehensive care plan that includes the resident's goals for admission and discharge 3) Discharge planning process (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455737 If continuation sheet Page 2 of 5 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 07/11/2023 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 0622 4) Level of Harm - Minimal harm or potential for actual harm Discharge summary 5) Residents Affected - Few Signed physician order of discharge 6) Notice to Adult Protective Service (APS) 7) Meeting with Interdisciplinary Team (IDT) about discharge 8) Required 30-day notice to Resident #1 9) No communication with receiving facility The ADM went on to say Resident #1 has some behavioral problems which included calling police for staff member. Resident #1 she said calls staff terrible names and was difficulty to care for. ADM explained when the hospital called to return Resident #1 to facility, she informed them she was not sure if the facility can meet the psychological needs of the resident. She told hospital she will contact corporate and let them know. In an interview with LVNA on 07/11/23 at 3:21p.m, she said was the charge nurse responsible for Resident #1 during the evening shifts. LVNA explained she admitted Resident #1to the facility and was familiar with her care. She said she was the nurse who transferred Resident #1 for suicidal ideation. She was told Resident was not coming back. LVNA explained Resident #1 was rude and hateful. She made it hard on staffs to care for her. Resident #1 she said, throws trays and utensils on the floor for no reason. She says racial words on demand and yells on staffs. LVNA stated resident told her she wanted to die which was the reason she transferred her to the hospital for psych evaluation and treatment. She said it was not safe for the Resident #1 to be in the facility because they don't have one-on-one care which she requires. During interview with PhyP on 07/11/23 at 3:45p.m, he said he was the medical doctor for Resident#1. PhyP explained Resident#1 was threatening to commit suicide and gave order to transfer resident to the hospital. He said Resident #1 was denied inpatient psychological care and the facility could not meet his needs. PhyP stated Resident #1 has chronic history attempting suicide and the facility don't have the needed staff to care for the resident. When informed of lack of documentation, phyP insisted the facility followed the discharge process. Review of Resident #1 clinical records revealed there was no documentation from the PhyP indicating the specific needs of the resident, the efforts to meet those needs and specific services the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455737 If continuation sheet Page 3 of 5 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 07/11/2023 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few receiving facility will be able to provide that was not present in the current facility. Furthermore, there was no documentation that the safety of the residents or other residents are endangered due to clinical or behavioral status of the resident. Closed record review of Resident #1's EHRs revealed there was no documentation of the following in either resident's record: The basis for the transfer or discharge (i.e., the specific resident needs that cannot be met, the facility's attempt to meet those needs); that an appropriate notice was provided to the resident and/or legal representative; disposition of personal effects, or any documentation by a physician that the transfer or discharge was necessary for the residents' welfare or the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident or the health of individuals in the facility would otherwise be endangered. Record review of undated facility policy Admission, Transfer and Discharge reflected The facility will permit each resident to remain in the facility, and not transfer or discharge the resident from the facility. In the following limited circumstances, this facility may initiate transfers or discharges: A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs services provided by the facility. C) The safety of individuals is endangered due to the clinical or behavioral status of the resident. D) The health of the individuals in the facility would otherwise be endangered. E) The resident has failed, after reasonable and appropriate notice to pay, or have paid under Medicare or Medicaid, for his or her stay at the facility. F) The facility ceases to operate. Emergent Transfers to Acute Care Residents who are sent emergently to the hospital are considered facility-initiated transfers because the resident's return is generally expected. Residents who are not sent to the emergency room, will be permitted to return to the facility, unless the residents meet one of the criteria under which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455737 If continuation sheet Page 4 of 5 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 07/11/2023 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 0622 the facility can initiate discharge. 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 5 of 5