Health inspection·November 16, 2023

F 0584 dated by Social Services Director, revealed a BIMS score of 04, which indicated severe cognitive impact. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #5's Face Sheet, dated 11/15/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5's diagnoses included Respiratory Failure (serious condition that makes it difficult to breathe on your own), Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing-related problems), and Acute Kidney Failure, Unspecified (kidneys suddenly become unable to filter waster products from your blood). Residents Affected - Some Record review of Resident #5 Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated intact cognitive response. During an interview on 11/07/2023 at 3:41 p.m., Resident #1 said the floor and the wall by his toilet was wet and had black stuff on the wall. Resident #1 said the black stuff was on the wall by his toilet and there was little space in between the wall area and the toilet. Resident #1 said the rubber area at the bottom of the wall started coming off approximately four to six weeks prior and the black stuff had been on his wall for about a month. Resident #1 said he told the big boss because she came in and looked at his bathroom. Resident #1 said he could not remember the name of the big boss, but said she was a woman. Resident #1 said housekeeping came in and cleaned his room, but he was not sure how often. Resident #1 said he was told the wall would be fixed but he had not heard when. During an observation on 11/07/2023 at 3:11 p.m., observed the bathroom of Resident #1. Observed an area from the corner behind the toilet, which expanded outwards parallel with the toilet that approximately five feet of the vinyl cove base trim (the piece of trim installed around the baseboard of a room that created a transition between the floor and the wall) had become unattached from the wall and damaged drywall and water-damaged wood was exposed. The drywall was covered with a black chalk-like substance. Observed the linoleum floor color was darker than the other floor areas of the bathroom and had sections near the wall, approximately 12 inches in length that were buckled out and water damaged. During an interview on 11/07/2023 at 4:05 p.m., Maintenance Director A said he was aware of the black discoloration on the wall by the toilet in Resident #1's bathroom. Maintenance Director A said he was made aware of the issue approximately three to four days prior and had the repair on his list to complete the week of the on-site investigation. Maintenance Director A said he was not able to repair the cove base or linoleum because he had to attend a meeting and was away from the facility for several days. Maintenance Director A said a process to report needed repairs was in place. Maintenance Director A said a work order book was located at the nurses' station and if staff found an issue that needed to be repaired, they would document the issue in the work order book. Maintenance Director A said he would check the book when he came on duty in the morning, or he would check the book several times throughout the day. Maintenance Director A said he was told verbally of the of the damaged wall in Resident #1's room. Maintenance Director A said all staff knew to document needed repairs in the work order book and he was not sure if staff had been in-serviced or not on the process. During an interview on 11/15/2023 at 12:35 p.m., CNA C said she was aware of Resident #1's issue with his bathroom floor. CNA C said she thought the damage had occurred due to a water leak. CNA C said she was not sure if the issue had been reported to the maintenance supervisor or had been documented in the work order book. During an observation on 11/07/2023 at 4:40 p.m., observed in the bathroom of Resident #3 and #5, a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455961 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 455961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palo Pinto Nursing Center 200 Southwest 25th Ave Mineral Wells, TX 76067 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 0584 Level of Harm - Minimal harm or potential for actual harm section of the cove base trim, approximately 12 inches in length, under the sink had separated from the wall and exposed untreated drywall and discolored paint. Observed a circular area of linoleum approximately the size of basketball by the toilet and approximately two inches in width around the base of the toilet, a dark gray discoloration. Observed the linoleum to be chipped and black in color around the base of the toilet. Residents Affected - Some Resident #3 was unable to be interviewed about the issue with the bathroom cove base and floor due to her cognitive function. During an interview on 11/07/2023 at 4:50 p.m., Resident #5 said the floor in the bathroom had been discolored for several months. Resident #5 said the toilet had leaked at for a couple of months and had dried. Resident #5 said the sink had leaked at the faucet and ran over onto the floor and the floor was wet. Resident #5 said she told the housekeeper, but she was not sure if anyone ever fixed the leak. During an interview on 11/15/2023 at 11:13 a.m., Housekeeper B said she had been at the facility for eight months. Housekeeper B said she had observed the black, wet area in Resident #1's bathroom and was aware of the issue for approximately one month. Housekeeper B said the water damage came from a water leak in the staff bathroom that was on the same wall as Resident #1's bathroom. Housekeeper B said she reported the issue to her supervisor. During an interview on 11/16/2023 at 10:30 a.m., the Administrator said she was not aware of the need for repair in Resident #1 and Resident #3 and #5's bathroom. After observations, the Administrator said the issues with Resident #1 and Resident #3 and #5's bathrooms did not meet her expectation. The Administrator said her expectation was for staff who assisted the residents with activities of daily living and were in the bathrooms daily, to report the need for repairs immediately and she expected to be made aware of issues as well. The Administrator said building maintenance should be monitored by the Maintenance Director A and herself. Record review of policy, Maintenance & Facilities, not dated, revealed the facility would establish an environmental plan to ensure a physical environment was safe, neat, and sanitary and met regulations to protect the health and safety of the residents. The procedure was to ensure the building was maintained in good order and kept clean and safe. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455961 If continuation sheet Page 3 of 3