Health inspection·September 11, 2025

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** In an observation on 09/10/2025 at 3:18 p.m., there did not appear to be any survey results in the lobby nor a sign indicating survey results were available and where to locate them. Survey binder observed to be placed in a bin down a hallway to the right of lobby with small print labeled survey results outside of the binder and on the bin. The survey binder did not have results from investigation visit on 04/10/2025 or most recent recertification visit on 08/20/2024.Resident #10Record review of quarterly MDS dated [DATE] reflected Resident #10 was a [AGE] year-old male who admitted into the facility on [DATE] with diagnoses to include: coronary artery disease (disease that affects the main blood vessels that supply blood to the hear reducing blood flow to the heart muscle), hypertension (high blood pressure), renal disease (kidneys do not work as well as they should) and hyperlipidemia (high cholesterol). Further review reflected Resident #10 had a BIMS of 14 which indicated his cognition was intact.During an interview on 09/09/2025 at 2:46 p.m., Resident #10 was sitting in his room with a family member. Resident #10 and his family member both stated that they were not aware that survey findings were available or where to find them.In an observation and interview on 09/11/2025 at 11:18 p.m., the ADMN verified that the survey binder did not have results from investigation visit on 04/10/2025 or most recent recertification visit on 08/20/2024. She stated her expectation would be for the last survey results and investigation results to be in the survey results binder. She stated she was responsible for making sure the survey results binder was updated. She stated that corporate may monitor required postings which included the survey binder during their annual mock survey. The ADMN stated she had worked for the facility before the last survey and did not know why those results were not in the folder. She stated the effect would be that the residents and visitors would not have access to survey and investigation results without asking for them. She stated the facility was not withholding information intentionally from residents or visitors. She stated the public would be notified of access to those results from the label outside of the bin the binder was kept in. She stated that label was not prominent for visitors. The ADMN stated she would update the binder with the missing results. Record review of facility admission agreement without a date reflected: Resident Rights Under Federal Law.The Resident has a right to examine the results of the most recent survey of the Facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the Facility. Record review of facility policy titled Availability of Survey Results revised on 02/08/2024 reflected: 1. A readable copy of our deficiencies is maintained in a 3-ring loose-leaf binder titled Results of Most Recent Survey.2. The survey binder is located (in the main lobby) and is available for review by interested persons who wish to review information relative to our company's compliance with federal or state rules, regulations, and guidelines governing our company's operation.3. A representative of management is assigned the responsibility of making weekly inspections of the Residents Affected - Many Page 1 of 3 455961 455961 09/11/2025 Palo Pinto Nursing Center 200 Southwest 25th Ave Mineral Wells, TX 76067

F 0577 Level of Harm - Potential for minimal harm Residents Affected - Many survey binder to ensure that the binder contains current information, is located in its designated area(s), and is readily accessible without one having to ask staff members for the information.4. The facility will maintain reports of any surveys, certifications, and complaint investigations made respecting the facility during the 3 proceeding years, and any plan of correction in effect with respect to the facility. This information will be available for any individual to review upon request.5. The facility shall not alter the survey results unless authorized by the state agency.6. Signs identifying the availability and location of our survey binder and availability of previous survey results are posted throughout the building and public bulletin boards. (See attached Notice.) 455961 Page 2 of 3 455961 09/11/2025 Palo Pinto Nursing Center 200 Southwest 25th Ave Mineral Wells, TX 76067

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the menu was followed for 1 of 2 (Resident #18) residents who received a pureed meal reviewed during 1 of 1 lunch meals. The facility failed to ensure Resident #18, who received a pureed diet, was provided the food according to the menu, including a roll on 09/09/2025. This failure could place residents that eat food from the kitchen at risk of poor intake, chemical imbalance and/or weight loss. Findings included: Record review of Resident #18's face sheet dated 09/11/2025 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included anorexia, heart failure and feeding difficulties. Record review of Resident #18's MDS dated [DATE] Section C -Cognitive Patterns revealed a BIMS score of 11 meaning moderate cognitive impairment; Section K Swallowing/Nutritional Status revealed Resident #18 received a mechanically altered diet. Record review of Resident #18's physician orders revealed a start date of 03/15/2024 Pureed texture, moderately thickened honey consistency.Record review of Resident #18's care plan dated 08/06/2025 revealed, Nutritional Status: {Resident Name} is on a puree diet.During an observation and interview on 09/09/2025 at 12:30 PM Resident #18's lunch tray left kitchen without a puree roll. The DM stated Resident #18's meal tray should have had a pureed roll. The DM stated the cook was responsible for ensuring a pureed roll was on Resident #18's tray. The DM stated residents not receiving all the menu items could have affected the residents by possible weight loss. The DM stated what led to failure was that dietary staff were distracted by state surveyor being in the kitchen. During an interview on 09/11/2025 at 11:30 AM [NAME] A stated residents were to get everything listed on the Menu. [NAME] A stated it was her responsibility to ensure all items were on the meal tray. [NAME] A stated residents could have been affected by not getting all of their food could have caused weight loss. [NAME] A stated what led to failure was she got distracted by the chicken waiting for it to get cooked. During an interview on 09/11/2025 at 12:11 PM the ADMN stated her expectation was residents should have received every item that was listed on the menu, and residents who received a pureed meal should have received a pureed roll. The ADMN stated the DM was responsible for ensuring trays contained all food items on the list. The ADMN stated the dietician was responsible for monitoring on her weekly visits. The ADMN stated residents could have been affected by their rights being violated by not receiving all the food they were supposed to receive. The ADMN stated what led to failure was that dietary staff were distracted because the state survey team were in the kitchen. Record review of facility policy titled, Menu Planning, Chef's Special (alternate Menu) or Static Menu dated 02.19.2028 revealed, The menus will be followed and served as written. 455961 Page 3 of 3