Health inspection·September 29, 2022

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 9/29/22 at 1:55 PM, the Administrator stated she knew she had done the EMR and NAR search for CNA A but was unable to locate it and did not know the date when she had done it. She stated the CNA was hired to work PRN and had not yet worked in the facility. The Administrator stated she thought LVN B had been employed at the mental health hospital in a nearby community. She stated the Maintenance Supervisor had worked in the oil field and had been employed by someone in the local community, and she had not done a reference check to verify his prior employment. Review of the facility's policy and procedure for Abuse Prevention Program, dated as revised May 2020, revealed the following [in part]: Policy Statements 1. The Administrator is responsible for the overall coordination and implementation of our facility's abuse prevention program policies and procedures . 2. Our residents have the right to be free from abuse, neglect, misappropriation or resident property and exploitation . 3. Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on direct access employees . Screening Background Screening Investigations 1. The Personnel/Human Resources Director, or other designee, will conduct background checks, reference checks and criminal history checks (including fingerprinting as may be required by state law) on all potential employees and contract personnel who meet the criteria for direct access employee . Such investigation will be initiated within two days of an offer of employment or contract agreement. 2. For any individual applying for a position as a Certified Nursing Assistant, the state nurse aide registry will be contacted to determine if any findings of abuse, neglect, mistreatment of individuals, and/or theft of property have been entered into the applicant's file . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675021 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 675021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Electra Healthcare Center 511 S Bailey St Electra, TX 76360 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 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a significant change MDS assessment within 14 days after a significant change in the resident's physical condition for 1 of 6 residents (Resident #17) reviewed for assessments in that: Residents Affected - Few 1. Resident #17 experienced a decline in ADLs, along with a significant weight loss. The facility did not complete a Significant Change MDS assessment. This failure placed residents who had recent health declines at risk for not having their individually assessed needs met which could result in a diminished quality of life and injury. Findings Include: Record review of Resident #17's admission sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of Cerebrovascular disease (group of conditions that affects the blood flow and blood vessels in the brain), Hemiplegia and Hemiparesis (weakness and partial paralysis) following Cerebral Infarction (disrupted blood supply that causes parts of the brain to die) and Aphasia (deficit in language due to brain injury). Record review of Resident #17's MDS Quarterly assessment dated [DATE] revealed he was assessed as having a BIMS (Brief Interview of Mental Status) score of 6 indicating severely impaired cognitive skills for daily decision making. He was assessed as requiring limited assistance with 1-person physical assist with bed mobility, transfers, dressing, toileting, and personal hygiene. Record review of Resident #17's MDS Quarterly assessment dated [DATE] revealed he was assessed as having a BIMS score of 4 indicating severely impaired cognitive skills for daily decision making. He was assessed as requiring extensive assistance with 1-person physical assist with bed mobility, transfers, dressing, toileting, and personal hygiene. Record review of Resident #17's Weight Variance Report showed a weight on 06/02/2022 of 152.30 lbs, a weight on 07/05/2022 of 149.20 lbs, a weight on 08/04/2022 of 147.80 lbs and a weight on 09/06/2022 of 140.80 lbs. Section K0200 was checked yes on a physician weight loss regimen for a loss of 5% or more in the last month or 10% or more in the last 6 months, During an interview with the CCM on 09/28/2022 at 3:00 PM, she stated she should have done a Significant Change Assessment to show the resident's recent decline. She had previously opened a Quarterly Assessment and forgot to change it to a Significant Change. She stated Resident #17 did have a recent weight loss, that was not physician prescribed. She stated that he did have a decline in his ADLs that was coded correctly in section G, but that should have triggered a Significant Change Assessment for the 09/05/2022 assessment. She said that she would be opening a new assessment to correctly capture the decline. During an interview on 09/29/2022 at 1:30 PM, the ADON stated Resident #17 did have a recent significant decline and it was the CCM's responsibility to capture the assessment correctly. Record review of the facility's policy and procedures showed that CMS's RAI Version 2.0 Manual, dated August 2003, page 2 directed that a Significant Change in Status Assessment (SCSA) must be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675021 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 675021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Electra Healthcare Center 511 S Bailey St Electra, TX 76360 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 0637 completed by the end of the 14th calendar day following determination that a significant change has occurred. 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: 675021 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 675021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Electra Healthcare Center 511 S Bailey St Electra, TX 76360 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on record review and interview, the facility failed to provide the required minimum of 80 square feet of space per resident in multiple occupancy rooms for 28 of 30 rooms (Rooms 3, 5, 8, 9, 10, 11, 12,13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 32, 32, 33, 34, and 35) reviewed for square footage. The facility failed to ensure multiple-bed resident rooms had the required 80 square feet of floor space per resident for rooms 3, 5, 8, 9, 10, 11, 12,13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 32, 32, 33, 34, and 35. This failure could place residents residing in these rooms at risk for not having adequate living space, and could adversely affect residents from attaining his or her highest practicable well-being. The findings included: Review of the facility's Form 3740 Bed Classifications, completed by the Administrator and dated 09/27/2022, revealed room numbers 3, 5, 8, 9, 10, 11, 12,13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 32, 32, 33, 34, and 35 were included in the licensed bed capacity as double occupancy rooms. Review of the prior completed Form 3762, Room Size Waiver for Facilities, dated 07/08/2021 revealed resident bedroom numbers 3, 5, 8, 9, 10, 11, 12,13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 32, 32, 33, 34, and 35 were listed as meeting the justification criteria for a room size waiver. In an interview on 9/27/22 at 10:02 AM, the Administrator stated she wanted to continue the room size waiver for all the rooms listed on the past Form 3762. * FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675021 If continuation sheet Page 5 of 5