Health inspection·August 24, 2023

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #204 ' s family that resident was no longer eligible for hospice services as of 07/02/2023 due to improved condition. Closed record review of Resident #204 ' s social worker progress notes dated 06/28/2023 documented SW had placed orders for medical equipment to be provided by residents ' insurance. On that same day, SW contacted Resident #204 ' s family member and informed her about the orders. Closed record review of social worker progress noted dated 07/02/2023 documented Resident #204 was discharged home with his family. Closed record review of hospice Discharge summary dated [DATE] documented Resident #204 had been admitted to hospice on 03/30/2022 and had been discharged on 07/02/2023 due to resident no longer needing hospice services. Closed record review of Resident #204 ' s medical record revealed a 5-Day Discharge Notice dated 06/26/2023 that documented Resident #204 would be discharged from hospice services. Closed record review of Resident #204 ' s medical record revealed a facility 30-day written discharge notice had not been given to the residents ' family representative. It also revealed a written notice had not been given to the ombudsman. An interview on 08/22/23 at 08:43 AM with Family Representative, revealed that on 06/14/2023, the facility had told her Resident #204 would no longer be needing hospice and would be discharged on 07/02/2023. She stated since the VA had been paying for the hospice and he no longer needed it, the family could not afford to pay for Resident #204 to stay longer. She stated she had asked the facility to send the family a formal letter notifying of the discharge, and the hospice sent her a 5-day discharge notice of hospice services. An interview on 08/23/23 at 08:47 AM with SW revealed the last time Resident #204 had been evaluated for hospice, he did not qualify for its services due to being stable and gaining weight. On 06/14/2023 hospice notified the family that he no longer qualified and would be discharged . She stated she had worked with Resident #204 ' s family to come up with a plan for him, but since he did not have insurance and could not pay for long-term care services, he was discharged on 07/02/2023. She said since he could not pay for services and did not qualify for hospice, he did not require a 30-day notice of discharge. She stated hospice had provided a 5-day notice but was unsure of what it was for. She said depending on the reason for discharge, then the facility would notify the ombudsman. She stated she did not think she had to notify the ombudsman of the discharge for Resident #204. She revealed she was not aware that the facility had to notify the ombudsman of every facility-initiated discharge. She could not state any risk to residents if the ombudsman was not notified, or if the family was not given a 30-day notice of discharge. An interview on 08/23/23 at 10:01 AM with Hospice DON revealed any resident who was receiving hospice services had to be evaluated to determine if hospice services were beneficial and determine if they were still needed. She stated that Resident #204 was doing better and had been gaining weight. She stated the family was given a verbal notification and was also given a 5-day notice on 06/26/2023 indicating Resident #204 would be discharged from hospice. She stated discharge planning was made with the family and medical equipment had been ordered. She revealed she was unaware of what a 30-day discharge notice was for. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 2 of 23 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 675025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White Acres Wellness & Rehabilitation 7304 Good Samaritan Court El Paso, TX 79912 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview on 08/23/23 at 1:52 PM with Ombudsman, revealed a discharge notice was required for all facility-initiated discharges regardless of the details with the discharge. He said it was in the state and federal regulations that there had to be a notice to the ombudsman when a resident was discharged . He said for Resident #204 there had to be a 30 day notice even though he was discharged from hospice. He said since he was still residing at the facility with hospice services, it was the facility's responsibility to provide a discharge notice, in order to give the resident an opportunity to appeal. He revealed a discharge notice had not been provided to him regarding Resident #204. An interview on 08/23/23 at 5:04 PM with DON revealed since Resident #204 had not been re-certified for hospice because he had been thriving and did not require the services. VA said if Resident #204 was not in hospice, the insurance would not pay for stay. He revealed Resident #204 ' s family was notified of discharge by SW. He revealed he did not think a 30-day notice had been given to Resident #204 ' s family because he had been discharged before the 30 day mark. He stated he did not know Ombudsman had to be notified of discharge, and that he had not been for Resident #204. Resident #30 Closed record review of Resident #30's face sheet dated 08/24/23 revealed an initial admission date of 12/10/2019 with a readmission of 07/20/23 to the facility. Closed record Review of Resident #30's history and physical dated 03/03/23 revealed an [AGE] year-old female diagnosed with dementia, anxiety, Parkinson's, glaucoma, visual disturbance, chronic embolism (blockage of the pulmonary arteries that occurs when prior clots in these vessels don ' t dissolve overtime despite treatment) and thrombosis of unspecified vein (occurs when a blood clot forms in one or more deep veins in the body), orthostatic hypertension(when your blood pressure suddenly drops when you stand up from a seated or laying position), osteoarthritis, and muscle weakness. Closed record review of Resident #30's readmission MDS assessment dated [DATE] revealed Resident # 30 required extensive assistance with ADLs for bed mobility, transfers, and personal hygiene. In section J, it stated Resident #30 had sustained 2 or more falls prior to readmission MDS with no injury. Closed record review of Resident #30 ' s discharge MDS assessment dated [DATE] revealed Resident #30 was a discharge with no return anticipated and was discharged to other. MDS documented Resident #30 had no behaviors, no depression, was total dependent for ADL care and history of falls with two or more falls with no injury and with major injury. Closed record review of Resident #30's care plan dated 02/05/23 documented the Resident #30 had multiple documented falls related to poor safety awareness, weakness, and Parkinson's. The goal was for the resident to resume usual activities without further incidents. Interventions included; monitor/document/report as needed for 72hrs to health care provider bruises, changes in mental status, confusion, agitation or inability to maintain posture, contact Physical therapy for consultation for strength and mobility, check for orthostatic hypotension and manage, educated resident not to pick up objects she drops and use call light for assistance, use appropriated footwear, observe for signs and symptoms of injury and check for range of motion at the time of fall, monitor resident between rounds, assist to bed after meals, and assist with toileting. Closed record review of Resident #30's falls tool assessment dated [DATE] indicated resident was a medium risk for falls since she had documented history of falls, due to her medication, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 3 of 23 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 675025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White Acres Wellness & Rehabilitation 7304 Good Samaritan Court El Paso, TX 79912 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 0623 psychological and cognitive status. Level of Harm - Minimal harm or potential for actual harm Closed record review of Resident #30 ' s incident report indicated Resident #30 had 5 falls in March 2023, 4 falls in February 2023 and 3 falls in January 2023 documented. Residents Affected - Few Closed record review of Resident #30 ' s progress notes dated 02/22/23 revealed social worker notified the hospital case worker that Resident #30 needed to be 72 hours without one-to-one supervision before the facility would accept her back in the facility. Closed record review of Resident #30 ' s progress notes dated 02/22/23, stated the social worker contacted Resident #30 family member to notify them that Resident #30 needed one to one since she was at a high risk for falls and endangering herself. The family member notified the social worker she was unable to provide one to one care for Resident #30. The social worker notified the family member they do not offer that service in the facility, family member stated she will start seeking alternatives. Closed record review of Resident #30 ' s progress notes dated 2/24/23, indicated residents' family member notified social worker that residents family all agreed Resident #30 could not go back to the community, and they were not able to take care of her at home, allowed referral to be sent to a facility out of town. Closed record review of Resident #30 ' s progress notes dated 2/24/23 stated that the social worker contacted local ombudsman, to notify him that Resident #30 required one to one and possible discharge due to resident needs. The social worker stated that the family wanted to take the resident home with family as per Resident #30 request to spend her last days at home. The local ombudsman stated that it was the residents right to be discharged if she did not want to return to the facility. Closed record review of Resident #30 ' s progress notes dated 3/2/23 stated Resident #30 family member contacted local ombudsman for resources for Resident #30 placement, since facility had notified the family, they could not provide services for Resident #30. Family member asked for referral to another local nursing home with a memory unit. Closed record review of Resident #30 ' s progress notes dated 3/10/23, stated Resident #30 was discharged to a foster home at the family's expense. Order for home health was submitted to an agency without confirmation of follow-up care, no medical equipment provided. No notification to local ombudsman noted. Closed record review of Resident #30 ' s progress notes dated 3/13/23 stated that social worker had received a voicemail confirming they had processed the order for home health and would forward the order to a local home health agency and required residents' history and physical to be provided. Interview on 08/24/23 with ombudsman at 05:35 PM revealed facility had not contacted him regarding Resident #30 discharge from the facility due to not being able to meet her needs or being aware she was discharged to a foster home prior to receiving assistance with the insurance to help cover the cost. Stated being aware of Resident #30 health status and family seeking assistance recall recommending local nursing home with memory unit and facility stating they were going to summit a referral. Interview on 08/24/23 at 05:01 PM with Social Worker revealed she did not issue a 30-day notice or notify local ombudsman of Resident #30 discharge. The social worker stated that they had met with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 4 of 23 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 675025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White Acres Wellness & Rehabilitation 7304 Good Samaritan Court El Paso, TX 79912 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the family to discuss Resident #30 discharge from the facility due to the resident requiring one to one care. The social worker stated that the facility did not provide one to one care since Resident #30 had repeated falls they were no longer able to meet her needs. The social worker denied having issued a 30-day notices since they did not have a set discharge date . The social worker verbalized working with the ombudsman for placement of Resident #30, stated that he was aware resident was going to be discharged . The social worker denied this was a facility-initiated discharge. The social worker stated working with the family to the best of her ability. The social worker stated being unclear of when the local ombudsman had to be notified, felt no negative outcome resulted even after becoming aware of Resident #30 being re-hospitalized 2 days after discharge. Interview on 08/23/23 at 05:10 PM with the DON validated Resident #30 had a history of repeated falls and fall preventions were in place. The DON stated that it was when Resident #30 required one to one care that they could no longer meet her needs due to staffing. The DON stated Resident #30 never ended up with major injuries with her falls, stated Resident #30 did have a large hematoma with her last fall in the facility. The DON stated they took every fall precaution possible such as floor mat, low bed, and encourage activities outside her room since however Resident #30 refused to participate since she preferred to stay in her room. The DON stated he did follow up with Resident #30 at the foster home since home health was not made available right away and with corporates permission. Stated he was sent to follow up to on Resident #30 safety and stable health condition. The DON stated that Resident #30 was re-hospitalized on [DATE], he verbalized being concern due to her high risk for injuries related to falls. The resident stated the discharge process was the responsibility of the social worker, to the best of his knowledge Resident #30 was not discharged prior to prevent allegations of patient dumping (abandoning resident at facility sent out to). Interview on 08/24/23 at 04:45 PM with the Administrator, revealed Resident #30 discharge was handled by the social worker and stated Resident #30 required one to one care that the facility could not provide. The Administrator verbalized being unsure if a 30-day notice was provided, stating he did not believe it was since the facility was working with Resident #30 family for them to find a safe discharge location for the Resident to go to. The Administrator stated they did not have a set date for the resident to be discharged since there were issues with family dynamics and who would provide care for the resident. The Administrator stated the social worker would be more aware of the notifications made. Review of facility policy titled Discharge and Transfer-Rehab/Skilled, Therapy and Rehab dated 12/27/2022 read in part .Before a location transfers or discharges a resident, the location must: Notify the resident and the resident ' s representative of the discharge and the reason for the move in writing and in a language and manner they understand. The notification of transfer or discharge, or other state-required form, will serve as the written notice to be given to the resident/and or representative .With a facility-initiated transfer or discharge, the location must send a copy of .state required form to a representative of the State Long-Term Care Ombudsman . Review of facility policy titled Resident ' s Rights for Skilled Nursing Facilities undated read in part .Before a facility transfers, or discharges a resident, the facility must: notify the resident and resident ' s representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the office of the state long-term care ombudsman . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 5 of 23 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 675025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White Acres Wellness & Rehabilitation 7304 Good Samaritan Court El Paso, TX 79912 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 - Few 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 observation, interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 2 of 6 residents (Resident #7 and Resident #25) reviewed for care plans in that: The facility failed to develop a comprehensive person-centered care plan for Resident #7 to address the resident's need for oxygen and monitoring for signs and symptoms of hypoxia (low levels of oxygen in the body). The facility failed to implement Resident #25's comprehensive person-centered care plan for finger nail care. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings include: Resident #7 Record review of Resident #7's face sheet dated 08/23/2023 reflected an [AGE] year-old male with an initial admission date of 05/18/2023, and a re-admission date of 08/18/23 to the facility. Review of Resident #7 's History and Physical dated 08/10/2023 documented a diagnosis of COPD and requiring use of oxygen. Resident #7 readmission diagnosis was respiratory failure with hypoxia (low levels of oxygen in the body) on 08/18/23 from the hospital. Record review of Resident #7's MDS assessment dated [DATE] reflected he had a BIMS of 08 (moderately impaired cognition). He was able to understand others and make his needs understood. In section I it documented Resident #7 had an active diagnosis of Chronic Obstructive Pulmonary diseases. Record review of Resident #7 's oxygen saturation summary reflected; 8/21/23 a value of 90% saturation with oxygen via nasal cannula indicating Resident #7 would have low saturation level at times even with oxygen administered. Record review of Resident #7's physician's orders dated 08/23/23 reflected Resident #7 had no active order for oxygen administration. Record review of Resident #7's Care Plan dated 08/18/2023 reflected no care plan for oxygen administration. Observation and interview on 08/21/23 at 02:30 PM with Resident #7, revealed he did not like wearing his oxygen when eating noted nasal cannula was not labeled connected to oxygen concentrator at 2 litters per minute. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 6 of 23 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 675025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White Acres Wellness & Rehabilitation 7304 Good Samaritan Court El Paso, TX 79912 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 - Few Interview on 08/23/23 at 02:04 PM with LVN B, verbalized Resident #7 uses oxygen continuously. LVN B, stated that Resident #7 had an order for oxygen to be administered at 2 Liters a min via nasal cannula. When LVN B looked for the oxygen order and care plan, stated she was not able to find an active order. LVN B, stated she was only able to find Resident #7 previous order for oxygen at night, but since it was change to continuous when Resident #7 return from the hospital she was unsure why it was not entered. LVN B said the resident ' s documentation and orders are ultimately the nursing staff ' s responsibility to ensure everything is entered correctly. Interview on 08/23/23 at 03:37 PM with the DON, revealed Resident #7 care plan did not include oxygen administration. Resident #7 had a diagnosis that required oxygen administration at all times, and intervention for oxygen monitoring was very important due to the Resident #7 history stated the DON. Resident #7 readmission diagnosis of respiratory failure with hypoxia made oxygen monitoring very important, the DON stated this was unacceptable. The DON stated it was the responsibility of all the nursing management team to review the admission to ensure they are done correctly, but ultimately it is the responsibility of the MDS nurse to ensure all care plans are done. If care plans are not accurate resident care may be affected and more importantly not reflect accurately the resident. The DON stated a new ordered was entered recently on 08/23/23 correcting the oxygen administration order, stated it read for Resident #7 to have 2 litters per minute of oxygen continuously. Resident #25 Review of Resident #25 face sheet dated 08/21/23 revealed admission on [DATE] to the facility. Review of Resident #25 history and physical dated 09//21/22 revealed a [AGE] year-old male diagnosed with dementia. Review of Resident #25 annual MDS assessment dated [DATE] revealed resident #25's cognitive score as a 6 with recall and understanding. Resident #25's ADLs indicated limited assistance with one person assist with personal hygiene. Resident #25's was diagnosed with non-Alzheimer's disease, and dementia. Review of Resident #25 care plan dated 07/28/18 revealed Resident #25's ADLs self-care performance due to weakness and inability to perform ADLs. (Does not specific anything regarding nail care) Review of Resident #25 care plan date 04/27/23, resident #25 had the potential for alteration in activity and accepts one to one activity in which resident will not have a decline in activity participation. Provide one to one (one to one; one staff to one resident) for nail care. The care plan does not specify as needed or when need fingernail care to be done. Observation and Interview on 08/21/23 at 9:37 AM with Resident #25 stated he could not remember the last time his fingernails were cut. Resident #25 stated he could not remember if he had told the nursing staff or if they had asked him if he wanted his fingernails cut. Resident #25 stated he wanted his nails to be cut and trimmed. Resident #25's fingernails were long and dirty. The nails had a black substance underneath the nails. Observation on 08/22/23 at 3:41PM revealed Resident #25 was in his room sitting down on his wheelchair. Resident #25 had his hands out in front of him. Resident #25's fingernails were long and had a black substance underneath the fingernails. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 7 of 23 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 675025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White Acres Wellness & Rehabilitation 7304 Good Samaritan Court El Paso, TX 79912 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 - Few Interview on 08/23/23 at 9:10 AM with LPN A revealed nurses and CNAs are to conduct rounds in which they check on the resident both visually and physically. LPN A stated the facility had brushes and nail equipment to clean the residents' nails. LPN A stated Resident #25's nail care only stated nail care but did not specific how often to clean, when to cut or when to clean and should have been stated in the care plan. Interview and Observation on 08/23/23 at 9:30 AM with LPN A revealed Resident #25 sitting down in his wheelchair with his hands out. Resident #25's fingernails were dirty with a black substance underneath the fingernails and were long. LPN A stated she had already observed Resident #25s fingernails and stated they were fine . LPN A stated to her the way they look was fine and there was no risk to the resident. Interview and Observation on 08/23/23 at 10:07 AM with the DON revealed that nurses and CNAs are to assess the residents to see if they need anything or see anything wrong. The DON stated the residents' nails need to be cleaned daily, trimmed by the nurses, and documented in the progress notes. At 10:10 AM the DON stated Resident #25's fingernails looked dirty, long, and had a black substance underneath his fingernails. The DON stated it was not acceptable to have his fingernails long and dirty. The DON stated the risk was infection control and scratches. The DON stated Resident #25's nail care and what it consists of should be in the care plan. Interview on 08/23/23 at 11:32 AM with the Activities Director revealed the activities department cuts the resident nails if they are not diabetic. The Activities Director stated nail care was placed into each resident's care plan. The Activities Director stated for nail care they do put as needed for each resident in case the resident needs to have their nails cut, trimmed, or cleaned. The Activities Director stated that Resident #25's care plan did not have as needed nail care and only stated nail care. The Activities Director stated her, and her assistant go around checking the residents if they need nail care done . The Activities Director stated residents that have long finger nails, have jagged edges, and are dirty would need as needed nail care. The Activities Director stated they also rely on the nurses to inform them if the residents need nail care done. The Activities Director stated they do check the nails every Friday. The Activities Director stated that Resident #25 needed to have as needed nail care in his care plan because if they get long or dirty it could be a risk of infection and the longer the nails the more, they collect dirt. Record review of the facility comprehensive care plan and care conferences policy dated 10/21/22 revealed the purpose was to develop a person-centered care plan for each resident that includes measurable objectives and timetables to meet his or her physical, mental, spiritual, and psychosocial wellbeing. Record review of the facility activities calendar for the month of August 2023 revealed at 11AM - Beauty Day with staff (Hair, Face, and nails). This means every Friday the Activities Department will go and check on every resident with nail care. Record review of Resident #25's POC (Plan of Care) dated 08/22/23 did not indicated anything regarding nail care. If it was done or not. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 8 of 23 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 675025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White Acres Wellness & Rehabilitation 7304 Good Samaritan Court El Paso, TX 79912 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who are unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident #25) reviewed for grooming, and personal and oral hygiene. Residents Affected - Few 1. Resident #25 had long fingernails that were dirty and had a black substance underneath them. This deficient practice could place residents who required assistance with showering and maintaining good personal hygiene at risk for not receiving care and services to meet their needs and avoid ADL decline. Findings include: Review of Resident #25 face sheet dated 08/21/23 revealed admission on [DATE] to the facility. Review of Resident #25 history and physical dated 09//21/22 revealed a [AGE] year-old male diagnosed with dementia. Review of Resident #25 annual MDS assessment dated [DATE] revealed resident #25's cognitive score as a 6 with recall and understanding. Resident #25's ADLs indicated limited assistance with one person assist with personal hygiene. Resident #25's was diagnosed with non-Alzheimer's disease, and dementia. Review of Resident #25 care plan dated 07/28/18 revealed Resident #25's ADLs self-care performance due to weakness and inability to perform ADLs. (Does not specific anything regarding nail care) Review of Resident #25 care plan date 04/27/23, resident #25 had the potential for alteration in activity and accepts one to one activity in which resident will not have a decline in activity participation. Provide one to one (one to one; one staff to one resident) for nail care. The care plan does not specify as needed or when need fingernail care to be done. Observation and Interview on 08/21/23 at 9:37 AM with Resident #25 stated he could not remember the last time his fingernails were cut. Resident #25 stated he could not remember if he had told the nursing staff or if they had asked him if he wanted his fingernails cut. Resident #25 stated he wanted his nails to be cut and trimmed. Resident #25's fingernails were long and dirty. The nails had a black substance underneath the nails. Observation on 08/22/23 at 3:41PM revealed Resident #25 was in his room sitting down on his wheelchair. Resident #25 had his hands out in front of him. Resident #25's fingernails were long and had a black substance underneath the fingernails. Interview on 08/23/23 at 9:10 AM with LPN A revealed nurses and CNAs are to conduct rounds in which they check on the resident both visually and physically LPN A stated the facility had brushes and nail equipment to clean the residents' nails. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 9 of 23 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 675025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White Acres Wellness & Rehabilitation 7304 Good Samaritan Court El Paso, TX 79912 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview and Observation on 08/23/23 at 9:30 AM with LPN A revealed Resident #25 sitting down in his wheelchair with his hands out. Resident #25's fingernails were dirty with a black substance underneath the fingernails and were long. LPN A stated she had already observed Resident #25s fingernails and stated they were fine . LPN A stated to her the way they look was fine and there was no risk to the resident. Interview and Observation on 08/23/23 at 10:07 AM with the DON revealed that nurses and CNAs are to assess the residents to see if they need anything or see anything wrong. The DON stated the residents' nails need to be cleaned daily, trimmed by the nurses, and documented in the progress notes. At 10:10 AM the DON stated Resident #25's fingernails looked dirty, long, and had a black substance underneath his fingernails. The DON stated it was not acceptable to have his fingernails long and dirty. The DON stated the risk was infection control and scratches. Interview on 08/23/23 at 11:32 AM with the Activities Director revealed the activities department cuts the resident nails if they are not diabetic. The Activities Director stated nail care was placed into each resident's care plan. The Activities Director stated for nail care they do put as needed for each resident in case the resident needs to have their nails cut, trimmed, or cleaned. The Activities Director stated that Resident #25's care plan did not have as needed nail care and only stated nail care. The Activities Director stated her, and her assistant go around checking the residents if they need nail care done . The Activities Director stated residents that have long finger nails, have jagged edges, and are dirty would need as needed nail care. The Activities Director stated they also rely on the nurses to inform them if the residents need nail care done. The Activities Director stated they do check the nails every Friday. The Activities Director stated that Resident #25 needed to have as needed nail care in his care plan because if they get long or dirty it could be a risk of infection and the longer the nails the more, they collect dirt. Record review of the facility nail care policy dated 03/28/23 revealed the purpose of nail care was to keep nails clean and trimmed to promote well-being, to observe nail condition, and prevent nail discomfort. Record review of the facility activities calendar for the month of August 2023 revealed at 11AM - Beauty Day with staff (Hair, Face, and nails). This means every Friday the Activities Department will go and check on every resident with nail care. Record review of the facility activities director progress notes dated 07/13/23 at 3:25 PM for Resident #25 indicated staff visit with resident 3 times per week and offer nail care as needed. Record review of Resident #25's POC (Plan of Care) dated 08/22/23 did not indicated anything regarding nail care. If it was done or not. Record review of facility activities of daily living policy dated 11/29/22 revealed was to provide residents with appropriate treatment and services to maintain or improve abilities in activities of daily living for the well-being of mind, body, and soul. ADLs are those necessary tasks conducted in the normal course of a resident's daily life. General personal, daily hygiene/grooming: Care of hair, hands, face, shaving, applying makeup, skin, nails and oral care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 10 of 23 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 675025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White Acres Wellness & Rehabilitation 7304 Good Samaritan Court El Paso, TX 79912 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 1 (Resident #38) of 2 residents reviewed for peripheral intravenous care. Residents Affected - Few 1. Resident #38 did not have his intravenous tube/dressing dated and orders did not indicate when to change the dressing. This failure placed residents at risk of developing an infection. Findings include: Resident #38 Review of Resident #38's face sheet dated 08/23/23 revealed admission on [DATE] to the facility. Review of Resident #38's history and physical dated 06/22/23 revealed an [AGE] year-old male diagnosed with UTI (urinary tract infection). Review of Resident #38's quarterly MDS assessment dated [DATE] revealed Resident #38's cognition to understand and recall at a score of 12 . Resident #38's IV medication was not indicated as this was administrated after this MDS assessment. Review of Resident #38's care plan reviewed on 08/21/23 reflected it did not indicate any new revision for IV focus, goals, and interventions. Review of Resident #38's orders dated 08/18/23 reflected IV - flush peripheral catheter: Use SAS (Saline/Administer medication/Saline/Heparin (SASH) method) Technique with each intermittent medication administration and change sterile end cap every 8 hrs. for IV patency for 7 days S: saline 5ml or 10ml before medication administration A: administer medication S: Saline 5ml or 10m after medication administration. This order has no indication when to change the tubing and labeling. Review of Resident #38's orders dated 08/23/23 reflected IV tubing/administration set change every 24 hours. Phone, intermittent (an infusion of a volume of fluid/medication over a set period of time at prescribed intervals and then stopped until the next dose is required) infusion . Change every 96 hours for continuous primary and/or secondary infusions. Change sterile end cap on administration set with each use, every 8 hours for infection control until 08/26/23. Label with: Date/Time/Initials . Observation and Interview on 08/21/23 at 9:54 AM of Resident #38 in his room. Resident #38 was sitting down in his wheelchair. Resident #38 had an IV line with a dressing on top of his left wrist. It had no date or labeling on either the tubing or dressing. Resident #38 stated last Saturday the 19th, he had it placed due to having a UTI . Interview on 08/23/23 at 9:40 AM with LPN A revealed residents with intravenous lines need to have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 11 of 23 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 675025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White Acres Wellness & Rehabilitation 7304 Good Samaritan Court El Paso, TX 79912 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few their tubing and dressing labeled. LPN A stated the purpose of labeling was so the nursing staff know when to change the tubing/dressing. LPN A stated not changing the tubing/dressing as needed could result in infiltration, lead to redness, and infection. LPN A stated the nurses are responsible for labeling the tubing/dressing. LPN A stated when she was doing her rounds, she did not see that it was not labeled. LPN A stated Resident #38 did not have any orders on when to change the tubing/dressing. LPN A stated it would be important to have orders that indicate when to change the tubing/dressing to know the time frame. LPN A stated all nurses are responsible for ensuring doctors' orders have everything a resident needs for whatever the order was being given. LPN A stated there was a risk if the orders are not done correctly depending on whatever the resident had and was missing could affect them negatively. Interview on 08/23/23 at 10:07 AM with the DON revealed residents with intravenous lines should have a date and initials of who placed the intravenous line or changed it out. The DON stated that was what the nurses go by so they know when to change the tubing/dressing. The DON stated the risk of not changing the IV tubing/dressing could be infection or redness. The DON stated that nurses should know when to change the intravenous tubing/dressing every 96 hours as it was considered a standing order but still a risk if not indicated in the resident's order like Resident #38's. Record review of the facility intravenous therapy - enterprise policy dated 05/24/23 revealed administration set (IV tubing) changes - label tubing with expiration date (INS). Dressing change/site care - change gauze dressings for both central and peripheral sites every 2 days and if they are damp, loosened or visibly soiled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 12 of 23 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 675025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White Acres Wellness & Rehabilitation 7304 Good Samaritan Court El Paso, TX 79912 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 2 (Resident #7 and Resident #15) of 10 residents observed for oxygen management. Residents Affected - Some -Resident #7 ' s oxygen tank was empty while being used. -Resident #7 did not have a physcian order for oxygen while receiving oxygen therapy. -Facility failed to follow oxygen policy stating disposable equipment had to be changed weekly and marked with date and initals for Resident #7 and Resident #15. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health. Findings included: Resident #7 Review of Resident #7 ' s Face Sheet dated 08/24/2023 documented an [AGE] year-old male with an initial admission date to the facility on [DATE] and a re-admission date of 08/18/2023. Review of Resident #7 ' s History and Physical dated 08/10/2023 documented a diagnosis of COPD (a condition that causes difficulty breathing and a cough) and requiring use of oxygen. Review of Resident #7 ' s Comprehensive MDS assessment dated [DATE] documented a BIMS score of 6; indicating severe cognitive impairment. It also documented a diagnosis of COPD while being dependent on oxygen therapy. Record review of Resident #7's physician's orders dated 08/23/23 reflected Resident #7 had no active order for oxygen administration. Observations on 08/21/23 at 12:00 PM revealed Resident # 7 in dining room receiving oxygen through a nasal cannula. The oxygen tank ' s meter was reading as empty in the red zone. The nasal cannula tubing was not labeled. An interview on 08/21/23 at 12:03 PM with LPN A revealed Resident #7 ' s oxygen tank was empty and was not providing oxygen. At this time, she was asked to check oxygen saturation for Resident #7. The oxygen reading was 90%. She stated CNAs and nurses were responsible for checking the oxygen tanks and ensuring they were full. She stated if the oxygen tanks were empty, it could cause residents to become hypoxic and be low in oxygen. She also revealed the oxygen tubing (nasal cannulas) had to be labeled to ensure the dates were correct of when they had been changed. She stated if the residents ' oxygen tubing was not checked correctly, it could cause an infection to their lungs. Interview on 08/23/23 at 02:04 PM with LVN B, verbalized Resident #7 uses oxygen continuously. LVN B, stated that Resident #7 had an order for oxygen to be administered at 2Liters a min via nasal canula. When LVN B looked for the order and care plan stated all she was able to find was the previous (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 13 of 23 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 675025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White Acres Wellness & Rehabilitation 7304 Good Samaritan Court El Paso, TX 79912 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some order before his readmission. LVN B, stated she was not sure why the order was not entered since she was new to that shift and section. LVN B stated that the resident ' s documentation and orders are ultimately the nursing staff responsibility to ensure everything is entered correctly. LVN B, also stated that Resident #7 requires continuous monitoring due to non-compliance with maintaining oxygen nasal canula in place, more specifically during mealtimes. LVN B, verbalized nurses and CNA's can connect the residents to a portable oxygen tank when taking the residents to the dining area. LVN B, did affirm that any staff member connecting residents to portable oxygen tanks need to ensure the oxygen tanks have sufficient oxygen. LVN B, stated the nurse is responsible to oversee the CNA is doing her job correctly when connecting the residents to the oxygen tanks to prevent residents from being connected to oxygen tanks that don ' t have sufficient oxygen. LVN B, stated they have portable oxygen tanks that are refilled by the oxygen company, staff only connects them to the residents and removes them when empty. LVN B, stated if they are not careful when administering oxygen, it can lead to residents not getting sufficient oxygen. Interview on 08/23/23 at 03:40PM with the DON, revealed Resident #7 did not have an order for oxygen administration. Resident #7 had a diagnosis that required oxygen administration at all times, and intervention for oxygen monitoring was very important due to the Resident #7 history stated the DON. Resident #7 readmission diagnosis was respiratory failure with hypoxia (low levels of oxygen in the body) making oxygen monitoring very important, the DON stated this was unacceptable. The DON stated it was the responsibility of all the nursing management team to review the admissions to ensure they are done correctly, but ultimately it is the responsibility of the admitting nurse, since the admitting nurse does the reconciliation of the orders from the hospital with the physician from the facility. The DON confirmed there was no order for oxygen administration, stated not having the correct orders in the system can negatively affect the residents by exposing them to get inaccurate care if the nurse is not familiar with the resident. The DON confirmed order was not present in Resident #7 order summary. The DON stated if the nasal canula is not changed every 7 days or as needed when it becomes dirty it can be infection control issue due to cleanliness. Resident #15 Review of Resident #15 ' s Face Sheet dated 08/24/2023 documented a [AGE] year-old male with an admission date to the facility of 11/09/2018. Review of Resident #15 ' s History and Physical dated 04/07/2023 documented a diagnosis of COPD and requiring use of oxygen. Review of Resident #15 ' s Quarterly MDS assessment dated [DATE] documented a BIMS score of 13; indicating resident was cognitively intact. MDS documented Resident #15 had a diagnosis of COPD and was receiving oxygen therapy. Review of Resident #15 ' s comprehensive care plan dated 08/16/2023 documented Resident #15 used oxygen therapy related to COPD. Goal was for Resident #15 to have no signs and symptoms of poor oxygen absorption through interventions of providing assurance to relieve anxiety, monitoring for signs of distress (increased heart rate, confusion, cough) and reporting those signs to the health care provider. Review of physician orders dated 03/30/2020 documented O2 (oxygen) at 2LPM via NC continuous every shift related to COPD. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 14 of 23 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 675025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White Acres Wellness & Rehabilitation 7304 Good Samaritan Court El Paso, TX 79912 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 0695 Level of Harm - Minimal harm or potential for actual harm Observation on 08/21/23 at 09:53 AM revealed Resident #15 was receiving oxygen through a nasal cannula. The nasal cannula tubing was not labeled with the date and time it was last changed. In an interview on 08/21/23 at 10:00 AM with Resident # 15, he said a staff member had changed the nasal cannula tubing, but he could not remember who it was or when it had been. Residents Affected - Some Interview on 08/23/23 at 9:40 AM LPN A revealed that oxygen tubing needed to be labeled. LPN A stated the purpose of labeling the oxygen tubing was so that nursing staff knew when to change it. LPN A stated the risk of not changing it was mold growing in the oxygen tubing, so residents don't share oxygen tubing, and know when to change it. LPN A stated the nurses are responsible for ensuring the oxygen tubing is labeled. LPN A stated it was pretty much standard that nurses knew when to change the tubing. Interview on 08/23/23 at 10:07 AM with the DON. The DON stated oxygen tubing needed to be dated, labeled, and have initials. The DON stated the purpose of labeling was to ensure that nursing knew when to change out the oxygen tubing. The DON stated not changing out the oxygen tubing could a bacteria grow. The DON stated the risk of the not having the changing of oxygen tubing in the order could be infection control. Record review of facility policy titled Oxygen Administration, Safety, Mask Types, LTC, Therapy and Rehab dated 06/30/2023 read in part .All oxygen therapy equipment will be clean, safe and functional at all times .Disposable equipment should be changed weekly or according to manufacturer ' s instruction and marked with date and initials. Document when these items are changed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 15 of 23 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 675025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White Acres Wellness & Rehabilitation 7304 Good Samaritan Court El Paso, TX 79912 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents were free of significant medication errors for 1 of 7 residents (Resident #39) reviewed for significant medication errors. Residents Affected - Few LVN B failed to administer insulin to Resident #39 according to Manufacturer's Specifications. This deficient practice could place residents at risk of hypoglycemia. The findings include: Record Review of Resident #39's face sheet, dated 08/22/23, revealed an [AGE] year-old female with an admission date of 09/16/21. Record Review of Resident #39's History and Physical, dated 05/03/23, revealed a diagnosis of Diabetes type 2. Record Review of Resident #39's physician orders, dated 1/20/22, revealed order for Insulin Lispro Solution inject as per sliding scale, subcutaneously before meals and at bedtime related to type 2 diabetes. Resident #39 was ordered to receive 2 units according to blood glucose of 172 mg/dl. Record Review of Resident #39's quarterly MDS assessment, dated 06/14/2023, revealed Resident #39 had a BIMS score of 7, which indicated she had severe cognitive impairment. In section I of the MDS assessment Resident #39 had an active diagnosis of diabetes, malnutrition (lack of proper nutrition). Record Review Resident #39's comprehensive care plan, dated 09/16/2021, revealed Resident #39 had diabetes and used insulin, will remain free of signs of hyperglycemia (elevated blood sugar) or hypoglycemia (low blood sugar). Diabetes medication as ordered by the doctor, monitor and document side effects and effectiveness. Observation on 08/21/23 at 11:40AM revealed LVN B obtained Resident #39 blood glucose result was 172 mg/dl. LVN B administered Lispro 2 units as per sliding scale to the right upper quadrant at 11:40 AM using aseptic technique (a method used to prevent infection/contamination with microorganisms). Observation of Resident #39 on 08/21/23 at 12:15 PM in the dining area revealed the resident obtained a lunch meal, 35 minutes after the indicated manufacturer's specification for meal intake 15 minutes after insulin administration. An interview with LVN B on 08/24/23 at 02:09 PM revealed Resident #39 was sitting in the dining area and received a lunch tray 35 minutes after insulin administration not following manufacturer specifications. LVN B, stated medication order is scheduled for 11:00 am and residents usually receive lunch at 11:45 am. LVN B, stated she can give the medication 1 hour before or 1 hour after the scheduled time as trained. LVN B stated she was not aware a meal or snack had to be provided within 15 minutes after insulin administration as per the manufacturer's indication. LVN B, stated fast-acting insulins could cause a resident's blood glucose level to drop making them hypoglycemic. Interview with the DON on 08/24/23 at 4:25 PM, revealed fast-acting insulin had an onset of 10-15 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 16 of 23 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 675025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White Acres Wellness & Rehabilitation 7304 Good Samaritan Court El Paso, TX 79912 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few minutes, and would require a meal or snack to be provided within 15 minutes, stated scheduled mealtime is 11:45 am was unsure why there was a delay. The DON stated, if food was not provided within 15 minutes the residents' glucose could decrease putting them at risk for hypoglycemia. The DON stated nurses received yearly training on insulin and as needed during the year. Record review of the Manufacturer's specifications, obtained on 8/21/2023 at https://www.humalog.com/u100#, documented to administer Lispro Injection within fifteen minutes before or right after you eat a meal. Record review of the facility policy Insulin Preparation and Administration revised date 06/19/2023 did not mention the half life of fast acting insulin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 17 of 23 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 675025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White Acres Wellness & Rehabilitation 7304 Good Samaritan Court El Paso, TX 79912 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for professional standards for food service safety. The following were observed: -1 unlabeled package of sliced wheat bread observed on shelf under steam table. -1 unlabeled package of 4 hamburger buns observed on shelf in dry storage room. -1 bottle of vanilla icing dated 03/2023. These failures could place residents at risk of food-borne illness. Findings included: Observation on 08/21/23 at 8:57 AM of kitchen revealed a package of sliced wheat bread on a shelf under steam table. The package was unlabeled and missing the date of when it was opened and expiration date. Observation on 08/21/23 at 9:07 AM of kitchen revealed a package of hamburger bread on a shelf in the dry storage closet. The package was unlabeled and missing the date of when it was opened and expiration date. Observation on 08/21/23 at 9:12 AM of refrigerator revealed a bottle of vanilla icing used for decoration dated 03/2023. An interview on 08/21/23 at 9:13 AM with Dietary Manager revealed whoever opened the packages such as the bread, was responsible for labeling it with the date it had been opened. He stated he was responsible for monitoring the food in the fridge and freezer to make sure it was not expired. He stated it was important to ensure foods were labeled correctly to not exceed the expiration date. He stated if that was not done, the residents could get sick from expired or spoiled foods. An interview on 08/23/23 at 2:15 PM with Dietary Supervisor B, revealed dietary aides were in charge of monitoring the food and ensuring it was labeled with date it was opened and when it expired. She stated every food item was used, was checked for its expiration date. She stated every food item was also labeled and stated the importance of doing so was because it could create bacteria. She stated if labels were not checked for their expiration date, the residents could get sick. Review of facility in-service titled Labeling/Storage/Trash dated 08/21/23 read in part All items are to be labeled as opened and used by .Be sure to check all food dates already labeled and if shown to expire sooner than the dates mentioned above you put the labeled . Review of facility policy titled Date Marking-Food and Nutrition dated 04/12/2023 read in part .date-marked when received, when manufacturer package is opened .dates are monitored to ensure food safety and quality for all foods . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 18 of 23 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 675025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White Acres Wellness & Rehabilitation 7304 Good Samaritan Court El Paso, TX 79912 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews the facility failed to dispose of garbage and refuse properly for 1 of 1 trash bins located in the dining room and 2 of 3 dumpsters (Dumpster #2 and #3) located outside of the facility. Residents Affected - Some -2 dumpsters located outside the facility were found without covers when not in use. -1 trash bin located in the dining room had trash coming out of the container. These failures could place residents at risk of decreased quality of life due to an exterior environment which could attract pests, rodents, and other animals. Findings included: Observation on 08/21/23 at 12:00 PM in dining room revealed trash bin next to handwashing sink located inside the dining room was overflowing with trash. Observation on 08/22/23 at 2:26 PM, 3 dumpsters were observed outside the facility on the back of the property. Dumpster #2 was covered with one lid with no trash exceeding its limit. Dumpster #3 was uncovered and had trash exceeding its limit. An interview on 08/21/23 at 12:32 PM with the Dietary Manager revealed he was responsible for overseeing the trash bin in the dining room and ensuring it did not overflow with trash. The Dietary Manager stated when the trash bin was full, it had to be thrown away because if the trash fell on the floor, residents could slip and because it did not look good. The Dietary Manager stated he would not have the trash bin overflowing with trash at his house. The Dietary Manager stated the risk to the residents was infection control, pest control, and residents could slip on it. An interview on 08/21/23 at 12:38 PM with Lead Assistant food Service revealed she was not responsible for throwing away the trash. Lead Assistant Food Service stated it was the previous night dietary staff that were responsible for throwing away the trash. She stated once the trash got full or to a certain height, the trash had to be thrown away. Lead Assistant food Service stated with the trash overflowing it could be a risk to the residents causing contamination. An interview on 08/21/23 at 1:20 PM with Dietary Supervisor revealed that housekeeping staff was responsible for throwing out the trash in the dining area. The Dietary Supervisor stated the housekeeping staff would throw out the trash in the morning, but it would get full during the lunch meal. The Dietary Supervisor stated he had seen the trash bin was full but did not think anything of it and should have thrown the trash away. The Dietary Supervisor stated if the staff saw the trash bins full or overflowing, they would have to throw the trash away. The Dietary Supervisor stated that having the trash overflowing did not look good, looked messy, attracted pests, and was infection control issue. An interview on 08/23/23 at 2:09 PM with Dietary Manager, revealed he would throw trash away as well as his staff, and it could occur after every meal. He stated the lids of the dumpster had to be closed in order to prevent pests and animals from having access to it. He also stated it could be an infection control issue. He revealed maintenance staff were responsible for overseeing the dumpsters, but anybody who would use them had a responsibility of ensuring it was used correctly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 19 of 23 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 675025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White Acres Wellness & Rehabilitation 7304 Good Samaritan Court El Paso, TX 79912 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 0814 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete An interview on 08/24/23 at 9:31 AM with Maintenance Worker revealed he did not know if the dumpsters had to be closed. He stated there was no risk because all the trash that was thrown in was in garbage bags. He stated he did not know who was responsible for overseeing the dumpsters. Record review of facility policy titled Trash Collection and Waste Removal dated 03/29/2023 read in part .Waste containers should contain a plastic liner. When ¾ full, tie the liner shut and collect into the housekeeping cart .Keep all exterior waste containers properly shut and secured at all timed for rodent control and to prevent trash from escaping the container . Event ID: Facility ID: 675025 If continuation sheet Page 20 of 23 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 675025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White Acres Wellness & Rehabilitation 7304 Good Samaritan Court El Paso, TX 79912 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 residents (Resident #9 and Resident #142) reviewed for infection control. Residents Affected - Some -CNA D failed to follow infection control practices when providing perineal care for Resident #9. - The facility failed to follow infection control practice when CNA C did not dispose of Resident# 142 soiled linen correctly. These failures could place residents at risk of infections. Findings included: Review of Resident #9 ' s Face Sheet dated 08/24/2023 documented a [AGE] year-old male with an admission date to the facility of 09/02/2020. Review of Resident #9 ' s History and Physical dated 03/17/2023 documented Resident #9 had a diagnosis of Parkinson ' s Disease; a neurological disease that causes stiffness and tremors. He also had a history of hemiplegia (paralysis) and hemiparesis (weakness) to the right side of the body after suffering a stroke with associated contractures. Review of Resident #9 ' s Quarterly MDS assessment dated [DATE] documented a BIMS score could not be complete due to resident not understanding. The assessment documented a diagnosis of Parkinson ' s Disease with contractures and also indicated Resident #9 required one person assistance with toileting activities. Review of Resident #9 ' s comprehensive care plan dated 07/05/2023 documented Resident #9 had ADL self-care performance deficit related to post CVA (stroke) and contractures. Goal was to maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene with intervention of total assistance from staff. Observation on 08/21/23 at 11:38 AM revealed CNA D was performing perineal care on Resident #9. CNA D put on clean gloves and undid brief to expose genitals. She took wipes and cleaned him down the sides of his legs and his genital area. She turned Resident #9 to his right side, took another wipe and cleaned his bottom. With the dirty gloves, she took a clean new brief and placed it under Resident #9. CNA D then removed her dirty gloves and changed them into a clean pair. Resident #9 was turned on his back and the brief was adjusted and straps placed. Resident #9 ' s pants were pulled back on, and pillows were placed for residents ' comfort. An interview on 08/21/23 at 11:41 AM with CNA D revealed when she is changing a resident, she changes gloves when they are dirty and that is how she had been trained. CNA D stated she should have changed gloves before placing new brief but could not give a reason as to why she had not. She stated the risk to the resident could be cross contamination. An interview on 08/23/23 at 5:04 PM with DON revealed perineal care had not been done correctly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 21 of 23 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 675025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White Acres Wellness & Rehabilitation 7304 Good Samaritan Court El Paso, TX 79912 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some because CNA D had not changed gloves when going from soiled to clean. CNAs have been taught to properly perform perineal care. He stated he monitored hand hygiene daily, and staff would complete training online. Risks to residents if perineal care was not done correctly could be infections and even sepsis (infection in the blood stream that causes fever and fast heart rate). An interview on 08/24/23 at 09:16 AM with CNA E revealed the procedure for performing perineal care was to wash hands and place clean gloves on. Then would clean the resident from front to back and remove soiled brief to throw away. Would then change gloves before taking a clean brief and place new brief on resident. She stated gloves had to be changed because the dirty gloves would contaminate the clean brief. She stated the resident could be at risk of contamination and infection. Resident #142 Record review of Resident #142 ' s face sheet dated 08/24/23 reflected an [AGE] year-old female with an admission dated of 08/17/23 to the facility. Record review of Resident #142 ' s History and Physical dated 08/11/23 reflected diagnoses of urinary tract infection, diabetes, and pressure ulcer stage IV being treated with antibiotics due to growth of Enterococcus, streptococcus, and E. Coli (bacterial infections which is difficult to treat and usually acquired in the hospital setting). Record review of Resident #142 ' s admitting MDS assessment dated [DATE] is still pending completion. Observation and interview on 08/23/23 at 11:59 AM in Resident #142 room there were some soiled linens in the corner of her room balled up on top of the resident's dresser. It was the resident's soiled linen from her bed, and the clothing she had on from the night before. The linen was soiled according to CNA C, she stated she had left the linen there earlier this morning unsure of the exact time. CNA C stated she left the soiled linen in the room due to not being able to find housekeeping for the linen containers. CNA C proceeded to get the resident soiled bed sheets and clothing making it into a ball and remove it without bagging the linen removed it from the room quickly. When CNA C returned stated she is trained to bag the soiled linen and dispose of it in the linen bin. CNA C indicated this is done due for hygiene purposes and for appearance since it did not look very sanitary to have soiled linen balled up in the resident's room. Interview on 08/24/23 at 01:50 PM with DON, revealed that CNA C did not follow infection control procedures by leaving the soiled linen in Resident #142 's room on 08/23/23 and utilizing improper technique when disposing of the soiled linen/laundry. The DON stated that all CNA ' s are trained to properly dispose of the soiled linen in the bins. The DON verbalized the CNA ' s need to place the soiled linen inside a bag trying to ensure least contact with themself when placing in the bag, and to ensure that soiled linen bin is sealed properly with lid. Stated the purpose of this is infection control to minimize the exposure of contamination, and if soiled linen is left in a room there is always the possibility another resident picking up the soiled linen with their bare hands causing a more severe infection control issue. Review of facility policy titled Perineal care dated 08/24/2022 read in part .Remove soiled pad Remove soiled gloves. Wash hands or use hand sanitizer before touching objects in the environment. Re-glove to resume perineal care .Put on clean gloves to put on a clean pad . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 22 of 23 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 675025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White Acres Wellness & Rehabilitation 7304 Good Samaritan Court El Paso, TX 79912 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 0880 Level of Harm - Minimal harm or potential for actual harm Review of facility policy titled Infection Prevention and Control Program, All Service Lines-Enterprise dated 10/21/2022 read in part Each Society location will maintain an infection prevention and control program desgned to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 23 of 23