Health inspection·October 16, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #22's Physician's Order Summary, dated 10/16/24, reflected Lactobacillus Oral Capsule give 1 capsule by mouth four times a day for Osteomyelitis (a serious bone infection that causes inflammation and swelling in the bone). Start Date: 12/08/2023. Record review of Resident #22's Physician's Telephone Orders, dated 10/14/24 written by LVN A, reflected discontinue Lactobacillus Oral Capsule four times a day. Lactobacillus Oral tablet give 4 tablets to equal 0.8 mg by mouth four times a day for supplement. Start Date: 10/15/24. Record review of the Medication Administration Record, dated October 2024, for Resident #22 reflected, Lactobacillus Oral Capsule give 1 capsule by mouth four times a day at 4:00 PM. LVN A documented on 10/14/24 at 4:00 PM, Code 8 (means to see Nurses Notes). Lactobacillus is used to treat chronic constipation. Treating symptoms of irritable bowel syndrome. Interview on 10/14/24 at 3:55 PM, during medication pass observation with Med Aide B said, Resident #22 had an order to administer Lactobacillus Oral Capsule at 4:00 PM, and she only had Lactobacillus tablets in the medication cart. She went to ask LVN A if they had Lactobacillus capsules in the medication prep room. She said they did not have Lactobacillus capsules on hand and was instructed by LVN A to hold the 4:00 PM dose, because he was going to call the doctor to change the Lactobacillus order to tablets. In an interview and record review on 10/15/24 at 4:00 PM, LVN A stated they did not have the Lactobacillus capsules on hand on 10/14/24 to administer at 4:00 PM, to Resident #22 according to physician's orders. He said he called the Nurse Practitioner on that day to change the Lactobacillus order to tablets. He said he documented a Code 8 (means to see Nurses Notes) on the Medication Administration Record on that day and had not documented in the Nurse's Notes he had called the Nurse Practitioner. He said licensed staff were trained to document in the resident's electronic record when the physician and/or Nurse Practitioner were called to request a change in physician's orders. LVN A stated, Lactobacillus tablets had not been administered on 10/14/24. In an interview on 10/15/24 at 3:00 PM, the DON revealed licensed staff were trained to administer medications correctly and in a timely manner and document in the resident's electronic record when the Physician and/or Nurse Practitioner were called to change physician's orders. Record review of the facility's policy & procedure, revised on 05/21/2024, on Medication Administration reflected Purpose: To administer medications correctly and in a timely manner. To provide direction regarding medication aide. 2. Record review of Resident #35's admission Record, dated 10/16/24, reflected [AGE] years old female who was admitted to the facility on [DATE]. Record review of Resident #35's Hospital History & Physical, dated 10/04/23, reflected she had diagnoses which included (COPD) (a common lung disease that causes breathing problems and restricted airflow) and Alzheimer's Dementia (a brain disorder that causes a gradual decline in memory, thinking, behavior, and social skills). Record review of Resident #35's Quarterly MDS, dated [DATE], reflected Active Diagnoses: Chronic obstructive pulmonary disease (COPD). Record review of Resident #35's Care Plan, revised 09/13/24, reflected, resident had oxygen therapy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 2 of 13 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 10/16/2024 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 0755 R/T COPD. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #35's Physician's Order, dated 10/16/24, reflected Trelegy Ellipta Inhalation Aerosol Powder 100 mcg/62.5 mcg/25 mcg give 1 puff inhaled orally in the morning for COPD. Residents Affected - Some Record review of the Medication Administration Record dated October 2024, for Resident #35 Trelegy Ellipta Inhalation Aerosol Powder 100 mcg/62.5 mcg/25 mcg give 1 puff inhaled orally in the morning for COPD. Rinse mouth with water and spit after use. Observation on 10/14/24 at 3:55 PM, during medication pass revealed LVN E, administered 1 puff of the Trelegy Ellipta Inhalation Aerosol Powder 100 mcg/62.5 mcg/25 mcg by mouth to Resident #35. The pharmacy label documented rinse mouth with water and spit after taking inhaler. LVN E handed the resident a cup of water with a straw and did not instruct the resident to rinse her mouth and spit the water into the cup. The Resident only took a sip of the water and swallowed the water and handed the nurse the cup of water. When the State Surveyor asked the nurse if there were any special instructions on the pharmacy label, she said yes that was why she gave the resident a cup of water so she could rinse her mouth and spit the water into the cup. LVN E said, she saw the resident spit the water into the cup and made no other comment. Record review of the manufacturer's User Guide for Trelegy Ellipta Inhalation Aerosol Powder revised 6/2023 reflected rinse your mouth with water without swallowing after using TRELEGY to help reduce your chance of getting thrush. Observation and record review on 10/14/24 at 3:26 PM, LVN E revealed she had counted controlled substances at the change of shift and had forgot to sign the Controlled Drugs - Audit Record after the count was completed. LVN E said licensed staff were trained to count controlled substances at the change of shift with the on-coming nurse to verify counts were accurate and immediately sign the Controlled Drugs - Audit Record after the count was completed. LVN E signed off on the Controlled Drugs - Audit Record that she had counted the controlled substances at the change of shift after the surveyor had made a copy of the document. Interview and record review on 10/14/24 at 2:40 PM, LVN C revealed she counted controlled substances at the change of shift and forgot to sign the Controlled Drugs - Audit Record after the count was completed. LVN C said licensed staff were trained to count controlled substances at change of shift with the on-coming nurse to ensure counts were accurate and to immediately sign the Controlled Drugs - Audit Record after the count was completed. LVN C signed off on the Controlled Drugs - Audit Record that she had counted the controlled substances at the change of shift after the surveyor had made a copy of the document. Observation and record review on 10/14/24 at 3:57 PM, Med Aide B revealed she counted controlled substances at the change of shift and forgot to sign the Controlled Drugs - Audit Record after the count was completed. Med Aide said she was trained to count controlled substances at change of shift with the on-coming nurse to verify counts were accurate and to immediately sign the Controlled Drugs - Audit Record after the count had been completed. Med Aide B signed off on the Controlled Drugs - Audit Record that she had counted the controlled substances at the change of shift after the surveyor had made a copy of the document. Observation and record review on 10/16/24 at 7:25 AM, LVN D revealed she had counted controlled substances at the change of shift and had forgot to sign the Controlled Drugs - Audit Record after the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 3 of 13 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 10/16/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm count was completed. LVN D said licensed staff were trained to count controlled substances at change of shift with the on-coming nurse to verify counts were accurate and to immediately sign the Controlled Drugs - Audit Record after the count had been completed. LVN D signed off on the Controlled Drugs - Audit Record that she had counted the controlled substances at the change of shift after the surveyor had made a copy of the document. Residents Affected - Some Interview and record review on 10/15/24 at 4:00 PM, with the DON revealed licensed staff were trained to count controlled substances at the change of shift with the on-coming nurse to verify counts were accurate, and to immediately sign the Controlled Drugs - Audit Record after the count had been completed. Record review of the facility's policy & procedure, revised on 05/06/2024, on Nursing Documentation reflected, Purpose: To ensure appropriate documentation is completed in a timely manner. Record review of the facility's policy & procedure, dated 07/2022, on Controlled Substance Administration & Accountability reflected, Purpose: To provide verification and reconciliation of all controlled medications. Procedure: Each time the keys that secure control medications change from one nurse/medication aide to another, the incoming and outgoing nurse/medication aide will work together to reconcile all controlled substances. For all schedule II-Controlled medications - The on-coming nurse will verify that the physical medication count matches the remaining amount listed on the Controlled Substance Bound Book for each medication. If the physical controlled medication count is in agreement, both nurses will sign the Controlled Drugs - Count Record for the appropriate date and shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 4 of 13 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 (X3) DATE SURVEY COMPLETED A. Building 10/16/2024 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 (#1) kitchen reviewed for kitchen sanitation and food storage. 1. -The facility failed to keep the tile floors free of black grease build-up in the dry storage room. 2. -The facility failed to store foods in the dry storage room in sealed containers. 3. -The facility failed to keep food containers free of grease build up, and food particles in the dry storage room. 4. -The facility failed to keep the Sheet Pan Rack in the dry storage room free of stains, dust accumulation directly above the casters. 5. -The facility failed to store food cans separately from chemicals. 6. -The facility failed to keep one 5-gallon plastic water bottle off the floor. 7. -The facility failed to keep stainless steel sheet pans free food particles, black grease build-up and dried white stains. 8. -The facility failed to store food stored in the walk-in refrigerator in sealed containers. 9. -The facility failed to discard perishable foods stored in the walk-in refrigerator. Cucumbers were soft to touch, mushy, and had fuzzy white surfaces. 10. -The facility failed to keep food preparation tables and equipment free of rust, white stains, and food particles. 11. -The facility failed to keep foods stored in the refrigerator free of dried drippings. 12. -The facility failed to label and date foods stored in refrigerator. 13. -The facility failed to keep the metal shelving in the food preparation area free of dust. 14. -The facility failed to keep food containers and spice bottles completely sealed, free of dried drippings, residual on the sides of bottles, and grease build-up; and failed to ensure a scoop was not stored in a food container. 15. -The facility failed to keep the deep fryer free of rust and grease build-up. 16. -The facility failed to keep the food warmer free of dried white spots and control knobs free of dust, and grease build-up. 17. -The facility failed to keep the juice machine free of black substances. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 5 of 13 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 10/16/2024 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 18. -The facility failed to serve food at the appropriate temperatures. Level of Harm - Minimal harm or potential for actual harm 19. -The facility failed to clean the food thermometer between foods when checking food temperatures. Residents Affected - Many 20. -The facility failed to keep the kitchen walls free of dried water stains, black substances directly above the Food Warmer and, ceiling directly above by food preparation area. These failures could place residents at risk of food borne illnesses. Findings include: Observation and interview on 10/14/24 at 7:45 AM, with Dietary Manager during the initial tour in the kitchen, revealed the following: The Dry Storage Area revealed: An opened bag of Spaghetti wrapped in Saran wrap was not completely sealed; there were large ingredient storage bins that contained flour, rice, and thicker which had food particles and grease build up on the cover. The rice container had dried green vegetable leaves stuck on the left side of the cover. The Dietary Manager said staff were trained to place opened food packages in sealed Ziploc bags and to clean large ingredient storage bins daily. The Chemical Room revealed: dented food cans were stored on metal shelving in the chemical room next to a box of Bath Tissue Rolls and chemical bottles were stored on metal shelving. The Storage Area next to Serving line revealed: a 5-Gallon plastic water bottle was on the floor in front of the metal shelving where 5-Gallon plastic water bottles were stored. The Walk in Refrigerator revealed the following: -Stainless steel sheet pans where bags of food were stored had food particles, black grease build-up and dried white stains. -The sides of the stainless-steel mobile sheet pan rack had accumulation of food particles and dried white stains on the sides of the rack shelves that held the sheet pans. -Multiple metal storage pans stored in the refrigerator were covered with Saran wrap and were not fully sealed. -There was a large plastic container with cucumbers. Some to the cucumbers were soft, mushy and had fuzzy white surfaces. The plastic containers with red apples had dried white spots, food particles and vegetable leaves were on the cover. The Refrigerator revealed the following: -3-gallon container of classic sherbet stored on the bottom shelf was opened and was not date. The container had dried drippings on the side of the container and was placed on top of pieces of foil paper. The Dietary Manager demonstrated the container was leaking from the bottom and did not know why the container was not discarded. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 6 of 13 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 10/16/2024 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 - A plastic container of sour cream had dried white stains on the cover. Level of Harm - Minimal harm or potential for actual harm The Food Preparation Area by Stove revealed the following: -The Metal shelving was dusty. Residents Affected - Many -There was one gallon of Worcestershire Sauce, 1 gallon of Vegetable/Olive oil, 1 gallon of Soy Sauce, 1 gallon of Less Sodium Soy Sauce, 1.32 gallon of Balsamic Vinegar, one 5 LB. plastic bottle of Honey, the bottles had dried stains and food residual on the covers and on the sides of the bottles. There was one 5 LB. plastic bottle of Ground Cinnamon, which had residual on the cover and sides of the bottle. -The Stainless steel table, where plastic food containers were stored, was rusted and had dried white stains. -The right side of the deep fryer was rusted and had grease build-up. -There was one 27 LB. plastic container that had powder residual and grease on the top and build-up on the sides of the container; one 20 LB. plastic container of Beef Base, cover was broken around the sides and had food particles and grease build-up; one 8 LB. plastic container of Chicken Flavored Base was opened and not covered. -The Food Warmer had grease build-up on the sides, food particles, the control knob was full of light gray lint, dust, and grease build-up. - The Large white countertop mixer had a dried white crusty white substance, dust, and grease build-up; and the countertop was full of dust and food particles. -A plastic container which contained kitchen tools had a cover full of dust and lint. -A one gallon plastic bottle of white pepper had grease build-up on the cover and residual on sides of the bottle; 3 gallon plastic bottles of Bay Leaves had grease build-up on the cover and residual on sides of the bottle; 1 gallon plastic bottle of Parley Flakes had grease build-up on the cover and residual on the sides of bottle; 1 gallon plastic bottle of Taco Mix had grease build-up on the cover and residual on the sides of the bottle; 1 gallon plastic bottle of onion powder, Thyme, Oregano, Chili Powder, Freeze Dried chopped chives, had grease build-up on the cover and residual on sides of the bottle; square plastic container with a green cover which contained Cilantro flakes, had food residual and grease build-up; a square plastic container with a green cover which contained thickener powder had a scoop in the container. Dietary Manager said staff should not store the scoop in the container. Two cans of cooking spray had grease build-up on the sides of the bottle. One 16-ounce box of Corn Starch was opened and was not sealed. The Dietary Manager said opened food containers should be stored in a sealed zip-lock bag and food containers should be cleaned by designated dietary staff once a month or as needed after each use. The Food Preparation Area by Food Warmer revealed: -44 plastic bottles of spices stored on metal shelves directly above the food preparation area had opened tops which were not sealed, there was residual on the tops and sides of bottles. The spice bottles were full of grease build-up. The wall directly above the Food Warmer, had multiple dark black (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 7 of 13 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 10/16/2024 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 substance. Level of Harm - Minimal harm or potential for actual harm Observation and interview on 10/14/24 at 8:42 AM, of the serving line, with Dietary Manager revealed the Juice Machine had a black substance directly below the juice dispensers. Dietary Manager said the machine was cleaned weekly by designated dietary staff. Residents Affected - Many Observation and interview on 10/14/24 at 8:43 AM, with Dietary Manager revealed a large, opened box of frozen biscuits was not sealed , in the walk-in freezer. Dietary Manager said dietary staff had been trained to store opened food containers in sealed containers or sealed plastic bags. In an interview on 10/14/24 at 1:00 PM, with Dietary Consultant revealed dietary staff had been trained to store foods in sealed and labeled containers; spice bottles should be kept sealed and cleaned after each use, dietary staff were all responsible for cleaning their designated areas daily and as needed. Environmental Check in Kitchen revealed: -there was extensive water damage to the ceiling, directly above the food preparation area by the stove and the ceiling in the Chemical room. The Dietary Manager said the ceiling in the kitchen and chemical room had been like that for several months, and they were trying to make the necessary repairs as soon as possible. There were dried light brown water stains on the wall and black substances on the walls directly above the Food Warmer. An Industrial Air Blower was directly above the exit door frame, had a screen cover full of dust and black grease build-up. The Dietary Manager said the maintenance staff were responsible for cleaning the Industrial Air Blower. Observation on 10/14/24 at 11:49 AM, the food temperature checks, with the Dietary Manager and [NAME] F revealed Spring rolls were 126 degrees Fahrenheit and were not re-heated prior to serving the lunch meal. The [NAME] did not clean the thermometer between foods when checking food temperatures . The Dietary Manager said the Cooks were trained to clean food thermometer with alcohol swab between foods to prevent food contamination. The [NAME] said she forgot to clean the thermometer between foods. Record review of the Food Code 2022 reflected the following: (C) Packaged Food shall be labeled as specified in law, including 21 CFR 101 Food Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under § 3-202.18. 3-202.15 Package Integrity. Food packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants. Record Review of the facility's policy & procedure on General Sanitation - Food and Nutrition, revised 06/25/2024, reflected Purpose: To provide guidelines that limit the chance of foodborne illnesses at locations that prepare and/or serve food. Policy: The location stores, prepares, distributes, and serves food under sanitary conditions at all times. The location's food preparation, kitchen, serving areas and dry storage are cleaned and sanitized on a regular basis to limit contamination and prevent foodborne illnesses. Record review of the facility's policy & procedure on Food Supply Storage, revised 05/02/2024, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 8 of 13 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 10/16/2024 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 reflected, Purpose: To ensure that food is stored properly. Policy: Food from approved food sources is stored in sanitary conditions and is not exposed to prolonged periods of excessive heat. Procedure: In the preparation and serving kitchen is obtained from approved food sources. Plastic bins may be used if preferred but must be in good repair and washed routinely. Stock items are individually dated with delivery date if removed from the original container. All food/supply items are stored 6 inches off the floor. Foods that have been opened or prepared are placed in an enclosed container, dated, labeled and stored properly. Chemicals are not stored near food items. Record review of the facility's policy & procedure on Food Temperature Monitoring, dated 12/21/2023, reflected, Purpose: To reinforce Hazard Analysis Critical Control Point (HACCP) guidelines and state and federal regulations regarding food temperature. Proper holding temperature - Temperature required for food safety (cold food <41 degrees Fahrenheit, hot food > 135 degrees Fahrenheit). Policy: Food is cooked, reheated or cooled to ensure proper holding temperature before each meal service. Food temperatures are taken and recorded before each meal service. Periodically, temperatures, are taken at other times during or at the end of meal service to ensure temperature are taken at other times during or at the end of meal service to ensure temperatures are held within acceptable ranges. Food is served at proper serving temperatures. Retake temperatures periodically throughout meal service to ensure TCS foods are held below 41 degrees Fahrenheit for cold foods or above 135 degrees Fahrenheit for hot foods. TCS hot foods should be served at 135 degrees Fahrenheit or higher. Hot foods are not heated in the steam table or temperature holding equipment. All foods are at appropriate temperatures prior to placing in serving equipment for hot holding. TCS cold foods will be held at or lower than 41 degrees Fahrenheit and served promptly after being removed from the refrigerator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 9 of 13 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 10/16/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were accurately documented for 1 of 8 residents (Resident #22) reviewed for medical records. -The facility failed to ensure LVN A documented in the Nurse's Notes when he called the Nurse Practitioner changed the order for Lactobacillus for Resident #22. This failure could place residents at risk of medication errors. Findings include: Record review of Resident #22's admission Record, dated 10/16/24, reflected 62-year-male who was admitted to the facility on [DATE]. Record review of Resident #22's Hospital History & Physical, dated 06/10/24, reflected he had diagnoses which included constipation and irritable bowel syndrome with diarrhea (is a common digestive disorder that affects the large intestine and causes chronic abdominal pain, bloating and changes in bowel habits. Symptoms can include diarrhea, Constipation, or both can come and go over time.) Record review of Resident #22's Quarterly MDS, dated [DATE], did not document he had any Gastrointestinal diagnoses. Record review of Resident #22's Care Plan revised 10/19/21, reflected resident had constipation related to decreased mobility. Interventions: Observe/monitor for signs and symptoms of complications related to constipation. Record review of Resident #22's Physician's Order Summary, dated 10/16/24, reflected Lactobacillus Oral Capsule give 1 capsule by mouth four times a day for Osteomyelitis (a serious bone infection that causes inflammation and swelling in the bone). Start Date: 12/08/2023. Record review of Resident #22's Physician's Telephone Orders, dated 10/14/24 written by LVN A, reflected discontinue Lactobacillus Oral Capsule four times a day. Lactobacillus Oral tablet give 4 tablets to equal 0.8 mg by mouth four times a day for supplement. Start Date: 10/15/24. Record review of the Medication Administration Record, dated October 2024, for Resident #22 reflected, Lactobacillus Oral Capsule give 1 capsule by mouth four times a day at 4:00 PM. LVN A documented on 10/14/24 at 4:00 PM, Code 8 (means to see Nurses Notes). Lactobacillus is used to treat chronic constipation. Treating symptoms of irritable bowel syndrome. In an interview and record review on 10/15/24 at 4:00 PM, LVN A stated they did not have the Lactobacillus capsules on hand on 10/14/24 to administer at 4:00 PM, to Resident #22 according to physician's orders. He said he called the Nurse Practitioner on that day to change the Lactobacillus order to tablets. He said he documented a Code 8 (means to see Nurses Notes) on the Medication Administration Record on that day and had not documented in the Nurse's Notes he had called the Nurse Practitioner. He said licensed staff were trained to document in the resident's electronic record when the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 10 of 13 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 10/16/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few physician and/or Nurse Practitioner were called to request a change in physician's orders. LVN A stated, Lactobacillus tablets had not been administered on 10/14/24. In an interview on 10/15/24 at 3:00 PM, the DON revealed licensed staff were trained to administer medications correctly and in a timely manner and document in the resident's electronic record when the Physician and/or Nurse Practitioner were called to change physician's orders. Record review of the facility's policy & procedures on Nursing Documentation Guidelines, Timelines, revised 05/06/24, reflected, Purpose: To ensure appropriate documentation is completed in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 11 of 13 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 10/16/2024 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 0941 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Based on interview and record review the facility failed to include effective communications as mandatory training for direct care staff for 4 of 9 staff (Administrator, Receptionist, LVN C, Dietary Manager) reviewed for trainings. The facility failed to ensure staff received training on effective communication for the Administrator, Receptionist, LVN C, and Dietary Manager. This failure could place residents at risk of not having a way to effectively communicate their wants or needs. Findings include: In an interview and record review of the facility employee listing, on 10/16/2024 , the Business Office Manager revealed the following employees had not completed training on effective communication: Administrator hire date 5/7/23, Dietary Manager 5/16/22, Receptionist hire date 12/2/13, LVN C hire date 9/29/23. She said it was important employees were trained to ensure the safety of the residents. She said the risk to residents was that they would be getting treatment from untrained personnel. In an interview on 10/16/24 4:34 PM, the Administrator said it was not acceptable for the facility not to have copies of the training records and employe files at the facility. The Administrator said the company kept all personal files and training records at corporate office . Record review of the facility's policy Competency and Mandatory Education Requirements, dated 09/17/2024, documented in part: Competency Achievements and mandatory education requirements are required to be documented and are reviewed as a part of the performance appraisal process. Every department/clinic is expected to ensure ongoing competencies and mandatory education requirements that apply to their employees are completed within the designated timeframe and documented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 12 of 13 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 10/16/2024 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 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on interview and record review the facility failed to ensure training was provided regarding dementia management and resident abuse prevention for 4 of 9 employees (Administrator, Receptionist, LVN C and dietary manager) reviewed for training. The facility failed to ensure the Administrator, Receptionist, LVN C and Dietary Manager received training on dementia management. This failure could place residents at risk of improper management of dementia-related issues. Findings include: In an interview and record review of the facility employee listing on 10/16/2024, the Business Office Manager, revealed the following employees had not completed training on dementia: Administrator hire date 5/7/23, dietary manager 5/16/22, Receptionist hire date 12/2/13, LVN C hire date 9/29/23. The Business Office Manager said it was important employees were trained to ensure the safety of the residents. She said the risk to residents was they would be getting treatment from untrained personnel. In an interview on 10/16/24 at 4:34 PM, the Administrator said that it was not acceptable for the facility not to have copies of the training records and employe files at the facility. The Administrator said the company kept all personal files and training records at corporate office . In an interview on 10/16/24 at 5:15 PM, the Administrator indicated the facility did not have any other documents they wished to provide to complete the review of personnel files. Record review of the facility's policy Competency and Mandatory Education Requirements, dated 09/17/2024, documented in part: Competency Achievements and mandatory education requirements are required to be documented and are reviewed as a part of the performance appraisal process. Every department/clinic is expected to ensure ongoing competencies and mandatory education requirements that apply to their employees are completed within the designated timeframe and documented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 13 of 13