Health inspection·January 8, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm she was fine and was only inconvenienced by the issue. Resident #1 said the issue may have been resolved faster had an immediate grievance been filed. Review of Resident #1's admission packet revealed a blank grievance form. The document of policy Resident Grievance/Complaint Procedures was not part of the packet. Residents Affected - Few During an interview on 01/07/2025 at 11:07 a.m., LVN C said the cable went out around Christmas time. LVN C said activities were provided to the residents who did not have other channels available. LVN C said Resident #1 was the person who complained about the cable not working. LVN C said she did not complete a written grievance form as the Maintenance Director was already aware and working on the issue. LVN C said she thought a grievance had already been filed. LVN C said if a resident had a grievance, the Grievance report forms are always located on a door file at the DON office and available. LVN C said she did not know if a grievance was filed for the issue. LVN C said the issue was not resolved until 01/06/2025. During an interview on 01/07/2025 at 1:15 p.m., the Maintenance Director said on Christmas day, the cable went out throughout the facility. He said due to a transition of new ownership, there was an issue with payment of services for the cable. The Maintenance Director said about 80% of the televisions in the facility were able to receive more channels by connecting to the internet. The Maintenance Director said Resident #1's television was one of the televisions that was not able to receive any other channels. The Maintenance Director said he was aware of the issue and attempted to rig the television to get more channels. The Maintenance Director said he did not file a grievance and only knew of the issue by visiting residents. The Maintenance Director said he did not know when administration learned of the issue. The Maintenance Director said the issue was resolved on 01/06/2025. Record review of the grievances for November 2024 through January 2025 revealed no grievance found for Resident #1's concern regarding the cable issue. During an interview on 01/07/2025 at 2:53 p.m., the Facility Administrator (FA) said she heard about the cable being out during a morning meeting on 12/27/2024. The FA said no formal written grievance was done. The FA said all grievances are forwarded to the Administrator to follow-up and address the issue until resolved. The FA said she was informed that the Maintenance Director would fix the issue. The FA said the activities department offered residents affected by the cable outage activities. The FA said on 12/30/2024, she learned that the issue was not resolved. The FA said Resident #1 was complaining about the issue and she went and spoke with the resident. The FA said she did not know that Resident #1 was only able to see one channel and not getting enough channels. The FA said she was told by Maintenance that it was a quick fix which did not turn out to be true. The FA said she did not complete a grievance for the issue and that a written grievance should have been completed. The FA said the facility grievance process broke down and she would have to take the hit for that one because there was no documented grievance and she believe she was given misinformation regarding the cable issue. The FA said if the process was followed, the issue may have been resolved sooner. The FA said there was no negative outcome to Resident #1, or any other residents affected by the cable outage. Record review of the facility provided Resident Grievance/Complaint Procedures, undated, reflected in part, A resident, representative, family member, visitor or advocate may file a verbal or written grievance or complaint concerning treatment, abuse, neglect, harassment, medical care, behavior of other residents or staff members, theft of property, etc., without fear of threat or reprisal in any form. It is the policy of the facility to assist you in filing a grievance or complaint. Requested (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2025 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 0585 Level of Harm - Minimal harm or potential for actual harm procedure to follow when filing a written grievance or complaint, obtain a Resident Grievance/Complaint Form from the nurse's station or from the Business Office; give the completed form to the Administrator or designee; after you have filed the grievance, you will receive a written summary of the results of the investigation within a reasonable time frame. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 3 of 3