Health inspection·March 13, 2025

F 0641 history of falling. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #8's quarterly MDS dated [DATE], revealed a BIMS of 04 indicating that the resident had severe cognitive impairment. Section I - Active Diagnoses revealed resident diagnosed with unsteadiness on feet. Section J - Health Conditions under fall history revealed that resident had not had any falls since admission or re-entry to the facility. Residents Affected - Some Review of Resident #8's fall history revealed that Resident #7 had a fall on 01/12/2025. Record review of Resident #8's Care Plan dated 02/27/2025, reads in part resident was found on the floor mat with no injury related to confusion and stated she was looking for her children. Another care area reads resident was at risk for falls related to weakness, anxiety, poor safety awareness, prefers to lie at the edge of the bed, confusion, nightmares, and history of recurring falls. Resident #9: Record review of Resident #9's admission Record dated 03/19/2025, revealed an [AGE] year-old male with admission date of 11/30/2018. Diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and unsteadiness on feet. Record review of Resident #9's quarterly MDS dated [DATE], revealed a BIMS of 12 indicating that the resident had moderate cognitive impairment. Section I - Active Diagnoses revealed resident diagnosed with unsteadiness on feet. Section J - Health Conditions under fall history revealed that resident had not had any falls since admission or re-entry to the facility. Review of Resident #9's fall history revealed that Resident #7 had a fall on 01/1/2025. Record review of Resident #9's Care Plan dated 02/27/2025, reads in part resident was at risk for falls related to CVA (cerebrovascular accident) weakness, left hemiparesis, history of falls, attempts to get out of bed. Another care area reads on 1/1/25 resident had an actual fall with minor injury of discoloration/abrasion/bruise to back of right hand. During an interview on 02/28/2025 at 1:04 p.m., the MDS Coordinator said an MDS covers everything about a resident's health conditions. The MDS Coordinator said it was very important for the MDS to be accurate as it was used to care plan. The MDS Coordinator said she was responsible to ensure that MDS was accurate and up to date. The MDS Coordinator reviewed Resident #7's, #8's, and #9's MDS's and said that the falls should have been captured on the assessments. The MDS Coordinator said the facility had undergone a change in ownership back in November 2024 and believes that she may not have had all the correct information when completing the MDS's for the residents. The MDS Coordinator said she should have followed up to ensure she had all the information she needed to complete the MDS . During an interview on 02/28/2025 at 3:15 p.m., the DON said the purpose of the MDS was assess resident in all care areas. The DON said it was very important for the MDS to be accurate as it may impact care planning for a resident. The DON said the MDS Coordinator was responsible for the MDS completion and accuracy. The DON said the MDS was done annually, quarterly, and when there was any change in condition including falls. The DON said the risk of falls not being captured accurately on the MDS may impact the interventions that were in place for the residents . Review of facility provided Fall Evaluation and Prevention policy dated 08/2020, reads in part The (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 03/13/2025 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 0641 facility will evaluate residents for their fall risk and develop interventions for prevention. Level of Harm - Minimal harm or potential for actual harm Review of RAI Version 3.0 manual dated October of 2019, reads in part regarding Section J fall assessment, the review period is from the day after the ARD of the last MDS assessment to the ARD of the current assessment; Review all available sources for any fall since the last assessment, no matter whether it occurred while out in the community, in an acute hospital, or in the nursing home. Include medical records generated in any health care setting since last assessment. All relevant records received from acute and post-acute facilities where the resident was admitted during the look-back period should be reviewed for evidence of one or more falls; Review nursing home incident reports and medical record (physician, nursing, therapy, and nursing assistant notes) for falls and level of injury; Ask the resident, staff, and family about falls during the look-back period. Resident and family reports of falls should be captured here, whether or not these incidents are documented in the medical record; Review any follow-up medical information received pertaining to the fall, even if this information is received after the ARD (e.g., emergency room x-ray, MRI, CT scan results), and ensure that this information is used to code the assessment . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 3 of 3