Health inspection·November 14, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the former Social Worker K revealed:08/08/25 Discharge Planning/Discharge. Resident will DC home with meds today. Discharging due to NOMNC from therapy department. Home Health for PT/OT, Nursing evaluation and home health aide. Resident's family member to provide transportation at 10 AM. Resident confirmed she does have a wheelchair and walker at home. Wound Care Services provider will continue to provide wound care upon discharge. Resident will follow up with PCP. No concerns at this time.Review of the undated Notice of Medicare Non-Coverage (NOMNC) revealed Medicare Coverage of Current Skilled Nursing Facility Services would end on 08/07/25. The NOMNC was signed by Resident #1 on 08/01/25 and stated, I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO.Review of the Discharge summary dated [DATE] for Resident #1 revealed, the form did not document if Influenza/Pneumovax were administered or declined. Under Discharge Summary, it stated patient completed all required exercises for skilled therapy. Disposition of Medications: documented See MARS. Prognosis was blank. Special Treatments/Procedures were blank. Summary of Course in Facility: patient completed all required exercises for skilled therapy. Medical (vital signs, labs, diagnostic, etc. were left blank. Follow-up and Discharge Medication (instructions to resident) were left blank. Cognitive Function: was left blank. Psychosocial: was left blank. Sensory & Physical Impairments: were left blank. Skin Condition at discharge: Intact. Dental Condition: was blank. Physician's Order for Immediate Care: See primary physician as soon as possible for continue medication regime. Status Upon Discharge comment was blank. The Discharge Summary was not signed by the physician. 2. Review of the admission Record dated 11/14/25 for Resident #2 revealed, admission date 07/28/25. discharge date [DATE]. Review of the History & Physical dated 07/30/25 for Resident #2 revealed, [AGE] year-old female with history of chronic urinary tract infection, hydronephrosis with ureteral calculus (one of the kidneys is swelling because a kidney stone got stuck in the tube (ureter) connecting it to the bladder, blocking urine flow) and weakness. The resident has mild cognitive impairment. Review of the PPS Scheduled Assessment for a Medicare Part A Stay 5-day dated 07/31/25 for Resident #2 revealed, Entry Date: 07/28/25. Entered from short-term general hospital. BIMS Summary Score - 13 (cognitively intact). Active Diagnoses: Obstructive Uropathy (medical condition where a blockage in the urinary tract prevents urine from flowing out of the body, causing it to back up and potentially injure the kidneys), Urinary Tract Infection (last 30 days), muscle wasting, muscle weakness, difficulty walking, unsteadiness on feet, lack of coordination. Section Q: Participation in Assessment and Goal Setting: Resident and Family. Resident's Overall Goal: Discharge to community. Source of information: Resident. Is active discharge Planning already occurring for the resident to return to community? Yes. Has a referral been made to the Local Contact Agency (LCA)? No. Reason Referral to Local Contact Agency (LCA) not made. Referral not wanted. Review of the Care Plan for Resident #2 revealed, Date initiated: 7/28/25 Resident wishes to discharge home. Approaches: Will make arrangements with required community resources. Review of the Social Worker's Progress Notes for Resident #2 written by Social Worker K revealed:-08/05/25 for Resident #1 revealed, Discharge Planning/Discharge. On this day, this worker met with resident regarding her discharge. This worker informed that her insurance issued a Notice of Medicare Non-Coverage with LCD 08/07/25. This worker explained the appeal process. Resident signed NOMNC. Will continue to f/u as necessary.-08/01/25 This worker contacted resident regarding her discharge plan. Resident informed her that her IV antibiotic will end on 08/05/25. Resident stated she wishes to d/c on 08/05/25. Resident declined home health services. Resident stated she is independent and active and does not feel she needs home health services. No other concerns were voiced at this time. Will continue to f/u as necessary. Review of the undated Notice of Medicare Non-Coverage documented Medicare (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coverage of your Current Skilled Nursing Facility Services Will End on 08/07/25. The NOMNC was signed by Resident #2 on 08/05/25 documented, I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO.Review of the Discharge summary dated [DATE] for Resident #2 revealed, the form did not document if Influenza/Pneumovax were administered or declined. Disposition of Medications: only documented See MARS. Prognosis was left blank. Special Treatments/Procedures were blank. Summary of Course in Facility: patient done with all treatment. Medical (vital signs, labs, diagnostic, etc. were left blank. Cognition Function was blank. Psychosocial was left blank. Follow-up and Discharge Medication (instructions to resident) were left blank. Cognitive Function: was left blank. Psychosocial: was left blank. Sensory & Physical Impairments: were left blank. Dental Condition: was left blank. Physician's Order for Immediate Care was blank. Status Upon Discharge was left blank. The Discharge Summary was not signed by the physician. 3. Review of the admission Record dated 11/13/25 for Resident #3 revealed, original admission date 07/29/23 and readmission date 08/28/25. discharge date was 09/16/2025. Review of the History & Physical dated 07/30/25 for Resident #3 revealed, [AGE] year-old female status post right total knee arthroplasty (surgery to replace the damaged surfaces of a knee joint with artificial parts made of metal and plastic) admitted for rehabilitation services. Abnormality in her gait secondary to surgery. Review of the admission MDS dated [DATE] for Resident #3 revealed, Entry Date: 08/28/25. Entered from short-term general hospital. BIMS Summary Score - 13 (cognitively intact). Active Diagnoses: right artificial knee joint, muscle wasting, muscle weakness, difficulty walking, unsteadiness on feet, muscle weakness generalized. Section Q: Participation in Assessment and Goal Setting: Resident. Resident's Overall Goal: Discharge to community. Source of information: Resident. Is active discharge Planning already occurring for the resident to return to community? Yes. Has a referral been made to the Local Contact Agency (LCA)? No. Reason Referral to Local Contact Agency (LCA) not made. Referral not wanted. Review of Care Plan for Resident #1 dated 08/29/25 revealed the resident's discharge plans to return home. An approach was to make arrangements with required community resources. Review of Social Worker Progress Notes for Resident #3 written by Social Worker K revealed:09/10/25 Discharge Planning discharge: Resident will DC home with meds on Friday. Discharge due to NOMNC from insurance. The Resident lives at home. Resident agreed to arrange her own transportation. Home Health for PT/OT, Nursing Evaluation and home health aide. Resident confirmed she does not need a manual wheelchair. Resident confirmed she does have an FWW at home. Resident agreed to f/u with PCP. No concerns at this time.Review of Orthopedic Surgeons prescription dated 09/15/25 for Resident #3 revealed, OK to discharge home tomorrow.Review of the undated Notice of Medicare Non-Coverage documented Medicare Coverage of your Current Skilled Nursing Facility Services Will End on 09/11/25. The NOMNC was signed by Resident #3 on 09/09/25 documented, I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO. Review of the Discharge summary dated [DATE] for Resident #3 revealed, the form did not document if Influenza/Pneumovax were administered or declined. Discharge Summary: Resident dc'd from facility. Status Upon Discharge was left blank. The Discharge Summary was not signed by the physician. An interview and record review with the DON and Medical Records Staff on 11/12/25 at 11:42 AM, revealed that Residents #1, #2, and #3 did not have Discharge Summaries in their electronic medical record. The Medical Records Staff stated that she was new and had a stack of documents in her office that needed to be scanned into the resident's clinical records. She said, let me bring the stack of papers to see if the Discharge Summaries are there. An interview on 11/13/25 at 11:29 AM, with LVN A, on the 6:00 AM- 2:00 PM shift assigned to Halls 100/200, revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Discharge Plan was started upon admission, and a Discharge Summary was completed at the time of discharge. He said, the Social Worker would notify the nurses of the projected discharge date , and the nurses will call the physician to get the discharge order. He said the Discharge Summary had a summary of the care and services, diagnoses, medications, and information regarding referrals for Home Health Services. He said the nurse who discharged the resident signed the Discharge Summary on the day of discharge. He said that he did not know if Discharge Summaries were signed by the resident's physician. An interview on 11/13/25 at 11:38 AM with LVN B, on the 6:00 AM- 2:00 PM shift assigned to Halls 200/300, revealed Discharge Plans were started upon resident's admission to the facility. He said the Discharge Summary was completed by the nurses at the time of discharge. He said the Discharge Summary had a summary of the care and services, and diagnoses. He said nurses called the physician to get the discharge order. He said the discharge summaries were electronically signed by the nurse, who completed the form, and had to be signed by the physician. An interview on 11/14/25 at 11:11 AM, with the Director of Nurses and ADON RN D, revealed the Discharge Summary was completed at the time of discharge. She said the Discharge Summary included a summary of the care and services, diagnosis, and any referral information, such as Home Health Services. She said the Discharge Summary was signed by the Physician after the resident was discharged from the facility. During an interview and record review at 11:45 AM, with the Director of Nurses and ADON RN D, revealed the Recapitulation of Stay Resident Discharge summary dated [DATE] for Resident #1 did not document if Influenza/Pneumovax vaccines were administered or declined; Discharge Summary patient completed all required exercises for skilled therapy; Disposition of Medications See MARS. Prognosis was blank. Special Treatments/Procedures were left blank; Summary of Course in Facility was left blank; Medical (vital signs, labs, diagnostic, etc. was blank; Follow-up and Discharge Medication (instructions to resident) was left blank. Cognitive Function: was blank. Psychosocial: was blank. Sensory & Physical Impairments: was blank. Dental Condition: was blank. Status Upon Discharge was blank. The DON said the Discharge Summary still had not been signed by the physician. The DON said she was not aware Discharge Summaries needed to be signed by physician within twenty days after being notified by the facility of the discharge. The DON said the nursing staff had been trained on 09/03/25 on proper documentation in the resident electronic clinical record to ensure the documentation was complete. During an interview on 11/14/25 at 12:20 PM with Social Worker L revealed Discharge Plans were initiated upon admission, and the nurses completed the Discharge Summary on the day of discharge. During an interview on 11/14/25 at 1:35 PM with LVN ADON E revealed the nurses completed the Discharge Summary on the day of discharge. He said the Discharge Summary should include included a summary of the care and services, diagnosis, and any referral information such as Home Health Services.During an interview on 11/14/25 at 2:32 PM with RN H, assigned to Halls 200/300 on the evening shift, revealed the Discharge Summary was completed at the time of discharge. She said the Discharge Summary included a summary of the care and services, diagnosis, medications, therapy referrals, disposition of personal belongings, Durable Medical Equipment, referrals for Home Health Services, and resident education. Review of the facility's Transfer and Discharge Planning Policy and Procedures Operational Manual - admission and Discharge revised October 24, 2025, provided by the DON, revealed Purpose: To ensure that residents are transferred and discharged from the facility in compliance with state and federal laws and to provide complete, safe and appropriate discharge planning and necessary information. To the continuing care provider. Prior to discharging the resident, the facility will prepare a discharge summary and will document the summary and the residence medical record. At a minimum, the discharge summary will contain a summary of the resident status, including a description to the resident, medically defined (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675025 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete conditions and prior medical history. Physical, mental, psychosocial functional status. The medical record will contain written documentation from the residence attending physician Related to reason for discharge.Review of the facility's Transfer and Discharge Planning Policy and Procedures Operational Manual - Social Services revised 02/2025 provided by the DON, revealed Purpose: To ensure that adequate Preparation and assistance is provided to residents prior to transfer or discharge from the facility. Documentation: A copy of the discharge summary will be provided to the resident and or the resident's family member upon discharge when return is not anticipated. The discharge summary will include the following information. Recapitulation of the resident stay, including, but not limited to, diagnosis, course of illness, treatment, pertinent labs, radiology and other consultation reports. A copy of the discharge summary and discharge care plan will be maintained in the residence medical record. Event ID: Facility ID: 675025 If continuation sheet Page 5 of 5