Health inspection·March 5, 2024

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some lobe infiltrate (substance denser than air, such as pus, blood, or protein, which lingers within the parenchyma of the lungs) with possible right pleural effusion (accumulation of fluid in between the parietal and visceral pleura, called the pleural cavity). Bilateral pulmonary vascular congestion (accumulation of fluid in the lungs, resulting in impaired gas exchange and arterial hypoxemia) is seen with mild cardiomegaly. Record review of Resident #1's progress note dated [DATE] written by LVN C revealed resident coughing, congestion noted. oxygen 86-88% at room air. History of COPD. NP order for chest x-ray. Results received NP notified. New order as needed ipatroprium-albulteral 1 vial inhale orally every 4 hours. Lasix 60 mg by mouth for 5 days, and as needed robitussin mucus and chest congestion 10 ml by mouth every 6 hours for pain and temperature . Placed in bed, bed in lowest position, call light in reach. Will continue to monitor. Record review of Resident #1's progress notes for [DATE] for morning shift (6am-2pm), no documentation on record. Record review of Resident #1's progress notes dated [DATE] at 9:41 pm written by LVN D revealed resident noted to be breathing through mouth when breathing so oxygen not being absorbed. Simple mask applied and oxygen saturation remain stable with simple mask. Nebulizer treatments administered, resident continues with audible congestion in both lungs, able to cough up phlegm. Record review of Resident #1's progress notes dated [DATE] at 12:50 am written by LVN E revealed NP notified at 10:36 pm ([DATE]) 911 activated . Altered mental status, hypoxia (oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis), tachycardia(heart rate over 100 beats a minute), resident noted to be lethargic (general state of fatigue that involves a lack of energy and motivation for physical and mental tasks), only wakes to answer simple questions. Respirations 25, oxygen saturation at 8 3% on 6 liters simple mask, sitting up at 90 degrees. Tachycardic pulse at 122, cyanosis to fingertips noted . At 10:43 pm EMS arrived; resident transferred out at 10:49 pm ([DATE]) to local hospital. Record review of local hospital record dated [DATE] revealed Resident #1 presented to emergency room with respiratory distress, hypoxia, and altered mental status. Chief complaint: altered mental status, respiratory distress, hypoxia, and fever. Chest x-ray revealed bilateral multifocal pulmonary infiltrates. Critical Care: Patient was critically ill due to hypoxia, bilateral pneumonia, sepsis, lactic acidosis, hypokalemia, elevated troponin levels. Resident #1 expired at the hospital on [DATE]. During an interview on [DATE] at 10:38 am, LVN A stated she worked on [DATE] the morning shift (6am-2 pm) and was the charge nurse for Resident #1. LVN A stated she had received report on [DATE] morning that Resident #1 had chest x-ray completed on [DATE] with new orders of nebulizers treatments to be administered. LVN A stated on the morning of 01/15 /2024 at around 7:30 am or 8:00 am she had been notified by CNA B that Resident #1's lips and fingertips were purple. LVN A stated she went to assess Resident #1 and her oxygen saturation were in the 70's at room air. LVN A stated placed Resident #1 on oxygen and her oxygen saturations were in the 90's. LVN A stated she had notified treating NP but could no provide evidence to support (no texts or call log). LVN A stated she had documented, when referred to Resident #1 electronic records, LVN A stated she had not completed a progress note and/or SBAR assessment. LVN A stated she could not remember why she failed to document the cyanosis incident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675106 If continuation sheet Page 2 of 14 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 675106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Pointe Wellness Center 2301 N Oregon St El Paso, TX 79902 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 0580 Level of Harm - Immediate jeopardy to resident health or safety During an interview on [DATE] at 10:52 am, CNA B stated she had worked the morning shift (6am to 2pm) on 01/15 /2024 and was the assigned to Resident #1. CNA B stated she had assisted Resident #1 to her wheelchair to start getting her ready for breakfast at around 7:30 am or 8:00 am. CNA B stated when she was getting Resident #1 ready, she noticed her fingertips were purple and then noticed her lips were purple too. CNA B stated she called LVN A to report and assess Resident #1 and saw LVN A place Resident #1 on oxygen. CNA B stated Resident #1 was ok the rest of the shift . Residents Affected - Some During an interview on [DATE] at 11:05 am, the DON stated she was not notified of Resident #1's cyanotic episode on the morning of [DATE] by LVN A. The DON stated she had reviewed the 24-hour report on the morning of [DATE] and did not see any documentation of the incident. The DON stated charge nurses were expected to document all incidents on electronic records on either progress notes or SBAR assessment. The DON stated the cyanotic episode should had been reported to NP/MD, DON, and RP. The DON stated the NP could answer risks for not reporting the cyanotic episode. The DON stated failure to document Resident #1's cyanotic episode on the morning of [DATE] could have affected the continuity of care and monitoring of respiratory status to identify change in condition. During an interview on [DATE] at 3:54 pm, NP stated she was out of town and did not have her notes available for reference. The NP stated she did not recall being notified of Resident #1's cyanotic episode on the morning of [DATE]. The NP stated if she had been notified, she would have given orders for ER transfer for further treatment. The NP stated she expected for staff to send residents to ER right away and not wait for condition to worsen. The NP stated risk of not being notified of cyanotic episode on the morning of [DATE] could had delayed care in treatment resulting in altered mental status due to hypoxia worsening. During an interview on [DATE] at 6:07 pm via text message, the NP sent Investigator screenshots of her phone and stated she had not received report of change in condition on the morning of [DATE]. The NP stated she would have given orders for immediate transfer to hospital. The NP stated if Resident #1 was having cyanotic changes that was a very delicate and important change to have been reported. The NP stated it did place Resident #1 at risk of decompensation and/or worsening status. Record review of Notifying the Physician of Change in Status policy dated [DATE] read in part the nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. The Administrator and DON were informed on [DATE] at 2:51 PM that Immediate jeopardy (IJ) had been identified and copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested within the hour. The plan or removal was accepted on [DATE] at 1:53 pm. The Plan of Removal revealed the facility took the following actions: 1. Immediate Actions Taken for Those Residents Identified: Resident #1: Documented that Resident #1 no longer resides at the facility. Conducted a thorough (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675106 If continuation sheet Page 3 of 14 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 675106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Pointe Wellness Center 2301 N Oregon St El Paso, TX 79902 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some review of Resident #1's records to ensure that all care needs were appropriately managed until their departure. A summary report of the care provided and any incidents leading to the change in residence status was compiled for internal review and learning. Notification: Implemented an immediate review process for all residents experiencing a change in condition to ensure that the NP and relevant healthcare professionals are immediately notified according to the facility's policy. Medical director was notified of immediate jeopardy on [DATE]. 2. How the Facility Identified Other Residents: Review Process: The Director of Nursing (DON) conducted a comprehensive review of the 24-hour reports for all residents over the past month to identify any documented changes in conditions. The results of findings were documented in the change of condition audit tool. Review was conducted on [DATE]. Documentation Audit: An audit was performed on resident files to ensure that all changes in condition were properly documented and that necessary notifications were made to the NP or responsible healthcare provider. The results of findings were documented in the change of condition audit tool. Review was conducted on [DATE]. Staff training for recognizing change of condition was initiated on [DATE]. Licensed staff will not work until they are serviced on change of conditions. Date of Completion [DATE]. Staff Interviews: Conducted interviews with nursing staff to gather additional insights into any undocumented or reported changes in resident conditions, aiming to identify gaps in communication or documentation. Interviews were conducted by DON and designee on [DATE] resulted in no negative findings. Results were reported on Change of Condition Audit Tool. 3. Measures Put into Place/System Changes: Staff Training: Director of Nursing and designee(s) implemented mandatory training sessions for all nursing and caregiving staff on the Notifying the Physician of Change in Status policy, emphasizing the importance of timely communication with healthcare providers regarding changes in resident conditions. Date of completion [DATE]. Communication Channels: Established a dedicated communication line / in-service utilizing the SBAR assessment for staff to use when reporting changes in resident conditions to the NP or other healthcare providers, ensuring immediate attention. SBAR assessments can be documented in the resident(s) clinical record. In-service was provided to licensed nurses and was completed by Director of Nursing and designee(s) as of [DATE]. DON and or Designee will review SBAR reports charted daily. The facility has implemented mandatory training sessions for licensed and non-licensed personnel on the policy relating to changes in resident conditions. Completion of this training is required before staff are permitted to work, ensuring they are well-versed in recognizing and reporting changes in resident conditions. This training will be completed by the Director of Nursing (DON) and or designee. Staff will be required to provide a return demonstration of education provided to them. Completion date [DATE]. 4. How the Corrective Actions Will be Monitored: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675106 If continuation sheet Page 4 of 14 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 675106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Pointe Wellness Center 2301 N Oregon St El Paso, TX 79902 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some LVN A will not return to work until she receives a comprehensive in-service regarding change of condition monitoring and documentation. LVN A will also need to complete a full clinical competency assessment performed by the Director of Nursing prior to returning to her scheduled shifts starting on [DATE]. Newly hired staff will be required to undergo comprehensive in-service training regarding change of condition monitoring and documentation, in addition to completing a full clinical competency assessment conducted by the DON and or designee before they can begin their scheduled shifts. This ensures that all staff, regardless of their employment status, are adequately prepared to care for residents; staff will be required to provide a return demonstration of the education provided to them. Daily audits of SBAR assessments, Weekly nursing summaries, and 24-hour report reviews will be conducted for the next 4 weeks. The audits on the documentation and notification process for changes in resident conditions, to be conducted by the DON and or designee; findings will be discussed in the morning clinical meeting. Date of completion [DATE]. Licensed nurses will complete a nursing summary assessment documented in the electronic medical record for each resident on a weekly basis. If a change of condition is noted with a resident by a licensed or non-licensed personnel an SBAR will be completed by the Licensed Nurse and change will be reported to the MD. The DON or designee will verbally follow up with each shift to ensure that any reported change in resident condition has been reported to the appropriate health care provider and documented in the patient's clinical record for the next 4 weeks or until assured compliance is met. The results of findings will be documented in the change of condition audit tool each shift. Date of completion [DATE]. SBAR assessment and 24-hour report audits will continue until assured compliance was met. Audit findings will be reviewed during the monthly QAPI meetings. Interviews and Record Review to confirm implementation of the Plan of Removal were conducted as follows: Per interview with MD on [DATE] he was not working on the weekend and would return my call on Monday [DATE]. Obtained screen shot from DON for time of notification on [DATE] at 5:01 pm. Interviews on [DATE]: 2:00 pm, LVN F (weekend shift) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:04 pm, LVN G (weekend shift) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:14 pm, LVN H (weekend shift and PRN weekday) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675106 If continuation sheet Page 5 of 14 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 675106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Pointe Wellness Center 2301 N Oregon St El Paso, TX 79902 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:42 pm, LVN I (weekday 6-2 shift/ telephone) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:53 pm, LVN J (weekday 2-10 shift/ telephone) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:57 pm, LVN D (weekday 2-10 pm/telephone) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 3:00 pm, LVN K wound care nurse (Monday Friday/ telephone) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 3:07 pm, called LVN A there was no answer and could not leave VM due to VM box full. 3:15 pm, called LVN A there was no answer and could not leave VM due to VM box full. Reviewed staff schedule for [DATE]-[DATE]- LVN A works 6-2 shift Monday thru Friday. Returns to work [DATE]. 2:22 pm, the DON stated expectations remained the same, charge nurses were to notify NP of any change in condition and document all interventions provided. The DON sated she notified MD of IJ on [DATE] via text. The DON sated the mandatory trainings were the in services, change in condition policy review with staff and obtain staff signatures on the policy, and post quizzes would be provided. The DON sated new staff would be trained the same way, the facility would go over the change in condition policy and have them signed and complete quiz. The DON sated she would be doing weekly audits of summary assessment documentation. The DON sated she would verify documentation was accurate and follow up with verbal report throughout the change in condition monitoring. The DON stated ADON will be the designee to assist with the change in condition monitoring. The DON stated staff would follow up on changes in condition reported during morning daily meetings. The DON stated LVN A was to return to work until Monday [DATE] but had already spoken to her and would be in-serviced in person before her shift on [DATE]. 3:11 pm, ADON confirmed training in SBAR completion, report change in condition and interventions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675106 If continuation sheet Page 6 of 14 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 675106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Pointe Wellness Center 2301 N Oregon St El Paso, TX 79902 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. ADON stated he would be assisting the DON with SBAR audits daily and would review during daily morning meetings. ADON stated he would be assisting with completing the SBAR audit tool and will be placed in the SBAR binder located in DON office. The ADON stated LVN A would return to work on Monday [DATE]. The ADON stated DON and ADON would be conducting in person training with LVN A, they would review change in condition policy, obtain signature on the policy and provide quiz before she was allowed to work the floor. Record reviews: Reviewed 72-hour summary pulled by DON and handwritten comments to follow up on and/or solidify dated [DATE]. Reviewed change in condition tool dated [DATE] to cross reference handwritten notes on 72-hour summary reports with no concerns identified. Reviewed change in condition nursing quiz dated [DATE]-[DATE] by charge nurses, administrative department, CNAs, and no licensed staff. Total of 60. Reviewed in-service dated [DATE]: change of condition notification with policy attached. Reviewed in-service dated [DATE]: change in residents' condition and reporting that change to the nurse (LVN or RN) at the facility immediately. Reviewed in-service dated [DATE]: observing a change in a resident's condition and reporting that change to the nurse immediately. Reviewed change in condition policies dated [DATE]-[DATE] by charge nurses (16 total). Reviewed in-service dated [DATE]: SBAR communication tool. The IJ was lowered on [DATE] at 3:35 pm, but the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm due to the facility's need to monitor their corrective actions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675106 If continuation sheet Page 7 of 14 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 675106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Pointe Wellness Center 2301 N Oregon St El Paso, TX 79902 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 5 (Resident #1) residents reviewed for quality of care. Residents Affected - Some The facility failed to immediately inform NP/MD of Resident #1's change in condition addressing cyanotic episode (change of body tissue color to a bluish-purple hue, as a result of decrease in the amount of oxygen) to fingertips and lips. Resident #1's MD/NP was not notified of change in condition from approximately 8:00 a.m. to 10:36 p.m. on [DATE]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. The IJ template was provided to the Administrator and DON on [DATE] at 2:51 p.m. The IJ was removed on [DATE], but the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm due to the facility's need to monitor their corrective actions. This failure could place residents at risk for diminished quality of care, untreated medical issues, and death. Findings included: Record review of Resident #1's face sheet dated [DATE] revealed an [AGE] year-old female who was readmitted to the facility on [DATE] with diagnoses of dementia and COPD (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 03, her cognitive was severely impaired. Record review of Resident #1's SBAR note dated [DATE] revealed a respiratory change with oxygen saturations of 88-90% on room air. Respiratory change was shortness of breath on exertion only and upper lung fields with wheezing when auscultated, diminished to bilateral bases. Chest x-ray results on [DATE] were right lower lobe infiltrate seen with possible right pleural effusion, bilateral pulmonary vascular congestion with mild cardiomegaly. Medication history of Lasix daily by mouth. Primary diagnoses were COPD and dementia. NP was notified at [DATE] at 4:50 pm. New orders provided by NP were to increase Lasix to 60 mg by mouth for 5 days then resume current dosing, ipratropium nebulizer 0.5 mg inhaler as needed every 4 hours, and robitussin mucus and chest as needed by mouth for cough. Record review of Resident #1's chest x-ray results dated [DATE] revealed findings of right lower lobe infiltrate (substance denser than air, such as pus, blood, or protein, which lingers within the parenchyma of the lungs) with possible right pleural effusion (accumulation of fluid in between the parietal and visceral pleura, called the pleural cavity). Bilateral pulmonary vascular congestion (accumulation of fluid in the lungs, resulting in impaired gas exchange and arterial hypoxemia) is seen with mild cardiomegaly. Record review of Resident #1's progress note dated [DATE] written by LVN C revealed resident coughing, congestion noted. oxygen 86-88% at room air. History of COPD. NP order for chest x-ray. Results received NP notified. New order as needed ipatroprium-albulteral 1 vial inhale orally every 4 hours. Lasix 60 mg by mouth for 5 days, and as needed robitussin mucus and chest congestion 10 ml by mouth (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675106 If continuation sheet Page 8 of 14 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 675106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Pointe Wellness Center 2301 N Oregon St El Paso, TX 79902 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some every 6 hours for pain and temperature . Placed in bed, bed in lowest position, call light in reach. Will continue to monitor. Record review of Resident #1's progress notes for [DATE] for morning shift (6am-2pm), no documentation on record. Record review of Resident #1's progress notes dated [DATE] at 9:41 pm written by LVN D revealed resident noted to be breathing through mouth when breathing so oxygen not being absorbed. Simple mask applied and oxygen saturation remain stable with simple mask. Nebulizer treatments administered, resident continues with audible congestion in both lungs, able to cough up phlegm. Record review of Resident #1's progress notes dated [DATE] at 12:50 am written by LVN E revealed NP notified at 10:36 pm ([DATE]) 911 activated . Altered mental status, hypoxia (oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis), tachycardia(heart rate over 100 beats a minute), resident noted to be lethargic (general state of fatigue that involves a lack of energy and motivation for physical and mental tasks), only wakes to answer simple questions. Respirations 25, oxygen saturation at 8 3% on 6 liters simple mask, sitting up at 90 degrees. Tachycardic pulse at 122, cyanosis to fingertips noted . At 10:43 pm EMS arrived; resident transferred out at 10:49 pm ([DATE]) to local hospital. Record review of local hospital record dated [DATE] revealed Resident #1 presented to emergency room with respiratory distress, hypoxia, and altered mental status. Chief complaint: altered mental status, respiratory distress, hypoxia, and fever. Chest x-ray revealed bilateral multifocal pulmonary infiltrates. Critical Care: Patient was critically ill due to hypoxia, bilateral pneumonia, sepsis, lactic acidosis, hypokalemia, elevated troponin levels. Resident #1 expired at the hospital on [DATE]. During an interview on [DATE] at 10:38 am, LVN A stated she worked on [DATE] the morning shift (6am-2 pm) and was the charge nurse for Resident #1. LVN A stated she had received report on [DATE] morning that Resident #1 had chest x-ray completed on [DATE] with new orders of nebulizers treatments to be administered. LVN A stated on the morning of 01/15 /2024 at around 7:30 am or 8:00 am she had been notified by CNA B that Resident #1's lips and fingertips were purple. LVN A stated she went to assess Resident #1 and her oxygen saturation were in the 70's at room air. LVN A stated placed Resident #1 on oxygen and her oxygen saturations were in the 90's. LVN A stated she had notified treating NP but could no provide evidence to support (no texts or call log). LVN A stated she had documented, when referred to Resident #1 electronic records, LVN A stated she had not completed a progress note and/or SBAR assessment. LVN A stated she could not remember why she failed to document the cyanosis incident. During an interview on [DATE] at 10:52 am, CNA B stated she had worked the morning shift (6am to 2pm) on 01/15 /2024 and was the assigned to Resident #1. CNA B stated she had assisted Resident #1 to her wheelchair to start getting her ready for breakfast at around 7:30 am or 8:00 am. CNA B stated when she was getting Resident #1 ready, she noticed her fingertips were purple and then noticed her lips were purple too. CNA B stated she called LVN A to report and assess Resident #1 and saw LVN A place Resident #1 on oxygen. CNA B stated Resident #1 was ok the rest of the shift . During an interview on [DATE] at 11:05 am, the DON stated she was not notified of Resident #1's cyanotic episode on the morning of [DATE] by LVN A. The DON stated she had reviewed the 24-hour report on the morning of [DATE] and did not see any documentation of the incident. The DON stated charge (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675106 If continuation sheet Page 9 of 14 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 675106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Pointe Wellness Center 2301 N Oregon St El Paso, TX 79902 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some nurses were expected to document all incidents on electronic records on either progress notes or SBAR assessment. The DON stated the cyanotic episode should had been reported to NP/MD, DON, and RP. The DON stated the NP could answer risks for not reporting the cyanotic episode. The DON stated failure to document Resident #1's cyanotic episode on the morning of [DATE] could have affected the continuity of care and monitoring of respiratory status to identify change in condition. During an interview on [DATE] at 3:54 pm, NP stated she was out of town and did not have her notes available for reference. The NP stated she did not recall being notified of Resident #1's cyanotic episode on the morning of [DATE]. The NP stated if she had been notified, she would have given orders for ER transfer for further treatment. The NP stated she expected for staff to send residents to ER right away and not wait for condition to worsen. The NP stated risk of not being notified of cyanotic episode on the morning of [DATE] could had delayed care in treatment resulting in altered mental status due to hypoxia worsening. During an interview on [DATE] at 6:07 pm via text message, the NP sent Investigator screenshots of her phone and stated she had not received report of change in condition on the morning of [DATE]. The NP stated she would have given orders for immediate transfer to hospital. The NP stated if Resident #1 was having cyanotic changes that was a very delicate and important change to have been reported. The NP stated it did place Resident #1 at risk of decompensation and/or worsening status. Record review of Notifying the Physician of Change in Status policy dated [DATE] read in part the nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. The Administrator and DON were informed on [DATE] at 2:51 PM that Immediate jeopardy (IJ) had been identified and copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested within the hour. The plan or removal was accepted on [DATE] at 1:53 pm. The Plan of Removal revealed the facility took the following actions: 1. Immediate Actions Taken for Those Residents Identified: Resident #1: Documented that Resident #1 no longer resides at the facility. Conducted a thorough review of Resident #1's records to ensure that all care needs were appropriately managed until their departure. A summary report of the care provided and any incidents leading to the change in residence status was compiled for internal review and learning. Notification: Implemented an immediate review process for all residents experiencing a change in condition to ensure that the NP and relevant healthcare professionals are immediately notified according to the facility's policy. Medical director was notified of immediate jeopardy on [DATE]. 2. How the Facility Identified Other Residents: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675106 If continuation sheet Page 10 of 14 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 675106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Pointe Wellness Center 2301 N Oregon St El Paso, TX 79902 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review Process: The Director of Nursing (DON) conducted a comprehensive review of the 24-hour reports for all residents over the past month to identify any documented changes in conditions. The results of findings were documented in the change of condition audit tool. Review was conducted on [DATE]. Documentation Audit: An audit was performed on resident files to ensure that all changes in condition were properly documented and that necessary notifications were made to the NP or responsible healthcare provider. The results of findings were documented in the change of condition audit tool. Review was conducted on [DATE]. Staff training for recognizing change of condition was initiated on [DATE]. Licensed staff will not work until they are serviced on change of conditions. Date of Completion [DATE]. Staff Interviews: Conducted interviews with nursing staff to gather additional insights into any undocumented or reported changes in resident conditions, aiming to identify gaps in communication or documentation. Interviews were conducted by DON and designee on [DATE] resulted in no negative findings. Results were reported on Change of Condition Audit Tool. 3. Measures Put into Place/System Changes: Staff Training: Director of Nursing and designee(s) implemented mandatory training sessions for all nursing and caregiving staff on the Notifying the Physician of Change in Status policy, emphasizing the importance of timely communication with healthcare providers regarding changes in resident conditions. Date of completion [DATE]. Communication Channels: Established a dedicated communication line / in-service utilizing the SBAR assessment for staff to use when reporting changes in resident conditions to the NP or other healthcare providers, ensuring immediate attention. SBAR assessments can be documented in the resident(s) clinical record. In-service was provided to licensed nurses and was completed by Director of Nursing and designee(s) as of [DATE]. DON and or Designee will review SBAR reports charted daily. The facility has implemented mandatory training sessions for licensed and non-licensed personnel on the policy relating to changes in resident conditions. Completion of this training is required before staff are permitted to work, ensuring they are well-versed in recognizing and reporting changes in resident conditions. This training will be completed by the Director of Nursing (DON) and or designee. Staff will be required to provide a return demonstration of education provided to them. Completion date [DATE]. 4. How the Corrective Actions Will be Monitored: LVN A will not return to work until she receives a comprehensive in-service regarding change of condition monitoring and documentation. LVN A will also need to complete a full clinical competency assessment performed by the Director of Nursing prior to returning to her scheduled shifts starting on [DATE]. Newly hired staff will be required to undergo comprehensive in-service training regarding change of condition monitoring and documentation, in addition to completing a full clinical competency assessment conducted by the DON and or designee before they can begin their scheduled shifts. This ensures that all staff, regardless of their employment status, are adequately prepared to care for residents; staff will be required to provide a return demonstration of the education provided to them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675106 If continuation sheet Page 11 of 14 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 675106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Pointe Wellness Center 2301 N Oregon St El Paso, TX 79902 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Daily audits of SBAR assessments, Weekly nursing summaries, and 24-hour report reviews will be conducted for the next 4 weeks. The audits on the documentation and notification process for changes in resident conditions, to be conducted by the DON and or designee; findings will be discussed in the morning clinical meeting. Date of completion [DATE]. Licensed nurses will complete a nursing summary assessment documented in the electronic medical record for each resident on a weekly basis. If a change of condition is noted with a resident by a licensed or non-licensed personnel an SBAR will be completed by the Licensed Nurse and change will be reported to the MD. The DON or designee will verbally follow up with each shift to ensure that any reported change in resident condition has been reported to the appropriate health care provider and documented in the patient's clinical record for the next 4 weeks or until assured compliance is met. The results of findings will be documented in the change of condition audit tool each shift. Date of completion [DATE]. SBAR assessment and 24-hour report audits will continue until assured compliance was met. Audit findings will be reviewed during the monthly QAPI meetings. Interviews and Record Review to confirm implementation of the Plan of Removal were conducted as follows: Per interview with MD on [DATE] he was not working on the weekend and would return my call on Monday [DATE]. Obtained screen shot from DON for time of notification on [DATE] at 5:01 pm. Interviews on [DATE]: 2:00 pm, LVN F (weekend shift) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:04 pm, LVN G (weekend shift) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:14 pm, LVN H (weekend shift and PRN weekday) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:42 pm, LVN I (weekday 6-2 shift/ telephone) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:53 pm, LVN J (weekday 2-10 shift/ telephone) confirmed training in SBAR completion, report change (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675106 If continuation sheet Page 12 of 14 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 675106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Pointe Wellness Center 2301 N Oregon St El Paso, TX 79902 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:57 pm, LVN D (weekday 2-10 pm/telephone) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 3:00 pm, LVN K wound care nurse (Monday Friday/ telephone) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 3:07 pm, called LVN A there was no answer and could not leave VM due to VM box full. 3:15 pm, called LVN A there was no answer and could not leave VM due to VM box full. Reviewed staff schedule for [DATE]-[DATE]- LVN A works 6-2 shift Monday thru Friday. Returns to work [DATE]. 2:22 pm, the DON stated expectations remained the same, charge nurses were to notify NP of any change in condition and document all interventions provided. The DON sated she notified MD of IJ on [DATE] via text. The DON sated the mandatory trainings were the in services, change in condition policy review with staff and obtain staff signatures on the policy, and post quizzes would be provided. The DON sated new staff would be trained the same way, the facility would go over the change in condition policy and have them signed and complete quiz. The DON sated she would be doing weekly audits of summary assessment documentation. The DON sated she would verify documentation was accurate and follow up with verbal report throughout the change in condition monitoring. The DON stated ADON will be the designee to assist with the change in condition monitoring. The DON stated staff would follow up on changes in condition reported during morning daily meetings. The DON stated LVN A was to return to work until Monday [DATE] but had already spoken to her and would be in-serviced in person before her shift on [DATE]. 3:11 pm, ADON confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. ADON stated he would be assisting the DON with SBAR audits daily and would review during daily morning meetings. ADON stated he would be assisting with completing the SBAR audit tool and will be placed in the SBAR binder located in DON office. The ADON stated LVN A would return to work on Monday [DATE]. The ADON stated DON and ADON would be conducting in person training with LVN A, they would review change in condition policy, obtain signature on the policy and provide quiz before she was allowed to work the floor. Record reviews: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675106 If continuation sheet Page 13 of 14 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 675106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Pointe Wellness Center 2301 N Oregon St El Paso, TX 79902 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Reviewed 72-hour summary pulled by DON and handwritten comments to follow up on and/or solidify dated [DATE]. Reviewed change in condition tool dated [DATE] to cross reference handwritten notes on 72-hour summary reports with no concerns identified. Reviewed change in condition nursing quiz dated [DATE]-[DATE] by charge nurses, administrative department, CNAs, and no licensed staff. Total of 60. Reviewed in-service dated [DATE]: change of condition notification with policy attached. Reviewed in-service dated [DATE]: change in residents' condition and reporting that change to the nurse (LVN or RN) at the facility immediately. Reviewed in-service dated [DATE]: observing a change in a resident's condition and reporting that change to the nurse immediately. Reviewed change in condition policies dated [DATE]-[DATE] by charge nurses (16 total). Reviewed in-service dated [DATE]: SBAR communication tool. The IJ was lowered on [DATE] at 3:35 pm, but the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm due to the facility's need to monitor their corrective actions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675106 If continuation sheet Page 14 of 14