Health inspection·May 31, 2023

F 0604 the prior assessment. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #11 ' s physician ' s order dated 08/08/2021 documented that she could have a mattress with raised parameters (bolsters) for resident safety. Residents Affected - Some Record review of Resident #11 ' s electronic Fall Assessment records accessed 05/11/2023 revealed four fall assessments over 2022 with no fall events, and one fall assessment in 2023 with no fall events. Observation of Resident #11 on 05/29/23 at 09:15 AM revealed that she was lying in bed and had contractures to her arms and hands, and to her legs. Her eyes were open, but she did not respond to attempts to greet her or ask for her name. Bolsters extending from hip-level to the foot of the bed covered by fitted sheets were observed on both sides of her bed. The fitted sheet was taut over the bolster and mattress. Her bed was lowered, and a fall mat was beside her bed. In an interview on 05/29/23 at 09:20 AM LVN B said Resident #11 sometimes wiggled in bed and that the bolsters on the bed were so that she did not fall out of bed. In an interview 05/30/23 at 01:20 PM NA A stated that when assisting Resident #11 with personal care she did not reach out to hold onto the assist bars or anything else to assist with personal care. Record review 05/23/2023 of Resident #11 ' s electronic chart in the consents ' area of her electronic chart reflected no consents documented for bolsters on her bed. Resident 55 Record review of Resident 55 ' s face sheet dated 05/30/2023 reflected in part that she was [AGE] years old, was first admitted to the facility on [DATE] and again on 02/14/2023. Record review of Resident 55 ' s History and Physical dated 02/15/2023 reflected that she had diagnoses including Parkinson disease with stiffness and diminished mobility. She had contractures in the hands and parkinsonian tremors. Record review of Resident 55 ' s quarterly MDS dated [DATE] reflected that her BIMS was 8 (moderate cognitive impairment). She was totally dependent on staff to move around in bed, transfer between surfaces, dress and use the toilet. She had functional limitation in range of motion of both her upper and lower extremities. She had no history of falls. Record review on 05/23/2023 of Resident 55 ' s electronic assessment log reflected that she had been assessed on 02/14/2023 as being at high risk for falls. Record review of Resident 55 ' s care plan for a diagnosis of fall risk revised 10/14/2020 reflected in part that she had a mattress with raised perimeters as an intervention. Record review of Resident 55 ' s physician's order dated 04/16/2020 stated the resident could have a mattress with raised perimeters for safety. In observation and interview on 05/29/23 beginning at 09:37 AM Resident #55 was observed in bed. Bolsters extending from hip-level to the foot of the bed and from the top of the bed to one foot from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675145 If continuation sheet Page 2 of 9 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 675145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vida Nursing and Rehab Odessa 3800 Englewood LN Odessa, TX 79762 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 0604 Level of Harm - Minimal harm or potential for actual harm the lower bolster were evident under the fitted sheets on one side of her bed. The other side of the bed was against the wall. The fitted sheet covering the bolsters was taut over the bolsters and mattress. Her bed was lowered, and a fall mat was beside her bed. She was observed to straighten out her legs during the interview. She responded to questions in a very low voice, and she was difficult to understand. She stated that she had Parkinson disease. Residents Affected - Some In an interview and observation on 05/30/23 beginning at 02:45 PM with Resident #55 and CNA C, the resident said sometimes she was able to turn herself by holding onto the sides of the mattress. CNA C said that she had not seen the resident use the mattress or any other device to help with turning because of the contractures of her hands. The resident was observed to have contractures of both hands. In an interview on 05/30/23 at 01:42 PM the Rehabilitation Director said that no assessment was completed by therapy for use of bolsters by Residents #11 or Resident #55. The Rehabilitation Director said that decisions to use bolsters for residents was usually initiated by nursing in response to resident falls or decreased mobility, and the DON usually interacted with the Rehabilitation director in relation to decisions about placing bolsters. In an interview on 05/30/23 at 02:10 PM with the DON the placement of bolsters for Residents #11 and #55 were discussed. She said that Resident #55 may have rolled off the bed because she had a lot of movement at night. She said that Resident #11 tended to squirm a lot which placed her at increased risk for falls. The DON said the decision to place bolsters for a resident depended on the resident's capacity to get out of bed, and the cause and frequency of falls. She said that if a resident was rolling out of bed at night bolsters might be considered, but they would not be used if it restricted the resident ' s ability to get out of bed on their own. She said that if a resident can ' t get out of bed on their own bolsters would not be a restraint. When a policy regarding restraints was requested from the DON she stated that restraints were not used or necessary in the facility setting. In an interview on 05/31/23 at 02:53 PM the Administrator said she was not aware of concerns about restraints for Residents #11 and #55. When the use of bolsters (scoop mattresses) for Residents #11 and #55 was raised, the Administrator stated that the residents were not able to get out bed by themselves so the bolsters could not be considered restraints. In an interview on 05/31/23 at 03:04 PM the Regional Compliance Nurse pointed out that the facility was not using scoop mattresses but was using bolsters, also known as mattresses with perimeters (mattress with bolsters) which did not constitute restraints. He said the bolsters were used for residents who were at risk of falling with the goal of increasing resident safety and minimizing injury. Record review of the facility policy titled Restraints dated 02/01/2007 reflected in part that a physical restraint was any physical \mechanical device, material or equipment adjacent to the resident's body that the resident cannot remove easily which restrict freedom of movement. A physician's order shall be necessary to begin a restraint assessment. Assessment shall include a physical therapy consultation as needed. The resident and/or family member shall be contacted to obtain informed consent if needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675145 If continuation sheet Page 3 of 9 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 675145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vida Nursing and Rehab Odessa 3800 Englewood LN Odessa, TX 79762 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program by referring all residents with newly evident or possible serious mental disorder for level II resident review upon a significant change in status assessment for 1 (Resident #23) of 3 resident's reviewed for PASARR coordination. The facility failed to refer Resident #23 to the local authority for Level 1 PASARR screening after he was given a new diagnosis of schizoaffective disorder. This failure could place residents at risk of not receiving specialized and/or habilitation services as needed to meet their needs. Findings included: Record review of Resident #23 ' s face sheet dated 05/31/2023 reflected he was [AGE] years old, was first admitted to the facility on [DATE] and again on 04/17/2023. Record review of Resident #23 ' s PASRR Level 1 Screening dated 11/18/2021 documented that there was no evidence or indicator that he had a mental illness. Record review of Resident #23 ' s History and Physical dated 11/23/2021 reflected he had diagnoses including dementia, chronic renal insufficiency (kidney failure), and Acute Anxiety. He was being given quetiapine (an antipsychotic) for dementia. Record review of Resident #23 ' s History and Physical dated 04/22/2023 reflected diagnoses of Dementia without behavioral disturbance, unspecified dementia type, and acute anxiety. Record review of Resident #23 ' s quarterly MDS dated [DATE] reflected he had a BIMS of 0 (severe cognitive impairment). He had diagnoses including dementia and Alzheimer ' s Disease, manic depression (bipolar disease), a psychotic disorder and Schizophrenia. Record review of Resident #23 ' s care plan dated 03/16/2023 reflected he required anti-psychotics for behavior management. Record review of Resident #23 ' s electronic diagnosis listing accessed on 05/29/2023 reflected that he had been identified as having a diagnosis of schizophrenia, unspecified on 09/06/2022. Additional diagnoses listed included of mood disorder due to known physiological condition with depressive features; psychotic disorder with delusions due to known physiological condition; anxiety disorder due to known physiological condition; vascular dementia, unspecified severity, without behavioral disturbance; Psychotic disturbance; mood disturbance; anxiety. Record review of Resident #23 ' s physician ' s letter dated 01/17/2023 from a consulting physiatrist reflected that the resident was taking Seroquel (quetiapine) for schizoaffective disorder. In an interview on 05/31/23 at 02:08 PM the MDS LVN Z accessed the Simple LTC portal (software used for reporting PASRR related information) and confirmed that Resident #23 had a PASRR Level 1 screen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675145 If continuation sheet Page 4 of 9 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 675145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vida Nursing and Rehab Odessa 3800 Englewood LN Odessa, TX 79762 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few completed on 11/18/2021 showing no evidence of mental illness, and that no other PASRR related activity had been completed in relation to the resident ' s PASRR status since then (11/18/2021). The MDS LVN Z confirmed that she saw a diagnosis of schizophrenia in Resident #23 ' s electronic record from 09/06/2022 and said it should have triggered a new PASRR Level 1 screen. She said that she did not usually deal with PASRR-related changes for long term residents such as Resident #23, and that the person who handled this had been out of the office for some time. She said that the risk to Resident #23 from not having a new PASRR Level 1 screen was that he might have missed some specialized psychiatric services for which he was eligible. In an interview on 05/31/23 at 02:37 PM the DON said she was not very familiar with the PASRR program but that it pertained to people with disabilities such as mental illness. She said the PASRR program might have provided Resident #23 some extra benefits like psychiatric services and extra health care services, and that the risk to him of not having been screened for the PASRR program was that he would not get those extra benefits. In an interview on 05/31/23 at 02:51 PM the Administrator said that the PASSR program was to provide necessary services to people with qualifying diagnoses such as mental illness or other disabilities. She said that not contacting the local authority to conduct the PASSR Level 1 screening for Resident #23 in response to his new diagnosis could put him at risk of not receiving services which could have been of benefit to him. Record review of the facility policy PASRR Nursing Facility Specialized Services Policy and Procedure revised 03/06/2019 reflected in part that it was the corporate policy to ensure required forms were submitted timely and accurately. The policy did not address how facilities were to respond to new diagnoses for existing facility residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675145 If continuation sheet Page 5 of 9 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 675145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vida Nursing and Rehab Odessa 3800 Englewood LN Odessa, TX 79762 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 2 (Resident #22 & #46) of 12 residents observed for oxygen management. Residents Affected - Few Residents #22 & #46, who used on oxygen, did not have oxygen sign posted outside their bedrooms. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health. Findings included: Record review of Resident #22's Face Sheet dated 05/29/2023 revealed admission on [DATE] to the facility. Record review of Resident #22's History and Physical dated 04/06/2023 revealed a [AGE] year-old female diagnosed with morbid (sever) obesity due to excess calories, dementia, neuroleptic induced parkinsonism. Record review of Resident #22's care plan dated 03/30/2023 indicated resident was on oxygen therapy but did not indicate nasal cannulas/mask had to be changed out week. Record review of Resident #22's admission MDS dated [DATE] revealed resident was diagnosed with epilepsy. Resident #22 was receiving oxygen therapy. Observation on 05/29/2023 at 8:01 AM revealed Resident #22 who had her cannula on. Outside of Resident #22's room there was no oxygen sign posted. Record review of Resident #46's Face Sheet dated 05/31/2023 admission on [DATE] and readmission on [DATE] to the facility. Record review of Resident #46's History and Physical dated 05/30/2023 revealed a [AGE] year-old female who was a former smoker for years. Record review of Resident #46's quarterly MDS dated [DATE] revealed she was on oxygen therapy before coming to the facility. Record review of Resident #46's Order Recap dated 05/11/2023 changing oxygen tubing and nasal cannula/mask every night shifts every Sunday for shortness of breath . Record review of Resident #46's Care Plan dated 11/28/2022 revealed altered respiratory, difficulty breathing and shortness of breath. Observation on 05/29/2023 at 9:31 AM Resident #46 had a concentrator with a nasal cannula on Observation on 05/29/2023 at 9:02 AM revealed oxygen was in use in Resident #46's room with no oxygen sign posted outside of the room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675145 If continuation sheet Page 6 of 9 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 675145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vida Nursing and Rehab Odessa 3800 Englewood LN Odessa, TX 79762 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 05/29/2023 at 10:28 AM with LVN F stated an oxygen sign meant that there was a concentrator or tank in use in the resident's room. LVN F stated an oxygen sign lets people know not to smoke or have flammables because the oxygen might blow up. LVN F stated the room needed an oxygen sign because oxygen was in use in the room. LVN F stated the nasal cannula needed to be dated so that nursing staff knows when it was changed. LVN F stated not changing the nasal cannula could have bacteria or could be dirty if not changed as ordered. Interview on 05/29/2023 at 10:35 AM DON stated oxygen signs lets people know there was oxygen use in a resident room who was using oxygen. DON stated the oxygen sign also lets smokers, visitors, and staff know not to smoke. DON stated the risk of not having an oxygen sign posted could be combustion or a blow up. DON stated rooms [ROOM NUMBERS] needed to have an oxygen sign posted as oxygen was in use in the room. DON stated nasal cannulas needed to be dated to prevent infection and to let nursing staff know the expiration of the oxygen tubing. Record review of the facility oxygen administration policy dated 2003 indicated Place no smoking signs in area when oxygen was administered and stored. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675145 If continuation sheet Page 7 of 9 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 675145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vida Nursing and Rehab Odessa 3800 Englewood LN Odessa, TX 79762 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on the observations, interviews, 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 kitchen reviewed for professional standards for food service safety. A bag of rolls was past the expiration date. The lids and handles of two food storage bins were covered with an accumulation of brown-tinged grime. This failure could place residents at risk of food borne illness. Findings included: Observation on 05/29/2023 at 7:52 AM in the dry storage room of the facility kitchen revealed a large plastic bag of about three dozen wheat rolls with a preparation date of 05/16/2023 and a use by date of 05/25/2023. In an interview on 05/29/2023 at 7:58 [NAME] D said that foods are labeled with date opened/prepared and expiration date which is seven days after preparation or opening. She said that the wheat rolls were prepared in the facility and had expired and so had to be thrown out. She said she saw the dietary manager check food expiration dates daily but that the dietary manager was out of town because of a death in the family. She did not know who was to take over this duty when the dietary manager was out of town. Observation on 05/29/2023 at 8:14 AM in the dry storage room of the facility kitchen revealed two large storage bins that were marked Sugar and Flour. The lids and handles for opening the bins both had accumulations of brown-tinged grime. The sugar bin had sugar crystals adhered to the lid and handle. In an interview on 05/29/2023 at 8:16 AM [NAME] D said that the tops of the flour and sugar bins were not clean. She said that the dietary manager was responsible for making sure the kitchen was clean, but the dietary manager was out of town for a family emergency. She said the kitchen staff did get training on infection control and the dirty food bins posed a risk for cross-contamination which could cause residents to get sick. In an interview on 05/29/2024 at 8:24 AM [NAME] E said that every kitchen worker was given responsibilities for keeping the kitchen clean. She said that the Dietary Aides were supposed to keep the floor of the dry storage room but did not know who was responsible for cleaning the food storage bins clean. In an interview on 05/30/2023 at 8:00 AM the Administrator said that the day before the cook had disposed of the rolls because they were outside the seven-day window for safe food storage. She said that no one had primary responsibility for making sure foods were not beyond the expiration date or that food storage bins were clean but that ultimately the responsibility fell to the kitchen supervisor. The kitchen supervisor was out of town due to a family emergency. The Administrator said that the expired rolls were thrown out because they might not be edible and could put residents at risk of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675145 If continuation sheet Page 8 of 9 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 675145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vida Nursing and Rehab Odessa 3800 Englewood LN Odessa, TX 79762 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 illness. Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy Food Storage and Supplies dated 2012 reflected in part that facility storage areas will be maintained in an orderly manner that preserves the condition of food. Dry bulk foods (e.g., flour, sugar) are stored in containers that are cleaned regularly. The policy did not address expiration time frames for in-house prepared foods such as the rolls. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675145 If continuation sheet Page 9 of 9