Health inspection·November 1, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #4's electric wheelchair safety assessment dated [DATE] revealed Resident #4 was admitted to the facility with a manual wheelchair. Power wheelchair came later and was given to the patient initially without therapy's safety assessment. Resident #4 was lacking (demonstrating of understanding of safety precautions, safely maneuver of the chair in and out of obstacles and around corners, stop in the chair command, checking for clearance before backing the wheelchair up or turning the wheelchair) in the areas indicated on page one due to medical/physical restrictions and would be referred to therapy for evaluation and treatment if appropriate. During an interview on 10/31/23 at 4:19 PM with the Physical Therapist and Director of Rehabilitation, the Physical Therapist stated when Resident #4 was admitted to the facility the resident was using a manual wheelchair. The Physical Therapist stated the facility had Resident #4's motorized wheelchair shipped from another facility. The Physical Therapist stated a couple of week ago, but did not know the exact date, it was shipped. The Physical Therapist stated Resident #4 had not had a motorized wheelchair assessment conducted when she received her motorized wheelchair a couple of weeks ago. The Physical Therapist stated he had conducted an assessment on Resident #4 in which he only used interviews to formulate (to express in precise form; state definitely or systematically) an assessment for Resident #4. The Physical Therapist stated he had completed the assessment on 10/27/23. The Physical Therapist stated the protocol for conducting an assessment for a motorized wheelchair included the use of obstacles to see how the resident maneuvered around cones with their motorized wheelchair and how well they did with instructions. The Physical Therapist stated he also used interviews in aiding in the assessment. The Physical Therapist stated he did not follow protocol in conducting the obstacle portion of the assessment for Resident #4 on 10/27/23 in which he stated was incomplete. The Physical Therapist stated it was because with the interviews he thought the resident was unsafe and based on immediate course of action. The Physical Therapist stated he normally did not do a motorized assessment with just interviews. The Physical Therapist did not indicate why he did the assessment like that. The Physical Therapist stated it was expected for the facility to notify the therapy department whenever a resident with a motorized wheelchair comes into the facility or has a change of condition that requires a motorized wheelchair. The Physical Therapist stated conducting the motorized assessment was to ensure the safety of the resident. The Physical Therapist stated the risk of not conducting a motorized assessment could be residents getting their feet ran over. The Director of Rehabilitation stated she observed Resident #4 using the motorized wheelchair pretty good but did not indicate when the observation occurred. The Director of Rehabilitation stated the motorized wheelchair assessment was a partial assessment. The Physical Therapist stated due to the assessment being partial, the facility should have not taken away Resident #4's motorized wheelchair on 10/27/23 and given her manual wheelchair which she did not want. The Physical Therapist stated the resident not having her motorized wheelchair was a violation of her rights. During an observation on 11/01/23 at 9:00 AM, revealed Resident #4 was in manual wheelchair moving through the hallway. During an interview on 11/01/23 at 1:52 PM, the Administrator stated when Resident #4 was admitted to the facility, she did not have her motorized wheelchair and the facility paid to have the motorized wheelchair shipped over. The Administrator stated when she received (did not indicate when the motorized wheelchair arrived to the facility) the motorized wheelchair the facility did not conduct a motorized wheelchair assessment for the resident to evaluate if she was safe to operate and use the motorized wheelchair. The Administrator stated the motorized wheelchair was taken on 10/27/23 (did not indicate who took the motorized wheelchair) and she was given a manual wheelchair until the motorized wheelchair assessment was conducted for safety of the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675317 If continuation sheet Page 2 of 13 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 675317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deerings Nursing and Rehabilitation, LP 1020 N County Rd West Odessa, TX 79763 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview on 11/01/23 at 2:40 PM, revealed Resident #4 was using her motorized wheelchair in the hallway near the nurse's station closest to the front entrance. Resident #4 stated she was not assessed when she received her motorized wheelchair. Resident #4 stated the facility took (did not indicate who took her motorized wheelchair) her motorized wheelchair and told her she needed to be assessed for it and could not understand why she was not assessed when she received her motorized wheelchair. Resident #4 stated they took the motorized wheelchair away but had assessed her last Friday (10/27/23) and today (11/01/23) the therapy department finished the assessment with an obstacle course. Resident #4 stated she was told she did great by the Physical Therapist and was educated on the safety and use of the motorized wheelchair. Record review of the facility's electric or motorized wheelchair policy dated 02/27/15 revealed resident's owning/using an electric wheelchair will be assessed on admission, quarterly and upon change of condition for their ability to guide/drive the wheelchair. If the resident was found to be unsafe to himself, others, and or property they will receive instructions on safety and proper operation of the chair by facility staff or therapy. Record review of the facility resident rights did not have a date revealed the right to be informed, in advance, of the care to be furnished and type of care giver or professional that will be furnish care. The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of others. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675317 If continuation sheet Page 3 of 13 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 675317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deerings Nursing and Rehabilitation, LP 1020 N County Rd West Odessa, TX 79763 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow an implemented comprehensive person-centered care plan that included measurable objectives and time frames to meet the residents medical and nursing needs to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #2) reviewed for care plans in that: The facility failed to follow and implement a comprehensive person-centered care plan for Resident #1 in which the resident had a cigarette lighter in his room. This failure could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans followed that address their needs. Findings include: Record review of Resident #2's face sheet dated 10/31/23 revealed admission to the facility on [DATE] to the facility. Record review of Resident #2's history and physical dated 07/03/23 revealed a [AGE] year-old male diagnosed with acquired immunodeficiency syndrome. Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS of 15, to be able to recall information. Resident #2's activities of daily living was supervision with set up only for eating. Resident #2 was diagnosed with cerebrovascular accident (a stroke) and seizure disorder. Record review of Resident #2's care plan dated 07/12/23 revealed no smoking materials or igniter's will be stored in the resident's rooms. During an observation and interview on 10/31/23 at 5:04 PM, revealed Resident #2 had a cigarette pack on his bed. Resident #2 stated he had his lighter and all smokers smoked outside of the facility. Resident #2 stated the facility allowed the residents to keep their lighters and cigarettes. During an interview on 11/01/23 at 7:54 AM, the Administrator stated some facility residents may keep their cigarettes in their rooms but have to turn in the lighters. The Administrator stated if a resident's care plan stated not to have lighters in their rooms, then the facility staff had to follow the care plan. The Administrator stated not following a care plan for a resident that should have lighters in their room could result in fire or the resident lightening up the cigarette. During an interview on 11/01/23 at 8:52 AM, the DON stated the facility residents could have their cigarettes in their rooms but not the lighters. The DON stated nursing staff had to follow a resident's care plan. The DON stated not following Resident #2's care plan could result in fire. the During an interview on 11/01/23 at 10:52 AM, the MDS Coordinator stated that comprehensive care plans made sure the resident got what they needed and identified problems areas as well as good ones. The MDS Coordinator stated it was expected for nursing staff to follow the care plans. The MDS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675317 If continuation sheet Page 4 of 13 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 675317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deerings Nursing and Rehabilitation, LP 1020 N County Rd West Odessa, TX 79763 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinator stated that was how the facility made sure they are meeting the resident's needs. The MDS Coordinator stated she did not know if there was a risk of not following the care plan. The MDS Coordinator stated as per the facility smoking policy there was a risk of the residents having their lighters in their rooms of fires, harming themselves and others. Record review of the facility smoking policy dated 11/01/17 revealed if the facility identified that the resident needed assistance/supervision and or additional protective devices for smoking, the facility included that s information in the resident's care plan, and reviewed and revised the plan periodically as needed. Record review of the facility resident care plan policy not dated revealed the plan of care provides us with a profile of the needs of each resident, identifies the role of each service in meeting these needs, and the supporting measures each service will use to accomplish these goals. Record review of the facility comprehensive care planning policy not dated revealed the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675317 If continuation sheet Page 5 of 13 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 675317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deerings Nursing and Rehabilitation, LP 1020 N County Rd West Odessa, TX 79763 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations, interviews, and record reviews, the facility failed to ensure that the residents environment remained free of accidents hazards as was possible and each resident receives adequate supervision to prevent accidents for 1 (Resident #2) of 6 residents reviewed for cigarette lighters and 1 (Resident #1) of 3 residents reviewed for elopement accidents. The facility failed to ensure Resident #2 had his cigarette lighter in his room. The facility changed the door pad locks and failed to test them which led to Resident #1 having an elopement. This failure could place residents at risk of fire and elopements. Findings include: Resident #2 Record review of Resident #2 face sheet dated 10/31/23 revealed admission on [DATE] to the facility. Record review of Resident #2's history and physical dated 07/03/23 revealed a [AGE] year-old male diagnosed with acquired immunodeficiency syndrome. Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS of 15 to be able to recall information. Resident #2's activities of daily living was supervision with set up only for eating. Resident #2 was diagnosed with cerebrovascular accident (a stroke) and seizure disorder. During an observation and interview on 10/31/23 at 5:04 PM Resident #2 had cigarette pack on his bed. Resident #2 stated he had his lighter and all smokers smoked outside of the facility. Resident #2 stated the facility allowed the residents to keep their lighters and cigarettes. During an interview on 11/01/23 at 7:40 AM, revealed Resident #3 was outside in the smoking area and stated the responsible residents were allowed to have and keep their lighters. Resident #3 stated it was okay with the facility staff. During an interview on 11/01/23 at 7:54 AM, the Administrator stated that residents may smoke by themselves with no supervision as they were cognitively (the mental processes that take place in the brain, including thinking, attention, language, learning, memory and perception) able to do so. The Administrator stated the facility residents who smoked had to request the lighter as they are not allowed to have the lighters in their rooms. The Administrator stated there was a risk if the residents had their lighters in their rooms. The Administrator stated anytime the facility staff are aware that the residents have lighters they do ask for them. The Administrator stated that the risk was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675317 If continuation sheet Page 6 of 13 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 675317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deerings Nursing and Rehabilitation, LP 1020 N County Rd West Odessa, TX 79763 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 0689 potentially the resident smoking in the room or lightening a fire. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 11/01/23 at 8:00 AM, the Administrator was seen going up and down hallways 400 and 300 with a list of smokers. Once the Administrator had gone through the list, he came back with 4 lighters in hand that residents had given him. Residents Affected - Some Observation on 11/01/23 at 8:20 AM with the Administrator revealed at the nurse's station that an orange tackle box (a box designed for fishing equipment) contained cigarettes but no lighters. LVN A stated the residents had the lighters. During an interview on 11/01/23 at 8:52 AM, the DON stated the residents could have their cigarettes in their rooms but not the lighters. The DON stated the risk of having the lighters in their rooms could be smoking in their rooms, fire, and flammability for oxygen. On 11/01/23 at 8:30 AM the Administrator was asked for the resident admission packet smoker notification sheets for those who smoke but did not receive them. Record review of the facility smoking policy dated 11/01/17 revealed matches, lighters or other ignition sources for smoking are not permitted to be kept or stored in a resident's room. Record review of the facility resident admission packet smoker notification sheet dated 11/01/17 revealed it was imperative that matches, lighters, and other sources of ignition for smoking be given to the charge nurses or one of the department heads at the nursing center. Under no circumstances can these items be kept in your room. Resident #1 Record review of Resident #1's face sheet dated 10/31/23 revealed admission on [DATE] and readmission on [DATE] to the facility. Record review of Resident #1's history and physical dated 05/04/23 revealed a [AGE] year-old female diagnosed with dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Alzheimer disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), and schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior). Record review of Resident #1's MDS dated [DATE] revealed a BIMS of 5, this interview was to see how much the resident could recalled information. Resident #1 was diagnosed with Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Record review of Resident #1's care plan dated 07/20/20 revealed at risk for wandering. Distract resident from wandering by offering pleasant diversions, structed activities, food, conversation, television, book. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. If the resident was exit seeking, stay with the resident and notify the charge nurses by calling out, sending another staff member, call system, etc. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675317 If continuation sheet Page 7 of 13 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 675317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deerings Nursing and Rehabilitation, LP 1020 N County Rd West Odessa, TX 79763 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #1's elopement assessment dated [DATE] revealed a score of 7 on resident wanting to leave the facility. Resident #1 understood and verbalized acceptance of need for nursing home care. No previous attempts to leave own residence/facility. Record review of Resident #1's progress notes dated 10/26/23 written at 6:31 PM revealed at 8:58 PM Resident #1 was noticed to be in the parking lot by the bushes, when coming to lobby the door alarms were sounding, resident was ambulating with rollator, wander guard in place, upon approaching resident she was mildly hesitant to return to building, but able to be redirected. When ask how she got out stated she held the hand bar down till opening. Placed resident on one-to-one watch, no injuries noted. Notified Administrator, DON, NP, and family. Record review of Resident #1's elopement nurses note 12-hour dated 10/27/23 revealed Resident #1 was placed on one to one, wander alarm bracelet, keypad door exit, scheduled medication. During an interview on 10/31/23 at 4:58 PM, Resident #1 stated she felt the walls were closing in and wanted to take a breather. Resident #1 stated she went out through the front entrance door of the facility while she had her wander guard on. Resident #1 stated she had no injuries and wanted to get away for a while. During an interview on 11/01/23 at 10:05 AM, the Maintenance Director stated he changed the door pad system at the front entrance of the facility on 10/26/23 and it lost power. The Maintenance Director stated he was not trained on the door pad system. The Maintenance Director stated if staff were trained on the secure care system, then there would have not been a risk. The Maintenance Director stated they did not test the wander guards when they re-set the system on 10/26/23. The Maintenance Director stated the wander guards were tested weekly. The Maintenance Director stated he had called the systems technician on 11/01/23 to re-inspect the system. The Maintenance Director stated the DON tested Resident #1's wander guard when the facility gave it to her on 10/11/23. The Maintenance Director stated Resident #1 was wearing her wander guard when she left the faciity on [DATE] when the door pad lost power. During an Interview on 11/01/23 at 10:32 AM, the Administrator stated that the door pad codes are changed every so often and when the Maintenance Director had changed the door pad system on 10/26/23 when something went wrong with the system. The Administrator stated the Maintenance Director was not trained on the door pad system and should have been properly trained on the secure care system. The Administrator stated the wander guard was not tested after the door pad codes were changed to ensure they were working properly. During an interview on 11/01/23 at 3:49 PM, the Administrator stated Resident #1 was last seen in the facility at 9:06 PM by CNA D. The Administrator stated at 9:41 PM when CNA D was clocking out, he exited the front door and saw Resident #1. The Administrator stated at 10:17 PM Resident #1 was assessed by nursing and found not to have any injuries. The Administrator stated nursing staff checked on residents every 2 hours. The Administrator stated Resident #1 was placed on one to one and remained in the lobby area until the door pad was fixed. The Administrator stated the wander guards were tested every month. The Administrator stated Resident #1 received a wander guard on 10/11/23 that was tested before being placed on her. The Administrator stated that had been the first time Resident #1 had eloped. The Administrator stated they conducted elopement drills every month. The Administrator stated the facility had two other residents who had wander guards on. The Administrator stated since the one to one staff member was at the front door with Resident #1 there was no need for any interventions to be placed on the other two residents with wander guards on. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675317 If continuation sheet Page 8 of 13 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 675317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deerings Nursing and Rehabilitation, LP 1020 N County Rd West Odessa, TX 79763 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the facility Task(s) testing sheets from 09/01-10/31/23 revealed that the wander guards and the secure care system were checked every week to ensure they were working. Record review of secure care installation manual 135DE system dated 07/01/10 revealed it was the responsibility to assure that any person who might be installing, setting up, testing, maintaining or repairing the secure care system knows the contents of and has access to the products manuals and has successfully completed secure care technical training. Secure Care does not authorize and strongly recommends against, any installation or field replacement of software, parts, or products by untrained contractors or facility staff. Such work can be hazardous, can render the system ineffective. Regardless of how secure cares software parts or products are obtained, they should not be installed, set-up, tested, supported, maintained or repaired by any person who has not satisfactorily completed that technical training (a qualified service technician). The manual had a section II Testing for wander guard. Record review of secure care 430KHz wander guard dated 04/13/22 revealed the secure care must be installed, set-up, tested, supported, operated, maintained, repaired and used only in accordance with all manuals and instructions (including the user, installation, technical and other manuals) issued by secure care. IT was your responsibility to assure that any person who might be installing, setting-up, testing, supporting, maintain or repairing the secure care system knows the contents of and has access to the product manuals and had successfully completed secure care technical training. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675317 If continuation sheet Page 9 of 13 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 675317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deerings Nursing and Rehabilitation, LP 1020 N County Rd West Odessa, TX 79763 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 1 (Resident #1) of 2 residents observed for oxygen management. Residents Affected - Few The facility failed to ensure Resident #1 had a physician's order for oxygen use. The facility failed to ensure Resident #1 had an oxygen sign posted outside of her bedroom. These failures could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support, decline in health, and may be exposed to potential flammability. Findings included: Record review of Resident #1's face sheet dated 10/31/23 revealed admission on [DATE] and readmission on [DATE] to the facility. Record review of Resident #1's history and physical dated 05/04/23 revealed a [AGE] year-old female diagnosed with chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). Record review of Resident #1's MDS dated [DATE] revealed a BIMS of 5, this interview was to see how much the resident could recalled information. Resident #1 was diagnosed with Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). The MDS did not indicate Resident #1 was on oxygen therapy. Record review of Resident #1's care plan dated 07/20/20 revealed Resident #1 had impaired gas exchange related to chronic obstructive pulmonary disease and to give oxygen therapy as ordered by the physician. Record review of Resident #1's physician's order recapitulation was reviewed on 10/31/23 revealing no new orders for oxygen use. During an observation on 10/31/23 at 4:55 PM, revealed Resident #1's room had a black colored concentrator in the room that was not being used. Resident #1 was in the room, lying down on her bed watching television. Resident #1 had no signs of respiratory distress. Observation at 4:56 PM revealed there was no oxygen sign posted outside of Resident #1's room. During an interview on 10/31/23 at 4:58 PM, Resident #1 stated she had oxygen and only used it when she needed it due to not being able to breathe. During an interview on 11/01/23 at 8:52 AM, the DON stated residents on oxygen required an oxygen sign posted outside of the resident's' room. The DON stated the oxygen signs let everyone know that there was oxygen in use in the room. The DON stated there was no risk of not having an oxygen sign posted outside of the residents' rooms who used oxygen. The DON stated Resident #1 does not use oxygen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675317 If continuation sheet Page 10 of 13 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 675317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deerings Nursing and Rehabilitation, LP 1020 N County Rd West Odessa, TX 79763 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 and had an incident earlier in the day yesterday (10/31/23) that required the use of oxygen as the resident had a fall. The DON stated Resident #1 should have had a doctor's order for the use of oxygen. The DON confirmed that Resident #1 had no doctor's order for oxygen use. The DON stated it was the responsibility of the nurses to make sure the orders are placed. The DON stated there was a risk for not placing orders but did not indicate what it was. Residents Affected - Few Observation and interview on 11/01/23 at 8:31 AM, revealed the Administrator viewed the concentrator inside of Resident #1's room and that there was no oxygen sign posted outside of Resident #1's room. The Administrator stated if residents were using oxygen, then an oxygen sign had to be posted outside of their rooms. The Administrator stated the risk of not having an oxygen sign posted was flammability. During an interview on 11/01/23 at 1:35 PM, the Administrator stated the facility did not have a physician's orders policy. Record review of the facility oxygen administration policy dated 02/13/07 revealed to place a no smoking signs in the area when oxygen was administered and stored. The policy did not address orders for oxygen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675317 If continuation sheet Page 11 of 13 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 675317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deerings Nursing and Rehabilitation, LP 1020 N County Rd West Odessa, TX 79763 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to store all drugs in locked compartments for 1 resident (Residents #2) of 4 reviewed for medication administration in that: Resident #2 had medication in a medication cup that he saved in his room to have tested to see if it was his correct medication in his drawer. This failure could result in a decline in health due to incorrect medication administration and inaccurate count of controlled medications. Findings included: Record review of Resident #2's face sheet dated 10/31/23 revealed admission on [DATE] to the facility. Record review of Resident #2's history and physical dated 07/03/23 revealed a [AGE] year-old male diagnosed with acquired immunodeficiency syndrome. Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS of 15 to be able to recall information. Resident #2's activities of daily living was supervision with set up only for eating. Resident #2 was diagnosed with cerebrovascular accident (a stroke) and seizure disorder. Record review of Resident #2's care plan dated 07/31/23 revealed Resident #2 used anti-anxiety medications (xanax). Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness. Resident had schizoaffective bipolar (bipolar disorder primarily causes extreme mood shifts, whereas schizophrenia causes delusions and hallucinations) type with delirium (a mental state in which you are confused, disoriented, and not able to think or remember clearly) due to physiologic condition (something that is normal, that is due neither to anything pathologic nor significant in terms of causing illness). Administer medications as ordered and monitor/document for side effects and effectiveness. Record review of Resident #2's physician's order recapitulation dated 07/12/23 indicated alprazolam oral tablet 0.25 MG (for anxiety), 1 tablet by mouth two times a day, Emtricitabine-Tenofovir (the prevention and treatment of HIV infection in adults) oral by mouth one time a day for HIV. Record review of Resident #2's administration report dated 10/31/23 for the month of October 2023 revealed Resident #2 had taken all his ordered medications everyday expect Alprazolam (anxiety medication) which was not marked down for one day (10/19/23). During an interview on 11/01/23 at 8:31 AM, the Administrator stated it was expected for nursing staff to witness the residents taking their medications. The Administrator stated it was an agreement between the facility and Resident #2 to leave the medication (crushed with apple sauce) on the nightstand until the resident was ready to take it. The Administrator did not indicate the risk of not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675317 If continuation sheet Page 12 of 13 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 675317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deerings Nursing and Rehabilitation, LP 1020 N County Rd West Odessa, TX 79763 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few observing the medication being taken by the resident. The Administrator stated they did not know Resident #2 had medication in his room. During an interview on 11/01/23 at 8:33 AM, the Medication Aide stated anytime a resident was given their medications the nurse or medication aide had to stay there and make sure the resident took the medication unless they refused. The Medication Aide stated the risk would be the resident pocketing the medication, overdosing on the medication, or they could bottom out (to have reached the lowest point in a continuously changing situation and to be about to improve). The Medication Aide stated if the risk for a resident on HIV medication and not taking it could cause the viral load to go back up. During an interview on 11/01/23 at 8:52 AM, the DON stated it was expected for the nursing and medication aide that when given residents' medication that they stay there to ensure the resident took it or refused it. The DON stated the risk of leaving the medication and not ensuring the resident took it was the resident could save it, someone else could grab it and take it. The DON stated she did not know if there was a risk if Resident #2 did not take his HIV medication. During an observation and interview on 11/01/123 at 8:57 AM, revealed Resident #2 showed a medication cup with yellowish material inside the cup. It had a tiny rock size material that was mixed and was not a lot. Resident #2 stated the nursing staff had left the medication cup on his nightstand and had left his room. Resident #2 did not indicate what day this happened on. Resident #2 stated he started taking his medication when he noticed it tasted weird and decided to keep it to have someone test it. Resident #2 stated normally he would receive his medication crushed and mixed in apple sauce. Resident #2 could not remember when that medication was from. During an interview on 11/01/23 at 9:50 AM, Resident #2 stated that it was an agreement between the facility and him to leave the medication on the nightstand. Resident #2 stated the nursing staff crushed the medication and mixed it was apple sauce but the cup he had did not taste right. Resident #2 stated he did not like the nursing staff who gave it to him, and the nursing staff did not come back to check on him to see if he had taken it. During an observation and interview on 11/01/23 at 10:14 AM with LVN C revealed LVN C was observed getting Resident #2's medication out and crushing it. It was then mixed with apple sauce. LVN C was seen going into Resident #2's room in which he was given his medication with LVN C standing there half in the room making sure Resident #2 took his medication. LVN C stated he had to make sure that all residents receiving medication were seen taking or refusing their medication. LVN C stated it was expected of the nurses and medication aides to stay there while the residents were taking their medications. LVN C stated there could be a risk if staff didn't visually see the resident taking the medication. LVN C stated the risk could be anything. Record review of the facility's medication administration policy dated 10/25/17 revealed medications were to be poured, administered and charted by the same licensed person. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675317 If continuation sheet Page 13 of 13