Health inspection·December 15, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #5's weekly ulcer assessment dated [DATE] revealed a coccyx unstageable pressure ulcer that measured 7.5 cm in length, 12.5 cm in width, and 0 for depth. Reason for no depth was marked as superficial. Eschar, black, brown or tan adhered to the wound. During interview on 12/15/23 at 9:57 am, Resident #5's RP stated she was not aware of Resident #5 coccyx wound had gotten significantly bigger. Resident #5's RP stated she was made aware of Resident #5 coccyx wound on 12/08/23 by a family member who had gone to visit Resident #5 at the hospital. Resident #5 RP stated she had called the DON asking questions and was told Resident #5's coccyx wound had gotten bigger after her return from the previous hospitalization. During interview on 12/15/32 at 11:11 am, the DON stated Resident #5 had a hospitalization in September per family request to revoke palliative care services. The DON stated when Resident #5 returned from that hospitalization in 9/21/23 her coccyx wound had gotten bigger, and the charge nurse should had reported that to the Resident #5's RP. The DON stated family had accompanied Resident #5 when she returned on 09/21/23 to the facility but was not sure if Resident #5's RP had been notified of the worsening coccyx pressure ulcer. The DON stated the charge nurses were responsible of notifying residents' RP of any changes to the resident. During an interview on 12/15/23 at 11:49 am, RN A stated she had worked the day Resident #5 returned from her last hospitalization and had seen her coccyx pressure ulcer had gotten bigger. RN A stated family was present upon Resident #5 readmission and they had seen her coccyx wound at bedside. RN A stated she did not document that in Resident #5 electronic records and had no documentation to show Resident #5's RP was made aware of Resident #5's coccyx wound worsening post hospitalization. Record review of Family Notification policy dated 2003 revealed in part Objective: To keep families informed. Procedure: The family will be notified of any resident change, i.e., health problem, new interest through: telephone call, verbal exchange when family member is in the facility, or regular report. Record review of Resident Rights policy undated revealed in part A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Exercise of rights: 3. In the case of a resident who has not been adjudged incompetent by the state court, the resident has the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by state law. The same-sex spouse of a resident must be afforded treatment equal to that afforded to an opposite-sex spouse if the marriage was valid in the jurisdiction in which it was celebrated. The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the resident representative; b. The resident retains the right to exercise those rights not delegated to a resident representative, including the right to revoke a delegation of rights, except as limited by State law; 4. The facility must treat the decisions of a resident representative as the decisions of the resident to the extent required by the court or delegated by the resident, in accordance with applicable law. Planning and implementing care: 3. The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-- a. Facilitate the inclusion of the resident and/or resident representative; b. Include an assessment of the resident's strengths and needs; c. Incorporate the president's personal and cultural preferences in developing goals of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675317 If continuation sheet Page 2 of 4 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 12/15/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 1 of 10 residents (Resident #6) reviewed for medical records. The facility failed to ensure Resident #6's electronic records accurately documented emesis assessment. This failure could place residents at risk of not receiving potential needed services. Findings include: Record review of Resident #6's face sheet dated 12/15/23 revealed a [AGE] year old female who was re-admitted to the facility on [DATE] with diagnoses of dementia (group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), acute on chronic congestive heart failure (long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), peptic ulcer (sore that develops on the lining of the esophagus, stomach, or small intestine), and ataxia (degenerative disease of the nervous system). Record review of Resident #6's history and physical dated 10/31/23 revealed diagnose of chronic deep vein thrombosis (blood clot in a deep vein, usually in the legs). Record review of Resident #6's quarterly MDS assessment dated [DATE] revealed a BIMS score of 04, she was severely cognitive impaired. Record review of Resident #6's electronic records revealed no emesis (vomiting) assessment completed on 12/11/23. Record review of Resident #6's TARS dated December 2023 revealed Zofran Oral Tablet 8 MG (nausea medication) was administered on 12/11/23 at 2:12 pm by RN A. During interview on 12/15/23 at 11:49 am, RN A stated she worked on 12/11/23 and was the nurse responsible for Resident #6. RN A stated that morning Resident #6 received a shower in the morning and appeared well. RN A stated at around 2 pm, CNA B had reported to her that Resident #6 had an emesis and was not feeling well. RN A stated she went to assess Resident #6 and saw emesis on her that was clear in color, could not remember the amount she noted, and had taken her vitals that were within normal range. RN A sated Resident #6 complained of nausea and administered Zofran shortly after. RN A stated she re-assessed Resident #6 around 3 pm and she appeared well, had stated she felt better. RN A stated she did not document her assessment for Resident #6 that day and did not give reason for failure. RN A stated risks included lack of monitoring that could result and not identifying a change in condition. On 12/15/23 at 2:28 pm, Surveyor called CNA B there was no answer and left a voicemail to return call. CNA B did not return call by date and time of exit. During interview on 12/15/23 at 3:26 pm, the DON stated she was aware of Resident #6 emesis on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675317 If continuation sheet Page 3 of 4 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 12/15/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 12/11/23. The DON stated RN A had reported to her Resident #6 had an emesis and was provided Zofran as ordered. The DON stated she had not checked the progress notes but was expected for the nurses do document all assessments on electronic records. The DON stated she was responsible for ensuring documentation was accurate and would check weekly and had not noticed Resident #6 had missing documentation. The DON stated risks included inaccurate records that could affect the monitoring the resident may require and failure to identify a change in condition. Record review of Documentation policy dated May 2015 revealed in part Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness, legibility and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets (daily, weekly, monthly, discharge). Documentation also occurs in the clinical software Point Click Care (PCC). All documentation and clinical records are confidential and can be released only with signed permission of the resident or legal representative. Goal: 1. The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. Procedure: 6. Document completed assessments in a timely manner and per policy. 7. Complete documentation in narrative nursing notes as needed in a timely manner. Each entry will be dated and timed. Each entry will be signed with proper signature and title. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675317 If continuation sheet Page 4 of 4