Health inspection·November 26, 2025

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated she had been working at the facility for 9 months and worked the morning shift. CNA A stated she was trained on restraints. The last training was last month in September 2025 and was instructed not to add any barriers to Residents that don't allow them from moving freely especially Residents who were fall risk. CNA A walked to Resident #4's room where she witnessed the pillow tucked underneath the bed sheet and Resident #4 lying in bed. CNA A stated, The pillow is used to keep the resident from falling out of the bed because the resident is a constant mover and staff does not want the resident to fall. So, they either place a triangle holder but when staff do not have one, staff will add pillows. CNA A stated fall precautions used where the bed was to the lowest position, floor mats in place, and call lights in reach for all residents. In an interview on 10/24/2025 at 02:25pm the DON was presented with pictures showing Resident #4 with pillows tucked under her bed sheets. The DON stated that the procedure was used to be for repositioning the patient if medically needed. The DON stated that Resident #4 was still capable of getting out of her bed so the pillow being inserted under the bedsheet was not a restraint, but all staff took training on not inserting pillows under bedsheets. Resident #4 does not need any device or pillow for medical needs. In an interview on 10/24/2025 at 02:38 PM, LVN B stated she was the LVN and charge nurse and worked only Monday-Friday from 6AM-2pm. LVN B was shown a picture that had been taken by the surveyor during rounds showing the pillows tucked underneath the bed sheets of residents to prevent them from falling. LVN B stated that the picture showing the pillow tucked under the bed sheets was considered a restraint. LVN B stated that the facility had trained all staff not to do that (referring to the pillow put under the sheet), and it was not medically necessary. LVN B stated Resident #4 had no care plan in her records indicating a medical device, and Resident #4 had been able to ambulate on her own. LVN B stated she had never seen anyone perform this restraint before and did not know if it was something they did to try to keep the residents safe from falling out of bed. CNA's and LVN's, along with all nursing staff, were trained the same way and took responsibility for ensuring these restraints were not being used on residents. Charge nurses were responsible for verifying that these residents were not applied to residents. Charge nurses were also responsible for rounding on residents every 2-3 hours or more if needed. The risk for a resident having that type of restraint could be that the resident could have fallen over the pillow, resulting in a higher and potentially more severe fall. The resident could have become trapped between the wall or bed sheets such as a resident arm or torso, and that practice was not a safe or appropriate situation for residents from safely getting out of bed. A pillow tucked under the bed sheet was considered a restraint because it restricted the residents movement and limited their freedom to move or reposition themselves. Fall Interventions are low beds, floor mats, nurse rounds, CNAs also have documentation in PCC (an electronic health record system tailored for the needs of skilled nursing facilities) on what residents are labeled as a fall risk. In an interview on 10/24/2025 at 03:25 PM, LVN C stated she had worked at the facility for 16 years on the long-term side of the facility. LVN C stated staff had been trained not to place any type of devices or pillows underneath the bed sheets which were considered restraints. LVN C stated if a resident could not move the pillow or device, then it was considered a restraint. LVN C was shown the picture of Resident #4 with a pillow tucked under the bed sheets, and LVN C stated that it was indeed a restraint. LVN C stated staff were not trained to insert any type of pillow or devices under the bed sheets. LVN C stated that the ADON's and the charge nurses on the floors were responsible for overseeing that staff did not apply any of these restraints to the residents. LVN C stated the charge nurses mad sure they conducted rounds every couple of hours to ensure residents were receiving the care they needed. LVN C stated a resident could be at risk of being trapped between the wall or bed sheet and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675479 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 675479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franklin Heights Nursing & Rehabilitation 223 S Resler El Paso, TX 79912 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few could sustain an injury. Resident #5Record review of Resident #5's face sheet dated 10/24/2025, revealed, admission on [DATE] and re-admission on [DATE] Resident #5 was a 90-[NAME] old male diagnosis with muscle weakness (muscles can't work making it hard to perform everyday activities), cerebral infraction (Stroke), dysphagia (difficulty swallowing), lack of coordination (uncontrolled movements or task), cognitive communication deficit (problems with communication), aphasia following cerebral infarction (difficult in communication after stroke), combined forms of age-related cataract, bilateral (in both eyes), acute myocardial infarction (heart attack), unspecified atrial fibrillation (irregular heartbeat), Dementia (affecting the memory), Alzheimer's disease (memory loss). Record review of Resident #5's history and physical dated 06/19/2025, revealed, readmission for Traumatic subdural hemorrhage (bleeding that occurs inside the skull) under total care skilled nursing.Record review of Resident #5's admission MDS dated [DATE], revealed, a severely impaired cognition BIMS score of 03 to be able to recall or make daily decisions. Functional limitation in range of motion revealed number 2 (impairment on both sides) on both upper extremity (Shoulder, elbow, Wrist, hand) and lower extremity (Hip, Knee, ankle foot). Functional abilities were all listed as 1 (Dependent - A helper completed all the activities for the residents. Helper does ALL the effort. Residents does none of the effort to complete the activity. Or the assistance of 2 or more helpers was required for the residents to complete the activity). The resident had a 0 (no) mark for no falls since admissions.Record review of Resident #5's care plan dated 09/16/2025, revealed that resident did not have any focus points on any fall hazards, goals or interventions. During an observation and interview with Resident #5, on 10/24/2025 at 04:53pm, revealed Resident #5 had bed at the lowest position as well as a floor fall mat and was lying at a 45-degree angle in bed. Resident #5 acknowledged the surveyor and stated that he was good. Resident #5 was not coherent and could not remember dates, times, or where he was. Resident # 5 was unaware of why there was a pillow shoved/propped under his bed sheet on his right-side shoulder. In an interview on 10/24/2025 at 03:39 PM, CNA D stated she had been employed at the facility for 18 years and works the morning shift from 6AM-2PM. CNA D stated she had received all training regarding restraints. She stated the training was provided by ADON's and DON's during which staff were instructed not to use pillows or devices for positing or prompting residents. A picture was shown to CNA D, and she stated that the pictures of Resident #5 were a restraint. Resident #5 could had been placed at risk by not being able to get out of bed as it restricts him from movement and reposition, and at risk of injury from attempting to get up or becoming trapped within the bed sheets and the wall. In an interview on 10/24/2025 at 04:23 PM, the Administrator stated that restraints were defined as anything that impeded a resident from performing an action. Pictures were shown to the Administrator, and she stated that if the item impeded the resident, then it was considered a restraint. The Administrator did not provide a direct yes or no answer when asked whether the pictures reflected restraints on residents. The Administrator was unable to identify specific risk on Resident #4 and Resident #5, and she continued to repeat that if it impeded the resident, then it was a restraint.Record review of the facility training dated 08/29/2025 titled Restraint Reduction in Nursing facilities revealed all staff had completed the training as it was a mandated course for September 2025.Record review of the facility's policy titled, Resident Rights, SS 03-09a revealed The resident has a right to be treated with respect and dignity including: 1. The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the residents' medical symptoms. Record review of the facility's policy titled, Nursing policy and procedure Manual; Abuse/Neglect revised 03/29/2018 revealed The resident has the right to be free from abuse, neglect, misappropriation of residents' property, and exploitation as defined in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675479 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 675479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franklin Heights Nursing & Rehabilitation 223 S Resler El Paso, TX 79912 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 Level of Harm - Minimal harm or potential for actual harm this subpart. This includes but was not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.Record review of the facility's policy titled, Restraint Mini Manual; Restraints, MM RE 03-3.0revealed, It is the policy of this facility to maintain an environment that prohibits the use of restraints for discipline or convenience. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675479 If continuation sheet Page 4 of 4