Health inspection·August 10, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few should use a napkin, but the napkin was already dirty. CNA C then went into the resident's bathroom and came back with a hand-full of paper towels. CNA C gave Resident #3 another bite of food and wiped her mouth with a paper towel. CNA C was then observed to feed Resident #3 several more bites of food, and scraped the excess food off Resident #3's mouth with the edge of the spoon several more times. In an interview on 08/08/2022 at 12: 30 PM, LVN C stated staff were supposed to wipe the resident's mouths with a damp wash cloth and they were not supposed to remove excess food from the resident's mouths using a spoon. Record review of the facility policy Assistance with Meals, dated 07/2021, documented in part residents would receive assistance with meals in manner that met their individual needs. Residents who cannot feed themselves would be fed with attention to dignity. Record review of the facility policy Quality of Life -Dignity, dated 08/2009, documented in part residents would be cared for in a manner that promoted and enhanced their dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 2 of 27 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 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nazareth Living Care Center 1475 Raynolds St El Paso, TX 79903 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the right to request, refuse and/or discontinue treatment to participate in or refuse to participate in experimental research, and to formulation an advance directive for one of 15 residents (Resident #20) reviewed for advance directives. The facility failed to ensure Resident #20's Out of Hospital Do Not Resuscitate order was completed correctly. This failure could place residents at risk of not having their health care wishes honored. Findings include: Record review of Resident #20's Electronic document called admission Record, dated 08/10/2022, documented in part that she was a [AGE] year old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. She had diagnoses which included Gastroparesis (problems with the normal muscle movements of the stomach) , hemiplegia and hemiparesis (Paralysis of one side of the body) following unspecified cerebrovascular disease affecting left dominant side, Chronic Obstructive Pulmonary disease, Type 2 diabetes, Major Depressive Disorder, Other Alzheimer's disease, and Anxiety disorder. Her Code Status was DNR (Do not resuscitate). Record review of Resident #20's quarterly MDS, dated [DATE], documented her BIMS was 12, which indicated moderate cognitive impairment. She had moderate symptoms of depression. She required extensive assistance for most activities of daily living. Record review of Resident #20's Medication Recap, for 08/02/2021 through 08/31/2022, documented in part physician's orders for a DNR were in place from 08/14/2019 through 05/02/2022. Beginning on 05/03/2022 a new order for DNR was put in place and was still in force. Record review of Resident #20's care plan, dated 05/09/2022, documented in part her code status was DNR. Record review of Resident #20's Out of Hospital Do-Not-Resuscitate Order, dated 10/17/2014 and 10/20/2014, documented in part no dates on which the resident's qualified relative signed the DNR, and no dates in the acknowledgement that the document had been properly completed. The instructions on the reverse of the DNR stated, in part, in Section C for residents who were incompetent or otherwise incapable of communication the DNR could be enacted by a qualified person by signing and dating the DNR. In an interview on 08/10/2022 at 3:38 PM, the DON said she had temporarily taken over social work duties in mid-May of 2022 and part of her duties were to review Advance Directives for completeness. She said if a Do Not Resuscitate order was not filled out properly, she would notify the physician in order to get it completed properly. She was not aware the DNR for Resident #20 was not completed properly and said it was important to have Advance Directive filled out correctly so the resident or family wishes were carried out. Record review of the facility policy Advance Directives, dated 12/2016, documented in part Advance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 3 of 27 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 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nazareth Living Care Center 1475 Raynolds St El Paso, TX 79903 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 0578 Directives would be respected in accordance with state law. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 4 of 27 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 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nazareth Living Care Center 1475 Raynolds St El Paso, TX 79903 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents had a safe, clean, comfortable and homelike environment, which included but not limited to clean bed and bath linens that were in good condition for three halls (Second floor halls) of five halls reviewed for sufficient bath towels. The facility failed to ensure towels were available on the second floor when residents were scheduled to be bathed. This failure could place residents at risk of decreased quality of life due to not having clean towels to dry off with after bathing. Findings include: Record review of Resident #44's electronic document titled admission Record, dated 08/10/2022, documented in part an [AGE] year-old female who was first admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included chronic obstructive pulmonary disease, asthma, chronic kidney disease, vascular dementia without behavioral disturbance, anxiety disorder, Parkinson's disease and hypertension (high blood pressure). Record review of Resident 44's quarterly MDS, dated [DATE], documented in part her BIMS was 10, which indicated moderate cognitive impairment. She required extensive assistance from one person to move around in bed, transfer between surfaces, move around the facility, eat, use the toilet and for personal hygiene. She needed physical help from one person in order to bathe. Record review of Resident #44's care plan, dated 03/29/2019, documented in part she required assistance with ADLs which included bathing to assist in maintaining a sense of dignity by being clean, dry, odor free, and well-groomed. This would be accomplished by providing physical help in part of bathing activity by one person. She preferred to get up at 06:30 AM and be ready for the morning meal. In an interview on 08/08/22 at 09:05 AM Resident #44 said her baths were scheduled for Tuesday, Thursday and Saturday mornings, but there were no towels available in the mornings. Staff had to use flannel sheets to dry her off, which she did not like. She said she heard from other residents that there was only one worker in the laundry so the laundry was behind in getting the towels washed in time. 2. Record review of Resident # 28's quarterly MDS, dated [DATE], documented in part her BIMS was 5, which indicated severe cognitive impairment. She required extensive assistance from one person to move around in bed, transfer between surfaces, move around the facility, use the toilet and for personal hygiene. She was totally dependent on one staff member for bathing. Record review of the facility floor plan documented there were three halls on the second floor labeled South, East and North, three of five halls reviewed for availability of clean towels. Observation on 08/08/22 at 09:45 AM of the linen closet in the East Hall revealed there were no towels in the linen closet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 5 of 27 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 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nazareth Living Care Center 1475 Raynolds St El Paso, TX 79903 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 0584 Observation on 08/10/22 at 08:13 AM of the linen closet on the South Hall revealed it contained no towels. Level of Harm - Minimal harm or potential for actual harm Observation on 08/10/22 at 08:16 AM of the linen closet in the East Hall revealed it contained no towels. Residents Affected - Some In an interview on 08/08/22 at 09:53 AM Resident #28 said sometimes there were no towels when it was time for her bath, which she said reflected poor planning on the part of the facility. In interview and observation on 08/10/22 at 08:16 AM, CNA C was seen looking in the East Hall linen closet. She said she was looking for bath towels. She said she had towels to bathe one resident but had two more to bathe that morning. CNA C was observed going to the North Hall linen closet and looking there for towels, but none were found. She was observed going to the South Hall linen closet where she found no towels. She said this was the first time she did not find towels, but when this happened, she would use a poncho to dry the resident. She pointed out flannel sheets in the linen closet. She said when there were no towels the lady from laundry would bring more. In an interview on 08/10/22 at 08:54 AM, CNA D said she looked for towels to bathe residents. CNA D said she thought the facility did not have enough towels. She said two or three times a week when she came to work in the mornings they were still washing and drying the towels. She said she thought this was because there were not enough laundry workers. She said when she arrived to work on 08/10/2022 there were no towels in the linen closets. She said some mornings there were a few towels in the closets and some residents had their own towels. More towels were put in the closets later in the morning, but many residents had their showers in the early morning before breakfast. In an interview on 8/10/2022 at 9:26 AM, Laundry Staff E said she was scheduled to work from 5:00 AM to 3:00 PM. When she arrived in the mornings, she gathered all the dirty linen and clothing from the first and second floors and washed them starting first with towels, washcloths, and sheets. After drying and folding, linens were distributed to the floor around 7:30 or 8:00 AM. She said the facility was most frequently short on towels and sheets, and sometimes she had to throw away heavily soiled or stained towels. She advised her manager (Housekeeping Manager) when she was short on linens, and it usually took a week to get more. She said that the Housekeeping Manager was no longer working at the facility. In an interview on 08/10/2022 at 3:13 PM, the Director of Support Services said he oversaw the Housekeeping Department, which over saw the Laundry, but the position of Housekeeping Manager was currently vacant and had been for 1.5 weeks. He said based on his understanding the facility had only been short on towels once. He said laundry workers picked up dirty linens throughout the day and clean linens were delivered to the floor about every 30 minutes or so. CNAs could advise anyone if they were short on linens and linens would be made available. New linens were ordered by Central Supply. In an interview on 08/10/2022 at 3:25 PM, the Central Supply Manager said she ordered new linens every 2-3 months. She heard that morning (08/10/2022) there was a shortage of towels, but she had already placed an order on 08/08/2022 for 180 washcloths and 2 dozen towels. In observation and interview on 08/10/2022 at 3:35 PM the Director of Support Services said the facility had received the towels ordered 08/08/2022 and showed the surveyor a box containing packaged towels and washcloths. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 6 of 27 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 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nazareth Living Care Center 1475 Raynolds St El Paso, TX 79903 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 0584 Record review of the facility policy, Laundry and Bedding, Soiled, dated 07/2009, did not address shortages of linens. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 7 of 27 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 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nazareth Living Care Center 1475 Raynolds St El Paso, TX 79903 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 4 residents (Resident #31) reviewed for MDS records. Residents Affected - Few The facility failed to ensure Resident #31's MDS reflected anticoagulant use on her most current MDS assessment. This deficient practice could place residents at risk by not having accurate and complete assessments which could cause them to not receive appropriate care. Findings include: Record review of Resident #31's face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included peripheral vascular disease and an internal pacemaker . Peripheral vascular disease is a condition that causes narrowing of blood vessels, which can lead to blood flow blockage. An internal pacemaker helps regulate the heart rate. Record review of Resident #31's History and Physical, dated 07/11/22, reflected she took an anticoagulant due to having an internal pacemaker. Record review of Resident #31's physician orders revealed Rivaroxaban Tablet 15 MG. Give 1 tablet by mouth one time a day for thromboembolism/stroke prophylaxis with dinner. Medication was ordered on 7/8/22. The order listed the medication under the anticoagulant category. Record review of physician progress notes dated 8/8/22, revealed Resident #31 was to continue with Deep Vein Thrombosis prophylaxis. Record review of care plan dated 7/15/22, revealed Resident #31 had Peripheral Vascular Disease related to heart disease. The goal for the diagnosis was to be free of symptoms from the Peripheral Vascular Disease. Interventions included giving anticoagulant medications as ordered to improve blood flow. Record review of the MAR revealed Resident #31 received Rivaroxaban every day starting on 7/9/22 and would continue to receive it. Record review of the admission MDS, dated [DATE], revealed in category N (medications) Resident #31 did not have anticoagulant medication listed under ''Medications Received.'' In an interview with the MDS nurse on 08/10/22 at 11:30 AM, he said his job was to ensure the MDS assessments were completed as well as the care plans. He said he participated in the care plan meetings and discharge process. He said if there was ever a change in a residents' condition then it would qualify it for a change in the MDS. He said if the resident had an anticoagulant, then more things would have to qualify it for it to be on the MDS ; such as when the medication was ordered and if the resident had been taking the medication. He said for Resident # 31, the anticoagulant section on MDS change would have to depend on the time frame from when the medication was ordered. He said, for [Resident #31] the original MDS was done on 7/12/22 and it was not coded for the anticoagulant because it was not given then. He looked at Resident #31's MAR and said he was wrong about the medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 8 of 27 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 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nazareth Living Care Center 1475 Raynolds St El Paso, TX 79903 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not being administered. He said Resident #31 got her first dose of anticoagulant on 7/9/22 and the MDS was done on 7/12/22. He said he was the one who completed her MDS. He said the anticoagulant section should have been marked under medications. He said I'm busy and sometimes I'm pulled in different directions. I did not notice the date of the medication. He said he did not know if the nurses used the MDS as their only source of information for resident care. He said, I can't speak for them. He said if the information on the MDS was incorrect, then it could put the resident at risk. He said, The resident can be put at risk, any risk really. I don't know In an interview on 8/10/22 at 2:16 PM with LVN C, she said she used MDS assessments as part of her job. She said they were used for care planning. She said she used the information from the MDS at times and had never encountered problems with the MDS being inaccurate. She said we have care plan meetings and the DON, ADON, and MDS nurse is there too. They see all the things that have been changed and are updated on the residents' condition. She said, I don't know what risk can happen with the MDS not being right. Record review of the facility's policy titled MDS Assessment Coordinator, revised in February 2008, read in part .each individual who completes a portion of the assessment (MDS) must certify the accuracy of that portion of the assessment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 9 of 27 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 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nazareth Living Care Center 1475 Raynolds St El Paso, TX 79903 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure assessments, including both the comprehensive and quarterly review assessments were reviewed and revised by the interdisciplinary team after each assessment for 4 of 6 residents (Resident #18, Resident #21, Resident #7, Resident #154) reviewed for assessments. 1. The facility failed to ensure Resident #18, Resident #21 and Resident #7's comprehensive care plan reflected they required a Hoyer lift transfer x2 people. 2. The facility failed to ensure Resident #154 comprehensive care plan reflected the resident had diabetes and lactose intolerance. These failures could place residents at risk of fall with potential injury, and at risk of not receiving necessary treatment for their diagnoses. Findings include: 1. Record review of Resident # 18's admission Record, dated 8/8/22, revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Record review of Resident # 18's History and Physical, dated 3/2/22, revealed diagnoses which included muscle wasting and atrophy, abnormalities of gait and mobility, lack of coordination, and stiffness of left shoulder. Record review of Resident # 18's Quarterly MDS assessment, dated 6/2/22, revealed a BIMS score of 08, which indicated she had moderate cognitive impairment. Section G. ADLs revealed B. Transfer: extensive assistance with two-person physical assist. Record review of Resident # 18's Care Plan, dated 4/4/22, revealed a focus ADL self-performance deficit related to generalized weakness with interventions for transfer indicated she required extensive assistance (x2) staff participation with transfers. The care plan did not address a Hoyer lift. Observation and Interview on 08/08/22 at 10:31 AM, Resident # 18 was sat in her wheelchair. Resident # 18 stated in the past 2 people would always do a Hoyer transfer. Resident # 18 stated CNA's have been transferred her using a Hoyer lift for a while now. Resident # 18 stated often times CNAs would transfer her with a Hoyer lift alone, rare times would they ask for help or do a two person Hoyer lift transfer. 2. Record review of Resident #21's admission record, dated 8/9/22, revealed a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident # 21's History and Physical, dated 12/29/21, revealed she had a diagnosis which included Osteoarthritis (the wearing down of the protective tissue at the ends of bones (cartilage) occurs gradually and worsens over time). Record review of Resident # 21's Annual MDS Assessment, dated 6/22/22, revealed a BIMS score of 08, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 10 of 27 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 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nazareth Living Care Center 1475 Raynolds St El Paso, TX 79903 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few which indicated moderate cognitive impairment. The ADL section revealed she was an extensive assistance with two-person physical assist for transfers. Record review of Resident # 21's care plan, dated 6/23/22, revealed she has an ADL Self Care Performance Deficit related to generalized weakness with interventions for transfer: requires extensive assistance (X2) staff participation with transfers. The Care plan did not address a Hoyer lift. Observation and interview on 08/08/22 at 9:30 AM revealed Resident #21, was sat in her wheelchair and the Hoyer sling was placed on a chair at the bedside. Resident # 21 stated the sling was used for when staff transferred her to and from the wheelchair and bed. Resident # 21 stated staff used a machine during transfers. Resident # 21 stated most of the transfers by Hoyer lift were done by one person. Resident # 21 stated it was very rare when staff would conduct a Hoyer lift transfer with two people when they assisted her. 3. Record review of Resident #7's admission record, dated 8/9/22, revealed a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #7's History and Physical, dated 3/8/22, revealed diagnoses which included low back pain and physical debility. Record review of Resident #7's quarterly MDS assessment, dated 5/9/22, revealed a BIMS score of 5, which indicated severe cognitive impairment. The ADL section revealed she was an extensive assistance with two-person physical assist for transfers. Record review of Resident #7's care plan, dated 6/22/22, revealed she requires extensive assistance (X2) staff participation with transfers. The care plan did not address a Hoyer lift. Interview on 08/08/22 at 10:15 AM CNA A, stated Resident #18 required a Hoyer lift during transfer. CNA A stated charge nurses would notify them of the type of transfer a resident was upon their admission or if any changes to the condition regarding their transfer. CNA A stated they knew who required a Hoyer lift transfer by noticing a sling in the room and through verbal report from the charge nurse. CNA A stated if she did not know what type of transfer a resident was, she would ask a nurse, therapy of another CNA. CNA A stated they had access to Kardex on the computer but only stated some residents were 2 two-person physical assist transfer and it does not specify whether they needed a Hoyer lift. Interview on 08/09/22 at 2:45 PM, the ADON stated residents who required a Hoyer lift should reflect on their comprehensive care plan. The ADON stated the MDS Nurse was the one in charge of updating care plans. Observation and interview on 08/09/22 at 3:01 PM, the MDS Nurse stated he was the one in charge of reviewing and revising comprehensive care plans. The MDS Nurse stated care plans were required to be reviewed and updated quarterly, annual, and on any change on condition. The MDS Nurse stated Resident #18 and Resident #27 required Hoyer lift transfers. The MDS Nurse looked at Resident #18 and Resident #27's electronic care plan and stated their care plans did not specify they required a two-person Hoyer lift transfer. The MDS Nurse stated a two-person physical assist transfer and two-person physical assist with Hoyer lift transfer were different types of transfers. The MDS Nurse stated by not having Hoyer lift included in their care plan could affect residents who required a Hoyer lift transfers; increase in accidents and injuries by not providing proper transfers. The MDS Nurse stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 11 of 27 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 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nazareth Living Care Center 1475 Raynolds St El Paso, TX 79903 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few their care plans were not individualized and centered to the needs they required. The MDS Nurse did not have a reason for Hoyer lift transfers not being included in the care plans. Interview on 08/10/22 at 2:05 PM, the DON stated care plans were reviewed and revised by the MDS Nurse quarterly, annually, and as needed if any change in condition occurred. The DON stated Hoyer lift transfers were expected to be included in residents care plans because CNAs referred to them when caring for residents to see the type of assistance and care they received. The DON stated comprehensive care plans should be individualized to resident's needs, for example if a resident required a Hoyer lift transfer, it was something required to be in their comprehensive care plan. The DON stated by not having Hoyer lift transfer specified on the comprehensive care plans for those residents who required it, could increase potential of injury, falls, or the wrong transfer. The DON did not have a reason for Hoyer lift transfer not being included in care plans. Interview on 08/10/22 at 04:01 PM, the Administrator stated the MDS Nurse was in charge of reviewing and updating care plans quarterly, annually, and as needed if any changes occurred. The Administrator stated all care plans should be individualized addressing each resident's specific care needs. The Administrator stated Hoyer lift transfers were required to be included in their care plan to avoid any confusion on the type of transfer a resident required that could potentially result in some type of injury. The Administrator did not have reason for Hoyer lift transfers not being included in care plans. 4. Record review of Resident #154's face sheet, dated 08/10/2022, documented an 88- year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. She had diagnoses which included unilateral inguinal hernia with obstruction without gangrene, recurrent; Peritonitis, unspecified (inflammation of the lining of the abdominal wall); enterocolitis (inflammation of the small intestine and colon) due to clostridium difficile (infection in the large intestine); and other postprocedural complications and disorders of digestive system. Record review of Resident #154's admission MDS, dated [DATE], documented in part she had a BIMS of 10, which indicated moderate cognitive impairment. Record review of Resident #154's laboratory report, dated 06/15/2022 documented she had a glucose test and her estimated mean blood glucose was out of normal range. Record review of Resident #154's Order Recap Report, for 08/31/2021 through 08/10/2022, documented in part she was lactose intolerant (inability to digest a type sugar found in milk). It documented a physician's order, dated 06/21/2022, she was to begin receiving 5 MG of Farxiga (diabetic medication) one time a day for a diagnosis of Diabetes Mellitus Type 2. Record review of Resident #154's nursing progress notes, dated 06/21/2022 at 11:27 AM, documented an order was received to start resident on Farxiga 5 mg daily, and to check blood glucose daily and document, for a diagnosis of diabetes type 2. In an interview on 08/08/22 at 03:22 PM, Resident #154 said her doctor had told her she was lactose intolerant. Record review of Resident #154's care plan, dated 06/13/2022, did not document she was lactose intoleranant or she was diabetic. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 12 of 27 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 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nazareth Living Care Center 1475 Raynolds St El Paso, TX 79903 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 08/10/2022 at 3:38 PM, the DON said diabetes and lactose intolerance should be on Resident #154's care plan. Record review of the Care Plans, Comprehensive Person- Centered policy, dated December 2016, revealed A comprehensive, person- centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will: B. describe services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being. G. Incorporate identified problem areas. H. incorporate risk factors associated with identified problems. Based on observation, interview and record review the facility failed to ensure assessments, including both the comprehensive and quarterly review assessments were reviewed and revised by the interdisciplinary team after each assessment for 4 of 6 residents (Resident #18, Resident #21, Resident #7, Resident #154) reviewed for assessments. 1. The facility failed to ensure Resident #18, Resident #21 and Resident #7's comprehensive care plan reflected they required a Hoyer lift transfer x2 people. 2. The facility failed to ensure Resident #154 comprehensive care plan reflected the resident had diabetes and lactose intolerance. These failures could place residents at risk of fall with potential injury, and at risk of not receiving necessary treatment for their diagnoses. Findings include: 1. Record review of Resident # 18's admission Record, dated 8/8/22, revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Record review of Resident # 18's History and Physical, dated 3/2/22, revealed diagnoses which included muscle wasting and atrophy, abnormalities of gait and mobility, lack of coordination, and stiffness of left shoulder. Record review of Resident # 18's Quarterly MDS assessment, dated 6/2/22, revealed a BIMS score of 08, which indicated she had moderate cognitive impairment. Section G. ADLs revealed B. Transfer: extensive assistance with two-person physical assist. Record review of Resident # 18's Care Plan, dated 4/4/22, revealed a focus ADL self-performance deficit related to generalized weakness with interventions for transfer indicated she required extensive assistance (x2) staff participation with transfers. The care plan did not address a Hoyer lift. 2. Record review of Resident #21's admission record, dated 8/9/22, revealed a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident # 21's History and Physical, dated 12/29/21, revealed she had a diagnosis which included Osteoarthritis (the wearing down of the protective tissue at the ends of bones (cartilage) occurs gradually and worsens over time). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 13 of 27 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 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nazareth Living Care Center 1475 Raynolds St El Paso, TX 79903 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident # 21's Annual MDS Assessment, dated 6/22/22, revealed a BIMS score of 08, which indicated moderate cognitive impairment. The ADL section revealed she was an extensive assistance with two-person physical assist for transfers. Record review of Resident # 21's care plan, dated 6/23/22, revealed she has an ADL Self Care Performance Deficit related to generalized weakness with interventions for transfer: requires extensive assistance (X2) staff participation with transfers. The Care plan did not address a Hoyer lift. 3. Record review of Resident #7's admission record, dated 8/9/22, revealed a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #7's History and Physical, dated 3/8/22, revealed diagnoses which included low back pain and physical debility. Record review of Resident #7's quarterly MDS assessment, dated 5/9/22, revealed a BIMS score of 5, which indicated severe cognitive impairment. The ADL section revealed she was an extensive assistance with two-person physical assist for transfers. Record review of Resident #7's care plan, dated 6/22/22, revealed she requires extensive assistance (X2) staff participation with transfers. The care plan did not address a Hoyer lift. Interview on 08/08/22 at 10:15 AM CNA A, stated Resident #18 required a Hoyer lift during transfer. CNA A stated charge nurses would notify them of the type of transfer a resident was upon their admission or if any changes to the condition regarding their transfer. CNA A stated they knew who required a Hoyer lift transfer by noticing a sling in the room and through verbal report from the charge nurse. CNA A stated if she did not know what type of transfer a resident was, she would ask a nurse, therapy of another CNA. CNA A stated they had access to Kardex on the computer but only stated some residents were 2 two-person physical assist transfer and it does not specify whether they needed a Hoyer lift. Interview on 08/09/22 at 2:45 PM, the ADON stated residents who required a Hoyer lift should reflect on their comprehensive care plan. The ADON stated the MDS Nurse was the one in charge of updating care plans. Observation and interview on 08/09/22 at 3:01 PM, the MDS Nurse stated he was the one in charge of reviewing and revising comprehensive care plans. The MDS Nurse stated care plans were required to be reviewed and updated quarterly, annual, and on any change on condition. The MDS Nurse stated Resident #18 and Resident #21 required Hoyer lift transfers. The MDS Nurse looked at Resident #18 and Resident #21's electronic care plan and stated their care plans did not specify they required a two-person Hoyer lift transfer. The MDS Nurse stated a two-person physical assist transfer and two-person physical assist with Hoyer lift transfer were different types of transfers. The MDS Nurse stated by not having Hoyer lift included in their care plan could affect residents who required a Hoyer lift transfers; increase in accidents and injuries by not providing proper transfers. The MDS Nurse stated their care plans were not individualized and centered to the needs they required. The MDS Nurse did not have a reason for Hoyer lift transfers not being included in the care plans. Interview on 08/10/22 at 2:05 PM, the DON stated care plans were reviewed and revised by the MDS Nurse quarterly, annually, and as needed if any change in condition occurred. The DON stated Hoyer lift transfers were expected to be included in residents care plans because CNAs referred to them when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 14 of 27 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 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nazareth Living Care Center 1475 Raynolds St El Paso, TX 79903 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few caring for residents to see the type of assistance and care they received. The DON stated comprehensive care plans should be individualized to resident's needs, for example if a resident required a Hoyer lift transfer, it was something required to be in their comprehensive care plan. The DON stated by not having Hoyer lift transfer specified on the comprehensive care plans for those residents who required it, could increase potential of injury, falls, or the wrong transfer. The DON did not have a reason for Hoyer lift transfer not being included in care plans. Interview on 08/10/22 at 04:01 PM, the Administrator stated the MDS Nurse was in charge of reviewing and updating care plans quarterly, annually, and as needed if any changes occurred. The Administrator stated all care plans should be individualized addressing each resident's specific care needs. The Administrator stated Hoyer lift transfers were required to be included in their care plan to avoid any confusion on the type of transfer a resident required that could potentially result in some type of injury. The Administrator did not have reason for Hoyer lift transfers not being included in care plans. 4. Record review of Resident #154's face sheet, dated 08/10/2022, documented an 88- year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. She had diagnoses which included unilateral inguinal hernia with obstruction without gangrene, recurrent; Peritonitis, unspecified (inflammation of the lining of the abdominal wall); enterocolitis (inflammation of the small intestine and colon) due to clostridium difficile (infection in the large intestine); and other postprocedural complications and disorders of digestive system. Record review of Resident #154's admission MDS, dated [DATE], documented in part she had a BIMS of 10, which indicated moderate cognitive impairment. Record review of Resident #154's laboratory report, dated 06/15/2022 documented she had a glucose test and her estimated mean blood glucose was out of normal range. Record review of Resident #154's Order Recap Report, for 08/31/2021 through 08/10/2022, documented in part she was lactose intolerant (inability to digest a type sugar found in milk). It documented a physician's order, dated 06/21/2022, she was to begin receiving 5 MG of Farxiga (diabetic medication) one time a day for a diagnosis of Diabetes Mellitus Type 2. Record review of Resident #154's nursing progress notes, dated 06/21/2022 at 11:27 AM, documented an order was received to start resident on Farxiga 5 mg daily, and to check blood glucose daily and document, for a diagnosis of diabetes type 2. In an interview on 08/08/22 at 03:22 PM, Resident #154 said her doctor had told her she was lactose intolerant. Record review of Resident #154's care plan, dated 06/13/2022, did not document she was lactose intoleranant or she was diabetic. In an interview on 08/10/2022 at 3:38 PM, the DON said diabetes and lactose intolerance should be on Resident #154's care plan. Record review of the Care Plans, Comprehensive Person- Centered policy, dated December 2016, revealed A comprehensive, person- centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 15 of 27 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 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nazareth Living Care Center 1475 Raynolds St El Paso, TX 79903 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 0657 Level of Harm - Minimal harm or potential for actual harm each resident. The comprehensive, person-centered care plan will: B. describe services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being. G. Incorporate identified problem areas. H. incorporate risk factors associated with identified problems. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 16 of 27 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 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nazareth Living Care Center 1475 Raynolds St El Paso, TX 79903 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one of 15 residents (Resident #44) reviewed for activities of daily living. Residents Affected - Some The facility failed to ensure Resident #44 received showers/baths as scheduled. This failure could place residents at risk of skin issues, hygiene-related concerns, and decreased sense of self-worth. Findings include: Record review of Resident #44's electronic document titled admission Record, dated 08/10/2022, documented in part an [AGE] year-old female who was first admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included chronic obstructive pulmonary disease, asthma, chronic kidney disease, vascular dementia without behavioral disturbance, anxiety disorder, Parkinson's disease and hypertension. Record review of Resident 44's quarterly MDS, dated [DATE], documented in part her BIMS was 10, which indicated moderate cognitive impairment. She required extensive assistance from one person to move around in bed, transfer between surfaces, move around the facility, eat, use the toilet and for personal hygiene. She needed physical help from one person in order to bathe. Record review of Resident #44's care plan, dated 03/29/2019, documented in part she required assistance with ADLs which included bathing to assist in maintaining a sense of dignity by being clean, dry, odor free, and well-groomed. This would be accomplished by providing physical help in bathing from a staff member. Record Review of Resident #44's POC (Point of Care) Response History, dated 08/10/2022, with a look-back of 30 days documented in part she received showers on five dates: 07/16/2022, 07/19/2022, 07/23/22, 08/02/2022 and 08/09/2022. No refusals of help with bathing or of the resident being unavailable for bathing were documented. In an interview on 08/08/22 at 09:05 AM, Resident #44 said her baths were scheduled for Tuesday, Thursday and Saturday mornings but sometimes her baths were skipped because the facility was short on staff. She said she was told by CNAs (unnamed) that if there were only two CNAs for the second floor instead of three, the CNAs would not be able to bathe her. In an interview on 08/10/22 at 08:28 AM, CNA C said there were times resident baths were skipped because there were not enough CNAs to help. She said if they were short of staff the DON or ADON would be notified and the time of resident baths would be changed so the resident could be bathed. In an interview on 08/10/2022 at 3:49 PM, the DON said she was aware that because of changes in staffing some residents did not receive help with baths at the time they were scheduled, but schedule changes were made so the residents did not go without a bath. She said missing baths could result in loss of dignity, poor hygiene, and skin issues for residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 17 of 27 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 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nazareth Living Care Center 1475 Raynolds St El Paso, TX 79903 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the facility policy titled Activities of Dailly Living, revised 03/2019, documented in part the facility was responsible to provide necessary care to all residents who were unable to carry out activities of daily living on their own to ensure they maintained proper grooming ad hygiene. This included tasks related to personal care which included bathing. Procedures included reviewing the resident's MDS to identify an inability to perform ADLs. Interventions would be developed and implemented in accordance with the resident's needs and preferences Event ID: Facility ID: 675723 If continuation sheet Page 18 of 27 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 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nazareth Living Care Center 1475 Raynolds St El Paso, TX 79903 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 - Few 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 observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 2 of 5 (Resident #18 and Resident #21) reviewed for transfers. A. The facility failed to ensure CNA A did not transfer Resident #18 and #21 alone using a Hoyer lift. This failure could place residents at risk for falls or injury. Findings include: 1. Record review of Resident # 18's Face sheet dated 8/8/22, revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Record review of Resident # 18's History and Physical, dated 3/2/22, revealed diagnoses which included muscle wasting and atrophy, abnormalities of gait and mobility, lack of coordination, stiffness of left shoulder. Record review of Resident # 18's Quarterly MDS assessment, dated 6/2/22, revealed a BIMS score of 08, which indicated she had moderate cognitive impairment. Section G. ADLs revealed B. Transfer: extensive assistance with two-person physical assist. Record review of Resident # 18's Care Plan, dated 4/4/22, revealed a focus ADL self-performance deficit related to generalized weakness with interventions for transfer indicated she required extensive assistance (x2) staff participation with transfers. The care plan did not address a Hoyer lift. Interview on 08/08/22 at 10:19 AM, LVN B stated CNA A assisted Resident # 18 with a bed bath in her room. LVN B stated CNA A was the CNA in charge of Resident # 18 care for the day. Observation and Interview on 08/08/22 at 10:22 AM revealed CNA A walked out of Resident #18 room with the Hoyer lift. CNA A stated she had finished assisting Resident # 18 with her bath and transferred her to her wheelchair. CNA A stated she transferred Resident # 18 from bed to wheelchair using the Hoyer lift. CNA A stated she did the Hoyer transfer alone. CNA A stated she did not receive any Hoyer lift transfer training upon hire because she already knew how to do transfers using a Hoyer lift. CNA A stated she did not ask any other staff for help to conduct a Hoyer transfer with Resident # 18 because the resident was small, and she was able to do transfer alone. CNA A stated she always did one person transfer using Hoyer lifts unless a resident was more on the heavy side and she would need additional help. CNA A stated Resident # 18 was not at any risk of injury or fall because she was able to do transfers using Hoyer lifts alone due to her petite size. Interview on 08/08/22 at 10:27 AM, LVN B stated all Hoyer lift transfers required two people. LVN B stated CNA A should have asked for help prior to transferring Resident # 18 alone with a Hoyer lift. LVN B stated all nurses staff were trained with Hoyer transfer upon hire. LVN B stated floor nurses were in charge of overseeing CNA 's conduct transfers properly. LVN B stated other CNA's worked as a team and would ask each other for help for transfers that required 2 people. LVN B stated she had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 19 of 27 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 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nazareth Living Care Center 1475 Raynolds St El Paso, TX 79903 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 - Few been asked several times before from CNAs for help with Hoyer lift transfers. LVN B stated CNA A did not ask her for help when she transferred Resident # 18 from bed to wheelchair. Observation and Interview on 08/08/22 at 10:31 AM, Resident # 18 was sat in her wheelchair. Resident # 18 stated in the past 2 people would always do a Hoyer transfer. Resident # 18 stated CNA's have been transferred her using a Hoyer lift for a while now. Resident # 18 stated often times CNAs would transfer her with a Hoyer lift alone, rare times would they ask for help or do a two person Hoyer lift transfer. Resident # 18 stated this concern did not affect her because the CNA's who would do a one person Hoyer lift transfer were more experienced and she trusted they would not drop her during the process. Resident # 18 stated she has never sustained an injury related to transfers. 2. Record review of Resident # 21's Face sheet dated 8/9/22, revealed a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident # 21's History and Physical, dated 12/29/21, revealed she had a diagnosis which included Osteoarthritis (the wearing down of the protective tissue at the ends of bones [(cartilage]) occurs gradually and worsens over time). Record review of Resident # 21's Annual MDS Assessment, dated 6/22/22, revealed a BIMS score of 08, which indicated moderate cognitive impairment. The ADL section revealed she was an extensive assistance with two-person physical assist for transfers. Record review of Resident # 21's Care plan, dated 6/23/22, revealed she has an ADL Self Care Performance Deficit related to generalized weakness with interventions for transfer: requires extensive assistance (X2) staff participation with transfers. The Care plan did not address Hoyer lift. Observation and interview on 08/08/22 at 9:30 AM revealed Resident #21, was sat in her wheelchair and the Hoyer sling was placed on a chair at the bedside. Resident # 21 stated the sling was used for when staff transferred her to and from the wheelchair and bed. Resident # 21 stated staff used a machine during transfers. Resident # 21 stated most of the transfers by Hoyer lift were done by one person. Resident # 21 stated it was very rare when staff would conduct a Hoyer lift transfer with two people when they assisted her. Resident # 21 stated she has not sustained any injuries during a transfer. Interview on 08/09/22 at 2:45 PM, the ADON stated Resident #18, and Resident #21 were both Hoyer lift transfers. The ADON stated Hoyer lift transfers required 2-person physical assist. The ADON stated all nursing staff were trained upon hire and at least annually by the therapy department. The ADON stated CNA's had been trained to ask for help when they conducted a Hoyer lift transfer, they were able to call another CNA, nurse on the floor and herself. The ADON stated all nursing staff had her personal phone number to call her if they needed assistance with Hoyer lift and no one else was available. The ADON stated she would get called or CNAs would come find her in the office to ask for help with Hoyer lift transfers. The ADON stated by not conducting a proper Hoyer lift transfer with two-person physical assist the risk for fall and/or injury would increase for the resident. The ADON did not have a reason for staff conducting a one person Hoyer lift transfer. Interview on 08/09/22 at 03:15 PM, OTA stated the therapy department was in charge of conducting transfer training for new staff. The OTA stated all staff were trained with Hoyer lift transfers in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 20 of 27 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 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nazareth Living Care Center 1475 Raynolds St El Paso, TX 79903 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 - Few which it had been instructed and repetitively told that a Hoyer lift required two people at all times. The OTA reported staff on the first floor would come and ask them for help when no other nursing staff was available to assist with a Hoyer transfer. The OTA did not know when the last time an in-service regarding Hoyer transfers was completed. The OTA stated by not conducting a proper Hoyer lift transfer with two-person physical assist put the resident at risk for potential injury due to a possible fall. The OTA did not have a reason for staff conducting a one person Hoyer lift transfer. Interview on 08/10/22 at 02:05 PM, the DON stated all nursing staff were trained on how to do Hoyer lift transfer upon hire and at least annually through competency check list. The DON stated Hoyer lift transfers always required two-person physical assist. The DON stated it was expected from staff to ask for help when needed, they were able to ask any other CNA, LVN, therapy, ADON and DON. The DON stated by not doing a 2 person Hoyer transfer, the possibility of injury or accidents increased. The DON did not have reason for staff conducting one person Hoyer lift transfer. Interview on 08/10/22 at 04:01 PM, the Administrator stated all Hoyer lift transfers required a two-person physical assist. The Administrator stated since the company took over, he did not know how often staff received training regarding Hoyer lift transfer. The Administrator stated it was expected for staff to ask for help if/ when needed when conducting a Hoyer lift transfer. The Administrator stated therapy was in charge of conducting transfer training. The Administrator stated by not doing a 2 person Hoyer transfer, the possibility of injury or accidents increased. The Administrator did not have reason for staff conducting one person Hoyer lift transfer. Record review of Lifting Machina, Using a Mechanical policy, dated July 2017, revealed the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. 1. At least two nursing assistance are needed to safely move a resident with mechanical lift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 21 of 27 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 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nazareth Living Care Center 1475 Raynolds St El Paso, TX 79903 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to post the total number and the actual hours worked by registered nurses, licensed practical nurses or licensed vocational nurses, certified nurse aides and resident census the licensed and unlicensed nursing staff directly responsible for direct resident care onfor 2 of 2 postings (Floor 1 and Floor 2 Nurse's stations) reviewed. Residents Affected - Some The facility failed to ensure The daily nursing staffing information was posted but did not include the total numbers of actual hours worked for RNs, LVNs, CNAs, and RNAs was posted. The facility'sThis failure could place residents, visitors, and staff at risk of not having accurate facility staffing information. The findings included: Observation on 08/08/22 at 10: 00 AM revealed, 1 of 2 forms titled, Nurse Staffing Information and posted at floor 1 main entrance counter. Observation on 08/08/22 at 10: 10 AM revealed, 2 of 2 forms titled, Nurse Staffing Information and posted at floor 2 Nurse's station. Record review of the Facility's Nurse Staffing Information form, dated 8/8/22 at 10:00 AM, and posted on floor 1 at the main entrance counter Did not include the actual resident census or the actual hours worked each shift for the following employees, 6 AM - 2 PM, RN - 1, RN Hrs. 8 LVN - 2, LVN Hrs.- 16, CNA - 2, CNA Hrs. - 15, 2 PM - 10 PM Shift RN - 0, RN Hrs.- 0, LVN - 2, LVN Hrs. - 16, CNA - 2, CNA Hrs.- 15, 10 PM - 6 AM, RN - 0, RN Hrs. - 0, LVN - 1 LVN Hrs.- 8, CNA - 1, CAN CNA Hrs.- -7.5. Record review of the Facility's Nurse Staffing Information form, dated 8/8/22 at 10:10 AM, and posted on floor 2 at the Nurse's station Did not include the actual resident census or the actual hours worked each shift for the following employees, 6 AM - 2 PM, RN - 1, RN Hrs. 8 LVN - 2, LVN Hrs.- 16, CNA - 3, CNA Hrs. - 22.5, Restorative - 0, Restorative Hrs. - 0, Med aide - 0, Med aide Hrs. - 0, 2 PM - 10 PM Shift RN - 0, RN Hrs.- 0, LVN - 2, LVN Hrs. - 16, CNA - 3, CNA Hrs.- 22.5, Restorative - 1, Restorative Hrs. - 8, Med aide - 0, Med aide Hrs. - 0, 10 PM - 6 AM, RN - 0, RN Hrs. - 0, LVN - 1 LVN Hrs.- 8, CNA - 2, CNA Hrs.- -15, Restorative - 0, Restorative Hrs. - 0, Med aide - 0, Med aide Hrs. - 0. Record review of the Facility's Nurse Staffing Information form, dated 8/9/22 at 10:15 AM, and posted on floor 1 at the main entrance counter Did not include the actual resident census or the actual hours worked each shift for the following employees, 6 AM - 2 PM, RN - 1, RN Hrs. 8 LVN - 2, LVN Hrs.- 16, CNA - 2, CNA Hrs. - 15, 2 PM - 10 PM Shift RN - 0, RN Hrs.- 0, LVN - 2, LVN Hrs. - 16, CNA - 2, CNA Hrs.- 15, 10 PM - 6 AM, RN - 0, RN Hrs. - 0, LVN - 1 LVN Hrs.- 8, CNA - 1, CAN CNA Hrs.- -7.5. Record review of the Facility's Nurse Staffing Information form, dated 8/9/22 at 10:20 AM, and posted on floor 2 at the Nurse's station Did not include the actual resident census or the actual hours worked each shift for the following employees 6 AM - 2 PM, RN - 1, RN Hrs. 8 LVN - 2, LVN Hrs.- 16, CNA - 3, CNA Hrs. 22.5, Restorative - 0, Restorative Hrs. - 0, Med aide - 0, Med aide Hrs. - 0, 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 22 of 27 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 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nazareth Living Care Center 1475 Raynolds St El Paso, TX 79903 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 0732 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some PM - 10 PM Shift RN - 0, RN Hrs.- 0, LVN - 2, LVN Hrs. - 16, CNA - 3, CNA Hrs.- 22.5, Restorative - 1, Restorative Hrs. - 8, Med aide - 0, Med aide Hrs. - 0, 10 PM - 6 AM, RN - 0, RN Hrs. - 0, LVN - 1 LVN Hrs.8, CNA - 2, CNA Hrs.- -15, Restorative - 0, Restorative Hrs. - 0, Med aide - 0, Med aide Hrs. - 0. Record review of the Facility's Nurse Staffing Information form, dated 8/10/22 at 11:00 AM, and posted on floor 1 at the main entrance counter revealed Did not include the actual resident census or the actual hours worked each shift for the following employees 6 AM - 2 PM, RN - 1, RN Hrs. 8 LVN - 2, LVN Hrs.- 16, CNA 2, CNA Hrs. - 15, 2 PM - 10 PM Shift RN - 0, RN Hrs.- 0, LVN - 2, LVN Hrs. - 16, CNA - 2, CNA Hrs.- 15, 10 PM - 6 AM, RN - 0, RN Hrs. - 0, LVN - 1 LVN Hrs.- 8, CNA - 1, CAN CNA Hrs.- -7.5. Record review of the Facility's Nurse Staffing Information form, dated 8/10/22 at 11:30 AM, and posted on floor 2 at the Nurse's station revealed, Did not include the actual resident census or the actual hours worked each shift for the following employees 6 AM - 2 PM, RN - 1, RN Hrs. 8 LVN - 2, LVN Hrs.- 16, CNA 3, CNA Hrs. - 22.5, Restorative - 0, Restorative Hrs. - 0, Med aide - 0, Med aide Hrs. - 0, 2 PM - 10 PM Shift RN - 0, RN Hrs.- 0, LVN - 2, LVN Hrs. - 16, CNA - 3, CNA Hrs.- 22.5, Restorative - 1, Restorative Hrs. - 8, Med aide - 0, Med aide Hrs. - 0, 10 PM - 6 AM, RN - 0, RN Hrs. - 0, LVN - 1 LVN Hrs.- 8, CNA - 2, CNA Hrs.- -15, Restorative - 0, Restorative Hrs. - 0, Med aide - 0, Med aide Hrs. - 0. Observation on 8/10/22 at 11:40 AM revealed the daily nursing staff posted hours and resident census had not been modified to reflect the actual staff present on each shift nor a change in the resident census from 8/8/22 - 8/10/22. In an interview on 8/10/22 at 1:50 PM, the DON stated she completed the daily staffing sheets every morning for floors 1 and 2 and all three shifts, morning 6 AM - 2 PM, evening 2 PM - 10 PM, and night 10 PM - 6 AM. According to the scheduled staff, not the actual staff and posts posted it outside her door. She further stated she was not aware the staffing sheets were supposed to be completed at the beginning of each shift and reflect the actual number of staff on the floor. And She stated this could negatively affect resident care and give anyone inquiring about the number of staff present inaccurate information. In an interview on 8/10/22 at 2:00 PM, the Administrator stated, the DON was responsible for posting the daily nursing staffing hours. and the posting of the actual staff present is a new one on me. The Administrator further stated, not having the actual hours posted could negatively affect resident care and give anyone inquiring about the number of staff present inaccurate information. Record review of the facility policy titled Posting Direct Care Daily Staffing Numbers, revised July 2016, showed: Policy Interpretation and Implementation 1. Within two (2) hours of the beginning of each shift .will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format . 3 .The information recorded on the form shall include: a. The name of the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 23 of 27 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 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nazareth Living Care Center 1475 Raynolds St El Paso, TX 79903 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 0732 b. The date for which the information is posted. Level of Harm - Minimal harm or potential for actual harm c. The resident census at the beginning of the shift for which the information is posted. d. Twenty-four (24)-hour shift schedule operated by the facility. Residents Affected - Some e. The shift for which the information is posted. f. Type (RN [registered Nurse], LPN [Licensed Practical Nurse], LVN [Licensed Vocational Nurse], or CNA [Certified Nursing Assistant]) and category (licensed or non-licensed) of nursing staff working during that shift. g. The actual time worked during that shift for each category and type of nursing staff. h. Total number of licensed and non-licensed nursing staff working for the posted shift FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 24 of 27 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 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nazareth Living Care Center 1475 Raynolds St El Paso, TX 79903 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. FACILITY Based on observation and interview the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed for storage of food in accordance with professional standards. 1. The facility failed to label and date and to ensure Lettuce was properly stored and did not show signs of spoilage. 2. The facility failed to ensure expired foods were disposed. These failures could place residents at risk of food-borne illness. Findings include: In an interview on 08/08/2022 at 7:58 AM, the Dietary Manager said food items were marked with a received date and an opened date and they should be disposed of seven days after the opened date. Items with manufacturer Use By dates would be disposed of on or before the use by date. In observation and interview on 08/08/2022 at 8:11 AM, with the Dietary Manager, in the walk-in refrigerator a wrapped partial head of lettuce was observed without any dates marked on the packaging. The lettuce was red along the margins where it had been previously cut. The Dietary Manager said the lettuce was brown where it had been cut and ''it would be tossed right away'' and he would dispose of it. Three heads of lettuce in an open package were observed to have some brown slimy leaf edges. The Dietary Manager said they should not be exposed to the refrigerator air and wrapped them up, closing the open packaging. In observation and interview on 08/08/2022 at 8:22 AM, with the Dietary Manager revealed a one gallon jar of ranch dressing with 1.5 inches of dressing in the bottom and it did not have a manufacturer date. An opened date of 05/16/2022 was observed on the lid of the container. The Dietary Manager said kitchen staff checked for expiration dates on Wednesdays and staff members must have seen the date on the top of the container and left it anyway. He did not know why the jar had not been disposed of and said residents could get an upset stomach from eating expired ranch dressing. A policy regarding food storage and disposal of expired foods was requested but was not received prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 25 of 27 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 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nazareth Living Care Center 1475 Raynolds St El Paso, TX 79903 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 interview and record review the facility failed to maintain medical records that were complete for 1 of 3 residents (Resident #1) reviewed for clinical records. The facility failed to ensure Resident #1's clinical record included documentation of skin excoriation while being treated and assessed for it. This deficient practice could place residents at risk of not receiving the appropriate care by not having complete information in their record. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year-old female who was admitted to the facility on of 5/17/22 and readmitted on [DATE]. Resident #1 had diagnoses which included of C.diff (C.diff is an infection that causes frequent episodes of diarrhea) and muscle weakness. Record review of Resident #1's history and physical, dated 6/16/2022, revealed she had a history of C.diff and had no skin rash. She was initially diagnosed with C.diff on 6/5/22, and received antibiotics to treat. Record review of Resident #1's total body skin assessment, dated 6/15/22, revealed normal and warm skin. There were no skin alterations. There was no other skin assessment documented. Record review of Resident 1#'s admission MDS , dated 6/21/22, revealed no Moisture Associated Skin Damage. Under category H, (bladder and bowel) it showed Resident #1 was incontinent of bowel and bladder. Record review of progress notes, dated 6/26/22, revealed Resident #1 had 4 episodes of diarrhea and would be tested for C.diff that day. MD was aware of change in condition. He ordered for resident to be monitored since she had been treated with C.diff on 6/5/22. Record review of progress notes dated 6/28/22, revealed Resident #1 continued to have episodes of diarrhea. She was diagnosed with C.diff that day. MD progress notes showed wound care would treat and evaluate. Record review of progress notes, dated 7/1/22, revealed Resident #1 continued to have episodes of diarrhea. Record review of the care plan dated 6/15/22, revealed Resident #1 had an ADL self-care deficit related to weakness. Interventions included helping her with toileting, bathing, and personal hygiene through 1-person extensive assistance. Record review of Resident #1's TAR for the month of June and July 2022 revealed no interventions or treatments were documented for any skin rash or excoriation. Record review of 24-hr reports for the month of July revealed Resident #1 had a diagnosis of C.diff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 26 of 27 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 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nazareth Living Care Center 1475 Raynolds St El Paso, TX 79903 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 and she was on antibiotics and probiotics. She was on contact precautions and had frequent loose stools. There was no note or documentation of Resident #1 having a skin rash or excoriation in progress notes or assessments. In an interview with Resident #1's family representative on 8/09/22 at 8:22 AM, she said Resident #1 had developed a rash from the diarrhea . She said the facility had applied cream on her and given her antibiotics. She said the staff knew she had a rash from the diarrhea because she wore briefs and they changed her. In an interview with LVN D on 8/9/22 at 2:12 PM, she said Resident #1 had C.diff and was treated with antibiotics and probiotics. She said she was super excoriated because of the diarrhea. We were putting cream on her. She said the doctor would recommend using barrier cream for the irritated areas. She did skin assessments daily, any time she would help change the resident. She said the excoriation would be documented on the progress notes or the 24-hour report . The 24-hour report was a document where nurses would note any changes or updates to the residents' condition. It was used during bed side report at change of shift. In an interview with LVN E on 8/10/22 at 9:09 AM, he said Resident #1 had C.diff and with the frequent episodes of diarrhea she would get a pink reddish skin color. He said the diarrhea caused the redness. He said her skin was treated with barrier cream. He said the skin redness would be documented in the progress notes. He said he did not know why it was not documented. He said it should have been documented on the TAR by the nurse. In an interview with CNA B on 8/10/22 at 10:52 AM, he said he took care of Resident #1 during both of her stays at the facility. He said she had C.diff and was incontinent of bowel and bladder. He said he noticed she had excoriation during perineal care and told LVN D about it. He said LVN D would tell him to use the barrier cream to help Resident #1 heal. He said he never wrote anything down but would tell LVN D verbally . He said he did not know if the nurses documented it on the computer. Record review of the facility's policy titled Charting and Documentation, revised in July 2017, read in part .All services provided to the resident, progress towards the care plan goals or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record .The following information is to be documented in the resident's medical record: objective observations, treatments performed; changes in the resident's condition. Documentation of procedures and treatments will include care-specific details including the date and time the treatment was provided . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 27 of 27