Health inspection·September 29, 2023

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #1's vital signs data sheet during her stay of 09/21/2023-09/25/2023 revealed heart rate documentation was blank in documentation for the following dates and shifts: 09/22/2023 2PM-10PM and 10PM-6AM; 09/23/2023 2PM-10PM and 10PM-6AM; 09/24/2023 2PM-10 PM and 10PM to 6AM. Record review of Resident #1's vital signs data sheet during her stay of 09/21/2023-09/25/2023 revealed respirations documentation was blank in documentation for the following dates and shifts: 09/22/2023 2PM-10PM and 10PM-6AM; 09/23/2023 6AM-2 PM, 2PM-10PM and 10PM-6AM; 09/24/2023 6AM-2 PM, 2PM-10 PM and 10PM to 6AM. Record review of Resident #1's vital signs data sheet during her stay of 09/21/2023-09/25/2023 revealed oxygen saturation (measurement used to determine how much oxygen is in the blood) documentation was blank in documentation for the following dates and shifts: 09/22/2023 10PM-6AM; 09/23/2023 2PM-10PM and 10PM-6AM. In an interview on 09/27/2023 at 3:52 PM Resident #1's Family representative revealed vital signs were only being taken during the morning shift. In an interview on 09/28/2023 at 8:38 AM with LVN A revealed she worked day shift from 6AM-2PM. She stated vital signs had to be taken daily before medication pass and as needed for change of condition such as pain. She said the vitals had to be taken more often if there was a physician's order for it. In an interview on 09/28/2023 at 9:11 AM with LVN B revealed he worked day shift from 6AM-2PM. He stated vitals needed to be done every shift to track of any changes in the residents. In an interview on 09/28/2023 at 2:46 PM with LVN C revealed she worked day shift from 6AM-2 PM. She stated vital signs were important to take every shift to monitor any side effects of medications, or any changes of condition in the residents. She stated the vitals had to be documented in the electronic record under vitals. She confirmed she was assigned to Resident #1 on 09/22/2023 and 09/25/2023. She stated she had taken Resident #1's vital signs in the morning during her shift and before the medication were administered. She could not confirm if the vital signs were not found in the medical record, they were not done. In an interview on 09/28/2023 at 4:28 PM with LVN D revealed she had been working at the facility for a month and a half and worked evening shift from 2PM-10PM. She confirmed she had admitted Resident #1 on 09/21/2023 and was her nurse again on 09/22/2023 during the evening shift. She stated she took vital signs when Resident #1 was first admitted on the evening of 09/21/2023 and thought she took vital signs on the evening of 09/22/2023. She stated she could not say why the vital signs had not been documented on the evening of 09/22/2023. She said if the order vital signs every shift did not appear on the MAR, then it was likely she did not document them. She stated, I don't know what to tell you because this system is still new to me and I'm trying to know it better. She stated she thought she remembered taking vitals on 9/22/2023 but could not be sure. She stated it was important to follow physician orders and take vitals to know how the residents were doing. She stated she did not know why she would not have taken them. She stated she had checked on Resident#1 several times during her shift, and Resident #1 did not display any changes of condition (change in mentation, looking weak, confused, etc.). She revealed she had been taught to follow physician orders and document vital signs on a resident's medical record. In an interview on 09/29/2023 at 12:08 PM with the DON revealed she did not have an answer as to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some why vital signs had not been documented or done for Resident #1. She stated if they were not documented, it did not mean that they were not done. She stated the nursing staff needed to know to take vital signs according to physician orders and should not rely on the computer system to prompt them to check vital signs. In a telephone interview on 09/29/2023 at 4:54 PM with LVN E revealed he worked night shift 10PM-6AM and confirmed was assigned to resident #1 on 09/23/2023.He stated since he was away from the facility he would not remember if he had documented vital signs but was sure that he had taken them. He stated he usually wrote them down on paper but could not remember if he had transferred them unto the electronic record. He stated he could not remember specifically if he had taken vital signs for Resident #1 since he took a lot of vitals that night. He stated it was very important to check vital signs for any residents because vitals had a lot of implications. He stated if a nurse was to rely on previous vital signs it could not be accurate. He stated he always preferred to do vital signs in the moment. He stated he had been taught to document on electronic record but could not give reason as to why the vital signs had not been documented for his shift. In a telephone interview on 09/29/2023 at 5:01 PM with LVN F revealed she had worked the day shift on the weekend of 09/23-09/24 and was assigned to Resident #1. She said she would check vital signs for her assigned residents every shift unless they were not feeling well, then she would check vital signs more often. She stated she could not remember if she took vital signs specifically for Resident #1 on her shifts, but that is what she accustomed in doing with all residents. She stated she probably did them, but they were not documented. She stated that at times, she would write the vitals down on a sheet of paper and would not record them in the electronic record. LVN F stated vital signs were important to establish a baseline for the resident and have something to go off in case there was a change of condition. It allowed for her to reference and look back to. In a telephone interview on 09/29/2023 at 5:12 PM with Medical Director revealed he remembered Resident #1 and assessing her on 09/25/2023. He stated if there was an order that he had placed to check vital signs once a shift, he expected staff to do what a prudent nurse would do. He said the expectation was not any different and when an order was given, he expected it to be carried out. He stated there might be certain circumstances as to why it was not done as required by the state, but it had to be done. Could not state a risk to the resident if orders were not followed. In a telephone interview on 09/29/2023 at 5:20 PM with the Weekend Supervisor revealed she worked on 09/23- and 09/24-day shift and provided over-sight supervision to the nursing staff. She stated she ensured charting was being done correctly on the weekends and had not checked if vital signs were being done according to physician's orders. She stated if there was an order for vital signs to be done every shift, then that had to be followed. She stated nurses were to take vital signs every shift to monitor the residents' condition. She said once that was done, then it should have been documented it should be documented in the electronic clinical record to keep record and note of what was occurring during the shift. In a telephone interview on 09/29/2023 at 5:25 PM with RN G revealed she assigned to Resident #1 on 09/23/2023 on the evening shift 2PM-10PM. She said she remembered Resident #1and stated the previous nurse had taken vital signs before she left for her shift; could not state at what time. She stated she thought she had taken vital signs for her but could not be sure. She said if the computer prompted for her to do them, then she must have. She said it was important to obtain the vital signs to know how the resident was doing and to know the condition they were in compared to their baseline. She stated of course there was a risk to the resident but could not state what it was. She stated it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 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 0684 was also important to document the vital signs after they were done. Level of Harm - Minimal harm or potential for actual harm In a follow-up interview on 09/29/2023 at 5:37 PM with the DON confirmed she provided over-sight supervision to the nurses and ensured they were following orders by reviewing the MAR but stated she did not look specifically check that vital signs are done according to physician's orders and documented in the electronic record. She said she expected the nurses to follow physician's orders for checking vital signs. She stated it was important to take vital signs to know the baseline of the resident and know how they were doing. Residents Affected - Some Review of facility policy titled Documentation-Licensed Nurse dated 6/2019 revealed in part .Temperature, Pulse, Blood Pressure and Respiration are charted in the electronic clinical record vital signs tab or the E-MAR as ordered . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 resident (Resident #1) of 5 reviewed for medication orders. The facility failed to administer 3 medications to Resident#1 per physician orders on several shifts. This failure could affect residents and cause a decline in health if medications are not given as ordered. Findings included: Closed record review of Resident #1's face sheet dated 09/29/2023 revealed an [AGE] year-old female with an admission date to the facility of 09/21/2023. Record review of Resident #1's medical diagnosis list accessed on 09/28/2023 revealed she had medical diagnoses to include Hypertension (high blood pressure), Hypokalemia (low potassium) and dizziness. Record review of Resident #1's History and Physical dated 09/25/2023 revealed Resident #1 had been admitted to the facility from a local hospital after suffering a fall at home. Medical diagnoses included high blood pressure, hypokalemia, and dizziness. Record review of Resident #1's baseline care plan dated 09/22/2023 revealed Resident #1's goal was to return to the community after receiving therapies at the facility. Record review of Resident #1's admission MDS assessment dated [DATE] revealed a BIMS score of 8, indicating a moderate cognitive impairment. BIMS assessment is used to determine cognition through a variety of questions. The MDS assessment also confirmed the diagnosis of hypertension, hypokalemia, and dizziness. Record review of Resident #1's physician's orders dated 09/21/2023 revealed the following Potassium Chloride Oral Tablet Extended Release 20 MEQ give 1 tablet by mouth two times a day for supplement for 30 Days, Systane Complete Ophthalmic Solution Propylene Glycol instill 1 drop in both eyes every 4 hours for dry eye and Meclizine HCl Oral Tablet 12.5 MG give 1 tablet by mouth two times a day for dizziness. Record review of Resident #1's MAR for September 2023 revealed blanks in documentation for Potassium Chloride on 09/22/2023 at 07:30 AM and on 09/23/2023 at 4:00 PM. It also revealed Systane Complete Ophthalmic Solution eye drops had blanks in documentation on 09/22/2023 at 10:00 AM and 2:00 PM, and again on 09/25/2023 at 10:00 AM and 2:00 PM. Lastly, it revealed Meclizine HCl Oral Tablet 12.5 MG had blanks in documentation on 09/23/2023 at 4:00 PM. In an interview on 09/28/2023 at 8:35 AM with LVN A revealed medications had to be given per physician orders. She said if the medications were not given to residents, it could affect the residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 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 0755 such as blood pressure getting higher, or blood sugars could be harder to control. Level of Harm - Minimal harm or potential for actual harm In an interview on 09/29/2023 at 10:47 AM with LVN C revealed she had worked on 09/22/2023 during the day shift 6 AM- 2PM. She stated she had not given Resident #1 her potassium tablet at 07:30 AM because the medication had not been delivered from the pharmacy and she had not seen potassium chloride in her medication cart. She stated when a medication was pending delivery, she normally checked the automated medication dispensing system, but she did not think of doing so on 09/22/2023 for the 7:30 AM dose. She stated she had not pulled the medication from the automated medication dispensing system on that day. She also stated the eyedrops had not been administered and she did not see them in the cart. She stated the risk of not administering the mediations was causing harm to the resident and affecting their laboratory work. She could not remember if she notified ADON/DON of her not administering the medications. Residents Affected - Some In an interview on 09/29/2023 at 12:12 PM with DON revealed if medications were to not be given to residents such as a medication for dizziness, the resident could feel dizzy and get worse. She also stated that if eyedrops did not get administered, could cause irritation to the eyes and could cause them to be in discomfort. In a follow-up interview on 09/29/2023 at 2:55 PM with LVN C revealed she had not seen the bottle of eye drops for Resident #1 in the medication cart. She stated she wished she would have seen them because then she would have given them to the resident. She stated the eye drops were probably behind another residents' box. She stated by not administering the eye drops, the residents' eyes could get dry and cause discomfort. She stated Resident #1 had not complained of discomfort or itchy eyes. In a telephone interview on 09/29/2023 at 5:12 PM with MD revealed there could be certain circumstances as to why medications might not be provided, however he stated that he expected his orders to be followed. He could not state a risk to the residents if they were to not have medications administered to them. In a telephone interview 09/29/2023 at 5:25 PM with RN G, revealed she had worked on 09/23/2023 during evening shift 2PM-10 PM. She stated she had not administered some of the medications to Resident #1because she had not seen them in the medication cart. She stated it was important to administer the medications because Potassium Chloride was for the heart and Meclizine was for dizziness and was important because Resident #1 could have had a fall. In a follow-up interview on 09/29/2023 at 5:37 PM with the DON revealed the nurses knew to pull medications from the medication dispenser if it was not available in the cart. She revealed all medications should have been given due to the fact that they were available either in the medication cart or at the facility. She stated it was important to do so to ensure residents' safety and to prevent a delay in the healing of the residents. Review of facility policy titled Medication Administration and Management dated 6/2019 reviewed in part .It is the policy of this facility will implement a Medication Management Program that incorporates systems with established goals to meet each resident's needs .The authorized licensed or certified/permitted medication aide or by the state regulatory guidelines staff member seeks assistance from the nursing supervisor/designee and consulting pharmacist when any aspect of medication administration is in question . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 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 clinical records that were complete and accurately documented for 1 (Resident #1) of 5 residents reviewed for clinical records. -The facility failed to document vital signs in Resident #1's clinical record for several shifts. Vital signs were blank on his vitals signs data sheet and TARs. This failure could cause a decline in health in residents if vital information is not being documented accurately. Findings included: Closed record review of Resident #1's face sheet dated 09/29/2023 revealed an [AGE] year-old female with an admission date to the facility of 09/21/2023. Record review of Resident #1's medical diagnosis list accessed on 09/28/2023 revealed she had medical diagnoses to include Hypertension (high blood pressure), Hypokalemia (low potassium) and dizziness. Record review of Resident #1's History and Physical dated 09/25/2023 revealed Resident #1 had been admitted to the facility from a local hospital after suffering a fall at home. It confirmed her medical diagnoses included high blood pressure, hypokalemia, and dizziness. Record review of Resident #1's baseline care plan dated 09/22/2023 revealed Resident #1's goal was to return to the community after receiving therapies at the facility. Record review of Resident #1's admission MDS assessment dated [DATE] revealed a BIMS score of 8, indicating a moderate cognitive impairment. BIMS assessment is used to determine cognition through a variety of questions. The MDS assessment also confirmed the diagnosis of hypertension, hypokalemia and dizziness. Record review of Resident #1's physician order dated 09/21/2023 revealed Vital Signs Q Shift. Record review of Resident #1's vital signs data sheet during her stay of 09/21/2023-09/25/2023 revealed blood pressure documentation was blank in documentation for the following dates and shifts: 09/22/2023 2PM-10PM and 10PM-6AM; 09/23/2023 2PM-10PM and 10PM-6AM; 09/24/2023 2PM-10 PM and 10PM to 6AM. Record review of Resident #1's vital sign data sheet during her stay of 09/21/2023-09/25/2023 revealed heart rate documentation was blank in documentation for the following dates and shifts: 09/22/2023 2PM-10PM and 10PM-6AM; 09/23/2023 2PM-10PM and 10PM-6AM; 09/24/2023 2PM-10 PM and 10PM to 6AM. Record review of Resident #1's vital signs data sheet during her stay of 09/21/2023-09/25/2023 revealed respirations documentation was blank in documentation for the following dates and shifts: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 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 09/22/2023 2PM-10PM and 10PM-6AM; 09/23/2023 6AM-2 PM, 2PM-10PM and 10PM-6AM; 09/24/2023 6AM-2 PM, 2PM-10 PM and 10PM to 6AM. Record review of Resident #1's vital signs data sheet during her stay of 09/21/2023-09/25/2023 revealed oxygen saturation (measurement used to determine how much oxygen is in the blood) documentation was blank in documentation for the following dates and shifts: 09/22/2023 10PM-6AM; 09/23/2023 2PM-10PM and 10PM-6AM. Record review of Resident #1's TAR for September 2023 revealed Vital Signs every shift -Start Date09/21/2023 2200. There were no entries with vital signs for any shifts during Resident #1's stay. In an interview on 09/28/2023 at 4:28 PM with LVN D revealed she had been working at the facility for a month and a half and worked evening shift from 2PM-10PM. She confirmed she had admitted Resident #1 on 09/21/2023 and was her nurse again on 09/22/2023 during the evening shift. She could not say why the vital signs had not been documented on the evening of 09/22/2023. She said if the order vital signs every shift did not appear on the MAR, then it was likely she did not document them. She stated, I don't know what to tell you because this system is still new to me and I'm trying to know it better. She stated it was important to follow physician orders and document vitals to keep track of how residents were doing. She stated she had been taught to follow physician orders and document vital signs on a resident's medical record. In an interview on 09/29/2023 at 12:08 PM with the DON revealed she did not have an answer as to why vital signs had not been documented for Resident #1. She stated if they were not documented, it did not mean that they were not done. She stated the nursing staff needed to know to take vital signs according to physician orders and should not rely on the computer system to prompt them to check vital signs. In a telephone interview on 09/29/2023 at 4:54 PM with LVN E revealed he worked night shift 10PM-6AM and confirmed was assigned to Resident #1 on 09/23/2023. He stated since he was away from the facility he would not remember if he had documented vital signs but was sure that he had taken them. He stated he usually wrote them down on paper but could not remember if he had transferred them unto the electronic record. He stated if a nurse was to rely on previous vital signs it could not be accurate, since they were not documented. He stated he had been taught to document on electronic record but could not give reason as to why the vital signs had not been documented for his shift. In a telephone interview on 09/29/2023 at 5:01 PM with LVN F revealed she had worked the day shift on the weekend of 09/23-09/24 and was assigned to Resident #1. She stated she could not remember if she took vital signs specifically for Resident #1 on her shifts, but stated they were probably done and just not documented. She stated that at times, she would write the vitals down on a sheet of paper and would not always place them unto the electronic record. She revealed vital signs were important document as it served as a reference and something to look back to. In a telephone interview on 09/29/2023 at 5:12 PM with Medical Director revealed he remembered Resident #1 and assessing her on 09/25/2023. He stated if there was an order that he had placed to check vital signs once a shift, he expected staff to do what a prudent nurse would do. He said the expectation was not any different and when an order was given, he expected it to be carried out. He stated there might be certain circumstances as to why it was not done as required by the state, but it had to be done. Could not state a risk to the resident if orders were not followed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675723 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 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 In a telephone interview on 09/29/2023 at 5:20 PM with the Weekend Supervisor revealed she worked on 09/23- and 09/24-day shift and provided over-sight supervision to nursing staff. She stated she ensured charting was being done correctly on the weekends and had not checked if vital signs were being done according to physician's orders. She stated if there was an order for vital signs to be done every shift, then that had to be followed. She stated nurses were to take vital signs every shift to monitor the residents' condition. She said once that was done, then it should be documented in the electronic clinical record to keep record and note of what was occurring during the shift. In a telephone interview on 09/29/2023 at 5:25 PM with RN G revealed she was assigned to Resident #1 on 09/23/2023 on the evening shift 2PM-10PM. She stated she thought she had taken vital signs for Resident #1 but could not be sure. She said if the computer prompted for her to do them, then she must have. She said it was important to obtain and document the vital signs to know how the resident was doing and to know the condition they were in compared to their baseline. She stated of course there was a risk to the resident but could not state what it was. In a follow-up interview on 09/29/2023 at 5:37 PM with the DON confirmed she provided over-sight supervision to the nurses and ensured they were following orders by reviewing the MAR but stated she did not check that vital signs are done according to physician's orders and documented in the electronic record. She said she expected the nurses to follow physician's orders checking vitals. She stated it was important to document vital signs to know the baseline of the resident and know how they were doing. Review of facility policy titled Documentation-Licensed Nurse dated 6/2019 revealed It is the policy of this facility that documentation pertaining to the resident will be recorded in accordance with regulatory requirements .The nursing staff will be responsible for recording care and treatment, observations and assessments and other appropriate entries in the resident clinical record .Temperature, Pulse, Blood Pressure and Respiration are charted in the PCC vital signs tab or the E-MAR as ordered .Documentation guidelines pertinent to good clinical record practice will be followed by all individuals who document in the medical record . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675723 If continuation sheet Page 9 of 9