Health inspection·August 9, 2023

F 0690 dysfunction of bladder; and Provide catheter care every shift. Level of Harm - Minimal harm or potential for actual harm Observation on 08/09/2023 at 9:18 a.m., revealed Resident #15's was lying in bed with a foley bag lying on the floor next to her bed. Residents Affected - Few During an interview on 08/09/2023 at 9:19 a.m., Resident #15 said she was unaware that her foley bag was lying on the floor. Resident #15 said she has multiple sclerosis and can't walk and requires total assistance. Resident #15 said that she was repositioned about thirty minutes earlier and did not know if during that time her foley bag came out of the privacy bag attached to the bed. During an interview and observation on 08/09/2023 beginning at 9:25 a.m., LVN E said that the foley bag should not be on the floor and should be in the privacy bag attached to the bed. LVN E said she did not know why the foley bag was on the floor. LVN E checked the bag and drainage. LVN E checked tubing and it was noted that Resident #15's did not have a catheter strap in place. LVN E said that when resident is lying in bed, she may not always need to have a catheter strap in place because she does not move. LVN E said that a catheter strap was used to prevent pulling or tugging. LVN E said that she was not sure of the specifics of the physician order for the catheter strap without referring to the order. LVN E referred to the order and said the catheter strap should be in place every shift. During an interview on 08/09/2023 at 4:18 p.m., the ADON said Resident #15 had not had any recent Urinary Tract Infections (UTI). The ADON said the risk of not having the catheter strap was the catheter could get pulled to tugged and must be readjusted or reinserted. The ADON said Resident #15 has had this foley for years and there are fistulas (an abnormal or surgically made passage between a hollow or tubular organ and the body surface) in the urethra, and it takes a lot to reinsert. The ADON said the catheter bag should be hung secure in a privacy bag on the side of the bed. The ADON said she did not know how the bag ended up on the floor. The ADON said the risk from the foley bag being on the floor was infection. Review of facility policy titled Catheter Care dated 02/13/2007, reflected in part Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. Keep tubing off floor and minimize friction or movement at insertion site. Review the resident plan of care daily for changes. Be sure the catheter tubing and drainage bag are kept off the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675928 If continuation sheet Page 2 of 6 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 675928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sienna Nursing and Rehabilitation 2510 W 8th Street Odessa, TX 79763 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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. Based on the observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food sanitation and storage, in that: 1. The facility failed to ensure that foods in the dry goods storage are sealed and labeled. 2. The facility failed to ensure that items in the walk-in refrigerator were sealed or dated 3. The facility failed to maintain cleanliness in the clean dishes area. These failures could affect residents by placing them at risk of food borne illness. Findings included: Observation on 08/09/2023 at 10:21 a.m., revealed in dry goods storage an open 29-ounce pack of dried refried beans in a storage bag that was not labeled. There was an opened (not properly sealed) storage bag of breadcrumbs that was not labeled. Observation on 08/09/2023 at 10:25 a.m., revealed in walk-in refrigerator an open package of turkey breast slices that was not sealed or dated to indicate the date the package was opened or the date the food should be discarded. Observation on 08/09/2023 at 10:28 a.m., revealed dirty and dusty ceiling vent over the clean dish area. It was noted near the dusty vent, a clean dish storage rack had approximately 12 drinking glasses on a tray turned upward on the top rack. During an interview on 08/09/2023 at 10:30 a.m., the Dietary Manager (DM) said that all opened food items in the dry good storage and in the refrigerator should be labeled and sealed properly. The DM said the items observed inappropriately sealed or not labeled was not acceptable and may place residents at risk of food borne illness. Review of facility policy Food Safety dated 2022, reads in part Food shall be handled in a safe manner. Food is to be wrapped or sealed and covered in clean containers. Opened food shall be labeled, dated and stored properly. Review of the Food Code (https://www.fda.gov/food/retail-food-protection/fda-food-code) (3-501.17) Refrigerated, READY-TO -EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES . or discarded when held at a temperature of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675928 If continuation sheet Page 3 of 6 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 675928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sienna Nursing and Rehabilitation 2510 W 8th Street Odessa, TX 79763 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 5ºC (41ºF) or less for a maximum of 7 days 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: 675928 If continuation sheet Page 4 of 6 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 675928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sienna Nursing and Rehabilitation 2510 W 8th Street Odessa, TX 79763 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for two bedrooms (rooms #108 and #109) reviewed for environment, in that: #1-room [ROOM NUMBER] (Resident #15) observed with ants inside a drawer and a hole on the wall behind the resident bed. #2-room [ROOM NUMBER] (Resident #10) observed with hole behind the resident bed. These failures could place residents and staff at risk of living in an unsafe, unsanitary, and uncomfortable environment Findings included: Observation and interview on 08/08/2023 beginning at 2:50 p.m., room [ROOM NUMBER] (Resident #10's bedroom) noted an approximately 3 inches by 1-inch vertical hole on the dry wall behind Resident #10's bed. Resident #10 said he does not know about any hole on the wall behind his bed. Observation and interview on 08/09/2023 beginning at 9:40 a.m., room [ROOM NUMBER] (Resident #15's bedroom) noted approximately 10 live ants on the top drawer of the resident's dresser drawers. It was noted there was a plastic spoon, fork, and plastic cup lid in the drawer. The drawers were approximately three feet away from the resident's bed. Resident #15 said she was not aware there were ants in the drawer. Resident #15 said she had not been bitten by any insects. HHSC Investigator looked around the room to try to find where the ants may be coming from. There were no other ants or trail of ants noted. Investigator noted a hole in the wall behind Resident #15's bed. Resident #15 said she did not know how long the hole was in the wall. Resident #15 said she believed the hole was most likely the result of staff moving the bed when assisting with bed mobility, dressing, or transferring. During an interview on 08/09/2023 at 9:52 a.m., the Maintenance Supervisor (MS) said he was not aware of ants found in the drawer of room [ROOM NUMBER]. The MS said he was aware of past issues with ants and there was a pest control service that routinely sprays the building for pests. The MS said he was not aware of hole in the wall behind the bed in room [ROOM NUMBER] or #109. The MS said the hole may be a possible entry point for ants. The MS said the process for addressing maintenance issues at the facility was for any staff who finds the maintenance issue to make a work order request through the computer, and as he received the orders, he would address the issue and when completed sign off on the computer work order as completed. The MS showed the HHSC Investigator recent work orders. There were no work orders for any holes in the wall in room [ROOM NUMBER] or #108. There were no work orders for ants in room [ROOM NUMBER]. During an interview on 08/09/2023 at 10:05 a.m., the Administrator said he just became aware of reported ants in room [ROOM NUMBER]. The Administrator ordered removal of the drawer from the room and inspection of the room. The Administrator said that he instructed the MS to contact the pest control agency to report the issue so that it can be addressed. The Administrator said no other ants in the building had been reported. The Administrator said that staff who see any maintenance issues including pests need to notify the MS so he can address the issue. The Administrator said there had been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675928 If continuation sheet Page 5 of 6 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 675928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sienna Nursing and Rehabilitation 2510 W 8th Street Odessa, TX 79763 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm no prior complaints of any ants. The Administrator said there had been no recent grievances regarding holes in the wall in the resident rooms. HHSC Investigator requested facility maintenance policy. Record review on 08/09/2023 at 10:30 a.m., revealed Perfect Pest Control makes monthly visits at the facility. The last visit was on 07/12/2023. Residents Affected - Some On 08/09/2023 at 4:30 p.m., the Administrator said he was not able to locate any policy regarding maintenance services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675928 If continuation sheet Page 6 of 6