Health inspection·November 1, 2023

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some surgical mask mandate because the facility is still in the window of COVID from the two previous staff who tested positive. The ADM stated that the only resident in isolation/quarantine was a female resident who tested positive for C-Diff. During an interview on 11/01/2023 at 10:35 a.m. the HK Supervisor stated that when Housekeeping performs cleaning services in Resident #1's room, they are required to wear gowns, masks and gloves, and when they exit, they discard the gown, mask and gloves in the resident room. The HK Supervisor stated that when they exit the room, they use hand sanitizer first and then go to the hopper room in the hallway to use soap and water to disinfect their hands. The HK Supervisor stated they cannot touch anything until they have washed their hands with soap and water. The HK Supervisor stated staff had been in-serviced on C-Diff protocols including DON/DOFF (put on and remove)PPE and proper handwashing requirements. During an observation and interview on 11/01/2023 at 12:55 p.m., HK was observed exiting Resident #1's room wearing a surgical mask and then proceeded to touch items on her supply cart and pull an unknown item from her shirt pocket. The HK did not use hand sanitizer, nor did she wash her hands with soap and water after exiting the room. The HK stated that she had entered Resident #1's room to put paper towels in the restroom and did not put on a gown before entering the room. The HK stated she wore gloves in the room and discarded them in the room before exiting. The HK stated that the resident has C-diff and is transferred by feces and particles in the air or on surfaces in the resident room. The HK stated, I was just putting paper towels in there. The HK stated she went into the restroom, used the HK cart key to open the paper towel dispenser and then loaded the paper towels and did not wash her hands after touching the paper towel dispenser. The HK stated she had been trained a few days ago on hand washing, wearing the appropriate PPE in Resident #1's room and that there was no excuse for not following the infection control procedures. The HK stated she also knew the resident was on isolation because of the postings on the resident door and the PPE cart outside the door. The HK stated she had not disinfected or washed her hands after exiting the room and she did not remove the surgical mask that she wore in the room. During an interview on 11/01/2023 at 1:07 p.m. the ADM stated that on 10/25/2023, the HK and staff were in-serviced on What are Universal Precautions, Bloodborne Pathogens, Hand Hygiene at Work, Infection Control Reminders and provided copies of the signed in-services to the Investigator. The Adm stated that regardless of if the HK was just putting paper towels in Resident #1's room, she was required to wear a gown, gloves and mask and then doff the PPE in the room, and wash hands with soap and water upon exiting. The ADM stated that by the HK not washing her hands with soap and water, wiping her hands on her work shirt and touching items on the housekeeping cart she contaminated those items with C-Diff. The ADM stated that the HK will immediately be sent home. The ADM stated that the HK was just in-serviced and knew the proper infection control procedures and policies. The ADM stated that by not following the infection control procedures the HK placed other residents and staff at risk of potentially contracting C-Diff. During an interview on 11/01/2023 at 1:13 p.m. the ADON stated that she was the infection control preventionist for the facility and staff were in-serviced over the weekend on C-Diff, Handwashing and PPE. The ADON stated that the HK was trained and there was a risk of the HK spreading C-Diff around the facility by not following PPE requirements or washing her hands with soap and water and by touching items outside the room. The ADON stated that C-Diff can spread from feces entering the air and getting in the air and on items. The ADON stated that I am going to send her (HK) home. She is spreading it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675978 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675978 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Grace Wellness Center 1241 W Marshall Howard Blvd Littlefield, TX 79339 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 11/01/2023 at 2:32 p.m., Resident #1's room door was fully opened, the resident room appeared empty, and Resident #1 was not visible from the hallway observation. LVN A was approached at the nurse's station and observed wearing a surgical mask. LVN A was informed of the observation of Resident #1 not observed in her room. LVN A walked down to Resident #1's room and DONNED PPE to include a gown and gloves and entered the resident room. LVN A left Resident #1's room door open, walked to the room restroom and located Resident #1. LVN A doffed the gown and gloves in the room and exited wearing a surgical mask. LVN A stated that Resident #1 was using the restroom and must have opened her door. LVN A walked down towards the nurses station and washed her hands with soap and water and exited wearing a surgical mask. During an interview and observation on 11/01/2023 at 2:36 p.m. with LVN A at the nurses station, LVN A stated that she washed her hands with soap and water after exiting the room but did not remove the mask she had worn in the room. The LVN A was observed touching items at the nurses station and touching her mask several times. LVN A stated she forgot to remove her mask after exiting the room. LVN A removed the surgical mask, threw it away at the nurses station, used hand sanitizer and then reached inside of the surgical mask box and put a new mask on. LVN A was asked what she should have done after removing her surgical mask and LVN A stated, I should have washed my hands. LVN A stated that she should have removed her mask after exiting the room because it gets particles on your mask, then I touch my mask and I spread it. LVN A then went to wash her hands with soap and water and put a new surgical mask on. LVN A stated that she had been trained on infection control and C-Diff, had observed the postings requiring PPE requirements and hand washing procedures. The LVN A stated that she did not follow the proper procedures after exiting the resident room. During an exit conference at 11/01/2023 at 2:40 p.m. with the ADM, ADON and Corporate Liaison, the ADM stated that LVN A should have removed her mask and then washed her hands with soap and water. The ADON stated that LVN A did not follow proper infection control procedures and the Corporate Liaison stated that staff know better. During a phone interview on 11/03/2023 at 1:38 p.m the ADON stated that staff are in-serviced on C-DIFF and infection control procedures and those in-services are left at the nurses station for staff to read and sign. The ADON stated that LVN A is from an agency, and if LVN A did not sign the in-service on the C-Diff precautions, then we dropped the ball because she should have been in-serviced and signed the in-service. The ADON stated that agency staff are trained on infection control and universal precautions at their agency and LVN A had worked in the facility before. Record Review of the in-service entitled What are Universal Precautions, dated and signed by HK on 10/25/2023, revealed, Universal Precautions are based on the principle that all blood and bodily fluids should be treated as if they are infectious, regardless of whether the source is know to be infected. Record Review of the in-service entitled Bloodborne Pathogens, dated and signed by HK on 10/25/2023, revealed: Staff must wear protective clothing when exposed to blood and bodily fluids at work. Record Review of the CDC in-service entitled Hand Hygiene at Work, dated and signed by HK on 10/25/2023, revealed: Handwashing benefits the entire community and reduces the number of people who get sick with diarrhea by 31% and reduces diarrheal illness in people with weakened immune systems by 58%. Good hand hygiene means regularly washing hands with soap and water for at least 20 seconds and then drying them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675978 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675978 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Grace Wellness Center 1241 W Marshall Howard Blvd Littlefield, TX 79339 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 0880 Level of Harm - Minimal harm or potential for actual harm Record Review of the in-service entitled Infection Control Reminders, dated and signed by HK on 10/25/2023, revealed: Staff are instructed that hand washing is the first and last thing you do; wash hands on entering and leaving a resident room, wash hands between handling residents or resident's items. Always follow standard precautions before and after every patient contact, use personal protective equipment when risk of body fluid exposure. Wearing gloves does not equal clean hands. Residents Affected - Some Record Review of the facility provided Med Pass 2001 policy entitled, Clostridium Difficile revealed, Preventative measures will be taken to prevent the occurrence of Clostridium difficile among residents and precautions will be taken while caring for residents with C. difficile (to prevent transmission to others). Residents with C. difficile will be placed on isolation, staff will wear gowns and gloves upon entering the room and will remove gowns and gloves prior to exiting the room. Staff will maintain vigilant hand hygiene, hand washing with soap and water upon exiting the room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675978 If continuation sheet Page 4 of 4