Inspection·November 22, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 11-21-2024 at 8:07 AM revealed Resident #24 lying in bed asleep. Resident #24's catheter bag was observed hanging from the left side of his bed with no protective cover, there was a small amount of amber liquid noted in the bag. During an interview on 11-20-2024 at 5:08 PM, Resident #24's family member stated during visits with Resident #24, she had observed the bag to be uncovered. The family member stated her grandchildren had wondered what was in the bag because it was uncovered and didn't think Resident #24 would want the bag covered. During an interview on 11-21-2024 at 8:10 AM, CNA D stated catheter bags should be covered at all times. CNA D stated a possible negative outcome for not having a bag covered could be an embarrassment for the resident. During an interview on 11-21-2024 at 10:07AM, CNA C stated all staff were responsible for ensuring privacy bags were put on catheter bags and not having a privacy bag was disrespectful to the resident. During an interview on 11-21-2024 at 1:33 PM, the ADON stated that all staff were responsible for making sure catheter bags were covered because it could be embarrassing to the resident. During an interview on 11-21-2024 at 1:39 PM, LVN A stated that all staff were responsible for making sure catheter bags were covered because it was a dignity issues. During an interview on 11-22-2024 at 8:48 AM, Resident #24 stated he would like his catheter bag covered. Record review of the facility provided policy titled, Quality of life-Dignity dated August 2009, reflected the following: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident to keep urinary catheter bags covered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675978 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 675978 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 13 residents (Resident #24) reviewed for quality of care, in that: Residents Affected - Few The facility failed to reposition Resident #24 every two hours according to his person-centered care plan. This failure could place residents at risk for not being provided with adequate care and treatment. The findings included: Record review of Resident #24's face sheet, dated 11-21-2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #24 had diagnoses which included, but not limited to, quadriplegia (a type of paralysis that affects all four limbs and the body from the neck down), central cord syndrome at unspecified level of cervical spinal cord(spinal cord injury in the neck) and muscle wasting and atrophy(gradual loss of muscle mass) Record review of Resident #24's Quarterly MDS dated [DATE] reflected the following: Section C : Resident #24 had a BIMS of 05 out of 15, which indicated he was severely cognitively impaired. Section GG: Resident #24 was dependent(helper does all of the effort, Resident does none of the effort to complete the activity) on roll left to right, sitting to lying, eating, oral hygiene, shower/bathe, upper and lower body dressing. Record review of resident #24's care plan reflected that Resident #24's was at risk for alteration in comfort at risk for pain presence with intervention with turning and repositioning every 2 hours or as needed for comfort. Observation of Resident #24 on 11/21/2024 at 8:07 AM, revealed the Resident was lying on his back, his head raised slightly 30-35 degrees, head drooping to the left side Observation of Resident #24 on 11/21/2024 at 10:00AM, revealed the Resident was lying on his back, his head raised slightly 30-35 degrees, head drooping to the left side Observation of Resident #24 on 11/21/2024 at 12:27 PM, revealed the Resident was lying on his back, his head raised slightly 30-35 degrees, head drooping to the left side During an interview with Resident #24 on 11/22/24 at 8:34 AM, Resident #24 stated that he did not know how many times each day they reposition him but stated it would feel better if they would reposition him more. An interview with Resident #24's family member on 11/21/24 at 1:28 PM revealed she was able to see Resident #24 on the camera they installed in his room. The family member said she did not see the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675978 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 675978 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2024 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 0684 Resident repositioned every two hours. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/22/24 at 1:33 PM, the ADON stated that they did not reposition Resident #24 as much as they used to because he was becoming stiffer. When asked why it was still documented in the care plan, she stated she did not know why and said if it was in the care plan it should have been done. The ADON stated a possible negative outcome for not repositioning Resident #24 as noted in the care plan would be that it could cause pressure ulcers. Residents Affected - Few During an interview on 11/21/24 at 1:39 PM, LVN A stated that Resident #24 should be repositioned every two hours. She said that CNAs were responsible for positioning residents, and the charge nurses were responsible for ensuring it was done. LVN A stated that a possible negative outcome for not repositioning residents every two hours could cause the resident pain. Record Review of the facility's Reposition Policy dated May 2013 reflected the following: Purpose: The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for reposition to promote comfort for all bed-or chair bound residents and to prevent skin breakdowns, promote circulation and proved pressure relief for resident. Preparation: 1. Review the resident's care plan to evaluate for any special needs of the resident. General Guidelines: 1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief . 2. Reposition is critical for a resident who is immobile or depend upon staff for repositioning . Interventions: Residents who are in bed should be on at least every two-hour repositioning schedule. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675978 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 675978 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2024 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interviews, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 (09/06/2024) of the 90 days reviewed. Residents Affected - Few The facility did not have an RN working in the facility on 09/06/2024. This failure has the potential to affect the residents in the facility and place them at risk of not having staff with advance care skills available to assist in their care needs. Findings included: Record review of the facility's last 6 months (06/1/2024-11/18/2024) of RN coverage provided by the BOM revealed the facility had no RN working in the facility for the following date: 9/6/24. During an interview on 11/22/24 at 9:15 AM, the ADON stated that a possible negative outcome for not having an RN working for 8 hours/day would be that if something bad happened, the staff would not know what to do and would not have anyone to go to. During an interview on 11/22/24 at 10:25 AM, the BOM verified that the facility did not have an RN working in the facility on 9/6/24. She stated the consequences of not having an RN in the facility would be not having another set of eyes for the residents. She stated she did not know why there was no RN working the day of 9/6/24 and it was just missed. During an interview on 11/22/24 at 10:55 AM, the ADM stated that she was not aware that a day of RN coverage had not occured on 9/6/24. She stated the negative outcome for not having an RN on staff each day would be that anything could happen. A policy for RN coverage was requested on 11/21/24 at 8:14 AM but was not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675978 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 675978 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on one of two carts the Treatment Cart. Treatment cart contained 1 vial Lantus insulin found open with no expiration date in the top drawer. This failure could place residents receiving medications at risk for drug diversion, drug overdose, and accidental or intentional administration to the wrong resident which could lead to exacerbation of their disease process and deterioration in general health. Findings include: During observation/interview on [DATE] at 10:08 AM of Treatment Cart with LVN A, observation of top-drawer holding insulin, found 1 vial of Lantus insulin with opened date penned [DATE], but without an expiration date. LVN A was asked how many days after opening the insulin before it expires. LVN A replied, This insulin expires 28 days after opening it. That means it is expired. When asked what possible negative outcomes of giving a resident expired insulin could be, he responded, Negative outcome could be deceased effectiveness resulting in elevated blood glucose. LVN A was asked who is responsible for putting expiration dates on medications he stated the nurses are responsible. LVN A took the medication and placed it with the medications to be destroyed. During interview on [DATE] at 10:10AM LVN B was asked about the expiration date of Lantus insulin after opening and stated, That insulin has 28 days after first use before it expires. Asked what possible negative outcomes could be, she stated, If given after it expires it may not be effective in managing blood glucose like it is supposed to. When asked who is responsible for putting expiration dates on medications, she replied the nurses are. During interview on [DATE] with ADON regarding the expired vial of Lantus insulin she stated, That should have been caught. Pharmacy was here on Tuesday and went through the Medication Carts and the Treatment Cart. They didn't say anything about any expiration dates. We haven't been putting on the expiration dates, just the opening dates on the insulins. We need to start putting expiration dates on, so we know when to discard the insulin. When asked about adverse possibilities of using expired insulin on resident's she stated, The insulin won't work well or maybe not at all. During record review of the facility's policy, 'Labeling of Medication Containers' dated revised [DATE] revealed in part: 3. Labels for individual drug containers shall include all necessary information such as: f. The date that the medication was dispensed h. The expiration date when applicable (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675978 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 675978 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2024 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 0761 5. Labels for each single unit dose package shall include all necessary information, such as: Level of Harm - Minimal harm or potential for actual harm c. The date dispensed e. The expiration date when applicable Residents Affected - Few During record review of facility's policy, 'Storage of Medications' date revised [DATE] revealed in part, Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received . The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675978 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 675978 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2024 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 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 observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure freezer items were labeled and dated. 2. The facility failed to ensure refrigerator items were properly stored, labeled, and dated. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings included: Observation of the walk-in refrigerator on 04/24/24 at 8:25 AM revealed the following: 1. (1) partially used package of ham lunch meat, in original package, with no date or label, open to air 2. (1) package of what looks to be lunch meat in saran wrap with no date or label 3. (1) bucket full of ½ sandwiches approximately 20 ½ sandwiches with no date or label 4. (1) ½ sandwich with no date or label, open to air 5. (2) plastic container of what appeared to be fruit cocktail no label or date 6. (1) container with approximately 20 cupcakes in the container with no date or label Observation of the freezer on 11/20/24 at 9:40 AM revealed the following: 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675978 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 675978 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2024 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 0812 (2) large packages of lemon bread with no date. Level of Harm - Minimal harm or potential for actual harm In an interview on 11/20/24 at 9:50AM, the DM stated that a possible negative outcome for not having labeled and dated food in refrigerator and freezers would be that the food could be outdated, and residents could get sick. The DM stated all staff were responsible for ensuring items were dated and labeled. The DM stated that she recently in-serviced her staff on this issue. Residents Affected - Some In an interview on 11/21/24 at 1:56 PM, DA E stated that a possible negative outcome for not having labeled and dated food in refrigerator and freezers would be that they wouldn't be aware if the food was good, and we could serve bad food to the residents, and they could get sick. The DA E stated that all kitchen staff were responsible for labeling and dating foods. Record review of the facility-provided policy dated July 2014 titled Food Safety and Storage stated in part: .All foods stored in the refrigerator or freezer will be covered, labeled, and dated FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675978 If continuation sheet Page 9 of 9