Health inspection·July 27, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 07/27/23 at 10:15 AM with Resident #43, he stated he is occasionally incontinent of urine. He stated he required staff to assist him to the toilet at time and in/out of bed. He stated he does not move much when he is in bed and liked to lay on his back most of the time. He stated it had been a while since his last fall but that he is unsteady at times. During an interview on 07/27/23 at 10:30 AM with the MDS Coordinator, she stated everyone had a section to complete on the care plan. She stated she was responsible for section V and care planning. She stated she pulled section V sheet and made sure all triggered care areas were care planned. She stated she made a mistake and the missing care areas for Resident #43 were not care planned. She stated section V was used to form the care plan along with assessments and resident interviews. She stated there was no reason a triggered care area would not be care planned. She stated the care plan was used to inform staff on how to care for residents and meet their needs the best they can. She stated nursing and CNA's used the care plan. She stated the potential negative outcome could be proper care would be missed. She stated she does not know why the triggered care areas were missed, maybe just an oversight. She stated there were no systems in place to ensure triggered care areas were not missed. She stated her expectations were all triggered care areas were care planned. She stated she had training on how to do care plans. During an interview on 07/27/23 at 10:45 AM with the DON, she stated the IDT was responsible for the care plan. She stated her main role in the care plan process was falls, nutrition, weights, dehydration, and feeding tubes. She stated all tasks were divided up between the team. She stated Sec V and assessments were used to form the care plan. She stated there should not be any reason a triggered care area was not care planned. She stated the care plan was used to take care of resident's needs and so everyone was on the same page for the best care for the resident. She stated everyone used the care plans. She stated the CNA's use the care plan related to activities of daily living. She stated the potential negative outcome could be resident would not get their needs met. She stated the triggered care areas that were missed was an oversight and human error. She stated the IDT all have sections to complete. She stated her expectations were all triggered care areas, medications, and anything the staff needed to know for that resident to be care planned. She stated she had training on care plans. During an interview on 07/23/23 at 11:00 AM with the ADM, she stated the MDS Coordinator was specifically responsible for care planning triggered care areas on section V. She stated Section V was used to form the CP. She stated there might be some triggered care areas that were not care planned depending on the resident. She stated the care plan was used to deliver care and a comprehensive view of the resident, on how to care for the resident. She stated nurses and CNA's used care plan . She stated missed care areas that were not care planned could cause the resident to not receive care that was needed. She stated missed triggered care areas was due to human error. She stated the care plan should include relevant variances outside residents' baseline. During an interview on 07/27/2023 at 11:11 AM with RN B, she stated she was familiar with Resident #43 and stated that he was a mild fall risk. She stated she was not sure if he was at risk for pressure ulcer development or UTI development. She stated he was able to urinate on his own using the toilet and he does spend a lot of time in bed. She stated they do not necessarily pull up the care plan and go through it when planning care for a resident. She stated the risk of not having care plan focus areas and appropriate interventions for areas like risk for UTI, fall risk, or risk for PU development, was that staff may be unaware of care areas or appropriate preventative interventions. During an interview on 07/27/23 at 11:15 AM with RN A, she stated IDT was responsible for care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676175 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 676175 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Permian Residential Care Center 1601 NE Mustang Andrews, TX 79714 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few plans. She stated her specific role was infection control. She stated the process in forming a care plan was section V, diagnosis and building care plan to be individualized. She stated there was no reason why a triggered care area should not be care planned. She stated the care plan was used for individual treatment. She stated everyone used the care plan. She stated missing care areas that were not care planned could cause the resident to be treated wrong and cause injury/ harm . She stated the triggered care areas were missed because she did not verify, they were done before signing the MDS complete. She stated they have a system in place. She stated the system will alert if triggered areas were not care planned and each IDT member was responsible for specific care areas. She stated her expectations of what should be care planned was anything that keeps the resident safe, abilities/disabilities, medications, infection and mental/physical health. She stated she has had training on care plans. During an interview on 07/27/23 at 11:22 AM with CNA A, she stated, she had worked at facility for about a year. She stated she does not use care plans for her day to day care but said care plans were in place for the wellness of the residents. She stated she would expect risk for pressure ulcer development, risk for falls, and risk for UTI to all be care planned. She stated if focus care areas like these were not included in a care plan the risk was that the resident may develop the condition if interventions are not known of by staff. She stated Resident #43 required staff assistance to transfer to wheelchair or the toilet. She stated he had incontinence episodes in his brief. Record review of the provided facility's policy titled Care Planning, revised June 2020, revealed: Purpose - to ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. Policy: I. The Facility's Interdisciplinary Team (IDT) will develop a Baseline and/or Comprehensive Care Plan for each resident in accordance with MDS guidelines. II. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs. III. A Licensed Nurse will initiate the Care Plan, and the plan will be finalized in accordance with MDS guidelines and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgment on an as needed bases. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676175 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 676175 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Permian Residential Care Center 1601 NE Mustang Andrews, TX 79714 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 0656 Procedure: . Level of Harm - Minimal harm or potential for actual harm IX. Each resident's Comprehensive Care Plan will describe the following: A. Services that are to be furnished to attain or maintain the resident's highest practicable Residents Affected - Few physical, mental and psychosocial well-being; B. Any services that would be required, but are not provided due to the resident's exercise of rights, which includes the right to refuse treatment; . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676175 If continuation sheet Page 4 of 4