Health inspection·January 5, 2024

F 0604 the use of bolsters for any purpose. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #84's physician's orders dated 10/09/2023 through 01/05/2024 revealed no orders for the use of bolsters. Residents Affected - Some Observation on 01/2/2024 at 10:30 AM of Resident #84 revealed he was in bed. When greeted Resident #84 made sounds but did not form any words. It was observed that on both sides of his bed the sheets were stretched over six-inch tall bolsters that were strapped along the edge of the mattress. The bolsters extended from within 20 inches of the head of the bed to within 15 inches of the foot of the bed. In an interview and observation on 01/05/24 at 08:23 AM, LVN C revealed that Resident #84 had bolsters on the sides of his bed, so he would not fall off the bed. She stated that CNAs also put a pillow under the sheet on the upper part of his bed because he may flip out the bed. She said that if he felt something at top of the mattress he would not lean in that direction. She said he slid around in bed and reached out and if he felt something at the side of bed he would not flip out of the bed, so the bolster helped prevent falls. She said he had not fallen during the time she had worked with him. In an interview on 01/05/24 at 03:22 PM, CNA G revealed that CNAs put the sheets over the bolsters when they made Resident #84's bed and in addition, they rolled up a pillow to put under the sheet to the left of the resident's head to help keep him from falling from the bed. Resident #71 Record review of Resident #71's face sheet dated 01/05/2024 revealed she was [AGE] years old, was initially admitted to the facility 12/28/2020 and re-admitted [DATE]. Record review of Resident #71's history and physical dated 11/15/2023 revealed she had diagnoses including CVA (a stroke) with severe aphasia (inability to talk), right sided hemiplegia (weakness or partial paralysis). Record review of Resident #71's quarterly MDS assessment dated [DATE] revealed a BIMS assessment interview was not conducted with her because she was rarely understood. Staff assessed her as having short- and long-term memory problems. She had no behavioral symptoms. She needed moderate assistance to move around in bed and was dependent on others to transfer from one surface to another. She did not have a history of falls prior to or since admission to the facility. She did not have any type of physical restraint. Record review of Resident #71's care plan initiated 12/28/2020 and revised 03/15/2022 revealed she had right sided weakness. The Care Plan for right-sided weakness said she was to have a bed bolster on the left side of the bed. Goals and interventions related to the resident's right sided weakness did not mention the use of bolsters on either the right or left side of the bed. Record review of Resident #71's physicians order dated 08/18/2023 revealed Bolster while in bed every shift for falls. Where the bolster was to be placed or the reason for use of a bolster was not indicated on the physician's order. In observation and interview on 01/02/2024 9:40 AM Resident #71 was awake and alert but was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676375 If continuation sheet Page 2 of 19 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 676375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Giles Nursing and Rehabilitation Center 950 Camino Del Rey Drive El Paso, TX 79927 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some able to respond to questions. It was observed that there were bolsters attached to both sides of her bed. The bolsters extended from within 20 inches of the head of the bed to within 15 inches of the foot of the bed. During an interview on 01/05/24 at 1:31 PM with LVN C, she stated there were some beds that have bolsters on the mattress. LVN C stated bolsters were not considered a restraint. LVN C stated the purpose of a bolsters was to help prevent a resident from falling . Resident #83 Record review of Resident #83's face sheet dated 01/03/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #83's history and physical dated 07/26/23 revealed a [AGE] year-old female diagnosed with diabetes mellitus type 2 (insulin resistance), dementia (the loss of cognitive functioning thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and hypertension (is when the pressure in your blood vessels is too high) dyslipidemia (imbalance of lipids such as cholesterol, low-density lipoprotein cholesterol, triglycerides, and high-density lipoprotein). Record review of Resident #83's care plan dated 08/19/23 revealed Resident #83 was at risk for history of balance problems. A scoop mattress while in place. Record review of Resident #83's physician orders dated 08/19/23 revealed a scoop mattress while in bed every shift for falls. Observation on 01/02/24 at 10:43 AM revealed Resident #83 asleep lying on a scoop mattress covered up except for her feet which she had two green cushion boots on. Bed was in low position with a fall mat on each side of the bed. During an interview on 01/04/24 at 3:02 PM with LVN A , she stated Resident #83 had her bed in a low position with fall mats on the side of the bed but did not indicate for how long. LVN A stated Resident #83 had a scoop mattress to have prevent her from falling. LVN A stated a scoop mattress was like a bowl that helped keep the resident in place in the middle of the bed. LVN A stated the scoop mattress was used to prevent falls due to Resident #83's history of falls. LVN A stated the facility used scoop mattress to keep facility residents from falling. During an interview on 01/04/24 at 3:54 PM with ADON B, she stated Resident #83 had a history of falls. ADON B stated Resident #83 had falls mats, her bed in a low position, monitoring, a scoop mattress. ADON B stated the scoop mattress was flat with the ends of the mattress curved upwards located on the sides of the ends of the feet and head areas. ADON B stated the scoop mattress was to prevent residents from falling. ADON B stated she had not been trained on restraints, but the facility staff were trained on restraints. ADON B stated restraints were not allowed in the facility at all. During an interview on 01/05/24 at 1:31 PM with LVN C, she stated interventions for a post fall that a resident had includeds fall mats, bed in the low position, items cleared from the area, and a scoop mattress. LVN C stated a scoop mattress was a curved mattress used for residents who were a fall risk. LVN C stated the purpose of a scoop mattress was to prevent residents from falling off the bed. LVN C stated she had been trained on restraints upon hire and as needed. LVN C stated one type of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676375 If continuation sheet Page 3 of 19 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 676375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Giles Nursing and Rehabilitation Center 950 Camino Del Rey Drive El Paso, TX 79927 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 0604 restraint was a physical restraint on the bed and wheelchair which could have straps or leg restraints. Level of Harm - Minimal harm or potential for actual harm During an interview on 01/05/24 at 2:21 PM with CNA D, she stated she had been trained on restraints. CNA D stated a restraint was when you take away the movement of a resident. Residents Affected - Some In an interview on 01/05/2024 at 2:52 PM the Rehabilitation Director revealed that assessments for bolsters or scoop mattresses for residents were not being done. She said that although therapists might suggest using bolsters or scoop mattresses, there were not any current residents for whom therapy had suggested bolsters or scoop mattresses. In an interview on 01/05/24 at 4:58 PM the DON revealed she did not think an assessment was needed to be made for bolsters or scoop mattresses. The DON stated the use of bolsters for a bed of a resident should be care planned and need to have doctors' orders. The DON stated the bolster's purpose was an intervention used for residents at high risk for falls. The DON stated bolsters addressed the issue with falls to keep the resident safe and in bed. The DON stated the facility had not had a restraint committee meeting; she did not indicate since when. The DON stated physical therapy did not assess the residents for a bolster or scoop mattress. The DON stated using the bolsters/scoop mattress would be a concern because the residents could injury themselves with the restraints as well as impede on their rights. In an interview on 01/05/2024 at 05:52 PM the Administrator revealed she would not be able to comment on whether residents should be assessed for use of bolsters or scoop mattresses without consulting with her nursing team or corporate compliance. She said the Restraint Assessment Committee mentioned in the facility Restraint policy dated 02/01/2017 might have been used to consider the use of bed rails but not for bolsters of scoop mattresses. She stated she did not know if consent was needed to use bolsters or scoop mattresses. She said that if bolsters or scoop mattresses were restraints, consent for their use would be needed. Record review of the facility policy titled Restraints dated 02/01/07 revealed, It is the policy of this facility to maintain an environment that prohibits the use of restraints for discipline or convenience. Restraint usage shall be limited to circumstances in which the resident had medical symptoms that warrant the use of restraints. A Restraint Assessment Committee will evaluate and establish the need for a restraint use or restraint reduction, for residents in our facility. Physical Restraints - Any manual method or physical\mechanical device, material, or equipment attached or adjacent to the resident=s (sic) body that the resident cannot remove easily, which restricts freedom of movement or normal access to one=s (sic) body. Restraint's will only be applied after it has been determined that a medical symptom requiring restraint usage exists, and only after other alternatives have been tried unsuccessfully. A physician's order shall be necessary to begin a restraint assessment/ evaluation for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676375 If continuation sheet Page 4 of 19 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 676375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Giles Nursing and Rehabilitation Center 950 Camino Del Rey Drive El Paso, TX 79927 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 0604 resident. Level of Harm - Minimal harm or potential for actual harm - Residents Affected - Some The Restraint Assessment Committee shall meet to assess the necessity of restraints for a resident by completing a Pre-Restraining Assessment worksheet. Facility staff will develop a care plan for the alternate method identified and or the restraint usage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676375 If continuation sheet Page 5 of 19 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 676375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Giles Nursing and Rehabilitation Center 950 Camino Del Rey Drive El Paso, TX 79927 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 - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement as well as develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 3 (Resident #84, Resident #40, and Resident #83) of 26 reviewed for care plans in that: The facility failed by implementing a comprehensive person-centered care plan for include a care plan for toenail care for Resident #40 and Resident #83; who were diabetic. The facility failed to include the use of bolsters (long thick pillows placed along the sides of the mattress that create a barrier to help stop residents from rolling or sliding out of bed) in Resident #84's care plan. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services. Findings include: Resident #84 Record review of Resident #84's face sheet dated 01/03/2024 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #84's history and physical dated 10/10/2023 revealed he had diagnoses of advanced dementia and Alzheimer's disease. Record review of Resident #84's quarterly MDS assessment dated [DATE] revealed a BIMS assessment interview was not conducted with him because he was rarely understood. Staff assessed him as having short- and long-term memory problems. He had no behavioral symptoms. Section DD of the MDS indicated he needed substantial assistance to move around in bed, to sit up or lie down, and was dependent on others to transfer from one surface to another. The resident did not have any history of falls prior to admission or since admission. He had impairment of his range of motion on one of his lower extremities (legs). His diagnoses included non-Alzheimer's dementia. He did not have any type of physical restraint. Record review of Resident #84's care plans last revised 10/23/2023 revealed no care plan related to the use of bolsters for any purpose. Record review of Resident #84's physician's orders dated 10/09/2023 through 01/05/2024 revealed none for use of bolsters. Observation on 01/2/2024 at 10:30 AM of Resident #84 revealed he was in bed. When greeted Resident #84 made sounds but did not form any words. It was observed that on both sides of his bed the sheets were stretched over six-inch tall bolsters that were strapped along the edge of the mattress. The bolsters extended from within 20 inches of the head of the bed to within 15 inches of the foot of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676375 If continuation sheet Page 6 of 19 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 676375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Giles Nursing and Rehabilitation Center 950 Camino Del Rey Drive El Paso, TX 79927 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 bed. Level of Harm - Minimal harm or potential for actual harm Observation on 01/2/2024 at 10:30 AM of Resident #84 revealed he was in bed. When greeted his response was not understandable. It was observed that on both sides of his bed the sheets were stretched over six-inch tall bolsters that were strapped along the edge of the mattress. The bolsters extended from within 20 inches of the head of the bed to within 15 inches of the foot of the bed. A rolled-up pillow was stuffed under the sheet at the head of the bed along the edge of the mattress. Residents Affected - Some Resident #40 Record review of Resident #40's face sheet dated 01/03/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #40's history and physical dated 07/02/23 revealed a [AGE] year-old female diagnosed with diabetes and dementia. Record review of Resident #40's quarterly MDS dated [DATE] revealed BIMS score (brief cognitive screening measure that focuses on orientation and short-term word recall) of 14 (cognitively intact). Resident #40's personal hygiene was a 3 indicating partial/moderate assistance in which the staff does less than half the work. Resident #40 was diagnosed with diabetes mellitus and Alzheimer's disease, lack of coordination, and abnormalities of gait and mobility. Record review of Resident #'s care plan dated 02/24/19 revealed activities of daily living for bath to check nail length and trim and clean on bath day as necessary. Report any changes to the nurse. If diabetic, the nurse will provide toenail care. Record review of Resident #40's orders dated 02/01/19 revealed may have podiatry consult as needed. Observation and interview on 01/04/24 at 9:00 AM with Resident #40 revealed she took off her sock to her right foot revealing a broken toenail chipped, jagged, and sharp areas of various toenails. Resident #40 stated people came to the facility to cut the toenails. Resident #40 stated she wanted the facility to take care of her toenails before she went to therapy that day. Resident #40 stated the toenails hurt a bit. Resident #40 stated she had told RN F that she wanted her toenails cut. Observation and interview on 01/04/24 at 9:06 AM with RN F revealed that Resident #40 told RN F that her toenails were hurting on the sides of the toes. Resident #40 was heard telling RN F she did not want any pain medication. RN F stated there were standing orders for podiatry consult (as needed). RN F stated Resident #40 had asked to have her toenails cut a month ago. RN F stated she notified the physician, but he did not call RN F back. RN F stated Resident #40's toenails not being trimmed or cut could cause discomfort to Resident #40. RN F stated she did not check to see if Resident #40 had any order for podiatry consult (as needed). Resident #83 Record review of Resident #83's face sheet dated 01/03/24 revealed admission on [DATE] and readmission on [DATE] to the facility. Record review of Resident #83's history and physical dated 07/26/23 revealed a [AGE] year-old (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676375 If continuation sheet Page 7 of 19 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 676375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Giles Nursing and Rehabilitation Center 950 Camino Del Rey Drive El Paso, TX 79927 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 female diagnosed with diabetes mellitus type 2 (insulin resistance), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and hypertension (is when the pressure in your blood vessels is too high) dyslipidemia (imbalance of lipids such as cholesterol, low-density lipoprotein cholesterol, triglycerides, and high-density lipoprotein). Residents Affected - Some Record review of Resident #83's order recap dated 01/03/24 revealed there were no orders for podiatry consult (as needed). Record review of Resident #83's care plan dated 07/03/23 revealed refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. Activities of daily living for bath was to check nail length and trim and clean on bath day as necessary. Report any changes to the nurse. If diabetic, the nurse will provide toenail care. During an interview on 01/04/24 at 9:06 AM with RN F, she stated the facility did not have a foot nurse and the wound care nurse would assess the residents looking for any skin issues. RN F stated residents who were diabetic need to have consent and podiatry orders to get their nails cut and trimmed. RN F stated nurses and CNAs do not cut the nails of residents who are diabetic because they could cut them risking infection. During an interview on 01/04/24 at 1:41 PM with Social Worker, she stated the purpose of a care plan was the plan of care of the resident and what they would require as services. The Social Worker stated nail and toenail care plan had to be care planned for the residents. The Social Worker said nurses would have to follow the care plan, and if it was not followed, the residents would not get their health care needs with toenail and fingernail care met. During an interview on 01/04/24 at 3:54 PM with ADON B, she stated care plans had interventions in place for the residents to keep them safe and follow up with their plan of care. ADON B stated there was a risk of not following the care plan which could be residents not seeing the podiatrist and toes getting infected. During an interview on 01/05/24 at 4:58 PM with the DON, she stated the purpose of a care plan was so the nursing staff would know the care of the resident, their needs, and know their health issues. The DON stated a care plan indicating, If diabetic, the nurse will provide toenail care, was an improper care plan as per facility policy. Record review of the facility Comprehensive Care Planning policy not dated revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that include measurable objectives and times frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Record review of the facility foot care policy dated 2003 revealed, Foot care was especially important in those residents with diabetes mellitus or peripheral circulatory conditions because of their susceptibility to infection and skin breakdown. IF required, trimming of the toenails was performed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676375 If continuation sheet Page 8 of 19 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 676375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Giles Nursing and Rehabilitation Center 950 Camino Del Rey Drive El Paso, TX 79927 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 by a podiatrist. Level of Harm - Minimal harm or potential for actual harm Request referral to podiatrist if nail trimming was needed. Residents Affected - Some Daily assessment of the feet should be done when care was given. The primary nurse will advise the physician and obtain a referral to the wound care nurse or the podiatrist. Record review of the facility nail care policy dated 2003 revealed, Nail care especially trimming was performed by a podiatrist in those with diabetes and peripheral vascular disease. Nails that are ingrown, thickened, or infected should be cared for by a podiatrist. Report conditions immediately to the primary nurse. The nurse will ensure a referral to the podiatrist. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676375 If continuation sheet Page 9 of 19 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 676375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Giles Nursing and Rehabilitation Center 950 Camino Del Rey Drive El Paso, TX 79927 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 0687 Provide appropriate foot care. 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 provide proper treatment and care to maintain mobility and good foot health in accordance with professional standards of practice, including to prevent complications from the resident's medical conditions and if necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments for 3 of 5 residents (Resident #19, Resident #40, and Resident #83) reviewed for foot care. Residents Affected - Some The facility failed to provide access to a podiatrist for Resident #19, Resident #40, and Resident #83 who were all diabetics. This deficient practice placed residents at risk of poor foot hygiene and decline in residents' physical condition. Findings include: Resident #19 Record review of Resident #19's face sheet dated 01/03/24 revealed admission on [DATE] and readmission on [DATE] to the facility. Record review of Resident #19's history and physical dated 12/13/23 revealed an [AGE] year-old female diagnosed with type 2 diabetes mellitus and dementia. Record review of Resident #19's quarterly MDS assessment dated [DATE] revealed severely impaired cognition of a BIMS (brief cognitive screening measure that focuses on orientation and short-term word recall) score of 3. Resident #19's personal hygiene activities of daily living was a 3 indicating partial/moderate assistance in which the staff does less than half the work. Resident #19 was diagnosed with diabetes mellitus and non-Alzheimer's dementia, abnormalities of gait and mobility. Record review of Resident #19's care plan dated 08/17/23 revealed give diabetes medication as ordered by the doctor. Notify the charge nurse for open areas, sores, pressure areas, blisters, edema, or redness to the feet. It did not indicate who was to cut, trim, or care for the toenails of Resident #19. Record review of Resident #19's orders dated 08/17/19 revealed may have podiatry consult as needed. During an interview on 01/04/24 at 9:16 AM with Resident #19, she stated she wanted her toenails cut and had told staff many times that she wanted them cut. Resident #19 stated she was not in pain. Resident #19 stated her toenails were long. Observation on 01/04/24 at 9:20 AM with RN F, she observed Resident #19's toenails. Resident #19's toenails were curved inwards on the sides of the toes. Resident #19's toenails were long. During an interview on 01/04/24 at 1:41 PM with Social Worker, she stated Resident #19 had been seen by podiatry on 11/01/23. The Social Worker stated she did not know the risk of a resident who was diabetic if they did not get their toenails cut and trimmed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676375 If continuation sheet Page 10 of 19 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 676375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Giles Nursing and Rehabilitation Center 950 Camino Del Rey Drive El Paso, TX 79927 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 0687 Resident #40 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #40's face sheet dated 01/03/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. Residents Affected - Some Record review of Resident #40's history and physical dated 07/02/23 revealed a [AGE] year-old female diagnosed with diabetes and dementia. Record review of Resident #40's quarterly MDS dated [DATE] revealed an independent cognition to be able to make daily decisions of a BIMS (brief cognitive screening measure that focuses on orientation and short-term word recall) score of 14. Resident #40's personal hygiene was a 3 indicating partial/moderate assistance in which the staff does less than half the work. Resident #40 was diagnosed with diabetes mellitus and Alzheimer's disease, lack of coordination, and abnormalities of gait and mobility. Record review of Resident #'s care plan dated 02/24/19 revealed activities of daily living for bath to check nail length and trim and clean on bath day as necessary. Report any changes to the nurse. If diabetic, the nurse will provide toenail care. Record review of Resident #40's orders dated 02/01/19 revealed may have podiatry consult as needed. Observation and interview on 01/04/24 at 9:00 AM with Resident #40, she took off her sock to her right foot revealing a broken toenail chipped, jagged, and sharp areas of varies toenails. Resident #40 stated people come to the facility to cut the toenails. Resident #40 stated she wanted the facility to take care of her toenails before she went to therapy that day. Resident #40 stated the toenails hurt a bit. Resident #40 stated she had told RN F that she wanted her toenails cut but did not remember when she told RN F. Observation and interview on 01/04/24 at 9:06 AM with RN F revealed that Resident #40 told RN F that her toenails were hurting on the sides of the toes. Resident #40 was heard telling RN F she did not want any pain medication. RN F stated there were standing orders for podiatry consult (as needed). RN F stated Resident #40 had asked to have her toenails cut a month ago. RN F stated she notified the physician, but he did not call RN F back. RN F stated Resident #40's toenails not being trimmed or cut could cause discomfort to Resident #40. RN F stated she did not check to see if Resident #40 had any order for podiatry consult (as needed). During an interview on 01/04/24 at 1:41 PM with Social Worker, she stated the nursing staff would provide her with residents that want or need to get seen by podiatry and she will add them to a list. The Social Worker stated Resident #40 was seen on 11/2023 by the podiatrist. The Social Worker stated Resident #40 may see the podiatrist as needed and in an emergency. The Social Worker said nurses can cut the nails of a diabetic if they feel comfortable doing it. The Social Worker stated the activities staff, and the CNAs will go and do nail care with the residents. Resident #83 Record review of Resident #83's face sheet dated 01/03/24 revealed admission on [DATE] and readmission on [DATE] to the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676375 If continuation sheet Page 11 of 19 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 676375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Giles Nursing and Rehabilitation Center 950 Camino Del Rey Drive El Paso, TX 79927 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 0687 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #83's history and physical dated 07/26/23 revealed a [AGE] year-old female diagnosed with diabetes mellitus type 2 (insulin resistance), dementia (the loss of cognitive functioning thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and hypertension (is when the pressure in your blood vessels is too high) dyslipidemia (imbalance of lipids such as cholesterol, low-density lipoprotein cholesterol, triglycerides, and high-density lipoprotein). Record review of Resident #83's care plan dated 07/03/23 revealed refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. Activities of daily living for bath was to check nail length and trim and clean on bath day as necessary. Report any changes to the nurse. If diabetic, the nurse will provide toenail care. Record review of Resident #83's order recap dated 01/03/24 revealed there were not orders for podiatry consult (as needed). During an interview on 01/04/24 at 9:06 AM with RN F, she stated the facility did not have a foot nurse and the wound care nurse would assess the residents looking for any skin issues. RN F stated residents who are diabetic needed to have consent and podiatry orders to get their nails cut and trimmed. RN F stated the nurses were responsible for placing in the orders. RN F stated nurses and CNAs do not cut the nails of residents who are diabetic because they could cut them risking infection. During an interview on 01/04/24 at 1:41 PM with Social Worker, she stated there were no orders for podiatry for Resident #83 and she had not received podiatry consent forms as she is responsible for scheduling the podiatry visits for the residents. The Social Worker stated the nurses should be communicating with her to let her know which resident needs nail care. During an interview on 01/04/24 at 2:38 PM with CNA E, she stated CNAs checked the resident skin for any issues such as tears or wounds. CNA E stated nail care was to be performed on Sundays for all residents. CNA E stated the facility supervisors wanted the CNAs to do toenails on diabetic residents in which they would have to be very careful. CNA E stated she had been trained to cut fingernails but not the toenails. CNA E stated a lot of the residents have long ingrown toenails. CNA E stated it could be risky to cut the toenails because you could cut the residents. CNA E stated when she showers the residents, the residents did not have their toenails cut. CNA E stated that residents had told her they wanted their toenails to be cut. CNA E said she would report this back to the nurse, who would then follow up with the resident. CNA E stated she had not been trained on providing toenail care to the facility residents. During an interview on 01/04/24 at 3:02 PM with LVN A, she stated activities personnel would cut and do manicures on the residents' nails. LVN A stated podiatry cut the diabetic residents' toenails. LVN A stated the nurses were to let the Social Worker know who needs to see podiatry and then she would put them on the podiatry list. LVN A stated the residents would need an order for podiatry if diabetic. LVN A said only the nurses could cut and trim the residents' toenails; not the CNAs. LVN A stated this was because if the residents were diabetic the nurses would have to be careful cutting their toenails. LVN A stated the risk to the residents if cut would be infection and they could get gangrene. During an interview on 01/04/24 at 3:54 PM with ADON B, she stated were not allowed to cut the nails of a diabetic resident because they could cut the residents. ADON B stated nurses or podiatry were the only ones allowed to cut or trim the toenails of a diabetic resident. ADON B stated nurses gave (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676375 If continuation sheet Page 12 of 19 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 676375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Giles Nursing and Rehabilitation Center 950 Camino Del Rey Drive El Paso, TX 79927 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 0687 Level of Harm - Minimal harm or potential for actual harm a list to the Social Worker of residents that need to see podiatry. ADON B stated they track diabetic residents who need nail care when they are told by CNAs and residents' families. ADON B stated nurses can assess the diabetic resident to see if they can cut or trim the toenails and if not, they can refer the residents to the podiatry. ADON B stated the facility had standing orders for podiatry. ADON B stated the risk to the residents would be ingrown toenails and possibly losing a toe. Residents Affected - Some During an interview on 01/05/24 at 4:58 PM with the DON, she stated nail care was done weekly and Sundays was dedicated to nail and toenail care of the residents. The DON stated nail and toenail care were to be completed by the CNAs but not for residents who were diabetic. The DON stated the nurses would be responsible for the diabetic resident's nail and toenail care such as cutting and trimming. The DON stated if the diabetic residents needed to have nail care done then they could send them out to the podiatrist. The DON stated there had to be an order for podiatry. The DON stated the risk to diabetic residents was infection. Record review of the facility's Foot Care policy dated 2003 revealed, Foot care was especially important in those residents with diabetes mellitus or peripheral circulatory conditions because of their susceptibility to infection and skin breakdown. IF required, trimming of the toenails was performed by a podiatrist. Request referral to podiatrist if nail trimming was needed. Daily assessment of the feet should be done when care was given. The primary nurse will advise the physician and obtain a referral to the wound care nurse or the podiatrist. Record review of the facility's Nail Care policy dated 2003 revealed, Nail care especially trimming was performed by a podiatrist in those with diabetes and peripheral vascular disease. Nails that are ingrown, thickened, or infected should be cared for by a podiatrist. Report conditions immediately to the primary nurse. The nurse will ensure a referral to the podiatrist. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676375 If continuation sheet Page 13 of 19 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 676375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Giles Nursing and Rehabilitation Center 950 Camino Del Rey Drive El Paso, TX 79927 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (dirty utility room) of 1 oxygen crate observed for oxygen management. Residents Affected - Some 1. The facility failed to ensure an oxygen crate with 24 cannisters, in the dirty utility room, was improperly stored. 2. The facility failed to ensure an oxygen sign was posted outside of the dirty utility room where the oxygen tanks were stored. These failures could place residents on oxygen therapy at risk of not receiving oxygen support due to improper storage. Findings include: Observation on 01/04/24 at 10:57 AM in the dirty utility room revealed a crate of oxygen with 24 oxygen cannisters standing up unsecured (not strapped down or chain up) on a moveable wagon/crate There were 4 wheelchairs with cardboard boxes filled with items in the dirty utility room. It was unknown if the cardboard boxes were filled with trash. A brown furniture cabinet and empty clear trash bag was also in the dirty utility room. During an interview on 01/05/24 11:43 AM with Central Supply, he stated when the oxygen cannisters were delivered, he needed to place the oxygen crate with cannisters somewhere and was too busy to place them in the approved oxygen storage located in the front entrance of hall 300. Central Supply stated the oxygen crate with cannisters being stored in the dirty utility room needed to have an oxygen sign posted outside of the room and should have not been stored in the dirty utilities room. Central Supply stated the reason the oxygen storage was the proper stored was being oxygen cannisters were volatile (unstable) and for safety reasons. Central Supply stated the oxygen crate with cannisters was not to be stored anywhere else because they were flammable. Central Supply stated he and the Maintenance Director were responsible for ensuring all oxygen crates with cannisters were stored in the oxygen storage room and nowhere else. During an interview on 01/05/24 at 4:58 PM with the DON, she stated oxygen signs were used to notify everyone that oxygen was in use and caution. The DON stated all oxygen was stored in the oxygen storage room and nowhere else because they were combustible. The DON stated the oxygen crate with cannisters in the dirty utility room did not go in there and was improperly stored. The DON stated everyone was responsible for ensuring oxygen crates were stored in the proper storage room. The DON stated there was a risk to storing and not placing an oxygen sign up outside of the storage but did not know what the exact risk would be. Record review of the facility's Oxygen Administration policy dated 2003 revealed, Place No Smoking signs in area when oxygen was administrated and stored. Store oxygen cannister in an area free of flammable substances. Avoid the use of electrical appliances in the area of oxygen use as well. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676375 If continuation sheet Page 14 of 19 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 676375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Giles Nursing and Rehabilitation Center 950 Camino Del Rey Drive El Paso, TX 79927 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 0759 Ensure medication error rates are not 5 percent or greater. 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 were free of a med error rate of 5% or greater (12.5%) for 2(Resident #6, 61) of 7 residents reviewed for medication administration. Residents Affected - Few The facility failed to prime insulin pen for Resident #6 before administering Lantus insulin to remove air bubbles from the pen needle to ensure that the needle was open and working. The facility failed to prime insulin pen for Resident #61 before administering Novolog insulin to remove air bubbles from the pen needle to ensure that the needle was open and working. The failures placed residents at risk of incorrect doses of medications. Findings included: Resident #6 Record review of Resident #6's Quarterly MDS dated [DATE] revealed a [AGE] year-old female with most recent readmission of 09/21/23. She had an active diagnosis of Diabetes Mellitus. She had a BIMS of 13 meaning no cognitive difficulties. Record review of Resident #6's Physician Orders dated 01/05/24 revealed an order for Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 20 unit subcutaneously one time a day related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA with a start date of 12/29/23. In an observation of medication administration on 01/02/24 at 07:03 AM, RN F administered 20 units of Lantus to Resident# 6 without first priming the insulin pen. Resident #61 Record review of Resident #61 Annual MDS dated [DATE] revealed a [AGE] year-old female with a most recent admission date of 07/29/21. Resident had an active diagnosis list that included Diabetes Mellitus. She did not have a BIMS score due she was rarely or never understood. Record review of Resident #61's Physician Orders dated 01/05/24 revealed: NovoLOG FlexPen Subcutaneous Solution Peninjector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 150 - 199 = 4 units; 200 - 249 = 6 units; 250 - 299 = 8 units; 300 - 349 = 10 units; 350 - 400 = 12 units If >400 and symptomatic notify MD, subcutaneously before meals related to DIABETES MELLITUS DUE TO UNDERLYING CONDITION WITH OTHER SPECIFIED COMPLICATION with a start date of 01/07/23. In an observation on 01/03/24 at 11:30 AM, LVN M checked Resident #61 blood glucose and obtained a reading of 270. Per resident sliding scale, LVN M gave Resident #61 8 units of Novolog without priming the insulin pen prior to administering the medication. In an interview on 01/04/24 at 4:46PM with RC, she said her expectation for nurses was to prime insulin pens per facility policy. She said the adverse outcome for residents could be not getting the correct dose of insulin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676375 If continuation sheet Page 15 of 19 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 676375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Giles Nursing and Rehabilitation Center 950 Camino Del Rey Drive El Paso, TX 79927 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 01/05/24 at 8:00AM with LVN M, he said he did not prime the insulin pen before administering insulin to resident # 61. He said he thought gravity took care of that. In an interview on 01/05/24 at 4:45PM with DON, she said any resident that received insulin via insulin pen could be affected by nurses not priming the insulin pens. She said the failure could cause a resident to not receive the correct dose of insulin. In an interview on 01/05/24 at 4:56PM with ADON, she said she would inject insulin via insulin pen by just adding an extra unit when priming so as an example instead of 2 units she would do 3 units. Record review of medication administration reconciliation included that the facility had 2 medication errors for a total of 12.5 % medication error rate. Record review of facility policy titled Medication Administration Procedures revised October 2017 revealed: #20: The 10 rights of medication should always be adhered to (in-part) 3. Right dose In a record review of Insulin Pen Use revised 04/01/15 revealed: Under step 3: Perform a safety test Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: Ensuring that the pen and needle work properly Removing air bubbles A. Select dose of 2 units by turning the dosage selector. B. B. Hold the pen with needle pointing upwards. C. Tsp the insulin reservoir so that any air bubbles rise up towards the needle. D. Press the injection button all the way in. Check if insulin comes out of needle tip. You may have to perform the safety test several times before insulin is seen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676375 If continuation sheet Page 16 of 19 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 676375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Giles Nursing and Rehabilitation Center 950 Camino Del Rey Drive El Paso, TX 79927 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 0759 If no insulin comes out, check for air bubbles, and repeat the safety test two or more times to remove them. Level of Harm - Minimal harm or potential for actual harm If still no insulin comes out, the needle may be blocked. Change the needle and try again. If still no insulin comes out after changing the needle, the pen may be damaged. If so do not use this pen. Residents Affected - Few Record review of Cleveland Clinic at Insulin Pen Injections (clevelandclinic.org) accessed on 01/12/24 revealed: Prime the insulin pen. Priming means removing air bubbles from the needle and ensures that the needle is open and working. The pen must be primed before each injection. To prime the insulin pen, turn the dosage knob to the 2 units indicator. With the pen pointing upward, push the knob all the way. At least one drop of insulin should appear. You may need to repeat this step until a drop appears. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676375 If continuation sheet Page 17 of 19 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 676375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Giles Nursing and Rehabilitation Center 950 Camino Del Rey Drive El Paso, TX 79927 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 (hot water heater for the kitchen) of 1 reviewed for essential equipment. Residents Affected - Some The facility failed to repair or replace the water heater that supplied hot water for washing dishes for the kitchen for 6 days. This failure could place residents who eat in the facility of risk of foodborne illness and decline in health. Findings included: Observation on 01/02/24 at 12:05 PM revealed residents were being served on paper plates and on to-goes (a container used to package leftovers or food for take-out from a restaurant or other food establishment). Residents were also given plastic cutlery. During an interview on 01/02/24 at 1:47 PM with the Dietary Service Manager, he stated he was notified at approximately 5:00 PM on 12/28/23 that the water in the kitchen was not getting hot. The Dietary Service Manager stated he notified maintenance that the hot water heater for the kitchen was not working. The Dietary Service Manager stated on the morning of 12/29/23, he instructed the dietary staff to begin using disposable plates, cups, bowls, spoons etc. The Dietary Service Manager stated he told the dietary staff to boil water to wash pots, pans, cooking spoons, and ladles to sanitize them. During an interview on 01/02/24 at 2:55 PM with the Maintenance Director, he stated he was notified at approximately 4:30 PM, the water was not getting hot in the kitchen. The Maintenance Director stated he called 3 contractors, and they were unable to repair the hot water heater for the kitchen and others were not able to come to the facility due to the time and holiday. Observation of receipts on 01/03/24 dated 12/28/23 revealed the facility had been trying to fix the hot water heater for the kitchen by trying to acquire Vendor A and had given a bid for a new 100-gallon water heater. Receipt dated 12/29/23 revealed Vendor B had given a bid for a 100-gallon water heater. Receipt dated 01/02/24 revealed Vendor C had given a receipt for 100-gallon water heater. Observation on 01/04/23 revealed new hot water heater for the kitchen was installed on 01/03/24. Observation on 01/04/24 at 8:00 AM revealed the dishwasher water temperature was 125 degrees and the liquid was sanitizing at 200 parts per million. Facility residents were not being served on regular dishware. During an interview on 01/05/24 at 4:30 PM with the Administrator, she stated the hot water heater for the kitchen had been inoperable since the evening of 12/28/23. The Administrator stated dietary began using disposable dishes and utensils per the facility's emergency preparedness plan. The Administrator stated the morning of 12/29/23, the facility had hot water by boiling it to wash the pots, pans, scoops, spoons, and ladles. The Administrator stated hot water was not required to sanitize them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676375 If continuation sheet Page 18 of 19 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 676375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Giles Nursing and Rehabilitation Center 950 Camino Del Rey Drive El Paso, TX 79927 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 0908 Level of Harm - Minimal harm or potential for actual harm Record review of the FDA Food Code 2022 dated 01/18/2023 revealed Water temperature is critical to sanitization in warewashing operations. This is particularly true if the sanitizer being used is hot water. The effectiveness of cleaners and chemical sanitizers is also determined by the temperature of the water used. Effective mechanical hot water sanitization occurs when the surface temperatures of utensils passing through the warewashing machine meet or exceed the required 71°C(160°F). Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676375 If continuation sheet Page 19 of 19