Health inspection·March 19, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm resident needs, call light within reach and safe environment with even floors, free from spills and/or clutter, working and reachable call light, handrails on walls, personal items within reach. Resident #1 has an ADL self-care performance deficit and requires 1 staff for assistance for bathing, bed mobility, dressing, eating, toilet use, transferring, walking, personal hygiene/oral care, uses wheelchair and encourage resident to use bell to call for assistance. Residents Affected - Some Record review of a face sheet dated [DATE] revealed Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Parkinson's, Cellulitis (bacterial infection involving inner layers of skin), Chronic Obstructive Pulmonary Disease (COPD refers to a group of diseases that cause airflow blockage and breathing-related problems), Muscle Wasting and Atrophy (breakdown of muscle), Muscle Weakness, Lack of coordination, history of falling, abnormal posture. Record review of the quarterly MDS dated [DATE] revealed Resident #2 had a BIMS of 13 which indicated intact cognition. Resident #1 required Substantial/Maximal assistance (helper does more than half the effort. Helper lifts or hold trunk or limbs and provides more than half the effort) for Shower/bathing and personal hygiene; Partial/Moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs but provides less than half the effort) for oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear; Dependent (helper does all the effort. Resident does none of the effort to complete the activity or requires 2 or more helpers) for tub/shower transfer. Resident #1 requires use of a manual wheelchair and has a documented history of falls in which fall that resulted in no injury. Record review of Resident #2's care plan dated [DATE] revealed a diagnosis of Parkinson's disease with an intervention to monitor for risk of falls; monitor/document ability to perform ADLS; Risk of falls due to incontinence, Parkinson's and fluctuating cognition, with interventions that included call light in reach, appropriate footwear, keep bed in lowest position with wheels locked, furniture in locked position, safe environment with even floors, free from spills and/or clutter, working and reachable call light, handrails on walls, personal items within reach, staff x1 to assist with transfers; ADL self-care performance deficit that requires interventions of 1x staff assistance for bathing, bed mobility, dressing, toilet use, transferring and requires use of wheelchair. Resident #2 requires total assist for bathing/showering. Record review of the facility provided Provider Investigation Report, revealed incident date [DATE] at 6:30 a.m. in Hall 200 shower room for Neglect of Resident #1 by alleged perpetrators CNA A and CNA B. Description of the allegation, it is alleged that staff left [Resident #1] in the shower room unattended for approximately 20 minutes. Investigation Summary: On [DATE], [Resident #1] was found unaccompanied in the shower room by day staff coming on shift. When asked why he was in the shower by himself, he stated that a lady had wheeled him in there to shower and left him there by himself. He stated that he had been in there approximately 20-30 minutes. He was found at approximately 6:04a.m. Staff said to be involved were suspended pending further investigation. Interviews were conducted and it was found that [CNA A] was working the 200 halls on [DATE] and admitted to leaving [Resident #1] in the shower room. Investigation findings: Confirmed. Post investigation provider action: Continued Resident monitoring, continued in-services of abuse/neglect and not leaving residents in the shower room unattended. [CNA A] was terminated, and [CNA B] was allowed to return to work. Record Review of the facility provided Incident Report dated [DATE] at 12:56 p.m. documented by the DON revealed: Received report from staff that while getting residents up for breakfast and doing initial beginning of shift rounds, resident was found to have been left in the shower room unattended. Mental status documented as: orientated to place, person, and situation. No injuries observed post (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676380 If continuation sheet Page 2 of 24 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 676380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Big Spring Center for Skilled Care 3701 Wasson Rd Big Spring, TX 79720 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 0600 incident. Level of Harm - Minimal harm or potential for actual harm Record review of CNA A's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, I worked hall 200 from 10 p-6a. In the beginning of my last round I asked [Resident #1] if he wanted to take his shower and he denied his shower but asked if I could help him get dressed. I proceeded with assisting him with getting dressed. After helping him I get [Resident #2] up for his shower and while gathering [Resident #2's] things for his shower, [Resident #1] asked if he could use the restroom. I informed him that [Resident #2] was in the shower already and it'd be a little bit and he asked if he could use another residents restroom, but I told him we can't go into another residents room to use their restroom. I told him I was on my way to the big shower room to grab towels for [Resident #2] and if he would like to use the restroom in there. He (Resident #1) agreed, and I took him. I told him I would be back soon and let him take his time while I showered [Resident #2]. I continue to check on him after I'm done with [Resident #2's] shower and he tells me after each time I've asked him, that he's not done yet. I told him to call me on the light when he's ready to get out, but he never does. I go back 3 minutes before 6 am to check on him and he informed me he still wasn't finished. I tell him to still call but it was close to shift change so I didn't know if it would be me or another CNA helping him out the restroom. Within the minutes passing, I'm on my way to tell a nurse but go back to my hall to gather my things before leaving. I do get distracted and made the mistake of not informing a charge nurse and leave the building. [Resident #1] was only in the shower room to use the restroom but never for a shower. Residents Affected - Some Record review of CNA C's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, The morning of [DATE] at approximately 6:04 a.m., upon unlocking shower room I noticed [Resident #1] completed unclothed, shaking from lack of heat on shower chair. My coworker LVN was also present in shower room and noticed patient unclothed in shower chair. I asked [Resident #1] why he was alone in shower room. [Resident #1] stated the girl (night shift aide) left me in here to shower and said she will be back but never followed back I was still waiting. So I assured [Resident #1] I would bathe and dress him to which he thanked me for not leaving patient by himself. Shower was completed. Patient dressed, assisted to chair, assisted to dining room for breakfast. Record review of the LVN's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, This morning upon entering locked shower room, patient [Resident #1] was on the shower chair completely undressed. Lights were on, heater off, water off as well. When this writer asked patient what are you doing in here by yourself? Patient stated, the girls told me to shower and would be back, but they never came back. I have been in here waiting. This writer and other aide (CNA C) repositioned patient on shower chair and bathed patient, clean clothes were put on patient and assisted patient to wheelchair. This writer then informed DON of what happened. [Resident #1] was assisted to dining room for breakfast. Record review of Resident #1's statement taken by the facility ADM, signed, and dated [DATE] from the [DATE] provider investigation report, revealed in part, Patient stated, I was undressed on the shower chair this morning. I say I was in there about 20 minutes alone in the shower. I was scared they wouldn't shower me since I hadn't been showered in 3 or 4 days. She has long black hair, real pretty, I don't remember the color of her shirt. She is one of the sisters that works here. Patient was asked by this writer Have they ever not showered you? Patient responded yes. I was glad [CNA C] came in and found me. Record review of CNA B's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, I was working hall 400, 2-27-24. I did not assist [Resident #1]. I had no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676380 If continuation sheet Page 3 of 24 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 676380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Big Spring Center for Skilled Care 3701 Wasson Rd Big Spring, TX 79720 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 0600 knowledge of the incident until 20 minutes after 6 a.m. that morning. Level of Harm - Minimal harm or potential for actual harm Record review of the BOM's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, I was serving as a witness to a phone call with [DON] and [CNA A] on [DATE]. During this phone call, [CNA A] stated she was at fault for the entire situation and stated [CNA B] had nothing to do with this as [CNA B] was on another hall. [CNA A] again stated, this is all on me. I did it, [CNA B] doesn't have anything to do with this. Residents Affected - Some Record review of the DOR's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, I spoke with [Resident #1] about what happened [DATE] with the shower room. [Resident #1] stated that a young pretty girl took me in the shower room. I sat in a shower chair. She left because she forgot something. I did ask [Resident #1] if he knew how long and he stated, no but felt like over 30 minutes. I asked him if he got worried about falling or when she would come back and he said no, I knew I would be ok. During an interview with the DON on [DATE] at 6:24 a.m. she stated on [DATE] she was informed by the LVN that she and CNA C found Resident #1 alone in the shower room on a shower chair and was he was nude. The DON stated that Resident #1 stated that he was left alone in the shower room by a female staff who was later identified as CNA A. The DON stated that initially the facility was unsure of which CNA it was because Resident #1 stated it was one of the sisters and CNA A and CNA B were sisters. The DON stated that CNA A stated that she had left Resident #1 on the commode, and he was fully dressed. The DON stated that Resident #1's care plan required assistance with transfers, using the restroom, showers and changing clothes. The DON stated she believed that CNA A neglected Resident #1 when she left Resident #1 alone in the shower room. The DON stated that the risk of CNA A leaving Resident #1 unattended included that Resident #1 could fall and that could result in injuries, and no one would have known to look for him in the shower room. The DON stated that Resident #1 was found on the shower chair and not on the commode and Resident #1 could not have transferred himself from the commode to the shower chair himself at that time. The DON stated Resident #1 had Parkinson's disease and a week prior leading up to the incident he had a decline and was completely dependent on staff. The DON stated that had Resident #1 had any significant health issue like a cardiac arrest and his decline, or if he had fallen or had a significant health issue, being left alone like that could have resulted in death and no one would have known he was in there until he was accidently discovered. The DON stated that all staff were trained on care plans and CNA A had been trained on showering, abuse, and neglect. The DON stated that Resident #1 was deceased and died a few days after the incident. The DON stated there was no reason to believe that the incident had anything to do with his death due to Resident #1 not having any injuries from being left alone. The DON stated that at no time should a resident who required 1 person assist be left alone in the shower room. During an interview on [DATE] at 8:40 a.m. the LVN stated that on [DATE] she arrived shortly after 6 a.m. to assist CNA C with shower duties. The LVN stated that shortly after 6:00 a.m. she entered the shower room behind CNA C. The LVN stated that Resident #1 was found sitting in the shower chair completely nude. The LVN stated Resident #1 stated he had not had a shower yet and said the girls left him in there. The LVN stated that Resident #1 was dry, the heat was off, and it was cold in the shower room. The LVN stated that Resident #1's wheelchair was not within reach and where Resident #1 was seated in the shower chair, the call light was not in reach. The LVN stated that the shower chair was between the commode and shower stall and a few feet forward from the wall where the call light was. The LVN stated that Resident #1 stated he was not cold but stated his skin was cold to the touch and he had goosebumps on his skin. The LVN stated that Resident #1 had an imprint on his buttocks from sitting in the shower chair but had no injuries. The LVN stated that she told CNA C to stay (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676380 If continuation sheet Page 4 of 24 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 676380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Big Spring Center for Skilled Care 3701 Wasson Rd Big Spring, TX 79720 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with Resident #1 to get warm towels. The LVN stated that Resident #1 had a recent decline after a hospital stay for a UTI (Urinary Tract Infection) and he was not at his baseline. The LVN stated that had Resident #1 been at his baseline, he still would have required 1 person assistance with his ADLS that included using the toilet, undressing, and showering. The LVN stated that Resident #1 could not have transferred himself from the toilet to the shower chair and required a gait belt for transfers. The LVN stated there was no gait belt on Resident #1 or in the shower room. The LVN stated that Resident #1's clean clothes were on the shower bench and his dirty clothes were thrown on the floor near soiled towels. The LVN stated that Resident #1 had a previous shoulder fracture that would have prevented him from removing his clothes. The LVN stated that CNA A was already gone before she arrived to work that day, and no one was aware that Resident #1 had been left in the shower room. The LVN stated that 1 person assist meant that staff must stay in the room at all times and Resident #1 should not have been left on the toilet alone or on the shower chair. The LVN stated that Resident #1 had no access to towels to cover himself. The LVN stated Resident #1 was upset and stated, I am so glad yall are here. The LVN stated that Resident #1 was at risk for falls and injuries by being left alone in the shower room. The LVN stated that Resident #1 was unsteady on his feet and required staff to be in there. The LVN stated that staff are trained on abuse and neglect and are trained on the care areas for the residents they work with. During an interview on [DATE] at 10:03 a.m. CNA C stated that on [DATE] she arrived at approximately 6 a.m. to assist the LVN with showers in 200 halls. Stated that she entered the shower room to grab supplies and found Resident #1 in the shower chair naked. CNA C stated it was approximately 6:04 a.m. and the LVN came in behind her. CNA C stated that Resident #1 stated that he was left in there by the girl. CNA C stated it was cold, the heat was off, and the water was off. CNA C stated she turned the heat on and turned the water on to warm up after Resident #1 stated he wanted a shower. CNA C stated that Resident #1 required staff to assist with showers, transfers and using the toilet because his gait was not steady, and he had a history of falls. CNA C stated that Resident #1's dirty clothes were on the floor, his clean clothes were on the bench and his wheelchair was against the wall across the shower room and not in reach. CNA C stated that Resident #1 was nude, had no gait belt on and there was no gait belt in the shower room. CNA C stated that Resident #1 required assistance to clean himself after a bowel movement and there was no evidence that he had a bowel movement in the toilet nor was there any feces on Resident #1. CNA C stated Resident #1 stated please, please help me. CNA C stated that Resident #1 stated that CNA A stated she would come back but never came back for him. CNA C stated that it was not possible for Resident #1 to transfer himself, get off the commode or get into the shower chair without assistance. CNA C stated staff had been trained on how to provide showers, not to leave residents alone, abuse and neglect and resident care plans. CNA C stated that Resident #1 should never have been left alone in the shower room and CNA A was gone before she arrived and none of the staff knew Resident #1 had been left alone. During a phone interview on [DATE] at 12:30 p.m. CNA A stated that on [DATE] she was in hall 200 and was in Resident #1 and Resident #2's room. CNA A stated that Resident #1 and Resident #2 are roommates and have a private restroom with shower in their room. CNA A stated that Resident #1 was asked if he wanted a shower, and he denied one. CNA A stated that the roommate, Resident #2 stated he wanted a shower and she put him into the shower chair in the room restroom, undressed him and got him ready to shower. CNA A stated that Resident #1 then asked if she could assist him and get him dressed. CNA A stated she dressed Resident #1 who then asked if he could use the restroom because he needed to have a bowel movement. CNA A stated that she told Resident #1 that Resident #2 was in there and Resident #1 asked if he could use another resident's restroom. CNA A stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676380 If continuation sheet Page 5 of 24 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 676380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Big Spring Center for Skilled Care 3701 Wasson Rd Big Spring, TX 79720 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some she told him he could not use another resident's restroom, but she was going to the shower room to get towels for Resident #2 and asked Resident #1 if he wanted to use the toilet in the shower room and Resident #1 stated yes. CNA A stated that she left Resident #2 in the restroom in his shower chair and took Resident #1 to the shower room and assisted him on the toilet and told him she would return. CNA A stated that she removed Resident #1's pants, moved the shower chair into the shower stall and put Resident #1's wheelchair right in front of him. CNA A stated she told Resident #1 to use the call light if he needed her and she was headed back to assist Resident #2 with his shower. CNA A stated she went back to the resident shared room and showered and dressed Resident #2, before going back to the shower room down the hall for Resident #1. CNA A stated that Resident #1 was still on the commode and stated he was not done, and she told him to use the call light to call when he was finished. CNA A stated that she returned five minutes later, and Resident #1 stated he was not done yet. CNA A stated that she returned to the shower room at 5:57 a.m. and Resident #1 was still on the toilet and stated he was not done. CNA A stated she reminded Resident #1 to use the call light and advised him her shift was almost over and another aide may be the one to assist him. CNA A stated that she left for the day and did not inform anyone that Resident #1 was in the shower room. CNA A stated she meant to tell the nurse that Resident #1 was in the shower room but forgot to. CNA A stated that Resident #1 had a recent decline and was not acting like himself and had pulled some stuff off a shelf in the dining room that day. CNA A stated that Resident #1 care plan stated that he required a one person assist but Resident #1 could transfer himself, undress himself and could get into a shower chair himself. CNA A stated that Resident #2 had to be supervised in the shower per his care plan but that he was in a shower chair and was fine when she left to get towels from the shower room. CNA A stated that she had been trained on Resident #1 and Resident #2's hallway and had been trained on Resident #1 and Resident #2's care plans and they required 1 person assist with showering, toileting, and transfers. CNA A stated that there was no risk of Resident #1 falling because she put his wheelchair in front of him when he was on the commode and the shower chair was out of reach. CNA A stated Resident #2 was not at risk of falling because she put him in the shower chair, and he needed assistance to get out of the shower chair. CNA A stated that Resident #1 was not in the right state of mind and had not been the same the last week or so. CNA A stated that she did not understand why she was being asked about Resident #2 because she was terminated for leaving Resident #1 alone in the shower and Resident #2 was not brought up. CNA A stated she had been trained on care plans, showers, transfers and abuse and neglect. CNA A stated she did nothing wrong except that she left at the end of her shift and did not inform anyone that Resident #1 was left on the commode. Record Review of CNA A's time punch detail revealed CNA A punched in at 6:16 p.m. on [DATE] and clocked out at 6:02 p.m. on [DATE]. During an interview on [DATE] at approximately 12:50 p.m. with the ADM, the ADM stated he had not been aware that CNA A left Resident #2 alone in the resident room restroom in the shower chair when she went to the shower room with Resident #1. The ADM stated that during the facility investigation it was not revealed that Resident #2 was also involved in this incident. The ADM stated that staff should never leave a resident alone in the shower room and that Resident #2 required assistance with his ADLS. During an interview and observation on [DATE] at 1:05 p.m. with Resident #2 revealed he was in his room sitting in his power wheelchair. Resident #2 stated that he has a restroom with a shower in his room. Resident #2 stated that Resident #1 was his roommate before Resident #1 passed away. Resident #2 stated that he remembered the day that CNA A assisted him with a shower. Resident #2 stated that CNA A put him into the shower and then left for a few minutes to get towels. Resident #2 stated that he was not aware that Resident #1 went to the shower room down (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676380 If continuation sheet Page 6 of 24 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 676380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Big Spring Center for Skilled Care 3701 Wasson Rd Big Spring, TX 79720 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the hall with CNA A when he was in the shower. Resident #2 stated that CNA A came back and got him out of the shower and put a towel on him to dry. Resident #2 stated that CNA A then left again for about 2 minutes to get him clothes from his room. Resident #2 stated that he felt safe and required assistance to get transferred from his wheelchair into the shower chair and to be dressed. Resident #2 stated that his roommate, Resident #1 needed his wheelchair to get around and needed staff to assist him with transfers. Resident #2 stated that Resident #1 had a history of falls and had been confused around the time leading up to his death. Resident #2 stated that CNA A knew that they both needed assistance with showers and transfers and that Resident #1 had falls in the past because she always worked their hall. During an interview on [DATE] at 1:25 p.m. CNA C stated that Resident #2 needed total assistance for transfers and bathing and Resident #2 was only able to wash his private area. CNA C stated that Resident #2 had a history of falls, and it was not safe to leave him alone in a shower chair. CNA C stated that Resident #2 could bear some weight on his legs and had he attempted to get up from the shower chair alone, he could have fallen on the wet floor. During an interview on [DATE] at 1:35 p.m. the DON stated that she was not aware that CNA A left Resident #2 alone in the shower when she took Resident #1 to the shower room. The DON stated that Resident #2 had a spine curvature and had he leaned to the side or the front he would fall face first and would be injured with no staff to assist because it was not known he had also been left alone. The DON stated that CNA A did not reveal in her facility statement that she left Resident #2 alone and CNA A had been trained to not leave residents alone during showers or if they needed 1 person assist. Record Review of facility provided policy, Toileting, Bedside Commode/Bathroom dated 2023, revealed in part: Become familiar with the ability of the resident to perform toileting procedures independently or amount of assistance needed, type of toileting facility the resident will use, need for monitoring. Assist to bathroom and assuming sitting position on toilet, assist with cleansing following elimination, encourage resident to use holding bars in the bathroom to prevent falls. Record Review of facility provided policy, Bath, Tub/Shower, dated 2023, revealed in part: Become familiar with the type and pattern of bathing, assistance or aids needed. Transport resident via shower chair; remain with the resident if he is weak or assistance is needed in washing, protect from drafts and chilling during bathing. Place call light in reach for resident to call for assistance; remain with the resident if weak. Assist out of the tub or shower, wrap in bath towel, allow to sit on a chair and assist to dry if needed. Assist to dress if needed or supply aids. Assist the resident with transfer to room or location of choice. Record Review of facility provided policy, Abuse/Neglect, Revised [DATE], revealed in part: The resident has the right to be free from abuse, neglect. This includes but not limited to, involuntary seclusion and any physical/chemical restraint note required to treat the resident's medical symptoms. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will train through orientation and on-going in-services on issues related to abuse/neglect prohibition practices regularly. Record Review of CNA A's employee record revealed that CNA A was hired, received, and signed orientation training on [DATE] that included the following topics: Resident dignity and privacy, No abuse, neglect and/or unnecessary restring; Resident abuse, neglect, and mandatory reporting. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676380 If continuation sheet Page 7 of 24 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 676380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Big Spring Center for Skilled Care 3701 Wasson Rd Big Spring, TX 79720 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record Review of CNA A's employee disciplinary record revealed that CNA A was terminated on [DATE] due to an incident of Neglect on [DATE]. Specific Reason for Disciplinary Action: On [DATE], [CNA A] was suspended pending an investigation into resident neglect: those allegations were substantiated. It was found that [CNA A] left a resident in the shower room, unattended, for at least thirty minutes. This is a violation of the resident's rights, a violation of her job duties/responsibilities and of the Corporate Code of Conduct. Employee confirmed during a neglect investigation that she knowingly left a resident unattended in the shower room and did not report to anyone that resident was in the shower room. Event ID: Facility ID: 676380 If continuation sheet Page 8 of 24 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 676380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Big Spring Center for Skilled Care 3701 Wasson Rd Big Spring, TX 79720 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of resident and misappropriation of resident property for 2 of 2 residents (Resident #1 and Resident #2) reviewed. Residents Affected - Some CNA A neglected Resident #1 by failing to provide 1 person assistance and clocking out without informing the oncoming shift when she left Resident #1 alone in the facility shower room. CNA A neglected Resident #2 by failing to provide 1 person assistance when she left Resident #2 in a shower chair alone in his restroom shower area when she took Resident #1 to the shower room down the hall. This failure could affect all residents by placing them at risk of neglect, falls, mental anguish and emotional distress. Findings include: Record review of a face sheet dated [DATE] revealed Resident #1 was a [AGE] year-old male and admitted on [DATE] with diagnoses including Parkinson's disease (a progressive disorder that affects the central nervous system), Muscle wasting and atrophy (breakdown of muscles), unspecified abnormalities of gait and mobility, lack of coordination, cognitive communication deficit, muscle weakness. Record review of the quarterly MDS dated [DATE] revealed Resident # 1 had a BIMS of 11 which indicated moderate cognitive impairment. Resident #1 required Supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for toileting hygiene, upper body dressing personal hygiene, Sit to lying, sit to stand, chair/bed to chair transfer and toilet transfer; Substantial/Maximal assistance (helper does more than half the effort. Helper lifts or hold trunk or limbs and provides more than half the effort) for Shower/bathing and tub/shower transfer; and Partial/Moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs but provides less than half the effort) for lower body dressing and putting on/taking off footwear. Resident #1 required use of a manual wheelchair and had a documented history of falls in which 2 or more resulted in no injuries and 1 fall that resulted in an injury. Record review of Resident #1's care plan dated [DATE] revealed a diagnosis of Parkinson's disease with an intervention to monitor for risk of falls; monitor/document/report signs/symptoms of poor coordination, tremors, gait disturbance and decline in range of motion. Focus area: Fall risk with actual falls on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] with interventions: anticipate and meet resident needs, call light within reach and safe environment with even floors, free from spills and/or clutter, working and reachable call light, handrails on walls, personal items within reach. Resident #1 has an ADL self-care performance deficit and requires 1 staff for assistance for bathing, bed mobility, dressing, eating, toilet use, transferring, walking, personal hygiene/oral care, uses wheelchair and encourage resident to use bell to call for assistance. Record review of a face sheet dated [DATE] revealed Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Parkinson's, Cellulitis (bacterial infection involving inner layers of skin), Chronic Obstructive Pulmonary Disease (COPD refers to a group of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676380 If continuation sheet Page 9 of 24 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 676380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Big Spring Center for Skilled Care 3701 Wasson Rd Big Spring, TX 79720 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some diseases that cause airflow blockage and breathing-related problems), Muscle Wasting and Atrophy (breakdown of muscle), Muscle Weakness, Lack of coordination, history of falling, abnormal posture. Record review of the quarterly MDS dated [DATE] revealed Resident #2 had a BIMS of 13 which indicated intact cognition. Resident #1 required Substantial/Maximal assistance (helper does more than half the effort. Helper lifts or hold trunk or limbs and provides more than half the effort) for Shower/bathing and personal hygiene; Partial/Moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs but provides less than half the effort) for oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear; Dependent (helper does all the effort. Resident does none of the effort to complete the activity or requires 2 or more helpers) for tub/shower transfer. Resident #1 requires use of a manual wheelchair and has a documented history of falls in which fall that resulted in no injury. Record review of Resident #2's care plan dated [DATE] revealed a diagnosis of Parkinson's disease with an intervention to monitor for risk of falls; monitor/document ability to perform ADLS; Risk of falls due to incontinence, Parkinson's and fluctuating cognition, with interventions that included call light in reach, appropriate footwear, keep bed in lowest position with wheels locked, furniture in locked position, safe environment with even floors, free from spills and/or clutter, working and reachable call light, handrails on walls, personal items within reach, staff x1 to assist with transfers; ADL self-care performance deficit that requires interventions of 1x staff assistance for bathing, bed mobility, dressing, toilet use, transferring and requires use of wheelchair. Resident #2 requires total assist for bathing/showering. Record review of the facility provided Provider Investigation Report, revealed incident date [DATE] at 6:30 a.m. in Hall 200 shower room for Neglect of Resident #1 by alleged perpetrators CNA A and CNA B. Description of the allegation, it is alleged that staff left [Resident #1] in the shower room unattended for approximately 20 minutes. Investigation Summary: On [DATE], [Resident #1] was found unaccompanied in the shower room by day staff coming on shift. When asked why he was in the shower by himself, he stated that a lady had wheeled him in there to shower and left him there by himself. He stated that he had been in there approximately 20-30 minutes. He was found at approximately 6:04a.m. Staff said to be involved were suspended pending further investigation. Interviews were conducted and it was found that [CNA A] was working the 200 halls on [DATE] and admitted to leaving [Resident #1] in the shower room. Investigation findings: Confirmed. Post investigation provider action: Continued Resident monitoring, continued in-services of abuse/neglect and not leaving residents in the shower room unattended. [CNA A] was terminated, and [CNA B] was allowed to return to work. Record Review of the facility provided Incident Report dated [DATE] at 12:56 p.m. documented by the DON revealed: Received report from staff that while getting residents up for breakfast and doing initial beginning of shift rounds, resident was found to have been left in the shower room unattended. Mental status documented as: orientated to place, person, and situation. No injuries observed post incident. Record review of CNA A's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, I worked hall 200 from 10 p-6a. In the beginning of my last round I asked [Resident #1] if he wanted to take his shower and he denied his shower but asked if I could help him get dressed. I proceeded with assisting him with getting dressed. After helping him I get [Resident #2] up for his shower and while gathering [Resident #2's] things for his shower, [Resident #1] asked if he could use the restroom. I informed him that [Resident #2] was in the shower already and it'd be a little bit and he asked if he could use another residents restroom, but I told him we can't go (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676380 If continuation sheet Page 10 of 24 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 676380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Big Spring Center for Skilled Care 3701 Wasson Rd Big Spring, TX 79720 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some into another residents room to use their restroom. I told him I was on my way to the big shower room to grab towels for [Resident #2] and if he would like to use the restroom in there. He (Resident #1) agreed, and I took him. I told him I would be back soon and let him take his time while I showered [Resident #2]. I continue to check on him after I'm done with [Resident #2's] shower and he tells me after each time I've asked him, that he's not done yet. I told him to call me on the light when he's ready to get out, but he never does. I go back 3 minutes before 6 am to check on him and he informed me he still wasn't finished. I tell him to still call but it was close to shift change so I didn't know if it would be me or another CNA helping him out the restroom. Within the minutes passing, I'm on my way to tell a nurse but go back to my hall to gather my things before leaving. I do get distracted and made the mistake of not informing a charge nurse and leave the building. [Resident #1] was only in the shower room to use the restroom but never for a shower. Record review of CNA C's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, The morning of [DATE] at approximately 6:04 a.m., upon unlocking shower room I noticed [Resident #1] completed unclothed, shaking from lack of heat on shower chair. My coworker LVN was also present in shower room and noticed patient unclothed in shower chair. I asked [Resident #1] why he was alone in shower room. [Resident #1] stated the girl (night shift aide) left me in here to shower and said she will be back but never followed back I was still waiting. So I assured [Resident #1] I would bathe and dress him to which he thanked me for not leaving patient by himself. Shower was completed. Patient dressed, assisted to chair, assisted to dining room for breakfast. Record review of the LVN's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, This morning upon entering locked shower room, patient [Resident #1] was on the shower chair completely undressed. Lights were on, heater off, water off as well. When this writer asked patient what are you doing in here by yourself? Patient stated, the girls told me to shower and would be back, but they never came back. I have been in here waiting. This writer and other aide (CNA C) repositioned patient on shower chair and bathed patient, clean clothes were put on patient and assisted patient to wheelchair. This writer then informed DON of what happened. [Resident #1] was assisted to dining room for breakfast. Record review of Resident #1's statement taken by the facility ADM, signed, and dated [DATE] from the [DATE] provider investigation report, revealed in part, Patient stated, I was undressed on the shower chair this morning. I say I was in there about 20 minutes alone in the shower. I was scared they wouldn't shower me since I hadn't been showered in 3 or 4 days. She has long black hair, real pretty, I don't remember the color of her shirt. She is one of the sisters that works here. Patient was asked by this writer Have they ever not showered you? Patient responded yes. I was glad [CNA C] came in and found me. Record review of CNA B's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, I was working hall 400, 2-27-24. I did not assist [Resident #1]. I had no knowledge of the incident until 20 minutes after 6 a.m. that morning. Record review of the BOM's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, I was serving as a witness to a phone call with [DON] and [CNA A] on [DATE]. During this phone call, [CNA A] stated she was at fault for the entire situation and stated [CNA B] had nothing to do with this as [CNA B] was on another hall. [CNA A] again stated, this is all on me. I did it, [CNA B] doesn't have anything to do with this. Record review of the DOR's statement signed and dated [DATE] from the [DATE] provider investigation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676380 If continuation sheet Page 11 of 24 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 676380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Big Spring Center for Skilled Care 3701 Wasson Rd Big Spring, TX 79720 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 0607 Level of Harm - Minimal harm or potential for actual harm report, revealed in part, I spoke with [Resident #1] about what happened [DATE] with the shower room. [Resident #1] stated that a young pretty girl took me in the shower room. I sat in a shower chair. She left because she forgot something. I did ask [Resident #1] if he knew how long and he stated, no but felt like over 30 minutes. I asked him if he got worried about falling or when she would come back and he said no, I knew I would be ok. Residents Affected - Some During an interview with the DON on [DATE] at 6:24 a.m. she stated on [DATE] she was informed by the LVN that she and CNA C found Resident #1 alone in the shower room on a shower chair and was he was nude. The DON stated that Resident #1 stated that he was left alone in the shower room by a female staff who was later identified as CNA A. The DON stated that initially the facility was unsure of which CNA it was because Resident #1 stated it was one of the sisters and CNA A and CNA B were sisters. The DON stated that CNA A stated that she had left Resident #1 on the commode, and he was fully dressed. The DON stated that Resident #1's care plan required assistance with transfers, using the restroom, showers and changing clothes. The DON stated she believed that CNA A neglected Resident #1 when she left Resident #1 alone in the shower room. The DON stated that the risk of CNA A leaving Resident #1 unattended included that Resident #1 could fall and that could result in injuries, and no one would have known to look for him in the shower room. The DON stated that Resident #1 was found on the shower chair and not on the commode and Resident #1 could not have transferred himself from the commode to the shower chair himself at that time. The DON stated Resident #1 had Parkinson's disease and a week prior leading up to the incident he had a decline and was completely dependent on staff. The DON stated that had Resident #1 had any significant health issue like a cardiac arrest and his decline, or if he had fallen or had a significant health issue, being left alone like that could have resulted in death and no one would have known he was in there until he was accidently discovered. The DON stated that all staff were trained on care plans and CNA A had been trained on showering, abuse, and neglect. The DON stated that Resident #1 was deceased and died a few days after the incident. The DON stated there was no reason to believe that the incident had anything to do with his death due to Resident #1 not having any injuries from being left alone. The DON stated that at no time should a resident who required 1 person assist be left alone in the shower room. During an interview on [DATE] at 8:40 a.m. the LVN stated that on [DATE] she arrived shortly after 6 a.m. to assist CNA C with shower duties. The LVN stated that shortly after 6:00 a.m. she entered the shower room behind CNA C. The LVN stated that Resident #1 was found sitting in the shower chair completely nude. The LVN stated Resident #1 stated he had not had a shower yet and said the girls left him in there. The LVN stated that Resident #1 was dry, the heat was off, and it was cold in the shower room. The LVN stated that Resident #1's wheelchair was not within reach and where Resident #1 was seated in the shower chair, the call light was not in reach. The LVN stated that the shower chair was between the commode and shower stall and a few feet forward from the wall where the call light was. The LVN stated that Resident #1 stated he was not cold but stated his skin was cold to the touch and he had goosebumps on his skin. The LVN stated that Resident #1 had an imprint on his buttocks from sitting in the shower chair but had no injuries. The LVN stated that she told CNA C to stay with Resident #1 to get warm towels. The LVN stated that Resident #1 had a recent decline after a hospital stay for a UTI (Urinary Tract Infection) and he was not at his baseline. The LVN stated that had Resident #1 been at his baseline, he still would have required 1 person assistance with his ADLS that included using the toilet, undressing, and showering. The LVN stated that Resident #1 could not have transferred himself from the toilet to the shower chair and required a gait belt for transfers. The LVN stated there was no gait belt on Resident #1 or in the shower room. The LVN stated that Resident #1's clean clothes were on the shower bench and his dirty (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676380 If continuation sheet Page 12 of 24 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 676380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Big Spring Center for Skilled Care 3701 Wasson Rd Big Spring, TX 79720 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some clothes were thrown on the floor near soiled towels. The LVN stated that Resident #1 had a previous shoulder fracture that would have prevented him from removing his clothes. The LVN stated that CNA A was already gone before she arrived to work that day, and no one was aware that Resident #1 had been left in the shower room. The LVN stated that 1 person assist meant that staff must stay in the room at all times and Resident #1 should not have been left on the toilet alone or on the shower chair. The LVN stated that Resident #1 had no access to towels to cover himself. The LVN stated Resident #1 was upset and stated, I am so glad yall are here. The LVN stated that Resident #1 was at risk for falls and injuries by being left alone in the shower room. The LVN stated that Resident #1 was unsteady on his feet and required staff to be in there. The LVN stated that staff are trained on abuse and neglect and are trained on the care areas for the residents they work with. During an interview on [DATE] at 10:03 a.m. CNA C stated that on [DATE] she arrived at approximately 6 a.m. to assist the LVN with showers in 200 halls. Stated that she entered the shower room to grab supplies and found Resident #1 in the shower chair naked. CNA C stated it was approximately 6:04 a.m. and the LVN came in behind her. CNA C stated that Resident #1 stated that he was left in there by the girl. CNA C stated it was cold, the heat was off, and the water was off. CNA C stated she turned the heat on and turned the water on to warm up after Resident #1 stated he wanted a shower. CNA C stated that Resident #1 required staff to assist with showers, transfers and using the toilet because his gait was not steady, and he had a history of falls. CNA C stated that Resident #1's dirty clothes were on the floor, his clean clothes were on the bench and his wheelchair was against the wall across the shower room and not in reach. CNA C stated that Resident #1 was nude, had no gait belt on and there was no gait belt in the shower room. CNA C stated that Resident #1 required assistance to clean himself after a bowel movement and there was no evidence that he had a bowel movement in the toilet nor was there any feces on Resident #1. CNA C stated Resident #1 stated please, please help me. CNA C stated that Resident #1 stated that CNA A stated she would come back but never came back for him. CNA C stated that it was not possible for Resident #1 to transfer himself, get off the commode or get into the shower chair without assistance. CNA C stated staff had been trained on how to provide showers, not to leave residents alone, abuse and neglect and resident care plans. CNA C stated that Resident #1 should never have been left alone in the shower room and CNA A was gone before she arrived and none of the staff knew Resident #1 had been left alone. During a phone interview on [DATE] at 12:30 p.m. CNA A stated that on [DATE] she was in hall 200 and was in Resident #1 and Resident #2's room. CNA A stated that Resident #1 and Resident #2 are roommates and have a private restroom with shower in their room. CNA A stated that Resident #1 was asked if he wanted a shower, and he denied one. CNA A stated that the roommate, Resident #2 stated he wanted a shower and she put him into the shower chair in the room restroom, undressed him and got him ready to shower. CNA A stated that Resident #1 then asked if she could assist him and get him dressed. CNA A stated she dressed Resident #1 who then asked if he could use the restroom because he needed to have a bowel movement. CNA A stated that she told Resident #1 that Resident #2 was in there and Resident #1 asked if he could use another resident's restroom. CNA A stated she told him he could not use another resident's restroom, but she was going to the shower room to get towels for Resident #2 and asked Resident #1 if he wanted to use the toilet in the shower room and Resident #1 stated yes. CNA A stated that she left Resident #2 in the restroom in his shower chair and took Resident #1 to the shower room and assisted him on the toilet and told him she would return. CNA A stated that she removed Resident #1's pants, moved the shower chair into the shower stall and put Resident #1's wheelchair right in front of him. CNA A stated she told Resident #1 to use the call light if he needed her and she was headed back to assist (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676380 If continuation sheet Page 13 of 24 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 676380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Big Spring Center for Skilled Care 3701 Wasson Rd Big Spring, TX 79720 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #2 with his shower. CNA A stated she went back to the resident shared room and showered and dressed Resident #2, before going back to the shower room down the hall for Resident #1. CNA A stated that Resident #1 was still on the commode and stated he was not done, and she told him to use the call light to call when he was finished. CNA A stated that she returned five minutes later, and Resident #1 stated he was not done yet. CNA A stated that she returned to the shower room at 5:57 a.m. and Resident #1 was still on the toilet and stated he was not done. CNA A stated she reminded Resident #1 to use the call light and advised him her shift was almost over and another aide may be the one to assist him. CNA A stated that she left for the day and did not inform anyone that Resident #1 was in the shower room. CNA A stated she meant to tell the nurse that Resident #1 was in the shower room but forgot to. CNA A stated that Resident #1 had a recent decline and was not acting like himself and had pulled some stuff off a shelf in the dining room that day. CNA A stated that Resident #1 care plan stated that he required a one person assist but Resident #1 could transfer himself, undress himself and could get into a shower chair himself. CNA A stated that Resident #2 had to be supervised in the shower per his care plan but that he was in a shower chair and was fine when she left to get towels from the shower room. CNA A stated that she had been trained on Resident #1 and Resident #2's hallway and had been trained on Resident #1 and Resident #2's care plans and they required 1 person assist with showering, toileting, and transfers. CNA A stated that there was no risk of Resident #1 falling because she put his wheelchair in front of him when he was on the commode and the shower chair was out of reach. CNA A stated Resident #2 was not at risk of falling because she put him in the shower chair, and he needed assistance to get out of the shower chair. CNA A stated that Resident #1 was not in the right state of mind and had not been the same the last week or so. CNA A stated that she did not understand why she was being asked about Resident #2 because she was terminated for leaving Resident #1 alone in the shower and Resident #2 was not brought up. CNA A stated she had been trained on care plans, showers, transfers and abuse and neglect. CNA A stated she did nothing wrong except that she left at the end of her shift and did not inform anyone that Resident #1 was left on the commode. Record Review of CNA A's time punch detail revealed CNA A punched in at 6:16 p.m. on [DATE] and clocked out at 6:02 p.m. on [DATE]. During an interview on [DATE] at approximately 12:50 p.m. with the ADM, the ADM stated he had not been aware that CNA A left Resident #2 alone in the resident room restroom in the shower chair when she went to the shower room with Resident #1. The ADM stated that during the facility investigation it was not revealed that Resident #2 was also involved in this incident. The ADM stated that staff should never leave a resident alone in the shower room and that Resident #2 required assistance with his ADLS. During an interview and observation on [DATE] at 1:05 p.m. with Resident #2 revealed he was in his room sitting in his power wheelchair. Resident #2 stated that he has a restroom with a shower in his room. Resident #2 stated that Resident #1 was his roommate before Resident #1 passed away. Resident #2 stated that he remembered the day that CNA A assisted him with a shower. Resident #2 stated that CNA A put him into the shower and then left for a few minutes to get towels. Resident #2 stated that he was not aware that Resident #1 went to the shower room down the hall with CNA A when he was in the shower. Resident #2 stated that CNA A came back and got him out of the shower and put a towel on him to dry. Resident #2 stated that CNA A then left again for about 2 minutes to get him clothes from his room. Resident #2 stated that he felt safe and required assistance to get transferred from his wheelchair into the shower chair and to be dressed. Resident #2 stated that his roommate, Resident #1 needed his wheelchair to get around and needed staff to assist him with transfers. Resident #2 stated that Resident #1 had a history of falls and had been confused around the time leading up to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676380 If continuation sheet Page 14 of 24 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 676380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Big Spring Center for Skilled Care 3701 Wasson Rd Big Spring, TX 79720 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some his death. Resident #2 stated that CNA A knew that they both needed assistance with showers and transfers and that Resident #1 had falls in the past because she always worked their hall. During an interview on [DATE] at 1:25 p.m. CNA C stated that Resident #2 needed total assistance for transfers and bathing and Resident #2 was only able to wash his private area. CNA C stated that Resident #2 had a history of falls, and it was not safe to leave him alone in a shower chair. CNA C stated that Resident #2 could bear some weight on his legs and had he attempted to get up from the shower chair alone, he could have fallen on the wet floor. During an interview on [DATE] at 1:35 p.m. the DON stated that she was not aware that CNA A left Resident #2 alone in the shower when she took Resident #1 to the shower room. The DON stated that Resident #2 had a spine curvature and had he leaned to the side or the front he would fall face first and would be injured with no staff to assist because it was not known he had also been left alone. The DON stated that CNA A did not reveal in her facility statement that she left Resident #2 alone and CNA A had been trained to not leave residents alone during showers or if they needed 1 person assist. Record Review of facility provided policy, Toileting, Bedside Commode/Bathroom dated 2023, revealed in part: Become familiar with the ability of the resident to perform toileting procedures independently or amount of assistance needed, type of toileting facility the resident will use, need for monitoring. Assist to bathroom and assuming sitting position on toilet, assist with cleansing following elimination, encourage resident to use holding bars in the bathroom to prevent falls. Record Review of facility provided policy, Bath, Tub/Shower, dated 2023, revealed in part: Become familiar with the type and pattern of bathing, assistance or aids needed. Transport resident via shower chair; remain with the resident if he is weak or assistance is needed in washing, protect from drafts and chilling during bathing. Place call light in reach for resident to call for assistance; remain with the resident if weak. Assist out of the tub or shower, wrap in bath towel, allow to sit on a chair and assist to dry if needed. Assist to dress if needed or supply aids. Assist the resident with transfer to room or location of choice. Record Review of facility provided policy, Abuse/Neglect, Revised [DATE], revealed in part: The resident has the right to be free from abuse, neglect. This includes but not limited to, involuntary seclusion and any physical/chemical restraint note required to treat the resident's medical symptoms. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will train through orientation and on-going in-services on issues related to abuse/neglect prohibition practices regularly. Record Review of CNA A's employee record revealed that CNA A was hired, received, and signed orientation training on [DATE] that included the following topics: Resident dignity and privacy, No abuse, neglect and/or unnecessary restring; Resident abuse, neglect, and mandatory reporting. Record Review of CNA A's employee disciplinary record revealed that CNA A was terminated on [DATE] due to an incident of Neglect on [DATE]. Specific Reason for Disciplinary Action: On [DATE], [CNA A] was suspended pending an investigation into resident neglect: those allegations were substantiated. It was found that [CNA A] left a resident in the shower room, unattended, for at least thirty minutes. This is a violation of the resident's rights, a violation of her job duties/responsibilities and of the Corporate Code of Conduct. Employee confirmed during a neglect investigation that she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676380 If continuation sheet Page 15 of 24 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 676380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Big Spring Center for Skilled Care 3701 Wasson Rd Big Spring, TX 79720 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 0607 knowingly left a resident unattended in the shower room and did not report to anyone that resident was in the shower room. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676380 If continuation sheet Page 16 of 24 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 676380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Big Spring Center for Skilled Care 3701 Wasson Rd Big Spring, TX 79720 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for 2 of 5 residents (Resident #1, Resident #2) in that: CNA A failed to provide Resident #1 adequate supervision by failing to provide 1-person assistance when she clocked out without informing the oncoming shift she had left Resident #1 alone in the facility shower room. CNA A failed to provide resident #2 adequate supervision by failing to provide 1-person assistance when she left Resident #2 in a shower chair alone in his restroom shower area when she took Resident #1 to the shower room down the hall. This failure could affect all residents by placing them at risk of falls, lacerations, fractures and pain. Findings include: Record review of a face sheet dated [DATE] revealed Resident #1 was a [AGE] year-old male and admitted on [DATE] with diagnoses including Parkinson's disease (a progressive disorder that affects the central nervous system), Muscle wasting and atrophy (breakdown of muscles), unspecified abnormalities of gait and mobility, lack of coordination, cognitive communication deficit, muscle weakness. Record review of the quarterly MDS dated [DATE] revealed Resident # 1 had a BIMS of 11 which indicated moderate cognitive impairment. Resident #1 required Supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for toileting hygiene, upper body dressing personal hygiene, Sit to lying, sit to stand, chair/bed to chair transfer and toilet transfer; Substantial/Maximal assistance (helper does more than half the effort. Helper lifts or hold trunk or limbs and provides more than half the effort) for Shower/bathing and tub/shower transfer; and Partial/Moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs but provides less than half the effort) for lower body dressing and putting on/taking off footwear. Resident #1 required use of a manual wheelchair and had a documented history of falls in which 2 or more resulted in no injuries and 1 fall that resulted in an injury. Record review of Resident #1's care plan dated [DATE] revealed a diagnosis of Parkinson's disease with an intervention to monitor for risk of falls; monitor/document/report signs/symptoms of poor coordination, tremors, gait disturbance and decline in range of motion. Focus area: Fall risk with actual falls on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] with interventions: anticipate and meet resident needs, call light within reach and safe environment with even floors, free from spills and/or clutter, working and reachable call light, handrails on walls, personal items within reach. Resident #1 has an ADL self-care performance deficit and requires 1 staff for assistance for bathing, bed mobility, dressing, eating, toilet use, transferring, walking, personal hygiene/oral care, uses wheelchair and encourage resident to use bell to call for assistance. Record review of a face sheet dated [DATE] revealed Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Parkinson's, Cellulitis (bacterial infection (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676380 If continuation sheet Page 17 of 24 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 676380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Big Spring Center for Skilled Care 3701 Wasson Rd Big Spring, TX 79720 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some involving inner layers of skin), Chronic Obstructive Pulmonary Disease (COPD refers to a group of diseases that cause airflow blockage and breathing-related problems), Muscle Wasting and Atrophy (breakdown of muscle), Muscle Weakness, Lack of coordination, history of falling, abnormal posture. Record review of the quarterly MDS dated [DATE] revealed Resident #2 had a BIMS of 13 which indicated intact cognition. Resident #1 required Substantial/Maximal assistance (helper does more than half the effort. Helper lifts or hold trunk or limbs and provides more than half the effort) for Shower/bathing and personal hygiene; Partial/Moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs but provides less than half the effort) for oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear; Dependent (helper does all the effort. Resident does none of the effort to complete the activity or requires 2 or more helpers) for tub/shower transfer. Resident #1 requires use of a manual wheelchair and has a documented history of falls in which fall that resulted in no injury. Record review of Resident #2's care plan dated [DATE] revealed a diagnosis of Parkinson's disease with an intervention to monitor for risk of falls; monitor/document ability to perform ADLS; Risk of falls due to incontinence, Parkinson's and fluctuating cognition, with interventions that included call light in reach, appropriate footwear, keep bed in lowest position with wheels locked, furniture in locked position, safe environment with even floors, free from spills and/or clutter, working and reachable call light, handrails on walls, personal items within reach, staff x1 to assist with transfers; ADL self-care performance deficit that requires interventions of 1x staff assistance for bathing, bed mobility, dressing, toilet use, transferring and requires use of wheelchair. Resident #2 requires total assist for bathing/showering. Record review of the facility provided Provider Investigation Report, revealed incident date [DATE] at 6:30 a.m. in Hall 200 shower room for Neglect of Resident #1 by alleged perpetrators CNA A and CNA B. Description of the allegation, it is alleged that staff left [Resident #1] in the shower room unattended for approximately 20 minutes. Investigation Summary: On [DATE], [Resident #1] was found unaccompanied in the shower room by day staff coming on shift. When asked why he was in the shower by himself, he stated that a lady had wheeled him in there to shower and left him there by himself. He stated that he had been in there approximately 20-30 minutes. He was found at approximately 6:04a.m. Staff said to be involved were suspended pending further investigation. Interviews were conducted and it was found that [CNA A] was working the 200 halls on [DATE] and admitted to leaving [Resident #1] in the shower room. Investigation findings: Confirmed. Post investigation provider action: Continued Resident monitoring, continued in-services of abuse/neglect and not leaving residents in the shower room unattended. [CNA A] was terminated, and [CNA B] was allowed to return to work. Record Review of the facility provided Incident Report dated [DATE] at 12:56 p.m. documented by the DON revealed: Received report from staff that while getting residents up for breakfast and doing initial beginning of shift rounds, resident was found to have been left in the shower room unattended. Mental status documented as: orientated to place, person, and situation. No injuries observed post incident. Record review of CNA A's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, I worked hall 200 from 10 p-6a. In the beginning of my last round I asked [Resident #1] if he wanted to take his shower and he denied his shower but asked if I could help him get dressed. I proceeded with assisting him with getting dressed. After helping him I get [Resident #2] up for his shower and while gathering [Resident #2's] things for his shower, [Resident #1] asked if he could use the restroom. I informed him that [Resident #2] was in the shower already and it'd (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676380 If continuation sheet Page 18 of 24 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 676380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Big Spring Center for Skilled Care 3701 Wasson Rd Big Spring, TX 79720 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some be a little bit and he asked if he could use another residents restroom, but I told him we can't go into another residents room to use their restroom. I told him I was on my way to the big shower room to grab towels for [Resident #2] and if he would like to use the restroom in there. He (Resident #1) agreed, and I took him. I told him I would be back soon and let him take his time while I showered [Resident #2]. I continue to check on him after I'm done with [Resident #2's] shower and he tells me after each time I've asked him, that he's not done yet. I told him to call me on the light when he's ready to get out, but he never does. I go back 3 minutes before 6 am to check on him and he informed me he still wasn't finished. I tell him to still call but it was close to shift change so I didn't know if it would be me or another CNA helping him out the restroom. Within the minutes passing, I'm on my way to tell a nurse but go back to my hall to gather my things before leaving. I do get distracted and made the mistake of not informing a charge nurse and leave the building. [Resident #1] was only in the shower room to use the restroom but never for a shower. Record review of CNA C's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, The morning of [DATE] at approximately 6:04 a.m., upon unlocking shower room I noticed [Resident #1] completed unclothed, shaking from lack of heat on shower chair. My coworker LVN was also present in shower room and noticed patient unclothed in shower chair. I asked [Resident #1] why he was alone in shower room. [Resident #1] stated the girl (night shift aide) left me in here to shower and said she will be back but never followed back I was still waiting. So I assured [Resident #1] I would bathe and dress him to which he thanked me for not leaving patient by himself. Shower was completed. Patient dressed, assisted to chair, assisted to dining room for breakfast. Record review of the LVN's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, This morning upon entering locked shower room, patient [Resident #1] was on the shower chair completely undressed. Lights were on, heater off, water off as well. When this writer asked patient what are you doing in here by yourself? Patient stated, the girls told me to shower and would be back, but they never came back. I have been in here waiting. This writer and other aide (CNA C) repositioned patient on shower chair and bathed patient, clean clothes were put on patient and assisted patient to wheelchair. This writer then informed DON of what happened. [Resident #1] was assisted to dining room for breakfast. Record review of Resident #1's statement taken by the facility ADM, signed, and dated [DATE] from the [DATE] provider investigation report, revealed in part, Patient stated, I was undressed on the shower chair this morning. I say I was in there about 20 minutes alone in the shower. I was scared they wouldn't shower me since I hadn't been showered in 3 or 4 days. She has long black hair, real pretty, I don't remember the color of her shirt. She is one of the sisters that works here. Patient was asked by this writer Have they ever not showered you? Patient responded yes. I was glad [CNA C] came in and found me. Record review of CNA B's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, I was working hall 400, 2-27-24. I did not assist [Resident #1]. I had no knowledge of the incident until 20 minutes after 6 a.m. that morning. Record review of the BOM's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, I was serving as a witness to a phone call with [DON] and [CNA A] on [DATE]. During this phone call, [CNA A] stated she was at fault for the entire situation and stated [CNA B] had nothing to do with this as [CNA B] was on another hall. [CNA A] again stated, this is all on me. I did it, [CNA B] doesn't have anything to do with this. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676380 If continuation sheet Page 19 of 24 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 676380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Big Spring Center for Skilled Care 3701 Wasson Rd Big Spring, TX 79720 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the DOR's statement signed and dated [DATE] from the [DATE] provider investigation report, revealed in part, I spoke with [Resident #1] about what happened [DATE] with the shower room. [Resident #1] stated that a young pretty girl took me in the shower room. I sat in a shower chair. She left because she forgot something. I did ask [Resident #1] if he knew how long and he stated, no but felt like over 30 minutes. I asked him if he got worried about falling or when she would come back and he said no, I knew I would be ok. During an interview with the DON on [DATE] at 6:24 a.m. she stated on [DATE] she was informed by the LVN that she and CNA C found Resident #1 alone in the shower room on a shower chair and was he was nude. The DON stated that Resident #1 stated that he was left alone in the shower room by a female staff who was later identified as CNA A. The DON stated that initially the facility was unsure of which CNA it was because Resident #1 stated it was one of the sisters and CNA A and CNA B were sisters. The DON stated that CNA A stated that she had left Resident #1 on the commode, and he was fully dressed. The DON stated that Resident #1's care plan required assistance with transfers, using the restroom, showers and changing clothes. The DON stated she believed that CNA A neglected Resident #1 when she left Resident #1 alone in the shower room. The DON stated that the risk of CNA A leaving Resident #1 unattended included that Resident #1 could fall and that could result in injuries, and no one would have known to look for him in the shower room. The DON stated that Resident #1 was found on the shower chair and not on the commode and Resident #1 could not have transferred himself from the commode to the shower chair himself at that time. The DON stated Resident #1 had Parkinson's disease and a week prior leading up to the incident he had a decline and was completely dependent on staff. The DON stated that had Resident #1 had any significant health issue like a cardiac arrest and his decline, or if he had fallen or had a significant health issue, being left alone like that could have resulted in death and no one would have known he was in there until he was accidently discovered. The DON stated that all staff were trained on care plans and CNA A had been trained on showering, abuse, and neglect. The DON stated that Resident #1 was deceased and died a few days after the incident. The DON stated there was no reason to believe that the incident had anything to do with his death due to Resident #1 not having any injuries from being left alone. The DON stated that at no time should a resident who required 1 person assist be left alone in the shower room. During an interview on [DATE] at 8:40 a.m. the LVN stated that on [DATE] she arrived shortly after 6 a.m. to assist CNA C with shower duties. The LVN stated that shortly after 6:00 a.m. she entered the shower room behind CNA C. The LVN stated that Resident #1 was found sitting in the shower chair completely nude. The LVN stated Resident #1 stated he had not had a shower yet and said the girls left him in there. The LVN stated that Resident #1 was dry, the heat was off, and it was cold in the shower room. The LVN stated that Resident #1's wheelchair was not within reach and where Resident #1 was seated in the shower chair, the call light was not in reach. The LVN stated that the shower chair was between the commode and shower stall and a few feet forward from the wall where the call light was. The LVN stated that Resident #1 stated he was not cold but stated his skin was cold to the touch and he had goosebumps on his skin. The LVN stated that Resident #1 had an imprint on his buttocks from sitting in the shower chair but had no injuries. The LVN stated that she told CNA C to stay with Resident #1 to get warm towels. The LVN stated that Resident #1 had a recent decline after a hospital stay for a UTI (Urinary Tract Infection) and he was not at his baseline. The LVN stated that had Resident #1 been at his baseline, he still would have required 1 person assistance with his ADLS that included using the toilet, undressing, and showering. The LVN stated that Resident #1 could not have transferred himself from the toilet to the shower chair and required a gait belt for transfers. The LVN stated there was no gait belt on Resident #1 or in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676380 If continuation sheet Page 20 of 24 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 676380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Big Spring Center for Skilled Care 3701 Wasson Rd Big Spring, TX 79720 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some shower room. The LVN stated that Resident #1's clean clothes were on the shower bench and his dirty clothes were thrown on the floor near soiled towels. The LVN stated that Resident #1 had a previous shoulder fracture that would have prevented him from removing his clothes. The LVN stated that CNA A was already gone before she arrived to work that day, and no one was aware that Resident #1 had been left in the shower room. The LVN stated that 1 person assist meant that staff must stay in the room at all times and Resident #1 should not have been left on the toilet alone or on the shower chair. The LVN stated that Resident #1 had no access to towels to cover himself. The LVN stated Resident #1 was upset and stated, I am so glad yall are here. The LVN stated that Resident #1 was at risk for falls and injuries by being left alone in the shower room. The LVN stated that Resident #1 was unsteady on his feet and required staff to be in there. The LVN stated that staff are trained on abuse and neglect and are trained on the care areas for the residents they work with. During an interview on [DATE] at 10:03 a.m. CNA C stated that on [DATE] she arrived at approximately 6 a.m. to assist the LVN with showers in 200 halls. Stated that she entered the shower room to grab supplies and found Resident #1 in the shower chair naked. CNA C stated it was approximately 6:04 a.m. and the LVN came in behind her. CNA C stated that Resident #1 stated that he was left in there by the girl. CNA C stated it was cold, the heat was off, and the water was off. CNA C stated she turned the heat on and turned the water on to warm up after Resident #1 stated he wanted a shower. CNA C stated that Resident #1 required staff to assist with showers, transfers and using the toilet because his gait was not steady, and he had a history of falls. CNA C stated that Resident #1's dirty clothes were on the floor, his clean clothes were on the bench and his wheelchair was against the wall across the shower room and not in reach. CNA C stated that Resident #1 was nude, had no gait belt on and there was no gait belt in the shower room. CNA C stated that Resident #1 required assistance to clean himself after a bowel movement and there was no evidence that he had a bowel movement in the toilet nor was there any feces on Resident #1. CNA C stated Resident #1 stated please, please help me. CNA C stated that Resident #1 stated that CNA A stated she would come back but never came back for him. CNA C stated that it was not possible for Resident #1 to transfer himself, get off the commode or get into the shower chair without assistance. CNA C stated staff had been trained on how to provide showers, not to leave residents alone, abuse and neglect and resident care plans. CNA C stated that Resident #1 should never have been left alone in the shower room and CNA A was gone before she arrived and none of the staff knew Resident #1 had been left alone. During a phone interview on [DATE] at 12:30 p.m. CNA A stated that on [DATE] she was in hall 200 and was in Resident #1 and Resident #2's room. CNA A stated that Resident #1 and Resident #2 are roommates and have a private restroom with shower in their room. CNA A stated that Resident #1 was asked if he wanted a shower, and he denied one. CNA A stated that the roommate, Resident #2 stated he wanted a shower and she put him into the shower chair in the room restroom, undressed him and got him ready to shower. CNA A stated that Resident #1 then asked if she could assist him and get him dressed. CNA A stated she dressed Resident #1 who then asked if he could use the restroom because he needed to have a bowel movement. CNA A stated that she told Resident #1 that Resident #2 was in there and Resident #1 asked if he could use another resident's restroom. CNA A stated she told him he could not use another resident's restroom, but she was going to the shower room to get towels for Resident #2 and asked Resident #1 if he wanted to use the toilet in the shower room and Resident #1 stated yes. CNA A stated that she left Resident #2 in the restroom in his shower chair and took Resident #1 to the shower room and assisted him on the toilet and told him she would return. CNA A stated that she removed Resident #1's pants, moved the shower chair into the shower stall and put Resident #1's wheelchair right in front of him. CNA A stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676380 If continuation sheet Page 21 of 24 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 676380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Big Spring Center for Skilled Care 3701 Wasson Rd Big Spring, TX 79720 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some she told Resident #1 to use the call light if he needed her and she was headed back to assist Resident #2 with his shower. CNA A stated she went back to the resident shared room and showered and dressed Resident #2, before going back to the shower room down the hall for Resident #1. CNA A stated that Resident #1 was still on the commode and stated he was not done, and she told him to use the call light to call when he was finished. CNA A stated that she returned five minutes later, and Resident #1 stated he was not done yet. CNA A stated that she returned to the shower room at 5:57 a.m. and Resident #1 was still on the toilet and stated he was not done. CNA A stated she reminded Resident #1 to use the call light and advised him her shift was almost over and another aide may be the one to assist him. CNA A stated that she left for the day and did not inform anyone that Resident #1 was in the shower room. CNA A stated she meant to tell the nurse that Resident #1 was in the shower room but forgot to. CNA A stated that Resident #1 had a recent decline and was not acting like himself and had pulled some stuff off a shelf in the dining room that day. CNA A stated that Resident #1 care plan stated that he required a one person assist but Resident #1 could transfer himself, undress himself and could get into a shower chair himself. CNA A stated that Resident #2 had to be supervised in the shower per his care plan but that he was in a shower chair and was fine when she left to get towels from the shower room. CNA A stated that she had been trained on Resident #1 and Resident #2's hallway and had been trained on Resident #1 and Resident #2's care plans and they required 1 person assist with showering, toileting, and transfers. CNA A stated that there was no risk of Resident #1 falling because she put his wheelchair in front of him when he was on the commode and the shower chair was out of reach. CNA A stated Resident #2 was not at risk of falling because she put him in the shower chair, and he needed assistance to get out of the shower chair. CNA A stated that Resident #1 was not in the right state of mind and had not been the same the last week or so. CNA A stated that she did not understand why she was being asked about Resident #2 because she was terminated for leaving Resident #1 alone in the shower and Resident #2 was not brought up. CNA A stated she had been trained on care plans, showers, transfers and abuse and neglect. CNA A stated she did nothing wrong except that she left at the end of her shift and did not inform anyone that Resident #1 was left on the commode. Record Review of CNA A's time punch detail revealed CNA A punched in at 6:16 p.m. on [DATE] and clocked out at 6:02 p.m. on [DATE]. During an interview on [DATE] at approximately 12:50 p.m. with the ADM, the ADM stated he had not been aware that CNA A left Resident #2 alone in the resident room restroom in the shower chair when she went to the shower room with Resident #1. The ADM stated that during the facility investigation it was not revealed that Resident #2 was also involved in this incident. The ADM stated that staff should never leave a resident alone in the shower room and that Resident #2 required assistance with his ADLS. During an interview and observation on [DATE] at 1:05 p.m. with Resident #2 revealed he was in his room sitting in his power wheelchair. Resident #2 stated that he has a restroom with a shower in his room. Resident #2 stated that Resident #1 was his roommate before Resident #1 passed away. Resident #2 stated that he remembered the day that CNA A assisted him with a shower. Resident #2 stated that CNA A put him into the shower and then left for a few minutes to get towels. Resident #2 stated that he was not aware that Resident #1 went to the shower room down the hall with CNA A when he was in the shower. Resident #2 stated that CNA A came back and got him out of the shower and put a towel on him to dry. Resident #2 stated that CNA A then left again for about 2 minutes to get him clothes from his room. Resident #2 stated that he felt safe and required assistance to get transferred from his wheelchair into the shower chair and to be dressed. Resident #2 stated that his roommate, Resident #1 needed his wheelchair to get around and needed staff to assist him with transfers. Resident #2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676380 If continuation sheet Page 22 of 24 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 676380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Big Spring Center for Skilled Care 3701 Wasson Rd Big Spring, TX 79720 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated that Resident #1 had a history of falls and had been confused around the time leading up to his death. Resident #2 stated that CNA A knew that they both needed assistance with showers and transfers and that Resident #1 had falls in the past because she always worked their hall. During an interview on [DATE] at 1:25 p.m. CNA C stated that Resident #2 needed total assistance for transfers and bathing and Resident #2 was only able to wash his private area. CNA C stated that Resident #2 had a history of falls, and it was not safe to leave him alone in a shower chair. CNA C stated that Resident #2 could bear some weight on his legs and had he attempted to get up from the shower chair alone, he could have fallen on the wet floor. During an interview on [DATE] at 1:35 p.m. the DON stated that she was not aware that CNA A left Resident #2 alone in the shower when she took Resident #1 to the shower room. The DON stated that Resident #2 had a spine curvature and had he leaned to the side or the front he would fall face first and would be injured with no staff to assist because it was not known he had also been left alone. The DON stated that CNA A did not reveal in her facility statement that she left Resident #2 alone and CNA A had been trained to not leave residents alone during showers or if they needed 1 person assist. Record Review of facility provided policy, Toileting, Bedside Commode/Bathroom dated 2023, revealed in part: Become familiar with the ability of the resident to perform toileting procedures independently or amount of assistance needed, type of toileting facility the resident will use, need for monitoring. Assist to bathroom and assuming sitting position on toilet, assist with cleansing following elimination, encourage resident to use holding bars in the bathroom to prevent falls. Record Review of facility provided policy, Bath, Tub/Shower, dated 2023, revealed in part: Become familiar with the type and pattern of bathing, assistance or aids needed. Transport resident via shower chair; remain with the resident if he is weak or assistance is needed in washing, protect from drafts and chilling during bathing. Place call light in reach for resident to call for assistance; remain with the resident if weak. Assist out of the tub or shower, wrap in bath towel, allow to sit on a chair and assist to dry if needed. Assist to dress if needed or supply aids. Assist the resident with transfer to room or location of choice. Record Review of facility provided policy, Abuse/Neglect, Revised [DATE], revealed in part: The resident has the right to be free from abuse, neglect. This includes but not limited to, involuntary seclusion and any physical/chemical restraint note required to treat the resident's medical symptoms. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will train through orientation and on-going in-services on issues related to abuse/neglect prohibition practices regularly. Record Review of CNA A's employee record revealed that CNA A was hired, received, and signed orientation training on [DATE] that included the following topics: Resident dignity and privacy, No abuse, neglect and/or unnecessary restring; Resident abuse, neglect, and mandatory reporting. Record Review of CNA A's employee disciplinary record revealed that CNA A was terminated on [DATE] due to an incident of Neglect on [DATE]. Specific Reason for Disciplinary Action: On [DATE], [CNA A] was suspended pending an investigation into resident neglect: those allegations were substantiated. It was found that [CNA A] left a resident in the shower room, unattended, for at least thirty minutes. This is a violation of the resident's rights, a violation of her job duties/responsibilities and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676380 If continuation sheet Page 23 of 24 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 676380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Big Spring Center for Skilled Care 3701 Wasson Rd Big Spring, TX 79720 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 0689 Level of Harm - Minimal harm or potential for actual harm of the Corporate Code of Conduct. Employee confirmed during a neglect investigation that she knowingly left a resident unattended in the shower room and did not report to anyone that resident was in the shower room. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676380 If continuation sheet Page 24 of 24