Health inspection·October 28, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the hall, text something and continue to push the resident into the dining room. The aide came out of the dining room on the phone. The visitor stated it made her mad because the residents were people and needed to be treated that way. The visitor looked at the surveyor and said, you wouldn't want to be treated like that. Interview on 10/28/22 at 3:58 PM the DON said cell phones should not be out or on the employee. She said if the staff had to have them, then the phone needed to be on silent and the call needed to be taken to a private area. The DON stated a resident's room, even if the resident was not in the room, was not a private area. She said if it was not a life-threatening call, then the staff member needed to be out of the resident's room. She stated this expectation applied to all staff. Interview on 10/28/22 at 04:43 PM the AD stated there was only 4 -6 residents who came to activities because the not-cognitive residents did not remember, or the staff were hiding in those resident's bathroom texting. The AD said when she caught this, she would text the DON to come to whatever room. The AD said staff cell phone use was a problem. Interview on 10/28/22 at 5:18 PM the Administrator said he would be irritated if staff members were on the cell phone while taking care of his family. He stated he would be annoyed if it was himself in the wheelchair. He stated the facility had been pushing customer service and that was part of it for the last few weeks. Review of the facility's employee handbook dated 10/10/22 revealed: an employee should refrain from usage of his/her personal cell phone during normal working hours; with the exception of his/her break time in the designated break areas only. Your personal cell phone should never be in use while you are performing your duties so as to cause the resident's need to not be met. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 2 of 15 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 676430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashton Medical Lodge 801 South Loop 250 West Midland, TX 79703 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and transmit a resident assessment within the required time frame for 1 of 12 residents (Resident #3) reviewed for data completion and transmission in that: Residents Affected - Few The facility failed to ensure Resident #3's quarterly MDS was transmitted within 14 days of being completed and instead was transmitted 36 days after the assessment reference date. These failures could place residents at risk of not having their assessments completed and transmitted timely. Findings included: Record review of Resident #3's admission record dated 10/28/22 indicated he was admitted to the facility on [DATE] with diagnoses which included lack of coordination and hemiplegia (one-sided paralysis). He was [AGE] years of age. Record review of Resident #3's MDS dated [DATE] indicated in part: Bladder and Bowel: Urinary Continence =. 3. Always incontinent (no episodes of continent voiding). Bowel Continence = 2. Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement). Resident #3's quarterly MDS dated [DATE] was not signed until 10/02/2022 and was not closed and transmitted until 10/28/2022. During an interview on 10/28/22 at 10:54 AM MDS coordinator A said Resident #3's 09/22/22 quarterly MDS had been completed but she had forgotten to transmit it timely. During an interview on 10/28/22 at 03:02 PM the MDS corporate nurse said MDS coordinator A had just submitted Resident #3's 09/22/2022 quarterly MDS today 10/28/2022 after being made aware by the state surveyor. The MDS corporate nurse said she monitored the MDS nurse coordinators to make sure they transmitted the MDS's timely. The MDS corporate nurse said Resident #3's MDS was not transmitted timely because it got missed. The MDS corporate nurse said they went by the RAI manual as a guide on how to transmit the MDS's. Record review of the RAI (Resident Assessment Instrument) Manual dated October 2019, page 5-2 read in part .5.2 Timeliness Criteria In accordance with the requirements at 42 CFR §483.20(f)(1), (f)(2), and (f)(3), long-term care facilities participating in the Medicare and Medicaid programs must meet the following conditions: · Completion Timing Assessment For the other comprehensive MDS assessments, Significant Change in Status Assessment and Significant Correction to Prior Comprehensive Assessment, the CAA Completion Date (V0200B2) must be no later than 14 days from the ARD (A2300) and no later than 14 days from the determination date of the significant change in status or the significant error, respectively Summary page 2-16 dated October 2011 revealed that the MDS (Minimum Data Set) completion date is to be no later than the discharge date plus 14 calendar days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 3 of 15 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 676430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashton Medical Lodge 801 South Loop 250 West Midland, TX 79703 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 0640 Level of Harm - Minimal harm or potential for actual harm Further record review of the RAI Manual dated October 2019 read in part .Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days) . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 4 of 15 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 676430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashton Medical Lodge 801 South Loop 250 West Midland, TX 79703 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 - Few 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 observation, interview and record review the facility failed to ensure each resident each resident received adequate supervision and assistive devices to prevent accidents for 1 of 2 residents observed for mechanical transfers (Resident #87). CNA C and D demonstrated improper transfer techniques for Resident #87. These failures could place residents at risk for injuries from inappropriate transfers. Findings included: Review of Resident #87's admission Record, dated 10/27/22, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included paralysis on one side, seizures, and stroke. Review of Resident #87's Significant Change MDS Assessment, dated 9/21/22 revealed: She scored a 4 of 15 on her mental status exam (indicating severe cognitive impairment) but showed no signs of delirium. She needed extensive assistance of two staff for transfers. Review of Resident #87's Care Plan, revised 3/24/ 22, revealed: Focus: Resident requires assist with late loss ADLs, use of wheelchair for locomotion. Able to feed self with set up. Goal: Resident is able to perform self-care to optimal level and maintains strength and endurance for 90 days. Interventions: encourage independence in performance of self-care and mobility within limitations. And Provide level of support to completed transferring needs each shift. Review of Resident #87's Care Plan, revised 6/3/19, revealed: Focus: The resident is at risk for falls related to gait/balance problems Goal: The resident will not sustain serious injury through the review date. (Revised 9/29/22) Intervention implemented 4/27/21 Resident to be two-person transfer at all times. The care plan did not address use of a mechanical lift. Interview on 10/25/22 at 3:21 PM Resident #87 stated the facility was short staffed because there was usually one person working on the hall. She stated sometimes there was only one person working the mechanical lift when they transferred her. Observation on 10/28/22 at 11:43 AM revealed CNA C and CNA D prepared Resident #87 for the lift with the sling. CNA C did not widen the legs on the mechanical lift but did lift Resident #87 up. CNA D scrambled to steady Resident #87 while moving up and then to move the wheelchair to the end of the bed. The wheelchair was not locked. CNA C moved Resident #87 to the end of the bed over the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 5 of 15 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 676430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashton Medical Lodge 801 South Loop 250 West Midland, TX 79703 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 - Few wheelchair, widened the legs of the lift around the wheelchair and immediately lowered the resident. CNA D did not have time to position Resident #87 in the wheelchair. Once Resident #87 was in the wheelchair, the aides removed the loops from the hanger bar, the hanger bar swung, striking Resident #87's nose causing her to exclaim oh! Interview on 10/28/22 at 11:55 AM CNA D said she did not feel the transfer went well. She said CNA C did not open the mechanical lift legs when she (CNA C) lifted the resident. CNA D stated CNA C did not communicate with her, and she (CNA D) did not feel she had time to position Resident #87. CNA D said the boom (the part the sling hooks too) was too close to the resident and confirmed the cross bar hit Resident #87 in the nose. CNA D said she did not have the chance to lock the wheelchair because CNA C went too fast, and CNA C did not do it. Interview on 10/28/22 at 12:25 PM CNA C said she thought the mechanical lift to her was okay. During a confidential interview on 10/25/22 between 1:00 p.m. and 4:30 p.m. an aide stated the staffing pattern on each hallway was supposed to be two aides on each hall during the day shift (6 a.m. - 6 p.m.) and one staff on the halls on the night shift (6 p.m. - 6 a.m.). The aide said if the hallway was short-staffed, they would try to get a nurse to help if she will. The aide reported if the nurse would not help, they would try to get another aide to help. The aide was asked what they would do if they could not find assistance and answered you don't want me to tell the truth. The aide stated they would end up doing a mechanical lift transfer by themselves probably every other day, maybe every three days depending on who showed up. Interview during Confidential Resident Council Meeting on 10/26/22 at 10:48 AM revealed nine alert, lucid residents unanimously said there was sometimes one aide on the floor and the nurses would not help. The two residents present who required mechanical lifts stated there was one aide assisting them with the transfer and it made them worried something would happen. Interview on 10/27/22 02:14 PM the DON stated Resident #87 recently declined significantly . Interview on 10/28/22 at 3:58 PM the DON stated her expectation for a mechanical lift was that there be two people, the sling be properly under the resident with one staff on each side of the resident to make sure the sling was properly placed. She stated generally one person would operate the lift while the other person would guide the resident. She stated the legs on the mechanical lift needed to spread to make sure the base was stable. The DON said the wheelchair needed to be locked. Interview on 10/28/22 at 5:18 PM the Administrator stated he had to print the instructions for the mechanical lift off the internet. He said the lifts were possible to use one-person, but it was not a good idea. Review of the facility's policy and procedure on Transfer of Patient, undated, revealed, in part: Two-Person Hoyer (Mechanical Lift) Purpose: to safely get resident from one surface to another when the resident is unable/unwilling to bear weight on his or her lower extremities and cannot be safely transferred using the 2-person total lift. Procedure: Gather equipment and bring to bedside. Position wheelchair so that you can maneuver the lift safely from the bed to over the chair. Lock wheels/brakes. Place sling under resident. Position lift over the bed. Spread the legs of the lift to the widest open position to maintain a broad base of support. Attach chains to the sling ensuring (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 6 of 15 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 676430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashton Medical Lodge 801 South Loop 250 West Midland, TX 79703 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 - Few the s hooks face away from the resident to prevent injury. Slowly guide the lift away from the chair and position lift above the chair. Lower the resident into chair. One staff member holds the sling to help keep the resident's hips, back, in the chair as the lift is being lowered. Unhook the chains and move the lift out of the way. The sling remains under the resident. Review of the facility's Hoyer Lift Transfer proficiency checklist, undated, revealed, in part: Move lift and sling into the resident's room. Request and addition staff member to assist with the transfer. ALWAYS HAVE TWO STAFF PERFORM HOYER LIFT TRANSFERS Move list into position. Open the legs of the lift to their widest position, the shift handle locked in place and DO NOT LOCK THE REAR CASTERS. Attach the proper sling loops onto the lift bar. Place both the (head end) upper loops for each side of sling on lift bar first, making sure the lift bar is parallel to the shoulders. Then, if resident is in the sitting position place larger and middle loops on the lift crossbar hooks. Two staff must be available to guide the resident to the bed chair, lifting legs over mattress. Review of the User Manual, undated, revealed: Warnings: Operating the lift (page 8) Although the manufacturer recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures, or equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the health care professional for each individual case. Lifting the Patient: when using an adjustable base lift, the legs MUST be in the maximum Opened/Locked position before lifting the patient. Transferring the Patient: Wheelchair locks MUST be in a locked position before lowering the patient into the wheelchair for transport. Operation (page 20) Warning The legs of the lift must be in the maximum open position for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position. The manufacturer recommends that two assistants be used for all lifting preparation and transferring to/from procedures. Lifting the Patient (page 24) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 7 of 15 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 676430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashton Medical Lodge 801 South Loop 250 West Midland, TX 79703 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 The manufacturer recommends that two assistants be used for all lifting preparations to/from procedures. Level of Harm - Minimal harm or potential for actual harm The legs of the lift must be in the maximum open position for optimum stability and safety. If it is necessary to close the legs of the lift, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position and lock the shift handle immediately. Press the legs open button on the hand control to open the legs of the patient lift to maximum. Position the patient lift using the steering handle Press the boom down button on the hand control to lower the boom for easy attachment of the sling. Transferring to a wheelchair (page 31) Residents Affected - Few Lift the patient from the bed. Ensure the legs of the lift with patient is in the sling are in the open position. Move the wheelchair into position. Engage the rear wheel locks of the wheelchair to prevent movement of the chair. WARNING: DO NOT place the patient in the wheelchair if the locks are not engaged. The wheelchair wheel locks MUST be in a locked position before lowering the patient into the wheelchair for transport. Otherwise, injury may result. Use the straps or handles on the side and the back of the sling to guide the patient's hips as far back as possible into the seat for proper positioning. Position the patient over the seat with their back against the back of the chair. Begin to lower the patient Two assistants are recommended for this step - one assistant stands behind the chair and the other operates the patient lift. The assistant behind the chair pulls back on the grab handle or sides of the sling to seat the patient well into the back of the chair. This will maintain a good center of balance and prevent the chair from tipping forward. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 8 of 15 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 676430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashton Medical Lodge 801 South Loop 250 West Midland, TX 79703 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have sufficient numbers of staff to provide nursing care to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 7 of 18 (Residents #8, #32, #34, #38, #60, #72, #87) and 9 of 9 resident confidential Resident Council Meeting reviewed for appropriate staff services. The facility failed to ensure there was sufficient staffing to: Answer Residents #8's, #34's, and #38's call lights timely; Ensure there were enough staff to perform Resident #87's and #32's mechanical lift transfers; Ensure that Resident #8 was able to be out of bed and shower when he chose; Ensure that Resident #60 and #87's eating habits were accommodated; Ensure Resident #87 received pain medication timely; Ensure staff was not short-tempered with Resident #72; These failures placed residents at risk for not receiving care and services to meet their needs. The findings included: Review of Resident #8's admission Record, dated 10/28/22, revealed he was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included complete paraplegia, morbid (severe) obesity, injury at unspecified level of thoracic spinal cord and muscle weakness. Review of Resident #8's Significant Change MDS Assessment, dated 7/24/22, revealed: He scored a 15 of 15 on his mental status exam (indicating intact cognition) and no signs of delirium. He required extensive assistance of two or more staff for all ADLs with the exception of eating in which he required setup only. Interview during initial pool rounds on 10/27/22 at 10:22 AM Resident #8 stated that he had been told the facility was understaffed. He stated the staff blow him off and they answer my call light but tell me they will be back and never come back. He stated he was supposed to get three showers a week, but most of the time he only got one because it took at least 2 staff to get him out of bed and there was never enough staff around to help. He stated he preferred to get up in the morning but there were times when he was left in bed until after lunch or longer. He stated sometimes he had to stay in bed all day because they did not get him up and they claimed it was because he was sleeping. Resident #8 stated he had told them to wake him up because he needs to be out of bed. He stated staff took too long to answer call lights. He stated the time varies but it could be up to an hour. He stated he had timed it on his cell phone timer on several occasions because he was curious to see exactly how long he was waiting. He had started using his cell phone to call the nurses station when staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 9 of 15 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 676430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashton Medical Lodge 801 South Loop 250 West Midland, TX 79703 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 0725 took too long to answer his call light. Level of Harm - Minimal harm or potential for actual harm Review of Resident #87's admission Record, dated 10/27/22, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included paralysis on one side, seizures, and stroke. Residents Affected - Some Review of Resident #87's Significant Change MDS Assessment, dated 9/21/22 revealed: She scored a 4 of 15 on her mental status exam (indicating severe cognitive impairment) but showed no signs of delirium. She needed extensive assistance of one or two staff for all ADLs. Interview during initial pool rounds on 10/25/22 at 3:21 PM Resident #87 said the facility was short staffed. She stated there was usually one aide on each hall. Resident #87 said she was a mechanical lift transfer and sometimes there was only one staff operating the lift. She added she sometimes had to wait a long time to get her pain medication. Observation and interview on 10/28/22 at 11:19 AM revealed Resident #87's family stated their biggest concern was the staffing because there did not seem to be around a lot . The resident stated she needed help eating and no one came to help her. Observation showed her breakfast still had the lid on top of it and it was completely untouched. CNA D told Resident #87 she was sorry no one came to help, and she was assigned to the dining room so could not do it. During a follow up interview on 10/28/22 at 12:23 PM Resident #87's family repeated the facility was short staffed and that was part of why the family was making the decision to put Resident #87 (admission date 10/28/22). Interview during rounds on 10/25/22 at 3:28 PM Resident #72 said sometimes the staff were short and that made them short tempered. During a confidential interview on 10/25/22 between 1:00 p.m. and 4:30 p.m. an aide stated staffing in the building was terrible and there was a lot of turn over. The aide stated there were new aides almost every day. The aide said the staffing pattern on each hallway was supposed to be two aides on each hall during the day shift (6 a.m. - 6 p.m.) and one staff on the halls on the night shift (6 p.m. - 6 a.m.). The aide said if the hallway was short staffed, they would try to get a nurse to help if she will. The aide reported if the nurse would not help, they would try to get another aide to help. The aide was asked what they would do if they could not find assistance and answered you don't want me to tell the truth. The aide stated they would end up doing a mechanical lift transfer by themselves probably every other day, maybe every three days depending on who showed up. The aide stated they were working six days a week to help cover the shortage. Interview during rounds on 10/25/22 at 4:20 p.m. Resident #34 said it could take up to 30 minutes for her call light to be answered. She said she knew it was 30 minutes because she could track it on her cell phone. Interview during Confidential Resident Council Meeting on 10/26/22 at 10:48 AM revealed nine alert, lucid residents unanimously said there was sometimes one aide on the floor and the nurses would not help. The two residents present who required mechanical lifts stated there was one aide assisting them with the transfer and it made them worried something would happen. The residents all unanimously stated the nurses would tell the aides it was not their problem and that made the aides too afraid (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 10 of 15 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 676430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashton Medical Lodge 801 South Loop 250 West Midland, TX 79703 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to ask them for help. The aides said it could take an hour for call lights to be answered and they knew it was an hour because they could check the clock on their cell phone. Review of Resident #60's admission Record, dated 10/28/22, revelaed she was a [AGE] year-old female admitted tothe facility on 9/11/20 with diagnoses which included dementia, dusphagia, feeding difficulties, Alzheimer's Disease and head injury. Review of Resident #60's Quarterly MDS assessment dated [DATE] revealed a scored of 00 on her mental status assessment (indicating severe cognitive impairment) and she was completely dependent on staff for all ADLs. Interview and observation during initial pool rounds on 10/26/22 at 09:28 AM Resident #60's family member stated, if you really want to see how the place runs you should come in on the night shift or the weekend. When asked to explain, she stated that normally each hall only had one CNA working at night and weekend shift and they were lucky when they had two during the day. She stated that she came to the facility every day for every meal to make sure that Resident #60 was fed. She stated that Resident #60 had a specific way she had to be fed after she had her stroke, and it was time consuming, and she knew that since the facility was understaffed the only way to make sure it was done was to do it herself. While she was explaining Resident #60's needs she was feeding her a thickened juice in very small bites over approximately 30 minutes. She stated that she did not get much help from the staff when providing care for Resident #60, and that she was the one who got her in and out of bed, got her dressed and did her incontinent care. She stated the facility had some very caring CNAs that were very good at their jobs, but they were overworked. She stated the nurses did not help the CNAs. Interview during initial pool rounds on 10/26/22 at 2:24 PM Resident #38 stated it could take up to an hour to have the call light answered if there was only one staff on the hallway. She said she kept track of the time on her phone. Interview during initial pool rounds on 10/26/22 at 2:24 pm. Resident #32 said there had been times when there was one staff operating the mechanical lift because the facility was short staffed. He said the last time it happened was in the previous week. Observation on 10/27/22 at 10:45 AM showed the call light on hall 100 was going off. The call light continued to go off until 11:10 a.m. Interview on 10/27/22 at 4:53 PM the DON said staffing was not good. She shared the facility was down 17 full-time aides. She said the facility tried to run 12 aides on the day shift and there were 2 rotations, but the facility was actually running with 10 aides. She said there were several aides who would pick up a shift and there were several as-needed staff. She shared the facility would also borrow staff from a sister facility in the area as well. The DON added there were also three MA and 3 full time nurses short as well. The DON stated she was at a loss about why the facility was so short staffed. The DON said corporate policy was no agency aides so they would pull the transportation aide to assist, and they got rid of a restorative aide at the time. The DON said the nurses knew they needed to answer call lights, and everyone needed to pitch in. Interview on 10/28/22 at 3:58 PM the DON stated the facility tried to do two aides for Halls 1 - 5. She stated since Hall 600 was such a heavy hall they tried to do three aides. She stated there was one aide on the hallway at night. She stated the ratio was 1 aide to 25 residents. The DON shared (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 11 of 15 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 676430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashton Medical Lodge 801 South Loop 250 West Midland, TX 79703 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some she thought Hall 3 could use two aides on the night shift, but she would never win that battle since it was above her paygrade (it was a corporate decision). Interview on 10/28/22 at 04:43 PM the AD stated she had one part-time assistant to help with activities. She said the aides would not help with assisting residents to activities or even turn on the radio for them. The AD said there was a lot of resistance from the floor staff (nurses and aides) because they felt like it was not their job to help. She said she did not know why they felt this way. The AD said she and/or the activity assistant would have to go room to room to invite the residents to activities and then tell the aide the residents needed assistance with transfers. She said as a result the residents got aggravated because the activity was running behind. The AD stated there was only 4 -6 residents who came to activities because the not-cognitive residents did not remember, or the staff were hiding in those resident's bathroom texting. Review of the Resident Council Minutes revealed: 9/14/22 - 12 residents attended and reported to the facility some nurses good and some bad 10/12/22 - 13 residents attended and reported to the facility they felt the Administrator did not treat the staff well and that was why they facility lost all the good help. The residents reported that some nurses were good, and some were bad. The residents informed the facility the staff did not take their time with the residents and could be very rough; nor did the staff come back to shower the residents or change them when they said they would. The residents complained they would like to get out of bed according to their care plan and not stay in bed most of the day. The residents voiced to the facility they were tired of being in bed all weekend and wanted the staff to get them out of bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 12 of 15 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 676430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashton Medical Lodge 801 South Loop 250 West Midland, TX 79703 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Residents #47 and #87) of 5 residents reviewed for infection control. Residents Affected - Some The facility failed to ensure PCA B changed her gloves after they became contaminated during incontinent care while assisting Resident #47. CNA D failed to turn off the faucet with a paper towel after washing her hands and then assisting Resident #87 with a transfer. This failure could place residents at risk for cross contamination and the spread of infection. Findings include: INCONTINENT CARE: Record review of Resident #47's admission record dated 10/25/22 indicated she was admitted to the facility on [DATE] with diagnoses which included dementia and muscle weakness. She was [AGE] years of age. Record review of Resident #47's MDS dated [DATE] indicated in part: Bladder and Bowel: Urinary Continence =. 3. Always incontinent (no episodes of continent voiding). Bowel Continence = 2. Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement). Record review of Resident #47's care plan dated 06/01/22 indicated in part: Focus: Resident has Urinary incontinence- Resident has bowel incontinence. Goal: I will become continent within next 90 days. Resident will be clean, dry and free from odors the next 90 days. Interventions: Give perennial care when resident is incontinent. Assist with applying pads/briefs. During an observation on 10/25/22 at 03:17 PM PCA B performed incontinent care for Resident #47. PCA B aide washed her hands and put on some gloves. PCA B undid the resident's brief, took some wet wipes and wiped the resident's vaginal and rectal area. During the wiping the PCA's gloves came in contact with the resident's vaginal and rectal area. While still wearing the same gloves, PCA B opened one of the drawers in the cabinet to obtain a new brief, turned the resident on her side, applied the new brief and covered the resident with the blankets. During an interview on 10/28/2022 at 11:12 AM the DON said staff were expected to change their gloves, wash their hands and put on new gloves once their gloves became contaminated. The DON said if staff did not change their gloves that could lead to cross contamination and infections. The DON said they had a nurse educator that would monitor and train the staff. The DON said she believed the failure occurred because the aide got nervous. During an interview on 10/28/2022 at 11:32 AM the nurse educator said she did random competency checks by asking aides to go and perform incontinent care and she observes them. The nurse educator said the aides had to remove their gloves once they became contaminated before touching the clean items (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 13 of 15 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 676430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashton Medical Lodge 801 South Loop 250 West Midland, TX 79703 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to prevent infection and cross contamination. The nurse educator said she trained the aides on changing their gloves once they became contaminated. During a telephone interview on 10/28/22 at 01:32 PM PCA B said she should have changed her gloves before applying the new brief on the resident. The aide said she got nervous and forgot to change them. The aide said her not changing her gloves could lead to possible cross contamination. Record review of the facility document titled Incontinent care procedure and proficiency evaluation dated 09/27/22 and signed by PCA B indicated in part: Perineal care - create clean field arrange supplies so they can be easily reached. Perform hand hygiene, don gloves. With wet washcloth or wipe cleanse perineal area wiping from font to back. Clean rectal area with new wash cloth/wipe using upward gentle strokes. Remove soiled pan and clothing and place in plastic bag. Remove gloves and discard. Perform hand hygiene, don gloves. The document was signed by PCA B. Record review of the facility undated document titled Infection prevention and control program indicated in part: Facility maintain an organized, effective facility wide program designed to systematically identify and reduce the risk of acquiring and transmitting infections among residents, visitors and health care workers. This program involves the collaboration of many programs and services with them the facility in his designed to meet the intent of regulatory agencies. HANDWASHING: Review of Resident #87's admission Record, dated 10/27/22, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included paralysis on one side, seizures, and stroke. Review of Resident #87's Significant Change MDS Assessment, dated 9/21/22 revealed: She scored a 4 of 15 on her mental status exam (indicating severe cognitive impairment) but showed no signs of delirium. She needed extensive assistance of two staff for transfers During an observation on 10/28/22 at 11:43 AM, CNA C and CNA D completed a transfer for Resident #87. They were both observed washing their hands at the same time before the transfer. CNA D was the last to complete the handwashing and turned off the faucet with her bare hands. During an interview on 10/28/22 at 12:25 PM CNA D stated her training for hand washing was to dry her hands and then use a paper towel to turn off the tap and open the door. When asked why she did not, she said I didn't? Sorry. During an interview on 10/28/22 at 3:58 PM the DON stated her expectation for hand washing was for staff to use a paper towel to turn off the faucet to avoid contaminating their hands. She said the Staffing Coordinator just watched a lot of staff do hand washing proficiencies. The DON added there was a computer training the staff had to do on hand washing. The DON said the staff covered handwashing all the time - we're saying it all the time: alcohol and wash your hands all day long. Review of the facility's policy and procedure on Hand Washing, undated, revealed: Standard: Mechanical removal of pathogenic organisms from the skin is accomplished by hand washing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 14 of 15 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 676430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashton Medical Lodge 801 South Loop 250 West Midland, TX 79703 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Policy: Hand washing is required before and after a procedure that involves direct or indirect contact with a resident, after contact with any wastes or contaminated materials, before handling any food or food receptacle, or at any time the hands are soiled. Procedure: dry hands from the fingers towards the forearm with a clean paper towel. Turn the faucet hands off using the paper towels. Review of the facility's competency checklist on Hand Hygiene Competency Validation - Return Demonstration, dated 5/9/20, revealed: Handwashing using soap and water: Use paper towel to shut off sink. Review of the In-Service Training Report, dated 7/15/22, documented: wash hands often to prevent spread of infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 15 of 15