Health inspection·December 21, 2023

F 0755 - expired ophthalmic solution, expired 08/23. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #271's admission record dated 12/21/2023 indicated that she was admitted to the facility on [DATE] with diagnoses which included dementia, anxiety, osteoarthritis. She was [AGE] years of age. Residents Affected - Some During an interview on 12/21/23 at 10:35 AM LVN C stated that this is her cart today and all nurses and medication aides were responsible for checking their medication carts daily to ensure there were no expired medication, loose pills and carts were clean and stocked. LVN C stated that the DON checked them occasionally. During an interview on 12/21/23 at 11:35 AM the DON stated she had assigned LVN B to check all carts on every hall to ensure that carts were locked, were clean, had no expired medications and definitely no loose pills. LVN B stated that she checked all carts and failed to find any expired or loose pills. During an interview on 12/21/23 at 2:52 PM the Administrator stated that his expectation was there should be no loose pills and no expired medications. The Administrator stated that staff should be cleaning their medication carts to decrease risk to residents. During an interview on 12/21/23 at 4:40 PM the Corporate Consultant Nurse stated that there was no policy in place. She stated that all nurses and medication aides received training regarding medication carts as stated in the check off training sheet (see below). Review of the facility's check off training, titled Medication Administration, undated, reflected (in part) that Med cart: no missing supplies or expired supplies, clean, visible and locked. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 2 of 8 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 12/21/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to medications in medication cart 1 of 8 reviewed for label and storage of drugs and biologicals. The facility failed to ensure medication cart #1 was locked when unattended on [DATE]. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings included: During an observation and interview on [DATE] at 9:30AM revealed Medication cart #1 was left unattended and unlocked by LVN B. The Surveyor was observing medication administration with LVN B. LVN B walked away from her medication cart to central supply, leaving her medication cart unlocked and unattended for 7 minutes. LVN B stated that she was not accustomed to passing medications for the entire hall and that she could not be perfect. LVN B stated she was aware that leaving the cart unattended and unlocked poses a risk for drug diversion. During an interview on [DATE] at 10:35 AM LVN C, the Charge nurse, stated that all nurses and medication aides are responsible for checking their medication carts daily to ensure there are no expired medication, loose pills and carts are clean and stocked. LVN C stated that the DON checked them occasionally. During an interview on [DATE] at 11:35 AM the DON stated that her expectation was that all medication carts were locked when unattended. DON stated that she assigned LVN B to check all carts on every hall to ensure that carts were locked. During an interview on [DATE] at 4:40 PM the Corporate Consultant Nurse stated that there was no policy in place for unlocked carts. The Corporate Consultant Nurse stated that all nurses and medication aides received training regarding locking medication carts. During an interview on [DATE] at 2:52 PM the Administrator stated that his expectation was that all medication carts were locked when unattended. The Administrator stated that he was disappointed because he walked through the halls daily and checked the medication carts to ensure they were locked. He stated that staff were aware that an unlocked unattended cart was a risk to residents' safety. Review of the facility's check off training, titled Medication Administration, undated, reflected (in part) that Med cart: no missing supplies or expired supplies, clean, visible and locked. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 3 of 8 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 12/21/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen: Residents Affected - Many The facility failed to label and date food items. The facility failed to maintain cleanliness in the kitchen. The kitchen staff did not practice proper hand hygiene. These failures could place residents who received meals prepared in the kitchen at risk for ingesting food borne pathogens resulting in gastrointestinal discomfort or illness and cross-contamination. Findings include: During an observation on 12/19/23 at 8:10 am during a walk-through inspection of the kitchen accompanied by the Dietary Director revealed the following: There was a large plastic bin with yellow particles in the dry storage room that did not have a label or date, and the cover was open and exposed to air. There were crumbs and other food particles on the shelf above the food preparation table. In an interview on 12/19/23 at 8:48 am with the Dietary Director, the Dietary Director was asked about the open and unlabeled bin in the dry storage room, and she indicated that it was parmesan cheese and that the bin should have been labeled and the cover closed. The Dietary Director also stated that the kitchen staff should have cleaned the shelf above the preparation table. During an observation on 12/19/23 at 12:11 PM of the freezer, revealed there were three rolls of meat, and two packages of brown color food in the shape of round balls, in the freezer that were not labeled or dated. During an observation on 12/19/23 at 12:12 PM revealed [NAME] E was observed changing gloves; however, she did not wash her hands after removing the gloves before putting on new gloves for 5 out of 6 glove changes. In addition, [NAME] E was observed using her gloved hand along with a pair of tongs to pick up meatballs out of the pan on the steam table. During an interview with [NAME] E on 12/19/23 at 12:15 PM, [NAME] E indicated that she needed to wash her hands every time she changed her gloves. During an interview on 12/19/23 at 12:20 PM with the Dietary Director, she indicated that the cooks needed to wash their hands each time after changing gloves and should only be using kitchen utensils for food distribution and not their gloved hands. In addition, the Dietary Director also indicated that all food in the freezer should be labeled with the contents and date. During an interview on 12/20/23 at 3:15 PM with the DON indicated that all kitchen staff had been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 4 of 8 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 12/21/2023 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 0812 trained on hand hygiene and food handling. Level of Harm - Minimal harm or potential for actual harm A record review of undated kitchen policies for checking food temperatures, handling food and hand hygiene, and labeling food products, indicated: Residents Affected - Many Policy 4.41, Subject: Safe Food Temperatures, Section: Sanitation, page 4-62, paragraph on Guidelines for Checking Food Temperature. The guideline required that thermometer is clean and has been sanitized with an appropriate sanitizer and thermometer must be cleaned and sanitized between each product that is tested. Policy 4.03, Subject: Indications for Glove Use, Section: Sanitation, page 4-4. The procedure, step 2, reflected, Hands are washed thoroughly before putting on gloves, when changing into a fresh pair of gloves, and immediately after removing gloves. Step 3 states, Appropriate food service gloves are available at all times in food production and meal service areas. Step 4 indicated that Disposable gloves appropriate for food service are worn when hands come in direct contact with ready-to-eat food or eating surfaces. Step 6 states, Gloves are changed whenever an unsanitized item or surface is touched. Operational Policy pages IX.8 and IX.9: Requires the Dietary Services Supervisor to orient all new dietary employees to the facility policies and procedures and the dietary policies and procedures. In addition, the policy indicated that Food in unlabeled or damaged containers shall not be accepted or retained. Review of FDA Food Code 2022 revealed the following for handwashing: (A) Except as specified in (D) of this section, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a HANDWASHING SINK that is equipped as specified under § 5-202.12 and Subpart 6-301. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 5 of 8 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 12/21/2023 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 0812 (I) After engaging in other activities that contaminate the hands. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 6 of 8 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 12/21/2023 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 1 (Resident #72) of 4 residents reviewed for infection control. Residents Affected - Few The facility failed to ensure RN A washed or sanitized her hands prior to putting gloves on and administering medication to Resident #72. This failure could place resident's risk for cross contamination and the spread of infection. Finding include: Record review of Resident #72's admission record dated 12/21/23 indicated she was admitted to the facility on [DATE] with diagnosis of osteomyelitis (inflammation or swelling that occurs in the bone). She was [AGE] years of age. Record review of Resident #72's order summary report dated 12/21/2023 indicated in part: (Piperacillin Sodium-Tazobactam Sodium in Dextrose) Use 1 dose intravenously four times a day for osteomyelitis until 12/28/2023. (Piperacillin and Tazobactam are antibiotic medications). Record review of Resident #72's care plan dated 12/18/23 indicated in part: Focus: The resident is on antibiotic therapy related to infection. Goal: The resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. Interventions: Piperacillin Sodium-Tazobactam Sodium in Dextrose) Use 1 dose intravenously four times a day for Osteomyelitis. During an observation on 12/19/23 at 10:27 AM revealed RN A entered Resident #72's room to administer some IV medications. After she entered the room RN A put gloves on without first washing or sanitizing her hands. RN A the prepared the antibiotic medication piperacillin and tazobactam which was in a vial. RN A then wiped the PICC line port (PICC line is a thin, soft tube that is inserted into a vein in the arm, leg or neck for long-term IV antibiotics) with an alcohol pad and flushed the port with some sodium chloride and then connected the antibiotic medication to the PICC line. RN A then removed her gloves and did not wash her hands or sanitize her hands and left the room. During an interview on 12/19/23 at 10:38 AM RN A said she forgot to sanitize or wash her hands prior to putting on gloves and administering the medication to Resident #72. RN A said she usually washed or sanitized her hand before putting on and after removing her gloves. RN A said she forgot to sanitize or wash her hands after removing the gloves. RN A said she became nervous and forgot the steps. RN A said if she did not wash or sanitize her hands, she could cause cross contamination or spread germs to other residents. During an interview on 12/21/23 at 3:54 PM the Corporate Consultant Nurse said the expectation was for staff to wash their hands or use alcohol-based hand rub prior to putting on gloves. The Corporate Consultant Nurse said any charge nurse could ensure infection control procedures were followed. The Corporate Consultant Nurse said the Staff Educator was also in charge of doing some of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 7 of 8 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 12/21/2023 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 - Few training. The Corporate Consultant Nurse said if staff did not wash or sanitize their hands they could spread infections. The Corporate Consultant Nurse said the failure probably occurred because the nurse got nervous and forgot the steps. During an interview on 12/21/23 at 4:22 PM the Staff Educator said it was expected for staff to wash or sanitize their hands prior to putting gloves on providing resident care. The Staff Educator was made aware of the resident care provided by RN A and not washing or sanitizing her hands prior to putting gloves on. The Staff Educator said she would have to provide more training and in-services. The Staff Educator said if the staff did not wash or sanitize their hands it could lead to the spread of infections. The Staff Educator said she believed the failure occurred because the nurse got nervous and forgot to wash or sanitize her hands. During an interview on 12/21/23 at 4:32 PM the Administrator said the expectations were for staff to wash their hands prior to performing care. The Administrator said the DON and the Staff Educator were usually the ones in charge of providing the training. The Administrator said if staff did not wash or sanitize their hands it could lead to the spread of infections. The Administrator said the failure probably occurred due to the nurse getting nervous and forgetting to wash or sanitize her hands prior to performing resident care. 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. 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. Record review of the facility's undated document titled Infection prevention and control program indicated in part: This company 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 8 of 8