Health inspection·February 6, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few out of the privacy bag when it was placed inside the clear plastic bag, but that it did not bothered her because that's how she was able to see how much urine there was inside the bag and determine if she needed to drain it. In an interview on 02/05/25 at 03:00 PM LVN H said that the expectation was for the nephrostomy bags to always be inside a privacy bag. She said not having a nephrostomy bag inside the privacy bag could result in a resident feeling ashamed and there was a probability of making the resident feel like their right to privacy was being violated. LVN H stated that it was also to protect other residents who might not want to see Resident# 45's bodily fluids. LVN H said nephrostomy bags needed to always be inside a privacy bag. In an interview on 02/05/25 at 03:14 PM with CNA I she stated the nephrostomy bag needs to be inside the privacy bag so that no outsiders can see the urine and to provide privacy and dignity to the resident as well as to their roommate. CNA I stated that not having a nephrostomy bag inside of a privacy bag could result in making the resident feel ashamed or that their privacy was not being respected. CNA I said that there was also a risk if the bag was not in the privacy bag it could tear and have spills which could potentially be carried by other staff into other rooms and infect other residents if that resident had some kind of infection. In an interview on 02/06/25 at 09:22 AM with the DON, she said the nephrostomy bag or any bag with bodily fluids should be covered for privacy and for infection control purposes. The DON said the risk of having a bag exposed was possibly violating Resident #45's rights and her privacy. She stated the resident could have feelings of shame and psychosocial issues. DON said if the bag was altered in any other way there would be a possibility of having those fluids spill and contaminate other areas. In an interview on 02/06/25 at 09:42 AM with the Administrator, he stated that the purpose of a privacy bag is to promote dignity and privacy for the residents. He stated that if a bag with bodily fluids is exposed and not inside a privacy bag, it could result in dignity issues or violations of a resident's rights. Record Review of the undated facility's policy titled Catheter Care reflected it did not address the necessity of the foley bag being placed into a privacy bag. The Administrator and the DON stated on 02/06/25 at 11:00 AM the facility did not have a policy addressing privacy bags . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 2 of 20 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 02/06/2025 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents were provided services with reasonable accommodation of needs and preferences for 2 (Resident #20, Resident #38) of 8 residents. Residents Affected - Few Resident call lights were not kept within reach for Resident #20 and Resident #38 This failure places residents at risk of having needs unmet when they are unable to contact staff. Findings included: Resident #20 Record review of Resident #20's face sheet dated 02/04/25 revealed he was admitted on [DATE]. Record review of Resident #20's history and physical dated 01/26/24 revealed he was an [AGE] year-old male diagnosed with generalized muscle weakness, difficulty in walking, abnormalities with mobility and lack of coordination. Record review of Resident #20's MDS revealed he had a BIMS score of 3 indicating severe cognitive impairment. Review of Resident #20's Functional Abilities revealed he required moderate assistance with oral hygiene and upper body dressing as well as maximal assistance with toileting hygiene, shower, lower body dressing, putting on or taking off footwear and personal hygiene. Record review of Resident #20's care plan reviewed on 12/12/24 revealed Resident # 20 was at risk for falls due to new environment and/or age and stated the resident's call light needed to be within reach and for staff to encourage the resident to use it for assistance as needed. It stated the resident needed a prompt response to all requests for assistance. Resident #38 Record review of Resident #38's face sheet dated 02/04/25 revealed he was admitted on [DATE]. Record review of Resident #38's history and physical revealed he was a [AGE] year-old male diagnosed with cerebral palsy (a group of disorders that affect movement and muscle tone or posture), unspecified lack of coordination, generalized muscle weakness, paraplegia (a type of paralysis that affects the lower half of the body.) and quadriplegia (a type of paralysis that affects all four limbs, both arms, and both legs.). Record review of Resident #38's MDS revealed he had a BIMS score of 0 indicating severe cognitive impairment. Review of Resident #38's Functional Abilities revealed he required moderate assistance for feeding as well as maximal assistance with oral hygiene, toileting hygiene, shower, upper and lower body dressing, putting on or taking off footwear and personal hygiene. Record review of Resident #38's care plan reviewed on 12/11/24 revealed that the resident's call light needed to be within reach and for staff to encourage the resident to use it for assistance as needed. It stated the resident needed a prompt response to all requests for assistance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 3 of 20 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 02/06/2025 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an observation on 02/04/25 at 09:05 AM in Resident #20's room, the resident was asleep facing up. His call light was tangled and hanging from his bed rails to his left side about two inches from the floor. In an observation on 02/04/25 at 09:05 AM in Resident #38's room, the resident was lying in bed facing up. Resident# 38 was interviewed and said he used the call light when he needed assistance from the staff. Resident #38 said he would not be able to reach his call light since it was hanging behind his bed out of his reach. Resident # 38 said that when this happened, he would wait until a staff member went into the room to check on him or his roommate to then request for his call light to be placed near him again. Resident # 38 said that sometimes it would take a long time for staff to check on them but was not able to say an approximate period . In an interview on 02/05/25 at 03:00 PM LVN H, she stated call lights needed to be within residents' reach. LVN H explained not having a call light within reach could result in a resident being unable to call for help, and subsequently, not receiving the help they needed. LVN H stated that all staff are responsible for conducting rounds of the residents' rooms to ensure that the call lights are properly placed and within reach. In an interview on 02/05/25 at 03:14 PM with CNA I, she stated she had received training regarding call lights, their use, and placement. CNA I said call lights were supposed to be within reach of every resident so that the residents could request assistance if needed. She said not having a call light within reach could result in the resident not getting help if they needed assistance, or if there was an emergency, they possibly could not contact staff to promptly help them. In an interview on 02/06/25 at 09:36 AM with the DON, she said the call light needed to be within reach of a resident to assist them with their needs and to help them with medications or toileting or whatever they needed help with. The DON said a risk could be that a resident tried doing something on their own, which could result in falls, injuries or staying wet or soiled which could result in issues with their skin integrity. DON said staff was to check for call light placement every two hours and as needed. She said having rounds every two hours helped to detect any call lights that were not within reach. In an interview on 02/06/25 at 09:42 AM with the Administrator, he said the call light being within the reach of a resident is for them to be able to call for assistance when they need it. Not having the call light within reach would delay the resident receiving help. If a resident does not receive assistance in a timely manner the resident could be left soiled and without being changed or if there was an emergency, it could delay the time for them to get assistance. Record review of the facility's policies and procedures, not dated, titled Section C, Call Lights, stated in part: The call light must always be within resident's reach before you leave the room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 4 of 20 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 02/06/2025 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for 1 of 6 residents (Resident #18) reviewed for ADL s. Residents Affected - Few The facility failure to provide nail trimming for Resident #18. This failure placed the resident at risk for injury, infection and decreased quality of life. Findings include: Record review of the Face Sheet for Resident #18 revealed she was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the following diagnoses: Muscular dystrophy (a group of genetic diseases that cause progressive weakness and loss of muscle mass), Type 2 Diabetes Mellitus. Record review of Resident #18's history and physical dated 12/03/24 revealed she is an [AGE] year-old female diagnosed with Muscular Dystrophy with progressive weakness, and Diabetes Mellitus type 2. Record review of Resident #18's care plan dated 02/06/25 revealed the resident is at risk for complications related to having Diabetes Mellitus and staff is to encourage Resident #18 to practice good general health practices including good hygiene. Review of the MDS admission assessment for Resident #18 dated 11/29/24 reflected a BIMS (a cognitive screening tool used to assess a person's orientation and short-term memory with a scoring range of 0-15, where higher scores indicate better cognitive function) score of 10 indicating moderate cognitive impairment. Review of MDS revealed Resident #18 scored a 2 under Personal Hygiene, which indicate the resident is in need of Substantial/Maximal assistance and the helper is to do more than half the effort with assistance. During an observation on 02/04/25 at 02:48 PM, Resident #18 was observed with long nails. Resident #18 stated the facility's staff have not offered to trim her nails. Resident #18 was unable to recall last nail trimming service. Resident #18's right thumb's nail was observed approximately 1/2 inch long. Resident #18's left thumb nail was observed approximately 2 centimeters long. Resident #18's left middle finger, ring finger, and the smallest finger, was observed approximately 2 centimeters long. During an Interview with LVN K on 02/06/25 at 01:04PM, she stated the resident's nail care is provided on the weekends. She stated the CNAs are reminded to provide nail care or grooming for residents via text message. LVN K stated the CNA's are responsible for nail care, unless the resident is diabetic. She stated the nurses will provide nail care for diabetic residents. LVN K stated the nurses are responsible for overseeing the CNA's. She stated activities staff also provide nail painting for residents and if there are concerns, it is brought to the attention of the nurses. LVN K stated, It is also the resident's choice to refuse nail care, but nursing staff is to educate the residents and clean the nails. She stated that Resident #18 does not like to have her nails clipped and refuses but will let the nursing staff clean her nails. LVN K stated Resident #18 is diabetic, so the nurses are responsible for nail trimming. She stated the risks include infection, or resident could scratch (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 5 of 20 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 02/06/2025 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 0677 self or others. Level of Harm - Minimal harm or potential for actual harm In an interview with ADON L on 02/06/25 at 01:19PM, she stated staff is to ask the resident for permission before providing nail care. She stated if the resident is diabetic, nails are to be cut only by a nurse. ADON L stated nursing staff tries to provide nail care regularly. ADON L stated the risks for residents with long nails include scratching self, others including residents or staff, and infection. Residents Affected - Few During an interview with Activity Director on 02/06/25 at 02:21 PM, she stated the activities staff paints residents' nails once a month. The Activity Director stated she will trim the residents' fingernails at that time if the resident is not diabetic. She stated if she has concerns about a resident's nail length, she will notify the nurse. She stated if there are requests for nail care on Saturdays, the Activity Assistant will provide the service. She stated Resident #18 is scheduled for 1-on-1 activities three times a week but refuses activities a lot. She stated the Activity Assistant usually does 1-on-1 with residents. During an interview with Activity Assistant on 02/06/25 at 02:27 PM, she stated she paints the residents' nails monthly, and during her 1-on-1 activities, if requested. She stated that she will get the nurse to cut the resident's nails if they are too long. Activity Assistant stated Resident #18 is scheduled for 1-on-1. Activity Assistant stated Resident #18 does not really want to do anything regarding her nails. She also stated Resident #18 was offered nail care approximately 1 month ago. The Activity Assistant stated the risks for the resident include bacteria can get underneath the nails. During an interview with DON on 02/06/25 at 02:55 PM, she stated CNA's trim or file down residents' nails once a week or as needed. She stateds Sundays are Nail Day, and CNA's offer nail care or other grooming to residents every Sunday. She stated the risk of residents having untrimmed nails included ripping of the nail, infection control as dirt can go underneath the nail. DON stated diabetic residents are at higher risk if nails are not cut or trimmed properly. Record Review of facility's policy Nail Care-Fingernails and Toenails with no date, read in part: Purpose 1. To promote cleanliness 2. To prevent injury 3. To prevent infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 6 of 20 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 02/06/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 (Resident #45) of 8 residents reviewed. Resident #45's urinary catheter nephrostomy bag bag was not placed below the bladder. This deficient practice could place the residents at risk of urinary tract infections. Findings include: Record review of Residents # 45's face sheet dated 02/05/2025 revealed she was admitted on [DATE] and readmitted on [DATE]. Record review of Resident # 45's history and physical dated 07/24/2024 revealed a 75-years-old-female diagnosed with other mechanical complication of other urinary devices and implants, pain due to genitourinary prosthetic devices (medical implants designed to restore or improve the function of the urinary system), hydronephrosis (a condition that occurs when urine backs up into the kidney), acute kidney failure with tubular necrosis (a type of kidney injury that occurs when the cells lining the tubules of the kidneys are damaged or destroyed), obstructive and reflux uropathy (conditions that affect the urinary tract). Record review of Resident # 45's quarterly MDS dated [DATE] revealed she had a BIMS of 9 indicating she was moderately cognitively impaired. Record review of Resident # 45's care plan reviewed on 11/01/2024 revealed she had an indwelling catheter related to acute pyelonephritis (a kidney infection that is usually caused by bacteria. It is a type or urinary tract infection that starts in the bladder and then spreads to the kidneys). During an observation and interview on 02/04/25 at 09:45 AM, Resident # 45 was laying in bed to her left side. A nephrostomy bag (a sterile disposable bag used to collect urine that is drained from the kidney through a tube) was on top of the bed sheets beside the resident. The bag was placed inside a clear plastic bag. Urine was noticed inside the bag and in the tubing. Resident #45 stated she liked the bag beside her because it was easier for her to reposition in bed and when transferring to her wheelchair. Resident #45 stated she had been educated of the risks for having the bag above the bladder but that it was her preference to have it next to her so she could see the amount of urine in the bag and that way she could drain the urine or request assistance to drain it. In an interview on 02/05/25 at 03:00 PM with LVN H, she stated that nephrostomy bags needed to be placed hanging from the bed frame below the resident's bladder or kidneys so that they could properly drain. LVN H stated the resident had been instructed on the risks of having the nephrostomy bag on her bed. LVN H said she did not remember if a care plan had been created regarding education being provided for Resident #45. She said risks discussed with the resident included the bag not draining properly and the risk of infection. LVN H mentioned Resident #45 sees a nephrologist and had been told they would remove the bags, but LVN H said she did not know when the bags would be removed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 7 of 20 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 02/06/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 02/05/25 at 03:14 PM CNA I stated the nephrostomy bags are supposed to be hanging on the side of the bed below the waist. CNA I said that the purpose of the bag placed below the bladder or kidneys of a resident was for urine to drain properly. CNA I said the risk of not hanging a nephrostomy bag below a resident as it's supposed to be placed, was that the cord could get wrapped around the resident and tug the nephrostomy tube or bag, causing pain or discomfort to the resident or the bag could tear spilling its contents. CNA I said there could be a risk of a Urinary Tract Infection (an infection that affects parts of the kidneys or urethra). In an interview on 02/06/25 at 09:22 AM with the DON she stated the nephrostomy bag should always be positioned lower than the bladder so it can properly drain, and it does not backflow. The DON stated if it did not drain properly the Resident could be susceptible to infection and UTIs and other complications with infections. DON said if the urine back flowed, it would also pose a risk for UTI . The DON said Resident #45 liked to manage her nephrostomy bag and place it on her side. The DON stated that Resident #45 was aware the bag needed to be below the bladder. The DON said that Resident #45 had expressed to the facility that she knew what she was doing and that she knew how to take care of herself. The DON expressed Resident #45 could get upset when placement of the nephrostomy bag was discussed with her. The DON informed that Resident #45 had received education on placement of her nephrostomy bag. The DON said she believed a conversation should happen between the facility and Resident #45's nephrologist regarding the removal of the nephrostomy bags, but to her knowledge that had not been done. In an interview on 02/06/25 at 09:42 AM with the Administrator, he stated the nephrostomy bag should be placed below the resident's waist so that it can properly drain and to avoid infections and for the urine to backflow. He stated that the risk of placing the bag at the same level as Resident #45, could put her at risk of infection. The Administrator stated that some residents signed an informed consent form where they are informed about the risks of refusing treatment and said he would look to see if Resident #45 had signed one for having her bag at bladder level. In an interview on 02/06/25 at 11:00 AM with the DON and Administrator revealed the care plan for Resident #45 stated the facility would monitor the resident for nephrostomy bag placement but did not note encouragement or interventions to relocate the nephrostomy bag below the bladder or kidneys. The DON and Administrator stated Resident #45 did not have a signed informed consent form mentioning that Resident #45 had received education on the risks for not placing the nephrostomy bag below the kidney/bladder level and denoting her refusal for proper treatment. The DON and the Administrator confirmed that the facility lacked a policy addressing Foley catheter and nephrostomy bag placement on 02/06/2025 at 11:00 AM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 8 of 20 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 02/06/2025 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment to prevent complications for 1 of 1 residents (Resident #83) reviewed who received their feeding through a percutaneous endoscopic gastrostomy (PEG) feeding tube. The facility failed to ensure CNA C and CNA E did not lower the head of the bed flat while the PEG (A PEG tube is a thin, flexible tube inserted through the abdominal wall and into the stomach. It is used to provide nutrition and medications to patients who cannot eat or drink normally) pump was still infusing the formula, during personal care performed for Resident #83. This failure could affect residents with PEG tubes and could result in unwanted outcomes such as aspiration pneumonia. The findings: Record review of Resident #83's admission record dated 02/06/25 indicated she was admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing) and dementia. She was [AGE] years of age. Review of Resident #83's quarterly MDS dated [DATE] indicated in part: Cognitive Skills for Daily Decision Making = severely impaired. Always incontinent of both bladder and bowel. Nutrition approach - feeding tube. Record review of Resident #83's Physicians Orders dated 02/06/2025 documented in part: Enteral Feed Order every shift G-TUBE- via g-tube and pump. Head of bed elevated 30-45 degrees at all times. During an observation on 02/04/25 at 12:21 PM CNA C and CNA E performed incontinent care for Resident #83. Both CNAs entered the room, washed their hands and then donned PPE. CNA C then lowered the head of the bed flat while the PEG pump was still flowing or infusing the formula. The CNAs performed all the incontinent care while the resident was flat and the pump was on the on position. There was no observation of the resident aspirating during the entire care process. During an interview on 02/04/25 at 03:32 PM CNA C said as far as she knew they never paused or touched the PEG pump when they performed incontinent care. The CNA said as far as she knew the nurses knew about them performing incontinent care and they had not paused the pump before. The CNA said she was not aware of an order indicating the HOB should be at 30-45 degrees up at all times. During an interview on 02/06/25 at 03:46 PM the ADON said it was expected for the CNAs to notify the nurse to pause the PEG pump before they performed incontinent care as they had to lay the head of the bed flat. The ADON was made aware of the observation of the incontinent care performed with the pump on the on position and the head of the resident's bed being flat. The ADON said if the CNAs left the pump on, and the resident's bed was totally flat then it could lead to aspiration pneumonia. The ADON said the failure occurred because the CNAs failed to notify the nurse to pause the pump. During an interview on 02/06/25 at 04:12 PM the DON said it was expected for the nurses to pause the PEG pump whenever the CNAs performed incontinent care on the residents. The DON said it was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 9 of 20 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 02/06/2025 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few expected for the HOB to be elevated to at least 30 degrees when the PEG pump was on. The DON said if the HOB was lowered with the PEG pump that could lead to the resident aspirating. The DON said she believed the failure occurred because the CNAs failed to notify the nurse to pause the pump and that they would be conducting more training. During an interview on 02/06/25 at 04:09 PM the Administrator was made aware of the observation of the CNA lowering the HOB flat during incontinent care and the PEG pump being on. The Administrator acknowledged it was an issue. Record review of the undated document titled Tube medication administration indicated in part: Leave head of bed elevated as ordered with call light accessible. This prevents aspiration of stomach contents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 10 of 20 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 02/06/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure that a resident who neededs respiratory care was provided such care, consistent with professional standards of practice for 1 (Resident #29) of 17 residents observed for oxygen management. Residents Affected - Few - The facility failed to ensure Resident #29's oxygen tank was not empty behind her wheelchair while she was in the dining area. These failures could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health. Findings included: Resident 29 Record review of Resident #29's face sheet dated 02/06/25, revealed an, admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #29's medical diagnoses dated 02/06/25, revealed, an [AGE] year-old female diagnosed with history of pneumonia unspecified organism and , chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs). Record review of Resident #29's MDS dated [DATE], revealed BIMS score of 15. Indicating that the resident has intact cognition and is likely to fuction normally and may need the least amount of support from staff. Record review of Resident #29''s orders dated 01/11/25, revealed, OXYGEN -- CONTINUOUSLY = Oxygen at 3 Liters per min via nasal cannula continuously. Check every shift. Check oxygen saturation every shift and keep oxygen saturation at or greater than 92%. Record oxygen saturation every shift. Record review of Resident #29's care plan dated 01/15/25, revealed, the resident has oxygen therapy as needed to keep saturations above 92%. An observation on 02/04/25 at 12:30 PM revealed resident having lunch in dining area, oxygen tank behind her chair was on empty. The State Surveyor brought this to a Medication Aide F's attention, and she went to retrieve another tank, and she also let the residents assigned nurse (LVN G) know. Medication Aide F changed the tank, and nasal cannula. LVN G measured oxygen saturation using a pulse oximeter. The oxygen saturation was at 90%. In an interview with Medication Aide F on 02/06/25 at 01:12 PM revealed that the protocol that she was trained to follow was to get the nurse to change oxygen because it was a medication. She stated that it was the responsibility of anyone who noticed the oxygen tank to be running low or to be empty to report it to the nurse to change the tank. She stated that the risk of residents having an empty oxygen tank was the residents could run low on oxygen and it could lead to trouble breathing. In an interview with LVN G on 02/06/25 at 01:16 PM revealed that all residents with oxygen tanks and concentrators were rounded on every morning and mid- day before going out to lunch. She stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 11 of 20 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 02/06/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm that Resident #29 was alert and oriented and she was usually the one who lets the staff know when her oxygen tank [NAME] running low. LVN G stated that she usually rounds on everyone in the morning and before lunch time. But, this resident was independent enough to wheel herself out of the room and into the dining area, that she wheeled her self to the dining area before she could verify that the tank was full . The risk of the resident running out of oxy gen was that it could lead to hypoxia. Residents Affected - Few In an interview with the DON on 02/06/25 at 02:48 PM revealed that oxygen tank rounds should be done in the dining room by nursing staff including CNA's and nurses. She stated and there was no set time for nurses to round on the oxygen tanks. All direct care staff were were required to monitor residents every 2 hours. The risks to residents that were not being properly oxygenated are desaturating, and hypoxia. She stated that residents have their oxygen for a purpose. In an interview with facility administrator on 02/06/25 at 04:35 PM revealed that residents should be checked if taken to the dining room, that particular resident makes their needs known. The resident will let the nurse know that oxygen was running low. The risk of the resident running out of oxygen was that it could cause harm by ineffective breathing. Record Review of the facility's oxygen policy and procedure provided titled Administration of Oxygen and Administration of Cannula, not dated, revealed no specific policy on rounding and checking oxygen tanks. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 12 of 20 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 02/06/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observations, interviews, and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents, for 1 (Hall 5 nurse cart) of 4 medication carts inspected for medication reconciliation. RN A did not document the administration of a controlled medication (Tramadol) on the individual controlled medication records after she had administered the medication on 02/04/2025. This failure could place residents at risk of under dose, overdose, and drug diversion. The findings were: During an observation on 02/04/25 at 10:46 AM the medication cart for hall 500 was inspected with RN A present. The controlled medication drawer was checked, and the medications were compared with their corresponding medication sheet. Two of the medication packets were found to be off by 1 number. The medication was Tramadol 50mg, the medication packet contained 20 pills, and the corresponding count sheet indicated 21 pills left in the packet. The second medication was Tramadol 50mg, and the packet contained 11 pills, and the corresponding count sheet indicated 12 pills left in the packet. During an interview on 02/04/25 at 10:54 AM RN A said that she usually signed the controlled medication sheets after she administered the medication and not after she poured the medication. RN A said as far as she knew this was okay to sign the medication afterwards or even at shift change. During an interview on 02/06/25 at 03:42 PM the ADON said it was expected for the nurses to sign out any controlled medications as soon as they administered them. The ADON said this was best practice and it was expected to be done to keep an accurate count of the controlled medications. The ADON said if for some reason the nurse had to leave immediately then this could lead to the count being off. The ADON said they had done training on signing out the controlled medications and they would do reminders for staff to sign out the medications. During an interview on 02/06/25 at 04:06 PM the DON said it was expected for the nurses to keep the control medication binder up to date such as the controlled medication count. The DON said there wasn't an exact expectation on when to document the count. The DON said it was best practice to document the controlled medication was administered, as soon as they administered the medication to keep an accurate count. During an interview on 02/06/25 at 04:07 PM the Administrator was made aware the controlled medication record was not correct when reconciled with the corresponding blister pack. The Administrator acknowledged it was an issue. Record review of the undated document titled Narcotic count indicated in part: The nurse (CMA) counting the pills will call out to the nurse (CMA) reading the narcotic count sheet how many pills are on hand. The nurse (CMA) reading the narcotic count sheet will confirm the number of pills, after the last recorded dose was given, matches the number of narcotics on hand. Any discrepancy will immediately be reported to the charge nurse and/or ADON, who will attempt to reconcile the discrepancy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 13 of 20 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 02/06/2025 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. Based on observations, interviews, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts (Hall 500 Nurse Med Cart) reviewed for medication storage. The facility failed to ensure the Hall 500 Nurse Medication Cart contained an insulin pen with an open date. This failure could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings included: During an observation on 02/04/25 at 10:46 AM the medication cart for hall 500 was inspected with RN A present. On the top drawer were several insulin pens. One of the insulin pens had been opened but there was no open date observed on the pen. During an interview on 02/04/25 at 10:55 AM RN A said that she was not sure why the insulin pen did not have an open date on it. The RN said she usually dated it when she opened it, the RN disposed of the insulin pen. The RN said she had disposed of the pen because now they would not be able to tell when it would expire as they were only good for 28 days. During an interview on 02/06/25 at 03:44 PM the ADON said it was expected for the nurses to label and write an open date on the insulin pens when opened. The ADON said the pens had to be dated when opened so they could tell when it had been 28 days since most insulin pens would expire. The ADON said if the insulin pen was used after it had expired it could not be as effective. The ADON said it was expected for the nurses to know when to dispose of expired insulin pens and they conducted training on monitoring their (nurses) carts. During an interview on 02/06/25 at 04:08 PM the DON said it was expected for the nurses to document an open date on the insulin pen when opened. The DON said it was supposed to be dated so that the nurse would know when the medication was expired as they usually only lasted 28 days. The DON said the failure occurred because whoever opened the insulin pen failed to document when it was opened. The DON said they checked the carts at least once a week for expired medications but not necessarily done weekly. During an interview on 02/06/25 at 04:09 PM the Administrator was made aware of the insulin pen not having an open date when opened. The Administrator acknowledged it was an issue. Record review of the undated document titled Administration of insulin did not indicate anything regarding dating of insulin. This was the only policy/document provided by the facility. Review of the undated insulin pen container indicated Discard unused portion 28 days after first opening. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 14 of 20 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 02/06/2025 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 3 diet test trays reviewed for food temperatures. Residents Affected - Few -The facility failed to maintain hot food on the served test trays. -This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. The findings included: Interviews with residents during initial rounds on 02/04/25 revealed 6 out of 20 residents complained of food being cold when served in their rooms. An observation on 02/05/25 at 5:45 PM revealed sample trays transported in open rolling cart because they did not fit in the insulated cart. One tray for a resident was observed to be placed on top of the insulated cart, due to it not fitting in the cart. Trays for the hall and sample trays all exited the kitchen at 5:53 PM and were taken to hall 500, all trays served to residents. Sample trays then transported to the conference room. Sampling of the test trays on 02/05/25 at 6:05 PM in the conference room, with the Dietary Director revealed: The Regular Diet Tray: Cheese ravioli with meat sauce was 122.2 degrees Fahrenheit. Mixed vegetables were 143.9 degrees Fahrenheit and bread roll was 100 degrees Fahrenheit. The Mechanical Diet Tray: Ravioli with meat sauce was 90 degrees Fahrenheit, mixed veggies were 100 degrees Fahrenheit, and bread roll was 98 degrees Fahrenheit. The Pureed Diet Tray: Ravioli with meat sauce was 95 degrees Fahrenheit, mixed vegetables were 90 degrees Fahrenheit, and bread was 80 degrees Fahrenheit. An interview with Dietary Director on 02/06/25 at 12:56 PM revealed the test tray temperatures were below temperature. , food should be at a temperature of 135 degrees Fahrenheit. She stated that the service cart was used because it was an extra insulated cart, and it would help keep temperatures at an adequate number. The risk of cold food served to residents included food borne illnesses from improper temperature foods. She also stated that food will not be as palatable for residents because the warmth keeps the aroma and makes the food enticing . An interview with the Administrator on 02/06/25 at 04:30 PM revealed that he noticed that sample trays were not in the insulated tray cart. He stated that there was an extra insulated cart in the kitchen, and he did not know why the Dietary Director did not use that one. He stated that it is all of the kitchen staffs responsibility to ensure food is kept warm. The risks of residents being served cold food could be the residents getting sick due to food borne illnesses and the food was not as palatable when it was cold . Review of grievances on 02/06/2025 at 09:00 AM revealed no grievances filed regarding kitchen food temperatures. Review of the facility's policy and procedure on Safe Food Temperatures dated 11/15/24 revealed in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 15 of 20 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 02/06/2025 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete part, Food temperatures will be maintained at acceptable levels during food storage, preparation, holding, service, delivery, cooling, and reheating. The time that food is in the temperature danger zone (41° to 135°) throughout the food handling process is minimized to no more than 4 hours. Food is cooked to at least 135° F or to its minimum safe internal cooking temperature (whichever is higher). Foods can be cooked to higher temps if the quality is not sacrificed. All previously cooked food is reheated to an internal temperature of at least 165° F for at least 15 seconds. This temperature is achieved within 2 hours of cooking. Foods are reheated only once. Hot foods are held at 135° F or higher during meal service (on the trayline). Event ID: Facility ID: 676430 If continuation sheet Page 16 of 20 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 02/06/2025 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 Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and food storage. -The facility failed to keep a plastic bottle of barbeque sauce free of dried drippings around sides of the bottle. -The facility failed to keep spice bottles completely sealed. These failures could place residents at risk of food borne illnesses. Findings included: Observation on 02/04/2025 at 09:05, with the Dietary Manager during the initial tour in the kitchen, revealed the following:, The food preparation area by the food warmer revealed: -16 plastic bottles of spices stored on metal shelves directly above the food preparation area of which 5 spice bottles had opened tops. The refrigerator revealed the following: -A plastic bottle of barbecue sauce had dry dripping running down the side of the neck of the bottle. Interview with the Dietary Director on 02/06/25 at 12:56 PM revealed that staff were trained to close all containers after using each one. She stated that staff were trained to wipe containers and bottles after each use and reclose them to prevent dust and other particles from getting into the containers. She stated that bugs could get in unsealed bottles and containers causing contamination of spices and condiments. Regarding the open container of barbecue sauce, the Dietary Director stated, staff were trained to wipe containers before sealing them. She stated that she had reexplained the importance of cleaning them after use and keeping them clean. She stated having dirty bottles looked unsightly and can lead to contamination and that can lead to foodborne illnesses for the residents. Record Review of the facility''s policy and procedure on Cleaning the Refrigerators and Freezers Section: Sanitation -- revised 10/21/2024, reflected, Policy: Refrigerators and freezers will be maintained in a clean, sanitary condition and will be free from spills, food particles and odors to prevent cross contamination and food borne illness. Procedure: Refrigerator (daily): Check that all foods are properly covered, labeled, and dated. Straighten refrigerator inventory, placing older inventory to front of shelves. Wipe down all exterior surfaces with a solution of warm water and an all-purpose cleaner. Wipe dry with a clean cloth. Clean rubber wheels if applicable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 17 of 20 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 02/06/2025 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 Record review of the facility's policy and procedure on Food Safety in Receiving and Storage Section: Sanitation revised on 10/21/24, reflected in part, Policy: Food will be received and stored by methods to minimize contamination and bacterial growth. Procedure: Dry Storage Guidelines reads in part, Clean exterior surfaces of food containers such as cans or jars of visible soil before opening Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 18 of 20 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 02/06/2025 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 Based on observations, interviews and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for the residents during lunch service observation. Residents Affected - Some -The Director of Rehabilitation did not don gloves or properly disinfect resident's bodily fluids observed on the floor of the main dining room. This failure could place the residents at risk for communicable diseases or viruses. The findings included: In an observation on 02/04/25 at 12:28 PM, a resident was observed spitting on the floor and the facility's Director of Rehabilitation moved the resident to another table. He was then observed using a paper towel without gloves to wipe a resident's spit on the floor next to the dining room table with other residents present and eating their lunch. The Director of Rehab was observed cleaning the area with new paper towels and without gloves. He was observed using the same paper towel to pick up a dirty napkin from the same dining room table with the other residents present and eating their lunch. No disinfectant used during observation. During an interview with LVN K on 02/06/25 at 12:28 PM, she stated in instances for spills or liquids observed on the floor, the nursing staff was to put up a sign. LVN K stated housekeeping staff were notified so they could clean and disinfect spills. LVN stated the risks of not wearing gloves when cleaning bodily fluids included bacteria or viruses which could endanger other residents if the site was not cleaned properly. She stated the responsibility belonged to all staff. During an interview with ADON L on 02/06/25 at 01:22 PM, she stated protocol for bodily fluids observed on the floor would indicate for nursing staff to don gloves, clean fluids with disposable tissue, dispose tissue, and then clean with a disinfectant. ADON L stated if nursing staff were not able to properly clean and disinfect the area, they were to notify housekeeping staff for proper cleaning. ADON L stated that the risk of not donning gloves and disinfecting the area was transmission of communicable disease to the person cleaning and other residents around the area. In an interview with the Housekeeper on 02/06/25 at 02:42 PM, she stated for bodily fluids observed on the floor would indicate cleaning the area with gloves on and then disinfecting the area. She stated they were trained to wait for the kill time as indicated on the disinfectant, and then housekeeping staff would mop the area. She stated they use a new mophead to clean bodily fluids, which will be bagged and placed in the laundry room, so the mophead was not used for any other reason. She stated the risks included the spread of hepatitis b, or other viruses if the area was not disinfected. In an interview with the DON on 02/06/25 at 02:52 PM, she stated staff were to wear gloves and clean bodily fluids such as saliva, with paper towels and notify housekeeping staff since they have the required chemicals to disinfect the area. She stated the risk was an infection control issue as saliva or bodily fluids can spread infection, or communicable diseases or viruses. The DON stated all staff were to wear gloves when in contact with bodily fluids. In an interview with the Director of Rehabilitation on 02/06/25 at 03:55 PM, he stated the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 19 of 20 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 02/06/2025 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 staff were to use gloves and disinfectant when in contact with bodily fluids. He stated this was to prevent skin contact from person to bodily fluid. He stated the responsibility belonged to all staff if a spill was observed. They were to clean and disinfect the area. The risks included transmission of illness to staff or other residents. The Director of Rehabilitation stated he was made aware of a resident spitting on the floor by a state surveyor and he then moved the resident to another dining room table. The Director of Rehabilitation stated he then cleaned the area without gloves. He stated he used paper towels because he did not think he could use cleaning solutions or disinfectants during the meal service. He stated the cleaning staff cleaneds and disinfecteds the dining room after each meal service. He stated that the risk of bodily fluids on the floor included falls, or transmission of illness. During an interview with the Administrator on 02/06/25 at 04:24 PM, he stated the proper protocol for cleaning of bodily fluids included hand hygiene, and donning PPE in order to prevent the spread of infection. He stated that typically housekeeping staff used chemicals to clean and disinfect areas exposed to bodily fluids. The Administrator stated using paper towels without gloves to clean bodily fluids could pose a risk for infection as the fluid couldan soak through the paper towel and contaminate the skin. The Administrator stated the cleaning chemicals and disinfectant were not to be used during meal service as it could contaminate the food being served. He stated all residents at the affected area should have been moved to another dining room table so housekeeping staff could clean and disinfect the bodily fluids properly to prevent infection or illness. Record Review of the facility's policy Infection Prevention and Control Program not dated, read in part: Employees -Supports resident safety by adhering to all policies and procedures related to infection prevention; Participates in performance improvement activities by promoting enhanced hand hygiene and adherence to respiratory hygiene/cough etiquette. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676430 If continuation sheet Page 20 of 20