Inspection·December 6, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for one of three (Resident #1) residents whose MDS records were reviewed for accuracy in that: Resident #1's care plan did not reflect that the resident had pneumonia. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #1's face sheet dated 12/06/2023 revealed a 72- year- old female admitted to the facility on [DATE] with a re admit date of 11/26/2023 with diagnoses that included heart failure, chronic obstructive pulmonary (diseases that cause airflow blockage and breathing-related problems), and type 2 diabetes. Review of Resident #1's care plan dated revised 12/01/2023 did not indicate that Resident #1 had pneumonia. Review of Resident #1 quarterly MDS completed 11/30/2023 indicated a BIMS score of 15 which indicated the resident was cognitively intact. Review of the nursing notes dated 12/02/2023 authored by LVN C revealed Received CXR results Impression shows mild pulmonary infiltrate in the lateral right lung base, significantly decreased as compared to the previous examination and a small right pleural effusion is unchanged. Findings are consistent with pneumonia versus CHF. NP notified and n/o given via phone to start resident on Zithromax 500 mg 1 po on first day, then 250 mg 1 po on day 2-5, Continue Prednisone 10 mg 1 po x7 more days and Tessalon [NAME] 200 mg TID x7 more days. Resident is own RP and is aware of n/o Review of Nursing notes dated 10/22/2023 authored by LVN D revealed Continues with ABT for TX of Pneumonia. Resident continues with moist sounding, non-productive cough. Encouraged to limit fluids D/T fluid restriction for resident's CHF Interview on 12/06/2023 at 3:21PM with Nurse practitioner revealed she completed the X ray on Resident #1 as a follow due to Resident #1 having recurrent pneumonia. The Nurse Practitioner stated she began treating Resident #1 for pneumonia a few weeks ago however she did not specify a date and it does get better however due to the resident having poor lung function the pneumonia would come back. Interview on 12/06/2023 at 3:45 PM with the Director of Nursing revealed she was not sure why the care plan did not contain information regarding Resident #1 having pneumonia. The Director of Nursing stated the care plan should have been updated to include the pneumonia when Resident #1 was first diagnosed. The Director of Nursing stated the MDS coordinator was responsible for ensuring the care plan was updated upon change in condition. The MDS Coordinator was not interviewed. The Director of Nursing stated the risk of not updating the care plan upon change in condition would be staff would not have the most updated information regarding the care the resident received. Review of the facility policy Care plans undated revealed The resident's care plan will be reviewed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455573 If continuation sheet Page 2 of 4 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 455573 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Texoma Healthcare Center 1000 Hwy 82 E Sherman, TX 75090 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455573 If continuation sheet Page 3 of 4 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 455573 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Texoma Healthcare Center 1000 Hwy 82 E Sherman, TX 75090 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 observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments of two medication carts (Med cart #1 and Med cart #2 ) reviewed for storage, in that: The facility failed to ensure Med cart #1 and Med cart#2 was locked when left unattended. This deficient practice could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations. Findings include: Observation and interview on 12/06/2023 at 11:40AM the Charge Nurse left Med Cart #1 unlocked while she entered to resident room to pass medication. Med Cart #1 was visible unlocked and all routine medications for the hall were accessible. Interview with the Charge Nurse revealed the medication cart should have been locked while she was away from the cart. The Charge Nurse stated the risk of leaving the medication cart unlocked would be that staff or residents would have access to the medication. Observation and Interview on 12/06/2023 at 12:00PM Med Tech A left the Med cart #2 unlocked and unattended while he went into a resident room. The medication cart was visibly unlocked and all routine medication for the hall was accessible. Med Tech A stated he would typically lock his cart when it was not in sight however, he got sidetracked. Med Tech A stated the risk leaving the medication cart unlocked would be staff or residents would have access to the medication. Interview on 12/06/2023 at 3:30PM with the Director of Nursing revealed the medication carts should be locked when not in use during medication pass. She stated the risk of leaving the medication carts unlocked would be staff or residents would have access to the medication. Review of the facility policy Medication carts undated revealed, The carts are to be locked when not in use or under the direct supervision of the designated nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455573 If continuation sheet Page 4 of 4