Inspection·November 13, 2024

F 0580 ADLs and he coughed or choked during meals. Level of Harm - Minimal harm or potential for actual harm Record Review of Resident #1's Care Plan dated 11/1/24 showed resident had a pressure ulcer or potential for a pressure ulcer development. Also, Resident #1 required antidepressant medication and had a communication problem. Furthermore, Resident #1 had an ADL Self Care Performance Deficit. Residents Affected - Few Record Review of Resident #1's Nursing Progress Notes revealed RN-A documented on 11/8/24 at 5:13 p.m. that on 11/8/24 at 4:55 p.m. she Noted resident somulent [sic], not arousing to voice and minimally responsive to tactile stimuli . Phone call to Dr [physician's name] who agrees to 911 to hospital for evaluation of change of condition. Verbal report given to 911 paramedics at 1705 [5:05 p.m.]. Interview on 11/13/24 at 12:17 p.m. with Resident #1's RR, she stated she was not informed by the facility Resident #1 went to the hospital until Monday, 11/11/24 by email. RR stated the hospital had contacted her and let her know Resident #1 was in the hospital. She stated Resident #1 was still in the hospital and was not doing well. She said her father was put on a ventilator, his sodium and blood sugar levels were off and he had an elevated white blood count. The RR stated the hospital asked her to sign a Do Not Resuscitate Order because they did not feel Resident #1 would make it. Interview on 11/13/24 at 2:41 p.m. with RN-A stated Resident #1 was somnolent (drowsy or inclined to sleep), had a lack of response on 11/8/24. She assessed Resident #1 by checking his vital signs and she called the doctor. She stated the doctor agreed to call 911. RN-A stated Resident #1 had lunch with his needed assistance due to cognitive problems and a risk of aspiration. She stated a CNA had fed Resident #1 lunch. RN-A said Resident #1 was his usual self-prior to her finding him somnolent. RN-A stated she was responsible for notifying the family. She did usually contact the family to let them know a resident had been sent out. She would call the family by phone and leave a voice mail asking for a call back if they did not answer. However, she stated she did not contact the family regarding Resident #1 being sent out to the hospital. RN-A it was the end of her shift on a Friday, she was tired, hungry, needed to go to the bathroom and just simply forgot to notify the family. She was off Saturday and Sunday but returned on Monday and found out someone had emailed the family. RN-A said they do abuse/neglect training at least once a month. Interview on 11/13/24 at 2:52 p.m. with CNA-B stated they did abuse/neglect training once a month. She stated if a resident had a change of condition, she would report it to the charge nurse right away. Interview on 11/13/24 at 2:56 p.m. with CNA-C stated they did abuse/neglect training at least once a month or more. She would report to the head nurse if a resident had a change in condition. Interview on 11/13/24 at 4:26 p.m. with ADON-D stated Resident #1 was discharged to the hospital on [DATE]. Resident #1 was somnolent, had respiratory issues and was admitted to the hospital. The family was not notified by the facility, but they should have been that day. The hospital notified RR that Resident #1 was admitted to the hospital. ADON-D said the facility normally notified family if a resident went to the hospital. ADON stated the resident could have passed without the family knowing due the facility not notifying the family he was sent to the hospital non-responsive. Record Review of the facility's Abuse/Neglect Policy, undated stated The facility will provide and ensure the promotion and protection of resident rights. Record Review of the facility's Family Notification Policy under Social Services Manual dated 2003, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455573 If continuation sheet Page 2 of 3 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 11/13/2024 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 0580 revealed: Level of Harm - Minimal harm or potential for actual harm Objectives: 1. To keep families informed. Residents Affected - Few Procedures: 1. The family will be notified of any resident change, i.e., . 2.Health problem . 2. Each resident, and/or family representative is asked to give a list of family members who can be contacted in a case of emergency or urgency. 3. Notification will occur in a timely manner 4. All current family names, telephone numbers, and locations for notification purposes will be kept in the residents' chart. Record Review of the facility's Resident Rights Policy, undated, under Planning and implementing care revealed The resident has the right to be informed of, and participate in, his or her treatment, including .The right to be informed, in advance, of changes to the plan of care. Also, under Information and Communication Notification of changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative (s), when there is- .A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment);. Record Review of the facility's Nursing Policy & Procedure Manual effective 12/2017 revised 4/10/2024, under Discharge or Transfer to another Facility and under subtitle Emergency Transfer revealed When a resident is temporarily transferred on an emergency basis to an acute care facility, this type of transfer is considered to be a facility-initiated transfer and a notice of transfer will be provided to the resident and the resident representative as soon as practicable. Record Review of the facility's SBAR (Situation, Background, Assessment and Recommendation) Policy, undated revealed the facility is to Notify the family of all new orders and changes in condition and document notification. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455573 If continuation sheet Page 3 of 3