Inspection·June 28, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 6/28/29 at 10:10 a.m., TNA A said she heard Resident #1 say to TNA B that CNA D was mean to her. TNA A said Resident #1 said CNA D did not like to help her and took the light because she used it too much. TNA A said Resident #1 was not talking to her, she was assisting TNA B and Resident #1 was telling TNA B. She said TNA B said she was going to report the concern. During an interview on 6/28/29 at 10:20 a.m., TNA B said she worked at the facility about 4 months. She said she was aware of what abuse was and who to report it to. TNA B said Resident #1 told her on Monday, 6/19/23, that CNA D snatched her call light and refused to give it back. She said Resident #1 said when CNA D was cleaning her up she told her not to S*** in her face. The resident had diarrhea. TNA B said she reported her concerns to the ADON and the DON and nothing was done. She said CNA D was not suspended and worked the next weekend. TNA B said she knew they had spoken to CNA D because she was present for some of the conversation. TNA B said she thought reporting Resident #1's concerns to her supervisor was all that was needed. During an interview on 6/28/29 at 10:40 a.m., the ADON said TNA B reported to her that Resident #1 said CNA D took her call light. The ADON said she had gone down and talked to Resident #1 and she told her the same thing. She said Resident #1 said CNA D had disregarded her concerns about the call light. She said she and the DON, who was currently on vacation, called CNA D into the office. The ADON said CNA D denied the allegation. The ADON said she and the DON talked to CNA D, but LVN C had already taken care of the incident. The ADON said LVN C told CNA D not to go back in Resident #1's room. The ADON said she did not know if they told the Administrator or not. She thought she had reported to the Administrator. The ADON said the DON was on vacation. During a telephone interview on 6/28/29 at 10:47 a.m., LVN C said she was not sure exactly who said Resident #1 told her CNA D took her call light. LVN C said someone reported it to her and she immediately went to Resident #1's room. She said she did not ask Resident #1 about the call light and the resident did not mention any incident to her. LVN C said she saw the call light tied to Resident #1's bed and felt nothing had happened. She said she talked to the RN supervisor, and they decided to remove CNA D from caring for Resident #1. She said she had not reported the incident and felt it was handled. She did not know how long it had been since the aide had been in the room, or if anyone gave the light back. She said she saw the resident with the light and felt there was no problem. The LVN said if she had suspected abuse, she would have reported it. During an interview on 6/28/29 at 11:40 a.m., the Administrator said TNA B, the ADON, nor the DON had informed him of the incident with Resident #1. He said they were all aware he was the abuse coordinator, and they should have reported to him immediately. During an interview on 6/28/29 at 11:54 a.m., TNA B said she had not reported her concerns about Resident #1 to the Administrator and knew she should have. She said she thought if she reported the incident to her supervisor that was sufficient. During an interview on 6/28/29 at 12:10 p.m. with the Administrator and Resident #1 in her room, Resident #1 said she did not know who she reported the incident to first. She said she was mad and upset and did not want to be hostile with other staff because of CNA D. She said CNA D had taken her call light and threw it on the floor. Resident #1 said when she asked her why she took her light she flipped her off like she was insignificant, like she was not even a person. Resident #1 said one of the other aides gave her the call light back. She could not be sure who it was, she did not know names that well. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455753 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 455753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Brook Health Care Center 107 Stacy Whitehouse, TX 75791 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 6/28/29 at 1:30 p.m., the Administrator said he suspended 5 staff associated with the Resident #1's incident. He suspended LVN C -charge nurse, CNA D, hospitality aide E, ADON, and CNT B. He said they were aware of the abuse and did not report the abuse to him. Record review of employee memorandum indicated LVN C, CNT B, Hospitality aide E, CNA D, and the ADON had suspension violations, dated 6/28/23, the action was the employee had information related to abuse or neglect and did not call the abuse coordinator. The employee's corrective action was an in service on abuse and suspension. Record review of a from titled QA Meeting indicated: on 6/27/23 the facility Administrator was alerted to potential abuse allegations regarding a staff member taking a call light from a resident. During the investigation on 6/28/23 due to the allegation of call light removed from the resident. The facility administrator suspended the ADON who did address the situation but failed to recognize this as a potential abuse and failed to report to the facility administrator. The facility also suspended the charge nurse on the well end as well as the alleged perpetrator pending investigation, in service and retraining. In services on abuse, neglect and reporting to the facility abuse preventionist. The facility Administrator reported to HHSC on 6/27/23 and the facility investigation is ongoing. Record review of the facility Abuse, Neglect Reporting and Investigating policy, last revised 2021, indicated all reports of resident abuse are reported to the local, state, and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Reporting allegations to the administrator and authorities. If abuse is suspected, the suspicion must be reported immediately to the administrator and the other officials according to state law. Any employee who had been accused of resident abuse is placed on leave with no resident contact until the investigation is completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455753 If continuation sheet Page 3 of 3