Inspection·June 23, 2022

F 0812 Dry storage under metal table Level of Harm - Minimal harm or potential for actual harm 1 tub of flour had a measuring cup inside. 1 tub of sugar had a measuring cup inside. Residents Affected - Some 1 tub of powdered thickener had a measuring cup inside. DM said the staff was not supposed to leave anything inside those tubs. She said the staff was supposed to use a measuring cup 1 time and then put it in dishroom to be washed. Dry seasoning shelf above food preparation sink 1 plastic container of Old Bay seasoning with an open lid. 1 plastic container of granulated onion powder seasoning with an open lid. DM said the cook should have closed the lids on the seasonings after they used them. Dining room [ROOM NUMBER]st storeroom Stacked boxes of food delivery in front of storeroom on the floor. Approximately 15 residents were in the dining room doing group exercise at that time. The food delivery items included: 1 box with 6 5lb bags of liquid egg mix. 1 box with 112 servings Coconut Pecan cookie dough. 1 box with 200 servings Ranger SF cookie dough. 1 box with 6 10lb logs of chuck ground beef. 1 box with 154 servings sausage patty's. 1 box with sliced bacon. 3 bags of mixed vegetables with broccoli, cauliflower, and carrots. Freezer in 1st storeroom in dining room 1 clear plastic storage bag with illegible marking. DM said it was crinkle cut French fries. 1 clear plastic storage bag with illegible marking. DM said it was steak fingers. 1 box of churro's frozen to the bottom of the freezer. DM said the delivery was an hour and a half ago, (approximately 8:30AM). During an observation of dining room on 06/21/22 at 10:47 AM, the stacked boxes of food delivery in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455934 If continuation sheet Page 2 of 7 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 455934 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northern Oaks Living & Rehabilitation Center 2722 Old Anson Rd Abilene, TX 79603 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 front of storeroom were on floor in dining room. There were approximately 10 residents in the dining room. Level of Harm - Minimal harm or potential for actual harm During an observation on 06/21/22 at 11:18 AM, the stacked boxes of food delivery in front of storeroom were on floor in dining room. There were approximately 10 residents in the dining room. Residents Affected - Some During an observation on 06/21/22 at 11:59AM, DM finished putting away the stacked boxes of food delivery on the floor in front of the storeroom in the dining room. During observation of meal service on 06/21/22 at 12:00PM revealed: 12:02PM [NAME] A returned from using telephone, doffed gloves, did not perform hand hygiene, donned new gloves, and continued to serve the noon meal. 12:05PM, [NAME] A went to storage room and got a pan, then went around to ice machine and got some ice in the pan for potato salad on the service line. [NAME] A doffed gloves, did not perform hand hygiene, donned new gloves, and continued to serve the noon meal. 12:20PM, [NAME] A picked up a handful of meat with gloved hand, placed it on a bun, doffed that glove from the right hand, did not perform hand hygiene, then donned a new glove for his right hand, and continued to serve the noon meal. 12:27PM, [NAME] A went to the walk-in refrigerator, removed a pre-made sandwich for a resident, and came back to the service line. [NAME] A removed gloves, did not perform hand hygiene, donned new gloves, and continued to serve the noon meal. 12:31PM, [NAME] A went to the walk-in refrigerator, pulled out a single slice of cheese, came back to the service line, and placed the cheese on a plate. [NAME] A then removed gloves, did not perform hand hygiene, donned new gloves, and continued to serve the noon meal. During an interview with [NAME] A on 06/21/22 at 12:47PM, he said that any time a person took off gloves, they should wash their hands before putting on a new pair of gloves. [NAME] A said that he did not wash his hands at any time during the meal service. During an interview with DM on 06/21/22 at 12:48PM, she said any time staff took off gloves they should wash their hands before putting on a new pair of gloves. DM said she reminded [NAME] A to wash his hands after going to the walk-in refrigerator to get items. She said the frozen food that had been on the floor in front of the storeroom in the dining room were fine to use. She said that she felt that the items should have still been frozen and that they were in a box, so they were fine on the floor in the dining room with residents around them. During an interview with ADM on 06/22/22 at 9:35AM, he said the frozen foods on the floor in the dining room should have been made a priority by the DM and should have been put away when they came in. During an interview with ADM on 06/22/22 at 10:10AM, he said that all the frozen items would be thrown out and they would just reorder new items. Record review of facility policy labeled General Food Preparation and Handling undated revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455934 If continuation sheet Page 3 of 7 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 455934 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northern Oaks Living & Rehabilitation Center 2722 Old Anson Rd Abilene, TX 79603 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Food will be received, checked, and stored properly . Leftovers must be dated, labeled, covered, cooled and stored in a refrigerator . Frozen foods must be maintained at a temperature to keep the food frozen solid . All foods should be covered, labeled, and dated . All foods will be stored off of the floor. Record review of facility policy labeled Hand Washing undated revealed: After handling soiled equipment or utensils. During food preparation, as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks. When switching between working with raw food and working with ready to eat food. Before donning disposable gloves for working with food and after gloves are removed. After engaging in other activities that contaminate the hands. Event ID: Facility ID: 455934 If continuation sheet Page 4 of 7 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 455934 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northern Oaks Living & Rehabilitation Center 2722 Old Anson Rd Abilene, TX 79603 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 control program to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of disease for 1 of 1 (Resident # 67) resident reviewed for droplet precautions. Residents Affected - Few The facility failed to ensure the residents were not exposed to droplet transmission infections. This failure could place residents at risk of development and transmission of droplet transmission infections. The findings include: Review of electronic Face Sheet accessed on 06/22/2022 revealed Resident #167 was [AGE] year-old male was admitted [DATE] with diagnosis includes Cellulitis (bacterial skin infection) of right upper arm, Hemiplegia (Paralysis) left arm, Dementia (loss of cognitive function), Tobacco Use. Review of electronic Face Sheet accessed on 06/22/2022 revealed Resident #167 was on droplet precautions due to being a new unvaccinated admit to the facility. Review of Resident #167's physician orders from 06/16/2022 to 06/23/2022 revealed that resident is to be on droplet isolation. Review of Resident #167's immunization record showed no vaccination for CoViD-19 recorded. Review of Resident #167's Social Services Assessment date 06/20/2022 BIMS score 15 (Intact Cognitive response). During observation on 06/21/2022 at 11:43 AM on Hall 100, droplet precautions sign posted on the door for Resident #167 and the door was open. During observation on 06/21/2022 at 12:35 PM on Hall 100, Resident # 167, who was on droplet precautions, was sitting in his wheelchair in the hallway not wearing a face covering. During observation on 06/21/2022 at 12:41 PM on Hall 100, CNA K entered room Resident #167's room, which was a droplet precaution room, not wearing required PPE. CNA K failed to don gloves, a face shield or change to another mask. CNA K wore surgical mask. CNA K doffed PPE in resident's room before exiting room. During observation on 06/22/2022 at 10:22 AM observed housekeeper in Resident #167's room, that had a sign on the door for droplet precautions with full PPE and door to room open. TBP room with cart was outside of door. During interview on 06/21/2022 at 12:50 PM with RN A, she stated that she was the Infection Preventionist. RN A stated that residents in room [ROOM NUMBER] were on Droplet precaution because they were new admissions and were not vaccinated and the Residents would be on Droplet precautions for 10 days. RN A stated that residents should be isolating int their room and if they leave their room, they should be wearing a mask. RN A stated that the doors to the Droplet Precaution residents should be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455934 If continuation sheet Page 5 of 7 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 455934 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northern Oaks Living & Rehabilitation Center 2722 Old Anson Rd Abilene, TX 79603 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 shut and not left open. RN A stated staff should doff (PPE) in the resident room, staff should not doff (PPE) in the hallway. RN A stated that staff are trained on proper PPE initially when they start and that she does random checks every month to ensure staff know how to wear PPE correctly. RN stated that CNA K had been trained on what PPE to wear and how to wear PPE properly. During interview on 06/23/2022 at 11:05 AM with RN A, Infection Control Preventions stated that staff are tested 2 times a week for COVID-19 and residents are tested if symptomatic and the expectation is that unvaccinated staff are to wear N-95 masks. RN A stated that staff who enter resident rooms that are on droplet Precautions should be wear gown, gloves, mask, goggles prior to entering room. RN A also stated the expectation was that the resident that was on droplet precautions should be wearing a mask when leaving their room. She stated that she did not know why staff and resident were not wearing appropriate PPE. She also stated the staff and the resident had been educated on the proper use of PPE, the door to the room should be always closed, even when staff are cleaning the room. She also stated that staff are trained upon orientation and provided in-services. During interview on 06/23/2022 at 12:07 PM with DON, DON stated staff should wear gown, gloves, mask, goggles/face shield prior to entering a room on Droplet Precautions and should remove all PPE prior to leaving the room and dispose of it in trash bag if not soiled. DON stated the expectation was a resident on Droplet Precautions should wear a mask when leaving their room. She did not know why that resident did not have on a mask when he was in the hallway. He had been educated and handed a mask before. DON also stated that RN A, Infection Control Nurse, trained the staff on proper PPE and then facility provided in-services on infection prevention to staff as needed. DON stated that a negative outcome from resident on droplet precautions not wearing a mask when out of his room would be that other residents could be exposed to COVID or other infection if resident tests positive. Record review on 06/22/2022 of CNA K training record CNA completed Using PPE Correctly for COVID-19: CDC Video on 10/22/21 and 11/09/21. Infection Prevention and Control on 11/09/21 Hand Hygiene on 11/09/21 Record review of facility's policy titled, Infection Prevention and Control Program Transmission Based Precaution and Isolation revealed: It is the policy of Northern Oaks to implement infection control measures and to prevent the spread of communicable diseases and conditions. Droplet precautions 1. Masks are indicated for those who come in close to patient 2. Gloves are indicated for touching infective material 3. [NAME] must be washed after touching the patient or potentially contaminated articles and before taking care of another resident 4. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455934 If continuation sheet Page 6 of 7 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 455934 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northern Oaks Living & Rehabilitation Center 2722 Old Anson Rd Abilene, TX 79603 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 Articles contaminated with infective material should be discarded or bagged and labeled before being sent for decontamination and reprocessing Droplet precautions are intended to prevent transmission of pathogens spread through [NAME] respiratory or mucous membrane contact with respiratory secretions. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455934 If continuation sheet Page 7 of 7