Inspection·June 22, 2023

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #1 MAR from 06/01/23 through 06/30/23 revealed there was no order for fentanyl 50 mcg for the resident. During an interview with the Responsible Party (RP) on 06/21/23, she said she had electronic monitoring for the resident which she reviewed daily. On 06/18/23 at 2:51 p.m., she observed a fentanyl patch being placed on Resident #1 when she reviewed the camera footage in Resident #1's room at 10:00 p.m. She was surprised to see a fentanyl patch on Resident #1. She knew Resident #1 did not have an order for a fentanyl patch. The RP called LVN A, who was the nurse on duty at the time, to find out if Resident #1 had new orders for any medications. LVN A informed her no new medications were ordered, however a fentanyl patch was found on Resident #1 without a physician order. LVN A removed the fentanyl patch from Resident #1. The RP explained she immediately went to visit Resident #1 because she saw changes in his behavior. During interview with LVN A on 06/21/23 at 3:14 p.m., she said she was the charge nurse on duty when the RP informed her the wrong medication was placed on Resident #1. She removed the fentanyl patch that was mistakenly placed on the resident. LVN A explained she was the incoming nurse when LVN B told her she placed a fentanyl patch on a resident but did not see or remove the old patch on the resident. She said she was very concerned and felt LVN B did not follow the 5 rights of medication administration which included the right patient, right medication, right dose, right route, and right time. LVN A explained if Resident #1 did have an old patch on him, that should have been a red flag for LVN B. She noted LVN B failed to follow common sense nursing practice. LVN A said she felt the mistake may involve Resident #2 who gets a fentanyl patch. She went to Resident #2 to check for the patch but the resident wanted to use the bathroom. LVN A said she got busy and could not check for the fentanyl patch until the RP called her more than 8 hours later. LVN A stated the harm could have been minimized if she had checked on Resident #2 earlier. She stated she administered a fentanyl patch to Resident #2 as ordered. LVNA said she notified physician for Resident #1 and Resident #2 and their families. She continued to monitor both residents. During interview with LVN B on 06/22/23 at 10:05 a.m., she said she worked for an agency. LVN B stated she mistakenly placed the wrong Fentanyl patch on Resident #1 instead of Resident #2. LVN B explained she was not aware she made a serious medical error. She was usually careful with giving residents medication. LVN B said she was very busy and was overwhelmed with trying to take care of many residents. She had a resident with colostomy that was leaking into her blood system. She was fighting to prevent her from having sepsis and lost track of following basic nursing practice. She said she should have looked at names in the rooms or the picture of the residents on the MAR. LVN B said she did not do that and took full responsible for her mistake. LVN B explained she learned from the incident to slow down and think instead of getting flustered. She said she was not aware of the mistake because no one contacted her from the facility till the next morning 06/19/23 at about 10:00 a.m. She received a text from ADON D which stated, You put fentanyl patch on the wrong resident. LVN B stated she did not hear again from the facility until 06/21/23 when she was informed by ADON D that a State Surveyor wanted to speak with her. LVN B stated she had not received training or orientation from the facility. In an interview with ADON D on 06/22/2023 at 11:35 a.m., she said she was informed by the DON Resident #1 was given wrong medication. The DON instructed her to contact LVN B regarding the incident of medication error on 06/19/23. She texted LVN B stating, You put fentanyl patch on the wrong resident. ADON D stated she did not communicate with LVN B again until 06/22/23 when the State Surveyor requested to talk to her. ADON D explained she took so long to contact LVN B to initiate the investigation because she knew LVN B worked at night and waited to call her. She said all staff received (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455934 If continuation sheet Page 2 of 10 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 06/22/2023 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some in-services except LVN A and LVN B. ADON D explained LVN B is no longer allowed work at the facility and LVN A would be in-serviced in the next scheduled shift on 06/22/23. Additionally, she said both residents were being monitor and appear to have no changes in behaviors. During interview with the DON on 06/22/2023 at 11:48 a.m., she said she was notified by LVN A that Resident #1 was given the wrong medication. She was told Resident #1 received a fentanyl patch that was meant for Resident #2. The DON explained she informed LVN A to notify the doctor and both resident's families. The DON said she had not got a chance to talk to LVN B to find out what happened. This was because she told ADON D to contact LVN B and find out what happened. The DON said she had conducted in-services on staff after the incident Record review of in-service training report dated 06/19/23 reflected signatures of staff members on medication administration. The in-services were conducted by DON. Record review of nurse's note on 06/18/23 at 23.06 p.m (incident date) by LVNA reflected, medication error noted at time: Fentanyl 50 mcg removed from patient's right anterior chest wall. Spouse/physician/facility ADM/DON were notified. Nurse to monitor patient for sedation q2hr. Record review of nurse's note on 06/19/23 at 14:33 p.m, reflected, NAR (no adverse reaction) noted at this time from medication error. VS (vital signs) continue to remain stable, BP122/67, HR78, 02 stat 97%, RA, R 18. No distress noted, no s/s drowsiness, resident up in wheelchair throughout shift, participating in therapy, up for meals eating independently. Record review of in-services and training report, dated 06/19/223, revealed LVA A and LVN B had not received training or in-services since Resident #1 was given Fentanyl 50 mcg. Record review of Resident #3's Quarterly MDS assessment, dated 04/25/2023, Section C: Cognitive patterns revealed a BIMS score of 0 because the resident was unable to complete the interview. Resident required supervision for most ADLs. It also reflected the resident receives opioid. 2. Record review of Resident #3's electronic face sheet, dated 06/22/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation, benign prostatic hyperplasia, atherosclerotic heart disease, dysphagia, gout, and cognitive communication deficit Record review of Resident #3's Quarterly MDS assessment, dated 05/25/2023, Section C: Cognitive patterns revealed a BIMS score of 14 out of 15, which indicated the resident was cognitively intact. Record review of Resident #3's physician orders, dated 06/22/23, reflected the following medications: -Acetaminophen -Codeine tablet 300-15-Give 1 tablet by mouth every 12 hours -Amlodipine Besylate tablet 5 mg-Give 1 tablet by mouth one time a day -Anoro Ellipta Aerosol powder breath Activated 62.5-25 mcg/inh-1 puff inhale orally one time a day -Aspirin tablet delayed release 81 mg-Give 1 tablet by mouth one time a day (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455934 If continuation sheet Page 3 of 10 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 06/22/2023 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 0760 -Docusate Sodium capsule 100 mg-Give 1 capsule by mouth two times a day Level of Harm - Minimal harm or potential for actual harm -Febuxostat tablet 40 mg-Give 1 tablet by mouth one time a day -Ferrous Sulfate tablet 325 mg-Give 1 tablet by mouth one time a day Residents Affected - Some -Finasteride tablet 5 mg-Give 1 tablet by mouth one time a day -Fluticasone propionate HFA Aerosol 110 mcg/act-1 puff inhale orally every 12 hours -Gabapentin capsule 100 mg-I capsule by mouth two times a day -Guaifenesin ER tablet extended release 12-hour 600mg-Give 1 tablet by mouth every 12 hours -Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3ml-3 ml inhale orally every 4 hours as needed -Loratadine oral tablet 10 mg-Give 10 mg by mouth every 24 hours as needed -Metoprolol Succinate ER tablet extended release 24-hour 50 mg-Give 1 tablet by mouth one time a day -Milk of Magnesium suspension 400 mg/5ml-Give 30 ml by mouth as needed -Miralax Oral Powder 17 gm/scoop) polyethylene glycol 3350)-Give 1 scoop by mouth one time a day -Robitussin Night cough DM liquid 12.5-30 mg/10ml-Give 5 ml by mouth every 4 hours as needed for cough -Vitamin B12 tablet extended release 1000 mcg-Give 1 tablet by mouth one time a day -Vitamin D3 tablet 125 mcg (5000 UT)-Give 1 tablet by mouth one time a day -Warfarin Sodium Oral Tablet-Give 3 mg by mouth one time a day every Saturday -Warfarin Sodium Oral Tablet-Give 2 mg by mouth one time a day every Tuesday, Thursday, Saturday, and Sunday. -Warfarin Sodium Oral Tablet-Give 4 mg by mouth one time a day every Monday, Wednesday, and Friday. Observation and interview with CMA E on 06/22/23 at 9:37 a.m. revealed she gave Resident #3 Metoprolol Tartrate 50 mg (short-acting) instead of Metoprolol succinate (long-acting) as ordered. CMA E said she was not paying attention when she made the medication error. She obtained the right medication and gave it to the resident. Record review of the facility's, undated, policy on Medication error and Adverse reaction reflected, It is the policy of this facility that medication errors and adverse clinical consequences must be reported to the resident's attending physician. Procedures: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455934 If continuation sheet Page 4 of 10 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 06/22/2023 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 0760 1) Level of Harm - Minimal harm or potential for actual harm Adverse drug reactions and medication errors with adverse clinical consequences must be reported to the resident's attending physician immediately Residents Affected - Some 2) Nursing service must immediately implement and follow the physician orders. The resident's condition must be closely monitored for seventy-two (72) hours or as may be directed 3) A detailed account of the incident must be recorded on an incident report. Clinically relevant information about follow-up of the resident should be recorded in the chart including 4) Documentation of the resident's condition and response to treatment must be recorded during the monitoring period 5) The medical director, director of nursing services, and consultant pharmacist must be informed of all medication errors and adverse reactions 6) An incident report must be completed and filed with the administrator. Record review of the facility's, undated, policy on medication administration reflected: It is the policy of this facility to ensure that thee twelve rights of medication administration are followed in order to ensure safety and accuracy of administration. Procedure: The 12 rights of medication administration are as follows in order to ensure safety and accuracy of administration 1) Right Patient 2) Right Drug 3) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455934 If continuation sheet Page 5 of 10 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 06/22/2023 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 0760 Right Preparation Level of Harm - Minimal harm or potential for actual harm 4) Right Dose Residents Affected - Some 5) Right time 6) Right Route 7) Right reason 8) Right education 9) Right history and assessment 10) Right to refuse 11) Right to response 12) Right Documentation FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455934 If continuation sheet Page 6 of 10 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 06/22/2023 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 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles for 1 of 2 employees (LVN B) reviewed for training requirements. Residents Affected - Few The facility failed to have documentation regarding training for LVN B (agency nurse). . This failure could place residents at risk of accidents with potential harm due to not having documentation to support agency nurses received proper training. Findings include: Record review of Resident #1's clinical record revealed an [AGE] year-old male with an admission date of 11/18/2022 and a readmit date of 05/23/2022. He had diagnoses which included dementia (impaired ability), post-traumatic stress disorder (mental condition triggered by a terrifying event), benign prostatic hyperplasia (overgrowth prostate tissue), hyperlipidemia (elevated lipids levels), osteoarthritis (degenerative joint), sensorineutral hearing loss (damaged hair cells in the inner ear), depressive episodes, muscle weakness, dysphagia (difficulty in swallowing), cognitive communication deficit, lack of coordination, limitation of activities due disability and reduced mobility. Record review of Resident #1's Quarterly MDS assessment, dated 05/25/2023, Section C: Cognitive patterns revealed a BIMS score of 3 out of 15, which indicated severe cognitive impairment. During interview with LVN B on 06/22/23 at 10:05 a.m., she said she worked for an agency. LVN B stated she mistakenly placed the wrong Fentanyl patch on Resident #1 instead of Resident #2. LVN B explained she was not aware she made a serious medical error. She is usually careful with giving residents medication. LVNB said she was very busy and was overwhelmed with trying to take care of many residents. She had a resident with colostomy that was leaking into her blood system. She was fighting to prevent her from having sepsis and lost track of following basic nursing practice. She said she should have looked at names in the rooms or the picture of the residents on the MAR. LVNB said she did not do that and takes full responsible for her mistake. LVNB explained she has learned from the incident to slow down and think instead of getting flustered. She said she was not aware of the mistake because no one contacted her from the facility till the next morning 06/19/23 at about 10:00a.m. She received a text from ADON D stating You put fentanyl patch on the wrong resident. She replied what? This is because she could not believe what she heard. LVNB stated she did not hear again from the facility until 06/21/23 when she was informed by ADON D that a surveyor wanted to speak with her. During interview with DON on 06/21/23 at 2:15p.m, she said stated the facility did not train/orient contract staffs as they were trained at their agencies. She explained they would start training agency staff going forward. Record review of in-service training report dated 06/19/23 reflected signatures of staff members on medication administration. The in-services were conducted by DON. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455934 If continuation sheet Page 7 of 10 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 06/22/2023 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 0940 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of contract staff indicated the facility employed seven contract staffs for the month of March, five contract staff for April, 18 staff for May and the start of June. This is a total of 30 untrained contract staff who administered medications and treatment to residents without proper training. Record review of in-services and training report, dated 06/19/223, revealed LVN B had not received training or in-services since she mistakenly gave Resident #1 Fentanyl 50 mcg without physician order. Record review of the facility's, undated, policy on Medication error and Adverse reaction reflected, It is the policy of this facility that medication errors and adverse clinical consequences must be reported to the resident's attending physician. Procedures: 1) Adverse drug reactions and medication errors with adverse clinical consequences must be reported to the resident's attending physician immediately 2) Nursing service must immediately implement and follow the physician orders. The resident's condition must be closely monitored for seventy-two (72) hours or as may be directed 3) A detailed account of the incident must be recorded on an incident report. Clinically relevant information about follow-up of the resident should be recorded in the chart including 4) Documentation of the resident's condition and response to treatment must be recorded during the monitoring period 5) The medical director, director of nursing services, and consultant pharmacist must be informed of all medication errors and adverse reactions 6) An incident report must be completed and filed with the administrator. Record review of the facility's, undated, policy on medication administration reflected: It is the policy of this facility to ensure that thee twelve rights of medication administration are followed in order to ensure safety and accuracy of administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455934 If continuation sheet Page 8 of 10 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 06/22/2023 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 0940 Procedure: Level of Harm - Minimal harm or potential for actual harm The 12 rights of medication administration are as follows in order to ensure safety and accuracy of administration Residents Affected - Few 1) Right Patient 2) Right Drug 3) Right Preparation 4) Right Dose 5) Right time 6) Right Route 7) Right reason 8) Right education 9) Right history and assessment 10) Right to refuse 11) Right to response (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455934 If continuation sheet Page 9 of 10 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 06/22/2023 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 0940 12) Level of Harm - Minimal harm or potential for actual harm Right Documentation Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455934 If continuation sheet Page 10 of 10