Health inspection·October 29, 2024

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few timely manner and for them to be accurate. She stated that clopidogrel bisulfate and aspirin were not anticoagulant medications but were antiplatelet medications. She stated no effect would have occurred to resident other than billing. During an interview on 10/29/2024 at 10:50 a.m., the ADMN stated the facility did not have policy for accuracy of assessments. He stated he expected the facility to follow the RAI manual. According to the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual (https://www.cms.gov/files/document/finalmds-30-rai-manual-v11811october2023.pdf accessed on 10/29/2024):

N0415: High-Risk Drug Classes: Use and Indication .Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). N0415E2. Anticoagulant: Check if there is an indication noted for all anticoagulant medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days) . N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g., aspirin/extended release, dipyridamole, clopidogrel) was taken by the resident at any time during the 7-day observation period (or since admission/entry or reentry if less than 7 days). N0415I2. Antiplatelet: Check if there is an indication noted for all antiplatelet medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days). 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 10/29/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview, and record review, the facility failed to develop and implement a comprehensive and person-centered care plan, including measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 1 of 18 (Resident #60) residents reviewed for comprehensive care plans. The facility failed to implement care plan for Resident #60 to receive house shake with meals. These failures could place residents at risk of not having preferences and weight goals being met. Findings included: Resident #60 Record review of Resident #60's electronic face sheet dated 10/29/2024 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: malnutrition. Record review of Resident #60's Quarterly MDS assessment dated [DATE] revealed: resident was rarely/never understood and no BIMS score. Further review of MDS assessment revealed diagnoses to include: malnutrition. Record review of Resident #60's IDT-BIMS assessment dated [DATE] revealed BIMS score of 03 meaning severe cognitive impairment. Record review of Resident #60's electronic physician orders dated 10/28/2024 revealed order written on 08/28/2024 stated, Provide resident with House Shakes with every meal at the request of the resident. Record review of Resident #60's comprehensive care plan completed on 10/21/2024 revealed Resident #60 had nutritional problem r/t GERD, Lewy bodies dementia, mechanically altered diet d/t edentulous status date initiated: 01/10/2024 revision on: 03/18/2024. Interventions included: House shake with every meal. Date initiated: 09/02/2024. Record review of Resident #60's comprehensive care plan during investigation on 10/29/2024 revealed: Resident #60 had nutritional problem r/t GERD, Lewy bodies dementia, mechanically altered diet d/t edentulous status date initiated: 01/10/2024 revision on: 03/18/2024. Interventions included: House shake per orders. Record review of Resident #60's electronic physician orders during investigation on 10/29/2024 revealed order written on 10/28/2024 which stated, Provide resident with House Shakes with meals. During an observation on 10/27/2024 at 11:42 a.m., Resident #60 was sitting in dining room eating meat that appeared to be a mechanical texture, potatoes, carrots, and cake. Meal was served on a red plate that had separated areas. Personal meal ticket for Resident #60 sitting beside her plate showed Serve shake with meals. No shake observed with meal. (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 10/29/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 10/27/2024 at 12:00 p.m., a staff member sitting next to Resident #60, assisting her with her meal. No shake observed on table at that time. During an interview on 10/28/2024 at 3:23 p.m., the DON stated all diabetic residents were given snacks at bedtime. She stated there were snacks available for all resident but that snacks were not handed to residents unless they requested them. During an interview on 10/28/2024 at 3:33 p.m., the ADMN stated all diabetic residents were to be offered snack at bedtime. He stated all residents were verbally offered snacks and that the residents knew to ask for snacks if they wanted them. During an interview on 10/29/2024 at 12:51 p.m., the MDS coordinator stated she thought care plan should show what facility staff were doing for the resident. She stated she tried to be specific on care plans and care plan stating house shake with all meals is okay. MDS coordinator stated audits to care plans are don't often and facility IDT members will update care plans often. When asked, If a care plan should include diabetic resident preference of wanting a snack after dinner, she stated I believe that a resident is able to request a snack at bedtime and all the residents have the right to request. If we had an order for snack at bedtime, we would carry it over into the care plans. She stated the care plans do not have a huge effect on the facility's residents because the facility had orders and other documentation to look at for residents' care. She stated the whole IDT team monitors that care plans are accurate and resident specific and added everyone can have an effect on the care plan. During an interview on 10/29/2024 at 1:19 p.m., the DON stated nurse management team was responsible for care plans. She stated care plans were updated daily and more often than daily when needed. She stated she expected for comprehensive care plans to be resident specific. She stated there was a difference in Resident #60's physician orders and her care plan. She stated they updated the care plan and orders after speaking with dietician and physician for clarification on orders. She stated the words resident request were removed from the orders. She stated if a diabetic resident requested a snack at bedtime, it did not need to be on care plan unless there was an order to give snack at bedtime. She denied stating all diabetic residents were to be given a snack at bedtime. She stated facility staff follow orders and she did not know if any negative effect would occur to resident care if care plan was not specific. The DON stated she did not know if the care plan needed to say house shake with every meal instead of per orders. She stated that meal tickets would have house shake listed on it to let CNAs know shake to be given. She denied any negative effect on residents from care plans not being specific. During a follow up interview on 10/29/2024 at 3:34 p.m., the DON stated nurse aides would know about administering house shakes with meals by looking at the care plan in the [NAME] and by looking at meal tickets. She stated that care plan changes were also verbally communicated with nurse aides to notify them of changes in the care plans. Review of facility policy titled Comprehensive Person-Centered Care Planning revision date 12/2023 revealed It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment .Person-centered care - means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives .The facility IDT will develop and implement a comprehensive person-centered, culturally-competent, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete 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 10/29/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm and trauma-informed care plan for each resident within seven(7) days of completion of the Resident Minimum Data Set (MDS) and will include resident's needs identified in the comprehensive assessment, and any specialized services as a result of PASARR recommendation, and resident's goals and desired outcomes, preferences for future discharge and discharge plan. Residents Affected - Some 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 10/29/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the comprehensive care plan was reviewed and revised by a team of qualified persons after each assessment for 2 of 18 (Resident #50, and Resident #281) residents reviewed for comprehensive person-centered care plans. 1. The facility failed to revise Resident #50's comprehensive care plan to remove use of medication no longer ordered within 7 days of the completion of the comprehensive assessment. 2. The facility failed to include hospice services within 7 days of the completion of Resident #281's comprehensive assessment. Thes failures could affect the residents by placing them at risk for not receiving current care and services to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being. Findings included: Resident #50 Record review of Resident #50's electronic face sheet dated 10/29/2024 revealed he was a [AGE] year-old male admitted to the facility most recently on 08/30/2024 and initially on 12/12/2023 with diagnoses to include: personal history of malignant neoplasm of prostate (prostate cancer), and acute kidney failure. Record review of Resident #50's Quarterly MDS assessment date 09/12/2024 revealed: BIMS score of 08 which indicated moderate cognitive impairment. Further review of MDS assessment revealed resident had an indwelling catheter. Record review of Resident #50's comprehensive care plan completed on 05/14/2024, 07/10/2024, 09/24/2024, and care plan reviewed on 10/29/2024 revealed: Resident #50 had indwelling catheter with interventions that included Administer medication per physician's orders; Myrbetriq (medication to treat overactive bladder). Monitor effectiveness and side effects. Date initiated: 12/30/2023 Record review of Resident #50's electronic physician orders dated 10/29/2024 revealed no active order for medication Myrbetriq. Further review of physician orders revealed Myrbetriq had been discontinued on 02/17/2024. Resident #281 Record review of Resident #281's electronic face sheet dated 10/29/2024 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: malignant melanoma of skin (skin cancer). (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 10/29/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #281's admission MDS assessment dated [DATE] revealed BIMS score of 02 meaning severe cognitive impairment. Further review of MDS assessment revealed resident had received hospice care while a resident. Record review of Resident #281's electronic physician orders dated 10/16/2024 revealed resident had been admitted to hospice care for terminal diagnosis of malignant melanoma of skin (aggressive skin cancer). Record review of Resident #281's comprehensive care plan revealed no evidence of hospice care addressed prior to care plan initiated on 10/27/2024. During an interview on 10/29/2024 at 12:51 p.m., the MDS coordinator stated any IDT member was responsible for care plans. She stated IDT members included ADON, DON, wound nurse, and MDS coordinator. She stated her expectation for care plans would be to include orders, diagnoses, and plan of care. She stated IDT members tried to put any type of behaviors in the care plan. She stated she thought care plan should show what facility staff were doing for the resident. MDS coordinator stated audits to care plans are don't often and facility IDT members will update care plans often. She stated that hospice services should be included into care plans. She stated the care plans do not have a huge effect on the facility's residents because the facility had orders and other documentation to look at for residents' care. She stated the whole IDT team monitors that care plans are accurate and resident specific and added everyone can have an effect on the care plan. During an interview on 10/29/2024 at 1:19 p.m., the DON stated nurse management team was responsible for care plans. She stated care plans were updated daily and more often than daily when needed. She stated she expected for comprehensive care plans to be resident specific. The DON stated she expected for hospice services to be included into comprehensive care plan. She stated care plan was updated on 10/27/2024 to include hospice services. She verified that Resident #281 was admitted into hospice care on 10/16/2024. She did not know if there was a specific time frame in which care plan needs to be updated. She denied any negative effect on residents from care plans not being specific. Review of facility policy titled Comprehensive Person-Centered Care Planning revision date 12/2023 revealed It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment .The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455934 If continuation sheet Page 7 of 7