Inspection·November 7, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documented falls by Resident #2.Review of Resident #2's Fall Risk Evaluation performed on 11/05/2025 reflected a score of 17 and a high-risk category. Further review reflected a history of 3 or more falls in the past 3 months. During an observation on 11/06/2025 at 10:08 a.m., Resident #2 was lying in bed on a scoop mattress and bed was in the lowest position. Resident was resting peacefully with unlabored breathing, and her eyes were closed. No floor mat was observed beside her bed.During an interview and observation on 11/06/2025 at 1:19 p.m., Resident #2 was sitting in a wheelchair in the lobby area attached to the dining room. She had steri-strips (adhesive wound strips) attached to her forehead covering a wound with no fresh drainage observed. She could not answer questions about where the wound on her forehead had come from looking confused and then feeling of her forehead when asked. There was one staff member sitting in a chair in that lobby and other residents surrounded her. There was a television on for the residents to watch. Resident #2 did not appear to be in any pain and was calm during interview. During a telephone interview on 11/06/2025 at 1:02 p.m., Resident #2's Representative stated she had been informed of the fall Resident #2 had on 11/05/2025. She stated Resident #2 had fallen out of bed in the past and the facility had changed her mattress to a scoop mattress which had helped tremendously. She stated she had asked for a floor mat during a care plan meeting but was told the facility does not use floor mats due to state guidelines. Resident #2's Representative stated she had participated in care plan meetings and that is where they had discussed the scoop mattress instead of the floor mat.During an interview on 11/06/2025 at 1:41 p.m., CNA A stated she had worked for the facility for approximately 2 months. She stated she had worked on the hall Resident #2 resided on and knew about her care. She stated Resident #2 had mostly fallen at night in the past and there had never been a floor mat used beside her bed. She stated she did not know how to look up a care plan. She stated when she asked to look at care plans, due to questions about the care she needed to provide, she had been told to ask the charge nurses about a resident's care needs. During an interview on 11/06/2025 at 2:50 p.m., CNA B stated he was working on Resident #2's hall today and had worked on that hall at nights sometimes. He stated she did not have a floor mat beside her bed today and could not remember if she ever had a floor mat. He stated Resident #2 had a scoop mattress to help prevent falling out of bed and he would make sure to keep her bed in the lowest bed position when she was in bed. He stated at night, he checked on Resident #2 more frequently than other residents to help prevent her from falling as well. He stated if he needed to know something about a resident plan of care, he had to ask the charge nurse.During an interview on 11/06/2025 at 2:58 p.m., LVN D stated she knew how to look up care plans. She stated she did not update the care plans, but the MDS RN would update them when needed. She stated the interventions that were being provided to Resident #2 included keeping her bed in the lowest position because she was a high fall risk. She stated a floor mat was like a fall mat but not as thick. She stated that Resident #2 did not have a fall in her room the last time, but the fall was in the lobby beside the kitchen. She stated she was on shift that day and had assessed the resident after the fall. She stated she did not believe there were any changes to Resident #2's care plan after that fall.During an observation on 11/07/2025 at 8:40 a.m., Resident #2 was lying in bed on a scoop mattress and bed was in the lowest position. Resident was resting peacefully with unlabored breathing, and her eyes were closed. The room was dim, and no floor mat was observed beside her bed. During an interview on 11/07/2025 at 8:44 a.m., CNA C stated she was an agency CNA and had just gotten access to the resident records this morning to be able to chart for the residents including Resident #2. She stated this was her first day working in the facility. She stated she did not know if the care plan was listed on the kiosk but would look. She logged into the resident's charting and saw floor mat beside bed listed. She stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455934 If continuation sheet Page 2 of 4 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 11/07/2025 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 - Few did not know why there was no floor mat in Resident #2's room but did see housekeeping pick up a floor mat this morning to clean it but could not remember which room that was from. She stated floor mats were needed to minimize injury. She stated if she had noticed the floor mat not being present, she would have reported it to the charge nurse.During an interview on 11/07/2025 at 8:53 a.m., the MDS coordinator stated she was working as a charge nurse on the hall that Resident #2 resided on today. She stated after a fall, the actual fall care plan was updated with new interventions, and a floor mat was not listed on the actual fall care plan as determine by herself and the DON. She stated the risk for fall care plan had intervention for floor mat beside Resident #2's bed but that was not the care plan that staff went by when providing care. She stated the floor mat had been put in the care plan by a different nurse two years ago and that was why it was on the care plan now. She stated the care plans should match the orders and since there was not an order for a floor mat, the staff should not put a floor mat down. When asked why the floor mat beside the bed was listed in the kiosk for the CNAs, she stated the CNAs should speak to the charge nurses to know what interventions were appropriate for the residents. The MDS coordinator stated she participated in care plan meetings. She stated after a fall, the actual fall care plan interventions were updated and the risk for falls care plan stayed the same. She stated the risk for falls care plan was put in place years ago and were due to the baseline care plan. She stated since the resident did not need a floor mat, the CNAs were providing care as needed for Resident #2 and no negative effect occurred from not placing the floor mat beside bed.During an interview on 11/07/2025 at 9:08 a.m., when the DON was asked how she monitored and provided oversight in order to assure care and services were implemented based upon the care plan the DON responded she looked at the actual falls care plan when there was a fall. The DON stated she and the MDS coordinator did not look at the risk for falls care plan because everyone residing in the facility was at risk for falls. She stated Resident #2's at risk for falls care plan had been placed about 2 years ago and she had not looked at interventions for that care plan. She stated the floor mat should not have been on the care plan if direct care staff were not providing that intervention but added the floor mat was not an intervention for an actual fall. The DON did not reveals why the floor mat was still on the care plan when it was not in use and had not been used. She stated Resident #2 would not benefit from a floor mat to help prevent her from falling and she did not see any negative impact from not placing a floor mat beside Resident #2's bed. She stated both her and the MDS coordinator updated the care plans. The DON stated she could resolve out and delete an intervention on a care plan but did not look at the at risk for falls care plan interventions. She stated during care plan meetings, the facility staff involved in that care plan would look at the actual fall care plan and not review the risk for fall care plan. She stated that if the care plan specifies a floor mat beside bed that meant there would be a floor mat placed beside that resident's bed. She stated direct care staff should not have placed a floor mat beside Resident #2's bed due to that was not part of the focus care plan for the actual fall. She stated the charge nurses were responsible for implementing interventions and monitoring that interventions were carried out by the CNAs. She stated the nurses knew not to go by the interventions on the focus: at risk for falls care plan and no negative impact had occurred from the floor mat being on the care plan interventions. She stated CNAs have access to the care plans using the kiosk. She stated temporary staff were oriented on the kiosk system by other CNAs and nurses. During an interview on 11/07/2025 at 9:25 a.m., the ADMN stated he expected the direct care staff to follow care plans to the best of their ability. He stated the direct care staff should reach out to himself or the DON if an intervention could not be carried out. He stated he had not been notified by staff that the floor mat beside Resident #2's bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455934 If continuation sheet Page 3 of 4 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 11/07/2025 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete could not be performed. He stated he expected for the IDT to monitor that the direct care staff followed the care plans. He clarified that the IDT consisted of department heads including the medical director, the MDS coordinator, the DON and himself. He stated the IDT communicated the interventions to the nurses who were expected to report those interventions to the CNAs. He stated he did not think there were any negative consequences from the floor mat not being beside Resident #2's bed when she was in bed. He stated he felt the care plan should reflect what the resident's care needs were and felt the interventions should be followed. Review of facility policy titled Comprehensive Person-Centered Care Planning revised on 12/2023 reflected: 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 IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care.6. 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.Review of facility policy titled Fall Management System revised on 01/2022 reflected: 1. On admission, the Fall Risk Evaluation will be completed to determine his/her risk for sustaining a fall.2. Residents with high risk factors identified on the Fall Risk Evaluation will have an individualized care plan developed that includes measurable objectives and timeframes.a. The care plan interventions will be developed to prevent falls by addressing the risk factors and will consider the particular elements of the evaluation that put the resident at risk.3. When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record.4. Review of the fall incident will include investigation to determine probable causal factors.5. The investigation will be reviewed by the Inter Disciplinary Team.6. Resident's care plan will be updated. Event ID: Facility ID: 455934 If continuation sheet Page 4 of 4