Health inspection·June 14, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, The facility failed to comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives) for 1 of 3 (Resident #41) residents reviewed for advance directive The facility failed to ensure Resident #41 ' s code status was communicated and correctly indicated in his physical chart. This failure could result in residents receiving unwanted treatment or not receiving desired treatment. Findings include: Record review of Resident #41's face sheet, dated [DATE], indicated a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included heart attack (when your heart muscle begins to die because it isn't getting enough blood flow), high blood pressure, dementia (impaired ability to remember, think, or make decisions), respiratory failure (when the respiratory system cannot adequately provide oxygen to the body), and anxiety (feelings of nervousness, panic and fear as well as sweating and a rapid heartbeat). Record review of Resident #41's admission MDS assessment, dated [DATE], indicated Resident #41 was understood and understood others. Resident #41's BIMs score was 12, which indicated he was moderately cognitively impaired. Resident #41 was independent with transfer, dressing, bathing, bed mobility, personal hygiene and required supervision with toilet use. The MDS indicate he received hospice care. Record review of Resident #41's physicians order dated [DATE] indicated: Code status Full Code. Record review of Resident #41's physical medical chart revealed behind the tab advanced directive a green sheet with the words, Full Code. Record review of Resident #41's hospice medical chart revealed a signed DNR dated [DATE]. Record review of Resident #41's comprehensive care plan, dated [DATE], indicated Resident #41 was a full code. The interventions of the care plan were for facility to honor full code status and staff would be advised of resident status of full code. Page 1 of 27 675379 675379 06/14/2023 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on [DATE] at 10:08 a.m., Resident #41 said he wished to be a DNR. He said, He was ready when the Lord called him home. During an interview on [DATE] at 10:18 a.m., the hospice administrator said they completed the DNR paperwork with Resident #41 on [DATE]. She said they placed the DNR signed copy in his hospice book and made the facility aware of his DNR status on admission. During an interview and observation on [DATE] at 10:30 a.m., RN B said Resident #41 was a full code. RN B opened his electronic chart and it revealed he was a Full Code. RN B opened his physical medical chart and looked behind the advanced directive tab which revealed a green sheet with the words, Full Code. RN B said he was a Full Code. RN B then looked in Resident #41's hospice chart and it revealed a signed DNR. RN B said she was not aware Resident #41 was a DNR and failure of her knowing his code status could lead to CPR being performed against his wishes. During an interview on [DATE] at 1:57 p.m., the Social Worker said she had not spoken to Resident #41 about his code status. She said she only explains the process of DNR verse Full code and if a resident elects to become a DNR then the BOM completes the paperwork. The social worker said she was not aware Resident #41 was a DNR. She said she did not know all the steps after a resident elected DNR while at the facility. During an interview on [DATE] at 2:21 p.m., the ADON said he was not aware Resident #41 was an DNR. He said he was the overseer of all DNRs. The ADON said the normal process was once he received a signed DNR, he would write an order, place in the resident's chart, and give a copy to the BOM. He said if they were not made aware of someone's code status on admission, they were full code until determined otherwise. The ADON said this failure could cause residents to receive unwanted wishes of CPR. During an interview on [DATE] at 2:43 p.m., the DON said she was not aware Resident #41 was an DNR. The DON said she assisted with the admission paperwork process for Resident #41 and he nor his family mentioned being a DNR. The DON said if they were aware they would have written the order and placed in his chart. The DON said Resident #41 was admitted from home and she was unaware he had hospice until the next day ([DATE]). She said hospice came in the next day ([DATE]) and handed her their book and orders. The DON said she did not open the book but did go ask Resident #41 if he wished to continue with hospice and he said, yes. She said the orders hospice brought them for Resident #41 did not have any orders indicating he was a DNR. The DON said she have had residents on hospice before who were full code so she did not find it odd his code status was full code. The DON said not having the correct code status placed Resident #41 at risk of receiving CPR against his wishes. During an interview on [DATE] at 3:42 p.m., the administrator said she was unaware Resident #41 was an DNR. She said the normal process was for the SW to explain what a DNR versus a full code was to the resident and or family. She said if they chose to be a DNR then the BOM would complete the paperwork and notarize the DNR. The administrator said the BOM would give the signed DNR to the ADON and he would write the order for the DNR and then would let the charge nurses know the code status. The administrator said if they came in as a DNR then the ADON would write the order and let the charge nurses know the code status. The administrator said this process did not happen for Resident #13 because they were unaware, he was a DNR on admission and therefore it was missed. The administrator said the conflicting information on the resident's code status could place him at risk of receiving CPR against his wishes. 675379 Page 2 of 27 675379 06/14/2023 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0578 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy titled, Advanced Medical Directives,' dated [DATE], indicated, The facility strives to comply with all valid Advanced Medical Directives (per state regulations). Inquire as to the existence of an Advanced Medical Directive at the time of admission. 2. Document in the resident/patient's medical record whether an Advanced Medical Directive has been executed by the resident/patient. 3. Place a copy of such Advanced Medical Directive in the permanent medical record. Residents Affected - Few 675379 Page 3 of 27 675379 06/14/2023 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0583 Keep residents' personal and medical records private and confidential. 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 ensure residents had a right to personal privacy and confidentiality of medical records for 1 (Resident #13) of 6 residents reviewed for privacy and confidentiality. Residents Affected - Few The facility failed to ensure RN A protected Resident#13's Medication Administration Record (MAR). This failure could place residents at risk for low self-esteem, loss of dignity and decreased quality of life due to medication administration record being accessible to others. Findings included: Record review of Resident #13's face sheet, dated 06/13/23, indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included diabetes (excess sugar in the blood), stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), glaucoma (eye diseases that can cause vision loss and blindness) and anxiety ( feelings of nervousness, panic and fear as well as sweating and a rapid heartbeat). Record review of Resident #13's quarterly MDS assessment, dated 05/24/23, indicated Resident #13 was usually understood and understood others. Resident #13's BIMs score was 15, which indicated she was cognitively intact. Resident #13 required total assistance with transfer, toilet use, dressing, bathing, bed mobility and limited assist with personal hygiene. The MDS indicate she received insulin during the 7 days look back period. Record review of Resident #13's physicians order dated 11/15/22 indicated: Give Novolog 22 units subcutaneous (an injection given in the fatty tissue, just under the skin) at 11:30a.m. Record review of Resident #13's comprehensive care plan, dated 06/01/23, indicated Resident #13 received an antidiabetic/hypoglycemic agent and has the potential for alterations in blood glucose levels (Hyper/hypoglycemia) due to diabetes. The interventions of the care plan were for staff to administer insulin as ordered by physician, including sliding scale, monitor blood glucose levels as ordered by physician and to monitor for signs and symptoms of hyper/hypoglycemia such as alterations in level of consciousness, cool/clammy or hot flashes, and to notify the physician of abnormal findings. During an observation on 06/12/23 at 11:32 a.m., RN A went to obtain Resident #13's blood sugar. RN A left the MAR opened on top of medication cart #2 when entering Resident's#13's room. Staff and other residents observed in hallway. RN A came out of Resident #13's room to record her blood sugar and check insulin order. RN A went in to administer Resident #13's insulin leaving the MAR open again clearly displaying personal information. During an interview on 06/12/23 at 11:44 a.m., RN A said she forgot to close the MAR before walking into Resident #13's room. RN A said she was aware she was supposed to close the MAR anytime she stepped away. RN A said she knew she was supposed to provide privacy and maintain confidentiality for all residents. RN A said she did not provide privacy for Resident #13 when she left the MAR opened. During an interview on 06/14/23 at 2:21p.m., the ADON said he expected the nurses to ensure their MARs were closed when not being used. He said he and the DON were the overseer of MARs being closed 675379 Page 4 of 27 675379 06/14/2023 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few but each nurse should be held accountable for leaving the MARs open. The ADON said failure to close the MAR when not in use could lead to privacy issues. During an interview on 06/14/23 at 2:43 p.m., the DON said all employees were expected to provide full visual privacy and confidentiality of information for all residents. The DON said failure to not protect the residents' information could lead to a HIPPA violation. During an interview on 06/14/23 at 3:42 p.m., the administrator said she expected the nurses to keep their MARs closed when not in use. The administrator said nurse managers were the overseer to ensure MARs were being closed when not in use. The administrators said the nurses should ensure MARs were closed when not used to provide privacy to all resident related to personal information. Record review of the facility's policy titled, Safeguarding and storing protected health information, dated September 2012 indicated, The purpose of this policy was to limit unauthorized disclosure of personal health information (PHI)that was contained in a residents medical record, while at the same time in ensuring such protective health information was easily accessible to those involved in the treatment of the resident. The policy of this facility was to ensure, to the extent possible, that PHI was not intentionally or unintentionally use or disclose in a manner that would violate the HIPAA privacy rule, facility policies and procedures or any other federal or state regulations governing confidentiality and privacy of health information. #4 medication administration records, treatment administration records, report sheets and other documents containing PHI shall not be left open and or unattended. 675379 Page 5 of 27 675379 06/14/2023 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents environment remained free of accident hazards by not adequately monitoring the proper storage of oxygen cylinders for 1 of 1 resident (Resident #16) reviewed for accident hazards. The facility failed to ensure Resident #16's oxygen cylinder was properly stored. This deficient practice could place residents at risk of injury. Findings included: Record review of Resident #16's face sheet, dated 06/13/23, indicated she was a [AGE] year-old female, admitted on [DATE]. She had diagnoses that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), muscle weakness (a lack of strength in muscles) , and chronic respiratory failure with hypoxia (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). Record review of Resident #16's quarterly MDS, dated [DATE], indicated she was usually able to make herself understood, and was usually able to understand others. She had a BIMS score of 14, which indicated intact cognition. She did not exhibit behaviors of rejection of care or wandering. She required extensive assistance to total dependence for all ADLs except for eating, which she required no assistance from staff. The MDS indicated she required oxygen therapy only while a resident in the facility. Record review of Resident #16's physician's orders, dated 06/01/23-06/30/23, indicated she had an order for 3L/min per nasal cannula continuously, every shift. The order start date was 06/02/23. Record review of Resident #16's care plan, dated 02/14/23, and revised on 05/17/23, indicated a problem of potential for ineffective breathing pattern related to chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). The goal was that resident will maintain adequate breathing pattern. The approaches included assess and report changes in level of consciousness, change oxygen tubing every week and as needed, elevate head of bed per request and to alleviate shortness of breath, monitor pulse oximetry per physician, and oxygen per physician's order. During an observation on 06/12/23 at 08:48 AM, Resident #16 was laying in bed in her room. There was a free-standing oxygen tank next to her oxygen concentrator. It was not attached to anything, and it was not in a cart or caddy. During an observation on 06/12/23 at 03:34 PM, Resident #16 was laying in bed in her room. There was a free-standing oxygen tank next to her oxygen concentrator. It was not attached to anything, and it was not in a cart or caddy. During an observation on 06/13/23 at 8:44 AM, Resident #16 was laying in bed in her room. There was a free-standing oxygen tank next to her oxygen concentrator. It was not attached to anything, and 675379 Page 6 of 27 675379 06/14/2023 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0689 it was not in a cart or caddy. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 06/13/23 at 11:07 AM, Resident #16 was laying in bed in her room. There was a free-standing oxygen tank next to her oxygen concentrator. It was not attached to anything, and it was not in a cart or caddy. Resident #16 said she was unsure how long the oxygen tank was there, and she was unable to recall any specific staff that could have brought it in her room. Residents Affected - Few During an interview on 06/13/23 at 11:08 AM, CNA E said she was taking care of Resident #16 on 06/13/23. She said she was not sure who left the portable oxygen tank in her room without a caddy or cart. She said it should be in a caddy or cart. She said the tank was a hazard and could fall and hurt a resident. During an interview on 06/13/23 at 11:11 AM, RN B said she was unsure who left the portable oxygen tank in Resident #16's room. She said the portable oxygen tank should be in a portable oxygen cart or caddy. She said it could fall over and hurt or trip a resident. During an interview on 06/14/23 at 11:41 AM, the ADON said he expected oxygen tanks to have been stored in a caddy for portable oxygen tanks. He said the charge nurse was responsible for monitoring that oxygen tanks were properly stored. He said the ADON and DON were ultimately responsible for the proper storage of oxygen tanks. He said Residents could suffer possible injury as a result of tripping over the tank or injury as a result of it falling on them. During an interview on 06/14/23 at 11:50 AM, the DON said she expected the portable oxygen tanks to have been stored either on a wheelchair oxygen holder or in an oxygen caddy. She said charge nurses were responsible for ensuring that oxygen tanks were properly stored. She said the ADON and ultimately the DON were responsible for monitoring the storage of oxygen tanks. She said residents could suffer possible injury as a result of tripping over the tank or injury as a result of it falling on them. During an interview on 06/14/23 at 12:56 PM, the Administrator said she expected the oxygen tanks to have been stored per facility policy. She said they should have been in a caddy instead of free-standing on the floor. She said the nurses and aides were responsible for ensuring that oxygen tanks were properly stored. She said the ADON should have caught it on his rounds. She said the DON was also responsible and ultimately the Administrator as the head of the building. She said the residents could be at risk of being injured by the oxygen tank falling over and being damaged. She said it was possible the tank could explode if it was damaged. She said residents could also fall over and potentially trip on the tank if it fell. Record review of the facility's oxygen storage policy, effective March 2019, stated: Subject Oxygen Storage Standard The facility requires that all personnel observe the center and regulatory guidelines for storage of oxygen. A no smoking sign must be displayed in all areas where oxygen is stored. 675379 Page 7 of 27 675379 06/14/2023 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0689 Procedure Level of Harm - Minimal harm or potential for actual harm Compressed Oxygen Cylinders 1. Label and separate empty and full cylinders. Residents Affected - Few 2. Keep Cylinders in an approved oxygen cart or storage bin. If cylinders are not in a storage cart or storage bin, they must be secured by a chain or other suitable retainer device. 3. Keep oxygen away from flammable materials 675379 Page 8 of 27 675379 06/14/2023 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services for 3 of 5 residents (Resident #13, #18, #215) reviewed for urinary catheters. 1.Resident #13 had an indwelling urinary catheter since admission on [DATE] without a physician's order with an acceptable diagnosis for use. 2.The facility failed to ensure Resident #215 had a physician's order for her indwelling urinary catheter with appropriate diagnosis for use. 3.The facility failed to ensure Resident #215's and Resident #18's foley catheters were properly secured to prevent pulling or trauma. These deficient practices could affect residents who had urinary catheters at risk of not receiving care needed. The findings included: 1.Record review of Resident #13's face sheet dated 06/14/23 indicated the resident was a [AGE] year old female who admitted to the facility on [DATE] with the diagnosis acute cystitis of the bladder (a urinary infection in the bladder), neuromuscular dysfunction of the bladder (the nerves don't work well to empty or fill the bladder), chronic obstructive pulmonary disease (lung disease causing difficulty breathing), chronic kidney disease, and heart failure. Record review of Resident #13's admission MDS assessment dated [DATE] indicated it was not due and not completed. Record review of Resident #13's admission orders date 06/07/23 indicated she had an order to Change F/C PRN for signs and symptoms of infection or obstruction. Resident #13's admission orders did not indicate resident had a foley catheter or for what diagnosis. Record review of Resident #13's Physician Order Report dated 06/01/2023-06/30/2023 indicated an order dated 06/07/2023, May change 16fr foley catheter PRN for blockage/leakage Every shift -PRN; PRN 1, PRN 2, PRN 3, PRN 4 with and end date open. During an observation on 06/11/23 at 10:46 AM Resident #13 had a foley catheter in place with a drainage bag hanging to the right side of her bed draining clear, yellow urine. During an observation on 06/12/23 at 08:54 AM Resident #13 had a foley catheter in place with a drainage bag hanging to the right side of her bed draining clear, yellow urine. During an observation on 06/14/23 at 2:20 PM Resident #13 had a foley catheter in place with a drainage bag hanging to the right side of her bed draining clear, yellow urine. Resident #13 refused foley care observation. 675379 Page 9 of 27 675379 06/14/2023 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 06/14/23 the DON said that the admitting charge nurse was responsible for writing the order for the foley catheter upon admission. She said the medical records nurse should have placed order in the computer when she received it and should have recognized the order for the catheter and diagnosis being missing. She said her and the ADON also reviewed orders after they are input, and they failed to catch the order for the catheter and diagnosis not being in the orders. The DON said the failure could have placed Resident #13 at risk for infection. During a telephone interview on 06/14/23 at 3:57 PM RN A said she was the admitting nurse for Resident #13 and knew every resident with a catheter required an order, but she had missed placing the order for the catheter and was unsure of the diagnosis. 2. Record review of Resident #215's face sheet dated 06/13/23, indicated a [AGE] year-old female who admitted to the facility on [DATE]. Resident #215's diagnoses included sepsis (a life-threatening complication of an infection), essential hypertension (high blood pressure), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), gastrostomy (artificial external opening into the stomach for nutritional support), and dysphagia (difficulty swallowing). Record review of Resident #215 baseline care plan dated 05/30/23, indicated Resident #215 had an alteration in urinary function related to indwelling catheter. The baseline care plan interventions included catheter care per facility protocol and physician orders, empty drainage bag every shift and change catheter per physician orders/facility protocol. Record review of Resident #215's physician order dated 05/30/23 indicate the following orders: * Foley catheter care every shift * Change 16 French foley as needed leakage and blockage * Change foley catheter drainage bag every two weeks Further review of this physician's order did not indicate a diagnoses for the use of the indwelling catheter. Record review of Resident #215's admission MDS assessment dated [DATE], indicated she rarely understood and rarely understood others. The MDS had no checked if a BIMS could be conducted. The MDS indicated Resident #251 required extensive assistance with bed mobility and was totally dependent on staff for dressing, eating, toileting, personal hygiene, and bathing. The MDS indicated Resident #215 had an indwelling catheter. The MDS indicated Resident #251 had one unhealed stage four pressure ulcer present on admission. During an observation on 06/11/23 at 10:52 AM, Resident #251's foley catheter was hanging on the left side of the bed with a privacy covering on it. Resident #251 was not interviewable. During an observation on 06/13/23 at 10:00 AM, LVN F pulled back Resident #251's blankets and no catheter leg strap was observed. Resident's 251 foley catheter was attached to the left side of the bed. LVN F said Resident #251 should have had a leg strap to keep the catheter secured and prevent from pulling. During an interview on 06/13/23 at 10:12 AM, RN A said Resident #251 admitted to the facility with 675379 Page 10 of 27 675379 06/14/2023 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the indwelling catheter in place. RN A said she was unsure as to why Resident #251 had a catheter. RN A said Resident #251 should have a leg strap to keep the catheter secure and prevent from pulling. RN A said by not having the catheter leg strap in place could cause the catheter to be pulled out and injure the resident. RN A said the charge nurse was responsible for ensuring the leg strap was in place. During an interview on 06/14/23 at 12:13 PM, RN A said Resident #251 should have had an order for her catheter with the appropriate diagnoses. RN A said she was unsure as to why the order for the catheter was needed. RN A said the admitting nurse was responsible for ensuring the order for the catheter with appropriate diagnoses was written. RN A said she was the nurse who admitted Resident #251 to the facility. RN A said she had never written an order for the catheter itself. RN A said they used to transcribe orders for catheter care but unsure as to why they stopped. RN A said the CNAs usually informed her if the catheter was not attached to the leg strap, but it was ultimately her responsibility to ensure the catheters were properly secured. During an interview on 06/14/23 at 12:40 PM, the DON said Resident #251 should have an order for the indwelling catheter with appropriate diagnoses. The DON said anything that was considered invasive required a doctor's order. The DON said she expected the foley catheters to be properly secured to reduce the risk of dislodgement. The DON said the admitting nurse was responsible for ensuring an order for the foley catheter was obtained. The DON said the ADON and herself were also responsible for ensuring Resident #251 had an order for her foley catheter with appropriate diagnoses. During an interview on 06/14/23 at 02:05 PM, the Administrator said she expected Resident #251 to have an order for her foley catheter with appropriate diagnosis for use. The Administrator said by not having an order, nursing staff would not know it was there or be able to properly care for it. The Administrator said it was missed communication by not having the foley catheter order. The Administrator said the ADON and the DON were responsible for ensuring the foley catheter order was in place. 3. Record review of Resident #18's face sheet, dated 06/13/23, indicated an [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included urinary retention (a condition where your bladder doesn't completely empty each time you urinate), benign prostatic hyperplasia (when your prostate gland becomes larger than normal), and heart failure (occurs when the heart muscle doesn't pump blood as well as it should). Record review of Resident #18's significant change in status MDS assessment, dated 06/08/23, indicated Resident #18 was usually understood and usually understood others. Resident #18's BIMs score was 10, which indicated he was moderately cognitively impaired. Resident #18 required total assist with toilet use and dressing, limited assist with transfer, bed mobility, supervision with personal hygiene and independent with eating. Record review of Resident #18's physicians order dated 05/31/23 indicated: May have foley catheter 14 FR PRN for blockage with diagnosis of urinary retention. Record review of Resident #18's baseline care plan dated 05/26/23 indicated Resident #18 had a foley catheter. The interventions were catheter care per facility protocol/physician orders. Empty drainage bag every shift and change catheter per physician orders/facility protocol. Monitor for sign and symptoms of UTI and encourage fluids. During an observation on 06/12/23 at 9:20 a.m., Resident #18 was in his bed with no catheter leg 675379 Page 11 of 27 675379 06/14/2023 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0690 strap. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 06/13/23 at 3:28 p.m., Resident #18 was in his bed with no catheter strap. RN B entered room and verified Resident #18 had no catheter strap in place. RN B said this resident should have a catheter strap to prevent dislodgement. She said she would go get a strap. Residents Affected - Some During an interview on 06/14/23 at 2:21p.m., the ADON said all foley catheters required a diagnosis, size, and frequency of changes. He said foley catheter care should be done with incontinent care. The ADON said all foley catheters should have a catheter secure strap. He said they were out of straps in the facility and had placed an order. The ADON said the catheter straps were used to secure the foley in place and prevent skin issues. During an interview on 06/14/23 at 2:43 p.m., the DON said all foley catheters required an order, size, and diagnosis. The DON said nurses were responsible to make sure residents with Foleys had a secure strap in place and she and the ADON were to make weekly spot checks. The DON said failure to have secure strap in place could cause dislodgement of the foley. During an interview on 06/14/23 at 3:42 p.m., the administrator said she knew secure catheter strap should be in place. She said the charge nurses were responsible to ensure catheter straps were in place and nurse management were to follow up. The administrator said the leg catheter straps were used to prevent foleys from coming out. Record review of the facility's policy titled, Urinary care and Maintenance, dated March 2019, indicated Standard precautions will be followed during the care and maintenance of urinary catheters and the collection system. The clinician will assess the catheter system for patency and integrity every shift and if the catheter system was damaged, blocked, leaking, or if any encrustation was present the catheter and catheter system will be changed. The purpose of the Foley catheter was to minimize the risk of urinary tract infection and to provide care and comfort to the residents or patient. #17 assure catheter was properly secured. #18 prevent catheter tubing from kinking. #33 check that the catheter was attached to the thigh or abdomen or as ordered. #44 monitor proper placement of the catheter cover, drainage bag and tubing every shift. Record review of the facility policy Physicians Orders effective December 2018 indicated .The facility would have physician's orders for their immediate care. 675379 Page 12 of 27 675379 06/14/2023 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.Record review of Resident #46's face sheet, dated 06/13/23, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Gastrostomy status (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (impaired ability to remember, think, or make decisions), and stroke( occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts). Record review of Resident #46's quarterly MDS assessment, dated 03/31/23, indicated Resident #46 was sometimes understood and sometimes understood others. Resident #46's BIMs score was 04s, which indicated she was severely cognitively impaired. Resident #46 required total assistance with eating, toilet use, dressing, and bathing, limited assist with bed mobility, transfer, and personal hygiene. The MDS indicate she received tube feeding during the 7 days look back period. Record review of Resident #46's physicians order dated 06/02/23 indicated: Enteral feedings: Jevity strength 1.5, flow rate at 70ml/hour x 14, water flush at 55ml/hour x 14hours. Special instructions: May give Glucerna 1.2 at 75ml/hr x 22 hours with 30ml of water flushes x 22 hours if Jevity not available. Record review of Resident #46's comprehensive care plan, dated 04/14/23, indicated Resident #46 had enteral feedings related to stroke, history of choking while swallowing and abnormal swallow study. The interventions were to administer tube feeding formula as ordered by the physician. Record review of Resident #46's medication administration record revealed Resident #46 received Jevity strength 1.5, flow rate at 70ml/hour x 14, water flush at 55ml/hour. x 14hours or Glucerna 1.2 at 75ml/hour x 22 hours with 30ml of water flushes x 22 hours if Jevity not available from 06/01/23 through 06/13/23. During an observation on 06/11/23 at 9:43 a.m., Resident #46 was in her bed receiving formula of Glucerna 1.2 at 80mls/hr with 55mls/hr of water via her gastrostomy tube. During an observation on 06/11/23 at 12:48 p.m., Resident #46 was sitting in the hallway in her wheelchair without any enteral feedings as ordered x 22 hours. During an observation on 06/12/23 at 9:52 a.m., Resident #46 was in her bed receiving formula of Glucerna 1.2 at 80mls/hr with 55mls/hr of water via her gastrostomy tube. During an observation on 06/12/23 at 1:48 p.m., Resident #46 was sitting in the hallway in her wheelchair without any enteral feedings as ordered x 22 hours. During an interview on 06/12/23 at 4:55 p.m., RN B said Resident #46 was on Jevity 1.5 but they were out so she had Glucerna 1.2 as the substitute. RN B said they started substituting with Glucerna 1.2 on Friday (06/09/23). RN B said she took down Resident #46's Glucerna 1.2 this morning (06/12/23) and yesterday (06/11/23) at 10:00am. During an interview on 06/13/23 at 1:34 p.m., the dietitian said she reviewed Resident #46's orders 675379 Page 13 of 27 675379 06/14/2023 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0693 Level of Harm - Minimal harm or potential for actual harm today (06/13/23) and recommended her orders to change to Glucerna 1.2 at 90mls/hr X14 hours with 35mls/hr of water to equal 1512kcal/day. The dietitian said she thought she had made formula recommendations in April 2023 but could not remember what the recommendations were. The dietitian said Resident #46 missed some calories if she was not receiving Glucerna 1.2 at 90mls/hr and could potentially cause weight loss and skin issues. Residents Affected - Few During an interview on 06/13/23 at 1:50 p.m., RN B said prior to today (06/13/23) Resident # 46 should have received Glucerna 1.2 at 75mls/hr X 22 hours. She said she was not following the correct orders. RN B said not following physicians order for Resident #46 could potentially cause weight loss, lead to skin or overall health issues. During an interview on 06/14/23 at 2:21p.m., the ADON said he expected the nurses to follow the physician's orders. He said he and the DON were responsible to ensure orders were followed. The ADON said failure to follow Resident #46's orders for enteral feedings could lead to potential weight loss. During an interview on 06/14/23 at 2:43 p.m., the DON said she expected the nurses to read all residents' orders daily because they could change. She said if the nurses did not understand an order, they needed to call the doctor to get further orders. The DON said she thought Resident #46's order were a transcription error because she remembered talking to the dietitian about her requesting to be up and off enteral feedings. She said her and the ADON were responsible to ensure nurses were following prescribed orders. The DON said this failure could place Resident #46 at risk for weight loss. During an interview on 06/14/23 at 3:42 p.m., the administrator said she expected the nurse to read the MARs correctly. She said nurse management should be reviewing the orders for accuracy. The administrator said this failure could cause potential weight lost. Record review of the facility policy Physicians Orders effective December 2018 indicated .At the time each resident/patient is admitted , the facility will have physician's orders for their immediate care. If the admitting physician is not going to be the patients/resident's attending physician while in the facility, the physician's orders will be verified by the attending physician at the facility .10. Discontinue the original physician's order when the physician changes an order that is currently in place. Assure the new order reflects the change . Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 2 of 2 residents reviewed for enteral nutrition (Resident #46 and Resident #215). The facility failed to follow the physician orders for enteral feedings (a form of nutrition that is delivered into the digestive system as a liquid form via the feeding tube) for Resident #215 and Resident #46. This failure could affect residents receiving enteral nutrition and hydration by placing them at risk of health complications. Findings included: 1. Record review of Resident #215's face sheet dated 06/13/23, indicated a [AGE] year-old female who admitted to the facility on [DATE]. Resident #215's diagnoses included sepsis (a life-threatening 675379 Page 14 of 27 675379 06/14/2023 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few complication of an infection), essential hypertension (high blood pressure), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), gastrostomy (artificial external opening into the stomach for nutritional support), and dysphagia (difficulty swallowing). Record review of Resident #215's baseline care plan dated 05/30/23, indicated Resident #215 had the potential for alteration in nutrition related to peg/enteral feedings. The baseline care interventions included to administer tube feedings/water flushes as ordered by the medical director. Record review of Resident #215's admission MDS assessment dated [DATE], indicated she rarely understood and rarely understood others. The MDS had no checked if a BIMS could be conducted, and the staff assessment for mental status indicated Resident #215 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident #215 required extensive assistance with bed mobility and was totally dependent on staff for dressing, eating, toileting, personal hygiene, and bathing. The MDS indicated Resident #215 had a feeding tube. Record review of Resident #215's physician order report dated 06/1/23-06/30/23 indicated Resident #215 had an order for enteral feeding Jevity 1.5 at 40ml/hr with water flush at 40ml/hr every shift with a start date of 05/30/23. During an observation on 06/11/23 at 10:52 AM, Resident #215 was receiving Glucerna 1.2 at 40mls/hr with 40mls/hr water flushes via her gastrostomy tube. During an observation on 06/12/23 at 01:55 PM, Resident #215 was receiving Glucerna 1.2 at 40mls/hr with 40mls/hr water flushes via her gastrostomy tube. During an interview and record review on 06/12/23 at 04:27 PM, LVN C said Resident #215 should be receiving Jevity but they were substituting with Glucerna as they were out of Jevity. LVN C said Resident #215 should have an order to substitute with Glucerna 1.2 at 40mls/hr. LVN C reviewed Resident #215 medical chart and said Resident #215 did not have an order to substitute with Glucerna. LVN C said the nurse who received the order was responsible for writing the order. LVN C said Resident #215 not receiving the correct enteral feeding would be considered a medication error. Record review of Resident #215's medication administration record dated 06/01/23-06/30/23, indicated Jevity 1.5 at 40mls/hr had been administered until 06/12/23. The medication administration record also indicated Resident #215 had an order for may substitute Jevity 1.5 with Glucerna 1.2 at 40ml/hr with water flush at 40mls/hr with a start date of 06/12/23 (after the surveyor's observation). During an interview on 06/14/23 at 12:40 PM, the DON said she expected the correct enteral feeding to be administered and the correct order of the feeding in place. The DON said they had been consulting with the dietician regarding supply issues and requesting substitute orders. The DON said Resident #215 was at risk for weight loss due to not receiving the ordered enteral feeding. During an interview on 06/14/23 at 02:05 PM, the Administrator said she expected Resident #215 to receive the correct feeding per the physicians' orders. The Administrator said previously the nurses had orders to subtitute Jevity for Glucerna. The Administrator said the nurse receiving the order was responsible for ensuring the order for substituting the feeding was in place. The Administrator said the ADON reviewed the physician's orders for accuracy. The Administrator said by not receiving the correct feeding the Resident #215 was at risk for weight loss. 675379 Page 15 of 27 675379 06/14/2023 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 1 storage area reviewed for expired and discontinued medications. The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. This failure could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion. Findings included: During an observation and interview on [DATE] at 02:00 PM, the following medications were observed in the controlled medication storage area waiting to be disposed: *Lorazepam 2mg/ml suspension- 22 mls RX# C743209 *ABH gel 2mg/25mg/5mg/ml- 4 mls RX# C742813 *Tramadol 50mg- 14 tablets RX# 4039352 *Lorazepam 1mg- 16.5 tablets RX# 529545 *Alprazolam 1mg- 29 tablets RX# 527251 *Tramadol 50mg- 8 tablets RX# 508628 *Lorazepam 0.5mg- 12 tablets RX# 527279 *Morphine 100mg/5ml- 18 mls RX# N743242 *Lorazepam 2mg/ml- 29.5 mls RX# 2406990 *Morphine 100mg/5mls- 15 mls RX# 3105239 *Diazepam 2mg- 25 tablets RX# 4052827 *Lorazepam 2mg/ml- 29mls RX# C742651 *Hydrocodone/APAP 5/325mg- 59 tablets RX# 110417 *Hydrocodone 10/325mg- 28 tablets RX # N742866 *Hydrocodone-APAP 10/325mg- 3 tablets RX N739199 675379 Page 16 of 27 675379 06/14/2023 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0755 *Clonazepam 1mg- 24 tablets- RX # C742371 Level of Harm - Minimal harm or potential for actual harm The DON said she did not keep a log of the controlled medications awaiting to be disposed. The DON said she logged all discontinued or narcotic medications on the day of the medication destruction with the pharmacist. The DON said she had always logged them the day of medication destruction and it had never been a concern. The DON said her process when she reconciled medications that need to be disposed of was as follows: when medications were brought to her, she checked the narcotic medication count to ensure the correct count was there, and then placed the medication in the locked cabinet . The DON said she was the only one with the key to the locked cabinet. The DON said by not logging the narcotic medications as soon as she received them, anything could come up missing. The DON said it was her responsibility to reconcile the narcotic medications. Residents Affected - Some Record review of the facility's medication destruction book on [DATE], indicated the last medication destruction was completed on [DATE]., During an interview on [DATE] at 02:05 PM, the Administrator said when narcotic medications were discontinued, the nurse takes the medication to the DON. The DON then checks the count and signs off the count was correct and locks the medication until the pharmacist comes to the facility for medication destruction. The Administrator said the DON logs the medications on the day they were destroyed. The Administrator said she was unsure if the DON logged the discontinued narcotic medication when she received them. The Administrator said it was best practice to log the medications as soon as they were received but it was not a requirement to log them. The Administrator said if the medications were not reconciled then you would not know if a medication was missing, diverted, or taken. The Administrator said the DON and the pharmacist were responsible of ensuring the narcotic medications were accurately reconciled. Record review of the facility's policy Medication- Controlled Administration effective [DATE], indicated .Medications included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal, and record keeping it the facility, in accordance with federal and state laws and regulations. 1. The Director of Nursing and the Consultant Pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications .3. Medications listed in Schedules, II, III, IV and V dispensed by the pharmacy will be adequately documented and accurately reconciled consistent with law and regulation .10. Controlled medications remaining in the facility after the order has been discontinued/expired are retained in the facility in a securely locked area with restricted access until destroyed by two licensed clinicians or as otherwise directed by state law . 675379 Page 17 of 27 675379 06/14/2023 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #41's face sheet, dated 06/14/23, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included heart attack (when your heart muscle begins to die because it isn't getting enough blood flow), high blood pressure, dementia (impaired ability to remember, think, or make decisions), respiratory failure (when the respiratory system cannot adequately provide oxygen to the body),and anxiety (feelings of nervousness, panic and fear as well as sweating and a rapid heartbeat). Record review of Resident #41's admission MDS assessment, dated 05/21/23, indicated Resident #41 was understood and understood others. Resident #41's BIMs score was 12, which indicated he was moderately cognitively impaired. Resident #41 was independent with transfer, dressing, bathing, bed mobility, personal hygiene and required supervision with toilet use. The MDS indicate Resident #41 received 6 doses of antianxiety medication during the 7 days look back period. Record review of Resident #41's physicians order dated 03/28/23 indicated: Xanax (antianxiety) 1 mg, give 1 tablet at night. Record review of Resident #41's medication administration record indicated he received Xanax nightly from 06/01/23 thru 06/13/23. Record review of Resident #41's medication administration record did not indicate any behavior monitoring for Xanax. Record review of Resident #41's comprehensive care plan, dated 05/31/23, indicated Resident #41 had potential for drug complications related to anxiolytic/sedative medication. The interventions of the care plan were to consult pharmacy on medication regimen every month and as needed, monitor for fall risk, monitor for orthostatic hypotension, monitor for side effects, and review and discuss during behavior intervention team meetings. During an interview on 06/14/23 at 2:21p.m., the ADON said the facility should have behavior monitoring sheets in place to ensure the medication was working. He said if the resident had increased or decreased anxiety this was a way to prove the medication was or was not working. The ADON said nursing staff usually checks the behavior monitoring sheets at the beginning of each month to ensure residents who needed them were in place. He said apparently, some of the resident sheets were missed. The ADON said without monitoring the behavior effects of the medication, they would not know if the medication was effective. During an interview on 06/14/23 at 2:43 p.m., the DON said all residents who required behavior monitoring should have sheets in place. She said nursing staff usually reviewed them monthly. The DON said she was unaware Resident #41 did not have a behavior monitoring sheet in place. She said she and the ADON were going to put a system in place to ensure everyone who needed behavior monitor sheets were in place. The DON said failure to monitor behaviors could lead to residents continuing an unnecessary medication. During an interview on 06/14/23 at 3:42 p.m., the administrator said nurses should be monitoring 675379 Page 18 of 27 675379 06/14/2023 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few behavior each shift for residents who required behavior monitor. She said nurse management should be following up on behavior monitoring sheets. The administrator said failure to monitor behaviors appropriately could lead to unnecessary medications. Record review of the facility's policy Psychotropic Medications effective August 2018 indicated .The facility strives to assure the appropriate use of psychotropic medications to enhance the quality of life of residents/patients who exhibit harmful behavioral symptoms .Verify the physician order contains the appropriate clinically supported diagnosis and reason for use . 13. Document frequency of behavioral symptoms on the Behaviors Tracking Record. Based on interview and record review the facility failed to have target behavioral monitoring in place for behaviors associated with the use of psychotropic medications and documented in the clinical record for 2 of 5 residents reviewed for unnecessary psychotropic drugs (Resident #25 and Resident #41). 1.The facility failed to adequately monitor Resident #25's behaviors regarding his antidepressant and antianxiety medications. 2.The facility failed to adequately monitor Resident #41's behaviors regarding his antianxiety medication. These failures could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: 1. Record review of Resident # 25's face sheet dated 06/14/23, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #25's diagnoses included diabetes (a group of diseases that result in too much sugar in blood), dementia (memory loss), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and metabolic encephalopathy (problem in the brain that is caused by chemical imbalance in the blood). Record review of Resident #25's significant change in status MDS assessment dated [DATE], indicated he was usually understood and usually understood others. The MDS indicated Resident #25 had a BIMS score of 12 which indicated his cognition was moderately impaired. Resident #25 required extensive assistance with bed mobility, transfers, locomotion, dressing, toileting, personal hygiene and was totally dependent on staff on bathing. The MDS indicated Resident #25 received antianxiety medications 5 days of 7 days and received antidepressant medication for 7 of 7 days of the look back period. Record review of Resident #25's comprehensive care plan dated 04/05/23 indicated he had the potential for drug related complications related to anxiolytics and antidepressant medications. The care plan interventions included to monitor for side of effects and if any side effects were noted, document side effects in the medical record and notify the physician. Record review of Resident #25's physician order report dated 06/01/23-06/30/23, indicted he had the following orders: *Lorazepam (antianxiety medication) 0.5mg one tablet by mouth twice a day with a start date of 675379 Page 19 of 27 675379 06/14/2023 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0758 05/31/23 Level of Harm - Minimal harm or potential for actual harm *Sertraline (antidepressant medication) 100mg one tablet by mouth twice a day with a start date of 05/31/23 Residents Affected - Few *anti-anxiety medication use- observe resident closely for significant side effects: sedation, drowsiness, ataxia (drunk walk), dizziness, nausea, vomiting, confusion, headache, blurred vision, skin rash- every shift with a start date of 05/31/23. *anti-depressant medication use- observe resident closely for significant side effects: sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photosensitivity (skin), excessive weight gain- every shift with a start date of 05/31/23. The physician order report did not indicate Resident #25 had any behavior monitoring for the use of antidepressant or antianxiety medications. During an interview on 06/14/23 at 12:13PM, RN A said when she received an order for psychotropic medications a consent was obtained, and the resident was monitored for behaviors and side effects. RN A said was unaware of what triggered the target behavior monitoring sheet. RN A said behavior monitoring was documented for the first 3 days after starting a psychotropic medication but after the initial 3 days behavior monitoring was no longer documented. During an interview on 06/14/23 at 12:28 PM, the ADON said when a psychotropic medication was initiated the family was notified to obtain a consent for the psychotropic medication. The ADON said they would also monitor for side effects and behaviors. The ADON said it was important to monitor for side effects and behaviors to evaluate if the medication was effective. During an interview on 06/14/23 at 12:40 PM, the DON said when a resident was on a psychotropic medication, behavior monitoring should be documented. The DON said not having behavior monitoring was a medical records oversight. The DON said it was the medical records nurse to ensure the behavior monitoring was in place. The DON said there was not a process in place for monitoring residents receiving antipsychotics medications. The DON said by monitoring the resident's behaviors would determine if the medication was beneficial to the resident. During an interview on 06/14/23 at 01:18 PM, LVN L said she did medical records. LVN L said she did not put in the behavior monitoring unless she has received an order for it. LVN L said she was unsure if psychotropic medications required behavior monitoring. LVN L said when a resident was started on psychotropic medication, she was only aware she had to include the side effect monitoring for those medications. During an interview on 06/14/23 at 02:05 PM, the Administrator said she expected residents that were receiving psychotropic medications to have their behaviors monitored. The Administrator said by not monitoring the resident's behaviors they would not know the effectiveness of medications. The Administrator said the DON and ADON were responsible to ensure behavior monitoring was in place. 675379 Page 20 of 27 675379 06/14/2023 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. 2.During an observation on 06/12/23 at 11:32 a.m., RN A left the medication cart #2 unlocked when entering a resident's room. Staff and other residents observed in hallway. RN A came back to the medication cart, left medication cart unlock again leaving access to unauthorized personal to enter the cart. During an interview on 06/12/23 at 11:44 a.m., RN A said she forgot to lock the medication cart before walking into the resident's room. RN A said she was aware she was supposed to lock the medication cart anytime she stepped away. RN A said failure to lock the medication cart could leave access for anyone to get into the cart and take medication. During an observation and interview on 06/13/23 at 8:53 a.m., RN B observed to walk down hallway leaving the treatment cart unlocked. Observed staff, residents and visitors walking the by the nurse's station unlocked treatment cart. RN B returned to the nurse's station and when questioned, said she did not lock the treatment cart because she did not have the key. She said she knew it could be a hazard to leave the treatment cart open because the residents could open the cart and take things out (the cart contained items such as: scissors, zinc oxide and bleach wipes that could potential be harmful). RN B said she would get with the DON about what steps she should take and ask about the key. During an interview on 06/13/23 at 9:15 a.m., the DON said the treatment nurse took the key home with her on yesterday (06/12/23). The DON said the ADON had a spare key to the treatment cart and they locked the treatment cart. The DON said she would get more keys made. During an interview on 06/14/23 at 2:21p.m., the ADON said he expected the nurses to always keep the medication and treatment carts locked for the security of the medications. He said he and the DON were responsible to ensure nurses locked the cart but all nurses should be accountability for their actions when medications carts were not locked while in use. The ADON said failure to lock the medication or treatment cart could lead to someone stealing medication or a resident opening the cart and taken the wrong medication. During an interview on 06/14/23 at 2:43 p.m., the DON said she expected the nurses to keep the treatment cart and medication cart locked while not in direction supervision. She said she and the ADON were the overseer of nurses locking their carts. The DON said leaving the treatment or medication cart open could potentially be harmful to residents who might take the scissors and hurt themselves or take medication thinking it was candy and overdose. During an interview on 06/14/23 at 3:42 p.m., the administrator said nurse management were the overseer of staff ensuring medication or treatment carts were locked. She said if carts were left open anyone could obtain anything off the carts without authorization. The administrator said she expect medication and treatment carts to be locked to ensure safety of others. Record review of the facility's policy Medication Administration Procedure, dated March 2019, indicated, Keep medication cart locked when not in use. Assure controlled substance are double locked. Maintain medication key with licensed nurse at all times. Record review of the facility's policy Medication- Controlled Administration effective December 675379 Page 21 of 27 675379 06/14/2023 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0761 Level of Harm - Minimal harm or potential for actual harm 2018, indicated .Medications included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal, and record keeping it the facility, in accordance with federal and state laws and regulations .c. Medications requiring refrigeration are stored in a refrigerator within a locked area, in a locked refrigerator, or in a locked and secured container within a refrigerator . Residents Affected - Some Based on observation and interview the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly for 2 of 4 medication carts (#2 medication cart and treatment cart) and 1 of 1 medication room observed for medication storage. The facility failed to ensure the lock box that contained narcotic medications was permanently affixed to the refrigerator in the medication room. The facility did not ensure #2 medication cart and the treatment cart were secured and unable to be accessed by unauthorized personnel. These failures could place residents at risk for not receiving drugs and biologicals as needed, medications being used passed their effective or expiration date, and a drug diversion. Findings include: 1. During an observation and interview on 06/12/23 at 09:35 AM, the facility's medication room storage was reviewed and inside the medication refrigerator was a lock box that was not permanently affixed. LVN F said there were narcotic medications inside the lock box and RN B had the key. During an observation and interview on 06/13/23 at 09:40 AM, RN B entered the medication storage room and obtained the lock box from the fridge and placed it on the counter. RN B opened the lock box and inside were two bottles of dronabinol (narcotic) medication. RN B said dronabinol was considered a narcotic medication and the reason why it had to be locked. RN B said the lock box had not been attached to the fridge. The refrigerator did not have a lock either. RN B said by the lock box not being permanently attached to the fridge someone could take it. During an interview on 06/12/23 at 09:50 AM, the DON said the lock box inside the fridge in the medication room had not been permanently affixed to the fridge and the fridge itself had never had a lock on it either. The DON said by not having the lock box permanently affixed, medications could come up missing. The DON said she believed she was responsible for ensuring the narcotic medications were properly secured. During an interview on 06/14/23 at 02:05 PM, the Administrator said the lock box containing the narcotic medications should have been permanently affixed because if someone went inside the medication room that was not supposed to, could take the lock box. The Administrator said the nurse, DON and pharmacy consultant were responsible for ensuring the lock box was permanently attached to the refrigerator. 675379 Page 22 of 27 675379 06/14/2023 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety in the facility's only kitchen, reviewed for kitchen sanitation. 1. The facility failed to ensure refrigerated foods were properly labeled and dated. 2. The facility failed to ensure expired foods were not in the refrigerator. 3. The facility failed to ensure food was thawed properly. These failures could place residents at risk for food-borne illness. Findings included: During an observation on 06/11/23 at 09:18 AM, two frozen pork loins and one roll of frozen ground beef were found in a sink full of water without running water. They were not labelled or dated. During an interview on 06/11/23 at 09:20 AM, [NAME] D said she was working in the kitchen on 06/11/23. She said she had just put the meat in the sink before surveyors arrived to the facility. She said she forgot to leave the water running over the thawing meat. She said there should have been running water over the thawing meat. She said residents could get sick if served improperly thawed food. During an observation of the refrigerators on 06/11/23 at 09:25 AM, there was one container labelled pureed desert without a date. There were two half-gallons of buttermilk that had expired on June 10th, 2023. There was a container labelled chicken noodle soup without an expiration date. During an interview on 06/11/23 at 9:30 AM, [NAME] D said she was unsure what the pureed desert was. She said it should have been labelled with the specific contents and should have been labelled with an expiration date. She said the chicken noodle soup should have been labelled with an expiration date. She said the buttermilk should have been thrown away when it was expired. She said residents could get sick if served expired food. During an interview on 06/12/23 at 12:10 PM, the Dietary Manager said she expected the kitchen staff to take out the meat the day before the meal to thaw. She said she expected the kitchen staff to submerge the meat in water and leave the faucet running with cold water to thaw the ground beef and pork loin. She said she expected the kitchen staff to label and date foods with the expiration date. She said she expected the staff to check for expired food daily and throw out expired food. She said residents could get sick if served improperly thawed or expired food. During an interview on 06/14/23 at 11:41 AM, the ADON said he was not aware of any residents that became sick directly because of the dietary department. He said he expected the kitchen staff to follow facility procedure and the regulation related to thawing food and storage and labeling of food. He said the DM was responsible for monitoring that the kitchen staff were properly thawing meat and properly storing and labeling foods. He said residents could suffer gastric upset, nausea, vomiting, or food poisoning if they were served improperly thawed or expired food. 675379 Page 23 of 27 675379 06/14/2023 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 06/14/23 at 11:50 AM, the DON said she was not aware of any issues of any residents getting sick as a result of the dietary department. She said she expected the kitchen staff to follow facility procedure and regulations related to thawing food and storage and labeling of food. She said the DM was responsible for monitoring kitchen staff were properly thawing meat, labeling food items, and disposing of expired food. She said residents could suffer food poisoning, gastric upset, nausea vomiting, and diarrhea if they were served improperly thawed or expired food. During an interview on 06/14/23 at 12:56 PM, the Administrator said no residents had been sick due to the dietary department. She said she expected the kitchen staff to follow the facility policy and the regulations for thawing food and storage and labelling of food. She said the DM was responsible for monitoring that kitchen staff were thawing food correctly, and storing and labelling food correctly. She said ultimately the responsibility falls to the Administrator as the head of the building. She said residents could suffer illness as a result of food borne pathogens if served improperly thawed food or expired food. Record review of the facility's thawing policy, effective September 2018, stated: Subject Thawing Purpose To thaw foods properly to prevent foodborne illness Procedure 1. Identify those foods needing to be thawed prior to the cooking process. 2. Pull food items (meat, supplements) from freezer and place in refrigerator 48-72 hours in advance to ensure the item is completely thawed a. Never thaw food at room temperature. b. Date the product the day it is placed in the refrigerator. 3. Thaw foods in the refrigerator at a temperature of 41 degrees F or less. a. Another approved method is to thaw food in the microwave only if it will be cooked immediately afterward .5. Thaw foods during the cooking process (i.e., hamburger patties, Salisbury steak, etc.) as long as the product reaches the minimum of 165 degrees F. Record review of the facility's storage policy, effective September 2018, stated: Subject Storage 675379 Page 24 of 27 675379 06/14/2023 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0812 Purpose Level of Harm - Minimal harm or potential for actual harm To store food, chemicals, and dishware in a safe manner. Procedure . Residents Affected - Some .Refrigerator storage . .6. Label products with delivery date indicating month, day, and year the product was received . .8. Label all leftovers with recipe name and date (month, day, year) of storage. 9. Discard refrigerated leftovers after 48 hours 675379 Page 25 of 27 675379 06/14/2023 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #13) reviewed for infection control. Residents Affected - Few The facility failed to ensure RN A performed hand hygiene while preforming glucometer checks (a small, portable device that lets you check your blood sugars) and administering insulin for Resident #13. This deficient practice could place residents at risk for infection due to improper care practices. Findings include: Record review of Resident #13's face sheet, dated 06/13/23, indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included diabetes (excess sugar in the blood), stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), glaucoma (eye diseases that can cause vision loss and blindness) and anxiety ( feelings of nervousness, panic and fear as well as sweating and a rapid heartbeat). Record review of Resident #13's quarterly MDS assessment, dated 05/24/23, indicated Resident #13 was usually understood and understood others. Resident #13's BIMs score was 15, which indicated she was cognitively intact. Resident #13 required total assistance with transfer, toilet use, dressing, bathing, bed mobility and limited assist with personal hygiene. The MDS indicate she received insulin during the 7 days look back period. Record review of Resident #13's physicians order dated 11/15/22 indicated: Give Novolog 22 units subcutaneous (an injection given in the fatty tissue, just under the skin) at 6:30a.m.,11:30a.m., and 4:30p.m. Record review of Resident #13's comprehensive care plan, dated 06/01/23, indicated Resident #13 received an antidiabetic/hypoglycemic agent and has the potential for alterations in blood glucose levels (Hyper/hypoglycemia) due to diabetes. The interventions of the care plan were for staff to administer insulin as ordered by physician, including sliding scale, monitor blood glucose levels as ordered by physician and to monitor for signs and symptoms of hyper/hypoglycemia such as alterations in level of consciousness, cool/clammy or hot flashes, etc. and to notify the physician of abnormal findings. During an observation on 06/12/23 at 11:32 a.m., RN A performed a blood sugar check on Resident #13. RN A came out to nurses' cart without sanitizing her hands and started touching other residents' insulin in medication cart while searching for Resident #13's insulin. RN A went into Resident #13's room, gave her the ordered insulin and came out of room without sanitizing her hands, then went to the next resident's room. During an interview on 06/12/23 at 11:44 a.m., RN A said she did not sanitize her hands after completing blood sugar check, before administrating insulin or after she completed insulin. LVN B said she was supposed to but she did not. RN A showed surveyor the ABHR gel sitting on top of cart and 675379 Page 26 of 27 675379 06/14/2023 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few again said, I should have hand sanitized before and after each procedure, but I did not. RN A said the failure of her not hand sanitizing could lead to infection control issues. During an interview on 06/14/23 at 2:21p.m., the ADON said he was the infection preventionist. He said he had done in-services on hand sanitizing. The ADON said all staff were required to hand sanitized before and after a procedure for sanitization, infection, and own personal hygiene. During an interview on 06/14/23 at 2:43 p.m., the DON said all staff should hand sanitize before and after a procedure to prevent the spread of infection. She said the ADON was the overseer of infection control. During an interview on 06/14/23 at 3:42 p.m., the administrator said she was not a nurse but knew nurses should preform hand hygiene before and after a procedure. She said nurse managers were the overseer for hand hygiene. The administrator said this was done to prevent infection control issues. Record review of competencies skills did not reveal RN A had been checked off on hand washing. Record review of the facility's policy, titled Handwashing/Hand Hygiene, dated September 2019, indicated The facility will follow the Center for Disease Control (CDC) guidelines for hand hygiene. Hand hygiene was the single most important procedure for preventing nosocomial infections. The facility requires personnel to wash hands thoroughly to remove dirt, organic material, and transient microorganisms. Hand washing or alcohol-based hand rub (ABHR) was mandated between resident/patient contact to prevent the spread of infection. Hands must be washed or ABHR after the following included, but not limited to: contact with body blood fluids, contact with mucus membranes, contact with residents or patients, touching wounds, contact with contaminated items or surfaces, removal of gloves following completion of a procedure, personal use of the toilet, and covering a cough or sneeze. Record review of the facility's policy titled, Infection Control, dated September 2019, indicated This facility strives to ensure the prevention and control of endemic or epidemic nosocomial infections for the protection of our residents, healthcare workers, and visitors. The goal of the program was to identify and reduce the risk of acquiring and transmitting infection among residents, employees, contract service workers, volunteers, students, and visitors. Healthcare workers will always utilize standard precautions and will utilize the transmission-based precautions such as contact, droplet or airborne as applicable. 675379 Page 27 of 27