Health inspection·December 11, 2025

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received therapeutic diets that were prescribed by the attending physician for 1 of 4 residents (Resident #1) reviewed for therapeutic diets. The facility failed to ensure Resident #1 received a diabetic diet (CCHO). This failure could place residents at risk for altered nutritional status and decreased quality of life.Findings included: Record review of Resident #1's electronic face sheet indicated a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #1 had diagnoses which included type 2 diabetes mellitus (high blood sugars), noninfective gastroenteritis and colitis (inflammation of the digestive tract), and gastrointestinal hemorrhage (bleeding from the digestive tract). Record review of Resident #1's Quarterly MDS assessment, dated 12/2/2025, indicated she usually understood others and was sometimes understood by others. Resident #1 had a BIMS score of 03, which indicated her cognition was severely impaired. Resident #1 required setup or clean-up assistance for eating. The MDS assessment did not indicate Resident #1 required a therapeutic diet. Record review of Resident #1's electronic Order Summary Report indicated she had an order for a regular diet with regular texture and thin consistency with a start date of 7/2/2024. Record review of Resident #1's care plan, last reviewed 5/12/2025, indicated she had the potential for nutritional problem/malnutrition related to diabetes mellitus with interventions that included: .2. Provide, serve diet as ordered. Monitor intake and record every meal. 3. RD to evaluate and make diet change recommendations PRN. Record review of Resident #1's care plan, last reviewed 5/12/2025, indicated she had GERD (gastroesophageal reflux disease) with interventions that included: .Avoid overeating. Provide small frequent meals rather than 3 large ones. Record review of Resident #1's electronic health record indicated the last nutrition assessment was completed was on 04/25/2025, and it did not address Resident #1's requirement of small frequent meals or diabetes mellitus. The nutrition assessment was signed completed on 04/25/2025. Record review of Resident #1's electronic health record indicated Resident #1 had a HGBA1C (blood test showing your average blood sugar levels over the past 2-3 months) level on 2/6/2025 of 7.3 (normal levels 4.7-5.7). Record review of Resident #1's electronic health record indicated Resident #1 had a HGBA1C (blood test showing your average blood sugar levels over the past 2-3 months) level on 11/21/2025 of 9.6 (normal levels 4.7-5.7). Record review of the facility's Concern/Grievance Report, dated 12/1/2025, filed by Resident #1's family member indicated Resident #1's family member was concerned about Resident #1's HGBA1C level had increased. The grievance indicated the report was received by the Administrator and did not include a resolution regarding Resident #1's family member's concern of Resident #1's HGBA1C level. The grievance indicated a care plan meeting would be scheduled to address concerns. During an observation on 12/11/2025 at 12:39 PM, LVN A showed the state surveyor her phone text messages to Resident #1's MD. At 10:35 AM, after state surveyor intervention, LVN A asked Resident #1's Page 1 of 3 675379 675379 12/11/2025 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few MD if Resident #1 could have a diabetic order diet. Resident #1's MD responded to the request and said yes, she could have an order for Resident #1 to have a diabetic diet. During an interview on 12/11/2025 at 9:45 AM, Resident #1's family member said Resident #1 had diabetes mellitus and GERD and was told she was supposed to have frequent small meals and a diabetic diet. Resident #1's family member said Resident #1 was supposed to have a diabetic diet and the facility could not accommodate her. She said she called the facility on 11/21/2025 and inquired about Resident #1's blood sugars and was told her HGBA1C level was a 9.6 (normal levels 4.7-5.7). She said when she asked about Resident #1 getting a diabetic diet, the ADON told her the facility did not offer a diabetic diet, and everybody received the same diet. During an interview on 12/11/2025 at 10:00 AM, Resident #1's family member #2 was at the facility and said when Resident #1 was at home they had always eaten healthy. He said they were able to control Resident #1's diabetes at home with her diet. He said since Resident #1 had been in the facility her blood sugars have been out of control. He said they feed Resident #1 hamburgers, hot dogs and all kinds of things a diabetic should not be eating. He said he addressed it with the facility, and nothing had changed. Resident #1's family member #2 said he had not been invited to attend any care plan meeting since Resident #1's family member had addressed concerns regarding her HGBA1C level. During an interview and record review on 12/11/2025 at 11:50 AM, the Dietary Manager said if a resident required a special diet the nursing staff notified dietary, and they tried to accommodate the diet. The Dietary Manager said a diet order should be completed and given to the kitchen. The Dietary Manager said she was not aware Resident #1 requested a diabetic diet and required small, frequent meals, and she was not provided with a diet order. During the interview with the Dietary Manager Resident #1's physician orders were reviewed and indicated Resident #1's diet order had been changed on 12/11/2025 at 11:10 am after State Surveyor intervention, to a diabetic diet (CCHO). During an interview and record review on 12/11/2025 at 11:55 AM, the RD said she had not assessed Resident #1, because she had taken over the facility in October of 2025 and Resident #1 had not triggered for her to be assessed. She said triggers for residents to be assessed consisted of weight gain, weight loss, and wounds which Resident #1 did not have. She said she would assess Resident #1 while she was at the facility that day. During an interview on 12/11/2025 at 12:50 PM, the DON said she changed Resident #1's diet order to a diabetic diet on 12/11/2025 at 11:10 AM after state surveyor intervention based on the RD's recommendation of a diabetic diet. She said she had a verbal discussion with the RD regarding Resident #1's HGBA1C level and the RD's recommendation was to change Resident #1's diet order to a diabetic diet (CCHO). When asked if it was normal to have a discussion with the RD regarding resident's lab values, she said yes, she called the RD at times to notify her of resident's lab values. When asked why Resident #1's lab values were discussed with the RD on 12/11/2025 instead of when Resident #1's lab values were received on 11/21/2025, she stated this was the first time the RD had been to the facility since Resident #1's lab values were received. During an interview on 12/11/2025 at 1:45 PM, the MD said he visited Resident #1 while at the facility on 12/11/2025. He said he changed Resident #1's medication on 11/21/2025 when he was notified of Resident #1's HGBA1C level of 9.6. He said had he known Resident #1 or her family wanted Resident #1 to have a diabetic diet he would have ordered it, but he was not told. He said he did not think a diabetic diet was sufficient in managing Resident #1's diabetes. He said he had previously spoken with Resident #1's family regarding insulin but they did not want her to take insulin but said he was going to speak with the family again about putting Resident #1 on insulin. During an interview on 12/11/2025 at 2:35 PM, the ADON said on 11/21/2025 Resident #1's family member found out Resident #1 had a hypoglycemic (low blood sugar) episode and requested Resident #1 have a HGBA1C level done. He said 675379 Page 2 of 3 675379 12/11/2025 The Oaks at Longview 111 Ruthlynn Dr Longview, TX 75601

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #1's family member called the facility and requested a diabetic diet, and he told her the facility did not offer a diabetic diet. He said he was not aware the facility offered a diabetic diet and would go and find out what that was. During an interview on 12/11/2025 at 3:00 PM, LVN B said on 11/21/2025 she received a call from Resident #1's family member asked about Resident #1 having a diabetic diet. She said she explained to Resident #1's family member that the facility did not offer a diabetic diet. She said Resident #1's family member got upset that they did not offer a diabetic diet, so she transferred the call to the ADON. She said she did not know the facility had a diabetic diet, and she had never heard of a CCHO diet. Record review of the facility's policy titled, Therapeutic Diets: dated 1/1/2025, indicated: Purpose: To ensure that the facility provides therapeutic diets to residents that meet nutritional guidelines and physician orders. Policy: Therapeutic diets are diets that deviate from the regular diet and require a physician's order. Per the physician's order, therapeutic diets are planned prepared and served in consultation with the registered dietician. The attending physician may delegate to a registered or licensed dietitian the task of prescribing a resident's diet, including a therapeutic diet, to the extent allowed by state law. Record review of the facility's, undated, Resident admission Guide indicated: Food and Nutrition Services: Our food and Nutrition Services Department offers therapeutically planned meals that are specially designed to meet each resident's nutritional needs. A registered dietitian will evaluate and review your diet and nutritional status on a regular basis and will coordinate your nutritional needs with you, your physician, and the facility staff. 675379 Page 3 of 3