Health inspection·July 26, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm 1. Record review of a face sheet dated [DATE] indicated Resident #19 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included atrial fibrillation (a type of irregular heartbeat), hypertension (a condition in which the force of the blood against the artery walls is too high), and myopathy (any disease that affects the muscles that control voluntary movement in the body). She was her own responsible party. She was designated as DNR. Residents Affected - Few Record review of the current MDS dated [DATE] indicated Resident #19 was alert to person, place, and time with a BIMS of 15 indicating she was cognitively intact. Record review of physician orders for [DATE] indicated Resident #19 had an order dated [DATE] for DNR. Record review of the EMR for Resident #19 had a scanned OOH-DNR dated [DATE] with witness signatures of the HR and Receptionist. During an observation and interview on [DATE] at 12:45 PM Resident #19 was sitting up in her bed. She said she did not want someone pounding on her chest if she died. 2. Record review of face sheet for Resident #65 indicated admitted [DATE] was [AGE] years old with diagnoses of chronic obstructive pulmonary disease (respiratory disease). Record review of the current MDS dated [DATE] indicated Resident #65 was alert to person, place, and time with a BIMS of 13 indicating he was cognitively intact. Record review of physician orders for [DATE] indicated Resident #65 had an order with start date of [DATE] for DNR. Record review of the EMR for Resident #65 had a scanned OOH-DNR dated [DATE] with witness signatures of the HR staff and another employee. During an interview on [DATE] at 9:31 AM, Resident #65 said he received hospice services and did not want CPR if he passed away. During an interview on [DATE] at 1030 AM, the HR staff said the signatures on Resident #65 OOH-DNR were herself and a former housekeeper, who had a termination date in 2023. The HR staff said she thought if they both did not perform direct care, it was ok. During an interview on [DATE] at 03:55 PM, the DON said she was unaware of the inaccurate DNRs. She said the DNRs could not have 2 staff signatures as witnesses. She said these issues would make the DNR invalid and the residents would be a full code. She said as a result of an inaccurate DNR the residents would have lifesaving procedures performed when they did not want them. During an interview on [DATE] at 4:00 PM, the administrator said for OOH-DNR forms they should have one facility staff as a witness signing the form and one witness, who was not a facility staff, as the secondary witness. She said the forms needed to be filled out correctly. An Advance Directives policy dated [DATE] mentioned OOH-DNR but there was no information about the facility ensuring the accuracy of the OOH-DNR. The policy did not address the issue with the witnesses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675394 If continuation sheet Page 2 of 23 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 675394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakwood Manor Nursing Home 225 S Main St Vidor, TX 77662 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported not later than 2 hours after the allegation is made, if the events that cause the allegation involves abuse or result in serious bodily injury, to the Administrator and the State Survey Agency, for 1 of 2 residents reviewed for reporting allegations of abuse. (Residents # 9 and #66) The facility did not report physical abuse within 2 hours when Resident #9 reported to facility staff that CNA B slapped her in the face. This failure could place the residents at risk of abuse and neglect. Findings include: Record review of clinical notes indicated on 6/28/2023 at 2:43 am resident ask to see nurse and she reported to LVN H that she did not want CNA B in her room anymore or to care from her anymore, said CNA had been rough with her when cleaning her, and she came in and slapped her in the face. Record review of an email to HHSC Complaint and Incident Intake dated 06/28/23 at 6:48 a.m. indicated the name and title of the person making the initial report; [ADM] the date and time the person became aware of the reportable incident; 06/28/23 approximately 01:30 p.m .a detailed narrative of the incident; [Resident #9] made a statement to staff member that on 6/28/2023 at approximately 1:30 a.m. the CNA B slapped her in the face. Record review of the Provider Investigation Form indicated the following: * Date Reported to HHSC-06/28/23 * Time: 08:20 a.m. * Incident Category: Abuse * Incident Date: 06/28/23; and * Time of Incident: 01:30 a.m. During an interview on 07/26/23 at 01:00 p.m. the ADM said she was the acting Abuse Coordinator (AC). She said on 6/28/2023 she woke up around 5:30 a.m. - 6 a.m., she realized she had 13 missed calls from the facility. She stated, I have never slept through that many calls before, I am still beating myself up for that one. She said the facility staff was calling to inform her that Resident #9 said that CNA B slapped her, incident occurred around 1:30 am and resident was assessed around 2pm. She said the facility staff did call the DON, the alternate AC, however, the DON did not know staff could not reach the administrator/AC. She said she emailed incident to HHS around 6:30am and faxed it in around 8:30 am. The administrator said the abuse allegation was not reported to HHS in the 2-hour time frame as required. She said she knew all allegations of abuse were to be reported to HHSC within 2 hours regardless of if there was serious bodily harm or not. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675394 If continuation sheet Page 3 of 23 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 675394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakwood Manor Nursing Home 225 S Main St Vidor, TX 77662 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 0609 Record review of Facility Abuse Protocol Revision dated April 2019 in part revealed: Level of Harm - Minimal harm or potential for actual harm Fundamental Information: (Protection) Residents Affected - Few 10. The Abuse Prevention Coordinator will: a. Immediately (within 2 hours) report to the Department of Aging and Disability Services (DADS) and other appropriate authorities' incidents of Patient Abuse as required under applicable regulations and regulatory guidance. Report events that cause reasonable suspicion of serious bodily injury immediately (within 2 hours) after forming the suspicion to THE Department of Aging and Disability Services (DADS) and other appropriate authorities as required under applicable regulations and regulatory guidance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675394 If continuation sheet Page 4 of 23 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 675394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakwood Manor Nursing Home 225 S Main St Vidor, TX 77662 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviewed, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically transmitted to the CMS System for 1 of 23 residents records reviewed for MDS assessments. (Residents #80) Residents Affected - Few The facility did not ensure the discharge MDS assessment was completed and transmitted as required for Resident #80. This failure could place residents at risk of not having their assessments transmitted timely. Findings included: Record review Resident #80's admission record dated 07/26/23 indicated she was admitted on [DATE] with a discharge date of 02/24/23. Resident #80's diagnoses included shortness of breath, chronic obstructive pulmonary disease and lung cancer. Record review of the MDS for Resident #80 indicated the most recent MDS completed was on 02\02\23. There was not a discharge MDS completed or transmitted after 02/24/23. Record review of the nurse's notes 01/18/23 to 02/24/23 indicated Resident #80 was discharged home on [DATE]. During an interview on 07/26/23 at 03:14 p.m., the DON said Resident #80 was discharged home and there should had been a discharge MDS completed and submitted. She said they used the RAI manual for the policy. During an interview on 7/26/23 at 3:30 p.m., the administrator said she expected the MDS to be completed and transmitted for discharge. Reference obtained on 07/31/23 from the CMS website, https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf indicated the following: CMS's RAI Version 3.0 Manual indicated . Discharge Assessment refers to an assessment required on resident discharge from the facility, or when a resident's Medicare Part A stay ends, but the resident remains in the facility (unless it is an instance of an interrupted stay, as defined below). This assessment includes clinical items for quality monitoring as well as discharge tracking information. RAI OBRA-required Assessment Summary .Discharge Assessment - return not anticipated (NoncComprehensive) A0310F = 10 discharge date + 14 calendar days . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675394 If continuation sheet Page 5 of 23 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 675394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakwood Manor Nursing Home 225 S Main St Vidor, TX 77662 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 0641 Ensure each resident receives an accurate assessment. 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 received an accurate assessment, reflective of the resident's status for 3 of 23 residents reviewed for accuracy of assessments. (Resident #s 40, 42 and 71) Residents Affected - Few The facility did not accurately complete the MDS assessment to indicate Residents #40 and #42 had dental concerns. The facility did not accurately complete the MDS assessment to indicate Resident #71 received continuous oxygen. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: 1. Record review of physician orders dated 07/26/23 indicated Resident #40, admitted [DATE] was [AGE] years old with diagnoses of diabetes (a disease in which the body ability to produce insulin is impaired resulting in high levels of glucose in the blood), heart failure (a chronic condition in which the heart does not pump blood efficiently) and end stage renal disease (condition in which a person's kidneys cease to function on a permanent basis). The orders indicated the resident may have dental care PRN. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #40 was alert, oriented and had a BIMS of 12 indicating moderate cognitive impairment. The assessment indicated the resident did not have oral or dental concerns. Record review of the care plans dated 03/3/22 to present indicated Resident #40 did not have dental concerns. The facility had a PIP (a project the facility puts in place to correct a concern they have found) in place for incomplete, nonresident-centered care plans dated 07/18/23 that was to be completed by 08/17/23. During observation and interview on 07/24/23 at 9:40 a.m., Resident #40 had no teeth to the top oral cavity and had multiple missing, broken and decayed teeth with black areas to the bottom oral cavity. The resident said she had not seen a dentist since being admitted to the facility. She said she would like to see a dentist. The resident denied dental pain. During an interview and record review on 07/26/23 at 11:54 a.m., the DON said the MDS dated [DATE] did not indicate Resident #40 had dental concerns and was completed incorrectly. She said the MDS nurse quit without notice on 07/14/23 and she had not hired a nurse to take her place. She said her expectations were for the residents' assessments to be completed correctly and accurately. She said the residents could possibly not receive the care they required if the MDS was not completed correctly. 2. Record review of the physician orders dated 07/26/23 indicated Resident #42, admitted [DATE], was [AGE] years old with diagnoses of congestive heart failure (a chronic condition in which the heart does not pump blood efficiently), chronic kidney disease (longstanding disease of the kidneys (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675394 If continuation sheet Page 6 of 23 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 675394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakwood Manor Nursing Home 225 S Main St Vidor, TX 77662 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few leading to kidney failure), and protein calorie malnutrition (inadequate intake of food to meet nutritional needs). The orders indicated the resident may have dental care PRN. Record review of the quarterly MDS dated [DATE] indicated Resident #42 was alert, oriented and had a BIMs of 15 indicating the resident was cognitively intact. The assessment indicated the resident did not have oral or dental concerns. Record review of the care plans dated 07/21/22 to present did not indicate Resident #42 had dental concerns. The facility had a PIP in place for incomplete, nonresident-centered care plans dated 07/18/23 that was to be completed by 08/17/23. During observation and interview on 07/24/23 at 10:07 a.m., Resident #42 was edentulous (had no teeth). She said she had lost weight over the last year and her dentures would not fit. She said the facility had referred her to the dentist. During an interview on and record review on 07/26/23 at 11:54 a.m., the DON said the MDS dated [DATE] did not indicate Resident #42 had dental concerns and was completed incorrectly. She said the resident wore dentures and the MDS should indicate so. She said the MDS nurse quit without notice on 07/14/23 and she had not hired a nurse to take her place. She said her expectations were for the residents' assessments to be completed correctly and accurately. She said the residents could possibly not receive the care they required if the MDS was not completed correctly. 3. Record review of physician orders dated July 2023 indicated Resident #71, admitted [DATE], was [AGE] years old with diagnosis of acute respiratory failure. The orders indicated Resident #71 received continuous oxygen at 2 L/min per nasal cannula. Record review of the quarterly MDS dated [DATE] indicated Resident #71 was alert and had a BIMS of 3 indicating the resident had severe cognitive impairment.) The assessment indicated the resident had no respiratory treatments such as oxygen. Record review of the care plans dated 11/11/22 to present indicated Resident #71 did not have oxygen concerns. The facility had a PIP in place for incomplete, nonresident-centered care plans dated 7/18/23 that was to be completed by 8/17/23. During observation on 07/24/23 at 09:00 a.m., Resident #71 was lying in bed with oxygen infusing at 2 L/min per nasal cannula via concentrator at bedside. Resident #71 was non-interviewable. During an interview on 7/26/23 at 4:05 p.m., the corporate nurse said the facility followed the RAI as policy for MDS assessment accuracy. Record review of the RAI section L0200: Dental indicated: . Poor oral health has a negative impact on quality of life, overall health, nutritional status. Assessment can identify periodontal disease that can contribute to or cause systemic diseases and conditions such as aspiration, malnutrition, pneumonia, endocarditis and poor control of diabetes. Based on observation, interview and record review, the facility failed to ensure residents received an accurate assessment, reflective of the resident's status for 3 of 23 residents reviewed for accuracy of assessments. (Resident #s 40, 42 and 71) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675394 If continuation sheet Page 7 of 23 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 675394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakwood Manor Nursing Home 225 S Main St Vidor, TX 77662 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 0641 Level of Harm - Minimal harm or potential for actual harm The facility did not accurately complete the MDS assessment to indicate Residents #40 and #42 had dental concerns. The facility did not accurately complete the MDS assessment to indicate Resident #71 received continuous oxygen. Residents Affected - Few This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: 1. Record review of physician orders dated 07/26/23 indicated Resident #40, admitted [DATE] was [AGE] years old with diagnoses of diabetes (a disease in which the body ability to produce insulin is impaired resulting in high levels of glucose in the blood), heart failure (a chronic condition in which the heart does not pump blood efficiently) and end stage renal disease (condition in which a person's kidneys cease to function on a permanent basis). The orders indicated the resident may have dental care PRN. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #40 was alert, oriented and had a BIMS of 12 indicating moderate cognitive impairment. The assessment indicated the resident did not have oral or dental concerns. Record review of the care plans dated 03/3/22 to present date indicated Resident #40 did not have dental concerns. The facility had a PIP (a project the facility puts in place to correct a concern they have found) in place for incomplete, nonresident-centered care plans dated 07/18/23 that was to be completed by 08/17/23. During observation and interview on 07/24/23 at 9:40 a.m., Resident #40 had no teeth to the top oral cavity and had multiple missing, broken and decayed teeth with black areas to the bottom oral cavity. The resident said she had not seen a dentist since being admitted to the facility. She said she would like to see a dentist. The resident denied dental pain. During an interview and record review on 07/26/23 at 11:54 a.m., the DON said the MDS dated [DATE] did not indicate Resident #40 had dental concerns and was completed incorrectly. She said the MDS nurse quit without notice on 07/14/23 and she had not hired a nurse to take her place. She said her expectations were for the residents' assessments to be completed correctly and accurately. She said the residents could possibly not receive the care they required if the MDS was not completed correctly. 2. Record review of the physician orders dated 07/26/23 indicated Resident #42, admitted [DATE], was [AGE] years old with diagnoses of congestive heart failure (a chronic condition in which the heart does not pump blood efficiently), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), and protein calorie malnutrition (inadequate intake of food to meet nutritional needs). The orders indicated the resident may have dental care PRN. Record review of the quarterly MDS dated [DATE] indicated Resident #42 was alert, oriented and had a BIMs of 15 indicating the resident was cognitively intact. The assessment indicated the resident did not have oral or dental concerns. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675394 If continuation sheet Page 8 of 23 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 675394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakwood Manor Nursing Home 225 S Main St Vidor, TX 77662 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the care plans dated 07/21/22 to present did not indicate Resident #42 had dental concerns. The facility had a PIP in place for incomplete, nonresident-centered care plans dated 07/18/23 that was to be completed by 08/17/23. During an interview on and record review on 07/26/23 at 11:54 a.m., the DON said the MDS dated [DATE] did not indicate Resident #42 had dental concerns and was completed incorrectly. She said the resident wore dentures and the MDS should indicate so. She said the MDS nurse quit without notice on 07/14/23 and she had not hired a nurse to take her place. She said her expectations were for the residents' assessments to be completed correctly and accurately. She said the residents could possibly not receive the care they required if the MDS was not completed correctly. 3. Record review of physician orders dated July 2023 indicated Resident #71, admitted [DATE], was [AGE] years old with diagnosis of acute respiratory failure. The orders indicated Resident #71 received continuous oxygen at 2 L/min per nasal cannula. Record review of the quarterly MDS dated [DATE] indicated Resident #71 was alert and had a BIMS of 3 indicating the resident had severe cognitive impairment. The assessment indicated the resident had no respiratory treatments such as oxygen. Record review of the care plans dated 11/11/22 to present indicated Resident #71 did not have oxygen concerns. The facility had a PIP in place for incomplete, nonresident-centered care plans dated 7/18/23 that was to be completed by 8/17/23. During observation on 07/24/23 at 09:00 a.m., Resident #71 was lying in bed with oxygen infusing at 2 L/min per nasal cannula via concentrator at bedside. Resident #71 was non-interviewable. During an interview on 7/26/23 at 4:05 p.m., the corporate nurse said the facility followed the RAI as policy for MDS assessment accuracy. Record review of the RAI section L0200: Dental indicated: . Poor oral health has a negative impact on quality of life, overall health, nutritional status. Assessment can identify periodontal disease that can contribute to or cause systemic diseases and conditions such as aspiration, malnutrition, pneumonia, endocarditis and poor control of diabetes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675394 If continuation sheet Page 9 of 23 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 675394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakwood Manor Nursing Home 225 S Main St Vidor, TX 77662 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure individuals identified with MD or ID are evaluated for 3 of 6 residents reviewed for PASRR. (Residents # 55, #73 and #89) Residents Affected - Few The facility did not have an accurate PASRR level 1 screening for Residents #55, #73 and #89 who identified with having a mental health diagnosis therefore they had no further evaluation. This failure could place residents who have a diagnosis of mental disorder or intellectual disability at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: 1. Record review of a face sheet indicated Resident #55 admitted [DATE], was a [AGE] year-old male, with diagnoses of PTSD (post-traumatic stress disorder -a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event with symptoms including flashbacks, nightmares and severe anxiety), anxiety (intense, excessive, and persistent worry and fear about everyday situations) and depression (a common and serious medical illness that negatively affects how you think and act.). Record review of PASRR level 1 screening completed by the transferring facility dated 03/27/23 indicated Resident #55 was negative for mental illness, intellectual disability, and developmental disability. No PASRR Level II (PE) Screening or a form 1012 (Mental Illness/Dementia Resident Review) was found in the clinical record. Record review of a care plan initiated 03/29/23 indicated Resident #55 was currently taking psychotropic medication for depression and anxiety and required monitoring for side effects, behaviors and mood problems. Record review of a quarterly MDS dated [DATE] indicated Resident #55 had a BIMS score of 10 indicating he had moderately impaired cognition, had diagnoses of PTSD, depression and anxiety and received medication for anxiety and depression 7 of 7 days. Record Review of physician orders dated July 2023 indicated Resident #55 had a diagnosis of PTSD. The orders indicated Resident #55 was prescribed duloxetine (an antidepressant medication) 20 mg daily for depression with a start date of 3/28/23, trazadone (an antidepressant medication)100 mg at bedtime for depression with a start dated of 04/04/23 and alprazolam (an antianxiety medication) 0.5 mg every 6 hours as needed for anxiety with a start date of 06/13/23. 2. Record review of a face sheet indicated Resident #73 admitted [DATE], was an 83- year-old male, had a diagnosis of bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels and concentration and makes it difficult to carry out day-to-day task) Record review of PASRR level 1 (PL1) screening completed by the transferring facility dated 05/24/23 indicated Resident #73 was negative for mental illness, intellectual disability, and developmental disability. No PASRR Level II (PE) Screening or a form 1012 (Mental Illness/Dementia Resident Review) was found in the clinical record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675394 If continuation sheet Page 10 of 23 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 675394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakwood Manor Nursing Home 225 S Main St Vidor, TX 77662 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of an annual MDS dated [DATE] indicated Resident #73 was moderately impaired of cognition, was negative for PASRR condition, had a diagnosis of bipolar disorder and received an antipsychotic medication 7 of 7 days. Record review of a care plan initiated 05/30/23 indicated Resident #73 was moderately impaired of cognition and currently taking psychotropic medication. Record Review of physician orders dated July 2023 indicated Resident #73 was prescribed divalproex 125 mg every 12 hours for dipolar disorder with a start date of 07/18/23 and quetiapine 25 mg every day at bedtime for bipolar disorder with a start date of 07/18/23. 3. Record review of a face sheet dated 07/25/23 indicated Resident #89 was a [AGE] year-old male admitted on [DATE]. He had diagnoses including post-traumatic stress disorder (disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), generalized anxiety disorder (persistent and excessive worry that interferes with daily activities), and major depression disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During an interview on 07/26/23 at 10:35 a.m., the DON indicated Resident #89 should have had a positive PL1 due to diagnosis of PTSD. She said he was supposed to be exempted hospital admission and stay less than 30 days but the PL1 was not marked for this. Record review of a PL1 completed by a transferring facility dated 06/26/23 indicated there was no evidence or indicator Resident #89 had a mental illness diagnosis. The section for Exempted Hospital Discharge which would indicate a resident to stay at a facility for less than 30 days was left blank. Record review of the admission MDS dated [DATE] indicated Resident #89 had moderately impaired cognition with a BIMs score of 08 out of 15; he had no behaviors; he had diagnoses of anxiety disorder, depression, and PTSD; and he received antianxiety and antidepressant medications for 7days of the 7 days look back period. During an interview on 07/25/23 at 11:13 a.m., the DON said the MDS nurse was responsible for the PASRR process and ensuring all PL1s were completed correctly. She said the MDS nurse quit 2 weeks ago without notice. The DON said herself and the SW were the back up to double check PL1s were completed correctly. She said Resident #55 and 73's PL1s were just missed. She said the PL1 for both Resident #55 and Resident #73 should have been should have been positive. The DON said the risk of a PL1 completed incorrectly was the resident may miss out on deserved services. During an interview on 07/26/23 at 10:21 a.m., the SW said he and the DON were responsible for completing the PL1s and putting the PL1 from the admitting facility into the computer system since they no longer had an MDS nurse. He said when entering the PL1 he referred to the resident's diagnoses to ensure the PL1 was correct. The SW said Resident #55's and #73's PL1 were put in the system by the last MDS nurse and she just missed it. He said the PL1s were negative and should have been positive. The SW said he was unaware PTSD was a PASRR potential diagnosis. The SW said the risk of a PL1 completed incorrectly was the resident could miss out on services. During an interview on 07/26/23 11:30 a.m., the administrator said her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675394 If continuation sheet Page 11 of 23 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 675394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakwood Manor Nursing Home 225 S Main St Vidor, TX 77662 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete expectation was PASRR forms to be completed correctly and timely. She said Resident #55 and #73's PL1s were just missed. The administrator said the MDS nurse was responsible for PASRR and PL1s to be completed correctly but the MDS nurse recently quit, and the DON and SW were the back up. She said the risk of a PL1 not being completed correctly was a resident could miss deserved services. Record review of an undated facility policy, titled Nursing Facility Responsibilities Related to PASRR, indicated, .PASRR is required of each state's Medicaid program to ensure that those with Mental illness (I) / Intellectual or Developmental Disability (IDD) are care for properly. CRC gathers information for PL1 for ALL patients and gives to PCC (patient care coordinator) prior to patient admission. PCC - submits PL1 and becomes the gate keeper of all things {PASSR}. Event ID: Facility ID: 675394 If continuation sheet Page 12 of 23 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 675394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakwood Manor Nursing Home 225 S Main St Vidor, TX 77662 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 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 resident environment remained free of accident hazards and the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 23 residents (Resident #55) reviewed for accidents and supervision. The facility failed to ensure adequate supervision for Resident #55 with the pruning shears and the shears were not stored securely. This failure could place residents at risk for injury due to the lack of supervision provided by the facility. Findings include: Record review of the face sheet for Resident #55 indicated he was admitted on [DATE], was [AGE] years old with diagnoses of PTSD (a disorder that develops in some people who have experienced shocking, scary or dangerous event), heart failure, high blood pressure and anxiety. Record review of physician orders dated July 2023 indicated Resident #55 had orders for morphine 15 mg immediate release tablet (1 1/2 tab) tablet every four hours and alprazolam 0.5mg 1 tablet as needed every 4 hours. Record review of the quarterly MDS assessment dated [DATE] for Resident #55 indicated BIMS (brief interview for mental status) was 13 which indicated moderately impaired cognition. He required minimal assistance of one staff member for transfer and grooming. Record review of the care plan with print date of 07/25/23 indicated Resident #55 was at risk for additional falls and risk for drowsiness when he received pain medications. The care plans did not address the resident using pruning shears outside. During a confidential interview, the person said Resident #55 had pruning shears and he pruned the bushes outside. During an interview on 07/25/23 at 945 a.m., Resident #55 was in his room and reached into his walker and pulled out the pruning shears. The shears were approximately 2-inch curved blade and approximately 6-inch handle. Resident #55 said he got them awhile back and could not remember the day or the month. He said he spoke with the maintenance supervisor about storing them in his office when he was not pruning the bushes, but nothing was decided. Resident #55 said he had just been keeping the shears in his walker when he was not using them. He denied any staff asked him to turn in the shears. He said he just goes outside and prunes the bushes unsupervised. During an interview 07/25/23 at 9:55 a.m., the DON said she was not aware that a resident had pruning shears. The DON said we should have care planned and provided outside gardening activity with supervision for Resident #55. During an interview on 07/25/23 at 9:57 a.m., the Maintenance Director denied talking to any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675394 If continuation sheet Page 13 of 23 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 675394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakwood Manor Nursing Home 225 S Main St Vidor, TX 77662 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete resident about using pruning shears. He said we were responsible for pruning bushes and the residents could get hurt if not supervised. During an interview 07/25/23 at 10:00 a.m., the administrator said she was unaware Resident #55 had pruning shears and did not know he was keeping them in his room. She said tools should be kept secure and if it was an activity of gardening, it would need to be care planned and supervised. She said the facility did not have a policy for pruning shears. Event ID: Facility ID: 675394 If continuation sheet Page 14 of 23 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 675394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakwood Manor Nursing Home 225 S Main St Vidor, TX 77662 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 that a resident who needed respiratory care was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 2 of 23 residents reviewed for oxygen therapy. (Resident #38 and Resident #71) Residents Affected - Few The facility did not obtain orders for Resident #38's oxygen. The resident received oxygen via nasal cannula connected to a portable oxygen concentrator. The facility did not ensure humidifier bottles contained liquids for Resident #s 38 and 71. The humidifier bottles for each concentrator were empty. This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: 1. Record review of the physician orders dated July 2023 indicated Resident #38, admitted [DATE], was [AGE] years old with diagnoses of cerebral palsy (a congenital disorder of movement, muscle tone, or posture which can contribute to lung disease). There was no documentation to indicate the resident had oxygen ordered. Record review of the most recent quarterly MDS dated [DATE] indicated Resident #38 was cognitively intact, had diagnoses of cerebral palsy. The assessment did not indicate the resident received oxygen. Record review of a care plan updated 10/14/20 through current date indicated Resident #38 was unable to maintain adequate oxygen saturation levels. Beginning 07/26/23, interventions were initiated to include oxygen use for Resident #38. During observation and interviews on 07/24/23 at 9:03 a.m., Resident #38 was lying in bed watching television. Oxygen via nasal cannula at 3 L/min portable concentrator was in use. An empty humidifier bottle was dangling from the concentrator. Resident #38 said she wore oxygen continuously due to shortness of breath. LVN G made entrance to Resident #38's room and made observation and acknowledged the humidifier bottle was empty and needed to be refilled. She said the strap used to anchor the humidifier bottle was not secure and she would change out humidifier bottle and repair the anchor. She added the night shift was responsible for changing tubing, humidifier containers, and cannulas every Sunday and as needed. She added all nursing staff were responsible as well. LVN G said a possible negative outcome for not having humidified oxygen could be dry nasal passages. During an interview on 07/25/23 at 9:47 a.m., LVN G said she could not locate orders for Resident 38's oxygen in the electronic records. She said the resident was discharged from hospice services on 07/21/23 and the oxygen orders apparently were not transferred to new orders. During an interview on 07/25/23 at 10:00 a.m., DON acknowledged there were no orders for oxygen, or changing humidifier bottle in Resident #38's electronic record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675394 If continuation sheet Page 15 of 23 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 675394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakwood Manor Nursing Home 225 S Main St Vidor, TX 77662 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few She said there should have been physician orders for the oxygen. The DON said her expectations were to have orders entered correctly. She said added possible negative outcomes for not having humidified oxygen were nostrils becoming dry, or infections. 2. Record review of the physician orders dated July 2023 indicated Resident #71, admitted [DATE], was [AGE] years old with diagnoses of acute respiratory failure, with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions). Orders included oxygen at 2 L/min per nasal cannula. Record review of the most recent quarterly MDS dated [DATE] indicated Resident #71 was alert and had a BIMs of 3 out of a total score of 15 (test used to determine cognitive function of a resident with BIMs score of 3 indicating the resident had severe cognitive impairment. Record review of the care plans dated 11/11/22 to present indicated Resident #71 did not have oxygen concerns. The facility had a PIP in place for incomplete, nonresident-centered care plans dated 07/18/23 that was to be completed by 08/17/23. During observation and interviews on 07/24/23 at 9:03 a.m., Resident #71 was lying in bed with oxygen infusing 2 L/min per nasal cannula via concentrator at bedside. Resident #71 was non-interviewable. During observation and interview on 07/24/23 at 9:20 a.m., Resident #71 was lying in bed. Oxygen via nasal cannula at 2 /L per minute per portable concentrator was in use. An empty humidifier bottle was attached to the concentrator. LVN A made observations to Resident #71's room and acknowledged the humidifier bottle was empty and needed to be refilled. She said the night shift was responsible for changing tubing, humidifier containers, and cannula's every Sunday and as needed. She said she would immediately change out the humidifier bottle. LVN A said a possible negative outcome for not using humidified oxygen could be dry nasal passages or irritation. Record review of a Protocol for Oxygen Administration policy dated as reviewed March 2019 indicated: Patients with oxygen therapy will have their plan of care updated to reflect their oxygen use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675394 If continuation sheet Page 16 of 23 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 675394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakwood Manor Nursing Home 225 S Main St Vidor, TX 77662 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 0791 Provide or obtain dental services for each resident. 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 obtained needed dental services, including routine dental services for 1 of 23 residents reviewed for dental services. (Resident #40) Residents Affected - Few The facility did not obtain dental services for Resident #40, who had missing and decayed teeth. This failure could place the residents at risk for not receiving care and services to prevent further decline and weight loss. Findings included: Record review of physician orders dated July 2023 indicated Resident #40, admitted [DATE] was [AGE] years old with diagnoses of diabetes (a disease in which the body ability to produce insulin is impaired resulting in high levels of glucose in the blood), heart failure (a chronic condition in which the heart does not pump blood efficiently) and end stage renal disease (condition in which a person's kidneys cease to function on a permanent basis). The orders indicated the resident may have dental care PRN. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #40 was alert, oriented and had a BIMs of 12 indicating moderate cognitive impairment. The assessment indicated the resident did not have oral or dental concerns. Record review of the care plans dated 03/03/22 to present date indicated Resident #40 did not have dental concerns. The facility had a PIP in place for incomplete care plans and care plans that were not resident-centered dated 07/18/23 that was to be completed by 08/17/23. Record review of Resident #40's electronic medical record from admission on [DATE] to current date did not indicate the resident had been referred or had seen a dentist. During observation and interview on 07/24/23 at 9:40 a.m., Resident #40 had no teeth to the top jaw and had multiple missing and multiple decayed teeth with black areas to the bottom jaw. The resident said she had not been seen by a dentist since she was admitted to the facility. She said she would like to see a dentist. The resident denied dental pain. During interview and record review on 07/26/23 at 10:02 a.m., the SW said he did not have a dental referral for Resident #40, and he did not know the resident had any issues with her teeth. He said none of the direct care staff had reported to him concerns with the resident's teeth. The SW said the facility had to contract with a new dental service company last week due to the previous company was not paying their bills. During record review of the electronic medical records with the SW, he said he did not find any information to indicate the resident received a dental referral since she had been admitted . He said the residents should be seen by the dentist, especially if they have decayed teeth. During interview and record review on 07/26/23 at 10:40 a.m., the SW provided a monthly dental provider lists of residents, who had been seen by the dentist. The monthly list of residents seen by the dental provider dated 09/06/22 to 7/26/23 did not indicate Resident #40 was seen by the dentist. The SW said he had looked back in the electronic medical records again and there was no documentation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675394 If continuation sheet Page 17 of 23 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 675394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakwood Manor Nursing Home 225 S Main St Vidor, TX 77662 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 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to indicate Resident #40 was seen by the dentist. The SW said the lists were all of the dental paper information he could find, and it was the list he started when he was hired on as the SW in September of 2022. During observation and interview on 07/26/23 at 11:24 a.m., with LVN A present, Resident #40 opened her mouth and lifted her top lip to show LVN A she had no top teeth. The resident's bottom teeth had multiple missing and multiple teeth with black decayed areas. The resident said she was not in pain. She said she could chew the food she was served. The resident said she wanted to see a dentist. The resident denied losing weight. LVN A said Resident #40 did need to see a dentist and she had not referred her to the SW for dental services. When asked why the resident had not been referred, the LVN said she did not know why but she should have referred her. She said the possible negative outcome of not seeing the dentist could be fragments of teeth falling out, pain, further decay, and weight loss. During an interview on 07/26/23 at 12:14 p.m., the DON said her expectations were for the residents to receive dental services as needed. She said the nurses should be assessing the residents initially and quarterly to ensure their needs are taken care of. She said the possible negative outcome could be infection, pain and/or weight loss. During an interview on 07/26/23 at 2:33 p.m., the corporate nurse said the facility did not have a dental policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675394 If continuation sheet Page 18 of 23 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 675394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakwood Manor Nursing Home 225 S Main St Vidor, TX 77662 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure food was provided that accommodated food preference for 4 of 23 residents reviewed for food choices (Resident #7, #43, #66 and #75) in that: Residents #7, #43, #66, and #75 preferred fried eggs and did not receive fried eggs. This failure could place residents at risk for poor oral intake, weight loss, and poor quality of life. Findings included: 1. Record review of an admission face sheet for Resident #7 indicated she was admitted [DATE] with diagnoses of high blood pressure and pain. Record review of the physician orders dated July 2023 indicated Resident #7 had a diet order for Low concentrated sweet, no salt on tray and no fried foods. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #7 had moderately impaired cognition with BIMS score of 12, could understand, and usually could make needs known. Record review of the care plan with print date of 07/26/23 indicated Resident #7 wanted to lose weight. Approaches included and not limited to: Serve diet per order - monitor intake. Discourage foods not within diet limits, to monitor/discuss preferences During an interview on 07/25/23 at 2:50 p.m. Resident #7 said the residents ' request for fried eggs was not a new problem. She said several residents requested fried eggs. She said one of the other residents turned in a list to the kitchen of all the residents who wanted eggs back in April 2023. 2. Record review of an admission face sheet for Resident #43 indicated she was admitted on [DATE] was [AGE] years old with diagnoses of fractured femur (leg), eating disorder and anxiety. Record review of the physician orders dated Resident #43 indicated her diet order was LCS diet, NSOT and no fried food. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #43 was cognitively intact with BIMS score of 15. During a group interview on 07/25/23 at 12:49 p.m., Resident #43 said she did not like scrambled eggs. She said she asked for a fried egg, but she did not get them. 3. Record review of an admission face sheet indicated Resident #66 admitted on [DATE] was [AGE] years old with diagnoses included anorexia (an eating disorder), respiratory failure, and depression. Record review of the physician orders dated July 2023 indicated Resident #66 had an order for regular diet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675394 If continuation sheet Page 19 of 23 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 675394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakwood Manor Nursing Home 225 S Main St Vidor, TX 77662 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the quarterly MDS assessment dated [DATE] indicated Resident #7 had moderately impaired cognition with a BIMS score of 09. Resident #7 usually understood and usually could make needs known. Record review of the care plan with print date 07/25/23 indicated Resident #66 had approaches which included monitor for weight loss and encourage intake within dietary limits. Resident #66 was at risk for unintended weight related to chemotherapy and approaches included but not limited to update food preferences, liberalized diet, and diet as ordered. During a group interview on 07/25/23 at 12:49 p.m., Resident #66 said she turned in a list with 13 names on it to the kitchen of residents who wanted fried eggs. She said, we never got fried eggs. During an interview on 07/25/23 at 2:45 p.m., Resident #66 said she knew other residents wanted fried eggs, like she wanted them. She said she went from room to room and asked the residents and made a list. She said she did not keep a copy. She said she knocked on the kitchen door and gave the list to the kitchen staff described her as a young little lady. 4. Record review of an admission face sheet indicated Resident #75 was admitted on [DATE] was 65 years with diagnoses of chronic pain, anxiety and vitamin deficiency. Record review of the physician orders dated July 2023 indicated Resident #75 was on LCS diet. Record review of the quarterly MDS assessment dated [DATE] indicated Resident was cognitively intact with BIMS score of 14. Record review of the care plan dated 12/22/22 indicated Resident #75 was at risk for impaired nutritional status related to multiple food preferences or complaints. Approaches included to monitor for signs or symptoms of dehydration, aspiration, or diet intolerance. During an observation on 07/25/23 at 7:45 a.m., no eggs were on Resident #75 ' s breakfast tray. During an interview on 7/24/23 at 2:00 pm, Resident #75 said she does not eat scrambled eggs. She said she liked fried eggs. She said she spoke with the dietary manager last month, but it did not help. She said she got fried eggs for 3 weeks last month (June), but then no more fried eggs. Record review of the menus for the week of 07/24/23 indicated eggs of choices for breakfast every day of the week. During an interview on 07/24/23 at 8:25 a.m., the dietary manager said we do not fry eggs because we do not have enough staff to cook fried eggs. DM said we serve scrambled eggs. During an interview on 07/26/23 at 8:30 a.m., the dietary manager denied she received a list back in April of 2023 but said she had heard there was a list. She said she did not question residents or dietary staff. She said in June 2023 the kitchen was giving one resident fried egg 3 times a week. The dietary manager said she did not think it was right to just give one resident fried egg and she told the administrator. She said they (DM and administrator) talked about her coming in early to cook the fried eggs because she did not have enough staff to fry eggs right now. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675394 If continuation sheet Page 20 of 23 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 675394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakwood Manor Nursing Home 225 S Main St Vidor, TX 77662 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 0806 During an interview on 07/26/23 at 11:00 a.m., the Administrator said she was unaware of a list provided to the dietary department and unaware the residents wanted fried eggs. Level of Harm - Minimal harm or potential for actual harm Record review of the last 3 months of resident council meetings did not include request for fried eggs. Residents Affected - Some Record review of the week at a glance dated 07/30/23 indicated egg of choice for breakfast every day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675394 If continuation sheet Page 21 of 23 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 675394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakwood Manor Nursing Home 225 S Main St Vidor, TX 77662 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to implement the ongoing system of surveillance to identify possible communicable diseases and infections before they can spread to other persons in the facility for 12 of 12 employees reviewed for annual tuberculosis (TB) screening. Residents Affected - Many The facility required TB screening annually but did not have documentation of the annual TB screening done for the ADM, AD, ADON, BOM, DM, HS, MD, PT, ST, LVN D, LVN E, and CNA F. This failure could place residents, staff, and visitors at risk of being exposed of being exposed to a communicable disease and the facility not being aware of TB to report to the health department. Findings included: Record review of the facility Employee Tuberculosis Screening Nursing Policy and Procedure revised March 2019 indicated Policy: The Facility must screen all employees before providing services in the facility and annually, according to CDC guidelines. The facility must require all persons providing services under an outside resource contract to provide evidence of current tuberculosis screening prior to providing services in the facility. The facility must document or keep a copy of the evidence provided. Procedure: .All employees will be evaluated annually, and after any suspected exposure to a documented case of active tuberculosis. Record review of employee files indicated the following: * ADM hire date was 05/16/16 with the last TB screening dated 05/17/16; * ADON hire date was 02/17/20 with the last TB screening dated 05/13/22; * BOM hire date was 09/26/19 with the last TB screening dated 09/26/19; * DM hire date was 06/11/12 there was no TB screening in the file; * HS hire date was 04/01/10 there was no TB screening in the file; * MD hire date was 04/11/22 with the last TB screening dated 04/13/22; * PT hire date was 11/15/21 with the last TB screening dated 11/15/21; * ST hire date was 01/31/22 with the last TB screening dated 01/31/22; * LVN D hire date was 08/12/19 with the last TB screening dated 08/12/19; * LVN E hire date was 08/12/19 there was no TB screening in the file; and * CNA F hire date was 02/18/22 with the last TB screening dated 02/18/22. There were TB Screening questionnaires in the medical portion of the employee files with no dates or names on them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675394 If continuation sheet Page 22 of 23 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 675394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakwood Manor Nursing Home 225 S Main St Vidor, TX 77662 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 07/26/23 at 03:40 PM, the DON said the IP was out and was not available. She said the TB screening was to be done upon hire and annually at the facility. She acknowledged TB Screening questionnaires in the employee files had no names or dates on them. She said she would look in the IP's office to try and locate anything showing documentation of TB Screening. During an interview on 07/26/23 at 04:18 PM, the DON said she located a folder with some TB Screening questionnaires. She acknowledged some of the forms had names and dates, but most did not have a date. She said she would look one more time. During an interview on 07/26/23 at 05:06 PM, the DON said she was not able to locate any TB screening documentation for the employees listed above. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675394 If continuation sheet Page 23 of 23