Health inspection·September 29, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an observation and interview with Resident#27 on 09/27/22 at 10:15 AM, he reported the back door was loud all day and night often causing him not to rest well. The door can be heard throughout interview slamming multiple times. He reported he did not file a complaint because it did not do any good. In an observation and interview with Resident#74 on 09/27/22 at 10:48 AM, he reported the back door was loud all day and night often causing him not to rest well. The door can be heard throughout interview slamming multiple times causing items on dresser to shake. In an observation and interview with Resident#82 on 09/27/22 at 10:57 AM, he reported the back door was loud all day and night often causing him not to rest well. Door can be heard throughout interview slamming multiple times causing items on dresser to shake. In an interview with Resident#36 on0 9/28/22 at 1:11 PM he reported back door was loud all day and night often causing him not to rest well. He said he feared his tv would fall off of the dresser because of the vibration when door slams shut. In an interview with Resident#82 on 09/28/22 at 1:11PM, he reported he did not sleep well last night because of the noise from back door. He said it was worse during the very early morning. He said the alarm went off last night and the overnight staff did not know the code so they had him get out of bed to type in the code because he knew the code but only if he typed the code in himself. In an observation and interview with Resident#27 on 09/28/22 at 1:18 PM, he reported the back door is loud all day and night often causing him not to rest well. The door can be heard throughout interview slamming multiple times. In an observation and interview with Resident#74 on 09/28/22 at 1:57 PM, he reported he did not sleep well last night because of the noise from back door. He said it is worse around 2:00 - 4:00 AM because staff was in and out of the door more frequently. The door can be heard throughout interview slamming multiple times causing items on dresser to shake. In an observation and interview with Resident#12 on 09/28/22 at 2:06 PM, she reported hearing the back door multiple times throughout the night causing her to wake up. She said she tried taking a nap before lunch, but the door was still loud. The door could be heard throughout interview slamming multiple times. In an interview on 09/28/22 at 9:05AM, LVN1 stated the door at the end of 300 hall was used throughout the day and night by multiple employees. She stated the door used to not be as loud but had been noisy for about 6 months. She stated she had heard residents on the 300 hall complain about the noise level from the door closing and the sound of the alarm frequently. She stated the noise from the door closing could prevent residents from sleeping. In an interview with the ADMIN and DON on 09/28/22 at 4:00PM, the ADMIN said they were aware the door on the 300 hall was loud and would have it fixed overnight. The DON said she would have an in-service started immediately regarding the response time to door alarms and make sure all employees knew the code. They said the loud noises from the door could prevent a resident from sleeping. In an observation and interview with Resident#74 on 09/29/22 at 9:40AM he reported the noise of the door was still very loud, but he did not hear the alarm as often last night. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675431 If continuation sheet Page 2 of 21 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 675431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Red Oak Health and Rehabilitation Center 101 Reese Dr Red Oak, TX 75154 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an observation and interview with Resident#36 on 09/29/22 at 9:42AM, he reported he had been trying to take a nap that morning because he was unable to sleep last night because of the door slamming. He said the alarms were turned off in a timely manner the previous night, but the door slamming kept him up. The back door could still be heard throughout the interview slamming multiple times. In an observation and interview with Resident#82 on 09/29/22 at 9:45AM he reported the noise from the back door was still very loud and woke him up throughout the night. He stated the number of times the door was slammed decreased and the alarm at back door was reset in a timely manner last night and this morning. The door can be heard slamming while in the room multiple times during visit. In an observation and interview with Resident#12 on 9/29/22 at 9:50AM, she stated the door was not slammed as often last night but was still loud that morning. The door could be heard slamming from her room with door closed. In an observation and interview with Resident#27 on 09/29/22 at 10:00AM, he reported the noise of the door was still very loud, but he did not hear the alarm as often last night. Record review revealed Homelike Environment- Quality of Life policy dated August 2009 Residents are provided with a safe, clean, comfortable home like environment. The facility staff and management shall minimize to the extent possible the characteristics for the facility that reflect a depersonalized institutional setting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675431 If continuation sheet Page 3 of 21 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 675431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Red Oak Health and Rehabilitation Center 101 Reese Dr Red Oak, TX 75154 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on observation, interview, and record review, the facility failed to ensure resident rights to voice grievances by not making information on how to file a grievance or complaint available to residents reviewed for grievances. 1. The facility failed to post, in prominent areas, the process for filing a grievance. 2. The facility failed to make grievance forms readily and visibly available for residents to complete individually, confidentially, and/or anonymously. These failures could place residents at risk of unresolved grievances and diminished quality of life. Findings included: In an interview on 09/27/22 at 10:15 AM, Resident #27 stated, Reporting complaints does not make a difference and are often ignored until you call the State. In an interview on 09/27/2022 at 10:57 AM Resident #82 stated, They never responded to grievances. So, he stopped reporting things to them. Observation on 09/28/2022 at 11:00 AM of the facility revealed there were no visible grievance forms or a grievance box throughout the facility. In an interview on 09/28/2022 at 1:00 PM, RP #1 stated he told staff for a year to help find Resident #79's glasses and it still had not been resolved and no one had followed up with him. He would just like better communication when he voiced a complaint about a resolution or how the facility would take care of it. On 09/28/2022 at 02:00 PM, during the Resident Council Meeting, six alert, oriented residents (Resident #12, #27, #36, #46, #82, and #94), stated they did not know how to file a grievance because they did not know where to find the forms. They had neither completed one, nor seen them. They stated they could not find a grievance box within the facility. Residents stated if they had a concern or complaint, they usually told a staff member, and the form was filled out by staff and given to someone in the front office. They believed there were forms but the forms are not given to us to fill out. Observation on 09/28/2022 at 03:30 PM of the facility revealed there were no visible Grievance Forms or a grievance box throughout the facility. In a follow-up interview on 09/29/2022 at 09:05 AM, Resident #46 stated, If they had known how to complete and file a grievance form, the Surveyors would have had about 100 grievances to read prior to the Resident Council meeting. In an interview on 09/29/2022 at 9:30 AM, RP #2 stated, [Resident #23] had requested that a doctor call her for several months to obtain an update on [Resident #23] and no one called her. He said a nurse called and updated them every so often but not the doctor as requested. He said they complained, and they had still not received a resolution. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675431 If continuation sheet Page 4 of 21 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 675431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Red Oak Health and Rehabilitation Center 101 Reese Dr Red Oak, TX 75154 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 09/29/2022 at 09:55 AM revealed a hanging wall file located outside of the ADM's office, the DON's office, and the Activity Room with Grievance Forms. The Grievance Forms were not identifiable or at eye level to residents who were non-ambulatory. Observation on 09/29/2022 at 10:00 AM of the facility revealed Grievance Forms, a Resident's Rights Poster, the Ombudsman's contact information, and the Texas Health and Human Services contact information, all located in the front of the facility tucked away inside of a small-opened space that the facility's mobile workers used while working onsite at the facility. On 09/29/2022 at 10:15 AM, during a RR of all grievances within the last year reflected that all forms were filled out by various staff members and two forms were completed by family members. In an interview on 09/29/2022 at 10:35 AM, the AD stated she never saw the grievance policy. However, she had been in-serviced about reporting grievances and the Grievance Policy. The forms are located outside of the Administrator's office, and in the small room right next door. The resident would turn the form into the DON, or the Administrator. Some of the residents may turn it into their respective ADON. They can also slide the Grievance Form under the DON's or the Administrator's door. In an interview on 09/29/2022 at 11:00 AM, the DON stated residents are made aware of the Grievance Policy upon admission to the facility. They also had the information and forms listed in the small opened-area in the front of the facility. They conducted Ambassador Rounds Monday through Friday, and the residents could let their assigned Ambassador know if they had any concerns. The Ambassadors consisted of the Infection Preventionist, the Treatment Nurse, the 2 ADONS, the 2 MDS Nurses, Central Supply, the Admissions Coordinator, the Van Driver, and the Business Office Manager and each Ambassador was assigned a collection of rooms. For the residents that could not make it to the front of the facility, the Ambassadors would write the grievance out for them. She had never thought about if the residents wished to remain anonymous. She then stated, she was sure the Ambassador would be able to give them the information. They also had grievance forms at the Nursing stations. They would start in-services on the grievance forms. She stated she believed it was important that the residents and their families knew how to file a grievance and had a place to submit them anonymously. In an interview on 09/29/2022 at 11:30 AM, the ADM stated upon admission, they went over the Residents' Rights and the Grievance process with all new residents and their families. They have Grievance forms located outside of his office, the DON's office, the Activity Room, and at all the nurses' stations. All grievances regarding Abuse and Neglect need to be reported to him immediately. For individuals that are bed-bound, the Activity Director completes one-on-one activities with them and ask about concerns. The Social Worker also visits with the Residents about the Grievance Process. At the Care Plan Meetings, they address any concerns and if there are any, they complete a Grievance Form. They will be making posters of the Ombudsman's and the Texas Health and Human Services contact information to hang on the walls in each Residents' room. Review of Grievances/Complaints, Filing policy with a revision date of April 2017 reads the following: 1) Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances may also be voiced or filed regarding care that has not been furnished. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675431 If continuation sheet Page 5 of 21 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 675431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Red Oak Health and Rehabilitation Center 101 Reese Dr Red Oak, TX 75154 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 0585 Level of Harm - Minimal harm or potential for actual harm 4) Upon admission, residents are provided with written information on how to file a grievance or complaint. A copy of our grievance/complaint procedure is posted on the resident bulletin board. 5) Grievances and/or complaints may be submitted orally or in writing and may be filed anonymously. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675431 If continuation sheet Page 6 of 21 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 675431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Red Oak Health and Rehabilitation Center 101 Reese Dr Red Oak, TX 75154 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 0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one of six residents (Resident #53) whose records were reviewed for behavioral health services. The facility failed to ensure Resident #53 received behavioral health services including effective interventions for behavior disturbance which resulted in him being attacked by other residents twice in a two-day period. This failure could place residents at risk for injury and decreased quality of life. Findings included: Review of Resident #53's face sheet dated 09/27/2022 revealed Resident #56 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with everyday activities), paranoid schizophrenia (mental disorder which can cause psychosis resulting in hallucinations and delusional thoughts), anxiety disorder, type 2 diabetes mellitus , Chronic Kidney Disease (gradual loss of kidney function which can cause dangerous levels of fluid, electrolytes and wastes to build up in your body), Major Depressive Disorder (persistent feeling of sadness and loss of interest), high blood pressure, chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs) and unspecified psychosis (psychosis not due to a substance or physiological condition). Review of Resident #53's quarterly MDS assessment, dated 08/14/2022, revealed Resident #53 had a BIMS score of zero to indicating severe cognitive impairment. Resident #53 did not have any behaviors noted on the assessment. Resident #53 had active diagnoses of anxiety disorder, psychotic disorder and schizophrenia. Resident #53 was noted to receive anti-psychotic medications seven days per week and none on an as needed basis. Review of Resident #53's care plan, dated 09/27/2022, revealed Resident #53 had the potential to be physically and verbally aggressive related to dementia with behaviors noted: 03/19/2022 - aggressive behavior with staff and verbal aggressive behavior with other residents 05/29/2022 - physical aggression noted 06/06/2022 - physical and verbal aggression 09/25/2022 - hitting at another resident, received three scratches on his face Goals included the resident will demonstrate effective coping skills through the review date and the resident will not harm self or others through the review date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675431 If continuation sheet Page 7 of 21 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 675431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Red Oak Health and Rehabilitation Center 101 Reese Dr Red Oak, TX 75154 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 0740 Interventions included: Level of Harm - Actual harm o3/19/2022- When the resident becomes agitated: Intervene before agitation Residents Affected - Few escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Have psychological services assess and treat-adjust medication. o 5/29/22 Medication Review o 9/25/22 Staff to monitor resident when he approaches another resident and gets in their personal space o Administer ABH Gel as needed for aggressive behaviors o Administer medications as ordered. Monitor/document for side effects and effectiveness. o Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Date Initiated: 03/24/2021 o Assess and address for contributing sensory deficits Date Initiated: 03/24/2021 o Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Date Initiated: 03/24/2021 o Be Cognizant when resident invades another resident's personal space Date Initiated: 09/26/2022 o COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Date Initiated: 03/24/2021 o Monitor q shift Document observed behavior and attempted interventions in behavior log. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675431 If continuation sheet Page 8 of 21 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 675431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Red Oak Health and Rehabilitation Center 101 Reese Dr Red Oak, TX 75154 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 0740 oMonitor/document/report PRN any signs and symptoms of resident posing danger to self and others. Level of Harm - Actual harm Date Initiated: 03/24/2021 Residents Affected - Few o Psychiatric/Psychogeriatric consult as indicated. Review of Resident #53's physician orders, dated 03/20/2022, revealed Resident #53 was prescribed Seroquel 25 mg one time a day for paranoid schizophrenia. Resident #53 was prescribed Seroquel 25 mg at bedtime for psychosis. Resident #53 was prescribed Depakote ER tablet Extended Release 24-hour 250 MG with instructions to give one tablet at bedtime for anxiety. Resident #53 was prescribed Donepezil HCl Tablet 10 MG with instructions to give one tablet by mouth at bedtime for memory care. An observation on 09/27/2022 at 10:47 AM revealed Resident #53 sat in his wheelchair and banged on the exit door of the locked unit. CNA L attempted to redirect him. Resident #53 was heard to calling CNA L a bitch. Overheard CNA L say to Resident #53, the ACT DIR would be there soon to take him outside. Resident #53 then wheeled himself down the hallway and started banging on the side exit door to the courtyard. CNA L attempted to redirect to an activity on the table. Resident #53 then wheeled himself down the hallway and started banging on the rear exit door. RN M said to Resident #53 you are going to break a window if you keep hitting it. Resident #53 opened and closed the fire extinguisher door on the wall and attempted to break the glass in it. CNA L redirected him down the hallway. Resident #53 wheeled himself back up the hallway towards the common area where six residents were sitting. Resident #53 removed a box of gloves from the side rail of the hallway and threw it down the hallway. CNA L attempted to stop Resident #53 and he swatted at her to try to hit her. Resident #53 said I am going to beat the shit out of you. He then grabbed the wrist BP cuff off the nurse medication cart and attempted to throw it when CNA N took it away from him. In an interview on 09/27/2022 at 10:54 AM, CNA N stated Resident #53's behavior was normal for him probably four out of seven days per week for several months at that time . She stated Resident #53 had a history of being combative with staff and residents. She said he just wanted out of the locked unit. She stated they tried to give him space and let him calm down. She said managing Resident #53's behavior was challenging at times. She said there were 23 residents on the locked unit with two CNA's and one charge nurse. She said at 2:00 PM, the ACT DIR came to help with residents and would take Resident #53 outside. In an observation on 09/27/2022 at 11:00 AM, Resident #53 banged on the front door and rattled the door handles on the locked unit multiple times. In an observation on 09/27/2022 at 11:06 AM, Resident #53 hit the side exit door multiple times and he attempted to hit CNA N. In an observation on 09/27/2022 at 12:36 PM, Resident #53 was hitting the front exit door of the locked unit and yelling. Resident #23 yelled at Resident #53 to stop hitting the door and then Resident #23 took the lid off his water cup and dumped the water on Resident #53. RN M redirected Resident #23 as CNA L and CNA N were feeding two other residents in the dining area. Resident #53 then wheeled himself to the side exit door in the dining area and started rattling the door handle and hitting the door. At 12:41 PM, Resident #17 stood up, went to Resident #53 and began yelling at him. RN M was in between them, separating them and made Resident #17 sit back down. Resident #17 and Resident #53 were yelling curse words at each other as eight residents continued to eat in the dining area. Resident #17 sat back down and began eating again. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675431 If continuation sheet Page 9 of 21 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 675431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Red Oak Health and Rehabilitation Center 101 Reese Dr Red Oak, TX 75154 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 0740 Level of Harm - Actual harm Residents Affected - Few In an observation and interview on 09/27/2022 at 12:52 PM, RN M walked to the medication cart and said Resident #53 did not have any PRN medications for agitation. He picked up his phone to call the physician and as he turned back to the dining area, Resident #17 stood up from his table with his plate and smashed it on the back of Resident #53's head. Both CNA's that were feeding residents at front of dining room and nurse responded and separated the residents. Resident #53 complained of head pain and was taken to his room for assessment. Resident #17 sat back down at his table and was quiet. ADON P came in the locked unit and assisted with Resident #53. Resident #77 was upset and crying. In an observation on 09/27/2022 at 12:58 PM, RN M gave Resident #53 two Tylenol and paged his physician who said to send Resident #53 to the ER for evaluation for CT scan of head. Resident #53 had a large hematoma on the back, left side of his head. In an interview on 09/27/2022 at 1:05 PM, the DON stated Resident #17 had no history of aggressive behaviors with staff or residents. She was shocked Resident #17 would hit Resident #53 with his plate. Review of Resident #53's health status note dated 09/25/2022, written by LVN J, revealed Note text: this writer witnessed this resident starting to talk to another resident and the resident asked him to leave her alone, then this resident (Resident #53) started throwing punches at this other resident. head to toe assessment done by the nurse, noted three scratches marks on this resident (Resident #53) face, no open areas, no bleeding noted. VS WNL. MD notified, DON and family notified. Review of Resident #53's Investigation Follow-up, dated 09/25/2022, revealed primary nurse witnessed resident starting to talk to another resident and the resident asked him to leave her alone, then then this resident (Resident #53) started throwing punches at another resident, resident never hit the other resident. Residents separated and re-directed. Resident #53 was noted to have three scratch marks. Recommendations/interventions noted were separate residents, continue to re-direct. Psych services to eval/treat and medication review management. Continue to monitor every 15 minutes. In a follow-up interview on 09/27/2022 at 3:50 PM, CNA L stated Resident #53's behavior had been worse since July 2022. She said he used to be nice to her and CNA N, they were his favorites, but now he tried to hit them and cursed at them routinely. She said they redirected him or tried to engage him in activities. She said once he was agitated, it was difficult to redirect him. She said she was not working on 09/25/2022, when Resident #53 started to punch Resident #97 and Resident #97 scratched him on the face . She said when she returned to work today she was not told of any new interventions put into place for Resident #53 to prevent him from upsetting or attacking other residents. In a follow-up interview on 09/27/2022 at 3:55 PM, RN M stated he was not aware of any new behavioral interventions the facility put into place for Resident #53 after the incident on 09/25/2022. He stated there were no medication changes made for Resident #53 and did not know whether psychological services had been notified of his escalating behavior. He stated he did not normally work on the locked unit and was not as familiar with Resident #53. In a follow-up interview on 09/27/2022 at 4:05 PM, CNA N stated she was not aware of any additional interventions put into place for Resident #53 following the incident on 09/25/2022. She stated they tried to redirect and distract him when he became agitated. In a follow-up interview on 09/27/2022 at 4:38 PM, the DON stated Resident #53 was at the ER pending evaluation and they had no update regarding his head injury. She stated Resident #17 was put on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675431 If continuation sheet Page 10 of 21 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 675431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Red Oak Health and Rehabilitation Center 101 Reese Dr Red Oak, TX 75154 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 0740 Level of Harm - Actual harm Residents Affected - Few one-on-one monitoring pending an evaluation by psychological services. She stated normally Resident #53 was easy to redirect and distract. She stated they would call his family who would speak with him on the phone and calm him down. She stated, in the past, Resident #53 had ABH gel ordered for when he became combative and unable to be calmed down. She stated his MD gave a one-time order for it on 09/26/2022 to be used for treatment of the scratches Resident #53 had from the altercation on 09/25/2022. She stated the other resident involved, was not injured. She stated the facility put additional interventions in place following the incident on 09/25/2022, including notifying psychological services to evaluate his medications. When asked why Resident #53 was not put one-on-one monitoring at that time pending the evaluation, she said she did not know and would find out. She stated the staff were to monitor him more closely and especially when interacting with other residents. In a follow-up interview on 09/28/2022 at 7:50 AM, the DON stated Resident #53 returned from the ER last night had no injury to his head besides the bruise. She said his CT scan was negative for any other injury. She stated Resident #53 was also on one-on-one monitoring since his return from the ER until he could be seen by psychological services. An observation on 09/28/2022 at 9:24 AM revealed Resident #53 had a staff member with him at all times and documentation every 15 minutes. Resident #53 sat in his wheelchair with his head on a pillow on the table sleeping beside staff members. In an interview on 09/28/2022 at 9:30 AM, LVN J stated she was the routine nurse for the locked unit and knew Resident #53 well and how to deal with his behaviors. She stated staff unknown to Resident #53 or agency nurses did not know how to deal with him. She stated she was his nurse on 09/25/2022 when he was agitated and upset. She said Resident #53 started throwing punches at Resident #97 who then scratched Resident #53 on the face. She said they were treating the scratches daily with normal saline. She said she and the aides started monitoring him more closely and did not leave him unattended when he was around other residents. She said Resident #53 was not put on one on ones and was not sure why since the facility immediately put Resident #17 on one on ones when he attacked Resident #53. She stated Resident #17 and Resident #97 were not typically aggressive or combative towards staff or residents, but seemed to be provoked or agitated by Resident #53's behavior. She stated one issue that increases his behavior was when he refused his medications. She stated she knew how to get him to take his medications and Resident #53 was doing well today. She said the activity aide would come at 2:00 PM, during the week, and that helped a lot with Resident #53 because she took him outside and he liked that. She stated besides watching Resident #53 closely, she was not aware of any additional interventions put into place by the facility that may have prevented the incident yesterday 09/27/2022. In a follow-up interview on 09/28/2022 at 1:48 PM, the DON stated Resident #53 was not put on one on ones after the 09/25/2022 incident and the facility's intervention was to refer to psychological services for a non-routine evaluation of his medications. In an interview on 09/29/2022 at 10:25 AM, NP R, mental health nurse practitioner for Resident #53, stated she did not feel any medication changes were necessary at this time. She stated she restarted the PRN ABH gel for agitation or refusal of care for 14 days and would reevaluate in 14 days, the need to continue the order. She stated she ordered for one on ones to continue until her visit next week for Resident #53 and to notify of her of any increased behaviors. In a follow-up interview on 09/29/2022 at 12:15 PM, the DON stated Resident #53 would remain on one on ones until behaviors were gone. She said after his behaviors were decreased, there would always (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675431 If continuation sheet Page 11 of 21 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 675431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Red Oak Health and Rehabilitation Center 101 Reese Dr Red Oak, TX 75154 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 0740 Level of Harm - Actual harm Residents Affected - Few be additional staff available, like the two ADON's and her to assist if Resident #53 was having a bad day. She said on the weekend, the house manager RN would assist if needed if Resident #53 had increased behaviors. She stated they would in-service the staff to notify of the need for additional assistance and updated Resident #53's care plan. She stated if they felt Resident #53 required additional PRN orders for the ABH gel, they would notify the physician. Review of Resident #53 Psychological progress note, written by a licensed psychologist dated 09/24/2022, revealed Resident #53 was seen weekly and was not displaying any risk factors including substance abuse, suicidal/self-injury, sexual acting out, homicidal or aggressive behavior. The psychologist documented Resident #53's target symptoms were anxiety, depression, and uncooperativeness which was noted as very mild. The plan for the next session was noted to be will explore reason for increased aggression and frustration. Review of Resident #53 Psychiatric Subsequent Assessment, dated 08/08/2022, written by NP R revealed the medical necessity for the visit was patient seen at staff request. Reason: Increased exit seeking behavior. It was noted that nursing staff reported patient was at the exit door multiple times but did not push on the door. No changes were made to Resident #53's medication regimen. Review of Resident #53's Health Status note, dated 09/26/2022 at 4:25 AM, revealed Resident #53 was alert and oriented with confusion, restless, attempting to get out from exit door. Agitated when redirect. ABH GELL applied to hands and shoulder with effective result. Three scratches to face is cleaned with normal saline. Review of Resident #53's Health Status note, dated 09/26/2022 at 11:08 AM, revealed Resident #53 was on follow up for altercation with another resident. Resident is alert, not violent to other residents nursing staff closely monitoring resident. Review of Resident #53's Health Status note, dated 09/27/2022 at 11:01 AM, revealed Resident #53 was noted to have Behavior: Resident is seeking exit, nursing staff closely monitoring and redirecting. Nonpharmacological interventions: Calm approach to redirect, offered snack but refused. PRN medications: NA Results: Helped a little bit. Review of Resident-to-Resident Altercations policy dated December 2016 revealed facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors or to the staff. If two residents are involved in an altercation, staff will: a. Separate the residents, and institute measures to calm the situation . f. make any necessary changes in the care plan approaches to any or all of the involved individuals g. Document in the resident's clinical record all interventions and their effectiveness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675431 If continuation sheet Page 12 of 21 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 675431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Red Oak Health and Rehabilitation Center 101 Reese Dr Red Oak, TX 75154 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prepare food in a form designated to meet individual needs for 1 (Resident #49) of six residents reviewed for diets. The facility failed to provide Resident #49 with mechanical soft meat as ordered at lunch and was provided a whole chicken thigh. This failure put residents at risk for poor oral intake, weight loss, malnutrition, and choking. Findings included: Review of Resident #49's face sheet, dated 09/29/2022, revealed Resident #49 was an [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with everyday activities), dysphagia (difficulty swallowing), high blood pressure, and chronic kidney disease (gradual loss of kidney function which can cause dangerous levels of fluid, electrolytes and wastes to build up in your body). Review of Resident #49's quarterly MDS assessment, dated 08/15/2022, revealed Resident #49 had a BIMS score of three indicating severe cognitive impairment. Resident #49 was noted to require a mechanically altered diet. Review of Resident #49's care plan, dated 05/13/2022, revealed Resident #49 required a therapeutic regular/dysphagia-advanced diet with regular consistency. Review of Resident #49's physician orders, dated 08/19/2022, revealed Resident #49 was ordered a regular diet, dysphagia advanced texture, regular consistency liquids. Review of Resident #49's Speech Therapy Plan of Care, dated 02/20/2022, revealed Resident #49 was admitted on a regular diet and then downgraded to a pureed diet due to not having teeth and extended chewing time. Resident #49 had the plan of care goal of being upgraded to a mechanical soft diet. Review of Resident #49's Speech Therapist Progress and Discharge summary dated [DATE] Resident #49 completed speech therapy and goal was met of Resident #49 safely upgraded to mechanical soft diet due to dentition status (teeth status). In an observation on 09/27/2022 at 12:18 PM, in the locked unit dining room, Resident #49 had a whole chicken thigh on her plate and it was not eaten. Review of Resident #49 Tray Card, dated 09/27/2022, revealed Resident #49 had a regular - dys adv diet order with ground marinated chicken thigh, parmesan noodles, sauteed green beans, dinner roll and chocolate pudding parfait. In an interview on 09/27/2022 at 12:20 PM, CNA L stated Resident #49 should have had a ground up chicken thigh instead of a whole chicken thigh because she has trouble chewing her food. She said she would cut it up for Resident #49, so Resident #49 could eat the chicken. She stated the nurse checked the trays prior to the trays being passed and Resident #49's was overlooked. She said she thought (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675431 If continuation sheet Page 13 of 21 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 675431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Red Oak Health and Rehabilitation Center 101 Reese Dr Red Oak, TX 75154 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 0805 Resident #49's RP had requested Resident #49's diet order be upgraded but was not sure. Level of Harm - Minimal harm or potential for actual harm In an observation on 09/27/2022 at 12:23 PM, Resident #49 was observed to eat the cut-up chicken thigh without issue. Residents Affected - Few In an interview on 09/28/2022 at 11:35 AM, Resident #49's RP stated, via a Spanish interpreter, Resident #49 did not have teeth and required her food to be soft and cut-up for her. She said she had not requested a different diet order for Resident #49. She said she had not noticed an issue with Resident #49's food in the past when she visited her. In an interview on 09/28/2022 at 1:55 PM, LVN J stated she checked the trays when they were received from the kitchen prior to the aides passing them to the residents on the locked unit. She stated she verified the food on the tray matched the tray card and diet order. She said she did not know why Resident #49 received a whole chicken thigh instead of a mechanical soft ground chicken thigh since she did not have any teeth. In an interview on 09/29/2022 at 8:55 AM, the DM stated it was a mistake by the kitchen staff that Resident #49 received a whole chicken thigh and not mechanical soft ground chicken thigh, as required by the dysphagia advanced diet order. He stated the nurse checking the trays, on 09/27/2022, should have caught the error as well, but he did not either. He stated Resident #49 required a dysphagia advanced/mechanical soft diet order because she had no teeth and it made it easier for her to eat her food. In an interview on 09/29/2022 at 9:51 AM, the RD stated she was not involved in the recommendation for Resident #49 to have a dysphagia advanced/mechanical soft diet order. She stated the ST made the recommendation for Resident #49. She stated a resident who received the wrong food texture could be at risk for poor intake, weight loss, and choking. In an interview on 09/29/2022 at 10:13 AM, the ST stated Resident #49 required the dysphagia advanced/mechanical soft food texture because she had no teeth and it made it easier for her to eat her food. She stated Resident #49 did not have issues with swallowing her food and was not at risk of aspiration. She stated Resident #49 had oral dysphagia and did not have issues with swallowing that put her at risk of her food going into her lungs. She stated, as the ST, she assessed residents on admission and every three months for appropriate diets and made recommendations to the physician for the diet order. She stated the physician ordered the diet recommended and nursing staff entered the order. Nursing staff then communicated the diet order the dietary manager. In an interview on 09/29/2022 at 12:15 PM, the DON stated Resident #49 should have had the correct food texture on her tray. She stated the nurse on the locked unit, on 09/27/2022, should have checked Resident #49's tray versus her tray card and caught the mistake. She stated not receiving the correct diet order put residents at risk for decreased intake, weight loss and in some cases choking. Review of Therapeutic Diets Policy dated November 2015 revealed therapeutic diets shall be prescribed by the attending physician and the facility will strive for the fewest possible dietary restrictions. The food service manager will establish and use a tray identification system to ensure that each resident receives his or her diet as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675431 If continuation sheet Page 14 of 21 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 675431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Red Oak Health and Rehabilitation Center 101 Reese Dr Red Oak, TX 75154 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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, distribute, and serve food under sanitary conditions in one (Nutrition Refrigerator #2) out of two nutrition refrigerators reviewed for dietary services. The facility failed to date two thickened liquids cartons once opened in Nutrition Refrigerator #2. These failures could place residents who received thickened liquids at risk of foodborne illness and decreased product quality. Findings included: An observation on 09/28/2022 at 9:38 AM revealed in the nutrition room, near the 500 hallway, two cartons of opened thickened liquids with no open date. In an interview on 09/28/2022 at 9:40 AM, LVN T stated she did not know who maintained the nutrition refrigerators to ensure products were labeled and dated and not expired. She said the facility only had five or six residents who required thickened liquids that she knew of that day. She said the kitchen stored the unopened thickened liquids cartons and the opened ones were stored until used or thrown away on the unit. In an interview on 09/28/2022 at 1:54 PM, ADON K stated the opened thickened liquids containers should have an open date because they would need to be disposed of within three days of opening to prevent food borne illness. She said the open thickened liquids cartons in Nutrition Refrigerator #2 did not have an open date and she would have to speak with the medication aide that opened them to find out when they were opened. In an interview on 09/29/2022 at 8:55 AM, the DM stated they stocked the thickened liquid in small single serve cups in the nutrition refrigerators and checked the expiration dates to make sure none were expired. He said nursing staff were responsible for the cartons of thickened liquids and ensuring an open date was on them when they opened the cartons. He said they were good for three days after opening and then would have to be thrown away. He said using opened thickened liquids cartons past three days could put residents at risk for food borne illness. In an interview on 09/29/2022 at 9:51 AM, the RD stated she did not check the nutrition refrigerators or monitor them. She said the nursing staff that used the thickened liquids to administer medications or provide hydration to residents should have monitored the refrigerators for expired products. She said the opened thickened liquids should be dated upon opening and disposed of within three to five days. She said providing residents thickened liquids after the throw away date, could be at risk for spoilage and food borne illness. She said the product may not be as palatable for residents as well as resulting in decreased fluid intake. Review of Food Receiving and Storage Policy dated July 2014 revealed Foods shall be received and stored in a manner that complies with safe food handling practices. Food items and snacks kept on the nursing units must be maintained as indicated below .Beverages must be dated when opened and discarded after twenty-four (24) hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675431 If continuation sheet Page 15 of 21 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 675431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Red Oak Health and Rehabilitation Center 101 Reese Dr Red Oak, TX 75154 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 5 of 5 residents reviewed (Resident #8, Resident #94, Resident # 74, Resident #25 and Resident#27) for incontinence care, use of wrist blood pressure monitor, tracheostomy care and wound care as indicated by: Residents Affected - Some 1. MA T and MA S did not sanitize the wrist blood pressure monitor after using it on Resident # 8 and before and after using on Resident #94. 2. CNA M did not wash or sanitize her hands before and after perineal care. She handled clean items with contaminated gloves while providing incontinent care on Residents # 8 and #94. 3. The facility's Wound Care Nurse did not wash hands and change gloves at appropriate times to prevent cross contamination. 4. Facility wound care nurse did not follow facility procedure to sterile gloves when physically touching the wound or holding a moist surface over the wound. These failures could place residents at risk for cross contamination and infection. Findings included: Review of Resident # 8's medical record reflected a [AGE] year-old female admitted on [DATE] with Diagnoses that includinged: Quadriplegia (paralysis of all four limbs), Type 2 Diabetes Mellitus, Essential (primary) Hypertension, COPD (Chronic Obstructive Pulmonary Disease) , Osteoarthritis (a degenerative joint disease), and Muscle weakness. Review of Resident # 8's MAR, for [DATE], reflected an order for Amlodipne Besylate Tablet 10 MG; Give 1 tablet by mouth one time a day for HTN hold for SBP <100, DBP <60, HR <60 Review of Resident # 94's medical record reflected a [AGE] year-old woman female initially admitted on [DATE] and the re-admitted on [DATE] with. Diagnoses including Cerebral infarction (stroke) , Dysphagia (difficulty swallowing), Psychosis , Generalized Anxiety Disorder, Insomnia due to other mental disorder, Bipolar II disorder, Vitamin D deficiency, Other Heart Failure , Hyperglycemia(high blood glucose), Hyperlipidemia ( High level of blood fats) , Bipolar Disorder, Anxiety Disorder, Arthropathies (a joint disease) , Chronic Kidney Disease, Adjustment Disorder ( an emotional or behavioral reaction to a stressful event or change in a person's life) ,Spastic hemiplegia ( part of the brain controlling movement is damaged) affecting left nondominant side, Herpes viral Vulvovaginitis (inflammation in the vagina and vulva), Type 2 diabetes Mellitus , Essential (primary) Hypertension, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675431 If continuation sheet Page 16 of 21 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 675431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Red Oak Health and Rehabilitation Center 101 Reese Dr Red Oak, TX 75154 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 - Some Hypertrophic pyloric stenosis ( a thickening or swelling of the muscle between the stomach and the intestines). Review of Resident # 94's MAR, for [DATE], reflected an order for Coreg Tablet 6.25 MG (Carvedilol); Give 1 tablet by mouth two times a day related to essential (primary) hypertension hold if SBP<110 or DBP<60. Observations of taking blood pressure using a wrist blood pressure monitor on [DATE] beginning at 9:00 am, on residents with blood pressure related issues revealed MA-T and MA-S failed to sanitize the wrist blood pressure cuff after using it on Resident #8 and before and after using it on Resident #94 There were three wrist blood pressure cuffs on the med cart. MA-T took one of them, and used it on Resident #8. She kept it back on the med cart and helped MA-S in dispensing morning medication for Resident #8. After the completion of medication administration, MA-T took the same blood pressure cuff, and used it on Resident #94. After the use, she put it back on the cart. When the surveyor clarified with MA-T and MA-S about the procedure and facility's policy within using reusable medical equipment, MA-T immediately sanitized the blood pressure cuff with the sanitizing wipe from one of the drawers of the med cart. During the interview on [DATE] at 9:20 am, MA T stated that, per the facility sanitation policies and procedure for hand and equipment sanitization, all the healthcare providers should sanitize their hands as well as reusable medical equipment after the use. She said that it was a mistake from her side and will remember not to repeat the same mistake in the future. During an observation on [DATE] at 10:00 AM, CNA M provided incontinent care first to Resident # 8 and afterwards to Resident#94 who resided in the same room. CNA M entered the room, took a pair of gloves from her scrub pocket, and donned them without washing or sanitizing hands. CNA M removed Resident #8's brief which was soaked with urine and then cleaned resident's perineal area. She then turned the resident to the left side and cleaned the back of the resident. Resident #8 had stage 4 pressure ulcers at her coccyx and right hip area measuring 1.8 cm L x 1.5 cm W x 0.5 cm D and 2 cm L x 0.8cm W x 0.9 cm D respectively. CNA M applied cream at the back and perineal area and then picked up a new diaper, without sanitizing or washing hands or changing the gloves, and put it on the resident. After the completion of the care, with the same gloves, CNA M pulled back the blanket on Resident #8, tidied up the bed, and then adjusted the bed level by operating the remote. She then removed the soiled gloves and put on new pair of gloves from her scrub pocket without sanitizing the hands, and moved on to Resident #94 and repeated the same procedure. She did not wash or sanitize her hands, induring the entire process. After the completion of the care, she operated the bed remote after removing the gloves. CNA M then exited the room without washing or sanitizing her hands. During an interview on [DATE] at 11:10 a.m , CNA M stated she forgot to sanitize her hands before, during and after the procedure and said it was a mistake. She said she was aware of the importance of sanitation to stop spreading infectious diseases. An interview on [DATE] at 12:10 pm with the DON revealed that her expectation was that the nursing staff followed the facility's policy and /procedures for washing hands before and after wound care, handwashing/ or sanitization and clean techniques while providing perineal care. Staffs are expected to wash their hands after using sanitizer three times consecutively. She said sanitizing after the use of reusable medical equipment was also important to minimize the spread of infectious diseases. The DON added that they have infection control training on a monthly basis. The IP does audits and identifies deficiencies in infection control practices through direct observations. She stated In (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675431 If continuation sheet Page 17 of 21 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 675431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Red Oak Health and Rehabilitation Center 101 Reese Dr Red Oak, TX 75154 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 -services were provided to relevant staff members, when any deficiencies identified. Level of Harm - Minimal harm or potential for actual harm Record review on [DATE] revealed that CNA M completed her proficiency Evaluation, that includes Perineal Care/ and Grooming, on [DATE]. There was in-serviced on Cleaning hands between passing meal trays and providing care to residents, donning and doffing of PPE, and how to wear a (surgical or (N95) mask, hand washing/ hand hygiene, cleaning medical equipment between residents, Kill time 3minute for micro kill bleach wipes, covid-19 prevention conducted on [DATE], [DATE],[DATE], [DATE], [DATE] and [DATE] . CNA M said she will be attending this In- Service next week. Residents Affected - Some An interview on [DATE] at 12:10 pm with the DON revealed that her expectation was that the nursing staff followed the facility's policy and procedures for washinghands before and after wound care, handwashing or sanitization and clean techniques while providing perineal care. Staffs were expected to wash their hands after using sanitizer three times consecutively. She said sanitizing after the use of reusable medical equipment was also important to minimize the spread of infectious diseases. The DON added that they had infection control training on a monthly basis. The IP did audits and identified deficiencies in infection control practices through direct observations. She stated in-services were provided to relevant staff members when any deficiencies identified. An interview on [DATE] at 12:30 pm with the IP revealed that she was vigilant about infection control protocol violations. She observed procedures like perineal care, wound care, and medication administration on a regular basis. If any deficiencies were found, in-services would be provided immediately. Record review on [DATE] revealed that CNA-M completed her proficiency evaluation, that included Perineal Care and Grooming, on [DATE] and in-serviced on Cleaning hands between passing meal trays and providing care to residents, donning and doffing of PPE, and how to wear a (surgical or N95 mask, hand washing/ hand hygiene, cleaning medical equipment between residents, Kill time 3minute for micro kill bleach wipes, covid-19 prevention conducted on [DATE], [DATE],[DATE], [DATE], [DATE] and [DATE] . In an observation on [DATE] at 9:05 AM, the Wound Care Nurse LVN D provided wound care to Resident # 74's skin tear on the right elbow. She cleansed the top of the rollator walker. She set up supplies applied normal saline soaked gauze to Resident #74's skin tear, applied xeroform, and applied a bandage. She gathered the supplies, washed her hands, and left the room without cleaning the rollator walker top, used as a table. B. In an observation on [DATE] at 9:15 AM with CRT E performing tracheostomy care for Resident #25 , she used hand sanitizer at the bedside. She then gathered her supplies, adjusted resident, touched ventilator tubing, and touched ventilator machine. She put on sterile gloves without her washing hands, and moved suction package, that had fallen outside of sterile field and was lying on table, with her sterile right hand. She then held suction tubing with right hand that was no longer sterile and suctioned the resident. CRT E used hand sanitizer and opened a second set of sterile gloves. With her right hand, she touched outer package of Yanker suction that was tucked under resident's pillow in a wrapper, then picked up sterile suction tubing from bedside table with contaminated right hand and suctioned Resident #25. CRTE used hand sanitizer and opened another trach care tray. She touched her left hand to unsterile normal saline opening then placed sterile right hand to opening where unsterile left hand was. She cleansed around the trach with the unsterile right hand, then dipped gauze (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675431 If continuation sheet Page 18 of 21 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 675431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Red Oak Health and Rehabilitation Center 101 Reese Dr Red Oak, TX 75154 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 - Some with right hand into sterile water. She continued to use her right hand to clean Resident #25's stoma. She touched the Yancher package under the resident's pillow and then put a gauze around trach with unsterile hands. In an interview on [DATE] at 9:48 AM, CRT E stated she knew she broke sterile field during tracheostomy care and switched gloves a couple times during tracheostomy care because of sterile field being broken. She stated she did not catch the times the sterile field was broken. She said the sterile field being broken, during tracheostomy care, can put the resident at an increased risk of infection. In an observation on [DATE] at 9:53 AM, LVN D washed her hands and gathered supplies before starting wound care on Resident #27wound to his left leg. LVN D put gloves on and removed old bandage. She washed hands and applied new gloves. She used a saline soaked gauze to wipe the wound. She then used the same gloves to apply the wound medication and bandage. In an interview on [DATE] at 10:04 AM , LVN D stated she was not aware of policy stating sterile gloves were to be worn when a wound was cleansed by touching saline soaked gauze to wound. She said she was aware she needed to change gloves and wash hands between cleansing wound and applying medication, but she forgot. She stated resident's are at an increased risk for infection when hands are not washed, gloves not changed, and wound care is not provided per facility policy using sterile gloves. In an interview on 09/28 /22 at 11:15 AM, the DON stated she was not aware of the policy stating sterile gloves were to be worn when a wound was cleansed by touching saline soaked gauze to wound and she knew gloves were to be changed and hands washed between going from clean to dirty during wound care. She stated anytime a sterile glove touched an unsterile field the gloves needed to be changed. She stated when the policy and procedure is not followed for wound care or tracheostomy care the residents are at a higher risk for infection. Record Review revealed Wound Care policy dated [DATE] revealed in step 9. Wear exam gloves for holding gauze to catch irrigation solutions poured directly over the wound. 10. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. Record review revealed tracheostomy care competency check off Suctioning the Upper Airway (Oral Pharyngeal Suctioning), and CPAP/BIPAP support for CRTE dated [DATE] and [DATE] stating sterile gloves are to be worn for tracheostomy care. Record review revealed the wound care competency check off for LVND dated [DATE], [DATE], and [DATE], stating hands are to be washed and gloves changed anytime gloves touched body fluids. Facility's policy Cleaning and disinfection of resident-care items and equipment' revised [DATE], it was stated that . c. non-critical items are those that come in contact with intact skin but not mucous membranes. 1. non-critical resident-care items include bedpans, blood pressure cuffs, crutches, and computers . d. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscope, durable medical equipment) . 3. Durable medical equipment (DME)must be cleaned and disinfected before reuse by another resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675431 If continuation sheet Page 19 of 21 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 675431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Red Oak Health and Rehabilitation Center 101 Reese Dr Red Oak, TX 75154 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 - Some 4. Reusable resident care equipment will be decontaminated and /or sterilized between residents according to manufacturer's instructions Review of the facility policy titled Handwashing/Hand Hygiene revised on August, 2015 stated, This facility considers hand hygiene the primary means to prevent the spread of infections All personnel shall follow the Handwashing/Hand Hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .b. Before and after direct contact with residents ., c. Before preparing or handling medications , f. Before donning sterile gloves, g. Before handling clean or soiled dressings, gauze pads, etc. h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin .k. After handling used dressings, contaminated equipment, etc. l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; m. After removing gloves . Applying and removing gloves: 1. Perform hand hygiene before applying non-sterile gloves . 4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. 5. Perform hand hygiene. Review of the facility policy titled Perineal Care revised on 10/2010 stated, Steps in the Procedure: 1. Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 7. Put on gloves. 11. discard disposable items into designated containers. 12. Remove gloves and discard into designated container. Wash and dry your hands thoroughly . 16. Clean the bedside stand. 17. Wash and dry your hands thoroughly. According to the website, https://www.cdc.gov/handhygiene/providers/guideline.html, dated [DATE], the Center for Disease Control (CDC) recommended the following for hand hygiene: Hand Hygiene Guidance The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices Before moving from work on a soiled body site to a clean body site on the same patient After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675431 If continuation sheet Page 20 of 21 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 675431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Red Oak Health and Rehabilitation Center 101 Reese Dr Red Oak, TX 75154 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 Healthcare facilities should: Level of Harm - Minimal harm or potential for actual harm Require healthcare personnel to perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendations Residents Affected - Some Ensure that healthcare personnel perform hand hygiene with soap and water when hands are visibly soiled Ensure that supplies necessary for adherence to hand hygiene are readily accessible in all areas where patient care is being delivered. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and, in the absence of a sink, are an effective method of cleaning hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675431 If continuation sheet Page 21 of 21