Inspection·August 17, 2023

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview with LVN A on 08/16/23 at 01:05 p.m. revealed any resident with oxygen had to have an order with the number of liters per hour to be delivered. She stated she had assessed Resident #8 when she came on duty and had checked her O2 saturation level but did not look to see what the O2 concentrator was set on. LVN A stated Resident # 8 had been on continuous O2 at 3 to 4 liters for several weeks. She stated she was not aware the orders had not been updated and stated she should have been verifying orders prior to administering any oxygen. She stated it should also have documented in the TAR. She stated providing inaccurate amounts of Oxygen could make the residents breathing worse. In an interview with the DON on 08/16/23 at 01:10 p.m. revealed any resident who required oxygen had to have an order from the physician which stated the number of liters to be delivered. She stated it was a requirement the physician determine how much supplemental oxygen someone needed and was not a nurse's judgement. She stated the nurses were supposed to assess the resident's respiratory status, including ensuring the Oxygen was delivered at the prescribed rate. She stated giving too much oxygen could lead to oxygen toxicity to the resident. Record review of the facility's policy, Oxygen Administration revised October 2010, reflected, .Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following .signs or symptoms of oxygen toxicity .signs and symptoms of hypoxia .the following information should be recorded in the resident's medical record .the rate of oxygen flow, route, and rationale .the frequency and duration of the treatment .all assessment data obtained before, during, and after the procedure . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675503 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675503 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beacon Hill 3515 S Park Ave Denison, TX 75020 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 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for facility's only kitchen reviewed for physical environment. Residents Affected - Some The facility failed to ensure kitchen was free of two faucet leaks for 3 compartment sink and garbage disposal sink faucet. The pipe under the 3-compartment sink was dripping in three different areas under the 3-compartment sink. The drain in the dish area of the kitchen was loose around the edges. These failures could place facility at risk for unsanitary and hazardous living conditions. Findings included: Observation on 08/15/23 at 9:40 AM revealed under the 3-compartment sink water dripping from the beginning of the bottom pipe where connecter was under the first sink and water dripping under the first sink in the middle of bottom of the pipes in 2nd area. One of the areas had a black plastic container under it full of water where 2nd water dripping was going into the container. Water was not running when pipes were dripping under the 3-compartment sink. It was dripping at the end of the pipe into the drain on floor. Interview on 08/15/23 at 9:45 AM with Dietary Aide C revealed the pipe had been leaking under the three-compartment sink and the plastic black container was placed under it since it was leaking. She stated the Dietary Manager was aware of it before she went on vacation last week and Maintenance Director was aware of it. Observations on 08/15/23 at 9:55 AM and 11:57 AM revealed the drain in the floor in dish area was loose around the edges and had openings of about ¼ inch around the edges of it. Interview on 08/15/23 at 11:59 AM with Dietary Aide B revealed he had noticed the drain being loose in the dish area for a while but had not reported it to anyone. He stated he thought the Maintenance Director had replaced the faucets above the garbage disposal dish area recently within the last month. He stated it had been leaking at the faucet when turned off about for a couple of weeks, but he was not sure if it was reported to the Maintenance Director. He stated the Dietary Manager usually reported any maintenance issues to the Maintenance Director. Interview on 08/15/23 at 11:10 AM the Maintenance Director stated he had just fixed the leak under the 3-compartment sink it was reported to him after surveyor went into kitchen. He stated it was no longer leaking under the 3-compartment sink since he fixed it. He said he had not been informed about the drain being loose in the dish area and would look at it. Observations on 08/16/23 at 11:20 AM and 12:10 PM revealed under the 3-compartment sink pipe was water dripping in two areas under the first sink in the middle of the bottom of pipe onto the floor. The first sink was full of water, but faucet was turned off. The 2nd faucet was turned off but was leaking in the in the middle between the hot and cold faucets into the 2nd sink of water. The pipe at the end under the 3-compartment sink was dripping into the drain even though water was turned off. Observations on 08/16/23 at 11:22 AM and 12:09 PM revealed the faucet at the sink above the garbage (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675503 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675503 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beacon Hill 3515 S Park Ave Denison, TX 75020 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some disposal was leaking in the middle when faucet was turned off. There was corrosion and metal turning yellowish color in the middle of the faucet. Interview on 08/16/23 at 11:23 AM the Dietary Manager stated the 3-compartment sink had been leaking since last week and it was in the Dietitian's sanitation report. She stated it was still leaking today. She stated she was not aware of faucet leaking at garbage disposal or the faucet leaking at 3 compartment sink, until now but had been off for a few days so this was her first day back. She stated she would report any maintenance issues in the kitchen to the Maintenance Director. She stated the leaks in the kitchen should be addressed before they got worse. Interview on 08/16/23 at 3:20 PM, the Maintenance Director stated he was not aware of the drain being loose in the dish area until yesterday when informed by surveyor. He stated he did not have a maintenance log for Kitchen staff to write down maintenance requests. He stated they usually inform him of maintenance needs verbally or by phone. He stated he thought he had fixed the leak under the 3-compartment sink yesterday and was not aware it was still leaking. He was not informed about the faucets leaking under the garbage disposal or the 3-compartment sink. Interview on 08/16/23 at 3:45 PM with the Maintenance Director stated he was sent the sanitation report last week by Dietitian and it was in there about the leaking from 3 compartment sink. He stated he had not read it to know about the repair. He stated this was the only maintenance repair he was informed of in the sanitation report. He stated he would be able to fix the drain and it needed to be regrouted to secure the drain. He provided surveyor with the sanitation report from the Dietitian. He stated the maintenance issues in the kitchen being unaddressed could get worse. Review of the Nutrition Services Sanitation Audit dated 08/10/23 completed by Dietitian reflected under maintenance about leaks under 3 compartment sink. Interview on 08/17/23 at 8:58 AM the Administrator stated the facility did not have a policy for maintenance services. The facility followed the state and federal guidelines in regard to maintenance repairs in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675503 If continuation sheet Page 4 of 4