Health inspection·August 16, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents have the right to formulate an advance directive for 2 of 24 residents (Resident #07, Resident #276) reviewed for advanced directives. The facility failed to have an Advanced Directive, Out of Hospital Do Not Resuscitate (OOHDNR) consent form which includes a Representative and physician signature and License # in the electronic charting or admission paperwork for Resident #07 and Resident #276. This failure could affect residents by not having their preferences honored concerning advanced directives. Finding included: Record review on [DATE] of the electronic face sheet revealed Resident #7 was an [AGE] year-old female, admitted on [DATE] with DNR status and a diagnosis of encephalopathy (A disorder of the brain that can be caused by disease, injury, drugs, or chemicals) and Congestive Heart Failure. Residents Brief Interview of Mental Status (BIMS) assessment on [DATE] was 11 (moderately impaired). Resident physician's orders dated [DATE] revealed an order for DNR. Residents electronic health record revealed: no evidence of an Advanced Directive for Out of Hospital Do Not Resuscitate Order (OOH-DNR) form; no evidence of documentation of progress notes relating to the DNR status; and no evidence of a preadmission Advanced Directive Information form; and no evidence of an Advanced Directive for Out of Hospital Do Not Resuscitate Order (OOH-DNR) verbal assessment. Record review on [DATE] of the electronic face sheet revealed Resident #276 was a [AGE] year-old male, admitted on [DATE] with a DNR status and a diagnosis of Type 2 Diabetes Mellitus, Muscle Weakness, Muscle Wasting and Chronic Obstructive Pulmonary Disease (COPD). Residents Brief Interview of Mental Status (BIMS) assessment dated [DATE] was 4 (severe Impairment). Residents physician's orders dated [DATE] revealed an order for a DNR. Residents electronic health record revealed: no evidence of an Advanced Directive for Out of Hospital Do Not Resuscitate Order (OOH-DNR) form; no evidence of documentation of progress notes relating to the DNR status; and no evidence of a preadmission Advanced Directive Information form; and no evidence of an Advanced Directive for Out of Hospital Do Not Resuscitate Order (OOH-DNR) verbal assessment. An interview on [DATE] at 06:09 PM, the RN E stated the protocols for an unresponsive resident would be to check the resident's DNR status (Full Code or DNR) on their electronic Facesheet. She stated if the Resident had an official DNR document, it should have been scanned into the Residents electronic record. Page 1 of 28 675944 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview on [DATE] at 6:31 PM, the DON stated the resident code status was located in the facility's Electronic Charting under Face sheet. She stated upon the resident's admission, if the resident has a signed OOHDNR, and admitted from the hospital with one, the residents DNR status would be documented on the Facesheet at that time. The DON stated if the resident verbalized that they prefer to be a DNR status, staff would perform a DNR assessment at that time. She stated this documentation would be found under assessments in the residents Electronic Charting. The DON stated anyone can initiate the DNR assessment and would be done immediately, then taken to the resident's Doctor to sign. She stated if the resident was on Hospice Services, Hospice would initiate the DNR paperwork consenting to the status with the Hospice book being left at the nurses' station, and if Hospice staff is in the facility to see the resident, they maybe would have taken the binder to the residents room. The DON stated Resident #276's was admitted to the facility on Hospice, and they would have a copy of the OOHDNR in the binder. She stated Resident #276's binder was not in the facility at that time of interview. The DON also stated since the OOHDNR was not in the facility, there should have been a DNR assessment done., She stated there was no DNR assessment previously done for Resident #276 as the nurse forgot to do so. The DON stated the responsible party for completing a DNR for the resident's end of life wishes would have been the DON or SW. She stated the previous SW had left, leaving the facility without one. The DON stated they fell short due to the hospice nurse visiting every day since this resident's admission and still did not have the DNR assessment nor the OOHDNR consent. She stated the negative impact to the resident could be death if resident has a status of DNR and was an actual Full Code status. She stated what led to the failure was that nurses had gotten too busy and had not documented correctly or following up with DNR statuses. The DON stated her expectations were that if a resident requested a DNR, the staff members need to document and follow up with the OOHDNR paper with the proper signatures. Once done, the paperwork should be uploaded in the resident Electronic Charting that same day or by the next morning. Record Review of a blank Out of Hospital Do Not Resuscitate (OOH-DNR) Order Tx Dept. of State Health Services consent form, page 1, reads in part: This document becomes effective immediately on the date of execution for health care professionals acting in out of hospital settings. It remains in effect until the person is pronounced dead by an authorized medical or legal authority or the document is revoked. Resuscitation measures include cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, Defibrillation, advanced airway management, artificial ventilation. Comfort care will be given with a Representative and physician signature and License # in the electronic charting or admission paperwork. The Physician Statement section and the final section instructs and reads in part, All persons who have signed above must sign, acknowledging the document has been properly completed. Record Review of page 2 of the Texas Out of Hospital Do Not Resuscitate form, Publication No EF01-11421 revised [DATE], by the Texas Department of State Health Services titled Instructions for Issuing an OOH-DNR Order reads in part: IMPLEMENTATION: A competent adult person .or the person's authorized representative or qualified relative may execute or issue an OOH-DNR Order. The person's attending physician will document existence of the Order in the person's permanent medical record. The OOH-DNR Order may be executed as follows: Section A-If an adult person is competent and at least [AGE] years of age, he/she will sign and date the Order in Section A. Section B-If an adult person is incompetent or otherwise mentally or physically incapable of communication and has either a legal guardian, agent in a medical power of attorney, or proxy in a 675944 Page 2 of 28 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few directive to physicians, a guardian, agent, or proxy may execute the OOH-DNR Order by signing and dating in section B. Section D if the person is incompetent and his/her attending physician has seen evidence of the person previously issued proper directive to physicians or observe the person competently issue and OH DNR order or a nonwritten manner, the physician may execute the order on behalf of the person signing and dating it in section D. In addition, the OOH-DNR order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either section B, C, or E, and if applicable have witnessed a competent adult person making an OOH-DNR order by nonwritten communication to the attending physician, who must sign in section D and also the physicians statement section. Record Review of the electronic Texas Health and Safety Code, Chapter 166 (C), Section 166.082 (b) stated The attending physician of the declarant must sign the order . (statutes.capitol.texas.gov/Docs/HS/htm/HS.166.htm). Record Review of the facility policy Do Not Resuscitate Order, revised [DATE] revealed: The facility will honor two types of Do Not Resuscitate orders; a physician's order for Do Not Resuscitate and the Texas Out of Hospital DNR Order. Goals: 1. The resident will verbalize end of life wishes. 2. The resident will execute a valid living will that reflects his/her wishes. 3. The resident verbalizes feelings about a decision for end of life wishes. 4. The resident and/or family receive support and education about end-of-life decisions Physician Order for Do-Not-Resuscitate According to CHAPTER 166. Advance Directives Sec 166.202 as it relates to application to a DR order issued in a health care facility or hospital. Procedure: Physician's order for DNR A DNR order issued for a patient is valid only if the patient's attending physician issues the 675944 Page 3 of 28 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0578 order, the order is dated, and the order: Level of Harm - Minimal harm or potential for actual harm (1) Is issued in compliance with: Residents Affected - Few (A) The written and dated directions of a patient who was competent at the time the patient wrote the directions; (B) The oral directions of a competent patient delivered to or observed by two competent adult witnesses (C) The directions in an advance directive (D) The directions of a patient's legal guardian or agent under a medical power of attorney The DNR order takes effect at the time the order is issued, provided the order is placed in the patient's medical record as soon as practicable 1. The physician's order for DNR should be maintained in the resident's clinical record. 2. Any resident who has a physician's order for DNR will have it noted in PCC 3. All validly executed physician orders for DNR orders will be honored by the facility. 4. Emergency workers will not honor the physician's order for DNR. Out of Hospital DNR Form The Out of Hospital DNR form was designed by the Texas Department of Human services to comply with the requirements as set forth in the Health and Safety Code for the purpose of instructing Emergency Medical personnel and other health care professionals to forgo resuscitation attempts 675944 Page 4 of 28 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents the right to be free from misappropriation of property for 1 of 24 (Resident #15) reviewed for personal property. Residents Affected - Few The facility failed to maintain a system to prevent Resident #15's personal money from being taken by a staff member. This failure placed residents at risk of loss of personal property and financial hardship. Findings included: Record review of Resident #15's Facesheet dated 08/16/23 revealed an [AGE] year-old male admitted to the facility on [DATE]. He had a diagnosis list that included: COPD (Primary), Generalized anxiety, Depression. Record review of Resident #15's admission MDS dated [DATE] revealed a BIMS of 9 meaning moderate cognitive impairment. He needed extensive 2-person assistance for most ADL functions, an indwelling catheter and was continent of bowel. Record review of Resident #15's Care plan dated 07/07/23 revealed no care areas regarding personal funds. Record review of PIR dated 07/25/23 revealed: Incident occurred 07/12/23 at 6:00PM and was reported by Resident #15 on 07/20/23. Description of Allegation: on 7/20/2023 at approx 5p NA-B reported to Admin, that Resident #15 said someone took his money while he was in rest room Investigation Summary: On 7/20/2023 at approx 5 pm NA B, reported to facility admin that Resident #15 was missing money. Facility admin interviewed Resident #15 and it was determined that NA A, was in the room when his money went missing on 7/12/2023, Res reported that he was missing $140, he stated he had the money in his motor wheelchair and after he went to the rest room, he was going to put it back in his drawer and noticed it was missing. Res reported that NA A, never went back to his room after the incident. Facility admin notified Police Department; Res doesn't wish to file any charges. NA A suspended immediately until further investigation. Resident is A&O X 4, and it was confirmed with resident's daughter that he had money in his possession. After facility administrators investigation, it is founded, and NA A will be terminated from facility. Witness statement signed 07/20/23 by NA B Wednesday July 19th, 2023, resident #15 reported to me did a couple weeks ago or possibly more recently, that an aide stole money from his drawer. He stated that the aide took him to the bathroom and closed the door. After using the bathroom, he noticed $140 missing from his drawer. He didn't get her name, but said she had a bun in her hair, and she was white. I made sure to have him tell me this story at two different times, and it was the same. I have not checked to see if he possibly just misplaced it for the reason being I don't want possible accusations towards me. he came to the conclusion it was stolen from him and did not want to cause trouble for her. During an observation and interview on 08/13/23 at 4:21PM with Resident #15, he was lying in bed with an electric wc in his room. Resident was pleasant and explained that he knew who took his money. He said the situation included that an NA A assisted him to the restroom and pulled his pants down for him to use the toilet and she removed the electric wc from the bathroom and shut the door. She left the door shut and stayed in the room and asked him repeatedly if he was ready for his chair while 675944 Page 5 of 28 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few he used the bathroom. He said that had been the first- and only-time staff ever took his electric wc out of the bathroom. Resident #15 said he was suspicious of the situation because they never took the chair out of the bathroom and the NA A kept asking him if he was finished. He said after he got finished and was back in his electric wc, he then looked into his black bag that he kept on the arm of his electric wc while out of bed and discovered money missing from his wallet. He said he was very upset and said he did not understand why the aide did not take all his money. He said he had 4 100-dollar bills and 5 20-dollar bills prior to her helping him in the restroom and when he checked his wallet a 100-dollar bill and 2 20-dollar bills were missing. Resident #15 said that aide never returned to his room ever again, and he told the nurse about the incident that night. Resident #15 said the aide had denied taking his money until being confronted with the sheriff, and she no longer worked at the facility as far as he knew. He said, There is nothing I hate more than a liar and a thief. During an interview on 08/15/23 at 9:10AM with ADM, she said the resident did not want to press charges on the aide, so she did not file a police report, the police department only did a service call because she had called them originally when she was made aware of the allegations. ADM said the aide never confessed to taking Resident #15's money, however she had a history of suspicious behavior and Resident #15 had been interviewed 3 different occasions by an aide he reported the incident to as well as 2 times he had been interviewed by ADM, and he had the same recall of events each time. ADM said the aide that allegedly taken the money had a history of trying to break into offices late at night. ADM said that she felt that even without the aide confessing to the incident that she may have very likely taken Resident #15's money. During an interview on 08/16/23 at 6:17PM with ADM, she said Resident #15 was never able to tell her a specific day that the event occurred, however, she reviewed the days worked by the now former aide and narrowed it down to occurring on 07/12/23 due to the fact that she called in any time she was scheduled to work until she came back and was suspended due to the allegations on 07/21/23. She was subsequently terminated on 07/26/23. ADM said she spoke to Resident #15 in length to determine a description of the alleged perpetrator and during his description, he stated that the person work a headband or bandana on her head. ADM said the aide that they terminated was the only staff member that wore anything on her head that could fit that description. ADM said that she also showed Resident #15 different staff member photographs that they utilized on their social media website and Resident #15 positively identified that aide. ADM said there had been a recent domestic violence issue between the former aide and her boyfriend that had been in the local paper. Record review of NA A personnel file revealed: Hire date of 10/22/21. -Her last EMR/NAR had been checked 11/1/22 with no noted issues. -Disciplinary Report Action Request dated 6/9/23. On 6/9/2023 ADM told employee NA A her boyfriend was not allowed at the facility while she was working. Admin also told NA A she was not allowed to use her cell phone in resident rooms or hallways. -Witness Statement dated 06/11/23. RN C Issue related to NA A. This nurse overheard other nurse saying that NA A was on her cell phone again. This nurse did not step in until resd fell, NA A showed up to scene with phone in hand saying, I will call you back. but continued to talk on phone while other nurse asked her to assist getting resd into wc from floor. Also, her boyfriend has been in car in parking lot most of night. 675944 Page 6 of 28 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -Disciplinary Report Action Request dated 06/15/23. Date of infraction 6/11/23, 6/14/23. Employee has continued to be late. As well as cell phone usage on the floor and in the resident's room. -Text message printed 08/15/23 at 11:42AM that was dated 06/12 at 1:29AM from Nurse NA A's bf (boyfriend) is sitting in the parking lot. She's been on the phone in residents' rooms and even FaceTime is what staff J said. ADM response Can you. Send her home I went up Friday night and told her this is not allowed with HR witness. -Text message printed 8/15/23 at 11:42AM. That was dated 6/7/ at 9:33AM from HR What would you write someone up for breaking into an office no response to the message from ADM. Record review of facility policy labeled Abuse/Neglect revised 03/29/18 revealed: Misappropriation of resident property: means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent . With an allegation of abuse, neglect. exploitation, mistreatment of residents or misappropriation of resident prope1ty, the employee(s) will immediately be suspended pending an investigation. The employee will have an opportunity to present a written statement to answer the allegation(s) of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. The employee will have the opportunity to be advised of the outcome of the investigation in the determination of disciplinary action and/or reinstatement. Abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property of residents by employees of any facility will be grounds for immediate termination. 675944 Page 7 of 28 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to implement written policies and procedures that protected residents from abuse, neglect, exploitation of residents, and misappropriation of resident property for 3 of 15 employees (ADM, LVN A, and LVN B) reviewed for EMR/NAR's. Residents Affected - Some The facility failed to conduct an EMR/NAR check ADM for 18 months from hire date of 02/14/22 to 08/12/23. The facility failed to conduct an EMR/NAR check on LVN B annually since her hire date of 07/26/22. The facility failed to conduct an EMR/NAR check on LVN C annually since her hire date of 01/09/18. These failures placed residents at risk of abuse, neglect, exploitation and misappropriation of property. Findings included: Personnel File review on 08/16/23 revealed: ADM hire date of 02/14/22 with an EMR/NAR EMR/NAR check on 08/14/23, with an 18-month space between initial and current EMR/NAR. LVN B was hired on 07/26/22 with her initial EMR/NAR checked on 06/20/22 and no further EMR/NAR checks. LVN C was hired on 01/09/18 with her initial EMR/NAR checked on 01/04/18. And no further EMR/NAR checks. During an interview on 08/16/23 at 7:26PM with ADM, she said the EMR/NAR check should have been performed before initial hire and within days of their anniversary of their hire date. She said the reason for the annual checks was to ensure that the staff had not committed crimes that would make the residents unsafe. Through her review, she verified that 3 employees, including herself had not had an annual EMR/NAR within the timeframe of the yearly anniversary of their hire date. Record review of facility policy labeled Abuse/Neglect revised 03/29/18 revealed: A. Screening: Criminal History and Background Checks The facility will conduct criminal background checks of all personnel in accordance with Texas Health and Safety Code, Chapter 250. 1.l11e facility administrator will be responsible for ensuring compliance with the policy and Texas state law regarding criminal background checks. All potential employees will be screened for history of abuse, neglect or mistreating of elderly/individuals as defined by the applicable requirements of 483.13 (c) (1) (ii) (A) and (B). Employees will be screened for abuse, neglect, and exploitation of the elderly by accessing the Employee Misconduct Registry by calling the Texas Department of Aging and Disability at [PHONE NUMBER]. The hiring authority will follow the automated response prompts to screen the employee for abuse, neglect, exploitation of a resident or misappropriation of a resident's or consumer's property. The hiring authority is responsible for training an individual to complete misconduct registry checks on every employee. The facility is 675944 Page 8 of 28 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0607 required to provide a written statement to the employee upon hire about the Employee Misconduct Registry including a statement indicating that a person may not be employed if listed on the registry. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 675944 Page 9 of 28 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

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 interviews and record reviews, the facility failed to ensure a Minimum Data Set (MDS) assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 17 (Resident #14) reviewed for MDS information. Residents Affected - Few The facility failed to encode, complete and submit a discharge MDS for Resident #14. This failure could place residents at risk of facilities have provided resident specific information for payment and quality measure purposes. Findings included: Record review of Resident #14's Facesheet dated 08/16/23 revealed an [AGE] year-old female that discharged on 05/05/23. Record review of Resident #14's Care plan last revised 03/01/23 revealed: Resident #14 wishes to return home. Establish a pre-discharge plan with resident/family/caregivers) and evaluate progress and revise plan. Evaluate and discuss with resident/family/caregivers the prognosis for independent or assisted living. Identify, discuss and address limitations, risks, benefits and needs for maximum independence. Record review of Resident #14's Discharge Summary completed 05/05/23 revealed: Date of discharge 05/05/23. Record review of Resident #14's MDS assessment completion list did not reveal a Discharge MDS had been completed. During an interview on 08/16/23 at 6:41 PM with MDS LVN, she said she had a 14-day window to complete any MDS be it an admission, quarterly or discharge MDS. She said Resident #14 discharged on 05/05/23 back to her assisted living facility. She reviewed Resident #14's MDS schedule and verified that Resident #14 did not have a Discharge MDS started, completed or submitted to CMS. She said she had a scheduler built into the EHR. She did not understand how she did not receive an alert that Resident #14 needed a Discharge MDS and said that the scheduler was in part a reason for the failure to complete and submit a Discharge MDS. She said that the DON was responsible for the RN signature on MDS's, but her signature was only to state that the MDS that was being submitted was complete. MDS LVN said that DON did not routinely manage her to ensure that resident MDS's were due or needed to be completed and submitted. During an interview on 08/16/23 at 7:01PM with DON, she said that she only signed MDS's that had already been completed to state that they were complete and nothing more. She said that she did not manage the MDS nurse to know if she had missed any resident's MDS's. Record review of facility policy labeled Resident assessment dated 2023 revealed: A comprehensive assessment will be completed within 14 days of admission and annually on each resident. The facility will utilize the Resident Assessment Instrument (RAI). The assessment will include at least the following .Discharge potential RAI assessments must be conducted within 14 days after the date of 675944 Page 10 of 28 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0640 admission; promptly after a significant change in the resident's physical or mental condition (as soon as the resident stabilizes at a new functional or cognitive level, or within two weeks, whichever is earlier) Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675944 Page 11 of 28 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to ensure the DON did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents for 6 (08/09/23, 08/10/23, 08/11/23, 08/12/23, 08/13/23, and 08/15/23) of 16 days reviewed for DON coverage. The facility failed to ensure the DON did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents on 08/09/23, 08/10/23, 08/11/23, 08/12/23, 08/13/23, and 08/15/23. This failure leaves residents without the nursing administrative oversight that only the DON can provide. Findings include: During an interview on 08/13/2023 at 10:15 am, the Area Director of Operations stated the DON would not be available for the next 2 days due to having to work night shift as a charge nurse. Review of daily staffing schedule revealed DON worked as a charge nurse on 08/09/23, 08/10/23, 08/11/23, 08/12/23, 08/13/23, and 08/15/23. During an interview on 08/15/23 at 05:20 PM, the Administrator stated the failures noted in the facility were because the DON, ADON, and treatment nurse had all been working night shift as charge nurses and had not been able to perform their management duties. She stated the MDS (LVN) had been running the building while the DON had been working as a charge nurse. During an interview on 08/16/23 at 06:22 PM, the DON stated she was responsible for monitoring her staff and ensuring things are done correctly. She stated the failure occurred because she had been working night shift as the charge nurse and had not been able to perform her DON duties. She stated no-one else had been designated to perform her duties while she had not been able to. Policy for RN/DON coverage was requested on 08/16/2023 but wasn't provided. Review of document titled, Job Description Director of Nursing dated 2014, revealed: The following is a non-exhaustive criterion that relates to the job of a Director of Nursing, and it is consistent with the business needs of the facility. These are legitimate measures of the qualifications for Director of Nursing. and are related to the functions that are essential to the job of a Director of Nursing. Knowledge Base: Working knowledge of nursing home regulations. Accountable for nursing compliance, excellence, and delivery of resident care services in adherence with The Company, local, state and federal regulations. Manage nursing staff through appropriate hiring, training, evaluation, assignment, and delegation of duties, within budget and resident census guidelines. Augment floor staffing if needed. o Ensure appropriate equipment 675944 Page 12 of 28 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents are free of any significant medication errors, for 4 of 8 Residents (Resident #31, Resident #18, Resident #276, and Resident #29) reviewed for medication administration. Residents Affected - Some 1. The facility failed to administer 7 doses of Creon (medication used to help digest food for people with pancreas issues and gastric issues) to Resident #31 due to medication not being available, but MAR indicated 3 of those doses were administered when they were not. 2. The facility failed to administer 4 doses of Empagliflozin (medication used to lower blood glucose) to Resident #18 due to medication not being available and did not monitor blood glucose per physicians' orders. 3. The facility failed to administer 6 doses of Albuterol Sulfate (medication used to help with breathing for people with lung disease) and 6 doses of Symbicort (medication used to help with breathing for people with lung disease) to Resident #276 due to medication not being available, but MAR indicated 2 of those doses were administered when they were not. 4. The facility failed to administer 2 weekly doses of Trulicity (medication used to lower blood glucose) to Resident #29. These failures placed residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: Resident #31 Review of Resident #31's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnosis that included: Gastro-Esophageal Reflux Disease, Type 2 Diabetes Mellitus, and Dementia. Review of Resident #31's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 10 (indicating moderate cognitive impairment). Review of Resident #31's Care Plan last revised on 06/11/2019 revealed: Focus: GERD. Goals: Will remain free from discomfort, complications, or signs and symptoms of GERD. Interventions .Give medications as ordered. Monitor/document side effects and effectiveness. 675944 Page 13 of 28 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #31's electronic physician ordered revealed: Creon Capsule Delayed Release Particles 6000 UNIT Give 1 capsule by mouth three times a day for before meals before meals. Review of Resident #31's MAR revealed Resident #31 had not received Creon on 08/13/23 at 12 pm and 5 pm and 08/15/23 at 8am and 12 pm. Further review of the MAR revealed Creon was administered on 08/14/23 at 8 am, 12 pm, and 5 pm by LVN C. Further review of MAR revealed Resident #31's Creon was ordered from the pharmacy on 08/14/2023 by RN A. During an observation of medication pass on 08/13/23 at 11:00 AM, RN A did not administer Creon to Resident #31 due to the medication not being available. During an interview on 08/13/23 at 11:50 AM, RN A stated Resident #31 was out of his Creon, and she did not have it to administer to him. She stated she ordered Resident #31's Creon on 08/12/23 but it had not come it yet. She stated she had not notified the physician of the missing medications. During an interview on 08/15/23 at 12:17 PM, Residents #31 stated he was not aware he had not received his medication. Review of pharmacy invoice dated 08/14/2023 6:16 PM revealed Resident #31's Creon was delivered to the facility on the night of 08/14/2023. During an interview via phone on 08/15/23 at 12:50 PM, LVN C stated she could not remember if she gave Resident #31 his Creon or not. She stated she would not have signed it off if it wasn't available. She then stated she might have been in a hurry and not realized she had not given when signing the MAR. Resident #18 Review of Resident #18's electronic face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included: Type 2 Diabetes Mellitus, heart failure, and Dementia. Review of Resident #18's admission MDS dated [DATE] revealed a BIMS score of 10 (indicating moderate cognitive impairment). Review of Resident #18's Care Plan last revised on 05/19/2023 revealed: Focus: Diabetes Mellitus. Goals: Will have no complications related to diabetes. Interventions .Give medications as ordered. Monitor/document side effects and effectiveness. During an interview on 08/13/23 at11:50 AM, RN A stated Resident #18 had not received her Empagliflozin the past 2 days due to not having the medication in stock. She stated Resident #18's Empagliflozin had already been ordered and she did not know why it wasn't available. She stated she had not notified the physician of the missing medication. Review of Resident #18's electronic physicians orders revealed: Empagliflozin Oral Tablet 10 MG (Empagliflozin) Give 1 tablet by mouth one time a day related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. Further review of electronic physicians' orders revealed no evidence of blood glucose monitoring. 675944 Page 14 of 28 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0760 Review of written physician's order dated 07/31/2023, revealed Recommend tight glucose control. Level of Harm - Minimal harm or potential for actual harm Review of Resident #18's MAR revealed Resident #18 had not received Empagliflozin on 08/12/23, 08/13/23, 08/14/23, and 08/15/23. Further review of MAR revealed Resident #18's Empagliflozin was ordered on 8/6/23 and again on 8/14/23. Residents Affected - Some Review of Resident #18's electronic record under the weights and Vitals tab revealed Resident #18's blood glucose had not been checked since 05/25/2023 with a result of 162 mg/dl. During an interview on 08/15/23 at 05:20 PM, the Administrator stated she was aware of Resident #18 not having her medication. She stated the family had refused to pay the pharmacy bill because the medication was high priced. She stated the facility had paid for the medication once and the family was supposed to make arrangements with another pharmacy to receive the medication. She stated she had not informed the DON or notified the doctor of the situation. She stated the only documentation she had was an email sent to the family on 08/01/2023. She stated the issue should had been addressed in a timelier manner and the doctor should had been notified. She stated the facility paid for one more fill and the medication would be delivered tonight. During an interview attempt on 08/15/23 at 05:40 PM, Resident #18's family did not answer the phone. Voice mail was left with no return call. Resident #276 Review of Resident #276's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis that included: Chronic Obstructive Pulmonary Disease (lung disease) and cancer of the lung. Review of Resident #276's admission MDS not completed yet. Review of Resident #276's Care Plan initiated on 08/06/2023 revealed: Focus: COPD. Goals: Will display optimal breathing pattern daily. Interventions .Give medications as ordered. Monitor/document side effects and effectiveness. Review of Resident #276's electronic physician ordered revealed: Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT 2 puff inhale orally every 6 hours. Further review revealed: Symbicort Inhalation Aerosol 160-4.5MCG/ACT Give 2 puffs inhale orally two times a day with a discontinue date of 08/09/23. Review of Resident #276's MAR revealed Resident #276 had not received Albuterol on 08/06/23 at 11 pm, 08/07/23 at 5 am, 11 am, 5 pm, and 11 pm, 08/08/23 at 5 am. Further review of MAR revealed Resident #276's Symbicort was ordered from the pharmacy on 08/06/2023. Review of pharmacy invoice dated 08/07/2023 4:11 PM revealed Resident #276's Albuterol was delivered to the facility on the night of 08/07/2023. Review of Resident #276's MAR revealed Resident #276 had not received Symbicort on 08/06/23 at 8 pm, 08/07/23 at 8 am and 8 pm, and 08/09/23 at 8 am. Further review of the MAR revealed Symbicort was administered on 08/07/23 at 8 am and 8 pm by LVN B and LVN D. Further review of MAR revealed Resident #276's Symbicort was ordered from the pharmacy on 08/06/2023. 675944 Page 15 of 28 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0760 Level of Harm - Minimal harm or potential for actual harm During an interview on 08/16/23 at 02:52 PM, the pharmacist stated Resident #276's Symbicort was never delivered due to it not being covered by insurance. He stated the order was discontinued and a new medication was ordered. Resident #29 Residents Affected - Some Review of Resident #29's electronic face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included: Type 2 Diabetes Mellitus, Stroke, and high blood pressure. Review of Resident #29's Quarterly MDS dated [DATE] revealed a BIMS score of 09 (indicating moderate cognitive impairment). Further review of MDS revealed: Section M: Medications: Insulin injections give 7 days in the last 7 days. Review of Resident #29's Care Plan last revised on 03/08/2023 revealed: Focus: Diabetes Mellitus. Goals: Will have no complications related to diabetes. Interventions. Give medications as ordered. Monitor/document side effects and effectiveness. Review of Resident #29's electronic physician ordered revealed: Trulicity Subcutaneous Solution Pen-injector 1.5 MG/0.5ML Inject 0.5 ml subcutaneously one time a day every Thursday. Review of Resident #29's MAR revealed Resident #29 had not received Trulicity on 08/03/23 at 5 am and 08/10/23 at 5 am. Further review of MAR revealed Resident #29's Trulicity was ordered from the pharmacy on 08/03/2023 by LVN D. Review of pharmacy invoice dated 08/11/2023 8:31 PM revealed Resident #29's Trulicity was delivered to the facility on the night of 08/11/2023. During an interview on 08/15/23 at 10:36 AM, Area Director of Operations stated it was unacceptable for residents not to have medications available. She stated she did not know the reason for the failure. During an interview on 08/15/23 at12:34 PM, the DON stated she was not aware that multiple residents had not received their medications. She stated the night shift nurse was responsible for ordering medications. She stated she had been working nights and forgot to order medications. She stated she had ordered some medications on 08/11/23 but had forgotten the pharmacy didn't deliver on weekends. She stated if a medication was not available, the nurse should have called the on-call pharmacy and ensured the medication was delivered. She stated there was always a way to get all medications and all medications should have been available for the residents. She stated documenting that a medication was given when it was not given was unacceptable. She stated Resident #31's Creon was not in the facility and there was no way the nurse gave it on 08/08/14/23. She stated this was false documentation and could lead to residents not receiving the medications they needed. She stated when a medication was not available, the physician and the family member should have been notified. She stated if the medication was not available, there should have been a doctor's order to hold and not give the medication. She stated her and other management staff received phone calls, emails, and other notifications when the medication was not available from the pharmacy for multiple reasons. She stated no family members or doctors had been notified of the missing medications. She stated she was not aware there was an issue with Resident #18's Empagliflozin. 675944 Page 16 of 28 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 08/15/23 at 05:20 PM, the Administrator stated the failure with not having the other residents' medications available was because the DON, ADON, and treatment nurse had all been working night shift and had not been able to perform their management duties. During an interview on 08/16/23 at 02:44 PM, the MDS nurse stated the pharmacy usually called the facility when medications were not available. She stated she had never seen any paper notifications. She stated medications were delivered at night, so the night nurse would have received the notifications and should have relayed them to management. She stated it was the nurses' responsibility to call the pharmacy and follow up if medications were not available, but they were not doing that. She stated if a medication dose was missed the dose should have been given as soon as the medication arrived, and dose and schedule changes should have been made. She stated if a resident received a weekly medication the day and time should have been adjusted, and no-one should have gone 2 weeks without receiving a medication. She stated the physician and family should have been notified. During an interview on 08/16/23 at 02:52 PM, the pharmacist stated the pharmacy called the facility to notify them any time a medication was not able to be filled when ordered. He stated the pharmacy also sent a paper notification every night with the delivery service. During an interview on 08/16/23 at 06:22 PM, the DON stated she was responsible for monitoring her staff and ensuring things were done correctly. She stated the failure occurred because she had been working night shift and had not been able to perform her DON duties. She stated no one else had been designated to perform her duties while she had not been able to. Review of the facility's policy titled, Ordering Medications dated 2023, revealed, Medications and related products are received from the pharmacy supplier on a timely basis. The facility maintains accurate records of medication order and receipt. Procedures:2. Repeat medication (refills) are written on a medication order form for that purpose an ordered as follows: Reorder medication three or four days in advance of need to assure an adequate supply is on hand . Review of the facility's policy titled, Medication Administration Procedures dated 2023, revealed, .5. After the resident has been identified, administer the medication and immediately chart doses administered on the medication administration record. It is recommended that medication be charted immediately after administration, but if facility policy permits, medication may be charted immediately before administration. Initials are to be used. Check marks are not acceptable. During the medication administration process, the unlocked side of the cart must always be in full view of the nurse. All nurses administering medication must sign and initial the designated area of each resident's medication/treatment administration record or resident specific master signature log for identification of all initials used in charting. 6. If a dose of regularly scheduled medication is withheld or refused, the nurse is to initial and circle the front of the medication administration record in the space provided for that dosage administration and an explanatory note is to be entered in the nursing notes or in the PRN nurses notes section of the medication administration record. In the presence of individual facility policies concerning refused and held documentation, the facility policy supersedes this policy .15. Medication errors and adverse drug reactions are immediately reported to the resident's Physician. In addition, the Director of nurses and/or designee should be notified of any medication errors. Any medication error will require a medication error report that includes the error and actions to prevent reoccurrence. 675944 Page 17 of 28 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled and discarded when expired in accordance with currently accepted professional principles and the open date and expiration date when applicable for 1 of 3 medication carts (medication cart on 100 hall) reviewed for labeling and storage. The facility also failed to store all drugs and biologicals in locked compartments for 2 (medication cart 100 hall and medication cart 200 hall) of 3 medication carts reviewed for medication storage. The facility failed to discard expired insulin for Resident # 10 from 100 hall medication cart. The facility failed to properly label insulin with open date for Resident # 6 from 100 hall medication cart. The facility failed to properly label insulin with open date for Resident # 40 from 100 hall medication cart. This failure could place residents who receive medications at risk for receiving outdated medications which could result in residents not receiving the intended therapeutic effects of their medications and health decline and of having access to unauthorized medications and medical supplies leading to possible harm or drug diversions. The facility failed to ensure medication cart 100 hall was locked when unattended by LVN B on 2 separate observations. The facility failed to ensure medication cart 200 hall was locked when unattended by RN A. Findings included: During an observation on 08/13/23 at 10:30 AM, medication cart 100 hall was unlocked against the wall across from the nurse's station. 3 nurses were sitting at nurses' station. Surveyor opened medication cart and no nurses noticed. Observation of medication cart revealed: expired Humalog (insulin) for Resident # 10, Admelog (insulin) with no open date for Resident # 6, and Insulin Glargine (insulin) with no open date for Resident #40. Surveyor asked nurses who was responsible for cart and LVN B stated she was. Inventory of medication cart hall 100 revealed: Prescription and OTC eye medication in the top left drawer, Insulin meds, syringes and scissors were in the top right drawer. The second left drawer of the cart contained blister packs of prescription medications, and the third left drawer contained overflow medications cards and over the counter liquid medications. The second right drawer contained narcotics in the single locked drawer. The third right drawer contained OTC medications and the fourth right drawer contained wound care supplies, such as gels, sprays, tape and gauze. All unlocked drawers were easily accessible. During an interview on 08/13/23 at 10:40 AM, LVN B stated she did not mean to leave her medication cart unlocked. She stated leaving her medication cart unlocked could lead to residents getting medications they did not need. She stated it could also lead to drug diversion. She stated insulin was to be dated when opened and must be discarded after 28 days. She stated the night nurses were responsible for auditing the carts for expired medications. She stated ultimately it was her responsibility 675944 Page 18 of 28 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0761 to check prior to giving the medications. Level of Harm - Minimal harm or potential for actual harm During an observation on 08/13/23 at 03:40 PM, medication cart 100 hall was unlocked in the 100 hallway. Observed 2 residents and 1 CNA in the hallway. LVN B was in a resident's room with back turned. Residents Affected - Some During an observation on 08/13/23 at 03:50 PM, medication cart 200 hall was unlocked in the 200 hallway with the keys laying on top of the cart. 2 CNAs were in the hallway. RN A was in a resident room. During an interview on 08/13/23 at 04:44 PM, RN A stated she did not mean to leave the med cart unlocked with the keys on top. She stated she was just in the resident's room for a minute, and she forgot to lock it. She stated residents and staff could get meds out of the cart. Review of medication cart audit performed by pharmacist on 05/01/2023 revealed expired and discontinued medication on cart and medications not dated. Review of Medication pass audit performed by pharmacist on 06/02/2023 revealed cart was left unlocked during medication pass. During an interview on 08/15/23 at 05:20 PM, the Administrator stated the failures noted in the facility were because the DON, ADON, and treatment nurse had all been working night shift and had not been able to perform their management duties. During an interview on 08/16/23 at 06:22 PM, the DON stated medication carts should be locked anytime the nurse was away from the cart. She stated leaving medication carts unlocked could lead to residents receiving the wrong medications by accident or staff stealing medications. She stated all expired medications should be removed from the medication cart and discarded. She stated all insulin bottles, and other multi dose containers should always be labeled with an open date. She stated the night nurses were responsible for auditing the medication cart, but it was ultimately her responsibility. She stated she had reviewed the pharmacy med pass audit and reviewed them with her nurses, but she had not done any in-services. She stated she is responsible for monitoring her staff and ensuring things are done correctly. She stated the failure occurred because she had been working night shift and had not been able to perform her DON duties. She stated no-one else had been designated to perform her duties while she had not been able to. Review of facility policy titled, Medication Labeling dated 2003, revealed: Medications are labeled in accordance with facility requirements and state and federal laws. Only the provider pharmacy modifiers or changes prescribed labels. Procedure: Each prescription medication label includes: 1) Residents name 2) Physicians name 3) Quantity 4) Expiration date of all time dated drugs 5) Name, address and telephone number of provider pharmacy 6) Prescription number 7) Accessory labels 8) Container number 9) Generic or trade Name of the medication 10) Recipient directions for use. Including route of administration 11) Strength of medication 12) Initials of dispensing pharmacist. Review of facility policy titled, Recommended Medication Storage revised 07/2012, revealed: Medications that required an open date as directed by the manufacturer should be dated when opened in a manner that it is clear when the medication was opened. 675944 Page 19 of 28 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0812 Level of Harm - Minimal harm or potential for actual harm 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 in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: Residents Affected - Many The facility failed to ensure open items in the freezer, refrigerator, and dry food storage were dated and labeled and free from expired foods. These failures could place residents at risk for food borne illness and cross-contamination. Findings included: An observation on 08/13/2023 at 10:20 AM, of the dry storage revealed: 1. 1 gallon bag of cooked cornbread not labeled or dated. 2. 1 gallon bag of dry toast not labeled or dated. 3. 1 gallon bag of croissants not labeled or dated. 4. 1 opened bag of powdered creamer not sealed or dated. 5. 1 opened bag of instant peppered old fashioned biscuit gravy mix with expiration date of 06/19/2023, not sealed or dated. 6. 1 opened bag of cornbread mix with expiration date of 05/25/2023, not sealed or dated. 7. 1 pan of sealed 1 oz containers of brown sugar not labeled or dated. 8. 1 small 8 oz container of white sugar with no lid, not labeled or dated. 675944 Page 20 of 28 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0812 9. Level of Harm - Minimal harm or potential for actual harm 1 pan of sealed 1 oz clear containers, with lids, of jelly not labeled or dated. 10. Residents Affected - Many 1 open (open to air) in original bag of French Vanilla Coffee Creamer not sealed or dated. An observation on 08/13/2023 at 11:09 AM, of 1 of 2 refrigerators revealed: 1. 2 open gallons of whole white milk with no open date. 2. 1-ounce containers of what appeared to be ketchup with lids, not labeled or dated. 3. 1 sealed clear bag of what appeared to contain butter, not labeled, or dated. 4. 1 gallon of lime juice with an expiration date of 06/18/2023. An observation on 08/13/2023 at 10:44 AM, freezer #1 of 4 revealed: 1. 2 unopened bags, out of original box, of frozen pepperonis not labeled or dated. 2. 1 opened, in original bag, open to air, not labeled or dated. 3. 1 opened box of frozen cheese omelets open to air. 4. 1 opened box of frozen carrots open to air. During an interview on 08/13/2023 at 2:04 PM, the DM stated all dry storage products were to be dated upon arrival when delivered to the facility. If removed from the products original box, a label should be placed which included the product as well as an in/opened date. The DM stated if there was an opened bag of food product, it should have been placed in an airtight container and sealed with labeling and dating of what was in the container. The DM stated the negative impact to residents 675944 Page 21 of 28 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many could be not knowing the expiration date, food could become spoiled which could have led to residents getting sick. He stated what led to the failure occurred with the previous DM not training the staff correctly. His expectations were for staff to follow company policy. During an interview on 08/15/2023 at 10:18 AM, the ADM stated the DM should have monitored the labeling/storage as well as the expiration dates on products. She stated the Dietary staff had been in-serviced on label/storage and expiration of food products. She stated all products needed to be labeled with an expiration date unless the original box had that information on it. Record Review of facility policy, Food Storage and supplies dated 2012, revealed: All facilities storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin and insects. Procedure: . .3. Dry bulk food (e.g., flour, sugar) are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized . .4. Open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened . .6. When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it so it is readily visible and noticeable. It is important to distinguish between an expiration date and a production date, or a best by or use by date. Production dates indicate when the product was manufactured, not when it expires, and should not be interpreted as a best by or use by date. Best by or use by dates indicate when a product will have best flavor or quality and are not an indicator of the products safety. As the quality may deteriorate after the date passes, the Dietary Manager should closely inspect any products that are past the best by date to determine if they are still good quality. If in doubt, discard the product. If any sent date is unclear, contact the food vendor for clarification. If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received, and shelf stable items will be stored in a first in, first out Manor, to be used within one year. After one year, any product that is shelf stable will be inspected by the dietary manager to ensure that it is good quality before it is used. Any product with a stamped expiration date will be discarded once that date passes. Review of Texas food Establishment Rules accessed https://www.fda.gov/media/164194/download 08/16/2023 revealed in annex 3 page 17: the manufacturer's use-by date is its recommendation for using the product while its quality is at its best. Although it is a guide for quality, it could be based on food safety reasons. It is recommended that food establishments consider the manufacturer's information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind. 675944 Page 22 of 28 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 (RN-A, LVN-B, and NA-G) staff observed during medication administration and incontinent care. Residents Affected - Some 1. The facility failed to ensure RN-A sanitized the glucometer before or after use on a resident. 2. The facility failed to ensure RN-A did not sanitize the blood pressure cuff before or after use on a Resident #29. 3. The facility failed to ensure LVN-B did not sanitize blood pressure cuff or use hand hygiene during medication pass. 4. The facility failed to ensure NA-G did not perform proper peri-care (incontinent care) or proper hand hygiene for Resident #13. These failures placed residents of the facility at risk of infections from medication administration and incontinent care. Findings included: Record Review of the resident #13's Face Sheet dated 08/14/2023, revealed she was an 84 yr. old female. Her original admit to the facility was on 03/02/2021. Resident 13 had a diagnosis of UTI, Peripheral Vascular Disease (slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), and Stroke followed by weakness. Resident #13's MDS assessment Section C, Cognitive Patterns dated 05/12/2023, revealed a BIMS score of 08 (moderately impaired). Resident #13's Care Plan dated 05/31/2023 revealed an ADL Deficit, were at risk of pressure injury related to immobility, CNA should follow facility policies/protocols for the prevention/treatment of skin breakdown, and do not massage over bony prominences and use mild cleansers for peri-care/washing. During observation on 08/14/23 at 2:05 PM, NA-G performed peri-care for Resident #13. No hand washing or hand gel use was observed throughout peri-care as well as the same gloves being used from beginning to end. The NA-G was observed folding each wipe 2-3 times, wiping each time after each fold, before getting another clean wipe. The NA-G also applied cream to Resident #13 with the same contaminated glove after peri-care was performed. An interview on 08/14/2023 at 2:32 PM, NA-G stated she only had on the job training. The NA-G stated what she had done in the resident's room was how she learned which was from the previous facility. She stated she had not been in-serviced on incontinent care once hired on with the current facility. She stated during incontinent care, she was not supposed to have wiped from back to front nor fold and re-wipe with one wipe. She stated the correct way was to always wipe once and discard into trash bag. The NA-G stated she knew she did not use proper hand hygiene such as wash and/or use hand gel. She stated she had hand gel in her pocket that she could have used and stated, I just didn't use it, but knew I had it. She stated with good hand hygiene not being performed while taking care of resident, especially during pericare, there could have been the possibility of spreading bacteria causing infections. 675944 Page 23 of 28 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0880 Level of Harm - Minimal harm or potential for actual harm An interview on 08/14/2023 at 2:45 PM, the ADM stated she did not think there were in-services performed with staff. She stated the DON monitored staff performing peri-care or incontinent care. The ADMN stated the negative impact to residents would be contamination and possible UTI's. She also stated the failure began with avoiding hand hygiene, and possibly not following hygiene and peri-care checkoffs. Her expectations were for all staff to be trained properly and not faulter from what they are taught. Residents Affected - Some During an interview on 08/15/23 at 2:55 PM, the DON stated she normally monitored staff who performs incontinent care on residents. She stated the staff have been in-serviced on incontinent care but could not show any proof of them having been completed. The DON stated the negative impact for resident were that bad incontinent care and hand hygiene could have led to infection and/or the possibility of death. She also stated in performing incontinent care incorrectly, it could have led to chronic UTI's. The DON stated what she felt led to the failure of poor hand hygiene and incontinent care were the lack of charge nurses; no follow up with their new hires and not having the correct protocols put in place or correctly. Her expectations were for all staff to perform proper hand hygiene and proper incontinent care. During an interview on 08/16/23 at 11:45 AM, the DON stated the facility had not tracked UTI's consistently, nor do they track the root cause analysis of infections. She stated when there were cultures performed, the Physician used the hospital protocols and not the facility's. She stated the facility did not keep any documentation as to such with the lab or physician had used phone calls to them daily to contact them with the updated information. The DON stated with the hospital having done it that way, there was a failure in the tracking of infections, as they had not previously documented tracking. She stated her expectations were for her or the facility should have documented and tracked such infections as soon as they are resulted from the lab. The DON stated she had also not mapped UTI's and feel there had been more in the facility recently. She stated there had been no in-services for staff on tracking. The DON stated without infection being tracked, that could have possibly caused an uptick of infections. During Observation on 08/13/2023 at 11:45 AM the RN A did not perform hand hygiene before or after taking a blood sugar on Resident #2. The RN A also did not clean the glucometer for hall 200 prior to being used on residents. The RN A also did not place a barrier between the glucometer and the shower room table, before being used on the resident. The RN A did not clean or sanitize the glucometer after using it on resident. During Observation on 08/13/23 at 04:15 PM the RNA did not wash her hands or sanitize the glucometer and blood pressure cuff before using it on the residents before or after use. The RN-A then performed blood sugar check and blood pressure check on Resident #29, then placed the glucometer and blood pressure cuff in her pocket. RN-A then walked to the medication cart and placed the glucometer in the top drawer without cleaning it. During an interview on 08/13/23 at 4:44 PM the RN-A stated the glucometer and blood pressure cuff should be cleaned after each use. She stated she did not know the proper procedure for how to clean them. She states she had never been in-serviced or trained on the procedures. She stated not cleaning the glucometer and blood pressure cuff could cause cross contamination. During observation on 08/13/23 at 04:50 PM of medication pass, the LVN-B entered Resident #54's room without washing her hands or cleaning blood pressure cuff before or after use and placed it back into the medication cart. The LVN-B then entered Resident #44's room and took his blood pressure with 675944 Page 24 of 28 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the same blood pressure cuff. The LVN-B again then placed the blood pressure cuff in the medication cart without cleaning it. During an interview on 08/13/23 at 5:35 PM the LVN-B stated the glucometer should be cleaned before and after each use. She stated the blood pressure cuffs should also be cleaned before and after each use. The LVN-B stated she had never been trained on the proper cleaning procedures for the glucometer or blood pressure cuff. During an interview on 08/16/23 at 6:22 PM the DON stated the glucometers and blood pressure cuffs should be cleaned before and after every use. She stated they should not be placed on contaminated services or placed in pockets while performing a blood sugar of blood pressure checks on or between each resident. She stated, not cleaning these items properly, could have led to the spread of infection. She stated she had reviewed the pharmacy medication pass audit and reviewed them with her nurses but stated she had not done any in-services with them. The DON stated she was responsible for monitoring her staff, ensuring things were done correctly. She stated the failure occurred because she had been working the night shift and had not been able to perform her DON duties. She stated no one else had been designated to perform her duties while she had not been able to. Record review titled Medication Pass Audit dated 06/02/2023, performed by pharmacist revealed: cart was left unlocked during medication pass did not wash hands before or after gather blood sugars and giving insulin. Recommended washing hands. Reviewed with nurse to sanitize blood pressure cuff and glucometer in between residents. of the medication pass audit revealed; cart was left unlocked during medication pass did not wash hands before or after gather blood sugars and giving insulin. Recommended washing hands. Reviewed with nurse to sanitize blood pressure cuff and glucometer in between residents. Record review of the policy titled Glucometer dated 2003 and revise February 13th of 2007, revealed: 4. Maintenance 1. Clean and inspect meter exterior with each use Record review of the policy titled Fundamentals of Infection Control Precautions dated 2019 revealed: 1. Hand Hygiene Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene; o 675944 Page 25 of 28 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0880 Before and after performing any invasive procedure (e.g. finger stick blood sampling); Level of Harm - Minimal harm or potential for actual harm o Before and after assisting a resident with personal care Residents Affected - Some o upon and after coming in contact with a residence in tech skin (e.g., when taking a pulse or blood pressure, and letting a resident); o after handling soiled or used linens, dressings, bedpans, catheters and urinals; o after removing gloves or aprons; 10. Other staff-Related Preventative Measures 3. Staff will wear intact disposable gloves in good condition and change after each use, which helps reduce the spread of microorganisms Record review of the policy titled Infection Control Plan: Overview dated 2019 revealed: Infection Control The facility will establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. Infection Control Program . (3) Maintains a record of incidences and corrective actions related to infections. Facility Assessment At least annually and on and as needed basis the facility will conduct a facility wide assessment to determine the resources needed to maintain an efficient and up-to-date infection control program. The facility assessment can assist in determining the types of residents being cared for, what is needed to care for those residents, and what education facility staff need. 675944 Page 26 of 28 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0880 Preventing Spread of Infection . Level of Harm - Minimal harm or potential for actual harm (3) Residents Affected - Some the facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice Intent; The intent of this policy is to assure that the policy develops, implements, and maintains an infection prevention and control program in order to prevent, recognize, and control, to the extent possible, the onset spread of infection within the facility. The program will; o Prevent and control outbreaks and cross contamination using transmission based precautions in addition to standard precautions; o implement hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross contamination Record review of the policy titled Perineal Care Female dated 2009 revealed; Purpose; To clean the female perineum without contaminating the referral area with germs from the rectal area. Procedural Guidelines A. Beginning Steps a. Wash hands F. If heavy soiling is present, wear gloves and it use tissues or wipes to remove heavy soiling prior to perineal care. DO NOT WIPE MORE THAN ONCE WITH THE SAME SURFACE OF THE TISSUE OR WIPES H. Wash hands and put on clean gloves for perineal care. I. Gently wash perineal area, wiping from clean urethral area toward dirty rectal area to avoid contaminating urethral area with germs from the rectum. DO NOT WIPE MORE THAN ONCE WITH THE SAME SURFACE 675944 Page 27 of 28 675944 08/16/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0880 Level of Harm - Minimal harm or potential for actual harm OF THE WASH CLOTH OR PRE-MOISTENED CLEANSING WIPES. IF AT ANYTIME YOUR GLOVES BECOME CONTAMINATED WITH FECES, CHANGE GLOVES c. Change the washcloth or free moistens cleansing white surface or use a new washcloth or pre moistened cleansing wipe with each wipe. Residents Affected - Some d. Change gloves J. Cleaning the rectal and buttocks area c. Change glove g. Apply moisture barrier, and less contraindicated h. Remove gloves K. Closing steps a. If gloved, remove and discard gloves. Wash hands No policy was provided for the sanitizing of Blood Pressure Cuffs before exit. 675944 Page 28 of 28