Health inspection·July 9, 2025

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 record review and interview, the facility failed to encode a resident's assessment within 7 days and complete and electronically transmit a resident's completed discharge MDS within 14 days for 2 ((Residents #36 and #67) of 2 residents reviewed for MDS transmittal.-Resident #36 passed away 3/8/2025 and Resident #67 passed away 4/11/2025 and their discharge MDS' were not encoded within 7 days after death and were not transmitted within 14 days after death. This failure could cause a resident's significant change such as their MDS to not be accurately reflected in their medical records. Record review of Resident #36's face sheet last updated 07/092025 reflected a [AGE] year-old male originally admitted on [DATE] with medical diagnoses including gout ( a form of arthritis affecting the joints), hypertension (high blood pressure), dementia (decline in cognitive function with symptoms including forgetfulness and limited social skills), Alzheimer's disease (progressive disease that destroys memory , thinking and ability to complete tasks), and heart failure. Record review of Resident # 36's progress notes, it was documented on 3/8/2025 at 11:33am, Resident #36's family were in the room and told staff he passed away.Record review of Resident #36's MDS assessment reflected the last completed MDS was a Comprehensive assessment on 03/03/2025. Resident #36 had no MDS for significant change, discharge or death. Record review of Resident #67's face sheet last updated 7/9/2025 reflected a [AGE] year-old female originally admitted on [DATE] with medical diagnoses including Type 2 diabetes mellitus (high blood sugar), hypertension (high blood pressure), hear failure, and chronic kidney disease. Record review of Resident #67's progress notes, revealed on 4/11/2025 at 7:00pm she was found unresponsive in her bed with no pulse, respiration or heart or breath sounds and Resident #67's death was pronounced at 7:15pm. Record review of Resident #67's MDS assessment reflected the last completed MDS was a significant change assessment on 03/03/2025. Resident #67 had no MDS for significant change, discharge or death.Interview on 7/8/2025 at 1:40pm with the MDS Coordinator, she said she did not send the final MDS assessments for Residents #36 and #67 and she did not know why she did not send it. The MDS Coordinator said she was responsible for transmitting the MDS' and there were no risks to the residents if the MDS Coordinator did not send it. The MDS Coordinator came back later and showed that she submitted the MDS' for Resident #36 and #67 on 7/8/2025. Interview on 7/8/25 at 4:56pm with the DON and President, the DON said that the MDS Coordinator and the Administrator were responsible for sending out the MDS' for Residents #36 and #67 and that the MDS' should have been sent. The DON said there was no harm to the residents since they passed away. Record review of the facility's policy on electronic submission of the MDS, undated, read in part, All MDS assessments .annual, significant change and discharge will be completed and electronically encoded into our facility's MDS information system, and transmitted to CMS' system in accordance with current . regulations . Residents Affected - Few Page 1 of 19 675996 675996 07/09/2025 Columbus Oaks Healthcare Community 300 North St Columbus, TX 78934

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene for one (Resident #6) out of eight residents reviewed for ADLs. The facility failed to provide skin care to Resident #6 which resulted in patches and dry flaky skin from below the knee to her feet. These deficient practices could place residents at risk of skin breakdown and reduced feelings of self-worth.Record review of Resident #6's face sheet dated 07/08/25 revealed a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #6 had diagnoses which included, hypertension (when the pressure in the blood vessels is too high), heart failure (heart is not pumping blood as effective as it should) and dementia (decline in mental ability, severe enough to interfere with daily life, affecting thinking, and reasoning)Record review of Resident #6's quarterly MDS, dated [DATE] revealed the BIMS was 07 out of 15 indicating severely impaired cognition. Further review of the MDS revealed the resident needed moderate assistance with one staff assist with ADL care. Record review of Resident #6's care plan revision on 07/08/25, revealed the resident had an ADL self-care performance deficit related to Dementia. Intervention: encourage the resident to participate to the fullest extent possible with each interaction. During an observation and interview on 07/08/25 at 10:02 a.m., revealed Resident #6 was lying on her left side facing the door when Resident #6 told the surveyor to look at her legs. Resident #6 uncovered her legs, and it was revealed Resident #6's skin was dry and flaky from below her knees to her feet. The bed linens revealed a substantial amount of dry, flaky skin. Resident #6 stated that she did not refuse the staff to apply lotion to her skin; however, she could not recall how often the staff applied lotion to her skin, and she sometimes refused to shower. During an interview on 07/07/25 at 10:21 a.m., RN Z stated that Resident #6's skin was dry and flaky on both legs, from below the knee to the feet, and flaky skin was on the bed. RN Z said the aide should apply lotion to Resident #6's skin on her shower days and as needed during care. RN Z said if the aides did not apply lotion to Resident #6's skin for some time, Resident #6's skin would become dry and flaky, and if it continued, the skin could crack or open up. RN Z said the nurses monitored the aides throughout the shift. She stated the nurse managers monitored the nurses during rounding. RN Z said she had a nursing skills check-off and was unsure if there was a section on applying lotion to the resident's skin. During an interview on 07/07/25 at 10:38 a.m., CNA MJ said she was Resident #6's CNA for today. CNA MJ stated that Resident #6 sometimes did not like lotion, but she had not reported to the nurse that Resident #6 had refused the lotion application. CNA MJ said Resident #6's shower was on Monday, Wednesday, and Friday. CNA MJ said she would apply lotion to Resident #6 on shower days and whenever she noticed Resident #6's skin was dry. She said Resident #6 had dressed herself, and she had not seen her legs today. She had just come back to work today because she was on vacation for a week. CNA MJ stated Resident #6's skin could crack, develop rashes, or open up and peel if lotion was not applied to resident's skin. CNA MJ said the nurses monitored the aides throughout the day. She said she had electronic training on ADL's, which included skin care, and the training was conducted monthly, along with in-services, which covered skin and nails. During an interview on 07/08 /25 at 9:00 a.m., the DON said Resident #6 did refuse care sometimes because she wanted to be independent, and when she refused, the aide should notify the charge nurse. The DON said Resident #6 was supposed to get showers three times a week, and the aides should apply lotion on Resident #6 on shower days and as needed. The DON said the staff had not complained to her that Resident #6 had dry skin or had refused for the staff to apply lotion or body cream to her skin. Residents Affected - Few 675996 Page 2 of 19 675996 07/09/2025 Columbus Oaks Healthcare Community 300 North St Columbus, TX 78934

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few She said if the aides did not moisturize Resident #6, it could lead to open areas on the skin. The DON said the CNAs were trained were trained electronically monthly and during orientation. The DON said the aides had a skills check-off during floor orientation. The DON stated that nurse managers monitored nurses during random rounds, and charge nurses monitored aides throughout the shift. Record review of the facility citified nurse's aide proficiency audit revealed CNA MJ signed the training on 04/28/25 and it had a section 4, comfort of residents/care, 4a. skin care lotions. Record review of the facility licensed nurse proficiency audit revealed . section #11 verbally prioritizes resident care activities with CNA as assignment are confirmed as appropriate and RN Z signed the proficiency on 04/28/25. Record review of the facility policy on ADL dated 2001 MED - PASS, Inc (Revised March2018) read in part . policy interpretation and implementation #2: Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: #2 a. Hygiene (bathing, dressing, grooming, and oral care) . 675996 Page 3 of 19 675996 07/09/2025 Columbus Oaks Healthcare Community 300 North St Columbus, TX 78934

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #11) reviewed for incontinent care. 1. The facility failed to ensure CNA G cleaned Resident #11 properly during incontinent care on 7/8/25. This failure could place residents at risk for pain, infection and hospitalization. Record review of Resident #11's face sheet dated 7/7/25 reflected date of admission was 4/8/22 and re admitted on [DATE]. Resident #11's diagnoses included history of transient ischemic attack (tia)mild stroke) cerebral infarction ( stroke), unspecified, unspecified atrial fibrillation ( heart beating too fast), essential (primary) hypertension( high blood pressure), hypothyroidism ( thyroid gland isn't producing enough thyroid hormones), unspecified, edema, unspecified, hemiplegia and hemiparesis( weakness to one side of the body) following cerebral infarction affecting left dominant side, hyperlipidemia ( high fat in the blood), aphasia (difficulty talking), expressive language disorder, Alzheimer's disease (is a progressive neuro degenerative disorder that causes disorientation and behavioral changes, and obstructs memory, thinking and judgment ) and with late onset, epilepsy (seizures). Record Review of Resident #11's quarterly MDS assessment dated [DATE] reflected Resident #11's BIMS score was 00, indicating resident's cognition was severely impaired. Resident #11 was incontinence of bladder and bowel. Record Review of Resident #11's care plan dated 5/24/2023 reflected:I have ADL self-care performance deficit and totally dependent on staff for all ADLs.I will remain clean, dry, without odor and comfortable every shift on a daily basis, with all needs to be anticipated and met by staff through the next 90 days. Observation on 07/08/25 at 03:17 PM of incontinent care done by MA/CNA G and CNA MM assisting Resident #11, revealed Resident #11 had large pasty BM. CNA/MA G did not open the labia to clean while performing incontinent care. Interview with CNA's (G and MM) on 7/8/25 at 3:40PM, they acknowledge not opening the labia and knew that not opening the labia could result in urinary tract and odors. CNA/MA G said she has been working over 6 months, and she had in-service for incontinent care and skilled check. Interview with the DON on 7/8/25 at 5:51 PM regarding incontinent care observed on Resident #11, she said C.NA had incontinent care training, DON said she and the ADON monitors the CNAs randomly monthly and not performing good incontinent care could result in infection and UTI. Interview with the ADON on 7/8/25 at 6:24 PM, regarding incontinent care observed on Resident #11, she said she had been working with the facility for 1 year, she does round with the nurse's aides before the CNA gets on the floor to work and check them off. Record review of the facility policy for Perineal Care undated reflected: Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition.For a female resident .C. Using a pre-moistened disposable wipe or non-disposable washcloth with peri-care skin cleaning agent to wash perineal area from front to back.1. Separate labia and wash area downward from t to back. 675996 Page 4 of 19 675996 07/09/2025 Columbus Oaks Healthcare Community 300 North St Columbus, TX 78934

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 Residents (Resident #20) whose records were reviewed for pain management. LVN H/Treatment Nurse, failed to ensure Resident #20 received a PRN pain medication prior to wound care. LVN H/Treatment Nurse failed to stop wound treatment when Resident #20 was grimacing and quizzing in pain on 7/8/25. This failure could affect any resident with DTR's, surgical wounds and pressure ulcer experiencing pain and mental distress.[SP1] .Review of Resident #20's face sheet, dated 7/7/25, revealed she was admitted to the facility on [DATE] with diagnoses cellulitis of right toe,) inflammation in your airways chronic obstructive pulmonary Disease cause breathing ( lung conditions that cause breathing difficulties), unspecified, transient cerebral ischemic attack ( mild stroke), osteoarthritis ( degenerative joint disease), unspecified sit, gastro-esophageal reflux disease ( gastric reflux)without esophagitis, other idiopathic peripheral autonomic neuropathy(happens when the nerves that affect the brain and spinal cord) cardiac pacemaker(used to control or increase the heartbeat), mixed hyperlipidemia (high fat in the blood), obesity, mycoses( fungi infection), nondisplaced fracture of distal of right great toe, subsequent encounter for fracture routine healing, atherosclerosis(the buildup of fats, cholesterol and other substances in and on the artery walls) of coronary artery bypass graft(s) without angina pectoris, essential (primary) hypertension (high blood pressure), other cerebral infarction (stroke ), weakness, muscle wasting and atrophy, not elsewhere classified, unspecified site, other lack of coordination, peripheral vascular disease, unspecified, acute kidney failure, unspecified type 2 diabetes mellitus with hyperglycemia (high glucose in blood), partial traumatic amputation of right great toe, subsequent encounter. Record review of the admission MDS dated [DATE] of Resident #11 reflected the BIMS score was 14 and 15 [SP3] which indicated his cognition was moderately impaired. MDS pressure ulcer M1200 revealed section F = had surgical wound care. Record review of Resident #20's physician order summary report, dated 06/27/25, indicated an active physician's order to cleanse Surgical Incision site to right lower leg cleanse w/ NS, pat dry, apply skin prep and LOTA everyday shift for promote healingCleanse left heel w/ normal saline, pat dry, apply skin prep, and cover w/ foam dressing every day shift every Tue, Thu, Sat for promote skin integrity, Incision site to right great toe cleansed w/ NS, pat dry, apply Xeroform, cover w/ gauze and wrap w/ kerlix every day shift for promote healing. Record review of the MAR dated 7/7/25 reflected Resident #20 had Acetaminophen-Codeine Oral Tablet 300-60 MG (Acetaminophen w/ Codeine) Give 1 tablet by mouth every 8 hours as needed Acetaminophen-Codeine Oral Tablet 300-60 MG (Acetaminophen w/ Codeine), administered on 07/07/25 at 11:00 PM. Record review of the Physician's order dated 07/01/25-07/31/25 reflected Resident #20 had the following order for:Record review of physician's order dated 7/7/25: Acetaminophen-Codeine Oral Tablet 300-60 MG (Acetaminophen w/ Codeine) Give 1 tablet by mouth every 8 hours as needed for moderate to severe pain. Cyclobenzaprine HCl Oral Tablet 10 MG (Cyclobenzaprine HCl) Give 1 tablet by mouth every 8 hours as needed for muscle spasms/muscle pain, physician's order was 6/23/25 Ibuprofen Oral Tablet 200 MG (Ibuprofen)Give 2 tablet by mouth every 6 hours as needed for pain, physician's order 6/20/2025. Record review of the care plan, dated on 06/22/25, reflected Resident #20 had: Assess for pain with interactions. Monitor for non-verbal S/S: facial grimacing, restlessness, moaning, guarding, rubbing and implement appropriate intervention. Monitor/document pain on a scale of 0 to 10 before and after implementing measures to reduce pain. I have a risk for chronic pain r/t Osteoarthritis, neuropathy, Residents Affected - Few 675996 Page 5 of 19 675996 07/09/2025 Columbus Oaks Healthcare Community 300 North St Columbus, TX 78934

F 0697 Level of Harm - Actual harm Residents Affected - Few right toe amputation. I will not have an interruption in normal activities due to pain through the next 90 days. Administer pain medications per physician order. Anticipate my need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions every shift. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Monitor/record pain characteristics every shift and PRN: Quality (e.g. sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset; Duration (e.g., continuous, intermittent); Aggravating factors; Relieving factors Monitor/record/report to Nurse any s/sx of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Observation and interview during wound care on 7/8/25 at 9:05 AM with TX Nurse revealed Resident#20 was lying in bed awake, LVN went in the room and talked to Resident #20 about changing the treatment to his right amputee great toe. Resident #20 told LVN that he was in pain, TX Nurse [SP6] did not assess resident pain. TX Nurse told Resident #20 I will let your nurse LVN T know to give him the pain medication. TX Nurse then went to the treatment cart to prepare Resident #20's medication to change resident surgical wound. TX Nurse got Opti form gentle EX silicone face, Xeroform Petrolatum dressing, 4 x4 gauze and wound cleanser. At 9:24 AM, TX Nurse entered Resident #20's room, she removed Resident #20's old dressing, changed gloves and used hand sanitizer. While cleaning Resident #20's surgical wound with sutures still on the site, he was grimacing and squinting his face in pain. The surveyor asked Resident #20 if he was in pain, he said yes, and his pain scale was 7 out of 10. At 9:30 AM TX Nurse said she was going to get LVN T because he was Resident #20's nurse and continued the treatment.At 9:34 AM Resident #20 confirmed that he told the TX nurse earlier that he was in pain before she started the treatment and said he had last pain at 11:00 PM last night and he had been managing his pain for 40 years and in the facility, it takes 30 minutes to get his pain medication.At 9:37 AM LVN T came to Resident #20's room to assess where resident's pain was, resident said it was in the surgical site and his pain level was 7. He gave Resident #20 Acetamin-Codeine #4 -300 mg-60mg 1 tablet po at 9:39 AM. Interview with LVN T at 9:40AM, he said he was not aware of Resident #20's pain till about 4 mins ago.Interview with the TX Nurse on 7/8/25 at 10:00AM she said she has been working at the facility since November 2024 as the treatment nurse. She said she was nervous, she said she should have premedicated Resident #20 before starting the treatment and make the treatment more tolerable and less uncomfortable. She said she was very sorry about not assessing Resident #20 for pain and had in-services. upon hire on pain assessment.During an interview on 7/8/25 at 4:49 PM., the DON stated TX Nurse should have medicated Resident #20 30 minutes prior to performing wound care. The DON stated TX Nurse should have followed up to ensure Resident #20 was comfortable prior to performing wound care. The DON stated when Resident #20 continued to grimacing and quizzing face out while she was performing wound care, she should have stopped the procedure and obtained pain medication. The DON stated she has watched TX Nurse perform wound care and has not noticed any of these issues. The DON stated TX Nurse had been in-serviced and performed a visual check off, but the information was not documented on paper. The DON stated if a resident's pain was not managed properly, it could affect their mood and their day-to-day activity. During an interview on 7/8/25 at 5:00 PM., the Administrator stated he expected TX Nurse to administer pain medication prior to providing wound care. The Administrator stated TX Nurse should ensure the resident was comfortable first before wound care was done. The Administrator stated the DON was responsible 675996 Page 6 of 19 675996 07/09/2025 Columbus Oaks Healthcare Community 300 North St Columbus, TX 78934

F 0697 Level of Harm - Actual harm Residents Affected - Few for monitoring and overseeing for compliance. The Administrator stated if a resident's pain was not managed properly, it could affect their day-to-day activity. The Administrator said she called incident to the state agency. Record review of the facility policy titled, Pain Assessment and Management dated 2001 med-pass: Purpose. The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and that address the underlying causes of pain. General Guidelines1. The pain Management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management.2. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals.3. Pain management is a multidisciplinary care process that includes the following:a. Assessing the potential for pain.b. Recognizing the presence of pain.c. Identifying the characteristics of paind. Addressing the underlying causes of the [NAME]. Developing and implementing approaches to pain managementf. Identifying and using specific strategies for different levels and sources of pain.g. Monitoring for the effectiveness of interventions; andh. Modifying approaches as necessary .4. Acute pain (for significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained.Steps in the procedureRecognizing Pain.2. Possible Behavioral signs of pain, includinga. Negative verbalizations and vocalizations such as groaning, crying, screamingb. Facial expressions such as grimacing, frowning, clenching of the jaw,etc. 675996 Page 7 of 19 675996 07/09/2025 Columbus Oaks Healthcare Community 300 North St Columbus, TX 78934

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain medical records on each resident that are accurately documented in accordance with accepted professional standards and practices and must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #41) of 5 residents reviewed for accurate documentation and pharmaceutical services. -Resident #41 was documented as receiving his Invega suspension prefilled syringe for his bipolar disorder on 7/4/2025 when he did not receive the medication. The medication was not in the building. This failure could put residents at risk of not receiving the needed treatments they need to promote their mental and physical well-being. Record review of Resident #41's face sheet last captured 7/9/2025 reflected a [AGE] year-old male originally admitted on [DATE] with medical diagnoses including Major Depressive Disorder (a mental illness characterized by prolonged periods of sadness and feelings of worthlessness), Anxiety Disorder (mental illness characterized by excessive worry), hypertension (high blood pressure), and Bipolar Disorder (mental illness characterized by extreme mood swings between mania and depression).Record review of Resident #41's Quarterly MDS dated [DATE] reflected Resident #41 had a BIMS score of 12, indicating high cognitive intactness. Resident #41 required moderate assistance with ADL's such as oral, personal and toileting hygiene and showering/bathing self. Record review of Resident #41's care plan last captured 07/07/2025, revealed he was care-planned on 10/10/2024 for psychotropic medications related to behavior management, with interventions including administering psychotropic medications as ordered by the physician and monitoring, documenting and reporting as needed any adverse reactions of the psychotropic medication and target behavior symptoms such as aggression and document per facility protocol.Record review of Resident #41's active physician's orders for July 2025, revealed he had orders for behavioral monitoring due to antipsychotic medications with a start date of 2/21/2025 and Invega Sustenna Intramuscular Suspension Prefilled Syringe 156 MG/ML one time a day starting on the 4th and ending on the 4th of every month related to bipolar disorder, with a start date of 4/4/2025.Record review of Resident #41's MAR for July 2025 revealed Resident #41's Invega suspension prefilled syringe 156 MG/ML was documented as administered on 07/04/2025 by LVN OS. Record review of Resident #41's progress notes for July 2025, revealed LVN R documented on 7/7/2025 at 9:08am that she told Resident #41's physician that his Invega shot was not available from the pharmacy on 7/4/2025 and per the physician they said it was okay to administer the medication on 7/7/2025 and to continue with Resident #41's regular monthly schedule on the 4th going forward. LVN R documented in the progress notes they administered the shot to Resident #41's right deltoid on 07/07/2025.Interview and observation on 7/7/2025 at 9:14am with Resident #41, he said he was doing good and had no concerns with medications. Resident #41 was in bed watching TV and appeared well-groomed, comfortable and in no discomfort. Interview on 07/07/2025 at 3:41pm with LVN R, she said that Resident #41 did not get his shot on 7/4/25 because the pharmacy never delivered it in time. LVN R worked on 7/5/25 and noticed Resident #41 did not get the shot the previous day and LVN R called the pharmacy who said they did not deliver it yet. LVN R said they told Resident #41's physician about the shot and the physician said it was okay that Resident #41's shot was delayed and to make sure Resident #41 continued to get it on the 4th of every month going forward. LVN R said when she came to work on 7/7/2025 LVN R saw the shot, called the doctor who gave the approval to administer the medication on 7/7/2025 and then she gave the shot to Resident #41 and documented it. LVN R did not know why the nurse on 7/4/2025 documented that Resident #41 got the 675996 Page 8 of 19 675996 07/09/2025 Columbus Oaks Healthcare Community 300 North St Columbus, TX 78934

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few shot when he did not.Interview on 07/08/2025 at 9:25am with LVN OS, they said they started working at the facility a few weeks ago. LVN OS said they did not administer Resident #41's monthly shot. LVN OS accidentally marked they administered the shot and was going to go back and document it was not given but forgot. LVN OS said they were trained on documenting medications at the facility. A risk to residents if their medications were marked as given when it was not would be them not getting medications they needed. Interview with the DON and President on 7/8/2025 at 4:56pm, the DON said that Resident #41's medication should not have been marked as administered when it was not and that a risk to a resident would be the possibility that the medication was missed and the resident not getting treatment. Record review of the facility's policy on adverse consequences and medication errors last revised April 2014 revealed in part, a 'medication error' is defined as the preparation or administration of drugs .which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services, including omission. 675996 Page 9 of 19 675996 07/09/2025 Columbus Oaks Healthcare Community 300 North St Columbus, TX 78934

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure its medication error rate was not 5 percent or greater for. There were 2 errors out of 29 opportunities, which resulted in a 6 percent error rate involving Resident #28 and Resident #39 observed for medication pass in that: -Medication Aide FF did not administer Resident #28 Tylenol ES as ordered by the Physician.-Medication Aide RR did not check Resident #39's blood pressure prior to administering blood pressure medication hydralazine 10 mg 2 tablets by mouth.These failures placed residents at risk for increase pain and decrease in quality of life. Resident #28Record review of Resident #28's face sheet dated 07/07/25 revealed an [AGE] year-old female admitted to the facility on [DATE]. Resident's diagnoses included type 2 diabetes mellitus (when the body has trouble controlling blood sugar and using for energy) with diabetic chronic kidney disease, peripheral vascular disease (circulatory condition in which narrow blood vessels reduce blood flow to the limbs (arm or leg), lymphedema (swelling in legs or arms), chronic peripheral venous insufficiency (when the veins in the legs are having trouble sending blood back to the heart causing blood to collect in the lower extremities), and low back pain. Record review of Resident #28's quarterly MDS dated [DATE] reflected a BIMS score of 15 indicating that resident cognition was intact. Record review of Resident #28's Comprehensive Care Plan dated 06/20/25 reflected resident being care planned for at risk for increase chronic pain r/t PVD and lymphedema. The intervention included administering pain medication per physician orders.Record review of Resident #28's Physician Order Summary Report reflected the following:-Dated 12/12/24 acetaminophen oral tablet 325mg give 2 tablets by mouth every 6 hours as needed for pain - Tylenol Extra Strength give 1 tablet by mouth two times a day for pain. This order was revised on 07/07/25 Tylenol Extra Strength oral tablet (Acetaminophen) give 500mg by mouth two times a day for pain.Record review of Resident #28's MAR for the month of June 2025 reflected that Tylenol ES was being administered twice a day at 9:00AM and 1800 (6:00PM). Observation on 07/07/25 at 8:27AM of medication pass for Resident #28 by Medication Aide FF revealed the medication Tylenol ES was not on Medication Aide FF's medication cart.Interview on 07/07/25 at 8:27AM with Medication Aide FF said the ADON had ordered Tylenol extra strength and that the medication would be arriving to the facility on [DATE].Interview on 07/07/25 at 8:30AM with Resident #28 said she was okay and did not complain of any pain or discomfort.Interview on 07/07/25 at 2:23PM with Medication Aide FF said the medication Tylenol 650mg had not arrived at the facility. Medication Aid FF said she went ahead and medicated Resident #28 with Tylenol 325mg 2 tablets by mouth around 11:00 AM or 11:30AM but had documented on the MAR by mistake of her administering the Tylenol ES instead of the Tylenol 325mg 2 tablets by mouth PRN and said scheduled medications could be given one hour before or one hour after the scheduled time. Medication Aide FF said if the scheduled medication was not administered by these parameters, the medication was considered late. Medication Aide FF said when Resident #28's Tylenol extra strength was not administered as ordered; it placed resident at risk for increase in pain. Medication Aide FF said she should have informed the nurse sooner, when she could not locate the Tylenol ES for Resident #28.Interview on 07/07/25 at 2:30PM with the ADON said she would have to look in the medication storage room to see if the facility had Tylenol ES and that a shipment was coming to the facility on [DATE]. The ADON said if Medication Aid FF had any issues with the medication Tylenol ES not being available on her medication cart all she had to do was inform her. The ADON said if the Tylenol ES 500mg was not available in the facility, the facility could go and purchase some at the store until the shipment arrived at the facility.Observation on 07/07/25 at 2:53PM of the facility medication supply room revealed the facility had 2 containers of Tylenol ES 500mg. Resident #39Record Residents Affected - Few 675996 Page 10 of 19 675996 07/09/2025 Columbus Oaks Healthcare Community 300 North St Columbus, TX 78934

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few review of Resident #39's face sheet dated 07/07/25 revealed an [AGE] year-old male admitted to the facility on [DATE] and again on 07/03/25. Resident's diagnoses included hypertension (high blood pressure) and urinary retention (difficulty urinating and completely emptying the bladder).Record review of Resident #39's quarterly MDS dated [DATE] revealed a BIMS score of 13 indicating that resident cognition was intact. Further review section O (Special Treatments, Procedures, and Programs) reflected that resident was receiving vasoactive medications (medication that effects the blood flow as well as the blood pressure).Record review of Resident #39's Comprehensive Care Plan dated 06/15/25 revealed that resident was being care planned for diuretic therapy r/t HTN with an intervention to monitor for drug interactions.monitor and document postural hypotension (low blood pressure that happens when standing after sitting or lying down) and increase risk for falls.Record review of Resident #39's Physician Orders for the month of July 2025 reflected the included the following order:-Dated 05/06/25 Hydralazine (vasoactive medication) 10mg give 2 tablets by mouth TID related to hypertension, hold for SBP < 110, DBP <60 or HR < 60. Record review of Resident #39 MAR for the month of July 2025 reflected that the facility was administering medication Hydralazine 10mg 2 tablets by mouth as ordered.Observation on 07/07/25 at 12:05 PM of medication pass for Resident #39 by Medication A RR. Medication Aide RR gathered the medication Hydralazine 10mg 2 tablets to be administered to resident by mouth and entered resident room. Medication Aid RR placed the medication that was in a medication cup on resident bedside table that was sitting in front of resident. The surveyor noticed that Medication Aid RR did not bring the blood pressure equipment in the room to take resident blood pressure prior to administering the medication and asked her to stop. At this time, Resident #39 took the cup from the bedside table and took the medication. Interview on 07/07/25 at 12:05PM with Medication Aid RR said the last time she had checked Resident #39's blood pressure was in the morning. Medication Aid RR immediately checked resident blood pressure that read 146/66 and HR of 81. Interview on 07/07/25 at 12:12PM with Medication Aid RR said she had been working at the facility for 30 years and been a medication aid for 20 years. Medication Aid RR said she was supposed to check any resident blood pressure who was on blood pressure medication prior to administering a blood pressure medication. Medication Aid RR said if this was not done, the resident could be placed at risk for getting sick and having to be admitted to the hospital. Medication Aid RR said she became nervous and started making mistakes. Medication RR said it was the nurses that did observation of medication pass with her but could not remember the last time that this was done and who the nurse was that did the medication pass competency with her. Interview on 07/07/25 at 2:09PM with the DON said the medication aids do skill competencies annually and was trying to do it quarterly as well. The DON said it was the ADON that did observation of medication pass with the medication aides. The DON said when administering blood pressure medications, the resident blood pressure should be checked every time prior to administering blood pressure medication. The DON said this was done to avoid a negative outcome for the resident. For example, further decrease in blood pressure or abnormal heart rate that that could send the resident to the hospital. Interview on 07/07/25 at 5:43PM with the ADON said the last time she did medication observation with the medication aides was in April 2025. The ADON said it was herself and the nurses on the unit that did the observation of medication pass with the medication aides.Interview on 07/09/25 at 6:00PM via phone with the pharmacist, she said she came to the facility every month. The pharmacist said she had not done medication observation with the staff since February 2025. The pharmacist said it was not in her contract to observe staff for medication pass and that the facility would have to request this. Record review of the facility policy on Administering Medications revised April of 2025 reflected in part: .Medications are administered in a safe and timely 675996 Page 11 of 19 675996 07/09/2025 Columbus Oaks Healthcare Community 300 North St Columbus, TX 78934

F 0759 manner, and as prescribed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675996 Page 12 of 19 675996 07/09/2025 Columbus Oaks Healthcare Community 300 North St Columbus, TX 78934

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 observation, interview, and record review the facility failed to ensure that its residents are free of any significant medication errors for 1(Resident #39) 7 residents reviewed for significant medication errors.-Medication Aide RR did not check Resident #39's blood pressure prior to administering blood pressure medication hydralazine 10 mg 2 tablets by mouth.This failure placed residents at risk for dangerous drop in blood pressure, organ damage, increase risk of falls, and hospitalization.Record review of Resident #39's face sheet dated 07/07/25 revealed an [AGE] year-old male admitted to the facility on [DATE] and again on 07/03/25. Resident's diagnoses included hypertension (high blood pressure) and urinary retention (difficulty urinating and completely emptying the bladder).Record review of Resident #39's quarterly MDS dated [DATE] revealed a BIMS score of 13 indicating that resident cognition was intact. Further review section O (Special Treatments, Procedures, and Programs) reflected that resident was receiving vasoactive medications (medication that effects the blood flow as well as the blood pressure).Record review of Resident #39's Comprehensive Care Plan dated 06/15/25 revealed that resident was being care planned for diuretic therapy r/t HTN with an intervention to monitor for drug interactions.monitor and document postural hypotension (low blood pressure that happens when standing after sitting or lying down) and increase risk for falls.Record review of Resident #39's Physician Orders for the month of July 2025 reflected the included the following order:-Dated 05/06/25 Hydralazine (vasoactive medication) 10mg give 2 tablets by mouth TID related to hypertension, hold for SBP < 110, DBP <60 or HR < 60. Record review of Resident #39 MAR for the month of July 2025 reflected that the facility was administering medication Hydralazine 10mg 2 tablets by mouth as ordered.Observation on 07/07/25 at 12:05 PM of medication pass for Resident #39 by Medication Aide RR. Medication Aide RR gathered the medication Hydralazine 10mg 2 tablets to be administered to resident by mouth and entered resident room. Medication Aid RR placed the medication that was in a medication cup on resident bedside table that was sitting in front of resident. The surveyor noticed that Medication Aide RR did not bring the blood pressure equipment in the room to take resident blood pressure prior to administering the medication and asked her to stop. It was at this time; Resident #39 took the cup from the bedside table and took the medication. Interview on 07/07/25 at 12:05PM with Medication Aide RR said the last time she had checked Resident #39's blood pressure was in the morning. Medication Aide RR immediately checked resident blood pressure that read 146/66 and HR of 81. Interview on 07/07/25 at 12:12PM with Medication Aide RR said she had been working at the facility for 30 years and been a medication aid for 20 years. Medication Aide RR said she was supposed to check any resident blood pressure who was on blood pressure medication prior to administering a blood pressure medication. Medication Aide RR said if this was not done, the resident could be placed at risk for getting sick and having to be admitted to the hospital. Medication Aide RR said she guess she became nervous and started making mistakes. Medication Aide RR said it was the nurses that done observation of medication pass with her but could not remember the last time that this was done and who the nurse was that done the medication pas competency with her. Interview on 07/07/25 at 2:09PM with the DON said the medication aids done skill competencies annually and was trying to do it quarterly as well. The DON said it was the ADON that done observation of medication pass with the medication aides. The DON said when administering blood pressure medications, the resident blood pressure should be checking every time prior to administering blood pressure medication. The DON said this was done to avoid a negative outcome for the resident for example further decrease in blood pressure or abnormal heart rate that that could send the resident to the hospital. Interview on 07/07/25 at 5:43PM with ADON said the last time she done Residents Affected - Few 675996 Page 13 of 19 675996 07/09/2025 Columbus Oaks Healthcare Community 300 North St Columbus, TX 78934

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication observation with the medication aides in April 2025. The ADON said it was her herself and the nurses on the unit that done the observation of medication pass with the medication aides.Interview on 07/09/25 at 6:00PM via phone with the pharmacist said she came to the facility every month. The pharmacist said she had not done medication observation with the staff since February 2025. The pharmacist said it was not in her contract to observed staff for medication pass and that the facility would have to request this. Record review of the facility policy on Administering Medications revised April of 2025 reflected in part: .Medications are administered in a safe and timely manner, and as prescribed. 675996 Page 14 of 19 675996 07/09/2025 Columbus Oaks Healthcare Community 300 North St Columbus, TX 78934

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 in the facility's only kitchen reviewed for food safety requirements and kitchen sanitation.-The facility failed to ensure foods stored in the walk-in cooler were labeled and dated.-The facility failed to ensure the kitchen back door was closed.-The facility failed to ensure the dry storage room floor did not have black build up on the floor and the walk-in-freezer did not have an accumulation of ice on the floor. These failures could place residents at risk of foodborne illness and food contamination.During an observation on 07/07/2025 between 8:21 a.m. and 9:12 a.m., the surveyor and the DM observed the following food items were opened and not dated with an open date, use-by date, and delivery date in the walk-in cooler:Walk-in Cooler:1. Two boxes of spread, 55% vegetable oil, were open, but there was no delivery date, open date, or use-by date.2. One big bar of open spread wrapped in foil and stored in a zip top bag was not dated with an open day, used by date, and delivery date.3. Six 46 oz thicken and easy clear iced tea containers were not labeled with a delivery date, and 3 of the 48 oz iced tea containers were open and not dated with an open date or used by date.4. Two 46 oz Thick and easy clear with a hint of lemon containers were opened and not dated with an open date or use-by date.5. A box of Hershey's (mini semi-sweet chocolate chips) was opened and not dated with a delivery date, open date, and use-by date.6. A head of cabbage and half a cucumber were wrapped in clear plastic in a plastic black container, and they were not dated with a delivery date or used by date.7. A box of [NAME] tomatoes had a delivery date of 06/12/25. Some of the tomatoes were spoiled with black patches and spots, and some had white spots.8. One gallon of prepared yellow mustard was opened and was not dated with a delivery date, open date, or used-by date.9. A gallon of extra heavy mayonnaise was opened and was not dated with a delivery date, open date, or use-by date.10. A gallon of Seafood Cocktail sauce (best if used by 03/30/2025) was open and not dated with a delivery date or open date. During an observation on 07/07/25 at 8:42 a.m., revealed the kitchen back door was partially open. During an observation and interview on 07/07/25 at 8:43 a.m., the DM said the kitchen back door was open and should be closed because pests could enter the kitchen. The DM stated that preparing meals in a kitchen with pest infestation was not sanitary. If the pest contaminated the food and was served to residents, they could become ill. The DM said if the door was not locked, strangers could enter the facility, and they could cause harm to the staff and residents.During an interview on 07/07/25 at 8:45 a.m., the DM said the staff should have labeled the food in the walk-in cooler with delivery date, open date, and use-by date to prevent the staff from using food products that had expired, which could cause food illness for the residents if it was prepared and served to residents. The DM said she was responsible for checking and making sure that food products were labeled to prevent the use of expired products. The DM said she had an in-service on labeling and storage of food for the kitchen staff. The DM said she would discard all the opened and undated food in the walk-in cooler. The DM said the tomatoes were spoiled, and the shelf life was 10 days, but the delivery date was 06/12/25.During an interview on 07/07/25 at 8:46 a.m., [NAME] NO stated that she had in-service training on food storage. [NAME] NO said staff should store food products with the delivery date, and any product opened should be dated with both the open date and use-by date to prevent the use of expired products and to prevent residents from getting sick. [NAME] NO stated that the DM monitors the cook throughout the shift, inspecting the cooler, freezer, and dry storage to ensure staff do not cook with expired food.During an interview on 07/07/25 at 9:12 a.m., Dishwasher 675996 Page 15 of 19 675996 07/09/2025 Columbus Oaks Healthcare Community 300 North St Columbus, TX 78934

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few X said the kitchen back door should be closed to prevent pests and unwanted persons from entering the kitchen. Dishwasher X said pests could enter into resident food, which could make the residents sick. Dishwasher X mentioned that he had an in-service on accident and hazard and was informed that the back door should always be closed. Dishwasher X said the DM monitors all kitchen staff throughout the shift. During an interview on 07/08/25 at 1:52 p.m., the Dietitian stated that if the frozen items in the box were packaged in bags, each bag should be dated with the receive date, open date, and best used by date. The Dietitian stated that there was a potential foodborne illness that could lead to an adverse clinical outcome for residents if they were served expired food. The Dietitian said she would do the in-service on food storage but had not done any in-service since she started working in the facility in June 2025. She said the kitchen back door should be closed to prevent pests from coming into the kitchen, and if the food was prepared in a pest-infected kitchen, it could cause foodborne illness and adverse clinical outcomes for the residents. The Dietitian stated that fresh produce has a shelf life of 10 days. She noted that the tomatoes had exceeded the shelf life since the delivery date was 06/12/25, and the presence of white and black spots indicated spoilage. She said any food product used in the facility should be dated with the delivery date, open date, and used by date, and the food products should be rotated by first in, first out to prevent using expired food products. The Dietitian stated she checks the refractor and the freezer once a month and ensured there was no expired food, and all the food products were labeled appropriately.Observation on 7/9/2025 at 2:20pm of the kitchen revealed the dry food storage room had an accumulation of dust and dirt on the floor. The baseboard to the floor had black stuff on the floor that looked like mold. The floor of the dry storage room looked like it was moisture from the walk-in-cooler which was situated next to the dry storage room. Further observation of the walk-in-freezer revealed an accumulation of ice on the floor in the corner opposite to the entrance door with white particles in it. In an interview with the Dietary Manager on 7/9/2025 at 2:25pm she said there was no water in the dry storage room. She said she did not know what caused the buildup of black stuff on the floor. She said the dry storage room was cleaned every two to three weeks and she was going to sweep and clean the dry storage room. Record review of the facility policy on food storage dated October 1, 2018, dated Revised June 1, 2019, revealed in part . Policy: To ensure that all food served by the facility is of good quality.procedure #2. Refrigerators. date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage.Where possible, leave items in the original cartons placed with the date visible .Use the first-in, first-out (FIFO) rotation method. Date packages and place new items behind the existing supplies, so that the older items are used and food safety read in part, .Food items in the freezer(s) are covered/sealed, labeled, dated, and shelved to allow air circulation. Refrigerator and freezer shelves and floors are clean and free of spillage. Foods are free of slime mold. 675996 Page 16 of 19 675996 07/09/2025 Columbus Oaks Healthcare Community 300 North St Columbus, TX 78934

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to store foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 1 of 1 resident fridges in the facility.-There was unlabeled and undated food was stored in the residents' refrigerator.-The residents' refrigerator had items belonging to nursing staff.This failure has the potential to place all the residents at risk for consuming food that has not been handled in a safe and sanitary manner. Observation on 07/08/25 at 2: 40 p.m., revealed there were items in the resident refrigerator near the front lobby which contained staffs' personal food items including: 1 fast food plastic orange container with the straw (undated), half-empty bag of tortilla chips (undated), three used water bottles, three lunch bags, two steel water containers, one glass coffee container, and one transparent container containing rice. There was also one plastic container of food dated 3-31 belonging to a resident. Interview on 07/08/25 at 2:43 p.m. with LVN T, he said he had been at the facility for 2 weeks, and that he knew the refrigerator was for resident foods only and the staff were not supposed to put their personal food in the resident refrigerator because of cross contamination. LVN T also said the refrigerator should be cleaned out once a week by housekeeping. LVN T did not know how the food brought from home should be labeled and he said he was going to call the DON to learn.Observation and interview on 07/08/25 at 2:45 p.m. with CNA JJ, she said she could see the lunch bags and other food items belonging to staff and residents were placed together in the residents only fridge. CNA JJ said the refrigerator should have had resident foods only and the housekeeping was supposed to clean this refrigerator once a week. CNA JJ said the nurses were supposed to take the food from the resident's family member and put the food in the refrigerator and that she did not know how the food should be stored and for how long but that the DON would know.Interview on 07/08/25 at 5;15 p.m. with the DON, she said the refrigerator was for residents food brought from outside the facility and food provided from the kitchen for the resident. The DON said the staff were not supposed to put their food or lunch bags in the resident refrigerator to prevent cross contamination. The DON stated the food for the residents should have been dated when the food was brought in and that food would be good for a week and the date should have been on the packet to prevent food from spoiling and causing food-born illnesses. The DON said housekeeping was responsible for cleaning the refrigeration.Record review of the facility's infection tracking and trending documentation for 2025 reflected no food-borne illnesses in the facility.Record review of the facility's policy on food brought by family and visitors, undated, revealed in part, food brought by family/visitors that is left with the resident to consume later will be labelled and stored in a manner that is clearly distinguishable from facility-prepared food .containers will be labeled with the resident's name, the item and the 'use by' date .the nursing staff will discard perishable foods on or before he 'use by' date. Residents Affected - Few 675996 Page 17 of 19 675996 07/09/2025 Columbus Oaks Healthcare Community 300 North St Columbus, TX 78934

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 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 2 of 3 residents (Resident #20 and Resident #74) observed for infection control. 1. The facility failed to ensure TX Nurse used the required PPE for Resident #20, who was on enhanced barrier precautions on 7/8/25. 2. The facility failed to ensure CNA RS used the required PPE for Resident #74, who was on enhanced barrier precautions. These failures could place the residents at risk of cross-contamination and development of infection.1.Record review of Resident #74's face sheet reflected an admission date of 01/17/25. Resident #74's diagnoses included essential (primary) hypertension (high blood pressure) , hypothyroidism,( low thyroid hormones to meet the needs of the body), dementia ( problem with memory, thinking and reasoning that are serious enough to impact a person's daily life), unspecified severity, without behavioral disturbance, psychotic ( losing touch with reality) disturbance, mood, disturbance, and anxiety ( feeling worried, uneasy or scared about something), metabolic encephalopathy ( a condition where the brain isn't working properly due to a problem with the body's metabolism, often causing confusion), hyperlipidemia,( high fat in the blood) unspecified, anemia, constipation, unspecified, dysphagia,, anemia in other chronic diseases classified elsewhere, gastrostomy status, unsteadiness on feet, functional quadriplegia, unspecified protein-calorie malnutrition, pressure ulcer of other site, unstageable, pressure-induced deep tissue damage of other site. Record review of Resident #74's quarterly MDS assessment dated [DATE] reflected resident had a BIMs score of 00 which indicated he was cognitively impaired. He had a gastrostomy tube and was always incontinent of bowel/bladder. Diagnoses included: unstageable, pressure-induced deep tissue damage of other site.An observation on 7/8/25 at 9:02 a.m. of incontinent care revealed CNA RS was in Resident #74's room. An EBP sign was posted outside of the room next to the door. There were supply of PPE observed outside of the room. CNA RS did not wear a PPE gown and proceeded to place soiled linen on the floor. CNA RS then picked the linen and placed it in a plastic bag. RN A sanitized the resident's overbed table, placed a barrier on the table and placed her wound care supplies on the barrier. RN A entered the room, performed hand hygiene, put on gloves, but did not put on a gown. RN A proceeded with the extensive wound care, changing her gloves, and performing hand hygiene between each wound. After completion of wound care, RN A retrieved the resident's wheelchair. RN A emptied Resident #74's urinary drainage bag and then assisted him into his wheelchair. RN A gathered the trash, removed her gloves, and performed hand hygiene and left the room. In an interview with CNA RS on 7/8/2025 at 9:20am regarding not wearing the PPE, she said she was nervous and was very sorry. she said she knew that not wearing the PPE could cause spreading of infection and she had training. 2.Review of Resident #20's face sheet, dated 7/7/25, revealed she was admitted to the facility on [DATE] with diagnoses of cellulitis of right toe,), unspecified asthma(Long-term(chronic) inflammation in your airways chronic obstructive pulmonary Disease cause breathing ( lung conditions that cause breathing difficulties), unspecified, transient cerebral ischemic attack ( mild stroke), cardiac pacemaker(used to control or increase the heartbeat), mixed hyperlipidemia (high fat in the blood), obesity, unspecified, other specified mycoses( fungi infection), nondisplaced fracture of distal of right great toe, subsequent encounter for fracture routine healing, atherosclerosis(the buildup of fats, cholesterol and other substances in and on the artery walls) of coronary artery bypass graft(s) without angina pectoris, essential (primary) hypertension (high blood pressure), other cerebral infarction (stroke ), weakness, unspecified type 2 diabetes mellitus with hyperglycemia Residents Affected - Some 675996 Page 18 of 19 675996 07/09/2025 Columbus Oaks Healthcare Community 300 North St Columbus, TX 78934

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (high glucose in blood), partial traumatic amputation of right great toe, subsequent encounter. Record review of Resident #20's admission MDS dated [DATE] revealed the BIMS score was 14 and 15 which indicated his cognition was moderately impaired. Section M1200 section F=surgical wound care.Observation of wound care on 7/8/25 at 9:05 AM with TX Nurse (LVN/Treatment Nurse) revealed Resident#20 was lying in bed awake, TX Nurse went in to Resident #20's room and talked about changing the treatment to his right amputee great toe. TX Nurse sanitized the resident's overbed table, placed a barrier on the table and placed her wound care supplies on the barrier. TX Nurse entered the room, performed hand hygiene, and put on gloves, but did not put on a gown. TX Nurse proceeded with the extensive wound care, changing her gloves, and performing hand hygiene between each wound. TX Nurse gathered the trash, removed her gloves, and performed hand hygiene and left the roomIn an interview with TX Nurse on 7/8/25 at 10:00 AM she stated any resident with wounds were supposed to be in Enhanced Barrier Precautions. She stated she should have worn a gown when she entered the room. She said she has been working at the facility since November 2024 as the treatment nurse. She said she forgot to wear PPE because she was nervous. She stated the risk of not following Enhanced Barrier Precautions was the spread of MDRO's. In an interview with the DON on 7/8/25 at 4:35 p.m. she stated any resident who had any type of wounds were placed on Enhanced Barrier precautions to help reduce the spread of MDRO's. She stated signage was posted outside to the door, which explains what PPE was to be worn and for what task the PPE was to be worn for. She stated any contact with a resident with a wound required the use of gown and gloves. She stated the staff had received trainings on the use of Enhanced Barrier Precautions. Record review of the facility policy revised October 2018 on Enhanced Barrier Precautions.Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDRO)Policy Interpretation and Implementation1. Enhanced barrier precautions (EBPs)refer to infection prevention and control interventions designed to reduce the transmission of multi-drug -resistant organisms (MDROs) during high contact resident care activities.2. Enhanced barrier precautions apply when: a. A resident with an infected or colonized with a CDC -targeted, MDRO but does have a wound or indwelling medical device and does not have secretions or excretions that cannot be covered or contained. b. Review of CDC guidelines revealed: https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning Personal protective equipment upon room entry and properly discarding before exiting the patient room is done to contain pathogens. 675996 Page 19 of 19