Inspection·March 6, 2024

F 0677 2/26/24 Level of Harm - Minimal harm or potential for actual harm 2/28/24 3/01/24 Residents Affected - Some 3/04/24 An interview on 3/06/24 at 9:48 AM with Resident #1 revealed she had only had 1 shower and 1 bed bath since her admission into the facility in December 2023. Resident #1 stated, the service here is not very good. She stated she once told an aide about not receiving showers and the aide told Resident #1 she did not have time to give her a shower. Resident #1 stated she did not ask for showers very often after that because it seemed like the staff did not have time but that she was scheduled and wanted to take showers three times a week on Mondays, Wednesdays, and Fridays. Resident #1 appeared clean; no odor was noted. Hair and nails appeared kept. An interview on 3/06/24 at 12:18 PM with LVN D revealed that a black binder with shower logs for all the residents was kept at the nurse's station. She stated that aides were to document in the shower log as well as electronically in the residents' daily ADL administration log when showers are offered and given to the residents. She stated Resident #1 is offered showers but sometimes refuses due to back pain. An interview on 3/06/24 at 12:35 PM with CNA A revealed she does not typically work the 100 Hall so she was not familiar with Resident #1's shower schedule but said that showers or refusal of showers should be documented in the shower log and electronically. An interview on 3/06/24 at 2:34 PM with CNA B revealed she has seen Resident #1 take showers a lot. She stated that the aides were supposed to document when they give residents showers, but some aides don't. She stated that there were many times that residents take showers and baths, and it was not documented. She stated that there were times it was not a designated shower day for a resident, but the staff would go ahead and give the resident a shower or bath. CNA B stated that when that happened, the aides often forgot to document it. She said the staff were supposed to document in the shower log binder and electronically. She stated she has given Resident #1 showers in the past. An interview on 3/06/24 at 2:42 PM with CNA C revealed she was an agency nurse (nurse who works for a nursing agency and is called in to work on an as needed basis). She stated that when she is working in the facility during the day, she was not usually responsible for Resident #1's care but was aware that Resident #1 took showers/baths on Mondays, Wednesdays, and Fridays on the 2-10 PM shower schedule. She stated she gave Resident #1 a paper to keep in her room with the days and shift of her scheduled shower days. CNA C stated the aides were responsible to document in a binder and in the electronic record under ADLs whenever the residents were given showers/baths. An interview on 3/06/24 at 3:03 PM with the ADON revealed the nurses were to oversee the CNAs. She stated that the shower documentation was an issue. The ADON stated she wanted all the showers done on every shift. She stated that she often reminds the CNAs to complete their shower sheets. The ADON stated that the nurses also remind the CNAs to complete their shower sheets. She stated the aides should document on Resident #1's electronic ADL record and the shower log if a resident received a shower or refused. The ADON stated she checks the shower sheets every Friday, at least once a week. She stated she recently initiated and implemented an in-service (training) on showering and ADLs. After (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676023 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676023 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Keller Oaks Healthcare Center 8703 Davis Blvd Keller, TX 76248 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some reviewing Resident #1's ADL Shower/Bath documentation, she stated she could not explain the lack of documentation for the resident. The ADON stated the expectation was that showers were offered and provided as scheduled and documented. She stated a risk of not providing showers for the residents could cause skin breakdown. The ADON stated it was also a dignity issue. An interview on 3/06/24 at 3:47 PM with the Administrator revealed that her expectation regarding resident showers/baths was that residents are offered showers/baths at the residents' preference and offered at least twice a week. She stated that she expects the aides to document the showers and baths because if it is not documented, it did not happen. The Administrator stated she recently went over the shower logs in an effort to improve this area. She stated that the nurses are responsible to oversee that the aides are carrying out the residents' showering and ADL care. The Administrator stated that following the chain of command, the ADONs oversee that the nurses and aides are providing care and documenting. She stated that not offering or providing showers to the residents affects resident dignity and can cause skin breakdown. Review of the facility policy Quality of Care- ADL, Services to Carry Out, revised 07/2020, reflected the following: It is the policy of this facility that residents are given the appropriate treatment and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care. 1. Maintenance and restorative programs will be provided to residents in accordance with the resident's comprehensive assessment. 2. If a resident is unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming, and personal oral hygiene will be provided by qualified staff. 3. Residents will be involved in decision making and given choices related to ADL activities as much as possible. 4. Bathing will be offered at least twice weekly, and PRN per resident request. 5. ADL care provided will be documented in the medical record accordingly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676023 If continuation sheet Page 3 of 3