Inspection·September 10, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side rails as ordered, handrails on walls, personal items within reach. Date initiated 03/06/2024. In an observation on 09/05/2024 at 12:15 pm, revealed Resident #1's door was closed. Signage on Resident #1's room read Enhanced Barrier Precaution on a second signage it listed that the resident was non-verbal and that he required max support to complete ADLs. Upon entry to Resident #1's room he was lying on a mattress on the floor. Resident #1 was lying on his left side and his g-tube was exposed, connected to a feeding pump. Resident #1's room had a strong foul odor of unknown substance. He had one black fly on his forehead, another fly on his g-tube, another fly on his stomach, two flies on his right leg, one fly on his feeding pump, and one fly floating and buzzing around Resident #1. Resident #1 reached his forehead to swish/remove the fly and two gnats were observed floating by his head. Resident #1 could not speak, nor could he express his thoughts on the flies in his room and him. In an interview with LVN A on 09/05/2024 at 12:20 pm, she stated Resident #1 preferred lying on the floor mat and after 6 weeks trying, he agreed to be transitioned to a mattress on the floor. She stated Resident #1's room smelled of bowel movement. She stated some of the smell was most likely coming from the tiles on the floor. She stated she had seen the flies in Resident #1's room and had reported it to housekeeping and maintenance two weeks ago. She stated management were aware of the flies. She stated the gnats could possibly be from Resident #1 spilling his milk. She stated Resident #1 refused assistance eating and on multiple occasions he spilled his milk. She stated she had used some peppermint oils to help with the flies. LVN A did not know who had brought the peppermint oil but was told to use it to keep flies away. She stated the risk to Resident #1 having flies on him and in his room was a dignity issue and flies carry germs that could cause illness. In an interview with the Housekeeping Supervisor on 09/05/2024 at 1:18 pm, she stated Housekeeper C had informed her about the flies in Resident #1's room. The Housekeeping Supervisor stated herself and Housekeeper C deep cleaned Resident #1's room including his mattress and curtains. She also instructed housekeeping staff to clean Resident #1's room two times a day in the morning and afternoon. She stated it was the responsibility of the nursing staff to make sure that trash with bowel movement diapers were removed out of the room to prevent flies. She stated that if the housekeeping staff were cleaning Resident #1's room in the afternoon and they found trash, she had instructed them to remove the trash even those diapers with bowel movement in the trash. The Housekeeping Supervisor stated she informed the Maintenance Director, and he called pest control. The Housekeeping supervisor stated it was not good having flies on Resident #1 because it was unhygienic. In an interview with Housekeeper C on 09/06/2024 at 1:41 PM, she stated LVN A had alerted her about the flies in Resident #1's room. She stated that she had noticed them two weeks ago and she notified her supervisor. She stated she had been instructed to start cleaning Resident #1's room two times a day and her supervisor wrote in the pest control book for Resident #1's room. She stated she had been in-serviced that if she sees anything bad to report it. She stated the risk to residents having pests in their room can cause them to be unwell and their stay was not better. She stated the risk to Resident #1 was it was not hygienic, and it was unhealthy to have pests in your room and on you. In an interview with the Maintenance Director on 09/05/2024 at 1:59 PM, he stated he did not see any flies when he went to Resident #1's room when housekeeping staff were cleaning the room. He stated he could not remember exactly when he had been informed of one of the resident's rooms had one fly in it, and he instructed housekeeping staff to increase cleaning to two times a day. He stated this was the first time he had learned of the flies and gnats in Resident #1's room since they started (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676023 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676023 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2024 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 0550 Level of Harm - Minimal harm or potential for actual harm cleaning his room twice a day. He stated the flies in Resident #1's room could be entering from the exit door because his room was close to the exit. He sated he had gone in Resident #1's room and checked his windows and screens which were in place. He stated pest control came two times a month to spray the main stations outside and if any rooms have any pest concerns. He stated housekeeping was responsible for deep cleaning rooms as needed and he got pest control within 24 hours of report of pests. Residents Affected - Few In an interview with LVN B on 09/05/2024 at 3:17 PM, she stated she treated Resident#1 on 08/23/24 due to having moisture associated skin damage on his back. She said Resident#1 was on a mattress on the floor. She said he does not stay on the bed. She stated she did not notice any flies or gnats in the room. She stated Resident#1 does not really communicate. She said he makes noises but does eye gestures and hand motions. LVN B stated flies should not be on a resident, just like she would not like them on her. She stated some flies can bite and can cause infection for Residents #1 with his with G-tube. Attempted phone interview with RP on 09/05/2024 at 3:45PM, RP could not be reached. In an interview with the DON on 09/05/2024 at 5:09 PM she stated she was not aware of the flies in Resident #1's room until today. She stated a head-to-toe assessment was completed on Resident #1. She stated there were no bite marks or any skin conditions found on Resident #1. The DON stated herself, the nursing staff, and housekeeping had deep cleaned Resident #1's room, including his walls, curtains, mattress switched to a new one, the equipment was wiped down with disinfectant, and a new order to clean Resident #1's room three times a day. The DON stated family may have brought in the peppermint oils because the RP had reported they liked to bring soothing natural oils. The DON stated it was likely the sweet oils were attracting flies and gnats. The DON stated she would monitor and follow-up with the ADON, CNAs, and housekeeping to make sure interventions were effective. The DON stated the floors were also the issue with smell and the facility was getting new floors which would help with the smell. She stated the risk to Resident #1 was potential discomfort. In an interview with the ADM on 09/10/2024 at 11:57 AM, she stated that the Maintenance Director was responsible for ensuring effective pest control for the facility which he did for Resident #1. She stated she expected the facility to have pest control twice a month and they can also be reached within 24 hours as needed. She sated the DON had in-serviced on pest control and potential hazards for cleanliness and a homelike environment. Record review of a service inspection invoice by [Pest Control Service] on 07/30/2024, general comments twice a month, treated bait stations on exterior, cleared out debris from bait stations, and treated general pests. Treatment on 07/10/2024 treated for ants and rodents. Invoice for 08/29/2024 reflected treatment twice a month, treated exterior bait stations for rodent activity, treated for general pest, cleared out debris from bait stations, and removed ant piles around the outside. The pest control service did not reflect treatment for flies and/or gnats. Residenst Right policy was requesed on 09/05/2024 at 09:43 AM, email was sent to both ADM and DON. Resident Right policy was not provided by exit date 09/10/2024. Record review of the facility's pest control service agreement, with an initial service date of 11-07-2019, stated Pest Services . Service Provider shall provide Services in accordance with all applicable federal and state laws and within the established policies of Facility . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676023 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676023 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2024 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the facility policy titled, Nursing Services: Quality of Care, ADL, Services to Carry Out, revised 07/2020, reflected, it is the policy of this facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident in accordance with a written plan of care. Policy read in part 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, it will be provide by qualified staff . Event ID: Facility ID: 676023 If continuation sheet Page 4 of 4