Inspection·May 8, 2025

F 0690 The care plan did not reflect catheter care and peri care for interventions. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #277's May 2025 physician order, reflected: Residents Affected - Some - Catheter care every shift. Monitor urethral site for s/s of skin breakdown, pain/discomforts, unusual odor, urine characteristic or secretions, catheter pulling causing tension. . Review of Resident #277 MAR for March 2025 did not reflect Catheter and peri care ordered. Review of Resident #277 MAR for April 2025 did not reflect Catheter and peri care ordered. In an observation and interview on 05/07/25 at 10:50 AM, it was revealed Resident #277 was with family at the bedside. Resident #277 was interviewable but she said she could not recall all the details. Resident #277's family stated on many occasions that she had visited Resident #277, and the resident was dirty with BM and her catheter was covered with BM. She said Resident #277 just returned to the facility on [DATE] after being in the hospital for a urinary infection. She said this was caused by not receiving incontinence care timely and not getting catheter care daily. Resident #277 family said she had pictures of the different times she came to the facility and found Resident #277 soiled with BM or her catheter would be leaking, and the resident would be wet. The family said they sent pictures to CII. Observation of pictures dated 1/27/25, 2/3/25, 2/26/25, 3/9/25, 3/18/25, 4/11/25 revealed Resident #277 had BM and BM was covering her catheter. Family stated on those days she would clean up Resident #277 by herself and cover her wound if the dressing was soiled. Resident #277 family moved the covers and revealed Resident #277 was clean, dry and catheter was clean. An interview with CNA C on 05/07/25 at 1:35 PM, revealed she emptied the catheter bag every two hours and made sure that it was not touching the floor and that it was not on top of the bed. She stated the nurses were responsible for making sure that catheter care was done and checking it off on the computer. She stated she had not completed catheter care for any resident since she had been employed for a month because her understanding was that the nurses did it. An interview with CNA D on 05/07/25 at 2:00 PM, revealed she completed catheter care daily on residents and if a resident had a BM, then she would complete catheter care, and during showers. She said peri care and catheter care was completed daily and sometimes multiple times on incontinence residents. She said foley care was important to prevent infections. Interview with LVN E on 05/08/25 at 9:00 AM, she stated the CNA were expected to complete catheter care, but it was the responsibility of the nurses to make sure that it was done. She said she always did her own catheter care so that she made sure that it was done. She said all catheters were changed every 15th of the month unless directed by the physician or urologist not to change them. She said it was important to complete catheter care to prevent catheter associated infection. In an interview with NP on 07/05/25 at 11:43 AM, it was revealed that all residents with a catheter had batch orders which included catheter care. She said she was not sure why some residents might have missing orders for catheter care. However, the expectation was that all residents who had a catheter received catheter care orders. She said orders drove care, and catheter care was important to help prevent infection. She said she was not sure if Resident #277 had been missing catheter care orders before she went to the hospital. She said she would verify and make sure that all orders related (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676023 If continuation sheet Page 2 of 8 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 05/08/2025 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 0690 to the catheter were in place. Level of Harm - Minimal harm or potential for actual harm In an interview with DON on 05/08/25 at 02:57 PM, it was revealed that catheter care was the responsibility of the nurses, and they needed to make sure that it was done on their shift. She said CNA were expected to provide catheter care when doing incontinence care and baths, and the nurses should follow up to make sure it was done. DON said the expectation was that there was an order for catheter care, and if there was none, to call the physician and obtain one. DON said she and the ADON's did random monitoring on orders, she was tracking UTI patterns, and there were no concerns at that time. She said catheter care was necessary to prevent infection control. Residents Affected - Some In an interview with ADM on 05/08/25 at 04:25 PM, she said expected for staff to follow the catheter policy , and if catheter care was not done risk of infection. Review of the facility policy and procedure titled Infection Control/Procedure: Resident Care; Catheter Care, Foley revision date July 2022 revealed It is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and PRN when soiling. Purpose: To promote hygiene, comfort, and decrease risk of infection for catheterized residents.17. Document. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676023 If continuation sheet Page 3 of 8 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 05/08/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for one of four hallways (A hallway) medications carts in hallways that were reviewed for security and storage of drugs and biologicals. The facility did not ensure A hallway medication cart was locked and medications were not left on top of the medication cart unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings included: Record review of Resident #44 active physician Order summary dated 05/06/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included cerebral palsy (a congenital disorder of movement, muscle tone and posture), gastrostomy status (this is a feeding tube that is placed through the abdominal cavity area into the stomach for nutritional purpose and medication for individual who have a difficulty swallowing), seizures, and other genetic related intellectual disabilities. Further review of the order summary reflected: - Keppra Oral Solution (Levetiracetam). Give 10 ml by mouth two times a day for seizures Keppra 100mg/ml. - Gabapentin Oral Solution 300 MG/6ML (Gabapentin). Give 6 ml via G-Tube three times a day for Neuropathy [nerve pain]. - Trileptal Oral Suspension 300 MG/5ML (Oxcarbazepine). Give 2.5 ml via PEG-Tube two times a day for seizures. Observation on 05/07/25 at 07:04 AM revealed the medication cart parked on A hallway between room [ROOM NUMBER] and 112, had the lock mechanism in the open (unlocked) position, and Resident #44's Keppra Oral Solution, Gabapentin Oral Solution and Trileptal Oral Suspension medications were left unattended on top of the medication cart . There were no staff next to the unlocked cart. Interview with LVN A on 05/07/25 at 07:07 AM revealed LVN A forgot to lock the medication cart. He said he was too focused on getting everything ready to be observed for G-tube medication observation and when he realized he had no wipes, walked away, and forgot to lock the medication cart to get a new bottle of wipes. LVN A said the expectation was that the medication cart was locked, and all medication was secured and not left on top of the cart which can be accessed. He said the potential risk was someone can come and get the medication and get into the cart. An interview with CMA F on 05/08/25 at 2:18 PM, revealed she was trained to make sure that the medication cart was locked and secured when not in use. She said all medications carts were the responsibility of the authorized person, and when not in attendance, the cart should be locked. She said it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676023 If continuation sheet Page 4 of 8 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 05/08/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was important to lock the cart because anyone can get into it, and if a resident was confused, they could get into something that they were allergic to, or a resident who could not swallow whole pills could choke and have adverse issues. She said she always made sure that her medication cart was locked, and the computer screen was hidden before she walked away from the medication cart. An interview on 05/08/25 at 2:57 PM with DON revealed, the expectation was the medication cart should be locked, and no medication left on top of the medication cart when staff was not directly working with the cart. She said LVN A should have locked the medications [for Resident #44] inside the cart or taken with him when he walked away from his cart. She said all nursing staff were responsible for securing medications when not in use. She stated an in-service would be completed with the nursing staff. She said the risk was anyone could have access to the medications. An interview on 05/08/25 at 4:39 PM with the Administrator revealed, the medication cart should be locked if it was out of site, and staff were not actively working in the cart so that unauthorized persons did not have access to it. Review of facility policy Storage of Medication revised in April 2019 reflected The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 9. Unlocked medication carts are not left unattended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676023 If continuation sheet Page 5 of 8 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 05/08/2025 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 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 safety in the facility's only kitchen. Residents Affected - Some 1. The facility failed to label and date three 1- gallon pitchers of liquid. 2. The facility failed to remove three dented cans from the dry food storage area. 3. The facility DA failed to wear a beard net while in the kitchen. The failures could place all residents at risk for food-borne illness. Findings included: In an observation on 05/06/25 at 6:47 AM, the kitchen reflected 1 of 1 refrigerator with a 1-gallon pitcher, with a red liquid that was not labeled or dated, a 1-gallon pitcher of dark colored liquid was not labeled, and a 1- gallon pitcher of a yellow liquid was not labeled. In an observation on 05/06/25 at 6:55 AM, the kitchen reflected 1 of 1 dry food storage with one dented can labeled apple slices on the second wired rack of the shelf, one dented can labeled baked beans on the third rack, and one dented can labeled spaghetti sauce on the fifth wired rack. In an observation on 05/06/25 at 7:05 AM of the kitchen reflected one DA without a beard net. In an observation on 05/06/25 at 12:41 PM of the dining area reflected the same DA without a beard net while serving trays from the kitchen. In an observation on 05/07/25 at 2:14 PM revealed DA was observed still in the kitchen with no beard net. In an interview on 05/07/25 at 7:05 AM, DA stated he was unaware he was supposed to wear a beard net. DA stated the risk of not wearing a beard net was that hair could fall into a resident's food. In an interview on 05/07/25 at 6:47 AM, DS stated the first pitcher of red liquid that contained no date or label was fruit punch, the second pitcher that was dark in color that contained no label was tea, and the last pitcher that contained no label was lemonade. DS stated all items must be labeled and dated. DS stated the risk of not labeling and dating items could cause a risk of sending out old food that can potentially harm the residents. At 7:00 AM, DS stated the dented cans were normally stored on the top rack of the shelf. DS stated the risk of serving food from the dented cans, could cause a food-borne illness. At 7:07 AM, DS stated all staff are required to wear hair nets and beard nets and the risk of them not wearing hair restraints is that hair can fall into a resident's food causing contamination. On 05/07/25 at 10:45 AM, ADM stated all kitchen staff should be wearing hair nets and beard nets. ADM stated it is the responsibility of the ADM and the employee to put hair nets and beard nets on. ADM stated the risk of not wearing beard nets could cause hair to contaminate the resident's food. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676023 If continuation sheet Page 6 of 8 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 05/08/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm ADM stated all items in the kitchen must be labeled and dated. ADM stated the canned food items that had dents in them should be stored in their own area. ADM stated failing to label, date, or removing dented items could place residents at risk for food-borne illnesses. Record Review of the facility policy Infection Control Policy/Procedure revised 02/05/24 reflected: A: Residents Affected - Some Proper attire for food handlers should include a hair covering (hair nets or caps), freshly laundered uniform and work shoes and short, clean fingernails. Moustaches and sideburns must be kept trimmed. Beards must be covered. B: Foods coming from broken packages or swollen cans or food with an abnormal appearance or odor will not be served. M: Leftovers must be dated, labeled, covered . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676023 If continuation sheet Page 7 of 8 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 05/08/2025 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 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 establish and 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 2 Residents (Resident #16 and Resident #84) observed for infection control. Residents Affected - Some The ABOM failed to perform hand hygiene while assisting Resident #16 and Resident #84 during the lunch meal on 05/06/2025. These failures could place residents at risk for cross contamination and infections. Findings included: Observation on 05/06/25 at 12:17 pm and at 12:30 pm revealed the ABOM sitting in between Resident #16 and Resident #84 during the lunch meal. The ABOM was observed feeding both residents at the same time without using hand sanitizer in between. Interview on 05/06/25 at 12:43 pm, the Administrator revealed the ABOM was also a CNA. She stated there was a potential risk for infection if staff did not perform hand hygiene while feeding residents. Interview on 05/06/25 at 12:43 pm, the DON stated her expectation was for staff to feed one resident and use hand sanitizer. She stated she expected staff to use hand sanitizer, and make sure not to cross contaminate as long as it did not impede the care. Interview on 05/06/25 at 1:09 pm, the ABOM stated she was a CNA and had not worked on the floor for about 6 months since switching positions to ABOM. She stated she thought she used hand sanitizer in between feeding Resident #16 and Resident #84. She said there could be a risk of cross contamination between residents, and she should have used hand sanitizer between each resident. Record review of facility policy titled Hand Washing revised 07/2021, revealed the procedure for hand washing, but did not indicate when hand hygiene was to be performed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676023 If continuation sheet Page 8 of 8