Health inspection·July 11, 2023

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. Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured properly for 1 of 2 medication rooms (Hall G) reviewed for drug storage. The facility failed to ensure Hall G medication room was secured when not in use or unattended. This failure could place residents who reside in the facility at risk of possible drug diversion. The findings included: During an observation on 07/09/23 at 8:42 a.m. the Hall G medication room door was not shut well and there were no staff present in the hall. This surveyor pulled on the door, and it opened. There were no nursing staff inside the medication room. Located in the medication room was an open shelf of facility stock medications. In a cubby on the side wall were prescription medication cards labeled with a resident's name, and in the small refrigerator were prescription suppositories labeled with another resident's name. No medication carts were in the med room. During an interview on 07/09/23 at 8:45 a.m., LVN C said she was not aware the medication door was not closed. She said she had not been in the med room since her arrival at the facility at 6:00 a.m. LVN C said there were two med rooms at the facility, and she normally used the one located beside the main nurse's station. She said she and the CMA had keys for the Hall G med room. She said possible negative outcome of med room door being open could be residents with dementia going into the med room and taking medications. She said there were residents on Hall G with dementia. During an interview on 07/09/23 at 8:50 a.m., CMA D said she had a key to the Hall G med room, but she had not been in the room since her arrival at the facility at 6:00 a.m. She said she was not aware the room was left open. She said all nurses and CMAs were to keep the med room and med carts locked when they were not present with them. During an observation and interview on 07/09/23 at 10:00 a.m., the maintenance supervisor said the automatic door closer on the Hall G med room was stripped/not working properly and the door was not automatically closing this morning when he checked it after this surveyor found the door open. He said he had replaced the automatic door closer to the med room this morning and demonstrated to this surveyor that the door now closed and locked automatically when leaving the med room. He said no one had reported to him about the Hall G med room door not closing properly until this morning when the DON reported it to him. Page 1 of 7 676122 676122 07/11/2023 Oak Grove Nursing Home 6230 Warren St Groves, TX 77619

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 07/10/23 at 3:00 p.m., the DON said possible negative outcome of a med room door being left open could be drug diversion. The DON said it was her expectation that med room doors remained locked. She said she was the supervisor of all nursing staff. Record review of facility policy Medication Storage in the Facility last revised August 2014 indicated, Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medication (such as medication aides) permitted access to medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. 676122 Page 2 of 7 676122 07/11/2023 Oak Grove Nursing Home 6230 Warren St Groves, TX 77619

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide food in a form designed to meet individual needs for 1 of 2 meals reviewed for food form. The facility failed to ensure the residents who required a pureed textured diet, received the appropriate food form to meet their needs on 07/10/23 for the noon meal. The pureed food had lumps of food, not fully pureed and was thick and dry in consistency. This failure could affect the 9 residents, who received a pureed diet, at risk of aspiration and choking. Findings included: 1. Record review of an admission face sheet indicated Resident #36, admitted [DATE], was [AGE] years old and included diagnoses of dysphagia (difficulty in swallowing). Record review of the physician orders dated July 2023 indicated Resident #36 orders included a puree diet with start date of 05/16/23. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #36 was severely impaired with cognition, swallow disorder and required extensive assistance of one staff with eating. Record review of the care plan dated 05/16/23 indicated Resident #36 was at risk for weight loss, and at risk for nutritional decline, on pureed diet for diagnosis of dysphagia (difficulty in swallowing). During an observation and interview on 07/10/23 at 10:30 a.m., the DM pureed gumbo and [NAME] A pureed the mixed vegetables, and the wheat bread. [NAME] A said she was going to cook the cream of rice for the residents on a pureed diet. The DM said there were 9 residents on a pureed diet, but one of the residents could not have rice. During an observation of the test tray on 07/10/23 at 11:50 a.m., the pureed wheat bread had small lumps of bread and was not pudding consistency. The cream of rice was a firm scoop of cream of rice. The cream of rice was sticky and dry, not creamy or pudding consistency. The pureed wheat bread and cream of rice were not easily swallowed. During an observation and interview on 07/10/23 at 11:52 a.m., the DM said the cook and her were responsible for ensuring pureed diet was the proper consistency. She said the pureed wheat bread did not puree easily and took longer than white bread. The DM said the wheat bread was not smooth. The DM said the cream of rice must have dried out on the steam table and was not creamy or pudding consistency as she tasted the cream of rice . During an observation on 07/10/23 at 12:15 p.m., CNA B was assisting Resident #36 with lunch. CNA B was mixing the cream of rice with the gumbo, mashing the lumps and continued to stir the gumbo as she fed Resident #36. 676122 Page 3 of 7 676122 07/11/2023 Oak Grove Nursing Home 6230 Warren St Groves, TX 77619

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 07/10/23 at 2:02 p.m., the Administrator said his expectation was for the pureed food to be creamy and smooth. During an interview on 07/11/23 at 12:05 p.m., [NAME] A said she had been trained to make pureed food items smooth and creamy like pudding. She said yesterday she placed the cream of rice in the oven to maintain the temperature. She said the cream of rice must have continued to cook. She said the pureed food items should be moist and have the consistency of pudding and should not be dry and sticky. [NAME] A said now after the test tray yesterday, the wheat bread and the cream of rice would be done last. She said to prevent items from continuing to cook making it sticky and lumping to prevent residents from choking. During an interview on 07/11/23 at 12:11 p.m., CNA B said she fed Resident #36 yesterday (7/10/23) at lunch. She said she took the cream of rice and mixed it with the gumbo. She said she mashed the cream of rice into the gumbo and kept mixing to prevent lumps. CNA B said the cream of rice and bread for the residents who received pureed food on 7/10/23 at lunch was not creamy. She said she had been trained on diets. CNA B said some residents have difficulty in swallowing or chewing and that was the reason why residents were ordered pureed food. Review of the undated Puree Diet policy indicated: POLICY: The Dietary Department shall serve a puree diet that is nutritionally adequate and texturally appropriate. PROCEDURE: . 3. The consistency of the pureed foods shall be like that of smooth pudding. 676122 Page 4 of 7 676122 07/11/2023 Oak Grove Nursing Home 6230 Warren St Groves, TX 77619

F 0851 Level of Harm - Potential for minimal harm Residents Affected - Some Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. The facility failed to submit direct care staffing information on the schedule specified by CMS (Centers for Medicare and Medicaid Services), but no less frequently than quarterly for 4 of 5 quarters reviewed for payroll data information. *The facility failed to submit staffing information to CMS for the 3rd and 4th quarter of the fiscal year 2022. *The facility failed to submit staffing information to CMS for the 1st and 2nd quarter of the fiscal year 2023. This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings included: Record Review of the facility's undated staff roster indicated the following: 1 Administrator 3 RN's (included DON) 1 Maintenance Worker 1 Activity Personnel 17 LVNs (including ADON, MDS, Infection control) 25 CNAs 5 CMA 9 Dietary 5 Housekeepers 1 Social Worker 2 Laundry workers Record review of the CMS PBJ Staffing Data Report (payroll-based staffing), CASPER Report (Certification and Survey Provider Enhanced Report)1705 D FY Quarter 3 2022 (April 1- June 30), dated 07/10/2023, indicated the following entry: Failed to Submit Data for the Quarter Triggered .Triggered=No Data Submitted for the Quarter. 676122 Page 5 of 7 676122 07/11/2023 Oak Grove Nursing Home 6230 Warren St Groves, TX 77619

F 0851 Level of Harm - Potential for minimal harm Residents Affected - Some Record review of the CMS PBJ Staffing Data Report, CASPER Report 1705 D FY Quarter 4 2022 (July 1September 30), dated 07/10/2023, indicated the following entry: Failed to Submit Data for the Quarter Triggered .Triggered=No Data Submitted for the Quarter. Record review of the CMS PBJ Staffing Data Report, CASPER Report 1705D FY Quarter 1 2023 (October 1- December 31), dated 07/05/2023, indicated the following entry: Failed to Submit Data for the Quarter Triggered .Triggered=No Data Submitted for the Quarter. Record review of the CMS PBJ Staffing Data Report, CASPER Report 1705D FY Quarter 2 2023 (January 1- March 31), dated 07/05/2023, indicated the following entry: Failed to Submit Data for the Quarter Triggered .Triggered=No Data Submitted for the Quarter. Record review of a third part vendor facility activity report indicated the facility had batches for 4th quarter, 3rd quarter 2022 and 2nd quarter, 1 quarter 2023 in the system but not sent. Documentation indicated 2nd Quarter 2022 staffing information was sent to CMS. Record review of Staff sign in sheets reviewed from 07/09/23 through 01/01/23 indicated 8+RN hours daily with adequate number of LVN hours, CNA hours, CMA hours daily. During an interview on 07/09/23 at 11:50 a.m., the DON was asked about low staffing in the CMS report. She said she was unsure why they had low staffing on the CMS report. The DON said the facility always had adequate staffing, they very seldom worked short staff and had RN coverage the required hours every day. During an interview on 07/09/23 at 11:53 a.m., the administrator said their staffing was being submitted quarterly by HR though a third-party vendor to CMS and he would check with them. The administrator said submission to the third-party vendor started about March of last year. It was supposed to help with quality measures and notify them if numbers were put in incorrectly. He said the facility had received no notification of any concerns or that the PBJ staffing information had not been sent. During an interview on 07/10/23 at 2:00 p.m., the administrator said he spoke with the third-party vendor, and they informed him the information had been put in the system and made into batches but the person submitting did not complete the process. She did not push the button to submit to CMS. During an interview on 07/10/23 at 2:22 p.m., HR said she was responsible for submission of the staffing data to CMS every quarter (every three months). She said she submitted the staffing data to CMS, then about March of 2022 the administrator changed the submission process to go through, a third-party vendor where MDS were submitted to CMS through. She said she did not receive any education on submission of the staffing data. HR said a staff member of the third-party vendor walked her through the submission process one time. She said she manually typed all the staff numbers in and submitted them to the third-party vendor and then pushed a button to submit to CMS. She said she never received a validation report, an email, or any indication the numbers were not being submitted correctly. HR said she was unaware the staffing data was not submitted to CMS until notified by surveyor. HR said she did not have a backup or anyone to double check behind her, she said she thought she was doing it correctly. She said the risk of not submitting the staffing data correctly and timely was not following CMS policy and low rates for the facility. During an interview on 07/10/23 at 2:35 p.m., the administrator said HR was responsible for submission of the PBJ (payroll-based journal) staffing data to CMS. He said about March 2022 he spoke with 676122 Page 6 of 7 676122 07/11/2023 Oak Grove Nursing Home 6230 Warren St Groves, TX 77619

F 0851 Level of Harm - Potential for minimal harm Residents Affected - Some a representative of a third-party vendor, the one that submits MDS's to CMS and signed a contract for the staffing data to be submitted through it starting with the 2nd quarter of last year (2022). He said the facility would upload all the staffing data into the system. It was supposed to notify them if numbers were put in incorrectly or not submitted and to help with the facilities quality measures. The administrator said there was no double check or back up but next week the DON, and himself were getting certified and trained by the third-party vendor and HR retrained on submission of the staffing report. He said the batch due to be sent August 15, 2023 would be sent correctly and timely. The administrator said he was unaware the staffing data had not been submitted to CMS. He said he knew HR had uploaded the data into the third-party vendors system every quarter but was unaware it was not being sent to CMS. The administrator said it was not an issue of staffing in the facility, it was an error in submission. He said last year he was operating at an over-staffed level. He said his facility is always overstaffed compared to the ratios. He said his expectation was for HR to submit the staffing data correctly and timely to CMS and the administrator and DON to be the backup and double check the submission. He said the risk of not reporting staffing data to CMS was not a risk to the residents, they had adequate staffing. The risk was a poor star level and missing out on admissions. The administrator said all their staffing data was still in the Simple system. He tried to send it to CMS on 07/10/23 but it was rejected due to being past the deadline to submit. During an interview on 07/11/23 at 1:00 p.m., the DON said HR was responsible for sending the staffing data to CMS. She said the administrator and DON would be the back and double check to make sure it was sent in correctly after this week. She said the staffing data was to be sent through a third-party vendor website. The DON said the administrator was sold on the features of tracking the staffing data. She said the risk of not submitting staffing data was a low star rating and the facility could lose admissions. The DON said there was no harm to residents because the facility had plenty of staff. During an interview on 07/12/23 at 8:50 a.m., third party representative E said the facility put documentation in the program, but the information was not sent to CMS. She said the facility needed some more training. She said the facility received daily emails from the system as a reminder saying don't forget to send their PBJ report up until the date it is too late to send for the quarter. Record review of the facility's policy, Reporting of Staffing Hours (Payroll-Based Journal) dated 07/11/23 revealed, . Facility staffing hours will be reported quarterly and according to CMS guidelines.2. Reporting of facility hours will be performed by Human Resource Director on designated schedule outlined by CMS. 676122 Page 7 of 7