Health inspection·January 20, 2024

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of Resident #1's physician orders, dated 01/19/24, revealed Augmentin Oral Tablet 500-125 MG {Amoxicillin (class: Penicillin) & Potassium Clavulanate} Give 1 tablet by mouth two times a day for UTI for 7 Days. Active date 01/11/24 and End date 01/18/24. Review of Resident #1's progress notes dated 01/07/24 and 01/11/24, revealed Resident #1 did not provide a consent stating he knew the risks, and outweighed benefits of taking medication he was allergic to, to treat his infection. Progress notes did not reveal Resident #1 got education about the antibiotic he was given, noting his allergy to penicillin. Review of Resident #1's care plan, dated 01/12/24, revealed Resident #1 was at risk for allergic reaction to the following: penicillin and tramadol. The goal was for Resident #1 to not have allergic reactions. Interventions included were: monitor for [signs] and symptoms of possible allergic reactions such as hives, rash, swelling, watery eyes, wheezing and report finding to MD as indicated. Notify MD if patient has an allergic reaction to new medications or food. Interview on 01/19/24 at with CNA A, revealed that Resident #1 was acting funny on 01/18/24 by dropping his remote on the floor multiple times and he spilled his ice water on his bed. CNA A said that he had to get him cleaned and got him fresh ice. He said that Resident #1 called multiple times asking for his remote control. CNA A said the remote was laying on Residents #1's bedside table next to him. CNA A said that he did not report this because Resident #1 sometimes had intermittent confusion. CNA A said he left facility at 10pm on 01/18/24 without giving report to the oncoming CNA (CNA B). Interview on 01/19/24 at 03:22pm with CNA B, revealed he worked a double shift on 01/18/24, from 02:00 pm-10:00 pm then again from10:00pm to 06:00am. CNA B said that he did not get report from outgoing CNA A. He said Resident #1 was already in bed when he checked on him at 11:20 pm. He said at around 11:45pm or 12 midnight LVN C was yelled for him to go and help her in Resident #1's room. CNA B said Resident #1 was on the floor in a seated position with chin tucked on his chest. Interview on 01/19/24 at 5:24 pm with LVN C, revealed she worked 10 pm to 6 AM shift, and did not normally administer any medications to Resident #1 unless it was as needed medication (PRN). She said when she went to do her rounds in Resident #1's room between 11:30 PM or 11:45 PM on 01/18/24, Resident #1 was on the floor close to window besides his bedside slumped over and pale. She said she called for help and called a Code Blue. EMS was called and they arrived within 5 minutes. She said EMS worked on Resident #1 to try and revive him for 20 minutes before pronouncing him dead. Interview on 01/20/24 at 3:15 pm with LVN H , revealed that she administered first doses of antibiotic Augmentin to Resident #1 on 01/07/24. LVN H said she was not aware that Augmentin contained Amoxicillin which was a penicillin antibiotic. She said if she knew, she would not have administered Augmentin to Resident #1. LVN H stated she was aware Resident #1 had a penicillin allergy. She said she monitored Resident #1 the entire shift of 01/07/24. She said Resident #1 had some wheezing before medication administration, and she gave him a breathing treatment and his shortness of breath and wheezing stopped. LVN H said the antibiotic was continued because Resident #1 was doing better and did not show any adverse reactions. She said she normally would send a text to the physician to tell them about a resident's allergies, but she did not do it for Resident #1. She said the risk of administering a medication a resident was allergic to could cause signs and symptoms of allergic reaction such as shortness of breath, rash, low or high blood pressure, dizziness, sweating, and throat swelling. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676139 If continuation sheet Page 2 of 6 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 676139 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Oaks Nursing & Rehabilitation 3033 W Green Oaks Blvd Arlington, TX 76016 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Interview on 01/20/24 at 4:20 pm with LVN D, revealed she did not know that Resident #1 had a penicillin allergy. LVN D said she was the charge nurse on the unit on 01/07/24 and LVN E asked her to transcribe Resident #1 antibiotic order to pharmacy. She said she did not verify Resident #1 allergies prior to transcribing order to pharmacy. She said she did not know that antibiotic Augmentin contained Amoxicillin, a penicillin antibiotic. She said that she always double checked the physician orders when someone asked her to transcribe for them. She said she asked for the original physician order and then transcribed to pharmacy to fill the medication. She said she did not verify that Augmentin contained penicillin that Resident #1 was allergic to. She said some risks of allergic reaction are hive, shortness of breath, hospitalization, anaphylactic shock, and death. Interview on 01/19/24 at 6:39 pm with DON, revealed she was not aware that Augmentin contained Amoxicillin a penicillin antibiotic, nor was she aware Resident #1 had a penicillin allergy. She said the pharmacy would not fill a prescription if a resident had an allergy to it. She said the process was to review a resident allergy before medication administration especially antibiotics. Risks were adverse reactions and anaphylactic reactions. Interview on 01/19/24 at 4:48 pm with Physician I, revealed he was not Resident #1 physician. He said Augmentin Oral Tablet 500-125 MG was a combination of Amoxicillin & Potassium Clavulanate. Physician I said Amoxicillin was in the penicillin class of drug. He said that people can have different reactions if they have a penicillin allergy. Some signs and symptoms are shortness of breath, rash, abdominal pain, and worst-case reaction is anaphylactic reaction. Interview on 01/19/24 at 7:04 pm with Physician H, revealed he was Resident #1's attending physician. He said Augmentin had a mixture of penicillin and other components. He said that it was unlikely for a person to show an allergic reaction after 2 weeks. The Doctor said that he prescribed the antibiotic for Resident #1. He said he was aware that Resident #1 received an antibiotic that had penicillin. He said the risk for taking medication a resident was allergic to was skin rash, hives, reaction with lots of redness, skin issues, diarrhea, nausea and vomiting, stomach upset. He said skin allergy showed within 12- 24 hours after exposure and it was unlikely the resident expired due to the medication prescribed since the resident did not have a reaction. Interview with the Pharmacist on 01/20/24 at 10:46 AM, revealed she cannot answer specific questions and would have to send inquires to QA department. She said that if a person was allergic to a medication noted on the patients' chart, then she would not fill the prescription. She would call facility to clarity and ask facility to contact physician to verify order or to change the order. The Pharmacist said that if she knew that a resident had a penicillin allergy, she would not give Augmentin to them. Interview on 01/20/24 at 10:53 am with Physician H, revealed he was aware that Resident #1 had penicillin allergy. He said that he would prescribe Augmentin to a Resident with Penicillin allergy because it was not a pure penicillin medication as it only had 50 % of penicillin and other additives. He said that he uses it in the hospitals, and it was a good antibiotic. Review of the facility's Administering Medications policy, revised December 2012, revealed . information must be checked /verified for each resident prior to administering medications: a. Allergies to medications . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676139 If continuation sheet Page 3 of 6 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 676139 B. Wing (X3) DATE SURVEY COMPLETED A. Building 01/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Oaks Nursing & Rehabilitation 3033 W Green Oaks Blvd Arlington, TX 76016 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of the facility's Medication Regimen Review policy, revised April 2007, revealed . the primary purpose is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medication appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible . The Administrator was informed on 01/20/24 at 12:00 PM that an Immediate Jeopardy (IJ) existed on 01/20/24, and a copy of the IJ Template was provided on 01/20/24 at 12:01 pm. The following Plan of Removal was accepted on 01/20/24 at 04:48 PM: [Impact Statement: On 1/20/24 an abbreviated survey re-entrance was initiated at [Facility Name] [Facility Address]. On 1/20/24 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to administering antibiotics that contained penicillin, in which resident was allergic to. How were other residents at risk affected by this deficient practice identified? The facility completed an audit of all Antibiotic medications ordered in the last 30 days to ensure the residents did not have a known allergy and received the treatment and care they required to ensure residents did not experience allergic interactions. Residents with new medication for Antibiotics orders have the potential to be affected by this deficient practice, 7 of the residents who were identified as being on antibiotics were not affected. What corrective actions have been implemented for the identified resident? The resident with deficient practice no longer resides in the building as 1/18/24. a. All Nurses to receive in-service on identifying known allergies when new orders are received for Antibiotics, medication administration related to checking for allergies prior to administering Antibiotic medications and monitoring for allergic reactions. b. All Med Aides received in-service on medication administration to include identification of known allergies prior to antibiotic medication administration and notifying charge nurse if identified. What corrective actions were taken? 1. The following actions were initiated immediately on 1/19/2024. c. On 1/19/2024 an audit was completed by DON (Director of Nursing) and/or designee on all residents with new medication orders for Antibiotics in the last 30 days to ensure the residents did not have a known allergy. 7 residents currently on Antibiotics were identified and noted not to be affected by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676139 If continuation sheet Page 4 of 6 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 676139 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Oaks Nursing & Rehabilitation 3033 W Green Oaks Blvd Arlington, TX 76016 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 0760 deficient practice. Level of Harm - Immediate jeopardy to resident health or safety d. Residents Affected - Some Director of Nursing was educated on 1/20/2024 by Clinical Services Director on identifying known allergies when new orders are received for Antibiotics, medication administration related to checking for allergies prior to administering Antibiotic medications and monitoring for allergic reactions. e. Initiated in-services on 1/20/24 with licensed nurses by Director of Nursing /Designee on identifying known allergies when new orders are received for Antibiotics, medication administration related to checking for allergies prior to administering Antibiotic medications and monitoring for allergic reactions. f. Initiated in-service on 1/20/24 with Licensed Medication Aides on medication administration to include identification of known allergies prior to antibiotic medication administration and notifying charge nurse if identified. g. Newly hired licensed nurses and medication aides will be in serviced during the on boarding process on identification of known allergies when obtaining antibiotic medication orders and verifying allergies prior to administering antibiotic medications, monitoring for allergic reactions. 2. How will the system be monitored to ensure compliance? A. DON/Designee Will review the ordering listing report for newly received orders and compare to resident allergies daily for 4 wks. If discrepancies identified will notify physician immediately. Staff will receive further training and disciplinary action up to termination. When discrepancies with medications are identified, The CMA will notify the charge nurse, the charge nurse will notify the physician. When obtaining an [ATB] order and a resident has a listed allergy the nurse will notify the physician. The pharmacy is integrated with [Electronic Record] and has the resident allergies. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 1/20/24 with the Medical Director. The Medical Director has reviewed and agrees with this plan of removal.] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676139 If continuation sheet Page 5 of 6 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 676139 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Oaks Nursing & Rehabilitation 3033 W Green Oaks Blvd Arlington, TX 76016 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 0760 Monitoring of the POR included the following: Level of Harm - Immediate jeopardy to resident health or safety Interviews were conducted with facility staff across multiple shifts on 01/20/24 from 12:15 p.m. to 6:50 p.m. Staff interviewed were RN C, RN G, LVN D, LVN E, LVN F, LVN H, LVN I, LVN J, and MA K. Residents Affected - Some Interviews with the staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on identifying known allergies when new orders are received for Antibiotics, medication administration related to checking for allergies prior to administering, antibiotic medications and monitoring for allergic reactions. They were all aware of the QA work sheet to fill and turn to the DON for any new medications. They stated that each time a nurse received a new order for antibiotics, the nurse must always check for allergies of medication type. They said that a resident will be monitored for 3 days after receiving an antibiotic. Record review of in-service training logs and competency tests, dated 01/19/24 and 01/20/24, revealed education included new orders for antibiotics, allergy orders on admission, incidents & accidents, fall precautions, how to prevent falls, abuse, neglect, exploration, allergic reactions signs & symptoms, notification to the DON after QA form is filled. The Administrator was informed the Immediate Jeopardy was removed 01/20/24 at 5:00 p.m. The facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of corrective systems that were put into place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676139 If continuation sheet Page 6 of 6