Health inspection·April 30, 2025

F 0641 -Having a hearing deficit. Date Initiated: 02/14/2024 Revision on: 06/21/2024. Level of Harm - Minimal harm or potential for actual harm Goal: maintain the highest level of communication for this resident through the next review date Initiated: 02/14/2024 Revision on: 06/21/2024 Residents Affected - Some Target Date: 07/21/2025 Intervention: Do not cut off or interject when [Resident #11] was speaking. o If resident has a device to assist them with hearing, encourage them to use it. o Maintain eye contact while speaking to resident. Monitor hearing ability and report any changes to the physician. -Having oral/dental health problems caries Date Initiated: 02/14/2024, Revision on: 06/21/2024. Goal: Resident #11 will comply with mouth care at least daily through review date. Initiated: 06/21/2024 Revision on: 06/21/2024 Target Date: 07/21/2025 Intervention-: Administer medications as ordered. Monitor/document for side effects and effectiveness. o Coordinate arrangements for dental care, transportation as needed/as ordered. o Monitor/document/report to MD PRN s/sx of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, lesions. o OT screen for adaptive equipment PRN Date Initiated: 06/21/2024. o Provide mouth care as per ADL personal hygiene Observation on 04/28/25 at 10:00AM, revealed Resident #11 was sitting on her wheelchair alert and oriented. In an attempted interview, she said speak louder I cannot hear. Her roommate said Resident #11 was hard of hearing and they need to speak loud and very close to her ear. Resident #35 Record review of Resident #35's admission Record revealed she was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure), dysphagia (difficulty or discomfort in swallowing), and chronic atrial fibrillation (an abnormal heartbeat where the two upper chambers of the heartbeat irregularly and quickly). Record review of Resident #35's Significant Change in Status MDS assessment dated [DATE] revealed in her BIMS score was 11 out of 15 indicating she had moderate cognitive impairment, and she was coded in Section N Medications as taking Anticoagulant medication. The column for Antiplatelet medication was blank. Section N was signed as completed by MDS Coordinator A on 4/25/25 and verified as completed by DON on 4/25/25. Record review of Resident #35's Q MDS dated [DATE] on 4/29/25 at 4:10pm revealed in Section N Medication Resident #35 was coded as follows: I. Antiplatelet . Is Taking .Section X. Correction revealed: Reasons for Modification .A .Transcription Error .B. Data Entry Error .Z. Other error requiring (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676307 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 676307 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Village Healthcare 204 Oak Drive South Lake Jackson, TX 77566 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some modification. Section Z Assessment Administration Signature of Persons Completing the Assessment of Entry/Death Reporting, was signed by MDS Coordinator A with Date Section Completed, 4/29/25. Record review of Resident #35's physician order summary report dated Active Orders As Of 04/01/2025 revealed Resident #35 had no order for any anticoagulant (medication that prevents or slows down the formation of blood clots). Resident #35 had the following order: Clopidogrel Oral Tablet 75 mg .Give 75 mg by mouth one time a day .Verbal Order .Order Status Active .01/30/2025 .Order Date .01/30/2025 . There was no end date. Resident #38 Record review of Resident #38's face sheet dated 04/29/25 revealed an 81- year -old female admitted to the facility on 0414/23. Her diagnoses included Essential hypertension (primary) diverticulitis of both small and large intestine without perforation or abscess (an inflammation or infection of the pouches formed in the colon), kidney failure, muscle weakness (generalized), chronic obstructive pulmonary disease with heart disease of native, liver disease. dementia, anxiety disorder, psychotic disturbance, and cognitive communication deficit. Record review of Resident #38's annual MDS assessment dated [DATE] revealed her BIMS score was 15 out of 15 indicated her cognition was intact. For hearing, she was coded as Adequate - no difficulty in normal conversation, social interaction, and listening to TV. Record review of Resident #38's care plan dated 12/26/23 with a revision date of 01/25/24 revealed Resident #38 had communication problem r/t . Goal- will maintain current level of communication function by (how, with what assistance. making sounds, using appropriate gestures, responding to yes/no questions, appropriately, using communication board, writing messages) through the review date Initiated: 12/26/2023 Revision on: 01/25/2024 Target Date: 07/28/2025. Intervention: Ensure availability and functioning of adaptive communication equipment message board, hearing aids, telephone amplifier, computer, pocket talker etc. Date Initiated: 12/26/2023, Revision on: 01/25/2024. CNA o Refer to Audiology for hearing consult as ordered. Observation and interview on 04/28/25 at 11:00AM, Resident #38 was in her room on her recliner. She was alert and oriented . In an attempted interview, she said, Speak louder. I cannot hear. Resident #38 said she had hearing aids and pointed to her hearing aids on her nightstand . She said she did not use them. During an interview with CNA J on 04/28/25 at 10:30AM, she said [Residents #11 and #38] are hard of hearing and you need to speak louder and close to Resident #11's her ear. She said Resident #38 did not have hearing aid. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676307 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 676307 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Village Healthcare 204 Oak Drive South Lake Jackson, TX 77566 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview with LVN E on 04/28/05 at 1:00PM, she said both Residents #11 and # 38 were hard of hearing. She said Resident # 38 have hearing aid on her nightstand, but she chose not to use her them. She said Resident #11 does not have hearing aid. Record review and interview with the MDS Coordinator A on 4/29/25 at 2:42pm revealed Resident #35 was taking Plavix (Brand Name)/Clopidogrel. When asked if Plavix was an anticoagulant or an antiplatelet medication they replied, Oh. It's an anti-platelet. When asked what was coded on Resident #35's Q MDS dated [DATE] the MDS Coordinator said they coded for anticoagulant medication and again on the significant change MDS dated [DATE]. The MDS Coordinator A said it was an error on her part in coding the MDS' and they were incorrect. The MDS Coordinator A said they would correct the MDS assessments. The MDS Coordinator A said they worked as the MDS Coordinator A at the facility since 2023 and the MDS Consultant was the oversight person over the MDS Department. MDS Coordinator A said they had been trained by the MDS Consultant and the Regional MDS and used the RAI manual as the policy and procedure for MDS completion and accuracy. Interview with the DON on 4/29/25 at 4:33pm, revealed they signed the facility MDS' for completion and did their best to ensure accuracy. When asked if they knew if Resident #35 was taking an anticoagulant, the DON looked at her mobile device which had access to Resident #35's EMR and replied, He's taking Plavix. RDO and RNC were present, and both stated quietly, that Plavix was antiplatelet. The DON said, yes that was correct, that Plavix was an antiplatelet and not an anticoagulant. The DON was not 100 percent sure who trained MDS Coordinator A, but said both the MDS Consultant and the Regional MDS were oversight over the faility's MDS department. Telephone interview with the MDS Consultant on 4/30/25 at 3:47 pm revealed they did not train MDS Coordinator A, but was over the MDS department. The MDS Consultant said MDS Coordinator A would have been trained by the Regional MDS. The MDS Consultant said the MDS Coordinator A had continuing education that included webinars, meetings, and on-line trainings. When asked if the MDS Coordinator A had been trained on how to code an anticoagulant versus an antiplatelet medication, the MDS Consultant said Clopidogrel/Plavix was not an anticoagulant medication and she had discussed this and reinforced the information with MDS Coordinator A when the MDS Coordinator A called the MDS Consultant on 4/29/25. Attempted a telephone interview with Regional MDS on 4/30/35 at 4:04 pm. There was no answer and was unable to interview prior to facility exit. Record review of CMS's RAI Version 3.0 Manual dated October 2024, read in part . the assessment accurately reflects the resident's status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676307 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 676307 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Village Healthcare 204 Oak Drive South Lake Jackson, TX 77566 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to develop and implement comprehensive care plans with measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs identified in the comprehensive assessment for 2 of 20 residents reviewed for care plan accuracy. --The facility failed to develop care plans for cognition, ADL assistance, Dialysis, anticoagulane and insulin for Resident # 12. --the facility failed to develop a care plan for ADL assistance for Resident # 100. These failures placed residents at risk of receiving inadequate care due to incomplete care plans. Findings include: Record review of Resident # 12's face sheet revealed admission date 3/10/25 with diagnoses including end stage renal disease (loss of kidney function), Diabetes (body's inability to produce or use insulin), schizoaffective disorder (a combination of mood disorders), hypertension (high blood pressure), heart failure (inability of the heart to pump efficiently), peripheral vascular disease (reduced blood flow to limbs). Record review of Resident # 12's quarterly MDS dated [DATE] revealed BIMS of 09, indicating moderately impaired cognitive skills, assistance for ADL's including supervision for eating and total assistance for toileting, bathing, dressing and hygiene, Dialysis (while a resident), anticoagulant (taking while a resident), insulin (taking while a resident). Record review of Resident # 12's undated care plan revealed no care plan with appropriate interventions developed for conditions including cognition (moderately impaired cognitive skills), ADL assistance (supervision/total) , Dialysis while a resident, insulin and anticoagulant use while a resident. Observation of Resident # 12 on 4/28/25 revealed she was in bed, alert, clean and groomed. Interview at that time revealed she said she has Dialysis tomorrow and it was going well. She said she needed help to dress and get up out of bed and was waiting for someone to come help her soon, and the nurse gave her insulin shots. Record review of Resident # 100's face sheet revealed admission date 3/26/25 with diagnoses including cerebral infarction (stroke), dysphagia (difficulty swallowing food or liquids), hypertension (high blood pressure), coronary atherosclerosis (damage in the heart's major blood vessels), depression (low mood), fibromyalgia (widespread pain throughout the body), aphasia (inability to speak). Record review of Resident # 100's Significant Change MDS dated revealed no speech, rarely or never understood by others, understands others, inattention, moderately impaired cognition, feeding tube, substantial assistance required for bathing, dressing, hygiene, and total assistance for toileting. Record review of Resident # 100's undated care plan revealed no care plan developed with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676307 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 676307 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Village Healthcare 204 Oak Drive South Lake Jackson, TX 77566 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 0656 appropriate interventions for ADL assistance (substantial/total). Level of Harm - Minimal harm or potential for actual harm Observation of resident # 100 on 4/28/25 at 9:40am revealed she was in bed, alert, dressed, with feeding tube infusing formula. Resident # 100 motioned to her throat to indicate she could not speak, but pointed to communication items on her bedside table with pictures and words printed on paper she could use to let staff know her needs. Residents Affected - Few Interview with MDS nurse on 4/30/25 at 2:40 pm revealed she said she was working on the care plans currently. She said she completes the care plans with input from nurses and morning meetings, and after the care plans were complete, she will ask the nurses to check their areas for accuracy. She said the risk of having incomplete care plans would be staff would not know what to do for the residents because the care plan directed care. Interview with the DON on 4/30/25 revealed she was aware some of the care plans were not complete, and they will be having some care plan training in the facility. She said the risk of having incomplete care plans would affect the residents because they wouldn't receive the care they needed. Record review of facility undated Care Plan policy revealed, in part, every resident will have a specialized care plan for all ADL needs .every resident will have all needs/specialized services care planned such as PASRR, Hospice, and reviewed routinely .care plans will be revised as needed weekly and/or between routine reviews. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676307 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 676307 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Village Healthcare 204 Oak Drive South Lake Jackson, TX 77566 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 Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The Dietary Manager failed to wear hair net in the kitchen. 2. The facility failed to keep the cooking area clean and free of grease build up on the stove. 3. The facility failed to ensure the tabletop can opener blade and base were free of grime and debris. 4. The facility failed to ensure kitchen cooking equipment was cleaned. 5. The facility failed to label, and date left over food items in walk in refrigerator\freezer. 6. The facility failed to ensure that expired food products were not stored in the welkin- cooler and in the dry goods storage area. These failures could place residents at risk for food contamination and foodborne illness. Findings included: Observation and interview on 04/28/25 at 8:45AM revealed the following: -The DM was observed in the kitchen on 04/28/25 at 8:45AM without a hairnet on. She looked at herself and said she forgot to wear her hair net. There was grease and debris on the stove and around the cooking area. One conventional oven had a tray with dark brown substances on the tray inside the conventional oven. The DM looked at the tray and said it needed to be cleaned. She said the tray was in the oven to collect the grease. -The tabletop can opener had grime, debris, and a dark looking substances between the cutting blades. The DM took it off and said it need to be cleaned . -The walk cooler\freezer had half 64 oz apple thickener with a manufacturer use-by of 04/16/25. Left over chicken parmesan in a plastic container had no labeled and was dated 04/24/25. This was identified by the DM. She said all left over food products in the [NAME] cooler \freezer should be labeled with food product for identification, the date opened and a use by date. She said left over food was discarded after 3 days if not use. -The dry goods storage had three 46 oz bottle of sweetened tea dated use-by 04/09/25, three 46 oz bottles of thickened water dated use-by 04/09/25. The DM took them out and said she would discard them. During an interview at 9:00 AM on 04/28/25, the DM said serving expired food may cause food borne (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676307 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 676307 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Village Healthcare 204 Oak Drive South Lake Jackson, TX 77566 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 Residents Affected - Some illness. She said she was new to the position, and was still learning and cleaning up. She said she was about 3 weeks in as the Dietary Manager. The DM said it was the responsibility of all staff to keep the kitchen clean. In an interview with the Administrator on 04/29/25 at 3:00PM, she said the DM was new and had been trying to clean up. She said the DM was still in training and the staff who was supposed to be training her was out sick. She said all food items out of original the container should be labeled and dated. She said all identified expired food products were trashed. Record review of facility's police dated 2001 revised April 2006 revealed 1. Clean storage areas: Food Services, or other designated staff, will maintain clean food storage areas at all times. 2. Storage of Prepared Food: Prepared food stored in the refrigerator until service shall be dated with an expiration date. Such food will be tightly sealed with plastic wrap, foil, or a lid . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676307 If continuation sheet Page 8 of 8