Health inspection·August 19, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 1 of 14 residents reviewed for ADL care (Residents #1). Facility staff failed to provide personal hygiene care to Resident #1 on 10/31/24. This failure could place residents at risk of not receiving necessary care and assistance when needed.Findings include:Record review of Resident #1's undated face sheet revealed a 73year-old female, originally admitted [DATE] and readmitted [DATE], with diagnoses including cerebral infarction (brain tissue death caused by a blocked artery supplying blood to the brain, leading to a lack of oxygen), spinal stenosis (space inside backbone is too small), respiratory failure (not enough oxygen in the body), hypothyroidism (thyroid gland does not make enough hormone).Record review of Resident #1's MDS Quarterly assessment, dated 05/28/25, revealed her cognitive level (BIMS) score was 0 (severely impaired). Section B: Hearing, Speech, and Vision revealed resident#1 is rarely/never understood and rarely/never understands others. Section C: Cognitive Patterns revealed Resident#1 unable to participate in the assessment because of rarely/never understood. Section GG: Functional Abilities revealed resident totally dependent on staff for all for all areas of ADL. Resident#1 was impaired of both sides of the lower extremity and uses a wheelchair. Record review of Resident # 1's care plan, dated 05/21/25, revealed ADLs Functional Status/Rehabilitation Potential: Resident #1 was dependent with all ADLs. Bed mobility with two to three persons assist, for transfers required total assistance with 3 staff, dressing was total assistance with 2 staff, and personal hygiene required 2 staff assist.Problem: The resident has an ADL self-care performance deficit r/t history of cerebral infarction (blood flow to the brain is interrupted, leading to tissue damage), confusion, impaired mobility, wheelchair bound, Adult Failure to Thrive (unexplained weight loss, malnutrition, decreased physical activity, and functional decline). 8/30/2024: Family requesting only bed baths. Date Initiated: 10/7/2022. Revision on 8/30/2024.Goal: The resident will maintain current level of function through the review date. Date initiated: 8/30/2024. Revision on: 8/30/2024. Target date: 8/16/2025.Interventions: Res with low air mattress with bolsters. Date initiated: 1/3/2024. BATHING/SHOWERING: The resident requires total assist by 2 staff with (bathing/showering) 3x a week and as necessary. Date Initiated: 10/07/2022. Revision on: 06/02/2025., BED MOBILITY: The resident requires air mattress and is Extensive assist by 2 staff to turn and reposition in bed and as necessary. Date Initiated: 10/07/2022. Revision on: 08/16/2024. BED MOBILITY: The resident uses enabler for positioning to maximize independence with turning and repositioning in bed. Date Initiated: 05/08/2023. Revision on: 05/08/2023. DRESSING: The resident requires Extensive assist by 2 staff to dress. Date Initiated: 10/07/2022. Revision on: 06/02/2025. NPO diet, NPO texture, NPO (Nothing by Mouth) consistency Date Initiated: 10/07/2022. Revision on: 4/23/2025. PERSONAL HYGIENE: The resident requires Extensive assist by 1 staff with personal hygiene and oral care.Date Initiated: 10/07/2022. Problem: The resident Residents Affected - Few Page 1 of 4 455876 455876 08/19/2025 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few has limited physical mobility r/t Stroke, Weakness. Date Initiated: 01/11/2024. Revision on: 01/11/2024.Goal: The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date. Date Initiated: 01/11/2024. Target Date: 08/16/2025Intervention: LOCOMOTION: The resident is totally dependent on 1 staff for locomotion usingwheelchair. Date Initiated: 01/11/2024. Revision on: 01/11/2024. Monitor/document/report PRN any s/sx of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury. Date Initiated: 01/11/2024.Provide gentle range of motion as tolerated with daily care. Date Initiated: 01/11/2024. Provide supportive care, assistance with mobility as needed. Document assistance as needed. Date Initiated: 01/11/2024. Problem: The resident has a communication problem related to Aphasia, non-verbal, unable to voice needs, able to nod head yes/no to simple yes/no questions at times. Date Initiated: 12/07/2023. Revision on: 12/07/2023Goal: The residents needs will be met on a daily basis through the review date. Date Initiated: 12/07/2023. Revision on: 12/07/2023. Target Date: 08/16/2025.Interventions: Anticipate and meet needs. Date Initiated: 12/07/2023. COMMUNICATION: Allow adequate time to respond, Repeat as necessary, Do not rush, Request clarification from the resident to ensure understanding, Face whenspeaking, make eye contact, Turn off TV/radio to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed. Date Initiated: 12/07/2023. Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, Avoid isolation. Date Initiated: 12/07/2023. Monitor/document for physical/ nonverbal indicators of discomfort or distress, and follow-up as needed. Date Initiated: 12/07/2023. Refer to speech therapy for evaluation and treatment as ordered.Date Initiated: 12/07/2023. Speak on an adult level, speaking clearly and slower than normal. Date Initiated: 12/07/2023. Problem: Family made allegations of potential neglect. Date Initiated: 01/06/2025. Revision on: 07/25/2025 Goal: Resident will be provided timely and appropriate care based on needs. Date Initiated: 01/06/2025. Target Date: 08/16/2025.Interventions: 10/31/24: Allegation that CNA did not provide care. Immediately received a full, head to toe, assessment thereafter by a licensed nurse and personal hygiene was provided. There were no new skin issues identified during her physical assessment. Date Initiated: 07/29/2025. 5/5/25: Had a care plan with Hospice, family, and facility to determine best plan of care to address allegation of neglect. Family agreed for res to be up by 10:30am daily with agreement to put back to bed at or before 3PM and provide care by 2 staff at all times. Date Initiated: 01/06/2025. Revision on: 07/25/2025. CNA to notified nurse for any G-tube (small tube in abdomen to deliver nutrition and medication) disconnection needs with ADL care. Date Initiated: 07/25/2025. Record review of the facility Investigation Report (#542162) dated 11/7/2024, revealed the CNA did not provide incontinent care to resident on 10/31/24 during her shift (6a-3p). The findings from the facility's investigation were Unsupported because the resident was not harmed, did not have skin break down, and was cared for by the nurse on duty. In a telephone interview on 8/12/25 at 12:28pm, the FM stated Resident #1 was not changed from 5am-5pm according to the Electronic Monitoring camera footage in her room. The FM stated she reviewed the camera footage for 10/31/24, at 5:00 am until 10/31/24 at 5:18 pm. She stated Resident #1's undergarments and night gown were never changed, she was never taken out of bed, nor was her face washed. The FM stated she called the facility and spoke with the nurse (RN) on duty to find out why these services had not been done by CNA A. The FM stated the RN could not give her a response as to the reason incontinent care was not provided to Resident #1. The FM stated at this time, she requested to speak with the DON or ADON and was informed they were not available to speak with her. FM stated according to the camera, there were two people that 455876 Page 2 of 4 455876 08/19/2025 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few entered the room. The FM stated one of the two people who entered Resident #1's room was the Nurse (RN) who administered meds, and the second person was a male that came to take Resident #1's blood and afterwards he walked out. The FM stated there were no nurses or aides that entered Resident #1's room to check on her throughout the day. The FM stated the camera footage from this date as well that was recorded; however, the DON stated she would investigate. The FM stated there are still issues with CNAs not going in to check on Resident #1 and she sent multiple emails to the facility, particularly the DON and Administrator, and the Ombudsman. The FM stated just last week (unable to recall the day or dated) Resident #1 was changed about 4:00pm in the evening and was not changed until 4:00am the next morning. The FM stated 12 hours had gone by. FM stated she has had to call Resident #1's CNAs to put her in proper position. She stated on one occasion they left her in an uncomfortable position with the covers almost covering her head. FM said per care planning meeting, Resident #1 was to be out of bed at 10:30a-11:00a daily for 4 hours. She stated this was discussed in the care plan meetings with facility.During an observation on 08/15/25 at 8:34am, Resident #1 was observed in the wheelchair facing the outside corridor window located in the visitor's area. Resident#1's eyes were closed and appeared to be sleeping. Her physical appearance revealed face washed and clean, dressed in clean clothes with a clean blanket over her lap, and free of marks and bruises. In a telephone interview on 8/15/25 at 4:45pm, CNA A stated she worked a double shift that day (10/31/2024). She stated she assumed she was to work in a certain hall and didn't realize she was working on the wrong hall. She agreed with the provider investigation. She stated she started working at the facility the end of September 2024 and was confused by the schedule. She stated it was an honest mistake and did not provide care 10/31/2024 during her 6:00am-2:00pm shift, which she was responsible for Resident#1's care. CNA A was terminated from the facility for unrelated reasons. In an interview on 8/17/25 at 10:30am, the OMB stated there are some issues with incontinent care not happening in nine hours. The OMB stated this was going on for about a year. The OMB stated the FM is being blown off (concerns dismissed) by facility. The OMB stated the OMB A had been more involved with the facility. The OMB stated she asked the facility to allow her to do resident rights training with facility staff, but the facility declined indicating they will do their own training. She stated the ADON typically responds to the FM and the OMB A's concerns. She believed there was a culture with aides doing whatever they want to without consequences.In a telephone interview on 8/17/25 at 11:12am, OMB Asst said during the care plan meeting a year ago the resident was supposed to be turned every two hours. These issues have been going on for over a year. She stated there has been 2 care plan meetings on Resident #1. The facility has stated they are doing training. The FM has spoken with Admin, DON, and corporate through the corporate hotline. OMB Asst stated the only response the facility gives to concerns are, staff are receiving training. OMB Asst stated she cannot say there was a staffing issue its just there is a staffing accountability. She stated she has not had other complaints from other residents at this time. OMB Asst stated there was not enough supervision from charge nurse on floor and believes there may be a leadership issue where the CNAs don't respect that authority; however, she can't say for sure. OMB Asst stated in the past she has received photos from FM showing Resident#1's neck extended, or wedges not put appropriately in place while she is in the bed. She stated FM has had to call the facility and have CNA's go into Resident#1's room and reposition her. OMB Asst stated Resident #1 is out of bed daily since the care plan meeting. She stated she has not observed Resident#1 soaked in urine. OMB Asst stated she arrives at the facility around 10:30am and observe Resident#1 completely and appropriately dressed.In a telephone interview on 8/19/25 at 12:10 pm with DON - She stated she was not employed at the facility at this time. However, the negative outcome for a resident 455876 Page 3 of 4 455876 08/19/2025 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not being changed or given incontinent care can cause skin breakdown. She stated between CNA's and Nurses a resident should be seen every two hours and repositioned. She stated charge nurses should ensure this by checking the POC on the karmex (CNA documentation) at that beginning of resident shift, middle and end of CNA's shift. [NAME] shift nurse should check the POC between 12:00pm -1:00pm. In an Interview with ADON on 8/19/25 at 1:45pm-She stated she is aware of the issues with Resident #1 not receiving in continent care on the 6am-2:00pm shift. She states the nurse completed a head-to-toe assessment after hearing about this. She stated the facility completed a report, investigation and training was provided to staff regarding this issue. She stated the negative outcome for a resident not receiving incontinent care can cause skin breakdown. In a telephone interview on 8/25/25 at10:43am CNA B, stated she has been working with Resident #1 since January 2025. CNA B stated she has never observed Resident #1 in her chair for hours. She stated she has experience in the past few months that Resident #1 tends to have a bowel movement before getting showers. She stated she has observed Resident #1 with a bowel movement and pamper soiled; however, she is unable to say how long her pamper has been soiled, which is why she never brought this concern to the attention of the facility. In a telephone interview on 8/25/25 at12:37pm CNA C stated she has been working with Resident #1 since March 2025. CNA C stated she has never observed Resident #1 in her chair for hours. However, she has noticed her pamper soiled when she and her partner arrives to give Resident #1 her shower. She stated she has not said anything to the facility because they are giving her a shower anyway, and she cannot say how long Resident #1's pamper has been soiled. Record review of the facility's Activities of Daily Living (ADL) Policy dated based 5/26/23 revealed, the facility will, based on the resident's comprehensive assessment and consistent with the residents needs and choices, ensure resident's abilities in ADL's do not deteriorate unless deterioration reaction is unavoidable. Care and services will be provided for the following activities of daily living:1. Bathing, dressing, grooming and oral care;2. Transfer and ambulation;3. Toileting;4. Eating to include meals and snacks; and5. Using speech, language, or other functional communication systems. 455876 Page 4 of 4