Health inspection·September 4, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 12 (Resident #1) reviewed for abuse. - The facility failed to report to the State Survey Agency a suspicious injury of unknown origin suffered when Resident #1 was found on the floor of his room on 07/29/25 with a deep 10 cm (3.9 inch) laceration (a tear or cut in skin and other tissues that causes bleeding) to the top of his head that required hospitalization and 15 staples. This failure could result in the state agency being unaware of alleged incidents of injury of unknown origin. Findings included: Record review of the HHSC TULIP (system to which providers report accidents and incidents) on 09/04/25 revealed, facility staff did not submit a submit a report of Resident #1's suspicious injury of unknown origin (deep 10 cm) laceration to the top of his head that required hospitalization and 15 staples.Record review of Resident #1's Face Sheet dated 08/26/25 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: heart failure, dementia, depression, high cholesterol, acid reflux, arthritis, abnormality in gait (how a person walks) and mobility and repeated falls.Record review of Resident #1's Quarterly MDS dated [DATE] revealed, minimal difficulty hearing, clear speech, moderately impaired cognition as indicated by a BIMS score of 10 out of 15, no upper or lower extremity functional limitation in range of motion and the use of a walker. Resident #1 required setup or clean-up assistance with putting on/taking off footwear and was independent for: roll left to right; moving from sitting to lying; moving from lying to sitting; sit to stand; chair/bed-to-chair transfer; toilet transfer; and the ability to walk 150 feet in a corridor or similar space. Resident #1 had 1 fall since the prior assessment that resulted in minor injuries.Record review of Resident #1's undated Care Plan revealed, Focus: ADL self-care performance deficit r/t Impaired balance, impulse control, and desired Independence, Resident #1 does not like to ask for assistance; Intervention: Resident uses rollator for ambulation independently and does not like to request assistance when ambulating or transfers, Res uses rollator for ambulation independently and does not like to request assistance when ambulating or transfers, The resident requires supervision by (1) staff to move between surfaces. Focus: he resident is High risk for falls r/t Gait/balance problems; Goal: The resident will not sustain serious injury through the review date; Intervention: Ensure that The resident is wearing appropriate footwear when ambulating or mobilizing in w/c. Focus: The resident is High risk for falls r/t Gait/balance problems, 5/29/2023: Page 1 of 5 455876 455876 09/04/2025 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Fall with laceration to Left side of head, transferred to hospital returned with seven sutures to area, 1/07/25 while trying to charge hearing aids - no injury, 1/15/25 fall- no injury noted, Goal: The resident will resume usual activities without further incident; Interventions: 1/15/25 fall educated resident to call for assistance, therapy to screen, 1/7/25- attempted to relocate hearing aids near resident refused and wants items to stay where they are. Nursing staff are to anticipate needs with hearing aid care, 11/12/24: Fall with minor injury (abrasion to right knee)- educate resident on using call light for assistance.Record review of Resident #1's Change of Condition Communication Form dated 07/29/25 at 11:18 AM signed by LVN A revealed, on 07/29/25 the resident had a suspected fall with head laceration & uncontrolled bleeding.Record review of Resident #1's Fall Risk Evaluation dated 07/29/25 at 11:42 AM revealed, low fall risk as indicated by a score of 03.Record review of Resident #1's Provider Progress Note dated 07/29/25 revealed, fall with head laceration. He is being seen today for management of multiple medical issues including fall with head laceration. Patient is found lying on the floor in his room with a head laceration to his scalp that is bleeding. Staff applied pressure for the bleeding and another staff called 911. Patient was lying in his back when assessed and was talking and answering questions. Staff advised not to pick up the patient from the ground as EMS needs to assess him and apply neck brace due to the fall. A dressing was applied to the scalp laceration to keep the area clean as the bleeding had improved. Patient being sent to the hospital for evaluation and treatment and staples will be needed for the head laceration. Fall was unwitnessed as stated by staff. He is not on any blood thinners. He does not think he lost consciousness. Review of SystemsNeurological: no loss of consciousness; skin: laceration to the scalp. Physical Exam- General: elderly male lying on the floor; Skin: Head laceration to scalp; Neurological- alert, oriented, denies headaches. Diagnosis and Assessment: Laceration of scalp without foreign body, initial encounter. Send to the ER for evaluation and treatment due to head laceration from fall.Record review of Resident #1's Progress Notes revealed,07/29/25 at 11:13 AM signed by LVN A: Resident left via 911- 07/29/25 at 11:15 AM signed by LVN A: Heard a loud thump at resident's room and observed resident on the floor, on his back. Resident has 1 shoe on and 1 shoe off. Noted resident with head laceration and uncontrolled bleeding. Pressure applied immediately on his head. NP in the facility notified. 911 was called and 2 personnel arrived. RP & ADON made aware. Report given to ER charge nurse.Record review of pictures of Resident #1's injuries revealed,- 07/29/25 at 03:09 PM- a deep sickle shaped laceration to the top of the resident's head. The laceration started at the crown of the head that curved toward the front of his right temple. The entire laceration was behind the resident's hairline and limited to the top of the head.-08/02/25 at 12:39 PM- there were injuries or bruising to the residents face, neck, back of head, or torso. The only other indication of injury outside of the laceration were the 2 circular bruises on the right forearm. Record review of the facility Incident Investigation dated 07/29/25 revealed, LVN A started an incident report for an un-witnessed fall for Resident #1. The report included witness statements from LVN A. The facility constructed a room diagram during an interview with LVN A and CNA A validated the location of Resident #1, the location of the roommates fall mat and the fact that Resident #1's roommate was in bed. Nursing Description: Heard a loud thump at resident's room and observed resident on the floor, on his back. Resident has 1 shoe on and 1 shoe off. Noted resident with head laceration and uncontrolled bleeding. Pressure applied immediately on his head. Resident Description: Resident Unable to give Description. Injury type: Laceration; location- top of the scalp. - LVN A's statement read: Nurse stated she was on the hall and heard a thump. As she approached she heard someone yell help. Upon entering the room, the resident was observed laying diagonally on his back with his head approximately a foot away from the 455876 Page 2 of 5 455876 09/04/2025 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few roommates foot of bed and he was bleeding from a laceration noted to his head. Resident had one shoe on and one off. His head was on the floor and his shoulder was halfway laying on the roommates fall mat. During this interview we constructed a drawing to map out the location to clearly understand exactly where he was. Pressure was applied to the laceration while ADON called 911. Resident was getting upset because he wanted to get up, but he was able to be redirected & remained on the floor until EMS arrived to transport to the ER for further evaluation. Resident was unable to explain what happened and he became agitated when asked questions. He could have been walking or just lost balance and fell back, I don't know how he fell. Resident was present in bed and he is unable to get up without assistance. There were no other residents in the room.- CNA A's statement read I was coming from a room and heard someone call help. I saw the nurse approaching from the other end of the hall. We met up together and entered resident's room together to check on resident. He was on the floor and was bleeding from his head. He started saying Help me up and we had to tell him that he was bleeding and we needed him to stay there until the ambulance arrived. The nurse held pressure to his head and I assisted with keeping him calm & still until help arrived. He never said what he was doing or how he fell. He had slept in this morning and refused breakfast. That's not unusual, we typically reheat or offer something when he's ready to get up. The ADON came to the room and I left to check on other patients because she said she would stay with the nurse. As I was leaving the room EMS were arriving. I showed her the room diagram that was constructed during Nurse interview & she validated that it was correct for the positioning of the resident, the location of the roommates fall mat, and that the roommate was in his bed. However, she could not recall the shoes, bedside table placement, or walker location. She said she was just focused on the resident himself and keeping him calm.Notes: 07/30/25- IDT Team reviewed & discussed resident fall and hospitalization. Care plan updated. Resident was up ambulating in room without assistance; walker was by his side. ADON searched area for blood spatter or item with blood on them to identify what resident might have struck his head on; there was no blood found anywhere near him. The only plausible explanation from the shape of the laceration and proximity of the resident's fall; was that he hit his head on the corner of the resident's roommate's bed. Resident has history of agitation and refusal of care along with verbal aggression with staff; staff will utilize behavioral interventions to attempt to assist resident when he'll allow & back off & reapproach when he is upset. Record review of Resident #1's Hospital Records with admission date of 07/29/25 revealed,07/29/25- CT ( medical imaging test that creates detailed images of the body) head without contrast; findings: no evidence of brain bleed, mass, or acute infarct (sudden blockage of blood flow to an organ or tissue leading to cell death); impression: No CT evidence of acute brain abnormality; small right frontal scalp laceration.07/29/25- Chief complaint: Fall; resident arrived to the hospital at 11:46 AM with a 10 cm laceration to the top of his scalp with no active bleeding and blood pressure of 191/79. Patient with a 10 cm scalp laceration repaired with 15 staples in the ER. Neosporin applied compressive wrap ordered. In an interview on 08/26/25 at 11:04 AM, Family Member #1 said Resident #1 admitted to the facility 2 years ago and prior to the fall the resident and his roommate were moved to a new room due to scheduled maintenance of his old room. She said the facility called her on 07/29/25 to notify her that Resident #1 had an unsupervised fall, and he was supposedly found on his back with a huge laceration and no other bruising except 2 spots on his arm. Family Member #1 said while the resident had dementia, he remembered what happened when he had previous falls but, in this situation he could not remember anything. She said Resident #1 had no recollection of the fall, he just remembered waking up in the hospital. Family Member #1 said Resident #1 was verbally aggressive, cursed a lot so she was concerned someone did something to him 455876 Page 3 of 5 455876 09/04/2025 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few because on all his previous falls he had some other bruising on his body. An observation and interview 08/26/25 at 12:08 PM revealed, Resident #1 sitting at his bed with a visiting family member with a healed sickle shaped area on the top on the top his heard covered with hair. He could not answer what happened to him, but he was pleasant. Resident #1 was observed with steady balance and slow gait as used his walker to use the bathroom and returned. Resident #1 was able to self-transfer himself in and out of bed with no difficulty. In an interview on 08/26/25 at 1:40 PM, LVN A said on 07/29/25 she and a CNA heard the sound of a fall and then observed Resident #1's laying on his back with his head close to his roommate's bed. She said the resident had one shoe off and his head was bleeding, so staff held pressure to his head and called 911. LVN A said she and the ADON inspected the residents room to identify what the resident could have hit his head on and there wasn't any blood splatter on any furniture, the bedside tables were not close to the resident, there were no items on the floor and Resident #1's head was over a foot away from his roommate's bed. LVN A said there were no fall mats around the residents bed because he was independent and wanted to have as much control as possible so a fall mat was a greater risk than benefit for the resident. She said during the investigation she recreated the incident with nursing administration and they were unable to determine how the injury occurred. In an interview on 08/26/25 at 2:03 PM, the ADON said she heard LVN A yelling so she went into the room and observed Resident #1 lying on the floor. She said when the resident was assessed and asked what happened he said, I don't know what the fuck happened, nothing was hurting and told the staff to get the fuck out. The ADON said the resident had both of his shoes on, and when she inspected the room there wasn't any blood on any surfaces in the room except for the spot Resident #1 was lying. There was nothing on the dresser and she could not identify what the resident possibly have hit his head on. In an interview on 08/26/25 at 2:33 PM, the Administrator said he was responsible for reporting and investigating incidents of abuse, neglect and injuries of unknow origin. He said all allegations of abuse and neglect must be reported but he was only required to report injuries of unknown origin that were suspicious in nature. The Administrator said he used the HHSC provider letter to determine the kind of incidents he reported, and he did not report the laceration to the top of Resident #1's head because after investigation he did not find it to be suspicious because the resident . He said Resident #1 was independent and his roommate could not get out of the bed to harm him. He said Resident #1 did not suffer from any fractures or broken bones so the incident did not require reporting even though the facility was unable to identify how Resident #1 got the laceration on his head. In an interview on 08/28/25 at 03:23 PM, the DON said the facility immediately lunched an investigation following Resident #1's laceration at the top of his head. She said following Resident #1's injury the facility place interventions of increased monitoring to preemptively meet the resident's needs and nursing staff also received in-servicing. In an interview on 08/28/25 at 03:23 PM, CNA A said she provided care to Resident #1 30 minutes prior to his fall. She said she heard someone say help and went she went to the room she saw Resident #1 lying on the floor saying help. CNA A said nursing staff asked Resident #1 what happened, but he was unable to answer. CNA A said Resident #1 was found on his back with his head partially on his roommate's fall mat and the other portion on the floor (over a foot away from the footboard); there was no blood splatter or drops of blood observed anywhere in the room except for where the resident's head lay. In an interview on 09/04/25 at 12:39 PM, the DON said the administrator was the abuse coordinator and a suspicious injury of unknown origin would be anything that could not be explained, bruising in unusual locations like the torso, or a resident with multiple bruises at different stages of healing. She said the facility investigation could not determine how the resident got the laceration on the top of his head, and 455876 Page 4 of 5 455876 09/04/2025 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few there was no evidence he hit his head on anything. In an interview on 09/04/25 at 01:22 PM, the Administrator said suspicious injuries were any injuries that could not be explained or something like fingerprint bruising. He said any suspicious injuries of unknown origin, neglect and abuse must be reported within 2 hours. The Administrator said no one saw how Resident #1 got the laceration to his head, there was no evidence he hit any furnishings, and there was nothing on the floor that could have contributed to the floor like water etc. The Administrator said he used deductive reasoning to rule out a suspicious injury of unknown origin. He could not confirm that Resident #1's fall was not due to the injury, or that the fall occurred at the same time the injury occurred, but he said no one was in the hall around the time the resident was found on the floor. He said failure to timely report alleged injuries of unknown origin could place the facility at risk of receiving a citation.Record review of the facility policy titled Incident and Accidents revised 08/15/22 revealed, Policy: It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. 3. Incidents that rise to the level of abuse, misappropriation, or neglect, will be managed and reported according to the facility's abuse prevention policy. 4. The following incidents/accidents require an incident/accident report but are not limited to: Unobserved injuries. 6. Any injuries will be assessed by the licensed nurse or practitioner and the affected individual will not be moved until safe to do so. First aid will be given for minor injuries such as cuts or abrasions.7. The supervisor or other designee will be notified of the incident/accident. If necessary, law enforcement may be contacted for specific events. 14. If an incident/accident was witnessed by other people, the supervisor or designee will obtain written documentation of the event by those that witnessed it and submit that documentation to the Director of Nursing and/or Administrator.Record revie of the HHSC provider letter titled Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility (NF) Must report to CII the following types of incidents, in accordance with applicable state and federal requirements: Suspicious injuries of unknown source. Reportable Incidents and Timeframes: Do Report: abuse (with or without serious bodily injury) an incident that results in serious bodily injury and that involves any of the following: neglect exploitation mistreatment injuries of unknown source misappropriation of resident property. When to Report: Immediately, but not later than two hours after the incident occurs or is suspected. Do Not Report: an injury that is not suspicious or of unknown source. Injuries of unknown source: Note: an injury should be classified as an injury of unknown source when ALL of the following conditions are met: The source of the injury was not observed by any person; and The source of the injury could not be explained by the resident; and The injury is suspicious because of: the extent of the injury; or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma); or the number of injuries observed at one point in time; or the incidence of injuries over time. 455876 Page 5 of 5