Inspection·December 21, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm interventions including independent transfers and ambulation, supervision with bathing and hygiene, and cuing related to dressing, grooming, and toileting. Observation of Resident #12's restroom vent fan revealed it appeared covered in a dust-like substance and the. The dust-like substance covered the vent blades and the interior of the vent surfaces. Residents Affected - Some Resident #26 Record review of Resident #26's face sheet dated 12/21/2023 revealed a [AGE] year-old woman admitted on [DATE]. The face sheet documented her diagnoses included chronic kidney disease (condition characterized by a gradual loss of kidney function), dry eye syndrome (condition that occurs when your tears aren't able to provide adequate lubrication for your eyes), asthma (lung disorder characterized by narrowing of the airways, the tubes which carry air into the lungs, that are inflamed and constricted, causing shortness of breath, wheezing and cough), and allergic rhinitis (disorder caused by allergy-causing substance, called allergens). Record review of Resident #26's quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating no cognitive impairment. The MDS documented she was independent, or required supervision or minimal assistance, with toileting, oral and self-hygiene, and toilet transfers. Record review of Resident #26's care plan dated 8/9/2023 revealed a focus on her ADL care with interventions including minimal assistance with restroom transfers, wheelchair transfers, and hygiene. Interview and observation on 12/20/2023 at 9:54 AM with Resident #26 revealed her air vent and restroom door were both dirty and had been for a long time. Resident #26 said she also had a hole in the bottom of her restroom door. Resident #26 said she did not recall how long the hole had been in the door. Resident #26's room revealed the air vent above her bed appeared to have a black and brown substance on the vents. There was also a black substance above and below the vent on the ceiling and wall. Resident #26's restroom door had a blueish stain. The stain was located on the center of the door beginning at approximately door handle height and ended just above the ground. The door also had a hole in the bottom corner near the hinge. Resident #200 Record review of Resident #200's face sheet dated 12/21/2023 revealed a [AGE] year old man admitted on [DATE]. The face sheet documented his diagnoses included shortness of breath, sepsis (blood poisoning), anxiety disorder (fear characterized by behavioral disturbances), Chronic Obstructive Pulmonary Disease (COPD, common, preventable, and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), and dependence on supplemental oxygen (external oxygen use). Record review of Resident #200's admission MDS dated [DATE] revealed a BIMS score of 14 indicating minimal cognitive impairment. The MDS documented he required assistance with showering, dressing, and personal hygiene, and setup assistance with eating, oral hygiene, and toileting. Record review of Resident #200's undated care plan revealed a focus on his oxygen therapy with interventions including oxygen administration, monitoring for signs of hypoxia (below-normal level of oxygen in the blood), and monitoring his lung sounds. The care plan documented a focus on his ADL care with interventions including extensive assistance with oral care, bathing, and grooming. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675229 If continuation sheet Page 2 of 5 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 675229 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodland Manor Nursing and Rehabilitation 99 Rigby Owen Rd Conroe, TX 77304 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 0584 Level of Harm - Minimal harm or potential for actual harm Interview and observation on 12/20/2023 at 9:39 AM with Resident #200, he said the black substance on his ceiling had been there since he had moved in. Resident #200 said the air vent had been dirty in the past as well, but the facility had replaced it approximately two weeks prior. Resident #200's room revealed two areas on the ceiling near the air vent that were darker than the rest of the ceiling. The darkest areas were concentrated near the air vent and then extended out. The air vent appeared clean and new. Residents Affected - Some Interview on 12/21/2023 at 10:40 AM with CNA I revealed she had been employed by the facility for three years. CNA I said her primary duties included providing care to residents including, feeding, and communicating with them. CNA I said the facility's rooms were not as clean as they should be. CNA I said the facility's vents and ceilings needed cleaned and/or replaced. Interview on 12/21/2023 at 11:29 AM with the Housekeeping Director (HKD) revealed her primary duties included training staff, ordering supplies, writing the housekeeping schedule, and ensure the housekeeping staff were completing their tasks as needed. The HKD said the residents' rooms were supposed to be cleaned once daily and then as needed after that. The HKD said all rooms were to be deep cleaned once monthly. The HKD said the air vents and ceilings should be cleaned during the monthly deep cleaning. The HKD said if air vents were not cleaned during the monthly deep clean, the staff who failed to clean the vent would be retrained. The HKD said if a resident had a breathing issue, a vent that was not cleaned could exacerbate the resident's breathing concerns. The HKD said some of the facility's ceilings were hard to clean because they were popcorn style ceilings. The HKD said she had informed the facility's administrator about the concerns. The HKD said the darkened areas in Resident #200's had been addressed in the past but had not been completely removed as the stains were difficult to remove. The HKD said the vents in room Resident #12's bathroom and Resident #26's should not look like they did. The HKD said the vents should have been cleaned. The HKD said it was ultimately her responsibility to ensure the vents were cleaned. The HKD said the door to the bathroom in Resident #26's room should have a stain and a hole. Interview on 12/21/2023 at 1:51 PM with the Admin, she said she expected housekeeping and maintenance to clean the resident rooms once daily and then staff to assist in keeping them clean. The Admin said the facility was in the process of replacing all the vents in the resident rooms. The Admin said the facility had purchased 50 new vents and still needed to purchase more to replace all of them. The Admin said the hole in Resident #26's bathroom door appeared to be from a wheelchair but would be replaced. The Admin said Resident #26's air vent would be replaced, and Resident #12's restroom vent should be cleaned. The Admin said the vent in Resident #12's restroom may not work because of the dust-like substance coating it. Record review of the facility's Maintenance Service policy dated November 2021 revealed a policy statement which read Maintenance service shall be provided to all areas of the building, grounds, and equipment. The policy documented the maintenance department was responsible for maintaining the buildings, grounds, and equipment of the facility. The policy revealed the building would be maintained in good repair and free from hazards. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675229 If continuation sheet Page 3 of 5 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 675229 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodland Manor Nursing and Rehabilitation 99 Rigby Owen Rd Conroe, TX 77304 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 6% based on 2 errors out of 32 opportunities, which involved 2 of 5 residents (Residents #37 and #38) reviewed for medication errors. Residents Affected - Few -MA A administered the wrong dose of Vitamin D to Resident #37 according to Physician orders. -MA A administered expired Sodium Bicarbonate tablets (an antacid that neutralizes stomach acid) to Resident #38. These failures could place residents at risk of inadequate therapeutic outcomes. Findings include: 1.Record review of Resident #37's face sheet revealed a [AGE] year-old male admitted on [DATE]. His diagnoses included: multiple sclerosis (a disease that affects the central nervous system), vitamin deficiency, displaced bimalleolar (broken ankle) fracture of right lower leg, and hypertension (elevated blood pressure) Record review of Resident #37's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 which indicated no cognitive impairment. He required assistance of staff for ADL care. Record review of Resident #37's physician orders for December 2023 revealed an order for Vitamin D3 125 mcg one tablet once a day for vitamin deficiency, order date 4/18/23. In an observation on 12/20/23 at 8:24 a.m. with MA A, she prepared Resident #37's morning medication for administration. She prepared Vitamin D3 25 mcg - 1 tablet, Baclofen 15 mg three 5 mg tablets, Sertraline 25 mg - 1 tablet, and Metoprolol 25 mg - 1 tablet for a total of six pills. She administered the medications to Resident #37 and documented the administration on the computer. In an interview on 12/20/23 at 8:34 a.m. MA A said she reviewed each of Resident #37's medications one by one and verified the right name, dosage, and time. She said the Vitamin D3 bottle said 25 mcg but also had 125% daily value written on it. She said she gave Resident #37 one tablet which equaled 25 mcg and 125% daily value. She said she thought the medication she gave was the same as the physician's order. She said if it was not the same, she would have to give five tablets for the dosage to be the same. She said the directions said to administer one tablet. She said she did not ask a nurse about it. She said the staff who trained her no longer worked at the facility. In an interview on 12/20/23 at 8:46 a.m. MA A showed this Surveyor a bottle of Vitamin D 125 mcg. She said the staff who trained her did not use the right Vitamin D during the training. In an interview on 12/21/23 at 12:19 p.m. the DON said nursing staff should verify the physician's order and the medication should match the order. He said nursing staff should verify the right dose, expiration date, patient, time, documentation, medication, and frequency. He said the MA should have stopped and verified the medication with the nurse. He said Resident #37 did not receive the full amount of Vitamin D3 but said he was unsure of the side effects because it was a vitamin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675229 If continuation sheet Page 4 of 5 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 675229 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodland Manor Nursing and Rehabilitation 99 Rigby Owen Rd Conroe, TX 77304 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Record review of Resident #38's face sheet revealed a [AGE] year-old male who readmitted on [DATE]. His diagnosis included chronic obstructive pulmonary disease, respiratory failure, diabetes, and heart failure. Record review of Resident #38's quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 out of 15 which indicated moderate cognitive impairment. He was independent with ADLs. Record review of Resident #38's physician orders for December 2023 revealed an order for Sodium Bicarbonate 650 mg give 2 tablets three times a day for deficiency of other specified nutrient elements, order date 7/23/23. In an observation and interview on 12/20/23 at 9:09 a.m. with MA A, she prepared Resident #38's morning medication for administration. She prepared and administered 11 medications which included Sodium Bicarbonate 650 mg - 2 tablets with an expiration date of 11/2023. MA A said the Sodium Bicarbonate was expired as of 11/2023. She said she checked expired medications prior to administering to the resident. She said expired medications should not be administered because it may not work and could affect the process. She said she checked her medication cart approximately once every other week for expired medications and said they should be removed from the cart and placed in the medication room. She said the medication aides were responsible for ensuring expired medications were not on the cart. In an interview on 12/21/23 at 12:19 p.m. the DON said nursing staff should check the expiration date before the medication was administered. He said expired medications could not be given because it was not what the facility did. He said expired medications should be removed from the cart. He said the nurses conducted random checks and the Pharmacist inspected the carts for expired medications. Record review of the facility's Administering Medications policy dated April 2019 read in part, .Medications are administered in a safe and timely manner, and as prescribed . 4. Medications are administered in accordance with prescriber orders . 10. The individual administering the medication checks the label THREE times to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication . 12. The expiration/beyond use date on the medication label is checked prior to administering . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675229 If continuation sheet Page 5 of 5