Inspection·December 24, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's vital signs report dated 12/14/24 reflected there was no record of resident vital signs being taken during the time he was lifted off the floor The vitals report reflected that Resident #1's vitals were checked early in the day of 12/14/24 at 8:10am by LVN A. Interview with LVN-A on 12/24/24 at 12:22pm, she said that when a resident is found on the floor and it is unknown how the resident ended up on the floor, then a head-to-toe assessment should be performed. She said that the reason for the head-to-toe assessment is to rule out any serious injuries before the resident is moved. She said that she did not perform a head-to-toe assessment on Resident #1 when he was found on the floor in his room on 12/14/24. She said that she did a quick visual assessment because Resident #1's family was belligerent and that she just wanted to get Resident #1 off the floor and into his bed. She said that a head-to-toe assessment should include the vitals being taken and the resident's range of motion being checked to ensure no dislocations or broken bones before the resident is removed from the floor. And the risk of not performing a head-to-toe assessment could lead to injury. Interview with CNA-A on 12/24/24 at 12:36pm, she said that if a resident is found on the floor and the fall is unwitnessed then a nurse must perform a head-to-toe assessment before the resident is removed from the floor. She said that the reason for the assessment is to make sure that the resident does not have any serious injuries that would prevent the resident from being removed from the floor. She said that the head-to-toe assessment includes vitals, range of motion check and a check for a fracture. Interview with DON on 12/24/24 at 3:30pm, she said that if a resident is found on the floor and it is not clear how the resident ended up on the floor then a head-to-toe assessment should be performed to ensure that the resident does not have any serious injuries before they are removed from the floor. She said that if the assessment is not performed by a nurse, then it could lead to serious injury when removing the resident from the floor. She said that a head-to-toe assessment should include vital signs, range of motion and check for any fractures. Interview with Administrator on 12/24/24 at 3:50pm, he said that if a resident has a fall, then the resident should be assessed before they are removed from the floor because it's not sure if the resident is injured or the extent of their injuries if there are any. He said that each nurse should know to perform an assessment on a resident that has a fall or suspected fall. Record review of the facility's fall prevention policy dated 11/2024 revealed that: 1. If a resident has just fallen or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. The resident is not moved until after evaluation by a nurse. 2. Obtain and record vital signs as soon as it is safe to do so. 3. (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 12/24/2024 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 0684 If an assessment rules out significant injury or complaints of pain, help the resident to a comfortable sitting, lying position, and then document relevant details. Level of Harm - Minimal harm or potential for actual harm 4. Residents Affected - Few Notify the resident's attending physician and family in an appropriate time frame. 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 12/24/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for (1) of (4) residents reviewed. The facility failed to use proper lifting technique or lifting device to remove resident#1 off the floor. This failure could place residents at risk of accidents and injuries. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included cerebral urinary tract infection, Unspecified Dementia, Muscle weakness (generalized), cognitive communication deficit, Hyperlipidemia, and Type 2 diabetes Mellitus without complications. Review of Resident #1's Quarterly MDS assessment dated [DATE], section C revealed a BIMS score of 4, indicating severe cognitive impairment. Section G regarding resident's Activities of Daily Living (ADL) Assistance revealed resident needs supervision and two persons assisting with bed mobility, transferring and toilet use. It also revealed resident required, two-person assistance with dressing, and personal hygiene. Record review of Resident#1's care plan dated 10/24/2024 revealed Resident #1 was care planned for falls. ADL Self Care Performance Deficit: Goal-Resident will remain free from falls. Approach- Resident's bed will be placed in its lowest position and a fall mat will be placed next to the resident's bed. Record review of video dated 12/14/24 revealed that Resident #1 was on the floor in his room in a prone position (lying on his stomach) with his head on a pillow. The video showed LVN A grabbed Resident #1 by his left arm while CNA A grabbed Resident #1's right arm and together they lifted Resident #1 off the floor by his arms. The video did not reflect a time stamp. Interview with LVN-A on 12/24/24 at 12:22pm she said that she along with CNA-A lifted rResident #1 off the floor and placed him in his bed. She said that they grabbed Resident #1 by his upper extremities. She said that they were just trying to get the resident off the floor as soon as possible because the family was belligerent. Interview with CNA- A on 12/24/24 at 1:01pm she said that she and LVN-A rolled Resident#1 over on his back and picked him up in a cradle position and put him in his bed. (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 12/24/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with CNA-B on 12/24/24 at 12:36pm she said that the correct and safest way to lift a resident off the floor is to get a mechanical lift and lift the resident off the floor. She said that at no time should a resident be lifted off the floor by their extremities because a dislocation may occur. Interview with LVN-B on 12/24/24 at 1:26pm she said that when a resident is on the floor in a prone position that the resident should be rolled over to their back and a mechanical lift should be used to lift the resident off the floor. And at no time should a resident be lifted off the floor by their extremities because of possible dislocation. Interview with DON on 12/24/24 at 3:30pm, she said that if a resident is found on the floor and after the resident has been assessed. Then the resident should be rolled over onto their back and a mechanical lift should be used to lift the resident off the floor. But at no time should the resident be lifted off the floor by their extremities are if the resident is on their stomach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675229 If continuation sheet Page 5 of 5