Health inspection·May 7, 2023

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of an Incident Report dated [DATE] indicated CNA A was giving Resident #1 a bed bath, she touched a sore place on his right buttocks causing him to flinch and move about the bed. Resident #1 rolled off the bed onto the floor face down, lying on his right shoulder. Resident #1 had a large hematoma (blood pooling) to his left forehead, swelling to his right shoulder (the shoulder was tender to touch), and an abrasion to his right knee. He was not able to give account of fall. Record review of a written and signed statement dated [DATE] by CNA A indicated she was giving Resident #1 a bed bath. She wrote while I was cleaning his butt I noticed a sore and I put cream on his butt, he gripped his butt cheeks and jumped. I had one hand holding his hip but when he jumped I tried to grab him, but he fell off the bed. Record review of nursing notes with: * Entry dated [DATE] at 01:00 p.m. indicated while CNA A was giving Resident #1 a bed bath, she touched a sore place on his right buttocks causing him to flinch and move about the bed. Resident #1 rolled off the bed onto the floor face down and lying on right shoulder. Resident #1 had a large hematoma (blood pooling) to left forehead, swelling to right shoulder, the shoulder was tender to touch, and an abrasion to right knee. An ice pack was applied to left forehead and 911 called for transportation to the local hospital emergency room for evaluation and treatment. * Entry dated [DATE] 01:30 p.m. indicated Resident #1 was transported to the local hospital emergency room with 2 EMTs. * Entry dated [DATE] 06:00 p.m. indicated the local hospital contacted the facility and informed them Resident #1 was being transferred to a higher level of care hospital due to subarachnoid and subdural bleeding. The hospital indicated there was no fracture to the right shoulder. Record review of a hospital Neurosurgical Consultation report dated [DATE] indicated Resident #1 was brought to the emergency department after a fall from the bed during care. He underwent a CT (special x-ray equipment to help assess head injuries) of the head at the local hospital and was found to have a small subdural hematoma as well as subarachnoid hemorrhage. He was transferred to another hospital for higher level of care. Neurosurgery was consulted for further evaluation recommendations. At this time, no acute neurosurgical intervention was recommended. Recommendations due to the head injuries included for him to have systolic blood pressure (measures the pressure in the arteries when the heart beats) less than 130, the head of the bed was to be kept greater than 30 degrees, and he was started on Keppra (anti-seizure medication) 500mg twice daily for seizure prophylaxis for 7 days. During an interview on [DATE] at 09:25 a.m. the ADM said Resident #1 was being provided a bed bath by CNA A and the resident fell out of bed hitting his head. He said the resident was sent to the hospital due to hitting his head and was found to have bleeding, so he called in a report to the state office of a fall with an injury. He said the resident should have had 2 staff with the bed bath. During an observation on [DATE] at 11:20 a.m. Resident #1 was in his bed. He was clean, neat, and had no odors. He was not able to answer questions appropriately. An attempt was made to contact CNA A on [DATE] at 11:58 a.m. and she was not available for interview at time of the investigation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 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 675484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodland Park Nursing & Rehab 101 Woodland Park Dr Shepherd, TX 77371 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 - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview on [DATE] at 12:46 p.m. the DON said Resident #1 was being provided a bed bath by CNA A. She said the CNA turned him to his side to clean his buttock and apply barrier cream. She said he jerked and fell off the bed. She said he was a 2-person assist with bed mobility and there should have been 2 staff for his bed bath to prevent him from falling off the bed. She said the residents' information on what type of care they needed was in the [NAME] in the Point of Care system accessed by the CNAs. She said she expected all residents requiring 2-person assist with bed mobility to have 2 staff to provide a bed bath. She said now they had put in place for all persons with bed baths to be 2-person assist. During an interview on [DATE] at 10:16 a.m. the DON said she could not recall if the facility had a QAPI meeting to review the incident of Resident #1 falling out of the bed. She said all staff were in-serviced on the care plans and [NAME]. She did not provide a copy of all staffs' signature and related training for review. The ADM was notified on [DATE] at 11:40 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The Immediate Jeopardy template was provided to the ADM. The facility's Plan of Removal was accepted on [DATE] at 01:00 p.m. PLAN OF REMOVAL read: The following is a plan of removal, which has been immediately implemented at the facility to remedy the Immediate Jeopardy which was imposed on [DATE]. 1. Resident #1 was assessed after the incident, Resident was treated for injuries. MD and family made aware of the incident the day it occurred, [DATE]. 2. Resident #1 was assessed for level of assistance during ADLs. 2 persons when turning in bed Resident #1's care plan was changed to 2 person bathing by Director of Nursing on [DATE]. She assessed him and also ordered assist rail to right side to assist resident to turn. Assist rails were installed on [DATE] by maintenance supervisor. 3. All residents in the facility were assessed by the DON and ADON to determine the level of assistance needed during care. Residents were all assessed by [DATE] by DON and ADON and again 5/6-7/23. All care plans and [NAME] will be updated by MDS nurse and corporate MDS nurse by [DATE] to reflect the level of care needed. 4. The DON and ADON will in-service all nursing staff on following the care plans and/or [NAME] and providing care with the appropriate level of assistance by [DATE]. Specifically noted on this in-service was one- or two-person care, for bed baths, bed mobility, and bathing and the difference between them and where to find the information. We must assist all residents in the safest manner possible. The shower list will also specifically say if the resident requires a two-person bed bath or for bed mobility as well, these will be the same. Transfer will only be listed on the [NAME]. For new residents always ask a charge nurse or use two people until the residents' abilities are assessed. A picture of the PCC was attached to in-service to show staff where to find the [NAME] tab. The levels of assistance will be available to find on PCC and at nurse's station. If staff not in-serviced by [DATE] they will be in-serviced prior to working shift. [NAME] and care plans updated by MDS nurse and corporate MDS nurse by [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 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 675484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodland Park Nursing & Rehab 101 Woodland Park Dr Shepherd, TX 77371 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 All residents have the potential to be affected by this alleged deficient practice. Level of Harm - Immediate jeopardy to resident health or safety The Medical Director was initially made aware of the Immediate Jeopardy, and has been involved in the development of the plan to remove. Residents Affected - Few To monitor for compliance the Administrator and/or designee will check 3 residents care per week to ensure the proper level of assistance is being provided. The monitored residents will always be different than the prior week's residents. Any negative findings will be remedied with further training or disciplinary actions. This plan was initially implemented [DATE] and will be monitored through completion by corporate and regional staff. Monitoring: Observations, interviews, and record reviews were conducted on [DATE] from 2:15 p.m. through 4:14 p.m. and included 2 alert residents, 4 LVNs, and 9 CNAs, 2 medication aides (who work all shifts), the ADON, and the DON. Staff were able to identify residents' the care plans, the [NAME] system and how to find level of resident care, and who the abuse coordinator was. Staff provided appropriate resident supervision and redirection. There were no observed concerns. Staff were able to discuss the required level of staff assistance for ADLs. Staff were able to demonstrate the use of the [NAME] system for resident care needs. [NAME] for 10 residents were reviewed to ensure they matched with the resident's level of assistance required. Care plans matched the [NAME]. Facility audit for all residents indicated no issues or concerns and all care plans matched level of care in the [NAME]. Nursing staff were in-serviced on [DATE] and [DATE] where to find a resident's level of assistance in the [NAME]. Nursing staff who were unavailable and not in-serviced were on a list to receive training prior to their next scheduled shift. The [NAME] showed that Resident #1 was a 2-person assist. During an interview on [DATE] at 2:56 p.m., the DON said the audit of all residents' care plans and [NAME] revealed no issues or concerns. She said all residents' charts were reviewed and the care plans and [NAME] were corrected. She said all care plans reflected what the residents' current care needs. She said there will be no changes made to resident care needs without IDT discussion. All residents who required 2-person bed mobility also required 2-person assist for bed baths. A facility record audit dated [DATE] indicated all 55 residents' [NAME] and care plans were reviewed and updated. No residents indicated they were afraid during care or had complaints of their care. On [DATE] at 4:14 p.m., the Administrator was informed the Immediate Jeopardy was removed; however, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 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 675484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodland Park Nursing & Rehab 101 Woodland Park Dr Shepherd, TX 77371 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 the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 5 of 5