Health inspection·May 10, 2023

F 0578 and time with a BIMS of 99 indicating she was unable to complete the interview. Level of Harm - Minimal harm or potential for actual harm Record review of physician orders for [DATE] indicated Resident #23 had an order dated [DATE] for DNR. Residents Affected - Some Record review of the EMR and hard chart for Resident #23 had a scanned OOH-DNR dated [DATE] with witness signatures of the AD and Admissions/Marketer. The physician signature was in the wrong section, was not dated, did not have his license number, and was on the wrong line on the bottom of the form. During an observation and interview on [DATE] at 01:20 PM Resident #23 was up in her wheelchair propelling herself in the hallway. She said she did not want someone pounding on her chest if she died. 3. Record review of a face sheet dated [DATE] indicated Resident #31 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included high blood pressure, seizures, and loss of cognitive functioning. She was designated as DNR. Record review of the current MDS dated [DATE] indicated Resident #31 was alert to person, place, and time with a BIMS of 14 of 15 indicating she was cognitively intact and could make her own decisions. Record review of physician orders for [DATE] indicated Resident #31 had an order dated [DATE] for DNR. Record review of the EMR and hard chart for Resident #31 had a scanned OOH-DNR dated [DATE]. The physician section did not have the printed name. During an observation and interview on [DATE] at 01:20 PM Resident #31 was in her room. She said she had a DNR because she did not want anything done. 4. Record review of a face sheet dated [DATE] indicated Resident #50 was a [AGE] year-old male admitted on [DATE]. His diagnoses included high blood pressure, a condition in which the heart's main pumping chamber (left ventricle) becomes stiff and unable to fill properly, chronic condition in which the pancreas produces little or no insulin, condition in which bones become weak and brittle, and bleeding from the small intestine or large intestine. He was designated as DNR. Record review of the current MDS dated [DATE] indicated Resident #50 was alert to person, place, and time with a BIMS of 08 of 15 indicating he had moderately impaired cognition and may need some help making decisions. Record review of physician orders for [DATE] indicated Resident #50 had an order dated [DATE] for DNR. Record review of the EMR and hard chart for Resident #50 had a scanned OOH-DNR dated [DATE] with witness signatures of the AD and Admissions/Marketer. During an observation and interview on [DATE] at 01:20 PM Resident #50 was in the bed. He said he thought he had a DNR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 2 of 16 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 05/10/2023 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on [DATE] at 8:10 a.m., the Admissions/Marketer said she was responsible to implement advance directive on admissions and most of the time the nurses would tell her if family or resident wanted a new directive. The Admissions/Marketer said she was trained that the employees could sign as a witness and could sign if they were not performing direct care to the residents. She said if the directive was not filled out correctly, they would not be able to honor their wishes and CPR would be started. During an interview on [DATE] at 8:35 a.m., The Administrator said he wanted the resident's advance directives to be filled out correctly. During an interview on [DATE] at 04:22 PM the DON said she was unaware of the incomplete DNRs and could not have 2 staff signatures. She said these issues would make the DNR invalid and the residents would be a full code. She said the residents would have lifesaving procedures performed when they did not want them. Record review of the Out-of-Hospital Do-Not-Resuscitate Order accessed on [DATE] at https://www.hhs.texas.gov/regulations/forms/advance-directives/out-hospital-do-not-resuscitate-ooh-dnr-order indicated on page 2: Instructions for Issuing An OOH-DNR Implementation: The OOH-DNR Order may be executed as follows: In addition, the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C, or E, and if applicable, have witnessed a competent adult person making an OOH-DNR Order by nonwritten communication to the attending physician, who must sign in Section D and also the physician's statement section The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals . Definitions: Qualified Witnesses One of the witnesses must meet the qualifications in HSC 166.003(2), which requires that at least one of the witnesses not (7) an employee of a health care facility in which the person is a patient if the employee is providing direct patient care to the patient or is an officer, director, partner, or business office employee of the health care facility or any parent organization of the health care facility. The policy for advance directives dated [DATE] indicated advance directive will be respected in accordance with state law and facility policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 3 of 16 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 05/10/2023 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure an accurate MDS was completed for 2 of 16 residents reviewed for MDS assessment accuracy. (Residents #23 and #46) Residents Affected - Few * The facility did not code Residents #23 and #46 for a daily use of a wander/elopement alarm on the MDS. This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: 1. Record review of a face sheet dated 05/10/23 indicated Resident #23 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included progressive disease that destroys memory and other important mental functions, and loss of cognitive functioning. Record review of the physician orders dated March 2023 indicated Resident #23 had an order dated 01/26/23 for a Wander Guard alarm bracelet day and change every three months. Record review of an MDS dated [DATE] indicated Resident #23 under Section P Restraints and Alarms had wander/elopement alarm marked as not used. 2. Record review of a face sheet dated 05/10/23 indicated Resident #46 was an [AGE] year old male admitted on [DATE] with diagnoses included Alzheimer's disease and dementia. Record review of the physician orders indicated Resident #46 had an order for a Wander Guard alarm bracelet daily and change every 3 months for wandering with a start date of 04/07/22. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #46 under Section P Restraints and Alarms had wander/elopement alarm marked as not used. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #46 under Section P Restraints and Alarms had wander/elopement alarm marked as not used. During an interview on 05/10/23 at 11:25 a.m., the MDS nurse said he was responsible for making sure the MDS were correct and completed. He said marking the MDS no for the elopement alarms must have been an error in transcription and the error could have affected the care planning process. During an interview on 05/10/23 at 04:22 PM the DON said she knew the MDS nurse was working on correcting some of the MDSs for corrections. She said she expected the MDSs to be coded correctly to capture a resident's care and needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 4 of 16 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 05/10/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program to the maximum extent practicable to avoid duplicative testing and effort for 1 of 5 residents (Resident #2) reviewed for PASARR. The facility failed to refer Resident #2 for PASARR Level II assessments after their PL 1 (PASARR Level 1 Screening) was negative but had a diagnosis of bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). This failure could place all residents who had a mental illness at risk for not receiving needed assessment, care, and specialized services to meet their needs. Findings included: Record review of face sheet dated May 2023 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of a PASARR Level 1 Screening (PL 1) for Resident #2, completed by the referring facility on 08/08/22, indicated the resident was negative for mental illness, developmental disability and intellectual disability. Record review of an annual MDS dated [DATE] indicated Resident #2 was not considered by the state level II PASARR process to have serious mental illness or intellectual disability or a related condition and a negative Level II Preadmission Screening and Resident Review diagnosis. The assessment indicated Resident #2 had a BIMS (brief interview of mental status) score of 15 of 15 indicating intact cognition with a diagnosis of bipolar disorder. Record review of a quarterly MDS dated [DATE] indicated Resident #2 had a BIMS score of 11 out of 15 indicating moderately impaired cognition and a diagnosis of bipolar disorder. Record review of physician orders dated 05/08/22, indicated Resident #2 was prescribed Venlafaxine (a medication to treat depression) 150 mg one time a day for depression related to bipolar disorder with a start date of 8/10/22. Record review of a MAR dated 05/09/23 indicated Resident #2 received Venlafaxine 150 mg daily for depression related to bipolar disorder. During an interview on 05/09/22 at 3:23 p.m., the MDS nurse said he has been the MDS nurse since March 2023 but was off for military service March 18 - April 18, 2023. He said he has received some education on PASARR forms but was still in training. He said the DOR (director of reimbursement) and the MDS consultant for the facility were his back up. The MDS nurse said he was unaware of the 1012 form (a form completed for nursing home residents with a negative PL1 to determine whether to submit a new positive PL1on the Long Term care Portal because futher evaluation is needed for mental illness) until 05/08/2023. He said he now has been educated on 1012 forms. He said Resident #2 should have had a 1012 form completed after admission, but he was not here. He said he completed a 1012 form (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 5 of 16 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 05/10/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and sent to the physician yesterday. The MDS nurse said he was responsible for PASARR with corporate consultants overseeing him. He said the risk of not having the 1012 form completed timely was the facility would not be in compliance with PASARR and a resident could miss out on deserved services. During an interview on 05/09/23 at 3:30 p.m., the DOR, said the MDS nurse was responsible for PASRR forms with the Corporate MDS Nurse as a backup/ double check when he was unable to work. She said Resident #2 should have had a 1012 form completed after the diagnosis was received. She said a 1012 form was completed 05/08/23 and sent to the nurse practitioner. The DOR said the MDS nurse was still in training. She said the Corporate MDS nurse who started 05/09/23 was his back up. She said the risk was potential resident behaviors and interactions with other residents, and a resident could miss out on PASRR services. During an interview on 05/10/23 at 11:10 a.m., the Corporate MDS Nurse said 5/9/23 was her first day. She said all PL1s should be completed correctly and timely. She said a resident with diagnosis that qualified for positive status would require the PL1 be resent checked positive so the local authority could decide the status. The Corporate MDS consultant said a resident who acquired a diagnosis after admission should have had a 1012 form completed on acquiring a PASRR qualifying diagnosis. She said the MDS nurse was responsible for PASRR forms. She said she was responsible starting 05/08/23 to double check PASRR form. She said there was a lot of staff turnover, and it was just missed. The Corporate MDS Consultant said the risk to the resident was a resident would not receive deserved services. During an interview on 05/10/23 at 2:30 p.m., the DON said her expectation was for all PASRR forms to be completed accurately, and timely. She said the MDS nurse was responsible for all PASRR forms. She said the MDS nurse was still in training, and it was an oversite. The DON said the Corporate MDS nurse was the double check/ back up for the MDS nurse. She said the risk to residents was they could miss out on PASRR services that they could be offered. During an interview on 05/10/23 at 3:10 p.m., the Administrator said the MDS nurse was responsible for PASRR forms with the Corporate MDS nurse as a double check and back up. He said his expectation was for all PASRR forms to be completed accurately and timely. The Administrator said it was overlooked due to inexperience, the MDS nurse was still in training. The Administrator said the risk to residents was a resident may not receive needed services. Record review of a facility policy, titled, Policy and Procedures for PL1/ PASRR/ . revised 01/16/2019 indicated, . The facility will ensure compliance will all phase I and II guidelines for the PASRR process for long term care. 15 The 1012 form will be used and fax to the LA (local authority) when a Positive Diagnosis is identified on previously submitted PL1 marked negative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 6 of 16 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 05/10/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 16 residents (Resident #36) reviewed for comprehensive care plans. The facility failed to develop a care plan for Resident #36's anticoagulant medication, Apixaban. This failure could place residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: Record review of a face sheet indicated Resident #36 was a [AGE] year-old female admitted [DATE] and readmitted [DATE] with diagnosis including atrial fibrillation (an irregular and often rapid heart rhythm that can lead to blood clots in the heart and increased the risk of a stroke). Record review of a quarterly MDS dated [DATE] indicated Resident #36 had a BIMS score of 6, indicating severely impaired cognition and received an anticoagulant medication 4 of 7 days. Record review of the physician orders dated May 2023 indicated Resident #36 was prescribed apixaban (a blood thinning medication) 5 mg two times a day for atrial fibrillation with a start date of 04/24/23. Record review of a care plan revised 05/03/23 did not indicate Resident #36 received anticoagulant therapy. Record review of MAR dated 05/09/23 indicated Resident #36 received apixaban 5 mg two times a day. Record review of the electronic record from May 1 to May 9, 2023, for Resident #36 did not include a care plan for the anticoagulant medication, apixaban. During an interview on 05/09/23 at 3:30 p.m., the MDS nurse said care plans were a team effort. He said the nurses were responsible for developing base line and acute care plans. The MDS nurse said he was responsible for updating the care plan when he completed the MDS. He said Resident #36's care plan for the anticoagulant was just overlooked. He said he had received education on care plans. The MDS nurse said the risk of not developing a care plan for a resident's anticoagulant was staff possibly not being made aware of needed care. During an interview on 05/09/23 at 3:55 p.m., RN A said she was Resident # 36's nurse on 05/08/23 and 05/09/23. She said Resident #36 received the anticoagulant apixaban but was not care planed and should have been. RN A said the nurse who received the order was responsible for developing care plans. She said the nurse who wrote the order was no longer at the facility. RN A said she was in-serviced on care plans. RN A said the risk of not developing a care plan addressing an anticoagulant medication was staff not monitoring the resident for side effects and staff not following what the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 7 of 16 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 05/10/2023 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 0656 physician intended with her care. Level of Harm - Minimal harm or potential for actual harm During an interview on 05/10/23 at 2:35 p.m., the DON said Resident #36's apixaban should have been care planned. She said it was overlooked. She said the MDS nurse was responsible for reviewing and updating the care plan after completing the MDS. The DON said the charge nurses completed baseline care plans. She said the staff were educated on care plans. The DON said the ADON and herself were responsible to double check care plans in the weekly standards of care meetings. The DON said she randomly spot-checked care plans occasionally. She said the most recent care plan in-service would be 5/10/23. The DON said the risk of not developing a care plan for anticoagulants was someone not made aware of the bleeding risk and a resident not monitored for bleeding. She said her expectation was care plans completed accurately and timely. Residents Affected - Few During an interview on 05/10/23 at 2:46 p.m., the ADON said the MDS nurse was responsible for care plans and the DON and ADON were responsible for double checking and being his backup. She said Resident #36's anticoagulant should have been care planned. She said it was missed. The ADON said the risk of not developing a care plan to address anticoagulants was staff may not be aware to monitor for side effects of the medication. During an interview on 05/10/23 at 3:20 p.m., the administrator said his expectation was care plans to be completed accurately, completely and timely. He said the DON and MDS nurse were responsible for care plans. He said it was overlooked. The administrator said Resident #36 anticoagulant should have been care planned. Record review of a facility policy , titled, Care Plans, Comprehensive Person Centered revised December 2016indicated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 8 of 16 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 05/10/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 provide the necessary care and services to maintain the highest practicable psychosocial well-being consistent with the resident's comprehensive assessment and plan of care for 1 of 1 resident reviewed for quality of life. (Resident #51) Residents Affected - Some The facility did not ensure Resident #51's orthopedic appointment report and orders were received and initiated causing a delay in her receiving physical therapy services as ordered by her orthopedic physician. This failure could contribute to residents decline in physical and psychosocial well-being. Findings included: Record review of a face sheet dated [DATE] indicated Resident # 51 was a [AGE] year-old female, admitted on [DATE]. Her diagnoses included fractured wrist and hand, fracture of the left socket of the hipbone, condition in which bones become weak and brittle, a mental health disorder characterized by persistently depressed mood or loss of interest in activities causing significant impairment in daily life. Record review of a hospital Discharge Assessment/Summary Report dated [DATE] indicated Resident #51 had discharge orders of non-weight bearing to right wrist and continue splint, toe-touch weight bearing to left lower extremity, follow up with orthopedic surgery, and 4 weeks of deep vein thrombosis prophylaxis (placed on blood thinner to prevent complications). Record review of physician orders indicated Resident #51 had an order dated [DATE] for follow up with orthopedic surgery. Record review of the admission MDS dated [DATE] indicated Resident #51 was cognitively intact with a BIMS score of 13 out of 15, she required extensive assistance of 2 persons for transfers, she was receiving no physical therapy, and she received restorative therapy for active range of motion and dressing and/or grooming. During interview on [DATE] at 10:30 a.m., Resident # 51 said she fell at the group home she lived in and injured her right wrist around the first of March this year. She said she later fell again and injured her hip and pelvis area. She said she just wanted to start her therapy so she can get better and go back to her group home. She stated, I don't want to stay here, my mother died in a nursing home. She said the bone doctor was not going to do any surgery for her hip and pelvis fractures just therapy to help her get stronger and back on her feet. During an interview on [DATE] at 8:30 a.m., the TA said Resident #51 saw the orthopedic physician on [DATE] at 1:45 p.m. because she took her to the appointment. She said she stayed with the resident for the appointment and the doctor verbally told the resident he was changing her weight bearing status to 50% and ordered therapy. She said the orthopedic office was supposed to fax over new orders to the facility and the DON or ADON would initiate the orders. She said she did not remember if she notified the DON of the appointment report. Record review of the EMR and hard chart from [DATE] through [DATE] for Resident #51 indicated: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 9 of 16 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 05/10/2023 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 0684 * there was no report from the orthopedic office visit from [DATE]; Level of Harm - Minimal harm or potential for actual harm * there was no documentation in the nursing notes for changes in weight bearing status or therapy; * there was no physician order for change in weight bearing or physical therapy. Residents Affected - Some A care plan initiated [DATE] and revised on [DATE] indicated Resident # 51 had an ADL Self Care Performance Deficit related to impaired mobility. Interventions included: * PT/OT evaluation and treatment as per physician orders. * Transfer-required 2-person staff participation for transfer with Hoyer lift There was no indication of her receiving PT or weight bearing status change. Record review of a quarterly MDS dated [DATE] indicated Resident #51 was cognitively intact with a BIMS score of 13 out of 15, she required extensive assistance of 2 persons for transfers, she was receiving no physical therapy, and she received restorative therapy for active range of motion and dressing and/or grooming. During an observation and interview on [DATE] at 11:00 a.m., the RA entered Resident #51's room to provide restorative care. The RA provided ROM exercises to the resident's left arm and ROM to her right lower extremity. The RA said Resident #51 only received restorative care not physical therapy at this time. During an interview on [DATE] at 8:15 a.m., the OT said therapy performed evaluations on residents once ordered from the physician. He said no order had been received for a therapy evaluation on Resident #51. He said the resident was receiving restorative care provided by the RA. During an interview and record review on [DATE] at 08:36 a.m., the TA entered the conference room and handed paperwork to the surveyor. She said the paperwork was from Resident #51's orthopedic appointment on [DATE]. The fax cover sheet with the paperwork was dated [DATE] at 08:35 a.m. Record review of an orthopedics office visit note dated [DATE] for Resident #51 indicated: 2. Fracture, Acetabulum, Closed, Left Plan: Order CT Protocol: Left Femur CT without contrast Plan: Physical therapy instructions/plan Physical therapy plan of care: 2-3 time(s) per week for 6-8 weeks. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 10 of 16 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 05/10/2023 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 0684 Weight bearing: Partial weight bearing 50% Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 9:30 a.m., the DON said the orders received today on Resident # 51 will be initiated today. She said the TA should notify the DON and/or the CN of any new orders or plan of care changes identified during a physician's appointment. The DON said a negative outcome for facility not receiving new orders or plan of care changes immediately following appointments could cause the resident to have a delay in care and cause a decline in their physical status and ADLs. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 11 of 16 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 05/10/2023 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 10 of 10 months reviewed. (August 2022 through May 2023) Residents Affected - Many * The facility did not have RN coverage for Saturdays (SA) and Sundays (SU) in August 2022, September 2022, October 2022, November 2022, December 2022, January 2023. * The facility did not have RN coverage for 11/24/22 (Thanksgiving Day). * The facility did not have RN coverage for 7 days in February 2023. * The facility did not have the required eight consecutive hours of RN coverage for 4 days in March 2023. * The facility did not have RN coverage for 8 days in April 2023. * The facility did not have RN coverage for 2 days in May 2023. This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters. Findings included: Record review of the CMS Payroll Based Journal report for the 4th quarter of 2022 (July1, 2022 through September 30, 2022) indicated there were no RN hours for the following dates: 08/06/22 (SA); 08/07/22 (SU); 08/13/22 (SA); 08/14/22 (SU); 08/20/22 (SA); 08/21/22 (SU); 08/27/22 (SA); 08/28/22 (SU); 09/03/22 (SA); 09/04/22 (SU); 09/10/22 (SA); 09/11/22 (SU); 09/17/22 (SA); 09/18/22 (SU); 09/24/22 (SA); and 09/25/22 (SU). Record review of the CMS Payroll Based Journal report for the 1st quarter of 2023 (October 1, 2022 through December 31,2022) indicated there were no RN hours for the following dates: 10/01/22 (SA); 10/02/22 (SU); 10/08/22 (SA); 10/09/22 (SU); 10/15/22 (SA); 10/16/22 (SU); 10/22/22 (SA); 10/23/22 (SU); 10/29/22 (SA); 10/30/22 (SU); 11/05/22 (SA); 11/06/22 (SU); 11/12/22 (SA); 11/13/22 (SU); 11/19/22 (SA); 11/20/22 (SU); 11/26/22 (SA); 11/27/22 (SU); 12/03/22 (SA); 12/04/22 (SU); 12/10/22 (SA); 12/11/22 (SU); 12/17/22 (SA); 12/18/22 (SU); 12/24/22 (SA); 12/25/22 (SU); and 12/31/22 (SA). Record review of RN time sheets for November 2022 indicated there was no RN coverage for the following dates: 11/05/22 (SA); 11/06/22 (SU); 11/12/22 (SA); 11/13/22 (SU); 11/19/22 (SA); 11/20/22 (SU); 11/26/22 (SA); 11/27/22 (SU) and on 11/24/22 (Thanksgiving). Record review of RN time sheets for December 2022 indicated there was no RN coverage for the following dates: 12/03/22 (SA); 12/04/22 (SU); 12/10/22 (SA); 12/11/22 (SU); 12/17/22 (SA); 12/18/22 (SU); 12/24/22 (SA); 12/25/22 (SU); and 12/31/22 (SA). Record review of RN time sheets for January 2023 indicated there was no RN coverage for the following dates: 01/01/23 (SU); 01/07/23 (SA); 01/08/23 (SU); 01/14/23 (SA); 01/15/23 (SU); 01/21/23 (SA); (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 12 of 16 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 05/10/2023 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 0727 01/22/23 (SU); and 01/28/23 (SA). Level of Harm - Minimal harm or potential for actual harm Record review of RN time sheets for February 2023 indicated there was no RN coverage for the following dates: 02/04/23 (SA); 02/05/23 (SU); 02/11/23 (SA); 02/12/23 (SU); 02/18/23 (SA); 02/19/23 (SU); and 02/26/23 (SU). Residents Affected - Many Record review of RN time sheets for March 2023 indicated there was no RN coverage for the following dates: 03/04/23 (SA); 03/18/23 (SA); 03/25/23 (SA); and 03/26/23 (SU). Record review of RN time sheets for March 2023 indicated there was less than 8 consecutive hours of RN coverage for the following dates: 03/04/23 (SA)-6.5 hours; 03/11/23 (SA)- 6.5 hours; 03/12/23 (SU)- 6.25 hours; and 03/19/23 (SU)-6.25 hours. Record review of RN time sheets for April 2023 indicated there was no RN coverage for the following dates: 04/01/23 (SA); 04/07/23 (SA); 04/08/23 (SU); 04/15/23 (SA); 04/16/23 (SU); 04/21/23 (SA); 04/22/23 (SU); and 04/29/23 (SA). Record review of RN time sheets for May 2023 indicated there was no RN coverage for the following dates: 05/06/23 (SA) and 05/07/23 (SU). During an interview on 05/09/23 at 3:18 p.m. BOM/HR said she was not able to obtain time sheets for prior to November 2022. She said they have had no RN for the weekends for several months. During an interview on 05/09/23 at 3:20 p.m. the ADM and Corporate Staff said they had no RN weekend coverage for over 8 months. They said they had advertised and listed on internet job sites but had no end results. They said their policy was to follow the regulations for the RN coverage. During an interview on 05/10/23 at 12 :42 PM the DON said they did not have RN coverage. She said they had a retired RN who was working some on the weekends but then had nurses leave and now she was using her just to keep the regular nursing staffing covered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 13 of 16 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 05/10/2023 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident's drug regimen was free of unnecessary medication for 1 of 16 residents reviewed for unnecessary medication (Resident #36) Residents Affected - Few The facility did not monitor Resident #36 for side effects of the anticoagulation medication apixaban (a blood thinning medication). This failure could place the residents at risk for adverse consequences of the anticoagulant medication. Findings included: Record review of a face sheet indicated Resident #36 was a [AGE] year-old female admitted [DATE] and readmitted [DATE] with diagnosis including atrial fibrillation (an irregular and often rapid heart rhythm that can lead to blood clots in the heart and increases the risk of a stroke). Record review of a quarterly MDS dated [DATE] indicated Resident #36 had a BIMS score of 6, indicating severely impaired cognition and received an anticoagulant medication 4 of 7 days. Record review of the physician orders dated May 2023 indicated Resident #36 was prescribed apixaban (a blood thinning medication) 5 mg two times a day for atrial fibrillation with a start date of 04/24/23. The orders dddid not address monitoring the anticoagulant medication. Record review of a care plan revised 05/03/23 did not indicate Resident #36 received anticoagulant therapy. Record review of MAR dated 0/5/09/23 indicated Resident #36 received apixaban 5 mg two times a day. Record review of the electronic record for Resident #36 did not indicate the nurses documented monitoring of side effects of anticoagulant daily with medication administration. During an interview on 05/09/23 at 3:55 p.m., RN A said she was Resident #36's nurse on 5/8/23 and 5/9/23. She said Resident #36 received the anticoagulant apixaban and was not monitored but should have been when she gave it. RN A said the nurses who provided care for Resident #36 were responsible to ensure the anticoagulant was monitored. She said the monitoring was usually in the MAR when she gave the medication. She said she was educated on monitoring anticoagulants. RN A said it was just missed. She said the risk of a resident on anticoagulants not monitored was a resident bleeding, a resident could fall hit their head and have a hematoma and staff be unaware the resident was on anticoagulants. During an interview on 05/10/23 at 2:35 p.m., the DON said Resident #36's apixaban was not monitored and should have been. She said her expectation was for all anticoagulants to be monitored as required. The DON said the nurses should have added monitoring into the computer on admission. She said the nurse who completed Resident #36's admission quit after less than a month. The DON said the ADON and herself were responsible for double check medications for monitoring. The DON said she looked over new admissions and the ADON looked over readmissions. She said Resident #36's monitoring was just (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 14 of 16 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 05/10/2023 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few overlooked. The DON said the risk of an anticoagulant medication not being monitored was staff possibly missing a resident having excessive bleeding or medication complications. During an interview on 05/10/23 at 2:45 p.m., the ADON said the nurses were responsible for adding monitoring into the computer system for anticoagulants. She said she and the DON were responsible for double checking to ensure anticoagulants were monitored. She said the staff were in-serviced on monitoring of medication but was unsure how long ago. The ADON said Resident #36's anticoagulant was not monitored and should have been. She said it was just missed. The ADON said the risk of an anticoagulant medication not monitored was possible missed bleeding, and excessive blood in stools missed. During an interview on 05/10/23 at 3:10 p.m., the administrator said his expectation was that all anticoagulant medications to be monitored as required accurately, completely and timely. The administrator said Resident #36's anticoagulant should have been monitored. He said it was just overlooked. Record review of a policy titled, Anticoagulant - Clinical Protocol revised November 2018, indicated, . The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. a. If an individual on anticoagulant therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 15 of 16 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 05/10/2023 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for 1 of 1 kitchen reviewed for the environment. Residents Affected - Some The facility did not maintain an effective pest control program to ensure the kitchen was free of fruit flies. This failure could place residents at risk of potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life. Findings included: During an observation and interview on 05/08/23 and started at 08:30 a.m., The DM pulled out a large box that contained approximately 8 bunches of 5-6 bananas each, and there were approximately 120 fruit flies flew out of the box. Approximately 20 flew to a standing cart that had trays of cookies and 2 of 3 trays were not covered and the fruit flies landed on the exposed cookies. The DM said there should not be fruit flies in kitchen at all, and the food would be thrown away. She denied knowing there were fruit flies in the kitchen and said the dietary staff were to report any pest to her and none had been reported. During an interview on 05/09/23 at 08:25 a.m., The Administrator said he wanted the kitchen not to have pests and provided the policy and the last reports from the pest control company. During an observation and interview on 05/09/23 at 11:00 a.m., observed approximately 2 fruit flies in the kitchen during the food serving process. The DM said there were still 1 or 2 fruit flies She said her and the administrator had thrown out the bananas yesterday and killed the fruit flies with spray and got another pest light for the kitchen. During a record review of the monthly pest control dated 04/20/23, 03/30/23 and 02/20/23 indicated the facility received monthly treatment for general pests. Review of the facility's policy on pest control dated May 2008 indicated Our facility shall maintain an effective pest control program. 1. The facility maintains an on-going pest control to ensure that the building is kept free of insects. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 16 of 16