Health inspection·July 24, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm embarrassed. Resident #14 said she was not abused; it just embarrassed her. She said she told LVN H and LVN H would talk to CNA W. Resident #14 said she knew LVN H did what she said she would do and took care of it. Resident #14 said she was not afraid of CNA W, and she felt safe in the facility. Resident #14 said she still wanted CNA H to be her CNA she just needed some training. Resident #14 said, They take really good care of us at this facility. Residents Affected - Few During an interview on 7/21/25 at 9:30 a.m., Resident #25 said she said she did not hear any staff being rude or any problems last night with her Roommate, Resident #14. She said her roommate Resident #14 was not upset last night. Resident #25 said she felt safe in the facility and was comfortable telling the nurse if she had a problem or concern. She said she was not abused or neglected by the staff. During an interview on 7/21/25 at 2:00 p.m., CNA W said she was not rude or abusive to Resident #14 last night. CNA W said she was pushing Resident #14 in a wheelchair, Resident #14's roommate back to her room. She said, (Resident #14) was going back to her room, and I was about 7 feet away and I ask her if she would use the restroom before going to bed so we would not have to get her right back up. CNA W said I know her knees hurt and was trying to save her knees. When I got to her room Resident #14 said so aides are giving orders now. I said I was not giving orders I just wanted to prevent her from having to get immediately back up after she got to bed. CNA W said I was not yelling or talking loudly, I just asked her. CNA W said she was educated on abuse/ neglect, and resident rights. She said I would report suspected abuse to the nurse and administrator immediately. During an interview on 7/21/25 at 4:35 p.m., LVN H said she had not had any allegations of abuse reported to her this week. She said on 07/21/25 she had an incident of miscommunication with CNA W and Resident #14. She said the incident was brought to her attention, but she did not witness the interaction. She said Resident #14 said CNA W was rude when she told her to go to the bathroom before going to bed. She said then she spoke to CNA W and she was worried Resident #14 would lose the ability to get up due to pain in her knees and was encouraging her to toilet herself before lying down. LVN H said I do not think it was abusive, just a miscommunication. Looking back, I should have told the DON and Administrator. When asked the resident's risk of a resident saying she was embarrassed by an incident LVN H said she did not how to answer that question. During an interview on 7/21/25 at 4:58 p.m., the Administrator said they had not reported the incident with Resident #14. The facility had decided it was not abuse. He talked to the Resident #14 and she said she was not abused. She was able to verbalize what abuse was. She said she was just embarrassed. Resident #14 said she still wanted CNA W to be her aide and provide care to her, she just needed more training. The Administrator said it was a dignity/ sensitivity issue. He said he in-serviced staff and would do a one-on-one in-service on sensitivity training with CNA W when she came back to work on 7/23/25 before she was allowed to work. During an interview on 7/23/25 at 11:22 a.m., the DON said CNA W should not have spoken rudely to Resident #14. She said all the facility staff were educated on abuse neglect, resident rights and customer service. She said she was unsure what happened due to not being there during the incident. The DON said she felt it was a misunderstanding or miscommunication. She said all staff must be mindful of how they say things and the tone they use when speaking with Residents. The DON said the resident risk was a resident may be not comfortable in their home. She said her expectation was all residents be treated with respect and dignity. During an interview on 7/24/25 at 8:40 a.m., the Administrator said he investigated the incident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 2 of 34 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 07/24/2025 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with Resident #14 and determined it was not abuse, it was a dignity issue. He said the staff were all educated on abuse/ neglect policy and procedures. The Administrator said CNA W was given an individual sensitivity training in-service on 7/23/25 before she returned to the facility. The Administrator said the resident risk of a resident thinking a staff member was rude was potentially a resident may not ask for assistance if needed. He said he thought the incident was a misunderstanding and miscommunication. The Administrator said his expectation was all staff treat all residents with respect and dignity and treat them as adults. 2. Record review of Resident #28's admission record dated 07/24/25 indicated Resident #28 was admitted on [DATE], was [AGE] year-old female with diagnoses of severe intellectual disability (delayed motor, language and social accomplishments), anxiety disorder (intense excessive fear), cognitive communication deficit (difficulties in communication), and dysphagia oropharyngeal phase (difficulty swallowing that originates in the mouth). Record review of the physicians' orders for Resident #28 dated July 2025 indicated the diet order with start date of 03/14/25 was low concentrated sweets diet mechanical soft texture, Regular consistency, ice cream with lunch and dinner, fortified food plan, divided plate and bedtime snack. Record review of the quarterly MDS dated [DATE] indicated Resident #28's cognitive skills for daily decision making were moderately impaired. Resident #28's ability to make her needs known and ability to understand others, she was rarely/never understood and understands. Record review of the care plan dated 05/08/25 indicated Resident #28 was positive for PASRR related to intellectual disabilities. The resident requires extensive assist by 1+ staff to eat. The resident has impaired cognitive function/dementia or impaired thought processes related to severe ID. During interview and observation on 07/21/25 at 11:15 a.m., Resident #28 was in the dining hall seated in her wheelchair at a table. Staff placed her plated lunch meal in front of her and walked away to allow Resident #28 to eat. CNA N walked over to Resident #28 and asked Resident #28 if she could assist her with feeding. Resident #28 approved, CNA N hand sanitized and picked up a fork and began cutting Resident #28 chunk ground beef and began assisting Resident #28 with feeding while standing. CNA N said I knew better than that, I should have been sitting down instead of standing up. I have been trained on sitting instead of standing while assisting with feedings. CNA N also said the risks of not sitting down while assisting with feeding was the resident thinking they are being rushed. During interview an interview on 07/24/25 at 2:19 p.m., the DON said she expected staff to follow facility's policy and be at the same level as the resident instead of hovering over the resident while assisting with feeding. She said she has trained her staff on dignity and sitting when assisting with meals. Record review of a revised facility policy titled Dignity indicated Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. b. allowed to choose when to sleep, eat, and conduct activities of daily living: . 8. Staff speak respectfully to residents at all times, . When assisting with care, residents are supported in exercising their rights. For example, residents are provided with a dignified dining experience. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 3 of 34 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 07/24/2025 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consult with the physician regarding a change in condition for 3 of 14 residents reviewed for physician notification. (Residents #3, #6, and #40)The facility failed to consult physician for Resident #3, #6, and #40 when their BP medications were held for patterns of vital signs being outside the prescribed parameters.These failures could place residents at increased risk for complications due to delayed physician intervention. Findings included:1. Record review of Resident #3's face sheet, dated 07/22/25, reflected Resident #3 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included diabetes (too much sugar in the blood), morbid obesity (a disorder that involves having too much body fat), and hypertension (high blood pressure)Record review of the quarterly MDS assessment, dated 05/21/2025, reflected Resident #3 usually made herself understood and usually understood others. Resident #3 BIMS score was 13, which indicated her cognition was intact. Record review of Resident #3's comprehensive care plan revised 07/22/2025 revealed altered cardiovascular status related to hypertension. Interventions included to monitor/document/report to MD any signs/symptoms of altered cardiovascular status. Review of Resident #3's physician orders dated 07/01/2025 included Lopressor 50 mg twice daily, clonidine HCl 0.3 mg twice daily, and cozaar 50 mg once daily. Each of these 3 medications were prescribed for hypertension and orders on each included parameters to hold medication for BP less than 110/60 or HR less than 60. Record review of Resident #3's July 2025 MAR indicated on the following dates and times, Resident #3's medications were held when vital signs were outside the prescribed parameters of BP less than 110/60 or HR less than 60:1) Lopressor 50 mg:*07/01/2025 - PM BP was 69/41;*07/02/2025 - AM BP was 108/57, PM BP was 107/57;*07/04/2025 PM BP was 102/63;*07/05/2025 - PM BP was 107/49;*07/06/2025 - PM BP was 95/53;*07/07/2025 - AM BP was 104/62, PM BP was 101/50;*07/08/2025 - PM BP was 100/50;*07/09/2025 - PM BP was 100/53;*07/11/2025 - AM BP was 104/63, PM BP was 108/62;*07/14/2025 - AM BP was held with no BP documented, PM BP was 107/54;*07/16/2025 - PM BP was 104/62;*07/21/2025 - AM BP was 120/53; and *07/22/2025 - PM BP was 81/41.2) Clonidine HCl 0.3 mg:*07/01/2025 - PM BP was 69/41;*07/02/2025 AM BP was 108/57;*07/04/2025 - PM BP was 102/63;*07/05/2025 - PM BP was 107/49;*07/06/2025 - PM BP was 95/53;*07/07/2025 - AM BP was 104/62, PM BP was 101/50;*07/08/2025 - PM BP was 100/50;*07/09/2025 - PM BP was 100/53;*07/11/2025 - AM BP was 104/63*07/14/2025 - AM BP was held with no BP documented, PM BP was 107/54;*07/21/2025 - AM BP was 120/53; and *07/22/2025 - PM BP was 81/41.3) Cozaar 50 mg:*07/02/2025 - BP was 108/57;*07/07/2025 - BP was 104/62;*07/11/2025 - BP was 104/63;*07/14/2025 - BP was 110/56; and *07/21/2025 - BP was 120/53.Record review of Progress Notes dated 07/01/2025 through 07/24/2025 gave no indication Resident #3's physician was consulted regarding the resident's patterns of low BP, and these three medications being held when the BP was outside prescribed parameters. 2. Record review of Resident #6's face sheet, dated 07/24/2025, indicated Resident #6 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included morbid obesity (a disorder that involves having too much body fat), and hypertension (high blood pressure).Record review of the significant change MDS assessment, dated 06/09/2025, reflected Resident #6 usually made herself understood and usually understood others. Resident #6 BIMS score was 14, which indicated her cognition was intact. Record review of Resident #6's comprehensive care plan 07/22/2025 indicated altered cardiovascular status related to hypertension. Interventions included to monitor/document/report to MD any signs/symptoms of altered cardiovascular status. Review of Resident #6's physician orders dated 07/01/2025 included spironolactone 50mg daily. The medication was indicated for hypertension and the physician order included (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 4 of 34 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 07/24/2025 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some parameters to hold medication for BP less than 110/60 or HR less than 55. Record review of the July 2025 MAR indicated on the following dates, Resident #6's spironolactone 50mg was held when vital signs were outside the prescribed parameters of BP less than 110/60 or HR less than 55:*07/01/2025 -BP was 106/62;*07/02/2025 - BP was 100/52;*07/04/2025 - BP was 106/52;*07/05/2025 - BP was 102/61;*07/06/2025 - BP was 103/54;*0707/2025 - BP was 97/49;*07/09/2025 - BP was 108/64;*07/14/2025 - BP was 92/54;*07/15/2025 - BP was 99/49; and*07/17/2025 - BP was 100/56.Record review of Progress Notes dated 07/01/2025 through 07/24/2025 gave no indication Resident #6's physician was consulted regarding the resident's patterns of low BP, and the spironolactone 50mg being held when the BP was outside prescribed parameters. 3. Record review of Resident #40's face sheet, dated 07/23/2025, indicated Resident #40 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included heart failure (a chronic condition in which the heart doesn't pump blood as well as it should) and hypertension (high blood pressure)Record review of the Quarterly MDS assessment, dated 05/22/2025, reflected Resident #40 usually made herself understood and usually understood others. Resident #40's BIMS score was 99, which indicated Resident #40 was unable to complete the interview. Record review of Resident #40's comprehensive care plan 05/09/2025 indicated give antihypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (a form of low BP that happens when standing up from sitting or lying down) and increased heart rate. Review of Resident #40's physician orders dated 07/01/2025 included amlodipine besylate 5mg daily. The medication was indicated for hypertension and the physician order included parameters to hold medication for BP less than 110/60 or HR less than 60. Record review of the July 2025 MAR indicated on the following dates, Resident #40's amlodipine besylate 5mg was held when vital signs were outside the prescribed parameters of BP less than 110/60 or HR less than 60:*07/01/2025 -BP was 99/59, HR 52;*07/02/2025 - BP was 106/54, HR 54;*07/03/2025 - BP was 128/57, HR 53;*07/04/2025 - BP was 122/59, HR 54;*07/05/2025 - BP was 118/54, HR 55;*07/06/2025 - BP was 103/54; HR 56;*07/07/2025 - BP was 129/48; HR 54;*07/09/2025 BP was 108/55; HR 52;*07/10/2025 - BP was 109/59, HR 57;*07/12/2025 - BP was 106/77,*07/13/2025 BP was 115/58, HR 55;*07/14/2025 - BP was 119/52, HR 53;*07/15/2025 - BP was 103/52, HR 55; *07/16/2025 - BP was 126/56, HR 55;*07/17/2025 - BP was 123/58; HR 53;*07/18/2025 - BP was 121/54, HR 57;*07/20/2025 - BP was 104/56, HR 57;*07/21/2025 - HR 55;*07/22/2025 - BP was 104/57, HR 56;*07/23/2025 - BP was 101/55, 54; and*07/24/2025 - BP was 100/54, HR 56.Record review of Progress Notes dated 07/01/2025 through 07/24/2025 gave no indication Resident #40's physician was consulted regarding the resident's patterns of low BP and/or HR, and amlodipine besylate 5mg being held when the BP/HR was outside prescribed parameters. During an interview on 07/24/2025 at 11:30 a.m., LVN B said the MAs were to inform the nurses anytime a resident's medication was held for any reason. She said she would go and assess the resident and notify physician. LVN B said nursing staff were to document in progress notes anytime a physician was consulted. LVN B said she was unaware of the quantity of times the BP medications were held. She said the physician should have been consulted regarding Resident #40's pattern of low BP and of medication being held. LVN B said not notifying the physician could affect Resident #40's overall health.During an interview on 07/24/2025 at 11:50 a.m., MA CC said anytime medications were held for any reason, the charge nurse was to be notified. She said Resident #40's BP tended to fluctuate, and the MD should be notified. She said if a resident's heart rate or blood pressure was outside parameters, she would recheck vital signs any notify the charge nurse. MA CC said the charge nurses would then assess residents and should notify physicians, especially if a pattern of being held was noted. MA CC said she had informed her charge nurse each time of Resident #40's medication being held due to low BP. During an interview on 07/24/2025 at 1:45 p.m., the DON said her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 5 of 34 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 07/24/2025 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 0580 Level of Harm - Minimal harm or potential for actual harm expectations were to make notifications to physician when vital signs were outside physician ordered parameters and to document notification and results in the resident's medical record. Review of a policy dated 01/2001 and titled Administering Medications indicated the following: . Medications will be administered in a timely manner and as prescribed by the resident's attending physician or the facility's medical director. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 6 of 34 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 07/24/2025 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 record review and interviews, the facility failed to assure that each resident receives an accurate assessment reflective of the resident's status at the time of the assessment for Resident #54. The facility failed to ensure Resident #54's Nursing admission Assessment was complete and reflected the resident's status at the time of the assessment. Resident #54's Nursing admission Assessment was incomplete due to unanswered medical history information. This failure could place the residents at risk for not receiving the appropriate care and services. Record review of Resident #54's face sheet, dated 07/18/2025, indicated a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included diabetes (too much sugar in the blood), obesity (a condition of having too much body fat, which increases the risk of health problems), insomnia (sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or both), and PPM (permanent pacemaker - a small battery-powered medical device that helps regulate the heart's rhythm by electrical impulses). Record review of the 5-day MDS showed in progress in Resident #54's clinical record due to the admission date of 07/18/2025. Record review of Resident #54's Nursing admission assessment dated [DATE] gave no indication of presence of PPM, including type or last checked. Resident #54 used a CPAP (continuous positive airway pressure machine used commonly for sleep apnea). The assessment gave no indication of the settings for the CPAP. The Nursing admission Assessment was based on specific questions related to an individual's overall health and medical history. Resident #54's admission Assessment was completed by the DON. Review of Progress notes indicated Resident #54 was admitted with redness to outer right ankle that was undocumented, and within 24 hours the skin had opened. Record review of Resident #54's admission Assessment indicated he had trouble falling asleep, and trouble staying asleep. The area to document sleep aides including medication, was left blank. Record review of Resident #54's admission Assessment physician orders indicated he had a prescribed medication for insomnia. During a phone interview on 07/23/2025 at 1:50 p.m., RN J said she had signed off on parts of Resident #54's Nursing admission Assessment as complete. RN J said when she had assessed the resident, he had a Stage 2 pressure sore to his right ankle, thick toenails, and what she described as a bunion to left lateral foot. During an interview on 07/23/2025 at 12:45 p.m., the DON said all fields of the Nursing admission Assessment for Resident #54, as well as all new admissions, should have been completed to reflect each resident's status. The DON said she had added to the admission Assessment as well. She said the weekend RN signed off on the completion of Resident #54's assessment. The DON said she was responsible for accuracy of assessments and Resident #54's admission Assessment was incomplete and not accurate in detailing his medical status. The facility did not have an assessment policy to review. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 7 of 34 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 07/24/2025 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care and the facility failed to provide the resident and their representative with a summary of the baseline care plan for 1 of 14 residents (Resident #54) reviewed for new admissions The facility failed to develop and accurately complete a baseline care plan within 48 hours of admission for Resident #54, and they failed to give a copy to him or his representative. This failure could lead to residents not receiving necessary care and decreased quality of life. Record review of Resident #54's face sheet, dated 07/18/2025, indicated a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included diabetes (too much sugar in the blood), obesity (a condition of having too much body fat, which increases the risk of health problems), insomnia (sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or both), and PPM (permanent pacemaker - a small battery-powered medical device that helps regulate the heart's rhythm by electrical impulses). Record review of the 5-day MDS showed in progress in Resident #54's clinical record due to the admission date of 07/18/2025. Record review of admission Order Summary dated 07/18/2025 indicated Resident #54 had physician orders for wound care to right ankle, barrier cream to buttocks, and open wounds on outer aspect of right ankle and outer aspect of left foot. He was to wear heel protectors bilaterally and utilize pillows to relieve pressure. Resident #54 was prescribed Eliquis (an anticoagulant blood thinner) for diagnosis of Atrial Fibrillation. Resident #54 was to receive Insulin daily as well as sliding scale insulin if needed. He was also to receive oral medication twice daily for diabetes. Resident #54 was prescribed a hypnotic medication at bedtime for diagnosis of insomnia. The baseline care plan dated 07/21/2025 for Resident #54 failed to contain the following required information:*Diabetic alert including specification of insulin, medications, and specific diet of low concentrated sweets. Resident #54 was a diabetic with prescribed daily insulin.*Anticoagulant therapy including prescribed Eliquis (blood thinner), did not address monitoring for signs of bleeding, safety measures.*Pressure sore including bilateral ankles and heel, protective boots worn in bed.*Gave no indication of Resident #54 having been on EBP due to wounds.*Failed to provide Resident #54 and his representative with a summary of the baseline care plan.Record review of a policy dated December 2016 titled Care Plans - Baseline indicated the following. 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within 48 hours of resident admission. 2. The interdisciplinary team will review the healthcare practitioner's orders (dietary needs, medications, routine treatment, etc) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to a) immediate goals based on admission orders, b) physician orders, c) dietary orders. 4.The resident and their representative will be provided a summary of the baseline care plan that includes but not limited to: a) the initial goal of the residents, b) a summary of the resident's medications and dietary instructionsDuring an interview on 07/24/2025 at 09:00 a.m., after reviewing Resident #54's baseline care plan together, the DON said the document should have contained dietary instructions, physician treatment orders, medication regime, especially insulin, and isolation status. The DON said all fields of the baseline care plan should be completed, a copy reviewed, signed by resident and his representative, and a copy provided to them. She said she knew it was due and was left incomplete due to survey team entering facility. The DON said potential risks for the resident would be to not receive adequate care and services necessary. The DON acknowledged the baseline care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 8 of 34 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 07/24/2025 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 0655 Level of Harm - Minimal harm or potential for actual harm was incomplete with accurate information regarding care for Resident #54 and a copy had not been presented to Resident #54 or his representative and should have been. The DON said she was responsible to ensure the baseline care plan was complete and completed timely. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 9 of 34 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 07/24/2025 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 - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 14 (Resident #41) reviewed for quality of care. The facility failed to ensure NP and MD was notified of UA/C&S results for Resident #41 on 01/11/25. The facility failed to ensure a urologist appointment was made for Resident #41 when he was seen at ER on [DATE]. The facility failed to ensure follow-up with the hospital's UA/C&S results on 07/07/25.An Immediate Jeopardy (IJ) was identified on 07/23/2025 at 4:50 p.m. The IJ template was provided to the facility on [DATE] at 5:17 p.m. While the IJ was removed on 07/24/2025, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.These failures could place residents at risk of delay in care, worsening of health conditions, adverse reactions, hospitalization, and death.Findings included: Record review of the face sheet dated 07/24/25 indicated Resident #41 admitted on [DATE], was a [AGE] year old male, with diagnoses including neuromuscular dysfunction of the bladder (bladder control problems caused by nerve or muscles) and a personal history of malignant neoplasm of prostate (cancerous tumor in the prostate [male gland]). Record review of the physician orders for July 2025 indicated Resident #41 had orders to change indwelling urinary catheter using a 22 Fr. with 30 ml bulb change every 30 days and Coude (catheter with curved or angled tip) catheter. Indwelling urinary catheter care every shift for prostate cancer with start date of 06/04/24. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #41 scored 14 on the BIMS (which indicates intact cognition) and had an indwelling urinary catheter. Record review of the care plans dated 06/19/25 indicated Resident #41 had indwelling urinary catheter and interventions included he was to receive catheter every shift and change catheter every 30 days. Record review of hospital records indicated Resident #41 was seen at ER on [DATE] for possible urosepsis (severe, life-threatening spreading illness caused by infection spreading in the body) or complex urinary tract infection with indwelling urinary catheter, was found to be hypotension low blood pressure). Resident #41 was treated with IV antibiotics and discharged on 11/21/24. Record review of Resident #41's laboratory results collected stat UA/C&S to rule out UTI on 01/11/25 at 7:00 a.m. and with date reported as 01/16/25 at 9:06 a.m. indicated the Urinary Pathogens & Antibiotic Resistance Genes Tested results of Proteus mirabilis (bacteria which frequently causes UTI) was detected at >100,000 CFU/ml. The Detailed Treatment Guideline Options for Proteus mirabilis recommendation was for treatment with antibiotics 100% listing the following recommended antibiotics: Ampicillin (penicillin antibiotic) , Ciprofloxacin (treats infections) and Levofloxacin (treats infections). Record review of emergency services dated 07/07/25 for Resident #41 indicated he was sent to ER for hematuria (blood in urine) and possible infection. Please call your urologist first thing in the morning to set up an appointment to be seen within the next 3-4 days. The notes indicated Resident #41 had a past medical history of stage IV prostate cancer in the nursing home presenting ED for traumatic Foley insertion resulting in hematuria (blood in urine) , denies hematuria prior to the catheter change.Urine was collected for UA and result indicated RBC and WBC were elevated and culture was requested. Record review of the culture and sensitivity that was performed at the ER for Resident #41 dated 07/10/25 was obtained by the DON on 07/23/25 and indicated a critical value - a positive urine culture for Proteus mirabilis. During an observation on 07/21/25 at 11:30 a.m., Resident #41's urine was cloudy, and the catheter bag tubing had whitish Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 10 of 34 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 07/24/2025 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few sediment. During an observation and interview on 07/22/25 at 4:30 p.m., LVN C said Resident #41's urine always looked cloudy and turbid (cloudy, hazy or milky). She said she had not called the physician about Resident #41's urine being turbid. During an observation and interview on 07/22/2025 at 5:35 p.m., the DON observed Resident #41's urine. The DON said Resident #41's urine looked bad. Record review of the NP note dated 03/14/25 indicated UA was completed and no new orders were given. The progress note did not contain evidence of when the UA was completed. During an interview on 07/22/25 at 5:47 p.m., the NP said the progress note she made dated 03/14/25 referenced the UA performed in November 2024. She said she was not aware of the positive UA with recommendations for antibiotics from January 2025. She said if she would have been notified or would have seen the lab results in the resident's chart, she would have had the facility call the resident's primary physician and the NP for that client and she would have notified them as well to prevent infection increasing and the resident could become septic. During interview on 7/22/2025 at 5:55 p.m., Resident #41 said he did not remember being offered a referral to urologist. He said he would not have refused a urologist appointment because he had one before. During record review and interview on 07/22/2025 at 6:15 p.m. the DON said Resident #41 was sent to the hospital on [DATE] for blood in his urine. The DON said she was unable to locate culture and sensitivity that was performed at the hospital in Resident #41's records. She said she would call the hospital for the results. She said her expectation was when the resident was readmitted to the facility, the nurses would have requested the complete hospital records and a few days later request the culture report. She said the records for Resident #41 did not contain any evidence they had made the urology referral or called the hospital for the culture report. She said there was an order for a referral to a urologist, but the resident's record did not contain any evidence of the referral being done. She said she would check into the referral and call the hospital for the results of the culture and sensitivity for the urinalysis completed at the hospital on [DATE]. During an interview and record review on 07/22/25 at 6:30 p.m., the DON said Resident #41 was not provided a urology consult because the resident had signed his name refusing to go to an appointment for a cat scan of his chest that was ordered in June. The note was dated 06/10/25. She stated, I told them (corporate) that this would not help. She said this note he signed from June was not valid and the resident should have been consulted about the urology consult. She said the appointment with urology should have been made for the resident at the time of his discharge from the hospital. During an interview on 07/23/25 at 10:44 a.m., Physician HH said he was not made aware of the UA/C&S results dated 01/11/25 and 07/07/25, and he probably would not had ordered any antibiotics unless the count was greater than 100,000. He said results could be the cancer or catheter. He said the facility should had referred Resident #41 to the VA urologist. During an interview on 07/23/25 at 11:27 a.m., Physician HH said he was not ordering an antibiotic when informed of the UA/C&S results were greater than 100,000 and said results could be related to catheter or the cancer. He said the urologist would follow up. Record review of nurse's notes dated 07/07/25 to 07/21/25 did not contain documentation of Resident #41 refusing the urologist appointment or documentation of nurse requesting or following up with the hospital for the culture and sensitivity on the UA performed at the hospital on [DATE]. During an interview on 07/23/25 at 1:21 p.m., the DON said she expected staff to notify her of labs ordered or if there was a consult ordered. She said the MD usually got copies of the hospital records - but when the resident returned from the hospital, staff should still follow-up with labs conducted at hospital, lab orders, or if hospital ordered a physician consult - so she could follow-up with it. She said she was not aware of the orders for Resident #41 from the hospital - and no staff notified her of the lab or urology consult. She said they did not have the UA C&S for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 11 of 34 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 07/24/2025 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #41 from his hospital visit on 07/07/25 - she would have to contact the hospital. She said not following up with these orders or notifying the MD could make the residents condition worse. She said if the nurse did not document the follow-up - it wasn't done. An Immediate Jeopardy (IJ) was identified on 07/23/2025 at 4:50 p.m. The IJ template was provided to the facility on [DATE] at 5:17 p.m. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 07/24/2025 at 9:13 a.m. and reflected the following: The following is a plan of removal, which was immediately implemented at facility, to remedy the Immediate Jeopardy which was imposed 07/23/2025 at 5:17 p.m. The POR indicated as follows: All items listed will be completed before 1:00 p.m. on 7/24/25 with continued follow-up for scheduled staff. Resident #41's physician was immediately contacted regarding the lab results from 7/7/25 and review of the resident's current condition for orders/updates. Resident #41's has been confirmed that he would go to a urology appointment and appointment to a urologist will be made today. All residents residing in the facility that currently have a urinary catheter will be reviewed for pertinent diagnosis and physician orders. The DON/Regional Nurse initiated an in-service regarding policy and procedure for urinary catheter care with licensed clinical staff. The purpose of the policy is to prevent urinary catheter infections for residents with urinary catheters. The DON/Regional Nurse initiated an in-service regarding policy and procedure for perineal care of the resident with a urinary catheter with certified nurse aide staff. The purpose of the policy is to prevent urinary catheter infections for residents with urinary catheters. The Regional Nurse initiated an in-service with the DON/ADON regarding assessment of a resident with urinary catheter as indicated in number 5 below to ensure the ADON and DON are competent in completion of the in- services for licensed clinical staff regarding assessment of the resident with a urinary catheter. The DON initiated an in-service regarding assessment of the urinary catheter with resident licensed nursing staff. The following learning objectives will be completed: A. Identify indications for urinary catheter use in long-term care. B. Demonstrate proper assessment techniques for residents with urinary catheters. C. Recognize signs of catheter-related complications or infections. D. Document catheter assessments accurately and consistently. A post - test will be completed with all licensed nursing staff and 100% grade will be achieved for compliance/completion. The DON initiated an in-service with all licensed nursing staff regarding physician notifications for change in condition with a focus on urinary catheter assessment and lab results. The purpose of the policy and in-service is to make sure the physician is promptly notified for resident's changes in condition upon assessment. The learning objectives include- A. What to notify the residents physician regarding, B. What constitutes a change in condition, C. What pertinent information to have ready from the SBAR completion, D. Who to notify regarding the change in condition, E. When to notify regarding a change in condition, F. Documentation. A post test will be completed regarding changes in condition that warrant physician notification for a resident with urinary catheters with licensed nursing staff. A 100% pass rate to be achieved for completion status. The DON initiated an in-service regarding order implementation post ER visits, hospital visits, MD appointments, or any entity that would change care. The in-service includes a focus on completion of orders as set forth by the physician and the process of implementing said orders for all licensed nursing staff and transportation aide. If staff are unable to attend any of the in-services, they will be required to complete the in-service before starting their assigned shift. Any agency staff will be in-serviced prior to the beginning of their shift. Any new hires will be in-serviced on hire, prior to working a shift. The Medical Director and other attending physician were made aware of the Immediate Jeopardy 7/23/25 at 6:10 p.m. and has been involved in developing the Plan of Removal. These conversations are considered part of the QA process. A QAPI meeting was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 12 of 34 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 07/24/2025 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few held on 7/24/25 with attendance of Administrator, Director of Nursing, MDS Coordinator, Regional Director of Clinical Services, and the medical Director via phone. This plan was initially implemented on 7/23/25 and will be monitored through completion by corporate and regional staff. Plan of Removal completion date is 7/24/25 by 1:00 p.m. with continuation of oncoming staff and follow-up. The surveyors confirmed the plan of removal as follows: Record review of the progress notes for Resident #41, Physician HH was notified of the laboratory of the culture and sensitivity from 07/10/25 by the DON on 7/24/25. Record review of 7 residents (Resident #3, Resident #6, Resident #11, Resident #18, Resident #31, Resident #41 and Resident #53) who had an indwelling urinary catheter for adequate diagnoses for the use of the indwelling urinary catheters, care plans updated as needed to include catheter care, monitoring and notify physicians as needed. Record review of training report dated 7/23/25 - 07/24/25 indicated the regional nurse provided training to the DON and ADON. During interview on 7/24/25 at 9:30 a.m., DON and ADON voiced the completion of training with the regional nurse. The training included assessment of a resident with urinary catheter, competent in completion of the in services for licensed clinical staff regarding assessment of the resident with a urinary catheter and for ensuring staff notify physicians as needed. Record review indicated licensed nurses were trained before their shift on the trainings listed below dated 07/23/25 to 07/24/25 and ongoing for staff not available at the time of training: 5 LVNs (LVN A, LVN B, LVN D, MDS, ADON) Licensed nursing staff were in serviced with training objectives of identify indications for urinary catheter use in long-term care. Demonstrate proper assessment techniques for residents with urinary catheters. Recognize signs of catheter-related complications or infections. Document catheter assessments accurately and consistently. Licensed nursing staff regarding physician notifications for change in condition with a focus on urinary catheter assessment and lab results. The learning objectives include- What to notify the residents physician regarding, What constitutes a change in condition, What pertinent information to have ready from the SBAR completion, Who to notify regarding the change in condition, When to notify regarding a change in condition, and documentation. Record review of the post-test indicated score of 100% was obtained of all staff available was 5 LVNs (LVN A, LVN B, LVN D, MDS, ADON), 6 CNA (CNA N, CNA P, CNA W, CNA X, CNA Y, CNA EE) and 2 MAs (MA CC, MA M). During interviews on 07/24/25 from 1:00 p.m. to 3:00 p.m. with 2 RNs (RN J, RN ZZ) 6 LVNs (MDS, LVN C, LVN D, LVN A, LVN L, LVN B) 11 CNAs (CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA W, CNA X, CNA Y, CNA EE and CNA YY) and 3 MAs (MA BB,MA CC, CNA/MA M). said they received the new training to report any changes or abnormal findings to the physicians, to monitor for UTIs, how to provide services for indwelling urinary catheter. Change of condition, SBAR forms and to report to the DON. The LVNs said they were retrained and were able to voice s/s of UTI, change of conditions, SBAR forms and to report to physicians and the DON. They were able to voice complication related to indwelling urinary catheters. They knew to check the documentation on readmissions and implement orders. The CNAs and MAs were able to voice procedures for indwelling urinary catheter care and who to report abnormal urine to the charge nurses and the DON. The staff said they completed the post-test and passed. During an interview on 07/24/25 at 3:30 p.m. the Medical Director's NP NN said her and the Medical Director were notified of the IJs and will continue to work with the facility with care and services. Record review of the Guidelines for Notifying Physician of Clinical Problems dated September 2017 indicated These guidelines are intended to help ensure that 1.) medical care problems are communicated to the medical staff in a timely manner efficient and effective manner and that 2) all significant changes in resident/ patient status are assessed and documented medical record. The immediate and non- immediate problems listed below listed below are not meant to be all-inclusive. The charge nurse or supervisor should contact (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 13 of 34 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 07/24/2025 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the attending physician if a clinical situation appears to require immediate discussion and management.Laboratory results . During an interview on 07/24/26 at 5:42 p.m., the Corporate Administrator, Corporate RN, the DON, and the Administrator were notified of lifting of both IJs. An Immediate Jeopardy (IJ) was identified on 07/23/2025 at 4:50 p.m. The IJ template was provided to the facility on [DATE] at 5:17 p.m. While the IJ was removed on 07/24/2025, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Event ID: Facility ID: 675484 If continuation sheet Page 14 of 34 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 07/24/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 14 residents reviewed for pressure sore management. (Resident #54)The nursing staff failed to document an accurate skin assessment and treat Resident #54's wounds from admission [DATE] through 07/23/2025.This failure could place residents at risk of not receiving appropriate care leading to worsening skin condition.Record review of Resident #54's face sheet, dated 07/18/2025, indicated a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included diabetes (too much sugar in the blood), obesity (a condition of having too much body fat, which increases the risk of health problems), insomnia (sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or both), and PPM (permanent pacemaker - a small battery-powered medical device that helps regulate the heart's rhythm by electrical impulses). Record review of the 5-day MDS showed in progress in Resident #54's clinical record due to the admission date of 07/18/2025. Record review of Resident #54's baseline care plan dated 07/18/2025 indicated redness to bilateral feet[VT1] . Record review of Resident #54's Weekly Ulcer assessment dated [DATE] indicated a Stage 2 pressure wound to right ankle measuring 2.5cm x 2.5cm x 0.1cm. [VT2] During an interview on 07/21/2025 at 08:21 a.m., Resident #54 said says he is was prone for sores and thinks thought he neededs a bigger bed as his feet have been like this - hanging on edge of the bed all weekend. He said he had a sore on his right ankle - admitted to the facility with it. He said he wasn't sure if he had any other areas. Resident #54's Weekly Skin assessment dated [DATE] indicated addition of pressure wound to right heel measuring 1.5cm x 2.5cm x 0.2cm. [VT3] Record review of admission Order Summary dated 07/18/2025 indicated Resident #54 had physician orders for wound care to right ankle, barrier cream to buttocks, and open wounds on outer aspect of right ankle and outer aspect of left foot. He was to wear heel protectors bilaterally and utilize pillows to relieve pressure. Record review of Resident #54's MAR indicated admission date of 07/18/2025. Beginning 07/21/2025, an order was started to cleanse wound to lateral right ankle with wound cleanser, pat dry, apply calcium alginate with silver, cover with dry dressing daily. Beginning 07/23/2025, an order was started for right heel which indicated to clean area, apply calcium alginate and cover with dry dressing. Also, for right heel - clean area, apply skin prep, wear bilateral boots to prevent further skin issues daily for wound healing. During an observation and interview on 07/21/2025 at 08:21 a.m., Resident #54 was observed lying in bed with heel protecting boots on both feet. He was in EBP - sign on door and PPE box inside room. Resident's feet in boots with heels hanging at the edge of the bed, slightly dangling off the end. Resident #54 said he was prone for sores and thought he needed a bigger bed as his feet have been like this - hanging on edge of the bed all weekend. He said he had a sore on his right ankle - admitted to the facility with it. He said he wasn't sure if he had any other areas. During an observation and interview on 07/22/2025 at 08:30 a.m., the ADON said she has not seen Resident #54 yet as he was just admitted Friday (07/18/2025) evening. She said she did not work yesterday (Monday). The ADON donned gown and gloves and placed wound care supplies on resident's overbed table. CNA Y at bedside dressed in PPE to assist with turn and reposition Resident #54 by holding his leg to allow observation and wound care. Boots removed. Dressing noted to right outer ankle and was removed. While observing foot, an open wound was noted on the back of the resident's right heel and was not covered. The wound was open with a whitish/yellow stringy like wound bed, covering approximately 75% of the wound bed. The rest of the wound bed was pale yellow in color and surrounding Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 15 of 34 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 07/24/2025 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 0686 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete skin appeared pale pink. The area was approx. the size of a nickel. Left outer foot with blanchable light pink area. The ADON applied skin prep to the area. She said this area would be closely watched but was not a pressure ulcer at this time. The ADON said she was not aware of this new area. The ADON said she was not sure if the admission nurse or weekend RN observed or assessed, and she was not sure who did his wound care yesterday (Monday 07/21). The ADON said she had not seen an order for this right heel wound or treatments on his orders. The ADON measured the area to be 1.5x 2.5 cm and said the white/yellow stringy wound bed was slough. She said he was wearing [NAME] boots -and they were not provided by the facility (he was admitted with them). The ADON removed her gloves and stepped outside of the room wearing the same gown to retrieve supplies from her cart. She reentered the room and donned gloves without hand hygiene. She cleaned the right heel with wound cleanser and applied silver alginate, covering with a dry dressing. The ADON said she would have to notify the Wound Care MD. She said he came to facility weekly and had not seen Resident #54 at this time. The ADON said Resident #54 had a physician order to consult the wound care physician. She said he was to assess Resident #54 this week when he made his weekly rounds. She said he did not have any areas on his buttocks that she knew of and nothing had been reported to her. CNA Y said she has not seen any open areas on Resident #54's buttocks. The ADON said in addition to being the ADON, she was the wound care nurse. The ADON said herself or Wound Care MD would measure resident wounds. A Charge nurse was to do wound care measurements if she was not there or if a new wound was found and she was not there. During an interview on 07/22/2025 at 10:35 a.m. LVN A said she had provided wound care to Resident #54's right outer ankle yesterday (07/21/2025) at the end of her shift (after 6 p.m.). She said she did not see any wounds on his right heel. She said there was not a dressing on his heel - just the ankle and she did not observe any other wounds when she did his right ankle. She said she followed the wound care assessment - and it only addressed the right ankle wound. She said she applied skin prep on his left outer foot - but for preventative. She said if a resident had a new wound - she would measure it and notify the wound care nurse (ADON). She said the charge nurse could do the initial assessment when it was discovered but had to notify the wound care nurse. LVN A said she would chart the new wound and notify the DON and MD. LVN A said she was not aware of any areas on his buttocks. Review of a policy dated October 2010 titled Wound Care indicated the following: . Documentation - following information should be documented in the resident's medical record: 5) any change in the resident's condition, 6) all assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound, 8) any problems or complaints made by the resident related to procedure. Event ID: Facility ID: 675484 If continuation sheet Page 16 of 34 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 07/24/2025 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 14 (Resident #24) residents reviewed for pain. The facility failed to administer Resident #24's pain medication for scheduled doses on 04/27/25 at 10:00 p.m., 04/28/25 at 8:00 a.m., 2:00 p.m. and 10:00 p.m.Resident #24's pain was not assessed 41 of 90 scheduled times of pain intensity level assessments for April 2025. This failure could place residents at risk for increased pain and decreased quality of life. Findings included: Record review of the face sheet dated 07/24/2025 indicated Resident #24 was admitted on [DATE], he was [AGE] years old with diagnoses including muscular dystrophy (genetic diseases that cause progressive weakness and loss of muscle mass) and abnormalities of gait and mobility. Record review of physician's orders dated July 2024 indicated Resident #24 had orders including Acetaminophen-Codeine Tablet 300-60 MG Give 1 tablet by mouth every 4 hours as needed for pain for use when out of Norco with start date of 04/28/25. Resident #24 had an order for Norco Tablet 7.5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth three times a day related to pain in unspecified joints with a start date of 7/02/2024. Record review of Resident #24's Quarterly MDS assessment dated [DATE] indicated the resident had a BIMS Summary Score of a 14 (cognitively intact). Resident #24 indicated the presence of pain was frequently. The last 5 days pain was frequently and often interfered with sleep. He rated his pain as a 7 on the pain scale. During last 7 days he received opioid medication. Record review of Resident #24's MAR dated April 2025 indicated Resident #24 did not receive his Norco on 04/27/25 at 10:00 p.m., 04/28/25 at 8:00 a.m., 2:00 p.m. and 10:00 p.m. Then 04/29/25 the Acetaminophen-Codeine Tablet 300-60 MG was given twice to Resident #24. Resident #24 pain level was not assessed and charted NA on the dates as follows: April 1 -April 7 at 8:00 a.m., NAApril 1- April 6 at 2:00 p.m., NA April 9- April 15 at 8:00 a.m., NAApril 9- April 15 at 2:00 p.m., NAApril 21- April 27 at 8:00 a.m., NAApril 21- April 27 at 2:00 p.m., NAApril 30 at 8:00 a.m. and 2:00 p.m., NA Record review of the care plan dated 06/20/25 indicated Resident #24 had muscular dystrophy and his goal was he will remain free from pain or at a level of discomfort acceptable to the resident. He had interventions of anticipate and meet his needs, call light is within reach and respond promptly to all requests for assistance. Give the analgesics as ordered by the physician. Monitor and document for side effects and effectiveness for Resident #24. During an interview on 07/21/25 at 10:00 a.m., Resident #24 said while residing in the facility, there were 4 times that he went without his scheduled Norco 7.5- 325 mg tablet dose. He said the nurses and med aides told him there was an issue getting the medication from the pharmacy. He was unsure which nurses or MAs he reported to, but he did not report to the DON or the Administrator. He was unable to give dates when he missed medication. During an interview on 07/21/25 at 2:00 p.m., MA BB said she had heard Resident #24 was out of pain medication 3 or 4 months ago. She said the nurses called the physician and they have some other medication to give him if they are out of Norco. She said the nurses have that on their cart. She said the MAs only give scheduled pain medication, not as needed. During an interview on 07/23/25 at 11:27 a.m., Physician HH said he had worked with the facility on ordering control medications early and gave an order for Resident #24 to have another medication if out of the Norco. He said if he was sick or out of town, the facility has another medication for pain. He said Resident #24 had chronic pain with his muscular dystrophy. During an interview on 07/24/2025 at 3:54 p.m., MA BB said she did not document the pain level for Resident #24, Sshe thought the nurses were supposed to ask and document the residents pain levels. She Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 17 of 34 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 07/24/2025 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete said she documented NA and thought it meant (not assessable). She said she had never been trained on assessing pain and was never told to chart pain level. During an Iinterview on 07/24/2025 at 4:00 p.m., MA CC said she documented the pain level and was taught in school and the facility trained her to document in the MAR. She said she had never seen others charting NA because you only see what you chart. She said if a resident was out of pain medication, she would notify the nurse to let her give another pain medication. During an interview on 07/24/25 at 4:10 p.m., LVN B said for Resident #24 if he runs out of Norco the MAs tell the nurse on duty and the nurse will give him the Acetaminophen-Codeine Tablet 300-60 MG. She said she had never seen him in severe pain or pain not being controlled. She said they always order medications early however the Norco required a triple prescription from the physician. During an interview on 07/24/25 at 4:16 p.m., the DON said she was not really sure if she was comfortable allowing MAs to ask residents about their pain level on the pain scale while administering routine pain meds. She said she has not made it clear what the expectations were for the MAs even though it was on the resident's MAR for the MAs to ask the resident about their pain level on scale. She said some might automatically do it based on what they either learned in school or what they did at their previous job. During an interview on 07/24/25 at 4:20 p.m., the Corporate RN said she would expect the MAs to ask residents their pain level on the pain scale as to assist the nurse with monitoring the pain. She said although the MA cannot assess the pain further - they help monitor for changes in the resident's levels and to notify the nurse for increase in levels. She said this assists monitoring the effectiveness of the routine pain med - so the MA can notify the charge nurse if the resident has increased pain - monitoring the effectiveness of the pain med. Record review of the Pain Clinical Protocol dated March 2018 indicated Assessment and Recognition I. The physician and staff will identify individuals who have pain or who are at risk for having pain. a. This includes reviewing known diagnoses and conditions that commonly cause pain; for example, degenerative joint disease, rheumatoid arthritis, osteoporosis (with or without vertebral compression fractures), diabetic neuropathy, oral or dental pathology, and post-stroke syndromes. b. It also includes a review for any treatments that the resident currently is receiving for pain, including complementary and non-pharmacologic treatments.The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity. a. Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. Monitoring I. The staff will reassess the individual's pain and related consequences at regular intervals, least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic. a. Review should include frequency, duration and intensity of pain, ability to perform activities of daily living (ADLs), sleep pattern, mood, behavior, and participation in activities. Event ID: Facility ID: 675484 If continuation sheet Page 18 of 34 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 07/24/2025 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 Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete 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 7 days a week for 1 of 4 quarters of 2024 and 2025 (Quarter 2 - January 01, 2025, through March 31, 2025) PBJ reports reviewed for RN coverage. The facility did not have RN coverage for 01/16/2025. This failure could place residents at risk of lack of nursing oversight and a higher level of care.Findings included: Record review of the CMS PBJ reports indicated:Quarter 2 2025 (January 01, 2025, through March 31, 2025) there were no RN hours on 01/03/25 (Friday), 01/10/25 (Friday), 01/16/25 (Thursday), 03/15/25 (Saturday), and 03/16/25 (Sunday). During an interview on 07/23/2025 2:06 p.m., the DON said she filled out a handwritten time sheet when she worked the floor as the RN supervisor. She said she had to work shifts on the weekends when the scheduled RN was not able to work. She said the facility worked very hard to have an RN 8 hours a day 7 days a week. During an interview on 07/23/25 10:30 a.m., Administrator provided RN time sheets for 8 hours coverage for 6/15/24, 06/16/24, 01/03/25, 01/10/25, 03/15/25, and 03/16/25. He said the facility did not have RN coverage for 01/16/25. During an interview on 07/24/2025 08:08 a.m., the Administrator said that the exit date of the last survey was 6/12/25 and the facility had tried after that exit date to have an RN present at the facility for 8 consecutive hours at the facility every day since that exit date. He produced sign in sheets indicating RN coverage for every day in the second quarter except 1/16/25. He said on 1/16/25 the RN that was scheduled did not call in or show up for work and there was not 8 hours of RN coverage at the facility for that one day. He said the PBJ data was submitted by the corporate office. He said his expectations were for the facility have 8 consecutive hours of RN coverage every day. he said the possible negative outcome of not having RN coverage was the nursing staff not having an RN supervisor for that day. Record review of an undated facility policy titled Staffing, . Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. An RN is available for coverage 8 hours a day 7 days a week. Event ID: Facility ID: 675484 If continuation sheet Page 19 of 34 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 07/24/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services to ensure the accurate administration of medications for 1 of 14 residents (Resident #54) reviewed for medication administration, in that: Resident #54 missed scheduled doses of 9 different medications due to availability from the pharmacy. This failure could place the residents at risk of not receiving necessary medications and a decline in health.Record review of Resident #54's face sheet, dated 07/21/25, reflected Resident #54 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included diabetes, obesity, insomnia (a sleep disorder characterized by difficulty falling asleep), and spondylolisthesis (a spinal disorder in which a vertebra slips forward onto the bone below it). Record review of the 5-day and admission MDS assessment were not available and were in progress due to new admission to facility on 07/18/2025. Record review of Resident #54's baseline care plan dated 07/18/2025 indicated diagnoses of diabetes and Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Record review of Resident #54's Order Summary Report indicated admission date of 07/18/2025. Physician orders included the following:*amlodipine besylate 2.5mg daily for hypertension;*carvedilol 3.125 mg daily for hypertension;*Eliquis 5mg every 12 hours for A-Fib;*furosemide 40 mg daily for heart failure;*gabapentin 300mg three times daily for pain;*insulin glargine 100units/ml - give 60 units at bedtime for diabetes;*lisinopril 40 mg daily for hypertension;*metformin 1000 mg twice daily for diabetes; and*zolpidem tatrate 10 mg at bedtime for 14 days for insomnia. Record review of Resident #54'sd MAR indicated admission date of 07/18/2025. On 07/19/2025, Resident #54 did not receive the prescribed medications due to unavailable from pharmacy:*amlodipine besylate 2.5mg;*aspirin 81mg;*carvedilol 3.125 mg;*Eliquis 5mg;*furosemide 40 mg;*gabapentin 300mg;*insulin glargine 100units/ml;*lisinopril 40 mg;*metformin 1000 mg; and*zolpidem tatrate 10 mg.Record review of Resident #54's MAR indicated these medications were not given. Resident #54's progress notes contained documentation the medications had not been delivered to facility at that time.Record review of the Emergency Medication Kit contents indicated amlodipine, carvedilol, Eliquis, furosemide, gabapentin, insulin glargine, lisinopril, metformin and zolpidem were available in the facility Emergency Medication Kit and were available for Resident #54. Aspirin 81 mg was a stock medication available as over-the-counter. The Emergency Medication Kit had a detailed list of medications available for review. The facility was required to notify pharmacy of any narcotic medications removed from kit, as well as document on form indicating what medications were removed.Record review of a policy dated April 2021 and titled Emergency Medications indicated the following.4. The contents of each emergency medication kit will be clearly listed. 7. Required documentation after dispensing an emergency medication is the same as for any other medication. 9. Medications and supplies used from the emergency medication kit must be replaced upon the next routine drug order. During an interview on 07/23/2025 at 1:50 p.m., LVN L said the medications were unavailable from pharmacy for Resident #54. LVN L said she had called the pharmacy twice on 07/19/2025 to inquire of delivery times. She acknowledged Resident #54 was without his morning medications on 07/19/2025. LVN L said she had not checked the emergency kit for medication availability. LVN L said Resident #54's medications were started on 07/19/2025 late in the day and the medications were started with the evening dosages. During an interview on 07/24/2025 at 9:40 a.m., the DON said the pharmacy requisition must be sent in daily to get the medications delivered on the same day in the evening. She said Resident #54 did not arrive to facility for admission until sometime after 5:30p.m. on 07/18/2025. The DON said they use medications, if available, from the emergency kit. The DON said the ekit had a list (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 20 of 34 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 07/24/2025 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 0755 of available medications attached to the container. The DON said she did not know if the prescribed medications for Resident #54 were available. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 21 of 34 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 07/24/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 1 treatment cart reviewed for storage of drugs and biologicals. The facility failed to ensure the treatment cart was locked and secured when left a medication cart unattended unlocked and unsecured on 07/22/25. This failure could place residents at risk of medication misuse or drug diversion. The findings included: Observation and interview on 07/22/25 at 8:09 a.m. revealed the treatment cart was left unlocked and unattended in front of the nurse's station, facing out into the main pathway where 2 residents were observed sitting in wheelchairs to the side of the treatment cart. Further observation revealed no staff at the nurse's station. The treatment cart contained antiseptic solution, which was labeled keep out of reach, 2 spray bottles of wound cleaner, bandages and dressings. The ADON walked up to the State Surveyor and said the treatment cart was left open by accident. The ADON said she was the last person using the treatment wound care cart. She said by the cart being open could result in someone coming by and getting something out of the cart. She said she had been trained on locking carts when finished using them. Record review of Storage of Medications dated November 2020 indicated The facility stores all drugs and biologicals in a safe, secure and orderly manner. 6. Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. Event ID: Facility ID: 675484 If continuation sheet Page 22 of 34 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 07/24/2025 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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 food that was palatable, attractive and at a safe and appetizing temperature for 1 of 2 meals (lunch) reviewed for palatability and temperature. The facility failed to provide food that was palatable and an appetizing temperature for 1 observed on 07/22/25 (lunch) meal. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: Record Review of the daily menu dated on 07/22/25, indicated the lunch meal (A) items included Swiss steak with gravy, roasted potatoes, mixed veggie, and iced tea. During an observation on 07/22/25 at 11:00 a.m., the plate warmer cabinet was not plugged in to the power source. During an observation and interview on 07/22/2025 at 12:25 p.m., the test tray had Swiss steak with gravy, roasted potatoes, mixed veggie. The DM measured temperature of the roasted potatoes at 108 degrees and said not warm enough. She said the food should be at least warm. During the tasting of the test tray the potatoes were not warm enough. The DM said [NAME] PP must had forgot to plug in the plate warmer. Record review of Resident #3's face sheet, dated 07/22/25, reflected Resident #3 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included diabetes (too much sugar in the blood), morbid obesity (a disorder that involves having too much body fat), and hypertension (high blood pressure). Record review of the quarterly MDS assessment, dated 05/21/2025, reflected Resident #3 usually made herself understood and usually understood others. Resident #3 BIMS score was 13, which indicated her cognition was cognitively intact. Record review of Resident #3's comprehensive care plan revised 07/22/2025 is at risk for unplanned weight loss or gain. Her intervention included determine food preferences and provide within dietary limitations. Encourage meal completion and document amount consumed. Review of Resident #3's physician orders dated 07/01/2025 included no salt on tray, low concentrated sweets diet with a start date of 02/25/2025. During an interview on 07/23/2025 at 4:00 p.m., Resident #3 had concerns about cold food on initial tour. She said the hot food would not even be warm and she had not reported to the facility. Team also received test trays to assess temperatures. Record review of the Food Preparation and Service dated November 2022 indicated . Food and nutrition services employee prepare, distribute and serve in a manner that complies with safe food handling practices.Food Distribution and Service 1. Proper hot and cold temperatures are maintained during food distribution and service. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 23 of 34 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 07/24/2025 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 14 residents (Resident #28) reviewed for meals. The facility failed to ensure that Resident #28 was served meat and vegetables that were the proper texture. This deficient practice could affect residents by placing them at risk for choking and weight loss. The findings were: 1.Record review of Resident #28's admission record dated 07/24/25 indicated Resident #28 was admitted on [DATE], was [AGE] year-old female with diagnoses of severe intellectual disability (delayed motor, language and social accomplishments), anxiety disorder (intense excessive fear), cognitive communication deficit (difficulties in communication), and dysphagia oropharyngeal phase (difficulty swallowing that originates in the mouth). Record review of the physicians' orders indicated Resident #28 dated July 2025 indicated the diet order with start date of 03/14/25 was low concentrated sweets diet mechanical soft texture, Regular consistency, ice cream with lunch and dinner, fortified food plan, divided plate and bedtime snack. Record review of the MDS dated [DATE] indicated Resident #28 cognitive skills for daily decision making were moderately impair ed. Resident #28's ability to make her needs known and ability to understand others, she was rarely/never understood and understands. Record review of the care plan dated 05/08/25 indicated Resident #28 was positive for PASRR related to intellectual disabilities. The resident requires extensive assist by 1+ staff to eat. The resident has impaired cognitive function/dementia or impaired thought processes related to severe ID. During lunch meal observation and interview on 07/21/25 at 11:15 a.m., Resident #28 held a spoon in her hand but would not eat the food. CNA N walked over and started cutting residents quarter and a half size meat. Chunks of meat noted on residents' plate were not softened. The zucchini and squash were not soft nor cuttable with spoon nor fork. CNA N said she noticed the resident was having a hard time with trying to eat so she came to cut up the meat into smaller pieces so she could eat, she said her meal ticket indicated mechanical soft. Record review of Resident #28's meal ticket indicated an ordered texture of mechanical soft diet. During an interview on 07/21/25 at 11:30 a.m., the DM said the meat in the bell pepper was ground beef, she said the meat should be smaller pieces, she said she was responsible to ensure her staff follow menus . During a record review and interview 07/21/25 at 1:00 p.m., the DM was holding the menu for mechanical soft diet which indicated the ingredients inside the stuff bell pepper should have been chopped. She said the ingredients inside the stuff bell pepper should had been chopped and vegetables could had been softer. Record review of the Mechanically Altered Textures dated 2019 indicated . Mechanically altered textures are available for persons having difficulty with chewing or swallowing as prescribed by their physician, speech therapist or registered dietitian. Dysphagia diets Used for residents with swallowing difficulties due to medical conditions such as stroke, degenerative diseases. MechSoft This is a step up from the pureed diet. Some chewing ability is required. The level 2 diet is for people with mild to moderate swallowing difficulty. This diet consists of foods that are moist, soft and easily formed into a bolus (soft wad of food). Avoid foods that are difficult to chew, dry and coarse. Meats should be ground or minced and should be keep moist with sauces and gravies. Mechanical / Ground Meat Entrees should be ground or chopped into bite size pieces. Most raw fruits or vegetables unless served finely chopped. FOOD ALLOWED Moistened ground cooked meat, poultry, or fish. Moist ground or tender meat may be served with sauce; well cooked pasta, protein salads without large chunks. All soft, well-cooked vegetables, should be easily mashed with a fork FOOD NOT ALLOWED Dry or tough meats, dry casseroles, or casseroles with large chunks. Event ID: Facility ID: 675484 If continuation sheet Page 24 of 34 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 07/24/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 1 of 1 main facility kitchen. The facility failed to ensure items stored in the refrigerator, and in the dry storage were labeled and discarded by the expiration date. The facility failed to ensure all staff wore hair restraints which covered all hair while in the kitchen. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During observations on 07/21/25 at 8:00 a.m., in the refrigerator revealed: white and yellow mushy substance in a 6 oz round container covered with tin foil in the fridge not labeled. 3 green jalapenos in a round 6 oz circle container uncovered and not labeled inside the refrigerator noted. During an interview on 07/21/25 at 8:20 a.m., [NAME] OO said the white and yellow mushy substance in a 6 oz round container covered with tin foil in the fridge not labeled and 3 green jalapenos in a round 6 oz circle container uncovered and not labeled should have not been in the refrigerator and should have been labeled if it was going to be stored in the facilities refrigerator. [NAME] OO said the risk of having non-labeled exposed food can spread germs and people wouldn't know how long it's good for. During an observation on 07/21/25 at 8:30 a.m., The dry storage area contained:a bag of opened potato slices had no use by or expiration date on bag;a closed bag of corn chips- use by date 07/14/2025; and an opened bag of cocoa baking powder was opened 10/14/2024 and had a use by date of 01/14/2025. Record review indicated the bag of cocoa baking powder once opened is only good for 8 months. During an interview on 07/21/25 at 8:50 a.m., the DM said she expected staff to have all items labeled and to throw away all expired items. She said had instructed the dietary staff on labeling and food storage. During an observation on 07/22/25 at between 11:00 a.m. to 12:00 p.m., Dietary staff JJ was cutting pies, and her hair restraint was not covering the lower 3 to 4 inches of her hair. The maintenance supervisor entered the kitchen walked past the steam table and food prep area then exited. He had no beard restraint covering his beard. During an interview 07/22/25 at 12:10 p.m., DM and Dietary staff JJ said the hair restraint had moved up while she was working. The DM said they all wear hair restraints to prevent hair from falling into the food. During an interview on 07/24/25 at 8:00 a.m., the Maintenance supervisor said he just forgot. He said he had a beard net on his desk and the DM had trained him. He was busy and just forgot. Record review of the Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices dated November 2022 indicated Policy Statement Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness.Hair Nets 15. Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens. Record review of the undated Food Storage indicated Food storage areas shall be maintained in a clean, safe, and sanitary manner. Prepared food stored in the refrigerator until service shall be dated with an expiration date. Such food will be tightly sealed with plastic wrap, foil, or a lid. Event ID: Facility ID: 675484 If continuation sheet Page 25 of 34 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 07/24/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 14 resident reviewed for infection control. (Resident # 3, #29, #37 and #54) The ADON failed to follow infection control procedures on 07/22/25 while providing wound care for Resident #3 who was on EBP. The ADON failed to follow infection control procedures on 07/22/25 after Resident #3's indwelling urethra catheter tubing disconnected from the urinary catheter bag tubing during wound care. The facility failed to ensure Resident #3 was placed in contact isolation on 07/22/25 and failed to ensure staff were made aware of Resident #3 requiring contact isolation until after surveyor intervention on 07/23/25. The ADON failed to follow infection control procedures on 07/22/25 while providing wound care for Resident #54 who was on EBP. CNA Y failed to follow infection control procedures on 07/23/25 while providing incontinent care for Resident #54 who was on EBP. MA CC and LVN D failed to follow infection control procedures on 07/23/25 while assisting Resident #54 who was on EBP. LVN A failed to follow infection control procedures on 07/22/25 when LVN A provided G-tube (a medical device that delivers liquid nutrition directly to the stomach) site care for Resident #29 who was on EBP. The ADON failed to follow infection control procedures on 07/22/25 when she assisted LVC with repositioning Resident #37 in bed who was on EBP. An Immediate Jeopardy (IJ) was identified on 07/23/2025. The IJ template was provided to the facility on [DATE] at 5:17 p.m. While the IJ was removed on 07/24/2025, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices. 1. Record review of Resident #3's face sheet, dated 07/22/25, reflected Resident #3 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included diabetes (too much sugar in the blood), morbid obesity (a disorder that involves having too much body fat), and osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wear down). Record review of the quarterly MDS assessment, dated 05/21/2025, reflected Resident #3 usually made herself understood and usually understood others. Resident #3 BIMS score was 13, which indicated her cognition was cognitively intact. Resident #3's MDS indicated she had an indwelling urinary catheter. Record review of Resident #3's comprehensive care plan revised 04/11/2025 reflected Resident #3 had an actual impairment to skin integrity MASD/fungal to right posterior thigh/buttock. Interventions included an indwelling urinary catheter for wound healing, keep in place until the MASD is well controlled per wound care physician, and may have low air mattress. Resident #3 had an indwelling urinary catheter due to skin breakdown initiated 04/08/2025. Interventions included position catheter bag and tubing below the level of the bladder, check tubing for kinks and maintain the drainage bag off the floor, and monitor/document for pain/discomfort due to catheter. During an observation and interview on 07/21/2025 at 09:30 a.m., Resident #3 had signage at entrance to room for EBP. There was PPE in a drawer inside of her room. Resident #3 was resting in her bariatric bed with a LALM. Resident #3 was morbidly obese. The indwelling urinary catheter was positioned on the side of the bed frame and was in a privacy bag to low gravity. The catheter tubing was noted to have white sediment throughout the tubing, unable to see through the tubing. The drainage bag had turbulent, pale yellow urine with sediment in the bag. Resident #3 said she had a UTI but was not taking antibiotics at the time. She said she had a wound to her buttocks. She was receiving daily wound Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 26 of 34 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 07/24/2025 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some care to the area. She said she had the urinary catheter due to her wounds to prevent areas from getting soiled with urine. During an observation and interview on 07/22/2025 at 10:53 a.m., the ADON gathered wound care supplies at the cart outside Resident #3's room. There was an EBP sign on the outside of the resident's door. The ADON entered the room and placed the wound care supplies on resident overbed table without a barrier or cleaning the table prior. Resident #3's room had a strong ammonia smell. CNA P and MA DD were assisting with positioning of resident for the wound care. Resident #3 was on her right side with the urinary catheter tubing under her right thigh, under the Hoyer lift pad, lift sheet and chuck pad. The urinary catheter tubing was filled with white sediment and the urinary catheter urine bag was on the bed. The urine in the bag was turbulent, pale yellowish.The ADON noted it to the CNAs and started trying to pull the tubing from under the resident's leg lifting the urine collection bag and tubing, attempting to remove it from under the resident's leg. While attempting to reposition Resident #3, the urinary catheter tubing that was inserted in her urethra was pulling taut under the resident's leg. The CNAs lifted Resident #3's leg and as the ADON unwrapped the tubing from under the resident's leg, urine sprayed across the room and the urinary catheter bag tubing was disconnected from the urethra tubing. Urine was leaked onto the resident's Hoyer lift pad and the bed. The ADON grabbed the bag tubing and urethra tubing. The ADON told CNA P to open the door and call out for alcohol pads. CNA P did not remove her gloves, and while wearing the same gloves, she opened Resident #3's door. After retrieving the pads from another staff, CNA P handed the pads to the ADON.The ADON, wearing soiled gloves, wiped both tubing tips with an alcohol pad and reconnected the tip of the bag tubing into the open port of the urethra tubing. CNA P said she emptied the resident's urine bag earlier and the urine has been looking the same for awhile.The ADON and CNAs assisted the resident with turning to her right side for the ADON to provide wound care. The ADON said the open areas on the resident's buttocks was from MASD -fungal. She removed the dressing from the resident's right buttock crease (where the upper thigh and buttock meet) and cleansed the right buttock open wound with gauze and wound care cleanser. The ADON then placed the soiled gauze on the resident's bedside table. She attempted to apply the collagen to the wound bed, but it stuck to her gloves. She removed her gloves and without hand hygiene, she stepped out of the room while wearing the same gown to retrieve more wound care supplies. The ADON donned gloves and covered right buttock wound. She wiped resident's left open left buttock MASD wound with gauze and wound cleanser placing the soiled dressing on the table again. The ADON applied the barrier cream with Nystatin powder to her left buttock rubbing it in the wound with her gloved hand. Using the same gloved hand, the ADON touched Resident #3's back, bed, and legs. She removed her gloves. While wearing the same gown and not conducting hand hygiene, she retrieved a catheter tubing anchor from her cart outside of the room, then donned gloves not washing her hands. The ADON applied the catheter anchor onto the resident's upper thigh and clipped catheter bag tubing into place. She then touched the soiled lines, picked up the soiled gauze from the resident's table, and placed the soiled tray on top of the resident's PPE cart inside the room. She removed her gown and put it in the resident's overflowing trash can. There were old gloves, paper towels, and the bag with soiled linen on the ground. The ADON did not sanitize the resident's overbed table and exited the room. CNA N entered the room to assist with transferring the resident from the bed to the wheelchair. CNA N said to the other 2 CNAs you can't put that dirty bag on the floor - it is infection control issues. CNA N asked CNA P and MA DD why the trash was overflowing onto the floor, and it was dirty. Resident #3 said she smelled pee. CNA P and MA DD indicated the pad was wet from the urine, removed the soiled lift pad, and without changing gloves put the new pad under the resident, touching the resident's body to position on the pad. While wearing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 27 of 34 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 07/24/2025 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the same gloves, CNA P and MA DD touched the lift and assisted Resident #3 with positioning into her wheelchair. During an interview on 07/22/25 at 12:00 p.m., the ADON said she should not have reattached the urinary bag tubing with the urethra tubing after it became dislodged. She said she should have removed it and reinserted a clean, sterile urinary catheter. She said she should have removed her gown before exiting the room, washed her hands, and donned new gloves throughout the procedure. She said she knew she should have, she just didn't. She said she should not have placed the soiled gauze on the resident's overbed table and should have sanitized it after care, but she did not. She said she was trained on Infection Control procedures recently and knew what she did was not preventing the spread of infections. She said she had not had any training in Wound Care, she just went off what she knew. During an interview on 07/22/2025 at 5:15 p.m., the DON said nurses should never reconnect indwelling urinary catheters. She said the nurse should have removed indwelling urinary catheter and reinserted a new one using sterile technique. She said she does not have to train nurses on basic nursing and infection control. Record review of Resident #3's UA results dated 07/22/2025 and electronically sent to facility at 5:08 p.m. indicated positive for multiple organisms including Escherichia Coli (a group of bacteria that CNA cause infection the urinary tract), Klebsiella Pneumoniae (bacteria in urine that indicates UTI) , Prevotella Bivia (bacteria commonly found in the female genital tract), Proteus Vulgaris (bacteria that CNA cause UTI and wound infections), and Pseudomonas Aeruginosa (bacteria that can CNA cause UTI, particularly in people with urinary catheters). Record review of Resident #3's July 2025 MAR indicated Contact Isolation for UTI was initiated 07/23/2025 at 06:00 a.m. During an observation and interview on 07/23/2025 at 08:40 a.m., the outside entrance to Resident #3's room gave no indication of being under Contact Isolation. EBP signage was posted to the left upper area of the door frame. CNA Y and CNA N were outside Resident #3's room and indicated the resident was on EBP. CNA N said Resident #3 had developed a foul odor and had episode of blood-tinged urine, and she had reported to the charge nurse. CNA Y said they were to receive report at the beginning of their shift from charge nurse and off-going aides' what type of isolation a resident required. MA CC walked up and asked CNA Y and CNA N if she needed a gown to enter Resident #3's room to administer her medications. CNA Y and CNA N pointed at the EBP signage at entrance to Resident #3's room. MA CC said she was not sure if was required. After surveyor intervention, CNAs Y and N went to speak to LVN B about her current isolation status. During an interview on 07/23/2025 at 09:00 a.m., LVN B told CNA Y and CNA N that Resident #3 had an UTI and was in Contact Isolation. LVN B said she had not had time to post the Contact Isolation signage this morning. She added she had failed to pass information to the aides earlier at shift change. She agreed the lack of communication, and no signage also meant the night shift possibly had entered Resident #3's room without proper PPE. During an interview on 07/23/2025 at 10:45 a.m., LVN B said she had been asked by the DON to check and see if Contact Isolation had been ordered for Resident #3 the previous evening. She said it had not been, so she wrote the order. She said she had failed to put the signage to entrance of Resident #3's door until surveyor intervention. During an interview on 07/23/2025 at 11:00 a.m., the DON said she had requested the previous evening shift to place Resident #3 on Contact Isolation. She said when she arrived at facility this morning at 06:30 a.m., Resident #3 did not have a Contact Isolation sign posted at her door. When asked how staff were informed of change in condition, isolation status, or type of isolation, she said the information was passed between staff at shift change. The DON said her expectations were for all staff to always follow Infection Control practices. She said this failure in communication could affect residents by spread of illness or infections. 2. Record review of Resident #54's face sheet, dated 07/21/25, reflected Resident #54 was a [AGE] year-old male, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 28 of 34 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 07/24/2025 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some admitted to the facility on [DATE] with diagnoses which included diabetes, obesity, insomnia (a sleep disorder characterized by difficulty falling asleep), and spondylolisthesis (a spinal disorder in which a vertebra slips forward onto the bone below it). Record review of the 5-day and admission MDS assessment were not available and were in progress due to new admission to facility on 07/18/2025. Record review of Resident #54's baseline care plan dated 07/18/2025 indicated redness to bilateral feet. The baseline care plan gave no indication of pressure sores or pertinent skin conditions. Record review of Resident #54's admission assessment dated [DATE] indicated he was alert, oriented to person, place, time, and situation. Answered questions appropriately. Understands verbal content and makes self-understood. Resident #54 noted to have unspecified skin problem to right foot and redness to outer left foot. Record review of Resident #54's Weekly Ulcer assessment dated [DATE] indicated a Stage 2 pressure wound to right ankle measuring 2.5cm x 2.5cm x 0.1cm. Resident #54's Weekly Skin assessment dated [DATE] indicated addition of pressure wound to right heel measuring 1.5cm x 2.5cm x 0.2cm. Record review of Resident #54's MAR indicated admission date of 07/18/2025. Beginning 07/21/2025, an order was started to cleanse wound to lateral right ankle with wound cleanser, pat dry, apply calcium alginate with silver, cover with dry dressing daily. Beginning 07/23/2025, an order was started for right heel which indicated to clean area, apply calcium alginate and cover with dry dressing. Also, for right heel - clean area, apply skin prep, wear bilateral boots to prevent further skin issues daily for wound healing. During an observation and interview on 07/21/2025 at 08:21 a.m., Resident #54 was observed lying in bed with heel protecting boots on both feet. There was an EPB sign on the outside of the resident's door. Resident #54 was lying in bed on back with HOB elevated >45 angle in a sitting up position. The bed was in a high position. Resident #54 was AAO and able to be interviewed. Resident #54's feet were in boots with heels hanging at the edge of the bed, slightly dangling off the end. Resident #54 said he was prone for pressure sores and thought he needed a bigger bed as his feet had been hanging on edge of the bed through the weekend. Resident #54 said he was admitted to the facility Friday evening/night and has been in bed all weekend. He said nobody had gotten him OOB as he was waiting on therapy to evaluate him before getting OOB. Resident #54 said he had a sore on his right ankle and had admitted to the facility with it. He said he wasn't sure if he had any other areas. He used a urinal but had leakage at times. During an observation and interview on 07/22/2025 at 08:30 a.m., the ADON said she has not seen Resident #54 yet as he was admitted Friday evening. She said she did not work yesterday (Monday). The ADON donned gown and gloves and placed wound care supplies on resident's overbed table. CNA Y was at bedside dressed in PPE to assist with turn and reposition of Resident #54. CNA Y held Resident #54's leg up to allow observation and wound care. Resident #54 was able to hold the grab bar but was unable to turn self without assist. Resident #54 needed full assistance by staff. The ADON repositioned the resident to left side. Resident #54 feet were in boots and were at the end of the bed. His boots were then removed. A dressing was noted to the right outer ankle and was removed. An open wound was noted on the back of the Resident #54's right heel. The wound was open with a whitish/yellow stringy like wound bed covering approximately 75% of the wound bed. The rest of the wound bed was pale yellow in color and surrounding skin appeared pale pink. The area was approximately the size of a nickel. Resident #54's left outer foot had a blanchable light pink area. The ADON applied skin prep and said this area was being watched but was not a pressure ulcer at this time.The ADON said she was not aware of this new area and was not sure if the admission nurse or weekend RN had observed or assessed it. She was not sure who did his wound care yesterday (Monday 07/21). The ADON said she had not seen an order for this right heel wound or treatments on his orders. The ADON measured the area to be 1.5x 2.5 cm and said the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 29 of 34 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 07/24/2025 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some white/yellow stringy wound bed was slough[JM7] . She said he was wearing [NAME] boots, and they were not provided by the facility (he was admitted with them). The ADON removed her gloves and stepped outside of the room wearing the same gown to retrieve supplies from her cart. She reentered the room and donned gloves without hand hygiene. The ADON cleaned Resident #54's right heel with wound cleanser and applied silver alginate, covering with a dry dressing. She said she would have to notify the Wound Care MD of the new wound. The ADON said Resident #54 had not been assessed by the Wound Care MD yet. She said he did not have any areas on his buttocks that she knew of, and nothing had been reported to her. CNA Y said she has not seen any open areas on Resident #54's buttocks. She said she only knew of areas to his feet. The ADON said in addition to being the ADON, she was the wound care nurse. She said she had been working as the charge nurse at night as well. The ADON said she had worked last night, and had stayed over for Wound Care MD to come do rounds. She added either herself or Wound Care MD does wound measurements. The ADON said the charge nurses were to do wound care measurements if she was not there or if a new wound was found and she was not there. During an observation and interview on 07/23/2025 at 2:00 p.m., CNA Y walked into Resident #54's room (on EBP) and was called out of the room by the DON who was passing in the hallway. The DON reminded her to don PPE before providing care. Resident #54 was sitting up in bed at a >45-degree angle with his feet hanging on the edge of the bed with boots on. CNA Y said she walked right by the sign not thinking and had not provided care yet. CNA Y donned PPE and assisted Resident #54 by herself to roll him to his right side. Resident #54 could only grab the grab bar and struggled to turn as CNA Y struggled to get him on his side. She said she was not sure if he was a 1-person or 2-person assist but he should be 2-person. Resident #54 had BM in his rectum and CNA Y told him she needed to clean him. CNA Y's gown was not tied and was hanging halfway down her scrub top as she grabbed wipes and began wiping feces from his rectum. CNA Y continued to wipe the BM while wiping his scrotum and in his skin folds without changing gloves. Resident #54 had a pinpoint open area on his right mid-buttock area near his buttock crease. It was open with red center and redness noted around the wound. Resident #54 told CNA Y it hurt as she wiped his buttock. She changed her gloves without performing hand hygiene. CNA Y then applied barrier cream to his open area and included his buttock, anal area, scrotum, skin folds. CNA Y touched his upper back, rubbing barrier cream on his upper back. CNA Y said she had not seen the open area as this was her first time providing care for him today. She said Resident #54 would use the urinal or if he needed the bed pan. CNA Y said she would give it to him, but she had not had to provide incontinent care today. She said she was not told of his buttock having any open areas and he had not reported anything to her. She said she would need to report it to the charge nurse. During an observation and interview on 07/23/2025 at 2:45 p.m., LVN D was called to the room. MA CC walked into Resident #54's room with her BP cuff to check resident vitals. CNA Y told her to put a gown and gloves on. MA CC said she did not see the sign as she walked right by it. Both MA CC and CNA Y said they were recently in-serviced on EBP and hand hygiene. MA CC checked the resident's BP with her cuff and asked out loud what should she do about the PPE. After removing the PPE, MA CC exited the room with the PPE and placed it in the trash in the hall. MA CC did not wash her hands. She placed the BP cuff on the handrail outside the Resident #54's door without sanitizing it. MA CC then reentered the resident's room to wash her hands. MA CC then picked up the BP cuff from handrail and carried it to another hall to her medication cart where she then pulled out sanitizer wipes to clean cuff. MA CC said she forgot about sanitizing the BP cuff until she was putting on the medication cart. LVN D entered the room and donned PPE. CNA Y donned another gown, but did not secure by tying it again. CNA Y pulled Resident #54 back onto his right side. LVN D said he needed to be 2-person assist and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 30 of 34 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 07/24/2025 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some pulled the pad with the CNA. CNA Y showed LVN D his buttock area, and LVN D said she could not see it. CNA Y pointed to the area again. LVN D said oh it is open and rubbed the open sore. She said it must have sloughed off and told CNA Y to rub barrier cream on it. CNA Y rubbed the cream on his buttock and touched the resident's scrotum area, checking under it. She did not change her gloves. CNA Y touched on Resident #54's back, bed linen, bedside table, and helped reposition him while wearing the same gloves. LVN D said it was a new open area and she would notify the ADON and call the provider. She did not measure it. She removed her PPE and walked out of the resident's room without conducting hand hygiene. LVN D then walked down the hall past the hand sanitizer on the wall and went to the nursing station. Along the way, she touched her phone in her pocket, items at the nursing station including computer and desk phone. LVN D said I should have changed my gloves prior to touching anything after touching his open wound on his buttock. LVN D said she should have washed her hands prior to walking out of his room. LVN D said she knew to do it, but she just didn't. LVN D said she was recently in serviced on Infection Control including EBP and hand hygiene. She said she would notify the ADON of the buttock area and give us copies of the orders and notes. 3. Record review of a face sheet dated 07/22/25 indicated Resident #29 was an [AGE] year-old female admitted to the facility 07/13/18. Her diagnosis included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dysphagia (difficulty swallowing foods or liquids) following cerebrovascular disease (a group of conditions that impact the brain's blood vessels and blood flow), aphasia (e disorder that affects a person's ability to communicate), and gastrostomy (the surgical opening (stoma) in the stomach, typically for a feeding tube). Record review of a care plan dated 01/30/25 indicated Resident #29 required enhanced barrier precautions related to wounds and a G-Tube. Goals included: enhanced barrier precautions would be performed daily with contact care. Interventions included: gloves and gowns would be used when performing contact activities. Record review of a significant change MDS dated [DATE] indicated a staff assessment for mental status indicated Resident #29 had severely impaired cognition, was dependent for all ADLs, and received all nutrition and water through her feeding tube while a resident at the facility. Record review of physician orders dated July 2025 indicated Resident #29 was NPO (nothing by mouth), Her G-Tube site was to be cleaned with normal saline and a clean dressing applied to G-tube site and secured with tape daily and as needed and required enhanced barrier precaution related to her wounds and G-Tube. During an observation on 07/21/25 at 8:14 a.m., Resident #29 was in bed in her room. A sign at her door indicated enhanced barrier precautions and to wear a gown and gloves for all direct contact care. Resident #29 was unable to respond to questions but did open her eyes when her name was called. She had a tube feeding of Isosource 1.5 cal running at 45ml/her per a feeding pump. During an observation of G-Tube site care on 07/22/25 at 11:14 a.m., LVN A washed her hands, gloved and sterilized the bedside table of Resident #29 and threw away her gloves. She exited the room, performed hand hygiene and applied a new pair of gloves and sterilized a small tray. She sterilized her hands, gloved, and collected her needed supplies and assembled them on the sterilized tray. She knocked and entered the room. She sterilized her hands and applied a new pair of gloves. She did not put on a gown as required by enhanced barrier precautions. During an interview on 07/22/25 at 4:10 p.m., LVN A said that she forgot to wear a gown while doing G-Tube site care for Resident #29. She said Resident #29 required EBP and a gown and gloves were required with direct contact care. She said the facility had trained her on the requirements of EBP and gloves and gown should be worn for all direct care. She said she forgot to wear the gown because she was being watched and she was in a hurry to get all her other tasks completed. She said the possible negative outcome for not wearing the gown could be cross contamination and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 31 of 34 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 07/24/2025 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some spread of infection to residents and staff. During an interview on 07/23/2025 12:25 p.m., the DON said a gown should have been worn to perform G-Tube care for Resident #29. She said her expectation was for all nursing staff to wear gown and gloves during close contact care including G-Tube care. She said all nursing staff are trained on EBP during orientation and annually after that. She said all nursing staff undergo skills check offs at orientation and annually and the check offs include appropriate use of PPE. She said the possible negative outcome for not wearing a gown during G-Tube care could be the spread of infection to other residents and staff. During an interview on 07/24/2025 8:57 a.m., the Administrator said the DON was the direct supervisor of all nursing staff. He said he expected all nursing staff to wear the appropriate gown and gloves when providing direct contact care to residents. He said the possible negative outcome of not wearing appropriate PPE during care could be the spread of infection. 4. Record review of Resident #37's face sheet, dated 07/23/25, indicated he was an [AGE] year-old male, admitted [DATE] and readmitted [DATE] originally admitted with diagnoses which included cerebral infarction (when a blood clot cuts off blood flow to an area of the brain leading to damage). Record review of the quarterly MDS assessment, dated 07/27/2025, indicated Resident #37 was severely impaired of cognition and total dependent for assistance with ADLs with diagnoses of cerebral infarct. Record review of Resident #37's comprehensive care plan revised 06/09/25 indicated he needed total dependency for ADLs and requires EBP to be used related to gastrostomy tube (a flexible tube surgically inserted through the abdomen and stomach wall to deliver nutrition and fluids directly to the stomach). During an observation on 07/22/2025 at 9:22 a.m., Resident #37's room had a sign indicating Enhanced Barrier Precautions beside the door with the Isolation cart filled with PPE inside the room near the door of Resident's #37's Room. LVN C was setting up her g tube medication to administer to Resident #37. She asked for a CNA to assist her pulling the resident up in bed and repositioning him. LVN C washed her hands and put on a pair of gloves. The ADON entered the room washed her hands and put on gloves and stood at the head of Resident #37's bed reached behind his back and grabbed the draw sheet as she was leaning her body against the resident's bed. LVN C grabbed the draw sheet on the left side of Resident #37's bed and the two staff members slid the resident up in bed and adjusted him in bed. The ADON started out the door and LVN C started putting on her gown and completed the medication pass without any other infection control concerns. LVN C said she was providing care for Resident #37 today and he was on EBP. LVN C said she should have put her gown on before assisting pulling the resident up in bed. She said she forgot about her gown when the ADON rushed into the room to assist her. LVN C said she was educated on EBP and should have worn her gown and gloves with direct patient care. She said the resident risk was potential infection. During an interview on 7/22/25 at 9:22 a.m., the ADON said she should have worn a gown along with her gloves when pulling Resident #37 up in bed and repositing him. She said Resident #37 was on EBP. The ADON was educated on EBP. She said the resident risk was infection. The ADON said she just did not think about it, she said she worked last night. During an interview on 7/23/25 at 11:12 a.m., the DON, said the ADON and LVN C should have worn a gown and gloves while providing high contact resident care for Resident #37 that was on EBP when pulling him up in bed and repositioning him in bed. She said all staff was educated on EBP with the most recent training on 7/11/25. The DON said the staff were not thinking and overlooked putting on their gowns. She said the resident risk of not wearing a gown for direct patient care for a resident on EBP was potential infection. The DON said the staff could pass an infection to him. She said her expectation was all staff follow EBP for all residents on EBP. During an interview on 7/23/25 at 8:45 a.m., the Administrator said the staff should not have provided direct patient care for Resident #37 without wearing a gown, he said it was an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 32 of 34 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 07/24/2025 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete oversite. He said all staff were educated on EBP. The Administrator said the resident risk of staff members providing high contact patient care on a resident with EBP precautions without wearing proper PPE was a potential infection. The Administrator said his expectation was all staff follow policy and procedures related to EBP. Record review of a facility policy dated August 2022, titled, Enhanced Barrier Precautions indicated, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showing; c. transferring; providing hygiene; changing linens; changing brief or assisting with toileting; g. device care or use ( . feeding tube, .) . 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. This was determined to be an Immediate Jeopardy (IJ) on 07/23/2025 at 5:17 p.m.]. The administrator and DON were notified. The administrator was provided with the IJ template on 07/23/2025 at 5:17 p.m.]. The following Plan of Removal submitted by the facility was accepted on 07/24/2025 at 9:13 a.m.:All items listed will be completed by 1PM on 7/24/25 with continued follow-up for scheduled staff.Resident #3 was placed in contact isolation and received catheter care and skin assessment to determine no negative outcomes.Resident #54 was assessed for skin and complications and determined no negative outcomes.Residents #29 and #37 were assessed for treatment area around g-tube and determined no negative outcome. All residents residing in the [Facility] that currently has a urinary catheter that were reviewed for complications related to urine such as urine color, smell and consistency by MDS nurse. Administrator/DON initiated an in-service regarding policy and proced Event ID: Facility ID: 675484 If continuation sheet Page 33 of 34 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 07/24/2025 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 so that the facility is free of pests for 1 of 1 kitchen reviewed for environmental conditions. The facility failed to have pest control effectively treat the kitchen for flies on 07/22/25 during lunch meal. This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life. Findings included: During an observation and interview on 07/22/25 at 11:35 a.m., Dietary staff JJ was cutting the pies and wrapping individual pieces for lunch, there were 3 flies flying around the prep area. A fly landed in the middle of the pie and DM saw the fly land on the pies, she went and stopped dietary aide JJ from using the pie the fly landed on. The DM placed the pie out of the way and said that will be thrown away. The DM said that every Friday the kitchen received groceries, and they fight flies several days after deliveries every week. The DM said she was not sure what else could be done for the flies. She said pest control company sprays every month, and they have a pest light to trap insects. She said she would report this to maintenance and the Administrator. The Pest Control Policy dated May 2008 indicated Policy Statement Our facility shall maintain an effective pest control program. 1. This facility maintains an ongoing pest control program to ensure that the building is kept free of insects. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675484 If continuation sheet Page 34 of 34