Health inspection·May 22, 2023

F 0609 Record review of the facility's revised April 2021 Abuse, Neglect, Exploitation and Misappropriation Prevention Program, read in part: Level of Harm - Minimal harm or potential for actual harm Policy Statement Residents Affected - Few Residents have the right to be free from .neglect. Policy interpretation and implementation The resident .neglect prevention program consists of a facility-wide commitment .to support the following objectives: 1. Protect residents from .neglect .by anyone including, but not necessarily limited to: j. any other individual. Record review of the facility's revised September 2017 Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy and procedure, read in part: Policy Statement All reports of resident .neglect .are reported to local, state, and federal agencies (as required by current regulations) and . Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities 1. If resident .neglect .is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; 3. Immediately is defined as: b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Record review of the facility's revised December 2017 Unusual Occurrence Reporting policy, read in part: Policy Statement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676021 If continuation sheet Page 2 of 9 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 676021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clarewood House Extended Care Center 7400 Clarewood Dr Houston, TX 77036 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 0609 As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees, or visitors Level of Harm - Minimal harm or potential for actual harm Policy Interpretation and Implementation Residents Affected - Few 1. Our facility will report the following events to appropriate agencies: g. Allegations of abuse, neglect, and misappropriation of resident property; and h. Other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees, or visitors. 2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676021 If continuation sheet Page 3 of 9 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 676021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clarewood House Extended Care Center 7400 Clarewood Dr Houston, TX 77036 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 0921 Level of Harm - Immediate jeopardy to resident health or safety Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, interviews, and records reviewed, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 facility reviewed for safe environment. Residents Affected - Many The facility failed to ensure the lock for the emergency exit door was functioning correctly resulting in an armed intruder gaining access into the facility. An Immediate Jeopardy (IJ) was identified on 05/19/2023. While the IJ was removed on 05/22/2023, the facility remained out of compliance at a scope of widespread and severity of potential for more than minimal harm that is not immediate due to the facility's need to complete evaluate the effectiveness of the corrective systems. This failure placed residents at risk for serious physical harm, injury, emotional distress, or even death. Findings included: Observation on 05/18/2023 at 9:22 a.m. of the facility's double emergency exit door, revealed there were posted signs on the inside and outside that read STOP Emergency Exit Only Door is Alarmed. Surveyor lightly pushed on door and the alarm did not sound or stay locked. The Executive Director (ED), Director of Nursing (DON), and Maintenance Director (MD) observed and acknowledged the door did not retract and lock. Observation on 05/18/2023 at 6:49 p.m. of the facility's security footage, revealed a male intruder entered through an unlocked emergency exit door located in hallway 300 at approximately 1:29 a.m. Once inside the building he walked down the hallway toward the nurse's station. There were 3 Certified Nurse Aides (CNAs) CNA G, M, and P when he arrived at the station. CNA G left the area shortly after he arrived. CNA P left not long after CNA G, and CNA M stayed behind at the nurse's station with the intruder, until he was arrested. Before the police arrived on scene, the intruder was seen walking around the station and tried opening a couple of doors that were locked. Afterwards, he went behind the station, opened a lower cabinet door, and placed something inside (later identified as a handgun) and closed the door. He then laid down on floor, placed his finger up to lips, motioning to be quiet. He proceeded to crawl around on the floor, got up, left the gun inside the cabinet, and went back around to the other side of the nurse's station. The intruder then paced around the station. At one point, CNA M was seen opening the cabinet door where the gun was located and took a picture. Shortly after, the intruder walked down one of the hallways, police entered view, walked down the same hallway, and arrested the intruder. CNA M kept her distance throughout the event but never left the area. The entire incident lasted approximately 18 minutes. During an interview on 05/18/2023 at 8:05 a.m., the Executive Director (ED) said on 05/12/2023 at 1:30 a.m. an intruder entered the facility. He said the security footage caught the intruder jumping the facility's gate. He said the intruder appeared to be running behind the facility toward an exit gate. He said the intruder walked across the parking lot, ran toward the building, and entered an unsecured emergency exit door. He said the door was a permanently locked door. He said the door was only closed and not locked when the intruder entered the building. He said they conducted run, hide, fight video training in the past but could not recall the date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676021 If continuation sheet Page 4 of 9 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 676021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clarewood House Extended Care Center 7400 Clarewood Dr Houston, TX 77036 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 0921 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many During an interview on 05/18/2023 at 9:08 a.m., CNA P said she worked the night of the incident. She said she was at the nurse's station when she heard the door alarm sound. She said Nurse G was doing rounds and waived at her because they did not see anything. She said they sat down at the nurse's station and when CNA G went to check on a resident, they saw the intruder going toward hallway 100. She said she asked him if she could help him, but he put his hand on his mouth and said, shh. She said he told her something was wrong. So CNA M and her stayed at the station. She said he went to the medication room, but it was locked. She said he then went inside the nurse's station, so they sat down and looked at him. She said she asked him again if she could help and she said he told her to shut up. She said he sat down on floor, and she got up and went to the cafeteria and hid. She said not long after, CNA P and she went and hid in a linen closet. She said CNA P told her the intruder had a gun. She said she did not know how the intruder got into the building. She said when the door was not locked all the way, someone could go in or out. She also said it could be a danger to workers and residents. She said a resident could get out and people could get inside that were not supposed to be there. During an interview on 05/18/2023 at 10:35 a.m., the Maintenance Director (MD) said he believed the emergency exit doors being unlatched was a mechanical malfunction. He said he did not know how, why, or how long the door was unlatched. He said maintenance staff checked the doors weekly and said it was fine. He said if the door was not latched anything could have happened to staff and residents and depending on the scenario, they could become unsafe. During an interview on 05/18/2023 at 12:38 p.m., CNA J said she had been working at the facility since 2018 and worked the night of the incident. She said she was scared and did not know how the intruder got in the door. She said they could have gotten hurt, or an intruder could have killed anyone. She said security was responsible for making sure the door was latched. During an interview on 05/20/2023 at 1:42 p.m., Nurse L said she worked the night before the incident, 05/11/2023, and left around 9:30 p.m. She said she used the emergency exit door that the intruder made entry through when she left the facility. She said she used the keypad to bypass the alarm. She said she did not physically check and/or pull on the door to ensure it had locked back into place. She said she was not aware that there were any issues with the door. She said she knew better and should have used the main entrance to exit the facility. She said she took the chance because it was late at night, dark, closer to her office, and there had been big loose dogs roaming around in the past. She said she did not recall active shooter/armed intruder being covered in safety in the workplace or the facility's emergency preparedness plan training. During an interview on 05/20/2023 at 3:28 p.m., CNA N said she had been working at the facility for about 4 years and worked different shifts. She said she never received training over the facility's active shooter/armed intruder protocol and never heard of it before. During an interview on 05/21/2023 at 6:41 a.m., Nurse G said she worked the night of the incident. She said she was in a resident's room when she heard the door alarm sound. She said she went to the hallway, looked at the emergency exit door, but did not see anything or anyone. She said she walked to the nurse's station and when she was almost there, she saw the intruder looking and walking around. She said she asked him what was going on, but he ignored her. She said CNA M told her the intruder had a gun. She said CNA M told the intruder to lie down on the floor and that it was ok. She said she left the area and called 911. She said she did not know how the intruder gained entry through he emergency exit door. She said to her knowledge the door worked properly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676021 If continuation sheet Page 5 of 9 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 676021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clarewood House Extended Care Center 7400 Clarewood Dr Houston, TX 77036 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 0921 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many During an interview on 05/21/2023 at 10:21 a.m., Security Officer B said she worked the night of the incident. She said she checked the door after the police arrived and it was open. She said she was not responsible for monitoring the emergency exit door. She said when COVID-19 started, the ED took that door away from the officers to check. During an interview on 05/21/2023 at 12:13 p.m., the Human Resources Director (HRD) said new hire training did not include active shooter/armed intruder training. She said she turned her office upside down looking for sign in sheets but could not find documentation to show staff received the training. She said their security officers were trained by the company they worked for and not the facility. She said the risk posed to staff and residents was they needed to stay safe from anything and be trained for the worst. The ED was notified on 05/19/2023 at 1:23 p.m. that an IJ was identified due to the above failures. The IJ template was presented to the facility at this time. The facility's Plan of Removal was accepted on 05/19/2023 at 11:15 p.m. and included: Plan of Removal Name of facility: [Facility] Address: [address] Date: 5/19/2023

F921 Safe/Functional/Sanitary/Comfortable Environment Immediate action: - Emergency door was repaired by Maintenance Director with the help of professional from a local door company on 5/18/23; they adjusted the door closure mechanism and door threshold to ensure the door retracts to lock in place when opened and pushed lightly. - All facility staff are trained on Active Shooter training/intruder in the building in all three shifts by DON/ED/Maintenance Director. All scheduled staff since 5/15/23 were trained, the staff who missed the training due to being off or not scheduled will be completed by 5/22/23. staff acknowledged understanding verbally. Staff will be checked for written competency test, which will complete by 5/24/23. DON/ADON will administer the competency testing, staff must score 75% or above. The staff who do not meet passing score, will be retrained and re-tested until they pass. Facilities Plan to ensure compliance quickly: - Maintenance will inspect the door once per day to ensure the door remains safe and locked. The Maintenance staff will be responsible for maintaining the logs on a daily basis. Maintenance Director will audit the logs on a weekly basis. Any negative finding will be reported to Executive Director. QAPI will be developed for the compliance of door inspection and log maintenance. The local door company trained the Maintenance director and Maintenance director is training the maintenance staff on How to inspect the emergency doors to ensure that they are safe and locked Training will be completed by 5/22/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676021 If continuation sheet Page 6 of 9 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 676021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clarewood House Extended Care Center 7400 Clarewood Dr Houston, TX 77036 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 0921 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many - Security staff will ensure the emergency exit doors are locked every two hours. The logs will be maintained for every 2 hours checks beginning 6:00am and every 2 hours thereafter. The local door company trained the Maintenance director and Maintenance director is training the security staff How to inspect the emergency doors to ensure that they are safe and locked. Training will be completed by 5/22/23. The staff who missed the training due to being off or not scheduled will be trained by 5/24/23. - Door Lock Policy is developed as below; Maintenance Director is responsible for the policy implementation effective 5/19/23 ED will oversight the Maintenance Director to ensure he is implementing the policy. - [Facility] - Locked Door Policy Purpose In order to comply with Clarewood[facility]'s safety protocols and to prevent unauthorized access to the building, this policy provides guidance regarding all emergency exit doors remaining locked and secured at all times. Policy It is the policy of this facility to ensure the security officer on duty checks the emergency exit doors locked every two hours. Doors will be checked from inside of the facility. Emergency doors were previously checked every 8 hours, which is now changed to every 2 hours. - All facility staff are trained on below topics in all three shifts by DON/ED/Maintenance Director. All scheduled staff since 5/15/23 were trained, the staff who missed the training due to being off or not scheduled training will be completed by 5/22/23. staff acknowledged understanding verbally. Staff will be checked for written competency test, which will complete by 5/24/23. 3) Safety in Workplace - 5/19/2023 4) Door Lock Policy - 5/19/2023 - DON and ED held a meeting with staff to inform them about the incident and Plan of actions taken on 5/16/23 for the scheduled staff in all 3 shifts. For the staff who were not in attendance were sent a memo via e-mail about the Incident happened and plan of actions taken on 5/17/23. Staff are informed to contact Social worker for emotional support as needed. - Effective 5/19/23, below trainings are included in New employee orientation and Annual Mandatory in-service. The staff will be trained by HR or delegate which will be monitored by HR Director or delegate for timely completion. Competency test will be taken at the end of the training. DON/ADON will administer the competency testing, staff must score 75% or above. The staff who do not meet passing score, will be retrained and re-tested until they pass. Results will be shared with management and employees and QAPI committee. 5) Safety in workplace (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676021 If continuation sheet Page 7 of 9 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 676021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clarewood House Extended Care Center 7400 Clarewood Dr Houston, TX 77036 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 0921 6) Active shooter training/ Intruder in the building Level of Harm - Immediate jeopardy to resident health or safety [Executive Director Name] Residents Affected - Many Following the acceptance of the facility's Plan of Removal (POR), the facility was monitored from 05/20/2023 through 05/22/2023. Executive Director. Observation on 05/20/2023 at 1:15 p.m. revealed the Emergency Exit Door had been fixed and was working properly. Door was lightly pushed, and it retracted, locked, and the alarm sounded when opened. The key panel had been removed. During an interview on 05/18/2023 at 9:16 a.m., CNA B said she received active shooter/armed intruder training. She said they watched a video on how to respond in case an event was to occur. She verbalized an understanding of the training and how to respond. During an interview on 05/20/2023 at 12:09 p.m., Security Officer A said she worked the 7:00 a.m. to 3:00 p.m. shift. She said she received training, and it included what to do in the event of an active shooter/armed intruder. She said she would try to remember as many details as possible, run to a safe place, try to help others that are walking to safety, call 911 when she was in a safe place, turn off her cell phone, and if necessary, fight. She said she would barricade herself behind the doors and be quiet as much as possible. She said they also talked about making sure everything was visually safe. She said doors that should be locked must be kept locked and doors that must be unlocked needed to remain unlocked. She said they also talked about rounds and that they must be conducted every two hours and that they reviewed the lock door policy. During an interview on 05/21/2023 at 6:41 a.m., Nurse G said she received active shooter/armed intruder training. She verbalized and understanding of the training and how to respond. She said active shooter/armed intruder response included the following three steps: run, hide, and fight. During an interview on 05/21/2023 at 9:37 a.m., CNA A said she worked the 7:00 a.m. to 3:00 p.m. shift. She said she received active shooter/armed intruder training and that they reviewed the Locked Door Policy. She said the active shooter/armed intruder training included a video and the steps to take in case an event occurred. She said she needed to run, hide to protect herself, call 911 when she was safe, and if need be, fight. Record review of the facility's in-service training records related to active shooter training, dated 05/15/2023, 05/16/2023, 05/17/2023, and 05/18/2023 confirmed all staff were trained. The training included a video and competency test. Record review of the facility's door logs revealed security checks on the emergency exit doors were being completed every two hours. Record review of the door company's invoice revealed the emergency exit door was checked and fixed on 05/18/2023. An Immediate Jeopardy (IJ) was identified on 05/19/2023 at 1:23 p.m. The ED was notified on 5/22/23 at 10:52 am that the IJ was removed. While the IJ was removed on 05/22/2023, the facility remained (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676021 If continuation sheet Page 8 of 9 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 676021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clarewood House Extended Care Center 7400 Clarewood Dr Houston, TX 77036 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 0921 out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy with a scope of widespread. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676021 If continuation sheet Page 9 of 9