Inspection·February 26, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some nutrition directly to the stomach) in place. Mild redness was noted on buttocks. She had a left upper arm double lumen (two ports) PICC line (thin flexible tubing inserted into a vein in the upper arm threaded into a large vein above the right side of the heart). Record review of Resident #1's Change in Condition clinical notes dated 02/05/2024 at 1:49 pm, indicated the charge nurse, LVN A, was notified by the CNA that she found a wound on the resident's left buttock and some redness to her bilateral (both) heels. The note did not indicate if FM F was notified of the new wound. Record review of Resident #1's incident report dated 02/05/2024 indicated while the resident was getting her brief changed, the aide found a wound on the resident's left buttock. The incident report indicated the resident's Responsible Party was notified, listing FM G as the one notified. The incident report indicated the resident's doctor was notified. LVN A signed the note as the staff who notified the resident's Responsible Party. During an interview on 02/22/2024 at 10:20 am, LVN C said she worked 6 am to 6 pm on 02/08/2024 and when she came on shift at 6 am during her initial rounds Resident #1 was breathing heavy, increased respiratory rate and oxygen saturation (test that measures the amount of oxygen being carried by red blood cells) was 91%, notified on-call doctor and he ordered for her to be sent to local ER for evaluation. LVN C said she notified family but did not recall which family she notified. During an interview and record review on 02/26/2024 at 10:20 am, LVN A said she worked 6 am to 6 pm on 02/05/2024 when the aide told her Resident #1 had a wound on her left buttock. She said she went to resident's room to assess the wound and found an area the size of ½ dollar piece, that was reddish purple. She said she notified the ADON for a referral for wound care and completed an incident report for the new wound. LVN A said she notified FM G who was present in the room when she assessed the new area. She acknowledged she did not review the resident's chart to obtain the assigned representative, she said she assumed it was the FM G in the room. LVN A said she did not notify FM F, Resident #1's assigned representative, of the resident's change in condition. LVN A said that not notifying assigned representative of change in condition could put resident at risk for receiving care and representative aware of resident's condition. Record Review of Resident #1's Skilled Daily Nurse's Note dated 02/05/2024 authored by RN B at 7:55 pm, the Nurse Summary indicated a large deep tissue injury with open skin on top of the left buttock. The note did not indicate if FM F was notified of the wound. During an interview on 2/26/2024 at 9:32 am, RN B said she provided care for Resident #1 during the 6 pm to 6 am shift on 02/01/2024 and 02/05/2024. She said she admitted Resident #1 to the facility on [DATE] and she did not recall the resident having any open wounds upon admission. RN B said on 02/05/2024 she received report during shift change that during shower this AM, Resident #1 was found to have a new wound on her left buttock and was report to doctor. RN B said she completed a head-to-toe assessment of Resident #1 and observed the new wound on her left buttock, it was the size of a ½ dollar coin and was dark pink/purple area, with thin top layer of skin missing, and applied barrier cream. Record review of Resident #1's lab results collected on 02/02/2024 indicated abnormal lab results of RBC (Red Blood Cell count - tells you how many red blood cells you have) 3.4 (Reference range 4,14-5.8), low Hemoglobin (measures the level hemoglobin (a protein in your red blood cells that carries oxygen from your lungs to the rest of your body) in your body) of 8.7 (Reference range 13.0-17.7), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676109 If continuation sheet Page 2 of 11 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 676109 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Calder Woods 7080 Calder Beaumont, TX 77706 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 low Hematocrit (measures the proportion of red blood cells in the blood - red blood cells carry oxygen throughout the body) of 27.3 (Reference range 37.5-51.0). Record review of Resident #1's clinical notes dated 02/05/2024 authored by the ADON indicated: Received lab results; RBC of 3.4 (Reference range 4,14-5.8), low Hemoglobin of 8.7 (Reference range 13.0-17.7), low Hematocrit of 27.3 (Reference range 37.5-51.0); will fax and call the physician about the above results. There was no indication that Resident #1's representative was notified of the results/findings. Record review of Resident #1's Change in Condition clinical notes dated 02/08/2024 at 6:38 am, authored by LVN C, indicated the physician was notified of Resident #1 experiencing a change in condition with respiratory distress, the on-call physician ordered for Resident #1 to be sent to the ER. Notified Family. The note did not indicate if FM F was notified of the transfer. Record review of Resident #1's hospital records dated 02/15/2024 indicated on 02/08/2024 Resident #1 was seen through the emergency room and later admitted and diagnosed with aspiration pneumonia (occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed), UTI (infection in part of urinary system), pulmonary embolism (a sudden blockage in your pulmonary arteries, the blood vessels that send blood to your lungs), myasthenia gravis (a rare chronic autoimmune disease causing abnormal weakness of certain muscles), and stroke (s loss of blood flow to part of brain, which damages brain tissue). During an interview on 2/22/2024 at 11:59 am, Resident #1's FM F said Resident #1 went to the emergency room on [DATE] with respiratory issues where she was diagnosed with aspiration pneumonia and dehydration. She said the ER physician showed the family wounds and skin impairments. FM F said no one from the facility had called her (assigned representative) to let her know Resident #1 was having any skin issues on 02/05/2024. FM F said someone was typically at the facility every day for Resident #1, but it was usually FM G and he is older and had memory issues, hence why she was the assigned representative. FM F said she was not aware of the wounds or skin impairment until she was shown by the ER physician. FM F said the facility did not notify her of the resident being transferred the local ER on [DATE]. During an interview on 02/26/2024 at 3:20 pm, the DON indicated she did not know Resident #1's representative was not notified of the deep tissue injury on the resident's left buttocks and/or the abnormal lab results on 02/05/2024. The DON said LVN A notified her and the ADON about the deep tissue injury on the resident's left buttocks on 02/05/2024, but she did not realize FM G who was present during the assessment and findings of the wound, was not Resident #1's representative. The DON said facility staff should have verified the resident's representative and the resident representative should have been notified of the wound at the time of the assessment and review of lab results so they would know what was going on and the assigned representative should have been notified of Resident #1's transfer to local ER. Record Review of the facility policy titled Notification of Changes revised date 2/23/2024 indicated: Service Standard: Facility communities - will notify the resident/resident responsible representatives and attending physician of change in the resident's condition or status to obtain orders for appropriate treatment and monitoring and promote the resident's right to make choice about treatment and care preferences. 1. The nurse will immediately notify the resident/resident's responsible representative (consistent with his/her authority) and physician for the following changes (this list is not all inclusive). An accident involving the resident, which results in injury and has the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676109 If continuation sheet Page 3 of 11 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 676109 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Calder Woods 7080 Calder Beaumont, TX 77706 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 FORM CMS-2567 (02/99) Previous Versions Obsolete potential for required physician intervention. a significant change in the resident's physical, mental, or psychosocial status that is a deterioration in the health mental or psychosocial status in their life-threatening condition or clinical complication. A need to alter treatment significantly (a need to discontinue or change an existing form of treatment due to adverse consequences) or to commence a new form of treatment. Any lab results that fall out of clinical references range into a panic level. Radiology and other diagnostic reports that are significantly outside the clinical reference range and have the potential of needing an immediate alteration to the resident's current treatment plan. A decision to transfer or discharge the resident from the facility. 2. the nurse will notify the resident/resident representative and the resident's physician for non-immediate change of condition in a timely manner. 3. document the notification and record any new orders in the resident's medical records. Event ID: Facility ID: 676109 If continuation sheet Page 4 of 11 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 676109 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Calder Woods 7080 Calder Beaumont, TX 77706 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on interview and record review, the facility failed conduct initially a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity within 14 calendar days of admission, excluding readmissions in which there was no significant change in the resident's physical or mental condition for 2 of 7 residents (Residents #1 and #2) reviewed for comprehensive assessments and timing. The facility failed to ensure a MDS Assessment for Residents #1 and #2 was completed within 14 days after admission. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings included: Record review of Resident #1's face sheet dated 02/21/2024 reflected an admission date of 02/01/2024 with diagnoses that included Nontraumatic Subarachnoid Hemorrhage (bleeding in the space that surrounds the brain), Nontraumatic intracerebral Hemorrhage, Intraventricular (the eruption of blood in the cerebral ventricular system), Myasthenia Gravis (chronic neuromuscular disease that causes weakness in the voluntary muscles), Dysphagia (difficulty or discomfort in swallowing), Dementia (loss of cognitive functioning), and weakness to both legs. Record review of Resident #1's admission MDS indicated in Section A - A1600 Entry Date 02/01/2024 and Section Z Assessment Administration - Z0400 A. Signature of Persons Completing the assessment or entry/death report Signature: MDS Coordinator Title LVN, RAC-CT, Sections: A, C, D, B, E, F, J Date sections completed 02/05/2024 and Signature of Persons Completing the assessment or entry/death report Signature: MDS Coordinator Title LVN, RAC-CT, Sections: A,B , E, GG, H, I, J, K, L, M, N, O, P, Q, Z Date completed 02/20/2024. Z 0500 Signature of RN Assessment Coordinator Verifying Assessment Completion Signature as DON on 02/20/2024 (6 days late). Record review of Resident #2's face sheet dated 02/26/2024 reflected an admission date of 02/10/2024 with diagnoses that included Acute and Chronic Respiratory Failure with Hypoxia (a condition where you don't have enough oxygen in the tissues in your body), Atrial Fibrillation (a type of irregular heartbeat), Hypertension (A condition in which the force of the blood against the artery walls is too high), and Congestive Heart Failure (condition that happens when your heart can't pump blood well enough to give your body a normal supply). Record review of Resident #2's admission MDS indicated in Section A - A1600 Entry Date 02/10/2024 and Section Z Assessment Administration - Z0400 A. Signature of Persons Completing the assessment or entry/death report Signature: MDS Coordinator Title LVN, RAC-CT, Sections: A Date sections completed 02/16/2024, no additional signatures or sections identified as completed, no signature or date on Z 0500 Signature of RN Assessment Coordinator Verifying Assessment Completion. The admission MDS was not completed as of 2/26/2024. During an interview on 02/26/2024 at 1:11 pm, the MDS Coordinator stated she was responsible for completing all MDS assessments. The MDS Coordinator stated the admission MDS assessment should be completed within 14 days of admission. The MDS Coordinator stated, she is behind on completing MDS, she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676109 If continuation sheet Page 5 of 11 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 676109 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Calder Woods 7080 Calder Beaumont, TX 77706 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few has been out of the facility for training last week and she is the only staff member completing the MDS/comprehensive assessments, trying to get caught up. The MDS Coordinator said she was working on getting all the MDS/comprehensive assessments completed, the management staff and corporate staff would be helping with the completion of overdo MDS/comprehensive assessments. She said that the incomplete admission MDS could put the resident at risk for improper or incorrect care. She stated the facility followed RAI (resident assessment instrument). During an interview on 02/26/2024 at 3:45 pm, the Administrator stated the facility followed the RAI manual guidelines for MDS assessments. The Administrator stated she expected the admission MDS to be completed within 14 days. The Administrator stated the MDS Coordinator was responsible for completing all MDS assessments but would get staff to help complete overdo MDS assessments. The Administrator stated it was important to complete the MDS assessment timely to ensure the regulations were followed and residents receive proper care. Record Review of the facility's Minimum Data Set (MDS) policy and procedure, revision date of 01/23/2024, indicated Service Standard: facility retirement system communities will complete accurate resident assessments and submit assessments in accordance with current federal and state submission time frames. 1. All associates responsible for completion of the MDS will be educated on the proper assessment and date entry codes in accordance with the MDS RAI manual. 2. The MDS coordinator will ensure the appropriate edits are made prior to submitting the MDS data. 3. Timeframes for completion and submission of assessments is based on current requirements published in the Rai manual. Record review of the mds-3.0-rai-manual-v1.18.11_October_2023 indicated The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 if: -this is the resident' s first time in this facility, OR -the resident has been admitted to this facility and was discharged return not anticipated, OR -the resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676109 If continuation sheet Page 6 of 11 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 676109 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Calder Woods 7080 Calder Beaumont, TX 77706 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment or no more than 21 days after admission for 1 of 7 residents reviewed for comprehensive plans of care. (Resident #3) The facility did not develop a comprehensive care plan within 7 days of the completion of the comprehensive assessment or no more than 21 days after admission for Resident #3. This failure could place residents at risk of not receiving appropriate care and services. Findings included: Record review of Resident #3's face sheet dated 02/26/2024 indicated she was a [AGE] year-old female admitted on [DATE]. Her diagnoses included chronic obstructive pulmonary disease with (acute) exacerbation (a lung disease that blocks airflow making it difficult to breathe), pneumonia (an infection that inflames the air sacs in one or both lungs), gastro-esophageal reflux disease (stomach contents leak backward from the stomach into the esophagus (food pipe)), muscle weakness, limited activity due to disability, and cognitive communication deficit. Record review of the clinical record from 01/24/2024 to 02/26/2024 for Resident #3 revealed no comprehensive care plan. During an interview on 02/26/2024 at 1:11 pm, the MDS Coordinator said Resident #3's comprehensive care plan was not completed and said, must have missed it. The MDS Coordinator said she was in the process of completing overdo MDS and comprehensive care plans. She said the care plan was not completed and available to staff. She said the facility nursing staff (ADON, DON, or CN) usually reviewed and completed the care plans after they were initiated in the computer. The MDS Coordinator said not having a comprehensive care plan in the medical records could put the resident at risk for receiving appropriate and adequate care. During an interview and record review 02/26/2024 at 3:20 pm, the DON was unable to locate a comprehensive care plan for Resident #3 in the electronic medical record. The DON said when a resident admitted to the facility there was a basic care plan in the computer. She said once the MDS/Comprehensive Assessment was completed then an IDT/care plan meeting was scheduled, and a comprehensive care plan was developed and should happen within 7 days of the compressive assessment completion. She said Resident #3's comprehensive care plan should have been completed by no later than 02/13/2024. The DON said not having a comprehensive care plan could put resident at risk for not receiving care, missing care, or appropriate/adequate care. During an interview 02/26/2023 at 3:30 pm, requested a facility policy for comprehensive care plans and the Administrator said the facility does not have a policy for comprehensive care plans, they follow the RAI manual. Record review of the mds-3.0-rai-manual-v1.18.11_October_2023 indicated The care plan completion date must be no later than 7 calendar days after the comprehensive assessment completion date (CAA(s) completion date = 7 calendar days). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676109 If continuation sheet Page 7 of 11 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 676109 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Calder Woods 7080 Calder Beaumont, TX 77706 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 (Resident #1) of 7 residents reviewed for accurate medical records. The facility staff (RN B) failed to document on the admitting orders and MAR/TAR regarding Resident #1's indwelling Foley catheter care and maintenance, PICC line care and maintenance, and enteral feeding dosing upon admitting to the facility. The facility staff (LVN A) failed to document an accurate assessment of a new wound identified on 02/05/2024. The facility staff (RN B) failed to ensure physician's orders were written for removing a PICC line on 02/05/2024. These failures could place resident at risk of having errors in care and treatment decisions being based on incomplete and inaccurate medical records. Findings included: Record review of face sheet dated 02/21/2024 indicated Resident #1 was admitted on [DATE], was a [AGE] year-old female with diagnoses that included nontraumatic subarachnoid hemorrhage (bleeding in the space that surrounds the brain), nontraumatic intracerebral hemorrhage, intraventricular (the eruption of blood in the cerebral ventricular system), myasthenia gravis (chronic neuromuscular disease that causes weakness in the voluntary muscles), dysphagia (difficulty or discomfort in swallowing), dementia (loss of cognitive functioning), and weakness to both legs. Record review of Resident #1's hospital discharge instructions note dated 02/01/2024 indicated the resident's discharge diet was by tube feeding (G-tube - a tube inserted through the belly that brings nutrition directly to the stomach): Paptamen AF 95 ml/hr. Patient Discharge condition indicated the resident had a G-tube, indwelling Foley catheter (catheter inserted for continuous drainage of the bladder), and a double lumen (two ports) PICC line (thin flexible tubing inserted into a vein in the upper arm threaded into a large vein above the right side of the heart) to left arm upon discharge. Record review of Resident #1's initial MDS assessment dated [DATE], indicated the resident had a memory problem and cognitive skills for decision making were severely impaired. The resident did not have any pressure injuries at the time of admission. The resident had an indwelling urinary catheter and received nutrition through parenteral or tube feedings. Record review of Resident #1's chart reflected there was no comprehensive care plan developed. The initial care plan dated 02/02/2024 indicated the resident had an alteration/potential alteration in nutrition with goals to maintain weight and meet nutritional needs at highest practicable level. The interventions included for the resident to be NPO and a diet order for G-tube feedings of Isosource upon admission. The resident did not have any pressure injuries addressed on the initial care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676109 If continuation sheet Page 8 of 11 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 676109 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Calder Woods 7080 Calder Beaumont, TX 77706 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's MAR (Medication Administration Record)/TAR (Treatment Administration Record) indicated no orders, treatments or interventions for Resident's # 1 indwelling foley catheter, PICC line and enteral feeding dosing was documented upon admission to the facility. Record Review of Resident #1's Skilled Daily Nurse's Note dated 02/01/2024 at 7:30 pm, authored by RN B, the Nurse Summary indicated: Patient here from local hospital post fall/subarachnoid hemorrhage. The resident had a history of: dementia, Alzheimer's, subarachnoid hemorrhage, myasthenia gravis, stroke, and pulmonary embolism (a sudden blockage in your pulmonary arteries, the blood vessels that send blood to your lungs). The resident was NPO after failing a swallow study and had a G- tube. The tube was secured in place with an adhesive holder on the abdomen, abdominal binder covering G-tube site. The resident had an indwelling urinary Foley catheter and Podus boots (multi-purpose foot boot helps in the healing and prevention of hell and toe ulcers and safeguards against foot drop) on both feet to protect her heels. No breakdown was noted on her heels. Mild redness was noted on her buttocks. The resident had a left upper arm double lumen PICC line with the dressing in place. Record review of Resident #1's Skilled Daily Nurses Note from 02/01/2024 to 02/08/2024 indicated there was not a Skilled Daily Nurse's Note assessment completed on 02/02/2024, 02/03/2024, or 02/04/2024. There was no documentation to address the resident's tube feeding and dosing, skin assessment, indwelling Foley catheter care or maintenance, or of the resident's medical or non-medical status with positive or negative changes. Record review of Resident #1's Change in Condition clinical notes dated 02/05/2024 at 1:49 pm, indicated charge nurse, LVN A, was notified by the CNA that she found a wound on the resident's left buttock and some redness to bilateral (both) heels. Record review of Resident #1's Skilled Daily Nurses Note indicated there was not a skilled daily nurses note assessment authored by LVN A, nor a wound assessment completed on 02/05/2024 at 1:49 pm when the resident had a change in condition of a new wound on her left buttock. Record Review of Resident #1's Skilled Daily Nurse's Note dated 02/05/2024 at 7:55 pm, authored by RN B, Nurse Summary indicated: the resident received Isosource @ 95ml/hr with water flushes @ 60ml/hr every 3 hours. Moderate sized abdominal hernia visible. The abdominal binder covering the G-tube site was in place. The resident's indwelling urinary Foley catheter was in place. The resident had Podus boots on with no breakdown noted on heels. She had a large deep tissue injury with open skin noted to the top of her left buttock. She had a left upper arm double lumen PICC line the dressing secured. PICC line removed per physician's orders using aseptic technique. Record review of Resident #1's physician's order summary dated 02/26/2024 of all orders, indicated there were orders dated 02/02/2024 for Resident #1 to admit to the facility with orders for NPO, HOB at 45 degrees at all times, and to check G-tube placement, and G-tube feedings, flushes, and residual checks. Record review of Resident #1's physician orders from 02/01/2024 to 02/08/2024 indicated no orders in electronic medical records were found for eternal feeding type or dosing, indwelling Foley catheter care or maintenance, removal of the PICC line and/or new orders for treatment of a new wound identified on 02/5/2024. During an interview on 2/26/2024 at 9:32 am, RN B said she provided care for Resident #1 during the 6 pm to 6 am shift on 02/01/2024 and 02/05/2024. She said she admitted Resident #1 to the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676109 If continuation sheet Page 9 of 11 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 676109 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Calder Woods 7080 Calder Beaumont, TX 77706 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on [DATE] and she did not recall the resident having any open wounds upon admission. RN B said on 02/05/2024 she received report during shift change that Resident #1 had a new wound on her left buttock. RN B said completed a head-to-toe assessment on Resident #1 and observed a new wound on left buttock, it was the size of a ½ dollar coin and was dark pink/purple area, with thin top layer of skin missing. RN B said she received approval from the physician to discontinue the PICC line on 02/05/2024, but she said she forgot to write the order. RN B said she did not recall if she flushed or maintained the resident's PICC line between 02/01/2024 to 02/05/2024. RN B said on 02/05/2024 she assisted the CNA with repositioning the resident, assisting with care and applying the barrier cream on the resident's buttocks. RN B said an order should have been obtained or written to provide treatment/care to the wound on Resident #1's left buttock. During an interview on 02/26/2024 at 10:20 am, LVN A said she worked 6 am to 6 pm on 02/05/2024 and the aide came to her and told her Resident #1 had a wound on her left buttock. She said assessed the wound to be a reddish/purple area the size of ½ dollar piece. She said she applied barrier cream, notified the ADON for a referral for wound care, and completed an incident report for the new wound. She said she notified the family member who was present in the room about the new wound. She said that she should have completed a skilled assessment note which included a head-to-toe assessment. LVN A said she should have identified the wound and provided a better description and location of the wound, she should have completed a wound assessment sheet, and she should have obtained treatment/orders from the MD. During an interview on 02/22/2024 at 10:20 am, LVN C said she worked 6 am to 6 pm on 02/03/2024 and 02/04/2024 providing care for Resident #1. She said the skilled assessment notes were done daily and during shift change while providing report, the off-going nurse would inform the oncoming nurse which residents needed daily skilled assessments. She said Resident #1's assessment was usually done on the late shift because she was admitted during the late shift. LVN C said therapists worked with the resident during the day shift and the resident required maximum assistance for all care. LVN C said Resident #1 had a DTI on her left buttock and staff were applying barrier cream to the area. LVN C said she recalled flushing the resident's G-tube, caring for the G-tube stoma (an artificial opening made into a hollow organ, especially one on the surface of the body leading to the gut or trachea) site and check tube placement. LVN C said if any changes occurred during the shift, she would document it in the clinical notes section of the electronic medical records. During an interview on 02/26/2024 at 2:45 pm, the DON said her expectation was when new residents were admitted to the facility for skilled therapy, staff should complete a head-to-toe assessment, document all findings in the electronic medical records, and generate orders for all medications and treatments required. The DON said all skilled residents should have a skilled nurse note/assessment completed at least daily. The DON said Resident #1 did not have a skilled nurse note completed on 02/02/2024, 02/03/2024, 02/04/2024, or 02/07/2024 and was transferred to hospital on [DATE]. DON said that the expectation now is that skilled residents have a skilled nurse note/assessment completed each shift, so there is no confusion of who is responsible to complete the assessment. She said Resident #1 was admitted late in the evening on 02/01/2024. She said the ADON should have done a chart review of the new admission and should have noticed there was no order for tube feeding, PICC line care and maintenance, indwelling urinary Foley catheter care and maintenance missing from orders and addressed the issues with RN B. The DON said she in-serviced staff on 02/15/2024 regarding newly admitted residents and the admitting nurse was to complete a head-to-toe assessment of the resident and document in a skilled nurse note and identify any skin abnormalities and document. The DON said inadequate or lacking documentation could put resident at risk for not receiving appropriate care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676109 If continuation sheet Page 10 of 11 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 676109 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Calder Woods 7080 Calder Beaumont, TX 77706 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record Review of the facility Charting and Documentation policy and procedure, dated 10/11/2021, indicated: Service Standard: All services provided to the resident, progress toward care plan goals, or changes in the resident's medical, physical, functional, or psychological condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the intradisciplinary team regarding the resident's condition and response to care.1.The following information is to be documented in the resident's medical record: a. objective observations; b. medication administrated c. treatment or services performed; changes in the resident condition; e. events, incidents or accidents involving the resident and f. progress toward or changes in the care plan goals and objectives, 2. Documentation in the medical record will be objective, complete and accurate.5. Per BRS expectations, the clinical record must contain per shift charting of resident's condition for a minimum of 3 days following incident. Record Review of the facility Gastrotomy (G-tube) policy and procedure, revision date of 2/20/2018, indicated: Service Standard: G-tube orders will be written based on each resident's individual needs and will follow current standards for regulatory and best practice guidelines. Procedure: 1. Residents who are admitted to skilled nursing with a G-tube on admission or receive a G-tube after admission will receive physician orders specific to their individual needs. Physician orders should address any specific G-tube care the physician orders, irrigation, specifics about the enteral feeding including formula type method (i.e., pump, bolus), specific about medication administration flush orders including solution type and site care. Any additional needs specific to the G-tube will also be included in the resident's orders. This information should be documented in the residence care plan, and other areas of the clinical records as appropriate. Progress notes and updates will be documented accordingly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676109 If continuation sheet Page 11 of 11