Health inspection·May 18, 2023

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 observation, interview, and record review 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 2 of 20 (Resident #3 and #41) residents reviewed for accuracy of MDS assessment. Residents Affected - Few Resident #3's and #41's MDS assessments accurately reflected the residents lack of natural teeth, tooth fragments, and/or dentures. This deficient practice could lead to diminished quality of life due to an inability to eat regular texture foods. The findings were: Resident #3 Record review of Resident #3's face sheet, dated 05/17/2023, revealed she was a 73- year-old female admitted to the facility on [DATE] with diagnoses including Close left fibula fracture (a type of fracture in which the broken bone does not penetrate the skin surface), cerebral infraction (A cerebral infarction, or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood), Type 2 Diabetes (a form of diabetes mellitus that is characterized by high blood sugar, insulin resistance, and relative lack of insulin), muscle weakness, and difficulty in walking and essential hypertension (high blood pressure). Record review of Resident #3's care plan updated 11/11/22 indicated that Resident # 3 had an oral denture health problem related to missing\missing\lose teeth. Observation and interview on 05/17/23 at 1:00 PM revealed Resident #3 had a mechanical altered diet for lunch. Observation revealed Resident #3 had missing teeth in her upper and lower mouth. In an interview at this time, she said her family were coming to visit. She did not follow interview but discussed her family's visit. She did not answer question about her teeth. Record review of Resident #3's significant change MDS dated [DATE], revealed a BIMS score of 3 which indicated severe impaired on cognition. Further review revealed in Section L: Oral/ Dental Status, boxes A-G were left blank. Box No natural teeth or tooth fragments was not checked and box Z: None of the above were present was checked indicating that the resident had no oral or dental concerns. Resident # 41 Record review of Resident #41's face sheet, dated 05/17/2023, revealed she was a 92- year-old female admitted to the facility on [DATE]. Her diagnoses including repeated falls, muscle weakness, major depression, dementia, adjustment disorder and difficulty in communication, muscle weakness, and difficulty in walking and essential hypertension (high blood pressure). Observation on 05/17/23 at 11:00 a.m. revealed resident #41 was sitting up in her room. Observation revealed she had no teeth in her mouth. During an interview she was alert and oriented to her name. During an interview she said she used to have dentures but did not know where they were. She said she ate soft food as much as she could. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676230 If continuation sheet Page 2 of 21 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 676230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #41's Significant change MDS dated [DATE], revealed a BIMS score of 5 which indicated severe impaired on cognition. Further review revealed Section L: Oral Dental, box A-G was left blank : No natural teeth, or tooth fragments not checked and box Z: None of the above was checked indicated that the resident #41 had no oral or dental concerns. During an interview with the MDS Coordinator on 05/17/2023 at 2:20 PM, the MDS Coordinator confirmed that resident # 3 had missing , cracked teeth and Resident #41 had no teeth. She said she was responsible for ensuring that the assessment accurately reflect the residents' status and an inaccurate assessment may result in residents not getting the necessary care and services needed. She said she was confused on how to code the dental section of the MDS. The facility's policy on accuracy of MDS assessments was requested on 05/25/23 at 11:00PM. She said she followed the RAI manual. Records review of the RAI manual dated 2017 revised October 2019 reflected in part-An assessment can identify periodontal disease that can contribute to or cause systematic disease and conditions, such as aspiration, malnutrition, pneumonia, endocarditis and poor control of diabetes. Coding Instructions o Check L0200A, broken or loosely fitting full or partial denture: if the denture or partial is chipped, cracked, uncleanable, or loose. A denture is coded as loose if the resident complains that it is loose, the denture visibly moves when the resident opens his or her mouth, or the denture moves when the resident tries to talk. o Check L0200B, no natural teeth or tooth fragment(s) (edentulous): if the resident is edentulous/lacks all natural teeth or parts of teeth. oCheck L0200C, abnormal mouth tissue (ulcers, masses, oral lesions): select if any ulcer, mass, or oral lesion is noted on any oral surface. o Check L0200D, obvious or likely cavity or broken natural teeth: if any cavity or broken tooth is seen. o Check L0200E, inflamed or bleeding gums or loose natural teeth: if gums appear irritated, red, swollen, or bleeding. Teeth are coded as loose if they readily move when light pressure is applied with a fingertip. o Check L0200F, mouth or facial pain or discomfort with chewing: if the resident reports any pain in the mouth or face, or discomfort with chewing. o Check L0200G, unable to examine: if the resident's mouth cannot be examined. o Check L0200Z, none of the above: if none of conditions A through F is present FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676230 If continuation sheet Page 3 of 21 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 676230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1of 5 residents (Resident #401) reviewed for ADLs. Residents Affected - Few The facility failed to ensure Resident #401 was provided personal grooming (shower and shaving) by facility staff. This failure could place residents at risk for discomfort, and dignity issues. Findings include: Resident #401 Record review of Resident #401's admission face sheet revealed an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included cerebral infraction (a result of disrupted blood flow to the brain), diabetes mellitus (the body does not make enough insulin or does not use it the way it should), atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup or plaque in the inner lining of an artery), and dementia (impaired ability to remember, think, or make decision that interferes with doing everyday activities ). Record review of Resident #401's admission MDS assessment, was not available because the resident was a newly admitted . Record review of Resident #401's care plan, initiated 05/10/23 and revised on 05/16/23, revealed the following: ADL self-care performance deficit related to dementia, weakness, mobility and CVA. Intervention: Bathing: staff will provide resident with required assistance needed for task. Personal hygiene routine: staff will provide resident with required assistance needed for task. During an observation on 05/16/23 at 11:38 a.m. revealed, Resident # 401 was in bed, had full white beard on his face, and appeared unkempt. During an interview on 05/16/23 at 11:39 a.m., Resident #401 said he had one shower since he came to the facility. Resident #401 had told the staff he wanted to be shaved , but it had yet to be done. Resident # 401 said he felt unclean and uncared for days and did not want his visitors to see him looking disheveled. During an interview on 05/16/23 at 11:40 a.m. Resident # 401's family member said Resident #401 had told the staff he needed to be shaved and showered, and she also asked the staff to shave the resident, but the aides had not saved the resident. She said she also asked the staff to give the resident a bath, but they had showered him but once, and he had the same clothes since the last shower, and it had been at least three to four days. During an interview on 05/16/23 at 1:00 p.m. LVN A said the night nurse told her Resident #401 had requested to be showered and shaved. She said the resident shower days was on Monday's, Wednesday's, and Friday's during the evening shift, and he would be showered by the aide tomorrow (05/17/23). LVN A said if Resident # 401 was not showered and shaved, it could affect how the resident felt about (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676230 If continuation sheet Page 4 of 21 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 676230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few himself. She stated the resident should have had three showers and shaved since he was admitted to the facility on [DATE]. She said Resident # 401 had a full face of hair, and he said he liked a clean shave. Record review of the facility shower binder for 200 hall with LVN A revealed one shower sheet dated 05/12/23 and there was no documentation on the shower sheet indicated that Resident # 401 refused to be shaved. During an interview on 05/16/23 at 1:05 p.m., CNA D said residents were showered three times a week and as needed. CNA D Resident # 401 had a full-face beard, and the nurse told her the resident wanted to be shaved and showered. CNA D said the resident shower was on the second shift on Monday's, Wednesday's, and Friday's. She said she would tell the evening aide to shower the resident. CNA D said if Resident #401 was not showered regularly and shaved, it could affect his dignity. CNA D was asked why Resident # 401 could not get a PRN shower today, according to what she stated, CNA D said if she had time today she would give Resident #401 a shower and shave him. When asked if she would have showered and shaved the resident if the surveyor did not mention it, CNA D did not respond. She said she had skills check-off on showers and shaving. She said the floor nurse monitored the aides to ensure they provided showers and grooming for residents. During an interview on 05/17/23 at 1:02 p.m., the DON said the residents should get showers three times a week and as needed. She said if the resident refused then the nurse should be informed. She said the nurse should try to see if the resident would take a shower and if the resident refused, it should be documented on the shower sheet, and the progress notes, and the family member would be notified. The DON said if Resident #401 refused a shower or shave the nurse should document and report to the RP. The DON stated the aide should record it on the shower sheet. The DON said it could be a dignity issue if Resident #401 did not get a shower or shave. During an interview on 05/18/23 at 2: 30 p.m. CNA E said she worked the 200 Hall and was the aide for Resident # 401. CNA E stated he got showered on Monday, Wednesday, and Friday. She said Resident #410 preferred a bed bath, and she bathed him once and did not shave the resident. She stated the resident refused to be shaved. CNA E said she reported to her nurse RN G and did not know if the nurse went and talked to the resident. She said she did not document on the shower sheet that the resident refused to be shaved. CNA E said she had an in-service on showering and shaving, and she was told to document it on the shower sheet, and she said she forgot to record it. However, the staffing coordinator did interpret for CNA E during the interview. During a telephone call on 05/18/22 at 2:58 p.m. RN G stated CNA E did not tell her Resident #401 refused to be shaved or showered. She said the resident was showered at least three times a week, and it would affect Resident #401's dignity because he would not feel clean but unkempt. Record review of the facility policy on ADL services revised 01/2020 reflected in part . procedures #2 . residents who are unable to catty out activities of daily living will receive necessary services to main grooming FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676230 If continuation sheet Page 5 of 21 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 676230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that a resident fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings, for 1 (Resident #77) of 3 resident that was reviewed for feeding tubes, in that: -The facility failed to ensure LVN C appropriately verified placement and amount of fluid to be used for Resident #77 during tube medication administration, lactulose 10gm/15ml, give 30 ml via g - tube one time a day. This failure could place residents at risk for adverse reactions, inadequate therapy, and a decreased quality of life. Resident #77 Record review of Resident #77's admission face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included cerebral infraction (a result of disrupted blood flow to the brain), gastrostomy (used to provide a route feeding to the stomach), dysphagia (impairment or difficulty in swallowing) and hypertension (blood is pumping with more force than normal through arteries). Record review of Resident #77's Quarterly MDS assessment, dated 01/30/23, revealed the BIMS score was 06, which indicated severely impaired cognition. Further review of the MDS revealed she required extensive assistance with one to staff assist with all ADLs. The resident had a g tube. Record review of Resident #77's care plan, initiated 01/30/22 and revised on 05/05/2022, revealed the following: Resident#77 required tube feeding related to dysphagia and CVA. Intervention: flush tubing with 5 ml - 10 ml of water between each medication. Record review of Resident # 77's medication review report for May 2023 reflected: Lactulose 10gm/15ml, give 30 ml via g - tube one time a day for constipation and order date was 05/12/22. Record review of Resident # 77's medication administration review report for May 2023 reflected: enteral feed order, every shift flush g - tube with 30 - 50 ml of water before and after medication administration, active date 01/28/22. The report further reflected, Enteral feeding order every shift check g - tube placement and patency prior to each feeding/flush/medication administration, active date 01/28/22. During an observation on 05/17/23 at 9:52 a.m., revealed LVN C inserted the syringe into Resident # 77 gtube, placed it close to her ear, and stated she was checking for placement, and she pushed in 5 cc of air into the g - tube. Then she flushed the tube with 10 ml of water before and after administering the medication lactulose 10gm/15ml, give 30 ml via g - tube one time a day. During an interview on 05/17/23 at 10:24 a.m., LVN C said she did not know why she placed the syringe to her ears or pushed five cc of air into the g - tube for a placement check. She said she did not know the quantity of air used to check for placement. She said if the tube was not flushed with the prescribed amount of water, some of the medication would be left on the tube, the resident would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676230 If continuation sheet Page 6 of 21 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 676230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not receive the prescribed dose, and the drug would not provide the required efficacy and the residue could clog the tube. LVN C said she had skills check off in medication administration which included g tube medication administration. During an interview on 05/17/23 at 3:16 p.m., the DON said LVN C should have checked for placement by pushing ten cc of air into Resident #77's tube and listened with a stethoscope. She said LNV C should use the amount of flush ordered by Resident #77's physician, and if there was no order, then she would have used the quantity of water per facility protocol or policy. She said if the water flush was not used properly, there might be some medication left in the tube. The DON said the flush was also calculated to the amount of water Resident #77 should receive daily because the resident was at risk for dehydration. She said she would review the resident's order and g - tube medication policy and get back to the surveyor. Record review of the facility policy on medication administration via feeding tube dated 1/2022 reflected in part . procedure #12 . check for proper placement of the feeding tube .#13 flush the feeding tube with at least 30 ml of water or other prescribed flush FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676230 If continuation sheet Page 7 of 21 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 676230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 ensure that a resident who needed respiratory care, which included tracheostomy care and tracheal suctioning, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences for 2 of 3 residents (Resident #88 and Resident # 6) reviewed for oxygen therapy. Residents Affected - Some The facility failed to ensure Resident #88's oxygen was set according to physician orders. The facility failed to ensure Resident #6's oxygen concentrator was functional, oxygen tank had oxygen and oxygen was set according to physician's order. These failures could place residents at risk of respiratory distress. The findings were: Resident #88 Record review of Resident #88's admission face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (inflammatory lung disease that causes obstructed air flow from the lung), Encephalopathy (any disease of the brain that attacks brain function or structure), pleural effusion (abnormal collection of fluid between the thin layers of tissue lining the lungs and the walls of the chest cavity), and acute respiratory failure (occur when your lungs cannot release enough oxygen into the bloodstream, and it also occurs when your lungs cannot remove carbon dioxide from your blood). Record review of Resident #88's admission MDS assessment, dated 04/05/23, revealed the BIMS score was 11, which indicated moderately impaired cognition. Further review of the MDS revealed It was not indicated Resident #88 used oxygen. Record review of Resident #88's care plan, initiated 04/07/23, revealed the following: Resident#88 has altered respiratory status/difficulty breathing related to COPD, respiratory failure, and pleural effusion. Intervention: oxygen at 2/min continues per nasal cannular . Record review of Resident #88's medication review report revealed oxygen at 2 liters per minute continuous per every shift for monitoring was dated 05/03/23. During an observation and interview on 05/16/23 at 12:37 p.m. revealed, Resident #88's oxygen concentrator was set to 3 liters, and the resident had a nasal cannula in her nostrils. Resident #88 said she did not know whatere her oxygen should be set at and did not change the setting. During an interview on 05/16/23 at 12:18 p.m., LVN A said she checked Resident #88 O2 sat at 8:30 a.m., and it was 95%. She said she did not check the oxygen setting on the concentrator . She said the nurse could increase the oxygen if the resident was in a crisis and then notify the doctor. She also said she did not get any report that Resident #88 was in distress during shift change. LVN A stated besides a crisis, the resident oxygen should not be changed without a doctor's order. She said it could cause more harm to Resident #88 because she had COPD. She said oxygen was considered medication, and a doctor's order was needed before it could be changed. She said the resident's oxygen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676230 If continuation sheet Page 8 of 21 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 676230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095 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 0695 should be set at 2 liters per minute. Level of Harm - Minimal harm or potential for actual harm Record review on 05/16/23 at 12:47 p.m., the surveyor and LVN A reviewed Resident #88 progress notes and SBAR from 05/09/23 to 05/16/23 which did not reveal the resident was in any crisis. Residents Affected - Some During an interview on 05/17/23 at 1:11 p.m., the DON said the nurse could change the oxygen from 2L/MIN to 3L/MIN in an emergency situation. She said she had not heard Resident #88 had any issues which would cause the oxygen to be increased. She said oxygen was considered medication and could only be changed with a doctor's order. She said if the resident had COPD, it would cause more harm than good. She said Resident #88 had COPD, and it caused the resident to go into respiratory distress because it could be hard for the resident to get rid of carbon dioxide. She said oxygen was medication, and a physician was needed before the oxygen setting could be changed. Resident #6 Record review of Resident #6's admission face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (inflammatory lung disease that causes obstructed air flow from the lung), emphysema (a disorder affecting the tiny air sacs of the lungs), dementia(The symptoms of number of illnesses that affect the brain and emphasis ability to perform everyday task) and acute respiratory failure (occur when your lungs cannot release enough oxygen into the bloodstream, and it also occurs when your lungs cannot remove carbon dioxide from your blood). Record review of Resident #6's Quarterly MDS assessment, dated 02/23/23, revealed the BIMS score was 02, which indicated severely impaired cognition. Further review of the MDS revealed Resident #6 was on oxygen therapy Record review of Resident #6's care plan, initiated on 01/11/23, revealed the following: Resident#6 has emphysema and COPD. Intervention: give oxygen therapy as ordered by the physician. Record review of Resident #6's medication administration record dated for May 2023 reflected oxygen at 2 liters per minute via nasal cannula PRN, keep oxygen saturation above 90%. During an observation and interview on 05/17/23 at 7:10 a.m. revealed Resident #6 was in bed and had a nasal oxygen cannula in her nostrils. She was not in distress. The oxygen concentrator was on, but the black flow ball indicator of where the oxygen was set was on 0. There was an oxygen tank hung on her wheelchair, and it was set at 3 liters, and the red indicator which showed how much oxygen was in the tank was on zero . Resident #6 was asked if she felt the air in her nostrils. The resident did not respond to this surveyor. O2 sats were not taken at this time. During an observation and interview on 05/17/23 at 7:25 a.m., LVN B said the O2 concentrator was on, the black ball indicator of where the oxygen was set was on zero, and she tried to adjust the oxygen, and the ball would not move up. She said the concentrator was not working because the flow dial would not move. She also said Resident #6 was not getting any oxygen. She said she was Resident # 6's nurse and had yet to check the resident's concentrator or oxygen saturation. LVN B said if the resident did not get oxygen, the resident could have hypoxia (lack of sufficient oxygen in the blood, tissue, and/or cells to maintain normal physiological function) and difficulty breathing. LVN B said she should have checked the setting on the concentrator when she made her rounds when she first came to work. She said she had an in-service and skills check-off for oxygen administration. She said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676230 If continuation sheet Page 9 of 21 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 676230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some because Resident #6 was not getting any oxygen from the concentrator or the oxygen tank and the setting on the tank was on 3 liters, then the physician's order was not followed. LVN B said she could not tell how long the oxygen was empty because this was the first time, she had seen it since she came to work at 6:00 a.m. During an observation and interview on 05/17/23 at 7:35 a.m., ADON A said Resident #6 was not hooked up to the concentrator but to the oxygen tank. She stated the concentrator in the resident room should be in good working condition, and the nurses should check the equipment during rounds. The ADON looked at the setting on the tank and said it was set at 3 liters. Then she looked at the oxygen quantity indicator and she said it was on red, and when she was asked what it meant, the ADON said the tank was empty. She said LVN B should ensure the tank had oxygen before the resident was hooked up to the tank. She said she could not tell how long the tank had been on red. She said Resident # 6 could have respiratory distress. She stated the ADON monitored the nurses by making rounds and asking the nurses about the resident's condition. She said if the tank was empty, the doctor's order was not followed, and the same applied to the concentrator that was not functional. During an interview on 05/17/23 at 1:17 p.m., the DON said LVN B should check the O2 sat, concentrator setting, oxygen tank setting, and amount of oxygen left in the tank at the same time. The DON said LVN B should check the concentrators throughout the shift when she rounded and at shift change. The DON said since the O2 tank was empty, Resident #6 was not getting any oxygen, which meant the physician's order was not followed. She said when the ball was on zero, it meant the concentrator was not functional. She said the setting on the oxygen tank was 3 liters per minute, and if it was not set at the prescribed liters, then the resident received more oxygen than ordered, and like another medication. She said i f the resident was in distress and needed more oxygen; the nurse could change it but had to notify the doctor and document it. The DON stated when the crisis was over, the oxygen would be reduced to the original order unless the doctor changed it. Record review of the facility's policy for licensed nurse procedures for oxygen administration, reviewed/revised 4/5/2023, reflected in part . oxygen therapy is administered, as ordered by the physician FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676230 If continuation sheet Page 10 of 21 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 676230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095 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 observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 2 of 10 residents (Resident #404 and Resident #77) reviewed for medication administration. -The facility failed to ensure LVN A followed proper medication administration of Enoxaparin (Lovenox ) injection to Resident #404. -The facility failed to ensure LVN C performed flushes as ordered during gastrostomy (G-tube) medication administration for Resident #77. These failures could place residents receiving medications at risk of adverse medication reactions. Findings include: Resident #404 Record review of Resident #404's admission face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. His diagnoses included hypertension (a condition in which the blood vessels have persistently raised pressure), diabetes mellitus (a disease the body does not control the amount of glucose in the blood) atherosclerotic heart disease (impairment or difficulty in swallowing) and peripheral vascular disorder (the reduced circulation of blood to body part, other than the brain or heart, due to narrowed or blocked blood vessel). Record review of Resident #404's care plan, initiated 05/16/23 , revealed the following: Resident #404 has actual impairment to skin integrity related to a surgical wound to the right groin. Record review of Resident #404's medication review report reflected Enoxaparin sodium solution 40mg/0.4ml, inject 40 mg subcutaneously (beneath, or under, all layers of the skin) one time to prevent blood clotting, active date 05/16/23. During an observation on 05/17/23 at 9:25 a.m., revealed LVN A pinched the skin right above the belly button, and it was not 2 inches away from the belly button; inserted the Enoxaparin at 90 degrees, released the pinched skin and administered the medication. During an interview on 05/17/23 at 9:40 a.m., LVN A said she did not know why she released the pinched skin during a subcutaneous medication administration. LVN B did not know the clinical indication of holding the pinched skin while she administered the medication. She also said she did not know how inches away from the belly button before the injection could be administered. LVN B said she had a medication skills check-off on injection administration but could not remember if there was a clinical indication of pinching the skin and how many inches away from the belly button. During an interview on 05/17/23 a 4:22 p.m., the DON said subcutaneous injections should be injected to the lower quadrant of the abdomen away from the umbilicus (the depression in the center of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676230 If continuation sheet Page 11 of 21 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 676230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095 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 surface of the abdomen) and the skin pinched while medication was administered. The DON said the medication should be given to the fatty tissue because they didn't want the drug in the blood, and the fatty tissue had less blood supply, and it would not bruise the muscle. She said LVN A did not follow the correct injection procedure for Lovenox, but she would review the injection policy and get back to the surveyor. Residents Affected - Few Resident #77 Record review of Resident #77's admission face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included cerebral infraction (a result of disrupted blood flow to the brain), gastrostomy (used to provide a route feeding to the stomach), dysphagia (impairment or difficulty in swallowing) and hypertension (blood is pumping with more force than normal through arteries). Record review of Resident #77's Quarterly MDS assessment, dated 01/30/23, revealed the BIMS score was 06, which indicated severely impaired cognition. Further review of the MDS revealed she required extensive assistance with one to staff assist with all ADLs. The resident had a g tube. Record review of Resident #77's care plan, initiated 01/30/22 and revised on 05/05/2022, revealed the following: Resident#77 required tube feeding related to dysphagia and CVA. Intervention: flush tubing with 5 ml - 10 ml of water between each medication. Record review of Resident # 77's medication review report for May 2023 reflected: Lactulose 10gm/15ml, give 30 ml via g - tube one time a day for constipation and order date was 05/12/22. Record review of Resident # 77's medication administration review report for May 2023 reflected: enteral feed order, every shift flush g - tube with 30 - 50 ml of water before and after medication administration, active date 01/28/22. The report further reflected, Enteral feeding order every shift check g - tube placement and patency prior to each feeding/flush/medication administration, active date 01/28/22. During an observation on 05/17/23 at 9:52 a.m., revealed LVN C inserted the syringe into Resident # 77 gtuber, placed it close to her ear, and stated she was checking for placement, and she pushed in 5 cc of air into the g - tube. Then she flushed the tube with 10 ml of water before and after administering the medication lactulose 10gm/15ml, give 30 ml via g - tube one time a day . During an interview on 05/17/23 at 10:24 a.m., LVN C said she did not know why she placed the syringe to her ears or pushed five cc of air into the g - tube for a placement check. She said she did not know the quantity of air used to check for placement. She said if the tube was not flushed with the prescribed amount of water, some of the medication would be left on the tube, the resident would not receive the prescribed dose, and the drug would not provide the required efficacy and the residue could clog the tube. LVN C said she had skills check off in medication administration which included g tube medication administration. During an interview on 05/17/23 at 3:16 p.m., the DON said LVN C should have checked for placement by pushing ten cc of air into Resident #77's tube and listened with a stethoscope. She said LNV C should use the amount of flush ordered by Resident #77's physician, and if there was no order, then she would have used the quantity of water per facility protocol or policy. She said if the water flush was not used properly, there might be some medication left in the tube. The DON said the flush was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676230 If continuation sheet Page 12 of 21 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 676230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095 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 also calculated to the amount of water Resident #77 should receive daily because the resident was at risk for dehydration. She said she would review the resident's order and g - tube medication policy and get back to the surveyor. Record review of the facility policy on subcutaneous injections dated 2001 MED -PASS, Inc. (Revised April 2011, May 2023) reflected in part . steps in the procedure . #8 . pinch skin with nondominant hand Record review of the facility policy on medication administration via feeding tube dated 1/2022 reflected in part . procedure # 12 . check for proper placement of the feeding tube .#13 flush the feeding tube with at least 30 ml of water or other prescribed flush Record review of the facility policy on pharmacy services Revised 5/2007 reflected in part . it is the policy of this facility to provide pharmaceutical services including . dispensing, and administering of all drugs . to meet the needs of each resident FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676230 If continuation sheet Page 13 of 21 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 676230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095 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 0759 Ensure medication error rates are not 5 percent or greater. 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 ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 7%, based on 2 errors out of 26 opportunities, which involved 2 (Residents #77, and Resident #4) of 10 residents reviewed for medication errors. Residents Affected - Some -LVN C left 5 ml of lactulose in the portion cup after the medication was administrated through a g - tube to Resident #77. -MA F administered eye drops to both eyes instead of in the left eye to Resident #4. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings included: Resident #77 Record review of Resident #77's admission face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included cerebral infraction (a result of disrupted blood flow to the brain), gastrostomy (used to provide a route feeding to the stomach ) dysphagia (impairment or difficulty in swallowing) and hypertension (blood is pumping with more force than normal through arteries). Record review of Resident #77's Quarterly MDS assessment, dated 01/30/23, revealed the BIMS score was 06, which indicated severely impaired cognition. Further review of the MDS revealed she required extensive assistance with one to staff assist with all ADL. The resident had a g tube. Record review of Resident #77's care plan, initiated 01/30/22 and revised on 05/05/2022, revealed the following: Resident#77 required tube feeding related to dysphagia and CVA. Intervention: flush tubing with 5 ml - 10 ml of water between each medication. Record review of Resident # 77's medication review report for May 2023 reflected: lactulose 10gm/15ml, give 30 ml via g - tube one time a day for constipation and the order date was 05/12/22. During an observation on 05/17/23 at 9:52 a.m., revealed LVN C administered 30 ml of lactulose through Resident # 77's g - tube, and some medication was left in the potion cup. During an interview on 05/17/23 at 10:24 a.m., LVN C stated there was 5 ml of medication left in the portion cup, and she should have added some water and administered it, but she did not . She said she did not follow the six rights of medication because she did not give the correct dose of medicine, which was a medication error. She said Resident # 77 might not get the intended outcome from the medication. During an interview on 05/17/23 at 3:16 p.m., the DON said Resident #77 did not get all the medication she should get, and it was a medication error because medication should be given as prescribed. In addition, she said the resident may not get desired out of the medicine since the 30 ml of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676230 If continuation sheet Page 14 of 21 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 676230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095 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 0759 lactulose was not administered. Level of Harm - Minimal harm or potential for actual harm Resident #4 Residents Affected - Some Record review of Resident #4's admission face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. His diagnoses included glaucoma (eyes disease that can cause vision loss and blindness) diabetes mellitus (a disease the body does not control the amount of glucose in the blood), dysphagia (impairment or difficulty in swallowing) and bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels and concentration). Record review of Resident #4's Quarterly MDS assessment, dated 03/23/23, revealed the BIMS score was 15, which indicated intact cognition. Further review of the MDS revealed he required extensive assistance with one to staff assist with all ADL. Record review of Resident #4's care plan, initiated 08/20/20 and revised on 03/21/22, revealed the following: Resident #4 was at risk for impaired visual function related to glaucoma and left eyes blindness. Goal: would have no indication of acute eye problems through the review date. Record review of Resident # 4's medication review report for May 2023 reflected: Combigan solution 0.2 -0.5 %, instill 1 drop in the left eye two times a day order dated 09/07/21. During an observation on 05/17/23 at 4:46 p.m. revealed MA F administered one drop to each eye. During an interview on 05/17/23 at 4:53 p.m., MA F said the eye drops was supposed to be instilled in both eyes of Resident # 4, and that was how it was written in the MAR. MA F was asked to read what was written in the MAR, when she read it reflected one drop to the left eye. MA F stated she was nervous and mistakenly administered eye drops to the right eye first and then had to administer one drop to the left eye. She said it was medication error because she did not give the correct dose. She said it could cause harm to the wrong eye (right). She said she had medication administration skills check-off , and she should have made sure the correct eye before she instilled the medication into the resident eyes. During an interview on 05/17/23 at 5:47 p.m., the DON said MA F did not follow the doctor's order. She said it was a medication error, and the resident could have a reaction in the eye. Record review of the facility policy on medication administration via feeding tube dated 1/2022 reflected in part . procedure # 14 . rinse medication cup with water or prescribed diluent and administer to assure administration of the complete dose of medication Record review of the facility policy on instillation of eye drops 2001 MED - PASS, Inc (Revised October March 2023) reflected in part . the purpose of this procedure is to provide guideline for instillation of eye drop FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676230 If continuation sheet Page 15 of 21 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 676230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095 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 - Some 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 drugs and biologicals used in the facility were secured and stored properly for two of four medication aide carts (100 and 300 Hall Medication aide Carts) reviewed for drug storage. -MA F failed to ensure a bottle or blister pack of Aspirin, Memantine HCL, Stool softener, loratadine, ClearLax 17 mg, multi-vitamins with minerals, Spironolactone 25mg were not left on top of 100 hall medication aide cart unattended on 05/17/23. -MA H failed to ensure 300 hall medication aide cart was locked when left unattended on 05/17/23. These failures could place residents at risk for possible drug diversions or accidental ingestion. Findings include: During an observation on 05/17/23 at 8:53 a.m. revealed MA H left the following medications a bottle or blister pack of Aspirin, Memantine HCL, Stool softener, loratadine, ClearLax 17 mg, multi-vitamins with minerals, Spironolactone 25mg on top of the medication cart, entered Resident # 36's room, and administered medication to the resident. MA H was out of sight of the medication cart, and there were residents and staff that walked past the medication cart. During an interview on 05/17/23 at 9:09 a.m., MA H said she was not supposed to leave the medications unattended on top of the medication cart because anybody could have taken the medicines from the top of the cart. She also said if any resident had taken the drug, the resident could become sick. MA H said she had a skills check-off on medication storage, including the medication cart. During an interview at 1:51. p.m., the DON said MA H should not have left the medication on the cart. The DON said instead MA H should have placed all the medications back into the medication cart. She said when medications were left on top of the cart unattended, the medicines could be taken by any resident, staff, or visitor. She said if the resident ingested the medication, the resident could have an adverse reaction which could send the resident to the hospital. This surveyor requested an in-service and medication skill check-offs for MA H from the DON. Resident # 4 During an observation on 05/17/23 at 4:47 p.m. revealed MA F left the 300 hall medication aide cart unlocked with the keys in the lock, entered Resident # 4 's, and administered eye drops to the resident. In an interview on 05/17/23 at 4:53 PM, MA F advised that the medication cart should always be locked when not in use to prevent harm to the residents. She explained that would also prevent any unauthorized access to the medication by staff or visitors. MA F mentioned that the medication cart contained all the medications for the residents on the 300 hall. She further added that during her in-service on medication storage, she was instructed to always lock the cart when not in use . MA F said she forgot to lock. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676230 If continuation sheet Page 16 of 21 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 676230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095 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 - Some During an interview on 05/17/23 at 5:57 p.m., the DON said MA F should have locked the medication cart and taken the keys with her whenever the cart was not in use to prevent anyone from getting into the cart and taking any medication. She said the medication cart for the 300 hall contained all the medications administered by the medication aide. The DON said the cart should be locked to prevent drug diversion and from residents taking medication they should not have taken, as it could harm the residents. This surveyor requested MA F's skills check-off and in-service on medication storage from the DON. Record review of the facility policy on medication storage 2001 MED - PASS, Inc (Revised April 2007) read in part . the facility shall storge all biological in a safe, secure . Record review of the facility policy on security of medication cart dated 2001 MED - PASS, Inc (Revised April 2007) read in part . the medication cart should be secured during medication passes . interpretation and implementation .#1. CMA must secure the medication cart during medication pass to prevent unauthorized entry . #4 . medication carts must be must securely locked at all times when out of the nurse's or CMA'S view . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676230 If continuation sheet Page 17 of 21 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 676230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095 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 - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 6 of 8 Staff (MA I, MA H, LVN A, LVN C , LVN J, and Wound care nurse) reviewed for infection control. Residents Affected - Some 1. The facility failed to ensure MA I followed proper hand hygiene and infection control procedures during medication administration for Resident # 301 and Resident #407. 2. The facility failed to ensure MA H followed proper hand hygiene during medication administration for Resident #36. 3. The facility failed to ensure LVN A followed proper hand hygiene and infection control procedure during medication administration for Resident #404. 4. The facility failed to ensure LVN C followed proper hand hygiene and infection control procedure during medication administration for Resident # 77. 5. The facility failed to ensure LVN J followed proper infection control procedure during medication administration for Resident #70. 6. The facility failed to ensure Wound care nurse followed proper hand hygiene and infection control during wound care for Resident # 10 These deficient practices could affect residents and place them at risk for infection, and reinfection. Findings include: Resident #301 During an observation on 05/17/23 at 8:14 a.m. for Resident # 301's medication administration revealed, MA I went to the medication room with the ADON, and she was given a pill in a blister pack. While MA I was entering the medication room, she touched the door and the countertops while waiting for the medication from the pyxis (electronic medication cart in the medication room). MA I opened the medication room door and walked to the medication cart. She took the keys from her uniform pocket, unlocked the cart, and placed the keys back into her pocket. She proceeded to pop pills from the blister packet and a medicine bottle without washing or sanitizing her hands. Then she took an ink pen from her uniform pocket and jabbed it into the medication blister pack from the pyxis and dragged it around the packet and opened the blister and took the pill from it. She placed it in the cup with other medications which she administered to Resident # 301. During an Interview on 05/17/23 at 8: 18 a.m., MA I said she should have washed her hands before she touched the medication blister parks to prevent transferring germs from her hand to the medication, and she should have pulled back the blister pack corner instead of using her ink pin from her pocket. She said her uniform pocket and other hard surfaces she touched were considered dirty. She said if Resident # 301 came into contact with germs, he could become sick. She said she had an in-service on infection control, and hand washing was part of the in-service. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676230 If continuation sheet Page 18 of 21 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 676230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095 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 - Minimal harm or potential for actual harm During an interview on 05/17/23 at 1:39 p.m., the DON said MA I should have washed her hands after she placed her hands in her pocket because it was an infection control issue, and she could transfer her germs to the blister packet and Resident # 301. She also said MA I should not have used her pen to open the blister packet because they did not know where the ink pen had been. Residents Affected - Some Resident # 407 During an observation on 05/17/23 at 8:26 a.m. revealed MA I took the cart key from her pocket, opened the medication cart, and placed it back in her uniform pocket. She did not wash or sanitize her hands before she popped out medications from the blister packet and administered the medication to Resident #407. During an interview on 05/17/23 at 8:41 a.m., MA I said she did not know what to answer because she did the same thing when she gave the last resident's medication. MA I said she was in- serviced on hand hygiene and medication administration skills check off. She said she could pass her germs to Resident # 407, and the resident could get an infection. During an interview on 05/17/23 at 1:43 p.m., the DON said MA I should have washed her hand after she placed her hands in her pocket because it was an infection control issue, and she could transfer her germs to the blister packet and Resident # 407. Resident # 36 During an observation on 05/17/23 at 8:53 a.m. revealed MA H took the cart key from her pocket and opened the medication cart, and placed it back in her uniform pocket. She did not wash or sanitize her hands before she popped out medications from the blister packet and administered the medication to Resident #36. During an interview on 05/17/23 at 9:09 a.m., MA H said she forgot to wash her hands or sanitize her hands after she took the cart key from her uniform pocket and placed it back in her pocket. As a result, she said it was cross-contamination, and Resident # 36 could get sick from her germs. She said she had an in-service and medication skill check-off and was taught during the in-service that staff should wash or sanitize their hands before medication administration. During an interview on 05/17/23 at 1:151 p.m., the DON said MA H should have washed her hands after she placed her hands in her pocket because it was an infection control issue, and she could transfer her germs to the blister packet and Resident #36 Resident # 404 During an observation on 05/17/23 at 9:25 a.m. revealed LVN A took the cart key from her pocket, opened it, and placed it back into her uniform pocket. LVN A did not wash or sanitize her hands before taking the medication from the cart and put the medication and the alcohol prep into her uniform pocket. LVN A then donned her gloves and took the medication and alcohol prep from her uniform pocket, and placed it on top of the resident's bedside table with the resident's personal items on the table. She opened the injection and alcohol prep with the same gloves and administered the medication to Resident # 404. During an interview on 05/17/23 at 9:40 a.m., LVN A said it was not sanitary because her uniform (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676230 If continuation sheet Page 19 of 21 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 676230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095 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 - Minimal harm or potential for actual harm Residents Affected - Some pocket was not clean, and she could have transferred germs to Resident # 404, which could cause an infection. LVN A said she should not have placed the medication in her uniform pocket and should have wiped the resident's bedside table before and after use. She said she had skills check-off and an in service in infection control , including hand washing. During an interview on 05/17/23 at 4:22 p.m., the DON said carrying medication in LVN A's uniform pocket, donning gloves without washing or sanitizing her hand, and not sanitizing the bedside table before and after use was infection control issues. Resident # 77 During an observation on 05/17/23 at 9:52 a.m., revealed LVN C assessed Resident # 77 g - tube site and did not wash or sanitize her hands before she took the syringe and inserted it into Resident # 77 g - tube. She placed it close to her ear, and the syringe's opening touched her hair. LVN C placed the syringe back into the plastic and placed the syringe under her armpit, and then placed it on the bedside table, where she later placed the medications for administration. She took off her gloves when she came out of the resident's room and took the cart keys from her uniform pocket, opened the cart, and placed the keys back into her uniform pocket, and she proceeded to prep medication for Resident # 77 without washing her hands. She placed the medications and water to flush the tube on the bedside table. She pushed the bedside table to the resident's room without washing her hands. She took sanitizer from her pocket, sanitized her hands, placed it back in her uniform pocket, and administered medication to Resident # 77. During an interview on 05/17/23 at 10:24 a.m., LVN C said she should have washed her hands after placing the cart key back into her uniform pocket and checking Resident #77 g tube site. LVN C said she did not know why she put the syringe close to her ears or placed it under her armpit. She said she did not know she was not supposed to carry sanitizer in her pocket. LVN C said she made some infection control mistakes which could transfer the infection to Resident # 77. She said she had skills check-offs and infection control training, and it included hand washing. During an interview on 05/017/23 at 1:30 p.m., the DON said all the nurses and medication aides should wash or sanitize their hands once their hands went into their uniform pocket. She said the nurse should not carry or use sanitizer from the uniform pocket because it was an infection control issue and possible infection to Resident # 77. The DON said she could not explain why LVN C had to place the syringe to her ear, and when her hair touched the syringe, it became contaminated. She also said LVN C should not have carried the syringe under her armpit because it was an infection control issue. Resident # 70 During an observation on 05/17/23 at 11:30 a.m. revealed LVN J placed the insulin medication pen for Resident # 70 into her uniform pocket after she administered the medication. She placed it back into the medication cart when she came out of the resident's room. During an interview on 05/17/23 at 11:35 a.m., LVN J said she should not have placed Resident # 70 insulin pen inside her uniform pocket because it was cross contaminated from her uniform pocket, which had her germs. She said she could transfer her germs to Resident # 70, and the resident could become sick. In addition, LVN J said she could have contaminated other insulin pens in the medication cart. LVN J said she had a skills check-off for medication administration and was trained not to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676230 If continuation sheet Page 20 of 21 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 676230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095 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 carry medication in her pocket. Level of Harm - Minimal harm or potential for actual harm During an interview on 05/17/23 at 5:24 p.m., the DON said LVN J should not put Resident #70's insulin pen medication in her uniform pocket because it was an infection control issue. Residents Affected - Some Resident#10 During an observation on 05/17/23 from 2:02 p.m. to 2:35 p.m., revealed the Wound care nurse provided wound care for Resident # 10. The Wound care nurse cleaned the wound bed and 2 cm around the peri-wound(outside the wound) and did not clean the rest of the peri-wound, which was covered by the wound dressing. The area that was not cleaned was 15 cm. She used the same dirty gloves she cleaned the wound bed and 2 cm peri-wound and patted the wound dry. She was about to apply a clean wound dressing when the surveyor intervened. Then the Wound care nurse cleaned the 15 cm area of the peri-wound, and patted the area dry with the same dirty gloves she cleaned the wound peri area which had wound drainage. During an interview on 05/17/23 at 2:40 p.m., the Wound care nurse said she should have cleaned all the peri area of the wound, including the areas the dressing covered, because the drainage from the wound could have touched the areas. The Wound care nurse said she did not change her gloves after she cleaned the wound, and she re-infected the wound when she patted the wound dry with the same gloves. She said the gloves she cleaned the wound was dirty from the wound drainage and had bacteria she wiped off the wound. She said the previous wound care nurse trained her, and she also did skills check-offs on wound care dressing change. Record review of wound care skills checklist for the wound care nurse signed by the Wound care nurse on 04/24/23 reflected place gauze to cover all broken and wash tissues around the wound that is usually covered by the dressing, tape or gauze. During an interview on 05/17/23 at 5:33 p.m., The DON said the wound care nurse should usually change her gloves after she cleaned the wound, sanitize her hands, don clean gloves, then dry the clean wound bed and peri area. She said if the gloves were not changed, the bacteria would be transferred back to the wound when patted dry. The DON said she would review the facility policy to see if the area the bandage covered should be cleaned. Record review of the facility administering oral medications dated MED - PASS, Inc . (Revised October 2010, March 2023) read in part . steps in the procedure . #1. Wash your hands or hand hygiene Record review of the facility on hand hygiene dated 05/2007, Revision/Review date 6/2021, 1/2022, 12/2022 reflected in part . purpose . hand hygiene is one of the most effective measures to prevent the spread of infection FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676230 If continuation sheet Page 21 of 21