Health inspection·September 17, 2025

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide personal privacy when providing personal care for 2 (Resident #12, Resident #150) of 7 residents observed for personal care. -CNA AR failed to provide privacy for Resident #150 during incontinent care. -LVN M failed to provide privacy for Resident #12 during tracheostomy care. This failure placed residents at risk for their loss of dignity, respect, and psychological distress. Findings included: Resident #150 Record review of Resident #150's face sheet, dated 09/16/25, revealed an [AGE] year-old female admitted on [DATE]. Resident #150's diagnoses included hypothyroidism, type 2 diabetes mellitus, protein-calorie malnutrition, hypertension (elevated blood pressure), pressure ulcer of left heel, chronic kidney disease, and gastrostomy (surgical procedure that creates an opening in the stomach to allow for feeding and medication administration into the stomach). Record review of Resident #150's MDS dated [DATE] coded 99 reflected a BIMS score of 15 indicating that resident cognition was intact. Record review of Resident #150's Care Plan, dated 09/07/25, reflected an ADL self-care performance deficit r/t disease process with an intervention the resident required incontinent care assistance. Observation on 09/09/25 at 9:15AM, CNA AR performed incontinent care for Resident #150. The CNA washed her hands and placed on her PPE (disposable gloves and gown). CNA AR proceeded to provide care for resident without pulling the resident's privacy curtain. During the care, there was a hospice CNA present in the room providing care for Resident #150's roommate. The hospice CNA was passing by Resident #150's bed to enter the bathroom while CNA AR continued to provide care for Resident #150. Interview on 09/09/25 at 9:28AM, CNA AR said she worked at the facility full time 6AM-2PM. CNA AR said she had worked at the facility for a year. CNA AR said she forgot to close Resident #150's privacy curtain while providing incontinent care. CNA AR said it was important to close the door as well as pull the privacy curtain to provide the resident privacy and dignity. Resident #12 Record review of Resident #12's face sheet, dated 09/11/25, revealed a [AGE] year-old female admitted on [DATE]. Resident #12's diagnoses included chronic respiratory failure (when the lungs are not performing adequately making it difficult to breathe), type 2 diabetes mellitus (when the body has trouble controlling blood sugar and using it for energy) cerebral infarction (interruption of blood flow in the brain), pressure ulcer of sacral (triangular shaped bone located at the base of the spine) stage 4 (deep wound exposing the muscles, ligaments, or bones), dysphagia (difficulty swallowing), Parkinson's Disease (disorder that effects movement and sometimes cause tremors), hypertension (elevated blood pressure), cognitive communication deficit, tracheostomy(surgical opening made in the windpipe to provide airway and to help with breathing), colostomy (surgical incision that creates an opening in the abdomen to reroute stool from the colon directly into an outside bag), and gastrostomy (surgical incision that creates an opening through the abdominal wall. A tube is inserted to provide nutrition, fluids, and medications directly into the stomach). Record review of Resident #12's quarterly MDS date 07/10/25 revealed a BIMS score of 3 indicating that resident Residents Affected - Few Page 1 of 34 676230 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cognition was severely impaired. Record review of Resident #12's Comprehensive Care Plan, dated 01/08/25, revealed that resident was care planned for being dependent for tracheostomy care r/t chronic respiratory failure. Observation on 09/10/25 at 10:03AM of tracheostomy care for Resident #12 by LVN M. LVN M entered the room and washed her hands with soap and water and began to don (put on) her PPE that consisted of disposable gown and gloves. LVN M went to the resident's bedside to perform tracheostomy care without closing the door or the pulling resident's privacy curtain. Resident #12's roommate was resting quietly in bed with eyes closed. Interview on 09/10/25 at 10:53AM, LVN M said when providing care for Resident #12 she was supposed to close the door and pull the resident's privacy curtain. LVN M said this was done to promote resident dignity. LVN M said she was nervous and forgot to close Resident #12's door and pull the privacy curtain. Interview on 09/10/25 at 12:12PM, the DON said whenever the nursing staff were providing care to a resident, they should provide privacy for the residents to promote dignity. Record review of the facility policy on Resident Rights/Dignity and Respect, dated revised October 2015, reflected in part: .It is the policy of this facility that all residents be treated with kindness, dignity and respect.The staff shall display respect for resident's when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings.Privacy of resident's body shall be maintained during toileting, bathing and other activities of personal hygiene. 676230 Page 2 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure MDS data was transmitted within 14 days of completion for 1 of 5 closed record reviews (CR #62), in that: -CR #62's MDS discharge assessment was not completed and submitted to CMS.This failure could place the resident at risk for receiving unnecessary services or inadequate care.Findings included:Record review of CR #62's face sheet, dated 09/17/2025, revealed a [AGE] year-old female admitted on [DATE] and discharged [DATE]. Her diagnoses included: pneumonia, ulcerative colitis (a chronic inflammatory bowel disease that affects the large intestine), moderate protein-calorie malnutrition, legal blindness, congestive heart failure, and muscle weakness.Record review of CR #62's most recent MDS, dated [DATE], was an admission MDS. Record review of CR #62's EMR on 09/17/2025 revealed the history and status of all of the residents' MDS assessments completed and submitted. A discharge MDS assessment was not completed or accepted for her 05/09/2025 discharge from the facility:4/14/2025 Medicare - 5 Day Completed4/14/2025 admission Accepted4/8/2025 Entry Accepted4/5/2025 Discharge Return Not Anticipated Accepted3/23/2025 Medicare - 5 Day Completed3/23/2025 admission Accepted3/17/2025 Modification of Entry Accepted3/17/2025 Entry ModifiedIn an interview on 09/17/25 at 12:46 PM, MDS A stated she did not know why the discharge MDS for the resident was not completed or submitted. She reported they would do an audit to determine if other discharge MDS assessments were not completed and if so, they would do a root cause analysis so that it would not happen again.Record review of Chapter 5 of the RAI Manual 3.0, revised October 2024, reflected that the submission time frame for a discharge assessment was no later than the date of the RN assessment coordinator's signature, indicating that the MDS assessment was complete, within 14 days. Residents Affected - Few 676230 Page 3 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment describing services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 12 residents (Residents #12, Residents #80 and Resident #84) reviewed for comprehensive care plans. - The facility failed to care plan Resident #80's incontinence care due to a neurogenic bladder disorder.-The facility failed to care plan Resident #12 for an intravenous mid-line.-The facility failed to care plan Resident #84 for mobility bars on her bed.This failure could place residents at risk of not having their individual, medical, functional, and psychosocial needs identified and cause a physical, mental or psychosocial decline in health. Resident #80Record review of Resident #80's face sheet, dated 09/11/2025, reflected a [AGE] year-old female admitted on [DATE] with diagnoses including stroke due to a blood clot, paralysis following stroke affecting left non-dominant side, dementia (loss of cognitive functioning like thinking, reasoning and memory and potential loss of emotional control and personality)., neuromuscular dysfunction of bladder (neurogenic bladder being a condition where an injury or disease leads to residents having urinary incontinence, loss of sensation of a full bladder, among other symptoms) and need for assistance with personal care.Record review of Resident #80's Quarterly MDS, dated [DATE], reflected a BIMS score of 03, indicating severe cognitive impairment. Resident #80 was totally dependent on staff for ADLs including eating, oral and personal hygiene and toileting. Resident #80 was totally dependent on staff to transfer from a bed to a chair and to get on and off a toilet. Record review of Resident #80's care plan reflected she was care-planned for having bowel and bladder incontinence related to stroke, impaired mobility and having a neurogenic bladder with a created date of 09/11/2025, with interventions including being checked as required for incontinence and care by staff and nurses monitoring skin at least weekly and reporting any changes to the doctor and POA. A later care plan dated 09/12/2025 reflected a focus area of Resident #80 being at risk for urinary retention related to a diagnosis of neurogenic bladder with interventions including monitoring and documenting for signs or symptoms of UTI and for therapy to evaluate and treat for pelvic floor exercise.Record review of Resident #80's skin assessments for August and September 2025reflected she had no skin issues documented. Record review of Resident #80's progress notes, MDS B documented on 9/11/2025 at 5:00pm that she notified Resident #80's physician assistant of her diagnosis for neurogenic bladder and order received for OT to evaluate and treat for pelvic floor exercise. MDS B documented that she notified the rehab ilitation department and left a message to Resident #80's RP. Observation and attempted interview with Resident #80 on 09/11/2025 at 11:00am, Resident #80 was in her chair outside her room with non-skid socks on and pillows propped under both legs. Resident #80 appeared in a pleasant mood and in no apparent discomfort or distress. Resident #80's face and hands had no signs of symptoms of dehydration or concerns. Resident #80 did not respond to questions and did not make eye contact.Interview with OT F on 09/13/2025 at 9:45am, she said she did not work with Resident #80. For residents with neurogenic bladder, OT F would look at frequency of voiding like the resident's schedule. OT F would monitor residents when they saw them in the hallways. OT F said therapy staff would educate nursing to monitor residents in the dining room. OT F said therapy did not have the certification to do bladder training for residents. OT F said the importance of monitoring was to ensure residents kept skin integrity and for excessive moisture. 676230 Page 4 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 09/14/2025 at 10:45am with MDS A and MDS B, they said they were not employed at the time that Resident #80 was admitted . They said during record review in the last few days, they found she had a neurogenic bladder due to stroke. The facility began Resident #80 on pelvic floor exercises. MDS B said resident #80 also did not have incontinent in her care plan and that was an oversight. MDS A said care plans were to make sure interventions were in place for residents and that MDS nurses were responsible for ensuring resident's conditions were care-planned. Interview on 9/14/2025 at 10:59am, the DON said the interdisciplinary team (a team consisting of therapy, nursing, social work and other department representatives working together to provide care to residents) was responsible for diagnoses, like during admission and the team included MDS, ADONs, and DON among other departments . The purpose of the care plan was to put in place interventions for residents' condition. The DON said things the facility would also put tasks in POC for staff to see interventions, telling nurses on the 24-hour report and put in ancillary or acute orders . Care plans were individualized, so if residents were not care-planned for diagnoses or conditions, residents could have a decline due to not be treated, missed out on potential treatments or prevented conditions. Care plans were also to let staff know that residents were stable. The MDS nurses were responsible for care plans and the DON was responsible for MDS nurses. The DON and MDS Nurses meet for morning clinicals and weekly meetings. When asked if the resident could have benefitted from therapy interventions when she was first admitted , the DON said the facility wanted to go through the motion of what she could benefit from so they referred Resident #80 to therapy but she had been totally incontinent upon admission.Interview with the Administrator and Regional Nurse on 9/14/2025 at 11:48am, she said the DON was responsible for ensuring residents were getting treatments for their diagnoses. If resident did not get treatments for diagnoses, it could affect their quality of life. The purpose of a care plan was an individualized intervention, and if they were not care-planned their condition would not get addressed. The Administrator said she would have to review Resident #80's full chart to see if she could have benefitted from intervention upon admission. The MDS Coordinator was over care-planning and Nurse Manager was responsible for oversight.Resident #12Record review of Resident #12's face sheet dated 09/11/25 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident diagnoses included the following: chronic respiratory failure, type 2 diabetes mellitus (when the body has trouble controlling blood sugar and using it for energy) cerebral infarction (interruption of blood flow in the brain), pressure ulcer of sacral (triangular shaped bone located at the base of the spine) stage 4 (deep wound exposing the muscles, ligaments, or bones), dysphagia (difficulty swallowing), Parkinson's Disease (disorder that effects movement and sometimes cause tremors), hypertension (elevated blood pressure), cognitive communication deficit, tracheostomy, colostomy (surgical incision that creates an opening in the abdomen to reroute stool from the colon directly into an outside bag, and gastrostomy (surgical incision that creates an opening through the abdominal wall. A tube is inserted to provide nutrition, fluids, and medications directly into the stomach).Record review of Resident #12's quarterly MDS revealed a BIMS score of 3 indicating that resident cognition was severely impaired.Record review of Resident #12's Physician Order Summary Report for the month of August 2025 reflected the following order:-Dated 08/05/25 Insert midline STAT-Dated 08/18/25 Monitor midline for s/s of infection/infiltrate (accumulation of a substance within a cell, tissue, or organ) every shift.notify provider if present.-Dated 08/18/25 Mid-line flushing with 5cc of 0.9% NS IV solution before and after each medication administration.-Dated 08/18/25 Mid-line care: change mid-line dressing q 7 days fi visible for assessment, change dressing PRN if wet, soiled, saturated or loose.-Dated 08/05/25 Cefepime intravenous solution 2gm/100ml one time a day for PNA for 7 days-Dated 08/13/25 Meropenem 676230 Page 5 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some intravenous solution 500mg every 6 hours for sacral ulcer for 2 weeks. Discontinued 08/28/25.Record review of Resident #12's MAR & TAR for the months of August 2025 and September 2025 reflected that the facility was following the above physician orders.Record review of Resident #12's Comprehensive Care Plan dated 01/08/25 did not reflect a care plan for resident's mid-line insertion.Observation on 09/10/25 at 10:22AM of Resident #12 revealed a mid-line to her right upper arm. Resident #84 Record review of Resident #84's face sheet dated 09/12/25 revealed that resident was admitted to the facility on [DATE]. Resident diagnoses included the following: hemiplegia (paralysis or weakness on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), dysphagia (difficulty swallowing), chronic kidney disease, syncope and collapse (temporary loss of consciousness/fainting caused by sudden , brief decrease in blood flow to the brain), cognitive deficit, falls, cerebral infarction (blood flow to the brain is interrupted), hypertension (elevated blood pressure), muscle wasting and atrophy (muscle lose mass and strength).Record review of Resident #84's Admissions MDS dated [DATE] BIMS score was coded 0 indicating that resident cognition was severely impaired. Record review of Resident Physician Order Summary Report for the month September 2025 did not reflect an order for mobility bars.Record review of Resident #84's Comprehensive Care Plan dated 08/08/25 did not reflect a care plan for mobility bars. Observation on 09/09/25 at 9:47AM of Resident #84 in room sitting on the left side of her bed. Resident #84 had mobility bars on her bed. Interview on 9/14/2025 at 10:59AM, the DON said the purpose of the care plan was to put intervention in place for residents' condition. The DON said the facility communicated interventions for staff to see by placing them in resident's medical records, communicating between nursing shifts through 24-hour reports and putting in ancillary or acute orders for staff to ensure interventions were being done for residents. The DON said care plans were individualized, so if residents were not care-planned for diagnoses or conditions, residents could have a decline due to not being treated and missing potential treatments. The DON said care plans were also utilized to let staff know that residents were stable. The DON said both herself and the MDS nurses were responsible for ensuring the residents had comprehensive centered care plans. Interview with the Administrator on 9/14/2025 at 11:48am, said the DON was responsible for ensuring residents were receiving treatments for their diagnoses. The Administrator said if resident did not get treatments for diagnoses, it could affect their quality of life. The Administrator said the purpose of a care plan was an individualized intervention, and if they were not care-planned their condition would not get addressed. Interview on 09/16/25 at 10:20AM with the MDS nurse said she had been working at the NF for over a year and became the MDS nurse September 01, 2025. The MDS nurse said she was responsible for Resident 84's care plan. The MDS nurse said it was important for the residents to have person-centered care plans to address the residents' diagnoses and needs. The MDS nurse said interventions also needed to be put in place to set obtainable goals, and to reduce the risk of further complications. The MDS nurse said she was not aware that Resident #84 was not being care planned for mobility bars. The MDS nurse said she recognized now that mobility bars needed to be specifically care planned for, because it placed the residents at risk for falls, entrapment, skin alterations such as skin tears, or other injuries.Interview on 09/16/25 at 10:30AM with MDS Coordinator said she was Resident #84's MDS nurse prior to MDS nurse. The MDS Coordinator said she was aware that Resident #84 had mobility bars on her bed. Further interview with the MDS Coordinator said it was an oversite on her part that Resident #84 was not care planned for mobility bars.Record review of the facility policy on Comprehensive Person-Centered Care Planning last revised April 2025 reflected in part: .It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive 676230 Page 6 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, which includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care. 676230 Page 7 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 7 residents (Resident #11) reviewed for accidents and supervision. The facility failed to ensure a disinfectant Sani-wipes container was not placed at the bedside of Resident #11. This failure could place residents at risk for unwanted injuries and a decreased quality of life. Findings include:Record review of Resident #11's face sheet, dated 09/17/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #11's had diagnoses which included the following: cerebral infarction (interruption of blood flow in the brain), aphasia (difficulty in communicating), type 2 diabetes mellitus (when the body is unable to utilize blood sugar for energy in the body), and malignant neoplasm (cancer). Record review of Resident #11 quarterly MDS, dated [DATE], reflected a BIMS score of 2, which indicated the resident cognition was severely impaired. Observation on 09/09/25 at 10:00 AM revealed Resident #11 was awake in bed resting quietly. On the right side of the resident's bed on the night stand was a purple top container labeled Super Sani-Cloth Germicidal Disposable Wipe. The container read the following: disinfect in 2 minutes, not a skin or baby wipe, keep out the reach of children, and not to dispose in commode. Observation on 09/11/25 at 10:32 AM revealed the Sani-Cloth Germicidal Disposable Wipes was still on the resident's right side of the bed sitting on Resident #11's nightstand. Interview on 09/11/25 at 10:35 AM, CNA E said the disinfectant sani-wipes were not supposed to be stored at the resident's bedside for safety reasons. CNA E said the resident could try and open the container or a staff member could mistake the sani-wipes as disposable wipes. CNA E said if the resident encountered the sani-wipes, it would place the resident at risk for skin irritation or infections. CNA E said the sani-wipes were supposed to be stored outside of the resident room on the nurse medication cart. CNA E removed the sani-wipes from Resident #11's room and disposed of the container inside of the soiled utility room. Interview on 09/11/25 at 10:58 AM, LVN M said sani-wipes should not be in a resident's room. LVN M said if the resident encountered the sani-wipes it could harm the resident due to certain chemicals in the sani-wipes. LVN M said the staff could mistakenly use the sani-wipes on the residents thinking they were using disposable wipes to provide incontinent care. Interview on 09/11/25 at 11:09AM, with the DON said the disinfectant sani-wipes were never to be left in a resident room at the bedside. The DON said some residents had dementia and could try and open the container. The DON said the sani-wipes would be toxic to the resident causing injury. The DON said each resident was assigned an ambassador. The DON said the ambassadors were supposed to make rounds on their assigned residents to make sure their rooms were okay and if the residents had any concerns or questions that needed to be addressed Interview on 09/11/25 at 2:38PM with the Dietary Supervisor said she was the ambassador for Resident #11. The Dietary Supervisor said she made rounds on her assigned residents in the morning. The Dietary Supervisor said she ensured the assigned residents' rooms were okay by assessing the following; if resident was receiving oxygen to make sure that they were wearing their oxygen, having hydration at the bedside, call light in reach, making sure the resident was groomed, and if they had any questions or concerns. The Dietary Supervisor said she normally made rounds around 8:30AM and did make rounds on Resident #11 room on 09/10/25 and 09/11/25. The Dietary Supervisor said she did not recall seeing any disinfectant sani-wipes in Resident #11's room on his nightstand. The Dietary Manager said disinfectant sani-wipes should not be stored in the resident room because it placed the resident at risk of chemicals getting on the resident hand or possible the resident ingesting them sani-wipes. Record review of the Ambassadors list for Resident #11 reflected 676230 Page 8 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0689 Level of Harm - Minimal harm or potential for actual harm the Dietary Supervisor was the ambassador for the resident room. Record review of the facility's, undated, policy on Accident Prevention reflected in part: .The purpose is to ensure that the facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident to prevent or minimize accidents. [ Residents Affected - Few 676230 Page 9 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

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 a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 3 residents (Resident #72) reviewed for enteral feeding.The facility failed to ensure Resident #72's enteral feeding was turned off during bowel rest between 9AM and 11AM on 9/10/2025 . This failure could place residents at risk of health complications such as aspiration pneumonia or gastrointestinal injury. Record review of Resident #72's face sheet, captured 09/11/2025, reflected an [AGE] year-old male originally admitted on [DATE] and last re-admitted on [DATE]. Resident #72 had diagnoses which included paralysis following stroke affecting left non-dominant side, type 2 diabetes mellitus (high blood sugar), cognitive communication deficit, gastrostomy status (tube that provides nutrition, medication and fluids directly to the stomach) and dementia (loss of cognitive functioning like thinking, reasoning and memory and potential loss of emotional control and personality).Record review of Resident #72's Quarterly MDS, dated [DATE], reflected he was rarely or never understood, and his BIMS was not coded, which indicated severe cognitive impairment. He was totally dependent on staff for all ADLs including eating, oral and personal hygiene and dressing and transferring in and out of bed. Resident #72 was coded for feeding tube and received 51% or more calories through parenteral or tube feeding.Record review of Resident #72's September 2025 MAR reflected he had bowel rest from 9AM and resumed feeding at 11AM ordered on 08/20/2025 and discontinued 09/11/2025.Record review of Resident #72's progress notes, on 9/11/2025 at 11:00AM, ADON A wrote, This writer reached out to NP that resident feeding was not turned off at 09:00, communicated with Dietician as well, received order to change Bowel rest time from 10:30 to 12:30PM, Communicated with Floor nurse.Record review of Resident #72's weights reflected no significant weight change from June 2025 to September 2025.Observation and attempted interview with Resident #72 on 09/09/2025 at 8:51 AM, he was aware and lying in a low bed on a feeding pump. Resident #72 appeared comfortable and in no respiratory distress and it was difficult to understand the resident's speech.Observation and interview on 09/11/2025 at 10:00 AM, revealed Resident #72 appeared to be asleep, in bed with no discomfort or distress. Resident #72's feeding pump was on. The DON was asked to come in, and she said Resident #72's feeding pump was still on. The DON went to get LVN H, who told the DON and the State Surveyor, LVN H had turned it off, but it turned back on. LVN H came in and turned off Resident #72's pump at 10:10 AM. LVN H said she remembered shaving Resident #72 and then turned on the pump. LVN H assumed the pump was going on for one hour and called the physician who said she would adjust the bowel rest period to 10:00 AM to 12:00 PM going forward. LVN H said she had no idea who turned it back on. LVN H said if residents did not get bowel rest, they could vomit, aspirate (when anything but air gets into your airways) or have diarrhea. LVN H received in-services and training on tube feeding and bowel rest at the facility.Interview with ADON A on 09/11/2025 at 1:13 PM, she said there was no excuse for Resident #72's pump to be on even if the nurse turned it off already. ADON A notified the RD and the NP. The RD said Resident #72 was okay, so nursing changed the bowel rest time to 10:30 AM to 12:30 PM. The ADON said the NP was also notified that Resident #72's feeding was on when it should have been off, and the NP had no concerns. ADON A said they were treating the event like there was no pause in Resident #72's feeding since she was not sure if the machine had turned back on or not. For safety purposes, ADON A said LVN H should have checked that she had turned 676230 Page 10 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the pump off. ADON A said nurses had competency checks and returned demonstration for enteral feeding. ADON A said bowel rest was to give residents' GI breathing time because humans did not eat 24 hours a day and that time was so the bowels could recuperate and prevent overfeeding. If residents did not get bowel rest as ordered it could cause overfeeding or aspiration because they would have had more than enough. Interview with the RD on 09/11/2025 at 12:42 PM, she said Resident #72's weights were stable. The RD said the purpose of bowel rest was to give residents time for activities throughout the day where they could not be on the feeding like for showering and she would account for the calories within the 22-hour timeframe. When the RD made recommendations, she would put 22 hours of feeding and 2 hours of rest and then nursing would decide when the 2 hours of rest was. The RD said if residents did not get bowel rest, they would not get the calories they needed and could have weight gain. Interview with the DON on 09/14/2025 at 10:59 AM, she said the purpose of bowel rest was to give residents time off the enteral feeding for ADLs. The DON did not know what really happened, but informed LVN H it was her responsibility to ensure she disconnected it completely. If residents did not get the prescribed bowel rest, they could either not get enough nutrition if they did not eat by mouth or if they got too much it could cause aspiration or adverse bowel reaction depending on the resident's diagnoses. Resident #72 was assessed and found to have no adverse reaction, and his bowel sounds were okay. The NP was notified. The Nurse managers followed nurses to ensure they were following orders for parenteral feeding and the DON in-serviced staff on g-tube, but she would do more in-services and was going to do one on disconnecting the pump completely and provide it. Interview with the Administrator on 09/14/2025 at 11:48 AM, she said the purpose of the bowel rest was for the resident to rest. She said risks to residents, if they had a delay or no bowel rest, would be a clinical question and referred to the nursing department. The Administrator said nursing management was responsible for monitoring nurses to ensure nurses were following orders. Record review of the facility's in-service on gastrostomy tube on 03/21/2025 read in part, it is the policy of this facility to provide proper care and maintenance of a gastrostomy tube. Only a licensed nurse may adjust, start, stop or disconnect the g-tube . 6. Follow physician orders for bowel rest. Record review of the facility's policy on gastrostomy tube care and management, last revised 04/2025, reflected the policy did not cover intermittent feeding. 676230 Page 11 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0694 Provide for the safe, appropriate administration of IV fluids 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 administer Parenteral fluids consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 7 (Resident #12) residents reviewed for parenteral fluids.The facility failed to obtain a physician order to discontinue Resident #12's mid-line that had been inserted on 08/05/25. The resident completed her IV antibiotic therapy on 08/28/25. The facility did not obtain an order to discontinue resident mid-line until 09/10/25. This failure placed Resident #12 at risk for unwanted infections and further decrease in quality of life. Resident #12Record review of Resident #12's face sheet, dated 09/11/25, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident diagnoses included chronic respiratory failure (difficulty breathing), type 2 diabetes mellitus (when the body has trouble controlling blood sugar and using it for energy) cerebral infarction (interruption of blood flow in the brain), pressure ulcer of sacral (triangular shaped bone located at the base of the spine) stage 4 (deep wound exposing the muscles, ligaments, or bones), dysphagia (difficulty swallowing), Parkinson's Disease (disorder that effects movement and sometimes cause tremors), hypertension (elevated blood pressure), cognitive communication deficit, tracheostomy, colostomy (surgical incision that creates an opening in the abdomen to reroute stool from the colon directly into an outside bag, and gastrostomy (surgical incision that creates an opening through the abdominal wall. A tube is inserted to provide nutrition, fluids, and medications directly into the stomach). Record review of Resident #12's quarterly MDS dated [DATE] revealed a BIMS score of 3 indicating that resident cognition was severely impaired. Record review of Resident #12's Physician Order Summary Report for the month of August 2025 reflected the following order: -Dated 08/05/25 Insert midline (type of IV catheter that is inserted into a vein in the upper arm) STAT -Dated 08/18/25 Monitor midline for s/s of infection/infiltrate (accumulation of a substance within a cell, tissue, or organ) every shift.notify provider if present. -Dated 08/18/25 Mid-line flushing with 5cc of 0.9% NS IV solution before and after each medication administration. -Dated 08/18/25 Mid-line care: change mid-line dressing q 7 days visible for assessment, change dressing PRN if wet, soiled, saturated or loose. -Dated 08/05/25 Cefepime intravenous solution 2gm/100ml one time a day for PNA for 7 days -Dated 08/13/25 Meropenem intravenous solution 500mg every 6 hours for sacral ulcer for 2 weeks. Discontinued 08/28/25. Record review of Resident #12's MAR & TAR for the months of August 2025 and September 2025 reflected that the facility was following the above physician orders. Record review of Resident #12's Comprehensive Care Plan, dated 01/08/25, did not reflect a care plan for resident's mid-line insertion. Observation on 09/10/25 at 10:22AM of Resident #12 revealed a mid-line to her right upper arm. Interview on 09/10/25 at 11:23AM, LVN M said she was the nurse for Resident #12. After LVN M reviewed Resident #12's physician orders and MAR & TAR, LVN M said the resident's antibiotic Meropenem IV was last given on 08/28/25. LVN M said normally when a resident received all their IV antibiotic therapy, the Physician or NP was called to get an order to discontinue the IV. LVN M said the nurses should perform a head-to- toe assessment on the residents at least once a shift. LVN M said if Resident #12 was no longer receiving medications through her mid-line, the Physician or NP should be called to get an order to discontinue the mid-line. LVN M said if this was not done, it placed the resident at risk for infections. LVN M said she was aware that Resident #12 had a midline line. LVN M said she normally did her head-to-toe assessments at the beginning of her shift. LVN M said she had not contacted the Physician or NP about discontinuing Resident #12's mid-line. Interview on 09/10/25 at 11:35AM, the NP, after reviewing Resident #12's chart, said Residents Affected - Some 676230 Page 12 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some antibiotic therapy stopped on 08/28/25. The NP said the facility had not notified her and that she learned from the surveyor that Resident #12 still had her midline. The NP said she would write an order to discontinue resident mid-line. The NP said if the mid-line was not being used, it needed to be discontinued. The NP said this placed Resident #12 at risk for infections. Interview on 09/10/25 at 12:12PM, the DON said the Infection Control Preventionist monitored resident IV lines, checked orders for antibiotic therapy, how long resident was on the antibiotic, and how long resident IV had been in. The DON said the Infection Control Preventionist should be assessing the IV lines weekly. The DON said she was aware that Resident #12 had a mid-line but did not know when resident completed her IV antibiotic therapy. The DON said after a resident's IV antibiotic was completed, the facility may wait a few days to see if the Physician wanted to draw labs afterwards from the line before discontinuing the IV. The DON said she was not aware that it had been pos 3 days that resident antibiotic IV therapy was completed. The DON said by not calling the Physician/NP to get an order to discontinue Resident #12's mid-line placed resident at risk for infections. The DON said the nurses should assess the residents at least once a shift addressing any abnormalities or new changes in resident condition and notifying the physician in a timely manner of their findings. The DON said the facility did not have a policy on when a mid-line needed to be discontinued. Interview on 09/10/25 at 1:12PM, the Infection Control Preventionist said she was the facility's Infection Control Preventionist for 1 year. She said it was part of her job description to check all new admissions for antibiotic therapy via IV or by mouth and monitor their therapy. She said she monitored residents that had intravenous lines. She said she assessed the resident IV lines on a weekly basis to see if the IV dressing was changed as ordered by the physician, for signs and symptoms of infection such as redness, drainage, or swelling at the site. The Infection Control Preventionist said she also monitored the stop dates of resident receiving antibiotic therapy. She said whenever a resident received IV antibiotic therapy, the IV line should be discontinued within 3-5 days to prevent infections. The Infection Control Preventionist said the Physician/NP should be called to get an order to discontinue the IV line. The Infection Control Preventionist said she believed Resident #12's IV antibiotic discontinued on 08/28/25 or 08/29/25. The Infection Control Preventionist said she did not call the Physician/NP to get Resident #12's mid-line discontinued and that it must have been an oversight on her part. Observation on 09/10/25 at 2:52PM, the Infection Control Preventionist removed Resident #12's midline practicing sterile technique. The tip of the midline insertion was still intact. The mid-line site was without redness, drainage, swelling, or foul odor. The facility only provided a policy on quality of care related to ADL's 676230 Page 13 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

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, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preference for 1 of 7 residents (Resident #12) reviewed for tracheostomy care. The facility failed to ensure -LVN M did not turn Resident #12's oxygen off for 2 minutes when providing resident tracheostomy (surgical opening that creates an opening in the trachea [(windpipe]) to allow air to enter and exit the lungs) care. This failure could place residents at risk for respiratory distress and hypoxia (deficiency of oxygen). Findings include: Record review of Resident #12's face sheet, dated 09/11/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #12 had diagnoses which included : chronic respiratory failure (difficulty breathing), type 2 diabetes mellitus (when the body has trouble controlling blood sugar and using it for energy) cerebral infarction (interruption of blood flow in the brain), pressure ulcer of sacral (triangular shaped bone located at the base of the spine) stage 4 (deep wound exposing the muscles, ligaments, or bones), dysphagia (difficulty swallowing), Parkinson's Disease (disorder that effects movement and sometimes cause tremors), hypertension (elevated blood pressure), cognitive communication deficit, tracheostomy (surgical opening in the windpipe to help with breathing), colostomy (surgical incision that creates an opening in the abdomen to reroute stool from the colon directly into an outside bag), and gastrostomy (surgical incision that creates an opening through the abdominal wall. A tube is inserted to provide nutrition, fluids, and medications directly into the stomach). Record review of Resident #12's quarterly MDS dated [DATE] revealed a BIMS score of 3, which indicated the resident's cognition was severely impaired. Record review of Resident #12's Physician Order Summary Report for the month of September 2025 reflected the following orders: -Dated 06/27/25 Tracheostomy aerosol (tiny solid particles or liquid droplets) trach collar @ 20psi 28% humidity, 5-8L O2 to keep SPO2 > 90%, Shiley flex 6 cuffed (an inflatable balloon at the end of tube that helps create a seal in the trachea to help maintain the correct pressure for safety and effectiveness) trach, every shift for trach related chronic respiratory failure. -Dated 08/18/25 Tracheostomy care every shift for trach care. -Dated 08/18/25 Check and record oxygen saturation every shift while suctioning and as needed for s/s of respiratory distress. Record review of Resident #12's TAR for the month of September 2025 reflected resident oxygen saturation ranged from 92%-98%. Record review of Resident #12' Comprehensive Care Plan, dated 01/08/25, reflected resident being care planned for dependent on tracheostomy r/t respiratory failure with an intervention that included administering oxygen as ordered. Observation on 09/09/25 at 10:06 AM revealed Resident #12 was resting in bed with a trach collar connected to the oxygen machine (on the left side of resident bed) at 5-liters with a humidifier bottle connected and dated 09/09/25. There was a suction cannister sitting on the night stand on the left side of bed. Inside of the suction canister was clear frothy secretions. The cannister was dated 09/08/25. Observation and interview on 09/10/25 at 10:05AM of tracheostomy care for Resident #12 by LVN M revealed. LVN M said she had already disinfected her workspace (bedside table) that was positioned on the left side of resident bed. On the bedside table was an unopen tracheostomy kit and a package of unopened sterile gloves. LVN M entered the room and washed her hands with soap and water and began to don (put on) her PPE that consisted of a disposable gown and gloves. LVN M then went to the right side of the resident's bedside to stop the resident's continuous gastrostomy feedings and placed a pulse oximeter on the resident's right- hand finger. Resident #12's oxygen saturation Residents Affected - Few 676230 Page 14 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few fluctuated between 91-93%. LVN M left the pulse oximeter on the resident's finger and proceeded to listen to the residents' lung sounds by using a stethoscope. LVN M went to the left side of the resident's bed stood by the resident oxygen machine and prepared to remove soiled gloves, placed the gloves inside of a red biohazard bag. LVN M proceeded to place on a set of sterile gloves after sanitizing her hands to remove the old dressing from around the resident's tracheostomy site and disposed the soiled materials inside of the red biohazard bag. LVN M sanitized her hands again and proceeded to open the sterile tracheostomy kit which consisted of pre-cut, non-woven tracheostomy dressing, gauzes, and normal saline. The time was 10:14 AM with LVN M continuing to monitor the resident's oxygen saturation which continued to fluctuate between 91-93%. Resident #12 did not appear to be in any distress. LVN M established her right hand would be her dominant hand to clean around the resident's tracheostomy. LVN M proceeded to clean around the tracheostomy site, being careful not to introduce bacteria to the site, cleaning one wipe at time away from the site. When LVN M was done cleaning around the resident tracheostomy site, she placed the new sterile dressing around the resident's tracheostomy site and placed all soiled materials inside of the red biohazard bag. The time was 10:16 AM when LVN M stated Now I will turn back on the oxygen. The resident continued to not appear to be in any distress with respirations even and unlabored at a rate of 18per minute. LVN M checked the resident's heart rate which was 68. Interview on 09/10/25 at 10:16 AM, LVN M said she made a mistake. LVN M said she was so nervous when being observed by the state surveyor. LVN M said she was not supposed to turn off the resident's oxygen because it could cause Resident #12 oxygen saturation to desaturate which could lead to hypoxia (decrease in oxygen level). LVN M said she turned off the resident's oxygen right before she began tracheostomy care. LVN M said the last time she received an in-service on tracheostomy care was last month by the Respiratory Therapist. Interview on 09/10/25 at 12:12 PM, the DON said when the nurse provided tracheostomy care, the oxygen should not be turned off at any time because it would place the resident at risk of their oxygen level dropping which could lead to respiratory distress. The DON said competency skills were done with the nurses at the time of hire, annually, and as needed, which included tracheostomy care. The DON said the Respiratory Therapist came to the NF every week normally on Monday's and as needed. The DON said the Respiratory Therapist assessed the facility trach resident (s), provided education to the nurses regarding tracheostomy care, addressed any other concerns the facility might have regarding respiratory. Interview on 09/10/25 at 2:04 PM, the Respiratory Therapist said he observed nurse, LVN M, providing trach care and knew better not to turn off Resident #12's oxygen. The Respiratory Therapist said after LVN M came and told him what she did during observation of tracheostomy care with the state surveyor, he went and assessed Resident #12, whose oxygen saturation was saturating between 93%-94%, at 5 liters. The Respiratory Therapist said the resident order said the resident could be given 5-8 liters to keep the resident's oxygen saturation above 90%. The Respiratory Therapist said at one time Resident #12's tracheostomy was downsized from size 6 to 4 and done well. The Respiratory Therapist said at one time he had done trials with the Passy-Muir Valve (one-way valve that attaches to the tracheostomy tube, allowing for communication and swallowing) as tolerated and resident did well. The Respiratory Therapist said because of Resident #12 comorbidities, recurrent pneumonia, infections associated with her wounds, and having to be transferred to the hospital, resident was no longer a candidate for decannulation (surgical removal of a tracheostomy tube, or trach, from the neck, allowing a person to breathe on their own again). The Respiratory Therapist said he came to the facility once a week and provided any necessary in-services with the staff or addressed any concerns the facility might have. The Respiratory Therapist said Resident #12 was the only resident at the facility with a tracheostomy. 676230 Page 15 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Respiratory Therapist said he ensured the nurses were competent in providing tracheostomy care by having the staff demonstrate the skill for him while maintaining sterile technique. Interview on 09/14/25 at 1:18 PM, the Nurse Practitioner said it was not detrimental to Resident #12 when LVN M turned off the resident's oxygen during tracheostomy care. The NP said the resident's oxygen saturation base line was 92%. The NP said if a resident's oxygen saturation dropped below 88% she would become concerned but even then, one would just need to increase Resident #12 oxygen back to her baseline. The NP said when good trach care was provided to a trach resident, Resident #12 would not be receiving 100% of their oxygen due to having to manipulate the oxygen mask to provide trach care or suctioning. Record review of the NF policy regarding Tracheostomy, Care and Cleaning, revised May 2007, did not reflect the resident oxygen being turned off. 676230 Page 16 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0700 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure appropriate alternatives prior to installing a side or bed rail were used and if bed or side rails are used, the facility failed to ensure correct installation, use and maintenance of bed rails, including, but not limited to assessing the resident for risk of entrapment from bed rails prior to installation, reviewed the risks and benefits of bed rails with the resident or resident representative and obtained informed consent prior to installation for 11 of 11 residents (Resident #8, #15, #22, #25, #44, # 60, #84, #90, #134, #145, and #149) reviewed for mobility bars/bedrails. 1. -The facility failed to assess Resident #84 for mobility bars, educate the resident RP on the risk and benefits of mobility bars, obtain a physician order and a consent for mobility bars. Resident #84 was observed in between the mobility and head of bed entrapped in her sheets and bedspread to her lower body torso (waist extending to lower legs). When Resident #84 attempted to get untangled, the mobility bar prevented her from moving. -2. The facility failed to assess residents, attempt alternatives, receive consent prior to placing bed rails on residents' beds for. Newly admitted residents, Residents #8, #90, #134, #145, #22, #66, #15, #25, #149 and #44 who had bedrails installed on their beds upon admission. An Immediate Jeopardy (IJ) situation was identified on 09/12/2025. While the IJ was removed on 09/16/2025, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of their corrective systems. -These failures could place residents at risk for entrapment and injuries. Findings include: 1. Record review of Resident #84's face sheet, dated 09/12/25, revealed reflected that the resident was admitted to the facility on [DATE]. Resident #84 had diagnoses which included the following: hemiplegia (paralysis or weakness on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), dysphagia (difficulty swallowing), chronic kidney disease, syncope and collapse (temporary loss of consciousness/fainting caused by sudden , brief decrease in blood flow to the brain), cognitive deficit, falls, cerebral infarction (blood flow to the brain is interrupted), hypertension (elevated blood pressure), muscle wasting and atrophy (muscle lose mass and strength). Record review of Resident #84's Physical Therapy evaluation, dated 08/08/25-09/04/25, and OT evaluation & Plan of Treatment, dated 08/08/25-09/04/25, did not reflect ed that residents' had been assessed for the safety of mobility bars on bed. Record review of Resident #84's Admissions MDS, dated [DATE], reflected the BIMS score was coded 0, which indicated indicating that resident cognition was severely impaired. Record review of Resident #84's Physician Order Summary Report, for the month September 2025, did not reflect an order for mobility bars. Record review of Resident #84's initial IDT meeting, dated 09/13/25, reflected mobility bars in place to aide in turning and repositioning while in bed. Further review did not reflect that the resident RP was educated on the risk and benefits of the mobility bars. Record review of Resident #84's Progress Notes for the month of August and September 2025 did not reflect that the nurses had assessed the resident for the safety of mobility bars on bed. Record review of Resident #84's Comprehensive Care Plan, dated 09/11/25, reflected that the resident was not being care planned for mobility bars on bed. Observation on 09/09/25 at 9:47 AM of revealed Resident #84 in room sitting on the left side of her bed. Resident #84 was sitting on the opposite side of the mobility bar in between the mobility bar and the head of bed. The resident was entrapped in her bed sheet and bedspread to her lower body torso. The resident could not figure 676230 Page 17 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0700 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some out how to untangle herself. Resident #84 then lay on her back unable to get herself out of the situation. Resident #84 continued to try and untangled herself but was not successful. The State Surveyor called for help. Entering RN F, the Therapy Aide and Physical Therapy entered Resident #84's room was RN F and the Therapy Aide from Physical therapy. Both staff members began to assist Resident #84 by untangling Resident #84 and assisting assisted the resident out of bed in a wheelchair. RN- F then left Resident #84's room and went to his cart in the hallway. Interview on 09/12/25 at 9:45 AM with the Administrator, regarding mobility bars on Resident #84's bed, the Administrator said the Physical Therapy Department assesses assessed each resident who utilized mobility bars on their beds. The Administrator said the Physical Therapy Department provided their recommendations to the nurse. The Administrator said the nurse then contacted the Physician for an order to utilize the mobility bars. The Administrator said the State Surveyor would not be able to access the Physical Therapy Department documentation of assessments done for Resident #84, because the Physical Therapy Department was not on the same charting system as the facility. Interview on 09/12/25 at 9:45 AM, with the Rehab Director said both the Physical Therapist and Occupational Therapist could both do an assessment for a resident to see if the resident met the criteria for mobility bars/bedrails. Interview on 09/12/25 at 10:23 AM via phone with Occupational Therapist ZO said that she worked at the facility PRN. Occupational Therapist ZO said she assessed Resident #84 upon admission for functional status. Occupational Therapist ZO said she did not assess Resident #84 for mobility bars. Occupational Therapist ZO said if a resident was not being assessed for mobility bars/bedrails, it placed the resident at risk of getting entrapped, injury, and death. Occupational Therapist ZO said it was a learning moment and that she would be contacting the Director of Rehab on how to move forward. Attempted interview via phone on 09/12/25 at 10:52 AM with the RP of Resident #84 regarding if the facility had contacted her regarding the risk and benefits of the mobility bars was unsuccessful therefore, a voicemail was left. Interview on 09/12/25 at 11:53 AM, with the DON regarding mobility bars on Resident #84 bed. The DON said most of the residents had mobility bars on their beds. The DON said that the nurses done did the assessment for mobility bars as well as the Physical Therapy Department. The DON said she would have to clarify with the Physical Therapy Department regarding who done did the assessment for a resident to have mobility bars on their bed. The DON said it was important for a resident to be assessed for safety prior to mobility bars being placed on their bed. The DON said if the resident was not assessed for mobility bars it placed the resident at risk for injury, falls, and skin tears. Further interview with the DON said there was an assessment that the nurses done did for bed safety and would have to review the assessment form first to see what all the form entailed2. Record review of Resident #8's face sheet, dated 09/09/25, reflected, a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #8's BIMS Assessment, dated 08/13/25, reflected, moderately impaired cognition as indicated by a BIMS score of 12 out of 15. Record review of Resident #8's, undated, Care Plan reflected, no documented focus area for the use of bed rails for mobility purposes. Record review of Resident #8's EMR on 09/12/15 reflected, no record of a bed rail consent form or a bed rail assessment. An observation and interview on 09/12/25 at 10:40 AM revealed, Resident #8 in bed with grab assist bed rails on both sides of her bed. She said she used the rails occasionally and they were present on her bed on admission. Resident #8 said she was never assessed for bed rails; she did not give consent for the bed rail, but she had no safety concerns about the bedrails. 3. Record review of Resident #90's face sheet, dated 09/12/25, reflected, an [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #90's BIMS Assessment, dated 08/28/25, reflected, intact cognition as indicated by a BIMS core of 15 out of 15. Record review of 676230 Page 18 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0700 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Resident #90's EMR on 09/12/15 reflected, no record of a bed rail consent form or a bed rail assessment. An observation and interview on 09/12/25 at 10:40 AM revealed, Resident #90 in bed with grab assist bed rails on both sides of her bed. She said she did not use the bars, and they were present upon admission. Resident #90 said she was not trained on the use of the bar, was not assessed for the use of the bar or gave consent for the use of the rail but it did not cause her any safety issues. 4. Record review of Resident #134's face sheet, dated 09/12/25, revealed, a [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #134's BIMS Assessment, dated 09/04/25, revealed, intact cognition as indicated by a BIMS score of 14 out of 15. Record review of Resident #134's EMR, on 09/12/15, revealed, no record of a bed rail consent form or a bed rail assessment An observation and interview on 09/12/25 at 10:45 AM revealed, Resident #134 in bed with grab assist bedrails on both sides of her bed. She said she used the bars to reposition herself and they were on her bed upon admission. Resident #134 said she was not assessed for the use of the bar or gave consent for the use of the rail but it did not cause her any safety issues because she had used them on a previous admission 5. Record review of Resident #145's face sheet, dated 09/12/25, reflected, a [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #145's BIMS Assessment, dated 09/08/25, reflected, moderately impaired cognition as indicated by a BIMS score of 12 out of 15. Record review of Resident 145's EMR on 09/12/15 reflected, no record of a bed rail consent form or bed rail assessment. Record review of Resident #145's, undated, Care Plan reflected, no documented focus area for the use of bed rails for mobility purposes. An observation and interview on 09/12/25 at 10:48 AM revealed, Resident #145 in bed with grab assist bed rails on both sides of her bed. She said she was not trained on the use of the bar; they were present upon admission, she was not assessed for the use of the bar or give consent for the use of the rail, but it did not cause her any safety issues, and she did not feel restrained by the bar. 6. Record review of Resident #146's face sheet, dated 09/12/25, reflected a [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident 146's EMR on 09/12/15 reflected, no record of a bed rail consent form or bed rail assessment. Record review of Resident #146's, undated, Care Plan reflected, no documented focus area for the use of bed rails for mobility purposes. An observation and interview on 09/12/25 at 10:48 AM revealed, Resident #146 in bed with grab assist bed rails on both sides of her bed. She said she did not use the bed rails and then sat up, in the bed, without the assistance of the rail. Resident #146 said was not trained on the use of the bar, they were present on admission, she was not assessed for the use of the bar or was given consent for the use of the rail, but it did not cause her any safety issues, and she did not feel trapped by the bar. 7. Record review of Resident #23's face sheet, dated 09/12/25, reflected, a [AGE] year-old male who admitted to the facility on [DATE]. Record review of Resident #23's BIMS Assessment, dated 09/08/25, reflected, intact cognition as indicated by a BIMS score of 15 out of 15. Record review of Resident #23's EMR on 09/12/15 reflected, no record of a bed rail consent form or bed rail assessment. Record review of Resident #23's, undated, Care Plan revealed, no documented focus area for the use of bed rails for mobility purposes. An observation and interview on 09/12/25 at 10:459 AM revealed, Resident #23 in bed with grab assist bed rails on both sides of his bed. He said he used the bar to get up in bed but was not trained on the use of the bar, they were present upon admission, he was not assessed for the use of the bar or gave consent for the use of the rail. Resident #23 said the rail did not cause him any safety issues and he did not feel restrained by the bar. 8. Record review of Resident #66's face sheet, dated 09/12/25, reflected, an [AGE] year-old male who admitted to the facility on [DATE]. Record review of Resident #66's BIMS Assessment, dated 08/13/25, reflected, moderately impaired cognition as 676230 Page 19 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0700 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some indicated by a BIMS score of 14 out of 15. Record review of Resident #66's EMR, on 09/12/15, reflected, no record of a bed rail consent form or bed rail assessment. Record review of Resident #66's, undated, Care Plan reflected, no documented focus area for the use of bed rails for mobility purposes. An observation and interview on 09/12/25 at 11:00 AM revealed, Resident #66 in bed with grab assist bed rails on both sides of his bed. He said he didn't use the bar; they were present upon admission, he was not trained on the use of the bar, was not assessed for the use of the bar or gave consent for the use of the rail. Resident #66 said the rail did not cause him any safety issues and he did not feel restrained by the bar. 9. Record review of Resident #15's face sheet, dated 09/12/25, reflected, a [AGE] year-old male who admitted to the facility on [DATE]. Record review of Resident #15's BIMS Assessment, dated 08/25/25, reflected, intact cognition as indicated by a BIMS score of 15 out of 15. Record review of Resident #15's EMR on 09/12/15 revealed, no record of a bed rail consent form or bed rail assessment. An observation and interview on 09/12/25 at 11:00 AM revealed, Resident #15 in bed with grab assist bed rails on both sides of his bed. He said he didn't use the bar; and they were present upon admission. Resident t#15 said he was not trained on the use of the bar, was not assessed for the use of the bar or gave consent for the use of the rail. Resident #15 said the rail did not cause him any safety issues and he did not feel restrained by the bar. 10. Record review of Resident #25's face sheet, dated 09/12/25, reflected an [AGE] year-old female who admitted to the facility on [DATE]. Resident #25 had diagnoses which included: difficulty walking and hip fracture. Resident #25 was at the facility for orthopedic aftercare. Record review of Resident #25's BIMS assessment, dated 09/01/25, revealed, intact cognition as indicated by a BIMS score of 15 out of 15. Record review of Resident #25's, undated, Care Plan revealed, no documented focus area for the use of bed rails for mobility purposes. Record review of Resident #25's EMR on 09/12/15 revealed, no record of a bed rail consent form or bed rail assessment. An observation and interview on 09/12/25 at 10:55 AM revealed, Resident #25sat in her wheelchair at her bedside table located in front of the foot of her bed. She said she did not use the bars; they were present upon admission, and her bars were wobbly. She said she notified maintenance of the wobbly bars, and he changed the bolts. Resident #25 said maintenance told her even though they wobbled they were still secure, but she didn't feel safe using it. She said she was not assessed for the use of the bar or gave consent for the use of the rail. 11. Record review of Resident #149's face sheet, dated 09/12/25, reflected, a [AGE] year-old male who admitted to the facility on [DATE]. Record review of Resident #149's BIMS Assessment, dated 09/08/25, revealed, intact cognition as indicated by a BIMS score of 15 out of 15. Record review of Resident #149's EMR on 09/12/15 revealed, no record of a bed rail consent form or bed rail assessment. An observation and interview on 09/12/25 at 11:07 AM revealed, Resident #149 in bed with grab assist bed rails on both sides of his bed. He said the bars were present upon admission, he was not trained on the use of the bar, was not assessed for the use of the bar or gave consent for the use of the rail. Resident #149 said the rail did not cause him any safety issues and he did not feel restrained by the bar. 12. Record review of Resident #44's face sheet, dated 09/12/25, reflected, a [AGE] year-old male who admitted to the facility on [DATE]. Record review of Resident #44's BIMS Assessment, dated 09/02/25, revealed, intact cognition as indicated by a BIMS score of 13 out of 15. Record review of Resident #44's EMR on 09/12/15 revealed, no record of a bed rail consent form or bed rail assessment. An observation and interview on 09/12/25 at 11:05 AM revealed, Resident #44 in bed with grab assist bed rails on both sides of his bed. He said the bars were present upon admission, he was not trained on the use of the bar, was not assessed for the use of the bar or give gave consent for the use of the rail. He said he used the bars but they were shaky so he was concerned about using them. 676230 Page 20 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0700 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some In an interview on 09/12/25 at 11:53 AM, the DON said all residents had mobility bars immediately upon admission because the facility did not consider them bed rails. She said upon admission nursing and therapy staff should assess residents for bed rail safety but at this time she did not know who was responsible for the task in the facility and she needed to clarify. The DON said only therapy had the competency to assess a resident's functional ability to determine their need for bed rails and to ensure residents were safe to use them. She said failure to assess a resident prior to the use of bed rails could place them at risk for skin tears, discoloration, fall and possible injury. In an interview on 09/12/25 at 01:32 PM, the Administrator said upon admission the admitting nurse was expected to assess resident's, but the facility did not call mobility bars, bed rails. She said it was an interdisciplinary effort between nursing, therapy and the IDT team to determine if a resident was appropriate for a bed rail. She said mobility bars were considered grab bars and assist bars and prior to use, the facility required consent from the resident or their RP. The Administrator said she did not know if the facility attempted to use alternatives prior to implementation of mobility bars and she would have to check with the nursing team but any attempted alternatives if applicable should be documented in the resident's chart. The Administrator could not answer if nurses, especially LVNs, had the competencies to assess a resident's appropriateness for mobility bars (bed rails) and she would have to clarify. She said failure to assess residents for their functional ability and safety to use a mobility bar (bed rail) could place them at risk of accidently hitting the bed rail, bruising and skin discoloration. The Administrator said confused residents or those with dementia were at a higher risk of injuries with mobility bars. Record review of the facility's policy on Bedrails, last revised April 2025, reflected in part: .It is the policy of this facility to attempt to use appropriate alternatives prior to installing a side rail or bed rail. If a bed or siderail is used, the facility must ensure correct installation, use, and maintenance of bedrails.Entrapment is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail.Examples of bed rails include, but are not limited to: siderails, bedrails, safety rails: and grab bars and assist bars.After the facility has attempted alternatives to bedrails and determined that these alternatives failed to meet the resident's assessed needs the facility interdisciplinary team (IDT) will assess the resident for risk of entrapment.If the resident use of bedrails is recommended by the IDT, the facility must obtain informed consent from the resident, or if applicable, the resident representative for the use of bedrails prior to installation or use.Update the resident care plan as needed related to the identified and/or ongoing need or resident choice for the use of bedrails. This was determined to be an Immediate Jeopardy (IJ) on 09/12/2025 at 3:16 PM. The Administrator and DON were notified. The Administrator was provided with the IJ template on 09/12/2025 at 3:16PM.The following Plan of Removal (POR) was submitted by the facility and was accepted on 09/14/25 at 2:02PM. PLAN OF REMOVAL F700 Name of facility: 09/13/2025 Immediate Action POR F-700 Facility failed to ensure residents were assessed and educated for the use of bed rails, bedrails are default, consent is not given, and alternatives are not attempted prior to initiation. Resident #84 was observed entrapped in a sheet between the mobility bar and the head of the bed.1. The Medical Director was notified of the IJ by the Executive Director on 9/12/2025 at 4:51 pm.2. Head to toe assessment on Resident #84 was completed on 09/12/2025 by the charge nurse for any signs or symptoms of injury. No injuries were noted. Resident #84 was screened by physical therapy and met the criteria for mobility bars. A bed rail safety assessment was completed on 09/13/2025 by the IDT that included a physical therapy screen where it was indicated that the resident requires mobility bars for increased independence and can utilize them appropriately. No issues were identified regarding safety during the use of mobility 676230 Page 21 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0700 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some bars. Maintenance director designee performed a bed safety assessment, and no issues were identified. Resident has floor mats in place on both sides of the bed and bed in lowest position already. Resident will be monitored every hour by nursing staff and documented in POC/ PCC. The least restrictive device recommended for this resident to aid in mobility is mobility bars. After a lengthy discussion with physical therapy, there is not a suitable alternative when mobility bars are used for their intended purpose of enhancing a resident's independence and functional mobility as is the case with this resident. If the mobility bars were removed, it would have a negative impact not only on this resident's physical capabilities, but her emotional well-being as she heavily relies on the mobility bars to turn and reposition self in bed. The risks and benefits of the mobility bars were discussed with the family member by nursing management on 09/12/2024 and again by the Executive Director on 09/14/2025. The Family Member agreed on the continued use of the mobility bars. The Care plan was updated with interventions by the MDS coordinator on 09/12/2025 and updated again on 09/13/2025.3. Facility-Wide Bed Audit: A comprehensive audit of all facility beds, both occupied and unoccupied, was completed on 09/12/2025 by Administrator/ designee. All mobility bars (bed rails) on unoccupied beds were removed by the Maintenance Director/ designee. All residents identified with mobility bars on their bed were screened by physical therapy for need of mobility bars, and if the resident was found to need a mobility bar, the IDT met and discussed and completed a bed rail safety assessment. This was completed by 09/13/2025.4. On 09/12/2025, a facility-wide evaluation of all residents was conducted by the Director of Nursing (DON) or designee, Nurse Managers, and cluster partners. The LN Restraint/Enabling Device/Safety Device Evaluation - V2 [ tool was utilized to identify which residents will benefit from mobility bars. For residents who were identified as not benefiting from mobility bars, those devices were immediately removed by the maintenance director/ designee. On 09/13/2025, all residents were screened by physical therapy for need of mobility bars. A note was entered into PCC. No risks were identified regarding safety for the use of mobility bars. A bed rail safety evaluation was completed by the IDT for all residents identified as needing mobility bars. This was completed by 09/13/2025.5. For residents determined to benefit from mobility bars per therapy screen, appropriate physician orders were obtained, informed consents were secured for residents missing consents that included education on risks and benefits, and care plans were updated with interventions. Administrative nurse and clinical resource nurses obtained the orders. MDS nurses updated the care plans. Administrative provided education to all licensed nurses. Training topics included but were not limited to: Proper completion of the LN Restraint/Enabling Device/Safety Device Evaluation - V2, review of the facility's bed rails policy, obtaining informed consent, including discussion of potential risks and benefits with the resident/ responsible party, obtaining physician orders when bed rails are indicated. All training will be completed before nurses begin their next shift. CNAs will be educated on the use of mobility bars that will also include risks/ benefits by 09/13/2025. Those residents that have mobility bars, will have that indicated in the resident care profile which pulls over to the CNA Kardex. A member of the management team will be present at each shift change to ensure completion. Nursing staff will not be allowed to work until training is completed. Training will be part of new hire orientation and mandatory for PRN staff before working on the therapy staff on completing a Therapy Consult screen and documenting with a note determining the need for mobility bars on all new admissions/ re-admissions by the next business day. This was completed 9/13/2025.8. The DON/designee administered post-training tests to nurses regarding the mobility bars protocol. Target 676230 Page 22 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0700 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some need for side rails/ mobility bars the next business day. The DON/ designee will be responsible for monitoring the process and ensure residents have completed assessments, care plans are updated with interventions, orders are obtained, and consents are secured.10. During the facility's weekly systems review, the Interdisciplinary Team (IDT) will review all residents currently utilizing mobility bars or other safety devices to ensure continued compliance, appropriateness of use, and documentation accuracy. In addition to the weekly reviews, these residents will be evaluated quarterly by the IDT.11. An ad hoc QAPI meeting regarding items in the IJ template was completed on 09/12/2025. Attendees included the Medical Director, Clinical Resource, Administrator, DON, ADON, and will include the plan of removal items and interventions.12. A summary of the IJ and corrective actions will be reviewed by the QA PI Committee:Weekly for 4 weeks or until substantial compliance is achieved.- Then monthly for 90 days to ensure ongoing compliance. Monitoring of the Plan of Removal included the following: Interview on 09/15/25 at 10:57AM via phone, RN F said he worked the 6PM-6AM shift. RN F said he received an in-service on bedrails twice from the DON and Unit Managers. RN F said the in-service included assessing all new residents and readmits for mobility bars to see if they would benefit from using the bars. RN F said the resident or RP would have to be educated on the use of mobility bars about the benefits as well as the risk. RN F said a resident with severe mental cognition or required total care should not have mobility bars on their bed. RN F said once the nurse assessed the resident for mobility bars and thought they could benefit from the bars being on their bed, the Physical Therapy Department would then do an assessment. RN F said an IDT meeting would be held to discuss the use of the mobility bars, the Physician/NP was notified to get an order, and a consent was signed. RN F said when mobility bars were on a resident bed, the resident should be monitored for safety on every shift at least every 30 minutes to an hour or sooner pending the circumstance. RN F said the resident care plan had to be updated. Interview on 09/15/25 at 11:15AM with RN G via phone said she worked at the facility from 6PM-6AM. She said she was in-serviced on bedrails along with the risk and benefits. RN G said before the mobility bars were placed on a resident bed, the resident had to be assessed by the nurse as well as the Physical Therapy Department. RN G said the resident or RP had to be informed about the pros and cons of the mobility bars. RN G said an IDT meeting was done, physicians were notified and consent needed to be signed along with updating the resident care plan. Interview on 09/15/25 at 11:35AM, CNA AG via phone said she worked at the facility from 10PM-6AM full time. CNA AG said she was in-serviced to search in the POC to see if the resident had mobility bars on the bed. CNA AG said she was also in-serviced on the risk and benefits of mobility bars. Interview on 09/15/25 at 12:13 PM, LVN K said she worked the 6AM-6PM shift full time. LVN K said she was in-serviced on the risk and benefits of mobility bars. The risks were entanglement, entrapment, skin alterations, and it could decrease the resident mobility due to resident becoming dependent on the mobility bars. The benefits of the mobility bars were helping the residents position themselves in bed during care, transfers from bed to chair and chair to bed, and offering the residents some sense of security. LVN K said before mobility bars were attached to a resident bed, the resident had to be assessed by the nurse and rehab, an IDT meeting had to be held, physician or NP had to be contacted, and a consent had to be signed. LVN K said the resident care plan had to be updated. LVN K said the resident had to be continuously monitored for safety risk. LVN K said a resident who required total care should not have mobility bars on their bed. Interview on 09/15/25 at 12:32 PM, CNA AR said she worked at the facility full time from 6AM-2PM. CNA AR said she received in-services on residents who had mobility bars to make rounds on the residents every 30 minutes while in bed to ensure 676230 Page 23 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0700 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the residents' safety. CNA AR said the in-service included the risk and benefits of mobility bars, how to assist the residents with the mobility bars, and to look in the POC to see what residents were utilizing the mobility bars on their beds. Interview on 09/15/25 at 12:28 PM, the treatment nurse said she worked at the facility every other weekend. The treatment nurse said she received in-service on mobility bars to review LN in the computer regarding assessment of mobility bars, restraints, and enablers. The treatment nurse said on any new admission or readmit, the resident had to be assessed for usage of mobility bars. The treatment nurse said if the resident met the criteria, before the mobility bars could be placed on their bed, the Rehab Department had to do an assessment, and an IDT had to be done. The treatment nurse said once it was decided that residents could benefit in having the mobility bars on their bed, the resident or RP would be educated on the risk and benefits, a doctor order had to be obtained, and the resident care plan had to be updated regarding mobility bars. The treatment nurse said the residents needed to be reassessed quarterly or experienced a changed in condition. Interview on 09/15/25 at 12:40 PM, the therapy aide said she received in-service on mobility bars and an assessment needed to be done on the resident by the Rehab Department, the resident had to be educated on the risk and benefits of having the bars on their bed and get an order from the physician. The therapy aide said she would have to look in PCC to see if the resident was assessed for mobility bars on their bed. Interview on 09/15/25 at 12:47 PM, the MDS nurse said she worked at the facility Monday through Friday. The MDS nurse said she received in-service on the importance of educating the resident or RP about the risk and benefits of mobility bars, making sure the resident as assessed for mobility bars, getting a physician order and consent from the resident or RP. The MDS nurse said prior to mobility bars being attached to the resident bed, and IDT 676230 Page 24 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0760 Ensure that residents are free from significant medication errors. 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 residents were free of any significant medication errors for 2 of 7 residents (Residents #2 and Resident #109) reviewed for significant medication errors. - The facility failed to ensure nursing staff administered pre-prandial (before a meal) insulin to Resident #2 safely by administering it more than 15 -minutes before meals on 25 occasions from 08/01/25 to 09/11/2025. - The facility failed to ensure nursing staff administered medication to Resident #109 as ordered when LVN K applied a Lidocaine patch to the resident's right knee without an order. These failures could place residents at risk of uncontrolled blood sugars, hypoglycemia (low blood sugars), hyperglycemia (high blood sugars), worsening of diabetes, medication errors and adverse reactions to medications. Findings include: Resident #2 Record review of the facility dining room meal teams revealed, Breakfast 07:45 AM to 08:15 AM, Lunch 11:45 AM to 12:15 PM, and Supper: 05:00 PM to 05:30 PM. Record review of the HumaLOG Highlights of Prescribing Information revised 03/2013 revealed, Subcutaneous (under the skin) Injection: Administer within 15 minutes before a meal or immediately after a meal. HUMALOG is a rapid-acting insulin. You should take HUMALOG within fifteen minutes before eating or right after eating a meal.Record review of Resident #2's face sheet, dated 09/17/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: kidney failure, enlarged prostate, irregular heartbeat and type 2 diabetes. Record review of Resident #2's Annual MDS, dated [DATE], revealed moderately impaired cognition as indicated by a BIMS score of 12 out of 15. Resident #2 used a wheelchair and required partial to moderate assistance with all ADLs. Record review of Resident #2's Order, dated 02/26/25, revealed, HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale subcutaneously before meals for diabetes : if 201 - 250 = 4 units SQ; 251 - 300 = 6units SQ; 301 - 350 = 8 SQ; 351 - 400 = 10 units SQ; 401 - 450 = 12 SQ; 451 -999 = Call MD/NP Call the MD/NP immediately for blood glucose greater than 451. Resident #2's HumaLOG was scheduled for 07:00 AM, 12:00 PM and 05:00 PM Record review of Resident #2's August 2025 MAR revealed Resident #2 received HumaLOG more than 15 minutes of scheduledmeals on: 1. 08/01/25 at 4:25 PM2. 08/01/25 at 11:33 AM3. 08/03/05 at 11:25 AM4. 08/03/25 at 07:02 AM5. 08/03/25 at 11:25 AM6. 08/03/25 at 04:48 PM7. 08/06/25 at 11:08 AM8. 08/09/25 at 11:19 AM9. 08/13/25 at 11:04 AM10. 08/18/25 at 11:03 AM11. 08/20/25 at 04:35 PM12. 08/23/25 at 06:21 AM13. 08/23/25 at 11:05 AM14. 08/24/25 at 04:20 PM15. 08/25/25 at 04:22 PM16. 08/27/25 at 11:20 AM17. 08/27/25 at 04:34 PM18. 08/28/25 at 11:13 AM19. 08/28/25 at 04:25 PM20. 09/01/25 at 04:23 PM21. 09/03/25 at 04:50 PM22. 09/04/25 at 02:30 PM23. 09/06/25 at 02:25 PM24. 09/07/25 at 11:05 AM25. 09/15/25 at 10:35 AM Record review of Resident #2's Progress Notes from 08/01/25 to 09/11/25 revealed, no documented episodes or signs and symptoms of hypoglycemia. Record review of Resident #2's Weight & Vitals: Blood Sugar dated 09/11/25 revealed, 11:31 AM- 181 An observation and interview on 09/11/25 at 11:30 AM revealed, LVM M prepared for insulin administration to Resident #2. She used a glucose meter to test the residents blood sugar on his left index finger and his result was 181. LVN M said the resident did not require insulin per his order and the resident ate his meals in the dining room. At 11:35 AM a CNA collected Resident #2 from his room and pushed him in his wheelchair to the dining area. An observation on 09/11/25 at 12:30 PM revealed residents sitting at tables in the dining area. Lunch had not been served; there was no food on Resident #2's table. In an interview on 09/15/25 at 12:29 PM, the DON said pre-prandial insulins were fast acting and they should be administered within 30 minutes of meals. She said pre-prandial insulin was administered before meals to treat high blood sugars and to also prevent spikes in blood sugar due to upcoming meals. The DON said pre-prandial insulin should not be Residents Affected - Some 676230 Page 25 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some administered early to prevent hypoglycemia and to ensure there was insulin available to treat the meal related blood sugar increase. She said prior to 09/11/25 the facility provided snacks after lunch and breakfast and not before breakfast or lunch so there was nothing in place to prevent hypoglycemia when meals were delayed. She said the facility had now moved Resident #2's insulin administration closer to his scheduled meals, trained nurses to hold insulin administration to within 30 minutes of meals and snacks were now available to resdients if meals were delayed. In an interview on 09/17/25 at 10:45 AM, NP A said pre-prandial (before eating) insulin was administered to treat blood sugars in anticipation of a meal and they should be administered not too long before meals, in a 30 minute window. She said failure to do so could place residents at risk for low blood sugars. In an interview on 09/17/25 at 10:50 AM, Resident #2 said he had not experienced any symptoms of hypoglycemia such as shaking or feeling weak or fatigued. Record review of the facility's policy titled Insulin Administration revised 10/2010 revealed, Onset of action - how quickly the insulin reaches the bloodstream and begins to lower blood glucose; Rapid- acting insulin had an onset of 10-15 minutes. Resident #109 Record review of Resident #109's face sheet, dated 09/10/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #109 had diagnoses which included: stroke due to a blood clot, type 2 diabetes and paralysis to the right dominant side and Gastrostomy status (a tube passed through the abdomen into the stomach used for feeding and medication administration). Record review of Resident #109's admission MDS, dated [DATE], revealed severely impaired cognitive skills for daily decision making, total dependence for all ADLs and functional abilities and presence of a feeding tube while a resident was at the facility. Record review of Resident #109's, undated, Care Plan revealed Focus: potential for alteration in comfort; Intervention: follow pain scale to medicate as ordered. Record review of Resident #109's Order Summary Report, dated 09/10/25, revealed Tylenol Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for pain. There were no other orders for pain management. Record review of Resident #109's Progress Notes, from 09/11/25 to 09/17/25, revealed the following- 9/11/2025 09:24 signed by LVN K: The Change In Condition/s reported on this CIC Evaluation are/were: Other change in condition. NP order to monitor for any changes. Family member is aware of lidocaine pain patches she states her [Resident #109] used them prior at home and was not concern or warrant about the error. Primary Care Provider Feedback : Primary Care Provider responded with the following feedback: A. Recommendations: Monitor site for any reaction. An observation and interview on 09/11/25 at 08:47 AM, revealed LVN K prepared for medication administration to Resident #109. She retrieved a Lidocaine 4% patch, performed hand hygiene, put on a pair of gloves and applied the patch to the resident's right knee. LVN K said prior to medication administration nursing staff must check against the orders and then against the medication to ensure the 5 rights, right time, right person, right medication, right dose. She said she mixed up the medication for Resident #109 and her roommate. She said Resident #109 did not have an order for the Lidocaine patch and she made a mistake. LVN K said she would immediately remove the patch from the residents knee and report the error to the NP and facility administration. She said failure to verify orders could place residents at risk for adverse events and allergic reactions. In an interview on 09/15/25 at 12:29 PM, the DON said all medications must be administered pursuant to a physician order and prior to administering medications staff must verify the orders against the MAR and the blister pack. She said failure to verify medications against a resident order could result in a medication error which could place residents at risk for adverse reactions such as skin irritation in the case of the Lidocaine Patch. The DON said the nurse reported the incorrect patch applied to Resident #1 and after assessment Resident #109 suffered no side effects. Record review of the facility policy 676230 Page 26 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Specific Medication Administration Procedures, revised 11/13/18, revealed General Procedures to follow for all medications: b. Check expiration date on package/container. c. Read medication label three (3) times before pouring. d. Identify resident before administering medication. These guidelines refer to all medications, in addition to specific procedures for each type of medication. Administration: m. Residents are identified before medication is administered. Methods of identification include: 1) Checking identification band 2) Checking photograph attached to medical record 3) Calling resident by name 4) If necessary, verifying resident identification with other facility personnel. 676230 Page 27 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 3 medication carts (200 Hall Nurse Cart) and 1 of 8 residents (Resident #52) reviewed for medication storage. LVN K failed to ensure Resident #52's Tresiba Insulin Pen was not left unattended on top of the nursing cart on the 200 Hall. This failure could place residents at risk of misappropriation of medication and adverse reactions. Findings include: Record review of Resident #52's face sheet, dated 09/17/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #52 had diagnoses which included: lack of coordination, high blood pressure, high cholesterol, dementia and type 2 diabetes. She discharged home from the facility on 09/11/25 at 05:55 PM. Record review of Resident #52's Order Summary Report, dated 09/17/25, revealed Tresiba FlexTouch (Insulin Degludec)- Inject 22 unit subcutaneously one time a day for type 2 diabetes. Record review of Resident #52's Location of Administration Report, dated 09/17/25, revealed on 09/11/25 at 08:04 AM LVN J administered Insulin Degludec to Resident #52 at 08:04 AM. An observation on 09/11/25 at 08:36 AM revealed an opened and in-use insulin pen on top of the locked 200 hall nursing cart located at the end of the hall. There were no residents or staff around the cart. In an interview on 09/11/25/25 at 08:40 AM, LVN K said medications were expected to be locked when not under direct supervision of nursing staff to prevent unauthorized access to medications. She said medications should not be left on the top of the nursing cart because it could place residents at risk of adverse health effects, change of condition, and allergic reaction if the medication was used by an unauthorized resident. LVN K said she forgot to lock the insulin pen when she went to provide care to another resident. Record review of LVN K's Orientation and Annual Skill Checklist: Licensed Nurse, dated 09/08/25, revealed VIII. Medication & Treatment Passes: 1. Understands Medication Pass Procedure Including Charting: Rights of Medication Administration. She was signed as competent for all skills assessed. Record review of the facility's policy titled Storage of Medication, revised 04/2007, revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 2. The nursing staff shall be responsible for maintaining medication storage ANDpreparation areas in a clean, safe, and sanitary manner. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Record review of the facility's policy Specific Medication Administration Procedures, revised 11/13/18, revealed During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. 676230 Page 28 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0880 Provide and implement an infection prevention and control program. 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 establish and maintain and infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1of 3 staff reviewed for infection control. 1) RN E failed to practice hand hygiene before and after assisting Resident #84' with care. 2) RN E failed to sanitize the blood pressure device after taking Resident #3's blood pressure. 3)The facility failed to label and bag all personal care items in room [ROOM NUMBER]. Resident #12 resided in room [ROOM NUMBER]. These failures placed the residents at risk for cross contamination and infections. Findings include: Record review of Resident #12's face sheet, dated 09/11/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #12 had diagnoses which included the following: chronic respiratory failure, type 2 diabetes mellitus (when the body has trouble controlling blood sugar and using it for energy), cerebral infarction (interruption of blood flow in the brain), pressure ulcer of sacral (triangular shaped bone located at the base of the spine) stage 4 (deep wound exposing the muscles, ligaments, or bones), dysphagia (difficulty swallowing), Parkinson's Disease (disorder that effects movement and sometimes cause tremors), hypertension (elevated blood pressure), cognitive communication deficit, tracheostomy (surgical opening in the windpipe to improve breathing), colostomy (surgical incision that creates an opening in the abdomen to reroute stool from the colon directly into an outside bag), and gastrostomy (surgical incision that creates an opening through the stomach wall to provide nutrition, fluids, and medications directly into the stomach). Record review of Resident #3's face sheet, dated 09/17/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had diagnoses which included dementia, dysphagia, hypertension, and bipolar disorder (mental illness that causes unusual shifts in mood, ranging from highs to low. with one experiencing a change in their thinking, behavior, and sleep. Record review of Resident #84's face sheet, dated 09/12/25, reflected the resident was admitted to the facility on [DATE]. Resident #84 had diagnoses which included the following: hemiplegia (paralysis or weakness on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), dysphagia (difficulty swallowing), chronic kidney disease, syncope and collapse (temporary loss of consciousness/fainting caused by sudden , brief decrease in blood flow to the brain), cognitive deficit, falls, cerebral infarction (blood flow to the brain is interrupted), hypertension (elevated blood pressure), muscle wasting and atrophy (muscle lose mass and strength).Observation on 09/09/25 at 9:40 AM of RN E at the bedside of Resident #3 revealed the RN was wearing gloves and took the resident's vital signs. When RN E was done, he removed his gloves and did not wash or sanitize his hands and left the room with the gloves in his hands walking back to the cart on the hallway. RN E laid the blood pressure machine on top of cart and did not sanitize the equipment and proceeded to work at his cart. Observation on 09/09/25 at 9:47 AM revealed RN E entered Resident #84's room and donned gloves to assist with care by assisting the resident to the wheelchair. Resident #84's brief was soiled with feces, and the resident had placed her brief on the floor. After RN E assisted Resident #84 and placed the soiled brief in trash can, RN E removed his gloves and left the room without washing his hands or sanitizing. RN E proceeded to go back to cart on the hallway and work. Observation on 09/09/25 at 10:13 AM revealed in room [ROOM NUMBER] (Resident #12's bathroom) was 2 gray wash basins on top of the commode chair. One of the wash basins were not labeled and the other had Resident #12's name on it. The wash pans were not inside of plastic bags. Interview on 09/09/25 at 10:19 AM, CNA V said she was the CNA for Residents Affected - Few 676230 Page 29 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #12. After CNA V observed the wash pans on the commode chair, she said all resident personal care items should be labeled and bagged to prevent cross contamination and infections. CNA V said she would take care of the incident right away. Interview on 09/09/25 at 3:30 PM, RN E said he received in-service on fall preventions, infection control, and hand washing to prevent cross contamination and infections. RN E said it was important to wash hands before putting on gloves and washing hands after removing gloves, before touching a resident, after assisting residents with carer, and before leaving a resident room. RN E said he was in-serviced on sanitizing resident care equipment which included blood pressure devices and blood glucose machines after using and in between usage on each resident to prevent cross contamination and the spread of infections. RN E said the reason he was not practicing infection control regarding handwashing/sanitizing hands and sanitizing resident care equipment was because he must have gotten in a hurry and forgot. RN E said this placed the residents at risk for cross contamination and infections. Interview on 09/11/25 at 10:58 AM, LVN M said resident personal care items such as wash pans should be labeled and bagged separately to prevent cross contamination and infections. LVN M said it was the CNA's who were supposed to label resident wash pans and bag them separately. LVN M said it was the nurse's responsibility to ensure was being done. Interview on 09/11/25 at 11:09 AM, the DON said the resident personal care items were supposed to be labeled and bagged to prevent cross contamination. The DON said the facility had not designated this task to anyone yet. The DON said the facility had just hired a new staff member who would be taking the resident weights and this particular staff member would be assuming the role of making sure all resident personal care items were labeled and bagged. The DON said although this role had not been assigned to the new hire, the nurses and the CNA's were responsible in making sure residents personal care items were labeled and bagged. Record review of the facility's policy on Equipment cleaning, revised May 2007, reflected in part: .It is the policy of this facility to implement the following procedures to ensure equipment is cleaned and care for appropriately. Durable medical equipment must be cleaned before reuse by another resident.Reusable resident items are cleaned and disinfected between residents . Record review of the facility's policy on Hand Hygiene, revised April 2025, reflected in part: .It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene, which is one of the most effective measures to prevent the spread of infection, based on accepted standards. Residents, family, and visitors will be encouraged to practice hand hygiene.Hand hygiene after removing gloves. 676230 Page 30 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 3 of 8 residents (Resident #25, Resident #38 and Resident #104) reviewed for environmental concerns. - The facility failed to ensure Resident #38's room door did not have a lock that required a key which resulted in the resident, who was bed bound with her ankle fixed with screws, being locked in the room and inaccessible for 15-20 minutes.- The facility failed to ensure Resident #25's dresser drawers did not swing open on their own, leaving the resident concerned that her head would be hit by the drawer.- The facility failed to ensure Resident #25 and Resident #104's bathroom door did not swing shut on its own.These failures could place residents at risk of falls, injuries, and decreased quality of life. Findings include: Resident #38 Record review of Resident #38's face sheet, dated 09/14/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #38 had diagnoses which included: a fall, lower leg fracture, ankle fracture and she admitted for orthopedic aftercare (care after a surgery on systems like the bones, joints, muscles and tendons). Record review of Resident #38's, undated, Care Plan revealed, Focus: multiple fractures: closed displaced fracture of lateral condyle of right femur and open displaced fracture of left ankle and underwent In situ fixation (R) lateral fracture and Ex-revision of left ankle with external fixation and flap (left lower leg fracture and ankle fracture, fixed with rods going through ankle and transplant of tissue from left thigh to right ankle); Interventions: Anticipate and meet needs. Be sure call light is within reach and respond promptly. Record review of Resident #38's admission MDS, dated [DATE], revealed intact cognition, as indicated by a BIMS score of 15 out of 15. Resident #38 had impairment of both lower extremities (both legs), use of a wheelchair, total dependence for functional abilities of: roll left and right, sit to lying, lying to sitting on side of bed and chair/bed-to-chair transfer. She could not be assessed for her ability to: walk, car transfer, toilet/tub/shower transfer or go from sit to stand. Surgical procedures: Repair fractures of the pelvis, hip, leg, knee, or ankle (not foot) and she received surgical wound care. Record review of Resident #38's BIMS assessment, dated 09/02/25, revealed intact cognition as indicated by a BIMS score of 15 out of 15. Record review of Resident #38's Progress notes, from 09/11/25 to 09/14/25, revealed the following, - 09/13/2025 at 2:27 PM: Patient was assessed head to toe neurological assessment done, patient is alert and oriented x 4, no distress or discomfort observed. No complaint of pain verbalized. An observation on 09/13/25 at 01:18 PM revealed, Family Member #2 waiting at the nursing station as facility staff gathered around Resident #38's door attempting to open the door. Staff pulled and pushed at the door lever in an attempt to open the door and tried multiple keys, but the door would not open. Family Member #2 attempted to open the door forcefully pushing up and down on the lever and pushed and pulled on the door with no success. At 01:25 PM, the DON arrived with keys and opened the door to Resident #38's room. An observation and interview on 09/13/25 at 01:26 PM revealed Resident #38's door opened and an interior push lock that required a key to unlock on the exterior was observed on the door handle. There was a window facing the street and Resident #38 was in bed in no immediate distress with her call light within reach, her right ankle was fixed in place a metal pin/rod going through her entire ankle. The stopper was mounted to the wall and the interior push button locking mechanism engaged when the door was pushed into the stopper. Family Member #2 said he did not lock the door when he left the room and when he returned Resident #38's room door was locked and he and staff were unable to access the resident for 15-20 minutes. Resident #38 said she had her call light within reach, did not need any care while the 676230 Page 31 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some door was locked and she would not have been able to open the door even if she wanted due to her leg being fixed with pins. An observation on 09/13/25 at 10:30 AM revealed no other resident rooms had a lock that required a key to open to gain access to the room from the corridor. At 10:30 AM, Resident #38's door lever was replaced with one that could not lock. In an interview on 09/13/25 at 01:50 AM, the Administrator said Resident #38's room door was locked and that was the only room in the facility that required a key to unlock from the exterior and she was unsure about how long the door was locked. She said no resident rooms should have a lock that restricted access for resident safety. She said the presence of a lock placed residents at risk of staff not being able to access them to provide services or under emergency conditions. The Administrator said the DON was able to unlock Resident #38's room with a universal key she had in her office. In an interview on 09/15/25 at 09:08 AM, Resident #38 said she only realized her door was locked when she heard people trying to get into the room, banging and pushing the door. She said when her door was locked, she did not need services, and her call light was within reach. Resident #38 said while her door was locked Family Member #2 went to her room window a bunch of time to check on her so she wasn't really concerned. In an interview on 09/15/25 at 09:12 AM, the Administrator said facility staff learned from Resident #38's family member the residents door was locked. She said the resident didn't need anything at the time and she did not miss any care because of the locked door and facility staff monitored the resident from the window. The Administrator said if there was an emergency and staff could not access Resident #38; they would have broke the window to gain access. Resident #25 Record review of Resident #25's face sheet, dated 09/12/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #25 had diagnoses which included: difficulty walking, hip fracture; she was at the facility for orthopedic aftercare. Record review of Resident #25's BIMS assessment, dated 09/01/25, revealed intact cognition as indicated by a BIMS score of 15 out of 15. Record review of Resident #25's, undated, Care Plan revealed Focus: fracture of left hip with surgical repair: Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Focus: ADL Self Care Performance Deficit due to left hip fracture; Interventions: Requires staff participation with transfers. Requires staff assistance with incontinent care. Requires staff participation with reposition and turn in bed. Requires staff assistance with bathing/showering as per schedule and as necessary. Record review of the facility work order reports submitted from 08/01/25 to 09/12/25 revealed, no work orders documented to address self-closing doors, doors with locks that required keys to open or loose and self-opening drawers. An observation and interview on 09/12/25 at 10:55 AM revealed Resident #25 sat in her wheelchair at her bedside table located in front of the foot of her bed. There was a built in cabinet less than a foot in front of the residents head with the top 2 drawers open. Resident #25 said the drawers in her cabinet did not stay closed, which was not safe because it could hit her in the head. Resident #25 said as a result of the sliding drawers she left them open out of fear of hitting her head against them. She said she put in a service request with the maintenance director when she initially admitted and he said he would place a clip at the top to stop the drawers from sliding forward but nothing had been done yet. Resident #25 pushed the drawers closed and they were observed to slide open on their own, holding the drawers closed was the only way to ensure they stayed closed. The State Surveyor observed the contents of the drawer to only occupy less than 1/2 of the space, all rails or tracks were clear from any debris or clutter. Resident #25 said her bathroom door closed by itself, it did not stay open and it hit the back of her wheelchair when she went to the restroom, but she was not injured. She said the door closed too fast for her to make it through before it hit her and she was scared she could be injured by the door so she waited 676230 Page 32 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for staff to assist her with the door when she wanted to use the restroom. Resident #25 said it was inconvenient to wait for someone to hold the door of the restroom open, since it could take a while, so she put in a request with the maintenance department but she was informed nothing could be done since it was required by the safety inspectors. The door was observed to be self-closing when opened, with the door closing faster the wider it was opened. The force at which the door closed was not hard but the speed at which it closed would not allow an unsteady, slow paced individual to make it into the bathroom without getting hit. Resident #104 Record review of Resident #104's face sheet, dated 09/12/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #104 had diagnoses which included: difficulty walking, fracture in the top of the left shin bone, (tissue located in the knee joint) injury and was at the facility for orthopedic aftercare. Record review of Resident #104's BIMS assessment, dated 09/01/25, revealed moderately impaired cognition as indicated by a BIMS score of 09 out of 15. Record review of Resident #104's, undated, Care Plan revealed Focus: left shin bone fracture; Interventions: Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Focus: ADL Self Care Performance Deficit r/t after care following orthopedic surgery r/t fracture of left lateral portion of left tibial plate. Interventions: Requires staff participation with transfers, Requires staff participation with reposition and turn in bed. In an interview on 09/14/25 at 12:02 PM, Resident #104 said her bathroom door was self-closing and she was informed by the Maintenance Director that nothing could be done due to fire and safety regulations. She said she had not suffered any injuries from the self-closing doors. In an interview on 09/14/25 at 09:36 AM, the Maintenance Director said he handled maintenance requests immediately once he received them, which was usually within 24 hours. He said he completed rounds in the facility, daily, weekly and quarterly and he inspected cabinets, beds and rails. The Maintenance Director said all cabinet drawers must close because if they didn't, the drawers could hit the resident and cause injury. He said Resident #25 notified him her drawers didn't close and when he inspected it, the cabinet was not leveled, and the rail mechanism that kept the door locked was worn which resulted in the drawer sliding open. The Maintenance Director said since the cabinet was built in, he could not level it so he installed a magnet as a mechanism to keep the drawer from swinging open. He said some resident rooms had swinging self-closing doors in order to prevent the levered door handles from the bathroom and room entrance from getting stuck together so he could not stop the doors from being self-closing. He said no residents had suffered any injuries due to the door. The Maintenance Director said self-closing doors placed residents at risk of having doors that closed on them which could cause injury. The Maintenance Director said prior to 09/13/25, he was unaware Resident #38's room door still had a door that required a key to unlock. He said Resident #38's room door had a lock because it was previously used as an office for MDS staff but when it was converted back to a resident room, the lock must not have been changed. The Maintenance Director said there were master keys with the DON, Administrator, himself and in a lock box by his office that could open doors in the facility in case of an emergency, but doors that required keys to unlock could place residents at risk of delayed care if something happened to them while they were locked in the room. In an interview on 09/15/25 at 01:24 PM, the Administrator said it was the maintenance director's responsibility to ensure the facility was in good and safe condition and no resident rooms should have locks on the doors. She said Resident #38's room used to be used as an office, but about 1 1/2 years ago it was converted back to a resident room, no one had ever been locked in the room in the past, and that was the only resident room that had a keyed lock. The Administrator said for a reason unknown Resident #38's room door became locked, but while facility staff tried to get access to 676230 Page 33 of 34 676230 09/17/2025 Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the resident in the room other staff observed the resident through the window that faced the street. She said the resident was in no immediate distress, and once staff got access to the room she was assessed, and no injuries or concerns were identified. The Administrator said facility staff immediately inspected all door handles to ensure there were no other keyed locks and once they got access to the resident, Resident #38's room door was immediately changed to one that did not lock. She said drawers in resident rooms should not swing open on their own and maintenance was notified. She said locked resident rooms and loose drawers could place residents at risk of delay in care during an emergency and injury if hit by the drawer. The Administrator said self-closing doors could potentially hit residents increasing their risk of falls and injuries. Record review of the Maintenance Supervisor Job Description revealed, Position Summary: The primary purpose of your job is to supervise the Maintenance Department in accordance with current federal, state, and local standards, guidelines, and regulations governing our facility, and as may be directed by the Executive Director, to assure that our facility is maintained in a safe and comfortable manner. The position may be classified as salaried exempt and is justified by a program requiring at least 50% of time dedicated to the management of the department and personnel. Essential Duties And Responsibilities: Coordinate daily maintenance services with nursing services when performing maintenance assignments in resident living and/or recreational areas. Promptly report equipment or facility damage. Record review of the facility's policy titled Quality of Life- Homelike Environment, revised 10/2009, revealed Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Record review of the facility's, undated, policy titled Accident Prevention revealed, 29. Any other unsafe condition or potential hazard should be reported to the Administrator or DNS. 676230 Page 34 of 34