Inspection·September 20, 2023

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few simple, directive sentences. Provide the resident with necessary cues-stop and return if agitated. Consult with family and interdisciplinary team, review chart to establish baseline level of functioning. Educate the resident/family/caregivers to observe for and report any s/sx of delirium. Focus - the resident uses anti-anxiety medications r/t anxiety disorder. Interventions included - administer anti-anxiety medications as ordered by the physician. Monitor/document/report PRN any adverse reactions: confusion, disorientation, impaired thinking, unexpected side effects: mania, hostility, rage, aggression, hallucinations. Monitor/record occurrence of target behavior symptoms (pacing, wandering, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) Focus - the resident used psychotropic medications r/t behavior management. Interventions included - administer psychotropic medications as ordered by the physician. Monitor for side effects and effectiveness. Discuss with MD, family regarding ongoing need for use of medications. Review interventions and alternate therapies attempted. Record review of Resident #1's active orders as of 05/18/2023 revealed a verbal order dated 05/18/2023 to admit the resident to the facility under the care of the physician. Further review revealed the following orders: Hydromorphone HCL oral liquid 1mg/ml, give 1 ml by mouth every 4 hours as needed for pain; Lorazepam 1mg tablet, give 1 tablet by mouth every 4 hours as needed for anxiety for 14 days; Quetiapine Fumarate 100 mg, give 1 tablet by mouth at bedtime for antipsychotics; Risperidone 0.5 mg tablet, give 1 tablet by mouth two times a day for antipsychotics. Record review of Resident #1's Behavior Note dated 5/20/2023 at 6:48 AM created by LVN A read, Resident had been awake and screaming all night, PRN meds given but not effective. Resident attempted to get out of bed so was put on a wheelchair and [NAME] to the nursing station to be safe, did one on one the whole night. Record review of Resident #1's Communication with Physician note dated 05/20/2023 at 12:11 PM, created by the DON read in part: Situation: Increase agitation, insomnia, hallucination/delusion, banging of head at the nurses' station counter, screaming Get me out of the shower, mama! Background: Resident was admitted 5/18 with no behaviors noted as the resident was asleep from time of admission till 0715 .Had breakfast .During that time resident has been showing behaviors of agitation and anxiety and to trying to get out of bed. A noted increase in agitation and hallucination at sundown Assessment (RN)/Appearance (LPN): Day shift staff noted no changes in resident behavior Recommendations: Per PCP on call send resident to ER for psych evaluation . Record review of Resident #1's physician verbal order dated 05/20/2023 at 11:48 AM, revealed the description: Send to ER for psych evaluation and treat for Medication management, with no appropriate dx with behavior of insomnia, psychosis, hallucinations/delusions. Record review of Resident #1's Behavior Note dated 5/20/2023 at 12:21 PM, created by LVN B read, Patient was found on morning rounds at 0630 at nurses' desk with outgoing nurse in w/c 1:1 ongoing. Patient is agitated at this time with multiple attempts to stand from w/c. Patient also attempting to tilt w/c backwards, was medicated x1 per PRN orders and assisted to bed. Patient slept for a few minutes before waking up. All morning medications given. VS 114/76-65-18-97.8. Record review of Resident #1's Health Status note dated 5/20/2023 at 1:06 PM created by LVN B read, Patient transferred to Hospital ER for evaluation and treatment. Dx of AMS, delusional behavior and agitation. Report called to ER department. Patient departed on stretcher with two EMTs. Patient calling out and crying continuously in low voice and unable to console. Will answer to name only. F/C patent, respirations even and nonlabored. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676244 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676244 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Creek Lodge 11830 Northpointe Boulevard Tomball, TX 77377 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's Communication with Family note dated 5/20/2023 at 2:31 PM created by the DON revealed the RP returned the call from DON. The RP was notified of Resident #1's behavior and the physician's order to send the resident to the ER. Record review of Resident #1's progress notes dated 05/18/2023 at 9:40 PM to 5/20/2023 at 4:05 PM revealed no evidence documented by the Physician to address the reason the resident was discharged , the needs of the resident the facility could not meet, the danger that failure to discharge would pose for the resident and the services available at the receiving facility to meet the needs of the resident. Further review of the electronic health records revealed no Physician Progress notes, no Transfer Summary and no Discharge Summary. During an interview with the Administrator and the DON on 9/19/2023 at 12:45 PM, the Administrator stated prior to Resident #1's admission the facility received the clinical paperwork and financial review. The Administrator stated yes, we were able to meet her needs. The Administrator stated the RP made promises to come and sign the admission paperwork but never showed up. The Administrator stated Resident #1 was psychiatric evaluation and we needed the right dx and pain management before accepting back. The Administrator stated the facility would have accepted the resident back only if the RP completed the paperwork and be available when needed. The Administrated stated technically Resident #1 was admitted to the facility and the RP gave a verbal OK to treat the resident. The Administrator stated the concern was the resident needed 1:1 sitter and the facility could not provide this. The DON stated the resident was no longer safe, she was banging her head. During an interview on 09/19/2023 at 3:35 PM, the DON stated the nurse in charge of the resident would be responsible to send a Discharge Summary. The DON stated for a transfer to hospital, the nurse would send the resident's face sheet, medication list, recent labs if any, history, and physical and physician orders to transfer. Resident #1 was sent to the hospital because the hospital had a psychiatric unit. During an interview on 09/19/2023 at 4:25 PM, the Administrator stated she did not notify the Ombudsman regarding Resident's emergency transfer/discharge to the hospital. The Administrator stated Ombudsman would be notified for a 30-day notice situation only. During a telephone interview on 9/20/2023 at 9:40 AM, LVN A who worked night shift stated Resident #1 was screaming out a family name, trying to get out of bed, banging her head. LVN A stated she was unsure exactly what [NAME] as banging her head on in her room. LVN A stated the bed was low. LVN A stated, we tried educating and redirecting her, but she did not understand. LVN A stated, she was really out of it, so we had to bring her to the nursing station. LVN A stated Resident #1 was banging her head at the nursing station counter. On 9/20/2023 at 10:45 AM, the Surveyor requested the following from the Administrator: Resident #1's Transfer Summary, Discharge Summary and the Physician letter/notes regarding the reason for Resident #1's discharge. During an interview on 9/20/2023 at 1:35 PM, the DON stated the RP called her the same day Resident #1 was transferred to the hospital and told her the resident was ready to return to the facility. The DON stated she contacted the ER and was told by the ER staff the resident was calm and asleep. The DON stated the following day the hospital case manager called and told the DON that Resident #1 was calm, not exhibiting behaviors and ready to return. The DON stated if the hospital sent clinicals containing information about what the hospital provided for Resident #1, the facility would have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676244 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676244 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Creek Lodge 11830 Northpointe Boulevard Tomball, TX 77377 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few been able to determine if services could be provided and the resident would be accepted back. The DON stated there were no physician notes for Resident #1, only the Physician orders to send her to the ER and there was no Transfer Summary or Discharge Summary. During an interview on 09/20/2023 at 1:55 PM, the Administrator stated Resident #1 would have been permitted to return to the facility under the condition there was communication with the RP and part of not accepting her back was the resident's behavior also that 24 hours under psych care was not enough time to see changes. The Administrator stated if the resident was in Psych management for 3-5 days, then things would be different. During an interview on 09/21/2023 at 5:30 PM, Resident #1's RP stated Resident #1 was currently at another nursing facility. Record review of the facility policy titled Transfer or Discharge Notice, revised March 2021 read in part: Policy Statement - Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge. Policy Interpretation and Implementation .2. Residents are permitted to stay in the facility and not be transferred or discharged unless a. the transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility 4. Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: .d. An immediate transfer or discharge is required by the resident's urgent medical needs .6. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. 7. Residents have the right to appeal a discharge, the facility will not discharge residents while the appeal is pending .8. The reasons for the transfer or discharge are documented in the resident's medical record 7. This policy applies to facility-initiated transfers, and not resident-initiated transfers. Further review of the policy revealed no physician required documentation in Resident #1's medical records. Record review of the facility policy titled Bed-Holds and Returns, revised March 2022, read in part: Policy Statement - Residents and /or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. Policy Interpretation and Implementation .6. If the resident is transferred with the expectation that he or she will return, but it is determined that the resident cannot return, that the resident will be formally discharged . Record review of the facility policy titled Discharging the Resident, revised December 2016 read in part: Purpose - The purpose of this procedure is to provide guidelines for the discharge process. Preparation .6. If the resident is being discharged to a hospital or another facility, ensure that a transfer summary is completed, and telephone report is called to the receiving facility . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676244 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676244 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Creek Lodge 11830 Northpointe Boulevard Tomball, TX 77377 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 3 residents (Resident #1) reviewed for pharmaceutical services. -The facility failed to accurately document on the MAR when the medication Hydromorphone solution (a medication for pain), was signed out on Resident #1's narcotic count sheet. This failure could place residents receiving medications at risk of inadequate therapeutic outcomes, uncontrolled pain, and uncontrolled anxiety. Findings included: Review of Resident #1's face sheet revealed a [AGE] year-old female admitted on [DATE] and was discharged on 05/20/2023. Her diagnoses included: metabolic encephalopathy (a problem with the brain d/t an underlying condition), altered mental status, muscle wasting, hypothyroidism (a condition in which the thyroid gland produces an insufficient amount of thyroid hormone, common symptoms include memory problems), dementia, depression, anxiety, HTN, heart disease, brain stroke, fracture of bones in the neck and cystitis (inflammation of the bladder). Record review of Resident #1's admission MDS, dated [DATE] revealed the resident's speech was unclear, was rarely/never understood and rarely/never understood others. She did not wear hearing aids and her vision was adequate. She had short term and long-term memory problems. Her cognitive skills for daily decision making were severely impaired. She did not have behavioral symptoms. Functional status under Section G revealed ADL activities occurred only once or twice and the resident required one-person physical assist. Section GG, prior functioning: Everyday Activities revealed the resident was dependent on a helper to complete self-care and functional cognition. Section N, Medications revealed the resident received antipsychotic, and antianxiety medications during the last two days since admission. The resident received opioid medications (used for pain) during the last day since admission. Record review of Resident #1's undated comprehensive care plan revealed, Focus - the resident had delirium or an acute confusional episode r/t Acute disease process, acute cystitis with metabolic encephalopathy, date initiated 05/19/2023. Goal - the resident will be free of s/sx of delirium (change in behavior, mood, cognitive function, communication, level of consciousness, restlessness) through the review date. Interventions included - reduce distractions. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues-stop and return if agitated. Consult with family and interdisciplinary team, review chart to establish baseline level of functioning. Educate the resident/family/caregivers to observe for and report any s/sx of delirium. Focus - the resident uses anti-anxiety medications r/t anxiety disorder. Interventions included - administer anti-anxiety medications as ordered by the physician. Monitor/document/report PRN any adverse reactions: confusion, disorientation, impaired thinking, unexpected side effects: mania, hostility, rage, aggression, hallucinations. Monitor/record occurrence of target behavior symptoms (pacing, wandering, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) Focus - the resident used psychotropic medications r/t behavior management. Interventions included - administer psychotropic medications as ordered by the physician. Monitor for side effects and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676244 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676244 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Creek Lodge 11830 Northpointe Boulevard Tomball, TX 77377 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few effectiveness. Discuss with MD, family regarding ongoing need for use of medications. Review interventions and alternate therapies attempted. Record review of Resident #1's active orders as of 05/18/2023 revealed the following orders: Hydromorphone HCL oral liquid 1mg/ml, give 1 ml by mouth every 4 hours as needed for pain; Lorazepam 1mg tablet, give 1 tablet by mouth every 4 hours as needed for anxiety for 14 days; Quetiapine Fumarate 100 mg, give 1 tablet by mouth at bedtime for antipsychotics; Risperidone 0.5 mg tablet, give 1 tablet by mouth two times a day for antipsychotics. Further review revealed the following orders: Anti-anxiety side effects monitoring: 0) No side effects noted 1) Hypotension 2) Sedation 3) Dizziness 4) Dry mouth 5) Blurred vision, 6) Urinary retention 7) Drowsiness 8) Slurred speech 9) Confusion 10) Fatigue 11) Nightmares 12) Appetite changes, every shift for Lorazepam. Anti-Psychotic Behavior monitoring: 0) No behaviors noted 1) Agitated 2) Angry 3) Compulsive 4) Pacing 5) Yelling 6) Danger to self or others 7) Fighting 8) Hallucinations 9) Insomnia 10) Nervousness 11) Mood changes 12) Uncooperative 13) Wandering 14) Refusal of care 15) Suicidal Ideation. Interventions: 0) None 1) Redirect 2) Change positions 3) Ambulate 4) 1 on 1 5) back rub. Outcome Codes: Improved (I) Same (S) Worsened (W): every shift for Quetiapine and Risperdal. Further review revealed no order to monitor for pain. Record review of Resident #1's May 2023 MAR revealed on 05/20/2023 at 7:05 AM, LVN B documented the administration of Hydromorphone HCL 1 ml, for a pain level of 10. LVN B documented the letter I for ineffective. On 05/20/2023 at 11:46 AM, LVN B documented the administration of Hydromorphone HCL 1 ml, for a pain level of 10. LVN B documented the letter I for ineffective. On 05/20/2023 at 7:06 AM, LVN B documented the administration of Lorazepam 1mg and documented the letter I for ineffective. On 05/20/2023 at 11:49 AM, LVN B documented the administration of Lorazepam 1mg and documented the letter I for ineffective. Further review revealed no documented administration of Hydromorphone on 05/19/2023 and no doses were documented as administered prior to 7:05 AM on 05/20/2023. Record review of the Controlled Drug Receipt/Record/Disposition Form for Resident #1 revealed LVN A signed out Hydromorphone solution 1ml, on 5/19/2023 at 11:00 PM and 5/20/2023 at 3:00AM. Record review of Resident #1's Behavior Note dated 5/20/2023 at 6:48 AM created by LVN A read, Resident had been awake and screaming all night, PRN meds given but not effective. Resident attempted to get out of bed so was put on a wheelchair and brought to the nursing station to be safe, did one on one the whole night. During a telephone interview on 9/20/2023 at 9:40 AM, LVN A who worked night shift stated Resident #1 was screaming out a family name, trying to get out of bed, banging her head. LVN A stated she was unsure exactly what she was banging her head on in her room. LVN A stated the bed was low. LVN A stated, we tried educating and redirecting her, but she did not understand. LVN A stated, she was really out of it, so we had to bring her to the nursing station. LVN A stated Resident #1 was banging her head at the nursing station counter. LVN A stated she did not remember if she gave any medications and that if she could see the chart she might remember. During an interview on 09/20/2023 at 4:45 PM, the DON stated the rule of thumb when administering narcotics is to check the PRN medication order and document the administration right away in the MAR. The DON stated this is what she expected the nurses to always do. The DON stated if the medication was given and documented, the system will have a red alert for the nurse to do a follow up on the effectiveness. The DON stated the nurse on night shift told her she was administering PRN medications at night for Resident #1. The DON stated the resident was screaming out in pain and needed the pain medication and not the Lorazepam. The DON stated PRN medications are given at the nurse's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676244 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676244 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Creek Lodge 11830 Northpointe Boulevard Tomball, TX 77377 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few discretion. The DON stated, going forward she will conduct inservice again for proper documentation of PRN medications and that her expectation was that documentation on the narcotic sheet should be the right count and should match up with the MAR because when the physician looks at the medications for the resident, the physician would not review the narcotic sheet but would instead be reviewing the MAR. The DON stated if a PRN medication was not documented as administered, then the resident did not receive it and the physician may possibly discontinue the medication since the resident was no longer needing it. The DON stated if the PRN medication was discontinued and the resident was still needing it, the behaviors will start up again. During an interview on 09/20/2023 at 6:00 PM, the DON stated she was told by the night nurse that PRN medications were given to Resident #1. The DON did not state which PRN medications. The DON stated even with the medications that were given on 9/20/2023 on day shift, they were ineffective and Resident #1's behaviors remained unchanged. The DON stated, moving forward she would conduct a 2-week plan inservice. The DON stated she would check the narcotic sheets against the PRN medications to make sure the nursing staff do things correctly and this would be a verbal warning to the nursing staff. Record review of the facility staff inservice dated 05/08/2023 for Proper Medication Pass Procedure and Infection Control was conducted by the Pharmacist. Nursing staff signed the sheet. Further review revealed no signature by LVN A. Record review of the facility policy and procedure titled Administering Oral Medications, revised October 2010 read in part: Purpose - the purpose of this procedure is to provide guidelines for the safe administration of oral medications. Preparation - 1. Verify that there is a physician's medication order for this procedure General Guidelines - Follow the medication administration guidelines in the policy entitled Administering Medications .Steps in the Procedure .9. b. For narcotics. Check the narcotic record for the previous drug count and compare with the supply on hand .Documentation - Follow documentation guidelines in the procedure entitled Documentation of Medications Administration . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676244 If continuation sheet Page 7 of 7