Inspection·July 17, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete but she needed help due to her limited mobility.An observation on 07/16/25 at 07:25 AM revealed Resident #83 was asleep in bed. A new stack of cleanly folded bed linens were observed on the chair in the resident's room where the bag of soiled linens sat the previous day.An observation and interview on 07/16/25 at 02:43 PM revealed, Resident #83 was lying on her right side on her dressed with patterned white sheets with folded clean white patterned bed linens in a chair across from her bed. Resident #83 said she woke up that night just soaked, and she felt disgusted that the staff did not take the time to change her sheets when they changed her brief. Resident #83 said her family member usually did her laundry, but the family member had been so sick that the facility needed to wash them. She said facility staff told her name had to be written on all her items, but no one would help her. In an interview on 07/17/25 at 08:00 AM, the DON said when a resident had an episode of incontinence where the bedding become soiled, nursing staff were expected to change the bedding and sanitize the mattress along with incontinence care. She said there was no point in changing the resident and leaving them in bodily waste. The DON said some residents had instructions that only their family did their laundry, and a sign would be visibly displaced in the resident's room, but she said she was unsure if Resident #83's family did her laundry. The DON said failure to change soiled bed linens after an episode of incontinence could place a resident at risk of skin breakdown, infections, and psychosocial harm (social and environmental influences on a person's mind and behavior. The DON said she was unaware of any issues Resident #83 had with her sheets not being changed or laundered.An observation and interview on 07/17/25 at 03:25 PM revealed Resident #83 was in bed talking to a family member on her phone. The resident and family member said the facility provided all laundry services for Resident #83 and the family did not do her laundry. There were no signs that reflected family does laundry observed in Resident #83's room. Resident #83 said the episode of incontinence occurred on Saturday at approximately 2-3 AM so she knew the staff were not too busy to change her linens, the staff were lazy and left her lying in her wet sheets. She said being left in wet sheets bothered her and made her feel cranky, but she did not have any redness, irritation, or wounds due to inappropriate incontinent care. Resident #83 said no one should be left to lay in soiled sheets and an unknown nurse helped her get her sheets washed yesterday (07/16/25).In an interview on 07/17/25 at 03:45 PM, LVN E said she worked with Resident #83 on 07/16/25 but she did not know Resident #83 had an issue with her sheets not being changed after incontinence care or being laundered all she saw was a stack of folded clean bedding on the chair in the resident's room.In an interview on 07/17/25 at 03:55 PM, the Laundry Director said all personal laundry was labeled when brought into the facility and personal sheets were washed with facility sheets daily to maintain the proper sanitizing temperatures and stacked in the residents room. He was unaware of any delay in resident laundry and said in cases such as Resident #83's sheets, the delay was most likely due to a CNA not moving the linens from the resident room to the soiled laundry area.Record review of Resident #83's Progress Notes from admission dated 07/17/25 revealed, no documentation of the resident's episode of incontinence on 07/12/25 and the need to launder her sheets.Record review of the facility's Grievance Log for July 2025 revealed, no grievances listed for Resident #83.Record review of the facility policy titled Perineal Care revised 02/2018 revealed, no instructions on changing clothing and linens after an episode of incontinence. Event ID: Facility ID: 676244 If continuation sheet Page 2 of 20 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 07/17/2025 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 0580 Level of Harm - Minimal harm or potential for actual harm Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled: Residents Affected - Few Number of residents cited: Based on interview and record review the facility failed to immediately consult with the resident's physician; when there wis an accident involving the resident which results in injury and has the potential for requiring physician intervention for 1 of 5 residents (Resident #67 ) reviewed for change of condition. - The facility failed to notify Resident #67's physician after she sustained a nickel sized skin tear on 07/10/25.This failure could place residents at risk for not receiving appropriate care and interventions.Finding include:Record review of Resident #67's Face Sheet dated 07/15/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: sepsis (bacterial blood infection), COPD (a lung disease that makes it difficult to breathe), high cholesterol, vitamin d deficiency, low blood pressure and acid reflux.Record review of Resident #67's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, she had no current or healed pressure injuries, no venous and arterial ulcers, and no other ulcers, wounds, or skin problems.Record review of Resident #67's undated Care Plan revealed, Focus- needs dialysis r/t kidney failure; intervention- monitor for dry skin and apply lotion as needed. There was no reference to any skin tears documented in Resident #67's care plan.An observation on 07/15/25 at 09:12 AM revealed Resident #67 was in bed with a dressing on her right lower arm that reflected 07/10. There was a nickel sized circle of dry blood visible through the dressing and the dressing appeared slightly dingy. Resident #67 said the dressing was old and she did not know how it happened.Record review of Resident #67's Progress Notes from 06/15/25 to 07/14/25 printed on 07/15/25 at 01:42 PM revealed no documentation of Resident #67's skin tear on 07/10/25 or notification to the physician.Record review of Resident #67's EMR on 07/15/25 revealed, no documented CIC, SBAR or skin note completed on 07/10/25.Record review of the facility Accident & Incident Report dated 07/15/25 with date range of 02/15/25 to 07/15/25 revealed, no documented accidents or incidents for Resident #67In an observation and interview with Resident #67 on 07/16/25 at 12:50 PM, revealed the Wound Care Nurse removed the dressing from Resident #67's lower right arm dated 07/10 and a circle of dried blood was observed on the dressing. There was a skin tear, and the resident said the wound did not hurt and an unknown staff put a dressing on it because it would not stop bleeding. The Wound Care Nurse said a skin tear was considered a CIC, and it should have been documented in the resident's chart as such. She said the staff member who identified the tear should have completed a CIC, Risk Management assessment, notified the Wound Care Nurse and sent notifications to the MD, nursing administration and family. The Wound Care Nurse said she was not notified of Resident #67's skin tear that occurred on 07/10/25 and that kind of injury warranted she received notification.In an observation and interview with Resident #67 on 07/16/25 at 01:40 PM revealed Resident #67 had a wound on her lower arm that appeared to be a superficial skin tear with the skin folded over itself in the corner and measured approximately 1' X 1.5. The Wound Care Nurse cleansed the area with wound cleanser and applied a new dressing dated 07/16/25. Resident #67 denied any pain associated with the skin tear.In an interview on 07/16/25 at 02:09 PM, the Wound Care Nurse said a skin CIC were any changes in color, break in skin, swelling and anything out of the norm. She said when a nurse observed a skin tear, they should immediately notify the wound care nurse, then the wound care doctor, complete a skin check and an SBAR. The Wound Care Nurse said if she was working at the time the orders were received, she would perform the initial care and if she was no, then the nurse would. She said neither she nor the Wound Care Doctor were notified of Resident #67's new skin tear and she did not see any documentation about (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676244 If continuation sheet Page 3 of 20 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 07/17/2025 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the injury on the resident's medical record.In an interview on 07/17/25 at 08:00 AM, the DON said any newly identified skin tear was a change of condition, and the identifying nurse immediately notified the wound care nurse who then received orders to perform treatment from the wound care doctor. She said nursing staff were expected to ask the resident how it occurred, then complete a skin check, pain assessment, CIC/SBAR documentation and complete an incident report. She said after investigation, she identified RN C as the nurse who placed the dressing on Resident #67. The DON said in an interview RN C said he was notified by an unknown therapy staff that the Resident #67 had a new skin tear, and he performed treatment on the wound but he got caught up and forgot to document it[BR1] . She said the PT staff should have completed stop and watch documentation and submitted it to the nurse, but there was no documentation of the injury from what she had seen. The DON said to her knowledge RN C did not notify anyone or document the incident and no action was taken following his initial care on 07/10/25. The DON said failure to notify the physician, document the incident or provide follow up care could result in the wound worsening and/or infection. On 07/17/25 at 12:33 PM, an attempt was made to contact RN C via telephone. The surveyor left a message on RN C voicemail and sent a text message requesting the staff return the call. RN C did not return the call or reply to the text message.In an interview on 07/17/25 at 01:57 PM, the Wound Care Doctor said she was not notified of a new skin tear for Resident #67 on 07/10/25 and the first time she was heard of it was on 07/16/25 when she was notified by the Wound Care Nurse, but she had standing orders that could be followed. She said her expectation was that the wound care nurse notified her of the incident, and the standing orders be followed. She said if a resident received inappropriate treatment for a wound at a minimum the wound could worsen and in a worst-case scenario they could suffer from infection.Record review of the facility's In-service/Education Sheet dated 06/26/25 revealed, subject: Wound Care, Skin Assessments, Reporting Skin Issues. During your shift if a new skin issue is identified, you are required to notify the wound care nurse and complete the following: Braden Assessment (used to predict the risk of a pressure ulcer), Risk Management which includes skin note under progress notes and skin check assessment; SBAR and notify the wound care nurse. Noncompliance with these procedures may result in disciplinary action. RN C signed the in-service documentation indicating he received the training. Record review of the facility's undated Wound Care Standing Orders revealed, -Standing Order #2: Skin Tear Management. Indication: Skin tears (open skin) . Order: Cleanse skin tear with wound cleanser. Apply xeroform to wound bed, cover with dry dressing. Frequency: Dressing change three times per week. (Monday, Wednesday, Thursday) or as needed if soiled or non-adherent. Duration: until healed or per Wound MD guidance. Record review of the facility policy titled Acute Condition Changes- Clinical Protocol revised March 2018 revealed, 3. Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the Nurse.4. Nursing assistants are encouraged to use the Stop and Watch Early Warning Tool to communicate subtle changes in the resident to the nurse. 7. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician; for example, the history of present illness and previous and recent test results for comparison.a. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident/patient's current symptoms and status. 8. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). 10. The nurse and physician will discuss and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676244 If continuation sheet Page 4 of 20 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 07/17/2025 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete evaluate the situation. a. The physician should request information to clarify the situation; for example, vital signs, physical findings, a detailed sequence of events and description of symptoms. Cause Identification: 1. The staff and physician will discuss possible causes of the condition change based on factors including resident/patient history, current symptoms, medication regimen, and diagnostic test results. Treatment/Management:1. The physician will help identify and authorize appropriate treatments. Monitoring and Follow-Up: 1. The staff will monitor and document the resident/patient's progress and responses to treatment, and the physician will adjust treatment accordingly.2. The physician will help the staff monitor a resident/patient with a recent acute change of condition until the problem or condition has resolved or stabilized. 3. At the next visit, the physician will review the status of the condition change and document his/her evaluation, including the anticipated impact on the individual's function, prognosis, and quality of life. a. The physician will make interim visits as needed to assess the situation (especially if the individual is not stable or is not improving as anticipated).Record review of the facility policy titled Change in a Resident's Condition or Status revised 02/2021 revealed, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discovery of injuries of an unknown source; 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. the resident is involved in any accident or incident that results in an injury including injuries of an unknown source. 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Event ID: Facility ID: 676244 If continuation sheet Page 5 of 20 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 07/17/2025 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled: Residents Affected - Some Number of residents cited: Based on observation, interview, and record review the facility failed to ensure assessments accurately reflected the resident's status for 3 of 5 residents (Resident #2, Resident #67, and Resident #83) reviewed for accuracy of assessments .- The facility failed to accurately assess Resident #2's use of antipsychotics on her Quarterly MDS dated [DATE].- The facility failed to accurately assess Resident #67's dialysis status and use of antiplatelets on her Admissions MDS dated [DATE].- The facility failed to accurately assess Resident #83's hospice status on her Quarterly MDS dated [DATE].Findings include:Resident #2Record review of Resident #2's Face Sheet dated 07/15/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: high blood pressure, unspecified psychosis, anxiety disorder, major depressive disorder, and unspecified dementia without behavioral disturbance.Record review of Resident #2's Order Summary Report dated 07/15/25 revealed, Resident #2 had orders for antipsychotic medication monitoring since 02/26/25. She was ordered Quetiapine (antipsychotic medication) 25 mg every 12 hours on admission on [DATE] and the medication was gradually increased to Quetiapine 100 mg ever morning and at bedtime on 06/17/25.Record review of Resident #2's July 2025 Medication Administration Record revealed, Resident #2 received Quetiapine 100 mg twice daily at 09:00 AM and 09:00 PM.Record review of Resident #2's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 04 out of 15, delusions, verbal behavioral symptoms and other behavioral symptoms not directed towards others, active diagnoses of: anxiety disorder, depression and psychotic disorder, resident was taking antianxiety medications and the indication for use was noted, and the resident had non-Alzheimer's Dementia. The MDS did not indicate Resident #67 was taking antipsychotic medications.Record review of Resident #2's undated Care Plan revealed, Focus- use of antipsychotic medications r/t fluctuating mood initiated on 02/24/25; intervention: Administer antipsychotic medication as ordered by a physician, monitor for side effects and effectiveness every shift.Resident #67Record review of Resident #67's Face Sheet dated 07/15/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: sepsis (bacterial blood infection), COPD ( a lung disease that makes it difficult to breathe), high cholesterol, vitamin d deficiency, CAD (disease were fats and cholesterol build up in blood vessels), low blood pressure and acid reflux.Record review of Resident #67's Progress Note dated 06/21/25 at 04:36 PM revealed, Resident #67 arrived in the facility with a previous medical history of CKD, CAD, DM, COPD, she had orthostatic hypotension (a drop in pressure after a change in position) and a dialysis port to her right upper chest.Record review of Resident #67's Progress Notes dated 06/21/25 at 04:36 PM revealed, resident goes to dialysis every Monday, Wednesday, and Friday.Record review of Resident #67's Order Summary Report dated 07/15/25 revealed,- Resident #67 had varied dialysis related orders since 06/22/25.- Clopidogrel 75 mg- give 1 tablet by mouth one time a day r/t coronary heart disease.Record review of Resident #67's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15. The MDS indicated Resident #67 did not receive dialysis on admission, while a resident at the facility and that she was not taking antiplatelet medications.Record review of Resident #67's undated Care Plan revealed, Special Instructions: Resident #83 received dialysis every Monday, Wednesday and Friday, her chair time was 3:30 PM and the EMS would pick her up at 02:30 PM. Focus- needs dialysis r/t renal failure; intervention- monitor for dry skin and apply lotion as needed. An observation on 07/15/25 at 09:12 AM revealed, Resident #67 in bed. There was a visible dressing on her right chest and Resident #67 said the dressing was over her dialysis port.Resident #83Record review of Resident #83's Face Sheet dated 07/15/25 revealed, an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676244 If continuation sheet Page 6 of 20 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 07/17/2025 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: COPD (a lung disease that makes it difficult to breath), dysphagia (difficulty swallowing), hypertension (high blood pressure), anxiety disorder and skin cancer.Record review of Resident #83's Quarterly MDS dated [DATE] revealed, minimal difficulty hearing, moderately impaired cognition as indicated by a BIMS score of 08 out of 15. The MDS did not indicate Resident #83 received Hospice Care while at the facility.Record review of Resident #83's undated Care Plan revealed; Special Instruction: Contact hospice provider with questions/concerns/change in condition, falls and death. Focus- terminal prognosis r/t COPD; the residents dignity and autonomy will be maintained at the highest level; intervention- consult with physician and social services to have hospice care for the resident in the facility, revised on 06/04/26.Record review of Resident #83's Order Summary Report dated 07/15/25 revealed,- Admit to hospice under the care of Dr. for a diagnosis of COPD, order date 04/30/25.- Contact Hospice with questions/concerns/change in condition/falls/death, order date 04/30/25.- No ER/Labs/Hospital visits without notifying hospice first, order date 04/30/25.In an interview on 07/16/25 at 02:39 PM, the MDS Nurse said she was responsible for completing resident MDSs and care plans and the MDS assessed the resident's functional abilities within a 7-day window. The MDS nurse said a resident's status of hospice, dialysis and other diagnosis/treatments should be accurately documented in their MDS because it triggered CAAs that were used to develop the care plan. She said an inaccurate MDS could result in a hinderance in a resident's plan of care, resulting in missed opportunity for treatment, untreated conditions and worsening of health conditions.In an interview on 07/17/25 at 08:08 AM, the DON said a resident's MDS told staff about patient needs and what would be done for them. She said the MDS triggered the CAAs and moved into the care plan so an incorrect MDS could place a resident at risk of not getting appropriate care. The MDS nurse said after review Resident #67's and Resident #83's care plans were inaccurate, and they should have included the residents' dialysis and hospice status. She said she did not know why they were not included and that they must have been missed.Record review of the facility policy titled Resident Assessment Instrument Process (RAI/MDS) with no revision date revealed, purpose: Gather data in order to develop comprehensive, individualized care plans that meet the medical, nursing, mental and psychosocial needs of each resident. Each care plan will describe services furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being as required. Care Area Assessments (CAAs) will be processed based on clinical analysis of the triggered MDS items. Individualized resident-centered care plans will be developed and updated as needed according to the data and resulting analysis utilizing CAA documentation. Event ID: Facility ID: 676244 If continuation sheet Page 7 of 20 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 07/17/2025 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled: Residents Affected - Few Number of residents cited: Based on interview and record review, the facility failed to ensure individuals identified with MI, DD or ID were evaluated for services for 2 of 5 residents (Residents #2 and #77) reviewed for PASRR.- The facility failed to ensure Resident #2's diagnosis of Dementia and Mental Illness ( MDD and psychosis) were accurately documented in her PL1.- The facility failed to ensure Resident #77's diagnosis of Mental Illness (MDD) was accurately documented in his PL1.This failure could place residents who had a mental illness at risk of not receiving needed assessments (PASRR Evaluation), and individualized specialized services to meet their needs.Findings included: Resident #2Record review of Resident #2's Face Sheet dated 07/15/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: unspecified psychosis, anxiety disorder, major depressive disorder, and unspecified dementia without behavioral disturbance.Record review of Resident #2's PL 1 completed 02/07/25 revealed, C0090 Primary diagnosis of dementia: the answer was NO for is there evidence that dementia is the primary diagnosis for this individual. C0100 Mental Illness: the answer was NO for is there evidence or an indicator this is an individual that has a mental illness.Record review of Resident #2's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 04 out of 15, delusions, verbal behavioral symptoms and other behavioral symptoms not directed towards others, active diagnoses of: anxiety disorder, depression and psychotic disorder, resident was taking antianxiety medications and the indication for use was noted, and the resident had non-Alzheimer's Dementia.Record review of Resident #2's undated Care Plan revealed, Focus- use of antipsychotic medications r/t fluctuating mood initiated on 02/24/25; intervention: Administer antipsychotic medication as ordered by a physician, monitor for side effects and effectiveness every shift. Focus- impaired cognitive function related to dementia; intervention- administer medications as ordered. Monitor/document for side effects and effectiveness.Record review of Resident #2's Order Summary Report dated 07/15/25 revealed, Resident #2 had orders for antipsychotic medication monitoring since 02/26/25. She was ordered Quetiapine (antipsychotic medication) 25 mg every 12 hours on admission on [DATE] and the medication was gradually increased to Quetiapine 100 mg ever morning and at bedtime on 06/17/25.Record review of Resident #2's July 2025 Medication Administration Record revealed, Resident #2 received Quetiapine 100 mg twice daily at 09:00 AM and 09:00 PM.Resident #77Record review of Resident #77's Face Sheet dated 07/15/25 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: adjustment disorder with mixed anxiety and depressed mood, MDD, anxiety disorder and dementia without behavioral disturbance.Record review of Resident #77's PL 1 dated 05/01/2023 revealed, C0090 Primary diagnosis of dementia: the answer was YES for is there evidence that dementia is the primary diagnosis for this individual. C0100 Mental Illness: the answer was NO for is there evidence or an indicator this is an individual that has a mental illness.Record review of Resident #77's Annual MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 08 out of 15, active diagnoses of: non-Alzheimer's Dementia anxiety disorder, depression, and psychotic disorder.Record review of Resident #77's undated Care Plan revealed, Focus- trauma screen performed which indicated trauma related to his stroke related loss of independence and the loss of his partner; Intervention- consult with social and psych services. Focus- impaired cognitive function and impaired though process r/t dementia; Intervention- administer medications as ordered. Monitor/document side effects and effectiveness. Focus: use of antidepressant medication r/t MDD, recurrent, severe with psychotic symptoms; Intervention: administer antidepressant medications as ordered by physician. Focus: use of psychotropic medications r/t (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676244 If continuation sheet Page 8 of 20 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 07/17/2025 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete behavior management; Intervention administer medications as ordered and monitor for side effects and effectiveness every shift. Focus: depression r/t dementia; intervention- administer medications as ordered and monitor for side effects and effectiveness. In an interview on 07/17/25 at 10:51 AM, the MDS nurse said when a resident admitted they should have a PASRR, she reviewed the information for completion and accuracy and enters it into the portal. She said if a resident had a positive PL 1 the appropriate behavioral health organization contacted the facility to initiate a meeting to determine if services were appropriate. She said regardless of whether a resident had a diagnosis of dementia or not if they had a diagnosis of mental illness such as Schizophrenia, mood disorder or MDD, mental illness should be indicated as yes in their PL1. She said an incorrect PASRR could place residents at risk of not being assessed for services and ultimately, they may not receive the services for which they are qualified. The MDS Nurse said based on what she saw in the system Resident #2's PASARR was inaccurate because she had dementia and a mental illness and Resident #77's was inaccurate because he also had a mental illness. She did not have a reason for why she did not identify the incorrect admitting PL1. Record review of the facility provided untiled document with no revision date revealed, 1 Purpose : This policy establishes procedures for complying with the federal Preadmission Screening and Resident Review (PASRR) program, as mandated by the Code of Federal Regulations, Title 42, Part 483, Subpart C, and Texas Administrative Code, Title 26, Part 1, Chapter 303. The PASRR process ensures that individuals seeking admission to or residing in [Nursing Facility Name], a Medicaid-certified nursing facility, are appropriately screened for mental illness (MI), intellectual disability (ID), or developmental disability (DD), also known as a related condition (RC), to determine the appropriateness of nursing facility placement and the need for specialized services. 2 Scope: This policy applies to all staff involved in the admission, assessment, and care planning processes at [Nursing Facility Name], including MDS coordinators, nursing staff, administrators, and billing personnel. It covers all individuals seeking admission, regardless of funding source (Medicaid, Medicare, private pay), and residents requiring ongoing reviews. 3 Definitions: PASRR Level I (PL1) Screening: A preliminary assessment to identify individuals with suspected MI, ID, or DD, completed prior to admission. [Nursing Facility Name] is committed to ensuring compliance with federal and Texas PASRR regulations by screening all applicants for MI, ID, or DD, facilitating appropriate placement, and providing required specialized services. The facility will collaborate with referring entities, local authorities, and the Texas Medicaid Healthcare Partnership (TMHP) to complete PASRR processes accurately and timely. Event ID: Facility ID: 676244 If continuation sheet Page 9 of 20 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 07/17/2025 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on interview, observation, and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission for 1 of 6 residents (Resident #96) reviewed for baseline care plan. - The facility failed to ensure Resident #96's baseline care plan addressed the resident's diagnoses of anxiety disorder and depression which were treated with medications, the presence of a pacemaker, his orders for the opioid pain medication morphine.This failure could place newly admitted residents at risk of not having their individual, medical, functional, and psychosocial needs identified, and services provided with could cause a physical or psychosocial decline in health. Findings includeRecord review of Resident #96's Face Sheet dated 07/15/25 revealed, Resident #86 admitted to facility on 07/11/25 with diagnoses which included: anxiety disorder, depression, irregular heartbeat, and the presence of a cardiac pacemaker. The resident was receiving hospice services.Record review of Resident #96's EMR on 07/15/25 revealed, the resident's MDS was not completed yet due to his recent admissionRecord review of Resident #96's baseline care plan signed 07/11/25 revealed, Initial discharge goals- receive hospice care/coordination; Medications- Opioids and Black box medications (medications with life threatening risks such as opioid pain medications, benzodiazepines such as lorazepam used to treat anxiety, antidepressants like sertraline) and black box medications were not selected. There was no reference to his diagnosis of anxiety disorder, depression, or the presence of a pacemaker.Record review of Resident #96's Order Summary Report dated 07/17/25 revealed:- Pacemaker: continuous monitoring at bedside with home transmitter.- Lorazepam 0.5 mg- 1 tabled every 2 hours as needed for anxiety and SOB for 14 days - Morphine Sulfate 100 mg/5 mL- give 0.5 ml by mouth every 2 hours as needed for pain and/or SOB.- Sertraline 100 mg - give 1 tablet by mouth one time a day for depression/anxiety.An observation and interview on 07/15/25 at 11:43 AM revealed Resident #93 was well dressed and in no immediate distress sitting in a wheelchair with his legs cross watching TV in the activities room. He said he was doing well, on hospice and had no issues or concerns.In an interview on 07/17/25 at 08:08 AM, the DON said the care plan represented a plan of care that is personalized to the resident, and it should address, everything including diagnoses, dietary; wounds; and supportive devices. She said an inaccurate care plan could place residents at risk of not receiving the care they need, and the resident's necessary interventions and goals would be possibly unknown. In an interview on 07/17/25 at 02:31 PM, the MDS Nurse said the baseline care plan was developed by nursing staff within the first 48 hours after admission in order to provide immediate care for the resident. She said failure to have an accurate baseline care plan could place residents at risk of not receiving the care they requiredRecord review of the facility policy titled admission of Resident with no revision date revealed, The Baseline Care Plan will be developed within 48 hours of the resident's admission to the facility. The resident or resident representative will be given a summary of the Baseline Care Plan by completion of the comprehensive care plan. The resident's medical record will reflect the provision of the written Baseline Care Plan summary. 13. The Licensed Nurse and IDT members will develop a baseline plan of care detailing the resident's care needs that will be utilized by all staff members until the admission MDS has been completed and the resulting comprehensive care plan has been developed. Event ID: Facility ID: 676244 If continuation sheet Page 10 of 20 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 07/17/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm 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** Number of residents sampled: Residents Affected - Some Number of residents cited: Based on observation, interview and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a residents' mental, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 5 Residents (Resident #2 and Resident #67) reviewed for care plans.- The facility failed to include Resident #2's diagnosis of MDD in her care plan.- The facilitate failed to include Resident #67's diagnosis of hypotension (low blood pressure), CAD (buildup of fats & cholesterol on the walls of blood vessel), hyperlipidemia (high cholesterol) , COPD (disease that makes it hard to breath), GERD (acid reflux) and her use of antiplatelet (clopidogrel) on her care plan.This failure could place residents at risk for inadequate care.Findings include:Resident #2Record review of Resident #2's Face Sheet dated 07/15/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: high blood pressure, unspecified psychosis, anxiety disorder, major depressive disorder, and unspecified dementia without behavioral disturbance.Record review of Resident #2's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 04 out of 15, delusions, verbal behavioral symptoms and other behavioral symptoms not directed towards others, active diagnoses of: anxiety disorder, depression and psychotic disorder, resident was taking antianxiety medications and the indication for use was noted, and the resident had non-Alzheimer's Dementia. Record review of Resident #2's undated Care Plan revealed, Focus- use of antipsychotic medications r/t fluctuating mood initiated on 02/24/25; intervention: Administer antipsychotic medication as ordered by a physician, monitor for side effects and effectiveness every shift. Focusimpaired cognitive function related to dementia; intervention- administer medications as ordered. Monitor/document for side effects and effectiveness. There was no focus area addressing Resident #2's diagnosis of MDD.Record review of Resident #2's Order Summary dated 07/15/25 revealed, - Mirtazapine (antidepressant) 7.5 mg- Give 2 tablet by mouth at bedtime r/t MDDResident #67Record review of Resident #67's Face Sheet dated 07/15/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: sepsis (bacterial blood infection), COPD (a lung disease that makes it difficult to breathe), high cholesterol, vitamin d deficiency, hypotension, CAD, and GERD.Record review of Resident #67's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, active diagnoses of orthostatic hypotension, CAD, GERD, Asthma/COPD/Chronic Lung Disease, and high cholesterol.Record review of Resident #67's undated Care Plan revealed, Special Instructions: Focus- needs dialysis r/t renal failure; intervention- monitor for dry skin and apply lotion as needed. There were no Focus areas for hypotension, CAD, COPD, hyperlipidemia, and her use of antiplatelets. Record review of Resident #67's Progress Note dated 06/21/25 at 04:36 PM revealed, Resident #67 arrived in the facility with a previous medical history of CKD[VT1] , CAD, DM[VT2] , COPD, she had orthostatic hypotension and a dialysis port to her right upper chest.Record review of Resident #67's Order Summary Report dated 07/15/25 revealed.- Midodrine 10 mg- give 1 tablet by mouth three times a day related to hypotension. - Clopidogrel 75 mg- give 1 tablet by mouth one time a day r/t coronary heart disease.An observation and interview on 07/15/25 at 09:12 AM revealed, Resident #67 in bed with a dressing on her right lower arm that read 07/10. There was a [NAME] sized circle of dry blood visible through the dressing and the dressing appeared slightly dingy. Resident #67 said the dressing was old and she did not know how it happened. There was a visible dressing on her right chest and Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676244 If continuation sheet Page 11 of 20 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 07/17/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete #67 said the dressing was over her dialysis port.In an interview on 07/16/25 at 02:39 PM, the MDS Nurse said she was responsible for resident MDSs and Care Plans. She said resident care plans should paint a full picture of the resident and document a plan of care for the patient. The MDS nurse said Resident #67's care plan was inaccurate because it should have had her diagnosis such as hypotension and COPD, but it did not. She said inaccurate care plans place residents at risk of an omission of assistance and not having a plan of care for an area of concern.In an interview on 07/17/25 at 08:08 AM, the DON said the care plan represents a plan of care that is personalized to the resident, and it should address, everything including diagnosis, dietary; wounds; supportive devices. She said an inaccurate care plan could place residents at risk of not receiving the care they need, and the resident's necessary interventions and goals would be possibly unknown.Record review of the facility policy titled Care Plans, Comprehensive Person-Centered revised 03/2022 revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of PASARR recommendations; and (3) which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons; b. culturally competent; c. trauma informed. Event ID: Facility ID: 676244 If continuation sheet Page 12 of 20 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 07/17/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled: Residents Affected - Few Number of residents cited: Based on observation, interview and record review, the facility failed to ensure that residents received care and services in accordance with professional standards of practice for 1 of 5 residents (Resident #67) reviewed for quality of care.- The facility failed to provide care to Resident #67 for 4 days after she suffered from a skin tear on 07/10/25. These failures could place residents at risk of delay in care, worsening of health conditions, adverse reactions, infection and hospitalizationFindings included:Record review of Resident #67's Face Sheet dated 07/15/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: sepsis (bacterial blood infection), COPD ( a lung disease that makes it difficult to breathe), high cholesterol, vitamin d deficiency, low blood pressure and acid reflux.Record review of Resident #67's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, she had no current or healed pressure injuries, no venous and arterial ulcers, an no other ulcers, wounds, and skin problems.Record review of Resident #67's undated Care Plan revealed, Focus- needs dialysis r/t renal failure; intervention- monitor for dry skin and apply lotion as needed. There was no reference to any skin tears documented in Resident #67's care plan.An observation and interview on 07/15/25 at 09:12 AM revealed, Resident #67 in bed with a dressing on her right lower arm that read 07/10. There was a [NAME] sized circle of dry blood visible through the dressing and the dressing appeared slightly dingy. Resident #67 said the dressing was old and she did not know how it happened.In an observation and interview with Resident #67 on 07/16/25 at 12:50 PM, the Wound Care Nurse removed the dressing from Resident #67's lower right arm dated 07/10 and a circle of dried blood was observed on the dressing. There was a skin tear, and the resident said the wound did not hurt and an unknown staff put a dressing on it because it would not stop bleeding. In an observation and interview with Resident #67 on 07/16/25 at 01:40 PM revealed, Resident #67's lower arm had a superficial skin tear with the skin folded over itself in the corner and measured approximately 1' X 1.5. The Wound Care nurse cleansed the area with wound cleanser and applied a new dressing dated 07/16/25. Resident #67 denied any pain associated with the skin tear.In an interview on 07/16/25 at 02:09 PM, the Wound Care Nurse said when a nurse observed a skin tear, they should immediately notify the wound care nurse, then the wound care doctor, complete a skin note with a skin check and an SBAR. The Wound Care Nurse said if she was working at the time the orders were received, she would perform the initial care and if she was not working, the nurse would. She said neither she nor the Wound Care Doctor were notified of Resident #67's new skin tear and she did not see any documentation about the injury on the resident's medical record. She said from what she saw Resident #67 had not received any treatment to the skin tear on her right arm since 07/10/25In an interview on 07/17/25 at 08:00 AM, the DON said a newly identified skin tear was a change of condition, and the identifying nurse must immediately notify the provider, wound care nurse who then received orders to perform treatment. She said after investigation she identified RN C as the nurse who placed the dressing on Resident #67 but there was no documentation of the injury, or care provided to the site from what she had seen. The DON said failure to provide follow up care could result in the wound worsening and/or infection. On 07/17/25 at 12:33 PM, an attempt was made to contact RN C via telephone. Surveyor left a message on RN C voicemail and sent a text message requesting the staff return the call; RN C did not return the call or reply to the text message.In an interview on 07/17/25 at 01:57 PM, the Wound Care Doctor said she was not notified of a new skin tear for Resident #67 on 07/10/25 and the first time she heard of it was on 07/16/25 when she was notified by the Wound Care Nurse, but she had standing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676244 If continuation sheet Page 13 of 20 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 07/17/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete orders that could be followed. The Wound Care Doctor said she was unaware of any care provided to the site since she was not notified. She said the expectation was that the wound care nurse notify her of the incident, and the standing orders be followed. She said if a resident received inappropriate treatment for a wound at a minimum the wound could worsen and in a worst-case scenario they could suffer from infection.Record review of Resident #67's Skilled Evaluation dated 07/10/25 revealed, no documentation of any skin tears. Only skin discoloration that was present upon admission was documented.Record review of Resident #67's Progress Notes from 06/15/25 to 07/14/25 printed on 07/15/25 at 01:42 PM revealed no documentation of Resident #67's skin tear on 07/10/25 or documentation of wound care to the tear of Resident #67's right lower arm.Record review of Resident #67's Skin Assessment completed on 07/14/25 revealed, no documentation of Resident #67's skin tear from 07/10/25.Record review of Resident #67's Active Order Summary dated 07/15/25 at 01:48 PM revealed, no orders for care to Resident #67's skin tear on her lower right arm.Record review of the facility's undated Wound Care Standing Orders revealed, -Standing Order #2: Skin Tear Management Indication: Skin tears (open skin) . Order: Cleanse skin tear with wound cleanser. Apply xeroform to wound bed, cover with dry dressing. Frequency: Dressing change three times per week. (Monday, Wednesday, Thursday) or as needed if soiled or non-adherent. Duration: until healed or per Wound MD guidance. Record review of the facility policy titled Acute Condition ChangesClinical Protocol revised March 2018 revealed, 3. Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the Nurse. The nursing staff will contact the physician based on the urgency of the situation 10. The nurse and physician will discuss and evaluate the situation. a. The physician should request information to clarify the situation; for example, vital signs, physical findings, a detailed sequence of events and description of symptoms. Cause Identification: 1. The staff and physician will discuss possible causes of the condition change based on factors including resident/patient history, current symptoms, medication regimen, and diagnostic test results. Treatment/Management:1. The physician will help identify and authorize appropriate treatments. Monitoring and Follow-Up: 1. The staff will monitor and document the resident/patient's progress and responses to treatment, and the physician will adjust treatment accordingly. 2. The physician will help the staff monitor a resident/patient with a recent acute change of condition until the problem or condition has resolved or stabilized. 3. At the next visit, the physician will review the status of the condition change and document his/her evaluation, including the anticipated impact on the individual's function, prognosis, and quality of life. a. The physician will make interim visits as needed to assess the situation (especially if the individual is not stable or is not improving as anticipated). Event ID: Facility ID: 676244 If continuation sheet Page 14 of 20 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 07/17/2025 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 0693 Level of Harm - Minimal harm or potential for actual harm 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** Number of residents sampled: Residents Affected - Few Number of residents cited: Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 Resident (Resident #4)reviewed for enteral nutrition. - The facility failed to administer medications safely to Resident #4 via G-tube (a feeding tube inserted into the stomach through the abdomen) by not checking for placement and forcefully pushing fluids into the residents G-tube with a syringe. These failures could place residents at risk of injuries, and hospitalization. Findings include: Record review of Resident #4's Face Sheet dated 07/17/25 revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: heart failure, MDD, dysphagia (difficulty swallowing), type 2 diabetes with kidney disease, dementia, and anxiety. Record review of Resident #4's Significant Change in Status MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making, active diagnosis of dysphagia and use of a feeding tube while a resident. Record review of Resident #4's undated Care Plan revealed, Focus- resident requires tube feeding r/t weight loss and lack of appetite; intervention- check placement of enteral tube before and after administering medications Record review of Resident #4's Order Summary Report revealed,- Omeprazole 20 mg DR- t daily for GERD.- Sennosides 8.6 mg- give 1 tablet via PEG-tube every morning and at bedtime for constipation.- Polyethylene Glycol 3350 Powder (MiraLAX) Give 1 packet via G-Tube two times a day for constipation mix with 4-8 oz beverage of choice. An observation and interview on 07/16/25 at 09:00 AM revealed, LVN D preparing for administration of medication via G-tube to Resident #4 with a Jug of cold water on the top of her medication cart. She retrieved 1 tablet of Omeprazole 20 mg (antacid for acid reflux) oral disintegrating tablets and placed it in a medication cup and then retrieved and crushed 1 Sennosides 8.6 mg (laxative) tablet and 17 grams of MiraLAX (stool softener) mixed in approximately 6 ml of water. LVN D then poured cold water into a cups and entered into the residents room. She then mixed and administered the disintegrating omeprazole to Resident #4 placing it on his tongue, mixed the crushed Sennosides 8.6 mg in cold water, mixed it with the syringe and paused the resident's continuous feed. LVN D withdrew approximately 10 cc of cold water into the syringe, attached it to the side port since the main port still had the paused continuous feed connected and pushed with force through the syringe 10 cc of water. She did not check for placement with osculation (listening for sounds) or check for residual by pulling volume from the syringe attached to the side port. LVN D withdrew the entire volume of mixed MiraLAX and attached the syringe to the side port and attempted to push the medication into the tube but there was resistance, and she was unable to administer the medication with force through the g-tube side port. LVN D said she could not administer medication through Resident #4's g-tube via gravity because the port was too small. She said she had administered medication via syringe to Resident #4 successfully in the past. LVN D attempted to disconnect the continuous feed from the other port to use but it was stuck so she stopped medication administration and said she would get one of the male staff to help her to disconnect the continuous feed. Resident #4 was chatty throughout the observation and did not show or verbalize any pain or discomfort. In an interview with on 07/16/25 at 09:14 AM, the ADON said when administrating medication via G-tube staff must first dissolve the medications in warm water. The nurse must then check for placement by checking the residual feed and if acceptable they can begin administration of a warm water flush followed by the medications with 5-10 ml warm water flushes in between and a flush after the last medication. She said cold water should not be used because it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676244 If continuation sheet Page 15 of 20 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 07/17/2025 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete could lead to residents having spasms and flushes/feeds must be done through gravity not by force of a syringe because the syringe can cause spasms if the medication is pushed too fast. In an interview on 07/17/25 at 08:08 AM, the DON said prior to administering medication via g-tube nursing staff must check for placement by injecting air and listening for bowel sounds and check for residual. She said they should not push the fluid with a syringe through the g-tube. The DON said medication must be administered via gravity because if force is used it could result in in internal injury to the resident or damage to the port. The DON said cold water should not be used to dissolve medication for g-tube administration because the medication would not dissolve which could cause the g-tube to become clogged, and the use of cold water could also cause cramping to the resident. The DON said nursing staff are not supposed to use the g-tube side port for medication administration because it was smaller . In an interview on 07/17/25 at 03:39 PM, LVN D said prior to medication administration nursing staff are expected to check for residual to make sure the feeding tube is in the right place and the resident is not full. She said if the residual is more than 30 mL nursing staff are expected to hold off on medication administration and failure to check placement could place residents at risk of the feed going into the wrong place if the tube was displaced which could lead to peritonitis (redness and swelling of the lining of your belly or abdomen). LVN D said g-tube medications should be administered via gravity because using force with a syringe could blow the tube or cause the resident injury. She said she attempted to administer medication to Resident #4 through the wrong port and she was not sure why, she said she should have used gravity, she had a brain fart and should have known better[VT3] . Record review of LVN D is undated Competency Assessment G Tube Medication Administration revealed, 4- dissolve crush medications in lukewarm water; 12- check for placement ; 13. Check for residual; 14. Flush tube with warm water. The assessment did not specify that medications were to be administered via gravity and LVN D was deemed competent in all tasks by the ADON.A request was made on 07/16/25 at 09:14 AM to the ADON for a policy on G-tube medication administration. The policy was not provided prior to exit, but a policy addressing the care of G-tubes was provided.Record review of the facility undated policy titled Enteral Feeding Tube, Care of revealed, no instructions on how to safely administer medications to resident's via G-tube. Event ID: Facility ID: 676244 If continuation sheet Page 16 of 20 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 07/17/2025 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled: Number of residents cited: Based on observations, interviews and record reviews the facility failed to ensure a resident who displays or is diagnosed with a mental disorder or psychosocial adjustment disorder received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1 of 5 residents (Resident #11) reviewed for treatment and services for mental and psychosocial concerns.- The facility failed to provide mental health services to Resident #11 who was diagnosed with MDD resulting in the resident feeling sad, lonely and crying.These failures could place residents at risk of minor and major injuries, suicide threats, attempted suicide, hospitalization, and death.Findings included:Record review of Resident #11's Face Sheet dated [DATE] revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis of: difficulty walking, lack of coordination, breast cancer in left breast, PVD ( circulatory disease where there is reduced flow to the limbs and other parts of the body), and MDD. Record review of Resident #11's admission MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 10 out of 15, her resident mood interview indicated mild depression with a score of 08 out of 27; the resident reported she felt down, depressed and hopeless nearly every day, but she did not feel bad about herself or have thoughts she would be better off dead or of hurting herself in any way. Resident #11 had no signs of psychosis and no behavioral symptoms, with an active diagnosis of depression.Record review of Resident #11's undated Care Plan revealed, Focus- MDD, single episode with severe psychotic features; Goal- resident will exhibit indicators of depression, anxiety or sad mood less than daily by review date; monitor/document/report any s/sx of depression including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness.An interview and observation on [DATE] at 09:30 AM revealed, Resident #11 was well groomed and in no immediate distress propelling herself down out of the therapy room and down the hall in a wheelchair. When she entered her room Resident #11 said she was doing pretty good, but she was sad because she was lonely. She said she missed her grandchildren, missed a birthday and her brother died since she admitted to the facility. As she transferred herself from her wheelchair to her bed, she cried stating that she could not go to her brother's funeral because she was in the facility. Record review of Resident #11's Initial Social Services Assessment & History dated [DATE] signed by the Social Worker revealed, psychological wellbeing: adjusts well to change, psychiatric diagnosis of MDD, single episode with severe psychotic features; Social Services Summary: referral to psych/psychological services.Record review of Resident #11's entire EMR on [DATE] revealed, no documentation of a psychological referral or evaluation. There were no practitioner notes for psych services or reference of any type of psychiatric evaluation. In an interview on [DATE] at 12:42 PM, the DON said when a resident arrived at the facility with a diagnosis of mental health issues or orders for psych medication, they automatically receive a referral for psychiatric services. She said a psychiatry referral is required for residents with mental health diagnosis to ensure that the residents are being followed. The DON said if a resident had a diagnosis of MDD and did not receive a psych evaluation then the resident would not receive care for their diagnosis which could place residents at risk for self-isolation and self-harm. She said if a resident with MDD refused psych services the MD would talk to them to understand the significance. The DON said Resident #11 was generally calm, participated in the facility and goes to therapy, she said she had not observed any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676244 If continuation sheet Page 17 of 20 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 07/17/2025 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete signs of depression in the resident. The DON was not sure if Resident #11 received any psychiatric services.[VT3] In an interview on [DATE] at 12:50 PM, Resident #11 said her mood was down because she wanted to go home. She said she did not want to die and would not try to harm herself. Resident #11 said no one from the facility had talked to her about her mood and she had not denied any offers for mental health services. In an interview on [DATE] at 01:13 PM, the Activities Director said Resident #11 liked to do word searches, plays bingo and exercises. She said the resident was sometimes withdrawn; the resident never told her she did not want to be at the facility, but she was excited about going home. The Activities Director said Resident #11 never showed or expressed signs of depression and suicidal ideation. In an interview on [DATE] at 01:20 PM, the Social Worker said Resident #11 lived with her son when she fell and was discovered hours later and due to this her son has concerns for her discharging home. She said Resident #11 wanted to discharge and live with her son, so her goal was to go home. The Social Worker said she assessed Resident #11's mood at the beginning of her stay and it was mild, so she asked if the resident wanted to talk to someone and she said no, so Resident #11 never received psychiatric services. She said residents with a diagnosis of MDD should be continuously evaluated because failure could result in a worsening of condition, but she had not observed any signs or symptoms of depression, sadness, or the resident crying. Record review of the facility provided list on [DATE] of residents who received behavioral health services with a licensed social worker revealed, Resident #11 was not being followed and had not received any psychological services. Record review of the facility Psychological Services Policy with no revision date revealed, Purpose & Context: As requested, the facility will provide or arrange for psychological services to meet the mental health needs of the residents. These services will support diagnosis, treatments and monitoring of psychiatric conditions and promote the quality of life for residents. Procedure: 1 Identification and referral. Residents may be referred for psychological services by physicians, nursing staff, social worker or upon admission screening. 2 Assessment: A licensed medical professional will assess the resident's mental health status, including cognitive, emotional, and behavioral functioning. 3 Treatment Planning: An individual treatment plan will be developed in coordination with the resident, their RP (when appropriate, and the interdisciplinary team. 4.Documentation: All assessments, interventions, progress notes and treatment plans will be part of the resident's medical record. Event ID: Facility ID: 676244 If continuation sheet Page 18 of 20 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 07/17/2025 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 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** Number of residents sampled: Residents Affected - Few Number of residents cited: Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #84) reviewed for infection control.- The facility failed to practice proper infection control when providing perineal care to Resident #84 following a bowel movement.These failures could place residents at risk of exposure to infection, decline in health and hospitalization.Findings included:Record review of Resident #84's Face Sheet dated 07/17/25 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: right side paralysis, difficulty swallowing, anxiety disorder, dementia and need for assistance with personal care.Record review of Resident #83's Quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 09 out of 15, and the resident was always incontinent of both bladder and bowel.Record review of Resident #84's undated Care Plan revealed, Focus: The resident has bowel incontinence r/t immobility; Goal: The resident will remain free from skin breakdown due to incontinence and brief use; Intervention: Check resident every two hours and assist with toileting as needed. In an observation and interview on 07/16/25 at 08:45 AM, CNA A provided incontinence care for Resident #84. The resident required EBP (a set of IC measures to reduce the spread of MDRO in healthcare settings), and CNA A wore the appropriate PPE. Resident #84 was observed to have stool inside his brief and on body; CNA A first used cleaned the black stool located around his testicles with wipes, then she wiped his groin, lower abdomen and then the resident's penis wearing the same gloves. She did not clean the tip of the penis, then turned the resident to his right side and wiped stool from the rectum and butt. CNA A then used a separate wipe to wipe Resident #84 down from front to back. After cleaning the dirty part CNA A changed gloves and did not sanitize or wash her hands. CNA A said she was supposed to clean the penis first and from tip on down; but she did not because she saw all the stool and wanted to clean that first. She said she should have started with penis first to prevent infection control; and should have washed her hands at the sink between changing gloves to prevent bacteria from spreading and transferring to clean items. She said she should not touch anything clean with dirty gloves.In an interview on 07/17/25 at 07:00 AM, the DON said during incontinence care nursing staff must begin at the top just like a sterile field. They must not use the same wipe and must pull back skin because elderly residents cannot perform self-care. She said staff must clean off the bowel movement and not go back and forth to prevent infection. The DON said the staff performing incontinence care must tuck the brief so as not to contaminate the front, then turn the resident and clean the backside of the resident from front to back, then clean and wipe again with new wipes until the wipes comes back clean; then remove gloves and perform hand hygiene. She said CNA A should not have cleaned from dirty to clean to prevent contamination and should not touch anything with dirty gloves. The DON said CNA A was nervous during the surveyor observed incontinence care and that partly attributed to her errors.Record review of CNA A's Competency Assessment for Perineal Care dared 04/29/24 revealed, she was assessed as competent for: Purpose: To clean the male perineum without contaminating the urethral area with germs from the rectal area. Emphasizing clean to dirty. 1 a- wash hands. Wear gloves and follow standard precautions.Record review of the facility provided undated Handwashing/Hand Hygiene policy revealed, no reference to washing from dirty to clean areas and no instructions to wash their hands between glove changes.Record review of the facility provided undated Infection Prevention and Control Guidelines revealed, ? Always wash your hands before and after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676244 If continuation sheet Page 19 of 20 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 07/17/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete procedures. Follow your facility's hand hygiene protocols. ? Always wash your hands before and after resident contact. Follow your facility's hand hygiene protocols. ? Use alcohol-based hand rub (ABHR) for hand hygiene, except when hands are visibly soiled. Follow your facility's hand hygiene protocols. ? Wear sterile or clean gloves when appropriate. Always wear gloves when working with or expecting to encounter body fluids.Record review of the facility policy titled Perineal Care revised 02/2018 revealed, For a male resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perinea! area starting with urethra and working outward. c. If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area. d. Retract foreskin of the uncircumcised male. e. Wash and rinse urethral area using a circular motion. f. Continue to wash the perineal area including the penis, scrotum, and inner thighs. g. Thoroughly rinse perinea! area in same order, using fresh water and clean washcloth. h. If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. i. Gently dry perineum following same sequence. j. Reposition foreskin of uncircumcised male. k. Ask the resident to turn on his side with his upper leg slightly bent, if able. 1. Rinse washcloth and apply soap or skin cleansing agent. m. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks. n. D1y area thoroughly. 9. Discard disposable items into designated containers. 10. Remove gloves and discard into designated container. 11. Wash and dry your hands thoroughly. 12. Reposition the bed covers. Make the resident comfortable. 13. Place the call light within easy reach of the resident. 14. Clean wash basin and return to designated storage area. 15. Clean the bedside stand. 16. Wash and dry your hands thoroughly. Event ID: Facility ID: 676244 If continuation sheet Page 20 of 20