Health inspection·July 21, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 07/21/23 at 10:21 a.m., at the hospital CR # 3 said she wanted to take showers and the staff told her they would give her a bed bath. She said she was given a bed bath once while she was in the facility because they said they had to use the mechanical lift to transfer her to the shower chair. She said she felt dirty and had odor and her family member came and took her to the shower and gave her a good bath. She said she told a couple of aides about not getting showers because she required a mechanical lift, and they told her shower was during the morning shift. During an interview on 07/21/23 at 6:09 p.m. CNA L said CR #3 told her the morning aides said she could not go to the shower room for bath because they had to transfer her to the shower chair with a mechanical lift. CNA L said her thought was the aides from the morning shift did not shower her because the facility had Mechanical lift the aides could have used to transfer her to the wheelchair. During an interview on 07/21/23 at 6:11 p.m., CNA M said CR #3 told him the morning staff said they would not give her a shower because she required a mechanical lift. He said he transfers his resident with mechanical lift onto the shower chair and take the resident to the shower room for shower. He said the aides used the mechanical lift as an excuse not to shower CR #3. He said when CR #3 told him he offered to shower her, but she told him her family member gave her a shower today. During an interview on 07/21/23 at 7:25 p.m., the DON said she was not aware CR #3 was not given a shower and was given one bed bath when she was in the facility. The DON said aides use a shower chair for residents who require Hoyer lifts (mechanical) and the resident could go to the shower room for a bath. She said CR #3 could have gotten showers because she was not aware she had any restrictions. She said it was the resident's right to get a shower if she wanted a shower. Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted om 02/01/23. Resident #1 had diagnoses which included dementia (loss of thinking, remembering and reasoning that could interferes with a person's daily life), hypertension (a condition in which the blood vessels have persistently raised pressure), and cerebral infarction (a result of disrupted blood flow to the brain due to problem with blood vessels). Record review of Resident #1's quarterly MDS assessment, dated 06/30/2023, revealed a BIMS score of 03 out of 15, which indicated the resident's cognition was severely impaired. Resident #1's functional status revealed she required extensive assistance with one staff assistance for bed mobility, transfer, dressing, and personal hygiene. Resident #1 was frequently incontinent of bladder and bowel. Record review of Resident #1's care plan target date 07/12/23, revealed: Resident #1 had bladder/bowel incontinence which places her at risk for skin breakdown and infection. Interventions: monitor for signs and symptoms of UTI , foul smelling urine, altered mental status and no output. Check the resident during rounds as required for incontinence. Wash, rinse and dry perineum, and change clothing PRN after incontinence episodes. During observation on 07/21/23 at 4:00 p.m. revealed Resident #1's pants were wet with urine from front to back. When CNA H opened the resident's incontinent brief, it was saturated with urine and the wet indicator line was mashed and the front part was faded out . Interview on 07/21/23 at 4:22 p.m., CNA H said CR #1's brief was saturated, and the wet indicator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 2 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deerbrook Skilled Nursing and Rehab Center 9250 Humble-Westfield Rd Humble, TX 77338 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some line was smashed. She said the brief may not have been changed by the day shift aide. She said it appeared it had not been changed for more than four hours. She also said Resident #1's pants were wet from urine from front to back. She also said the resident's wheelchair was also wet with urine. She said she had not checked the resident since she came to work today at 2:00 p.m., until now. She said if a resident was left with urine soaked brief for a long time the resident could breakdown or she could get an infection. She said aides should make rounds for residents who were incontinent every two hours and check on their residents during shift change. She said she had in service and skills check off on incontinent care. She said the nurse monitored the aides by making random checks on residents. Interview on 07/21/23 at 5:52 p.m., the Unit manager said CNA H should make rounds when she came to work every two hours and if the resident was a heavy wetter (urinate more often)the aide should make rounds more often. She said if Resident #1's incontinent brief was saturated, and the line indicators were mashed, and the pants are wet it could mean the resident had not been changed for an extended period. She said the resident's skin could become red, have skin breakdown, rashes, and UTI. Interview on 07/21/23 at 6:45 P.M., with the DON and Administrator, the DON said her expectations were to provide incontinent care for resident correctly. The DON said the staff are trained upon hire and as needed yearly to make rounds frequently at least every two hours. She said if Resident #1 was left on wet incontinent brief and clothes for an extended period of time the resident would have skin break down and infection. She said the charge nurse monitors the aides while the nurse manager monitored the nurses by making random rounds. Resident #2 Record review of Resident #2's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had diagnoses which included discitis (an infection of the intravertebral disc space), extradural and subdural abscess (a pocket of pus that develops between the skull and the top tissues coving the brain.), and cerebral fluid leak (a tear or hole in the membranes surrounding the brain or spinal cord). Record review of Resident #2's admission MDS assessment reflected he was newly admitted and the MDS was not due. During an observation and interview on 07/21/23 at 4:56 p.m., Resident #2 said he preferred a shower than a bed bath, but the staff would not give him a shower and told him he would get a bed bath. He said he had one bed bath since he came to the facility. He said he had not been given a bed bath for this week and he said he felt dirty and the worst was how he smelled bad because he goes to therapy, and he knew they could perceive his odor. He said he would like a shower. He said his nails were too long and he had asked to be shaved and have his nails trimmed and you can see the beautiful care they have given him (sarcastically). All the fingernails on the resident's hands were about 1 inch long and three on the right hand had a brown substance under the nails and two on the left hand also had a brown substance. The resident's beard was long. During observation and interview on 07/21/23 at 5:07 p.m., CNA L said she saw Resident #2's fingernails were long and nice size for him , and Resident #2 said his fingernails were long for him and he was a man. She said Resident #2's beard was long. She said she was not the resident aide and she just came to answer the call light. She said if the resident wanted his fingernails cut, then the aide would cut them if he was not diabetic, and he could be shaved on shower days and as needed. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 3 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deerbrook Skilled Nursing and Rehab Center 9250 Humble-Westfield Rd Humble, TX 77338 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 said it was a dignity issue for Resident #2 if he felt unkempt. Level of Harm - Minimal harm or potential for actual harm During an observation on 07/21/2023 at 5:10 p.m., with LVN D said she observed Resident #2's fingernails were long and dirty. She said the resident's beard was long and it looked unkempt. Residents Affected - Some During an Interview on 07/21/23 at 5:18 p.m., LVN D said Resident #2's fingernails were long, and had some black and brown dirt in his fingernails and his beard was long and unkempt. She said the staff should ask the resident if he wanted his fingernails cut. She said she did not know how often the residents' fingernails are cut and she would ask the management about it. She said the nurse monitors the aides to make sure that they are providing care to the resident. She said today was her first time she met Resident #2. She said she made rounds when she took over the shift and she saw the resident but did not notice his fingernails or ask him if he wanted his fingernails cut or his beard shaved. She said the resident's beards are shaved on shower day or they go to the beauty parlor. She said she did not know how often the residents are supposed to be showered and she would find out from the aide. She said if a resident wants a bed bath, then the resident should get a bed bath and if the resident wanted a shower the resident should get a shower unless it was contraindicated. Interview on 07/21/23 at 5:23p.m., LVN D said an aide told her the aides were supposed to have showered Resident #2 on Monday, Wednesday, and Friday during the morning shift. She said she found out if a resident was diabetic the nurse should cut the resident's fingernails. She said the DON said everybody should cut the resident's fingernails, but she did not ask when nails should be cut. She said she did skills check - off and she does not know if they included providing care to residents. She said she would go and find out from the DON when residents fingernails are cut. Interview on 07/21/23 at 5:42 p.m., the Unit manager said Resident #2 should get showered three times a week. She said the residents should be shaved when they see the resident's facial hair was long and the same for the nails. They should do the nails on shower days and shave on shower days. She said she was not sure if Resident #2 had any restriction which would have stopped him from getting a shower and getting only a bed bath. She said she was not aware the resident refused bed bath this week . She said the nurses and aides have skill check offs on providing showers, fingernail care and shaving for residents. She said the nurse monitors the aides and the nurse managers monitor the nurse by making rounds. She said the resident would not feel good at all if he did not get showers. She said the resident can get skin break down, body odor and infection. She said Resident #2's fingernails were long, and he said he wanted them cut. She said the facility did not use shower sheets but the aides charted on the electronic health record in the computer. Interview on 07/21/23 at 6:03 p.m., CNA M said he was Resident #2 's CNA, and his shower should be during morning shift. He said he had not seen Resident #2 until now because he was in therapy. He said he worked with the resident yesterday but did not check his fingernails or ask him if he needed to be shaved because his shower was in the morning. He said he was not sure if Resident #2 was diabetic. He said he shaves residents when he does showers and anytime the resident asked. He said he does not honestly ask resident if they needed to be shaved when he was not showering the resident. He said Resident #2 can get skin break down, body odor if Resident #2 was not showered and the resident could have skin tears if his nails were long. During an interview on 07/21/23 at 7:15 p.m., the DON said the aides did fingernail care unless the resident was a diabetic, then the nurse would cut the nails. She said the residents' fingernails care was done as needed, either cutting or cleaning the fingernails. She said the staff must ask the resident and the resident can ask but ultimately the staff should ask the resident. She said the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 4 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deerbrook Skilled Nursing and Rehab Center 9250 Humble-Westfield Rd Humble, TX 77338 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some residents are shaved during showers. She said if Resident #2's fingernails are not cleaned it could cause infection, and skin tears. She said the shaving and the fingernails would be dignity issues. She said the staff were in - serviced on fingernail care, shower and shaving. During an interview on 07/21/23 at 7:20 p.m., the DON said Resident #2 should be showered three times a week. She said there should not be any reason for a Resident not getting a shower if he wanted unless he was bedbound and had an order not to get up from the bed. She said Resident #2 could have skin breakdown, rashes, and infection if he was not given a shower or bed bath. She said she was not aware Resident #2 refused showers. Record review of the facility policy on quality-of-life (revised August 2009) read in part . each resident shall be cared for in a way that promotes and enhances quality of life .policy interpretation and implementation #3 . residents shall be groomed as they wish to be groomed (hair style, nails, facial hair etc.) . Record review of CNA L's proficiency evaluation clinical skill check - offs revealed she signed the skills check on personal care/grooming on 06/14/23. Record review of CNA H's proficiency evaluation clinical skill check - offs revealed she signed the skills check on personal care/grooming on 05/01/23 and 05/03/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 5 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deerbrook Skilled Nursing and Rehab Center 9250 Humble-Westfield Rd Humble, TX 77338 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #1) reviewed for incontinent care. - The facility failed to ensure CNA H followed proper infection control procedures and did not completely clean Resident #1 during incontinent care. These failures could place residents at risk for pain, infection, injury, and hospitalization. Findings included: Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted om 02/01/23. Resident #1 had diagnoses which included dementia (loss of thinking, remembering and reasoning that could interferes with a person's daily life), hypertension (a condition in which the blood vessels have persistently raised pressure), and cerebral infarction (a result of disrupted blood flow to the brain due to problem with blood vessels). Record review of Resident #1's quarterly MDS assessment, dated 06/30/2023, revealed a BIMS score of 03 out of 15, which indicated the resident's cognition was severely impaired. Resident #1's functional status revealed she required extensive assistance with one staff assistance for bed mobility, transfer, dressing, and personal hygiene. Resident #1 was frequently incontinent of bladder and bowel. Record review of Resident #1's care plan target date 07/12/23, revealed: Resident #1 had bladder/bowel incontinence which places her at risk for skin breakdown and infection. Interventions: monitor for signs and symptoms of UTI (urinary tract infection), foul smelling urine, altered mental status and no output. Check the resident during rounds as required for incontinence. Wash, rinse and dry perineum, change clothing PRN after incontinence episodes. During an observation on 07/21/23 at 4:00 p.m., of Resident #1's, incontinent care provided by CNA H, revealed she donned a pair of gloves, she did not wash her hands, and she pulled the resident's pants to her ankles. The resident's pants were wet from front to back, and her wheelchair was wet. She did not have any supply for the incontinent care set. She unfastened the incontinent brief. It was saturated from front to back, and the wet line indicator was mashed and partially faded. She turned Resident #1 and was about to pull the dirty brief off, and she said she had to get a clean brief and towel. She went and opened the resident's closet with the dirty gloves and went through the items in the closet. Then she went to the resident's drawers, and she did not find any clean incontinent briefs. She went into the roommate's drawers with the same dirty gloves, opened the four drawers, and finally found one incontinent brief. She took it and placed it on the bed. She returned to the resident's closet, still wearing the same gloves, and took a bathmat-size towel and folded it multiple times. She took it to the resident's bathroom, applied the hand-washing soap and water on the towel, and returned to the resident's bedside. She wiped Resident #1's peri area once, and she did not separate the labia. She turned the resident to the right side and wiped the buttocks once, and she did not separate the buttocks and cleaned the rectum area. She did not rinse off the soap from the peri area or buttocks area. She still wore the same dirty gloves and applied the incontinent brief from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 6 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deerbrook Skilled Nursing and Rehab Center 9250 Humble-Westfield Rd Humble, TX 77338 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the roommate's drawer. Resident #1 stated she did not want the brief from her roommate's drawer. Resident #1 said she wanted a pull-up and to place a pad inside the pull-up. Meanwhile, she left the saturated incontinent brief on the resident's bed towards the foot of the bed. CNA H went to the trash can, still wearing the same gloves; she reached into the trash can, pulled out four pads, and placed them on the floor. She took a trash bag and put the dirty incontinent brief, and another trash bag and placed the towel she cleaned the resident with. Then CNA H reached back into the resident's closet, took a pull-up, took one of the pads from the floor, placed it inside the pull-up, and applied it on the resident, still wearing the same dirty gloves. She removed the gloves, dirty linen, and trash bag from the resident's room without washing or sanitizing her hands. During an interview on 07/21/23 at 4:25 p.m., CNA H said she did not separate Resident #1's labia, buttocks or clean the anal area. She used the same towel and wiped the peri area and the buttocks. She said she had no reason for not rinsing off the soap from the resident's skin. CNA H stated because she did not rinse off the resident's peri area, it could cause itching, skin breakdown, or infection for Resident #1. CNA H said she cleaned the resident with a towel when she provided incontinent care because she did not have peri wipes. CNA H said she used the same gloves throughout incontinent care and went into another resident's drawer to get incontinent brief . She said she also used the same gloved hand to pull trash bags from the trash container and place Resident pads on the floor from the trash container. She said she took a pull-up from the resident's closet and applied one of the pads she put on the floor in the pull-up and used it on the resident. She also said she dressed the resident in clean pants with the same gloves. CNA H said her gloves were not dirty, she knew when to change her gloves, she knew what infection control is, and she had in-service on infection control . During an interview on 07/21/23 at 6:53 p.m., the DON said CNA H should knock on the door and have their supplies, such as wipes, incontinent briefs, trash bags for the Resident's clothes, and dirty linens. She said the bedside table should be disinfected and a protective barrier placed on the table. She said the CNA should then set up the care supplies, provide privacy for Resident #1, wash her hands, and don gloves, and proceed to provide care for the Resident. She said if the facility does not have wipes, the CNA must have two basins, one with soap and one with clean water. She said to use one towel for the peri area, and the Resident's labia should be separated and cleaned properly to prevent infection; then, the towel would be placed in the trash bag for the dirty linen. She said then use a clean towel from the other basin, rinse the area, put it in the dirty linen trash bag, and repeat the procedure for the buttocks. She said the nursing staff monitored aides, and the unit manager monitored the nurses by making random rounds. The DON said CNA H should have washed her hands before she donned her gloves. She said CNA H should remove gloves and wash or sanitize her hands before entering Resident #1's closet and drawers. She also said she should not have gone into Resident #1 roommate's drawer while providing care for Resident #1 to prevent cross-contamination. She stated CNA H should not have thrown Resident #1's pad on the floor and later used it on the Resident, and resident pads should not be in the trash can in the first place. She said CNA H should remove the dirty gloves and have washed her hands when going from dirty to clean during incontinent care and before she left the Resident's room to prevent the spread of germs. She said CNA H should have separated Resident#1's labia and cleaned the area properly to prevent UTI and skin breakdown. Record review of the facility perineal care policy (Revised October 2010) read in part .procedures are to provide cleanliness and comfort to the resident, to prevent infection and skin irritation . preparation . #2 . assemble the equipment and supplies . steps in the procedure #9b1 . separate labia and wash . #9e . wash the rectal area thoroughly . #12 . remove gloves . wash hands and dry your thoroughly hands . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 7 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deerbrook Skilled Nursing and Rehab Center 9250 Humble-Westfield Rd Humble, TX 77338 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of CNA H's proficiency evaluation clinical skills check - off revealed she signed the skills check on perineal care and hand hygiene on 05/01/23 and 05/03/23. Record review of the facility policy on hand washing . (Revised August 2015) read in part . considers hand hygiene the primary means to prevent the spread of infection . policy interpretation and implementation . #7h . before moving from a contaminated body site to a clean site during resident care . #8 . hand hygiene is the final step after removing and disposing of personal protective equipment . washing hands . #3 . dry hands thoroughly with paper towel and then turn off faucet with a clean, dry paper towel . applying and removing gloves . #1 . perform hand hygiene before applying non - sterile gloves . Event ID: Facility ID: 676263 If continuation sheet Page 8 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deerbrook Skilled Nursing and Rehab Center 9250 Humble-Westfield Rd Humble, TX 77338 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** Based on observation, interview, and record review the facility failed to establish and 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 3 residents (Resident #1) reviewed for incontinent care. Residents Affected - Few - The facility failed to ensure CNA H followed proper infection control procedures and did not completely clean Resident #1 during incontinent care. These failures could place residents at risk for pain, infection, injury, and hospitalization. Findings included: Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted om 02/01/23. Resident #1 had diagnoses which included dementia (loss of thinking, remembering and reasoning that could interferes with a person's daily life), hypertension (a condition in which the blood vessels have persistently raised pressure), and cerebral infarction (a result of disrupted blood flow to the brain due to problem with blood vessels). Record review of Resident #1's quarterly MDS assessment, dated 06/30/2023, revealed a BIMS score of 03 out of 15, which indicated the resident's cognition was severely impaired. Resident #1's functional status revealed she required extensive assistance with one staff assistance for bed mobility, transfer, dressing, and personal hygiene. Resident #1 was frequently incontinent of bladder and bowel. Record review of Resident #1's care plan target date 07/12/23, revealed: Resident #1 had bladder/bowel incontinence which places her at risk for skin breakdown and infection. Interventions: monitor for signs and symptoms of UTI (urinary tract infection), foul smelling urine, altered mental status and no output. Check the resident during rounds as required for incontinence. Wash, rinse and dry perineum, change clothing PRN after incontinence episodes. During an observation on 07/21/23 at 4:00 p.m., of Resident #1's, incontinent care provided by CNA H, revealed she donned a pair of gloves, she did not wash her hands, and she pulled the resident's pants to her ankles. The resident's pants were wet from front to back, and her wheelchair was wet. She did not have any supply for the incontinent care set. She unfastened the incontinent brief. It was saturated from front to back, and the wet line indicator was mashed and partially faded. She turned Resident #1 and was about to pull the dirty brief off, and she said she had to get a clean brief and towel. She went and opened the resident's closet with the dirty gloves and went through the items in the closet. Then she went to the resident's drawers, and she did not find any clean incontinent briefs. She went into the roommate's drawers with the same dirty gloves, opened the four drawers, and finally found one incontinent brief. She took it and placed it on the bed. She returned to the resident's closet, still wearing the same gloves, and took a bathmat-size towel and folded it multiple times. She took it to the resident's bathroom, applied the hand-washing soap and water on the towel, and returned to the resident's bedside. She wiped Resident #1's peri area once, and she did not separate the labia. She turned the resident to the right side and wiped the buttocks once, and she did not separate the buttocks and cleaned the rectum area. She did not rinse off the soap from the peri area or buttocks area. She still wore the same dirty gloves and applied the incontinent brief from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 9 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deerbrook Skilled Nursing and Rehab Center 9250 Humble-Westfield Rd Humble, TX 77338 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 the roommate's drawer. Resident #1 stated she did not want the brief from her roommate's drawer. Resident #1 said she wanted a pull-up and to place a pad inside the pull-up. Meanwhile, she left the saturated incontinent brief on the resident's bed towards the foot of the bed. CNA H went to the trash can, still wearing the same gloves; she reached into the trash can, pulled out four pads, and placed them on the floor. She took a trash bag and put the dirty incontinent brief, and another trash bag and placed the towel she cleaned the resident with. Then CNA H reached back into the resident's closet, took a pull-up, took one of the pads from the floor, placed it inside the pull-up, and applied it on the resident, still wearing the same dirty gloves. She removed the gloves, dirty linen, and trash bag from the resident's room without washing or sanitizing her hands. During an interview on 07/21/23 at 4:25 p.m., CNA H said she did not separate Resident #1's labia, buttocks or clean the anal area. She used the same towel and wiped the peri area and the buttocks. She said she had no reason for not rinsing off the soap from the resident's skin. CNA H stated because she did not rinse off the resident's peri area, it could cause itching, skin breakdown, or infection for Resident #1. CNA H said she cleaned the resident with a towel when she provided incontinent care because she did not have peri wipes. CNA H said she used the same gloves throughout incontinent care and went into another resident's drawer to get incontinent brief . She said she also used the same gloved hand to pull trash bags from the trash container and place Resident pads on the floor from the trash container. She said she took a pull-up from the resident's closet and applied one of the pads she put on the floor in the pull-up and used it on the resident. She also said she dressed the resident in clean pants with the same gloves. CNA H said her gloves were not dirty, she knew when to change her gloves, she knew what infection control is, and she had in-service on infection control . During an interview on 07/21/23 at 6:53 p.m., the DON said CNA H should knock on the door and have their supplies, such as wipes, incontinent briefs, trash bags for the Resident's clothes, and dirty linens. She said the bedside table should be disinfected and a protective barrier placed on the table. She said the CNA should then set up the care supplies, provide privacy for Resident #1, wash her hands, and don gloves, and proceed to provide care for the Resident. She said if the facility does not have wipes, the CNA must have two basins, one with soap and one with clean water. She said to use one towel for the peri area, and the Resident's labia should be separated and cleaned properly to prevent infection; then, the towel would be placed in the trash bag for the dirty linen. She said then use a clean towel from the other basin, rinse the area, put it in the dirty linen trash bag, and repeat the procedure for the buttocks. She said the nursing staff monitored aides, and the unit manager monitored the nurses by making random rounds. The DON said CNA H should have washed her hands before she donned her gloves. She said CNA H should remove gloves and wash or sanitize her hands before entering Resident #1's closet and drawers. She also said she should not have gone into Resident #1 roommate's drawer while providing care for Resident #1 to prevent cross-contamination. She stated CNA H should not have thrown Resident #1's pad on the floor and later used it on the Resident, and resident pads should not be in the trash can in the first place. She said CNA H should remove the dirty gloves and have washed her hands when going from dirty to clean during incontinent care and before she left the Resident's room to prevent the spread of germs. She said CNA H should have separated Resident#1's labia and cleaned the area properly to prevent UTI and skin breakdown. Record review of the facility perineal care policy (Revised October 2010) read in part .procedures are to provide cleanliness and comfort to the resident, to prevent infection and skin irritation . preparation . #2 . assemble the equipment and supplies . steps in the procedure #9b1 . separate labia and wash . #9e . wash the rectal area thoroughly . #12 . remove gloves . wash hands and dry your thoroughly hands . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 10 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deerbrook Skilled Nursing and Rehab Center 9250 Humble-Westfield Rd Humble, TX 77338 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 Record review of CNA H's proficiency evaluation clinical skills check - off revealed she signed the skills check on perineal care and hand hygiene on 05/01/23 and 05/03/23. Record review of the facility policy on hand washing (Revised August 2015) read in part . considers hand hygiene the primary means to prevent the spread of infection . policy interpretation and implementation . #7h . before moving from a contaminated body site to a clean site during resident care . #8 . hand hygiene is the final step after removing and disposing of personal protective equipment . washing hands . #3 . dry hands thoroughly with paper towel and then turn off faucet with a clean, dry paper towel . applying and removing gloves . #1 . perform hand hygiene before applying non - sterile gloves . Event ID: Facility ID: 676263 If continuation sheet Page 11 of 11