Health inspection·November 16, 2023

F 0656 breathing problem), and dependence on renal dialysis (on dialysis). Level of Harm - Minimal harm or potential for actual harm Record review of Resident #36's entrance MDS, dated [DATE], revealed a BIMS score of 10 out of 15 which indicated moderately impaired cognition. It also revealed her vision was severely impaired in adequate light, meaning she had no vision or saw only light, colors or shapes; her eyes did not appear to follow objects. The MDS indicated Resident #36 felt it was somewhat important to listen to music, do things with groups of people, go outside, and get fresh air, be around animals, and participate in religious services. According to the MDS, the resident required extensive assistance with dressing and 2+ persons physical assistance. She required extensive assistance with eating and 1-person physical assist. Also, she required extensive assistance with personal hygiene and 2+ persons physical assist. Residents Affected - Some Record review of Resident #36's care plan, dated 10/23/23, revealed a focus: ADL self-care performance deficit r/t weakness, confusion initiated 1/27/22. Goal: Will remain current level of function in bed mobility, transfers, eating, dressing, toilet use, and personal hygiene through the review date, initiated 1/27/22. Interventions: Resident #36 required extensive assist from one staff member participation to dress. Resident required limited assist to eat. Resident required limited assist from 1 staff members participation with personal hygiene and oral care. Interventions initiated 1/27/22. There was no mention of special activities on Resident #36's care plan, due to her being blind. Record review of Resident #36's medical record revealed an Activity Evaluation performed on 1/23/22 at 7:36pm. According to the evaluation the resident said she enjoyed exercise/walking/jogging, music, spiritual/religious activities, walking/wheeling outdoors, watching TV/movies/radio, talking/conversing, and keeping up with the news. In an interview and observation on 11/12/23 at 12:15pm, Resident #36 was sitting up in bed and had just finished lunch. She said she used to like to play bingo, but she could not play bingo anymore since she could not see. She said she did not participate in any activities since she could not see. She said she liked music and liked to talk to people. She also said she went to dialysis on MWF. Resident #36 had a telephone on her nightstand, but said she had no idea she had a phone in her room. She said it would not do any good because she could not see to push the numbers, and no one had helped her to call anyone. However, she said she would like to call her family member. In an interview and observation on 11/14/23 at 10:29am. Resident #36 was sitting up in bed. She said no one had tried to help her with the phone in her room. Surveyor attempted to call the resident's family member for her, but the call was long distance, and it would not allow the call to go through. In an interview on 11/15/23 at 9:00am, Nurse Aide A said she would go in and talk with Resident #36 because she liked to talk. She also said she would go in and dial numbers for her if they were local numbers, but she could not if they were long distance. She said the resident did not get out of bed unless she was going to dialysis. In an observation on 11/16/23 at 9:12am, Resident #36 was sitting up in bed with eggs all over her chest and was not participating in any activities. In an interview on 11/16/23 at 9:40am, the Activities Director said she had only been employed with the facility for 1 month. She said Resident #36 received in room visits and she would frequently go in her room and talk to her, since she liked to talk. She said the resident would come out of her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 2 of 28 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 11/16/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm room on the days she did not have dialysis and that she came out of her room on Monday (11/13/23). The Activities Director said the resident also liked to attend church and that she would make phone calls at night, and the staff would help her make them. She said staff went in the resident's room a lot to talk to her because she liked to talk about her family. A lot of times, she would not want to leave her room and would prefer to stay in her room and listen to music on a phone. Residents Affected - Some 2. Record review of Resident #53's undated face sheet, revealed she was a [AGE] year-old female admitted [DATE] with diagnoses of metabolic encephalopathy (problem in the brain), cognitive communication deficit (difficulty with thinking or how someone uses language), type 2 diabetes (problem producing insulin or resisting it), unspecified dementia, acute kidney failure (kidneys are not filtering anymore), and acquired absence of left leg above knee (left above the knee amputation). Record review of Resident #53's admission MDS assessment dated [DATE], revealed a BIMS score of 10 out of 15 which indicated moderately impaired cognition. According to the MDS, the wander/elopement alarm was marked as not used. Record review of Resident #53's care plan dated 8/25/23, did not mention exit seeking behavior or the Wander Guard. Record review of Resident #53's chart revealed multiple progress notes which described exit seeking behavior, starting in August 2023, and continued to October 2023. Record review of Resident #53's physician orders revealed the following orders from MD A: Wander Guard: Replace Wander Guard PRN upon expiration/not working properly, as needed, ordered on 8/28/23 at 1:47pm. Wander Guard: Check for proper functioning daily, every shift, ordered on 8/28/23 at 2:00pm. Wander Guard: Check for proper placement Q shift, every shift, ordered on 8/28/23 at 2:00pm. Record review of Resident #53's November MAR revealed documentation of the Wander Guard every day, with a start date of 8/28/23. In an observation on 11/14/23 at 10:37am Resident #53 was sitting in a wheelchair in the dining room, participating in activities. A Wander Guard was observed on her left wrist. The resident was speaking Spanish to another resident. 3. Record review of Resident #69's undated face sheet, revealed she was a [AGE] year-old female admitted [DATE] with diagnoses of unspecified encephalopathy (problem with brain), schizoaffective disorder, bipolar type (psychotic symptoms and symptoms of a mood disorder), cognitive communication deficit (difficulty with thinking or how someone uses language), severe protein-calorie malnutrition, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 3 of 28 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 11/16/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some rhabdomyolysis (damaged muscle tissue that release protein/electrolytes into blood), and acute kidney failure (sudden failure of the kidneys to filter). Record review of Resident #69's annual MDS, dated [DATE], revealed a BIMS score of 11 out of 15 which indicated moderately impaired cognition. According to the MDS the resident had two Stage 4 pressure ulcers on admission and had been taking antibiotics prior to admission. The MDS revealed the resident had IV access while a resident. Record review of Resident #69's care plan, dated 10/31/23, did not mention the IV access (midline) or the IV antibiotics she was receiving. Record review of Resident #69's medical record revealed a consent for a midline signed by the resident on 11/7/23 at 2:15am. The consent revealed it was placed on 11/7/23 at 2:32am by RN A. Record review of Resident #69's medical record revealed the following orders by MD A: PICC/Midline/Central IV (a deeper IV then a regular IV that lasts longer): Change IV dressing Q7 days and PRN, ordered 11/6/23 at 12:46pm. Midline IV: No BP or Venipuncture (lab draw) to arm, ordered on 11/6/23 at 1:03pm. IV: Monitor IV insertion site for s/s of infection/infiltration Q shift, ordered 11/6/23 at 1:03pm. Midline IV: Change IV dressing Q7 days and PRN, ordered 11/6/23 at 1:03pm. In an observation and interview on 11/12/23 at 2:01pm Resident #69 was lying in bed, with a midline to her left upper arm. She stated she received IV antibiotics for an infection in her left hip wound. The resident was on contact isolation for her left hip wound. In an interview with LVN B on 11/16/23 at 1:53pm she stated she would get all her diagnoses from the hospital records, nursing documentation, CAA areas that triggered, and MD orders, for admissions. She said every morning they had clinical meetings with herself, Unit Managers, the DON, the ADON, Wound Care Nurse, and the Charge Nurse. She said if something was left off the care plan, the plan of care could be missed for the patient, and they would not receive the treatment ordered. She said the Wander Guard was not on the care plan for Resident #53 and it should have been. She revealed it was her mistake and she overlooked it. Also, she said the IV antibiotics/Midline should have been on the care plan for Resident #69 and the Infection Control Nurse must have missed it. She said she would let her know. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 4 of 28 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 11/16/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the facility's policy and procedure on Care Plans-Comprehensive (Revised December 2009) read in part: .Policy Interpretation and Implementation: .2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS Assessments of residents are ongoing and care plans are revised as information about the resident's condition change . 5. The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans: a. When there has been a significant change in the resident's condition. b. When the desired outcome is not met. c. When the resident has been readmitted to the facility from a hospital stay. d. At least quarterly. Record review of the facility's policy and procedures for Care Plans-Comprehensive (Revised December 2009) read in part: Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The facility will ensure the resident has the right to participate in the development and implementation of his or her person-centered plan of care. Policy Interpretation and Implementation: 1.Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a person-centered comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain through establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and other factors related to effectiveness of the plan of care. 2.The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 3.Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; c. Build on the resident's strengths; d. Reflect the resident's expressed wishes regarding care and treatment goals; e. Reflect treatment goals, timetables and objectives in measurable outcomes; f. Identify the professional services that are responsible for each element of care; g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and i. Reflect currently recognized standards of practice for problem areas and conditions . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 5 of 28 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 11/16/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure comprehensive care plans were reviewed and revised by the Interdisciplinary Team after each assessment for 1 (Resident #36) out of 18 residents reviewed for care plan accuracy. The facility failed to ensure Resident #36's comprehensive care plan had the correct ADL interventions. This failure could place residents at risk for their medical, physical, and psychosocial needs not being met. Findings include: Record review of Resident #36's undated face sheet revealed she was a [AGE] year-old female admitted on [DATE] with diagnoses of end stage renal disease (kidneys do not work anymore), dysphagia (trouble swallowing), metabolic encephalopathy (brain disorder), cognitive communication deficit (difficulty with thinking or how someone uses language),, physical debility, type 2 diabetes mellitus with diabetic neuropathy (body does not produce insulin or resists it and nerve pain), transient ischemic attack (mini stroke), blindness and low vision, heart failure (heart does not pump as well), peripheral vascular disease (circulation problems in extremities), chronic obstructive disease (chronic breathing problem), and dependence on renal dialysis (on dialysis). Record review of Resident #36's admission MDS, dated [DATE], revealed a BIMS score of 10 out of 15 which indicated moderately impaired cognition. It also revealed her vision was severely impaired in adequate light, meaning she had no vision or saw only light, colors or shapes; her eyes did not appear to follow objects. According to the MDS, the resident required extensive assistance with dressing and 2+ persons physical assistance. She required extensive assistance with eating and 1-person physical assist. Also, she required extensive assistance with personal hygiene and 2+ persons physical assist. Record review of Resident #36's care plan, dated 10/23/23, revealed a focus: ADL self-care performance deficit r/t weakness, confusion initiated 1/27/22. Goal: Will remain current level of function in bed mobility, transfers, eating, dressing, toilet use, and personal hygiene through the review date, initiated 1/27/22. Interventions: Resident #36 required extensive assist from one staff member participation to dress. Resident required limited assist to eat. Resident required limited assist from 1 staff members participation with personal hygiene and oral care. Interventions initiated 1/27/22. The interventions for ADL care did not match the MDS assessment. The MDS assessment revealed Resident #36 required extensive assistance with eating and personal hygiene, while the care plan revealed the resident required limited assistance with eating and personal hygiene. In an interview and observation on 11/12/23 at 12:15pm, Resident #36 was blind, sitting up in bed, and had just finished feeding herself lunch. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 6 of 28 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 11/16/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 11/15/23 at 9:00am, Nurse Aide A said she would go in and talk with Resident #36 because she liked to talk. She said the resident fed herself and did not get out of bed unless she was going to dialysis. In an observation on 11/16/23 at 9:12 am, Resident #36 was sitting up in bed with eggs all over her chest. The resident stated she fed herself but would like more help. In an interview with LVN B on 11/16/23 at 1:53pm, she stated she would get all her diagnoses from the hospital records, nursing documentation, CAA areas that triggered, and MD orders, for admissions. She said every morning they had clinical meetings with herself, Unit Managers, the DON, the ADON, Wound Care Nurse, and the Charge Nurse. Per LVN B, activities were not usually on the care plan unless it triggered the CAAS. She said if something was left off the care plan, the plan of care could be missed for the patient, and they would not receive the treatment ordered. Record review of the facility's policy and procedure on Care Plans-Comprehensive (Revised December 2009) read in part: .Policy Interpretation and Implementation: .2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS Assessments of residents are ongoing and care plans are revised as information about the resident's condition change . 5. The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans: a. When there has been a significant change in the resident's condition. b. When the desired outcome is not met. c. When the resident has been readmitted to the facility from a hospital stay. d. At least quarterly. Record review of the facility's policy and procedures for Care Plans-Comprehensive (Revised December 2009) read in part: Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The facility will ensure the resident has the right to participate in the development and implementation of his or her person-centered plan of care. Policy Interpretation and Implementation: 1.Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a person-centered comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain through establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and other factors related to effectiveness of the plan of care. 2.The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 3.Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; c. Build on the resident's strengths; d. Reflect the resident's expressed wishes regarding care and treatment goals; e. Reflect treatment goals, timetables and objectives in measurable outcomes; f. Identify the professional services that are responsible for each element of care; g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and i. Reflect currently recognized standards of practice for problem areas and conditions . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 7 of 28 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 11/16/2023 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure services provided by the facility met professional standards of quality for 1 of 18 residents (Residents #7) for professional standards. Residents Affected - Few The facility failed to follow physician orders and remove a Wander Guard from Resident #7 when it was discontinued 10/29/23. This failure could place residents at risk of unnecessary treatment and from maintaining their highest practicable quality of life. Findings include: Record review of Resident #7's undated care plan revealed she was a [AGE] year old female admitted [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (paralysis and weakness on the left side due to a stroke), abnormalities of gait and mobility, abnormal posture, fracture of shaft of left tibia (fracture of the left lower leg bone), muscle wasting and atrophy (muscles are shrinking due to non-use), lack of coordination, cognitive communication deficit (difficulty with thinking or how someone uses language), unspecified psychosis (had a psychotic episode), Bipolar disorder (mental disorder causing shifts in mood, energy, and concentration), generalized anxiety disorder (working constantly and uncontrolled worrying), adjustment disorder with mixed anxiety and depressed mood (worrying constantly without control), and repeated falls. Record review of Resident #7's annual MDS assessment, dated 8/24/23 revealed she was positive for PASRR and the state level II PASRR due to a serious mental illness. She had a BIMS score of 3 out of 15, which indicated severely impaired cognition. According to the MDS the resident required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene, and required 1 to 2+ persons physical assist. She was totally dependent for bathing and required 1-person physical assist. Resident #7 had impairment on one side of her upper extremities, and impairment on one side of her lower extremities. She used a wheelchair for mobility. The MDS revealed the resident had a wander/elopement alarm that was used daily. Record review of Resident #7's care plan, dated 11/2/23, revealed a focus: Elopement risk/wanderer AEB history of attempts to leave facility unattended, impaired safety awareness, initiated 7/15/21. Goal: Will not leave facility unattended through the review date. Safety will be maintained through the review date, initiated 7/15/21, target date 11/28/23. Interventions: Assess elopement risk, check for wander guard proper functioning daily. Check for wander guard placement every shift. Replace wander guard upon expirations/not working properly. Wander alert/alarm. Initiated 7/15/21. Record review of Resident #7's medical record revealed an Elopement Risk Assessment completed on 8/28/23 at 3:08pm, by LVN B. According to the assessment the resident had a history of leaving the facility without supervision and without informing staff. Resident #7 was at risk for elopement/wandering according to the assessment and a Wander Guard was in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 8 of 28 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 11/16/2023 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 0658 Record review of Resident #7's physician orders revealed the following orders from MD A: Level of Harm - Minimal harm or potential for actual harm Wander Guard: Replace Wander Guard PRN upon expiration/not working properly, as needed and Residents Affected - Few every shift. Ordered on 8/8/23 at 2:14pm and discontinued 10/29/23 at 1:19pm. Wander Guard: Check for proper placement Q shift, Right Ankle, every shift. Ordered 8/8/23 at 2:13pm and discontinued 10/29/23 at 1:19pm. In an observation and interview on 11/15/23 at 9:15am Nurse Aide A and Nurse Aide D transferred Resident #7 from her bed to a Geri chair, using a Hoyer lift. Observed resident had a Wander Guard on her right ankle. Nurse Aide D confirmed it was a Wander Guard on the Resident's ankle. In an observation on 11/16/23 at 9:37am Resident #7 was asleep in the Geri chair in the dining room. She had the Wander Guard present on her right ankle. In an interview on 11/16/23 at 9:45am with the DON she said the order had been discontinued for Resident #7 because she went to the hospital for a fracture, and it was forgotten to be added back on. She said the nurse who admitted the resident and entered the orders probably did not know she had a Wander Guard from before. The DON said even though she did not look like she moved around very much, it was only because she had just had a fracture. She said the resident normally tried to exit all the doors. Record review of the facility's policy and procedure on Medication Orders (Revised November 2014) read in part: .Supervision by a Physician: . 2. A current list of orders must be maintained in the clinical record of each resident. 3. Orders must be written and maintained in chronological order . 6. Treatment Orders When recording treatment orders, specify the treatment, frequency and duration of the treatment . Record review of the facility's policy and procedure on Charting and Documentation (Revised July 2017) read in part: Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care . 2. The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives . 7. Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment; d. How the resident tolerated the procedure/treatment; e. Whether the resident refused the procedure/treatment; f. Notification of family, physician or other staff, if indicated; and g. The signature and title of the individual documenting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 9 of 28 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 11/16/2023 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 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 2 (Residents #6 and #61) out of 18 residents reviewed for ADL care. Residents Affected - Few The facility staff failed to provide scheduled showers to Resident #6, and Resident #61. This failure could place residents who were unable to carry out ADLs independently, at risk of skin breakdown, pain, and infection. Findings include: 1. Record review of Resident #6's undated face sheet, revealed an [AGE] year-old female admitted on [DATE] with diagnoses of muscle wasting and atrophy (muscles are shrinking from non-use), type 2 diabetes (body does not make insulin or resists it), acute and chronic respiratory failure (lungs are not working and not getting enough oxygen), non-pressure chronic ulcer of back (wound on the back not caused by pressure), age related cognitive decline (decline of brain's normal functioning), and colostomy (opening in the colon through abdomen where bowel movements go into a pouch). Record review of Resident #6's entrance MDS assessment dated [DATE], revealed a BIMS score of 13 out of 15, which indicated normal cognition. According to Resident #6's daily preferences, it was very important for her to choose between a tub bath, shower, bed bath, or sponge bath. According to the MDS, the resident required extensive assistance with personal hygiene, toilet use, dressing, transfers, and bed mobility. She was totally dependent and required one-person physical assistance with bathing. Resident #6 had an indwelling catheter and a colostomy. She received continuous oxygen at 3 lpm via NC. Record review of Resident #6's care plan, dated 10/31/23, revealed a focus: Resident #6 had an ADL self-care performance deficit r/t weakness, confusion. Goal: Will be cleaned, well-groomed, appropriately dressed and weight maintained through next review date. Interventions: Resident #6 required extensive assistance from one staff member participation to use toilet. Required total assistance from one staff member participation with bathing. Wanted bed baths only. Required extensive assist from one staff member staff participation with personal hygiene and oral care. Required extensive assist from one staff member participation to dress. Record review of Resident #6's bathing documentation for November 2023 revealed she received a shower on Thursday 11/2/23, Saturday 11/4/23, Thursday 11/9/23, and Tuesday 11/14/23. According to the shower schedule, Resident #6 was scheduled to have a shower on Tuesday 11/7/23, and Saturday 11/11/23 which were documented that she did not receive a shower. On Tuesday 11/14/23 it was documented that a shower was given, but the resident stated she did not have a shower on that day. Record review of Resident #6's progress notes for November 2023 revealed no refusals of showers. In an interview and observation of Resident #6 on 11/12/23 at 1:09pm it was observed that she was sitting in a wheelchair next to the bed with continuous oxygen on via NC. Resident #6 had a purple (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 10 of 28 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 11/16/2023 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 - Few shirt on. Resident #6 revealed she was not getting baths/showers three times a week like she was supposed to. She stated she was only getting them one time a week. In an interview and observation of Resident #6 on 11/15/23 at 9:36am it was observed that she was sitting in a wheelchair next to the bed with continuous oxygen on via NC. Resident still had a purple shirt on. Resident #6 revealed she still had not received a shower and she did not get a shower on Tuesday 11/14/23, like she was supposed to. Her last shower was Saturday, 11/11/23. Per the resident, there was only 1 aide covering more than 1 hall and the aide told the resident she was too busy to give her a bath. 2. Record review of Resident #61's undated face sheet, revealed an [AGE] year-old female admitted on [DATE] with diagnoses of intracerebral hemorrhage (bleeding inside the brain), pseudobulbar affect (sudden uncontrollable/inappropriate laughing or crying), cognitive communication deficit (difficulty with thinking or how someone uses language), physical debility, transient cerebral attack (mini stroke), flaccid hemiplegia affecting left nondominant side (paralysis of left side), rheumatoid arthritis (autoimmune disorder that attacks joints), difficulty in walking, and abnormalities of gait and mobility. Record review of Resident #61's annual MDS, dated [DATE], revealed a BIMS score of 9 out of 15, which indicated moderately impaired cognition. According to Resident #61's daily preferences, it was very important to choose between a tub bath, shower, bed bath, or sponge bath. According to the MDS, the resident used a wheelchair and was dependent for showers/baths. Also, the MDS revealed the resident was always incontinent of bowel and bladder. Record review of Resident #61's care plan, dated 10/28/23, revealed a focus: Resident #61 had an ADL self-care performance deficit r/t CVA (stroke), weakness. Goal: Will improve current level of function in bed mobility, transfers, eating, dressing, toilet use, and personal hygiene through the review date. Interventions: Resident #61 required total assistance from one staff member's participation with bathing. Resident #61 required partial/moderate assist from one staff member's participation to use toilet. Resident #61 required assistance from staff members participation to dress. Record review of Resident #61's bathing documentation for November 2023 revealed she received a shower on Wednesday 11/1/23, Friday 11/3/23, and Friday 11/10/23. Resident #61 was scheduled to receive a shower on Monday 11/6/23, Wednesday 11/8/23, and Monday 11/13/23, which were documented that she did not receive a shower. Record review of Resident #61's progress notes for November 2023 revealed no refusals of showers. In an observation and interview on 11/12/23 at 1:46pm, Resident #61 was sitting in her wheelchair in her room with a family member and another resident. The resident said she was not getting showers 3 x week like she was supposed to be and did not get changed regularly. She also said the facility was always out of wipes and diapers. Resident #61 was supposed to get showers MWF on the 2p-10p shift. The resident stated she would go into the bathroom and try to wipe her underarms and her face when she did not get a shower, so she could feel a little clean. In an observation and interview on 11/15/23 at 9:45am Resident #61 was in her wheelchair and was going into the bathroom to brush her teeth. She said the 2p-10p shift was the worst at giving showers. She said she did not remember when her last shower was, but she knew she was not getting them 3 x week. She stated residents brought it up at Resident Counsel, but nothing was ever done about it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 11 of 28 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 11/16/2023 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 - Few Record review of facility Grievances from August 2023 through November 2023 revealed numerous complaints from residents about not receiving showers. In an interview with Nurse Aide A on 11/15/23 at 9:00am it was revealed showers were given to the even room numbers on MWF and showers were given to odd room numbers on TTS. She said the 2-10p shift gave showers to the residents by the window and the 6a-2p shift gave showers to the residents by the door. In an interview on 11/15/23 at 1:01pm with LVN A, it was revealed she covered the 300/400 halls. She said showers were Monday through Saturday. She said residents in even rooms got their showers MWF, the 6a-2p shift would give the residents on the door side, and the 2p-10p shift would give the window side. She said residents in odd rooms received their baths on TTS, following the same pattern of door side residents being bathed in the morning, and window side in the afternoon/evening shift. She said the aides did the bathing and they bathed the residents first, and then documented the task had been completed. She said she was not aware of showers not being given, or of any residents that refused. She said if a resident refused, the nurse would try to talk to the resident to see if she could get them to understand the importance of it. If the resident continued to refuse, the nurse would document the refusal and call the RP to notify them. In an interview on 11/15/23 at 1:20pm with Nurse Aide A it was revealed she worked rooms 301-308. She said she had been at the facility for 1 year. She said that her roles included providing care, feeding, showering, making sure call lights were in place, and preventing falls. She said she felt that she had enough help to complete all tasks expected of her. She said the shower schedule was as follows- MWF even door residents got showers on the 6a-2p shift, window residents would get showers on the 2p-10p shift. She said on TTS, residents in odd rooms got their baths/showers, with door side residents from 6a-2pm and window residents from 2p-10p. She said, there was not an issue with getting to all the showers lately, and if she did not have enough time to bathe all her residents, she would ask aides on other halls to help. She said if a resident refused a shower, she would report it to the nurse and offer a bed bath. She said if a resident requested a shower on their unassigned day, she would provide the shower per resident request. In an interview with Nurse Aide C on 11/15/23 at 1:27pm it was revealed she worked on the 100 hall and had been at the facility for about 6 years on and off. Her responsibilities were to assist with ADLs, bathing, feeding, nail care, ROM, and to provide compassionate care- which she felt was the most important thing. She said the first thing she did every day was mouth care. Also, every day she provided a bath to her residents even if it was not their scheduled shower day. She said she applied lotion, did their hair, and made sure to take the residents, who were able to, to the restroom. She said that she also repositioned tube feeders. She said if a resident refused care at the time, she would go get the nurse. However, she said they must know how to talk to people and try to persuade them. She said they must be kind, have a heart, be compassionate, have care and concern, and make them feel comfortable. Nurse Aide C said even though she was assigned to the 100 hall, it was their job to take care of all the residents and to work as a team. So, if she needed to help someone in another hall, she would because that was a part of her job as well. Nurse Aide C never assisted with Resident #6 or Resident #61's ADLs. In an interview with the DON on 11/15/23 at 3:46pm she revealed it was never acceptable to falsify documentation because it was unethical. The DON said Administration ensured accurate documentation by reading the 24-hour report for inaccuracies and verifying the information, or if residents brought something to their attention, they would file a grievance and follow up. She said if a resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 12 of 28 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 11/16/2023 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 - Few said they did not get a shower, but documentation said that they did, she would check the linens, check with the nurse, check the resident BIMS, check with other nurses on the hall, see what the resident was wearing, and check the resident's skin. The DON said skin breakdown and infections could occur if residents did not get showers. She said a few months back there was an issue with resident's not getting showers, but she did not know of any problems now. The process was for CNAs to report to the nurses that they had given resident's showers, and if the resident refused, they notified the nurse and documented it. The DON also said they had Angel rounds, which were done by department heads to verify residents were getting their showers, and the administrator kept a record of it. She did not know there was a problem with showers and did not know why the Aides were not showering the residents. Record review of the facility's policy and procedure on Shower/Tub Bath (Revised October 2010) read in part: Documentation: The following information should be recorded on the resident's ADL record and/or in the resident's medical record: 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath .5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data. Reporting: 1. Notify the supervisor if the resident refuses the shower/tub bath . Record review of the facility's Certified Nursing Assistant Job Description (2003) read in part: Purpose of Your Job Position: The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan, and as may be directed by your supervisors .Duties and Responsibilities-Personal Nursing Care Functions: .Assist residents with bath functions (i.e., bed bath, tub, or shower bath, etc.) as directed .Assist residents with dressing/undressing as necessary. Assist residents with hair care functions (i.e., combing, brushing, shampooing, etc.). Assist residents with nail care (i.e., clipping, trimming, and cleaning the finger/toenails). (Note: Does not include diabetic residents.) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 13 of 28 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 11/16/2023 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 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** Based on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the residents' choices for 1 of 18 residents (Resident #2) reviewed for quality of care. Residents Affected - Few The facility failed to ensure nursing performed thorough skin assessments on Resident #2. The facility failed to ensure nurse aides communicated Resident #2's skin tear to nursing staff for at least 2 weeks. These failures could place residents at risk for skin breakdown, infection, and hospitalizations. Findings include: Record review of Resident #2's undated face sheet revealed she was an [AGE] year-old female admitted on [DATE] with diagnoses of unspecified dementia, muscle weakness, lack of coordination, anxiety disorder (excessive worry), dysphagia (trouble swallowing), cognitive communication deficit (difficulty with thinking or how someone uses language), type 2 diabetes (body does not produce insulin or is resistant to it), and history of falling. Record review of Resident #2's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 3 out of 15 which indicated severely impaired cognition. The resident required extensive assistance with bed mobility and 2+ person physical assist. She also required extensive assistance with dressing and 1-person physical assist. She was totally dependent for bathing and required 1-person physical assist. Resident #2 used a wheelchair for mobility. According to the MDS, the resident was always incontinent of bowel and bladder. The MDS revealed Resident #2 had no pressure ulcers or any skin issues, including skin tears. Record review of Resident #2's Quarterly MDS dated [DATE] revealed no skin issues, including skin tears. Record review of Resident #2's Care Plan dated 11/1/23, revealed a Focus: Resident #2 has bowel and bladder incontinence which places her at risk for skin breakdown. Goal: Will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: Brief Use- The resident uses disposable briefs, change PRN. Incontinent- Check the resident during rounds and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. Focus: Resident #2 has an ADL self-care performance deficit r/t dementia, limited mobility. Goal: Will maintain current level of function in bed mobility, transfers, toilet use, and personal hygiene through the review date. Interventions: Resident #2 requires limited assist from one staff member participation to use toilet. Resident #2 requires limited assist from one/two staff members participation with transfers. Resident #2 requires extensive assist from two staff members participation to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 14 of 28 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 11/16/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reposition and turn in bed. Focus: Resident #2 has the potential for pressure ulcer development r/t decreased mobility and incontinence. Goal: Will have intact skin, free of redness, blisters, or discoloration by/through review date. Interventions: Check for incontinence during rounds, provide care as needed. Keep skin clean and dry. Notify nurse immediately of any signs of skin breakdown; redness, blisters, bruises, and discoloration noted during bath or daily care. Turn and reposition during rounds. Weekly head to toe skin assessments by RN/LVN. Record review of Resident #2's Skin Assessment's dated 11/2/23 and 11/9/23 revealed no bruises, no redness, and the skin was intact. The skin assessment from 11/15/23 revealed no bruises. The assessment reflected redness to bilateral breasts and sacrum, and the skin was intact. Record review of Resident #2's wound care notes revealed a note by MD B on 11/15/23 at 11:13am stating non-pressure wound sacrum full thickness. The cause of the wound was from trauma/injury and the size was 1cm x 0.5cm x 0.1cm. MD B ordered house barrier cream once a day for 30 days and then cover with gauze island dressing with border to be changed once a day. Record review of Resident #2's progress notes revealed a note by RN B on 11/15/23 at 11:50pm regarding a sacrum non-pressure wound, and to cleanse the sacrum every shift and apply zinc oxide for barrier. Record review of Resident #2's Physician Orders revealed an order for Pain Code Intervention for the sacrum (triangular bone between hipbones and pelvis) non-pressure wound, every shift. Cleanse sacrum and apply zinc oxide for barrier and every 8 hours PRN. Ordered on 11/15/23 at 3:15pm by MD A. Record review of Resident #2's November 2023 MAR revealed documentation on 11/15/23 for the hours of 10pm-6am and 11/16/23 for the hours of 6am-2pm, under Pain Code Intervention for the sacrum non-pressure wound, every shift. Cleanse sacrum and apply zinc oxide for barrier and every 8 hours PRN. In an interview with Nurse Aide A on 11/15/23 at 9:00am, she revealed she worked the front part of the hall that Resident #2 stayed on. She said the staff checked residents every 2hrs to see if they needed to be changed. If the residents were in the lobby or somewhere else, they would bring them back to their room or take them to the shower room and checked them to see if they needed to be changed. In an interview and observation with Resident #2 on 11/15/23 at 9:30am, the resident stated she had a skin tear on her buttock. She said she got it from the aides being too rough with her when they take her diapers off, but she was unsure of how long it had been there or when it exactly happened. Resident #2 said the aides pull the diapers off in a hurry and it ripped her skin. She said she had been asking for some kind of cream to help with it, but she had not received anything. She also said it burned. In an interview observation with Nurse Aide E on 11/15/23 at 9:40am, she provided incontinence care on Resident #2. When she turned the resident to her left side, the Surveyor observed a skin tear at the top of her gluteal fold/sacrum area. The skin tear was observed to be red, about 1 inch in length, about ¼ inch wide, and was right at the tailbone. Nurse Aide E stated she knew it was there and said it had been there for more than 2 weeks. She did not say if she had told anyone. In an interview with LVN D who was the wound care nurse, on 11/16/23 at 9:21am, she stated she performed the skin assessments weekly on the residents who already had wounds, the admissions, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 15 of 28 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 11/16/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few readmissions. She said the nurses would inform her if they found wounds on any of the other resident's and then she would follow up and perform her own assessment and add them to her wound care list. LVN D said she had no knowledge of a wound on Resident #2. In an interview with LVN C on 11/16/23 at 9:28am, she revealed head to toe assessments were to be performed by the nurse every shift and were supposed to be a thorough assessment. She said if something was found on the assessment, the MD and DON were to be notified and then it was supposed to be documented on the Skin Assessment sheet and on the progress note. She said if a Nursing Aide found something on a resident, they were supposed to tell the nurse and then the nurse completed a thorough head to toe assessment to confirm. In an interview with LVN E on 11/16/23 at 9:32am it was revealed she was Resident #2's nurse for the day. She stated the EMR system they used, triggered the skin assessment task to pop up and would let the nurse know to perform the assessment, and it was done weekly. She also said when the CNAs performed showers and saw something wrong with the resident's skin, they were supposed to inform the nurse. The nurse would then go assess the resident while they were in the shower. LVN E also stated the nurse should perform a head-to-toe assessment on her residents every shift. LVN E stated she had already performed an assessment on Resident #2 for the day. LVN E stated she did not see a skin tear on Resident #2's sacrum. She said she saw redness under her breasts, but that was the only skin issue she saw. In an interview with the ADON on 11/16/23 at 3:50pm she stated the Nurse Aides were expected to report any DTIs, pressure wounds, or skin tears to the nurse. She said the nurse would then follow up with the resident to assess the skin problem. She said if there was a skin issue, the nurse informed the MD and the Treatment Nurse (Wound Care Nurse). The ADON was informed during incontinent care with Nurse Aide E and Resident #2, a skin tear was found in the gluteal folds/sacrum. She was also informed that Nurse Aide E said it had been there for over 2 weeks, but she had not reported it to anyone, and the skin tear was not documented anywhere in the skin assessments. The ADON said Nurse Aide E should have known to report it to the nurse, and she would in-service her. The ADON said when the nurse performed the head-to-toe assessments it was supposed to be done thoroughly, and the nurse was supposed to look well in the cracks/crevices of the resident to ensure they did not miss anything. The ADON was informed the skin tear was not documented on the skin assessments for Resident #2 and LVN E said she did not see anything on the resident when she performed the skin assessment that day (11/16/23). Record review of the facility's undated, Nursing Skills Checklist revealed an area .20. ASSESSMENTS: Integumentary- Lesion Identification: Stage I, Stage II, Stage III, Stage IV, SDTI, Turgor, Color, Sensitivity, Skin Assessment, Wound Tx and Progress Note . Record review of the facility's Certified Nursing Assistant Job Position (Revised 2003) read in part: .Purpose of Your Job Position: The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan, and as may be directed by your supervisors .Report all changes in the resident's condition to the Nurse Supervisor/Charge Nurse as soon as practical. Report all accidents and incidents you observe on the shift that they occur .Report all complaints and grievances made by the resident .Assist residents with bath functions (i.e., bedbath, tub or shower bath, etc.) as directed .Observe and report the presence of pressure areas and skin breakdown to prevent decubitus ulcers (bedsores). Report injuries of an unknown source, including skin tears . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 16 of 28 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 11/16/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the facility's policy and procedure on Charting and Documentation (Revised July 2017) read in part: Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .2. The following information is to be documented in the resident medical record: a. Objective observations .d. Changes in the resident's condition e. Events, incidents or accidents involving the resident .3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate . Record review of the facility's policy and procedure on Pressure Ulcer Risk Assessment (Revised March 2005) read in part: .Purpose: The purpose of this procedure is to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers .1. Risk Assessment: A pressure ulcer risk assessment will be completed upon admission, with each additional assessment; quarterly, annually and with significant changes. 2. Skin Assessment: Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. 3. Monitoring: a. Staff will maintain a skin alert, performing routine skin inspections daily or every other day as needed. b. Nurses are to be notified to inspect the skin if skin changes are identified. c. Nurses will conduct skin assessments at least weekly to identify changes . Documentation: .5. Any change in the resident's condition. 6. The condition of the resident's skin (i.e., the size and location of any red or tender areas.) . Record review of the facility's policy and procedure on Shower/Tub Bath (Revised October 2010) read in part: Purpose: The purposes of this procedure are to promote cleanliness . and to observe the condition of the resident's skin .General Guidelines: .5. Observe the resident's skin for any redness, rashes, broken skin, tender places, irritation, reddish or blue-gray area of skin over a pressure point, blisters, or skin breakdown .Steps in the Procedure: .20. Dry the resident from the head to the waist before assisting him or her from the tub or shower. (Note: Observe skin for any rashes, reddened areas, skin discoloration, etc.) . Documentation: . 3. All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath .Reporting: . 2. Notify the physician of any skin areas that may need to be treated . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 17 of 28 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 11/16/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 14.29%, based on 5 errors out of 35 opportunities, which involved 1 of 7 residents (Resident #31), and 1 of 5 staff (LVN F) reviewed for pharmacy services. Residents Affected - Few The facility failed to ensure LVN F diluted crushed medications in water (Carvedilol 3.125mg, Docusate Sodium 100mg, Midodrine 5mg, and Renal-Vite 0.8mg), and instead poured the crushed medication directly into the G-tube syringe. The facility failed to ensure LVN F diluted Potassium Chloride liquid 20meq/15ml, with 3oz of water first, and instead poured the liquid straight into the G-tube syringe. These failures could place residents at risk for not receiving therapeutic effects of their prescribed medications, possible adverse reactions, and a clogged G-tube. Finding included: Record review of Resident #31's undated face sheet, revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses of end stage renal disease (kidneys do not work anymore), dysphagia (trouble swallowing), cerebrovascular disease (conditions that affect blood flow in the brain), contracture (shortening and hardening of muscles, tendons leading to deformity) of the right shoulder, right elbow, right knee, and left knee, type 2 diabetes (body does not produce insulin or resists it), dementia, seizures, hypertension (high blood pressure), hyperlipidemia (high cholesterol), gastrostomy (tube that goes into the stomach to receive nutrition from), aphasia following cerebral infarction (trouble talking after a stroke), hemiplegia and hemiparesis affecting right dominant side (paralysis and weakness on the right side), and dependence on renal dialysis (on dialysis). Record review of Resident #31's quarterly MDS assessment dated [DATE], revealed a BIMS score of 3 out of 15, which indicated severely impaired cognition. It also revealed he had unclear speech, could sometimes be understood, could sometimes understand others, and had moderately impaired vision. According to the MDS Resident #31 required extensive assistance with personal hygiene, toilet use, eating, dressing, and bed mobility. He also required 1-person physical assist with those activities. The resident was totally dependent with bathing and required 1-person physical assist. He had impairment of his upper extremity on 1 side and impairment of his lower extremities on both sides. He had a wheelchair for mobility but was unable to get into it. According to the MDS, Resident #31 had a feeding tube for nutrition, and received hemodialysis. Record review of Resident #31's Care Plan dated 11/13/23, revealed a Focus: Resident #31 required (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 18 of 28 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 11/16/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tube feeding r/t dysphagia. Goal: Will remain free of side effects or complications related to tube feeding through review date. Will maintain adequate nutritional and hydration status AEB weight stable, no s/sx of malnutrition or dehydration through review date. Interventions: The resident is dependent on staff for tube feeding and water flushes. Provide local care to G-tube site as ordered and monitor for s/sx of infection. Monitor/document/report to MD PRN: tube dislodged, tube dysfunction or malfunction. Focus: Resident #31 has potential fluid deficit r/t NPO status and dependence on staff for all hydration via g-tube. Goal: Will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor. Interventions: Administer fluids via g-tube per physician's orders. Administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #31's Physician Orders revealed the following orders, ordered by MD A: Midodrine HCl Tablet 5mg, Give 1 tablet via G-tube QD every Mon, Wed, Fri for hypotension on dialysis days only to prevent hypotension. Ordered on 11/3/22 at 1:24pm. Renal-Vite Tablet 0.8mg, Give 1 tablet via G-tube QD for vitamin B supplement. Ordered on 11/3/22 at 1:24pm. Potassium Chloride Solution 20meq/15ml, Give 15ml via G-tube QD for potassium deficiency, dilute with 3oz of water prior to administration. Ordered 3/22/23 at 4:16pm. Docusate Sodium Oral Tablet 100mg, Give 1 tablet via G-tube BID for constipation. Ordered 10/8/23 at 9:46am. Carvedilol Tablet 3.125mg, Give 1 tablet via G-tube BID for HTN. Ordered 11/6/23 at 11:35am. In an observation with LVN F on 11/13/23 at 8:50am she was giving medications to Resident #31. LVN F crushed the medications for the resident, and each were kept separately. After disconnecting the resident from his feeding pump, a large syringe was attached to the resident's G-tube port. LVN F poured each crushed medication (Midodrine HCl Tablet 5mg, Renal-Vite Tablet 0.8mg, Docusate Sodium Oral Tablet 100mg, Carvedilol Tablet 3.125mg) into the syringe and then poured water into the syringe after each medication. LVN F was seen swirling the syringe around trying to get the medication and water to go down. Medication appeared to be settled at the bottom of the syringe and not going into the G-tube, which required LVN F to add more water to make it go down. LVN F also gave Potassium (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 19 of 28 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 11/16/2023 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 0759 Chloride liquid 20meq/15ml, straight into the syringe without diluting it first with 3oz of water, as directed. Level of Harm - Minimal harm or potential for actual harm In an interview and observation with LVN G on 11/13/23 at 3:40pm she crushed the G-tube medications and diluted each one separately with water before giving them through the syringe. She said she would never give crushed medications directly into the syringe without diluting them. She said she was always trained to dilute the medications with liquid, and they did not put the crushed medications directly into the syringe at that facility. She said if the crushed medications were put directly into the syringe, it could cause problems for the PEG tube; it could clog the tube and cause it not to work. Residents Affected - Few In an interview with LVN F on 11/14/23 at 1:25pm, she revealed she normally did not pour the crushed medication directly into the G-tube syringe like she did with Resident #31, and she diluted the medication in water first. She said she was nervous and that was why she did it that way. She said if she puts the crushed medications directly into the syringe it could clog the G-tube. LVN F also confirmed she did not dilute the Potassium Chloride liquid per Physicians orders. LVN F said Resident #31 did not have a clogged PEG tube and had not had any issues with his PEG tube that she was aware of. In an interview with the DON on 11/15/23 at 3:50pm she said the process for giving medications through a G-tube entailed crushing the medication and diluting it before giving it through the syringe. She also said each medication was kept separate when it was crushed, and they were given separately. She said it was acceptable to put the crushed medication directly into the syringe if it was followed with the appropriate amount of measured water. She stated she assessed the nurse's competency on G-tube medications by educating them and through random checks by unit managers. The DON also said the nurses received training with their preceptors before they were allowed to go on their own. The DON said if crushed medications were given directly into the syringe and not diluted, it could cause the G-tube to become clogged and not work. The DON also mentioned some liquid medications had to be diluted before being given. She stated Potassium Chloride was one of the medications that had to be diluted before it was given due to it being irritating to the GI tract. Record review of the facility's Administering Enteral Nutrition via Gastrostomy or Jejunostomy Tube Skills Checklist for LVN F, dated 10/23/23, did not have any performance skills on administering medications through a gastrostomy (tube into the stomach for nutrition) or jejunostomy (tube into a part of the intestine for nutrition). Record review of the facility's Administering Medications Through an Enteral Tube (Revised March 2015) read in part: Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube .2. Do not add medication directly to the enteral feeding formula. 3. Do not mix medications together prior to administering through an enteral tube. Administer each medication separately. 4. Do not crush or split medications for administration through an enteral tube unless first checking with the pharmacy or facility approved Do Note Crush Medication List .5. Do not administer oily medications through an enteral tube. 6. Dilute medications and flush the tube with room temperature tap water .Steps in the Procedure: .9. Prepare the correct dose of medication: .b. Dilute powdered, crushed, or split (capsule) medications at the bedside .23. Dilute the crushed or split medication with 15-30ml room temperature tap water (or prescribed amount) .25. Administer medication by gravity flow. a. Pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion. b. Open the clamp and deliver medication slowly .26. If administering more than one medication, flush with 15ml (or prescribed amount) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 20 of 28 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 11/16/2023 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 0759 room temperature tap water between medications . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 21 of 28 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 11/16/2023 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure residents were free from any significant medication errors for 1 of 18 (Resident #31) residents reviewed for pharmacy services. Residents Affected - Few - The facility failed to dilute Resident #31's G-tube medication (Carvedilol 3.125mg), which lowers BP, before administering it into the syringe. This failure could place the resident at risk of not receiving the intended dosage, causing high BP, a clogged G-tube, and potential hospitalization. Findings included: Record review of Resident #31's undated face sheet, revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses of end stage renal disease (kidneys do not work anymore), dysphagia (trouble swallowing), cerebrovascular disease (conditions that affect blood flow in the brain), contracture (shortening and hardening of muscles, tendons leading to deformity) of the right shoulder, right elbow, right knee, and left knee, type 2 diabetes (body does not produce insulin or resists it), dementia, seizures, hypertension (high blood pressure), hyperlipidemia (high cholesterol), gastrostomy (tube that goes into the stomach to receive nutrition from), aphasia following cerebral infarction (trouble talking after a stroke), hemiplegia and hemiparesis affecting right dominant side (paralysis and weakness on the right side), and dependence on renal dialysis (on dialysis). Record review of Resident #31's quarterly MDS dated [DATE], revealed a BIMS score of 3 out of 15, which indicated severely impaired cognition. It also revealed he had unclear speech, could sometimes be understood, could sometimes understand others, and had moderately impaired vision. According to the MDS Resident #31 required extensive assistance with personal hygiene, toilet use, eating, dressing, and bed mobility. He also required 1-person physical assist with those activities. The resident was totally dependent with bathing and required 1-person physical assist. He had impairment of his upper extremity on 1 side and impairment of his lower extremities on both sides. He had a wheelchair for mobility but was unable to get into it. According to the MDS, Resident #31 had a feeding tube for nutrition, and received hemodialysis. Record review of Resident #31's Care Plan dated 11/13/23, revealed a Focus: Resident #31 required tube feeding r/t dysphagia. Goal: Will remain free of side effects or complications related to tube feeding through review date. Will maintain adequate nutritional and hydration status AEB weight stable, no s/sx of malnutrition or dehydration through review date. Interventions: The resident is dependent on staff for tube feeding and water flushes. Provide local care to G-tube site as ordered and monitor for s/sx of infection. Monitor/document/report to MD PRN: tube dislodged, tube dysfunction or malfunction. Focus: Resident #31 has potential fluid deficit r/t NPO status and dependence on staff for all hydration via g-tube. Goal: Will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor. Interventions: Administer fluids via g-tube per physician's orders. Administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #31's Physician Orders revealed the following order, ordered by MD A: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 22 of 28 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 11/16/2023 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 0760 Carvedilol Tablet 3.125mg. Give 1 tablet via G-tube BID for HTN, Hold if SBP < 110 or HR < 60. Level of Harm - Minimal harm or potential for actual harm Ordered 11/6/23 at 11:35am. Residents Affected - Few In an observation with LVN F on 11/13/23 at 8:50am she was giving medications to Resident #31. LVN F crushed the medications for the resident, and each were kept separately. After disconnecting the resident from his feeding pump, a large syringe was attached to the resident's G-tube port. LVN F poured the crushed medication, Carvedilol Tablet 3.125mg, into the syringe and then poured water into the syringe after the medication. LVN F was seen swirling the syringe around trying to get the medication and water to go down. Medication appeared to be settled at the bottom of the syringe and not going into the G-tube which required LVN F to add more water to make it go down. In an interview and observation with LVN G on 11/13/23 at 3:40pm she crushed G-tube medications and diluted each one separately with water before giving them through the syringe. She said she would never give crushed medications directly into the syringe without diluting them. She said she was always trained to dilute the medications with liquid, and they did not put the crushed medications directly into the syringe at that facility. She said if the crushed medications were put directly into the syringe, it could cause problems for the PEG tube; it could clog the tube and cause it not to work. In an interview with LVN F on 11/14/23 at 1:25pm, she revealed she normally did not pour the crushed medication directly into the G-tube syringe like she did with Resident #31, and she usually diluted the medication in water first. She said she was nervous and that was why she did not dilute it. She said she could clog the G-tube by putting the crushed medications directly into the syringe. In an interview with the DON on 11/15/23 at 3:50pm she said the process for giving medications through a G-tube was crushing the medication and diluting it in water before giving it through the syringe. She also said each medication was kept separate when it was crushed, and they were given separately. She said it was acceptable to put the crushed medication directly into the syringe if it was followed with the appropriate amount of measured water. She stated she assessed the nurse's competency on G-tube medications by educating them and through random checks by unit managers. The DON also said the nurses received training with their preceptors before they were allowed to go on their own. The DON said if crushed medications were given directly into the syringe and not diluted, it could cause the G-tube to become clogged and not work. Record review of the facility's Administering Enteral Nutrition via Gastrostomy or Jejunostomy Tube Skills Checklist for LVN F, dated 10/23/23, did not have any performance skills on administering medications through a gastrostomy or jejunostomy. Record review of the facility's Administering Medications Through an Enteral Tube (Revised March 2015) read in part: Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube .2. Do not add medication directly to the enteral feeding formula. 3. Do not mix medications together prior to administering through an enteral tube. Administer each medication separately. 4. Do not crush or split medications for administration through an enteral tube unless first checking with the pharmacy or facility approved Do Note Crush Medication List .5. Do not administer oily medications through an enteral tube. 6. Dilute medications and flush the tube with room temperature tap water .Steps in the Procedure: .9. Prepare the correct dose of medication: .b. Dilute powdered, crushed, or split (capsule) medications at the bedside .23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 23 of 28 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 11/16/2023 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 0760 Level of Harm - Minimal harm or potential for actual harm Dilute the crushed or split medication with 15-30ml room temperature tap water (or prescribed amount) .25. Administer medication by gravity flow. a. Pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion. b. Open the clamp and deliver medication slowly .26. If administering more than one medication, flush with 15ml (or prescribed amount) room temperature tap water between medications . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 24 of 28 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 11/16/2023 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 8 residents reviewed (Resident #339) for infection control, in that: Residents Affected - Few The facility failed to ensure LVN F donned (put on) an isolation gown when she entered Resident #339's room who was on contact isolation for MRSA (Methicillin Resistant Staphylococcus Aureus Infection). This failure could place residents at risk of contracting a communicable disease. Findings included: Record review of Resident #339's face sheet revealed an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included MRSA (infections caused by specific bacteria that are resistant to commonly used antibiotics), sepsis (an infection of the blood stream), heart failure, hemiplegia (complete paralysis) and hemiparesis (partial weakness) following cerebral infarction (stroke) affecting left non-dominant side, acute respiratory failure with hypoxia (below-normal level of oxygen in your blood), bacteremia (presence of live bacteria in the bloodstream), gastrostomy status (a surgical procedure for inserting a tube through the abdomen wall and into the stomach), and acute kidney failure. Record review of Resident #339's admission MDS assessment dated [DATE] revealed a BIMS score of 0 out of 15 which indicated severe cognitive impairment. She was dependent on staff for ADL care. She was on isolation or quarantine for active infectious disease while a resident. Record review of Resident #339's care plan dated 11/3/23 revealed she had MRSA bacteremia. Interventions included: instruct family/visitors/caregivers to wear disposable gown and gloves during physical contact with resident. Discard in appropriate receptacle and wash hands before leaving room. Record review of Resident #339's physician orders revealed an order for: strict contact isolation for MRSA, order date 11/3/23. In an observation and interview on 11/15/23 at 9:25 a.m., Resident #339's door was open. LVN F was in the room standing near Resident #339 with no gown on. After handling the resident's equipment at the resident's bedside, LVN F walked toward the doorway and said she would put a gown on at that time. There were signs on the door that read in part, .Report to nurse before entering, stop . Contact precautions in addition to standard precautions . before care: 3. wear gown to enter the room, discard gowns in the room. Do not reuse . There was an isolation cart next to the doorway that contained gowns. LVN F said Resident #339 was on contact isolation for MRSA and said she should have put a gown on before entering the room to prevent transmission of the infection. She said she did not put a gown on because she heard the resident's feeding machine beeping, and she just ran in to check it. She said while in the room she had to touch the resident's machine. She said she received contact isolation training during orientation and training from the Administrator and ADON. In an interview on 11/15/23 at 3:17 p.m., the ADON said nursing staff could refer to the signage on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 25 of 28 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 11/16/2023 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 outside of the resident's door. She said staff should don PPE before entering the room. She said if a resident had MRSA, staff should put on a gown, gloves, and mask in the room. She said it was important to wear PPE to prevent the spread of infection and to protect themselves. She said she provided in-services to staff on donning and doffing PPE. In an interview on 11/15/23 at 3:53 p.m., the DON said staff should put on a gown and gloves for contact isolation to protect themselves from the resident. She said it would be a problem if the gown was not put on because the staff would not be following protocols. She said the Infection Preventionist/ADON conducted random monthly checks on donning and doffing PPE. She said notifications were available on the doorway to instruct what type of isolation and PPE should have been used. Record review of the facility's Infection Prevention and Control Program policy dated August 2016 read in part, .The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. 2. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety . 7. Prevention of infection a. important facets of infection prevention include . 6. Implementing appropriate isolation precautions when necessary . Record review of the facility's Isolation - Categories of Transmission-Based Precaution policy dated January 2012 read in part, .1 Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others .Contact Precautions .2. Examples of infections requiring contact precautions include but are not limited to: . a. infections with multi-drug resistant organisms . 5. Gown a. wear a disposable gown upon entering the contact precautions room or cubicle. B. After removing the gown, do not allow clothing to contact potentially contaminated environmental surfaces . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 26 of 28 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 11/16/2023 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 5 (Resident rooms 303D, 403D, 306W, 301D, 301W) out of 18 resident rooms reviewed for physical environment. Residents Affected - Some The facility failed to ensure call lights were properly functioning for resident rooms 303D, 403D, 306W, 301D, 301W. This failure could place residents at risk of falls and/or injuries if they are unable to get staff assistance when needed. Findings include: In an observation on 11/12/23 at 12:15pm, the call light did not light up on the outside of the door for room [ROOM NUMBER]D. In an observation on 11/14/23 at 10:29am, the call light would light up on the wall when the button was pushed, but it did not light up on the outside of the room for room [ROOM NUMBER]D. In an observation on 11/14/23 at 10:32am, the call light did not work on the wall or outside the room when the button was pushed for room [ROOM NUMBER]W. In an observation on 11/14/23 at 10:35am, the call light did not work on the wall or outside the room when pushed for room [ROOM NUMBER]D. In an observation on 11/14/23 at 10:35am, the call light did not work on the wall or outside the room of 301D. It was also observed the call light did not light up outside the room for 301W. In an interview on 11/15/23 at 9:00am with Nurse Aide A, it was revealed she was not aware that 301D's call light was not working. She said that the call light used to stay on, so they put a work order in recently. Nurse Aide A stated she was unaware of a protocol for checking call lights to ensure they were working. However, she said maintenance checked the call lights every so often to make sure they were working. In an observation on 11/15/23 at 9:12am, the call light was not working on the outside of the door for room [ROOM NUMBER]D. In an observation on 11/15/23 at 9:36am, the call light was not working on the wall or outside of room [ROOM NUMBER]D. In an interview with Nurse Aide B on 11/15/23 at 9:41am, it was revealed she did not know the call light was not working in room [ROOM NUMBER]D. Nurse Aide B went in the room and pushed the call light and saw that it was not working and went and informed the nurse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 27 of 28 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 11/16/2023 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview with the Maintenance Director on 11/15/23 at 10:10am, it was revealed he randomly checked the call lights every morning and each department head was assigned certain rooms to check every morning, to ensure the call lights were working. He said if a call light was not working the staff reported it in a system the facility used, which went directly to his phone. If a call light was not working the facility gave the resident a bell to use. He printed a report monthly also that gave information about what was reported. Per the Maintenance Director, if a resident did not have a working call light, they would not be able to reach a CNA/nurse, and it was important the resident be able to reach someone in case of an emergency. He said the department heads must have not been checking the call lights when they did their rounds. He also said the call light needs to be within reach and he checked placement when he went in the room. He stated no reports of broken call lights had been reported to him, before today (11/15/23). He said he had already fixed rooms 301D, 301W, 303D, and 403D call lights. In an interview with the Administrator on 11/15/23 at 11:20am, it was revealed the facility was performing 30-minute checks on the residents to ensure all resident's needs were met, while maintenance checked all the call lights. The Administrator revealed if the call lights were not working the residents would not be able to call in an emergency and it could be dangerous for the residents. In an observation on 11/16/23 at 3:30pm the call lights in rooms 301D, 301W, 303D, 403D, and 306W were working on the wall and outside of the room when pushed. Record review of the facility's undated, policy and procedure regarding Emergency Call Light System Back Up Plan read in part: If any problems or function of the call light systems interrupts its proper function the facility staff will retrieve a call bell from the CENTRAL SUPPLY located in the emergency facility system box and place in the resident room or bathroom effected. If a facility wide call light system malfunction is to occur the facility will implement 15-minute resident and bathroom room checks for all resident rooms and bathrooms in the facility. These 15-minute room checks will be documented by room number, time, and staff member. Record review of the facility's policy and procedure on Answering the Call Light (Revised October 2010) read in part: The purpose of this procedure is to respond to the resident's requests and needs. General Guidelines: .4. Be sure that the call light is plugged in at all times .6. Some residents many not be able to use their call light. Be sure you check these residents frequently. 7. Report all defective call lights to the nurse supervisor promptly . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 28 of 28