Health inspection·February 14, 2025

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of CR #1's care plan, last review date completed 09/20/24, revealed the resident had altered cardiovascular status r/t atrial fibrillation, a communication problem r/t hearing deficit, and an ADL self-care performance deficit r/t weakness. Record review of CR #1's progress notes written by Nurse B, dated 10/02/24 at 12:37 p.m., revealed a reported change in condition of Stroke/CVA/TIA/new neurological signs and Other change in condition. Mental status noted altered level of consciousness (hyperalert, drowsy but easily aroused. Functional status noted swallowing difficulty. Neurological status evaluation noted Altered level of consciousness (hyperalert, drowsy but easily aroused. Further review read in part .Nursing observations, evaluation, and recommendations are: Resident sudden onset of mental status, neuro deficits. Resident is usually alert and aggressive from time to time with an adequate appetite. Usually responds with words or nodding of the head .Primary Care Provider responded with the following feedback: A. Recommendations: Send to ER for further evaluation and treatment of neurological Granchanges [sic] .Blood pressure, pulse, respiration rate, pulse oximetry, and blood glucose were taken. No additional vital signs were noted after this time. Record review of CR #1's progress notes, dated 10/02/24 at 17:09 p.m. (4:09 p.m.), read in part .Resident was picked up by transfer service to be taken to [hospital]. Record review of CR #1's hospital records, dated 10/02/24, read in part .clinically suspect patient had a CVA .The patient presents with an illness or injury that acutely impaired one or more vital organ systems. There was a high probability of imminent or life threatening deterioration in the patient's condition during their evaluation in the ED .MRI brain wo IV contrast, result date 10/03/24 .impression small acute nonhemorrhagic (not causing or associated) bilateral (two-sided) cerebral hemispheric (symmetrical halves of the cerebrum (largest part of the brain) and cerebral infarcts (ischemic stroke), the distribution of which suggests embolic etiology (cause of an embolic stoke) . Record review of CR #1's hospital Discharge summary, dated [DATE], read in part .presented with AMS and found to have acute CVA .pt passed at 16:06 (4:06 p.m.) . During an interview on 01/24/25 at 10:38 a.m., Nurse B said anytime there was an order to send the resident out to the hospital the doctor would let the facility know if they needed to be sent out regular transport or 911. She said due to the resident's dementia, she was not very verbal, but she could communicate in her own way. She said on 10/02/24 CNA B noticed resident CR #1 was not really wanting to eat and drink and would pocket food in her mouth. She said her vital signs remained perfect, stable. She said she would squeeze her hands. She said she had altered mental status and had to have her food taken out of her mouth. She said resident CR #1 gripped both of her hands, followed her fingers, and pupils were normal, it was more that she was nonverbal and pocketing her food. She said the change in condition occurred approximately between 12:00 p.m. and 1:00 p.m. She said the NP gave the order for the resident to be sent out via regular transport. She said she called the transportation company at approximately 1 p.m. She said the transport company told her it would be 1 ½ to 2 hours when the resident would be picked up. She said she notified NP, and she said it was okay. She said come end of her shift, 2:00 p.m., she gave a report to the oncoming nurse, Nurse C, and told her about the situation and that if the transportation company did not show up by 3:00 p.m. to follow-up with them and the NP. She said she did not suspect resident was having a stroke and on the change in condition form she marked stroke/CVA/TIA/new neurological signs and other change in condition and listed altered mental status. She said she was just referring to the altered mental status. She said she remembered asking the ADON about what she should mark because she felt the resident was not having a stroke and she said the ADON said to select it and to note altered mental status. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 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 - Immediate jeopardy to resident health or safety said if there was a place to click neurological symptoms, she would have just clicked neurological symptoms. She said her shift ended at 2: 00 p.m. and she was not aware of what happened after she left. She said the only signs the resident presented with was altered mental status, non-verbal, and pocketing food. She said CR #1's baseline was that one could ask her yes and no questions and she would answer, she would jibber jabber (speech that is or appears to be nonsense) and would always drink water when offered. She said when she left work, resident CR #1 was still at the facility. Residents Affected - Some During an interview on 01/24/25 at 11:22 a.m., CNA B said CR #1 had dementia but would regularly greet her. She said on the morning of 10/02/24, CR #1 was kind of quiet but alert. She said the resident would look at her when she entered her room and then would look at the ceiling but would not speak. She said at breakfast she fed her, and she ate well. She said at lunch she was the same but not as alert. She said she would ask her if she was okay, but she would not speak and would only look at her and around the room. She said for lunch the resident would close her lips like she did not want to eat. She said the resident opened up her mouth and she fed her a spoonful of food. She said she thought she was chewing her food, but she was pocketing her food. She said she told the resident to swallow her food, but she would not. She said she massaged her cheeks and told her to swallow her food, but she spit it out. She said she told another CNA to tell Nurse B and Nurse B came in the room and took over. She said Nurse B checked her vitals and the resident followed her finger. She said the resident was still at the facility when her shift was over at 2:00 p.m. During an interview on 01/24/25 at 1:03 p.m., the DON said she remembered the staff came to her and asked her to look at CR #1. She said she did not know how she normally presented and when asked they told her that she was normally aggressive but recently had been declining as in not eating as much, not being aggressive, and was being treated for an UTI. She said she knew with UTI residents that their mental status could be altered. She said CR #1 was responding, would open her eyes, would follow her, so she told the Nurse B to call the doctor to see what recommendations they suggest. She said Nurse B made the call to the doctor. She said she does not remember if the NP saw the resident earlier that morning but thinks she may have. She said Nurse B told her it was okay to send the resident to the hospital. She said Nurse B did not specify if it was a non-emergent or emergent transport. She said she remembered everything was stable and vital signs were within normal limits. She said she looked at CR #1's chart and saw he was sent out at 5 p.m. She said she did not go back and check on the resident during the time period in between because it was her understanding CR #1 was being sent out to the hospital and she was not notified that the resident was still in the building. She said she is not included in shift reports from one nurse to the other. She said Nurse C never mentioned anything to her about the resident. She said she did not suspect resident was having a stroke. She said days prior to 10/02/24, she was not eating, or her normal self, and it was not a sudden change. She said they had already told the doctor that the resident was eating less. On 01/24/25 at 2:36 p.m., a telephone call made to CNA C, but call went unanswered. Left a voicemail requesting a return phone call. On 01/24/25 at 2:39 p.m., a text message was sent to CNA C requesting she call. During an interview on 01/24/25 at 3:19 p.m., NP said she did not recall the conversation on 10/02/24. She said per her notes, later in the day nurse sent CR #1 out due to acute altered mental status, was not responding to stimuli, was sent to ED. She said she also documented resident was a high risk for rehospitalization. She said she did not see the patient when she had her change in condition so she did not know if it should have been a regular or 911 transport. She said based on her professional opinion, patient not responding to stimuli or is weak, it is usually 911. She said she doubts (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Some CR #1 would have been a resident the facility would have sent out regular transport. She said she should have gone out 911 based on their documentation and hers. She said if she had been asked specifically, she would have said to send out 911. She said she did not receive any other follow-ups from the facility about transportation. During a follow-up interview on 01/24/25 at 5:04 p.m., DON she said she knows the transportation company would have done a set of vitals when they arrived. She said she does not know why it took them so long to arrive at the facility to pick the resident up. During a follow-up interview on 01/25/25 at 9:39 a.m., Nurse B said she told the NP she felt CR #1 was having altered mental status, was responding to stimuli, gave her vital signs which were all stable, when attempted to be fed she was holding food in her mouth, CNA encouraged chewing movements, but resident just spit the food out. She said when she would call out resident's name, she would not make any sounds or acknowledgements and would only look at the person who was speaking to her. She would turn her head look at her but did not make any noises. She was blinking when she looked at her. She said the NP said as long as CR #1's vital signs were normal they could use regular transport. She said she took the resident's vital signs approximately 2 additional times but did not document. During an interview on 01/25/25 at 10:09 a.m., EMS Representative said they received a call from the facility on 10/02/24 at 13:12:32 (1:12 p.m.) and picked up at 16:39:11 (4:39 p.m.). He said it was called in as ER altered mental status and vitals showed she was stable. Record review of the facility's Charge Nurse job description, dated 2023, read in part .The primary purpose of your job position is to provide direct nursing care to the residents .to ensure that the highest degree of quality care is maintained at all times . Record review of the facility's Change in a Resident's Condition or Status policy, revised 2016, did not include sending a resident 911 versus regular transport. The Administrator was notified on 01/24/25 at 5:34 p.m. that an IJ was identified due to the above failures and the IJ template was provided. The following Plan of Removal (POR) was accepted on 01/25/25 at 12:31 p.m.: [] Plan of Removal [] submits the following Plan of Removal for the alleged failure to ensure treatment and care was provided to CR #1 consistent with professional standards of practice. By submitting this plan of removal [] does not admit to the accuracy of the alleged deficient practice. What corrective actions have been implemented for the identified residents? A. On 10/02/2024 resident CR#1 involved in alleged deficient practice was discharged to the hospital. B. On 01/24/2025 at 6:00 pm the Administrator notified the Medical Director of the alleged deficient practice. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Some C. Nurse Managers completed a 100% assessment of all residents residing in the facility for changes in condition on 01/24/2025, and none were identified. D. On 1/24/2025 LVN B was in-serviced on Recognizing a Change in Condition & Monitoring While Awaiting Transport to the Emergency Room. The facility audited the change in conditions for the last 3 days for altered mental status concerns, monitoring of residents, and notification to the physician 1/24/2025, no concerns were identified. E. On 1/24/2025 LVN C was in-serviced on Recognizing a Change in Condition & Monitoring While Awaiting Transport to the Emergency Room. F. The Corporate Clinical Service Director reviewed facility policy on 01/24/2025 regarding change in condition and no revisions were deemed necessary. How were other residents at risk to be affected by this deficient practice identified? A. All residents have the potential to be affected by the alleged deficient practice. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? A. An in-service was completed on 1/24/2025 by the Corporate Clinical Service Director with the Director of Nursing on residents with changes in condition must be monitored closely to ensure that documentation reflects the completion of required assessments, physician notification, on-going documented monitoring of resident status, and transported to the hospital in a timely manner based on resident assessment and physician recommendation. B. The Director of Nursing completed an in-service on 1/25/2025 with the licensed nursing staff on residents with changes in condition must be monitored closely to ensure that documentation reflects the completion of required assessments, physician notification, on-going documented monitoring of resident status, and transported to the hospital in a timely manner based on resident assessment and physician recommendation. Licensed nurses will not be allowed to return to work until they receive this in-service. C. Newly hired nurses will be in-serviced by the Director of Nursing or designee on changes in condition must be monitored closely to ensure that documentation reflects the completion of required assessments, physician notification, on-going documented monitoring of resident status, and transported to the hospital in a timely manner based on resident assessment and physician recommendation. D. The Director of Nursing or designee completed an in-service on 1/25/2025 with the licensed nursing on when to send a resident to the hospital when there is a change in condition that cannot be managed in the facility. Licensed nurses will not be allowed to return to work until they receive this in-service. a. Use non-emergency transport for stable residents requiring evaluation or treatment for non-urgent conditions, such as worsening chronic symptoms or mild infections. b. Call 911 for life-threatening emergencies or rapidly deteriorating conditions, such as chest pain, severe respiratory distress, unresponsiveness, or suspected trauma. Always assess vital signs, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 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 - Immediate jeopardy to resident health or safety consult facility protocols or providers as needed, and document the decision-making process thoroughly to ensure appropriate and timely care. E. On 1/25/2025 CNA's received in-services on Changes in Condition and Their Signs and Symptoms/Who to Notify When a Change in Condition is Observed. CNAs will not be able to work until they have completed this in-service. Residents Affected - Some F. Newly hired CNA's will be in-serviced by the Director of Nursing or designee on Changes in Condition and Their Signs and Symptoms/Who to Notify When a Change in Condition is Observed. How will the system be monitored to ensure compliance? A. The 24-hour report will be reviewed daily by the Director of Nursing or designee to audit nurse documentation in progress notes of change in conditions and the documentation reflects the completion of required assessments, physician notification, on-going documented monitoring of resident status, and transported to the hospital in a timely manner based on resident assessment and physician recommendation. Discrepancies noted during reviews will be immediately corrected by contacting the attending physician of the change of condition and completing documentation in the patient's progress note. Further training will be provided as identified by the nurse manager who identified the discrepancy when and if necessary. The review will be documented on an audit report form. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 01/24/2025 with the Medical Director. The Medical Director has reviewed and agrees with this plan. On 01/25/25-01/26/25, surveyor monitoring confirmed the facility implemented their plan or removal (POR) to sufficiently remove the IJ by: Record review revealed on 01/24/25, the facility completed an assessment for all residents in the facility for changes in conditions, and none were identified. Record review revealed on 01/24/25, Nurse B was in-serviced on recognizing a change in condition and monitoring while awaiting transport to the emergency room. Record review revealed on 01/24/25 the facility audited changes in conditions for the last 3 days for altered mental status concerns, monitoring of residents, and notification to the physician. Record review revealed on 01/24/25, Nurse C was in-serviced on recognizing a change in condition and monitoring while awaiting transport to the emergency room. Record review revealed on 01/24/25, the DON was in-serviced on managing and monitoring changes in resident condition. Record review revealed in-service was completed on 01/24/25 with the DON on Managing and Monitoring Changes in Resident Condition. Record review revealed on 01/25/24, in-service was completed with 40 licensed nursing staff on when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 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 to send a resident to the hospital when there is a change in condition that cannot be managed in the facility. Level of Harm - Immediate jeopardy to resident health or safety Record review revealed, on 01/24/24 in-service was completed with 40 nurses on the ongoing monitoring and assessing of residents scheduled for transport to the hospital. Residents Affected - Some Record review revealed, on 01/24/25 in-service was completed with 40 CNAs and 7 MAs on recognizing a change in condition and who to notify. Interviews were conducted from 01/25/25 to 01/26/25 with staff from all shifts: DON, 2 RNs, 7 LVNs, and 9 CNAs. Licensed Nursing staff verbalized an understanding on when to send a resident to the hospital when there is a change in condition that cannot be managed in the facility, the ongoing monitoring and assessing of residents scheduled for transport to the hospital and recognizing a change in condition and monitoring while awaiting transport to the emergency room. CNAs verbalized an understanding on recognizing a change in condition and who to notify The Administrator was notified the Immediate Jeopardy was removed on 01/26/2025 at 11:36 a.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 7 of 7