Health inspection·October 27, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few deficits are moderately severe. His symptoms are chronically present during the whole day. (CR #1) exhibits the following moderate symptoms: He confabulates stories or details to hide defects in memory; restless behaviors like pacing. has increased; He cannot organize thoughts or follow logical explanations; poor judgment is creating safety issues when left alone. (CR #1's) memory problems are prominent. he forgets more frequently than previously. He loses track of what is happening . Exam: . His thoughts are loosely associated in a circumstantial way. Psychotic or borderline psychotic symptoms seem to be present. Disorganized behavior has been observed. Bizarre behavior has been observed. Delusional ideas are expressed. Paranoid ideas are expressed.moderate cognitive loss is present. this patient is not aware of current events. There is difficulty thinking abstractly. He does not correctly give the current date and time. He correctly gives his current location. He correctly gives his name. He is not aware of his current situation. Diffuse memory loss for recent and remote events is present. Periods of confusion with disorientation and memory problems are in evidence. (CR #1) presents as alert. Insight into problems appears to be poor. Judgment appears to be poor. There are signs of anxiety. A short attention span is evident. He is easily distracted.Record review of CR #1's progress note dated 3/11/25 written by NP Q revealed he was confused but was able to provide some insight on current complaints.Record review of an undated soft file document entitled CR #1 Investigation of events - leaving facility unattended provided by the facility on 10/23/25 at 10:00 a.m. read in part, at approximately 2:50 p.m. (LVN K) contacted the facility to report that she observed (CR #1) walking near a restaurant. (LVN K) stated that when she attempted to turn her vehicle around to reach the resident, she lost visual contact and immediately notified the facility. In response, a caravan of facility staff proceeded toward the area to locate the resident. The resident was located within approximately one hour, walking in the direction of the facility. Upon approach, he was calm and cooperative, stating that he was attempting to visit his (family member's) home but decided to return once he realized the distance was too great. The resident demonstrated awareness of his location and route back to the facility. Administrator interview with the resident confirmed his initial statement regarding going to visit his (family member) and realizing that the distance was too far. Resident was last seen by the Administrator approximately 30 minutes prior to (LVN K's) call notifying the facility of the resident's whereabouts. A head-to-toe assessment was conducted upon his return. No injuries or signs of distress were observed. The resident was assigned a wander guard device for additional safety monitoring. The resident's responsible party was notified of the incident and the facility's findings. Immediate Facility Actions: conducted a head-to-toe assessment upon the resident's return; no injuries noted. Conducted monitoring of resident for signs and/or symptoms of distress. Educated resident on notifying staff on desire to leave facility. Initiated a wander guard device for the resident and verified activation. Conducted an audit of all wander guard assignments - confirmed devices were present and operational for all assigned residents. Conducted an audit of the elopement binder - confirmed all documentation and response protocols were current and in compliance. Notified the resident's responsible party of the event and outcomes. Conducted an in-service for all staff titled Identifying residents at risk for leaving unattended. Updated care plan to reflect elopement risk and wander guard use. Recommendations/Follow up: Evaluate all residents for elopement risk to ensure accurate risk coding and care plan alignment. Re-educate staff on maintaining visual supervision during resident transport and outdoor activities.Record review of CR #1's nursing note dated 3/21/25 written by the DON read in part, .rec'd a call from resident's (family member) stating she would prefer he not go out walking beyond our facility gate. She wants him to continue to enjoy sitting in front of the building in the patio area but not any farther (sic). She states there was no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 2 of 22 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 10/27/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few need for a wander guard because (CR #1) is very obedient. If she tells him to do something, he does it. (CR #1) was made aware of (family member's) wishes and nurse will continue to monitor.Record review of CR #1's weekly skin assessment dated [DATE] and documented by LVN W revealed a head-to-toe skin assessment was performed. There were no skin tears or ecchymosis (bruise) noted. Record review of CR #1's BIMS completed 3/21/25 by the Social Worker revealed it was 3 out of 15 which indicated severe cognitive impairment. Record review of CR #1's Release of Responsibility for Leave of Absence revealed he was not signed out of the facility on 3/21/25. Record review of CR #1's 15-minute surveillance program dated 3/21/25 revealed he was monitored every 15 minutes from 3/21/25 to 3/26/25.Record review of the Texas Unified Licensure Information Portal revealed there was no incident report regarding CR #1's elopement on 3/21/25 indicating the facility did not submit a self-report. Record review of CR #1's Order Summary Report dated 10/27/25 revealed orders for: wander guard: check for proper function daily every day shift, order date 3/26/25; wander guard: check for proper placement every shift, order date 3/26/25. In a telephone interview on 10/22/25 at 9:17 a.m. CR #1's family member said the facility called (on unknown date) and asked her if she picked up CR #1 from the facility. She said no. She said she was notified that he had been missing for two hours. The facility called her back approximately 1 to 1 and 1/2 hours later and said they found him at a nearby business, and he was safe and back in the facility. She said CR #1 left the facility because it was not completely fenced and he did not realize it because of his dementia. She said it was absolutely unsafe for him to be out alone, and it was a miracle of God that they found him. She said when he was at home, he wore a dementia/Alzheimer's bracelet and took long walks around the gated neighborhood to release anxiety. She said the facility was aware of his previous walking habits. She said after the incident she asked the facility to put a wander bracelet on him, which she said took several days. She said the DON demanded that she sit and watch CR #1 over the weekend. She said CR #1 was no longer at the facility and currently resided in a lockdown unit.In an interview on 10/22/25 at 9:59 a.m. the Social Worker said CR #1 typically sat outside in the front of the building. She said one day (3/21/25) around lunchtime they could not find CR #1 and almost every department head looked for him. She said he left the building and walked down to a fast-food restaurant and was unsure who noticed him leave. She checked the perimeter doors and around the building. She said another resident (unknown) saw him walk down the street. She said when he returned to the facility, staff asked her to conduct a BIMS score and CR #1 was anxious. She said the Administration determined he was cognitive enough to make his own decision. She said CR #1's cognition fluctuated, and he knew what was going on. She said on admission his cognition was low, and he would say things such as ‘he did not remember. When he first admitted he felt his family member was abandoning him. She said CR #1's family member shared he was getting out of the house and had left when she was not there. She said he was cognitively impaired and had confusion. As CR #1 got familiar with the new setting he established a routine. She said he was not appropriate to walk outside alone because he was familiar with the facility but not the surrounding area. She said it was not safe and there was a highway right there. She said CR #1 had not expressed that he wanted to leave. She said she recently found out that CR #1 would walk around the building. She said staff were supposed to check on the residents who sat outside. She said she was unsure if there was a designated person to watch the residents outside. She said if a resident was a known wanderer or wore a wander guard, a CNA would take them outside, otherwise the resident could sit outside alone.In an interview on 10/22/25 at 10:52 a.m. the previous Administrator said she recalled a resident was found down the street at a fast-food restaurant and had not been gone long. She said she could not recall his BIMS score, but he presented high level. She said the DON found him, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 3 of 22 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 10/27/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few brought him back to the facility and conducted a head-to-toe assessment. She said she would not let any resident leave on their own to ensure they were protected. After the incident they placed a wander guard on him, and he could not go outside by himself anymore. She said residents could get hurt if they eloped. She said she could not recall if she reported the incident (to HHS) but said any documentation such as in-services, assessments, wander guard information, and safe surveys would be at the facility for review. She said this was a reportable incident because of the elopement but she could not recall reporting it. She said one reason she would not report a reportable incident was if she was directed not to, she said the RVP and CSD would review the incident and confirm whether it was a reportable. She said the Administrator was responsible for reporting incidents. She said she would not report if her managers told her not to. She said the risk of not reporting to HHS would be not following the guidelines and alleviating the oversight.In an interview on 10/22/25 at 11:21 a.m. the Administrator said she was not working for the facility when the incident occurred with CR #1. She said he could have been hit and/or killed. She said residents who had a BIMS score above 13 would be considered to leave the building. She said it was her job to report incidents (to HHS). She said CR #1's BIMS score on admission was an 11, was a 3 (on 3/21/25) and a 3 on the next one (4/18/25). She said the incident should have been reported immediately due to her license. She said the DON was seasoned and could have also reported the incident. In an interview on 10/22/25 at 11:41 a.m. the CSD said he was in the facility the day of the incident. He said CR #1 was going to his family member's apartment and when he discovered it was not the right way he headed back to the facility. Prior to the incident, CR #1 would normally sit outside the building and come back in. He said that was the first time CR #1 left the building. He said for safety reasons residents should let staff know that they want to go off property so the staff can assist. He said he would want CR #1 to be escorted and would have preferred CR #1 to let staff know he wanted to leave the building instead of venturing out on his own. He recalled his BIMS score was 11 out of 15. He said a BIMS score of 11 was cognitive impairment and the facility preferred the resident to be with someone while out of the facility for safety. He said when CR #1 returned to the facility he thought his BIMS score was an 11 and did not recall it being a 3. He said a BIMS score of 3 was severe impairment and that would mean it was not safe for him to go out by himself. He said he was unsure how the resident's BIMS score resulted in a 3 and said that would have changed the decision of the incident being reported. He said any incidents of elopement should be reported. He said an elopement was when a resident tried to get away with no knowledge of what they were doing. He said the Administration discussed the incident and decided not to report it because CR #1 knew what he was trying to do and was trying to come back to the building and was educated.In an interview on 10/22/25 at 1:46 p.m. the RVP said CR #1 had a BIMS score of 11 and was able to say where he was going. He was able to say where he was trying to go and was coming back towards the facility. She said she was not aware of the BIMS he had when he returned to the facility and did not recall if he had a physical address to his family member's house. She said the previous Administrator completed a soft file with in-services. In an interview on 10/22/25 at 2:04 p.m. CR #1's family member said CR #1 would not know how to get to her apartment and had no idea where she lived. She said her apartment was approximately a 20-minute drive from the facility.In an interview on 10/22/25 at 4:17 p.m. the CSD said CR #1 was able to verbalize where he was going and knew what he was trying to do. He said he was unsure if CR #1 made prior arrangements with the family member to meet. He said the facility did not classify him as missing and a missing resident would be someone who did not have a clue of what they were trying to do or where they were trying to go. He said the facility did initiate a search of the grounds for the resident. He said CR #1 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 4 of 22 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 10/27/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete conversational, upset, and could not understand why the facility made a big deal of it. He said the facility follows the provider letter dated 8/24 and needed to report elopements within 24 hours to HHS.In an observation on 10/22/25 at 4:45 p.m. of the street CR #1 allegedly walked down revealed cars consistently drove down the street at moderate speed. The posted speed limit was 45 mph. The nearby business where CR #1 was found was located near the freeway and on the opposite side of the street from the facility.In an interview on 10/23/25 at 11:02 a.m. LVN K said one day when she was leaving work after 2:00 p.m. she saw CR #1 walking down the street in the direction of the freeway. She said she turned the car around to look for him but did not see him, she called the traveling DON to report CR #1 was out of the building. She said before CR #1 left the building, she last saw him at the nursing station around 2:00 p.m. She said he could have gotten hit crossing the street or dehydrated because it was hot that day. She said CR #1 was not capable of signing himself out, was confused and not in his right mind. In an interview on 10/24/25 at 11:23 a.m. the traveling DON said on an unknown date, a nurse saw CR #1 walking on the street. She said she and the DON jumped in the car and went down the street to look for him. She said she saw him headed back towards the facility. She got out of the car and asked if he was ok. She said he told her he left the facility to look for his family member's house/apartment, he realized he did not know how to get there and was headed back to the facility. She said he had no injuries and was not in distress but felt bad he left and was apologetic for leaving and not saying where he was going. She said that was her last day working at the facility and the DON had already taken over and was not working under her. She said she did not conduct any in-services with the staff. The DON and previous Administrator were in charge at the time. In an interview on 10/27/25 at 9:10 a.m. LVN W said the incident with CR #1 occurred during change of shift and he was not assigned to CR #1 yet because CR #1 was not in the building. He said the previous Administrator made an announcement that CR #1 was missing and told everyone to go look for and find the patient. He said he searched around the building, in the trash cans and dumpster. He said a head-to-toe assessment was completed probably by the DON, but he was unsure. He said CR #1 sometimes heard voices in his mind and might have come up with the idea of meeting his family member at the local business. He said CR #1 could hold a basic conversation but anything in depth was not reliable because of his cognition, but he was cognitive enough to not injure himself or others. He said CR #1 was not one to sign himself out of the building and said he did not even know what that was. He said he was not told it was an incident because CR #1 walked off and then walked back to the facility. He said the DON was the lead nurse and took over the documentation. Record review of Long-Term Care Regulation Provider Letter dated 8/29/24 provided by the facility read in part, ‘.2.1 Incidents that a NF must report to HHSC. A NF must report to CII the following types of incidents, in accordance with applicable state and federal requirements: abuse, neglect. a missing resident.2.4 Reportable Incidents and Timeframes. Do Report: an incident that does not result in serious bodily injury but that involves any of the following: . a missing resident. when to report:. immediately, but not later than 24 hours after the incidents occurs or is suspected . Missing resident: example of a missing resident: A resident is not in his room when staff wake residents up in the morning and the bed appears not to have been slept in. Staff search the facility and cannot find the resident. Event ID: Facility ID: 676263 If continuation sheet Page 5 of 22 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 10/27/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained free of accident hazards, and each resident received adequate supervision to prevent accidents for 1 (CR #1) of 7 residents reviewed for accidents and supervision.The facility failed to ensure CR #1 did not leave the facility unattended on 3/21/25. CR #1 was found by another staff member approximately 1 mile away in a parking lot near the freeway. An immediate jeopardy (IJ) was identified on 10/22/25. The IJ template was provided to the facility on [DATE] at 5:01 p.m. While the IJ was removed on 10/24/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.This failure could place residents at risk of accidents hazards.Findings include:Record review of CR #1's face sheet dated 10/22/25 revealed he was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 6/27/25 to another nursing facility. His diagnosis included dementia, mood disorder, anxiety, and bilateral hearing loss. Record review of CR #1's Elopement Risk assessment dated [DATE] revealed he was not at risk for elopement/wandering. Record review of CR #1's admission MDS assessment dated [DATE] revealed a BIMS score of 11 out of 15 which indicated moderate cognitive impairment. He was independent with ADLs and there was no wandering behavior exhibited. Record review of CR #1's care plan revealed he had impaired cognitive function/impaired thought processes related to dementia. Interventions were to discuss concerns about confusion and disease process and keep the resident's routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion, initiated 2/26/25.Record review of CR #1's Complete Evaluation/Psychosocial dated 2/26/25 written by the Psychologist indicated CR #1 had moderate cognitive loss. On exam he was cooperative and attentive with no gross behavioral abnormalities. The therapy content/clinical summary read in part, .he was open about memory, secondary to dementia. and depression about my (family member) left me recently, after she put me here. he talked about last few months at home being challenging with him wandering out of house and getting very frustrated with his cognitive challenges.Record review of CR #1's Physician/NP/PA/H&P progress note dated 3/6/25 written by NP V indicated the patient had severe deficits in cognition and memory.Record review of CR #1's behavioral complete evaluation dated 3/10/25 written by the Psychiatric Mental Health NP read in part, .Patient carries a diagnosis of dementia, anxiety and depression. Patient was seen in the common area ambulating. He reports my (family member) brought me here since I am not safe at home. Dementia: patient exhibits symptoms of dementia. Symptoms are observable. Onset: (CR #1's) symptoms were first noticed a few years ago. The first symptoms reported were: . got lost in familiar settings and began losing things.Course of illness: (CR #1's) symptoms have been slowly progressive. Recent symptoms suggest that cognitive deficits are moderately severe. His symptoms are chronically present during the whole day. (CR #1) exhibits the following moderate symptoms: He confabulates stories or details to hide defects in memory; restless behaviors like pacing. has increased; He cannot organize thoughts or follow logical explanations; poor judgment is creating safety issues when left alone. (CR #1's) memory problems are prominent. he forgets more frequently than previously. He loses track of what is happening . Exam: . His thoughts are loosely associated in a circumstantial way. Psychotic or borderline psychotic symptoms seem to be present. Disorganized behavior has been observed. Bizarre behavior has been observed. Delusional ideas are expressed. Paranoid ideas are expressed.moderate cognitive loss is present. this patient is not aware of current events. There is difficulty thinking abstractly. He does (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 6 of 22 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 10/27/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few not correctly give the current date and time. He correctly gives his current location. He correctly gives his name. He is not aware of his current situation. Diffuse memory loss for recent and remote events is present. Periods of confusion with disorientation and memory problems are in evidence. (CR #1) presents as alert. Insight into problems appears to be poor. Judgment appears to be poor. There are signs of anxiety. A short attention span is evident. He is easily distracted.Record review of CR #1's progress note dated 3/11/25 written by NP Q revealed he was confused but was able to provide some insight on current complaints.Record review of an undated soft file document entitled CR #1 Investigation of events - leaving facility unattended provided by the facility on 10/23/25 at 10:00 a.m. read in part, at approximately 2:50 p.m. (LVN K) contacted the facility to report that she observed (CR #1) walking near a restaurant. (LVN K) stated that when she attempted to turn her vehicle around to reach the resident, she lost visual contact and immediately notified the facility. In response, a caravan of facility staff proceeded toward the area to locate the resident. The resident was located within approximately one hour, walking in the direction of the facility. Upon approach, he was calm and cooperative, stating that he was attempting to visit his (family member's) home but decided to return once he realized the distance was too great. The resident demonstrated awareness of his location and route back to the facility. Administrator interview with the resident confirmed his initial statement regarding going to visit his (family member) and realizing that the distance was too far. Resident was last seen by the Administrator approximately 30 minutes prior to (LVN K's) call notifying the facility of the resident's whereabouts. A head-to-toe assessment was conducted upon his return. No injuries or signs of distress were observed. The resident was assigned a wander guard device for additional safety monitoring. The resident's responsible party was notified of the incident and the facility's findings. Immediate Facility Actions: conducted a head-to-toe assessment upon the resident's return; no injuries noted. Conducted monitoring of resident for signs and/or symptoms of distress. Educated resident on notifying staff on desire to leave facility. Initiated a wander guard device for the resident and verified activation. Conducted an audit of all wander guard assignments - confirmed devices were present and operational for all assigned residents. Conducted an audit of the elopement binder - confirmed all documentation and response protocols were current and in compliance. Notified the resident's responsible party of the event and outcomes. Conducted an in-service for all staff titled Identifying residents at risk for leaving unattended. Updated care plan to reflect elopement risk and wander guard use. Recommendations/Follow up: Evaluate all residents for elopement risk to ensure accurate risk coding and care plan alignment. Re-educate staff on maintaining visual supervision during resident transport and outdoor activities.Record review of CR #1's weekly skin assessment dated [DATE] at 3:30 p.m. documented by LVN W revealed a head-to-toe skin assessment was performed. There were no skin tears or ecchymosis (bruise) noted. Record review of CR #1's BIMS on 3/21/25 at 3:37 p.m. conducted by the Social Worker was 3 out of 15 which indicated severe cognitive impairment. Record review of CR #1's nursing note dated 3/21/25 at 4:27 p.m. written by the DON read in part, .rec'd a call from resident's (family member) stating she would prefer he not go out walking beyond our facility gate. She wants him to continue to enjoy sitting in front of the building in the patio area but not any farther (sic). She states there was no need for a wander guard because (CR #1) is very obedient. If she tells him to do something, he does it. (CR #1) was made aware of (family member's) wishes and nurse will continue to monitor. Record review of CR #1's Release of Responsibility for Leave of Absence revealed he was not signed out of the facility on 3/21/25. Record review of CR #1's 15-minute surveillance program dated 3/21/25 revealed he was monitored every 15 minutes from 3/21/25 to 3/26/25.Record review of the facility's Incidents by Incident Type dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 7 of 22 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 10/27/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 10/21/25 revealed there were no incidents recorded for CR #1 on 3/21/25.Record review of CR #1's Order Summary Report dated 10/27/25 revealed orders for: wander guard: check for proper function daily every day shift, order date 3/26/25; wander guard: check for proper placement every shift, order date 3/26/25. In a telephone interview on 10/22/25 at 9:17 a.m. CR #1's family member said the facility called (on unknown date) and asked her if she picked up CR #1 from the facility. She said no. She said she was notified that he had been missing for two hours. The facility called her back approximately 1 to 1 and 1/2 hours later and said they found him at a nearby business, and he was safe and back in the facility. She said CR #1 left the facility because it was not completely fenced and he did not realize it because of his dementia. She said it was absolutely unsafe for him to be out alone, and it was a miracle of God that they found him. She said when he was at home, he wore a dementia/Alzheimer's bracelet and took long walks around the gated neighborhood to release anxiety. She said the facility was aware of his previous walking habits. She said after the incident she asked the facility to put a wander bracelet on him, which she said took several days. She said the DON demanded that she sit and watch CR #1 over the weekend. She said CR #1 was no longer at the facility and currently resided in a lockdown unit. In an interview on 10/22/25 at 9:59 a.m. the Social Worker said CR #1 typically sat outside in the front of the building. She said one day (3/21/25) around lunchtime they could not find CR #1 and almost every department head looked for him. She said he left the building and walked down to a fast-food restaurant and was unsure who noticed him leave. She checked the perimeter doors and around the building. She said another resident (unknown) saw him walk down the street. She said when he returned to the facility, staff asked her to conduct a BIMS score and CR #1 was anxious. She said the Administration determined he was cognitive enough to make his own decision. She said CR #1's cognition fluctuated, and he knew what was going on. She said on admission his cognition was low, and he would say things such as ‘he did not remember. When he first admitted he felt his family member was abandoning him. She said CR #1's family member shared he was getting out of the house and had left when she was not there. She said he was cognitively impaired and had confusion. As CR #1 got familiar with the new setting he established a routine. She said he was not appropriate to walk outside alone because he was familiar with the facility but not the surrounding area. She said it was not safe and there was a highway right there. She said CR #1 had not expressed that he wanted to leave. She said she recently found out that CR #1 would walk around the building. She said staff were supposed to check on the residents who sat outside. She said she was unsure if there was a designated person to watch the residents outside. She said if a resident was a known wanderer or wore a wander guard, a CNA would take them outside, otherwise the resident could sit outside alone. In an interview on 10/22/25 at 10:19 a.m. Resident #15 said CR #1 would walk around the facility and exercise. She said one day he went outside, walked out of the gate, and kept going. She said she was outside that day, and he was also outside but she did not witness him leave the premises. In an interview on 10/22/25 at 10:31 a.m. the DON said on the day of the incident, an unknown resident came in the building from outside and told staff that CR #1 left out of the gate. She said a code white was called and the facility staff immediately searched for the resident. She found CR #1 at a nearby business, and he told her he was going to see his family member whose house was right over there. She said CR #1 was alert and oriented x 3 with some confusion at times. She said it was not appropriate for him to leave alone, he did not sign out of the facility independently, he had not received permission from his family member to leave, and the street was very busy. She assessed the resident, he had no injuries, and she brought him back to the facility. She said all residents, including CR #1, required supervision (not direct) while on the patio and various staff would go out and promote (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 8 of 22 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 10/27/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few hydration and ensure the residents were brought back in. She said she could see the residents from her workspace inside of the facility and there were no specific staff assigned to monitor. She said if a resident had a wander guard, a staff member would accompany that resident outside. She said CR #1 did not have a wander guard at the time of the incident and she was unaware of any desire for him to leave the facility. She said she notified the MD and family member and conducted training with the staff which included monitoring, abuse/neglect, elopement, and assessment risk. She updated the status of wander guard status and submitted everything to the previous Administrator so she could take care of the reporting. This Surveyor requested documentation of the in-services conducted by the DON but did not receive them prior to survey exit. In an interview on 10/22/25 at 10:52 a.m. the previous Administrator said she recalled when a resident was found down the street at a fast-food restaurant and had not been gone from the facility long. She said she could not recall his BIMS score, but he presented high level. She said the DON found him, brought him back to the facility and conducted a head-to-toe assessment. She said she would not let any resident leave on their own to ensure they were protected. She said she could not recall if she reported the incident but said it was a reportable event because the resident eloped. She said the risk of elopement was that a resident could get hurt. She said any documentation such as in-services, assessments, wander guard information, and safe surveys would be at the facility for review.She said after the incident they placed a wander guard on him, and he could not go outside by himself anymore. In an interview on 10/22/25 at 11:21 a.m. the Administrator said she was not working for the facility when the incident occurred with CR #1. She said he could have been hit and/or killed. She said the residents who sat out front on the patio were monitored by staff and staff checked on them during their frequent rounding. She said she could also see the residents from her office. She said residents who had a BIMS score above 13 would be considered to leave the building. She said the facility had never completed elopement drills previously. She said elopement drills were not required but she would implement monthly drills.In an interview on 10/22/25 at 11:41 a.m. the CSD said he was at the facility the day of the incident (3/21/25). He said CR #1 was going to his family member's apartment and when he discovered it was not the right way he headed back to the facility. Prior to the incident, CR #1 would normally sit outside the building and come back in. He said that was the first time CR #1 left the building. He said for safety reasons residents should let staff know that they want to go off property so the staff can assist. He recalled his BIMS score was 11 out of 15 which indicated cognitive impairment. He said the facility preferred CR #1 to be with someone while out of the facility for safety and to let staff know he wanted to leave the building instead of venturing out on his own. He said when CR #1 returned to the facility he thought his BIMS score was an 11 and did not recall it being a 3. He said a BIMS score of 3 was severe impairment and that would mean it was not safe for him to go out by himself. He said he was unsure how the resident's BIMS score resulted in a 3 and said that would have changed the decision of the incident being reported. He said the facility explored a wander guard at the time and put one on later because they were not sure if the resident would follow through with notifying the facility of his desire to leave. He said CR #1 had not been at the facility that long, was adjusting, and did not know he was not supposed to leave. In an interview on 10/22/25 at 2:04 p.m. CR #1's family member said CR #1 would not know how to get to her apartment and had no idea where she lived. She said her apartment was approximately a 20-minute drive from the facility.In an interview on 10/22/25 at 2:30 p.m. CR #1's MD said CR #1 liked to walk around and enjoyed being outdoors. She said it was not appropriate for him to leave the facility on his own. She said she was aware he went missing on 3/21/25 but could not recall when she was notified. In an interview on 10/22/25 at 2:36 p.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 9 of 22 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 10/27/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the RVP said she would look for the soft file that the previous Administrator completed (regarding when CR #1 left the building).In an interview on 10/22/25 at 3:02 p.m. the DON said CR #1 was away from the facility for a maximum of 15-20 minutes. She said he was found in a fast-food restaurant parking lot that required him to cross the street. She said she could not find any additional information regarding the incident in CR #1's record and there was no adequate documentation from the nurse. She said there should have been documentation about the incident because there was a change in behavior and the resident left the grounds. She said there was a notification to the family member documented but she did not see a conversation with the physician and there was no incident report. She said the 15-minute surveillance for monitoring was in the chart. She said everyone was responsible for the whereabouts of the residents and the DON and Administrator were ultimately responsible. She said she was not aware he had stepped out of the facility gate until another resident informed her. She said if a resident wanted to leave the building they should check with the nurse, sign themselves out, and be responsible, safe, and aware independently. She said staff who were more familiar with CR #1 said he was responsible to be on his own but was unsure how that was determined. She said the criteria for residents going out of the building alone was based on BIMS score, family input and MD orders. She said residents who were not cognitively impaired (BIMS score 13 and above) should be able to move around responsibly. She said sometimes residents who had a BIMS score below 13 could also be responsible but it depended on the person. She said everything was so new to her since she just started at the facility when the incident occurred.In an interview on 10/22/25 at 4:00 p.m. Resident #15 said the staff did not come outside to check on residents very often unless there was an exercise activity. She said there was no need for the staff to come outside and monitor. She said the staff never came until after CR #1 left the building. In an interview on 10/22/25 at 4:17 p.m. the CSD said CR #1 was able to verbalize where he was going and knew what he was trying to do. He said he was unsure if CR #1 made prior arrangements with the family member to meet. He said the facility did not classify him as missing and a missing resident would be someone who did not have a clue of what they were trying to do or where they were trying to go. He said the facility did initiate a search of the grounds for the resident. He said CR #1 was conversational, upset, and could not understand why the facility made a big deal of it.In an observation on 10/22/25 at 4:45 p.m. of the street CR #1 allegedly walked down revealed cars consistently drove down the street at moderate speed. The posted speed limit was 45 mph. The nearby business where CR #1 was found was located near the freeway and on the opposite side of the street from the facility.In an interview on 10/23/25 at 9:45 a.m. CNA AA said CR #1 always wanted to sit out on the patio and had never walked away before. She said she never took CR #1 outside or sat out on the patio prior to the incident. She said she was in the building the day of the incident and heard he was out of the building. She said facility staff instructed everyone to check every room and bathroom. She said after the incident they had an in-service and placed a wander guard on him. In an interview on 10/23/25 at 11:02 a.m. LVN K said CR #1 liked to walk and would walk around the inside and outside of the facility. She said one day when she was leaving work after 2:00 p.m. she saw CR #1 walking down the street in the direction of the freeway. She said she turned the car around to look for him but did not see him, she called the traveling DON to report CR #1 was out of the building. She said before CR #1 left the building, she last saw him at the nursing station around 2:00 p.m. She said he could have gotten hit crossing the street or dehydrated because it was hot that day. She said CR #1 was not capable of signing himself out, was confused and not in his right mind. She said she did not recall any in-services or elopement training given after the incident.In an interview on 10/23/25 at 2:37 p.m. CNA CC said he worked the day of the incident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 10 of 22 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 10/27/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few with CR #1. He said facility staff told him CR #1 was missing and to stop what he was doing and look for him. He said he looked on the 400 hall and the outside perimeter. He said the previous Administrator in-serviced staff on code white protocol.In an interview on 10/24/25 at 9:53 a.m. the DON said at the time of the incident (3/21/25) she was not the DON yet and that was why she did not do all the normal training that she would have done with the staff. She said the traveling DON was the active DON at the time and she was in orientation. In an interview on 10/24/25 at 11:23 a.m. the traveling DON said on an unknown date, a nurse saw CR #1 walking on the street. She said she and the DON jumped in the car and went down the street to look for him. She said she saw him headed back towards the facility. She got out of the car and asked if he was ok. She said he told her he left the facility to look for his family member's house/apartment, he realized he did not know how to get there and was headed back to the facility. She said he had no injuries and was not in distress but felt bad he left and was apologetic for leaving and not saying where he was going. She said that was her last day working at the facility and the DON had already taken over and was not working under her. She said she did not conduct any in-services with the staff. The DON and previous Administrator were in charge at the time. In an interview on 10/24/25 at 1:20 p.m. the RVP said the DON was the DON in charge on 3/21/25. She said the DON or charge nurse and was responsible for documenting the incident. In an interview on 10/24/25 at 1:22 p.m. the Administrator said the DON was hired on 3/19/25. In an interview on 10/27/25 at 9:10 a.m. LVN W said the incident with CR #1 occurred during change of shift and he was not assigned to CR #1 yet because CR #1 was not in the building. He said the previous Administrator made an announcement that CR #1 was missing and told everyone to go look for and find the patient. He said he searched around the building, in the trash cans and dumpster. He said a head-to-toe assessment was completed probably by the DON, but he was unsure. He said CR #1 sometimes heard voices in his mind and might have come up with the idea of meeting his family member at the local business. He said CR #1 could hold a basic conversation but anything in depth was not reliable because of his cognition, but he was cognitive enough to not injure himself or others. He said CR #1 was not one to sign himself out of the building and said he did not even know what that was. He said he was not told it was an incident because CR #1 walked off and then walked back to the facility. He said the DON was the lead nurse and took over the documentation. Record review of the facility's in-service training report dated 3/21/25 conducted by the previous Administrator read in part, .Identifying residents at risk for leaving facility. it is important to educate residents on notifying staff that they want to leave the premises. This will provide open dialogue that will address and identify residents at risk for leaving without notice. Residents desiring to leave the premises unattended should be reported to the DON and Administrator. Residents need to be educated on the safety of remaining onsite. The facility can assist with offsite events. There were 56 signatures.Record review of the facility's Elopements policy dated December 2007 read in part, .Staff shall investigate and report all cases of missing residents. 2. If an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the departure in a courteous manner.3.when a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. examine the resident for injuries; b. notify the attending physician;. d. complete and file report of incident/accident; and e. document the event in the resident's medical record.On 10/22/25 at 5:01 p.m. the Administrator was notified of the Immediate Jeopardy due to the above failures. The IJ template was provided to the Administrator and a plan of removal was requested at that time. The following Plan of Removal (POR) was submitted by the facility and accepted on 10/23/25 at 11:20 a.m.:PLAN OF REMOVALF-689Date: October 23, 2025(Facility Name) submits the following Plan of Removal for the alleged failure to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 11 of 22 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 10/27/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few ensure the resident area remained free of accident hazards, and each resident received adequate supervision to prevent accidents for CR #1.The Texas Department of Health and Human Services entered the facility on October 21, 2025 for a Complaint Survey. During the survey process, on October 22, 2025 an IJ (Immediate Jeopardy) was cited regarding F689 - Accidents/Hazards.The facility failed to ensure CR # 1 did not elope from the facility on 3/21/25 while sitting out on the patio. CR # 1 was found by another staff member approximately 1 mile away in a parking lot near the freeway.Immediate action:.What corrective actions have been implemented for the identified residents? CR #1 discharged from the facility on 6/27/25 to another Nursing Facility and did not return to the facility. On 10/22/2025 at 5:34 pm the Administrator notified the Medical Director of alleged deficient practice. On 10/22/25, the Clinical Service Director in-serviced the nurse managers to include the DON to immediately page code white over the paging system whenever it is deemed there is a missing resident, initiate a search throughout the inside of the facility and facility grounds. If the resident is still not located, extend search to the immediate neighborhood. If the resident is still not located within 30 minutes, notify the Police Department for further assistance to search for the missing resident. Completion date 10/22/25. On 10/22/25, DON/designees in-serviced all licensed nurses (full-time, part-time, and PRN) to immediately page code white over the paging system whenever it is deemed there is a missing resident, initiating a search throughout the inside of the facility and facility grounds. If the resident is still not located, extend search to the immediate neighborhood. If the resident is still not located within 30 minutes, notify the Police Department for further assistance to search for the missing resident. Completion date 10/22/25 No Nurse Manager will be allowed to work until training is completed. Completion date 10/22/25 No staff will be allowed to work until training is completed. Completion date 10/22/25 On 10/22/25, all facility residents had an elopement risk assessment completed by the Nurse Managers and no new residents were identified to be at risk. Completion date 10/22/25 On 10/22/25, facility residents' elopement risk assessments were reviewed by the Clinical Services Director to ensure safety measures are in place for residents that are at risk for elopement. All residents that are at risk for elopement have safety measures in place to prevent elopement. Completion date 10/22/25 The DON/ADON will validate all elopement risk assessments are accurately completed during clinical morning meetings, ensure care plans and CNA Kardex are updated to reflect residents at risk for elopement and safety measures that are implemented. The Clinical Services Director reviewed facility Elopement Policy on 10/22/25 no revisions were deemed necessary. How were other residents at risk to be affected by this deficient practice identified? A. Residents that are at risk of elopement 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. Residents assessed to be at risk for elopement will be monitored by staff while sitting on the patio.B. An in-service was initiated on 10/22/25 by the Clinical Service Director, DON, and Nurse Managers with the licensed nursing staff on the Elopement Policy. Licensed nurses will not be allowed to return to work until they receive this in-service. Completion date 10/22/25.C. An in-service was initiated on 10/22/25 by the Nurse Managers with the facility frontline staff on the procedure to follow when it is deemed there is a missing resident. Completion date 10/22/25.D. Newly hired nurses will be in-serviced by the DON/designee on the Elopement Policy. Licensed nurses will not be allowed to work until they receive this in-service. Completion date 10/22/25. E. Newly hired frontline staff will be in-serviced by the DON/designee on the Elopement Policy. They will not be allowed to work until they receive this in-service. Completion date 10/22/25.F. New Admissions and Readmissions Elopement Assessment and Risk Management will be reviewed daily in the morning meeting to identify (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 12 of 22 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 10/27/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete residents at risk for elopement and ensure adequate supervision is in place. The Charge Nurse will routinely conduct every 2 rounds and document knowledge of residents' whereabouts throughout their shift on an audit form. Any episode of elopement will be documented in the risk management system portal and notify the DON/Administrator immediately. The DON/designee will monitor the risk management system portal 3 times a week X 6 weeks and document findings on an audit report form. Quality AssuranceAn impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 10/22/25 with the Medical Director. The Medical Director has reviewed and agrees with this plan. On 10/22/25, DON/Nurse Managers assessed all residents for elopement risks. No new residents were found to be affected. Training conducted with staff to immediately page code white over the paging system whenever it is deemed there is a missing resident, initiate a search throughout the inside of the facility and facility grounds. If the resident is still not located, extend search to the immediate neighborhood. If the resident is still not located within 30 minutes, notify the Police Department for further assistance to search for the missing resident. Training to be conducted during the orientation of newly hired staff (full-time, part-time, and PRN). The DON/designees to provide oversight and ensure compliance. No staff will be allowed to work without receiving the in-service on the regarding the elopement policy.Monitoring for implementation of the POR was conducted on 10/23/25 and 10/24/25:Record review of the facility's undated Off Cycle (ADHOC) QA meeting document read in part, .ADHOC QAAC for identification of a system in need of immediate attention by QAPI Committee was conducted and had 7 signatures. Record review of the facility's Elopement Policy in-service dated 10/22/25 read in part, .Immediately Event ID: Facility ID: 676263 If continuation sheet Page 13 of 22 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 10/27/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure Residents who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 4 residents (Resident#1) reviewed for incontinent care.CNA A failed to wash Resident #1 external urethral orifice (the opening at the end of the urethra where urine exits the body) during perineal care (cleansing of the genital and anal areas to maintain hygiene).This failure could place residents at risk of infection and hospitalization. Findings included:Record review of Resident #1's face sheet dated 10/21/25 revealed a [AGE] year-old first admitted to the facility on [DATE] with diagnoses to include COPD (chronic obstructive pulmonary disease, a lung condition caused by damage to the airway), muscle weakness, abnormalities of mobility, cerebral vascular accident (stroke), anxiety and depression.Record review of Resident #1's quarterly MDS (a resident assessment and care screening tool) dated 08/19/2025 revealed a BIMS score of 15 indicating intact cognition. Resident #1 was dependent on staff for all ADLs including the ability to maintain perineal hygiene. Resident #1 was frequently incontinent of bowel and bladder.Record review of Resident #1's undated care plan included: Focus-Resident #1 has bowel and bladder incontinence which places him at risk for skin breakdown and UTI. Goal-Will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included - Brief Use: the resident uses disposable briefs. Change as needed. Incontinent: Check the resident during rounds and as required for incontinence. Wash, rinse and dry perineum.In an interview on 10/22/25 at 3:05PM, the DON stated pericare for both male and female should start with cleansing the urethra first, the actual opening should be cleansed then move further away from opening so not to bring bacteria to the opening of the urethra.Observation of peri care for Resident #1 on 10/24/25 at 6:45AM, revealed CNA A was walking down the hall and entered Resident #1's room. CNA A was holding white square patches in her hand. CNA A closed the door and gathered supplies. Resident #1 was alert, oriented and lying on his back with pillows under his knees watching TV. CNA A removed gloves from her pocket and put them on. CNA A told Resident #1 that she was going to clean him up. CNA A helped Resident #1 remove his pants, lowered the head of the bed, unfastened the tabs on the brief, used one disposable cleansing wipe and cleaned the left groin area. CNA A then cleansed right groin area with a clean wipe, disposed the wipe and with a clean wipe CNA A wiped from the base of the penis in the direction towards the tip of penis once. CNA A did not cleanse the external urethral orifice of the penis. CNA A assisted Resident #1 in rolling to his left side. Resident #1 had a bowel movement. CNA A cleansed the perineal area, buttocks then disposed of the soiled brief. CNA A removed gloves, disposed them into trash can, removed gloves from her pocket and put them on. CNA A proceeded with applying a clean brief and assisted the resident with dressing. CNA A and CNA F transferred the resident from the bed to the wheelchair. CNA A removed gloves. CNA A did not perform hand hygiene. CNA A assisted Resident #1 to the dining room by pushing the wheelchair using her hands. CNA A touched a chair and moved it, walked to where the ice chests were and lifted the lids using her hands then walked to the nurse station. CNA A then walked down the hall to Resident #1's room put on clean gloves and began to clean up.In an interview on 10/24/25 at 7:15 AM, CNA A stated the facility policy was to wash or sanitize hands prior to entering resident rooms and stated she did that when she was down the hall before entering Resident #1's room. CNA A stated she should have sanitized between glove changes for infection control and she did not do this because it skipped her mind. CNA A stated she kept gloves in her pocket because some rooms did not have her size gloves. CNA A stated she did not always keep (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 14 of 22 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 10/27/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete gloves in her pocket. CNA A stated it was not hygienic to keep gloves in pockets and it was not an encouraged habit. CNA A checked the doorway and stated she didn't know there was a box of extra large gloves available. CNA A stated she did clean Resident #1's penis by wiping with cleansing cloth twice. CNA A stated she learned male peri care when she first stated working at the facility several months ago and had inservices on infection control and peri care for both male and female. CNA A stated she was supposed to perform hand hygiene prior to leaving Resident #1's room but got nervous. CNA A stated the risk of not doing hand hygiene was the germs from hands can get onto items touched and a resident could get infected if they touch the same items.In an interview on 10/27/25 at 12:30 PM, the DON stated she expected nursing staff to change gloves, sanitize or wash hands to prevent infection as much as possible any time they are working from a clean area to a dirty area such as during peri care. The DON stated the CNAs may have been rushing through their work and did not perform hand hygiene as she expected. The DON stated she expected the nursing staff to wash their hands, change gloves to help prevent UTI. The DON stated residents who have a long history of UTIs, and the elderly population are examples or residents who are susceptible to UTIs.Record review of the facility policy for Perineal Care, revised in December 2011, read in part: The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition.Steps in the Procedure.10. For a male resident.b. Wash perineal area starting with urethra and working outward.12. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 13. Put on clean gloves and place new brief and secure in place.18. Remove gloves and 19. Wash and dry your hands thoroughly. Event ID: Facility ID: 676263 If continuation sheet Page 15 of 22 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 10/27/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 8 resident (Resident #1) reviewed for pharmaceutical services. The facility failed to have an authorized staff administer medication to Resident #1. MA-I instructed CNA- A who was not authorized to apply Lidocaine patches to Resident #1's hips. The facility failed to clarify the physician order for Resident #1's Lidocaine patch as to which hip the patch was to be applied. CNA-A applied one patch to Resident #1's right hip and a second patch to the left thigh. This failure could place residents at risk of not receiving medications as ordered by the physician. This failure could place residents at risk of not receiving the desired therapeutic effects of their medications and uncontrolled pain.Findings included: Record review of Resident #1's face sheet dated 10/21/25 revealed a [AGE] year-old first admitted to the facility on [DATE] with diagnoses to include COPD (chronic obstructive pulmonary disease, a lung condition caused by damage to the airway), muscle weakness, abnormalities of mobility, cerebral vascular accident (stroke), anxiety and depression. Record review of Resident #1's quarterly MDS (a resident assessment and care screening tool) dated 08/19/2025 revealed a BIMS score of 15 indicating intact cognition. Resident #1 was dependent on staff for all ADLs. Record review of Resident #1's undated care plan included: Focus-Resident #1 was at risk for pain r/t generalized pain. Interventions included administer analgesics as per ordered. Record review of Resident #1's physician order dated 03/17/2025 revealed a medication order for Lidocaine External Patch 4 %, apply to hip topically one time a day for pain and remove per schedule. Record review of Resident #1's October 2025 MAR (medication administration record) printed in 10/24/25 at 9:14 AM revealed Lidocaine External Patch 4%, Apply to hip topically one time a day for pain and remover per schedule was marked as administered on 10/24/25 at 8:00 AM by LVN J and not MA-I. Observation and interview of peri care for Resident #1 on 10/24/25 at 6:45AM, revealed CNA A was walking down the hall holding white square patches in her hand and entered Resident #1's room. CNA A closed the door and gathered supplies. Resident #1 was alert, oriented and lying on his back with pillows under his knees watching TV. CNA-A removed gloves from her pocket and put them on. CNA-A told Resident #1 that she was going to clean him up. CNA-A helped Resident #1 remove his pants, lowered the head of the bed, unfastened the tabs on the brief, and cleaned the front of Resident #1's peri area. Resident #1 stated the two Lidocaine patches were removed at nighttime and he gets new patches in the morning. CNA-A assisted Resident #1 in rolling to his left side. Resident #1 had a bowel movement. CNA-A cleansed the perineal area and buttocks then disposed of the soiled brief. CNA-A removed gloves, disposed them into trash can, removed gloves from her pocket and put them on. CNA-A proceeded with applying a clean brief. While Resident #1 was still on his left side, CNA-A applied a white patch to the right hip and fastened the tabs of the brief over the patch. Resident #1 rolled to his right side. CNA-A fastened the tabs of the brief on the left hip and applied the second white patch to the upper right thigh, below the brief. CNA-A stated they were pain patches, and the medication aide gave them to her so she could apply them onto Resident #1's skin. CNA-A removed gloves, disposed of them into trash can, removed gloves from her pocket and put them on then proceeded with helping Resident #1 get dressed. CNA-F entered the room and offered assistance. CNA-A and CNA-F transferred the resident from the bed to the wheelchair. CNA-A removed gloves. CNA-A assisted Resident #1 to the dining room by pushing him in the wheelchair. In an interview on 10/24/25 at 7:45 AM, MA-I stated she gave CNA-A two Lidocaine patches because she knew Resident #1 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 16 of 22 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 10/27/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few getting peri care which was the opportunity to apply the Lidocaine patches before he got up and into the wheelchair. MA-I stated she was in the middle of dispensing medications for another resident. MA-I stated that once and awhile she would ask CNAs to help by applying the patches because she may not always get to him before he gets up out of bed. MA-I stated Resident #1 would complain of pain during the day if the Lidocaine patches were not put on before he gets up out of bed. MA-I stated the medication aides and nurses were responsible for administering the Lidocaine patches and that it was not policy to ask a CNA to apply them as she was the one signing off as administered. MA-I stated the patches should be applied to both hip areas where the brief would cover the hip. MA-I stated she was aware she made a mistake in giving the Lidocaine patches to the CNA. In an interview on 10/27/25 at 11:35AM, MA-I stated she did not sign out the Lidocaine patches for Resident #1 on 10/24/25 because someone else took over for her right after the incident and she didn't get a chance to document. MA-I stated the nurse signed it out along with his other medications and she did not know the name of the nurse. MA-I stated the Lidocaine patches were supposed to be applied over both hips because he used to be in another hall and that was what his orders were at the time. MA-I stated the nurses were responsible for confirming the orders and if she discovered a discrepancy in the order she would usually report to the nurse or ADON. MA-I stated she did not report the discrepancy on 10/24/25. In an interview on 10/27/25 at 11:40AM, the MD stated she believed the Lidocaine patch for Resident #1 was for his left hip only but was unsure if it was to be for both hips. The MD stated she would need to clarify the order. The MD stated the Lidocaine patch was for his arthritis and that she checked the resident in the morning and reported that he denied hip pain. In an interview on 10/27/25 at 12:30 PM, the DON stated the nurses and medication aides were responsible for administering Lidocaine patches. The DON stated CNA-A was not a medication aide and was not licensed to administer medications. The DON stated CNAs were not authorized to administer Lidocaine patches. The DON stated it was a silly mistake and not within the CNAs scope of practice. The DON stated that CNA-A had not been trained and would not have known the rights of administration. The DON stated Resident #1 received Lidocaine patches for hip pain and if not applied as ordered the resident could have increased pain. The DON stated she would expect only one patch to be applied since the order reads Lidocaine external patch 4 % apply to hip topically every day for pain. The DON stated she expected the nurses to clarify the order as to which hip to place the patch. The DON stated she would need to speak with the MD first to see if the order was intended for both hips and that everyone knew there was a verbal order for the patches to be applied to both hips. The DON stated her expectation was for the medication aide to notify the nurse that the order was unclear. The DON stated she was unable to find out which nurse would have been responsible for clarifying the order. The DON stated it was considered a medication error; she wrote a medication error report and notified the physician. The DON stated Resident #1 was assessed and had no adverse effects. On 10/27/25 at 2:06PM, an attempt was made to contact LVN J via telephone to confirm she signed out and administered the Lidocaine patch on 10/24/25 8:00AM for Resident #1. No call back was received to confirm whether LVN J signed out and administered the Lidocaine patch. Record review of the facility's policy for Adverse Consequences and Medication Errors, revised on June 2025, read in part: .The interdisciplinary team monitors medication usage to prevent and detect medication-related problems such as adverse drug reactions (ADRs) and side effects.Medication Errors 1. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with provider's orders, manufacturers specifications, or accepted professional standards and principles of the professional(s) providing services. 2. Examples of medications errors include:.b. unauthorized drug - a drug is administered without a provider's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 17 of 22 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 10/27/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete order. Record review of the facility's undated job description for Certified Nursing Assistant read in part: .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 car plan and as may be directed by your supervisors. Record review of the facility's undated job description for Certified Medication Aide read in part: .The primary purpose of your job position is to assist in the administering of medications to residents as ordered by the attending physician, under the direction of the attending physician, the nurse supervisor or charge nurse, and the Director of Nursing Services. The administration of medications shall be in accordance with established nursing standard's, the policies, procedures and practices of this facility and the requirements of this state.As a Certified Medication Aide, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Event ID: Facility ID: 676263 If continuation sheet Page 18 of 22 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 10/27/2025 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 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 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 three of three residents (Resident #1, #2 and #3) reviewed for infection control.CNA B failed to perform hand hygiene after pericare for Resident #2 and before exiting the resident's room.CNA B, CNA H and CNA C failed to follow EBP (enhanced barrier precaution) signs and did not wear gowns during high contact resident care activities for Residents #2 and #3.CNA C failed to sanitize the mechanical lift between use for Resident #3 and Resident #2.CNA A failed to put on clean gloves during pericare for Resident #1. CNA A put on gloves from her pocket and not from the box of gloves in the room.CNA A failed to perform hand hygiene between glove changes during peri care, after pericare and before exiting Resident #1's room.These failures could affect residents at risk of infection and hospitalization.Findings included: Record review of Resident #1's face sheet dated 10/21/25 revealed a [AGE] year-old first admitted to the facility on [DATE] with diagnoses to include COPD (chronic obstructive pulmonary disease, a lung condition caused by damage to the airway), muscle weakness, abnormalities of mobility, cerebral vascular accident (stroke), anxiety and depression.Record review of Resident #1's quarterly MDS (a resident assessment and care screening tool) dated 08/19/2025 revealed a BIMS score of 15 indicating intact cognition. Resident #1 was dependent on staff for all ADLs including the ability to maintain perineal hygiene. Resident #1 was frequently incontinent of bowel and bladder.Record review of Resident #1's undated care plan included: Focus-Resident #1 has bowel and bladder incontinence which places him at risk for skin breakdown and UTI. Goal-Will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included Brief Use: the resident uses disposable briefs. Change as needed. Incontinent: Check the resident during rounds and as required for incontinence. Wash, rinse and dry perineum.Record review of Resident #1's progress note written on 03/19/25 at 11:13AM by the MD revealed Resident #1 was hospitalized for pneumonia and UTI on 3/11/25.Record review of Resident #1's order summary report dated 10/23/25 revealed an order dated 08/15/25 to 8/22/25 for contact isolation for ESBL (extended Spectrum Beta-Lactamase is an enzyme produced by certain bacteria) in the urine.Record review of Resident #1's infection progress note written on 08/21/25 at 4:42 PM by LVN E revealed the resident was receiving a 7-day course of IV antibiotics for ESBL.Record review of Resident #2's face sheet dated 10/21/25 revealed a [AGE] year-old admitted to the facility on [DATE] and originally admitted on [DATE]. His diagnoses included chronic pulmonary edema (abnormal buildup of fluid in the lungs), diabetes, PVD (peripheral vascular disease: a slow progressive disorder of the blood vessels), aftercare following surgery on the nervous system, fracture of the vertebrae and anxiety. Record review of Resident #2's annual MDS dated [DATE] revealed a BIMS score of 9 out of 15 indicating moderate cognitive impairment. Resident #2 required substantial/maximum assistance with toilet hygiene. Resident #2 was frequently incontinent of bowel and bladder. Section M of the MDS revealed Resident #2 had a diabetic foot ulcer.Record review of Resident #2's undated care plan included: Focus - Resident #2 has bowel and bladder incontinence which places him at risk for skin breakdown and UTI. Interventions included - the resident uses disposable briefs, change as needed. Check the resident during rounds and as required for incontinence. Wash, rinse and dry perineum. Focus - Enhanced Barrier Precautions, at risk for infection r/t wounds. Interventions included sanitize hands before entering and leaving the resident's room, wear gloves and gown during high-contact care activities for residents with indwelling medical devices, wounds. Focus - Resident #2 has actual impairment to skin Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 19 of 22 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 10/27/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some integrity r/t diabetic ulcer to the left first toe. Interventions included - administer treatment as ordered, follow facility protocols for treatment of injury. Focus - Resident #2 has an ADL self-care performance deficit r/t weakness and Myasthenia Gravis (muscle weakness and fatigue). Interventions included Resident #2 required substantial/maximum assistance with transfers, use Hoyer (a mechanical lift).Record review of Resident #2's progress note dated 10/23/25 and written by RN G revealed Resident #2 had a reopened diabetic wound to toes on the left foot.Record review of Resident #3's face sheet dated 10/27/25 revealed a [AGE] year-old admitted to the facility on [DATE] and originally admitted on [DATE]. Her diagnoses included orthopedic aftercare following surgical amputation, paraplegia (paralysis of the legs and lower body), anemia, diabetes, obesity, neuromuscular dysfunction of the bladder (when an injury or disease interrupts the electrical signals between your nervous system and bladder function) and colostomy status. Record review of Resident #3's quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Resident #3 required supervision for toileting hygiene and personal hygiene. Resident #3 required substantial assistance with lower body dressing. Resident #3 had pressure injuries.Record review of Resident #3's undated care plan included: Focus - Resident #3 had a suprapubic catheter r/t neuromuscular dysfunction of the bladder. Interventions included - Change/empty catheter as indicated. Monitor and document intake and output as per facility policy. Focus - Resident #3 has a colostomy; resident is known to change own colostomy bag. Interventions included - notify nurse if wafer or pouch detaches or becomes loose. Focus - Enhanced Barrier Precautions, at risk for infection r/t wounds. Interventions included - sanitize hands before entering and leaving the resident's room, wear gloves and gown during high-contact care activities for residents with indwelling medical devices, wounds. Focus Resident #3 has a pressure injury stage 4 to right buttocks and stage 3 pressure injury to the sacrum with potential for further pressure injury development. Interventions included - check/observe dressing to ensure it is intact and adhering. Report loose dressing to treatment nurse. Focus - Resident has actual impairment to skin integrity r/t surgical wound to right posterior lower leg. Interventions included - assist resident with turning and repositioning during rounds. Focus - Resident #3 has an ADL self-care performance deficit r/t Lupus (an autoimmune disease). Interventions included Resident #3 was dependent with transfers using the mechanical lift.Observation of peri care for Resident #2 on 10/22/25 at 9:20 AM, revealed an EBP sign on the door. CNA B and CNA H sanitized hands and put on clean gloves. Resident #2 had loose stools. CNA B and CNA H performed peri care. Resident #2 had a wound on the toes of the left foot. The wound was dressed with a bandage. The wound had drainage that had dried onto the sock. After peri care CNA H performed hand hygiene prior to leaving the room. After peri care was completed CNA B removed the gloves, picked up the garbage bag, walked to the dirty utility room and placed garbage bag into the barrel then walked to Resident #3's room where CNA C was performing resident care. Observation on 10/22/25 at 10:00AM, revealed an EBP sign on Resident #3's door. Observed CNA C empty urine from Resident #3's foley catheter bag. CNA C had gloves on and no gown.Observation on 10/22/25 at 10:05AM, CNA H moved the mechanical lift from Resident #3's room into the hallway. The mechanical lift was not sanitized. CNA B moved the mechanical lift from the hallway to Resident #2's room. CNA B and CNA H donned gloves and transferred Resident #2 into the wheelchair using the resident's individual sling the mechanical lift. In an interview on 10/22/25 at 10:25AM, CNA H stated the sign for EBP was to be followed during direct contact with a resident when doing resident care. CNA H stated she did not put on a gown during care for Resident #3 because the resident did a lot of her own care but then stated that she did change Resident #3's brief and should have put on a gown for infection control. CNA H stated Resident #3 did have a wound, a colostomy and a urinary catheter. When (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 20 of 22 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 10/27/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some asked what should happen after using the mechanical lift on a resident and before using on another resident, CNA H stated she was PRN staff and usually only performs medication aide tasks but she would wipe down her cart for infection control reasons.In an interview on 10/22/25 at 10:30AM, CNA B stated the EBP sign was for Resident #2's former roommate who was in the hospital and that the sign was not for Resident #2. CNA B stated Resident #2 had loose stools and she should have washed her hands with soap and water as it would be best for infection prevention, prior to leaving the room. CNA B stated she just forgot to and was just not thinking as she was often in a rush. CNA B stated moving forward she would take the time and make sure she washed her hands with soap and water after peri care and prior to leaving the resident's room. CNA B stated she sanitized her hands before putting on gloves to assist CNA C with Resident #3.In an interview on 10/22/25 at 10:40 AM, LVN D stated the EBP signage was for residents who have open wounds, anything that has pierced the skin, any residents with appliances such as colostomies and urinary catheters. LVN D stated she expected nursing staff to wash hands prior to and after peri care. LVN D stated Resident #2 had an EBP sign on the door due to a wound on the toe. LVN D stated the mechanical lift should be sanitized between resident use and that the risks would be transfer of germs from one resident to another. LVN D stated she would re-educate the CNAs on infection control practices.In an interview on 10/22/25 at 10:55 AM the DON stated the EBP and PPE are required when doing close bodily contact with residents who, for example have g-tubes (feeding tubes) or wounds and that the risks to the residents was infection and cross-contamination. The DON stated her expectations that the nursing staff wash hands before leaving the resident room when providing peri care. The DON stated the mechanical lift was moved around the building a lot when used and should be cleaned by wiping down using disinfectant wipes to help stop the spread of infection and transfer of germs. The DON stated she expected nursing staff to wear gloves, gown, and mask when emptying urine from a catheter bag. The DON stated gown and gloves provide barriers from germs that nursing staff encounter and that germs are spread by what are on bodies so wearing PPE helps ensure germs are not carried to residents who may be susceptible to infection.Observation of peri care for Resident #1 on 10/24/25 at 6:45AM, CNA A closed the door and gathered supplies. Resident #1 was alert, oriented and lying on his back with pillows under his knees watching TV. CNA A removed gloves from her pocket and put them on. CNA A told Resident #1 that she was going to clean him up. CNA A helped Resident #1 remove his pants, lowered the head of the bed, unfastened the tabs on the brief, performed peri care, cleansed the perineal area, buttocks then disposed of the soiled brief. CNA A removed gloves, disposed them into trash can, removed gloves from her pocket and put them on. CNA A proceeded with applying a clean brief and assisted the resident with dressing. CNA A and CNA F transferred the resident from the bed to the wheelchair. CNA A removed gloves. CNA A did not perform hand hygiene. CNA A assisted Resident #1 to the dining room by pushing the wheelchair using her hands. CNA A touched a chair and moved it, walked to where the ice chests were and lifted the lids using her hands then walked to the nurse station. CNA A then walked down the hall to Resident #1's room put on clean gloves and began to clean up.In an interview on 10/24/25 at 7:15 AM, CNA A stated the facility policy was to wash or sanitize hands prior to entering resident rooms and stated she did that when she was down the hall before entering Resident #1's room. CNA A stated she should have sanitized between glove changes for infection control and she did not do this because it skipped her mind. CNA A stated she kept gloves in her pocket because some rooms did not have her size gloves. CNA A stated she did not always keep gloves in her pocket. CNA A stated it was not hygienic to keep gloves in pockets and it was not an encouraged habit. CNA A stated she was unaware there was a box of extra large gloves available in the doorway. CNA A stated she was supposed to perform hand (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676263 If continuation sheet Page 21 of 22 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 10/27/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete hygiene prior to leaving Resident #1's room but got nervous. CNA A stated the risk of not doing hand hygiene was the germs from hands can get onto items touched and a resident could get infected if they touch the same items.In an interview on 10/27/25 at 12:30 PM, the DON stated she expected nursing staff to change gloves, sanitize or wash hands to prevent infection as much as possible any time they are working from a clean area to a dirty area such as during peri care. The DON stated the CNAs may have been rushing through their work and did not perform hand hygiene as she expected. The DON stated she expected the nursing staff to wash their hands, change gloves to help prevent UTI. The DON stated residents who have a long history of UTIs, and the elderly population are examples or residents who are susceptible to UTIs.Record review of the facility's policy on Enhanced Barrier Precaution, effective date April 1, 2024 revealed in part: The policy outlines the guidelines and procedures to implement enhanced barrier precautions to prevent the spread of infectious diseases among residents and staff. Definitions, Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. EPB are indicated for residents with any of the following:.Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: Dressing.Transferring.changing briefs.Device care or use.urinary catheter.Wounds generally include chronic wounds.examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds.Record review of the facility policy for Perineal Care, revised in December 2011, read in part: The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition.Steps in the Procedure.2. Wash and dry your hands thoroughly.Put on gloves.12. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 13. Put on clean gloves and place new brief and secure in place.18. Remove gloves and 19. Wash and dry your hands thoroughly.Record review of the facility's policy for Using a Mechanical Lifting Machine, revised July 2017, read in part: .Lift Care: 1. Disinfect lift surfaces. 2. Wipe with a clean towel until dry. Event ID: Facility ID: 676263 If continuation sheet Page 22 of 22