Health inspection·October 2, 2023

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a baseline care plan within 48 hours that included the minimum healthcare information necessary to properly care for the immediate needs of 1 of 18 residents, (Resident #131), in that: -The facility failed to ensure Resident #131's ADLs were included in her baseline care plan. This failure placed residents at risk of not receiving adequate care in a timely manner. Findings include: Record review of Resident #131's face sheet revealed a [AGE] year-old female who was admitted into the facility on 9/25/2023 and was diagnosed with hyperlipidemia, Crohn's disease (chronic inflammatory disease of the intestines), type II diabetes mellitus and presence of an artificial left knee joint. Record review of Resident #131's baseline care plan, undated, revealed the resident did not have a care plan documented to inform staff of what level of assistance was needed for all ADLs, including toileting. Interview with Resident #131 on 09/26/2023 at 3:50 PM, she said her concern at this facility was that she waited a while to be changed. Interview with Medical Records on 09/29/2023 at 2:10 PM, she said she reviewed Resident #131's medical records upon request of the surveyor, made by 0/29/2023 at 2:05 PM, and found there was no baseline care plan for her. Interview with the DON on 10/02/2023 at 2:00PM, she said baseline care plans were supposed to be in place within 48 hours. She said she just learned today, that admitting nurses were responsible for adding care areas to the baseline care plan under assessment. She said there was no one person in charge of ensuring care plans were done, but care plans and MDS for residents were to be completed by the nurse management team, including herself, the MDS nurse, and unit managers. She said before the recent change in facility management, they used to have two MDS nurses to help with care plans, but found out 30 -45 days into her role as the DON that she and nursing management should have been involved in updating the resident's care plans. She said, oxygen use, tube feeding care, dementia care and ADLs were all care areas that were supposed to be care planned to inform the nursing team on what care was to be provided to the residents. She said without a care plan in place, the staff may not be able to know the details of which care was to be provided to each patient. Interview with the MDS Nurse on 10/02/2023 at 2:17PM, he said he had been here for 2.5 months. Baseline care plans were supposed to be started within 48 hours. He said he did not do the care plans as much as he had done in other facilities, but the unit managers at the facility did most of the care planning, alongside the DON. He said he had no part in auditing or monitoring to ensure care plans were completed on time. He said, however, he could add to care plans during morning meetings if there was an issue mentioned during the meeting. He also said he had a hard time completing MDS assessments due to the nurses not completing the weekly nursing assessments, which was the main document he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 2 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 referred to for the MDS in general. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy on Patient Care Management System, undated, revealed, 4. A Baseline, Person-centered Plan of Care for each patient that includes the instructions needed to provide effective and person-centered care of the patient that meet professional standards of quality care. The baseline care plan must be initiated within 48 hours of admission (including re-admission). The care plan must include Initial goals be based on admission orders, physician orders, dietary orders, therapy services, social services and PASRR recommendation if applicable. The Baseline Care Plan must be derived from the Nursing Assessment Form, Fall Assessment, Braden Assessment, Bowel/Bladder Assessment, Pain Assessment and Medication orders. If the comprehensive, Person-centered plan of care is developed within 48 hours of admission the baseline care plan is not required . The interdisciplinary Care Plan team members includes but is not limited to the attending physician, the RN with responsibility for the Patient/Resident, a nurse aide with responsibility for the Patient/Resident, a member of food and nutrition services staff, participation of the Patient/Resident and Patient's/Resident's representative, and other appropriate staff or professionals as determined by the Patient's/Resident's needs. Residents Affected - Few ? Consultation with the Patient and the Patient's representative must include: 1. The Patient's goals for admission and desired outcomes. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 3 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan describing services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 18 residents, (Resident #132 and Resident #40), in that: Resident #132 was not care for dementia diagnosis. Resident #40 was not care planned for PEG tube and oxygen use. This failure placed residents at risk of not receiving adequate medical care in a timely manner. Findings include: Resident #132 Record review of Resident #132's face sheet revealed an [AGE] year-old female admitted on [DATE] and was diagnosed with dementia, major depressive disorder, restless leg syndrome and GERD. Record review of Resident #132's MDS assessment, dated 09/08/2023, revealed the resident's BIMS score was 8, indicating the resident's cognition was moderately impaired and the resident was marked to have non-alzheimer's dementia. Record review of the care plan on 09/27/2023, revealed the resident did not have care areas and interventions related to dementia. Observations of Resident #132 on 09/26/2023 at 10:37AM, revealed the resident sitting in her wheelchair at the nurses stations behind LVN R. Interview with RN B Won 09/26/2023 at 10:37AM, he stated the resident had to sit out at the nurses stations because she needed increased supervision for her falls. Resident #40 Record review of Resident #40's face sheet revealed a [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with Parkinson's disease and dysphagia (difficulty swallowing). Record review of admission MDS, undated but accepted 9/4/23, revealed the resident was assessed to have a BIMS score of 14, indicating the resident's cognition was intact. The resident was assessed to have a feeding tube. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 4 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #40's physician orders revealed the resident was ordered Oxygen at 4L/min per nasal cannula by shift starting 08/31/2023. Record review of Resident #40's care plan, undated, revealed the care plan did not mention tube feeding care or oxygen use. Residents Affected - Some Record review of Resident #40's physician orders revealed the resident had an order for -Isosource HN 0.05 gram-1.2 kcal/mL liquid for tube feed every shift at 75ML/he via G-tube. -Oxygen per nasal cannula at 4L/min every shift. Observations of Resident #40 revealed the resident was lying in bed with his tube feeding running via PEG tube and his oxygen cannula on with oxygen set to 4 L/min. Record review of the facility's policy on Patient Care Management System, undated, revealed, . 6. A Comprehensive, Person-centered Plan of Care, consistent with the resident rights must be completed by the 21st day after admission (or, within 7 days of the CAA completion date), and must include discharge planning, as appropriate. Each Care Plan must be reviewed and updated by the interdisciplinary Care Plan team quarterly, upon each change in condition and upon re-admission. The care plan must be based on assessments completed within the previous 15 months in the Patient's/Resident/s active record and use the results of the assessments to develop, review and revise the Patient's/Resident's comprehensive care plan. The interdisciplinary Care Plan team members includes but is not limited to the attending physician, the RN with responsibility for the Patient/Resident, a nurse aide with responsibility for the Patient/Resident, a member of food and nutrition services staff, participation of the Patient/Resident and Patient's/Resident's representative, and other appropriate staff or professionals as determined by the Patient's/Resident's needs. ? Consultation with the Patient and the Patient's representative must include: 1. The Patient's goals for admission and desired outcomes. 2. The Patient's preference and potential for future discharge. (Documentation of the Patient's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities). 3. Discharge plans in the comprehensive care plan. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 5 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure pain management was provided to and monitored for 2 of 4 residents (Resident #128 and Resident #228), in that: Residents Affected - Few -Resident #128 experienced pain after admission without her ordered Oxycodone available for use. -Resident #228 verbalized pain that without and pharmacological or non-pharmacological treatment offered to him. An Immediate Jeopardy (IJ) was identified on 09/27/2023 at 11:15AM. While the IJ was removed on 09/29/2023 at 06:37 PM, the facility remained out of compliance at a scope and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure caused Resident #128 and #228 to experience pain that went unmanaged and placed additional residents at risk for experiencing unmanaged pain. Findings include: Resident #128 Record review of Resident #128's face sheet revealed a [AGE] year old female who was admitted into the facility on [DATE] and was diagnosed with anxiety disorder, dementia, and the presence of an artificial left hip joint. Record review of Resident #128's hospital discharge 7-day medication summary, dated 09/23/2023, revealed the resident was ordered Oxycodone 2 - 5mg tablets every 4 hours PRN for pain score 7-10 starting on 09/21/2023 with her last dose given in the hospital by 09/23/2023 at 11:52AM. Record review of Resident #128's physician's orders revealed the resident was ordered: 1. Acetaminophen 2-500 mg tablets every 6 hours on 09/04/2023 at 7AM. 2. PRN Oxycodone 5mg tablet every 4 hours as needed for pain score 7-10 starting 09/24/2023 at 7AM. 3. Tramadol 50mg tablet one time daily only one time on 09/25/23 at 11:59PM. 4. pain assessment every shift starting on 09/24/2023 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 6 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of Resident #128's TAR revealed the resident had orders for a pain scale assessment every shift starting on 09/24/2023. LVN J checked off that pain assessment was done on 09/24/2023 but did not document a number on the scale of 0 - 10. Record review of Resident #128's clinical note, dated 09/23/2023 11:34PM, revealed LVN H noted Resident #128, . arrived to facility via EMS . Left hip replacement. Uses walker to ambulate, Not happy about her pain meds being unavailable and wanting to go back to the hospital until we get her pain meds. Stable. Pain 10/10. Surgical wound to left hip. Resting in bed with call light within reach . Record review of Resident #128's clinical notes, revealed in September 2023, there were no other notes about the resident's pain aide from her admission note on 09/23/2023 at 11:34PM. Record review of the Resident #128's progress note, dated 09/25/2025, written by NP D, revealed he documented, . Patient is a [AGE] year-old female with past medical history of significant for longstanding left hip and back pain. She presented for elective hip surgery . Patient is seen and evaluated today while laying in bed. She is complaining of pain to left hip. Given Tylenol but not effective. Declined to attend therapy session until stronger pain medication was administered . Record review of Resident #128's hospital discharge 7-day medication summary, dated 09/23/2023, revealed the resident was ordered Oxycodone 2 - 5mg tablets every 4 hours PRN for pain score 7-10 starting on 09/21/2023 with her last dose given in the hospital by 09/23/2023 at 11:52AM. Observation of Resident #128 on 09/26/2023 at 10:52AM, revealed the resident sitting up on the side of her bed wearing a hospital gown. Interview with the Resident #128 on 09/26/2023 at 10:52AM, she said she was dumped there from the hospital on Saturday 09/23/23 where there was no in-house pharmacy to access her Oxycodone. She said .why put me here if her medications would not be here? She said she needed her pain medications to allow her to move and get physically fit enough to discharge from the nursing home. She said she was in absolute tears and in excruciating pain over the weekend from her hip replacement and all they had to offer her was Tylenol, but she kept refusing it because it did not work for her. She said they gave her some other unknown medication recently, but she was not sure if it worked because it put her to sleep shortly after. She said she rather go back to the hospital at this point to get her pain medication. Record review of Resident #128's physician's orders revealed the resident was ordered: 1. Acetaminophen 2-500 mg tablets every 6 hours on 09/04/2023 at 7AM. 2.1. PRN Oxycodone 5mg tablet every 4 hours as needed for pain score 7-10 starting 09/24/2023 at 7AM. 3.1. Tramadol 50mg tablet one time daily only one time on 09/25/23 at 11:59PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 7 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 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 0697 4.1. Level of Harm - Immediate jeopardy to resident health or safety pain assessment every shift starting on 09/24/2023 Residents Affected - Few Record review of Resident #128's clinical note, dated 09/23/2023 11:34PM, revealed LVN H noted Resident #128, . arrived to facility via EMS . Left hip replacement. Uses walker to ambulate, Not happy about her pain meds being unavailable and wanting to go back to the hospital until we get her pain meds. Stable. Pain 10/10. Surgical wound to left hip. Resting in bed with call light within reach . Record review of Resident #128's TAR revealed the resident had orders for a pain scale assessment every shift starting on 09/24/2023. LVN J checked off that pain assessment was done on 09/24/2023 but did not document a number on the scale of 0 - 10. Record review of Resident #128's clinical notes, revealed in September 2023, there were no other notes about the resident's pain aide from her admission note on 09/23/2023 at 11:34PM. Record review of the Resident #128's progress note, dated 09/25/2025, written by NP D, revealed he documented, . Patient is a [AGE] year-old female with past medical history of significant for longstanding left hip and back pain. She presented for elective hip surgery . Patient is seen and evaluated today while laying in bed. She is complaining of pain to left hip. Given Tylenol but not effective. Declined to attend therapy session until stronger pain medication was administered . In a phone interview with a Pharmacist on 09/26/23 at 2:10PM, he stated he had just received the electronic script from the doctor less than an hour ago. He said Oxycodone is a CII medication, if there was no script for it, it could not be sent out to the nursing home, and the admission nurse should have known this. If the script was sent upon admission, then the medication could have been delivered the same day. Interview with the DON on 09/26/2023 at 2:34PM, she reported that acquiring medication had been an ongoing problem since she started working in the facility in July 2023. She said she could not say how quickly she expected the scripts to be sent but the admitting nurses were responsible for calling the pharmacy and following up if a medication was needed stat. She said the situation involving Resident #128 was never brought to her attention until then. Interview with LVN Q on 09/26/2023, she said she called the pharmacy on 09/26/23 at 11:27 AM that morning. She said she worked with Resident #128 for the first time on Monday, 09/25/23. She revealed she texted the NP on 9/25/23 at 8:47AM reminding him to send a triplicate for the resident's medication, but she believed the doctor forgot to send it. She said there were orders to check Resident #128's pain level every shift but she never performed or documented pain assessments because whenever she went in her room, Resident #128 would all already be complaining of her pain. Interview with NP D, on 09/26/23 at 3:00 PM, he said he was messaged by LVN Q yesterday about Resident #128's oxycodone. He said he sent the script out on 09/25/23 but there could have been an issue with the system if the pharmacy did not receive it then. He said he was not reminded by the nurse again until that morning, on 09/26/23. He said the resident reported to him in the morning on 09/26/2023 that her pain was still at a 10/10 and the Oxycodone had been ordered today and was in route to arrive in the facility by tonight. He stated the risks of delayed acquiring of pain medication is the resident remaining in pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 8 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview with LVN Q on 09/27/2023 at 1:46 PM, she said Resident #128 did not perform a pain scale assessment on 09/24/23 because the resident did not complain of pain to her only tenderness during her shift. In a phone interview with LVN H on 09/27/2023 at 2:06PM, she stated she was the admitting nurse for Resident #128 who came into the facility around 7:00PM on 09/23/2023. She stated she texted the Physician the resident's hospital discharge medication list. She said the Physician approved her to fax the medication list to the pharmacy but she did not follow up to see if the pharmacy received the fax. She said she did not bother to follow up because it typically took two days to receive ordered medications from the pharmacy over the weekends. Interview with LVN H, on 09/29/2023 at 6:22PM, she said she gave Resident #128 gabapentin and Tylenol on 09/23/2023 after she made complaints about her pain. She said when she went back an hour later to follow up with the resident, she was sleeping. She said on Sunday she reported to LVN J, the day nurse, that Resident #128 refused to take her pain meds in the morning of 09/24/2023. She said the order she received, was supposed to be faxed the pharmacy with state written on the list printed directly from the system. She said she did not call to follow up with the pharmacy and verify the fax was received. She said because it usually took days to get ordered medication in general, she did not think about acquiring the Oxycodone as soon as possible especially after Resident #128 did not have any additional complaints of pain on Sunday, 09/24/2023. Record review of Resident #128's TAR, dated September 2023, revealed resident's first dose of Oxycodone in the facility was not administered until 09/26/2023 at 8:00 PM. Resident #228 Record Review of Resident #228's Face Sheet revealed a [AGE] year-old male with a diagnosis of Acute Kidney Failure. Other diagnoses were Pain, Constipation, and other General Symptoms. Record Review of Resident # 228's Care Plan dated 9/26/2023 to present read in part . PROBLEMS . Pain Management (Acute) (Chronic) STATUS: Active (Current) . will achieve an acceptable level of pain control. Record review of Resident #228's nursing notes dated 9/23/2023 6:09pm revealed Resident #228 was admitted from hospital to facility on 9/23/2023 with diagnosis of Obstructive Uropathy (Blocked Urinary Flow), Benign Prostatic Hypertrophy (Enlarged Prostate), and Foley Catheter. Notes reveal resident had pain of 7 out of 10 under his left knee. On 9/26/2023 10:00 am Surveyor observed Resident #228 in bed moaning. Interview on 9/26/2023 at 10:01am with Resident #228 he said he was in pain and the only medication they gave him was acetaminophen and it did not work for him. He said they should have known he was in pain. On 9/26/2023 at 11:03am surveyor reviewed nursing notes dated 9/24/2023 at 11:08am for Resident #228, resident requested pain medication from nursing and was administered acetaminophen. Resident #228 had become upset when acetaminophen was offered for pain. Resident was informed acetaminophen was the only medication prescribed for his pain and resident informed nursing the acetaminophen was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 9 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few enough medication to control his pain. LVN J outreached physicians phone number and was informed they do not prescribe pain medications over the weekend and the resident would have to wait until Monday when he would be seen by the physician. Resident was informed of this answer. Record review on 9/26/2023 at 2:00 pm revealed no documented follow up for Resident #228's pain control. Interview on 9/26/2023 at 4:00pm with LVN Q she said it was not relayed to her in report that Resident #228 needed something other than acetaminophen for pain over the weekend. She said the resident rating for pain on the pain scale was an 8 today and she had administered acetaminophen. Interview on 9/27/2023 at 9:03am with LVN J she said she had been a nurse for about a year and had worked at the facility since February, she said she called the NP on Sunday 9/24/2023 and spoke with two different people to get pain medication for Resident #228. She said she called more than once. She said they could not initially find Physician #1 in the system. She said they could not prescribe the resident anything and they would have to talk to the doctor on Monday. LVN J said the NP was on call the past weekend on Sunday 9/24/23. She said they told her he would not be able to call back until Monday 9/25/2023. She said the facility referred to all the nurses as charge nurses on the weekend. LVN J said there was no charge nurse or manager on the weekend. She said the DON and ADON were on call over the weekend and she did not call them because they could not do anything to help. She said when she was hired, she was not oriented to the facility and had never been in-serviced on pain management. Interview on 9/27/2023 at 9:08:am with the Unit Manager she said the nurses were in charge over the weekend. She said there was a manager on duty as well. She said she and the DON were on call over the weekend and they were in the process of hiring an ADON. She said the process for narcotics was the on-call physician prescribed narcotics over the weekend. She said the nurses go to the physician's binder and get the on-call number for the weekend. They get the order and put it in the computer, print the order, fax the order to pharmacy and do a follow up phone call. The Unit Manager said they did have some narcotics in their lock box. She said if nurses could not get pain management, they are supposed to call the DON and they would call the Medical Director. She said she had been a nurse for 26 years and had worked at the facility since July of 2023. She said the last in-service on pain management was yesterday 9/26/2023 after the surveyors arrived. She said there were no in-services on pain management prior to the surveyors arriving. She said prior to that they went by word of mouth or did a one-to-one conference. Record review of the facility's policy on pain management, dated March 2016, stated: .5. A Pain Assessment must be completed for a Patient upon admission, including re-admission, the onset or an increase in Pain, quarterly and with any significant change in the Patient's condition. 6. Every Patient must be assessed for pain utilizing the Pain Intensity Scale (Faces/ 0-10) or PAINAD for the non-verbal, cognitively impaired patient. a) Every shift 7. If a Patient's Pain intensity score is 1 or has been assessed with non-verbal/non-cognitive signs of Pain; the Pain must be addressed through pharmacological and/or non-pharmacological Pain interventions and documented. An Immediate Jeopardy (IJ) was identified on 09/27/2023 at 11:15 PM. On 09/27/2023 at 4:20PM the Administrator was notified of the IJ. The IJ template was left with the Administrator and a plan of removal (POR) was requested at that time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 10 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 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 0697 The POR was accepted on 09/28/2023 at 5:12 PM. The POR revealed: Level of Harm - Immediate jeopardy to resident health or safety F-697 Pain Management Residents Affected - Few Assessment Systematic Approach: Resident #128 did not receive pain management on 9-23-23. Resident has orders for Acetaminophen 500mg 2 tablets every 6 hours as needed and Oxycodone 5mg tablet every 4 hours as needed. Resident #128 was offered Acetaminophen but she refused. Oxycodone 5mg was not available. Facility received Oxycodone on afternoon of 9/26/23. Resident received Oxycodone at 8:00pm 9/26/23. Oxycodone order verified Q4hrs x 7 day. On 9/27/23 at 4:30pm Resident immediately assessed for pain, pain level noted at 0. Care plan reviewed, no changes needed. The Director of Nursing notified the facility Medical Director of the Immediate Jeopardy on 9/27/23 at 4:30 pm. All residents pain medication will be audited by the Director of Nursing, Unit Manager, Treatment Nurse and/or Patient Care Coordinator by 9/27/2023 to identify any current residents that are missing their pain medication. After completion of pain medication audit, no other residents were found to be missing pain medication. The pain medication audit includes the following information: Checking the pain medication order against the medication in the cart. The pain medication audit is to determine if any resident is missing pain medication. Who will be responsible: Nurse Managers. Who Will monitor: Director of Nursing/Regional Director of Clinical Services. Completion Date: By 9/27/23 and ongoing thereafter. Actions Actions taken for the incident involving Resident #128 include the following: All resident's were assessed for pain as of 9/27/2023 and for any for pain medication needs by the RDCS/DON/Nurse. The result of this reflected no other residents were identified with pain that was not being managed. All facility licensed nursing staff (RNs and LVNs) have received in services on pain assessments and pain management on 9/27/2023. All licensed nurses will be required to complete the in service prior to working their next shift for those who are not present in the facility on 9/27/2023. All new licensed nurses will receive the in services on pain assessments and pain management as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 11 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few part of the onboarding orientation process. The in-services will be completed before the employee works with residents. All newly admitted residents will have a medication review reports daily Monday - Friday during morning clinical stand-up meeting, and Wknd Supervisor and/or designee will review Saturday and Sunday to ensure pain medication that is needed has been ordered and delivered to prevent neglect related to pain management. In-Services All licensed nurses were educated on pain assessments and pain management and to notify the Physician and Director of Nursing immediately of residents' with any pain that is not being managed. This education was provided by the Regional Director of Clinical Services and/or designee by 9/28/2023. All licensed nurses will not be allowed to begin their shift until the education has been completed. The DON and RDCS will be responsible to ensure education has been completed. Each licensed nurse completed a post-test after their education was completed to ensure staff were able to identify pain management needs. If the employee did not pass the test with at least 90% correctly answered the staff member was re-educated and re-tested until at least 90% pass rate was met. A staff roster was utilized to ensure 100% of licensed nursing staff were in-serviced and tested. In-services were deemed to be effective by the in-services post-test scores and verbalization of understanding by all facility staff (clinical, non-clinical and ancillary). Who will be responsible: Nurse Managers Who Will monitor: Director of Nursing. Completion Date: 9/28/2023 Policy and Procedures Policy and procedures were reviewed by Senior [NAME] President of Operations, [NAME] President of Clinical Services, Regional Director of Clinical Services, Senior Executive Director and Director of Nursing. These policies included Neglect, Pain Management and Pharmacy Services. No policies needed any revisions. Monitoring: Record review of six sampled residents revealed pain assessments were completed by 09/27/2023. Record review of six sampled residents' clinical records revealed for all six residents, their pain medications were reconciled from hospital discharge order records, and residents had orders in place for pain scale assessments every shift. Observations of the med carts revealed that all ordered medication for six sampled residents were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 12 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 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 0697 on the carts. Level of Harm - Immediate jeopardy to resident health or safety Record review of in-services on 09/29/2023 revealed all nurses who worked since 09/27/2023 were trained on pain management policy and controlled substance policy, including how to order a script. Trainings were conducted by the RN, RDSC for LVNs, RNs, CMAs and the DON. 10 of 10 post-tests completed and passed. Residents Affected - Few Interview with day shift nurse, LVN S and Unit Manager, on 09/29/2023 at 5:00 PM, she said the pain intensity scale should be used on residents every shift, before and an hour after administration of pain medication and after an invasive procedure. She said pain intensity scores of at least 1 should be managed through use of pharmacological and non-pharmacological methods and documented in the skilled notes. She said if she was unable to obtain and order from the doctor, that she would notify the DON. Interview with day shift nurse, LVN J, on 09/29/2023 at 5:05 PM, she said the pain intensity scale should be used on residents every shift, before and an hour after administration of pain medication and after an invasive procedure. She said pain intensity scores of at least 1 should be managed through use of pharmacological and non-pharmacological methods and documented in the skilled notes. She said if she was unable to obtain and order from the doctor, that she would notify the DON. Interview with day shift nurse, LVN L, on 09/29/2023 at 5:08 PM he said the pain intensity scale should be used on residents every shift, before and an hour after administration of pain medication and after an invasive procedure. He said pain intensity scores of at least oned should be managed through use of pharmacological and non-pharmacological methods and documented in the skilled notes. He said if he was unable to obtain and order from the doctor, that he would notify the DON. Interview with the DON on 09/29/2023 at 5:30PM, she said on the weekends, or any time, the manager on duty was in the building was to assist the nurse in acquiring scripts for the pharmacy for new and current residents. She said the pain intensity scale should be done by nurses every shift and they address the pain as ordered. If there was no ordered pain medicine, they needed to contact the physician. She said examples of non-pharmacological pain management strategies included music, distraction, repositioning, and conversation. She said a pain scale was to be assessed when the complaint was made, as well as intensity and location, and after PRN meds are administered, the system would trigger to document follow up pain assessment for effectiveness. She said new orders came from the clinician (MD or NP), and if no order was provided upon request by nurse and manager on duty, they should contact DON to escalate this issue again to the doctor. She said if pain remained unresolved after all attempts, they would have conversation to with clinician to have the resident sent out to the hospital for care. Interview with day shift nurse, RN D, on 09/29/2023 at 5:53 PM, she said to acquire and order for new medication, you could always reach an NP in the case there was no on-call doctor. She said she can also utilized the E-kit for narco, tramadol, Tylenol 3 or morphine if ordered stat. She said if nothing could be done for the patient, they would send them out to ER for pain management. She said scripts were called in by the doctor by phone, and nurses sent the fax of the script request. She said she would follow up daily with the pharmacy and doctor to ensure a script was received. Interview with day shift nurse, LVN Q, on 09/29/2023 at 6:01 PM, she said new orders were called in over the phone by the doctor and faxed orders are printed of from their system. She said a text message was not acceptable for ordering medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 13 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview with night shift nurse, LVN P, on 09/29/2023 at 6:13 PM, she said she received training on pain management and was taught to assess for resident's pain every shift. She said in response to pain complaints, she would administer scheduled or PRN medications. She said she could utilize e-kit if doctor gave a new order. After the pain medication was administered, she would follow up with patient 30 minutes to an hour to reassess if pain was alleviated. She said she would offer residents needing pain management pharmacological and non-pharmacological methods to manage pain. She said to obtain an order and send a script to the pharmacy, she would call the doctor, medical director and DON if there was a failure to reach any of them, and she would call to follow up to ensure order was received. Verbal orders were put into the computer and then faxes of scripts were sent by them. Interview with night shift nurse, LVN H, on 09/29/2023 at 6:22 PM, she said she received training on pain management and was taught to notify the DON in the case she has trouble obtaining orders for pain management. She said pain assessments are to be every shift and when pain medication is administered, a pain assessment should be done within the hour afterwards to ensure medication managed the pain. The immediate Jeopardy (IJ)was lowered on 09/29/2023 at 6:37 PM. While the IJ was removed 09/29/2023 at 6:37PM, the facility remained out of compliance at a scope of actual harm. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 14 of 32 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 676357 B. Wing (X3) DATE SURVEY COMPLETED A. Building 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 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 - Immediate jeopardy to resident health or safety 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 to meet the resident needs when the facility did not acquire the prescribed pain medications for 2 of 4 residents (Resident #128 and Resident #228) reviewed for medication administration, in that: -Resident #128 experienced pain after admission when her ordered Oxycodone was not available for use at the facility. -Resident #228 verbalized pain and was not offered pharmacological or non-pharmacological treatment to relieve his discomfort. An Immediate Jeopardy (IJ) was identified on 09/27/2023 at 11:15AM. While the IJ was removed on 09/29/2023 at 06:37 PM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure caused Resident #128 and #228 to experience pain that went unmanaged and placed additional residents at risk for experiencing unmanaged pain. Findings include: Resident #128 Record review of Resident #128's face sheet revealed a [AGE] year old female who was admitted into the facility on [DATE] and was diagnosed with anxiety disorder, dementia, and the presence of an artificial left hip joint. Record review of Resident #128's hospital discharge 7-day medication summary, dated 09/23/2023, revealed the resident was ordered Oxycodone 2 - 5mg tablets every 4 hours PRN for pain score 7-10 starting on 09/21/2023 with her last dose given in the hospital by 09/23/2023 at 11:52 AM. Record review of Resident #128's physician's orders revealed the resident was ordered: 1. Acetaminophen 2-500 mg tablets every 6 hours on 09/04/2023 at 7 AM. 2. PRN Oxycodone 5 mg tablet every 4 hours as needed for pain score 7-10 starting 09/24/2023 at 7 AM. 3. Tramadol 50mg tablet one time daily only one time on 09/25/23 at 11:59 PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 15 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 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 4. Level of Harm - Immediate jeopardy to resident health or safety pain assessment every shift starting on 09/24/2023 Residents Affected - Few Record review of Resident #128's TAR revealed the resident had orders for a pain scale assessment every shift starting on 09/24/2023. LVN J checked off that pain assessment was done on 09/24/2023 but did not document a number on the scale of 0 - 10. Record review of Resident #128's clinical note, dated 09/23/2023 11:34 PM, revealed LVN H noted Resident #128, . arrived to facility via EMS . Left hip replacement. Uses walker to ambulate, Not happy about her pain meds being unavailable and wanting to go back to the hospital until we get her pain meds. Stable. Pain 10/10. Surgical wound to left hip. Resting in bed with call light within reach . Record review of Resident #128's clinical notes, revealed in September 2023, there were no other notes about the resident's pain aide from her admission note on 09/23/2023 at 11:34 PM. Record review of the Resident #128's progress note, dated 09/25/2025, written by NP D, revealed he documented, . Patient is a [AGE] year-old female with past medical history of significant for longstanding left hip and back pain. She presented for elective hip surgery . Patient is seen and evaluated today while laying in bed. She is complaining of pain to left hip. Given Tylenol but not effective. Declined to attend therapy session until stronger pain medication was administered . Record review of Resident #128's hospital discharge 7-day medication summary, dated 09/23/2023, revealed the resident was ordered Oxycodone 2 - 5mg tablets every 4 hours PRN for pain score 7-10 starting on 09/21/2023 with her last dose given in the hospital by 09/23/2023 at 11:52 AM. Observation of Resident #128 on 09/26/2023 at 10:52 AM, revealed the resident sitting up on the side of her bed wearing a hospital gown. Interview with the Resident #128 on 09/26/2023 at 10:52 AM, she said she was dumped there from the hospital on Saturday 09/23/23 where there was no in-house pharmacy to access her Oxycodone. She said .why put me here if her medications would not be here? She said she needed her pain medications to allow her to move and get physically fit enough to discharge from the nursing home. She said she was in absolute tears and in excruciating pain over the weekend from her hip replacement and all they had to offer her was Tylenol, but she kept refusing it because it did not work for her. She said they gave her some other unknown medication recently, but she was not sure if it worked because it put her to sleep shortly after. She said she rather go back to the hospital at this point to get her pain medication. In a phone interview with a Pharmacist on 09/26/23 at 2:10 PM, he said he had just received the electronic script from the doctor less than an hour ago. He said Oxycodone is a CII medication, if there was no script for it, it could not be sent out to the nursing home, and the admission nurse should have known this. If the script was sent upon admission, then the medication could have been delivered the same day. Interview with the DON on 09/26/2023 at 2:34 PM, she reported that acquiring medication had been an ongoing problem since she started working in the facility in July 2023. She said she could not say how quickly she expected the scripts to be sent but the admitting nurses were responsible for calling the pharmacy and following up if a medication was needed stat. She said the situation involving (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 16 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 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 Resident #128 was never brought to her attention until then. Level of Harm - Immediate jeopardy to resident health or safety Interview with LVN Q on 09/26/2023, she said she called the pharmacy on 09/26/23 at 11:27 AM that morning. She stated she worked with Resident #128 for the first time on Monday, 09/25/23. She revealed she texted the NP on 9/25/23 at 8:47 AM reminding him to send a triplicate for the resident's medication, but she believed the doctor forgot to send it. She said there were orders to check Resident #128's pain level every shift but she never performed or documented pain assessments because whenever she went in her room, Resident #128 would all already be complaining of her pain. Residents Affected - Few Interview with NP D, on 09/26/23 at 3:00P M, he said he was messaged by LVN Q yesterday about Resident #128's oxycodone. He said he sent the script out on 09/25/23 but there could have been an issue with the system if the pharmacy did not receive it then. He said he was not reminded by the nurse again until that morning, on 09/26/23. He said the resident reported to him in the morning on 09/26/2023 that her pain was still at a 10/10 and the Oxycodone had been ordered today and is in route to arrive in the facility by tonight. He said the risks of delayed acquiring of pain medication is the resident remaining in pain. Interview with LVN Q on 09/27/2023 at 1:46 PM, she said Resident #128 did not perform a pain scale assessment on 09/24/23 because the resident did not complain of pain to her only tenderness during her shift. In a phone interview with LVN H on 09/27/2023 at 2:06 PM, she said she was the admitting nurse for Resident #128 who came into the facility around 7:00 PM on 09/23/2023. She said she texted the Physician the resident's hospital discharge medication list. She said the Physician approved her to fax the medication list to the pharmacy but she did not follow up to see if the pharmacy received the fax. She said she did not bother to follow up because it typically took two days to receive ordered medications from the pharmacy over the weekends. Interview with LVN H, on 09/29/2023 at 6:22 PM, she said she gave Resident #128 gabapentin and Tylenol on 09/23/2023 after she made complaints about her pain. She said when she went back an hour later to follow up with the resident, she was sleeping. She said on Sunday she reported to LVN J, the day nurse, that Resident #128 refused to take her pain meds in the morning of 09/24/2023. She said the order she received, was supposed to be faxed the pharmacy with state written on the list printed directly from the system. She said she did not call to follow up with the pharmacy and verify the fax was received. She said because it usually took days to get ordered medication in general, she did not think about acquiring the Oxycodone as soon as possible especially after Resident #128 did not have any additional complaints of pain on Sunday, 09/24/2023. Record review of Resident #128's TAR, dated September 2023, revealed resident's first dose of Oxycodone in the facility was not administered until 09/26/2023 at 8:00 PM. Resident #228 Record Review of Resident #228's Face Sheet revealed a [AGE] year-old male with a diagnosis of Acute Kidney Failure. Other diagnoses were Pain, Constipation, and other General Symptoms. Record Review of Resident # 228's Care Plan dated 9/26/2023 to present read in part . PROBLEMS . Pain Management (Acute) (Chronic) STATUS: Active (Current) . will achieve an acceptable level of pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 17 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 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 control. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #228's nursing notes dated 9/23/2023 6:09 pm revealed Resident #228 was admitted from hospital to facility on 9/23/2023 with diagnosis of Obstructive Uropathy (Blocked Urinary Flow), Benign Prostatic Hypertrophy (Enlarged Prostate), and Foley Catheter. Notes reveal resident had pain of 7 out of 10 under his left knee. Residents Affected - Few On 9/26/2023 10:00 am Surveyor observed Resident #228 in bed moaning. Interview on 9/26/2023 at 10:01 am with Resident #228 he said he was in pain and the only medication they gave him was acetaminophen and it did not work for him. He said they should have known he was in pain. On 9/26/2023 at 11:03 am surveyor reviewed nursing notes dated 9/24/2023 at 11:08am for Resident #228, resident requested pain medication from nursing and was administered acetaminophen. Resident #228 had become upset when acetaminophen was offered for pain. Resident was informed acetaminophen was the only medication prescribed for his pain and resident informed nursing the acetaminophen was not enough medication to control his pain. LVN J outreached physicians phone number and was informed they do not prescribe pain medications over the weekend and the resident would have to wait until Monday when he would be seen by the physician. Resident was informed of this answer. Record review on 9/26/2023 at 2:00 pm revealed no documented follow up for Resident #228's pain control. Interview on 9/26/2023 at 4:00 pm with LVN Q she said it was not relayed to her in report that Resident #228 needed something other than acetaminophen for pain over the weekend. She said the resident rating for pain on the pain scale was an 8 today and she had administered acetaminophen. Interview on 9/27/2023 at 9:03 am with LVN J she said she had been a nurse for about a year and had worked at the facility since February, she said she called the NP on Sunday 9/24/2023 and spoke with two different people to get pain medication for Resident #228. She said she called more than once. She said they could not initially find Physician #1 in the system. She said they could not prescribe the resident anything and they would have to talk to the doctor on Monday. LVN J said the NP was on call the past weekend on Sunday 9/24/23. She said they told her he would not be able to call back until Monday 9/25/2023. She said the facility referred to all the nurses as charge nurses on the weekend. LVN J said there was no charge nurse or manager on the weekend. She said the DON and ADON were on call over the weekend and she did not call them because they could not do anything to help. She said when she was hired, she was not oriented to the facility and had never been in-serviced on pain management. Interview on 9/27/2023 at 9:08 am with the Unit Manager she said the nurses were in charge over the weekend. She said there was a manager on duty as well. She said she and the DON were on call over the weekend and they were in the process of hiring an ADON. She said the process for narcotics was the on-call physician prescribed narcotics over the weekend. She said the nurses go to the physician's binder and get the on-call number for the weekend. They get the order and put it in the computer, print the order, fax the order to pharmacy and do a follow up phone call. The Unit Manager said they did have some narcotics in their lock box. She said if nurses could not get pain management, they are supposed to call the DON and they would call the Medical Director. She said she had been a nurse for 26 years and had worked at the facility since July of 2023. She said the last in-service on pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 18 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 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 - Immediate jeopardy to resident health or safety Residents Affected - Few management was yesterday 9/26/2023 after the surveyors arrived. She said there were no in-services on pain management prior to the surveyors arriving. She said prior to that they went by word of mouth or did a one-to-one conference. Record review of the facility's policy on pain management, dated March 2016, stated: .5. A Pain Assessment must be completed for a Patient upon admission, including re-admission, the onset or an increase in Pain, quarterly and with any significant change in the Patient's condition. 6. Every Patient must be assessed for pain utilizing the Pain Intensity Scale (Faces/ 0-10) or PAINAD for the non-verbal, cognitively impaired patient. a) Every shift 7. If a Patient's Pain intensity score is 1 or has been assessed with non-verbal/non-cognitive signs of Pain; the Pain must be addressed through pharmacological and/or non-pharmacological Pain interventions and documented. An Immediate Jeopardy (IJ) was identified on 09/27/2023 at 11:15PM. On 09/27/2023 at 4:20PM the Administrator was notified of the IJ. The IJ template was left with the Administrator and a plan of removal (POR) was requested at that time. The POR was accepted on 09/28/2023 at 5:12PM. The POR revealed: F-697 Pain Management Systematic Approach: Assessment Resident #128 did not receive pain management on 9-23-23. Resident has orders for Acetaminophen 500mg 2 tablets every 6 hours as needed and Oxycodone 5mg tablet every 4 hours as needed. Resident #128 was offered Acetaminophen but she refused. Oxycodone 5mg was not available. Facility received Oxycodone on afternoon of 9/26/23. Resident received Oxycodone at 8:00pm 9/26/23. Oxycodone order verified Q4hrs x 7 day. On 9/27/23 at 4:30pm Resident immediately assessed for pain, pain level noted at 0. Care plan reviewed, no changes needed. The Director of Nursing notified the facility Medical Director of the Immediate Jeopardy on 9/27/23 at 4:30 pm. All residents pain medication will be audited by the Director of Nursing, Unit Manager, Treatment Nurse and/or Patient Care Coordinator by 9/27/2023 to identify any current residents that are missing their pain medication. After completion of pain medication audit, no other residents were found to be missing pain medication. The pain medication audit includes the following information: Checking the pain medication order against the medication in the cart. The pain medication audit is to determine if any resident is missing pain medication. Who will be responsible: Nurse Managers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 19 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 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 Who Will monitor: Director of Nursing/Regional Director of Clinical Services. Level of Harm - Immediate jeopardy to resident health or safety Completion Date: By 9/27/23 and ongoing thereafter. Residents Affected - Few Actions taken for the incident involving Resident #128 include the following: Actions All resident's were assessed for pain as of 9/27/2023 and for any for pain medication needs by the RDCS/DON/Nurse. The result of this reflected no other residents were identified with pain that was not being managed. All facility licensed nursing staff (RNs and LVNs) have received in services on pain assessments and pain management on 9/27/2023. All licensed nurses will be required to complete the in service prior to working their next shift for those who are not present in the facility on 9/27/2023. All new licensed nurses will receive the in services on pain assessments and pain management as part of the onboarding orientation process. The in-services will be completed before the employee works with residents. All newly admitted residents will have a medication review reports daily Monday - Friday during morning clinical stand-up meeting, and Wknd Supervisor and/or designee will review Saturday and Sunday to ensure pain medication that is needed has been ordered and delivered to prevent neglect related to pain management. In-Services All licensed nurses were educated on pain assessments and pain management and to notify the Physician and Director of Nursing immediately of residents' with any pain that is not being managed. This education was provided by the Regional Director of Clinical Services and/or designee by 9/28/2023. All licensed nurses will not be allowed to begin their shift until the education has been completed. The DON and RDCS will be responsible to ensure education has been completed. Each licensed nurse completed a post-test after their education was completed to ensure staff were able to identify pain management needs. If the employee did not pass the test with at least 90% correctly answered the staff member was re-educated and re-tested until at least 90% pass rate was met. A staff roster was utilized to ensure 100% of licensed nursing staff were in-serviced and tested. In-services were deemed to be effective by the in-services post-test scores and verbalization of understanding by all facility staff (clinical, non-clinical and ancillary). Who will be responsible: Nurse Managers Who Will monitor: Director of Nursing. Completion Date: 9/28/2023 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 20 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 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 Policy and Procedures Level of Harm - Immediate jeopardy to resident health or safety Policy and procedures were reviewed by Senior [NAME] President of Operations, [NAME] President of Clinical Services, Regional Director of Clinical Services, Senior Executive Director and Director of Nursing. These policies included Neglect, Pain Management and Pharmacy Services. No policies needed any revisions. Residents Affected - Few Monitoring: Record review of six sampled residents revealed pain assessments were completed by 09/27/2023. Record review of six sampled residents' clinical records revealed for all six residents, their pain medications were reconciled from hospital discharge order records, and residents had orders in place for pain scale assessments every shift. Observations of the med carts revealed that all ordered medication for six sampled residents were on the carts. Record review of in-services on 09/29/2023 revealed all nurses who worked since 09/27/2023 were trained on pain management policy and controlled substance policy, including how to order a script. Trainings were conducted by the RN, RDSC for LVNs, RNs, CMAs and the DON. 10 of 10 post-tests completed and passed. Interview with day shift nurse, LVN S and Unit Manager, on 09/29/2023 at 5:00 PM, she said the pain intensity scale should be used on residents every shift, before and an hour after administration of pain medication and after an invasive procedure. She said pain intensity scores of at least 1 should be managed through use of pharmacological and non-pharmacological methods and documented in the skilled notes. She said if she was unable to obtain and order from the doctor, that she would notify the DON. Interview with day shift nurse, LVN J, on 09/29/2023 at 5:05 PM, she said the pain intensity scale should be used on residents every shift, before and an hour after administration of pain medication and after an invasive procedure. She said pain intensity scores of at least 1 should be managed through use of pharmacological and non-pharmacological methods and documented in the skilled notes. She said if she was unable to obtain and order from the doctor, that she would notify the DON. Interview with day shift nurse, LVN L, on 09/29/2023 at 5:08 PM he said the pain intensity scale should be used on residents every shift, before and an hour after administration of pain medication and after an invasive procedure. He said pain intensity scores of at least oned should be managed through use of pharmacological and non-pharmacological methods and documented in the skilled notes. He said if he was unable to obtain and order from the doctor, that he would notify the DON. Interview with the DON on 09/29/2023 at 5:30 PM, she said on the weekends, or any time, the manager on duty was in the building was to assist the nurse in acquiring scripts for the pharmacy for new and current residents. She said the pain intensity scale should be done by nurses every shift and they address the pain as ordered. If there was no ordered pain medicine, they needed to contact the physician. She said examples of non-pharmacological pain management strategies included music, distraction, repositioning, and conversation. She said a pain scale was to be assessed when the complaint was made, as well as intensity and location, and after PRN meds are administered, the system would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 21 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 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 - Immediate jeopardy to resident health or safety Residents Affected - Few trigger to document follow up pain assessment for effectiveness. She stated new orders came from the clinician (MD or NP), and if no order was provided upon request by nurse and manager on duty, they should contact DON to escalate this issue again to the doctor. She said if pain remained unresolved after all attempts, they would have conversation to with clinician to have the resident sent out to the hospital for care. Interview with day shift nurse, RN D, on 09/29/2023 at 5:53 PM, she said to acquire and order for new medication, you could always reach an NP in the case there was no on-call doctor. She said she can also utilized the E-kit for narco, tramadol, Tylenol 3 or morphine if ordered stat. She said if nothing could be done for the patient, they would send them out to ER for pain management. She said scripts were called in by the doctor by phone, and nurses sent the fax of the script request. She said she would follow up daily with the pharmacy and doctor to ensure a script was received. Interview with day shift nurse, LVN Q, on 09/29/2023 at 6:01 PM, she said new orders were called in over the phone by the doctor and faxed orders are printed of from their system. She said a text message was not acceptable for ordering medication. Interview with night shift nurse, LVN P, on 09/29/2023 at 6:13 PM, she said she received training on pain management and was taught to assess for resident's pain every shift. She said in response to pain complaints, she would administer scheduled or PRN medications. She said she could utilize e-kit if doctor gave a new order. After the pain medication was administered, she would follow up with patient 30 minutes to an hour to reassess if pain was alleviated. She said she would offer residents needing pain management pharmacological and non-pharmacological methods to manage pain. She said to obtain an order and send a script to the pharmacy, she would call the doctor, medical director and DON if there was a failure to reach any of them, and she would call to follow up to ensure order was received. Verbal orders were put into the computer and then faxes of scripts were sent by them. Interview with night shift nurse, LVN H, on 09/29/2023 at 6:22 PM, she said she received training on pain management and was taught to notify the DON in the case she has trouble obtaining orders for pain management. She said pain assessments are to be every shift and when pain medication is administered, a pain assessment should be done within the hour afterwards to ensure medication managed the pain. The immediate Jeopardy (IJ)was lowered on 09/29/2023 at 6:37 PM. While the IJ was removed 09/29/2023 at 6:37PM, the facility remained out of compliance at a scope of actual harm. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 22 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 8 % based on 3 errors out of 35 opportunities, which involved 2 of 6 residents (Resident #9 and Resident #13) reviewed for medication errors. Residents Affected - Some - RN C failed to observe Resident #13 self-administer her Fioricet with Codeine, a control substance used to treat headaches. - RN C failed to observe Resident #9 self-administer his Trelegy Ellipta inhaler, an inhaler used to treat COPD. - RN C failed to administer pre-meal HumaLOG insulin to Resident #9 due to the medication being unavailable. These failures could place residents at risk of not receiving the desired therapeutic effect of their medications and uncontrolled health conditions. Findings Include: Resident #13 Record review of Resident #13's Face Sheet dated 09/28/23 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: muscle weakness, pain and migraines. Record review of Resident #13's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 05 out of 15, independent with most ADLs, always continent of bladder and occasionally incontinent of bowel. Record review of Resident #13's undated Care Plan revealed, Problem- Resident #13 has had recent deterioration in behaviors as evidenced by hoarding items in her room, yelling at staff, episodes of anger and refusing showers. Problem- Resident #13 complains of increased pain/discomfort and is at risk for injury from decreased ADLs due to joint pain. Migraines were not identified as a problem for Resident #13 Record review of Resident #13's Physician Order Sheet dated 09/29/23 revealed, Fioricet with Codeine- 1 capsule every 6 hours as needed for migraine; do not give with Gabapentin 600 mg. The order was started on 09/13/23. Record review of Resident #13's Nursing Notes dated 09/19/23 signed by LVN J revealed, Housekeeping reported sweeping up red/white jelly-like pills in residents' room for the past 3 days. Showed them a stool softener& they confirmed that is what they'd been finding in the resident's room. Changed the order to PRN stool softeners because the resident stated she did not want a stool softener every day. Informed resident to tell staff when she does not want her medicine instead of holding it in her mouth and throwing it around the room when we leave. The resident verbalized understanding and went to sleep. ADON notified of the change. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 23 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #13's EMR revealed, no documented assessment for the self-administration of medication. An observation on 09/27/23 at 07:15 AM revealed, RN C standing at his nursing cart close to the [NAME] Hall nursing station. Resident #13 walked to RN C using her walker and asked for her migraine medication. She said she was in pain and wanted her medication. RN C retrieved Resident #13's Fioricet with codeine, placed it in a medication cup and handed it to Resident #13. RN C said he didn't have water for Resident #13 to take her medication to which the resident said she had water in her room and started to walk towards her room. As the surveyor observed Resident #13 walking to down the hall and entering her room, RN C returned to working with his medication cart and started preparing medications for Resident #9, he did not watch Resident #13 walking down the hall, enter her room or take her medication. Interview and observation on 09/27/23 at 07:35 AM with RN C, Resident #13 said she took her Fioricet when she returned to her room. She would not answer questions about self-administration of medications and would deflect questions and start talking about her old pain management doctor. Interview on 10/2/23 at 02:30 PM, Resident #13 said she remembered a few days ago the nurse came to give her medications, it was dark as always and when taking her pills, she felt the one that was the stool softener. Resident #13 said she didn't take it and put in back into the plastic cup, she told the nurse she didn't want the stool softener and it must have fallen out of the cup because housekeeping told her they found the pill. Resident #13 said the nurses always watch her take her meds, do not leave her alone until she takes the medications. She said she didn't throw her medications away or spit them out when the nurses leave. Resident #9 Record review of Resident #9's Face Sheet dated 09/29/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes and COPD. Record review of Resident #9's Quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 09 out of 15, independent with most ADLs, occasionally incontinent of bladder and always continent of bowel. Record review of Resident #9's undated Care Plan printed 09/29/23 revealed, problem- extensive assistance with ADLs and functional mobility; intervention- assist with ADLs as needed. Problem- risk of hyper or hypoglycemic (low blood sugar) episodes secondary to diabetes; intervention- medication as ordered. Record review of Resident #9's Physician Order Sheet dated 09/29/23 revealed, Trelegy Ellipta- 1 blister (1 pudd) with inhalation device rinse and spit after dose; Frequency- one time daily starting 07/27/22 scheduled for 09:00 AM. Humalog Insulin 100 unit/mL vial- Check Blood Sugar and follow sliding scale: 61-150 = 0 units 151-200 = 2 units 201-250 = 4 units 251-300 = 6 units 301-350 = 8 units 351-400 = 10 units 401or greater = 12 units and Re-check Blood Sugar in 15 Minutes. If Blood Sugar still401 or greater, CALL MD; frequency- two times daily starting 03/13/23 scheduled for 07:00 AM and 08:00 PM. Lantus Insulin- 35 units to times daily starting 09/19/23, scheduled for 06:30 AM and 08:00 AM. Record review of Resident #9's 9/29/23 MAR completed at 10:00 AM revealed, RN C documented (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 24 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 administration of 2 units of HumaLOG insulin to Resident #9. Level of Harm - Minimal harm or potential for actual harm An observation and interview at starting at on 09/27/23 at 07:21 AM revealed, RN C preparing medication for administration to Resident #9. He entered the room and measured Resident #his blood sugar with result 152 mg/dL. RN C returned to his nursing cart and retrieved a vial of Lantus, retrieved a packaged alcohol wipe with his bare hands, opened the wipe touching both sides with his bare hands and wiped the septum (the rubber stopper) of the vial. He then inserted an insulin syringe into the vial and withdrew 35 units, when RN C pulled out the syringe from the vial the needle was bent so he inserted the needle back into the vial injecting the 35 units he withdrew prior back into the vial. RN C retrieved a second syringe and withdrew 35 units from the vial without wiping down the septum of the vial. RN C entered into Resident #9's room and administered 35 units SC to Resident #9 in his left lower abdomen. RN C then returned to his cart to retrieve the Resident #9's HumaLOG insulin but there was none present, he then went to the medication room fridge but there was no HumaLOG Insulin available for Resident #9. RN C then grabbed a vial of HumaLOG and when the surveyor asked is the insulin was prescribed and dispensed for Resident #9, he said it did not belong to the resident and he would have to contact the pharmacy for a replacement and returned it to the fridge. RN C returned to his nursing cart and retrieved a Trelegy inhaler labeled for Resident #9, entered into the resident's room (leaving his nursing cart unlocked) and placed the inhaler on the bedside table. RN C said he needed a stethoscope to listen to the resident's breathing sounds, walked out of the room to the nursing station leaving the inhaler on the bedside table. While RN C was at the nursing station, the surveyor observed Resident #9 administer 1 inhalation of his Trelegy inhaler. RN C returned to Resident #9's room, listened to the resident's breathing sounds, retrieved the inhaler and then exited the resident's room. The surveyor notified RN C that he left his nursing cart unlocked at 07:30 AM. RN C said nursing carts are expected to be locked at all times to prevent unauthorized access to the carts. Residents Affected - Some Interview on 09/27/23 at 07:32 AM, RN C said he knew Resident #9 and Resident #13 were capable to self-administer their own medications, so he was comfortable allowing them to do so without supervision. RN C said that Resident #9 and Resident #13 were assessed for the self-administration of medication and knew them very well but he wouldn't allow other residents to administer their own medications unsupervised. When asked what the facility policy for medication administration and self-administration of medication, RN C said he was not familiar with the policy. When asked how he was sure Resident #9 actually took her medication, didn't pocket it or didn't choke on the medication, he said he didn't know, and he would go check on the resident. As RN C left to check on Resident #13, he left his cart unlocked. Interview on 09/27/23 at 10:10 AM, the DON said the facility did not have an emergency kit for insulin and RN C had not informed her of HumaLOG being unavailable for Resident #9. Interview on 09/27/23 at 10:24 AM, the DON said prior to medication administration nursing staff were expected to follow the rights, to ensure it's the right resident, right medication, right route and once all of that is verified, they were to watch the resident take their medication. She said failure to observe residents take their medication could place them at risk for choking or hoarding of medication. The DON said each resident had their own medications and insulin should not be used for multiple resident's since it could lead to incorrect medications being administered or infections. Interview on 10/02/23 at 12:38 PM, the DON said there was no documentation of Resident #9 and Resident #13 being assessed for self-administration of medication. She said nursing staff were expected to observe resident's when administering medications to ensure the resident's do not pocket the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 25 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medication or choke on the medication. The DON said that nursing carts were expected to be locked at all times, to prevent unauthorized access by staff or residents. When asked the risk to patients of leaving carts unlocked, the DON would not answer, she just repeated carts must be locked to prevent unauthorized access to the cart. Record review of RN C's Medication Administration Clinical Checklist dated 08/02/23 revealed, the form was left blank, there was no documented satisfactory completion date or indication of needs more training, there was no documented employee signature or date. The assessment included task 12-A Maintained security of medications during medication administration, that section was left unchecked. Record review of the facility policy titled Medication Administration with no revision date revealed, The 6 Rights of Medication Administration a. Right Patient. Identify correct patient before preparing medications and check patient location to ensure your patient ready to receive medications. ADMINISTRATION OF INHALERS Shake well, Place mouthpiece on resident mouth, (or allow them to hold if self-administration order/assessment/care plan on file), Instruct them as follows: Exhale completely, Breathe in slowly and deeply while depressing the container to administer dose, Hold breath as long as comfortably possible before exhaling, Clean the mouthpiece before placing back in med cart, Once diskus has been clicked it MUST REMAIN LEVEL - DO NOT SHAKE, Wait 1 minute between puffs of same medication, Wait 5 minutes between puffs of different medications, Store inhalers separate from other routes of administration in med cart, can be the same drawer utilizing clear dividers and date when open on container, Rinse/spit after the use of steroids to prevent thrush. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 26 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation interview and record review, drugs and biologicals used in the facility must be secured in locked compartments, labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 3 of 4 medication carts (500 Hall Nursing Cart, 200 Hall Nursing Cart, and 2-4 Med Aide Cart,) reviewed for drug labeling and storage. - The facility failed to ensure the 500 Hall Nursing Cart did not contain prescription medication with an illegible label. - RN C failed to ensure the 500 Hall Nursing Cart was locked when not in use and failed to ensure medication was not left at a Resident #9's bedside. - The facility failed to ensure Resident #133's Tramadol, a controlled substance pain medication, was behind a double lock in the 200 Hall Nursing Cart did not contain. - The facility failed to ensure the 2-4 Med Aide Cart did not contain unlabeled prescription eye drops for Resident #130. These failures could place residents at risk of adverse medication reactions. Findings Include: 500 Hall Nursing Cart An observation and interview at starting at on [DATE] at 07:21 AM revealed, RN C preparing medication for administration to Resident #9. After administering insulin to Resident #9. RN C returned to his nursing cart and retrieved a Trelegy inhaler labeled for Resident #9, entered into the resident's room (leaving his nursing cart unlocked) and placed the inhaler on the bedside table. RN C said he needed a stethoscope to listen to the resident's breathing sounds, walked out of the room to the nursing station leaving the inhaler on the bedside table. While RN C was at the nursing station, the surveyor observed Resident #9 administer 1 inhalation of his Trelegy inhaler. RN C returned to Resident #9's room, listened to the resident's breathing sounds, retrieved the inhaler, and then exited the resident's room. The surveyor notified RN C that he left his nursing cart unlocked at 07:30 AM. RN C said nursing carts are expected to be locked at all times to prevent unauthorized access to the carts. He said medications should be locked in the carts and not left at the resident's bedside. In an observation on [DATE] at 07:34 AM, after the surveyor completed an interview with RN C, the nurse said he would go check on Resident #13, when he walked to the resident's room RN C left his cart unlocked. The surveyor notified RN C that he left his cart unlocked at 07:36 AM. An observation and interview on [DATE] at 02:45 PM, inventory of the 500 Hall Nursing Cart with LVN A revealed: - A pharmacy liquid bottle with an illegible label pharmacy label. There was no visible resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 27 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 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 0761 name, drug name, expiration date, administration instructions, the text was washed out. Level of Harm - Minimal harm or potential for actual harm - A bottle of OTC Refresh Eye Drops with no resident's name. Residents Affected - Some LVN A said nursing staff were expected to check their carts daily as used for expired and inappropriately labeled medications. She said all prescription medications should have a pharmacy label indicating the resident and medication information and stock bottle OTC medications like eye drops should have resident identifiers. LVN A said since the bottle of unknown liquid prescription medication and the stock eyedrops did not have patient identifiers or a prescription label they could not be used and must be discarded in the drug disposal bin located in the med room. She said inadequately labeled medications could be used on the wrong patient or administered at the wrong dose placing residents at risk for side effects. 200 Hall Nursing Cart An observation and interview on [DATE] at 02:45 PM, inventory of the 200 Hall Nursing Cart with RN A revealed: - A large Ziplock bag containing multiple prescription vials included a bottle of Tramadol 50 mg for Resident #133 in the 2nd drawer. The medication was not locked in the secure compartment used to store controlled medication. RN A said the resident's medication was just delivered and she did not have a chance to look through the medications yet. She said all controlled medications should be logged and secured in the locked compartment used for controlled substances in the cart. RN A said multiple staff members have the code to enter the cart but only the assigned employee working with the cart had the key to the locked compartment. She said failure to account for and secure controlled substances in the designated locked compartment placed residents at risk for side effects if the medications were accessed as well as drug diversion. 2-4 Med Aide Cart An observation and interview on [DATE] at 03:1- PM, inventory of the 2-4 Medication Aide Cart with MA B revealed: - An unlabled Ziplock bag containing and open an in use vial of GenTeal Tears, a lubricant eye drop, with no resident identifiers; an open and in use bottle of Moxifloxacin eye drops, an antibiotic eyedrop, with no resident identifiers; and an open and in use bottle of Dorzolamide 2% eye drops used to treat high pressure in the eye labeled for Resident #130. MA B said she believed the medication belonged to Resident #130. She said all prescription medications should have a pharmacy label that included the resident identifiers, directions for use, drug information and all stock medications should have resident identifiers. She said nursing staff check their carts daily for expired and inappropriately labeled medications. MA B said since the medications were not labeled, they could not be used and must be discarded in the drug destruction bin located in the med room. She said inappropriately labeled medications could place residents at risk of adverse reactions or infection if the medications are used incorrectly, on the wrong patient or on multiple patients. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 28 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on [DATE] at 12:38 PM, the DON said that medications should not be left at a resident's bedside and must be in locked medication carts when not in use. She said all medications should have appropriate pharmacy labels that provided resident identifiers, medication information and directions for use. The DON said nursing staff are expected to check their carts daily as used for loose pills, expired, and inappropriately labeled medications. She said if a medication did not have adequate labeled it must be removed from the nursing cart and discarded in the drug disposal bin located in the medication storage rooms. The DON said failure to have adequate labeling on prescription and OTC medications could lead to the medication being used on the wrong resident, the medication being used on multiple residents, or the wrong dose being administered placing residents at risk for adverse reactions or infections. The DON said all controlled substances should be logged in and behind a double lock in the control locked box located in the nursing cart. The DON said that medications are to be in nursing carts when not in use or under the supervision of nursing staff and nursing carts were expected to be locked at all times, to prevent unauthorized access by staff or residents. When asked the risk to patients of leaving carts unlocked, the DON would not answer, she just repeated carts must be locked to prevent unauthorized access to the cart. Record review of the facility policy titled Storage of Medications revised 04/2007 revealed, 2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. 3.Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Record review of the facility policy titled Labeling of Medication Containers revised 04/2019 revealed, 1. Medication labels must be legible at all times. 2. Any medication packaging or containers that are inadequately or improperly labeled are returned to the issuing pharmacy. 3. Labels for individual resident medications include all necessary information, such as: a. the resident's name. b. the prescribing physician's name. c. the name, address, and telephone number of the issuing pharmacy. d. the name, strength, and quantity of the drug. e. the prescription number (if applicable). f. the date that the medication was dispensed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 29 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 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 0761 g. appropriate accessory and cautionary statements. Level of Harm - Minimal harm or potential for actual harm h. the expiration date when applicable; and i. directions for use. Residents Affected - Some 4. Labels for stock medications include all necessary information, such as: a. the name and strength of the drug. b. the lot and control number. c. the expiration date when applicable. d. appropriate accessory and cautionary statements; and e. directions for use. Record review of the facility policy titled Management of Controlled Medications revised 03/2016 revealed, 2- upon receipt, controlled medications will be logged on a control receipt/record/disposition form if the form did not come from pharmacy. 30 controlled medications will immediately be laced under double lock, in the appropriate medication cart. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 30 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 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 1 of 6 Residents (Resident #9) reviewed for infection control Residents Affected - Few - RN C failed to ensure he used appropriate infection control practices while administering insulin to Resident #9. This failure could place residents at risk of skin infections. Findings include: Resident #9 Record review of Resident #9's Face Sheet dated 09/29/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes and COPD. Record review of Resident #9's Quarterly MDS assessment dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 09 out of 15, independent with most ADLs, occasionally incontinent of bladder and always continent of bowel. Record review of Resident #9's undated Care Plan printed 09/29/23 revealed, problem- extensive assistance with ADLs and functional mobility; intervention- assist with ADLs as needed. Problem- risk of hyper or hypoglycemic episodes secondary to diabetes; intervention- medication as ordered. Record review of Resident #9's Physician Order Sheet dated 09/29/23 revealed, Trelegy Ellipta- 1 blister (1 pudd) with inhalation device rinse and spit after dose; Frequency- one time daily starting 07/27/22 scheduled for 09:00 AM. Humalog Insulin 100 unit/mL vial- Check Blood Sugar and follow sliding scale: 61-150 = 0 units 151-200 = 2 units 201-250 = 4 units 251-300 = 6 units 301-350 = 8 units 351-400 = 10 units 401or greater = 12 units and Re-check Blood Sugar in 15 Minutes. If Blood Sugar still401 or greater, CALL MD; frequency- two times daily starting 03/13/23 scheduled for 07:00 AM and 08:00 PM. Lantus Insulin- 35 units to times daily starting 09/19/23, scheduled for 06:30 AM and 08:00 AM. An observation and interview at starting at 09/27/23 at 07:21 AM revealed, RN C preparing medication for administration to Resident #9. He entered the room and measured Resident #9's blood sugar with result 152 mg/dL. RN C returned to his nursing cart and retrieved a vial of Lantus, retrieved a packaged alcohol wipe with his bare hands, opened the wipe touching both sides with his bare hands and wiped the septum (the rubber stopper) of the vial. He then inserted an insulin syringe into the vial and withdrew 35 units, when RN C pulled out the syringe from the vial the needle was bent so he inserted the needle back into the vial injecting the 35 units he withdrew prior back into the vial. RN C retrieved a second syringe and withdrew 35 units from the vial without wiping down the septum of the vial. RN C entered into Resident #9's room and administered 35 units SC to Resident #9 in his left lower abdomen. An attempt was made on 09/27/23 at 02:30 PM to interview RN C, the DON informed the surveyor that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 31 of 32 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 676357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389 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 the staff member had been suspended. Level of Harm - Minimal harm or potential for actual harm Interview on 10/02/23 at 12:38 PM, the DON said prior to insulin administration nurses must check the resident's blood sugar to ensure the medication to be administered was within the ordered parameters. She said after performing hand hygiene the nurse must put on a pair of gloves and then wipe the septum of the vial with an alcohol wipe. The DON said holding the alcohol wipe with bare hands would contaminate the wipe and anything the wipe is used on. She said once a volume was withdrawn from an insulin vial it should not be reinjected back into the vial because the needle could have debris in the needle that could be injected into the insulin and wiping the rubber septum with a contaminated wipe was a risk of infection. Residents Affected - Few Record review of RN C's Medication Administration Clinical Checklist dated 08/02/23 revealed, the form was left blank, there was no documented satisfactory completion date or indication of needs more training, there was no documented employee signature or date. The assessment included task 12-A Maintained security of medications during medication administration, that section was left unchecked. Record review of the facility policy titled Infection Control revised 11/2017 revealed, no specific instructions regarding infection control during injectable medication preparation. Record review of the facility policy titled Injection (Subcutaneous) revised 09/2016 revealed, wash your hands, gather equipment and take to bedside. The policy did not address infection control practices during injectable medication preparation. Record review of the facility policy titled Medication Administration with no revision date revealed, The 6 Rights of Medication Administration a. Right Patient. Identify correct patient before preparing medications and check patient location to ensure your patient ready to receive medications . 12. ADMINISTRATION OF INJECTABLE MEDICATION a. WASH HANDS and dawn gloves, b. Clean the application site with alcohol wipe and clean vial with separate alcohol wipe. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676357 If continuation sheet Page 32 of 32