Shepherd Ltc Partners Inc.

F-F656-

All items listed will be completed by 5:00 PM on 4/24/25 with continued follow-up for scheduled staff.

1. Administrator/DON initiated an in-service regarding policy and procedure for initiation of care plans for falls for licensed staff on 4/23/25. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved.

2. The corporate MDS Nurse and the facility MDS Nurse initiated a review of all care plans for current accident/interventions in place to ensure it's on the care plan and a viable intervention. This action started on 4/23/25.

3. Administrator/DON initiated an update on all fall risk assessments that they are accurate, interventions are

in place and care plan coincides.

4. The Administrator and DON all licensed nursing staff on fall policy procedure and interventions post fall.

This action started on 4/23/25.

5. MDS Nurse and DON will ensure new admissions have appropriate care plans placed for risk assessments. All licensed nursing staff will in-serviced on implementing interventions for new admissions.

This action started on 4/23/2025.

6. Administrator and DON were in-serviced on 4/24/2025 by Regional Director of Clinical Services on all the policy mentioned above, and to notify regional/corporate staff of ALL falls/incidents care plans and are to notify regional/corporate staff of any discrepancies. Regional/corporate staff will follow-up on each fall/incident in question and direct with appropriate interventions.

If staff are unable to attend any of the in-services, they will be required to complete the in-service before starting their assigned shift. Any agency will be in-serviced prior to the beginning of their shift. Any new hires will be in-serviced on hire, prior to working a shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 21 675484 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675484 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Park Nursing & Rehab 101 Woodland Park Dr Shepherd, TX 77371

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 The Medical Director was made aware of the Immediate Jeopardy 04/23/25 at 5:15 p.m. and has been involved in developing the Plan of Removal. These conversations are considered part of the QA process. Level of Harm - Immediate jeopardy to resident health or A QAPI meeting was held on 04/23/25 with attendance of Administrator, Director of Nursing, MDS safety Coordinator, Regional Director of Clinical Services, and Chief Operating Officer.

Residents Affected - Few This plan was initially implemented 04/23/25 and will be monitored through completion by corporate and regional staff.

Plan of Removal completion date is 04/24/25 by 5:00 p.m. with continuation of oncoming staff and follow-up.

Monitoring: Record review and interviews of completed:

* Record review of the In-Services indicated the Administrator and DON H were in-serviced on 4/24/2025 by Regional Director of Clinical Services on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, and to notify regional/corporate staff of ALL falls/incidents care plans and are to notify regional/corporate staff of any discrepancies.

* Record review of a resident list indicated the Corporate Nurse, DON H, and the MDS Nurse reviewed all care plans for current accident/interventions in place to ensure it's on the care plan and a viable intervention. Completed on 04/24/25.

* Record review of a resident list indicated the Corporate Nurse, DON H, and the MDS Nurse initiated an update on all fall risk assessments that they are accurate, interventions are in place and care plan coincides. Completed on 04/24/25.

* Record review of an In-Service signature sheet indicated the Administrator/DON H initiated an in-service regarding policy and procedure for initiation of care plans for falls for licensed staff on 4/23/25. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. On 04/24/25 at 01:20 p.m. 13 licensed staff employed were in-serviced. One licensed staff on FMLA was left to in-service.

* Record review of an In-Service signature sheet indicated the Administrator and DON H initiated an in-service for all licensed nursing staff on fall policy procedure and interventions post fall. On 04/24/25 at 01:20 p.m. 13 licensed staff employed were in-serviced. One licensed staff on FMLA was left to in-service.

During an interview on 04/24/25 at 08:20 a.m., DON H said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented,

the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, to notify regional/corporate staff of all falls/incidents care plans, and to notify regional/corporate staff of any discrepancies.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 21 675484 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675484 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Park Nursing & Rehab 101 Woodland Park Dr Shepherd, TX 77371

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 During an interview on 04/24/25 at 08:25 a.m., the Administrator said he had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be Level of Harm - Immediate implemented, the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, to jeopardy to resident health or notify regional/corporate staff of ALL falls/incidents care plans, and to notify regional/corporate staff of any safety discrepancies.

Residents Affected - Few During an interview on 04/24/25 at 08:35 a.m., the MDS Nurse said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.

During an interview on 04/24/25 at 08:45 a.m., the ADON said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented,

the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.

During an interview on 04/24/25 at 09:15 a.m., RN A said she worked the 6a to 6p shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.

During an interview on 04/24/25 at 09:25 a.m., LVN B said she worked the 6a to 6p shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.

During an interview on 04/24/25 at 10:03 a.m., LVN C said she worked the 6p to 6a shift. She said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.

During an interview on 04/24/25 at 10:06 a.m., LVN D said she worked PRN. She said she had in-services

on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.

During an interview on 04/24/25 at 12:02 p.m., LVN E said she worked the 6p to 6a shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.

During an interview on 04/24/25 at 12:49 p.m., RN F said she was the weekend RN. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 21 675484 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675484 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Park Nursing & Rehab 101 Woodland Park Dr Shepherd, TX 77371

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 During an interview on 04/24/25 at 01:08 p.m., LVN G said she worked the 6p to 6a shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment Level of Harm - Immediate interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation jeopardy to resident health or of care plans for falls. safety

The Administrator and Regional Director of Operations were informed the Immediate Jeopardy was removed Residents Affected - Few on 04/24/25 at 02:50 p.m. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrected system that were put into place.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 21 675484 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675484 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Park Nursing & Rehab 101 Woodland Park Dr Shepherd, TX 77371

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 30664 safety Based on observation, interview, and record review the facility failed to provide supervision and assistance Residents Affected - Few devices to prevent accident for 3 of 10 residents (Resident #1, Resident #2, and Resident #3) reviewed for accidents/supervision.

* The facility failed to ensure Resident #1 had interventions in place that addressed Resident #1's Fall Risk Assessment which indicated he was a high risk for falls. Resident #1 had a fall and was sent to the emergency room for assessment. A CT scan of the neck determined he had a fracture of one of the cervical vertebrae.

* The facility failed to ensure Resident #2 had interventions in place after she had 2 falls.

* The facility failed to ensure Resident #3 had interventions in place that addressed Resident #3's Fall Risk Assessment which indicated she was a high risk for falls after she had a fall.

An Immediate Jeopardy (IJ) was identified on 04/23/25 at 04:44 p.m. and the IJ template was provided to the Administrator. While the immediacy was removed on 04/24/25 at 02:50 p.m., the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems.

This failure could place residents who were assessed as high risk for falls at risk of at risk of potential accidents, serious injuries, serious harm, or death.

Findings included:

1. Record review of face sheet dated 09/19/2024 indicated Resident #1 was a [AGE] year-old male admitted

on [DATE REDACTED]. His diagnoses included traumatic brain injury (head injury causing damage to the brain by external force or mechanism) from a MVA [AGE] years ago; paraplegia (injury to the spinal cord or brain that stops signals from reaching the lower body); arterial ulcers (skin injuries caused by inadequate blood supply to the affected area) to heel, ankle, and toe; intracranial injury (any injury occurring within the skull) with loss of consciousness; lack of coordination; osteoarthritis (inflammation of one or more joints); and abnormalities of gait and mobility.

Record review of Fall Risk Assessments dated 07/06/24 and 08/04/24 indicated Resident #1 was a high risk for falls.

Record review of Resident #1's comprehensive care plans initiated on 07/08/24 did not address Resident #1's Fall Risk Assessment of high risk with interventions to implement to prevent falls or injuries from falls.

Record review of Resident #1's quarterly MDS assessment dated [DATE REDACTED] indicated a BIMS score of 6 indicating Resident #1 had severely impaired cognition. Resident #1 required substantial/maximal assistance for transfers and all ADLs. He used a manual wheelchair. He had no falls since admission.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 21 675484 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675484 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Park Nursing & Rehab 101 Woodland Park Dr Shepherd, TX 77371

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Record review of Nurse Notes indicated an entry on 08/16/24 at 02:00 p.m. that Resident #1 was placed on

a low air loss mattress due to open area to his sacrum. There was no documentation of interventions to Level of Harm - Immediate prevent potential falls after placement. jeopardy to resident health or safety Record review of Nurse Notes indicated an entry on 08/17/2024 01:40 p.m. that Resident #1 was on his right side on the floor by his bed. He was assisted back to the bed. Resident #1 said he did not know how he fell . Residents Affected - Few He just knew he was on the floor. He had a 5cm x 3cm swollen area right side of head, 3cm x 2cm skin tear

on the lateral aspect of the right elbow, and the right side of his face had swelling.

Record review of a telehealth noted dated 08/17/24 indicated Resident #1 had unwitnessed fall with a knot to right side of forehead and redness to right side of face.

Record review of an incident report dated 08/17/24 indicated Resident #1 was found on the floor. According to the incident report, he was put back in the bed and a head-to-toe assessment was done with a 5cm x 3cm swollen area to the right side of head, a 3cm x 2cm skin tear on the lateral aspect of his right elbow, and the right side of his face had swelling. The NP saw Resident #1 via telehealth and ordered him to be sent to the hospital ER.

Record review of the hospital CT scan report of the neck dated 08/17/24 showed Resident #1 had a question age-indeterminate non-displaced type 3 (extend into the body of the vertebra) odontoid (a bony element extending superiorly from the second cervical vertebra) fracture (break). He returned to the facility with an order to wear a neck brace for 8 weeks.

Record review of a Bed Rail/Assist Bar Evaluation dated 08/18/24 indicated Resident #1 had assessment done for post fall. A. Evaluation Factors 1. Resident has expressed a desire to have bed rails/assist bar while

in bed for their own safety and/or comfort. 1A. If selected, explain: Resident will use for turning and repositioning 6. Resident has a history of falls. 7. The resident is having problems with balance or poor trunk control. 7A. If yes, explain: Resident is on low air loss mattress and needs the rails for support C. Summary of Findings 1. Summary of findings: Resident will use rails as assist bar and bed bolsters used to help prevent legs from slipping over edge of the air mattress. Resident uses call light for assistance and historically has not tried to get up alone.

Resident #1 had been discharged to the hospital on 09/16/24, did not return to the facility, and was not available for interview.

During an interview on 04/22/25 at 03:15 p.m. DON J said she was working at the facility when Resident #1 had his fall that ended with the fractured neck. She said she remembered he could be non-compliant at times. She said the resident had no issues with any falls prior to the fall but if he was a high risk according to

the assessment then interventions should have been in place. She said she did not remember if there were fall mats placed. She said she did remember the bed had partial rails on it prior to them having to put an air mattress on the bed due to an open wound. She said the air mattress obtained was too big, so they had to take the rails off. She said they had obtained one to fit the bed, but she guessed the rails were not put back

on the bed and he fell the next day. She said the air mattress could be an increased risk for falls since they are slick, and you can't put sheets on them.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 21 675484 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675484 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Park Nursing & Rehab 101 Woodland Park Dr Shepherd, TX 77371

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 2. Record review of a face sheet dated 04/23/2025 indicated Resident #2 was a [AGE] year-old female initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED]. Her diagnoses included cerebral palsy Level of Harm - Immediate (congenital disorder of movement, muscle tone, or posture due to abnormal brain development), jeopardy to resident health or schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood safety disorder), chronic osteomyelitis of the left tibia and fibula (bone infection of the 2 bones of the lower leg), and lymphedema (a condition characterized by swelling caused by an accumulation of protein-rich fluid in the Residents Affected - Few body's tissues primarily affecting the arms or legs).

Record review of the current MDS dated [DATE REDACTED] indicated Resident #2 had severely impaired cognition, required substantial/maximal assistance for all ADLs, and had no falls since last assessment.

Record review of a Fall Risk assessment dated [DATE REDACTED] indicated Resident #2 was not a high risk for falls.

Record of the Incident Log from 07/21/24 through 12/07/24 indicated Resident #2 had an unwitnessed fall on 12/07/24.

Record review of a care plan initiated on 12/07/24 indicated Resident #2 was a high risk for falls. She had a fall with no injury on 12/07/24. The only intervention was sent to ER for eval and treat of unrelieved pain. No other interventions to prevent falls or potential injuries from falls were developed.

Record review of a Fall Risk assessment dated [DATE REDACTED] indicated Resident #2 was a high risk for falls.

Record of the Incident Log from 07/21/24 through 02/11/25 indicated Resident #2 had an unwitnessed fall on 02/11/25.

Record review of a Fall Risk assessment dated [DATE REDACTED] indicated Resident #2 had a fall and was a high risk for falls.

Record review of a care plan revised on 02/22/25 indicated on 02/11/25 Resident #2 had a fall with no injury and intervention was FNP review of medications, lab work, psych notified, notified PASRR LA for behavioral assessment. No other interventions to prevent falls or potential injuries from falls were developed.

During an observation and interview on 04/23/25 at 11:25 a.m., Resident #2 was in her room in a wheelchair. Her bed had 1/4 side rails. There were no fall mats on the floor by the bed and the bed was not in the lowest position. She was not able to answer questions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 21 675484 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675484 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Park Nursing & Rehab 101 Woodland Park Dr Shepherd, TX 77371

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 3. Record review of a face sheet dated 04/23/25 indicated Resident #3 was a [AGE] year-old female admitted on [DATE REDACTED]. Her diagnoses included end stage renal disease (last stage of long-term kidney Level of Harm - Immediate disease), chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to jeopardy to resident health or breathe), type 2 diabetes mellitus (A chronic condition that affects the way the body processes blood sugar), safety bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), hypertension (condition in which the force of the blood against the artery walls is too high), Residents Affected - Few atrial fibrillation (a type of irregular heartbeat), cardiac arrhythmia (occurs when the electrical signals that tell

the heart to beat do not work properly), and heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs).

Record review of the current MDS dated [DATE REDACTED] indicated Resident #3 was cognitively intact, required partial/moderate assistance for bed mobility, was dependent with transfers, required substantial/maximal assistance with most ADLs, used a manual wheelchair, and had no falls since prior assessment.

Record review of a Fall Risk assessment dated [DATE REDACTED] indicated Resident #3 was not a high risk for falls.

Record review of an incident report dated 01/22/25 indicated Resident #3 said she was sitting in her wheelchair getting a breathing treatment. She saw a bug crawling up the wall. She rolled to the wall, leaned forward. She forgot to lock the wheels. The wheelchair rolled out from under her. She landed flat on her bottom. Her back and tail bone hurts, 9/10 rating.

Record review of an x-ray result for Resident #3 dated 01/22/25 indicated 1) x-ray of lumbar spine impression: No acute fracture or dislocation of the lumbar spine. 2) x-ray of sacrum/coccyx impression: No acute fracture or dislocation of the sacrum/coccyx.

Record review of Resident #3's Fall Risk assessment dated [DATE REDACTED] indicated the assessment was done due to a fall and she was at high risk for falls.

Record review of Resident #3's care plan dated 01/24/25 indicated revisions to the care plan on 01/30/25 for 1/4 rails on the bed for safety/enabler. There was no care plan for the fall she had on 01/22/25.

During an observation and interview on 04/23/25 at 09:20 a.m., Resident #3 was in her bed and the bed had 1/4 rails. There were no fall mats on the floor next to the bed and the bed was not in the lowest position. She said she had a fall a few months ago. She said the rails on her bed to help her with being able to turn in the bed.

During an interview on 04/23/25 at 12:40 p.m., DON H said the MDS Nurse, the CN, the ADON, or herself were responsible for completing comprehensive care plans and updating the care plan as needed. DON H said her expectation would be for all residents at risk for falls or had a fall to have care plan initiated and updated with additional interventions. She said an air mattress would not increase a resident's risk for falls.

She said interventions would be based on the resident's needs.

During an interview on 04/23/25 at 01:30 p.m., the Administrator said nursing was responsible to complete all

the care plans and updating them for the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 21 675484 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675484 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Park Nursing & Rehab 101 Woodland Park Dr Shepherd, TX 77371

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Record review of a Falls and Fall Risk Managing policy revised March 2018 indicated:

Level of Harm - Immediate Policy Statement jeopardy to resident health or safety Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from Residents Affected - Few falling.

Policy Interpretation and Implementation

Fall Risk Factors:

2. Resident conditions that may contribute to the risk of falls include:

a. fever;

b. infection;

c. delirium and other cognitive impairment; pain;

d. lower extremity weakness;

e. poor grip strength;

f. medication side effects;

g. orthostatic hypotension;

h. functional impairments;

i. visual deficits; and

j. incontinence.

3. Medical factors that contribute to the risk of falls include:

a. arthritis;

b. heart failure;

c. anemia;

d. neurological disorders; and balance and gait disorders; etc.

Resident-Centered Approaches to Managing Falls and Fall Risk

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 21 675484 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675484 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Park Nursing & Rehab 101 Woodland Park Dr Shepherd, TX 77371

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls Level of Harm - Immediate jeopardy to resident health or Monitoring Subsequent Falls and Fall Risk safety 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or Residents Affected - Few the risks of falling

The Administrator and DON H were notified of the Immediate Jeopardy on 04/23/25 at 04:44 p.m. and was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address

the Immediate Jeopardy.

The following Plan of Removal was submitted by the facility and accepted on 04/23/25 at 8:30 p.m.

All items listed will be completed by 5:00 PM on 4/24/25 with continued follow-up for scheduled staff.

1. Administrator/DON initiated an in-service regarding policy and procedure for initiation of care plans for falls for licensed staff on 4/23/25. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved.

2. The corporate MDS Nurse and the facility MDS Nurse initiated a review of all care plans for current accident/interventions in place to ensure it's on the care plan and a viable intervention. This action started on 4/23/25.

3. Administrator/DON initiated an update on all fall risk assessments that they are accurate, interventions are

in place and care plan coincides.

4. The Administrator and DON all licensed nursing staff on fall policy procedure and interventions post fall.

This action started on 4/23/25.

5. MDS Nurse and DON will ensure new admissions have appropriate care plans placed for risk assessments. All licensed nursing staff will in-serviced on implementing interventions for new admissions.

This action started on 4/23/2025.

6. Administrator and DON were in-serviced on 4/24/2025 by Regional Director of Clinical Services on all the policy mentioned above, and to notify regional/corporate staff of ALL falls/incidents care plans and are to notify regional/corporate staff of any discrepancies. Regional/corporate staff will follow-up on each fall/incident in question and direct with appropriate interventions.

If staff are unable to attend any of the in-services, they will be required to complete the in-service before starting their assigned shift. Any agency will be in-serviced prior to the beginning of their shift. Any new hires will be in-serviced on hire, prior to working a shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 21 675484 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675484 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Park Nursing & Rehab 101 Woodland Park Dr Shepherd, TX 77371

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 The Medical Director was made aware of the Immediate Jeopardy 04/23/25 at 5:15 p.m. and has been involved in developing the Plan of Removal. These conversations are considered part of the QA process. Level of Harm - Immediate jeopardy to resident health or A QAPI meeting was held on 04/23/25 with attendance of Administrator, Director of Nursing, MDS safety Coordinator, Regional Director of Clinical Services, and Chief Operating Officer.

Residents Affected - Few This plan was initially implemented 04/23/25 and will be monitored through completion by corporate and regional staff.

Plan of Removal completion date is 04/24/25 by 5:00 p.m. with continuation of oncoming staff and follow-up.

Monitoring: Record review and interviews of completed:

* Record review of the In-Services indicated the Administrator and DON H were in-serviced on 4/24/2025 by Regional Director of Clinical Services on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, and to notify regional/corporate staff of ALL falls/incidents care plans and are to notify regional/corporate staff of any discrepancies.

* Record review of a resident list indicated the Corporate Nurse, DON H, and the MDS Nurse reviewed all care plans for current accident/interventions in place to ensure it's on the care plan and a viable intervention. Completed on 04/24/25.

* Record review of a resident list indicated the Corporate Nurse, DON H, and the MDS Nurse initiated an update on all fall risk assessments that they are accurate, interventions are in place and care plan coincides. Completed on 04/24/25.

* Record review of an In-Service signature sheet indicated the Administrator/DON H initiated an in-service regarding policy and procedure for initiation of care plans for falls for licensed staff on 4/23/25. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. On 04/24/25 at 01:20 p.m. 13 licensed staff employed were in-serviced. One licensed staff on FMLA was left to in-service.

* Record review of an In-Service signature sheet indicated the Administrator and DON H initiated an in-service for all licensed nursing staff on fall policy procedure and interventions post fall. On 04/24/25 at 01:20 p.m. 13 licensed staff employed were in-serviced. One licensed staff on FMLA was left to in-service.

During an interview on 04/24/25 at 08:20 a.m., DON H said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented,

the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, to notify regional/corporate staff of all falls/incidents care plans, and to notify regional/corporate staff of any discrepancies.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 21 675484 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675484 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Park Nursing & Rehab 101 Woodland Park Dr Shepherd, TX 77371

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During an interview on 04/24/25 at 08:25 a.m., the Administrator said he had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be Level of Harm - Immediate implemented, the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, to jeopardy to resident health or notify regional/corporate staff of ALL falls/incidents care plans, and to notify regional/corporate staff of any safety discrepancies.

Residents Affected - Few During an interview on 04/24/25 at 08:35 a.m., the MDS Nurse said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.

During an interview on 04/24/25 at 08:45 a.m., the ADON said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented,

the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.

During an interview on 04/24/25 at 09:15 a.m., RN A said she worked the 6a to 6p shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.

During an interview on 04/24/25 at 09:25 a.m., LVN B said she worked the 6a to 6p shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.

During an interview on 04/24/25 at 10:03 a.m., LVN C said she worked the 6p to 6a shift. She said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.

During an interview on 04/24/25 at 10:06 a.m., LVN D said she worked PRN. She said she had in-services

on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.

During an interview on 04/24/25 at 12:02 p.m., LVN E said she worked the 6p to 6a shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.

During an interview on 04/24/25 at 12:49 p.m., RN F said she was the weekend RN. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 21 675484 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675484 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Park Nursing & Rehab 101 Woodland Park Dr Shepherd, TX 77371

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During an interview on 04/24/25 at 01:08 p.m., LVN G said she worked the 6p to 6a shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment Level of Harm - Immediate interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation jeopardy to resident health or of care plans for falls. safety

The Administrator and Regional Director of Operations were informed the Immediate Jeopardy was removed Residents Affected - Few on 04/24/25 at 02:50 p.m. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrected system that were put into place.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 21 675484