Inspection·March 21, 2024

F 0622 required extra time to make her needs known. Level of Harm - Minimal harm or potential for actual harm * On 07/20/23 at 12:55 p.m. The resident was alert and oriented to her name. Her speech was clear, but she was soft spoken. She was able to make her needs known. She denied pain or discomfort at this time. Her vital signs were BP-139/68, P-72, O2-98% on room air, R-18 even and unlabored with no SOB. Her blood sugar was 125 for breakfast time and 182 for lunch time which required 2 units of Humalog per sliding scale administered. Her morning meds were administered along with an ABT for UTI (bladder infection). She was able to swallow the pills without complications. She had a TB test administered to the right forearm and she tolerated it well. She received a shower this morning. Family members were in the room with her. They were feeding her lunch at this time. The call light and hydration were within reach. Residents Affected - Few * On 07/20/23 at 09:13 p.m. the nurse documented at 02:00 p.m. the resident was in bed resting and the call light was within reach. She denied having any pain and there were no signs or symptoms of distress. No family present at this time. At 4:30 p.m. an accucheck done with the blood sugar being 157. The resident was informed she needed 2 units of Humalog insulin which were given with the dinner tray to her left arm. She denied any pain at this time. Her family was at the bedside. At 06:00 p.m. the family was informed to not put any trays on the floor due to it being a hazard and the family verbalized understanding. At 08:00 p.m. the resident was in bed with her room filled with family. Her vital signs were B/P-140/64, P-74, and blood sugar was 160. The resident received all night medications as ordered. She denied any pain and no distress or discomfort was noted. * On 07/21/23 at 01:52 p.m. the physician was notified of resident discharging immediately. The nurse obtained orders were to discharge resident home and the resident to follow up with her primary physician in the community. The resident would discharge with all current medications. She did not require any special equipment and the Responsible Party currently resided with the resident. * On 07/21/23 at 01:58 p.m. the resident discharged home with family members in family personal vehicle at 01:30 p. m. She was rolled out in a facility wheelchair and helped into family vehicle by therapy staff without incident. She had no complaint of pain or discomfort. She had no skin issues. All medications were given to the resident prior to discharge were tolerated well. Her vital signs 01:00 p.m. were BP-152/73, P-74, and BS-191 which she was given 2 units of Humalog insulin. All discharge paperwork was signed, copied, and given to the resident and RP. She and her family were educated on how to and when to administer her medications. The nurse explained to the resident family members the signs and symptoms to look for if resident was experiencing low blood sugars and what to do if the situation occurred and when to call 911. Family verbalized understanding of proper medication administration. This nurse educated resident family on how to properly monitor blood sugar level and family verbalized understanding of checking resident blood sugar 4 times daily as well as giving insulin according to the sliding scale. This nurse educated the resident and family on the importance of following the parameters for her blood pressure medication administration and the family verbalized understanding of the importance of the parameters. Record review of physician orders for July 2023 indicated Resident #2 had an order dated 07/21/23 to discharge home. Record review of a SW note dated 07/21/23 at 03:33 p.m. indicated Resident #2 was issued an immediate discharge today due to a family member's aggressive verbal behavior with staff. The resident was no problem, but her family member was unable to be satisfied with anything the DON or the Administrator was offering her. The family member came into the facility yesterday morning interrupting the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455538 If continuation sheet Page 2 of 6 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 455538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Manor 4400 Gulf St Groves, TX 77619 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few morning Stand Up Meeting by banging on the conference door, demanding to speak to the Administrator about the resident's breakfast. The family member was inconsolable about the resident being served grits with butter on them. Her family member was yelling and banging on the table as she spoke to the Administrator and the other IDT members. Unfortunately, the saga continued today, and it led to the Administrator issuing the discharge and calling the local police to ensure that the family exited the facility without further verbal aggression. Her records were sent to another facility. Record review of a Patient Discharge Plan of Care for Resident #2 dated 07/21/23 indicated she was being discharged with no information as to who or where she was being discharged to. Dietary recommendations were to avoid salt and to avoid sugar. Patient Instructions/Teaching included medication education, follow up with her physician, bathe and moisturize skin 3 times weekly, and follow dietary recommendations. There was section of an acknowledgement of receipt signed by someone who was not the RP but another family member. During an interview on 03/21/24 at 10:00 a.m. the DON said Resident #2 was discharged because of how her RP treated the previous Administrator, her, and her staff. She said the resident herself was no problem at all and was very pleasant. She said the RP wanted the resident in a private room which she was placed in one. She said the RP would stay the day at the facility due to the electricity at the home not being on. She said the RP wanted a bigger room for the resident so other family members could stay also but they would not move her to a larger room because the insurance would not pay for it. She said on the morning the Administrator discharged the resident, they were in their morning meeting and the RP was banging on the conference room door demanding to speak with the Administrator. She said the RP called them names she would not repeat, and the Administrator had had enough so she discharged her. During an interview on 03/21/24 at 12:32 p.m. the SW said she had not assisted Resident #2's RP with finding other placement for the resident. She said her documentation in the resident's clinical records was her understanding regarding the resident's discharge from the facility. She said she sent the information to the other facility after the resident had been discharged . During an interview on 03/21/24 at 01:28 p.m. the Administrator said she understood the documentation appeared to be an immediate discharge of Resident #2. She said residents were to be discharged based on the appropriate requirements. Record review of a Transfer or Discharge, Facility-Initiated policy dated October 2022 indicated Policy Statement: Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. Policy Interpretation and Implementation: Each resident will be permitted to remain in the facility, and not be transferred or discharged unless: a. the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility; b. the transfer or discharge is appropriate because the resident's health has improved sufficiently so 1he resident no longer needs the services provided by this facility; c. the safety of individuals in the facility is endangered due to the clinical or behavioral status of 1he resident; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455538 If continuation sheet Page 3 of 6 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 455538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Manor 4400 Gulf St Groves, TX 77619 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 0622 d. the health of individuals in the facility would otherwise be endangered; Level of Harm - Minimal harm or potential for actual harm e. the resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at this facility Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455538 If continuation sheet Page 4 of 6 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 455538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Manor 4400 Gulf St Groves, TX 77619 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure recommendations from PASARR evaluation were incorporated for 1 of 1 resident reviewed for coordination of PASARR services. (Resident #1) Facility failed to provide specialized services for PASARR positive residents as agreed to during Resident #1's meeting by the required timeframe. This failure could place the residents with intellectual and developmental disabilities at risk of not receiving specialized services that would enhance their highest level of functioning. Findings included: Record review of a face sheet dated 10/25/23 indicated Resident #1 was a [AGE] year-old female who admitted on [DATE]. Her diagnoses included intellectual disabilities (limitations in mental abilities that affect intelligence, learning and everyday life skills), epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of a PASARR Level 1 Screening dated 05/10/23 indicated Resident #1 had mental illness, intellectual disability, and developmental disability. Record review of a PASARR Evaluation dated 05/12/23 indicated Resident #1 did not meet criteria for MI but did meet criteria for ID and DD. Record review of the admission MDS assessment dated [DATE] indicated Resident #1 was currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Record review of a LIDDA Habilitation Service Plan dated 05/17/23 indicated Resident #1 would be receiving a CMWC (customized manual wheelchair) and be fitted for it. She would also be getting a special mattress. Record review of Resident #1's PASRR Comprehensive Service Plan form Quarterly Meeting dated 08/02/23 indicated in section A2800. Nursing Facility Specialized Services: B. Customized Manual Wheelchair was marked 3 for ongoing and in section A2900. Durable Medical Equipment (DME): Specialized or Treated Pressure-Reducing Support Surface Mattress was marked 2 for new. Record review of the June 2023 (2) PASRR Compliance call report.HHSCREG (1) provided by the PASRR Unit complainant indicated: * Resident #1 was listed * a Customized Manual Wheelchair (CMWC) was marked new * NF was contacted on 09/28/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455538 If continuation sheet Page 5 of 6 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 455538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Manor 4400 Gulf St Groves, TX 77619 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 0644 * NF staff contacted was [DON] Level of Harm - Minimal harm or potential for actual harm * Due Date for NF to submit NFSS form in LTC Portal (CMWC/DME) was 10/05/23 * Request initially found in LTC Portal was marked No Residents Affected - Few * NFSS form submitted in LTC Portal by due date was marked No. Record review of a PASRR Nursing Facility Specialized Services form for Resident #1 indicated an assessment for the CMWC dated 01/10/24 and signed by the therapist on 01/17/24. During an interview 03/18/24 at 03:00 p.m. the DON and the CN said normally the PCC was responsible for following up with the PASARR services. They said the DON had submitted some of Resident #1's information into the LTC Portal. They said Resident #1 originally came from another state and did not have Texas Medicaid, so the paperwork was kicked back in the LTC Portal for her. They said the NFSS form was submitted and acknowledged it was submitted late on 01/10/24 when it was due by the PASRR unit on 10/05/23. They said it was important to follow up with the recommended services to meet the resident's needs. During an interview on 03/19/24 at 09:30 a.m. Resident #1 said she liked her new wheelchair. Record review of the facility's undated PASARR Process indicated 6) Within 20 business days after the IDT meeting, submit a completed and accurate request for Nursing Facility Specialized Services (NFSS) in the LTC Online Portal (TMHP or Simple LTC) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455538 If continuation sheet Page 6 of 6