Health inspection·November 14, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Customer Concern Log dated 6/23/2024recorded by the Administrator revealed, Received: Nature of Concern, Resident #30 alleged content of wallet missing included cash app card, food stamp card, green card, social security card, and 10.00 cash. Resolved: Resolution, Alert and oriented to person, place, and time. Reported to HHSC. PD notified and investigation. During rounds on 6/21/2024, Resident #30 refused to allow DNS to assist with placement of belongings inventory. Social services followed-up with Resident #30 and he called to replace items from wallet. There was no assistance needed. Interview on 11/14/2024 at 3:35p.m., Administrator said DON went to Resident #30's room on 6/21/24 and tried to complete an inventory regarding his items and to help him put away his personal belongings but he refused to have the inventory done. She said when she was informed that Resident #30's wallet was missing, she reported it to the state, searched for items, and reported it to the police. She said staff were also Interviewed. She said she did not look further into Resident #30's missing items because he had two friends that would go to the store for him. She said Resident #30 was able to make phone calls to replace the items. She said to her knowledge Resident #30 was able to replace all his missing items. She said if surveyor needed copies of his identifiable information, she could speak with the Business Office Interview on 11/14/2024 at 3:48p.m., Social Worker said the facility did not follow up with Resident #30 regarding his missing items. He said they took Resident #30's word regarding him taking the initiative to replace his own items. The Social Worker said the grievance process could have been better. He said if there had been a more thorough investigation, the facility could have made sure Resident #30 received the things that he needed while at the facility. Interview on 11/14/2024 at 3:54p.m., Resident #30 said he was not able to replace all his items. He said the facility did not assist him with replacing the items. He said his family member helped him replace all his items except for his social security and green card. He said he was having a hard time renewing his Citizenship because he was still working on replacing his missing green card. He said there were no cameras in his room. He said all those items were in his wallet because he lived at the facility, and he did not think someone would steal from him. He said he also left a lift stick on the van and the facility never delivered it to him. Interview on 11/14/2024 at 4:17p.m., Business Office Manager said she was required to meet with residents within 72 hours to go over insurance, and who will pay for room and board upon their admission to the facility. She said Resident #30 came to the facility with his social security card, green card, electric express card. She said he would give his identification information if he had it. She said she made copies of the items and uploaded it to his files and to PCC for his documents. On 11/14/2024 at 4:25p.m., surveyor went to the business office to obtain copies of Resident #30's documentation that was supposedly scanned upon his admission at the facility, that the Business Office Manager said she would provide. When the Surveyor arrived at the Administrator's office to obtain those items, she refused to give a copy of the inventory and identifiable documentation for the resident such as his social security card, green card, and bank card. Surveyor requested the items from the Administrator, and she said she did not have the items and eventually shut the door. Record Review of the facility's policy titled Filing Grievances/Complaints, revised on 09/2005 reflected in part . our facility will assist residents, their representatives (sponsors), other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 2 of 3 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 455682 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Afton Oaks Nursing and Rehabilitation Center 7514 Kingsley St Houston, TX 77087 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete interested family members, or resident advocates in filing grievances or complaints when such requests are made. Any resident, his or her representative (sponsor), family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, staff members, theft of property, etc. without fear of discrimination, threat, or reprisal in any form. Grievances and/or complaints may be submitted orally or in writing. The Grievance Official will oversee the grieving process, receiving and tracking through conclusion. Event ID: Facility ID: 455682 If continuation sheet Page 3 of 3