Health inspection·October 27, 2025

F 0551 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Former RP could not have signed to change his insurance because he resided out of state. He said he called the Former RP in the presence of Administrator A and the Former RP denied signing any paperwork to change his insurance provider. In a phone interview on 10/21/2025 at 12:28pm with the previous RP, he said he always made it clear he was not Resident #7's responsible party and he was only next of kin. He said it was his understanding he would be contacted in the event of an emergency. He said Resident #7's health was not good at the time of admission but he had enough mental capacity to make his own decision then and now. He said someone called him about a special problem that would not be a charge to Resident #7, that would provide him with snacks and do his nails, but he told the person they would need to contact Resident #7 at the facility. He denied he authorized a change in Resident #7's insurance. In an interview on 10/22/2025 at 10:25 AM, Resident #7 said he was legally blind and his previous health insurance plan covered for him to have eye surgery, but when his insurance plan was changed the physician doing the surgery was no longer in network. He said the Former RP denied he changed the insurance, and he never told anyone at the facility the Former RP could make his decisions a RP. He said he was now his own RP at the facility he switched his insurance back and he was scheduled to have his eye surgery in November of 2025. He said the eye surgery was to help him regain some of not all his eyesight. He said his surgery was delayed for about one month. In an interview on 10/23/2025 at 12:12 PM with the Social Worker, he said Resident #7 filed a grievance after he went to a pre-operation appointment with an eye surgeon to discover the physician was no longer in network with his current insurance provider, PPHP. He said Resident #7 was blind, and he believed the surgery was to restore or improve his eyesight. He said while investigating the grievance Resident #7 was told his RP authorized the change in insurance. He said Resident #7 expressed wanting to be his own responsible party, he wanted to be clear his family member did not make his decisions, never made decisions on his behalf, and no one at the facility asked him if he wanted a responsible party. He said he believed the admission Coordinator and the BOM established the responsible party at the time of admission. He said there should be a conservation at the time of admission with a resident about who they wanted to be the responsible party. He said Resident #7 had always been verbal, with a BIMS of 15, alert and oriented, and able to make his wishes known. He said it would have been a violation of resident rights if he was not consulted about who he would want to be his responsible party at the time of his admission. In an interview on 10/23/2025 at 2:08 PM with Resident#7, he said no one ever asked him about his wishes at the time of admission about who he would want to be his responsible party. He said he should have been asked, his cognition was intact, and he had a high IQ. He said that because he was not his own RP at the time of admission, someone was able to change his insurance without his knowledge, and his was not able to have his eye surgery. In an interview on 10/23/2025 at 3:23 PM with admission Coordinator A, she said she started at the facility on 09/08/2025. She said if a resident was alert and oriented time 3-4, the resident should be asked about who they would want to be a responsible party. She said if relative signed a resident into the facility, the resident if alert and oriented should still be consulted on if they wanted the relative who signed them in to be the responsible party or emergency contact at the time of admission. She said if a resident was not consulted it would be a violation of the resident's rights. She said that she had not had conversations with Resident#7 because he admitted prior to her hire date. In an interview on 10/23/2025 at 4:12 PM with the BOM, she said her duties were to process admission packets, establish financial responsibility, an a payer source at the time of admission. She said the Admissions Coordinator advised her who to contact as the responsible party at the time of admission to establish financial responsibility. She said it should be determined if a resident was alert and oriented, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 2 of 66 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 10/27/2025 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 0551 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had the cognitive ability to know what they were signing in efforts to be the responsible party and the sign admission packet at the time of admission. She said there was a 72 hour care plan with Resident #7 after his admission in which he stated he wanted his family member to be his responsible party, and it was documented in a progress note. In an interview on 10/23/2025 at 4:38 PM with the MDS Coordinator, she said the admission Coordinator and BOM worked together to establish a responsible party at the time of admission. She said if a resident was alert and oriented the resident could participate in their plan of care and make their wishes known about who should be the responsible party. She said the resident had a right to know and appointment someone to make their decisions. She said she signed off on all of Resident #7's MDS assessments from the time of admission in which he had a BIMS of 15, to indicate he was cognitively intact, and able to make his own decisions. She said she was at the 72-hour care plan, and there was never a conversations with Resident #7 about who he wanted to be his responsible party. She received the progress note, dated 02/21/2025, of the care plan and indicted there was no documentation about who would be the responsible party. She said she was under the impression Resident #7's family member was his responsible party from the time of admission, until it was changed after the resident expressed concerns about being his own responsible party, and she had a discussion with the Social Worker who said he wanted it changed to himself on 10/14/2025. In a phone interview on 10/27/2027 at 12:11 PM with Admissions Coordinator B, she worked at the facility for one year, and her last day was sometime in August 2025 or September of 2025. She said establishing who was going to be a residents RP at the time of admission and entering the information in the resident electronic medical record was part of her job duties. She said if a resident was alert and oriented, they should be consulted about who the RP would be at the time of admission, if a resident was not consulted when they were able to make their wishes known, it could be a violation of their resident rights. She said she recalled Resident #7, and he was able to make his wishes known at the time of his admission. She said Resident #7's family member was the RP at the time of admission, she was unsure why he needed an RP when he was able to make his wishes known, and she did not recall asking Resident #7 if he wanted an RP. In an interview with the Administrator, RNC B and Interim DON present, the Administrator said a resident who was alert and oriented at time of the admission, should be consulted about their wishes of who they wanted to be their responsible party. The Administrator said Resident #7 always was alert and oriented, but she was unsure of his BIMS score. The Administrator said she was not aware of conversations between Resident #7, the family and staff about Resident #7's wishes at the time of the admission about who would the responsible party. She said since corporate entities changed on 07/01/2025, she no longer had access to their policies. Both RNC B and the Interim DON said a resident who was alert and oriented at the time of the admission, should be consulted about their wishes of who they wanted to be their responsible party from the time of admission under the current cooperate entity. Record review of a witness statement, dated 10/24/2025, signed by the BOM, read in part On February 24, 2025; we have a 72 hour care plan conference regarding the admission and financial paperwork. stated, I have an [family member] we can call at this time who will be signing the required documents and his primary point of contact. Record review of the facility's, undated, policy of current corporate entity, titled Resident Rights, read in part, The resident has a right to a dignified existence, self-determination, and communication with a and access to persons and services inside and outside the facility, include those specified in this policy . Exercise of Rights - the resident has the right to exercise his or her rights as a resident of the facility and as citizen or resident of the United States. 1. The facility must ensure the resident can exercise his or her right without interference, coercion discrimination, or reprisal from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 3 of 66 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 10/27/2025 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 0551 the facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 4 of 66 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 10/27/2025 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 13 residents (Resident#2) reviewed for resident rights. 1. The facility failed to notify Resident #2's Physician when they failed to administer IV antibiotic, Zosyn, as ordered from admission on [DATE] through 10/04/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities. 2. The facility failed to notify Resident #2's Physician when she was unable to receive Hemodialysis treatment as ordered on 10/03/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities. 3. The facility failed to notify Resident #2's Physician when Resident # 2 had not received all ordered treatments for all of her 14 wounds from 09/30/2025 through 10/02/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities. 4. The facility failed to notify Resident #2's Physician when the orders given on 10/02/2025 for wound care had not been entered into Resident #2's electronic medical records or implemented from 10/02/2025 through 10/04/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities. 5. The facility failed to notify Resident #2's Physician when Resident #2 had only as needed, over the counter regular strength Tylenol ordered for pain medications, had not received any pain medication prior to any of the wound care treatments, or had not had pain assessments prior to wound treatments for her 14 wounds. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities. An Immediate Jeopardy (IJ) was identified on 10/11/2025. The IJ template was provided to the facility on [DATE] at 12:02 PM. While the IJ was removed on 10/19/2025, the facility remained out of compliance scoped at pattern with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. These failures could place residents at risk of delays in treatment, worsening of condition, hospitalization, and death. Findings include: Record review of Resident#2's facesheet dated 10/09/2025, reflected she was a [AGE] year-old female, who admitted to the facility on [DATE] with a principal diagnosis of cerebral infarction, unspecified (stroke), admitting diagnosis of sepsis due to Escherichia Coli (E.Coli a bacteria) and serve sepsis with septic shock (a life-threatening condition that occurs when an infection leads to dangerously low blood pressure and organ failure, and secondary diagnosis of End Stage Renal Disease(ESRD the final stage of chronic kidney disease, where the kidneys can no longer function adequately to sustain life without treatment) pressure ulcer of sacral region, unstable, and UTI, site not specified. Secondary diagnosis dated 10/03/2025 for pressure ulcers of right buttock stage 4, left buttock stage 4,right ankle unstageable, left ankle unstageable, left heel unstageable, and other site unstageable. Secondary diagnosis dated 10/03/2025 for non-pressure chronic ulcer of right heel and midfoot, right foot, and left foot with fat layer exposed. Record review of Resident#2's admission assessment dated [DATE] reflected a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 5 of 66 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 10/27/2025 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some BIMS(Brief Interview for Mental Status) was not available as the resident rarely /never understood with severely impaired cognitive skills for daily decision making in Section C. In Section I for active diagnosis, she was triggered for ERSD, Pneumonia, Septicemia, and UTI. In Section M for skin, she was triggered to have 2 stage 4 pressure ulcers, 6 unstageable pressure ulcers, and 5 venous and arterial ulcers present upon admission. In section M she was triggered to have infection of the foot (e.g., cellulitis, purulent drainage.) In Section N for Medications, she was triggered to have antibiotics. In Section O for Special Treatments, Procedures, and Programs, she triggered to have IV medication and hemodialysis. Record review of Resident#2's comprehensive care dated 10/06/2025 reflected:Focus: Resident#2 needs hemodialysis MWF(Monday, Wednesday, and Friday) r/t(related to) renal failure.Goal: The resident will have immediate intervention should any s/sx(sign and symptoms) of complications from dialysis occur through the review date. Intervention: Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis (MWF). Monitor labs and report to doctor as needed. Monitor/document report to MD (Doctor of medicine) s/sx of depression. Obtain order for mental health consult if needed. Monitor/document/report to MD PRN any s/sx of infection to access site: Redness, Swelling, warmth or drainage. Monitor/document/report to MD PRN for s/sx of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Monitor/document/report to MD PRN for s/sx of the following: Bleeding, Hemorrhage, Bacteremia, septic shock. Obtain vital signs and weight per protocol. Report significant changes in pulse, respirations and BP immediately. Focus: Resident#2 has pressure ulcers and potential for more pressure ulcer development r/t immobility, fragile skin, Diabetes Mellitus (DM), incontinence. Present on admission: Two stage 4, Six unstageable, Five Venous/arterial ulcers, One diabetic foot ulcer. Goal: Resident#2's Pressure ulcer will show signs of healing and remain free from infection by/through review date.Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness. Administer protein supplements as ordered. Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings PRN. Administer Vitamin C as ordered. Administer Zinc as ordered. Assess/record/monitor wound healing at least weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD. Focus: Resident #2 is on Antibiotic Therapy r/t sepsis r/t wounds, UTI, and aspiration PNA(Pneumonia).Goal: Resident#2 will be free of any discomfort or adverse side effects of antibiotic therapy through the review date.Intervention: Administer medication as ordered. Antibiotics are non-selective and may result in the eradication of beneficial microorganisms and the emergence of undesired ones, causing secondary infections such as oral thrush, colitis, and vaginitis. Any antibiotic may cause diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions. Monitor q-shift (each shift) for adverse reaction. Observe for possible side effects every shift. Report pertinent lab results to MD. Record review of Resident #2's comprehensive care plan review with a review completed date of 10/06/2025 revealed no care plan for pain Record review of Resident#2's hospital clinical record dated 09/25/2025 reflected diagnosis of sepsis with fever leukocytosis, multifactorial; infected sacral ulcer/pneumonia, status post septic shock, unstageable sacral ulcer infected status post surgical debridement 9/16 up to muscle; not bony involvement, Post E.coli UTI, Right lower lobe/aspiration pneumonia, acute hypoxic respiratory failure, end-stage renal disease on dialysis, peripheral arterial disease, toe gangrene. Plan, Zosyn 2.25g IV every 8 hours for pansensitive E. coli wound culture plus empirical anaerobic coverage. Anticipate another 2 weeks of IV antibiotics. Record review of Resident#2's hospital clinical discharge record dated 09/29/2025 reflected a discharge diagnosis of sepsis with discharge medication, sodium chloride 0.9% (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 6 of 66 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 10/27/2025 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some SOLN(solution) 100 ml (Milliliter) with piperacillin-tazobactam (Zosyn)4.5 (4-0.5) g(gram) SOLR(Solution Reconstituted) 4.5g, Inject 4.5g into the vein every 12 (twelve) hours for 14 days qty(quantity): 100 GM(gram), refills: 0. The discharge summary did not give an account of how many wounds were identified while Resident#2 was admitted , the stage of the wounds, or what treatment orders were to continue after Resident#2 discharged to treat the wounds. Record review of Resident #2's out of state hospital records, dated 09/29/2025, revealed she had the following as needed (PRN) orders for pain:Acetaminophen 650 mg tablet Q 6 hours PRN mild pain.Acetaminophen 650 mg tablet Q 6 hours PRN pain or temperature 100.4 or greater which Resident #2 was documented as having received on 9/28/25 at 5:28 PM.Hydromorphone PF Dilaudid 0.5mg IV Q 4 hours prn for severe pain which Resident #2 was documented as having received on 9/28/25 at 12:36 PM. Record review of Resident #2's hospital clinical record dated 9/30/2025 reflected in part: wound care orders for her sacrum and right lateral ankle/foot. Arterial changes to RLE. Toes continue to harden, gangrenous. Right lateral leg remains purple/black. Gangrene to L 2nd -4th toes.Unstageable sacral ulcer infected status post-surgical debridement 9/16 up to muscle: not bony involvement. Infected sacral ulcer/pneumonia.Post E. Coli UTI. Record review of Resident #2's facility Order Recap, dated September 2025, revealed an order for Acetaminophen oral tablet 325 MG Give 2 tablets by mouth every 6 hours as needed for pain. The order was for an oral/by mouth administration and Resident #2 was a gastrostomy status resident. Record review of Resident #2's MAR, dated September 1, 2025 through September 30, 2025 revealed Resident #2 did not receive any Acetaminophen during the month of September. Record review of Resident#2's facility phone medication order date 09/30/2025 at 7:15pm for piperacillin sod-tazobactam ((piperacillin sodium-tazobactam sodium) So intravenous solution reconstituted 4.5 (4-0.5) GM (piperacillin sodium-tazobactam sodium) Use 100 gram intravenously every 12 hours for wound infection for 14 days, prescribed by Medial Director and confirmed by LVN B. Record review of Resident#2's MAR for the month of September 2025 no Zosyn administered to Resident #2 on her admission day of 9/30/2025. Record review of Resident #2's initial skin assessment dated [DATE] at 9:22pm by LVN A, read in part, .Resident #1 had redness to left abdomen.excoriation to vaginal area and buttocks. Moisture associated skin damage present: Yes; see ulcer assessments for details.Other skin findings: Pressure wound to sacral area, DTI(Deep Tissue Injury) to Right lateral lower leg near ankle, DTI to right heel, DTI to right lateral mid foot, DTI to Right medial ankle, Necrotic digits to all toes of right and left foot, DTI to left lateral front foot and DTI to left lateral mid foot, DTI to left heel and left lateral ankle. Central Cath to upper left chest (for dialysis use) and PEG tube. Record review of Resident#2's MAR for the month of September 2025 reflected no wound care treatments administered to Resident #2 on her admission day of 9/30/2025. Record review of the Resident#'2 physician order summary report reflected the following orders to treat a DTI to right lower lateral leg near ankle, right heel, left lateral mid foot, left heel, and left lateral ankle from admission on [DATE] were not entered and implemented until 10/04/2025. Record review of Resident #2's MAR for the month of October 2025 reflected Zosyn administered to Resident #2 on 10/04/2025 at 8:00 PM for the initial dose. Record review of the Resident#'2 physician order summary report reflected the a wound consult was not entered at resident#2's admission on [DATE] and was entered an implemented 10/02/2025. Record review of Resident #2's initial wound evaluation and management summary, dated 10/02/2025, completed by Wound Care Doctor A revealed 14 wound sites, read in part, Site 1; Diabetic Wound of the Right Heel Full thickness (refers to a deep wound that extends through all layers of the skin and may also involve deeper structures such as muscle, tendon or bone). Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 2; Unstageable (Due to necrosis [cell death that occurs when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 7 of 66 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 10/27/2025 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some most or all of the cells in an organ or tissue are irreversibly damaged and lose their normal function]) Right, Lateral Ankle Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 3; Arterial Wound (a type of open sore that develops when blood flow to the affected area is reduced) of the Right First Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 4; Arterial Wound of the Right Second Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 5; Arterial Wound of the Right Third Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 6; Arterial Wound of the Right Lateral Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 7; Unstageable (Due to Necrosis) of the Left Heel Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 8; Arterial Wound of the Left Second Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 9; Stage 4 Pressure Wound of the Right Buttock Full Thickness with a Surgical Excisional Debridement Procedure (a procedure where a surgeon uses a scalpel to cut away and remove dead or contaminated tissue from a wound until healthy, viable tissue is exposed), performed on the site. Treatment Plan, Primary Dressing(s) Leptospermum honey apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Gauze sponge non-sterile apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Negative pressure wound therapy apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days: 125 mm Hg Secondary Dressing(s) Gauze island w/bdr apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days Peri Wound Treatment Skin prep apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days.Site 10; Stage 4 Pressure Wound of the Left Buttock Full Thickness with a Surgical Excisional Debridement Procedure (a procedure where a surgeon uses a scalpel to cut away and remove dead or contaminated tissue from a wound until healthy, viable tissue is exposed), performed on the site. Treatment Plan, Primary Dressing(s) Leptospermum honey apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Gauze sponge non-sterile apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Negative pressure wound therapy apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days: 125 mm Hg Secondary Dressing(s) Gauze island w/ bdr apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days Peri Wound Treatment Skin prep apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days.Site 11; Unstageable (Due to Necrosis) of the Right, Medial Ankle Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 12; Unstageable (Due to Necrosis) of the Right, Medial Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 13; Unstageable (Due to Necrosis) of the Left, Lateral Ankle Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 14; Unstageable (Due to Necrosis) of the Right, Lateral Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Record review of physician order summary for October 2025 reflected that the orders provided initial wound evaluation and management summary dated 10/02/2025 completed by Wound Care Doctor A were not entered until 10/04/2025. Records Record review of Resident#2's progress note dated 10/03/2025 at 6:27am and completed by RN A reflected that NP A was notified of change, but there was no information detailing what the change was or orders to address the change. Records Record review of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 8 of 66 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 10/27/2025 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Resident#2's SBAR dated 10/03/2025 at 6:05am and completed by RN A did not reflect specific information of notifying NP A her missed hemodialysis session or orders from NP A to address the missed hemodialysis session. Record review of Resident #2's MAR, dated October 1, 2025, through October 31, 2025, revealed the following order: Acetaminophen oral tablet 325 MG Give 2 tablets by mouth every 6 hours as needed for pain. D/C Date 10/10/2025. Resident #2 did not receive this medication. Record reviews of Resident #2's electronic medical record revealed no PAINAD assessments for Resident #2. In an observation on 10/09/2025 at 10:57 AM revealed ADON A performed Resident#2's wound care with assistance from CNA A. ADON A said at the start of the treatment Resident #2 was medicated for pain about 30-40 minutes prior. Resident #2 was observed to tolerate the wound care treatment without any visible, verbal, or audible reaction until ADON A painted betadine on her left lateral ankle which was the last treatment. Resident #2 could be heard inhaling deeply with her eyes closed as if she were in pain. In an interview on 10/09/2025 at 2:46pm with LVN A, she said that she was the admitting nurse for Resident#2 on 09/30/2025. She said that she completed a skin assessment on Resident#2 at the time of admission, she had multiple wounds at the time of the admission, and she did not recall the location of the wounds. She said that she reconciled the medication list and treatments for the wounds with the on call nurse practitioner for the primary care physician, and the nurse practitioner gave orders to continue all treatments and medications as detailed in the medical records until the next rounding day. She said that she enlisted the help of LVN B to help her enter the medications and treatments as ordered by the nurse practitioner at the time of Resident#2's admission. She said that Resident#2's hospital medical records said that she was continue with an antibiotic Zosyn every 12 hours via a dialysis port, but she was unsure what type of infection the Zosyn was to treat. She said that the her clinical impression was that some of Resident#2's wounds were infected at the time of admission, and it was apparent that she had recent debridement of the wounds prior to being discharged from the hospital. In an interview on 10/09/2025 at 4:36pm with the Medical Director, she said that she was the primary physician for Resident#2. She said that staff should notify the primary care physician at the time of admission to obtain orders for medications and treatments. She said that she did not want to speak on potential risks to residents if staff did not obtain medication and treatment orders at the time of admission. She said that Resident#2 IV antibiotics should be arranged prior to a residents admission, and if it was not available orders could be arranged to switch to an oral antibiotic until it was available. She said that a wound consult should made upon admission, and the orders given after the wound consult should be entered and carried out. In a follow up interview on 10/09/2025 at 5:14pm with ADON A, she said that that the admitting nurse completes an initial skin assessment at the time of admission. She said that the treatment nurse should complete a second skin assessment on new admission with wounds identified within 24 hours of admissions. She said that the treatment nurse should review the facility clinical records and hospital clinical records. She said that the treatment should be reviewing the admission nurse work for accuracy and correcting any errors made. She said that there should be a clinical review of all new admissions the next business day with the Administrator and clinical department heads present. She said that she worked as treatment nurse on 09/30/2025 and 10/01/2025. She said that Resident#2 admitted on [DATE] with wounds, and orders for Zosyn. She could not recall if the order for Zosyn was to treat a wound infection or UTI. She said that she did not complete the second skin assessment for Resident#2 at the time of admission, she asked ADON B to complete the second skin assessment, and ADON B would help complete treatment duties when she is not able to finish by the end of her shift. She said that ADON B would have been responsible for complete Resident#2's wound care treatment after admission. She said that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 9 of 66 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 10/27/2025 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some she did not recall if she attended the clinical admitting on 10/01/2025. She said that LVN A was responsible for ensuring that medications and treatments were reconciled at the time of admission and entering the orders. She said that Resdient#2 did not have orders treat all her wounds or Zosyn at the time of admission. She said that a clinical review of Resident#2's admission should have caught the error. She said that the risk to Resident#2 was the worsening of wounds and infection. In an interview on 10/09/2025 at 5:30pm with ADON B, she said that she worked on 09/30/2025 and 10/01/2025 from 10:00pm -6:00am. She said that she did not assist with the admission of Resident#2, and the admission was completed by LVN A. She said that LVN A did tell her that Resident #2 admitted with wounds with treatment orders from the hospital. She said that she did complete Resident#2's wound care on 10/01/2025. She said that no one communicated to her to complete a skin assessment as the treatment nurse for Resident#2. She said that she is not the treatment nurse for the facility, but she does help with wound care. She said that she started as an ADON on 10/09/2025, prior to she was a floor nurse, she was not sure who was responsible for completing wound care at the facility, and she was not sure what the facility was communicating her role to be at the facility prior to 10/09/2025. In an interview on 10/09/2025 with the DON, she said that she worked on 09/30/2025 and 10/01/2025, and Resident #2 admitted on [DATE]. She said that there should be a clinical review of all new admissions on the next business day after the admission with the clinical department heads and Administrator present. She said that the clinical review should be to review the admission process for accuracy and correcting errors made. She said that she had not completed an assessment of Resident#2 since the time of admission. She said that she was not aware of Resident#2 to have not received antibiotics from the time of admission. She said that she was not aware that Resident#2 did not have skin assessment completed by a treatment nurse after admission. She said that it was the responsible of both ADON A and ADON B to complete wound care in the absence of a permanent treatment nurse. She said that she was not aware that resident did not have orders to treat all wounds or wound consult upon admission. She said that she was not aware that Resident#2 had missed a dialysis treatment after admission. She said that she could not recall if there was a clinical review of Resident#2 after admission, and if there was a review then admission errors would have been caught and corrected. In an interview on 10/09/2025 at 6:41pm with the Administrator, she said that she does not always stay for daily clinical meetings with the clinical department heads after the daily stand up meeting. She said that she did not believe that she participated in the clinical meeting on 10/01/2025, and she took a phone call. She said that the DON is the clinical oversight for the facility. She said that the DON should review all new admissions, re-admission, change in conditions, and the 24 hour report for accuracy. She said that the DON should review all medical clinical records prior to a residents admission. In an observation on 10/10/2025 9:32am at the beside of Resident#2 who was non-verbal or interviewable . In an interview on 10/10/2025 at 9:38am with in-house Hemodialysis Nurse, she said that on 10/03/2025 Resident#2 could not receive hemodialysis due to a change in condition, elevated heart rate around 120 beats each minute, she contacted the Nephrologist who ordered Metoprolol to Resdient#2, and she communicated with Resident #2's nurse(name unknown) about the the order for Metoprolol. She said that Resident#2 was referred back to the facility nurse (name unknown) for further intervention and treatment. She said that when a resident does not receive hemodialysis as scheduled, they are usually sent to the hospital to receive hemodialysis. She said that she later found out that Resdient#2 was not sent to the hospital. In a phone interview on 10/10/2025 at 10:05 am with RN A who worked the 10:00pm-6:00am, said she notified NP A that Resident #2 had not received her hemodialysis on that 10/03/2025, because her hear rate was too high. RN A said NP A gave an order to re-evaluate Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 10 of 66 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 10/27/2025 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some #2's vital signs and heart rate within an hour and call him back. She said that Resident#2's heart rate remain high, she sent a text message to notify NP A, NP A never responded to her text, and she did not receive any orders to administer medications to Resident #2. She said that she never administered any medication to Resident #2 because it was the end of her shift and that the Hemodialysis Nurse was the one who gave Resident #2 Metoprolol. RN A did not reply when asked why she documented in Resident #2's SBAR dated 10/03/2025 that she had spoken with NP A and received orders for medication Metoprolol. RN A said that this all happened at the end of her 10pm-6am shift, and she gave report to the on-coming nurse(LVN D) about Resident #2's elevated heart rate and missed dialysis. RN A said she could not recall if she specifically asked NP A about any orders for Resident #2 to receive dialysis and said she did tell NP A that Resident #2 had missed or was unable to get dialysis that day. RN A said she either told ADON A or LVN D about the missed dialysis and elevated HR, she was unsure if she did tell ADON A or LVN D, and unsure if she documented the information on the 24 hour report In an interview on 10/10/2025 at 11:10am with NP B, he said that he is the nurse practitioner for the facilities Medical Director. He said that Resident#2 admitted on [DATE] while he was off, NP B covered for him, and NP B saw Resident#2 on 10/01/2025. He said that Resident#2 admitted with wounds, and she was being treated with IV antibiotics, Zosyn, for UTI and Wound culture for E.Coli while in hospital, and the Zosyn was to continue for 2 weeks after discharge. He said that he was asked to see resident number today on 10/10/2025 by the Medical Director and that was his first time meeting Resident#2. He was unsure when the Resident#2 received the first dosage of the Zosyn, but it should start no later than the next day after admission. He said that his expectation would be that all medications and treatments start no later than the next day after the order is given. He said that the risk is that conditions or infections could worsen. He said that it was his expectation that a physician or nurse practitioner be notified when medications were not available to seek additional orders to treat. He said that if he had been notified that Resident#2's Zosyn was not available he would have send her back to the hospital, as there would ve no reason for her to remain in the building without the medications, and the risk to Resident#2 would have been the infection could have worsen. He said that he was not aware of Resident#2 to missed dialysis for any day or reason, but the physician should be notified if there was a change in condition that would affect a resident not receiving dialysis or any care. He said that if a resident missed dialysis, they would be sent to the hospital to get the treatment. He said that it was important for staff to notify a physician of wounds upon admission and once identified. He said that the standards were to continue with orders from the hospital until a wound care physician can take over or the primary physician makes changes to the treatment from the hospital. In an interview on 10/10/2025 at 11:10am with the DON A, she said that RN A completed the SBAR on 10/03/2025 for Resident#2, she reviewed the SBAR (Situation, Background, Assessment, and Recommendation), and there was nothing documented about a change in the residents conditions that prevented Resident#2 from receiving dialysis, that notification was made to a physician or nurse practitioner, or what a physician or nurse practitioner wanted to do about the missed dialysis. In an interview on 10/10/2025 at 11:33am with NP A, he said that he was contacted at the time of Resident#2's admission, he reviewed medications and treatments for wounds with the admitting nurse, and he gave order to continue with treatment and medication orders from the hospital medical records. He said that he rounded with Resident#2 on 10/01/2025, she was prescribed Zosyn a broad-spectrum treatment for an E. Coli infection of her urinary tract, wounds, and pneumonia. He said that he was asked to clarify the order for Zosyn with the pharmacy, and he was under the impression that the medication would be delivered and administered the same day. He said that if he had been informed, he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 11 of 66 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 10/27/2025 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete would have decided on a different treatment plan. He said that he was not contacted to address interventions for a missed hemodialysis on 10/03/2025, he was notified of an elevated heart rate during dialysis that was addressed by another doctor. He said that he would not speak on risks to residents, or if Resident#2 should have been sent to the hospital. He said that his expectation is that staff make enter orders from the time of admission, follow orders, and make notifications to a physician when medications are not available, treatments are missed, and when there is a change in condition. In an interview and observation on 10/10/2025 4:59pm at the beside of Resident#2 of ADON B to perform Resident#2's wound care treatment with MA E, and DON present. Both ADON B and MA E said that Resident#2 were medicated prior to treatment for pain. Observation of ADON B to cut away the bandage to Resident#2 left foot that was stuck to the wound without using a saline spray to loosen the bandage. ADON B was observed not to look a Resident#2 to non verbal signs of pain. Resident#2 was observed to show facial grimace. ADON B was asked if she would use a saline spray to loosen the bandage in which she did, and continued to pull the bandage from the wound. Resident#2 was observed with tears in both eyes. ADON B was asked what medication was used to manage the pain of Resident#2, to which she replied Extra Strength Tylenol. ADON B was asked to stop the treatment. DON A told ADON B to contact the physician to see if Resident #2 could have something stronger for pain. In an interview on 10/10/25 at 5:26pm with the Administrator A, she was told of the observation made of Resident#2's wound care and concern for pain management. Administrator A said the concerns were clinical concerns and she would have to speak with the DON Ato gather more information on the sit Event ID: Facility ID: 455682 If continuation sheet Page 12 of 66 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 10/27/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment for 2 of 4 halls; Hall 300 and Hall 400 reviewed for homelike environment.Based on observation, interview, and record review, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment for 2 of 4 halls; Hall 300 and Hall 400 reviewed for homelike environment. The facility failed to ensure Hall 300 was free of odors. The facility failed to deodorize Resident #21 and Resident #31's room resulting in foul orders filling the 300 Hallway and other residents rooms on the 300 hall resulting in complaints from other residents and family members. The facility failed to ensure construction-renovations were completed in Hall 400 resulting in 2 residents (Resident #11 and Resident #22) not getting wound care and living in an unpleasant and uncomfortable environment for the residents. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, uncomfortable, and unsafe. The findings included: Record review of Resident #21's Electronic Health Record revealed a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses including Pressure Ulcer of Sacral Region, Stage 4 (a deep wound with full-thickness tissue loss that has damaged muscle, tendon, or bone), Pressure Ulcer of Left Lower back, stage 3 (a full-thickness skin and tissue loss injury that has damaged the skin and fat layer, creating deep crater, but has not yet exposed muscle, bone, or tendon), Pressure Ulcer of Right hip, Stage 4 (a severe, full thickness wound that extends through the skin and fat to expose underlying muscle, tendon, or bone), Pressure Ulcer of Left Ankle, Unstageable, Pressure Ulcer of other site (full thickness tissue loss, but the depth cannot be determined because it is covered by eschar (dead tissue) or other slough (dead or dying tissue)), Major Depressive Disorder(a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), Generalized Anxiety disorder (a common mental health condition characterized by excessive, persistent, and uncontrollable worry and anxiety about various aspects of life), and Benign Prostatic Hyperplasia without Lower Urinary Tract symptoms ( a condition where the prostate gland enlarges but does not cause any noticeable urinary problems) and Colostomy Status (refers to the condition of having a surgical procedure called colostomy). Record review of the Resident #21's Quarterly MDS revealed a BIMS score of 14, which indicates cognitively intact. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating and oral hygiene. Resident #21 required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts or holds trunk or limbs but provides less than half the effort) for rolling left to right. Resident #21 required substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with shower/bathe self, upper body dressing, personal hygiene, sit to lying, and lying to sitting on side of bed. Record review of Resident #21's care plan dated 09/17/25 revealed the following in part: Focus: I am Non-Complaint daily to care and refuse care (Peri-care-wound care-ADL Care) has a preference to not wear briefs, refuses nail care, shaving, haircut, showers, and grooming and wound care.Goal: Prevent New Wounds and Heal Current Wounds- I will be free of Pain or Discomfort Focus: The resident has a behavior problem refusing medications, wound care, ADL care, grooming, no sheet on bed and meals Goal: The resident will have fewer episodes of refusing medications by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 13 of 66 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 10/27/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some review date Record review of Resident #31's Electronic Health Record revealed a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses including Unspecified Dementia (a diagnosis used when a person exhibits symptoms of dementia by the specific underlying cause cannot be determined), Local Infection of the skin and subcutaneous tissue (an infection that affects the layers of skin and underlying fat), Chronic Venous Hypertension with Ulcer of Right Lower Extremity (there is high blood pressure in the veins of the right leg, which has caused an open sore (ulcer) to form due to poor circulation), Chronic Venous Hypertension with Ulcer of Left Lower Extremity (high blood pressure in the veins of the left leg has caused a non-healing sore (ulcer) to form due to poor blood flow), Schizophrenia, Unspecified (a diagnostic category used in psychiatry when a person exhibits symptoms of schizophrenia but does not meet the full criteria for any specific subtypes of schizophrenia), Pressure Ulcer of Sacral Region, Stage 4 (a severe form of pressure injury where there is full-thickness tissue loss with exposed bone, muscle, or tendons), Pressure Ulcer of Right Heel, Stage 4 (the most severe type of pressure injury, involving deep-tissue damage with full-thickness tissue loss that exposes muscle, tendon, or bone), and Cognitive Communication Deficit (a communication challenge caused by problems with thinking abilities like attention, memory, and executive function, rather than a language or speech problem). Record review of the Resident #31's Quarterly MDS revealed a BIMS score of 11, which indicates moderately impaired cognition. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or ouching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating and oral hygiene. Resident #31 required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts or holds trunk or limbs but provides less than half the effort) for rolling left to right. Resident #31 required substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, and personal hygiene. Record review of Resident #31's care plan dated 09/19/25 revealed the following in part: Focus: Resident #31 is resistive to care relate to refusing incontinent care, wound treatment, weight and height management, refuses to bathe, shaving, haircuts, nail care, grooming, refuse to allow mid-line to be flushed.[sic] Goal: The resident will minimize refusal with care through next review date. Record review of Resident #11's Electronic Health Record revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Atherosclerosis of Native Arteries of Extremities with Gangrene, Right Leg (Severe plaque buildup in the arteries of the right leg, blocking blood flow to the point where tissue has died), Peripheral Vascular Disease( a circular disorder where narrowed, blacked, or spasming blood vessels outside the heart and brain reduce blood flow to the limbs and organs), Atherosclerosis of native arteries of right leg with ulceration of other part of foot (refers to a serious condition where atherosclerosis, the build-up of plaque in the arteries, has severely narrowed the arteries of the right leg, leading to gangrene (tissue death) and ulceration (an open sore) on the foot), non-pressure chronic ulcer of other part of right food with fat layer exposed (a non-healing open sore on the right foot that has penetrated through the skin to the subcutaneous fat layer, but was not caused by external pressure) Hypothyroidism (an underactive thyroid condition where the gland does not produce enough thyroid hormones, causing many of the body's function to slow down), and Hyperlipidemia (high levels of lipids like cholesterol and triglycerides in the blood). Record review of the Resident #11's Quarterly MDS revealed a BIMS score of 15, which indicates cognitively intact. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 14 of 66 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 10/27/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some supervision or touching assistance (Helper provides verbal cues and/or ouching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with oral hygiene, rolling left and right, sit to lying, and lying to sitting on side of bed. Resident #11 requires partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs and provides less than half the effort) with Toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, car transfer. Record review of Resident #11's care plan dated 09/30/25 revealed the following in part:Focus: Resident #11 has arterial ulcer related to Peripheral Arterial DiseaseRelated to third toe status post amputation secondary to gangrene. Goal: Resident #11 will be free from infection or complications related to arterial ulcer through review date. Record review of Resident #11's October 2025 Order Summary revealed an order to Cleanse right third toe arterial ulcer wound with Vashe, pat dry, apply lodosorb Gel to would bed, gauze sponge, cover with gauze border dressing dated 10/11/25. Record review of Resident #11's wound physician progress note dated 10/13/25 revealed: The patient's visit was rescheduled, unable to access room due to construction in the hallway. Record review of Resident #22's Electronic Health Record revealed a [AGE] year old male re-admitted to the facility 02/10/25 with diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer, Non-pressure chronic ulcer of left heel and midfoot with unspecified severity (long standing, non healing wound on the left heel and midfoot that was not caused by pressure), Non-pressure chronic ulcer of other part of left foot with fat layer exposed (A significant wound requiring medical attention, as it is a deeper ulcer that one limited to the skin and suggests damage has reached the subcutaneous tissue), Hereditary sideroblastic anemia (a rare genetic disorder where the body cannot produce sufficient hemoglobin due to a genetic defect) and Encounter for orthopedic aftercare following surgical amputation. Record review of Resident #22's Quarterly MDS revealed a BIMS score of 11, which indicates moderately impaired cognition. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or ouching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating and oral hygiene. Resident #22 required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and tub/shower transfer. Record review of Resident #22's care plan dated 08/08/25 revealed the following in part:Focus: Resident #22 is at risk for infection related to a site for organism invasion. Goal: Early recognition of infection to allow for prompt treatment.Focus: Resident #22 has a surgical site to LT proximal plantarGoal: Resident's surgical site will show signs of improving and remain free from s/s of infection with treatment as ordered over the next 90 days.Interventions:- Administer supplements as ordered. - Administer treatments as ordered. - Surgeon follow up as needed. Assist Resident/Responsible party with scheduling/transportation as needed. - Wound Doctor Consult. Record review of Resident #22's October 2025 Order Summary revealed an order for Wound Consult dated 10/11/25 and an order for wound care site 6 Post-Surgical Wound Left Heel every day shift for left heel wound dated 10/12/25. Record review of Resident #22's wound physician progress note dated 10/13/25 revealed: The patient's visit was rescheduled, unable to access room due to construction in the hallway. In an interview/observation on 10/13/25 at 2:56pm; while walking rounds the back of 400 hallway was observed that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 15 of 66 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 10/27/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some had 1 side of the hallway closed off with a closed door and on the other side of the door there was a clear plastic sheet covering the open side of the door. There were no signs posted on the closed door or plastic sheet or signs as to what type of work was being done. There were 3 men on the other side of the door and clear plastic sheet wearing N95 mask or respirator masks and actively spraying the walls and ceilings of the unit. Some residents' doors were closed and the floor was covered with slippery plastic sheeting. All of the residents' doors were covered with plastic sheets that were taped at the top and did not create a complete covering or seal over the entire door and most only partially covered the door with the bottom of at least 8 rooms uncovered and exposed to the sprayed material and dust. The 400 hallway appeared hazy with dust like material floating in the air. There were at least 2 rooms that had EBP signs posted and at least 4 rooms that had residents inside of the rooms. When staff were asked what was happening CNA B and LVN B said they did not know and that administration had not told them anything. Staff said they would like to know as well so they could wear appropriate masks because they did not know what they were breathing or what the residents were breathing. CNA B and LVN B said they had no advanced notice that the work was being done and had no way of notifying residents before the work started. The machine used to spray the cloudy material was extremely loud and sounded like a jackhammer or drill. Interviews and observations with Resident #8, Resident #9 and Resident #11 who were all in their rooms and had EBP signs posted outside their doors. Resident #8 and Resident #9 said they felt ok but were advised they could not leave their rooms while the workers were outside. They said it was loud, but they had no feelings of illness or difficulty breathing at that time. When asked how they felt about being sealed inside their rooms during the work, Resident #8 said he was ok with it and Resident #9 said it was inconvenient. All 3 of the Residents said it was too loud. All of the Residents said no one told them the work would be done that day and no one offered them masks or an option to move or change rooms. In an interview on 10/13/25 at 3:00pm with CNA-AG, she was observed with no mask on. She reported there were about 12-13 residents behind the plastic barrier on hall 400. She stated she was not told what the workers were doing or what they were spraying. She stated she did not know why the plastic barrier was needed. In an interview/observation on 10/13/25 at 3:18pm-Notified Admin, DON and Corporate staff about immediate environmental concerns on 400 hallway and safety of residents who remained on the hallway while the substance was being sprayed. Admin said they had notified residents and family members about the renovations, and she was unsure what the substance was the workers were spraying but she could find out. She said she was unsure if anyone was required to wear any PPE or masks and said that they had signs posted on the front entry regarding the remodeling. The Admin said the facility was undergoing renovations with the new company and it was not construction. She said the workers were painting and had started renovations on 200 hall and were slowly working their way around the building. In an interview on 10/13/25 at 3:56pm with LVN B, she stated there were residents behind the plastic barriers on 400 hall. She stated she was not told what the workers were doing or what they were spraying. She stated she did not know why the plastic barrier was needed. She stated she did not know why the workers were wearing masks. She stated she thought the workers were sanding before painting. She stated that if the workers had masks the residents and staff should have masks as well. She stated there were no residents on oxygen on the 400 hall. She stated there was one resident with COPD. She stated she did not smell any fumes but it was dusty on the hall and it was loud. She stated she was not sure if the residents were asked to move. In an interview on 10/13/25 at 3:59pm with CNA-AG, she stated she was not told what the workers were doing or what they were spraying. She stated she did not know why the plastic barriers was needed and she did not know why the masks were needed. She stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 16 of 66 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 10/27/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some she thought the workers were sanding prior painting the hallway. She stated that if the workers had on masks then the residents and staff should have on masks as well. She stated the renovations were loud and she was not sure if the residents were asked to move rooms or not. In an interview on 10/13/25 at 4:04pm with Contractor AO, he stated that he and the workers were spraying texturizer on the ceiling, and they would paint on 10/14/25. He stated that they were wearing the masks because it leaves dust that you should not breathe in. In an interview on 10/14/25 at 11:48am with Resident #7, he stated he did not get any notice that the facility was doing any construction in the building. He stated he resides on hall 400. He stated the contractors were scraping, drilling, and painting in the hallway and it was loud. He stated everything had been flying in the air and it was affecting his sinuses, causing him to become congested and he reported he had diarrhea. In an interview on 10/15/25 at 12:11pm with ADON-M, she stated some of the residents on Hall 400 were not seen by the wound care doctor (Resident #11 and Resident #22). She stated she was not given a reason why the residents were not seen but she stated the wound care doctor reported that she did not want to go behind the barrier of the renovations on the 400 hall. She stated there was a barrier cutting off the hallway where renovations were being completed (painting). She stated Resident #11 and Resident #22 will not be seen until the following week (Mondays is the wound care doctors rounding days). She stated there was a barrier cutting off the hallway where they were painting. In observation rounds on 10/20/25 at 2:13pm on Hall 300, the hall smelled of urine and feces. In an interview on 10/20/25 at 2:14pm with Resident #21 and Resident #31, both residents were observed lying in their beds. Upon entering Resident #21 and Resident #31's room, the smell intensified. The room smelled of urine, feces, and body odor. The surveyor had on a mask but was able to smell the odor through the mask. Resident #21 stated he did not have any concerns with the smell of the room and reported that the room smelled fine. In an interview on 10/20/25 at 2:45pm with Regional Compliance Nurse-R, Regional Compliance Nurse-R was observed entering the room of Resident #21 and Resident #31. He stated the residents' room did have an odor and described the smell as body odor, feces and body fluid. He stated the smell was contributed to the lack of wound care. He stated Resident #21 and Resident #31 refuse wound care and stated it smells sour in the residents' room. He stated he was unsure of what had been done by the administrator to address the smell. In an interview on 10/21/25 at 3:31pm with Resident #38, the resident resides on the 300 hall. He stated he did not like the smell of the 300 hall and he described the smell as different then said it was like poop. He stated he could not smell it in his room but reported he could smell it when he goes in the hallway. He stated he would like for the hallway to smell better, because it smells that way all the time and he was sick of it. He stated this was his home and he would want it to smell better. He stated he has not spoken to anyone regarding his concern for the smell. He stated he felt as if staff knows that it smells and does not care. In an interview on 10/21/25 at 3:34pm with MA-AE, she stated there had always been an odor on the 300 hall and it was resulting from two of the residents (Resident #21 and Resident #31) in one of the rooms on the 300 hall. She stated the smell emits from the room into the hallway and into some of the other residents' rooms. She stated she did not know what the facility management was doing to address the problem. She stated she did not know if the facility staff had spoken to the other residents about the concern. She stated whatever the facility management was doing about the smell was not effective. In an interview on 10/22/25 at 9:20am with Family Member #40, she stated the facility smelled horrible. She stated she was able to smell it as soon as she turns the corner to walk down hallway 300. She stated the smell hits you in the face. She stated it smelled like urine, sh**, and like something spoiled. She stated she smell was coming from one of the rooms on the 300 hall. She stated she could smell (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 17 of 66 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 10/27/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete it down the hall and reported that the smell lingers into Resident #33's room. She stated she had not complained about the smell but reported Resident #33 has complained to corporate about the smell. In an interview on 10/22/25 at 9:25am with Resident #37, the resident resides on the 300 hall. He stated he did not like the way his room or the facility smelled and stated who would like the smell. He stated the smell was worse in the hallway. He stated the smell was coming from one of the rooms on the 300 hall and stated the residents in that room does not allow staff to wash their a**, change their diapers, or tend to their wounds. It smells sh** and rotten flesh. He stated he felt helpless because this was his home and he could not do anything about the smell. He stated if this was his own home it would not have this smell. He stated the staff had not asked him how he felt about the smell, and no one had asked him if he wanted to change halls. In an interview on 10/22/25 at 9:35am with CNA-AJ, she reported there was a concern with odor on Hall 300 because some of the residents refuse care. She stated she could not think of words to describe the smell but it was bad. She stated she did not know what the facility was doing about the smell but reported it has always smelled that way since she started working at the facility, she stated she started working at the facility in November 2024. She stated that this was the residents' home and they have a right to an odor free home. In an interview on 10/22/25 at 9:40am with Housekeeper-AL, she stated she had been employed at the facility for 2 months. She stated there was an issue with odor on the 300 hall. She stated the odor was indescribable and stated it had always smelled bad ever since she started working there and the smell had gotten worse. She stated she was told the source of the smell was from residents refusals of baths and wound care. She stated she cleans each room one time a day and the rooms of concern are cleaned two times a day. She stated she sprays odor neutralizer upon entering and exiting each room and she also sprays the hallways as she exits each room. She stated that she goes through 2-3 bottles of odor neutralizer a week for one hall to try to help the smell but it does not work. She stated the additional cleaning was not helping the odor. She stated that it was the residents' home, and they have the right to have an odor free home. In an interview on 10/22/25 at 10:20am with Resident #33, he did not have any concerns for the smell in his room or in the hallway. In an interview on 10/22/25 at 11:20am with Administrator-A, she stated she does daily observation rounds of the entire facility. She stated she had not observed a pronounced odor to any part of the facility. She stated she had only observed there to be a smell associated with incontinent care and that was normal from residents getting brief changes at every facility. She stated there had not been complaints or grievances about odors in the building. She stated housekeeping does have some targeted rooms that received additional cleaning at the back of 300 hall and 400 hall. Administrator-A sent an email to surveyors with the list of targeted rooms that get additional cleanings, but she reported she did not recall the reason as to why the rooms get additional cleanings. On 10/22/2025 at 1:06pm, a policy was requested for homelike environment, and it was not provided prior to exit. Event ID: Facility ID: 455682 If continuation sheet Page 18 of 66 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 10/27/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident had the right to be free from neglect for 2 of 13 residents (CR#1 and Resident #2) reviewed for neglect.1. The facility failed to treat the wound of CR#1's buttock from admission on [DATE]-[DATE].2. The facility failed to notify Resident #2's Physician when they failed to administer IV antibiotic, Zosyn, as ordered from admission on [DATE] through 10/04/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities.3. The facility failed to notify Resident #2's Physician when she was unable to receive Hemodialysis treatment as ordered on 10/03/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities.4. The facility failed to notify Resident #2's Physician when Resident # 2 had not received all ordered treatments for all of her 14 wounds from 09/30/2025 through 10/02/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities.5. The facility failed to notify Resident #2's Physician when the orders given on 10/02/2025 for wound care had not been entered into Resident #2's electronic medical records or implemented from 10/02/2025 through 10/04/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities. 6. The facility failed to notify Resident #2's Physician when Resident #2 had only as needed, over the counter regular strength Tylenol ordered for pain medications, had not received any pain medication prior to any of the wound care treatments, or had not had pain assessments prior to wound treatments for her 14 wounds. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities. An Immediate Jeopardy (IJ) was identified on 10/13/2025. The IJ template was provided to the facility on [DATE] at 12:13 PM. While the IJ was removed on 10/20/2025, the facility remained out of compliance scoped at pattern with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. These failures could place residents at risk for delayed treatment, worsening of condition, increased pain, hospitalization, and death Findings include:1. Record review of CR#1's face sheet, dated 09/30/2025, reflected a [AGE] year-old male, who admitted to the facility on [DATE]. CR#1 had a diagnosis which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and weakness resulting from a stroke). CR#1 was transferred to a local hospital on [DATE] related to a percutaneous gastrostomy endoscopic (PEG) tube replacement (feeding tube replacement). Record review of CR#1's admission MDS assessment, dated 06/03/2025, reflected a BIMS was not available as the resident rarely /never understood with severely impaired cognitive skills for daily decision making. In Section M for skin, he was triggered to have 1 stage 2 pressure ulcer upon admission. Record review of CR#1's comprehensive care, dated 09/26/2025, reflected:Focus: CR#1 has a pressure ulcer to the sacrum, back (2), left ankle, left foot, left heel, Right lower legand right heel related to limited mobility, incontinence, end stage skin failure.Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date.Intervention: Administer treatments as ordered and monitor for effectiveness. Record review of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 19 of 66 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 10/27/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some CR#1's hospital clinical record, dated 05/27/2025, reflected a pressure ulcer located to the buttock on 05/26/2025, with no orders identified for continued treatment upon discharge. Record review of CR#1's progress notes, dated 05/28/2025 at 9:56 PM by ADON B, read in part, .[CR#1] has dressing to sacral area and has a peg tube. No other skin issues observed to resident. Record review of CR#1's total body skin assessment, dated 05/29/2025, reflected 1 wound with no documentation of the wounds stage or size. Record review of CR#1's MAR for the month of May of 2025 reflected no wound care treatment. Record review of CR#1's May 2025 order summary reflected no orders for wound treatment or wound consult. Record review of CR#1's physician order, dated 06/03/2025, read in part, wound (1) pressure stage 2 coccyx (tailbone). Cleanse with normal saline or wound wash, pat dry, apply comfort foam border 2x (times) weekly and PRN (as needed) if soiled or dislodged. Record review of CR#1's MAR for the month of June of 2025 reflected wound care treatment for a stage 2 coccyx an initial documentation on 06/04/2025. 2. Record review of Resident #2's face sheet, dated 10/09/2025, reflected a [AGE] year-old female who admitted to the facility on [DATE]. Resident #2 had a principal diagnosis which included cerebral infarction, unspecified (stroke), admitting diagnosis of sepsis due to Escherichia Coli (E.Coli a bacteria) and serve sepsis with septic shock (a life-threatening condition that occurs when an infection leads to dangerously low blood pressure and organ failure), and secondary diagnosis of End Stage Renal Disease[ESRD] the final stage of chronic kidney disease, where the kidneys can no longer function adequately to sustain life without treatment) pressure ulcer of sacral region, unstable, and UTI, site not specified. Secondary diagnosis, dated 10/03/2025 for pressure ulcers of right buttock stage 4, left buttock stage 4,right ankle unstageable, left ankle unstageable, left heel unstageable, and other site unstageable. Secondary diagnosis, dated 10/03/2025, for non-pressure chronic ulcer of right heel and midfoot, right foot, and left foot with fat layer exposed. Record review of Resident#2's admission assessment dated [DATE] reflected a BIMS(Brief Interview for Mental Status) was not available as the resident rarely /never understood with severely impaired cognitive skills for daily decision making in Section C. In Section I for active diagnosis, she was triggered for ERSD, Pneumonia, Septicemia, and UTI. In Section M for skin, she was triggered to have 2 stage 4 pressure ulcers, 6 unstageable pressure ulcers, and 5 venous and arterial ulcers present upon admission. In section M she was triggered to have infection of the foot e.g., cellulitis (a common bacterial infection of the skin and underlying tissues), purulent drainage. In Section N for Medications, she was triggered to have antibiotics. In Section O for Special Treatments, Procedures, and Programs, she triggered to have IV medication and hemodialysis. Record review of Resident #2's comprehensive care, dated 10/06/2025, reflected:Focus: Resident #2 had pressure ulcers and potential for more pressure ulcer development r/t immobility, fragile skin, DM, incontinence. Present on admission: Two stage 4, Six unstageable, Five Venous/arterial ulcers, One diabetic foot ulcer. Goal: Resident #2's Pressure ulcer will show signs of healing and remain free from infection by/through review date.Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness. Administer protein supplements as ordered. Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings PRN. Administer Vitamin C as ordered. Administer Zinc as ordered. Assess/record/monitor wound healing at least weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD. Focus: Resident #2 is on Antibiotic Therapy r/t sepsis r/t wounds, UTI, and aspiration PNA.Goal: Resident #2 will be free of any discomfort or adverse side effects of antibiotic therapy through the review date.Intervention: Administer medication as ordered. Antibiotics are non-selective and may result in the eradication of beneficial microorganisms and the emergence of undesired (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 20 of 66 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 10/27/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some ones, causing secondary infections such as oral thrush ( fungal infection of the mouth), colitis (inflammation of the lining of the colon), and vaginitis (an inflammation of the vagina). Any antibiotic may cause diarrhea, nausea, vomiting, anorexia (a serious and potentially life-threatening eating disorder), and hypersensitivity/allergic reactions. Monitor q-shift for adverse reaction. Observe for possible side effects every shift. Report pertinent lab results to MD.Focus: Resident #2 needs hemodialysis MWF r/t renal failure.Goal: The resident will have immediate intervention should any s/sx of complications from dialysis occur through the review date. Intervention: Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis (MWF). Monitor labs and report to doctor as needed. Monitor/document report to MD s/sx of depression. Obtain order for mental health consult if needed. Monitor/document/report to MD PRN any s/sx of infection to access site: Redness, Swelling, warmth or drainage. Monitor/document/report to MD PRN for s/sx of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Monitor/document/report to MD PRN for s/sx of the following: Bleeding, Hemorrhage, Bacteremia, septic shock. Obtain vital signs and weight per protocol. Report significant changes in pulse, respirations and BP immediately. Record review of Resident #2's comprehensive care plan review with a review, completed date of 10/06/2025, reflected no care plan for pain. Record review of Resident #2's hospital clinical record, dated 09/25/2025, reflected diagnosis of sepsis (a life-threatening condition where the body's extreme response to an infection damages its own tissues and organs) with fever leukocytosis, multifactorial; infected sacral ulcer/pneumonia, status post septic shock, unstageable sacral ulcer infected status post-surgical debridement 9/16 up to muscle; not bony involvement, Post E.coli UTI, Right lower lobe/aspiration pneumonia, acute hypoxic respiratory failure, end-stage renal disease on dialysis, peripheral arterial disease, toe gangrene. Plan, Zosyn 2.25g IV every 8 hours for pansensitive E. coli wound culture plus empirical anaerobic coverage. Anticipate another 2 weeks of IV antibiotics. Record review of Resident #2's hospital clinical discharge record, dated 09/29/2025, reflected a discharge diagnosis of sepsis with discharge medication, sodium chloride 0.9% SOLN100 ml with piperacillin-tazobactam (Zosyn) 4.5 (4-0.5) g SOLR 4.5g, Inject 4.5g into the vein every 12 (twelve) hours for 14 days qty: 100 GM, refills: 0. The discharge summary did not give an account of how many wounds were identified while Resident #2 was admitted , the stage of the wounds, or what treatment orders were to continue after Resident #2 discharged to treat the wounds. Record review of Resident #2's hospital clinical record dated 9/30/2025 reflected in part: wound care orders for her sacrum and right lateral ankle/foot. Arterial changes to RLE. Toes continue to harden, gangrenous. Right lateral leg remains purple/black. Gangrene to L 2nd -4th toes.Unstageable sacral ulcer infected status post-surgical debridement 9/16 up to muscle: not bony involvement. Infected sacral ulcer/pneumonia.Post E. Coli UTI. Assessment and Plan.1. ESRD on HD.Resident #2 has been getting HD TTS.Resident #2 pending DC to skilled nursing (out of state).However, unable to DC today because she needs to leave early enough to arrive there before 2PM so she can be admitted to the facility.Tomorrow will be her dialysis day and she will most likely not be able to DC in time if we do dialysis tomorrow. I will run her dialysis today and that way she will not need dialysis tomorrow.I have discussed with dialysis nurse that the patient will have dialysis orders for today to help facilitate her discharge in the morning.Record review of Resident #2's facility phone medication order, date 09/30/2025 at 7:15 PM for piperacillin sod-tazobactam (piperacillin sodium-tazobactam sodium) So intravenous solution reconstituted 4.5 (4-0.5) GM (piperacillin sodium-tazobactam sodium) Use 100 gram intravenously every 12 hours for wound infection for 14 days, prescribed by Medial Director and confirmed by LVN B. Record review of Resident #2's MAR for the month of September 2025 reflected no Zosyn (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 21 of 66 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 10/27/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some was administered to Resident #2 on her admission day of 9/30/2025.Record review of Resident #2's initial skin assessment, dated 09/30/2025 at 9:22 PM, by LVN A, read in part, .[Resident #2] had redness to left abdomen.excoriation to vaginal area and buttocks. Moisture associated skin damage present: Yes; see ulcer assessments for details.Other skin findings: Pressure wound to sacral area, DTI to Right lateral lower leg near ankle, DTI to right heel, DTI to right lateral mid foot, DTI to Right medial ankle, Necrotic digits to all toes of right and left foot, DTI to left lateral front foot and DTI to left lateral mid foot, DTI to left heel and left lateral ankle. Central Cath to upper left chest (for dialysis use) and PEG tube. Record review of the Resident #2's physician order summary report reflected the following orders to treat a DTI to the right lower lateral leg near ankle, right heel, left lateral mid foot, left heel, and left lateral ankle from admission on [DATE] were not entered and implemented until 10/04/2025. Record review of the Resident #2's physician order summary report reflected that a wound consult was not entered at Resident #2's admission on [DATE] and was entered an implemented 10/02/2025. Record review of Resident#2's MAR for the month of September 2025 reflected no wound care treatments administered to Resident #2 on her admission day of 9/30/2025. Record review of Resident #2's hospital records ,dated 09/29/2025, reflected she had the following as needed (PRN) orders for pain:Acetaminophen 650 mg tablet Q 6 hours PRN mild pain.Acetaminophen 650 mg tablet Q 6 hours PRN pain or temperature 100.4 or greater which Resident #2 was documented as having received on 9/28/25 at 5:28 PM.Hydromorphone PF Dilaudid 0.5mg IV Q 4 hours PRN for severe pain which Resident #2 was documented as having received on 9/28/25 at 12:36 PM. Record review of Resident #2's MAR, dated 09/01/25, through 09/30/25 reflected Resident #2 did not receive any Acetaminophen during the month of September. Record review of Resident #2's facility Order Recap, dated September 2025, reflected an order for Acetaminophen oral tablet 325 MG Give 2 tablets by mouth every 6 hours as needed for pain. Continued record review revealed the order was for an oral/by mouth administration and Resident #2 was a gastrostomy status resident. Record review of Resident #2's MAR for the month of October 2025 reflected Zosyn was administered to Resident #2 on 10/04/2025 at 8:00 PM for the initial dose. Record review of Resident #2's initial wound evaluation and management summary, dated 10/02/2025, completed by Wound Care Doctor A revealed 14 wound sites, read in part, Site 1; Diabetic Wound of the Right Heel Full thickness (refers to a deep wound that extends through all layers of the skin and may also involve deeper structures such as muscle, tendon or bone). Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 2; Unstageable (Due to necrosis [cell death that occurs when most or all of the cells in an organ or tissue are irreversibly damaged and lose their normal function]) Right, Lateral Ankle Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 3; Arterial Wound (a type of open sore that develops when blood flow to the affected area is reduced) of the Right First Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 4; Arterial Wound of the Right Second Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 5; Arterial Wound of the Right Third Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 6; Arterial Wound of the Right Lateral Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 7; Unstageable (Due to Necrosis) of the Left Heel Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 8; Arterial Wound of the Left Second Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 22 of 66 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 10/27/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some days.Site 9; Stage 4 Pressure Wound of the Right Buttock Full Thickness with a Surgical Excisional Debridement Procedure (a procedure where a surgeon uses a scalpel to cut away and remove dead or contaminated tissue from a wound until healthy, viable tissue is exposed), performed on the site. Treatment Plan, Primary Dressing(s) Leptospermum honey apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Gauze sponge non-sterile apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Negative pressure wound therapy apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days: 125 mm Hg Secondary Dressing(s) Gauze island w/bdr apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days Peri Wound Treatment Skin prep apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days.Site 10; Stage 4 Pressure Wound of the Left Buttock Full Thickness with a Surgical Excisional Debridement Procedure (a procedure where a surgeon uses a scalpel to cut away and remove dead or contaminated tissue from a wound until healthy, viable tissue is exposed), performed on the site. Treatment Plan, Primary Dressing(s) Leptospermum honey apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Gauze sponge non-sterile apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Negative pressure wound therapy apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days: 125 mm Hg Secondary Dressing(s) Gauze island w/ bdr apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days Peri Wound Treatment Skin prep apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days.Site 11; Unstageable (Due to Necrosis) of the Right, Medial Ankle Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 12; Unstageable (Due to Necrosis) of the Right, Medial Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 13; Unstageable (Due to Necrosis) of the Left, Lateral Ankle Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 14; Unstageable (Due to Necrosis) of the Right, Lateral Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Record review of Resident #2's physician order summary, for October 2025, reflected the orders provided initial wound evaluation and management summary, dated 10/02/2025, completed by Wound Care Doctor A were not entered until 10/04/2025. Record review of Resident #2's MAR, dated 10/01/25, through 10/31/25 reflected the following order: Acetaminophen oral tablet 325 MG Give 2 tablets by mouth every 6 hours as needed for pain. D/C Date 10/10/2025. Resident #2 did not receive this medication. Records Record review of Resident#2's progress note dated 10/03/2025 at 6:27am and completed by RN A reflected that NP A was notified of change, but there was no information detailing what the change was or orders to address the change. Records record review of Resident#2's SBAR, dated 10/03/2025 at 6:05 AM and completed by RN A, did not reflect specific information of notifying NP A her missed hemodialysis session or orders from NP A to address the missed hemodialysis session. Record reviews of Resident #2's electronic medical record reflect no PAINAD assessments completed for Resident #2 to show that Resident#1 had been assessed for pain. In an interview on 10/08/2025 at 3:09 PM with Treatment Nurse A, she said CR#1 admitted to the facility sometime in May 2025, he had a wound, but she was not sure of the location of the wound. She said residents should have orders upon admission but no later than 24 hours to treat wounds. She said wound care was documented the MAR, without an order there would be no way to document wound care treatment, and if the standard of practice was without documentation it did not happen. She said the risk of no wound care treatment from 05/28/2025-06/03/2025 could be the wound deterioration, possible infection, and possible hospitalization. She said to go without wound care treatment from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 23 of 66 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 10/27/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 5/28/2025-06-3-2025 was a significant amount of time. In an interview on 10/08/2025 at 4:49 PM with ADON A, she said she started at the facility on 06/30/2025. She said CR#1 was already admitted to the facility when she started so she was not sure what wounds he had at the time of admission. She said residents should have orders upon admission but no later than 24 hours to treat wounds. She said that wound care was documented in the MAR, without an order there would be no way to document wound care treatment, and the standard of practice was without documentation it did not happen. She said the risk of no wound care treatment from 05/28/2025-06/03/2025 could be that the wound got worse, became infected and could lead to hospitalization. She said CR#1 did not have orders upon admission to treat the wound on the coccyx on 05/28/2025, orders were entered on 06/03/2025, and initial treatment was completed on 06/04/2025. She said CR#'1s treatment was delayed, placing him at risk of wound worsening, infection, and hospitalization. In an interview on 10/08/2025 at 5:33 PM with DON A, she said she started at the facility on 05/27/2025. She said residents should have orders upon admission but no later than 24 hours to treat wounds. She said that wound care was documented on the MAR, without an order there would be no way to document wound care treatment, and the standard of practice is without documentation it did not happen. She said residents should have orders upon admission but no later than 24 hours to treat wounds. She said wound care was documented in the MAR, without an order there would be no way to document wound care treatment, and the standard of practice was without documentation, it did not happen. She said she reviewed the clinical record of CR#1, he admitted with a wound to the coccyx on 05/28/2025, there were no orders to treat the wound entered until 06/03/2025, he did not receive initial treatment until 06/04/2025, his treatment was delayed, and he was placed at risk of wound worsening, infection, and hospitalization. In an interview on 10/08/2025 at 6:18 PM with Administrator A, she said residents should have orders upon admission to treat wounds. She said if a resident admitted on [DATE] and did not have orders to treat a wound until 06/03/2025, that would be a delay in treatment. She said the risk to the resident could cause the wound to worsen depending on the clinical condition of the residents and location of wound. In an interview and observation on 10/09/2025 at 10:57 AM of ADON A to perform Resident #2's wound care with assistance from CNA A. ADON A said at the start of the treatment Resident #2 had been medicated for pain about 30-40 minutes prior. Resident #2 was observed to have tolerated the wound care treatment without any visible, verbal, or audible reaction until ADON A painted betadine on her left lateral ankle, which was the last treatment. Resident #2 could be heard inhaling deeply with her eyes closed as if she were in pain. Resdient#2 was not interviewable and non-verbal. In an interview on 10/09/2025 at 2:46pm with LVN A, she said that she was the admitting nurse for Resident#2 on 09/30/2025. She said that she completed a skin assessment on Resident#2 at the time of admission, she had multiple wounds at the time of the admission, and she did not recall the location of the wounds. She said that she reconciled the medication list and treatments for the wounds with the on call nurse practitioner for the primary care physician, and the nurse practitioner gave orders to continue all treatments and medications as detailed in the medical records until the next rounding day. She said that she enlisted the help of LVN B to help her enter the medications and treatments as ordered by the nurse practitioner at the time of Resident#2's admission. She said that Resident#2's hospital medical records said that she was continue with an antibiotic Zosyn every 12 hours via a dialysis port, but she was unsure what type of infection the Zosyn was to treat. She said her clinical impression was that some of Resident #2's wounds were infected at the time of admission, and it was apparent she had recent debridement (a medical procedure that involves removing dead, infected, or damaged tissue from a wound) of the wounds prior to being discharged from the hospital. In an interview on 10/09/2025 at 4:36 PM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 24 of 66 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 10/27/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some with the Medical Director, she said she was the primary physician for Resident #2. She said staff should notify the primary care physician at the time of admission to obtain orders for medications and treatments. She said she did not want to speak on potential risks to residents if staff did not obtain medication and treatment orders at the time of admission. She said a wound consult should have been made upon admission, and the orders given after the wound consult should have been entered and carried out. She said that Resident#2 IV antibiotics should have been arranged prior to admission, and if it was not available orders could be arranged to switch to an oral antibiotic until it was available. In a follow up interview on 10/09/2025 at 5:14 PM with ADON A, she said the admitting nurse completed an initial skin assessment at the time of admission. She said the treatment nurse should complete a second skin assessment on new admissions with wounds identified within 24 hours of admissions. She said the treatment nurse should review the facility clinical records and hospital clinical records. She said the treatment should be reviewing the admission nurse work for accuracy and correcting any errors made. She said there should be a clinical review of all new admissions the next business day with Administrator A and clinical department heads present. She said she worked as the treatment nurse on 09/30/2025 and 10/01/2025. She said Resident #2 admitted on [DATE] with wounds. She said she did not complete the second skin assessment for Resident #2 at the time of admission, she asked ADON B to complete the second skin assessment, and ADON B would help complete treatment duties when she was not able to finish by the end of her shift. She said ADON B would have been responsible for completing Resident #2's wound care treatment after admission. She said she did not recall if she attended the clinical admitting on 10/01/2025. She said LVN A was responsible for ensuring medications and treatments were reconciled at the time of admission and entering the orders. She said Resident #2 did not have orders to treat all her wounds at the time of admission. She said that Resdient#2 did not have orders treat infections with Zosyn at the time of admission. She said a clinical review of Resident #2's admission should have caught the error. She said the risk to Resident#2 was the worsening of wounds and infection. In an interview on 10/09/2025 at 5:30 PM with ADON B, she said she worked on 09/30/2025 and 10/01/2025 from 10:00PM -6:00AM. She said she did not assist with the admission of Resident #2, and the admission was completed by LVN A. She said LVN A told her Resident #2 admitted with wounds with treatment orders from the hospital. She said she completed Resident #2's wound care on 10/01/2025. She said no one communicated to her to complete a skin assessment as the treatment nurse for Resident #2. She said she was not the treatment nurse for the facility, but she did help with wound care. She said she started as an ADON on 10/09/2025, prior to that she was a floor nurse, she was not sure who was responsible for completing wound care at the facility, and she was not sure what the facility was communicating her role to be at the facility prior to 10/09/2025. In a follow up interview on 10/09/2025 with the DON, she said she worked on 09/30/2025 and 10/01/2025, and Resident #2 admitted to the facility on [DATE]. She said there should be a clinical review of all new admissions on the next business day after the admission with the clinical department heads and Administrator A present. She said the clinical review should be to review the admission process for accuracy and correcting errors made. She said she had not completed an assessment of Resident #2 since the time of admission. She said that she was not aware Resident #2 did not have skin assessments completed by a treatment nurse after admission. She said it was the responsibility of both ADON A and ADON B to complete wound care in the absence of a permanent treatment nurse. She said she was not aware Resident #2 did not have orders to treat all wounds or wound consult upon admission She said that she was not aware of Resident#2 to have not received antibiotics from the time of admission. She said she could not recall if there was a clinical review of Resident #2 after admission, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 25 of 66 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 10/27/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete if there was a review then admission errors would have been caught and corrected. In an interview on 10/09/2025 at 6:41 PM with Administrator A, she said she did not always stay for daily clinical meetings with the clinical department heads after the daily stand-up meeting. She said she did not believe she participated in the clinical meeting on 10/01/2025, and she took a phone call. She said the DON was the clinical oversight for the facility. She said the DON should review all new admissions, re-admission, change in conditions, and the 24-hour report for accuracy. She said the DON should review all medical clinical records prior to a residents admission. In an observation on 10/10/2025 at 9:32 AM at the beside of Resident #2 revealed the resident was non-verbal or not interviewable. In an interview on 10/10/2025 at 9:38 AM with the in-house Hemodialysis Nurse, she said on 10/03/2025, Resident #2 could not receive hemodialysis due to a change in condition, which was an elevated heart rate around 120 beats each minute, she contacted the Nephrologist who ordered Metoprolol to Resident #2, and she communicated with Resident #2's nurse (name unknown) about the order for Metoprolol. She said Resident #2 was referred back to the facility nurse (name unknown) for further intervention and treatment. She said when a resident did not receive hemodialysis as scheduled, they were usually sent to the hospital to receive hemodialysis. She said she later found out Resident #2 was not sent to the hospital.In a phone interview on 10/10/2025 at 10:05 AM with RN A who worked the 10:00PM-6:00AM, said she notified NP A that Resident #2 had not received her hemodialysis on 10/03/2025, because her hea Event ID: Facility ID: 455682 If continuation sheet Page 26 of 66 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 10/27/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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, based on the comprehensive assessment of a resident, a residents with pressure ulcers received necessary treatments and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 13 residents (CR #1 and Resident #2) reviewed for pressure ulcers. -The facility failed to treat the wound of CR#1's buttock from admission on [DATE]-[DATE]/2025. 2.--The facility failed to identify and treat the wounds of Resident #2 from admission on [DATE]-[DATE]. An Immediate Jeopardy (IJ) situation was identified on 10/11/2025.?While the IJ was removed on 10/20/2025, the facility remained out of compliance, at a scope of pattern with a potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for delayed treatment, worsening of condition, hospitalization, and death. Resident #2 was admitted to the hospital on [DATE] with a critically elevated white blood cell count (WBC), sepsis and had an above the knee amputation of both legs due to gangrene. Findings include: 1. Record review of CR#1's face sheet dated 09/30/2025, reflected he was a [AGE] year-old male, who admitted to the facility on [DATE] with a principal diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and weakness resulting from a stroke).? CR#1 was transferred to a local hospital on [DATE] related to a percutaneous gastrostomy endoscopic (PEG) tube replacement (feeding tube replacement).? Record review of CR#1's admission MDS (Minimum Data Set) assessment dated [DATE] reflected a BIMS (Brief Interview for Mental Status) was not available as the resident rarely /never understood with severely impaired cognitive skills for daily decision making.? In Section M for skin, he was triggered to have 1 stage 2 pressure ulcer upon admission.? Record review of CR#1's comprehensive care dated 09/26/2025 reflected: Focus:? CR#1 has a pressure ulcer to sacrum, back (2), left ankle, left foot, left heel, Right lower leg and right heel related to limited mobility, incontinence, end stage skin failure. Goal: The resident's Pressure ulcer will show signs of healing and remain free from infection by/through review date. Intervention: Administer treatments as ordered and monitor for effectiveness.? Record review of CR#1's hospital clinical record dated 05/27/2025 reflected a pressure ulcer located to the buttock on 05/26/2025.? Record review of CR#1's progress notes dated 05/28/2025 9:56pm by ADON B, read in part, .CR#1 has dressing to sacral area and has a peg tube. No other skin issues observed to resident. Record review of CR#1's total body skin assessment dated [DATE] reflected 1 wound.? Record review of CR#1's Medication Administration Record (MAR) for the month of May of 2025 reflected no wound care treatment.? Record review of CR#1's May 2025 order summary reflected no orders for wound treatment or wound consult.? Record review of CR#1's physician order dated 06/03/2025 read in part, wound(1) pressure stage 2 coccyx(tailbone).? Cleanse with normal saline or wound wash, pat dry, apply comfort foam border 2x(times) weekly and PRN (as needed) if soiled or dislodged.? Record review of CR#1's MAR for the month of June of 2025 reflected wound care treatment for a stage 2 coccyx an initial documentation on 06/04/2025.? Record review of Resident #2's admission Record dated 10/22/2025 revealed she was a [AGE] year old female who admitted to the facility on [DATE] from another state with diagnoses that included: cerebral infarction (a condition that occurs when blood flow to the brain is interrupted, causing brain cells to die), sepsis due to Escherichia Coli (a life-threatening infection, where bacteria from the intestine spreads to the blood stream and triggers a systemic inflammatory response in the body), severe sepsis with septic shock (an infection that leads to life threatening organ dysfunction and failure), pressure ulcer of sacral region (a skin and soft tissue injury that develops over the sacrum Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 27 of 66 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 10/27/2025 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some (the bone at the base of the spine) due to prolonged pressure, friction or shear which causes the tissue to breakdown and form an open wound), dependence on renal dialysis (a lifelong, and life sustaining therapy involving regular treatments that perform the function of the kidneys to filter waste and remove excess fluid from the blood for people with severe or permanent kidney failure), and gastrostomy status (an opening in the abdomen with insertion of a tube directly into the stomach that allows for nutrition, medication and fluids to be administered to a person unable to eat or drink anything by mouth). Record review of Resident #2's admission Minimum Data Set (MDS) dated [DATE] revealed she had a SAMS (Staff Assessment for Mental Status) completed and was coded as being severely impaired in cognitive skills for daily living decision making. Resident #2 was also coded as having upper and lower extremity impairments on one side of her body and was totally dependent on at least one staff member to provide all ADL (Activities of Daily Living) care. Continued record review revealed Resident #2 was coded in Section M related to Skin Conditions as having two stage four pressure ulcers upon admission. Six unstageable wounds upon admission, and five venous or arterial ulcers. Resident #2 was also coded under Section M as having an infection of the foot. Record review of Resident#2's comprehensive care plan dated 10/06/2025 reflected: Focus:? Resident#2 has pressure ulcers and potential for more pressure ulcer development r/t immobility, fragile skin, Diabetes Mellitus (DM), incontinence.? Present on admission: Two stage 4, Six unstageable (a type of pressure ulcer or wound that cannot be accurately staged due to the presence of slough [dead, yellow or gray tissue that forms in a wound] or eschar [a layer of dead, dried tissue that forms over a wound]), Five Venous (a chronic open sore that develops when blood pools in the veins of the lower legs)/arterial (a break in the skin that occurs when there is a blockage or narrowing of the arteries) ulcers, One diabetic foot ulcer.? Goal: Resident#2's Pressure ulcer will show signs of healing and remain free from infection by/through review date. Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness.? Administer protein supplements as ordered.? Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings PRN.? Administer Vitamin C as ordered.? Administer Zinc as ordered.? Assess/record/monitor wound healing at least weekly.? Measure length, width and depth where possible.? Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD. Record review of Resident#2's hospital clinical record dated 09/25/2025 reflected diagnosis of sepsis with fever leukocytosis, multifactorial; infected sacral ulcer/pneumonia, status post septic shock, unstageable sacral ulcer infected status post-surgical debridement 9/16 up to muscle; not bony involvement, Post E.coli UTI, Right lower lobe/aspiration pneumonia, acute hypoxic respiratory failure, end-stage renal disease on dialysis, peripheral arterial disease, toe gangrene.? Plan, Zosyn 2.25g IV every 8 hours for pan sensitive E. coli wound culture plus empirical anaerobic coverage.? Anticipate another 2 weeks of IV antibiotics.? Record review of Resident#2's hospital clinical discharge record dated 09/29/2025 reflected a discharge diagnosis of sepsis with discharge medication, sodium chloride 0.9% SOLN(solution) 100 ml (Milliliter) with piperacillin-tazobactam (Zosyn)4.5 (4-0.5) g(gram) SOLR(Solution Reconstituted) 4.5g, Inject 4.5g into the vein every 12 (twelve) hours for 14 days qty(quantity):? 100 GM(gram), refills:? 0.? The discharge summary did not give an account of how many wounds were identified while Resident#2 was admitted , the stage of the wounds, or what treatment orders were to continue after Resident#2 discharged to treat the wounds.?? Record review of Resident #2's hospital clinical record dated 9/30/2025 reflected in part:? wound care orders for her sacrum and right lateral ankle/foot.? Arterial changes to RLE. Toes continue to harden, gangrenous.? Right lateral leg remains purple/black.? Gangrene to L 2nd -4th toes.Unstageable sacral ulcer infected status post-surgical debridement 9/16 up to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 28 of 66 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 10/27/2025 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some muscle: not bony involvement. Infected sacral ulcer/pneumonia.Post E. Coli UTI.? Assessment and Plan.1. ESRD on HD.Resident #2 has been getting HD TTS.Resident #2 pending DC to skilled nursing (out of state).However, unable to DC today because she needs to leave early enough to arrive there before 2pm so she can be admitted to the facility.[sic]Tomorrow will be her dialysis today and she will most likely not be able to DC in time if we do dialysis tomorrow. I will run her dialysis today and that way she will not need dialysis tomorrow.I have discussed with dialysis nurse that the patient will have dialysis orders for today to help facilitate her discharge in the morning. Record review of Resident#2's facility phone medication order date 09/30/2025 at 7:15pm for piperacillin sod-tazobactam ((piperacillin sodium-tazobactam sodium) intravenous solution reconstituted 4.5 (4-0.5) GM (piperacillin sodium-tazobactam sodium) Use 100 gram intravenously every 12 hours for wound infection for 14 days, prescribed by Medial Director and confirmed by LVN B. Record review of Resident#2's MAR for the month of September 2025 revealed no Zosyn administered to Resident #2 on her admission day of 9/30/2025. Record review of Resident#2's MAR for the month of October 2025 reflected Zosyn administered to Resident #2 on 10/04/2025 at 8:00pm for the initial dose.? Record review of Resident #2's initial skin assessment dated [DATE] at 9:22pm by LVN A, read in part, .Resident #1 had redness to left abdomen.excoriation to vaginal area and buttocks. Moisture associated skin damage present: Yes; see ulcer assessments for details.Other skin findings:? Pressure wound to sacral area, DTI(Deep Tissue Injury) to Right lateral lower leg near ankle, DTI to right heel, DTI to right lateral mid foot, DTI to Right medial ankle, Necrotic digits to all toes of right and left foot, DTI to left lateral front foot and DTI to left lateral mid foot, DTI to left heel and left lateral ankle.? Central Cath to upper left chest (for dialysis use) and PEG tube. Record review of the Resident#'2 physician order summary report reflected the following orders to treat a DTI to right lower lateral leg near ankle, right heel, left lateral mid foot, left heel, and left lateral ankle from admission on [DATE] were not entered and implemented until 10/04/2025. Record review of the Resident#'2 physician order summary report reflected a wound consult was not entered at resident#2's admission on [DATE] and was entered an implemented 10/02/2025.? Record review of Resident#2's MAR for the month of September 2025 reflected no wound care treatments administered to Resident #2 on her admission day of 9/30/2025. Record review of Resident #2's initial wound evaluation and management summary dated 10/02/2025 completed by Wound Care Doctor A revealed 14 wound sites, read in part, Site 1; Diabetic Wound of the Right Heel Full thickness (refers to a deep wound that extends through all layers of the skin and may also involve deeper structures such as muscle, tendon or bone).? Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 2; Unstageable (Due to necrosis (cell death that occurs when most or all of the cells in an organ or tissue are irreversibly damaged and lose their normal function) Right, Lateral Ankle Full Thickness.? Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 3; Arterial Wound (a type of open sore that develops when blood flow to the affected area is reduced) of the Right First Toe Full Thickness.? Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 4; Arterial Wound of the Right Second Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 5; Arterial Wound of the Right Third Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 6; Arterial Wound of the Right Lateral Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 7; Unstageable (Due to Necrosis) of the Left Heel Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 29 of 66 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 10/27/2025 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some dislodged. For 30 days. Site 8; Arterial Wound of the Left Second Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 9; Stage 4 Pressure Wound of the Right Buttock Full Thickness with a Surgical Excisional Debridement Procedure (a procedure where a surgeon uses a scalpel to cut away and remove dead or contaminated tissue from a wound until healthy, viable tissue is exposed), performed on the site. Treatment Plan, Primary Dressing(s) Leptospermum honey apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Gauze sponge non-sterile apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days, Negative pressure wound therapy apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days: 125 mm /Hg Secondary Dressing(s) Gauze island w/ bdr apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days Peri Wound Treatment Skin prep apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days. Site 10; Stage 4 Pressure Wound of the Left Buttock Full Thickness with a Surgical Excisional Debridement Procedure (a procedure where a surgeon uses a scalpel to cut away and remove dead or contaminated tissue from a wound until healthy, viable tissue is exposed), performed on the site. Treatment Plan, Primary Dressing(s) Leptospermum honey apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Gauze sponge non-sterile apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days, Negative pressure wound therapy apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days: 125 mm Hg Secondary Dressing(s) Gauze island w/ bdr apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days Peri Wound Treatment Skin prep apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days. Site 11; Unstageable (Due to Necrosis) of the Right, Medial Ankle Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 12; Unstageable (Due to Necrosis) of the Right, Medial Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 13; Unstageable (Due to Necrosis) of the Left, Lateral Ankle Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 14; Unstageable (Due to Necrosis) of the Right, Lateral Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Record review of physician order summary for October 2025 reflected that the orders provided initial wound evaluation and management summary dated 10/02/2025 completed by Wound Care Doctor A were not entered until 10/04/2025. In an interview on 10/08/2025 at 3:09pm with Treatment Nurse A, she said that she started at the facility in 2022 as a floor nurse but was promoted to weekend treatment nurse? in 2005.? She said that CR#1 admitted to the facility sometime in May 2025, he had a wound, but she was not sure of the location of the wound.? She said that residents should have orders upon admission but no later than 24 hours to treat wounds.? She said that wound care was documented the MAR, without an order there would be no way to document wound care treatment, and the standard of practice is without documentation it did not happen.? She said that the risk of no wound care treatment from 05/28/2025-06/03/2025 could be that the wound deterioration, possible infection, and possible hospitalization.? She said that to go without wound care treatment from 5/28/2025-06/03/2025was a significant amount of time.? In an interview on 10/08/2025 at 4:29pm with ADON A, she said that she started at the facility on 06/30/2025.? She said that CR#1 was already admitted to the facility when she started so she was not sure what wounds he had at the time of admission.? She said that residents should have orders upon admission but no later than 24 hours to treat wounds.? She said that wound care was documented the MAR, without an order there would be no way to document wound care treatment, and the standard of practice is without (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 30 of 66 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 10/27/2025 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some documentation it did not happen.? She said that the risk of no wound care treatment from 05/28/2025-06/03/2025 could be that the wound gets worse, becomes infected, and could lead to hospitalization.? She said that CR#1 did not have orders upon admission to treat wound on the coccyx on 05/28/2025, orders were entered on 06/03/2025, and initial treatment was completed on 06/04/2025.? She said that CR#'1s treatment was delayed placing him at risk. In an interview on 10/08/2025 at 5:33pm with DON A, she said that she started at the facility on 05/27/2025.? She said that residents should have orders upon admission but no later than 24 hours to treat wounds.? She said that wound care was documented on the MAR, without an order there would be no way to document wound care treatment, and the standard of practice is without documentation it did not happen.? She said that residents should have orders upon admission but no later than 24 hours to treat wounds.? She said that wound care was documented the MAR, without an order there would be no way to document wound care treatment, and the standard of practice is without documentation it did not happen.? She said that she reviewed clinical record of CR#1, he admitted with a wound to the coccyx on 05/28/2025, there were no orders to treat the wound entered until 06/03/2025, he did not receive initial treatment until 06/04/2025, his treatment was delayed, and he was placed at risk.? In an interview on 10/08/2025 at 6:18pm with the Administrator, she said that residents should have orders upon admission to treat wounds.? She said that if a resident admitted [DATE] and did not have orders to treat a wound until 06/03/2025 that would be a delay in treatment.?? She said that the risk to the residents could be that the wound could worsen depending on the clinical condition of the residents and location of wound.? Observation on 10/09/2025 of Resident #2's wound care treatment at 10:57am performed by ADON A and assisted by CNA A. ADON A was asked prior to the start of Resident #2's treatment if Resident #2 had been medicated for pain and ADON A said Resident #2 had been medicated 30-40 minutes earlier. Observation of Resident #2 who was dressed in a clean facility gown and had just been showered and transferred back into her bed. None of the wounds were covered with any dressings as they had been removed or became dislodged during the shower. Resident #2 was nonverbal and did not respond with hand gestures as both of her hands and arms were contracted. She was awake and alert with her eyes open and her facial expression appeared calm and relaxed. Enhanced Barrier and Universal Precautions were maintained throughout the procedure and staff donned and doffed PPE appropriately, before, during and after the procedure. Resident #2's privacy was maintained throughout the wound care procedure. The wound care treatments began with Resident #2's sacrum which had no dressing post shower. The sacral wound was shaped like a large kidney bean. The surface area of the wound was large; she had wounds on both her right and left buttock's that appeared to have merged or blended into one giant wound with a thin strip of skin separating each buttock cheek and appeared tethered from the base of her back through her anus. The right buttock surface area appeared to be approximately 12 x 2 X 4, and the left buttock surface area appeared to be 15 X 4 X 4. The right buttock was a red beefy color with brown edges. It was leaking a copious amount of serosanguinous fluid after ADON A cleansed the area per treatment orders. There was some active bleeding of bright red blood as ADON A continued with the treatment as ordered and Resident #2 appeared to have no facial or physical response during the treatments to her bilateral buttocks. The left buttock had the same amount of serosanguinous leakage of fluid and brown edges of the perimeter of the wound. The wound bed was paler pink, with no active bleeding observed at that time. ADON A completed the treatments to Resident #2's bilateral buttock area. Resident #2's bilateral lower legs appeared emaciated and thin. Her right lateral leg just above her ankle appeared to be exposed to the tendon, and her right heel appeared black. Her right ankle was a black circle where her ankle was located. Resident #2's first, second and third toes of her right foot were completely (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 31 of 66 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 10/27/2025 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some black and appeared shriveled and fragile. Resident #2's right lateral foot was also black. Resident #2's Left lateral ankle was black and her left heel had an open ulcer that was approximately 4X2 in size. The second toe of her left foot was completely black, shriveled and appeared fragile. Resident #2 tolerated the wound care treatments without any visible, verbal, or audible reaction until ADON A painted betadine on her left lateral ankle which was the last treatment. Resident #2 could be heard inhaling deeply with her eyes closed. Resident #2 had her eyes closed throughout the treatment but had been breathing calmly and quietly up until that point. ADON A spoke calmly to her and reassured her she was done with the treatment. Resident #2 briefly opened her eyes and then closed them again, resuming her calm breathing and appeared to be in no apparent distress. In an interview on 10/09/2025 at 2:46pm with LVN A, she said that she was the admitting nurse for Resident#2 on 09/30/2025.? She said that she completed a skin assessment on Resident#2 at the time of admission, she had multiple wounds at the time of the admission, and she did not recall the location of the wounds.? She said that she reconciled the medication list and treatments for the wounds with the on-call nurse practitioner for the primary care physician, and the nurse practitioner gave orders to continue all treatments and medications as detailed in the medical records until the next rounding day.? She said that she enlisted the help of LVN B to help her enter the medications and treatments as ordered by the nurse practitioner at the time of Resident#2's admission.? She said that Resident#2's hospital medical records said that she was continue with an antibiotic Zosyn every 12 hours via a dialysis port, but she was unsure what type of infection the Zosyn was to treat.? She said that her clinical impression was that some of Resident#2's wounds were infected at the time of admission, and it was apparent that she had recent debridement of the wounds prior to being discharged from the hospital.? In an interview on 10/09/2025 at 4:36pm with the Medical Director, she said that she was the primary physician for both CR#1 and Resident #2.? She said that staff should notify the primary care physician at the time of admission to obtain orders for medications and treatments.? She said that she did not want to speak on potential risks to residents if staff did not obtain medication and treatment orders at the time of admission.? She said that Resident #2 IV antibiotics should be arranged prior to a resident's admission, and if it's not available orders could be arranged to switch to an oral antibiotic until it was available.? She said that a wound consult should be made upon admission, and orders should be given after the wound consult should be entered and carried out. In a follow up interview on 10/09/2025 at 5:14pm with ADON A, she said that that the admitting nurse completes an initial skin assessment at the time of admission.? She said that the treatment nurse should complete a second skin assessment on new admission with wounds identified within 24 hours of admissions.? She said that the treatment nurse should review the facility clinical records and hospital clinical records.? She said that the treatment should be reviewing the admission nurse work for accuracy and correcting any errors made.? She said that there should be a clinical review of all new admissions the next business day with the Administrator and clinical department heads present.? She said that she worked as treatment nurse on 09/30/2025 and 10/01/2025.? She said that Resident #2 was admitted on [DATE] with wounds, and orders for Zosyn.? She could not recall if the order for Zosyn was to treat a wound infection or UTI.? She said that she did not complete the second skin assessment for Resident #2 at the time of admission, she asked ADON B to complete the second skin assessment, and ADON B would help complete treatment duties when she is not able to finish by the end of her shift.? She said that ADON B would have been responsible for complete Resident #2's wound care treatment after admission.? She said that she did not recall if she attended the clinical admitting on 10/01/2025.? She said that LVN A was responsible for ensuring that medications and treatments were reconciled at the time of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 32 of 66 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 10/27/2025 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some admission and entering the orders.? She said that Resdient#2 did? not have orders treat all her wounds or Zosyn at the time of admission.? She said that a clinical review of Resident#2's admission should have caught the error.? She said that the risk to Resident#2 was the worsening of wounds and infection.? In an interview?on 10/09/2025 at 5:30pm with ADON B, she said that she worked on 09/30/2025 and 10/01/2025 from 10:00pm -6:00am.? She said that she did not assist with the admission of Resident#2, and the admission was completed by LVN A.? She said that LVN A did tell her that Resident #2 was admitted with wounds with treatment orders from the hospital.? She said that she did complete Resident #2's wound care on 10/01/2025.? She said that no one communicated to her to complete a skin assessment as the treatment nurse for Resident #2.? She said that she is not the treatment nurse for the facility, but she does help with wound care.? She said that she started as an ADON on 10/09/2025, prior to she was a floor nurse, she was not sure who was responsible for completing wound care at the facility, and she was not sure what the facility was communicating her role to be at the facility prior to 10/09/2025.? In a follow up interview on 10/09/2025 with the DON, she said that she worked on 09/30/2025 and 10/01/2025, and Resident #2 admitted on [DATE].? She said that there should be a clinical review of all new admissions on the next business day after the admission with the clinical department heads and Administrator present.? She said that the clinical review should be to review the admission process for accuracy and correcting errors made.? She said that she had not completed an assessment of Resident #2 since the time of admission.? She said that she was not aware of Resident#2 having not received antibiotics from the time of admission.? She said that she was not aware that Resident #2 did not have skin assessment completed by a treatment nurse after admission.? She said that it was responsibility of both ADON A and ADON B to complete wound care in the absence of a permanent treatment nurse.? She said that she was not aware that resident did not have orders to treat all wounds or wound consult upon admission.? She said that she was not aware that Resident #2 had missed a dialysis treatment after admission.? She said that she could not recall if there was a clinical review of Resident #2 after admission, and if there was a review then admission errors would have been caught and corrected.? In an interview on 10/09/2025 at 6:41pm with the Administrator, she said that she does not always stay for daily clinical meetings with the clinical department heads after the daily stand-up meeting.? She said that she did not believe that she participated in the clinical meeting on 10/01/2025, and she took a phone call.? She said that the DON was the clinical oversight for the facility.? She said that the DON should review all new admissions, re-admission, change in conditions, and the 24-hour report for accuracy.? She said that the DON should review all medical clinical records prior to a residents admission.? In an interview on 10/10/2025 at 11:10am with NP B, he said that he is the nurse practitioner for the facilities Medical Director.? He said that Resident#2 admitted on [DATE] while he was off, NP B covered for him, and NP B saw Resident#2 on 10/01/2025.? He said that Resident#2 admitted with wounds, and she was being treated with IV antibiotics, Zosyn, for UTI and Wound culture for E. Coli while in hospital, and the Zosyn was to continue for 2 weeks after discharge.? He said that he was asked to see resident number today on 10/10/2025 by the Medical Director and that was his first time meeting Resident#2.? He was unsure when the Resident#2 received the first dosage of the Zosyn, but it should start no later than the next day after admission.? He said that his expectation would be that all medications and treatments start no later than the next day after the order is given.? He said that the risk is that conditions or infections could worsen.? He said that it was his expectation that a physician or nurse practitioner be notified when medications were not available to seek additional orders to treat.? He said that if he had been notified that Resident#2's Zosyn was not available he would have send her back to the hospital, as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 33 of 66 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 10/27/2025 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete there would be no reason for her to remain in the building without the medications, and the risk to Resident#2 would have been the infection could have worsen.? He said that it was important for staff to notify a physician of wounds upon admission and once identified.? He said that the standards were to continue with orders from the hospital until a wound care physician can take over or the primary physician makes changes to the treatment from the hospital.???? In a telephone interview on 10/10/2025 at 11:33am with NP A, he said that he was contacted at the time of Resident #2's admission, he reviewed medications and treatments for wounds with the admitting nurse, and he gave order to continue with treatment and medication orders from the hospital medical records.? He said that he rounded with Resident #2 on 10/01/2025, she was prescribed Zosyn a broad-spectrum treatment for an E. Coli infection of her urinary tract, wounds, and pneumonia.? He said that he was asked to clarify the order for Zosyn with the pharmacy, and he was under the impression that the medication would be delivered and administered the same day.? He said that if he had been informed, he would have decided on a different treatment plan.? He said that he was not contacted to address interventions for a missed hemodialysis on 10/03/2025, he was notified of an elevated heart rate during dialysis that was addressed by another doctor.? He said that he would not speak on risk to residents, or if Resident#2 should have been sent to the hospital.? He said that his expectation is that staff make enter orders from the time of admission, follow orders, an Event ID: Facility ID: 455682 If continuation sheet Page 34 of 66 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 10/27/2025 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 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 that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 13 residents (Resident #2) reviewed for pain. -The facility failed to ensure that pain management was provided for Resident #2, who was crying in pain, during the treatment of her 14 individual wounds. -The facility failed to assess Resident #2 accurately and appropriately, for pain prior to Resident #2 receiving wound care treatments for 14 separate wounds. -The facility failed to provide timely medication interventions for Resident #2's pain management for daily wound care treatments of her 14 individual wounds. An immediate Jeopardy (IJ) was identified on 10/10/2025. The IJ template was provided to the facility on [DATE] at 6:39 PM. While the Immediacy was removed on 10/19/2025 at 5:44 PM, the facility remained out of compliance scoped at pattern with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. These failures placed residents at risk of increased or unmanaged pain and actual harm. Findings Include: Resident #2 Record review of Resident #2's admission Record dated 10/22/2025 revealed she was a [AGE] year old female who admitted to the facility on [DATE] from another state with diagnoses that included: cerebral infarction (a condition that occurs when blood flow to the brain is interrupted, causing brain cells to die), sepsis due to Escherichia Coli (a life-threatening infection, where bacteria from the intestine spreads to the blood stream and triggers a systemic inflammatory response in the body), severe sepsis with septic shock (an infection that leads to life threatening organ dysfunction and failure), pressure ulcer of sacral region (a skin and soft tissue injury that develops over the sacrum (the bone at the base of the spine) due to prolonged pressure, friction or shear which causes the tissue to breakdown and form an open wound), dependence on renal dialysis (a lifelong, and life sustaining therapy involving regular treatments that perform the function of the kidneys to filter waste and remove excess fluid from the blood for people with severe or permanent kidney failure), and gastrostomy status (an opening in the abdomen with insertion of a tube directly into the stomach that allows for nutrition, medication and fluids to be administered to a person unable to eat or drink anything by mouth). Record review of Resident #2's admission Minimum Data Set (MDS) dated [DATE] revealed she had a SAMS (Staff Assessment for Mental Status) completed and was coded as being severely impaired in cognitive skills for daily living decision making. Resident #2 was also coded as having upper and lower extremity impairments on one side of her body and was totally dependent on at least one staff member to provide all ADL (Activities of Daily Living) care. Continued record review revealed Resident #2 was coded in Section M related to Skin Conditions as having two stage four pressure ulcers upon admission. Six unstageable wounds upon admission, and five venous or arterial ulcers. Resident #2 was also coded under Section M as having an infection of the foot. Record review of Section V of the MDS related to Resident #2's Care Area Assessment Summary (CAA) had no care area triggers for pain and had no care planning decision made for pain. Record review of Resident #2's comprehensive care plan review with a review completed date of 10/06/2025 revealed no care plan for pain. Record review of Resident #2's out of state hospital records dated 09/29/2025 revealed she had the following as needed (prn) orders for pain: Acetaminophen 650 mg tablet Q 6 hours prn mild pain. Acetaminophen 650 mg tablet Q 6 hours prn pain or temperature 100.4 or greater which Resident #2 was documented as having received on 9/28/25 at 5:28 PM. Hydromorphone PF Dilaudid 0.5mg IV Q 4 hours prn for severe pain which Resident #2 was documented as having received on 9/28/25 at 12:36 Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 35 of 66 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 10/27/2025 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some PM. Record review of Resident #2's facility Order Recap dated September 2025 revealed an order for Acetaminophen oral tablet 325 MG Give 2 tablets by mouth every 6 hours as needed for pain. Continued record review revealed the order was for an oral/by mouth administration and Resident #2 was a gastrostomy status resident. Record review of Resident #2's Medication Administration Record (MAR) dated September 1, 2025, through September 30,2025 revealed Resident #2 did not receive any Acetaminophen during the month of September. Record review of Resident #2's MAR dated October 1, 2025, through October 31, 2025, revealed the following order: Acetaminophen oral tablet 325 MG Give 2 tablets by mouth every 6 hours as needed for pain. D/C Date 10/10/2025. Resident #2 did not receive this medication. Observation on 10/09/2025 of Resident #2's wound care treatment at 10:57am performed by ADON A and assisted by CNA A. ADON A was asked prior to the start of Resident #2's treatment if Resident #2 had been medicated for pain and ADON A said Resident #2 had been medicated 30-40 minutes earlier. Observation of Resident #2 who was dressed in a clean facility gown and had just been showered and transferred back into her bed. None of the wounds were covered with any dressings as they had been removed or became dislodged during the shower. Resident #2 was nonverbal and did not respond with hand gestures as both of her hands and arms were contracted. She was awake and alert with her eyes open and her facial expression appeared calm and relaxed. Enhanced Barrier and Universal Precautions were maintained throughout the procedure and staff donned and doffed PPE appropriately, before, during and after the procedure. Resident #2's privacy was maintained throughout the wound care procedure. The wound care treatments began with Resident #2's sacrum which had no dressing post shower. The sacral wound was shaped like a large kidney bean. The surface area of the wound was large; she had wounds on both her right and left buttock's that appeared to have merged or blended into one giant wound with a thin strip of skin separating each buttock cheek and appeared tethered from the base of her back through her anus. The right buttock surface area appeared to be approximately 12 x 2 X 4, and the left buttock surface area appeared to be 15 X 4 X 4. The right buttock was a red beefy color with brown edges. It was leaking a copious amount of serosanguinous fluid after ADON A cleansed the area per treatment orders. There was some active bleeding of bright red blood as ADON A continued with the treatment as ordered and Resident #2 appeared to have no facial or physical response during the treatments to her bilateral buttocks. The left buttock had the same amount of serosanguinous leakage of fluid and brown edges of the perimeter of the wound. The wound bed was paler pink, with no active bleeding observed at that time. ADON A completed the treatments to Resident #2's bilateral buttock area. Resident #2's bilateral lower legs appeared emaciated and thin. Her right lateral leg just above her ankle appeared to be exposed to the tendon, and her right heel appeared black. Her right ankle was a black circle where her ankle was located. Resident #2's first, second and third toes of her right foot were completely black and appeared shriveled and fragile. Resident #2's right lateral foot was also black. Resident #2's Left lateral ankle was black and her left heel had an open ulcer that was approximately 4X2 in size. The second toe of her left foot was completely black, shriveled and appeared fragile. Resident #2 tolerated the wound care treatments without any visible, verbal, or audible reaction until ADON A painted betadine on her left lateral ankle which was the last treatment. Resident #2 could be heard inhaling deeply with her eyes closed. Resident #2 had her eyes closed throughout the treatment but had been breathing calmly and quietly up until that point. ADON A spoke calmly to her and reassured her she was done with the treatment. Resident #2 briefly opened her eyes and then closed them again, resuming her calm breathing and appeared to be in no apparent distress. Observation and interview on 10/10/2025 at 4:59 PM with ADON A and DON of wound care performed on Resident #2. ADON A was assisted by MA E. ADON A was asked prior to the start of Resident #2's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 36 of 66 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 10/27/2025 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some treatment if Resident #2 had been medicated for pain and ADON A said yes about 30-40 minutes ago. When asked how she assessed Resident #2 for pain, ADON A said she used the PAINAD facial expression tool. The wound care treatments began with Resident #2's lower extremities. During the observation, the DON came to the bedside to also observe Resident #2's wounds for the first time since her admission on [DATE]. ADON A began removing the cling gauze wrap from Resident #2's left and right lower extremities by using wound care scissors to cut away at the tightly wrapped bandages. Resident #2 was observed by both surveyor at the bedside, wincing repeatedly each time the bandage was moved or cut which prompted this surveyor to ask ADON A if she ever used any saline or solution to moisten and loosen the adhered bandages so as to ease in the removal of the bandages so there would be less pulling, ripping or tugging at Resident #2's delicate skin. ADON A replied quickly and stated, oh yes and then began spraying a liquid solution onto the adhered bandages while still cutting. There was some brownish drainage, skin and mucous like debris observed on the inside of the bandages as ADON A continued to peel, tear, and cut the bandages away from Resident #2's right lower leg and foot. Resident #2 began to inhale and exhale deeply and became tearful, with tears brimming in her eyes. ADON A had her back to Resident #2's face and appeared focused on her wound care task, while MA A tried to speak to Resident #2 softly and reassure her, however, neither staff member stopped the procedure to reassess Resident #2 for pain. Surveyor stopped ADON A and asked what pain medication Resident #2 had been given prior to the procedure and ADON A replied Tylenol, to which surveyor replied, regular strength, to which ADON A replied, extra strength. Both surveyors requested wound care treatment be stopped immediately and DON also said they would stop the treatment, notify the physician, and get an order for a different and or stronger pain medication. Record review post observation revealed Resident #2 had received no Tylenol regular or extra strength on 10/09/2025 or 10/10/2025. Continued record review of Resident #2's MAR dated October 1, 2025, through October 31, 2025, revealed the following orders: Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet via G-Tube every 6 hours as needed for pain. Continued record review of Resident #2's, physician orders and MARs for the months of September 2025 and October 2025, revealed she had no other pain medication ordered and had not received any pain medication from her admission on [DATE] through 10/10/2025. Interview on 10/10/2025 at 5:26 pm with facility Administrator who was advised of the wound care observation of Resident #2 and the major concerns regarding the lack of any pain management for Resident #2 since her facility admission on [DATE]. The Administrator said the concerns were clinical concerns and she would have to speak with the DON to gather more information on the situation. The Administrator said she had no dealings with and did not handle anything to do with the clinical side of things, such as medication, pain management, or wound care because she was not a clinician. The Administrator said the responsibility for those things would be for the DON and she would need to follow up with the DON to determine what happened. Telephone interview on 10/10/2025 at 5:33 pm with Wound Care Doctor A who said he was notified on 10/02/2025 of Resident #2's admission and need for a wound care consultation. Wound Care Doctor A said the first time he examined or assessed Resident #2 was on 10/02/2025 and from what he could remember, she admitted with multiple extensive wounds, including her sacrum and buttocks and her toes were at risk of auto (self) amputation. Wound Care Doctor A said he did not ever see any evidence of Resident #2 being in pain during his assessments or treatments of her multiple wounds. Wound Care Doctor A said he had not prescribed anything for Resident #2's pain because he had not ever witnessed any signs or symptoms of her being in pain and had not been notified by staff that the resident ever had signs or symptoms of pain. Wound Care Doctor A said that in most instances he would defer to the resident's attending physician for any pain medication orders. When asked if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 37 of 66 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 10/27/2025 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some he thought a person with 14 wounds could have pain, he said pain was subjective and he would not speculate. Record review of Wound Care Doctor A's progress note dated 10/2/25 for the initial assessment and treatment of Resident #2's wounds revealed the following 14 wound sites: Site 1; Diabetic Wound of the Right Heel Full thickness (refers to a deep wound that extends through all layers of the skin and may also involve deeper structures such as muscle, tendon, or bone) . Site 2; Unstageable (Due to necrosis (cell death that occurs when most or all of the cells in an organ or tissue are irreversibly damaged and lose their normal function) Right, Lateral Ankle Full Thickness. Site 3; Arterial Wound (a type of open sore that develops when blood flow to the affected area is reduced) of the Right First Toe Full Thickness. Site 4; Arterial Wound of the Right Second Toe Full Thickness. Site 5; Arterial Wound of the Right Third Toe Full Thickness. Site 6; Arterial Wound of the Right Lateral Foot Full Thickness. Site 7; Unstageable (Due to Necrosis) of the Left Heel Full Thickness. Site 8; Arterial Wound of the Left Second Toe Full Thickness. Site 9; Stage 4 Pressure Wound of the Right Buttock Full Thickness with a Surgical Excisional Debridement Procedure (a procedure where a surgeon uses a scalpel to cut away and remove dead or contaminated tissue from a wound until healthy, viable tissue is exposed), performed on the site. Site 10; Stage 4 Pressure Wound of the Left Buttock Full Thickness with a Surgical Excisional Debridement Procedure (a procedure where a surgeon uses a scalpel to cut away and remove dead or contaminated tissue from a wound until healthy, viable tissue is exposed), performed on the site. Site 11; Unstageable (Due to Necrosis) of the Right, Medial Ankle Full Thickness. Site 12; Unstageable (Due to Necrosis) of the Right, Medial Foot Full Thickness. Site 13; Unstageable (Due to Necrosis) of the Left, Lateral Ankle Full Thickness. Site 14; Unstageable (Due to Necrosis) of the Right, Lateral Foot Full Thickness. Interview with DON on 10/11/2025 at 10:00am who said she was unaware of any issues with Resident #2's pain medication or lack of receiving pain medication for wound care. The DON said they had followed up on 10/10/205 after the observation and spoke with Resident #2's doctor and Resident #2 had a scheduled and prn order for Acetaminophen and had only prescribed Acetaminophen because she could not take NSAIDS (Non-Steroidal Anti-Inflammatory Drug) because of her hemodialysis status and history of end stage renal disease, as these drugs can cause severe kidney damage and dangerous complications. The DON said Resident #2 should have been medicated for pain prior to the treatment procedure and did not know why or how her pain management had been missed all this time. The DON said it was the responsibility of the clinical team to ensure residents are managed properly for pain. The DON said she was part of the clinical team and was partially responsible for ensuring residents had effective pain management. The DON said she was unsure if Resident #2 had been care planned for pain but said she should be. Interview on 10/11/2025 at 10:12 am with ADON A who said she believed Resident #2 had received pain medication prior to both wound care observation on 10/09/2025 and 10/10/2025. ADON A said that there was no pain medications listed for her to administer prior to wound care and only her treatments populated in the computer system for her to document on. ADON A said she was under the impression that LVN C and LVN D had premedicated Resident #2 on both 10/09/2025 and on 10/10/2025 because she told them she was going to perform wound care. When asked where the PAINAD assessments for Resident #2 could be located in the electronic medical record, ADON A said that she had looked for one and could not locate the assessment template in the facility's computerized system. ADON A said she assessed Resident #2 visually for PAINAD signs and symptoms of pain but never actually documented on an assessment form, and 10/10/2025 was the first time she ever saw Resident #2 react in pain to wound care treatments she provided. ADON A said Resident #2 should have been medicated for pain because she had a lot of wounds that could potentially be painful. ADON A said she was unsure if Resident #2 had been care planned for pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 38 of 66 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 10/27/2025 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Interview with LVN D on 10/11/2025 at 3:15 pm regarding pain medication administration for Resident #2 prior to wound care on 10/10/2025. LVN D said ADON A never asked him to premedicate Resident #2 prior to wound care. LVN D said he had never given Resident #2 any pain medication since her admission on [DATE] during his shifts. LVN D said Resident #2 only received medication from licensed nurses because of her gastrostomy tube status. LVN D said that Resident #2 never indicated she was in any pain when he provided care and that no CNA or MA staff had ever reported to him that Resident #2 was in pain. LVN D said he was unsure if Resident #2 always had pain medications ordered before, but he was sure she had orders for scheduled and prn pain medications now. LVN D said he used the PAINAD facial expression pain scale to assess Resident #2 because she was non-verbal but said he could not tell surveyor how to locate a copy of the form in the electronic medical record. Interview with LVN C on 10/13/2025 at 2:15pm regarding pain medication for Resident #2 on 10/09/2025. LVN C said she was never asked by ADON A to give Resident #2 any pain medication and had not given Resident #2 any pain medication. LVN C said Resident #2 received all her medication through her gastrostomy tube, so only the charge nurses could give pain medication. LVN C said she never observed Resident #2 having any signs or symptoms of pain but if she did, she should be medicated. LVN C said she was unsure if Resident #2 was care planned for pain. LVN C said Resident #2 had new orders for pain medications now and was unsure what the orders had been previously. LVN C said they assessed Resident #2 using a facial expression pain scale and said the assessment tool pops up in the MAR just prior to any pain medication administration but did not know how to print out the assessment tool or access it outside of the medication administration times. LVN C said the only time she had seen the tool was right before a pain medication would be given. Interview with Medical Director on 10/13/2025 at 4:00pm who said she was the attending physician for Resident #2. The Medical Director said they were contacted by the facility late Friday 10/10/2025 and Resident #2 was reassessed for pain, and she gave a new order for the Tylenol to be scheduled every 8 hours instead of just prn. The Medical Director said they conducted a virtual visit with Resident #2 on Saturday 10/11/2025 and asked the male charge nurse about the assessment. The Medical Director said initially she would only prescribe Tylenol because of Resident #2's hemodialysis dependence and potential risk of medication not being processed or excreted properly. The Medical Director said she ordered a very small trial dose of an opioid analgesic Tramadol but was starting the resident on 1/2 of the 25 mg dose for a dose of 12.5 mg so the resident could be watched and reassessed properly. When asked if she thought Resident # 2 should have had stronger and or scheduled pain medication for the daily wound care treatments, of her 14 separate wounds, the Medical Director said pain was subjective and she would not speculate, but staff should have been assessing and evaluating the resident for pain. The Medical Director said no one had notified her prior to 10/10/2025 that Resident #2 had any signs or symptoms of pain and that once she was notified Resident #2 was evaluated/re-evaluated and additional pain management interventions were ordered and implemented. Record review of facility policy procedure titled Pain Management, Assessment Scale revealed in part: Policy Complaints of pain will be assessed accordingly by the nurse and effectively managed through. prescribed medications, and comfort measures, and all available resources of the facility. Goals 5. Cognitively impaired residents will demonstrate actions of pain relief. Complaints of pain will be assessed accordingly by the nurse and effectively managed through. prescribed medications, and comfort measures, and all available resources of the facility. Procedure 1. Assess resident's physical symptoms of pain, physical complaints, and daily activities. Pain questions based on a resident's communication ability were included in the Admission/readmission and Weekly Nursing Summary. If a resident is non-verbal, the questions will be a PAINAD assessment. There is no QM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 39 of 66 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 10/27/2025 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some criteria for a resident who is non-verbal. If a resident scores 7-10 on the PAINAD scale, then a (sic)PAIND SBAR will be triggered. It is directed toward residents who are non-verbal or cannot communicate. Administer pain medications as prescribed. Monitor and record medication's effectiveness and side effects. PRN - if the resident complains of pain the nurse will assess, implement relief measures as ordered and/or care planned. This was determined to be an Immediate Jeopardy (IJ) on 10/10/2025. The Administrator was notified on 10/10/2025. The IJ template was provided to the facility on [DATE] at 6:39 pm. The following Plan of Removal (POR) submitted by the facility was accepted on 10/12/2025 at 1:08 p.m. The plan of removal reflected the following: Facility Name: Date: October 12th, 2025 IJ Component: F697: Quality of care: Pain Management Facility failed to ensure that pain management was provided for Resident #2. During an observation of Resident #2's wound care on 10/10/25, Resident #2 was observed exhibiting signs/symptoms of pain. Immediate Actions: The treatment where the resident was experiencing pain on 10/10/2025 was stopped until adequate pain relief could be achieved. Primary care provider was contacted by the director of nurses on 10/11/2025 and Tylenol order changed to Extra Strength 650 mg every 8 hours scheduled and an additional dose 30 minutes prior to wound care. The Primary care provider stated that the resident was not eligible for narcotic pain relief due to renal failure. Facility Plan to ensure compliance: 100% review of residents receiving wound care for PRN pain medication orders that may be given 30 minutes prior to wound care was completed on 10/11/2025 by Regional Compliance nurse/DON/Designee. 12 of 13 residents identified requiring wound care received new orders/order clarifications to ensure adequate pain management prior to wound care from audit completed 10/11/25. 1 resident identified in the audit has an allergy to acetaminophen. Care plans for 13 of 13 facility residents with wounds were updated on 10/12/25 by Regional Compliance Nurse and DON with interventions to monitor, assess, and report pain during care, including wound care, and what to do if pain management is not effective. Regional Compliance Nurse provided in-service to DON/ADON on 10/11/2025 regarding: Pain management during care and procedures following facility's policy for enforcement, requiring no change in company policy as the policy was effective but not being followed. Communication with medical provider for any resident that is experiencing uncontrolled pain during care and/or procedures using the SBAR as communication tool. 5. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting 10/11/25 regarding pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool. Goal for completion of this education to be completed by end of day on 10/12/25. All nurses (LVN/RNs), including PRN nurses, who are not in serviced by 10/12/25 will not be allowed to provide resident care until training has been completed. 6. The Medical Director was notified by the Administrator on 10/11/25 at 7:51pm regarding the immediate jeopardy citation. 7. An Ad-hoc QAPI meeting was held on 10/12/25 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. Monitoring: DON/Designee will observe wound care, Mon-Fri, x 4 weeks to ensure any residents that is receiving wound care receive effective pain management during the procedure. DON/Designee will review order listing report in point click care (facility electronic medical record) daily, Mon-Fri x4 weeks to see any new wound care orders and ensure that pain management orders are in place. The Plan of Removal was confirmed for the IJ by monitoring from 10/11/2025 through 10/19/2025 as follows: On 10/10/2025 at 4:59 p.m., request was made with the DON to review the pain management and orders for Resident #2. On 10/10/2025 at 5:26 p.m., a request was made with the Administrator to review the pain management for Resident #2. The Administrator said she was not clinical and would have to discuss with the DON. During an interview with DON at 10:00 a.m. on 10/11/2025 she said she was unaware that Resident #2 had no correct orders for pain medications and had not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 40 of 66 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 10/27/2025 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some received pain medication prior to daily wound care treatments until the shared observation of wound care on 10/10/2025. During an interview with ADON A at 10:12 am on 10/11/2025 she said she was under the impression that Resident #2 had received pain medication prior to wound care on 10/9/25 and 10/10/2025 because she had told the charge nurses to give it. ADON A could not articulate or show examples of PAINAD assessment tool she used to assess Resident #2 for pain on 10/09/2025 or 10/10/2025 and clarified that she was not the one administering pain medications. Interviews with LVN D on 10/11/2025 at 3:15 pm he said he never observed Resident #2 in pain and that ADON A had not asked him to medicate Resident #2 prior to wound care or at any other time. LVN D said he had never administered pain medication to Resident #2. In an interview on 10/12/2025 with licensed nurses who work the 6:00am-2:00pm, at 2:03 p.m., who were all knowledgeable of the step-by-step process for pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool. Treatment Nurse A, ADON A, LVN B and LVN D said that for verbal residents they can assess pain on a scale of 1-10 and for non-verbal residents they can assess pain using a PAINAD scale for facial expressions. All licensed nurses gave examples of non-verbal signs/symptoms or cues for pain could be crying, breathing heavy or fast, wincing, and flinching and that they should evaluate for any pain signs or symptoms prior to, during and after a procedure or treatment. All licensed staff at that time said if a resident were exhibiting signs and symptoms of pain, they were to stop the treatment or procedure, redo the assessment and check for any other orders for interventions and if interventions were ineffective, they would initiate SBAR for pain and notify the MD and RP for the resident. On 10/12/2025 at 5:24 pm a request was made with Administrator, DON, Corporate and Regional staff to review the pain medication orders for Resident #2 as she had not received her pain medication as ordered that day. In an interview on 10/13/2025 at 3:18 pm with licensed nurses who worked the 2:00pm-10:00pm shift, who were all knowledgeable of the step-by-step process for pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool. LVN C and LVN G said that for verbal residents they can assess pain on a scale of 1-10 and for non-verbal residents they can assess pain using a PAINAD scale for facial expressions. All licensed nurses gave examples of non-verbal signs/symptoms or cues for pain could be crying, breathing heavy or fast, wincing, and flinching and that they should evaluate for any pain signs or symptoms prior to, during and after a procedure or treatment. All licensed staff at that time said if a resident were exhibiting signs and symptoms of pain, they were to stop the treatment or procedure, redo the assessment and check for any other orders for interventions and if interventions were ineffective, they would initiate SBAR for pain and notify the MD and RP for the resident. In an interview on 10/13/2025 at 4:00 PM the Medical Director, who said that she was notified about the IJ being called, and she had been included on the POR. She said that all treatments and care should have orders, should be documented, and standard. On 10/13/25 at 5:07pm a request was made with the Administrator, DON, Corporate and Regional staff to review the records for Resident #2 and provide details about her SBAR and transfer to hospital. In an interview on 10/14/2025 at 2:13 pm with MDS Coordinator, who said that she worked full time Monday through Friday on the day shift. She said she was able to articulate the step-to-step process for pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool. She gave examples of non-verbal signs/symptoms or cues for pain could be crying, breathing heavy or fast, wincing, and flinching and that she should evaluate any pain signs or symptoms prior to, during and after a procedure or treatment. She said if a resident were exhibiting signs and symptoms of pain, they were to stop the treatment or procedure, redo the assessment and check for any other orders for interventions and if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 41 of 66 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 10/27/2025 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete interventions were ineffective, she would initiate SBAR for pain and notify the MD and RP for the resident. On 10/14/25 at 6:56 pm a request was made with the Administrator, DON, Corporate and Regional staff requested staff list, wound care list and medication orders status post wound care doctor B's visit on 10/13/25, no MAR to support pain medication audits. Still pending facility audit of Resident #2's transfer to the hospital on [DATE]. In an interview on 10/15/2025 at 6pm with RN A who said she worked at the facility fulltime and usually on the 10pm to 6am shift but would sometimes pick up extra shifts or different shifts prn. She was able to articulate the step-to-step process for pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool. She gave examples of non-verbal signs/symptoms or cues for pain could be crying, breathing heavy, flinching and that she should evaluate any pain signs or symptoms prior to, during and after a procedure or treatment. She said if a resident were exhibiting signs and symptoms of pain, to stop the treatment or procedure, redo the assessment and check for any other orders for interventions and if interventions were ineffective, she would initiate SBAR for pain and notify the MD and RP for the resident. On 10/15/2025 at 4:44pm a request was made with the Administrator, DON, Corporate and Regional staff to review enteral feeding orders and medication orders for Resident #34 who was a new admission to the facility on [DATE]. Observations on 10/16/2025 at 6:00 a.m.- 2:00 p.m. shift of 3 out of 5 residents for wound care, Resident #11, Resident #12, and Resident #20 who did not have adequate pain management prior to or during the wound observations and wound care treatments needed to be stopped. Event ID: Facility ID: 455682 If continuation sheet Page 42 of 66 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 10/27/2025 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 0698 Provide safe, appropriate dialysis care/services 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 interview and record review the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice for 1 of 4 residents (Resident #2). The facility to ensure that Resident #2 received hemodialysis as ordered on 10/03/2025, which resulted in her not receiving any hemodialysis for a total of four days. An immediate Jeopardy (IJ) was identified on 10/10/2025. The IJ template was provided to the facility on [DATE] at 8:11 PM. While the Immediacy was removed on 10/16/2025 at 7:43 PM, the facility remained out of compliance scoped at pattern with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. This failure placed residents at risk for delayed treatments, and actual harm. Findings Include: Resident #2 Record review of Resident #2's admission Record dated 10/22/25 revealed she was a [AGE] year old female who admitted to the facility on [DATE] from another state with diagnoses that included: cerebral infarction (a condition that occurs when blood flow to the brain is interrupted, causing brain cells to die), sepsis due to Escherichia Coli (a life-threatening infection, where bacteria from the intestine spreads to the blood stream and triggers a systemic inflammatory response in the body), severe sepsis with septic shock (an infection that leads to life threatening organ dysfunction and failure), pressure ulcer of sacral region (a skin and soft tissue injury that develops over the sacrum (the bone at the base of the spine) due to prolonged pressure, friction or shear which causes the tissue to breakdown and form an open wound), dependence on renal dialysis (a lifelong, and life sustaining therapy involving regular treatments that perform the function of the kidneys to filter waste and remove excess fluid from the blood for people with severe or permanent kidney failure), and gastrostomy status (an opening in the abdomen with insertion of a tube directly into the stomach that allows for nutrition, medication and fluids to be administered to a person unable to eat or drink anything by mouth). Record review of Resident #2's admission Minimum Data Set (MDS) dated [DATE] revealed she had a SAMS (Staff Assessment for Mental Status) completed and was coded as being severely impaired in cognitive skills for daily living decision making. Resident #2 was also coded as having upper and lower extremity impairments on one side of her body and was totally dependent on at least one staff member to provide all ADL (Activities of Daily Living) care. Continued record review revealed Resident #2 was coded in Section I for an active diagnosis of Renal Insufficiency, Renal Failure, or End-Stage Renal Disease (ESRD). Record review of Section O of the MDS for Special Treatments, Procedures, and Programs was coded for Dialysis while a resident. Record review of Resident #2's comprehensive care plan review with a last care plan review completed date of 10/06/2025 revealed in part: .Focus.Resident #2 needs hemodialysis MWF r/t renal failure.Goal.The resident will have immediate intervention should any s/sx of complications from dialysis occur through the review date.Target Date: 10/12/2025.Interventions/Tasks.obtain vital signs and weight per protocol. Report significant changes in pulse, respiration, and B/P immediately. Record review of Resident #2's out of state hospital records dated 09/29/2025 revealed the following entry: Assessment and Plan.1. ESRD on HD.Resident #2 has been getting HD TTS.Resident #2 pending DC to skilled nursing (out of state).However, unable to DC today because she needs to leave early enough to arrive there before 2pm so she can be admitted to the facility.Tomorrow will be her dialysis today and she will most likely not be able to DC in time if we do dialysis tomorrow. I will run her dialysis today and that way she will not need dialysis tomorrow.I have discussed with dialysis nurse that the patient will have dialysis orders for today to help facilitate her discharge in the morning. [sic] Continued record review revealed Resident #2 had a Dialysis Central Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 43 of 66 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 10/27/2025 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 0698 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Line Catheter Tunneled Right Subclavian dialysis access site. (A long flexible, hollow tube that is inserted into the large subclavian vein (a large deep vein located on each side of the body) beneath the right collar bone and then tunneled under the skin to an exit port, typically on the chest wall). Record review of Resident #2's progress note dated 10/03/2025 and created by RN A at 6:27 am revealed the following entry: .Observed in bed resting comfortably this morning. Vital signs are Temp:97.6, RR: 20, Pulse 106, B/P: 126/66, POX % is 98% on room air. No distress noted. NP A [sic]notified this morning about the situation/and the change. Resident RP. was called and notified also. Continued record review at the bottom of the entry for .Show on Shift Report, show on 24 Hour Report, Show on MD/Nursing Communication Report were unchecked and remained blank. Record review on 10/09/2025 at 11:48am of Resident #2's progress notes revealed she received in-house hemodialysis as prescribed on 10/01/2025.Record review on 10/09/2025 at 11:55 am of Resident #2's SBAR by RN A dated 10/03/2025 at 5:27 am revealed the following: I am contacting you about the following (select all that apply) .5. Cardiovascular change.14. Other.Pulse 123.5c. Describe symptoms or sign Increased pulse rate of 112.14. Other N/A.R. Request .1. I suggest or request (Check all that apply) .Monitor vital signs (box checked) .5. Provide visit (MD/NP/PA) (box was checked) .3. Date and time MD or NP notified 10/03/2025 05:50 am.1. Follow-up Orders.1. Note any new orders from the MD or NP.Metoprolol Succinate Oral Capsule ER 24-hour 25 MG (Metoprolol Succinate) Give 1 capsule via PEG Tube one time a day for HTN/Increased HR> 100. Hold for HR < 100. The document was signed and completed by RN A on 10/09/2025. Telephone interview on 10/10/2025 at 10:05 am with RN A who worked overnight shift 10 pm to 6 am and was the charge nurse assigned to Resident #2 the morning of 10/03/2025. RN A said she notified NP A that Resident #2 had not received her hemodialysis on that Friday, 10/3/25, because her HR was too high. RN A said NP A gave an order to re-evaluate Resident #2's vital signs and heart rate within an hour and call him back. When asked if RN A re-evaluated Resident #2's heart rate and called NP A back as ordered, she said it was at the end of her shift. When asked if she followed NP A's order, she said she did retake Resident #2's heart rate but it remained high, so she sent a text to NP A to notify him that Resident #2's HR remained elevated, but she did not recall if NP A ever responded or if she received any orders to administer medications to Resident #2. When asked about the Metoprolol order she documented in Resident #2's SBAR, Metoprolol Succinate Oral Capsule ER 24-hour 25 MG (Metoprolol Succinate) Give 1 capsule via PEG Tube one time a day for HTN/Increased HR> 100. Hold for HR < 100. RN A said she never administered any medication to Resident #2 because it was the end of her shift and that the Hemodialysis nurse was the one who gave Resident #2 Metoprolol prior to sending her back to the unit without dialysis. When asked if RN A could send surveyor a copy of the text message she sent to NP A, RN A said she would have to look for it. RN A again, said that she could not recall if NP A ever replied and when asked why she documented in Resident #2's SBAR dated 10/3/25 that she had spoken with NP A and received orders for medication Metoprolol, RN A did not reply or respond, she just repeated that this all happened at the end of her 10pm-6am shift and she gave report to the on-coming nurse about Resident #2's elevated HR and missed dialysis. RN A said she could not recall if she specifically asked NP A about any orders for Resident #2 to receive dialysis or an alternate intervention, RN A said she did not remember which nurse she gave report to about Resident #2 not receiving Dialysis and could not recall if she placed any of that information on the facility 24 hour communication report. RN A said she either told ADON A or LVN D about the missed dialysis and elevated HR, but she was unsure. Record review of facility 24 Hour report dated 10/03/2025 on 10/09/2025 at 3:44pm revealed no documentation of note from RN A about Resident #2's missed dialysis or change in condition/SBAR and under the Weights and Vitals section if the entry Pulse read None (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 44 of 66 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 10/27/2025 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 0698 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some entered. Record review on 10/09/2025 at 2:47 pm of Resident #2's MAR dated October 1,2025 through 10/31/2025, revealed Metoprolol Succinate Oral Capsule ER 24-hour 25 MG (Metoprolol Succinate) Give 1 capsule via PEG Tube one time a day for HTN/Increased HR> 100. Hold for HR < 100, was not administered by any facility staff on 10/03/2025. Interview with DON on 10/09/2025 at 2:50 pm she said she was unaware that Resident #2 had not received dialysis on 10/03/2025. When asked if she should have known that Resident #2 had not received dialysis on 10/03/2025 the DON said that normally if a dialysis session was missed the resident would make it up on the next dialysis day. The DON said that normally the dialysis MD would order and have dialysis staff/nurse administer any medications for any altered vital signs. The DON said that there should be a clinical review each business day to address any new concerns, change in conditions, 24-hour reports, and speaking with direct care staff to ensure that residents with orders for hemodialysis receive treatments. She said that she was not aware that there were any concerns with Resident#2's receiving hemodialysis. She said that a nurse should notify a physician if a resident does not complete hemodialysis so that the physician can give interventions. The DON said Resident #2's dialysis MD would normally agree to have any IV meds administered through the dialysis port/shunt or site to save resident vasculature meaning only one access site in case of dialysis shunt failure or if the shunt site needed to be changed. Using only the dialysis shunt site would allow for a resident to have multiple sites in their arms/hands etc. The DON said she would have to look into why Resident #2 did not have any dialysis from Wed 10/01/2025 until Monday 10/06/2025. The DON said the last QAPI was last Thursday, and the facility had monthly QAPI's and weekly SOC's, (standards of care). The DON said she could not recall if she reviewed Resident #2's clinical hospital records prior to her admission but that was part of the admission process, so she most likely did. The DON said she could not recall if they discussed Resident #2 in any morning stand up or weekly SOC but since Resident #2 was admitted on [DATE] they would not have discussed any issues regarding the resident yet for QAPI. The DON said they would most likely discuss Resident #2 in this week's SOC meeting. Brief interview with ADON A on 10/10/2025 at 2:00 pm who said she did not recall speaking with RN A specifically about any orders or missed dialysis interventions for Resident #2 on that day. ADON A said she did recall discussing the resident's elevated heart rate and missed dialysis session after the fact. Interview with LVN D on 10/10/2025 at 2:13pm who said he had no memory of RN A speaking to him about Resident #2 and any missed dialysis or elevated heart rate. LVN D said he heard something about the situation later but never spoke directly with RN A or NP A about getting orders for missed dialysis intervention. Interview on 10/10/2025 at 9:38 am with Hemodialysis Nurse who said she recalled and was familiar with Resident #2. Hemodialysis Nurse said she remembered Resident #2 having a change in condition during one of her dialysis sessions and not being able to receive hemodialysis that day because of an elevated HR around 120 beats per min. The Hemodialysis nurse said that Resident #2 had an early chair time of around 4-5am and that Resident #2 was on a MWF dialysis schedule. The Hemodialysis nurse said that on 10/03/2025 Resident #2 could not get dialysis because of an elevated HR in the 120's and she called Nephrologist for orders and intervention. The Hemodialysis Nurse said she tried various interventions, including medication Metoprolol, as ordered, to get Resident #2's HR down so she could safely receive dialysis, but the interventions were unsuccessful. The Hemodialysis Nurse said she had to refer Resident #2 back to her charge nurse around 5 am because her HR remained outside of the safety parameters for her to receive dialysis. The Hemodialysis nurse said that she communicated with Resident #2's charge nurse about the medication Metoprolol that had been given to Resident #2, while she was in dialysis, per Nephrologist's order. The Hemodialysis nurse said it was not recommended for residents/patients to miss dialysis. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 45 of 66 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 10/27/2025 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 0698 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Hemodialysis Nurse said she would have definitely communicated the missed dialysis treatment to Resident #2's attending MD/NP because usually the doctor would send the resident to the hospital to receive dialysis, so they did not miss a treatment. The Hemodialysis nurse said she only found out that Resident #2 never went to the hospital after the fact on the following Monday, 10/06/2025, and was concerned that Resident #2 had not received dialysis for 4 days. In an interview with NP B on 10/10/2025 at 10:25 am who said he was not at work on 10/03/2025 and was not notified that Resident #2 had not received her dialysis. NP B said that the physician should be notified so they could give an order if a resident had a change in condition or anything that could affect a resident not receiving dialysis. NP B said that usually if a resident misses dialysis they wound be sent to the hospital to receive dialysis. Telephone interview with NP A on 10/10/25 at 11:33 am said he was covering NP B for one week, from 09/29/20255 through 10/03/2025, and he came to see Resident #2 on 10/01/2025 within 24 hours of her facility admission. NP A said he was notified on 10/3/25 that Resident #2 had an elevated heart rate while at dialysis and that they were unable to continue dialysis that day. NP A said he called the facility three times to provide orders but there was no answer. NP A said when he finally reached a nurse, the nurse said that an order was given to treat Resident #2's elevated heart rate, by another doctor. NP A said he was never asked what to do about Resident #2's incomplete dialysis and was under the impression the dialysis doctor/nephrologist should have made the decision of what to do if a resident did not receive dialysis. NP A said he would not speculate on if Resident #2 could or would have been sent to the hospital for dialysis, but he would expect staff to follow all orders regarding residents' treatments, medication, and care. When NP A was asked if he thought Resident #2 not receiving dialysis for four days was a concern or risk to the resident, NP A said he would not speculate about any potential risk to the resident. Attempts to contact and interview Nephrologist on 10/10/2025 at 4:13pm and on 10/11/2025 at 11:33am were unsuccessful. Record review of facility policy titled Dialysis and dated as revised November 2013 revealed in part: Dialysis is a process used to remove fluid and waste products from the body when the kidneys are unable to do so because of impaired function or when toxins or poisons must be removed immediately to prevent permanent or life-threatening damage. The purposes of dialysis are to maintain the life and well-being of the patient until kidney function is restored and to remove unwanted substances from the blood if renal function does not return. Methods of therapy include hemodialysis, hemofiltration, and peritoneal dialysis. 13. The medication regimen will be assessed by the physician and the pharmacist. When the resident is dialyzed, drug administration times may need to be changed to coincide with the dialysis schedule to prevent their removal. Medication review will be ongoing. Record review of undated facility policy titled Notifying the Physician of Change in Status, revealed in part: 1. The nurse will notify the physician or their delegated nurse practitioner or physician assistant with change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, the physician's orders and the resident's status and response to interventions. If the resident remains in the facility and a significant change has occurred, update the care plan accordingly. This was determined to be an Immediate Jeopardy (IJ) on 10/10/2025. The Administrator was notified on 10/10/2025. The IJ template was provided to the facility on [DATE] at 8:14 pm. A plan of removal was requested. The following Plan of Removal (POR) submitted by the facility was accepted on 10/11/2025 at 2:39 p.m. The plan of removal reflected the following: Facility Name: Date: October 11, 2025 IJ Component: F698: Quality of care: Hemodialysis Facility failed to ensure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 46 of 66 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 10/27/2025 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 0698 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some resident #2 received hemodialysis on 10/3/25. Immediate Actions: SBAR/Change of condition assessment completed on 10/10/25 with notification of provider and responsible party. No new orders were obtained for Resident #2. Hemodialysis was resumed on next scheduled day (10/06/25) with no missed treatments since 10/06/25. Facility Plan to ensure compliance: 1. 100% review of all facility residents receiving dialysis completed by DON, ADON, and Regional Compliance Nurse on 10/10/25 to identify any other residents receiving dialysis treatments. 3 additional residents identified as receiving dialysis services. 2. 100% assessment of all facility residents ordered to receive hemodialysis treatments were audited on 10/10/25 to ensure no other residents missed hemodialysis treatments. One resident identified as unable to fully complete the session on 10/10/25, charge nurse completed SBAR and notification to MD with new monitoring orders obtained. 3. Regional Compliance Nurse provided in-service to DON, ADON, and Administrator on 10/10/2025 regarding a. Change of Condition: When to Report to MD/NP/PA and follow-up communication b. Abuse/Neglect c. Dialysis: Facility's dialysis policy in-serviced for enforcement. (No revision of policy needed as policy is effective but was not being followed). 4. DON/ADON will in-service facility staff by phone and/or in person starting 10/10/2025 regarding facility policy on Abuse/Neglect. Goal for completion of this education to be completed by end of day on 10/11/25. Facility staff, including PRN staff, not in serviced by 10/11/25 will not be allowed to provide resident care until training has been completed. 5. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting 10/10/25 regarding Change of Condition to include when to Report to MD/NP/PA. Goal for completion of this education to be completed by end of day on 10/11/25. All nurses (LVN/RNs), including PRN nurses, not in serviced by 10/11/25 will not be allowed to provide resident care until training has been completed. 6. DON/ADON will in-service nurses (LVN/RN) by phone and/or in person starting 10/10/25 regarding facility's dialysis policy. Goal for completion of this education to be completed by end of day on 10/11/25. All nurses (LVN/RNs), including PRN nurses, not in serviced by 10/11/25 will not be allowed to provide resident care until training has been completed. 7. Nurses (LVN/RNs) will utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to missed hemodialysis treatments and other changes in condition in the facility's electronic medical record (EMR). 8. The Medical Director was notified by Administrator on 10/10/25 at 8:50pm regarding the immediate jeopardy citation. 10. An Ad-hoc QAPI meeting was held on 10/10/25 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. Monitoring: DON/Designee will monitor changes of condition x 4 weeks to ensure changes of condition have been reported to the MD and followed up. DON/Designee will monitor Dialysis residents x 4 weeks to ensure that residents did not miss any dialysis or had any incomplete dialysis session, if dialysis sessions were missed or incomplete that an SBAR was completed, and was the resident monitored. The Plan of Removal was confirmed for the IJ by monitoring from 10/12/2025 through 10/16/2025 as follows: On 10/10/2025 at 7:30 p.m., request was made with the Administrator and DON to review the dialysis communication sheet, progress note and SBAR for Resident #2 regarding her missed dialysis treatment on 10/03/2025. In an interview on 10/12/2025 with licensed nurses who worked 6:00am-2:00pm, at 2:03 p.m., Treatment Nurse A, ADON A, LVN A, LVN B, LVN C, LVN D, LVN E, LVN G, and RN B who were all knowledgeable regarding facility policy on Abuse/Neglect. They were all able to articulate numerous examples of ANE including physical, sexual, verbal, emotional and misappropriation of property. They all gave multiple examples of neglect that included isolating a resident or not changing or feeding them. They were all able to explain what a change in condition and the facility policy and procedure on identifying changes in condition and proper notification of changes in condition to physicians and resident responsible parties. They were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 47 of 66 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 10/27/2025 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 0698 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some all able to articulate the facility's dialysis policy and when and how to utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to missed hemodialysis treatments and other changes in condition in the facility's electronic medical record (EMR). On 10/12/25 at 5:24 pm a request was made with Administrator, DON, Corporate and Regional staff to review the audits as there was no updated information to review for F798 related to Dialysis residents from Friday because their POR only indicated audits would be conducted Monday through Friday. In an interview on 10/13/2025 at 3:18 pm with licensed nurses who worked the 2:00pm-10:00pm shift, who were all knowledgeable of the step-by-step process using the SBAR as a communication tool and the facility's dialysis policy and when and how to utilize the skilled nurse's notes, and/or other routine follow-up documentation to document the change in condition related to missed hemodialysis treatments and other changes in condition in the facility's electronic medical record (EMR). RN B, Treatment Nurse and ADON A said they were all knowledgeable regarding facility policy on Abuse/Neglect. They were all able to articulate various examples of ANE including physical, sexual, verbal, emotional and misappropriation of property. They all gave multiple examples of neglect that included isolating a resident or not changing or feeding them. They were all able to explain what a change in condition and the facility policy and procedure on identifying changes in condition and proper notification of changes in condition to physicians and resident responsible parties. In an interview on 10/13/2025 at 4:00 PM the Medical Director said that she was notified about the IJ being called, and she had been included on the POR. She said that all treatments and care should have orders, should be documented, and standard. The Medical Director said that all residents who receive dialysis should have orders, and the orders should be followed. She said that the physician should be notified if or when a resident did not receive hemodialysis as ordered. On 10/13/25 at 5:07pm a request was made with the Administrator, DON, Corporate and Regional staff to review the records for Resident #2 and provide details about her SBAR and transfer to hospital. Resident #2's dialysis sheet was incorrect. In an interview on 10/14/2025 at 2:13 pm with MDS Coordinator, who said that she worked full time Monday through Friday on the day shift. She said she was able to articulate the step-to-step process for using the SBAR as a communication tool. She gave multiple examples of ANE including physical, sexual, verbal, emotional and misappropriation of property. They all gave multiple examples of neglect that included isolating a resident or not changing or feeding them. She was able to explain what a change in condition and the facility policy and procedure on identifying changes in condition and proper notification of changes in condition to physicians and resident responsible parties. She was able to articulate the facility's dialysis policy and when and how to utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to missed hemodialysis treatments and other changes in condition in the facility's electronic medical record (EMR). On 10/14/25 at 6:56 pm a request was made with the Administrator, DON, Corporate and Regional staff requested staff list, wound care list and medication orders status post wound care doctor, no MAR to support pain medication audits. Still pending facility audit of Resident #2's transfer to the hospital on [DATE]. Dialysis and other documentation remained incomplete. In an interview on 10/15/2025 at 6pm with RN A who said she worked at the facility fulltime and usually on the 10pm to 6am shift but would sometimes pick up extra shifts or different shifts prn. She was able to articulate the step-to-step process for using the SBAR as a communication tool. She gave multiple examples of ANE including physical, sexual, verbal, emotional and misappropriation of property. She gave multiple examples of neglect that included isolating a resident or not changing or feeding them. She was able to explain what a change in condition was and the facility policy and procedure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 48 of 66 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 10/27/2025 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 0698 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete on identifying changes in condition and proper notification of changes in condition to physicians and resident responsible parties. She was able to articulate the facility's dialysis policy and when and how to utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to missed hemodialysis treatments and other changes in condition in the facility's electronic medical record (EMR). The Administrator was informed that the immediacy was removed on 10/16/2025 at 7:43 p.m. The facility remained out of compliance at a scope of pattern at a severity level of no actual harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Event ID: Facility ID: 455682 If continuation sheet Page 49 of 66 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 10/27/2025 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 0760 Ensure that residents are free from significant medication errors. 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 residents were free of significant medication errors for 1 of 3 residents (Resident #2) - The facility failed to administer Resident#2's IV antibiotic as ordered from her admission on [DATE]-[DATE]. An immediate Jeopardy (IJ) was identified on 10/10/2025. The IJ template was provided to the facility on [DATE] at 8:11 pm. While the Immediacy was removed on 10/19/2025 at 5:44 pm, the facility remained out of compliance scoped at pattern with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. This failure had the potential to place residents at risk for delayed treatment, and worsening infections which can lead to actual harm. Resident #2 was admitted to the hospital with critically elevated white blood cell count, sepsis and had an above the knee amputation of both of her legs. Findings Included: Resident #2 Record review of Resident #2's admission Record dated 10/22/25 revealed she was a [AGE] year old female who admitted to the facility on [DATE] from another state with diagnoses that included: cerebral infarction (a condition that occurs when blood flow to the brain is interrupted, causing brain cells to die), sepsis due to Escherichia Coli (a life-threatening infection, where bacteria from the intestine spreads to the blood stream and triggers a systemic inflammatory response in the body), severe sepsis with septic shock (an infection that leads to life threatening organ dysfunction and failure), pressure ulcer of sacral region (a skin and soft tissue injury that develops over the sacrum (the bone at the base of the spine) due to prolonged pressure, friction or shear which causes the tissue to breakdown and form an open wound), dependence on renal dialysis (a lifelong, and life sustaining therapy involving regular treatments that perform the function of the kidneys to filter waste and remove excess fluid from the blood for people with severe or permanent kidney failure), and gastrostomy status (an opening in the abdomen with insertion of a tube directly into the stomach that allows for nutrition, medication and fluids to be administered to a person unable to eat or drink anything by mouth). Record review of Resident #2's admission Minimum Data Set (MDS) dated [DATE] revealed she had a SAMS (Staff Assessment for Mental Status) completed and was coded as being severely impaired in cognitive skills for daily living decision making. Resident #2 was also coded as having upper and lower extremity impairments on one side of her body and was totally dependent on at least one staff member to provide all ADL (Activities of Daily Living) care. Continued record review revealed Resident #2 was coded in Section M related to Skin Conditions as having two stage four pressure ulcers upon admission. Six unstageable wounds upon admission, and five venous or arterial ulcers. Resident #2 was also coded under Section M as having an infection of the foot. In Section N of the MDS for Medications she was coded as having received antibiotics within the last 7 days. Record review of Resident #2's comprehensive care plan review with a review completed date of 10/06/2025 revealed in part: Focus.Resident #2 is on antibiotic therapy r/t sepsis, r/t wounds, UTI and aspiration PNA.Goal.The resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. Target Date: 10/12/2025.Interventions.Administer medications as ordered. Record review of Resident #2's out of state hospital records dated 09/29/2025 revealed she had the following order: Piperacillin Tazobactam (Zosyn) 4.5 g in Sodium Chloride 0.9% 100 ml IVPB Dose: 4.5 g.Freq: every 12 hours.Route: IV.Indications of use: Cellulitis. Record review of Resident #2's physician order dated 9/30/25 at 7:15 pm revealed the following order: Piperacillin Sod-Tazobactam So Intravenous Solution Reconstituted 4.5 (4-0.5) GM (Piperacillin Sodium Tazobactam Sodium) Use 100 gram intravenous every 12 hours for wound infection for 14 days, and was confirmed by LVN B. Record review of Resident #2's MAR dated September 1, Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 50 of 66 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 10/27/2025 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 2025, through September 30, 2025, revealed Resident #2 did not receive Piperacillin Sod-Tazobactam So Intravenous Solution Reconstituted 4.5 (4-0.5) GM (Piperacillin Sodium Tazobactam Sodium) Use 100 gram intravenous every 12 hours for wound infection for 14 days, as ordered. Continued record review revealed Resident #2 did not receive the medication on 9/30/25 and the order was discontinued on 10/01/25. Record review of Resident #2's Medication Administration Record (MAR) dated October 1, 2025, through October 31,2025 revealed the following: Zosyn Intravenous solution 4-0.5 GM/100 ML Piperacillin Sodium-Tazobactam Sodium in Dextrose (sugar water) Use 100 ml intravenously every 12 hours for Sepsis r/t E. Coli Continue until 10/16/2025.D/C Date: 10/04/2025 at 5:25pm. There was no administration of the medication documented on 10/01/25 for the 06:00 am dose or the 5:00pm dose. There was no documentation on 10/02/25 for the 06:00am dose and the 9=other/see nurse notes. was documented by RN A for the 5:00pm dose. Continued record review revealed no corresponding nurse notes. Record review of Resident #2's progress notes revealed Resident #2 had no IV access for antibiotic to be administered as ordered. Record review of ADON A's note dated 10/3/25 at 9:56 am revealed in part, Spoke with Hemodialysis Nurse this am.OK received to insert midline (a type of long IV catheter inserted into a large vein in the upper arm and is the middle ground between a standard peripheral (type of IV catheter inserted into a vein near the surface of the skin) IV and a central line) for IV ABT therapy. Continued record review of ADON A note dated 10/3/25 at 10:32 am Consent received from RP to insert midline for ABT use. Call placed to IV Company for insertion. Record review of Resident #2's progress notes dated 10/04/25 revealed LVN C documented the following: Note Text: Called Pharmacy A regarding Zosyn IV 4.5 gm which wrong dose (3.375gm) was dispensed to facility and altered dosage in resident's order by pharmacy; spoke with pharmacist on call who apologized for their mistake and confirmed the current dose of Zosyn 4.5 gm is no available in facility's pyxis to be administered. Medical Director notified, new order to administer Zosyn 3.375 gm IV every 8 hours until pharmacy delivers Zosyn 4.5gm and stop date changed to 10/19/25. Called Pharmacy A and Pharmacist notified. Record review of Resident #2's MAR dated October 1, 2025, through October 31,2025 revealed, Zosyn Intravenous Solution 3- 0.375 GM/50ML (Piperacillin Sodium-Tazobactam Sodium in Dextrose) Use 3.375 gram intravenously three times a day related to URINARY TRACT INFECTION, SITE NOT SPECIFIED. administer every 8 hours until Zosyn 4.5gm delivered from pharmacy, was documented as administered to Resident #2 by LVN C on 10/04/25 at 8:00pm. Record review of Resident #2's MAR dated October 1, 2025, through October 31,2025 revealed her admission order for Zosyn Intravenous Solution 4-0.5 GM/100ML (Piperacillin Sodium Tazobactam Sodium in Dextrose) Use 100 ml intravenously every 12 hours for SEPSIS R/T E. COLI until 10/19/2025 was documented as administered to Resident #2 on 10/05/25 at 5 pm, by RN A. Observation on 10/09/2025 of Resident #2's wound care treatment at 10:57 am performed by ADON A and assisted by CNA A. ADON A was asked prior to the start of Resident #2's treatment if Resident #2 had been medicated for pain and ADON A said Resident #2 had been medicated 30-40 minutes earlier. Observation of Resident #2 who was dressed in a clean facility gown and had just been showered and transferred back into her bed. None of the wounds were covered with any dressings as they had been removed or became dislodged during the shower. Resident #2 was nonverbal and did not respond with hand gestures as both of her hands and arms were contracted. She was awake and alert with her eyes open and her facial expression appeared calm and relaxed. Enhanced Barrier and Universal Precautions were maintained throughout the procedure and staff donned and doffed PPE appropriately, before, during and after the procedure. Resident #2's privacy was maintained throughout the wound care procedure. The wound care treatments began with Resident #2's sacrum which had no dressing post shower. The sacral wound was shaped like a large kidney bean. The surface area of the wound was large; she had wounds on both (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 51 of 66 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 10/27/2025 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some her right and left buttock's that appeared to have merged or blended into one giant wound with a thin strip of skin separating each buttock cheek and appeared tethered from the base of her back through her anus. The right buttock surface area appeared to be approximately 12 x 2 X 4, and the left buttock surface area appeared to be 15 X 4 X 4. The right buttock was a red beefy color with brown edges. It was leaking a copious amount of serosanguinous fluid after ADON A cleansed the area per treatment orders. There was some active bleeding of bright red blood as ADON A continued with the treatment as ordered and Resident #2 appeared to have no facial or physical response during the treatments to her bilateral buttocks. The left buttock had the same amount of serosanguinous leakage of fluid and brown edges of the perimeter of the wound. The wound bed was paler pink, with no active bleeding observed at that time. ADON A completed the treatments to Resident #2's bilateral buttock area. Resident #2's bilateral lower legs appeared emaciated and thin. Her right lateral leg just above her ankle appeared to be exposed to the tendon, and her right heel appeared black. Her right ankle was a black circle where her ankle was located. Resident #2's first, second and third toes of her right foot were completely black and appeared shriveled and fragile. Resident #2's right lateral foot was also black. Resident #2's Left lateral ankle was black and her left heel had an open ulcer that was approximately 4X2 in size. The second toe of her left foot was completely black, shriveled and appeared fragile. Resident #2 tolerated the wound care treatments without any visible, verbal, or audible reaction until ADON A painted betadine on her left lateral ankle which was the last treatment. Resident #2 could be heard inhaling deeply with her eyes closed. Resident #2 had her eyes closed throughout the treatment but had been breathing calmly and quietly up until that point. ADON A spoke calmly to her and reassured her she was done with the treatment. Resident #2 briefly opened her eyes and then closed them again, resuming her calm breathing and appeared to be in no apparent distress. In a telephone interview on 10/09/25 at 2:46 pm with the admitting nurse LVN A, she said she reviewed the hospital records of Resident #2 on 09/30/2025 to have orders to treat her wounds and infection. She said that she clarified the admission orders with NP A, entered the orders, and enlisted the help of other staff on duty to help enter the admission orders, but she failed to ensure that all the orders were entered before her shift ended. She said that Resident #2 was admitted with a wound infection, and was prescribed IV Zosyn to treat the infection, she called to clarify with NP A an order to administer the Zosyn through her pre-existing hemodialysis site, and NP A said that he would address the issue when he rounded on 10/01/2025. In a telephone interview on 10/09/2025 at 4:46 pm with Medical Director who was also the attending physician for Resident #2. The Medical Director said that she was not notified of any issues or concerns with Resident #2 receiving the IV antibiotic Zosyn as ordered. The Medical Director said she would not speculate what potential impact could result from Resident #2 not receiving the antibiotic as prescribed from her admission on [DATE] until the evening of 10/04/2025. The Medical Director said she would expect staff to follow physician orders and to notify them if or when there were any changes or issues. Interview with Hemodialysis Nurse on 10/10/2025 at 9:38 am who said she was familiar with Resident #2. Hemodialysis Nurse said that she had been contacted by facility nurse regarding a midline IV insertion for the resident but could not recall the date. Hemodialysis Nurse said Resident #2 admitted to the facility with a central line dialysis access port to her right chest and sometimes a facility will ask the Nephrologist if medications like antibiotics could be administered during dialysis through the dialysis port. The Hemodialysis Nurse said she was not asked to administer any antibiotic for Resident #2 through her dialysis port and was not aware that Resident #2 did not receive her antibiotics as ordered from her admission on 0 9/30/2025 until 10/04/2025. The Hemodialysis Nurse said that Resident #2 should have received her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 52 of 66 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 10/27/2025 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some antibiotic as ordered because any infection she may have had could have gotten worse. Interview with the DON on 10/10/2025 at 10:18 am who said the admitting nurse should identify any skin issues at the time of admission, obtain orders from the primary physician for all medications and wound care and notify the acting wound care nurse to complete a second skin assessment within 24 hours. She said that there should be a clinical review of all new admissions on the next business day to ensure the accuracy of the admission process, that orders were entered and implemented, and she did not remember if there was a clinical review on 10/01/2025 for Resident #2. She said that there should be a clinical review each business day to address any new concerns or changes in conditions. The DON said that in the clinical review 24-hour reports, and direct care staff provide reports in the morning clinical stand-up meetings to help ensure continuity of resident care because they discuss medication orders, any obstacles, or delays in getting medications or orders. They discuss treatments that would include wound care and or hemodialysis treatments, to ensure residents with these orders receive the proper medications and treatments. She said that she was not aware that there were any concerns with Resident #2's wound care, IV antibiotics or dialysis and that the nurse at the time would be responsible for notifying the MD if Resident #2's IV antibiotic medication needed clarification of the strength or if the incorrect dose was delivered or if the resident had no other IV access except the dialysis port. The DON said the nurse at the time would be responsible for notifying the MD if Resident #2 had not completed hemodialysis so that the physician could give an intervention. The DON said she was not sure why that had not been done for Resident #2. The DON said she could not recall if she reviewed Resident #2's clinical records prior to her facility admission or facility electronic clinical records since admission. The DON said that she had not completed a physical assessment of Resident #2 since her admission on [DATE]. Interview at 10:25 am on 10/10/25 with NP B who said he had been out of town when Resident #2 admitted to the facility and NP A was covering for him and had seen Resident #2 the day after her admission on [DATE]. NP B said that Resident #2 was admitted with multiple wounds and was already being treated with IV antibiotics in the hospital and was positive for urine and wound with the same organism E. Coli. NP B said he was unaware of Resident #2 not receiving IV Abt Zosyn as ordered and would not speak to why it was or was not started from admission on [DATE]. NP B said today was the first day he saw Resident #2 and his expectation was that if a resident discharged from a hospital on medications, those medications would be continued as ordered. When asked what could happen if a resident were supposed to be on antibiotics and did not get them as ordered, NP B said the infection could get worse and he received an emergency text from the Medical Director this morning to see Resident #2. In a telephone interview on 10/10/2025 at 11:33am with NP A, he said that he was contacted at the time of Resident #2's admission, he reviewed medications and treatments for wounds with the admitting nurse, and he gave order to continue with treatment and medication orders from the hospital medical records.? He said that he rounded with Resident #2 on 10/01/2025, she was prescribed Zosyn a broad-spectrum treatment for an E. Coli infection of her urinary tract, wounds, and pneumonia.? He said that he was asked to clarify the order for Zosyn with the pharmacy, and he was under the impression that the medication would be delivered and administered the same day.? He said that if he had been informed, he would have decided on a different treatment plan.?? He said that he would not speak on risk to residents, or if Resident #2 should have been sent to the hospital.? He said that his expectation is that staff enter orders from the time of admission, follow orders, and make notifications to a physician when medications are not available, treatments are missing, and when there is a change in condition. Telephone interview with Wound Care Doctor A on 10/10/2025 at 5:33pm who said he had not been notified prior to 10/02/2025 of Resident #2's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 53 of 66 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 10/27/2025 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some admission or need for a wound consultation. Wound Care Doctor A said the first time he examined/assessed Resident #2 was on 10/02/2025 and from what he could remember, she admitted with multiple extensive wounds, including her sacrum and buttocks and her toes were at risk of auto (self) amputation. Wound Care Doctor A said he did not know that the orders he wrote for recommended treatments for Resident #2 had not been implemented by facility staff until 10/04/2025. Wound Care Doctor A said that while he did not see or notice any indication of infection of Resident #2's wounds while he provided care, orders for treatments and any antibiotics should be followed. Wound Care Doctor A said he was not aware that Resident #2 had not received her IV antibiotic as ordered from admission. Record review of policy titled, Medication Administration and General Guidelines, with a date of 2025 read in part, Policy Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication, monograph of all medications is available in LinkRx otherwise authorized personnel should refer to Drug Reference material provided by facility. Procedure. 2. Medications are administered in accordance with written orders of the attending physician. 6. All current medications and dosage schedules, except topicals used for treatments, are listed on the resident's medication administration record (MAR). This was determined to be an Immediate Jeopardy (IJ) on 10/10/2025. The Administrator was notified on 10/10/2025.? The IJ template was provided to the facility on [DATE] at 8:14pm.? A plan of removal was requested. The following Plan of Removal (POR) submitted by the facility was accepted on 10/11/2025 at 2:27 p.m. PLAN OF REMOVAL Name of Facility: Date: October 11, 2025 IJ Component: F760: Significant Medication Errors Facility failed to administer Resident #2's IV antibiotic as ordered to treat UTI, wound sepsis, and Pneumonia from admission 9/30/25-10/5/25. Immediate Actions: SBAR/Change of condition assessment completed on 10/10/25 with notification of provider and responsible party regarding the missed IV antibiotics. Correct dosage of IV antibiotics have been obtained by facility and are being administered as ordered. Facility Plan to ensure compliance: 1. 100% audit completed of facility residents completed on 10/10/25 to identify any residents with IV antibiotics No additional residents identified as receiving IV antibiotics. 2. 100% audit completed on 10/10/25 of facility residents to identify any missed medications and/or treatments. Providers for residents identified as missing medications/treatments were notified and medication error documentation completed on 9 facility residents identified as missing medications/treatments. 3. Regional Compliance Nurse provided in-service to DON, ADON, and Administrator on 10/10/2025 regarding: a. admission Process to include reconciling treatment and medication orders. b. Medication Administration policy in-serviced for enforcement (no revision of policy required, as policy is effective but not being followed). 4. DON/ADON will in-service facility staff by phone and/or in person starting 10/10/2025 regarding facility policy on Abuse/Neglect. Goal for completion of this education to be completed by end of day on 10/11/25. Facility staff, including PRN staff, not in serviced by 10/11/25 will not be allowed to provide resident care until training has been completed. 5. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting 10/10/25 regarding the admission Process to include reconciling treatment orders and medication orders. Goal for completion of this education to be completed by end of day on 10/11/25. All nurses (LVN/RNs), including PRN nurses, not in serviced by 10/11/25 will not be allowed to provide resident care until training has been completed. 6. DON/ADON will in-service nurses (LVN/RN) by phone and/or in person starting 10/10/25 regarding Medication Administration. Goal for completion of this education to be completed by end of day on 10/11/25. All nurses (LVN/RNs), including PRN nurses, not in serviced by 10/11/25 will not be allowed to provide resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 54 of 66 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 10/27/2025 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some care until training has been completed. 8. The Medical Director was notified by Administrator on 10/10/25 at 8:50pm regarding the immediate jeopardy citation. 9. An Ad-hoc QAPI meeting was held on 10/10/25 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. Monitoring: DON/Designee will monitor admission Process daily, Mon-Fri, x 4 weeks to ensure any new admissions and readmissions had reconciled treatment and medication orders. Nursing administration designee will complete admission checklist audit to ensure medication reconciliation has been double checked from what was ordered versus what the facility staff enters into (EMR) the facility's electronic record. DON/Designee will monitor Medication & Treatment Administration Records daily, Mon-Fri x 4 weeks to ensure all medications & treatments were signed out, administered, and available by utilizing the Missed Med Report during morning clinical meeting. The Plan of Removal was confirmed for the IJ by monitoring from 10/11/2025 through 10/19/2025 as follows: Interview on 10/10/2025 at 4:00 p.m. with the Medical Director, who said that she was notified about the IJ being called, and she had been included on the POR. In an interview on 10/12/2025 with licensed nurses who worked 6:00am-2:00pm, at 2:03 p.m., Treatment Nurse A, ADON A, LVN A, LVN B, LVN C, LVN D, LVN E, LVN G, and RN B who were all knowledgeable regarding facility policy on Abuse/Neglect. They were all able to articulate numerous examples of ANE including physical, sexual, verbal, emotional and misappropriation of property.? They all gave multiple examples of neglect that included isolating a resident or not changing or feeding them. They were all able to explain what a change in condition and the facility policy and procedure on identifying changes in condition and proper notification of changes in condition to physicians and resident responsible parties.? They were all able to articulate the facility's admission Process to include reconciling treatment orders and medication orders. policy and when and how to utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to missed hemodialysis treatments and other changes in condition in the facility's electronic medical record (EMR).?? ? ? On 10/12/2025 at 5:24 pm a request was made with Administrator, DON, Corporate and Regional staff to review the audits as there was no updated information to review F760 related to medications because their POR only indicated audits would be conducted Monday through Friday. Record review of Resident #2's progress note dated 10/13/2025 at 12:33pm and completed by ADON A read in part, 12:30-Call received from Lab with critical lab value of WBC @21.1. 12:31-Call placed to NP B and informed at this time of results. NP B stated he would call back. Waiting for return call. Record Review of Resident #2's SBAR and Transfer Summary dated 10/13/2025 and completed by ADON A, did not have details as to what the change in condition was or why Resident #2 was being transferred. Interviews on 10/13/2025 with licensed nurses at 3:18pm who worked the 2:00 pm-10:00 pm shift, who were all knowledgeable of the step-by-step process using the SBAR as a communication tool and were all able to articulate the facility's admission Process to include reconciling treatment orders and medication orders, dialysis policy and when and how to utilize the skilled nurse's notes, and/or other routine follow-up documentation to document the change in condition related to missed hemodialysis treatments and other changes in condition in the facility's electronic medical record (EMR).?? LVN A, LVN C and LVN G said they were all knowledgeable regarding facility policy on Abuse/Neglect. They were all able to articulate various examples of ANE including physical, sexual, verbal, emotional and misappropriation of property.? They all gave multiple examples of neglect that included isolating a resident or not changing or feeding them. They were all able to explain what a change in condition and the facility policy and procedure on identifying changes in condition and proper notification of changes in condition to physicians and resident responsible parties.?? ? In an interview on 10/13/2025 at 4:00 pm the Medical Director said that she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 55 of 66 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 10/27/2025 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some notified about the IJ being called, and she had been included in the POR. She said that all treatments and care should have orders, should be documented, should be followed as ordered and should be standard. The Medical Director said that any resident who received hemodialysis should receive the treatments as ordered and the physician should be notified if and when a treatment or order cannot be followed so they can prescribe an alternative treatment order or intervention. On 10/13/2025 at 5:07 pm a request was made with the Administrator, DON, Corporate and Regional staff to review the records for Resident #2 and provide details about her SBAR and transfer to hospital. Resident #2's dialysis sheet was incorrect. In an interview on 10/15/2025 at 9:40am with an Attending Physician at a local hospital, she said Resident #2 was admitted with a chief complaint of elevated WBC, diagnosed with sepsis, and was treated with the IV antibiotic Vancomycin.? She said that there was blood culture pending to establish the cause of the infection.? She said that Resident #2 admitted with extensive wounds.? She said that Resident #2's wounds to her feet were necrotic with no blood flow, and has been recommended for bilateral AKA.? She said that they will continue to monitor after the surgery for signs of infection because it is possible the infection has spread to the bone.? She said that Resident #2 was nonverbal and not able to express if she was in pain, but she did respond to stimuli with facial cues.? She said that Resident #2 had PRN morphine to manage her pain.? She said that in the absence of antibiotics or wound care her infection and wounds could worsen.? She said that Resident #2 needed regularly scheduled dialysis, and a physician should be consulted regarding any missed treatment to decide on an alternate treatment plan.? In an interview on 10/15/2025 at 6:00 pm with RN A who said she worked at the facility fulltime and usually on the 10pm to 6am shift but would sometimes pick up extra shifts or different shifts prn.? She was able to articulate the step-to-step process for pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool.? She gave examples of non-verbal signs/symptoms or cues for pain could be crying, breathing heavy, flinching and that she should evaluate any pain signs or symptoms prior to, during and after a procedure or treatment.? She said if a resident were exhibiting signs and symptoms of pain, to stop the treatment or procedure, redo the assessment and check for any other orders for interventions and if interventions were ineffective, she would initiate SBAR for pain and notify the MD and RP for the resident. In an interview on 10/16/2025 during the 6:00am-2:00pm shift with the Assistant Business Manager at 11:05am and Human Resources Director at 11:05am, both acknowledged being trained on abuse and neglected, provided types of abuse and neglect, reporting concerns with abuse and neglect to the Administrator who was the Abuse Coordinator immediately.? In an interview on 10/16/2025 at 6:01pm with LVN C, she stated she has been employed at the facility since June or July of 2025. She stated she works the 10pm-6am shift on weekends. She stated her last in-service on abuse and neglect was that morning. She stated they went over skin, abuse, neglect, pain, weekly skin assessments, MARs and admission process including all documentation. She stated she knew the different types of abuse and was knowledgeable about the different types of abuse. She stated that abuse was reported to the facility Administrator who was also the Abuse Coordinator. She stated that when working with a dialysis resident, they would complete a dialysis communication sheet before and after the dialysis treatment. LVN C said the residents would be assessed for pain, and vital signs would be checked to ensure they were normal. She was able to articulate the step-to-step process for pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool.? She gave examples of non-verbal signs/symptoms or cues for pain could be crying, breathing heavy, flinching and that she should evaluate any pain signs or symptoms prior to, during and after a procedure or treatment.? She said if a resident were exhibiting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 56 of 66 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 10/27/2025 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete signs and symptoms of pain, she would stop the treatment or procedure, redo the assessment and check for any other orders or interventions and if interventions were ineffective, she would initiate an SBAR for pain and notify the MD and RP for the resident. LVN C stated if a resident were on dialysis, she would complete the required dialysis communication sheets before and after dialysis and notify the physician, as appropriate regarding any changes in the resident's condition. She stated once a resident had a change in condition, they were to do the change in condition-SBAR, call the physician, call the family and call the DON to notify them of the change in condition and follow the physician orders. She stated she thought the physicians came to see the residents weekly. She stated when working with any resident that was refusing care, the physician, DON, and family would be notified, and physicians' orders would be followed, and she would ensure it had all been documented. LVN C said that the physician and RP also need to be notified if a resident did not receive any medication/s so new or different orders could be implemented. In an interview on 10/16/2025 at 6:13pm with RN J, she stated she has been employed at the facility for 10 years. She stated that she worked the 10pm-6am shift. She stated her last in-service was last night for abuse and neglect. She stated they also reviewed pain and abuse and neglect, and she was knowledgeable about the different types of abuse. She stated abuse was reported to the Administrator/Abuse Coordinator. She stated she was in-serviced on the dialysis process, and that when working with a dialysis resident, she ensured the resident was clean and dry and ensured that they were stable, which included assessing their vital signs. She sta Event ID: Facility ID: 455682 If continuation sheet Page 57 of 66 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 10/27/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for 2 of 4 halls; Hall 300 and Hall 400 reviewed for physical environment. Based on observation, interviews, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for 2 of 4 halls; Hall 300 and Hall 400 reviewed for physical environment. The facility failed to ensure Hall 300 was free of odors. The facility failed to deodorize Resident #21 and Resident #31's room resulting in foul orders filling the 300 Hallway and other residents rooms on the 300 hall resulting in complaints from other residents and family members. The facility failed to ensure construction-renovations were completed in Hall 400 resulting in 2 residents (Resident #11 and Resident #22) not getting wound care, unpleasant and uncomfortable environment for the residents. The facility failed to keep the dining room door closed by propping it open with a zip tie. These failures could place residents at risk of living in an unsafe, uncomfortable environment and decreased quality of life. The findings included: Record review of Resident #21's Electronic Health Record revealed a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses including Pressure Ulcer of Sacral Region, Stage 4 (a deep wound with full-thickness tissue loss that has damaged muscle, tendon, or bone), Pressure Ulcer of Left Lower back, stage 3 (a full-thickness skin and tissue loss injury that has damaged the skin and fat layer, creating deep crater, but has not yet exposed muscle, bone, or tendon), Pressure Ulcer of Right hip, Stage 4 (a severe, full thickness wound that extends through the skin and fat to expose underlying muscle, tendon, or bone), Pressure Ulcer of Left Ankle, Unstageable, Pressure Ulcer of other site (full thickness tissue loss, but the depth cannot be determined because it is covered by eschar (dead tissue) or other slough (dead or dying tissue)), Major Depressive Disorder(a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), Generalized Anxiety disorder (a common mental health condition characterized by excessive, persistent, and uncontrollable worry and anxiety about various aspects of life), and Benign Prostatic Hyperplasia without Lower Urinary Tract symptoms ( a condition where the prostate gland enlarges but does not cause any noticeable urinary problems) and Colostomy Status (refers to the condition of having a surgical procedure called colostomy). Record review of the Resident #21's Quarterly MDS revealed a BIMS score of 14, which indicates cognitively intact. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating and oral hygiene. Resident #21 required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts or holds trunk or limbs but provides less than half the effort) for roll left to right. Resident #21 required substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with shower/bathe self, upper body dressing, personal hygiene, sit to lying, and lying to sitting on side of bed. Record review of Resident #21's care plan dated 09/17/25 revealed the following in part: Focus: I am Non-Complaint daily to care and refuse care (Peri-care-wound care-ADL Care) has a preference to not wear briefs, refuses nail care, shaving, haircut, showers, and grooming and wound care.Goal: Prevent New Wounds and Heal Current Wounds- I will be free of Pain or Discomfort Focus: The resident has a behavior problem refusing medications, wound care, ADL care, grooming, no sheet on bed and meals Goal: The resident will have fever episodes of refusing medications by review date Record review of Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 58 of 66 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 10/27/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #31's Electronic Health Record revealed a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses including Unspecified Dementia (a diagnosis used when a person exhibits symptoms of dementia by the specific underlying cause cannot be determined), Local Infection of the skin and subcutaneous tissue (an infection that affects the layers of skin and underlying fat), Chronic Venous Hypertension with Ulcer of Right Lower Extremity (there is high blood pressure in the veins of the right leg, which has caused an open sore (ulcer) to form due to poor circulation), Chronic Venous Hypertension with Ulcer of Left Lower Extremity (high blood pressure in the veins of the left leg has caused a non-healing sore (ulcer) to form due to poor blood flow), Schizophrenia, Unspecified (a diagnostic category used in psychiatry when a person exhibits symptoms of schizophrenia but does not meet the full criteria for any specific subtypes of schizophrenia), Pressure Ulcer of Sacral Region, Stage 4 (a severe form of pressure injury where there is full-thickness tissue loss with exposed bone, muscle, or tendons), Pressure Ulcer of Right Heel, Stage 4 (the most severe type of pressure injury, involving deep-tissue damage with full-thickness tissue loss that exposes muscle, tendon, or bone), and Cognitive Communication Deficit (a communication challenge caused by problems with thinking abilities like attention, memory, and executive function, rather than a language or speech problem). Record review of the Resident #31's Quarterly MDS revealed a BIMS score of 11, which indicates cognitively intact. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or ouching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating and oral hygiene. Resident #31 required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts or holds trunk or limbs but provides less than half the effort) for roll left to right. Resident #21 required substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, and personal hygiene. Record review of Resident #31's care plan dated 09/19/25 revealed the following in part: Focus: Resident #31 is resistive to care relate to refusing incontinent care, wound treatment, weight and height management, refuses to bathe, shaving, haircuts, nail care, grooming, refuse to allow mid-line to be flushed. Goal: The resident will minimize refusal with care through next review date. Record review of Resident #11's Electronic Health Record revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Atherosclerosis of Native Arteries of Extremities with Gangrene, Right Leg (Severe plaque buildup in the arteries of the right leg, blocking blood flow to the point where tissue has died), Peripheral Vascular Disease( a circular disorder where narrowed, blacked, or spasming blood vessels outside the heart and brain reduce blood flow to the limbs and organs), Atherosclerosis of native arteries of right leg with ulceration of other part of foot (refers to a serious condition where atherosclerosis, the build-up of plaque in the arteries, has severely narrowed the arteries of the right leg, leading to gangrene (tissue death) and ulceration (an open sore) on the foot), non-pressure chronic ulcer of other part of right food with fat layer exposed (a non-healing open sore on the right foot that has penetrated through the skin to the subcutaneous fat layer, but was not caused by external pressure) Hypothyroidism (an underactive thyroid condition where the gland does not produce enough thyroid hormones, causing many of the body's function to slow down), and Hyperlipidemia (high levels of lipids like cholesterol and triglycerides in the blood). Record review of the Resident #11's Quarterly MDS revealed a BIMS score of 15, which indicates cognitively intact. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 59 of 66 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 10/27/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cues and/or ouching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with oral hygiene, roll left and right, sit to lying, and lying to sitting on side of bed. Resident #11 requires partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs and provides less than half the effort) with Toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, car transfer. Record review of Resident #11's care plan dated 09/30/25 revealed the following in part:Focus: Resident #11 has arterial ulcer related to Peripheral Arterial DiseaseRelated to third toe status post amputation secondary to gangrene. Goal: Resident #11 will be free from infection or complications related to arterial ulcer through review date. Record review of Resident #11's October 2025 Order Summary revealed an order to Cleanse right third toe arterial ulcer wound with Vashe, pat dry, apply lodosorb Gel to would bed, gauze sponge, cover with gauze border dressing dated 10/11/25. Record review of Resident #11's wound physician progress note dated 10/13/25 revealed: The patient's visit was rescheduled, unable to access room due to construction in the hallway. Record review of Resident #22's Electronic Health Record revealed a [AGE] year old male re-admitted to the facility 02/10/25 with diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer, Non-pressure chronic ulcer of left heel and midfoot with unspecified severity (long standing, non healing wound on the left heel and midfoot that was not caused by pressure), Non-pressure chronic ulcer of other part of left foot with fat layer exposed (A significant wound requiring medical attention, as it is a deeper ulcer that one limited to the skin and suggests damage has reached the subcutaneous tissue), Hereditary sideroblastic anemia (a rare genetic disorder where the body cannot produce sufficient hemoglobin due to a genetic defect) and Encounter for orthopedic aftercare following surgical amputation. Record review of Resident #22's Quarterly MDS revealed a BIMS score of 11, which indicates cognitively intact. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or ouching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating and oral hygiene. Resident #22 required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and tub/shower transfer. Record review of Resident #22's care plan dated 08/08/25 revealed the following in part:Focus: Resident #22 is at risk for infection related to a site for organism invasion. Goal: Early recognition of infection to allow for prompt treatment.Focus: Resident #22 has a surgical site to LT proximal plantarGoal: Resident's surgical site will show signs of improving and remain free from s/s of infection with treatment as ordered over the next 90 days.Interventions:- Administer supplements as ordered. - Administer treatments as ordered. - Surgeon follow up as needed. Assist Resident/Responsible party with scheduling/transportation as needed. - Wound Doctor Consult. Record review of Resident #22's October 2025 Order Summary revealed an order for Wound Consult dated 10/11/25 and an order for wound care site 6 Post-Surgical Wound Left Heel every day shift for left heel wound dated 10/12/25. Record review of Resident #22's wound physician progress note dated 10/13/25 revealed: The patient's visit was rescheduled, unable to access room due to construction in the hallway. In an interview/observation on 10/13/25 at 2:56pm; while walking rounds the back of 400 hallway was observed that had 1 side of the hallway closed off with a closed door and on the other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 60 of 66 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 10/27/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some side of the door there was a clear plastic sheet covering the open side of the door. There were no signs posted on the closed door or plastic sheet and signs as to what type of work was being done. There were 3 men on the other side of the door and clear plastic sheet wearing N95 mask or respirator masks and actively spraying the walls and ceilings of the unit. Some residents' doors were closed and the floor was covered with slippery plastic sheeting. All of the residents' doors were covered with plastic sheets that were taped at the top and did not create a complete covering or seal over the entire door and most only partially covered the door with the bottom of at least 8 rooms uncovered and exposed to the sprayed material and dust. The 400 hallway appeared hazy with dust like material floating in the air. There were at least 2 rooms that had EBP signs posted and at least 4 rooms that had residents inside of the rooms. When staff were asked what was happening CNA B and LVN B said she did not know and that administration had not told them anything. Staff said they would like to know as well so they could wear appropriate masks because they did not know what they were breathing or what the residents were breathing. CNA B and LVN B said they had no advanced notice that the work was being done and had no way of notifying residents before the work started. The machine used to spray the cloudy material was extremely loud and sounded like a jackhammer or drill. Interviews and observations with Resident #8, Resident #9 and Resident #11 who were all in their rooms and had EBP signs posted outside their doors. Resident #8 and Resident #9 said they felt ok but were advised they could not leave their rooms while the workers were outside. They said it was loud, but they had no feelings of illness or difficulty breathing at that time. When asked how they felt about being sealed inside their rooms during the work, Resident #8 said he was ok with it and Resident #9 said it was inconvenient. All 3 of the Residents said it was too loud. All of the Residents said no one told them the work would be done that day and no one offered them masks or an option to move or change rooms. In an interview on 10/13/25 at 3:00pm with CNA-AG, she was observed with no mask on. She reported there were about 12-13 residents behind the plastic barrier on hall 400. She stated she was not told what the workers were doing or what they were spraying. She stated she did not know why the plastic barrier was needed. In an interview/observation on 10/13/25 at 3:18pm-Notified Admin, DON and Corporate staff about immediate environmental concerns on 400 hallway and safety of residents who remained on the hallway while the substance was being sprayed. Admin said they had notified residents and family members about the renovations, and she was unsure what the substance was the workers were spraying but she could find out. She said she was unsure if anyone was required to wear any PPE or masks and said that they had signs posted on the front entry regarding the remodeling. The Admin said the facility was undergoing renovations with the new company and it was not construction. She said the workers were painting and had started renovations on 200 hall and were slowly working their way around the building. In an interview on 10/13/25 at 3:56pm with LVN B, she stated there were residents behind the plastic barriers on 400 hall. She stated she was not told what the workers were doing or what they were spraying. She stated she did not know why the plastic barrier was needed. She stated she did not know why the workers were wearing masks. She stated she thought the workers were sanding before painting. She stated that if the workers had masks the residents and staff should have mask as well. She stated there were no residents on oxygen on the 400 hall. She stated there was one resident with COPD. She stated she did not smell any fumes but it was dusty on the hall and it was loud. She stated she was not sure if the residents were asked to move. In an interview on 10/13/25 at 3:59pm with CNA-AG, she stated she was not told what the workers were doing or what they were spraying. She stated she did not know why the plastic barriers was needed and she did not know why the mask were needed. She stated she thought the workers were sanding prior painting the hallway. She stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 61 of 66 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 10/27/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that if the workers had on mask then the residents and staff should have on masks as well. She stated the renovations were loud and she was not sure if the residents were asked to move rooms or not. In an interview on 10/13/25 at 4:04pm with Contractor AO, he stated that he and the workers were spraying texturizer on the ceiling, and they would paint on 10/14/25. He stated that they were wearing the masks because it leaves dust that you should not breath in. In an interview on 10/14/25 at 11:48am with Resident #7, he stated he did not get any notice that the facility was doing any construction in the building. He stated he resides on hall 400. He stated the contractors were scraping, drilling, and painting in the hallway and it was loud. He stated everything had been flying in the air and it was affecting his sinuses, causing him to become congested and he reported he had diarrhea. In an observation on 10/14/25 at 9:38am, the dining room door was open and there was a zip tie propping the door open. There was also an extension cord running from inside of the dining room onto the outside of the dining room. The extension cord was zip tied to the hinges of the door, impeding it from closing. Surveyor attempted to close the door but it would not shut due to the extension cord being zip tied to the hinges of the door. In an interview on 10/14/25 at 9:41am with the Director of Food and Nutrition, he stated the zip tie had been on the door for about 2 months. He stated the facility did not put the tie zips there, he reported the company that had come out for their Air Conditioning had put the zip ties on the door. He stated the zip ties and extension did not stop the doors from closing. In an interview on 10/14/25 at 11:40am with Administrator-A, she stated the extension cord and zip tie was put there by the air conditioning company. She stated she would take it down and plug it somewhere else. In an interview on 10/15/25 at 12:11pm with ADON-M, she stated some of the residents on Hall 400 were not seen by the wound care doctor (Resident #11 and Resident #22). She stated she was not given a reason why the residents were not seen but she stated the wound care doctor reported that she did not want to go behind the barrier of the renovations on the 400 hall. She stated there was a barrier cutting off the hallway where renovations were being completed (painting). She stated Resident #11 and Resident #22 will not be seen until the following week (Mondays is the wound care doctors rounding days). She stated there was a barrier cutting off the hallway where they were painting. In observation rounds on 10/20/25 at 2:13pm on Hall 300, the hall smelled of urine and bowel movement. In an interview on 10/20/25 at 2:14pm with Resident #21 and Resident #31, both residents were observed lying in their beds. Upon entering Resident #21 and Resident #31's room, the smell intensified. The room smelled of urine, bowel movement, and body odor. The surveyor had on a mask but was able to smell the odor through the mask. Resident #21 stated he did not have any concerns with the smell of the room and reported that the room smelled fine. In an interview on 10/20/25 at 2:45pm with Regional Compliance Nurse-R, Regional Compliance Nurse-R was observed entering the room of Resident #21 and Resident #31. He stated the residents room did have an odor and described the smell as body odor, bowel movement and body fluid. He stated the smell was contributed to the lack of wound care. He stated Resident #21 and Resident #31 refuse wound care and stated it smells sour in the residents room. He stated he was unsure of what had been done by the administrator to address the smell. In an interview on 10/21/25 at 3:31pm with Resident #38, the resident resides on the 300 hall. He stated he did not like the smell of the 300 hall and he described the smell as different, then said it was like poop. He stated he could not smell it in his room but reported he could smell it when he goes in the hallway. He stated he would like for the hallway to smell better, because it smells that way all the time and he is sick of it. He stated this is his home and he would want it to smell better. He stated he has not spoken to anyone regarding his concern for the smell. He stated he felt as if staff knows that it smells and does not care. In an interview on 10/21/25 at 3:34pm with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 62 of 66 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 10/27/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some MA-AE, she stated there had always been an odor on the 300 hall and it was resulting from two of the resident in one of the rooms on the 300 hall. She stated the smell emits from the room into the hallway and into some of the other residents room. She stated she did not know what the facility management was doing to address the problem. She stated she did not know if the facility staff had spoken to the other residents about the concern. She stated whatever the facility management was doing about the smell was not effective. In an interview on 10/22/25 at 9:20am with Family Member #40, she stated the facility smelled horrible. She stated she was able to smell it as soon as she turns the corner to walk down hallway 300. She stated the smell hits you in the face. She stated it smelled like urine, sh**, and like something spoiled. She stated she smell was coming from one of the rooms on the 300 hall. She stated she could smell it down the hall and reported that the smell lingers into Resident #33's room. She stated she had not complained about the smell but reported Resident #33 has complained to corporate about the smell. In an interview on 10/22/25 at 9:25am with Resident #37, the resident resides on the 300 hall. He stated he did not like the way his room or the facility smelled and stated who would like the smell. He stated the smell was worse in the hallway. He stated the smell was coming from one of the rooms on the 300 hall and stated the residents in that room does not allow staff to wash their a**, change their diapers, or tend to their wounds. He stated it smells sh** and rotten flesh. He stated he felt helpless because this was his home and he could not do anything about the smell. He stated if this was his own home it would not have this smell. He stated the staff had not asked him how he felt about the smell and no one had asked him if he wanted to change halls. In an interview on 10/22/25 at 9:35am with CNA-AJ, she reported there is a concern with odor on Hall 300 because some of the residents refuse care. She stated she could not think of words to describe the smell but it was bad. She stated she did not know what the facility was doing about the smell but reported it has always smelled that way since she started working at the facility, she stated she started working at the facility in November 2024. She stated that this was the residents home and they have a right to an odor free home. In an interview on 10/22/25 at 9:40am with Housekeeper-AL, she stated she had been employed at the facility for 2 months. She stated there was an issue with odor on the 300 hall. She stated the odor was indescribable and stated it had always smelled bad ever since she started working there and the smell had gotten worse. She stated she was told the source of the smell was from residents refusals of baths and wound care. She stated she cleans each room one times a day and the rooms of concern are cleaned two times a day. She stated she spray odor neutralizer upon entering and exiting each room and she also sprays the hallways as she exits each room. She stated that she goes through 2-3 bottles of odor neutralizer a week for one hall to try to help the smell but it does not work. She stated the additional cleaning was not helping the odor. She stated that it was the residents home and they have the right to have an odor free home. In an interview on 10/22/25 at 10:20am with Resident #33, he did not have any concerns for the smell in his room or in the hallway. In an interview on 10/22/25 at 11:20am with Administrator-A, she stated she does daily observation rounds of the entire facility. She stated she had not observed a pronounced odor to any part of the facility. She stated she had only observed there to be a smell associated with incontinent care and that was normal from residents getting brief changes at every facility. She stated there had not been complaints or grievances about odors in the building. She stated housekeeping does have some targeted rooms that received additional cleaning at the back of 300 hall and 400 hall. Administrator-A sent an email to surveyors with the list of targeted rooms that get additional cleanings but she reported she did not recall the reason as to why the rooms get additional cleanings. On 10/22/2025 at 1:06pm, a policy was requested for physical environment and it was not provided (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 63 of 66 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 10/27/2025 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 0921 prior to exit. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 64 of 66 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 10/27/2025 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 4 hallways, (Hall 300) and Resident #21's and Resident #31's room. The facility had live flies in areas of the facility including Halls 300, and Resident #21 and Resident #31's room. This failure could place residents at risk for decreased health, safety and quality of life. Findings included: Record review of Resident #21's Electronic Health Record revealed a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses including Pressure Ulcer of Sacral Region, Stage 4 (a deep wound with full-thickness tissue loss that has damaged muscle, tendon, or bone), Pressure Ulcer of Left Lower back, stage 3 (a full-thickness skin and tissue loss injury that has damaged the skin and fat layer, creating deep crater, but has not yet exposed muscle, bone, or tendon), Pressure Ulcer of Right hip, Stage 4 (a severe, full thickness wound that extends through the skin and fat to expose underlying muscle, tendon, or bone), Pressure Ulcer of Left Ankle, Unstageable, Pressure Ulcer of other site (full thickness tissue loss, but the depth cannot be determined because it is covered by eschar (dead tissue) or other slough (dead or dying tissue)), Major Depressive Disorder(a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), Generalized Anxiety disorder (a common mental health condition characterized by excessive, persistent, and uncontrollable worry and anxiety about various aspects of life), and Benign Prostatic Hyperplasia without Lower Urinary Tract symptoms ( a condition where the prostate gland enlarges but does not cause any noticeable urinary problems) and Colostomy Status (refers to the condition of having a surgical procedure called colostomy). Record review of the Resident #21's Quarterly MDS revealed a BIMS score of 14, which indicates cognitively intact. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating and oral hygiene. Resident #21 required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts or holds trunk or limbs but provides less than half the effort) for rolling left to right. Resident #21 required substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with shower/bathe self, upper body dressing, personal hygiene, sit to lying, and lying to sitting on side of bed. Record review of Resident #31's Electronic Health Record revealed a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses including Unspecified Dementia (a diagnosis used when a person exhibits symptoms of dementia by the specific underlying cause cannot be determined), Local Infection of the skin and subcutaneous tissue (an infection that affects the layers of skin and underlying fat), Chronic Venous Hypertension with Ulcer of Right Lower Extremity (there is high blood pressure in the veins of the right leg, which has caused an open sore (ulcer) to form due to poor circulation), Chronic Venous Hypertension with Ulcer of Left Lower Extremity (high blood pressure in the veins of the left leg has caused a non-healing sore (ulcer) to form due to poor blood flow), Schizophrenia, Unspecified (a diagnostic category used in psychiatry when a person exhibits symptoms of schizophrenia but does not meet the full criteria for any specific subtypes of schizophrenia), Pressure Ulcer of Sacral Region, Stage 4 (a severe form of pressure injury where there is full-thickness tissue loss with exposed bone, muscle, or tendons), Pressure Ulcer of Right Heel, Stage 4 (the most severe type of pressure injury, involving deep-tissue damage with full-thickness tissue loss that exposes muscle, tendon, or bone), and Cognitive Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 65 of 66 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 10/27/2025 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Communication Deficit (a communication challenge caused by problems with thinking abilities like attention, memory, and executive function, rather than a language or speech problem). Record review of the Resident #31's Quarterly MDS revealed a BIMS score of 11, which indicates moderately impaired cognition. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or ouching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating and oral hygiene. Resident #31 required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts or holds trunk or limbs but provides less than half the effort) for rolling left to right. Resident #31 required substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, and personal hygiene. In an observation on 10/20/25 at 02:05pm, approximately 16 flies were observed on Hall 300. In an interview/observation on 10/20/25 at 2:14pm with Resident #21- The resident was observed in his room lying in bed and there was a live fly on his blanket. There were 4 live flies observed on his wall. Resident #21 stated he sees flies in his room often, he stated he thinks the flies come from the towels the staff use to wipe the tables in the rooms. In an observation on 10/20/25 at 2:17pm with Resident #31, he was observed in his room lying in bed and there were 2 live flies on his blanket and approximately 2 flies observed flying around the room. In an interview on 10/20/25 at 2:54pm with the Regional Compliance Nurse, he acknowledged that there were flies in the residents' room. He stated pest control has been called out to the facility to make additional visits. He stated they were initially coming out to the facility monthly but they now come out more often. Record review of the facility's service inspection report revealed the facility was treated 10/07/25. The facility was treated for House/Fruit/Blow/Flesh/Stable Flies, German Roaches and Fire Ants. The areas treated were the Dining-> Device Fly Light, Common Area>Device Fly Light1, Common Area->Device Fly Light2, Common Area->Device Fly Light3, Interior, Common area and Exterior; the light traps were also inspected. Prior to 10/07/25, the facility was treated on 09/30/25. The facility was treated for American Roach and Bed Bugs. The area treated was the interior. The facility was not treated for flies during this visit. Record review of the facility's pest control policy dated 2012 reflected, The facility will maintain an effective pest control program in order to provide an insect and vermin free food service department. 1. Arrangements are made with a reputable company for regular spraying for insects which includes rodent control when required. Event ID: Facility ID: 455682 If continuation sheet Page 66 of 66