Inspection·August 11, 2022

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few refused the services most of the time. it was entered incorrectly. She said to help prevent this from occurring again they would do more audits. Interview on 08/11/22 at 1:10 PM the Administrator stated the MDS staff was responsible for completing the PASRR. Major Depressive Disorders and Schizophrenia were qualifying diagnosis for a positive PASRR. The risk of an incorrectly coded PASRR would result in the resident not getting the needed services. During an interview on 08/11/2022 at 1:28 p.m., the Interim Agency DON stated she had been working at the facility for 2 days on an 8-week contract. She said the DONs were responsible for conducting PASSRs. The RN ACs also were responsible for the PASSRs. Further interview with the DON said the risk of not having a correctly coded PASRR services on the MDS could affect the services the residents are provided. In an interview with RN AC on 8/11/22 at 3:15 pm, she said that the facility did not have a policy and procedure on MDS completion or process but that they followed the CMS RAI 3.0 Manual. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 2 of 27 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 455703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Healthcare and Rehabilitation Center of Ka 1525 Tull Dr Katy, TX 77449 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 2 of 18 residents (Residents #67 and Resident #69) reviewed for PASRR Level I screenings. Residents Affected - Few -The facility failed to ensure Resident #67's PASRR Level 1 indicated she had a diagnosis of mental illness, although diagnosis was present upon admission. -The facility did not have a PASRR Level 2 Evaluation for Resident #69 with diagnosis of Bi-Polar disorder. This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: Resident #67 Record review of Resident #67's face sheet revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: schizophrenia, (a mental disorder characterized by disorganized speech or behavior and decreased participation in daily activities), type 2 diabetes mellitus ( high glucose level in the blood), major depressant disorder single episode ( mood disorder), quadriplegia (paralysis of all four limbs), neuromuscular dysfunction of the bladder (lack of bladder control due to brain, spinal cord or nerve problems). Record review of Resident #67's care plans dated 1/19/2022 revealed a care plan: Focus: Resident #67 was at risk for altered mood problems related to a history of depression and anxiety; Goal: Resident #67 will have no mood issues through the review date; Interventions: Behavior health consults as needed. Record review of Resident #67's Psychologist Services Supportive Care Progress Note dated 06/01/2022 read in part diagnosis schizoaffective disorder depressive type. Psychological symptoms revealed depression, delusion, and adjustment. Record review of Resident #67's PASRR level 1 screening dated 06/14/2021 Section C revealed her PASRR screening was documented no for the question was their evidence or indicator the individual had mental illness. Record review of Resident #67's admission MDS dated [DATE] revealed she had a BIMS score of 09 out 15 indicating her cognition was moderately impaired. Her Active diagnoses included Depression other than bipolar and Schizophrenia. Medication received during the last 7 days were Antipsychotic and Antidepressant. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 3 of 27 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 455703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Healthcare and Rehabilitation Center of Ka 1525 Tull Dr Katy, TX 77449 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of facility form titled Active Residents with PASRR Positive PASRR EVAUATION undated did not reveal Resident #67. Observation on 08/9/2022 at 9:10AM revealed Resident #67 was in bed, the head of her bed was elevated. The resident had tube feeding and water flush bags on the pump next to the bed turned off. Resident #67 was unable to be interviewed. In an interview on 08/11/2022 at 10:54 AM, RNAC stated she worked in the MDS department, and it was the MDS staff who was responsible for completing the PASRR and ensuring it was correct. RNAC stated if the PASRR Level one was not coded correctly a 1012 form ( a form to assist nursing facilities with a negative PASRR level 1 needed further evaluation) would be completed and resubmitted. RNAC stated schizophrenia and major depressive disorder were diagnosis that would qualify for a positive level 1. She stated Resident #67 had a diagnosis of Major Depressive Disorder and Schizophrenia, she should have a positive level 1. RNAC stated the risk of not having a correctly coded level 1 PASRR was the resident could miss out on services. During the interview RNAC stated Resident #67's PASRR was completed on admission than redone during the facility Change of Ownership survey and when it was reentered it was entered incorrectly. She stated it was corrected yesterday, a 1012 form was completed and submitted. RNAC stated the representative from The local center for mental health was here yesterday to see Resident #67. To help prevent this from occurring again we would do more audits. Resident #69 Record review of the Face Sheet printed 08/11/22 indicated Resident #69 was a [AGE] year-old female initially admitted on [DATE] with diagnoses including other Bi-Polar disorder. Record review of the PASRR Level 1 screening dated 02/16/17 for Resident #69 indicated the resident was marked as having a mental illness. There was no indication Resident #69 had a PASRR Level 2 Evaluation done. Record review of an admission MDS dated [DATE] for Resident #69 indicated the PASRR section was marked no for serious mental illness. The MDS indicated a diagnosis of Bi-Polar. Record review of the current MDS dated [DATE] for Resident #69 indicated the PASRR section was marked no for serious mental illness. The MDS indicated a diagnosis of Bi-Polar. During an interview and record review on 08/09/2022 at 3:12 p.m., MDS Coordinator stated the PASSR 2 on Resident #69 was not done. A new one has been resubmitted (08/09/2022) and that it was an oversight. On the screening it showed 0,0,0. The MDS Coordinator stated she completed a 1012 Form (08/09/2022). During an interview on 08/11/2022 at 1:28 p.m., the Interim Agency DON stated she's been there 2 days on an 8-week contract. She said the DONs were responsible for conducting PASSRs. The RN ACs also were responsible for the PASSRs. If a correction was needed, then it needs to be done. She said triggers for a PASSR level 2 were things like, Schizophrenia, Bi-Polar, Depressive disorder. The risk of not having a correctly coded PASSR was the resident not getting the services they needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 4 of 27 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 455703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Healthcare and Rehabilitation Center of Ka 1525 Tull Dr Katy, TX 77449 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 0645 She said she cannot accurately state how an incorrect PASSR level 1 could be prevented because she does not know the details. Level of Harm - Minimal harm or potential for actual harm During an interview on 08/11/2022 at 12:28 p.m., RN AC stated she's worked there for 19 years. Residents Affected - Few If PASSAR level 1 not completed correctly then the 1012 form is completed. Diagnoses such as Schizophrenia, Bi-polar, schizo-affective would trigger a PASSR level 2. RN AC stated that last year when the company turned over, everyone's PASSR was entered incorrectly. LIDDA- the [NAME] Center was there yesterday. RN AC stated, The risk of having an incorrectly level 1 PASSR was that the residents could miss out on services from the [NAME] Center. To prevent incorrect entries the facility could perform periodic audits. RN AC stated she does not know if the facility uses a policy or the State TAC to complete PASSRs. RN AC stated, That if residents were positive on the PASSR screening then a PASRR level 2 needs to be done. In an interview on 08/11/2022 at 12:35 PM Interim DON stated the MDS nurses were responsible for completing the PASRR. If the PASRR was not correct, then they should make corrections. She continued and stated Schizophrenia and Major Depressive Disorder were diagnosis that qualify for a positive level 1 PASRR. The risk of not having a correctly coded level I PASRR was the residents would not be followed by the needed services and would not get the services they need. Interview on 08/11/22 at 1:10 PM the Administrator stated, The MDS staff was responsible for completing the PASRR. Major Depressive Disorders and Schizophrenia were qualifying diagnosis for a positive PASRR. The risk of an incorrectly coded PASRR would result in the resident not getting the needed services. The Administrator continued and stated Resident #67 had her PASRR corrected yesterday. The [NAME] Center representative was here to see the resident yesterday and the representative reported the resident's status would not change. To prevent this from occurring again we would add the PASRR to the admission check list. Interview on 08/11/22 at 3:04PM with the Director of Clinical Operation she stated, The facility does not have a policy for PASRR, they follow the Texas Administrative Code. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 5 of 27 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 455703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Healthcare and Rehabilitation Center of Ka 1525 Tull Dr Katy, TX 77449 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 residents (Resident #67) reviewed for gastrostomy tube management. - RN D failed to elevate Resident #67's head to a 45 degree angle prior to administering medication via gastrostomy tube (G-tube). - RN D failed to appropriately check the placement of Resident #67's G-tube, a tube inserted through the belly that brings nutrition directly to the stomach, by pushing by force 45 ml of water instead of air into the resident's G-tube. These failures could place residents who receive medication at risk for adverse reactions, inadequate therapy, and a decreased quality of life. Findings included: Record review of Resident #67's Face Sheet dated 08/11/22 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: quadriplegia, hypotension, gastrostomy status, type 2 diabetes, schizophrenia, A fib and colostomy status. Record review of Resident #67's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 8 out of 15, extensive assistance with most ADLs, wheelchair use, an indwelling catheter and an ostomy. Record review of Resident #67's Care Plan revised 08/07/22 revealed, focus- receiving nutrition via PEG in addition to diet r/t poor intake; intervention- check tube placement every feeding, elevate head of bead 30-45 degrees during and for 30-60 minutes after feeding, water flushes as ordered. Focus- colostomy and need staff to empty and change as needed but sometimes I refuse, intervention- change or empty colostomy bag as ordered. Record review of Resident # 67's August Order Summary Report dated 08/11/22 revealed, may crush medications and administer per G-tube; Baclofen 10 mg- 1 tablet via G-tube three times a day for muscle spasm; Bupropion 10 mg- 1 tablet via G-tube one time a day for depression; Gabapentin 250 mg/5 ml- 15 ml (600 mg) via G-tube four times a day; Midodrine 10 mg- 1 tablet via G-tube three times a day for hypotension; Multivitamin Vitamin- 1 tablet via G-tube one time a day for vitamin deficiency; Pantoprazole 40 mg- 1 packet per G-tune one time a day; Risperidone 2 mg- 1 tablet via G-tube for schizophrenia; Vitamin D- 2000 units per G-tube one time daily for vitamin deficiency. An observation on 08/11/22 at 07:40 AM revealed, RN D preparing medication for administration via G-tube for Resident #67. She prepared each of the medications (Baclofen, Bupropion, Midodrine, Multivitamin, Pantoprazole powder packet, Risperidone, Vitamin D3 and Gabapentin liquid) by placing each tablet in individual medication cups and pouring liquid medication into individual medication cups. At 08:04 RN D crushed each medication individually, returned them to their medication cups and entered into the resident's room at 08:11 AM. She retrieved warm temperature water and suspended the crushed medication in 5-10 ml of water. Resident #67 was observed lying in bed with bed slightly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 6 of 27 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 455703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Healthcare and Rehabilitation Center of Ka 1525 Tull Dr Katy, TX 77449 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few elevated, the angle of elevation was less than 45 degree and RN D did not raise the resident's head at a 30 to 45 degree angle. RN D prepared the resident for G-tube medication administration by disconnecting the continuous feed. As RN D disconnected the continuous feed she said the resident needed incontinent care and the surveyor observed visible soil leaking from Resident 21's colostomy site as well as a paper towel with visible soil was observed below the G-tube tubing. At 8:15 AM RN D drew up 45 ml of warm water in a syringe, pushed down the paper towel and the resident's brief, connected the syringe containing water to the resident's G-tube port and pushed the water through the G-tube while attempting to listen for bowel sounds. After attempting to listen to Resident #67's bowel sounds she checked for residual and returned the contents to the residents tube. At 08:17 PM, RN D attached the syringe and performed a 30 ml water flush via gravity, and at 08:20 AM began administrating the suspended medication with a 10 ml flush in between each medication. As RN D attempted to administer the resident's Protonix she mistakenly uncapped one of the ports not in use resulting in the Protonix that was poured into the syringe leaked out of the uncapped port and onto the resident. For all further administrations and flushes, RN D used the toggle to close the additional ports when she poured the medication into the syringe. Once medication administration was completed RN D reconnected Resident #67's continuous feed, cleaned her syringe, discarded the waste and left the resident room. She did not elevate the residents head to a 45 degree angle after medication administration was completed. In an interview on 08/11/22 at 9:15 RN D said, when she checked for Resident #67's G-tube placement she mistakenly injected water instead of air while checking for bowel sounds. When asked RN D did not know why checking for placement had to be performed with air and not water and she said that there was no difference with pushing fluid through the syringe or administering fluid via gravity. She said that as she administered Resident #67's Protonix she observed it spill out of the second port and that was why she began to toggle the port from open to close between medications. RN D said that the patient received some of the medication so she could not readminister it. In an interview at 08/11/22 at 12:40 PM, the DON said, that prior to administration of medication via G-tube nursing staff were expected to check for placement by auscultation (listening for sounds) by injecting a small amount of air into the port while listening to bowel sounds. She send auscultation should be performed using air because you cannot hear bowel sounds with water. The DON said that fluid should be administered via gravity and force should not be used because it could damage the tubing. She said if medication leaks during G-tube administration and nursing staff were not sure of the amount of medication the resident received their ordered dose their provider should be notified and orders should be followed . Record review of the facility policy titled Medication Administration through Enteral Tube revised 12/19/21 revealed, 15- facility should check the placement of the naso-gastric or gastrostomy tube in accordance with facility policy. Verify that the tube is functioning before administering medications. 16- Facility should insert medication syringe in appropriate port. Remix medication and pour into medication syringe so entire dose is administered. Do not push medications through the tube. Record review of RN D's Medication Administration Competency Audit-Enteral Tube revealed, Action- 10. Places resident in proper position. If resident is in bed, elevates head of bead to 45 degrees. 12. Verifies tube placement, a- unclamps tube and either inserts a small amount of air into the tube with syringe and listen to stomach with stethoscope for gurgling sounds or aspirates stomach contents with syringe . 16Allows flushes and meds to flow down tube via gravity. Gives gentle boosts with plunger if the meds will not flow by gravity. Does not push meds through tube 21- leaves head of bed elevated as order. RN D met criteria for the competencies assessed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 7 of 27 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 455703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Healthcare and Rehabilitation Center of Ka 1525 Tull Dr Katy, TX 77449 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of 17 of 24 residents (Resident #3,# 7, #9, #10, #16, #18, #21, #39, #42, #51, #59, #63, #65, #74, #75, #336) and establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 1 of 4 medication carts (West Back CMA Medication Cart) reviewed for pharmacy services in that: - Resident #21's ordered Insulin was not available for administration, resulting in the resident receiving insulin over 5 hours after his meal was completed and a blood sugar of 460. - RN D failed to administer the Resident #21's medication per the providers order by assessing his BS and administering his pre-prandial (pre-meal) Insulin after meals. - The facility failed to ensure that controlled substances contained in the [NAME] Back MA Medication Cart were accurately reconciled The facility failed to provide sufficient staffing to ensure that resident's received medications timely by administering Resident #3, #7, #9, #10, #16, #18, #39, #42, #51, #59, #63, #65, #74, #75, and Resident #336's medications late. These failures could place residents at risk of not receiving medications as ordered by their physician, inadequate disease management, medication errors, hospitalization and drug diversion. Findings Included: West Back MA Medication Cart In an observation and interview on 08/11/22 at 9:52 AM, inventory of the Nurse Medication Cart with MA E revealed: - Resident #34's medication Card for FYCOMPA, a schedule III controlled substance used for the treatment of epilepsy, with a physical count of 5 pills. -Individual Control Drug Record for Resident #34's FYCOMPA with a recorded count of 6 pills and the last dose administered on 08/09/22 at 9 PM. Once the missing pill was identified, MA E checked Resident #34's MAR and confirmed that Resident #34 was administered a dose of FYCOMPA on 08/10/22 at 9 PM by MA F but no corresponding documentation occurred on the 10th. MA E said even though the medication administration was not documented on 08/10/22 the medication was accounted for after reviewing the residents MAR so she would inform her DON of the discrepancy in the residents control drug record. She said nursing staff were expected to reconcile their control substances at each change of shift but she could not explain the discrepancy. In an interview on 08/11/22 at 12:40 PM, the DON said, Resident # 21's Humalog orders as written had a sliding scale based on his blood sugar prior to meals and the dose to be administered was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 8 of 27 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 455703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Healthcare and Rehabilitation Center of Ka 1525 Tull Dr Katy, TX 77449 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many calculated to adjust his blood sugar in anticipation of a meal. She said that the resident's order and care plan did not specify that his blood sugar assessment and insulin administration were ordered after meals. The DON said by checking his blood sugar after his meals staff were not getting a true reflection of the resident's blood sugar and the dose administered would not lower his blood sugar as expected by the providers order. She said Resident # 21's Humalog insulin was ordered by RN D from the pharmacy, and she did not know how it ended up being unavailable for administration. The DON said failure to have insulin available as ordered places residents at risk for adverse reactions and hyperglycemia that can lead to hospitalization. She said investigation revealed that the unaccounted FYCOMPA pill was because MA F failed to document the dose administered on 08/10/22 at 9 PM on the controlled drug log even though she signed the electronic record and MA F returned to the facility to document the missing dose. She said that at the end of each shift nursing staff were expected to reconcile their controlled substances at a change of shift and failure to properly document controlled substances could result in drug diversion placing residents at risk of inadequate pain control. In an interview on 08/11/22 at 3:40 PM, the NP said Resident #21's insulin administration was complicated by the resident's refusal of care and mood swings so his diabetes was managed by the endocrinologist. She said the insulin orders as written were for before meals but due to the resident's difficulty they try to work with him and go with his mood swing. The NP said that she was informed in the morning (08/11/22) that the facility did not have the resident's Humalog available and at around 1:00 PM that the residents BS was 460 mg/dl. She said once notified of the BS reading of 460 mg/dl she ordered that he receive a onetime dose of 14 units and her goal was to keep his BS above 300 because she didn't want him to have hypoglycemia. In an interview on 08/11/22 at 4:00 PM, the Director of Clinical Operations said, RN D immediately ordered Resident #21's insulin from the pharmacy, once it arrived he was administered the medication and his NP was notified of the unavailable medication. She said that Resident #21's last BS reading was 460 at 3:57 so he was administered 12 units of Humalog as ordered by the provider and the NP was notified. Record review of the Package Insert for Humalog revealed, Dosage and Administration- Subcutaneous injection: Administer HUMALOG U-100 or U-200 by subcutaneous injection into the abdominal wall, upper arm or buttocks within 15 minutes before a meal or immediately after a meal. Record review of the facility policy titled Controlled Substances Accountability Guideline with no revision date revealed, Chapter 4 Change of Shift Reconciliation: two licensed nurses (or one licensed nurse and one certified medication technician or two certified medication technicians- where allowed by law) typically the nurse/medication tech arriving on duty and the nurse/medication tech departing from duty; are required to conduct the reconciliation (i.e. Change of Shift Count) of patient specific controlled substances and sign a signature log attesting to the completion and accuracy of the count. Verification of controlled substance count must occur whenever medication keys change hands . The reconciliation process shall include A count comparing the number of medication packages (i.e. cards, boxes, bottles, vials, etc.) versus the number of controlled substances count sheets; the number of medications should be equal; for each package, there should be a corresponding count sheet . Both team members authorized to perform the reconciliation shall visualize the medications being counted and the count sheet . If inaccuracies are noted, the DON or designee should be notified immediately. Chapter 5 Controlled Substances Count SheetsRecords of usage shall be maintained in sufficient detail to allow reconciliation. This is typically accomplished utilizing controlled substance count sheets/ perpetual inventory sheets (I.e. proof of use sheets.). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 9 of 27 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 455703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Healthcare and Rehabilitation Center of Ka 1525 Tull Dr Katy, TX 77449 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Resident #3 Level of Harm - Minimal harm or potential for actual harm An observation at 08/11/22 at 10:50 with MA A revealed, Resident #3's MAR as red (late) indicating the resident had not yet received his: Amiodarone 200 mg (a medication for irregular heartbeat), Apixaban (blood thinner), Finasteride (treatment of an enlarged prostate), Baclofen (muscle relaxer), Pantoprazole (acid reducer), diltiazem (blood pressure medication) and Tylenol (pain medication). All the medications listed were scheduled for administration at 8 AM. Residents Affected - Many Record review of Resident #3's face sheet dated 08/11/22 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of type 2 diabetes without complication, hypertension, GERD, colostomy status, protein-calorie malnutrition. Record review of Resident #3's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 8 out of 15, extensive assistance with most ADLs, use of a wheelchair, frequently incontinent of bladder and an ostomy. Record review of Resident #3's care plan with last revision on 03/08/22 revealed, focus- DM, goal- no complications to r/t diabetes, interventions- diabetes medication as ordered by doctor. Focus- currently on antidepressant, interventions- administer antidepressant medications as ordered by physician. Record review of Resident #3's Order Summary Report dated 08/11/22 revealed, Amiodarone 200 mg Tablet- 1 tablet one time a day for Afib (irregular heartbeat); Apixaban 5 mg Tablet- 5 mg two times a day for Afib; Baclofen 10 mg Tablet- 1 tablet one time a day related to muscle wasting and atrophy (breakdown); Diltiazem 360mg ER Capsule- 1 tablet once a day for HTN; Finasteride 5 mg Tablet- 1 tablet once a day related to BPH; Pantoprazole 40 mg- 1 tablet one time a day for ulcer r/t GERD; and Tylenol Extra Strength 500 mg- 2 tablets two times a day for pain management. Record review of Resident #3's August MAR revealed, the medications Amiodarone 200 mg, Apixaban 5 mg, Finasteride 5 mg, Baclofen 10 mg, Pantoprazole 40 mg, Diltiazem 360 mg and Tylenol 500 mg were scheduled for administration at 8 AM. Resident #7 An observation at 08/11/22 at 11:00 with MA A revealed, Resident #7's MAR as red indicating the resident had not yet received his: Aspirin, Sennoside (stool softener), Tramadol (pain medication) and Tylenol which were all scheduled for 8 AM. The resident had the Ocular Vitamins which were scheduled for 9 AM. Record review of Resident #7's face sheet dated 08/11/22 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: dementia, hypertension, pain, muscle weakness, constipation, dry eye syndrome and cognitive communication deficit. Record review of Resident #7's MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS Score of 3 out of 15, supervision for all ADLs and occasionally incontinent of both bladder and bowel. Record review of Resident #7's care plan revised 07/15/22 revealed, focus- increased risk for pain r/t history of prostate cancer, hip and leg pain; intervention- medicate for pain as directed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 10 of 27 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 455703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Healthcare and Rehabilitation Center of Ka 1525 Tull Dr Katy, TX 77449 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Focus- uses anti-anxiety medications r/t anxiety disorder, inability to sleep through the night at times; interventions- administer anti-anxiety medications as ordered by physicians. Record review of Resident #7's Order Summary Report dated 08/11/22 revealed, Ocular Vitamins Tablet- 2 tablets by mouth two times a day for macular degeneration; Aspirin 81 mg- 1 tablet by mouth one time a day; Sennosides 2 tablets by mouth two times a day, Tramadol 50 mg- 1 tablet by mouth three times a day; Tylenol 325 mg- 2 Tablet by mouth 2 times a day. Record review of Resident #7's MAR August revealed, Aspirin 81 mg, Sennosides, Tylenol 325 mg, Tramadol 50 mg were all scheduled for administration at 8 AM. Ocular Vitamins were scheduled for administration at 9 AM. Resident #9 An observation at 08/11/22 at 11:00 with MA A revealed, Resident #9's MAR as red indicating the resident had not yet received his: Amlodipine (blood pressure medication), Aspirin, Clopidogrel (heart attack/stroke prevention), Folic Acid (dietary supplement), Levocetirizine (allergy medication), Lisinopril (blood pressure medication), Pantoprazole, Tamsulosin (treatment of BPH), Thiamine (dietary supplement), Zinc (dietary supplement), Duloxetine (mental health), Hydralazine (blood pressure medication), Metoprolol (blood pressure medication) and Med Plus (nutritional supplement). Record review of Resident #9's face sheet dated 08/11/22 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: dementia, muscle wasting and atrophy, high cholesterol, high blood pressure, coronary artery disease, COPD, BPH (enlarged prostate). Record review of Resident #9's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 10 out of 15, worsening of behavior, supervision on most ADLs, frequently incontinent of bladder and always incontinent of bowel. Record review of Resident #9's care plan revised on 05/24/22 revealed, focus- communication problem r/t dementia; Focus- use of antidepressant medication r/t depression, interventions- administer antidepressant medications as ordered by physician. Record review of Resident #9's Order Summary Report dated 08/11/22 revealed Amlodipine 10 mg- 1 tablet by mouth one time a day for hypertension; Aspirin 81 mg- 1 tablet by day r/t hypertension; Clopidogrel 75 mg- 1 tab by mouth one time a day for coronary artery disease; Duloxetine 60 mg- 1 capsule by mouth two times a day; Folic Acid- 1 tablet one time a day; Hydralazine 50 mg- 1 tablet two times a day for hypertension; Levocetirizine 2.5 mg- 1 Tablet by mouth one time a day for fever/hives; Lisinopril 40 mg- 1 tablet by mouth in the morning for hypertension; Metoprolol 25 mg- 1 tablet by mouth two times a day for hypertension; Pantoprazole 40 mg- 1 tablet by mouth one time a day for heartburn; Tamsulosin 0.4 mg- 1 capsule by mouth in the morning for BPH, Thiamine 250 mg- 1 tablet by mouth one time a day for supplement and Zinc 50 mg- 1 tablet one time a day for immune support. Record review of Resident #9's August MAR revealed, Amlodipine 10mg, Aspirin 81 mg, Clopidogrel 75 mg, Folic Acid 1 mg, Levocetirizine 2.5 mg, Pantoprazole 40 mg, Thiamine 250 mg, Zinc 50mg, Duloxetine 60 mg, Hydralazine 50 mg, Metoprolol 25 mg, Med Plus were scheduled for administration at 8 AM. Lisinopril 40 mg, Tamsulosin 0.4 mg, were both scheduled for administration at 9 AM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 11 of 27 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 455703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Healthcare and Rehabilitation Center of Ka 1525 Tull Dr Katy, TX 77449 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Resident #10 Level of Harm - Minimal harm or potential for actual harm An observation at 08/11/22 at 11:00 with MA A revealed, Resident #10's MAR as red indicating the resident had not yet received her: Amlodipine, Lisinopril, Med Plus, Risperidone, Metoprolol, MiraLAX, D-Mannose (dietary supplement) , Senna, Baclofen and Tylenol. Residents Affected - Many Record review of Resident #10's face sheet dated 08/11/22 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: multiple sclerosis, schizophrenia, paraplegia, heart failure, cramp and spasm, type 2 diabetes, hypertension and low potassium. Record review of Resident #10's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 8 out of 15, extensive assistance with most ADLs, use of a wheelchair, always incontinent of bladder and bowel. Record review of Resident #10's care plan revised 06/10/22 revealed, focus- risk of pain or discomfort related to MS, interventions- administer pain medication as directed. Focus- use of anti-psychotic medication r/t do dx of schizophrenia, intervention- administer medication as directed. Focus- risk of elevated blood pressure r/t to HTN, intervention- give anti-hypertensive medications as ordered. Record review of Resident #10's Order Summary Report dated 08/11/22 revealed, Med Plus- 120 ml one time a day; Amlodipine 2.5 mg- 1 tablet by mouth one time a day for hypertension; Baclofen 10 mg- 1 tablet by mouth three times a day r/t MS; D-Mannose 500 mg- 1 capsule by mouth two times a day for cystitis prevention; Lisinopril 20 mg- 1 tablet by mouth one time a day for hypertension; Metoprolol 25 mg- 1 tablet by mouth two times a day for hypertension; MiraLAX- 17 gm by mouth two times a day for constipation; Risperidone 0.5 mg- 1 tablet by mouth one time a day for schizophrenia; Senna 8.6 mg- 1 tablet by mouth tw0 times a day for constipation; Tylenol 325 mg- 2 tablet by mouth every 8 hours for pain related to cramps and spasm. Record review of Resident #9's August MAR revealed, Amlodipine 2.5 mg, Lisinopril 10 mg, Risperidone 0.5 mg, D-Mannose 500 mg, Metoprolol 25 mg, MiraLAX 17 gm, Senna 8.6 mg, Baclofen 10 mg, Tylenol 325 mg and Med Plus were scheduled for administration at 8 AM. Resident #16 An observation at 08/11/22 at 11:00 with MA A revealed, Resident #16's MAR as red indicating the resident had not yet received his: Amlodipine, Acetaminophen, Namenda (memory), Pantoprazole and Ropinirole. Record review of Resident #16 face sheet dated 08/11/22 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: early onset Alzheimer's, protein-calorie malnutrition, Afib, muscle wasting, cognitive deficit, pain in left hip, presence of a cardiac pacemaker, schizoaffective disorder, panic disorder, anxiety, Parkinson's and GERD. Record review of Resident #16's MDS dated [DATE] revealed, severely impaired cognition as indicated by a BUMS score of 5 out of 15, limited assistance with most ADLs, wheelchair use and occasionally incontinent of both bladder and bowel. Record review of Resident #16's care plan revised 7/21/22 revealed, focus- risk for pain r/t (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 12 of 27 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 455703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Healthcare and Rehabilitation Center of Ka 1525 Tull Dr Katy, TX 77449 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm history of chronic back pain, intervention- medicate for pain as directed. Focus- gastrointestinal distress due to peptic ulcer disease, intervention- administer medications as ordered. Focus- altered skin integrity non pressure r/t rash, intervention- medication as ordered. Focus- anticoagulant therapy r/t Afib, interventionadminister anti-coagulant as directed. Focus- risk of altered mood problem r/t Residents Affected - Many schizophrenia, intervention- administer medications as ordered. Record review of Resident #16's Order Summary Report dated 08/11/22 revealed, Med Plus- 90 ml twice daily; Acetaminophen 325 mg- 2 tablets by mouth two times daily; Amlodipine 10 mg- 1 tablet by mouth one time a day for hypertension; Namenda 10 mg- 1 tablet by mouth two times a day for dementia; Pantoprazole 40 mg- 1 tablet by mouth two times a day for acid reflux r/t GERD and Ropinirole 1 mg- 1 tablet by mouth three times a day for Parkinson's disease. Record review of Resident #16's August MAR revealed, Amlodipine 10 mg, Acetaminophen 325 mg, Med Plus, Namenda 10 mg, Pantoprazole 40 mg and Ropinirole 1 mg were scheduled for administration at 8 AM. Resident #18 An observation at 08/11/22 at 11:00 with MA A revealed, Resident #18's MAR as red indicating the resident had not yet received his: Clopidogrel, Aspirin and MiraLAX. Record review of Resident #18's face sheet dated 08/11/22 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: dementia with behavioral disturbances, cognitive communication deficit, cerebral infarction and constipation. Record review of Resident #18's MDS dated [DATE] revealed , moderately impaired cognition as indicated by a BIMS score of 8 out of 15, extensive assistance with most ADLs, use of a wheelchair, and always incontinent of both bladder and bowel. Record review of Resident #18's Care Plan revised 03/08/22 revealed, focus- impaired cardiovascular status r/t to hypertension and hyperlipidemia, intervention- medications as ordered by physician. Focus- risk for altered mood r/t feelings of depression and anxiety, intervention- administer medications as ordered Record review of Resident #18's Order Summary Reported dated 08/11/22 revealed, Clopidogrel 75 mg- 1 tablet by mouth one time a day for anticoagulation; Aspirin 81 mg- 1 Tablet by mouth one time a day for anticoagulation, MiraLAX- 17 mg by mouth one time a day for constipation. Record review of Resident #18's August MAR revealed, Clopidogrel 75 mg and Aspirin 81 were scheduled for administration at 8 AM while MiraLAX was scheduled for administration at 9 am. Resident #21 An observation and interview on 08/11/22 at 9:00 AM revealed, RN D preparing for insulin administration to Resident #21. RN D stated that the resident preferred to receive insulin after his meals. She prepped her blood sugar monitoring equipment, entered the resident's room and tested his blood sugar which resulted in a reading of 316 mg/dl. RN D returned to her nursing cart to prepare Resident #18's fast acting insulin but after checking her cart and the medication room she confirmed that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 13 of 27 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 455703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Healthcare and Rehabilitation Center of Ka 1525 Tull Dr Katy, TX 77449 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm there was no fast-acting insulin on hand for Resident #21 . She then administered his long-acting insulin (Levemir 20 units) and contacted the pharmacy for a stat supply of the resident's Humalog insulin. RN D said that Resident #21 was supposed to receive 8 units of Humalog (fast acting insulin) because of his sliding scale order, and this was the first time the facility has run out of Resident #21's insulin. She said she did not know how the resident's medication became unavailable. Residents Affected - Many In an observation and interview on 08/11/22 at 9:05 AM, Resident #21 said he was a liver transplant patient and he was very upset that the facility did not have his fast acting insulin. He said this was the first time the facility didn't have his medication since he was admitted to the facility and he was concerned that his untreated blood sugar could result in him getting sick. The surveyor typed sign was observed above the Resident #21's bed that said Humalog (fast acting insulin) should be administered after meal. Record review of Resident #21 face sheet dated 08/11/22 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses: seizures, GERD, constipation, chronic viral hepatitis, type 2 diabetes, liver transplant status, congestive heart failure and history of immunosuppression therapy. Record review of Resident #21 MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 9 out of 15, supervision with most ADLs, use of a wheelchair and always continent of both bladder and bowel. Record review of Resident #21's Care Plan with revision date 04/01/22 revealed, focus- risk of elevated blood pressure r/t HTN, interventions- give anti-hypertensive medications as ordered. Focus- DM, with risk of hyperglycemia/hypoglycemia, interventions- diabetes medication as ordered. Focus- liver transplant that requires daily immunosuppressive medications, interventions- administer medications as directed. Record review of Resident #21's Order Summary Report dated 04/11/22 revealed, Humalog Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 150 - 199 = 2; 200 - 249 = 4; 250 - 299 = 6; 300 - 349 = 8; 350 - 399 = 10; 400 - 449 = 12 >449 give 12 units and call MD, subcutaneously at three times a day r/t type 2 diabetes. Levemir FlexTouch Solution Pen injector 100 UNIT/ML (Insulin Detemir) Inject 20 unit subcutaneously one time a day for DM. Record review of Resident #21's August MAR revealed, his morning blood sugar reading was 316 but the resident did not receive his fast acting insulin (Humalog) scheduled for 8:30 AM. The resident received his first dose of insulin at 1:57 PM. Record review of Resident #21's Progress notes dated 08/11/22 at 10:05 AM by RN D revealed, the resident's fast acting was not administered due to the medication not being available, the medication was re-ordered from the pharmacy and Resident #21's NP was notified. Record review of Resident #21's Progress notes dated 08/11/22 at 01:57 PM by RN D revealed, the resident's blood sugar was 460, he was administered 12 units of fast act insulin and when his NP was notified no new orders were received. Record review of Resident #21's Weight and Vitals Summary printed on 08/11/22 at 3:40 PM revealed, at 08/11/22 at 10:05 AM the resident's BS was 316 mg/dL and at 08/11/22 at 13:57 AM the resident's BS was 460 mg/dL. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 14 of 27 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 455703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Healthcare and Rehabilitation Center of Ka 1525 Tull Dr Katy, TX 77449 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Resident #39 Level of Harm - Minimal harm or potential for actual harm An observation at 08/11/22 at 11:00 with MA A revealed, Resident #39's MAR as red, the resident had not yet received her: Aspirin, Furosemide (diuretic), Cholecalciferol (Vitamin D3), Omeprazole, Clopidogrel, Oxcarbazepine, docusate, potassium chloride and sennosides. Residents Affected - Many Record review of Resident #39's face sheet dated 08/11/22 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: heart failure, pain, edema (excessive fluid), anxiety disorder, depression, hypertension, Parkinson's disease and Constipation. Record review of Resident #39's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 9 out of 15, supervision for all ADLs, use of a wheelchair and occasionally incontinent of both bladder and bowel. Record review of Resident #39's Care Plan revised 08/08/22 revealed, focus- use of antidepressant medication r/t depression and insomnia, intervention- administer antidepressant medications as ordered. Record review of Resident #39's Order Summary Reported dated 08/11/22 revealed, Aspirin 81 mg- 1 tablet by mouth one time a day for heart health; Cholecalciferol 25 mcg- 2 tablets by mouth one time a day for vitamin D deficiency; Docusate 100 mg- 1 tablet by mouth one time a day for constipation; Furosemide 40 mg- 1 time by mouth a day for edema; Omeprazole 20 mg- 2 tablets by mouth one time a day for GERD; Oxcarbazepine 300 mg- 1 tablet by mouth one time a day for Parkinson's disease; Clopidogrel 75 mg- 1 tablet by mouth one time a day for CAD, Potassium Chloride ER 20 mEq- t tablet by mouth one time a day for hypokalemia; Senna 8.6 mg- 1 tablet by mouth two times a day for constipation. Record review of Resident #39's August MAR revealed, Aspirin 81 mg, Cholecalciferol 25 mcg (Vitamin D3), Docusate 100 mg, Furosemide 40 mg, Omeprazole 20 mg, Oxcarbazepine 300 mg, Clopidogrel 75 mg, Potassium Chloride 20 mEq, and Senna 8.6 mg were scheduled for administration at 8 AM. Resident # 42 An observation at 08/11/22 at 11:00 with MA A revealed, Resident #42's MAR as red indicating the resident had not yet received her: Depakote (medication for bipolar disorder), Apixaban, Spironolactone (diuretic for HTN), Gabapentin (medication for nerve pain) and Nuedexta (medication for PBA). Record review of Resident #42's Face Sheet dated 08/11/22 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included; chronic embolism and thrombosis of unspecified deep veins of right lower extremity, bipolar disorder, pseudobulbar effect ( inappropriate laughing and crying), major depressive disorder and hypertension. Record review of Resident #42's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 9 out of 15, extensive assistance for most ADLs, wheelchair use and always incontinent of both bladder and bowel. Record review of Resident #42's Care Plan revised 06/13/22 revealed, focus- use of antidepressant medications r/t depression, intervention- administer antidepressant medications as ordered. I am on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 15 of 27 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 455703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Healthcare and Rehabilitation Center of Ka 1525 Tull Dr Katy, TX 77449 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many anticoagulant therapy r/t history of CVA, intervention- administer anticoagulant medications as ordered by physician. Focus- risk for altered mood problem r/t to bipolar/depression, intervention- administer medications as ordered. Focus- seizure disorder r/t stroke, intervention- give seizure medication as ordered. Record review of Resident #42's Order Summary Reported dated 08/11/22 revealed, Apixaban 5 mg- 1 tablet by mouth two times a day for Afib r/t chronic embolism and thrombosis (blood clots); Depakote DR 500 mg- 1 tablet two times a day for mood disorder related to bipolar disorder, current episode depressed with psychotic features; Gabapentin 600 mg- 1 tablet by mouth two times a day for pain r/t pain in right let; Nuedexta 20-10 mg- 1 capsule by mouth 2 times a day for antipsychotic therapy and Spironolactone 25 mg- 1 tablet by mouth one time a day for CHF. Record review of Resident #42's August MAR revealed, Depakote DR 500 mg, Apixaban 5mg , Spironolactone 25 mg, Gabapentin 600 mg and Nuedexta 20-10 mg were scheduled for administration at 8 AM. Resident #51 An observation at 08/11/22 at 11:00 with MA A revealed, Resident #51's MAR as red indicating the resident had not yet received her: Lisinopril, Docusate, Senna and Acetaminophen. Record review of Resident #51's Face Sheet dated 08/11/22 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: dementia, right + left knee pain, constipation and hypertension. Record review of Resident #51'S MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 3 out of 15, extensive assistance with most ADLs, wheelchair use and always incontinent of both bladder and bowel. Record review of Resident #51's Care Plan last revised 04/02/21 revealed, focus- risk for pain, interventionmedicate for pain as directed. Record review of Resident #51's Order Summary Reported dated 08/11/22 revealed, Docusate 10 mg- 1 capsule by mouth two times a day for constipation; Lisinopril 20 mg- 1 tablet by mouth one time a day for HTN, Senna 8.6 mg- 2 tablets by mouth two times a day for constipation and Acetaminophen 500 mg- 1 tablet by mouth two times a day for chronic pain. Record review of Resident #51's August MAR revealed, Senna 8.6 mg, Acetaminophen 500 mg were scheduled for administration at 8 AM while Lisinopril 20 mg, Docusate were scheduled for administration at 9 AM. Resident #59 An observation at 08/11/22 at 11:00 with MA A revealed, Resident #59's MAR as red indicating the resident had not yet received his: Ascorbic Acid, Aspirin, Iron, Multivitamin, Carvedilol, Tamoxifen and clopidogrel. Record review of Resident #59's Face Sheet dated 08/17/22 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: iron deficiency anemia, hypertension and personal history of malignant neoplasm of the breast (breast cancer). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 16 of 27 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 455703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Healthcare and Rehabilitation Center of Ka 1525 Tull Dr Katy, TX 77449 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Record review of Resident # 59's MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 5 out of 15, worsening of behavior, extensive assistance on most ADLs and always incontinent of both bladder and bowel. Record review of Resident #59's Care Plan revised 07/10/22 revealed, focus- risk of pain r/t wounds and decreased mobility, intervention- administer pain medication as ordered. Focus- alteration in respiratory status due to COPD and CHF, intervention- administer medications as ordered. Record review of Resident #59's August Order Summary Report revealed, Ascorbic Acid 500 mg- 1 tablet by mouth in the morning for supplement; Aspirin 81 mg- 1 tablet by mouth in the morning for clot prevention; Carvedilol 25 mg - 1 tablet by mouth two times a day for HTN; Ferrous Sulfate 325 mg (Iron)- 1 tablet by mouth 3 times a day for anemia; Multivitamin with Minerals- 1 tablet by mouth in the morning for supplement; Plavix (Clopidogrel) 75 mg- 1 tablet by mouth in the morning of CAD and Tamoxifen 20 mg - 1 tablet by mouth in the morning for malignant neoplasm of the breast. Record review of Resident #59's August MAR revealed, Ascorbic Acid 500 mg, Aspirin 81 mg ,Carvedilol, Ferrous Sulfate 325 mg, Multivitamin with Minerals, Plavix (Clopidogrel) 75 mg, and Tamoxifen 20 mg were scheduled for administration at 8 AM. Resident # 63 An observation at 08/11/22 at 11:00 with MA A revealed, Resident #63's MAR as red indicating the resident had not yet received her: Claritin(allergy medication), Senna Plus, Escitalopram (mental health medication), Vitamin D, Keppra(seizure medication) and MiraLAX. Record review of Resident #63's Face Sheet dated 08/11/22 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: seizures, depression, anxiety and hypertension. Record review of Resident #63'S MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, extensive assistance with most ADLs, wheelchair use, and frequently incontinent of both bladder and bowel. Record review of Resident #63's Care Plan revised 06/28/22 revealed, focus- risk for seizures, interventionmedication as ordered by physician. Focus- chronic pain related to spinal stenosis, intervention- administer medication as ordered. Record review of Resident #63's Order Summary Reported dated 08/11/22 revealed, Claritin 10 mg- 1 tablet by mouth one time a day for allergies; Escitalopram 10 mg- 1 tablet by mouth one time a day for depression; Keppra 250 mg- 1 tablet by mouth two times a day for seizure; MiraLAX- 1 packet by mouth two times a day for constipation; Senna Plus- 8.6/50 mg- 2 tablets by mouth one time a day for constipation; Vitamin D3- 2 tablets by mouth one time a day for Vitamin D3 deficiency. Record review of Resident #63's August MAR revealed, Claritin 10 mg, Escitalop[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 17 of 27 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 455703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Healthcare and Rehabilitation Center of Ka 1525 Tull Dr Katy, TX 77449 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 57 %, based on 16 errors out of 28 opportunities, which involved 3 of 5 residents (Resident#21, Resident#67, and Resident #67); and 2 of 3 staff (RN D and MA A) reviewed for medication errors. Residents Affected - Some - RN D failed to administer Resident #21's Humalog insulin as ordered because it was unavailable in the facility. - RN D failed to administer the full dose of Pantoprazole to Resident #67 during G-tube medication administration. -MA A failed to administer Resident #336's medications within 1 hour of the scheduled administration time . These failures could place all residents receiving medication at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Resident #21 An observation and interview on [DATE] at 09:00 AM revealed, RN D preparing for insulin administration to Resident #21. RN D stated that the resident preferred to receive insulin after his meals, she prepped her blood sugar monitoring equipment, entered the resident's room and tested his blood sugar which resulted in a reading of 316 mg/dl. RN D returned to her nursing cart to prepare Resident #18's fast acting insulin but after checking her cart and the medication room she confirmed that there was no fast acting insulin on hand for Resident #21. She then administered his long acting insulin (Levemir 20 units) and contacted the pharmacy for a stat supply of the resident's Humalog insulin. RN D said that Resident #21 was supposed to receive 8 units of Humalog (fast acting insulin) because of his sliding scale order, and this was the first time the facility has run out of Resident #21's insulin. She said she did not know how the resident's medication became unavailable. In an observation and interview on [DATE] at 09:05 AM Resident #21 said he was a liver transplant patient and he was very upset that the facility did not have his fast acting insulin. He said this was the first time the facility didn't have his medication since he admitted to the facility and he was concerned that his untreated blood sugar could result in him getting sick. The surveyor typed sign was observed above the Resident #21's bed that said Humalog (fast acting insulin) should be administered after meal. Record review of Resident #21 face sheet dated [DATE] revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses revealed, seizures, GERD, constipation, chronic viral hepatitis, type 2 diabetes, liver transplant status, congestive heart failure and history of immunosuppression therapy. Record review of Resident #21 MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 9 out of 15, supervision with most ADLs, use of a wheelchair and always continent of both bladder and bowel. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 18 of 27 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 455703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Healthcare and Rehabilitation Center of Ka 1525 Tull Dr Katy, TX 77449 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #21's Care Plan with revision date [DATE] revealed, focus- risk of elevated blood pressure r/t HTN, interventions- give anti-hypertensive medications as ordered. Focus- DM, with risk of hyperglycemia/hypoglycemia, interventions- diabetes medication as ordered. Focus- liver transplant that requires daily immunosuppressive medications, interventions- administer medications as directed. Record review of Resident #21's Order Summary Report dated [DATE] revealed, Humalog Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 150 - 199 = 2; 200 - 249 = 4; 250 - 299 = 6; 300 - 349 = 8; 350 - 399 = 10; 400 - 449 = 12 >449 give 12 units and call MD, subcutaneously at three times a day r/t type 2 diabetes. Levemir FlexTouch Solution Pen injector 100 UNIT/ML (Insulin Detemir) Inject 20 unit subcutaneously one time a day for DM. Record review of Resident #21's August MAR revealed, his morning blood sugar reading was 316 but the resident did not receive his fast acting insulin (Humalog) scheduled for 8:30 AM. The resident received his first dose of Humalog at 1:57 PM. Record review of Resident #21's Progress notes dated [DATE] at 10:05 AM by RN D revealed, the resident's fast acting was not administered due to the medication not being available, the medication was re-ordered from the pharmacy and Resident #21's NP was notified. Record review of Resident #21's Progress notes dated [DATE] at 01:57 PM by RN D revealed, the resident's blood sugar was 460, he was administered 12 units of fast act insulin and when his NP was notified no new orders were received. Record review of Resident #21's Weight and Vitals Summary printed on [DATE] at 3:40 PM revealed, at [DATE] at 10:05 AM the resident's BS was 316 mg/dL and at [DATE] at 13:57 AM the resident's BS was 460 mg/dL. In an interview on [DATE] at 12:40 PM, the DON said Resident # 21's Humalog insulin was ordered by RN D from the pharmacy, and she could did not know how it ended up being unavailable for administration. The DON said failure to have insulin available as ordered places residents at risk for adverse reactions and hyperglycemia. In an interview on [DATE] at 4:00 PM the Director of Clinical Operations said, RN D immediately ordered Resident #21's insulin from the pharmacy and once it arrived he was administered the medication and his NP was notified of the unavailable medication. She said that Resident #21's last BS reading was 460 at 3:57 so he was administered 12 units of Humalog as ordered by the provider and the NP was notified. Resident #67 An observation on [DATE] at 07:40 PM revealed, RN D preparing medication for administration via G-tube for Resident #67. She prepared each of the medications (Baclofen, Bupropion, Midodrine, Multivitamin, Pantoprazole powder packet, Risperidone, Vitamin D3 and Gabapentin liquid) by placing each tablet in individual medication cups and pouring liquid medication into individual medication cups. At 08:04 RN D crushed each medication individually, returned them to their medication cups and entered into the resident's room at 08:11 AM. She retrieved warm temperature water and suspended the crushed medication in 5-10 ml of water. Resident #67 was observed lying in bed with bed slightly elevated, the angle of elevation was less than 45 degree and RN D did not raise the resident's head at a 30 to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 19 of 27 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 455703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Healthcare and Rehabilitation Center of Ka 1525 Tull Dr Katy, TX 77449 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 45 degree angle. RN D prepared the resident for G-tube medication administration by disconnecting the continuous feed. As RN D disconnected the continuous feed she said the resident needed incontinent care and the surveyor observed visible soil leaking from Resident 21's colostomy site as well as a paper towel with visible soil was observed below the G-tube tubing. At 8:15 AM RN D drew up 45 ml of warm water in a syringe, pushed down the paper towel and the resident's brief, connected the syringe containing water to the resident's G-tube port and pushed the water through the G-tube while attempting to listen for bowel sounds. After attempting to listen to Resident #67's bowel sounds she checked for residual and returned the contents to the residents tube. At 08:17 PM, RN D attached the syringe and performed a 30 ml water flush via gravity, and at 08:20 AM began administrating the suspended medication with a 10 ml flush in between each medication. As RN D attempted to administer the resident's Protonix she mistakenly uncapped one of the ports not in use resulting in the Protonix that was poured into the syringe leaked out of the uncapped port and onto the resident. For all further administrations and flushes, RN D used the toggle to close the additional ports when she poured the medication into the syringe. Once medication administration was completed RN D reconnected Resident #67's continuous feed, cleaned her syringe, discarded the waste and left the resident room. She did not elevate the residents head to a 45-degree angle after medication administration was completed. Record review of Resident #67's Face Sheet dated [DATE] revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included, quadriplegia, hypotension, gastrostomy status, type 2 diabetes, schizophrenia, Afib and colostomy status. Record review of Resident #67's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 8 out of 15, extensive assistance with most ADLs, wheelchair use, an indwelling catheter and an ostomy. Record review of Resident #67's Care Plan revised [DATE] revealed, focus- receiving nutrition via PEG in addition to diet r/t poor intake; intervention- check tube placement every feeding, elevate head of bead 30-45 degrees during and for 30-60 minutes after feeding, water flushes as ordered. Focus- colostomy and need staff to empty and change as needed but sometimes I refuse, intervention- change or empty colostomy bag as ordered. Record review of Resident # 67's August Order Summary Report dated [DATE] revealed, may crush medications and administer per G-tube; Baclofen 10 mg- 1 tablet via G-tube three times a day for muscle spasm; Bupropion 10 mg- 1 tablet via G-tube one time a day for depression; Gabapentin 250 mg/5 ml- 15 ml (600 mg) via G-tube four times a day; Midodrine 10 mg- 1 tablet via G-tube three times a day for hypotension; Multivitamin Vitamin- 1 tablet via G-tube one time a day for vitamin deficiency; Pantoprazole 40 mg- 1 packet per G-tune one time a day; Risperidone 2 mg- 1 tablet via G-tube for schizophrenia; Vitamin D- 2000 units per G-tube one time daily for vitamin deficiency. In an interview on [DATE] at 09:15 RN D said, when she administered Resident #67's Protonix she observed it spill out of the second port and that was why she began to use the toggle the port from open to close between medications. RN D said that the patient received some of the medication so she could not readminister it. Resident # 336 An observation at [DATE] at 09:45 with MA E revealed, Resident #75's MAR as red indicating the resident had not yet received his: Lactulose (stool softener), Nystatin (antifungal), Spironolactone, Senna, Thiamin (Vitamin B-1), Furosemide, Gabapentin, Guaifenesin, Omeprazole, Folic Acid, Nifedipine, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 20 of 27 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 455703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Healthcare and Rehabilitation Center of Ka 1525 Tull Dr Katy, TX 77449 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Sucralfate, Propranolol and Polyethylene Glycol 3350 (MiraLAX). MA E prepared Resident #75's medication entered into his room and administered the medication. Record review of Resident # 336's Face Sheet revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: alcoholic cirrhosis of the liver with ascites (fluid buildup in the belly), hypertension and type 2 diabetes. Record review of Resident #336's MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 14 out of 15, disorganized thinking, worsening of behavior, extensive assistance with most ADLs, wheelchair use, always incontinent of both bladder and bowel. Record review of Resident #336's Baseline Care Plan dated [DATE] revealed, barriers to transition- diabetic management. A care plan was requested on [DATE] at 11:27 AM, the facility did not provide the document prior to the surveyors exit. Record review of Resident #336's Order Summary Reported dated [DATE] revealed, Folic Acid 1 mg- 1 tablet by mouth one time a day for supplement; Furosemide 20 mg- 1 tablet by mouth one time a day for liver ascites; Nifedipine 30 mg ER- 1 tablet one time a day for CAD; Sennosides 8.6 mg- 2 tablets by mouth one time a day for constipation; Spironolactone 50 mg- 1 tablet by mouth one time a day for liver cirrhosis/ascites; Thiamine 100 mg- 1 tablet by mouth one time a day for supplement; Guaifenesin ER 600 mg- 1 tablet by mouth two times a day for cough; Lactulose Solution 10 gm/5ml- 15 ml by mouth two times a day for constipation; Omeprazole 20 mg- 1 capsule by mouth two times a day for GERD; MiraLAX- 17 gm by mouth two times a day for constipation; Sucralfate 1 gm- 1 tablet by mouth 2 times a day for stomach ulcer; Gabapentin 100 mg- 2 capsules by mouth three times a day for pain, Nystatin 100,000- 10 ml by mouth four times a day for infection and Propranolol 10 mg- 1 tablet by mouth three times a day for HTN. Record review of Resident #336's August MAR revealed, Folic Acid 1 mg, Furosemide 1 mg, Nifedipine 30 mg, Sennoside 8.6 mg, Spironolactone 50 mg, Thiamine 100 mg, Guaifenesin ER 600 mg, Lactulose Solution 10 gm/5ml, Omeprazole 20 mg, MiraLAX, Sucralfate 1 gm and Gabapentin 100 were scheduled for administration at 8 AM. In an interview on [DATE] at 10:35 AM, MA A said that resident medications administration windows were 1 hour before to 1 hour after the scheduled administration time. She said that the facility only had 2 medication aides in the facility and they were responsible for passing all scheduled oral medications to all the resident's. MA A said she was running late on [DATE] because she started later than usual due to issues she had with a resident. She said late administration of medication places resident's at risk of pain and not timely treatment of conditions. In an interview on [DATE] at 12:40 PM the DON said , she this was an interim position and she had just joined with the facility 2 days ago so she was not very familiar with the staffing. She said resident medications administration windows were 1 hour before to 1 hour after the scheduled administration time and she was not aware of any unusual occurrences that delayed medication administration on [DATE] and the facility has been actively trying to hire more staff. The DON said late administration of medication could place residents at risk of in delay in treatment of health conditions, seizures in the case of late seizure medications and place residents outside the therapeutic range for their medications. She said if medication leaks during G-tube administration and nursing staff were not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 21 of 27 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 455703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Healthcare and Rehabilitation Center of Ka 1525 Tull Dr Katy, TX 77449 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some sure of that the resident received their ordered dose their provider should be notified and orders should be followed. The DON said, Resident # 21's Humalog insulin was ordered by RN D from the pharmacy, and she could did not know how it ended up being unavailable for administration. The DON said failure to have insulin available as ordered places residents at risk for adverse reactions and hyperglycemia. Record review of RN D's Medication Administration Competency Audit-Enteral Tube revealed, Action- 14Administer each medication separately, unless Dr. has given the approval to mix the medications. Flushes tube with 5 ml or more of water after each dose. Does not add to feeding solution . 16- Allows flushes and meds to flow down tube via gravity. Give gentle boosts with plunger if meds will not flow by gravity. Does not push meds through tube. RN D met criteria for the competencies assessed. Record review of the facility policy titled General Dose Preparation and Medication Administration revised [DATE] revealed, 5- During medication administration, facility staff should take all measures required by facility policy and applicable law, including but not limited to; . 5.4- Administer medications within timeframes specified by the facility policy or manufacturer's information . Record review of the facility policy titled Medication Administration through Enteral Tube revised [DATE] revealed, 15- facility should check the placement of the naso-gastric or gastrostomy tube in accordance with facility policy. Verify that the tube is functioning before administering medications. 16- Facility should insert medication syringe in appropriate port. Remix medication and pour into medication syringe so entire dose is administered. Do not push medications through the tube. Record review of the facility policy titled Disposal/Destruction of Expired or Discontinued Medication revised [DATE] revealed, 1- facility should destroy and dispose of medications in accordance with facility policy and applicable law, and applicable environmental regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 22 of 27 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 455703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Healthcare and Rehabilitation Center of Ka 1525 Tull Dr Katy, TX 77449 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, the expiration date when applicable and stored all drugs and biologicals in locked compartments and under proper temperature controls, and permitted only authorized personnel to have access to the keys for 3 out of 5 medication carts ( Unknown Medication Cart, [NAME] Back MA Medication Cart, East Nurse Medication Cart) reviewed for medication storage. - The facility failed to ensure an Unknown Medication Cart was locked when not in use resulting in Resident #37 gaining access to the content of the cart. - The facility failed to ensure the [NAME] Back MA Medication Cart did not contain protein supplement with no open date. - The facility failed to ensure the East Nurse Medication Cart did not contain expired insulin. These failures could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings Included: Unknown Medication Cart Observation and interview on 8/10/22 at 3:02 p.m. revealed two staff sitting at the nurse station working on the computers. There was an unattended open med cart placed beside the nurse station; front of the med cart was facing away from the nurse station. Resident #37 was sitting in her wheelchair in front of the med cart, out of view of staff at the nurse station. The resident had the bottom drawer of the med cart open, and she had taken a box out of the cart and was trying to open it. Surveyor intervened and notified LVN F that Resident #37 was rummaging through the med cart. LVN F immediately went to the med cart, grabbed the box from Resident #37's lap, placed it back in the drawer, closed and locked the cart. The LVN moved the resident away from the med cart. Interview with LVN F said he was not aware the resident had opened the med cart and could not see the resident in front of the med cart. He said he was sitting at the nurse station next to the med cart was unlocked. He said he had left the med cart unlocked because I was close by at the nurse station. He said the policy was for the med cart to be locked when not in view and because it was not locked she was at risk of taking something or causing injury. Record review of face sheet indicated Resident #37 was an [AGE] year-old female admitted on [DATE] and last readmitted on [DATE] and had diagnoses of cognitive communication deficit, and dementia without behavioral disturbances. Record review of Resident #37's Comprehensive MDS dated [DATE] revealed a BIMS score of 2 indicating severe cognitive impairment. Record review of Resident #37's Care plan print date of 8/11/22 read in part .Resident #37 has (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 23 of 27 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 455703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Healthcare and Rehabilitation Center of Ka 1525 Tull Dr Katy, TX 77449 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some impaired cognitive function/ dementia or impaired thought process related to dementia . Resident #37 has an ADL self-care performance deficit related to dementia . West Back MA Medication Cart In an observation and interview on 08/11/22 at 09:52 AM, inventory of the Nurse Medication Cart with MA E revealed: - an open and in use bottle of ProHeal, a protein supplement, with no open date and manufacturers instructions to discard 60 days after opening. MA E said that when a multidose bottle was opened it should be labeled with the date which was used to track the expiration date. She said that nursing staff are expected to check their carts daily as used for inappropriately labeled medication and since the protein supplement did not have an open date it could not be used. She said use of expired protein supplement can place resident's at risk for GI upset and since she didn't know when the bottle of ProHeal was opened it can not be used and must be discarded in the trash. East Nurse Medication Cart In an observation and interview on 08/11/22 at 10:12 AM, inventory of the Nurse Medication Cart with LVN D revealed: - an open, in use and expired Humalog insulin pen with an open date of 07/08/22 with a pharmacy label of expires after 28 days (08/05/22). LVN D said that Humalog insulin expires 28 days after opening/removal from the fridge and the pen was expired. She said after insulin expires it loses efficacy and can become contaminated. LVN D said nursing staff were expected to check their carts daily as used for expired medications and since the pen was expired it could not be used and must be discarded in the sharps container and reordered. She said use of expired insulin places residents at risk for inadequate blood sugar control and infection. In an interview on 08/11/22 at 12:40 PM, the DON said that nursing staff were expected to check their carts daily for expired and inappropriately labeled medications. She said all medications should be used prior to their manufacturers specified beyond use date and discarded once expired and multi dose containers should be labeled with the date opened in order to track their expiration date. She said the use of expired medications could place residents at risk of adverse reactions so all inappropriately labeled or expired medications must be removed from use and discarded. Interview on 8/11/22 at 1:24 p.m. with the interim DON said med carts were to be locked at all times when not in eyesight. She said the risk of open med carts would be a resident taking medications or adverse reaction to a medication. She said she had been working at the facility for 3 days and voiced no further concerns with staff leaving the med carts open. Record Review of facility policy LTC Facility's Pharmacy Services and Procedures Manual dated January 2022 read in part 3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/ cart or locked medication room that is inaccessible by residents and visitors . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 24 of 27 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 455703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Healthcare and Rehabilitation Center of Ka 1525 Tull Dr Katy, TX 77449 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the facility policy titled Storage and Expiration Dating of Medications, Biologicals/ revised 07/21/22 revealed, 4- facility should ensure that medications and biologicals that: (1) have and expiration date on the labeled; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate for other medications until destroyed or returned to the pharmacy or supplier. 5- Once any medication or biological package is opened, facility should follow manufacturers/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened . 5.3- if a multi-dose vial of an injectable medication has been opened or access(e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial . 6- Facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged or missing labels or cautionary instructions. Record review of the facility policy titled Disposal/Destruction of Expired or Discontinued Medication revised 01/01/22 revealed, 1- facility should destroy and dispose of medications in accordance with facility policy and applicable law, and applicable environmental regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 25 of 27 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 455703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Healthcare and Rehabilitation Center of Ka 1525 Tull Dr Katy, TX 77449 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 Residents (Resident #67) reviewed for infection control. Residents Affected - Few - RN D administered medication via G-tube to Resident #67 without first performing colostomy care when the resident had visible soil on her abdomen from a leaking colostomy bag . This failure could place residents at risk of acquiring infections. Findings included: An observation on 08/11/22 at 07:40 AM revealed, RN D preparing medication for administration via G-tube. After entering Resident #21's room, RN D disconnected the continuous feed from the resident's G-tube port and said the resident needed incontinent care. The surveyor observed visible soil leaking from Resident 67's colostomy site and a paper towel with visible soil placed beneath the G-tube port. RN D administered medication to the resident without first completing colostomy care and left the room without completing incontinence care. An observation on 08/11/22 at 09:25 AM revealed, Staff in Resident #67's room completing colostomy care. Record review of Resident #67's Face Sheet dated 08/11/22 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included, quadriplegia, hypotension, gastrostomy status, type 2 diabetes, schizophrenia, Afib and colostomy status. Record review of Resident #67's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 8 out of 15, extensive assistance with most ADLs, wheelchair use, an indwelling catheter and an ostomy. Record review of Resident #67's Care Plan revised 08/07/22 revealed, focus- receiving nutrition via PEG in addition to diet r/t poor intake; intervention- check tube placement every feeding, elevate head of bead 30-45 degrees during and for 30-60 minutes after feeding, water flushes as ordered. Focus- colostomy and need staff to empty and change as needed but sometimes I refuse, intervention- change or empty colostomy bag as ordered. In an interview on 08/11/22 at 09:15 RN D said, Resident #67's colostomy bag had a tendency to leak, and colostomy care was a long process, so she just pushed the resident's brief down in order to complete medication administration in a timely manner. The nurse could explain the infection control risks associated with performing G-tube medication administration to a resident with a leaking colostomy bag. In an interview at 08/11/22 at 12:40 PM, the DON said , prior to completing medication administration RN D should have completed colostomy care for Resident 67's. She said by completed medication administration when the resident had a leaking colostomy bag the resident's g-tube could possibly become contaminated with fecal matter placing her at risk for GI issues and sepsis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 26 of 27 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 455703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Healthcare and Rehabilitation Center of Ka 1525 Tull Dr Katy, TX 77449 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm In an interview on 08/11/22 at 4:00 PM, the Director of Clinical Operations said that the facility did not have a policy that addressed infection control during G-tube medication administration. She said completing the incontinence care is a general nursing expectation. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455703 If continuation sheet Page 27 of 27