Health inspection·March 30, 2023

F 0693 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #78's last MDS was a quarterly completed on 01 13 2023 with a BIMS of 03 indicating he was severely cognitively impaired and that he required 1 2 people for assistance with activities of daily living. Resident #78 was also marked in section K0510 Nutritional . Approach as B. Feeding Tube while a resident. Residents Affected - Some Record review of physician order's active dated 2/8/23 revealed Senna syrup 5 ml Solution Give 5 ml via G Tube two times a day related to constipation. Record review of Resident #78's care plan dated of 04 07 2022 revealed the following: Focus: Altered Nutritional Status PEG Feedings . date Initiated: 04 07 2023 During an observation on 03 28 2023 at 4:28 AM, RN A stopped Resident #78's enteral feeding to start his medication administration. RN A did not verify placement of the feeding tube. RN A did not palpate Resident #78's stomach. RN A used a 60 cc syringe, then installed 20 cc of air via G Tube (gastrostomy tube) without using the stethoscope to auscultate for placement and did not flushed with water before administering medication. RN A picked up the following medication blister packets and placed in the medication cups Amlodipine 10mg 1 tablet crushed and diluted with 10cc of water, Thiamin vitamin B 100 mg 1 tablet crushed and diluted with 10cc of water, Poured Senna syrup 7cc a cup and diluted with 10 cc of water. RN A then poured each medication into the G Tube without flushing with water in between medication administration. Resident # 62 Record review of the face sheet dated 3 30 2023 in the clinical record for Resident # 62 revealed a [AGE] year old male resident admitted to the facility on 07 08 2020 and with diagnoses to include pneumonia,( is a lung infection caused by bacteria, viruses or fungi) acute respiratory failure with hypoxia ( happens when your lungs cannot get enough oxygen into the blood), essential (primary) hypertension) dysphagia; oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), aphasia (loss of the ability to understand or express speech caused by brain damage), essential primary hypertension( high blood pressure) and convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contractures of muscles and associated especially with brain disorders such as epilepsy). Record review of Resident #62's last MDS was a quarterly completed on 02 23 2023 with a BIMS of 99 indicating he was severely cognitively impaired and that he required 1 2 people for assistance with activities of daily living. Resident #62 was also marked in section K0510 Nutritional Approach as B. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455800 If continuation sheet Page 2 of 11 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 455800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lev at Town Park 8820 Town Park Dr Houston, TX 77036 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 Feeding Tube while a resident. Level of Harm - Minimal harm or potential for actual harm Record review of physician order's active dated 3/8/23 revealed Levetiracetam solution 100 MG/ML Give 10 ml via G Tube two times a day related to conversion disorder with seizures or convulsions. Residents Affected - Some Record review of Resident #62's care plan with an quarterly dated of 02 23 2023 revealed the following:Focus: Altered Nutritional Status . PEG Feedings . date Initiated: 07 07 2022 During an observation on 03 28 2023 at 4:42 PM, RN A stopped Resident #62's enteral feeding to start his medication administration. RN A did not verify placement of the feeding tube. RN A did not palpate Resident #62's stomach. RN A used 60 cc syringe, then installed 30 cc of air via G Tube without using the stethoscope to auscultate for placement and did not flush with water before administering medication. RN A picked up the following medication bottle poured in the medication cup: Levetiracetam Solution 100 MG/ML poured 12 cc and diluted with 15 cc of water and administered via Resident #62's G Tube and flushed with 30 cc of water. During an interview with RN A on 03/29/23 at 8:50 AM regarding checking GTube placement and flushing Resident #78 and Resident # 62's GT before medication administration, he said , he checked G tube placement during his initial rounds for breath sound and he always flush G Tube with water after medication administration, RN A said not checking for placement could cause aspiration pneumonia, bloating and being too full. Further interview with RN A on 3/29/23 at 5:00 PM regarding medications Levetiracetam solution and Senna syrup not given as ordered by the doctor. RN A said he would be more careful and would double check after pouring medication. RN A said he had medication training upon hire by former DON. Record review of RN A's personnel file revealed date of hire was 2/24/21 and document regarding his training on medication was on 10/15/22. Record review of enteral feed order schedule for [DATE], every shift check tube for proper placement by visual inspection of aspirated stomach content prior to instilling medication, initiating a feeding or when there is an interruption of feeding ,or at least every shift for continuous feeding. Further review revealed enteral feed order schedule for [DATE], had every shift flush with 30 60 ml water before and after medication, before initiating feedings or when there is an interruption of feeding to maintain tube patency. Resident #8 Record review of the face sheet dated 3 30 2023 in the clinical record for Resident #8 revealed a [AGE] year old female resident admitted to the facility on 06 03 2019 and was re admitted on [DATE] with diagnoses to include bipolar disorder ( formerly called manic depressive illness or manic depression) is a mental illness that causes unusual shifts in a person's mood, energy activity levels and concentration), schizoaffective disorder ( is a mental health disorder that is marked by a combination of schizophrenia symptoms such as hallucinations acute and chronic respiratory failure with hypoxia,( a serious condition that makes it difficult to breathe on your own, the lungs can't get enough) oxygen into the blood) dysphagia; oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), aphasia (loss of the ability to understand or express speech caused by brain damage), essential primary hypertension( high blood pressure) and convulsions (a sudden, violent, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455800 If continuation sheet Page 3 of 11 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 455800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lev at Town Park 8820 Town Park Dr Houston, TX 77036 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 - Some irregular movement of a limb or of the body, caused by involuntary contractures of muscles and associated especially with brain disorders such as epilepsy), ` Record review of Resident #8's last MDS was a quarterly completed on 02 24 2023 with a BIMS of 03 indicating he was severely cognitively impaired and that he required 1 2 people for assistance with activities of daily living. Resident #8 was also marked in section K0510 Nutritional Approach as B. Feeding Tube while a resident. Record review of physician order's active dated 2/20/23 revealed Levetiracetam Solution 100 MG/ML,Give 15 ml via G Tube every 12 hours related (Focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable with status epilepticus. Record review of Resident #8's care plan with a quarterly dated of 02 24 2023 revealed the following Focus: Altered Nutritional Status . PEG Feedings . date Initiated: 06 03 2023 During an observation on 03 29 2023 at 9:38 AM LVN A stopped Resident #8's enteral feeding to start his medication administration. LVN A verified placement of the feeding tube. LVN A palpated Resident #8's stomach. LVN A used 60 cc syringe, then plunged 60 cc of water via G Tube without allowing water flow via gravity before administering medication. LVN A picked up the following medication bottle poured in the medication cup: Levetiracetam Solution 100 MG/ML poured 13 cc and diluted with 10 cc of water and administered via Resident #8's G Tube and flushed with 10 cc of water. During an interview with LVN A on 3/30/23 at 10:50 AM regarding Levetiracetam Solution not administered as ordered by the physician and also plunging 60mls of water via G Tube before administering medication. LVN A said she would double check medication before administering. She said she did know that plunging water with the syringe via G Tube was wrong. She further stated she always used the syringe to plunge water via G Tube from that state she used to work and she was corrected by the unit manager on 3/29/23 to let the water flow by gravity. LVN A said she had training for medication administration. Record review of enteral feed order schedule for [DATE] had every shift check tube for proper placement by visual inspection of aspirated stomach content prior to instilling medication, initiating a feeding or when there is an interruption of feeding, or at least every shift for continuous feeding. Further review revealed enteral feed order schedule for [DATE], had every shift flush with 30 60 ml water before and after medication, before initiating feedings or when there is an interruption of feeding to maintain tube patency. Record review of LVN A's personnel file revealed date of hired was 12/21/22 and document regarding his training on medication was on 12/21/22 . During an interview on 03/30/23 at 01:40 PM, the DON reported that a feeding tube should be verified with a stethoscope and that a staff member should listen to gurgling. The DON reported that if you do not verify that a feeding (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455800 If continuation sheet Page 4 of 11 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 455800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lev at Town Park 8820 Town Park Dr Houston, TX 77036 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 tube is in the right place then a resident could receive a feeding or medication that could result Level of Harm - Minimal harm or potential for actual harm in infection, bloating, or discomfort. The DON verified that the two policies provided were what Residents Affected - Some the facility had for feeding tube administration and that they did have a policy specific on verifying feeding tube placement. Record review of facility provided policy titled Flushing a Feeding Tube revised 2021, revealed the following: Policy Explanation and compliance Guidelines: 9. Prior to flushing the feeding tube, the administration of medication or providing tube feedings, the nurse verifies the proper placement by noting the length of the tubing or performing a measure of the PH of gastric secretions , if performed in the facility. 10. After tube placement has been verified, flush the tube utilizing the 60 ml, catheter tip syringe with the prescribed amount of water every four(4) hours, before and after feedings and medications or as directed by the physician. Allow medications to flow down the medication syringe FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455800 If continuation sheet Page 5 of 11 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 455800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lev at Town Park 8820 Town Park Dr Houston, TX 77036 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 the medication Residents Affected - Some error rate was not five percent (%) or greater. The facility had a medication error rate of 7%, based on 3 errors out of 38 opportunities, which involved 3 of 11 residents (Resident #8, #62, and #78) reviewed for medication administration. LVN A did not administer Resident #8's Levetiracetam medication ( medication used to treat seizures epilepsy , is classified as anticonvulsants) according to Physician orders RN A did not administer Resident #62's Levetiracetam medication ( medication used to treat seizures epilepsy , is classified as anticonvulsants)) according to Physician orders. RN A did not administer the prescribed amount of Senna syrup ( a laxative medication) to Resident # 78 according to Physician orders. These failures could place residents at risk of inadequate therapeutic outcomes and a decline in health. Findings included: Resident #78 Record review of the face sheet dated 3 30 2023 revealed Resident #78 was a [AGE] year old male resident admitted to the facility on 04 07 2022, and was re admitted on [DATE] with diagnoses to include hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, (one weakness cause by lack of oxygen in the brain) dysphagia; oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), aphasia (loss of the ability to understand or express speech caused by brain damage), sepsis (the extreme response to an infection), essential primary hypertension( high blood pressure), and convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contractures of muscles and associated especially with brain disorders such as epilepsy). Record review of physician order's dated 2/8/23 revealed Senna syrup 5 ml Solution .Give 5 ml via G Tube two times a day related to constipation. During an observation on 03 28 2023 at 4:28 AM,RN A stopped Resident #78's enteral feeding to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455800 If continuation sheet Page 6 of 11 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 455800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lev at Town Park 8820 Town Park Dr Houston, TX 77036 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 start his medication administration. RN A did not flushed with water before administering medication. RN A Level of Harm - Minimal harm or potential for actual harm picked up the following medication bottle and poured in the medication cups. Poured 7 cc of Senna Syrup in a cup and diluted with 10 cc Of water. Residents Affected - Some RN A then poured each medication into the GTube without flushing with water in between medication administration. Resident # 62 Record review of the face sheet dated 3 30 2023 in the clinical record for Resident # 62 revealed a [AGE] year old male resident admitted to the facility on 07 08 2020 and with diagnoses to include pneumonia,( is a lung infection caused by bacteria, viruses or fungi) acute respiratory failure with hypoxia ( happens when your lungs cannot get enough oxygen into the blood), essential (primary) hypertension) dysphagia; oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), aphasia, (loss of the ability to understand or express speech caused by brain damage), essential primary hypertension( high blood pressure) and convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contractures of muscles and associated especially with brain disorders such as epilepsy), Record review of physician order's active dated 3/8/23 revealed Levetiracetam Solution 100 MG/ML. Give 10 ml via G Tube two times a day related to CONVERSION DISORDER WITH SEIZURES OR CONVULSIONS. During an observation on 03 28 2023 at 4:42 PM,RN A stopped Resident #62's enteral feeding to start his medication administration. RN A picked up the following medication bottle poured in the medication cup: Levetiracetam Solution 100 MG/ML poured 12 cc and diluted with 15 cc of water and administered via Resident #62's GTube and flushed with 30 mls of water. ( instead of Levetiracetam Solution 10 ml as ordered by physician) During an interview with RN A on 03/29/23 at 8:50 AM, he always flush G Tube with water after medication administration, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455800 If continuation sheet Page 7 of 11 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 455800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lev at Town Park 8820 Town Park Dr Houston, TX 77036 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 Further interview with RN A on 3/29/23 at 5:00 PM regarding medications Levetiracetam Solution and Senna syrup not given as ordered by the doctor. RN A said he would be more careful and would double check after pouring medication. RN A said he had medication training upon hire by former DON. Record review of RN A's personnel file revealed Residents Affected - Some date of hired was 2/24/21 and document regarding his training on medication was on 10/15/22 Resident #8 Record review of the face sheet dated 3 30 2023 in the clinical record for Resident #8 revealed a [AGE] year old female resident admitted to the facility on 06 03 2019 and was re admitted on [DATE] with diagnoses to include bipolar disorder ( formerly called manic depressive illness or manic depression) is a mental illness that causes unusual shifts in a person's mood, energy activity levels and concentration), schizoaffective disorder ( is a mental health disorder that is marked by a combination of schizophrenia symptoms such as hallucinations acute and chronic respiratory failure with hypoxia, ( a serious condition that makes it difficult to breathe on your own, the lungs can't get enough oxygen into the blood) dysphagia; oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), aphasia (loss of the ability to understand or express speech caused by brain damage), essential primary hypertension( high blood pressure) and convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contractures of muscles and associated especially with brain disorders such as epilepsy). Record review of physician order's active dated 2/20/23 revealed Levetiracetam Solution 100 MG/ML Give 15 ml via G Tube every 12 hours related (Focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable with status epilepticus. During an observation on 03 29 2023 at 9:38 AM, LVN A stopped Resident #8's enteral feeding to start his medication administration. LVN A picked up the following medication bottle poured in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455800 If continuation sheet Page 8 of 11 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 455800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lev at Town Park 8820 Town Park Dr Houston, TX 77036 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 medication cup: Level of Harm - Minimal harm or potential for actual harm Levetiracetam Solution 100 MG/ML poured 13 cc and diluted with 10 cc of water and administered via Resident #8's GTube and flushed with 10 cc of water. Residents Affected - Some During an interview with LVN A on 3/30/23 at 10:50 AM regarding Levetiracetam Solution not administered as ordered by the physician LVN A said she would double check medication before administering. Record review of LVN A personnel file revealed date of hired was 12/21/22 and document regarding his training on medication was on 12/21/22 . During an interview on 3/30/23 at 1:40 PM, the DON said nursing staff were to identify the resident's name, medication and to compare the information on the MAR when a medication is prepared, give medication as ordered by the physician. She said she would be in servicing the nursing staff on medication administration. Record review of facility provided policy titled Medication Administration Via Enteral Tube revised 2022, revealed the following: Policy : It is the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines . 9. Procedure: j. Dilute the solid or liquid medication as appropriate and administer using a clean oral syringe( > 30 mL in size). k. Flush tube again with at least 15 mL water taking into account resident's volume status l. Repeat with the next medication ( if appropriate) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455800 If continuation sheet Page 9 of 11 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 455800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lev at Town Park 8820 Town Park Dr Houston, TX 77036 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 - Few 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. Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured properly for one of fifteen rooms (Resident #61's room) as evidenced by: -Resident #61 had medication on top of bedside table and was unattended. This deficient practice could place residents at risk for harm and place the facility at risk for a possible drug diversion. The findings include: Observation on 3/28/2023 at 10:20 a.m., on top of the Resident #61's bedside table a bottle of liquid medicine labeled Polyethylene Glycol 3350 milliliters (medication to treat constipation) and a bottle of pills labeled Bisacodyl 5 mg EC tablets (medication to treat constipation). Continued to monitor medications on the bedside table until 12:00 pm. Observed on 3/28/23 at 12:00 p.m., LVN X walking out of Resident #61's room with two medications in her right hand. Interviewed LVN X on 3/28/23 at 12:01 p.m., she stated no medications were to be in resident room without being locked and should have been placed in medication cart. She stated the reason medications are to be in the Medication cart are a residents could take too much medication, a confused resident could walk into the room and take medications that are not for them causing an adverse effect. Interview on 3/28/23 at 12:11 p.m., LVN Z said he was responsible for the care of resident#61. He stated resident came from the hospital via EMS at 8:00 am and did not receive medications from EMS or see any medications on the bedside table. He reported residents are not allowed to have medications at bedside as there is a potential for overdose, other residents could possibly take the medications and become ill. Interviewed on 3/28/23 CNA Z at 12:25 p.m., she stated she did not see any medications on Resident #61's bedside table. She stated she is aware that medications are not allowed in patient rooms as it is dangerous if the resident takes too much, or another resident takes medications that is not theirs. Interviewed on 3/30/23 at 10:02 a.m., the Director of Nurses (DON), she stated she was made aware of medication at bedside on 3/28/23 not under lock and key for Resident#61. She stated it is important to have all medications under lock and key for safety, because the resident is not able to remember if they took medications or may take too much, also the nurses don't know what medication have been taken, and any resident wonder into room may take medication and could potentially have adverse reaction. Interviewed on 3/30/23 at 10:30 a.m., the Administrator regarding medication found at bedside not under lock and key without staff being aware it was there. She stated medication should always be under lock and key for safety, so resident doesn't take wrong amount of medication, or taken by another (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455800 If continuation sheet Page 10 of 11 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 455800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lev at Town Park 8820 Town Park Dr Houston, TX 77036 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 resident. Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy titled Medication Storage (Copyright 2022 The Compliance Store, LLC. All rights reserved. Page 1 of 2) read in part: Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455800 If continuation sheet Page 11 of 11