Inspection·November 17, 2025

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some table 325 MG- Give 2 tablet by mouth every 6 hours as needed for pain/fever (order dated 7/28/25 at 5:59pm-D/C dated 11/10/25 at 9:55am); -Norco (Narcotic pain medication) Tablet 7.5-325 MG (PRN as needed)-Give 1 tablet by mouth every 8 hours as needed for pain (order dated 7/28/25 at 5:59pm-D/C dated 11/10/25 at 9:55am); -Biofreeze Cool the pain external Gel to apply to affected areas for pain PRN (as needed) (order date 11/7/25 at 4:49pm-D/C 11/10/25 9:55am); x-ray to left femur, left knee, and left tibial/fibula once only for pain (order date 11/7/25 at 4:51pm-D/C 11/10/25 at 9:55am). Record Review of MAR dates of 11/5/25 - 11/8/25 revealed, CR#1 was administered pain medications on 11/7/25 only. Reviewed Record of CR#1'nursing notes dated 11/6/2025 thru 11/7/2025, revealed no nursing notes regarding CR#1's complaint of pain regarding his knee nor was there an assessment for the night shift on 11/6/2025. Reviewed Record of CR#1's nursing notes dated 11/7/25 at 2:27pm revealed CR#1 was administered Norco (325mg) for a swollen knee and pain level 8. The note on 11/7/25 at 3:41pm revealed CR#1 was administered 2-Tylenols (650mg total) for pain level 8. The nursing notes on 11/7/25 created 5:46pm effective 5:00pm revealed LVN A noted a change in condition for CR#1 due to ineffective pain medication, and notification of NP was made. Record review of CR#1's pain assessment revealed the following: 11/7/25 at 8:07am Pain level 0 11/7/25 at 1:18pm Pain level 0 11/7/25 at 2:27pm Pain level 8 11/7/25 at 3:41pm Pain level 8 11/7/25 at 4:18pm Pain level 8 11/6/25 at 8:21am Pain level 0 11/6/25 at 2:26pm Pain level 0 11/6/25 at 10:51pm Pain level 0 11/5/25 at 8:37am Pain level 0 11/5/25 at 3:31pm Pain level 0 11/5/25 at 11:49pm Pain level 0 Record review the Radiology Results report dated 11/8/25 revealed a finding of: Displaced distal femoral shaft fracture. Reviewed Record the Radiology Results report dated 11/8/25 revealed a finding of: Displaced distal femoral shaft fracture. On 11/10/25 at 3:33pm, a telephone interview with FM revealed on Wednesday evening 11/05/25, during a visit with CR #1, she was informed by CR#1 his left knee was hurting. FM observed the knee was noticeably swollen at which time she went to the nurses' station and spoke with LVN C, who had just arrived for her night shift (10pm-6am). FM stated she insisted LVN C come to CR#1's room to see his knee. After LVN C came to CR#1's room, FM removed the sheet exposing both knees, FM stated LVN C took a quick visual look (without touching), at both knees, then LVN C told FM that CR#1's knee looked okay to her and abruptly left the room. FM stated on Thursday 11/6/25, she telephoned the facility to let the nursing staff know CR#1 was still calling her and was still in a lot of pain. FM stated she could not recall the name of the person she spoke with, nor could she recall the time she called. FM stated on Friday, 11/07/25, CR#1 called and said his left knee was hurting so bad and no one had given him anything for pain. FM stated she called the facility and spoke with LVN A who told her he had given CR#1 a Norco pain medication. FM stated on Saturday, 11/08/2025 at 4:51pm, she received a call from LVN B indicating she was waiting for the doctor to return the call due to the result of CR#1's x-ray, which was a femur fracture, and she needed permission to send CR#1 out. FM stated it took the facility more than 2 hours before CR#1 was sent out to hospital. On 11/10/25 at 5:14pm, in an interview with LVN A, he stated he worked the 2:00pm - 10:00pm shift on 11/7/25 and CR#1 was assigned to him. LVN A stated CR#1 called for assistance and he went to CR#1's room. He stated CR#1 informed him his leg was hurting, and he was in pain. LVN A stated he observed CR#1's left knee and it was kind of swollen. He stated he completed an assessment and CR#1 stated the knee was painful when he touched it. LVN A stated at that time (2:27pm), he administered a PRN 325 mg Norco pain medication. LVN A stated he followed up with CR#1 who stated the Norco was not working and he was still in a lot of pain. LVN A stated at 3:41pm, he then administered 2-325mg Tylenol tablets. LVN A stated when he followed up with CR#1, he stated that he was still in pain. LVN A stated at 5:00pm, LVN stated he called the MD and NP that was assigned to CR#1 and did not get an immediate response. LVN A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455800 If continuation sheet Page 2 of 12 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 11/17/2025 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some stated he waited over an hour for a call back before texting the afterhours NP services, which took an additional hour to receive a call back from the on-call NP who gave an order to call for an x-ray on CR#1's knee area. LVN A stated he called the mobile x-ray company the facility used, and they never arrived. He stated at 8:00pm, they still hadn't arrived. LVN A stated he followed up with the x-ray company and was informed someone was enroute but was not given an ETA. LVN A stated when he informed CR#1 that an x-ray tech was coming to the facility to x-ray his knee, CR#1 stopped calling for help. LVN A stated he left the facility after 10:00pm and the mobile x-ray still had not arrived at the facility. He stated he did not call the MD or NP at this time. LVN A stated even though CR#1 had a stroke, he was cognizant and understood when they speak to him, and staff were aware of his needs. On 11/10/25 at 5:45pm, in an interview with LVN B, LVN B stated she only worked on the weekend. LVN B stated on 11/8/25, she was scheduled to work 6:00am - 2:00pm. However, she was late and arrived to work sometime after 6:30am. LVN B stated because she was late, she was unable to have a shift change from the 10:00pm-6:00am nurse, but the nurse left a note that CR#1 had x-rays and results were pending. LVN B stated around 9:30am, she observed a paper on the fax machine and when she looked at it, it was CR#1's x-ray report. She stated when she read it, she immediately called the on-call answering services and was waiting for doctor to give her a call back. LVN B stated she observed CR#1's knee with some mild swelling. The call back was around 5:00pm, which she was authorized to send CR#1 out to hospital. She stated she also called and texted the ADON after receiving authorization to send CR#1 out. She stated transportation took 2 hours to transport CR#1. On 11/10/25 at 7:40pm, in an interview with the HN, he stated CR#1 arrived in the ER on [DATE] at 7:30pm and the admittance diagnosis revealed a close displace spiral fracture of shaft left femur. The HN stated CR#1 had emergency surgery on 11/09/25 for an open reduction internal fixation and according to the doctor's notes, CR#1 needed to be in a skilled nursing facility for rehab. On 11/11/25 at 10:00am, during a follow-up interview, at the local hospital, CR#1 revealed while in the facility he kept pushing his call button because his left leg was in pain for a few days. CR#1 stated LVN A came to his room, and it felt like he twisted his leg in the knee area, and he screamed. CR#1 stated he was in a lot more pain. He stated LVN A gave him Norco, but it (pain) didn't get any better. CR#1 stated LVN A did not give him a Tylenol nor put bio freeze on his leg. CR#1 stated he kept calling his wife letting her know he was in a lot of pain. During a telephone interview on 11/11/25 at 1:00PM with the MD, it was revealed he read the x-ray, and it showed CR#1 had a spiral fracture. He stated the spiral fracture could have been a result of a fall, someone twisting the knee or being mishandled or several other fractures. MD stated he could not say the fracture was the result of abuse because there were many factors that could cause this. However, CR#1was bedbound. During a telephone interview on 11/11/25 at 3:13pm with the RD. it was revealed the mobile x-ray records showed that on 11/7/25, a routine order was created for CR#1 at 4:51pm. On 11/8/25 at 6:33am, a fax was sent to the facility regarding CR#1's diagnosis of the spiral fractured femur (occurs when a long bone is broken by twisting force). The RD reported that an electronic medical record, which was part of point click care (nursing notes), was also submitted to CR#1's dashboard. During a telephone interview on 11/12/25 at 11:34am with CNA A revealed on 11/8/25 between 3:00pm - 4:00pm while providing care to CR#1, he told her he was experiencing pain on his, she believed, right side. She told her charge nurse, who said it was being handled. She stated she could not remember the nurse's name. In an interview on 11/12/25 at 1:27pm, DON, it was revealed she was initially notified of the Change in Condition on Saturday 11/8/25 regarding CR#1's leg being swollen. DON stated it was a common courtesy to notify her of a change in condition, but not all staff do it. The DON stated it should be a waiting period of 30 minutes to an hour, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455800 If continuation sheet Page 3 of 12 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 11/17/2025 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some depending on doctor's orders, to administer additional pain medication after asking a resident if their pain has increased or decreased. The DON stated in her professional opinion, CR#1's change of condition should have been noted on 11/7/25 at 3:41pm when CR#1's pain level was 8, and the MD should have been notified at that same time. The DON stated the x-ray report did come into the facility fax machine at 6:33am and it was also in the electronic health record located on CR#1's dashboard. She stated when nursing staff signed in to the resident file, the dashboard immediately showed an alert and anything new or out of the ordinary was there. The DON stated it should not have taken 13 hours after the x-ray was noted to send CR#1 out. The DON stated CR#1 should have been sent out via 911 if transportation had taken more than 4 hours. The DON stated the situation with CR#1 could have been handled better and staff dropped the ball. DON stated the negative outcome could have been continued pain and an adverse reaction that could have caused death. On 11/15/25 at 8:23am, an interview with LVN C, revealed that she worked 11/5/25 and did speak with FM regarding CR#1's leg. LVN C stated she looked at both legs for a comparison since FM stated CR#1 was in pain and had a swollen knee. LVN C stated she asked the resident if he was in pain and he said no. She stated she did palpitations (pressing on his left leg with her fingers) to see the blood flow in that area. LVN C stated CR#1 pointed at his knee. She stated she asked CR#1 if he mentioned his knee to the nurse on 2p -10p, and he stated he did not. LVN C stated she didn't document, because she had just came on shift and it slipped her mind. She stated she did not normally work with CR#1 and that side was unfamiliar to her. LVN C stated she believed she should have documented immediately. LVN C stated the negative outcome was she learned CR#1 had a fracture and was in pain and his pain should have been addressed. An additional negative outcome was she failed to complete a change in condition, which also delayed CR#1's treatment and left other nursing staff uninformed. On 11/17/25 at 10:40am, during a telephone interview with NP, he stated he should have been called immediately. He stated he didn't work the weekend. However, the NP should have been notified after administering Norco. The NP stated for an acute fracture that CR#1 had, he should have been sent out within two hours of receiving the results of the x-ray. NP stated if transportation took longer than 2 hours, then CR#1 should have been sent out in emergency transportation. Record review of the Notifications of Changes policy dated August 2024 reflected: Compliance Guidelines:The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification.Circumstances requiring notification include: 1.Accidents Resulting in injury. Potential to require physician intervention.2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status.This may include: Life-threatening conditions, or Clinical complications. Circumstances that require a need to alter treatment.This may include: A. New treatment. B. Discontinuation of current treatment due to:S Adverse consequences.S Acute condition.S Exacerbation of a chronic condition. An Immediate Jeopardy (IJ) was identified on 11/13/2025. The IJ template was provided to the facility (administrator) on 11/13/2025 at 1:00pm.and Plan of Removal requested. Review of the facility's Plan of Removal reflected: FACILITY: SURVEY TYPE: Complaint Survey ABATEMENT PLAN: F580 Notify of Changes 11/13/25 Plan to remove immediate jeopardyThe facility failed to meet one or more state health, safety, and/or quality regulations. F-580 Notify of ChangesThe facility failed to ensure CR#1 was free from neglect. CR #1 is currently in the hospital. On 11/13/25: DON and Unit Manager provided education to Charge nurses to immediately assess residents with a reported change of condition. Charge nurses, CNA's and Med Aides were educated that pain is a clinical change that requires immediate assessment and timely physician notification. Charge nurses were instructed to conduct and document a Pain Assessment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455800 If continuation sheet Page 4 of 12 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 11/17/2025 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Notify the PCP immediately when a resident exhibits new or worsening pain or when contributes to a suspected change in condition. DON or designee (Unit Manager or Administrator) are to be notified of a change in condition. Implement and document physician orders in PCC. Reassess pain within one hour of pain medication and document effectiveness, if applicable.Change of Condition E-Interact UDA in PCC will be completed upon determination a change in condition has occurred. Residents with a change of condition will be noted on the 24-hour report for oncoming shifts. DON or designee will review the 24-hour report and nurses' notes daily to ensure: Change of conditions identified, Pain Assessments were completed, The PCP was notified when pain or other symptoms indicated a change in condition, and Orders were implemented and followed.On 11/13/25: Charge nurses were educated when receiving new x-ray results, they are to: Notify the practitioner immediately, Notify DON or designee (Unit Manager or Administrator), Document notification in PCC, Enter and new orders in PCC, If the PCP cannot be reached and results indicate a fracture, the resident is to be sent out to the ER immediately for emergency evaluation.On 11/13/25 Charge nurses were further instructed that pain associated with suspected fractures, injuries, or clinical decline must be reported immediately to the PCP and should not wait for the next shift or routing rounding.All residents have the potential to be affected by this alleged deficient practice. On 11/13/25 all residents were assessed for a change of condition, including assessment for new or worsening pain, by the DON and Unit Managers. Any noted changes of condition - including pain related changes - will be reported to the PCP immediately, Change of Condition E-Interact UDA will be completed in PCC, 24 Hour report will be updated and family notified. No changes in condition noted during the assessments, all assessments completed.The facility will provide education regarding reporting recognition of chance of condition, including pain, and immediate reporting to the PCP to all licensed nurses upon hire, as well as ongoing on a monthly basis for a minimum of 6 months. This education includes: Completing and documenting Pain Assessments, Notifying the PCP promptly for any unrelieved, new or worsening pain, Documenting PRN pain medication response, Understanding when pain represents a significant change in condition.Charge Nurses, CNA's and Med Aides will be required to have training on change of condition and proper reporting, including pain recognition and escalation, prior to assuming resident care responsibilities and will not be allowed to work their next scheduled shift until training is completed.The process outlined above was reviewed by the Director of Nursing, Nursing Home Administrator and Medical Director during an Ad Hoc QAPI meeting on 11/13/25. The medical director was involved with the review and the plan of removal. The Administrator will be responsible for monitoring the above actions for compliance which will be an ongoing process. The Administrator will ensure the plan is completed in full by 11/13/25.Charge Nurses, CNA's and Med Aides will not be allowed to work next shift without in-service. On 11/14/25 at 8:00am the Monitoring Began. All In-service sign-in sheets were requested and reviewed. Interviews were conducted on 11/14/25 through 11/15/25 on all shifts with Admin, DON, RC (physical therapy). LVN D and LVN E (6a-2p shift), LVN F (6a-2p and 2p-10p shifts), CMA A and CMA B (6a-2p & 2p-10p shifts), CNA B (6a-2p shift), LVN G (2p-10p shift), CNA C and CNA D (2p-10p shift), LVN H and LVN I (2p-10p shift), RN (10p-6a shift), CNA E and CNA F (10p-6a shift), LVN J (10p-6a shift) and LVN C (All shifts) to verify the in-services and competencies had been conducted, and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material and expectations. All the staff interviewed were able to explain what constituted residents' change in condition that may be pain or anything new that happened to a resident. The nursing staff revealed that a notification to the MD/NP/Admin/DON and Unit Mangers and family were required. Each nursing staff were able to explain the pain assessment process on verbal and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455800 If continuation sheet Page 5 of 12 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 11/17/2025 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete non-verbal residents and how to assess both. In the non-verbal resident a facial expression of grimacing, moaning or groaning during the physical assessment. They were able to explain the importance of documentation of all medications, even the PRN medications. Each nurse was able to explain when to send a resident out without authorization in an emergency. The nurses indicated that residents should be sent out if there was a fall, bleeding, a resident was on anticoagulants and if there was a break in the limbs. Each staff member relayed the importance and process for accurate documentation. The CNAs and CMAs were able to explain the Stop N Watch procedure, completing their documentation in the POC (plan of care) as well. Both were to immediately notify charge nurses when a resident appeared different than normal. All staff were able to identify three types of Neglect and give an example of Neglect. 11/15/25 at 1:00am IJ Lowered Administrator and DON notified. On 11/17/25 at 1:08pm, during an interview with the Admin, she stated she became aware of CR#1 hospitalization on 11/10/25 and was informed by nursing staff that CR#1 was in the hospital because it was medically related. Admin stated she started the Self Report on 11/10/25. The Admin started the IJ's have taught her to be more thorough in looking at systems in place and talking with families more. Admin stated if she had had a relationship with FM this issue may have been eliminated, and she may have known about CR#1's injury sooner. Admin stated the process now is to send residents out immediately if there is a suspected injury, communication forms to unit manager, DON and herself. She stated there are now systems in place to eliminate these issues in the future. An Immediate Jeopardy (IJ) was identified on 11/13/2025 at 4:34 p.m. While the IJ was removed on 11/15/2025 at 1:00am, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a pattern identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. Event ID: Facility ID: 455800 If continuation sheet Page 6 of 12 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 11/17/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the residents' choices for 1 of 10 residents (CR# 1) reviewed for quality of care. 1. The facility failed to immediately seek medical guidance or send CR#1 out for higher level of care (ER) after receiving results of CR#1's x-ray, which revealed a Left Displaced distal femoral shaft spiral fracture . 2. The facility failed to notify the physician or NP of CR#1's change in condition, failed to monitor, and complete assessments on 11/5/25 and 11/6/25. 3. The facility failed to immediately transport CR#1 to the hospital on [DATE] after becoming aware of the result of an xray, which reflected an acute fracture. The facility waited approximately 13 hours to transport CR#1 to the hospital, where CR#1 was diagnosed with a spiral fracture of his femur and required emergency surgery. These failures could place residents at risk for continued pain, serious injuries, harm and death to residents who require total supervision. An Immediate Jeopardy (IJ) was identified on 11/13/2025. The IJ template was provided to the facility (administrator) on 11/13/2025 at 1:00pm. While the IJ was removed on 11/15/2025 at 1:00am, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems.Findings included: Reviewed Record of CR#1's undated face sheet, revealed CR#1 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with active diagnosis of non-Alzheimer's Dementia (decline in cognitive function), and stroke (loss of blood flow in the brain). Reviewed Record of CR#1's Quarterly MDS (resident assessment) dated 8/11/2025 revealed CR#1's BIMS score of 00 indicated CR#1's cognition is severely impaired. The MDS further revealed CR#1 had severely impaired vision, he uses a wheelchair mobility resident totally dependent on staff for eating, oral and toileting hygiene, shower/bathing, upper and lower body dressing, personal care, and sit to lying in bed. Reviewed Record of CR#1's care plan dated 7/28/25 revealed the following:Focus: Resident has an alteration in hematological (clotting problem) status r/t receiving anticoagulant (Date Initiated: 7/21/25 and Revision 11/10/25).Goal: The resident will remain free of complications related to altered hematological (clotting problem) status through the review date (Date Initiated: 7/21/25, Revision date: 11/10/25, and Target date: 1/12/26).Interventions: Complete fall risk assessment and increase vigilance for falls (Date initiated: 7/21/25). Reviewed Record of CR#1's orders dated 7/28/25 revealed:-CR#1 is to be assessed for pain every shift (order dated 7/28/25 at 5:59pm-D/C dated 11/10/25 at 9:55am); PRN (as needed) -Acetaminophen (Tylenol) oral table 325 MG- Give 2 tablet by mouth every 6 hours as needed for pain/fever (order dated 7/28/25 at 5:59pm-D/C dated 11/10/25 at 9:55am); Norco (Narcotic pain medication) Tablet 7.5-325 MG (PRN as needed)-Give 1 tablet by mouth every 8 hours as needed for pain (order dated 7/28/25 at 5:59pm-D/C dated 11/10/25 at 9:55am); -Biofreeze Cool the pain external Gel to apply to affected areas for pain PRN (as needed) (order date 11/7/25 at 4:49pm-D/C 11/10/25 9:55am); x-ray to left femur, left knee, and left tibial/fibula once only for pain (order date 11/7/25 at 4:51pm-D/C 11/10/25 at 9:55am). Record Review of MAR dates of 11/5/25 11/8/25 revealed, CR#1 was administered pain medications on 11/7/25 only. Reviewed Record of CR#1'nursing notes dated 11/6/2025 thru 11/7/2025, revealed no nursing notes regarding CR#1's complaint of pain regarding his knee nor was there an assessment for the night shift on 11/6/2025. Reviewed Record of CR#1's nursing notes dated 11/7/25 at 2:27pm revealed CR#1 was administered Norco (325mg) for a swollen knee and pain level 8. The note on 11/7/25 at 3:41pm revealed CR#1 was administered 2-Tylenols (650mg total) for pain level 8. The Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455800 If continuation sheet Page 7 of 12 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 11/17/2025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some nursing notes on 11/7/25 created 5:46pm effective 5:00pm revealed LVN A noted a change in condition for CR#1 due to ineffective pain medication, and notification of NP was made. Record review of CR#1's pain assessment revealed the following: 11/7/25 at 8:07am Pain level 0 11/7/25 at 1:18pm Pain level 0 11/7/25 at 2:27pm Pain level 8 11/7/25 at 3:41pm Pain level 8 11/7/25 at 4:18pm Pain level 8 11/6/25 at 8:21am Pain level 0 11/6/25 at 2:26pm Pain level 0 11/6/25 at 10:51pm Pain level 0 11/5/25 at 8:37am Pain level 0 11/5/25 at 3:31pm Pain level 0 11/5/25 at 11:49pm Pain level 0 Record review the Radiology Results report dated 11/8/25 revealed a finding of: Displaced distal femoral shaft fracture. On 11/10/25 at 3:33pm in a telephone Interview with FM revealed on Wednesday evening 11/05/2025, during a visit with CR #1 she was informed by CR#1that his left knee was hurting. FM observed the knee was noticeably swollen at which time she went to the nurses' station and spoke with the LVN C who had just arrived for her night shift (10pm-6am). FM stated she insisted LVN C come to CR#1's room to see his knee. After LVN C came to CR#1's room, FM removed the sheet exposing both knees, FM stated LVN C took a quick visual look, without touching, at both knees, then LVN C told CR#1's knee looked okay to her and abruptly left the room. FM stated on Thursday 11/6/25, she telephoned the facility to let the nursing staff know CR#1 was still calling her and was still in a lot of pain. FM stated she could not recall the name of the person she spoke with, nor could she recall the time she called. FM stated on Friday, 11/07/25, CR#1 called and said his left knee was hurting so bad and no one had given him anything for pain. FM stated she called the facility and spoke with LVN A who told her he had given CR#1 a Norco pain medication. FM stated on Saturday, 11/08/25 at 4:51pm, she received a call from LVN B indicating she was waiting for the doctor to return the call due to the result of CR#1's x-ray, which was a femur fracture, and she needed permission to send CR#1 out. FM stated it took the facility more than 2 hours before CR#1 was sent out to hospital. On 11/10/25 at 5:14pm in an Interview with LVN A he stated he worked the 2:00pm - 10:00pm shift on 11/7/25 and CR#1 was assigned to him. LVN stated CR#1 called for assistance and he went to CR#1's room. He stated CR#1 informed him his leg was hurting, and he was in pain. LVN A stated he observed CR#1's left knee and it was kind of swollen. He stated he completed an assessment and CR#1 stated the knee was painful when he touched it. LVN A stated at this time (2:27pm) he administered a PRN 325mg Norco pain medication. LVN A stated he followed up with CR#1 who stated the Norco was not working and he was still in a lot of pain. LVN A stated at 3:41pm he then administered 2-325mg Tylenol tablets. LVN A stated he followed up with CR#1 and was informed that he was still in pain. LVN A stated at 5:00pm, he called the MD and NP that is assigned to CR#1 and waited over an hour for a call back. LVN A stated he texted the NP after hours service and after an hour received a call back from the on-call NP who gave an order to call for an x-ray on CR#1's knee area. LVN A stated he called the mobile x-ray company the facility uses, and they never arrived. He stated at 8:00pm they still hadn't arrived. LVN A stated he followed up with the x-ray company was informed someone was enroute but was not given an ETA. LVN stated when he informed CR#1 that an x-ray tech was coming to the facility to x-ray his knee, CR#1 stopped calling for help. LVN stated he left the facility after 10:00pm and the mobile x-ray still had not arrived at the facility. He stated he did not call the MD or NP at this time. LVN A stated even though CR#1 has had a stroke he is cognizant and understands when you speak to him and staff are aware of his needs. On 11/10/25 at 5:45pm in an interview with LVN B regarding CR#1. LVN B stated she only works on the weekend. LVN B stated on 11/8/25 she was scheduled to work 6:00am - 2:00pm; however, she was late and arrived to work sometime after 6:30am. LVN B stated because she was late she was unable to have a shift change from the 10:00pm-6:00am nurse, but the nurse left a note that CR#1 had x-rays and results were pending. LVN B stated around 9:30am she observed a paper on the fax machine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455800 If continuation sheet Page 8 of 12 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 11/17/2025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some and when she looked at it it was CR#1's x-ray report. She stated when she read it, she immediately called the on-call answering services and was waiting for doctor to give her a call back. LVN B stated she observed CR#1's knee with some mild swelling. The call back was around 5:00pm, which she was authorized to send CR#1 out to hospital. She stated she also called and texted the ADON after receiving authorization to send CR#1 out. She stated transportation took 2 hours to transport CR#1. Observation and interview on 11/10/25 at 7:00pm at the local hospital of CR#1 where CR#1 was lying in hospital bed. CR#1 initially stated that LVN A was rough with him and admitted he gave him pain medications. However, CR#1 began to fall asleep, at which time No further information could have been gathered regarding CR#1's injury at that time. On 11/10/25 at 7:40pm in an interview with HN who stated CR#1 arrived in the ER on [DATE] at 7:30pm and the admittance diagnosis revealed a close displace spiral fracture of shaft left femur. NH stated CR#1 had emergency surgery on 11/09/2025 for an open reduction internal fixation and according to the doctor's notes, CR#1 needed to be in a skilled nursing facility for rehab. On 11/11/25 at 10:00am during a follow-up interview, at the local hospital, CR#1 revealed while in the facility he kept pushing his call button because his left leg was in pain for a few days. CR#1 stated LVN A came to his room, and it felt like he twisted his leg in the knee area, and he screamed. CR#1 stated he was in a lot more pain. He stated LVN A gave him Norco, but it (pain) didn't get any better. CR#1 stated LVN A did not give him a Tylenol nor put bio freeze on his leg. CR#1 stated he kept calling his wife letting her know he was in a lot of pain. During a telephone interview on 11/11/25 at 1:00PM with MD it was revealed he read the x-ray, and it showed CR#1 had a spiral fracture. He stated the spiral fracture could have been a result of a fall, someone twisting the knee or being mishandled or several other fractures. MD stated he can't say the fracture was the result of abuse because there are many factors that could cause this; however, CR#1 is bedbound. During a telephone interview on 11/11/25 at 3:13pm with DR it was revealed the mobile x-ray records show that on 11/7/25 a routine order was created for CR#1 at 4:51pm. On 11/8/25 at 6:33am a fax was sent to the facility regarding CR#1 diagnosis of the spiral fractured femur (occurs when a long bone is broken by twisting force). The DR reported that an electronic medical record, which is part of point click care (nursing notes), was also submitted to CR#1's dashboard. During a telephone interview on 11/12/25 at 11:34am with CNA A revealed on 11/8/2025 while providing care to CR#1 told her he was experiencing pain on his, she believes, right side. She told her charge nurse who said it was being handled. She stated she could not remember the nurse's name. In an interview on 11/12/25 at 1:27pm with the DON revealed she was initially notified of the Change in Condition on Saturday 11/8/25 regarding CR#1's leg being swollen. The DON stated it is a common courtesy to notify her of a change in condition, but not all staff do it. The DON stated it should be a waiting period of 30 minutes to an hour, depending on doctor's orders, to administer additional pain medication after asking a resident if their pain has increased or decreased. The DON stated in her professional opinion, CR#1's change of condition should have been noted on 11/7/25 at 3:41pm when CR#1 pain level was 8, and the MD should have been notified at this same time. The DON stated the x-ray report did come in to the facility fax machine at 6:33am and it was also on the PCC dashboard. She stated when nursing staff sign in to the resident file, the dashboard immediately shows an alert and anything new or out of the ordinary is there. The DON stated it should not have taken 13 hours after the x-ray was noted to send CR#1 out. DON stated CR#1 should have been sent out 911 if transportation had taken more than 4 hours. The DON stated the situation with CR#1 could have been handled better and staff dropped the ball. DON stated the negative outcome could have been continued pain and an adverse reaction that could have caused death. On 11/15/25 at 8:23am in an interview with LVN C it was revealed that she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455800 If continuation sheet Page 9 of 12 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 11/17/2025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some worked 11/5/25 and did speak with FM regarding CR#1's leg. LVN C stated she looked at both legs for a comparison since FM stated stated CR#1 was in pain and had a swollen knee. LVN C stated she asked the resident if he was in pain and he said no. She stated she did palpitations (pressing on his left leg with her fingers) to see the blood flow in that area. LVN C stated the CR#1 pointed at his knee. She stated she asked CR#1 if he mentioned his knee to the nurse on 2p -10p and he stated he did not. LVN C stated she did not document, because she had just came on shift and it slipped her mind. She stated she does not normally work with CR#1 and this side was unfamiliar to her. LVN C stated she believes she should have documented immediately. LVN C stated the negative outcome was she learned CR#1 had a fracture and was in pain and his pain should have been addressed. Additional negative outcome was she failed to complete a change in condition, which also delayed CR#1's treatment and left other nursing staff uninformed. On 11/17/25 at 10:40am during a telephone interview with NP he stated he should have been called immediately. He stated he doesn't work weekends; however, NP should have been notified after administering the Norco. NP stated for an acute fracture that CR#1 had, he should have been sent out within two hours of receiving the results of the x-ray. NP stated if transportation would take longer than 2 hours, then CR#1 should have been sent out in emergency transportation. On 11/17/25 at 1:08pm during an interview with Admin stated she became aware of CR#1 hospitalization on 11/10/25 and was informed by nursing staff that CR#1 was in the hospital because it was medically related. Admin stated she started the Self Report on 11/10/25. The Admin started the IJ's have taught her to be more thorough in looking at systems in place and talking with families more. Admin stated if she had had a relationship with FM this issue may have been eliminated, and she may have known about CR#1's injury sooner. Admin stated the process now is to send residents out immediately if there is a suspected injury, communication forms to unit manager, DON and herself. She stated there are now systems in place to eliminate these issues in the future. Record review of the Facility's Provision of Quality-of-Care policy (dated: October 2022 revision) reflected:1. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being.2. Qualified persons will provide the care and treatment in accordance with professional standards of practice, the resident's care plan, and the resident's choices. An Immediate Jeopardy (IJ) was identified on 11/13/2025 at 4:34 p.m. While the IJ was removed on 11/15/2025 at 1:00am, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a pattern identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. Review of the facility's Plan of Removal reflected: FACILITY: SURVEY TYPE: Complaint Survey ABATEMENT PLAN: F684 Quality of Care 11/13/25Plan to remove immediate jeopardy Noncompliance: The facility failed to meet one or more state health, safety, and/or quality regulations. F-684 Quality of CareThe facility failed to ensure CR#1 received treatment and are in accordance with professional stances of practice. CR #1 is currently in the hospital. On 11/13/25:DON and Unit Manager provided education to Charge nurses to immediately assess residents with a reported change of condition. Charge nurses, CNA's and Med Aides were educated that pain is a clinical change that requires immediate assessment and timely physician notification. Charge nurses were instructed to conduct and document a Pain Assessment. Notify the PCP immediately when a resident exhibits new or worsening pain or when contributes to a suspected change in condition. DON or designee (which will be the Unit Manager or Administrator), will be notified of a change in condition. Implement and document physician orders in PCC. Reassess pain within one hour of pain medication and document effectiveness, if applicable.Change of Condition E-Interact UDA in PCC will be completed upon determination a change in condition has occurred. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455800 If continuation sheet Page 10 of 12 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 11/17/2025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Residents with a change of condition will be noted on the 24-hour report for oncoming shifts. DON or designee will review the 24-hour report and nurses' notes daily to ensure: Change of conditions identified, Pain Assessments were completed, The PCP was notified when pain or other symptoms indicated a change in condition, and Orders were implemented and followed.On 11/13/25:Charge nurses were educated when receiving new x-ray results, they are to: Notify the practitioner immediately, Notify DON or designee (Unit Manager or Administrator) Document notification in PCC, Enter and new orders in PCC, If the PCP cannot be reached and results indicate a fracture, the resident is to be sent out to the ER immediately for emergency evaluation.On 11/13/25 Charge nurses were further instructed that pain associated with suspected fractures, injuries, or clinical decline must be reported immediately to the PCP and should not wait for the next shift or routing rounding. All residents have the potential to be affected by this alleged deficient practice. On 11/13/25 all residents were assessed for a change of condition, including assessment for new or worsening pain, by the DON and Unit Managers. Any noted changes of condition including pain related changes - will be reported to the PCP immediately, Change of Condition E-Interact UDA will be completed in PCC, 24 Hour report will be updated and family notified. No changes in condition noted during the assessments, all assessments completed.The facility will provide education regarding reporting recognition of chance of condition, including pain, and immediate reporting to the PCP to all licensed nurses upon hire, as well as ongoing on a monthly basis for a minimum of 6 months. This education includes: Completing and documenting Pain Assessments, Notifying the PCP promptly for any unrelieved, new or worsening pain, Documenting PRN pain medication response, Understanding when pain represents a significant change in condition.Charge Nurses, CNA's and med Aides will be required to have training on change of condition and proper reporting, including pain recognition and escalation, prior to assuming resident care responsibilities and will not be allowed to work their next scheduled shift until training is completed.The process outlined above was reviewed by the Director of Nursing, Nursing Home Administrator and Medical Director during an Ad Hoc QAPI meeting on 11/13/25. The medical director was involved with the review and the plan of removal. The Administrator will be responsible for monitoring the above actions for compliance which will be an ongoing process. The Administrator will ensure the plan is completed in full by 11/13/25.Charge Nurses, CNA's and Med Aides will not be allowed to work next shift without in-service. On 11/14/25 at 8:00am the Monitoring Began. All In-service sign-in sheets were requested and reviewed. Interviews were conducted on 11/14/2025 through 11/15/2025 on all shifts with Admin, DON, RC (physical therapy). LVN D and LVN E (6a-2p shift), LVN F (6a-2p and 2p-10p shifts), CMA A and CMA B (6a-2p & 2p-10p shifts), CNA B (6a-2p shift), LVN G (2p-10p shift), CNA C and CNA D (2p-10p shift), LVN H and LVN I (2p-10p shift), RN (10p-6a shift), CNA E and CNA F (10p-6a shift), LVN J (10p-6a shift) and LVN C (All shifts) to verify the in-services and competencies had been conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material and expectations. All the staff interviewed were able to explain what constitutes residents' change in condition that may be pain or anything new that has happened to a resident. The nursing staff revealed that a notification to the MD/NP/Admin/DON and Unit Mangers and family is required. Each nursing staff were able to explain the pain assessment process on verbal and non-verbal residents and how to assess both. In the non-verbal resident a facial expression of grimacing, moaning or groaning during the physical assessment. They were able to explain the importance of documentation of all medications, even the PRN medications. Each nurse was able to explain when to send a resident out without authorization in an emergency. The nurses indicated that residents should be sent out if there is a fall, bleeding, a resident is on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455800 If continuation sheet Page 11 of 12 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 11/17/2025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety anticoagulants and if there is a break in the limbs. Each staff member relayed the importance and process for accurate documentation. The CAN's and CMA were able to explain the Stop N Watch procedure, completing their documentation in POC (plan of care) as well. Both are to immediately notify charge nurses when a resident appears different than normal. All staff were able to identify three types of Neglect and give an example of Neglect. 11/15/25 at 1:00am IJ Lowered Administrator and DON notified. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455800 If continuation sheet Page 12 of 12