Health inspection·October 27, 2023

F 0644 negative for mental illness. Level of Harm - Minimal harm or potential for actual harm Review of Resident #3's clinical records revealed there was no documented request to have Resident #3 further evaluated by local authorities for mental illness due to her diagnoses of schizophrenia and major depressive disorder. Residents Affected - Few Resident #41 Record review of Resident #41's Face Sheet dated 10/25/2023 revealed a [AGE] year-old man admitted on [DATE]. The face sheet documented his diagnoses included cerebrovascular disease (conditions that affect blood flow to the brain), dysphagia (difficulty swallowing), hemiplegia (paralysis of one side of the body), cerebellar stroke syndrome (blocked blood vessel or bleeding causing a complete interruption to a portion of the cerebellum), hypertension (high blood pressure), type 2 diabetes mellitus (condition results from insufficient production of insulin, causing high blood sugar), hypothyroidism (condition resulting from decreased production of thyroid hormones), anxiety disorder (fear characterized by behavioral disturbances), hyperlipidemia (high cholesterol), major depressive disorder (disorder having episodes of psychological depression), bipolar disorder (mental illness characterized by extreme mood swings), insomnia (trouble falling and/or staying asleep), conversion disorder (condition in which a person experiences blindness, paralysis or other nervous system symptoms that cannot be explained by illness or injury), and psychotic disorder (mental disorders that cause abnormal thinking, perceptions, and loss of reality)with hallucinations (false perception of objects involving the senses). Record review of Resident #41's diagnoses report dated 10/25/2023, revealed his bipolar disorder and conversion disorder with seizures were identified as an active diagnosis on 3/27/2017. The report documented his anxiety, major depressive disorder, psychotic disorder, and insomnia were all diagnosed on [DATE]. Record review of Resident #41's quarterly MDS dated [DATE] with an ARD of 9/9/2023 revealed a BIMS score of six, indicating a significant cognitive impairment. The MDS documented he had no potential indicators of psychosis, behaviors affecting others, behaviors affecting others, and/or wandering behaviors. Per the MDS, Resident #41 required limited one person assistance with bed mobility, transfers, walking, locomotion, dressing, toileting, and personal hygiene. The MDS revealed he was diagnosed with anxiety disorder, depression, bipolar disorder, and psychotic disorder. The MDS documented Resident #41 was prescribed and administered an antidepressant medication. Record review of Resident #41's undated Care Plan revealed a focus on his medications for depression and insomnia with interventions including monitoring for mood or behavior problems, medication administration, monitoring for side effects of the medications, assessing the effectiveness of the medications, and provision of a psychiatric consultation as needed. Record review of Resident #41's medication report dated 10/25/2023 revealed by prescriptions for Zoloft (medication used to treat depression, panic attacks, obsessive compulsive disorder, and/or social anxiety disorder) 50mg tablet one time daily, Melatonin (over the counter medication used to treat insomnia) 3mg tablet one tablet at bedtime, Trileptal (medication used to treat seizure disorders) 150mg tablet one tablet every twelve hours, and Neurontin (medication used to prevent and control seizures) 300mg capsule one capsule every twelve hours. Record review of Resident #41's PASRR Level 1 Screening document dated 5/17/2023 revealed a no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675423 If continuation sheet Page 2 of 8 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 675423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashford Gardens 7210 Northline Dr Houston, TX 77076 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few answer to questions C0100 which read Is there evidence or an indicator this is an individual that has a Mental Illness. The facility did not provide any additional PASRR documentation for Resident #41's later MI diagnoses. Record review of Resident #41's Psychiatric Initial assessment dated [DATE] revealed he was evaluated for depression. The assessment documented he endorsed symptoms of sad moods and fatigue. Per the assessment, Resident #41 would continue his use of Zoloft and Trileptal. The assessment revealed the Zoloft was used to treat his depression and the Trileptal was used to decrease possible aggression and/or self-harm behaviors, decrease psychotic symptoms, and avoid inpatient treatment. On10/24/23 at 09:05 AM, during an attempted interview, the Resident #41 appeared agitated and upset, he was unable to communicate effectively. Observation on 10/26/2023 at 11:04 AM, revealed Resident #41 was lying in his bed. Resident #41 got up and sat down in a chair. Resident #41 was unable to communicate effectively. Resident #41's responses to all questions were yes, no, or everything. Resident #41 wrote on a notebook but while the words were legible, they were unintelligible. Resident #41 appeared to be in a better mood and pointed to religious pictures on his wall and smiled. Resident #41 also pointed out the religious music coming from his computer and smiled. Interview on 10/26/2023 at 8:54 AM with the Admin, she said they had no other documentation for PASRR for Resident #3, Resident #41, or Resident #47 other than their original PASRR 1 documents. The Admin said she did not know why there was no other documentation related to PASRR for those residents, or if their new diagnoses should have triggered a new PASRR, but they had no other PASRR information. The Admin said those diagnose fell through the cracks. Interview on 10/26/2023 at 9:12 AM, with the MDS RN and the MDS LVN revealed the MDS RN had been employed since April of 2023 and the MDS LVN had been employed since March of 2022. The MDS LVN said his primary duties were to complete the MDS assessments and care plans. The MDS RN said her primary duties were to complete the skilled nursing resident and Medicare resident MDS assessments. The MDS LVN said they did not complete the PASRR assessments or have any responsibility for PASRR. The MDS LVN said PASRR was completed by the facility's SW. Interview on 10/26/2023 at 9:33 AM, with the SW revealed she had been employed by the facility as the Director of Social Services for one year. The SW said her primary duties included discharge planning and coordination, care plan meeting coordination, PASRR, responding to resident concerns, and scheduling appointments with the podiatrist, psychiatrist, optometrist, and/or dentist for residents. The SW said she receives the PASSR 1 from the admitting facility for a resident, and she uploaded the completed PASSR 1 into the electronic system. The SW said [NAME] County then reviewed the PASSR 1 to determine if a resident qualified for additional services provided by the county. The SW said she had just learned that if a resident who admitted to the facility with a negative PASRR 1 was diagnosed with a qualifying concern, that resident should have a new PASRR 1 completed. The SW said she would be reviewing the diagnoses for all the residents in the facility to determine if any required a new PASSR 1 due to new qualifying diagnoses. The SW said she completed an online training related to PASRR in the past, but the training did not present any materials related to a resident with a new qualifying diagnoses. The SW said she still should have been aware that residents required a new PASRR 1 with a new qualifying diagnosis. The SW said if a resident who had a qualifying diagnosis did not have a new PASRR 1 completed, that resident would not receive services they were entitled to. The SW said the policy and procedure she adhered to was when she received the PASRR from the admission (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675423 If continuation sheet Page 3 of 8 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 675423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashford Gardens 7210 Northline Dr Houston, TX 77076 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few team provided her the PASRR information she uploaded it to the electronic system. The SW said that was the extent of her understanding of the facility's PASRR policy and procedure. The SW said she was going to review all the current residents' diagnoses for any qualifying diagnoses, and she would create new PASRR 1's for those residents. Resident #41 may have a qualifying diagnosis, but she was unsure. The SW said Resident #3 had a qualifying diagnosis. The SW said she would be reviewing all residents so she would determine if any residents had any qualifying diagnoses. Interview on 10/27/23 at 3:05 PM, DON B said the PASRR came from the hospital and the Social Worker put in the information. DON B said if there was another psych diagnosis, the facility would have to conduct another PASRR 1. Record review of the facility's undated PASRR policy revealed the PASRR was required to ensure residents with MI, ID, or DD were properly cared for. The policy documented the purpose of the PE was to evaluate residents to determine if they had MI, ID, or DD, the correct setting for the resident's care, and what services could be provided to the resident. Per the policy, if a resident was positive for MI, ID, or DD, the policy must contact the LIDDA and/or the LMHA within two days and schedule an IDT meeting with them to discuss specialized services for the resident within two days of notification of the diagnosis. The policy revealed a PASRR positive resident should begin receiving the therapeutic services within three business days of approval from HHSC. The policy documented the facility should update and print the Positive PASRR list and review it at least weekly, with positive PASRR residents reviewed at each weekly care coordination meeting with all IDT members present. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675423 If continuation sheet Page 4 of 8 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 675423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashford Gardens 7210 Northline Dr Houston, TX 77076 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 0790 Provide routine and 24-hour emergency dental care for each resident. 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 provide or obtain from an outside source routine dental service to meet 1 of 8 residents (Resident #34) reviewed for dental services. Residents Affected - Few The facility failed to provide dental services for Resident #34 who had loose teeth and a diagnosis of periodontal disease. This failure placed resident at risk for infection and unwanted hospitalization. Findings include: Record review of Resident #34's face sheet revealed a [AGE] year old male admitted to the NF on 12/23/2022 with diagnoses that included the following: adult neglect or abandonment, adult physical abuse, open-angle glaucoma (vision loss), chronic pain syndrome, hypertension (elevated blood pressure), and periodontal disease (gum disease). Record review of Resident #34's MDS dated [DATE] revealed that resident had a BIMS score of 15 indicating that resident cognition was intact. Record review of Resident #34's Nursing admission assessment dated [DATE] revealed that resident ate independently, good appetite, oral mucosa (inside surface of the mouth) intact, resident has own teeth no dentures, no active infection, and no specialized diet. Record review of Resident #34's Care Plan dated 09/14/2023 revealed that Resident #34 was being care planned for periodontal disease with an intervention that included schedule dental evaluation; arrange for follow-up care as indicated. Record review of Resident #34's History & Physical dated 12/27/2022 revealed that resident had dental caries (oral disease). Record review of Resident #34's Physician Orders revealed an order dated 12/27/2022 for a regular diet. Further review revealed an order dated 12/27/2022 may have dental care. Record review of Resident #34's weights revealed resident weight upon admission dated 12/23/2022 revealed 142lbs. with last weight documented on 03/01/2023 weight of 146lbs. Further review revealed that from the month of April 2023 to present resident refused to be weighed. Observation on 10/24/23 at 10:27 a,m,, Resident #34 was in room sitting up on the side of his bed. Further observation was made resident top front teeth were crooked and appeared to be rotten. Interview on 10/26/23 at 10:58 a.m., Resident #34 said he had a few loose teeth. Further interview with resident said sometimes it hurt for him to chew pending on the texture of the food and therefore chewed on the side of his mouth at times. Resident said he was admitted to the NF in December of 2022 and had not been seen by a Dentist. Resident #34 said the NF had not asked him if he wanted to see the Dentist. Interview on 10/26/23 at 11:55 a.m., the SW said the NF had a dental provider but would have to see (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675423 If continuation sheet Page 5 of 8 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 675423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashford Gardens 7210 Northline Dr Houston, TX 77076 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 0790 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few what insurance Resident #34 had. After the SW reviewed Resident #34's insurance and reviewed the list of residents being seen by the Dentist the SW said Resident #34 was not on the list to be seen by the Dentist. The SW said she would have to search for a dental provider that accepted Resident #34's insurance. The SW said she went by what the NF provided to her of what residents needed to be seen by the Dentist. The SW said conditions that would warrant a resident to be seen by the Dentist was if the resident was experiencing tooth pain, loose teeth, etc. The SW said she could not say why Resident #34 had not been assessed by the Dentist. Interview on 10/27/23 at 8:04 a.m., the MDS LVN said the resident (s) care was discussed in the morning meetings. The MDS LVN said he did not know who done Resident #34's care plan. The MDS LVN said he knew resident was being care planned for periodontal disease and refusing ADL's. The MDS LVN said when he assessed the residents upon admission, he also assessed their mouth as well. Interview on 10/27/23 at 9:35 a.m., DON A said she worked at the sister facility as the DON and was helping the facility out. DON A said all residents care were discussed in the morning meetings with all disciplinaries being present including the SW. DON A said if Resident #34 had not been thoroughly assessed, it would be missed. DON A said the nurses will only report to the doctor if the resident is complaining about something such as pain. DON A said the nurses was not thinking critically on the importance of dental care regarding periodontal disease. DON A said she had spoken with the NP regarding periodontal disease. DON A said the NP said that when a resident has periodontal disease and not being followed by dental services, it placed the resident at risk for weight loss as well as infections that could get into the blood stream which could affect the resident heart. Interview on 10/27/23 at 2:54 p.m., DON B said residents that are admitted to the NF are assessed for dental services by doing an assessment regarding oral health such as loose teeth, pain etc. DON B said a resident with the diagnosis of periodontal disease the NF should have attempted to have resident assessed by the Dentist. DON B said periodontal disease placed Resident #34 at risk for infections of some kind. Record review of a clinical note for Resident #34 dated 10/27/2023 documented by the NF SW revealed in part . Resident #34 has dental appointment scheduled . for Monday 10/30/2023 at 11:00am. Facility will provide transportation . Record review of the NF Policy on Routine Dental Care revised April 2007 revealed in part . each resident will receive routine dental care. The Nursing care staff will conduct ongoing health assessments to ensure that each resident receives adequate oral hygiene . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675423 If continuation sheet Page 6 of 8 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 675423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashford Gardens 7210 Northline Dr Houston, TX 77076 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on interview, record review and observation, the facility failed to ensure each resident was provided with food prepared by methods that conserve nutritive value, flavor, and appearance and is nourishing, palatable, attractive and at a safe and appetizing temperature for 1 of 1 kitchens in the facility. Residents Affected - Many -The facility failed to ensure the dessert cook prepared food according to the recipe and utilized all ingredients in the specified amounts which resulted in residents receiving food that did not have nutritive value and flavor. This failure had the potential to affect all facility residents who consumed food from the facility's kitchen. Findings include: Record review of the Week- at- a Glance Fall-Winter 23-24 Week 2 Menu revealed the lunch served on 10/24/23: Fried Chicken Steamed Broccoli Macaroni and Cheese Fruit Crisp Observation on 10/24/23 at 12:24 PM revealed approximately 25 residents in the upstairs dining area with fruit crisp on their lunch tray. No alternative dessert observed. Observation on 10/24/23 at 12:50 PM of a regular texture and a pureed texture test trays for the lunch meal period revealed both included a fruit crisp dessert except it was presented in pureed form on the pureed tray. Observed the crisp on the regular tray consisted of blueberry pie filling with 15 pieces of oats sprinkled on top and a few more pieces of raw oats suspended in the filling. Interview on 10/24/23 at 1:10 PM with the DM. He said that the dessert on the lunch test tray was a fruit crisp, and he said it was the same dessert that was served to the residents for lunch. He said that the DA C had started to prepare the wrong dessert because she thought she supposed to be making blueberry cobbler. He said when DA C realized she was making the wrong dessert, she threw out the crust and tried to hurry and make the crisp. He said he was not present that morning when DA C was making the dessert. Interview on 10/24/23 at 1:30 PM with DA C. She said that she prepared a blueberry crisp for lunch on 10/24/23. She said it was a crisp because it had oats on top, and she baked it in the oven. She said that she prepared the dessert by spraying a pan with butter, pouring in the blueberry filling, and sprinkling the fruit with oats and sugar. She said she could not confirm how much of which ingredient she used. She said that she is aware there is a recipe, but she did not follow it because she did not have all the ingredients. She said the crisp was supposed to have been made with apples, but she did not have any apples and substituted for blueberry. She said that she did not make the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675423 If continuation sheet Page 7 of 8 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 675423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashford Gardens 7210 Northline Dr Houston, TX 77076 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many topping per recipe because she did not have flour or brown sugar, and she said, to be honest half the oven is not heating like it should. DA C said if she were to prepare a dish but happened to be out of an ingredient, she would prepare a close substitution. She said failure to provide close substitutions could be that the residents don't get all the nutrition they are supposed to get. Observation on 10/24/23 at 1:45 PM revealed a large container of flour and 7 bags of brown sugar in the dry storage area. Observed 4 1lb sticks of margarine in walk-in- refrigerator. Record review of Crisp (Fruit Filling) recipe revealed the following ingredients were needed to make this dish: 2 #10 cans of Pie Filling, 3 cups of All Purpose Flour, 2 Cups of brown sugar, 1 quart of oatmeal, 2.5 cups of margarine. Interview on 10/24/23 at 1:45 PM with the DM. He confirmed with visual inspection and said that the facility had all the necessary ingredients to make the fruit crisp according to the recipe. He said that the oven works fine. He said failure to follow the recipes could result in residents receiving a lower quality or less appetizing food product as well as not getting all the nutrients they should get from that prepared food item. Interview on 10/24/23 3:00 PM, the Administrator said kitchen staff are expected to follow the recipe to ensure residents receive adequate nutrition. Interview on 10/26/23 at 11:10 am DA D. She said she has been working in her position for 3 months. She said that she follows a recipe to prepare her desserts and the cooks provide guidance as well. She said it is important to follow the recipe to make sure the residents get what they are supposed to. She said she received training upon hire and the cooks are readily available to provide guidance. Record review of Use of Recipes Policy dated September 15, 2006 read in part, . Recipes are to be used when preparing menu items . Procedure: . 3. Cooks are expected to use and follow the recipes provided . 5. Any problems the cooks have with recipes should be discussed with the Dietary Services Manager so that they can be resolved . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675423 If continuation sheet Page 8 of 8