Health inspection·October 25, 2025

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete that the resident had to have a doctor's order for the bed rails before using the rails. She said Resident #5 did not have an order for bed rails. She said the facility started using two bed rails on Resident #5's bed about a month ago. She said the rails were used on Resident #5 to keep her in the bed. She said the bed rails were not a restraint because the facility did not use all four rails. She said Resident #5 did not have a decline due to the bed rails being used. She said Resident #5 could advocate for herself. During an interview on 10/24/2025 at 1:03 p.m., RN O revealed she was trained on restraints. She said the facility had a procedure for the bed rails. She said the procedure was staff could use the rails for four hours at a time. She said the facility had to have a doctor's order to use the bed rails. She said the risk of using the bed rails was that the resident could get hurt. She said the benefits were that the resident could not get out of bed and fall. She said she was not sure who monitored to ensure the resident's had a doctor's order for the bed rails. She said she did not know when the staff started using the bed rails for Resident #5. She said she did not know why the bed rails were being used for Resident #5 without a doctor's order. During an interview with the DON on 10/25/2025 at 12:45 p.m., she said she and staff were trained on resident rights. She said the policy for bed rails was staff were to do an assessment on the resident, and if the facility was going to use bed rails staff needed to get a doctor's order. She said the facility did not utilize full bed rails. She said the facility used assist rails, and staff needed to get consent from the resident and the RP. She said she was not sure when staff started using the bed rails on Resident #5. She said for the half bed rails the facility needed a doctor's order. She said the nurse was responsible for monitoring to ensure the facility had orders for the half bed rails. She said a resident could get hurt if staff misused the bed rails. She said if the bed rails were used for the intended purpose, the resident could not get hurt. She said the bed rails assisted the resident and the staff. She said that Resident #5 required extensive assistance with her functional ability. She also said she dd not know how long the bed rails stayed up on Resident #5. She said she did not know why staff were using the bed rails on Resident #5. She said she thought the bed rails were used on Resident #5's bed so that Resident #5 could assist staff when rolling. Record Review of Restraint Free Environment Policy, dated 8/1/2025, revealed, It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical or chemical restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of such restraints. Physical restraints may be used in emergency care situations for brief periods to permit medically necessary treatment that has been ordered by a practitioner unless the resident has previously made a valid refusal of the treatment in question. Falls do not constitute self-injurious behavior or a medical symptom that warrants the use of a physical restraint. Event ID: Facility ID: 675423 If continuation sheet Page 2 of 9 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 10/25/2025 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 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish and follow a written policy on permitting residents to return to the facility after being hospitalized for 1 resident (Resident #1) of 5 residents reviewed for transfer/discharge. The facility failed to ensure Resident #1, was given his medication when he went out on pass. Resident #1 had behavior and mental illness issue that required medication. This failure could place residents at risk for serious injury, harm, and/or death due to lack of appropriate supervision.The findings included:Record review of Resident #1's, face sheet, dated 10/22/2025, revealed a [AGE] year-old male, admitted [DATE]. Resident #1's diagnosis included metabolic encephalopathy (reversable brain dysfunction caused by metabolic imbalances such as liver failure, kidney failure or severe electrolyte disturbances), psychosis (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality), schizophrenia (a chronic mental health condition characterized by a combination of symptoms that affect a person's thoughts, perceptions, emotions, and behavior), and schizoaffective disorder, bipolar type (mental health condition that causes extreme mood swings). Record review of Resident #1's entry MDS, dated [DATE], revealed a BIMS of 14 which indicated intact cognitive functions. The MDS revealed Resident #1 was a smoker.Record review of Resident #1 care plan, dated 08/18/2025, revealed Resident #1 was a smoker and at risk of injury with the following interventions, assisted to smoking area on request, check for burns (clothing, fingers, skin); report to the nurse. Keep matches/lighters at the Nurses Station. Perform smoking assessment according to facility policy. Post smoking schedule for residents to refer to facility smoking times.Record review on 10/22/25 of Resident #1's electronic medical record for smoking assessment and policy acknowledgement revealed Resident #1 did not have a smoking assessment uploaded to his medical records.During an interview with Resident #1's PCP on 10/24/2025 at 12:46 p.m., it revealed if Resident #1 left the facility without medications he was at risk for increased psychotic episodes and may have increased hallucinations. She stated he would not be safe in making any type of judgements for himself. PCP stated he was not safe to be on the streets or anywhere without his medications being administered. She stated he did not have any homicidal or suicidal issues in the past, however, there was a possibility he may become homicidal or suicidal without the proper medication to treat his mental issues. During an interview with RN O on 10/24/2025 at 12:50 p.m., it was revealed that she had been trained on signing out on pass. She said the policy was the residents had to sign out when they were leaving the facility. She said when a resident leaves the facility overnight the nurse was supposed to give the resident their medication if the resident was cognitive. She said if the resident was going out on pass overnight with family the nurse was to give the medication and instructions to the family. She said if a resident does not have their medications when they are out on pass the resident could have become unstable from not having their medications. She said the nurse was responsible for ensuring the resident signed out on pass and give the resident his medication. She said she did not think Resident #1 was cognitive enough to follow the directions to take the medication. She said the nurses had to educate him on his medication for him to take them. She said the resident had been sent to the hospital in the past for his behavior. She said she did not think it was a good idea Resident #1 was out in the community without his medication. She said she believed Resident #1 might hurt himself or someone else. She said she did not know why Resident #1's medication was not sent with him. During an interview with the DON on 10/24/2025 at 1:12 p.m. it was revealed the policy was the residents were allowed to leave but they had to sign out before leaving. She also said that the residents were to sign back in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675423 If continuation sheet Page 3 of 9 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 10/25/2025 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 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete when they returned to the facility. She said that when the residents were going to sign out the resident was to notify the nurse. She also said the residents would have their medication sent with them. She said several things could happen. She also said the residents could have issues if they did not have their medication. She said the nurse was responsible for ensuring the resident signed out and the resident had their medication when they left. She said she did not know who monitored to ensure the signing out policy was being followed. She said she thought that Resident #1 left before the nurse was notified. She said she thought he was safe and functional. She also said she felt that Resident #1 needed his medication. Record review of Resident #1's progress notes from the SW dated 10/22/2025 revealed Resident #1 walked up to SW while I was standing at the Nursing station and asked why he was being held prisoner. SW explained that he is not being held prisoner. Resident #1 asked why he could not leave. SW explained that Resident #1 has the right to leave but SW would like to assist him with finding a safe location. Resident #1stated that he did not need the SW help and that he could return to his last place. Resident #1 then stated that he has money in the bank and did not need my help. Resident #1 then went to the BOM's office and said that he was leaving. The BOM tried to convince Resident #1 to stay and get some help finding a place and Resident #1 started yelling that he did not need any help and we did not have a reason to keep him here. Resident #1 then left out the front door. SW, Nurse Manager, Psychologist & BOM tried to convince resident to return the facility, but he refused. Although Resident #1has a right to leave with a BIMS of 14, SW will contact the non-emergency line to [NAME] (be on the lookout), for resident in case he needs assistance. Resident #1 has not done anything wrong, just wanted to ensure resident's safety.Record review of Signing Residents Out policy dated 8/2006 revealed that Each resident leaving the premises (excluding transfers/discharges) must be signed out. A sign-out register is located at each nurses' station. Registers must indicate the resident's expected time of return. Unless otherwise prohibited by law, medications that must be administered while the resident is out will be given to the resident/person signing the resident out. Written and/or oral instructions on when and how to administer the medication will be provided to the resident or to the person signing the resident out. Only medications that must be administered while the resident is out will be issued. Event ID: Facility ID: 675423 If continuation sheet Page 4 of 9 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 10/25/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed make sure that drugs are stored properly and only authorized persons have access for 5 of 5 medication carts (MC #1, MC #2, MC #3, OFMC #4, and MC #5) reviewed for drug storage and labeling.The facility failed to ensure MC #1, MC #2, MC #3, MC #4, MC #5, and OFMC #6 were locked, and medications were secured, and not accessible to other staff, residents, or visitors.This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications. Findings included:During an observation on 10/21/2025 at 8:56 a.m., of MC #5, revealed the MC was near the nurse's station on the second floor between 2300 hall and 2400 hall. MC #5's bottom drawer was not closed completely and was unlocked. The bottom drawer consisted of pain relief lidocaine patches, MiraLAX and other medications. MC #5 also had the reconciliation binder with information about residents and their medications. During an observation on 10/22/2025 at 4:10 p.m., MC #1 on 1300 hall was near the front of the right side of the hallway. MC #1 appeared to be locked but when surveyor pushed the lock downward on the MC. The MC was not locked, and the surveyor was able to open all the drawers on the MC. MC #1 had over the counter medications belonging to residents.During an observation on 10/22/2025 at 4:26 PM, MC #2 was toward the end of 1100 hall. The Surveyor touched the locking device on MC #2, when the surveyor touched the device the medication cart unlocked. During an observation on 10/23/2025 at 7:40 AM while entering the facility, MC #3, and OFMC #4 were unlocked. MC #3 was displaying the red on the MC that was visible when the MC was unlocked. MC #3 had residents' prescription drugs, and over the counter medications. The surveyor opened OFMC #3 and there was a resident's medication in the cart for nausea, vomiting, and needles for insulin, medical supplies, and enema. During an interview with CMA S on 10/21/25 at 9:15AM, it was revealed that CMA S did lock MC #5, but she did not notice the bottom drawer was not all the way closed before she locked MC #5. She said the medication carts were supposed to always be locked when not in use. She said if a medication cart was left unattended and unlocked residents and visitors could potentially get into them and take some medication that was stored in the medication cart. She said the medication aide and the nurses were responsible for ensuring the medication carts were locked. She said she overlooked the bottom drawer and thought the cart was locked. During an interview on 10/21/25 at 10:15 AM, the DON revealed all medication carts were to be always locked when not in use. She also said some medication carts needed to be repaired, and the issue was reported to the MS. She said the medication carts had a battery on the back of the cart and when the CMA's or nurses hit the medication cart against the wall sometimes, it would affect the battery, and the medication cart will not lock properly. She said she was not aware MC #1 and MC #2 were not locked properly. She said if a resident had taken medications there was a possibility a resident may have an allergic reaction to the medications or potentially harm the resident. She also said she could not know exactly what could happen to the resident because she would not know what medication the resident ingested. During an interview on 10/22/2025 at 4:05 PM, the MS revealed he had fixed some of the medication carts before. He said he also had replaced the batteries on the back of the medication carts. He said there were times the staff would bang the medication carts against the walls, and the batteries would get loose. He said because of the batteries coming loose, the code for opening and locking the medication carts did not work. He said the DON was responsible for training nursing staff on how to lock and unlock the medication/nursing carts. The MS said he was responsible for repairing the medication carts. He said in this case the medication carts' batteries just needed to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675423 If continuation sheet Page 5 of 9 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 10/25/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete adjusted on the back of the medication carts. He said staff were trained on how to replace the batteries and how to check them. He said the nursing staff should have known how to check the batteries. During an interview on 10/22/2025 at 4:14 PM, CMA BB revealed the medication carts were to always be locked unless the nurse or CMA was dispensing medications. She said MC #1 was not locking. She said there was a code staff needed to enter to unlock MC #1. She also said only the nurses knew the code for MC #1. She said she did not remember if she had reported to anyone the medication cart was not locking. She said she was responsibility to ensure the medication cart was locked and secured. She said if a resident had accessed the medication cart the resident could have overdosed, taken the wrong medication, had an allergic reaction, and possibly could have been admitted to the hospital. She said MC #1 contained residents' prescription medication. Interview on 10/22/2025 at 4:29 PM, CMA CC revealed MC #2 did not lock. She said MC #2 looked like it was locked but it would not lock. She said she did not recall who she told about the medication cart not remaining locked. She said all medication carts were to be locked except when a nurse or CMA was dispensing medications from the cart to give to a resident. She said anytime a nurse or CMA walked away from the medication cart they were to ensure it was locked. She said if a resident opened the medication cart and took some medications there was a possibility of an allergic reaction to someone else's medication. She said a resident could become severely sick such as decrease in blood pressure if the resident ingested another resident's blood pressure medication. She said there was a possibility a resident could die from taking medications not prescribed by their physician. CMA CC said there were all types of medications in the medication cart. She stated the narcotics were locked and the nurses were the only staff with access to the narcotics. During an attempted interview on 10/23/2025 at 7:43 AM, LVN F revealed she did not know why MC #3 and OFMC #4 was unlocked. She said OFMC #4 was not in use. She would not answer any questions and walked away from surveyor. During an interview on 10/24/2025 at 9:30 AM, the DON revealed the OFMC #4 that was found unlocked on 10/23/2025 was an extra cart the facility used when there was an increase of census. She said at this time that medication cart should not have been in use. She said the medication in the cart belonged to a resident who was no longer at the facility. She said the OFMC #4 was expected to be locked. She also said she was investigating why it was unlocked and had medication in the cart. She said in-services were given prior to all nursing staff on locking medication carts. She said she in serviced all CMA and nurses this week on locking medication carts and reporting when medication cart would not lock. Record review of Medication Labeling and Storage Policy, dated 02/2023, revealed, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. Event ID: Facility ID: 675423 If continuation sheet Page 6 of 9 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 10/25/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection control prevention and control program designed to provide a safe sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards. 1. The facility failed to ensure CNA Q followed standard precautions by leaving soiled gloves and gowns in a clear plastic bag and leaving soiled linens on top of the chest of drawers and on the floor in Resident # 6 on enhanced barrier precautions. 2. The facility failed to ensure CNA R followed enhanced barrier precautions when providing assistance with toileting for Resident # 6. These failures could place residents at risk for developing infection from cross contamination.Findings included: Record review of Resident # 6 face sheet, dated 10/21/2025, reflected a [AGE] year-old female who was admitted on [DATE] with a diagnoses which included dependence on renal dialysis ( a situation where a person's life depends on the ongoing use of treatment to survive because their kidneys have failed), chronic kidney disease ( a condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood), and encephalopathy ( any disease or damage that affects the brain's function, resulting in a decline in mental ability and brain function), and other cirrhosis of liver ( a chronic condition in which the liver becomes permanently damaged and scarred). Record review of Resident # 6's admission MDS dated [DATE] was in process. Record review of Resident # 6 Baseline Care Plan, dated 10/17/2025, reflected Resident # 6 had an intravenous access device dialysis catheter for the purposes of receiving hemodialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so). Interventions: were to administer Resident #6's intravenous fluids as prescribed. Change Resident # 6's tubing and site dressing every 72 hours. Check Resident # 6's IV site every two hours. Observe for signs of infection (redness, swelling, pain at site), and infiltration (swelling, blanching at site). Resident #6 was on enhanced barrier precautions (an infection control intervention) due to hemodialysis catheter, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Observation on 10/20/2025 at 8:51 a.m. in Resident #6's room there were not any staff in the room. Resident # 6 was lying in bed. There was a clear plastic bag with soiled gloves, garbage, and soiled gown in the bag beside the bedside table. There were dirty sheets lying on the floor near Resident 's foot of her bed. There was a soiled bedspread and blanket lying on the chest of drawers. CNA Q entered Resident 's room without washing her hands and without wearing a gown. CNA Q picked up the soiled linens and placed them in a clear plastic bag. CNA Q gathered a clear plastic bag and exited Resident # 6's room. CNA Q walked down the hall and entered room [ROOM NUMBER]'s and placed both clear plastic bags on the floor in room [ROOM NUMBER]. CNA Q was in room [ROOM NUMBER] approximately 7 minutes and exited room [ROOM NUMBER] and carried the clear plastic bags with dirty gloves, gowns and garbage in the garbage can located in soiled room and carried the dirty linens to the laundry (the part of laundry where dirty soil was stored). Interview on 10/20/2025 at 9:10 AM CNA Q stated she did change Resident # 6 clothes and gave ADL care to Resident # 6. CNA Q was asked what type of ADL care she provided for Resident # 6. CNA Q did not respond to the question. She stated she was in a hurry to get all her work finished and forgot to pick up the dirty linens and the garbage. She stated she did leave it in the room, and she knew she was to take the dirty linens and the garbage out of Resident # 6 room when she finished giving care. CNA Q stated it was infection control issue leaving dirty linens on floor and on the chest of drawers. She stated there was a possibility Resident # 6's roommate may contract some type of infection from Resident #6. CNA Q stated there was dirty gloves, dirty gown, and Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675423 If continuation sheet Page 7 of 9 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 10/25/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some garbage in the clear plastic bag on the floor. She stated that was her gown and gloves she was wearing when she was giving care to Resident # 6. She stated she was not to take garbage bags full of soiled linens, dirty gowns, gloves, and garbage into another resident's room. She stated she was in a hurry and forgot to take the garbage in the appropriate garbage area and the soiled linen to the laundry area where soiled linen is kept until the laundry staff can place them in the washer. She stated she was expected to place gown on and gloves on when in Resident #6 room when she entered the room to pick up the soiled linen and place the linen in the clear garbage bag. CNA Q stated she had been in-service on Enhanced Barrier Precautions and Infection control. She stated she did not remember the date of the in-service. Interview on 10/20/2025 at 9:25 AM Infection Control Nurse stated CNA Q did not follow the facilities infection control protocol. She stated that anyone on Enhanced Barrier Precautions whose soiled linens was expected to be placed immediately in a clear plastic bag and the staff was expected to wear a gown and gloves when handling soiled linen from a Resident on Enhanced Barrier Precautions. She stated CNA Q was not to leave any type of garbage in clear garbage bag on the floor in any resident's room. The Infection Control Nurse stated CNA Q was not to carry the dirty linen and garbage into another resident room. She stated there was a possibility infection could be spread from one room to another room. She also stated with soiled linens placed on furniture and in floor there was a potential Resident # 6 roommate may develop some type of infection. She stated the staff has been in service on infection control and Enhanced Barrier Precautions. She stated she did not recall the date of the last in-service. Infection Control Nurse stated anytime staff gave care to a Resident on enhanced barrier precautions all staff was to sanitize or wash their hands prior to donning gloves and gown. She stated anytime a staff member touched something that was considered contaminated they were to change gloves and wash their hands prior to donning new gloves. Observation on 10/20/2025 at 1:05 PM CNA R entered Resident # 6 room to assist with transferring and cleaning Resident # 6 to the toilet. When CAN R entered Resident # 6 room she did not sanitize or wash her hands. She donned her gown and touched the front right side of her scrub top. CNA R reached for gloves in the glove box and touched the outside of fourchettes (the separate sheaths for the fingers on a glove) and the inside of the glove with her soiled hands. CNA R entered the bathroom where Resident # 6 was located, and surveyor was unable to observe the care. Resident #6 was not completely dressed. Interview on 10/20/2025 at 1:10 PM CNA R stated she was assisting giving hygiene care to Resident # 6 when she was in the bathroom. She stated she did not wash her hands prior to placing gown and gloves on her body and hands. She stated she may have touched her scrub top. She stated everything was happening so fast she did not notice if she did touch her top. CNA R stated she was expected to wash or sanitize her hands prior to touching the gloves and placing gloves on her hands. She stated she did touch outside of the gloves and there was a possibility of cross contamination. CNA R stated when she was giving care to Resident # 6 there was a possibility of transferring bacteria onto Resident # 6. She stated she knew Resident # 6 was on enhanced barrier precautions. She was asked what specific type of care she gave to Resident # 6, and she did not respond to the question. She stated she had been in-service on infection control and enhanced barrier precautions CNA R stated she did not recall the date. Interview on 10/24/2025 at 8:45 AM the Director of Nurses stated all staff providing care to any resident on enhanced barrier precautions was expected to wash or sanitize their hands prior to donning gloves and gown. She stated if the staff touched their clothes prior to donning gloves, the staff was expected to wash or sanitize their hands after they had touched their clothes. She stated clothes was considered contaminated. The Director of Nurses stated all soiled linen was expected to be placed in a bag immediately and not left on chest of drawers or on floor in a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675423 If continuation sheet Page 8 of 9 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 10/25/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete resident's room. She stated there was a potential of spread of infection. The Director of Nurses stated staff was immediately to place the garbage in appropriate trash container and place the soiled linen in the portion of the laundry room where soiled clothes and linen were stored until laundry staff washed them. She stated it was not the proper protocol to take dirty linens in a bag and garbage to another resident's room and place it on the floor. The Director of Nurses stated there was a potential to transfer infection from one resident to another resident. She stated the staff had been in serviced on infection control and enhanced barrier precautions. The Director of Nurses stated she did not recall the date of the in-service. Record review of the Facility Policy on Enhanced Barrier Precautions, dated August 2022, reflected. Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. Policy Interpretation and Implementation 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing. b. bathing/showering. c. transferring. d. providing hygiene. e. changing linens. f. changing briefs or assisting with toileting. g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc. (and similar things); and h. wound care (any skin opening requiring a dressing). Event ID: Facility ID: 675423 If continuation sheet Page 9 of 9