Inspection·January 26, 2023

F 0645 responsible for the accuracy of PASRR screenings. Level of Harm - Minimal harm or potential for actual harm In an interview on 1/23/23 at 3:33 p.m. the Administrator said the MDS nurse was the person responsible for ensuring the accuracy of PASRR screenings. He said the purpose of the screening was to identify individuals who needed to receive services they could benefit from. He said he was unsure if there was a process to monitor for accuracy of the screenings. Residents Affected - Few Record review of the facility's admission Criteria policy dated 3/2019 read in part, .our facility admits only resident whose medical and nursing care needs can be met . 9. All new admissions and readmission are screened for mental disorders, intellectual disabilities (ID) or related disorders per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. A. the facility conducts a level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a mental disorder, ID, or related disorder, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 2 of 19 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 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, which included both the comprehensive and quarterly review assessments for 1 of 18 residents (Resident's #15) reviewed for care plan timing and revision. The facility failed to ensure Resident #15's care plan included her visual function, communication and dental care triggered on her admission MDS assessment dated [DATE]. This failure could place residents at risk for not receiving needed care. Findings include: Record review of Resident #15's admission face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included, unspecified dementia (a group of symptoms affecting memory, thinking and social abilities) without behavioral, anxiety, Aphasia (a disorder that results from damage to portions of the brain that are responsible for language) hypertension (High blood pressure) and chronic kidney disease Record review of Resident #15's admission MDS, dated [DATE], revealed a BIMS of 00, which indicated her cognition was severely impaired. Section B (Vision) of the MDS indicated she was impaired which indicated she could only see large print. Section B-600 revealed her speech pattern was unclear. Ability to understand others and be understood was coded as usually understood. Section L dental was coded having obvious or likely cavity or broken natural teeth. Record review of Section V for CAAS of the MDS revealed vision, communication, and dental were triggered. Record review of Resident #15's care plan, with a revision date of 01/19/23, revealed her care plan did not address her vision, communication and dental. Observation on 01/22/23 at 9:00 a.m., revealed Resident #15 was in bed and was not interviewable. In an interview with the MDS Coordinator on 01/24/23 at 1:00 p.m., she said she was responsible for completing the MDS by reviewing all data from all disciplines. She said she also visited each resident to interview and assessed them prior to completing the assessment and care plan. She said the care plan was the responsibility of all nursing personnel and social work. During an interview with the facility Social Worker on 01/24/23 at 3:00 p.m., she said she assessed residents on section B (Hearing, speech, and vision), C (Cognitive patterns), D (Mood), E (Behavior) & Q (Participation in assessment and goal setting) and gave the results of her assessment to her supervisor to complect. An attempt was made to interview the MDS Coordinator's Supervisor by phone and was unsuccessful. During an interview with the DON on 01/25/23 at 10:00 a.m., she said resident assessment and care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 3 of 19 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 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few plans were the responsibility of all nursing staff. She said all nursing staff should be updating their resident's care plan as new development arose on a regular basis because if the care plans were not updated, residents may not get the care and treatment needed to improve their health. Record review of the facility's policy for care plans, dated 2001, revised September 2013, read in part-policy statement: Our facility's care planning /interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. The Mechanics of how the interdisciplinary team meets its responsibilities in the development of the interdisciplinary car plan (e.g. face to face, teleconference, written communication etc.) is at the direction of the care planning committee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 4 of 19 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 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that it was not possible or resident preferences indicated otherwise for 10 of 86 residents (Resident #56, #7, #44, #59, #18, #23, #72, #5, #14, and #45) reviewed for weight loss. Residents Affected - Some 1. The facility failed to obtain accurate monthly weights for Resident #56. 2. The facility failed to ensure Resident #56 had appropriate interventions in place to prevent a severe weight loss of 39.3 % from 10/10/22 to 1/17/23. 3. The facility failed to obtain accurate monthly weights for residents from October 2022 to January 2023. The facility identified 10 (Residents #56, #7, #44, #59, #18, #23, #72, #5, #14, and #45) of 86 residents sustained significant and/or severe weight loss when an accurate weight was obtained by facility staff in January 2023. The noncompliance was identified as past noncompliance (PNC). The Immediate Jeopardy (IJ) began on 1/18/23 to 1/20/23. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of severe weight loss, delayed interventions, hospitalization, worsening health condition, and death. Findings include: Record review of Resident #56's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #56 had diagnoses which included Alzheimer's disease, unspecified severe protein-calorie malnutrition (1/21/21), vitamin B-12 deficiency anemia (11/16/21), anorexia (an eating disorder characterized by relentless drive for thinness with a fear of gaining body weight associated with self-induced behaviors towards thinness), weakness (12/2/20), vascular Parkinsonism (a disorder that affects muscle movement), and hospice care. Record review of Resident #56's quarterly MDS assessment, dated 12/8/22, revealed a BIMS score of 0 out of 15, which indicated severe cognitive impairment. She required extensive assistance of one person for eating. The assessment indicated no symptoms of poor appetite and no weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Record review of Resident #56's care plan, revised on 1/22/23, revealed she had a potential for nutritional problem related to inadequate meal intake. Interventions were to have the RD (registered dietitian) evaluate and make diet change recommendations PRN and weigh and record: monthly and PRN. Record review of Resident #56's weight summary revealed the following: 10/10/22: 107.5 pounds 11/2022: no weight recorded (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 5 of 19 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 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 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 0692 12/2022: no weight recorded Level of Harm - Immediate jeopardy to resident health or safety 1/17/23: 65.2 pounds Residents Affected - Some Record review of Resident #56's nutritional assessment, dated 2/28/22, written by the RD revealed a weight of 115.7 pounds and a BMI of 29 (normal BMI range was 23 - 30). Resident #56 was reviewed for her annual assessment. The RD documented the resident was readmitted to hospice. There was no significant weight loss but some weight loss with overall decline was expected with hospice and diagnosis. There was a calculated weight loss of 39.3% over 3 months. Record review of Resident #56's hospital record, dated 9/2/22, revealed a weight of 85 pounds. Record review of Resident #56's multidisciplinary care conference, dated 12/12/22, revealed the resident's appetite was fair. Her oral intake was 25-50%. Her weight was recorded at 107.5 pounds (from October 2022). There were no issues at the time. Patient was on hospice services. Record review of the facility's nutrition recommendations from August 2022 - January 10, 2023, revealed no dietary recommendations were made for Resident #56. Record Review of Resident #56 Hospice Records dated 1/2/23 revealed Resident gargling when she drinks water and unable to tolerate but able to eat regular food. HN recommended to change thin liquid to thickened liquid and was approved. Resident appears to be weak and frail and sleeps +12 hours a day. Record review of Resident #56's nutrition/dietary note, dated 1/18/23, written by the RD read in part, .CBW (current body weight) is at 65.2 pounds, -39.3% in 90 days, -40.8% in 180 days. BMI is below favorable for age at 16.3. Noted facility recently had scale recalibrations. Resident also on hospice care at this time . weekly weights ordered to monitor and re-establish baseline. Resident is on a regular, mildly thick liquid diet and has PO intake average at less than 50% but varies with sometimes increased intake. No recent labs, noted hospice. Resident with sacral and hip wounds being followed by wound care. Weight loss with overall decline is expected with hospice. Recommend magic cup TID with meals. Recommend increase 2.0 supplement to 60 cc TID related to weight loss. Recommend snacks of preference as desired. Goal is for resident to enjoy meals and supplements for comfort care. RD will continue following this resident Record Review of Resident #56 laboratory results dated [DATE] revealed resident's pre-albumin level was 7.2 mg/dL (normal range 17.0 - 34.0) and her albumin level was 2.5 mg/dL (normal range: 3.5-5.7). (The prealbumin blood test helps determine if you ' re getting enough nutrients -- namely, protein -- in your diet. Albumin is a protein in the blood plasma.) Record review of Resident #56's arm body mass measurements summary measured by hospice revealed (upper-arm circumference roughly correlates with BMI in the average person. A measure below 23.5 centimeters indicates that the person may be underweight or borderline underweight with a BMI of 20 or lower): 01-03-23 13.5 cm (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 6 of 19 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 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 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 0692 01-02-23 13.5 cm Level of Harm - Immediate jeopardy to resident health or safety 12-27-22 13.5 cm Residents Affected - Some 12-05-22 14 cm 12-07-22 14 cm 11-21-22 14 cm 11-14-22 14 cm 11-28-22 14 cm 10-24-22 14 cm 09-29-22 14.5 cm 08-29-22 15 cm In an interview on 1/22/23 at 3:21 p.m., the Administrator said the previous ADON oversaw a lot of the facility's systems and was recently let go. He said the facility noticed significant discrepancies in the weight logs and submitted a self-report to the state survey agency. He said the weight logs reflected some residents were repetitively documented as weighing the same every month. He said approximately 34 residents were identified with weight changes in January, all were reweighed, and would be weighed every Thursday for the next 4 weeks. He said the identified concern was taken to quality assurance, in-services were done, and the RD was consulted. In an interview on 1/22/23 at 3:22 p.m., the Corporate Nurse said it appeared the previous staff responsible for weights were making up weights. He said a QAPI was done, and the facility was aggressively working to turn it around. He said both persons involved were terminated. In an interview on 1/23/23 at 1:18 p.m., the RD said the DON and Administrator notified her of a weight discrepancy this month when they had someone else weigh the residents. She said she did an intervention for approximately 35 residents who had significant weight loss and said some residents needed more supplements than others. She said Resident #56's weight loss was not seen or documented (prior to the discovery). She said the resident was on hospice services but made recommendations for hospice residents the same way as non-hospice residents. She said she did not want the resident to starve to death and her meal intake flexed up and down. She said, prior to the facility becoming aware of the weight discrepancy in January 2023, she did not assess Resident #56 and said there were no dietary recommendations for the resident between August 2022 and January 2023 because the resident did not flag for weight loss. The last Nutrition assessment was completed on 2/28/22. The RD said she only assessed residents for weight or nutritional needs if there was a referral from the facility based off a trigger of significant weight gain or loss. She said skin issues and abnormal laboratory values could be a negative outcome of the untreated weight loss. She said the dietitians came to the facility three times a month and reviewed admissions, readmissions, annuals, weight loss, dialysis, pressure wounds, tube feedings, and any consults. She said residents were reviewed annually if there was no weight loss identified. She said the review consisted of interpreting the BMI, identifying weight goals, diet order, preferences, reviewing supplements, laboratory values, skin for pressure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 7 of 19 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 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 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 0692 wounds, and nutritional needs. Level of Harm - Immediate jeopardy to resident health or safety In an interview on 1/24/23 at 11:30 a.m., the Administrator said he terminated the previous ADON on 1/3/23 due to integrity issues. He said they noticed a big discrepancy with actual weights and recorded weights. He said as they reviewed the weight logs, they noticed the previous RA was the one consistently entering the weights. He said the previous staffing coordinator weighed most of the residents and asked other CNAs to give her weights. He said during their QAPI meetings prior to the discovery, there were no alarms of weight loss. The previous ADON and previous RA were responsible for accuracy of weights. He said the previous ADON was the analyzer and should have been reviewing dietitian recommendations, physician notes, and overseeing the weight system. He said Resident #56 currently weighed 65 pounds. He said the wound care nurse conducted a head-to-toe assessment of the resident and said she did not have any new pressure ulcers but did have excoriation (damage or remove part of the surface of the skin). Residents Affected - Some In an interview on 1/24/23 at 1:27 p.m., the RD said it was normal for hospice resident's dietary plans to be reviewed only annually. It would be reviewed more if there were concerns noted. She said, at the time, there were no concerns noted for Resident #56. In an interview on 1/24/23 at 3:07 p.m., the DON said she began employment with the facility in September 2022. She said the previous ADON was responsible for obtaining the weight data from the floors and ensuring the data was entered into PCC. She said she became suspicious of the weights in January 2023 because there was a delay in obtaining the weights of newly admitted residents, in addition to other concerns. She assigned a new team to obtain resident weights and noticed discrepancies in previously documented weights and current weights. She said upon review of previous weights they found several resident weights did not fluctuate more than 0.1 to 0.3 pounds in a 2-year period. She said in her professional opinion those were not realistic weight fluctuations. The DON said prior to December 2022, no one identified any weight changes, and no one reported changes in condition related to skin turgor, change in overall appearance, dehydration, lethargy, decrease activity, or skin impairment to her. During the QAPI meetings no issues were reported with the weights. She said she acknowledged there was a weight loss in some residents but questioned a lot of the weights. She said on 1/18/23 it was discovered Resident #56 had severe weight loss. She said Resident #56 was on hospice care and had a progressive decline in her ADLs and ability to mobilize. She said she had a history of not eating a lot and her family brought in food from home that she liked. She said she consulted with the MD and families and did not think any of the residents were harmed due to the unidentified weight loss. She said she would need to speak with Resident #56's MD about her decline to determine if it was a progression of her illness. In an interview on 1/24/23 at 3:15 p.m., the Corporate Nurse said the MDs and families did not report any concerns regarding weight loss. He said he spoke with the previous Staffing Coordinator and was informed she weighed over half of the residents. He said he could not confirm the integrity of the weights. In an interview on 1/24/23 at 3:17 p.m., the RD said the staff reported meal intake issues to her. She said Resident #56's dietary recommendations would depend on her nutritional needs. She would recommend fortified meals if the resident was still eating and then after that supplements, ice cream, and med pass 2.0. In an interview on 1/25/23 at 10:47 a.m., the NP said she recently started seeing Resident #56. She said the resident was on hospice care due to dementia and did not want to do aggressive measures (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 8 of 19 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 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 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 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some such as inserting a PEG tube. She said she expected the resident to decline with normal process. She said she referenced the monthly weight to ensure the resident was not losing too much weight. She said a significant weight loss or a drop of 40 pounds in a month would raise red flags. She said she would do a dietary consultation and if the RD made recommendations, they would get approval from hospice. She said she would also try Remeron (an appetite stimulant) if hospice approved. She said she would recommend these interventions to prevent the resident from losing too much weight but if hospice did not think it was appropriate, they would not implement it. She said with residents on hospice you want to ensure the quality of life but not prolong life. In an interview on 1/25/23 at 11:33 a.m., Resident #56's RP said the family noticed the resident was losing weight but could not tell how much. He said the resident lost more weight than he expected and said he was shocked to learn how much. He said the resident's normal weight was 115 pounds, but the facility recently informed him she weighed 75 pounds. He said the resident was put on hospice care because he and his family member were unable to see the resident during COVID-19 and the facility nurse said if the resident was put on Hospice care another nurse would come in and make her comfortable. He said he and his family member made a plan to encourage the resident to eat more because she slept so much and would gradually eat less and less. He said around the start of COVID-19, she lost a lot of weight but was still responsive and could walk around. He said the facility did not say what they would do to help with her appetite. He said when he was at the facility, he tried to assist her with meals and notified the CNAs when she would not eat well. He said they informed him they would try to get her to eat later. He said the resident got weaker and every time she walked around, she would fall and go to the hospital. He said he wanted the resident on physical therapy to walk and move around again so he removed her from hospice, but when she plateaued in therapy the facility convinced him to place her back on hospice. He said she had not been able to get out of bed very often because of unsteadiness. He said he had a care plan meeting in the past to discuss her diet preferences, such as no bones in her chicken and no spicy foods, but they did not discuss her specific dietary requirements. He said last Wednesday, 1/18/23, the facility changed her diet to a higher calorie, soft food diet which the resident took to very readily. He said she took everything on her plate on Friday, 1/20/23 but was unable to wake her to eat on Monday 1/23/23. He said she used to be able to feed herself and would eat the regular diet. He said he expressed to the facility there must be a high calorie diet that would help her eat, because the amount she was eating was small. He said he informed the facility that whatever they could do to help with her nutrition would be great. He said the hospice agency did not specifically say the resident would progressively lose weight. In an interview on 1/25/23 at 12:06 p.m., CNA A said she noticed Resident #56 lost weight and reported it to LVN A. She said the resident did not eat too much. She said last month the resident ate approximately 75% of a meal she assisted her with. She said she noticed the resident did not eat by herself but previously did not like when people fed her. In an interview on 1/25/23 at 12:29 p.m., LVN A said she noticed a few residents lost weight on her hallway not too long ago, which included Resident #56. She said she normally reported weight loss concerns to the resident's hospice nurse. She said Resident #56 was always fatigued and would refuse everything with feeding. She said her meal intake was around 25% but she liked to drink. She said her weight loss was obvious when the staff got her up to weigh her last week. She said she did not know who weighed the residents prior to January 2023. She said the RP would come to ensure she got enough food. She said the resident was on med pass 2.0 and the hospice nurse started her on Sucralfate. She said she was supposed to report weight concerns to the facility doctor and the hospice nurse, and they would schedule blood work and send it to the doctor. She said she was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 9 of 19 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 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 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 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some sure when to notify the RD. She said she reported Resident #56's weight concerns to the previous ADON and was informed to notify hospice and the resident's doctor. She said the previous ADON did not say anything about informing the RD. She said the RD monitored the food the residents ate and monitored the weight. Based on the weights they could tell if the patient was going up or down. She said the CNAs would report Resident #56's appetite changes to her. She said she reviewed Resident #56's weight and noticed the weight was previously around 100 and now it went down to 67. She said she knew the resident was losing weight based on her intake but never questioned the weights in the system because they looked right. She questioned the amount of weight she lost because it was a lot. She said she was recently in serviced on reporting weight concerns to the RD and conducting an assessment when there was a decline. In an interview on 1/25/23 at 2:00 p.m., Resident #56's Hospice Nurse said she assessed Resident #56 for the last 2 years. She said in the last 3-4 months Resident #56 had a decline in appetite and weight loss. The Hospice Nurse said the resident declined food and had low food intake. The Hospice Nurse determined the resident had a decline in body mass based off the mid-upper arm circumference body mass checked every 2 weeks during hospice visits. She said she received weight updates from various CNAs and nurses when she visited the resident. The last weight recording the Hospice Nurse recalled was approximately 97 pounds from the resident's recent hospital visit (exact date unknown). In an interview on 1/25/23 at 4:09 p.m., the DON said she was not previously aware of any weight changes for Resident #56. She said the Hospice Nurse, previous ADON, and charge nurses did not report any information about Resident #56's weight or appetite changes to her. She said if she was aware of the weight or intake changes, she would have notified the physician and obtained appropriate referrals such as for the RD. In an interview on 1/26/23 at 9:31 a.m., the previous ADON said she never weighed residents or documented weights. She said she only followed up on any recommendations from the RD if the RD saw weight loss or weight changes and if she wanted supplements or adjustments made. She said any CNA on the hall did the weights then gave those weights to the previous Staffing Coordinator. In an interview on 1/26/23 at 10:00 a.m., the previous Staffing Coordinator said the facility told her she falsified resident weights. She said she documented weights in the system when the CNAs gave them to her. She said she did weigh some residents and a lot of their weights changed. She said she recorded weekly weights in a binder but corporate was destroying papers in her old office when she was suspended. She said the scales were not calibrated and there was always an issue with the Hoyer lift scales jumping up and down. She said the last time she weighed Resident #56 was in November because the RD said she did not have to weight hospice residents. In an interview on 1/26/23 at 11:12 a.m., the DON said because of the internal audit, weights would be obtained on admission, the day after, and weekly for 4 weeks. She said she would review the weights and look at consistency in weighing procedures (i.e. hoyer lift, wheelchair scale, and same time of day). She said the DON, Administrator, or designee would be responsible for weekly spot checks of weights on each hall. She said they would select a resident and verify their weight with another person. In an interview on 1/26/23 at 11:24 a.m., the DON said the previous Staffing Coordinator was not the only person weighing residents but was the person who made sure the weights were done and entered in the system. She said the previous Staffing Coordinator worked with different CNAs to obtain weights. She said after the facility identified the weight discrepancies, she educated the lead nurses on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 10 of 19 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 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 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 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some how to identify weight loss and when to report. She said the scales were calibrated quarterly and no one ever reported any issues with the scale. Record review of the 10 residents identified with weight loss revealed new dietary physician orders were obtained and entered and care plans updated. Record Review of Resident #7 revealed was a [AGE] year-old female admitted on [DATE] with diagnoses mobility (severe) obesity due to excess calories, moderate protein- calorie malfunction, gastrostomy status, chronic kidney disease stage 3 unspecified, and gastro-esophageal reflux disease without esophagitis. Record Review of Resident #7 weights revealed that resident had a weight loss of 37.2% weight loss from 12/05/22 to 01/18/23. Resident #7 weight 155.5 lbs. dated 01/18/23 and 247.7 lbs. dated 12/05/22. Record Review of Resident #44 revealed was a [AGE] year-old female initially admitted on [DATE] with diagnoses chronic diastolic (congestive) heart failure, morbid (severe) obesity due to excess calories, vitamin B12 deficiency anemia, unspecified, vitamin D deficiency, unspecified gastro-esophageal reflux disease without esophagitis, and muscle weakness (generalized). Record Review of Resident #44 weights revealed that resident had a weight loss of 36.9% weight loss from 10/10/22 to 01/18/23. Resident #7 weight 201 lbs. dated 01/19/23; 318.6 lbs. dated 12/12/22; 317.57 lbs. dated 11/07/22 and 318.8 lbs. dated 10/10/22. Record Review of Resident #59 revealed was a [AGE] year-old female initially admitted on [DATE] acquired absence of left leg below knee, acquired absence of right leg below knee, cerebral infarction, unspecified, essential primary hypertension, anemia in other chronic diseases classified elsewhere, slow transition constipation, pressure of artificial left leg (complete) (partial), encountered for surgical aftercare following surgery on the digestive system, iron deficiency, anemia, unspecified, abnormal posture, muscle weakness (generalized), bed confinement status, Record Review of Resident #59 weights revealed that resident had a weight loss of 17.8% weight loss from 09/08/22 to 01/17/23. Resident #59 weight 97.6 lbs. dated 01/17/23; 118.8 lbs. dated 12/12/22; 119 lbs. dated 11/09/22; and 119.8 lbs. dated 09/28/22. Record Review of Resident #18 revealed was a [AGE] year-old male initially admitted on [DATE] with diagnoses of unspecified severe protein-calorie malnutrition, chronic kidney disease, stage 3 unspecified, anemia in chronic kidney disease, and benign prostatic hyperplasia without lower urinary tract symptoms, Record Review of Resident #18 weights revealed that resident had a weight loss of 18.5% weight loss from 10/14/22 to 01/19/23. Resident #18 weight 149.4 lbs. dated 01/19/23; 183.3 lbs. dated 12/10/22; 184.0 lbs. dated 11/09/22; and 184.4 lbs. dated 10/14/22. Record Review of Resident #23 revealed was a [AGE] year-old female admitted on [DATE] with diagnoses of heart failure, single episode, unspecified, gastro-esophageal reflux disease without esophagitis. Record Review of Resident #23 weights revealed that resident had a weight loss of 10.1% weight loss (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 11 of 19 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 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 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 0692 Level of Harm - Immediate jeopardy to resident health or safety from 10/10/22 to 01/17/23. Resident #23 weight 145.2 lbs. dated 01/17/23; 161.5 lbs. dated 12/10/22; 161.9 lbs. dated 11/07/22; and 161.6 lbs. dated 10/10/22. Record Review of Resident #72 revealed was a [AGE] year-old female admitted on [DATE] with diagnoses of deficiency of vitamin K, aphasia, muscle weakness generalized, cognitive communication deficit, and dysphonia, oropharyngeal phase. Residents Affected - Some Record Review of Resident #72 weights revealed that resident had a weight loss of 22.1% weight loss from 10/10/22 to 01/17/23. Resident #72 weight 106.2 lbs. dated 01/17/23; 136.3 lbs. dated 12/09/22; 136.8 lbs. dated 11/09/22; and 136.3 lbs. dated 10/10/22. Record Review of Resident #5 revealed was a [AGE] year-old male admitted on [DATE] with diagnoses of type 2 diabetes mellitus without complications, vitamin D deficiency, unspecified, and muscle weakness (generalized). Record Review of Resident #5 weights revealed that resident had a weight loss of 22.4% weight loss from 10/10/22 to 01/17/23. Resident #43 weight 143.4 lbs. dated 01/17/23; 176.8 lbs. dated 12/09/22; 176.2 lbs. dated 11/09/22; and 176.8 lbs. dated 10/10/22. Record Review of Resident #14 revealed was an [AGE] year-old male admitted on [DATE] with diagnoses of type 2 diabetes,unspecified severity protein calorie value function now nutrition mode morbid severity obesity due to excess calories, anemia and other chronic diseases classified elsewhere, vitamin D deficiency, other specified disorders of bone density and structure, unspecified site, other specified disorders of bone intensity and structure, unspecified site, bed confinement status, and muscle weakness (generalized). Record Review of Resident #14 weights revealed that resident had a weight loss of 27.5% weight loss from 9/9/22 to 01/19/23. Resident #43 weight 122 lbs. dated 01/19/23; 190 lbs. dated 11/09/22; 190.6 lbs. dated 10/10/22; and 191.8 lbs. dated 9/9/22. Record Review of Resident #45 revealed was an [AGE] year-old male admitted on [DATE] with diagnoses of heart failure, unspecified, atherosclerotic heart disease of native coronary artery without angina pectoris, type 2 diabetes mellitus with diabetic neuropathy, unspecified, Record Review of Resident #45 weights revealed that resident had a weight loss of 27.5% weight loss from 11/7/22 to 01/19/23. Resident #45 weight 97 lbs. dated 01/19/23; 134.3 lbs. dated 12/10/22; 134.3 lbs., and 134.0 lbs. dated 11/7/22. Record Review of the facility's, undated, Weight Assessment and Intervention Policy Statement revealed: Weight Assessments 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 5. The dietitian will review the unit weights record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for 'significant' weight change has been met. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss =(usual wight - actual weight) / (usual weight) x 100]: a. 1 month - 5% weights loss is significant; greater than 5% is severe. b. 3 month - 7.5% weights loss is significant; greater than 7.5% is severe. c. 6 month - 10% weights loss is significant; greater than 10% is severe. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 12 of 19 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 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 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 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record Review of the facility's, undated, Weighing and Measuring the Resident Level II. revealed Preparation 4. Weight is usually measured upon admission and monthly during the resident's stay. Documentation: The following information should be recorded in the resident's medical record. 2. The name and title of the individual(s) who performed the procedure. Record Review of the facility's, undated, Nutritional Assessment Policy Statement revealed: As part of the comprehensive assessment and nutritional assessment including current nutritional status and risk factors for impaired nutrition shall be conducted for each resident A. Nursing: (1) usual body weight (2) current height and weight (3) a description of the resident's usual intake and appetite (4) a history of reduced appetite or progressive weight loss or gain prior to admission (5) current clinical conditions and recent events that may have affected the residents nutritional status and risk factor (7) general appearance under scription of the residence overall appearance (8) the residents usual routine(s) intake (e.g. , oral, enteral, parenteral). Record Review of In-Service Education Program Record dated 1/18/23 Instructed by DON on the subject of Weight Assessment and Interventions and Review of Facility Policy and Procedures for Obtaining Resident Weights, Signs and Symptoms of Weight Loss of Resident and reporting Suspected wight Loss . Record Review of Statement of Inservice Training for Employees dated 1/20/23 Instructed by DON on the subject of Weight Assessment and Interventions and Review of Facility Policy and Procedures for Obtaining Resident Weights, Signs and Symptoms of Weight Loss of Resident and reporting Suspected wight Loss . This was determined to be a Past Noncompliance IJ that began on 1/18/23 and ended on 1/20/23. The Administrator was notified on 1/26/23 at 5:37 p.m. The Administrator was provided with IJ template on 1/26/23 at 5:37 p.m. No plan of removal was required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 13 of 19 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 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident and failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 3 of 6 residents (Residents #31, #29 and #67) reviewed for pharmacy services. The facility failed to ensure LVN E administered Lorazepam (an antianxiety medication) to Resident #31 every 12 hours (twice per day) per physician's order and instead administered the medication three times per day. The facility failed to ensure LVN E administered Hydrocodone-Acetaminophen (a controlled medication used to treat moderate to severe pain) to Resident #29 every 4 hours, as ordered by the physician, and instead administered the medication every 2 hours. The facility failed to ensure LVN E signed Resident #67's' Alprazolam controlled drug inventory sheet timely. These failures could place residents at risk of medication error and drug diversion. Findings include: Resident #31 Record review of Resident #31's face sheet revealed an [AGE] year-old female who was readmitted to the facility on [DATE]. Resident #31 had diagnoses which included Alzheimer's disease (a progressive neurologic disorder that causes the brain to shrink (atrophy) and brain cells to die), anxiety disorder (the mind and body's reaction to stressful, dangerous, or unfamiliar situations), paranoid schizophrenia (subtype of schizophrenia), major depressive disorder (mental health disorder having episodes of psychological depression), and cognitive communication deficit. Record review of Resident #31's annual MDS assessment, dated 12/7/22, revealed a BIMS score of 0 out of 15, which indicated severe cognitive impairment. Record review of Resident #31's, undated, care plan revealed she used an anti-anxiety medication related to anxiety disorder. The interventions were to administer anti-anxiety medication as ordered by the physician and monitor for side effects and effectiveness. Record review of Resident #31's order summary report for January 2023 revealed there was no active order for Lorazepam 0.5 mg. The last order for Lorazepam 0.5 mg was completed on 12/20/22 and the directions were to give 1 tablet by mouth every 12 hours as needed for anxiety/restlessness for 14 days, order date 12/6/22, end date 12/20/22. Record review of Resident #31's controlled drug declining inventory sheet for Lorazepam 0.5 mg dated 11/17/22 revealed LVN E administered one Lorazepam tablet to Resident #31 on 12/10/22 at 9 a.m., 12 p.m., and 6 p.m. for a total of 3 tablets in a day. She also administered one Lorazepam tablet to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 14 of 19 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 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #31 on 1/21/23 at 8 a.m. and one on 1/21/23 at 5 p.m. (32 days after the order was completed). There were 6 tablets remaining on the inventory sheet. The directions on the blister pack were to give 1 tablet by mouth every 12 hours as needed for anxiety/restlessness. Record review of Resident #31's medication administration record for January 2023 revealed Lorazepam 0.5 mg was not listed on it. There was no documentation to show LVN E administered it to Resident #31 on 1/21/23 at 8 a.m. and 5 p.m. Observation on 1/24/23 at 10:36 a.m. of the nurse cart on D hall revealed 6 Lorazepam 0.5 mg tablets for Resident #31 remained in the blister pack. In an interview on 1/25/23 at 1:52 p.m., the DON said controlled medications were to be turned in timely to herself or the Administrator when discontinued or discharged . She said LVN E informed her she looked at Resident #31's order and thought it was more frequent than scheduled. In an interview on 1/25/23 at 3:40 p.m., LVN E said Resident #31's Lorazepam order was completed on 12/6/22. She said the order was not active and she was not the only one who administered it after the completion date. She said the medication was still on the cart but should have been removed and handed to the DON to prevent a medication error. She said she pulled the medication from the cart and administered it to Resident #31. After administration she checked the computer, but the order was not there. She said she administered the Lorazepam three times a day (on 12/10/22) because she thought it was scheduled for three times a day. She checked the directions on the medication blister pack if she did not have access to the MAR. She said she called the pharmacy and they informed her no one should have administered it after 12/6/22. She said she assumed the medication error but was tired from working nearly 24 hours. She said no one assessed the resident or notified the MD. In an interview on 1/25/23 at 4:09 p.m., the DON said once the medication was discontinued it should be removed from the cart to prevent diversion and administration. She said nurses should not give a medication that was not on the MAR because they would not know the correct dose. She said medication should not be administered without a physician's order because the order guides the practice and nurses could not determine what to give. She said the controlled drug inventory sheet was used for inventory and the eMAR documented administration. Observation on 1/26/23 at 1:57 p.m. of Resident #31 revealed she was in her room lying in bed. She was not interviewable. Resident #29 Record review of Resident #29's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #29 had diagnoses which included Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), pain, dementia, and heart failure. Record review of Resident #29's quarterly MDS assessment, dated 11/23/22, revealed a BIMS score of 15 out of 15, which indicated intact cognition. Record review of Resident #29's, undated, care plan revealed she was on pain medication therapy related to disease process. Her interventions were to administer analgesic medications as ordered by the physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 15 of 19 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 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #29's order summary report revealed an order for Hydrocodone-Acetaminophen 10-325 mg give 1 tablet by mouth every 4 hours for severe pain, order date 10/27/22. Record review of Resident #29's controlled drug record form, for Hydrocodone/Acetaminophen 10-325 mg dated 1/17/23, revealed LVN E administered one tablet to Resident #29 on 1/22/23 at 10 a.m., 12 p.m., 2 p.m., 4 p.m., and 10 p.m. for a total of 5 tablets. The directions on the drug record were to take 1 tablet by mouth every 4 hours as needed for pain or shortness of breath. The medication was not administered every 4 hours according to physician orders. Nineteen tablets remained in the blister pack. Record review of Resident #29's medication administration record for January 2023 revealed Hydrocodone-Acetaminophen was scheduled to be given every 4 hours at 2:00 a.m., 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., and 10 p.m. The medication was documented as given by LVN E on 1/22/23 at 10:00 a.m., 2:00 p.m., 6:00 p.m., and 10 p.m. There was no documentation to show LVN E administered an additional tablet at 12 p.m. as recorded on the controlled drug record. In an observation on 1/24/23 at 10:45 a.m. of the nurse cart on D hall there were 19 Hydrocodone-Acetaminophen 10/325 mg tablets for Resident #29 in the blister pack. In an interview on 1/25/23 at 2:18 p.m., the DON said when administering a medication, nursing staff should pull up the eMar and check for time and frequency. She said not following the physician's order could run the risk of under medicating or over medicating the resident which could cause harm. In an interview on 1/25/23 at 2:26 p.m., the Corporate RN said LVN E gave Resident #29 one too many tablets. In an interview on 1/25/23 at 2:40 p.m., LVN E said she thought the documentation in Resident #29's MAR matched the documentation in the controlled drug record sheet for the Hydrocodone-Acetaminophen. In an observation and interview on 1/26/23 at 2:00 p.m., Resident #29 was in her room lying in bed. She said she received her pain medication and normally requested it every 4 hours. She said she did not remember receiving the pain medication every 2 hours but could use it sooner. Resident #67 Record review of Resident #67's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #67 had diagnoses which included anxiety disorder and major depressive disorder. Record review of Resident #67's quarterly MDS assessment, dated 12/28/22, revealed a BIMS score of 14 out of 15, which indicated intact cognition. Record review of Resident #67's, undated, care plan revealed she displayed anxious mood as evidenced by generalized anxiety disorder. Her interventions were to give anti-anxiety medication as ordered. Record review of Resident #67's order summary report for January 2023 revealed an order for Alprazolam 0.5 mg give 1 tablet by mouth every 12 hours as needed for anxiety, order date 1/19/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 16 of 19 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 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #67's medication administration record for January 2023 revealed Alprazolam 0.5 mg was documented as administered on 1/24/23 at 8:24 a.m. by LVN E. Record review of Resident #67's controlled drug declining inventory sheet for Alprazolam 0.5 mg revealed the medication was last documented as given on 1/23/23 at 8:20 a.m. by LVN D. There was 1 tablet remaining according to the inventory sheet. In an observation and interview on 1/24/23 at 10:05 a.m. of the E hall nurse cart with LVN E, the state surveyor and LVN E conducted a controlled medication count by comparing the controlled medications on the cart to the inventory log. Resident #67's controlled drug declining inventory sheet for Alprazolam 0.5 mg indicated there was 1 tablet remaining. LVN E said there was no blister pack for the Alprazolam on the cart and said she administered the last one to Resident #67 this morning but did not document it on the inventory sheet because she did not have a pen. LVN E then signed the inventory sheet for Resident #67's Alprazolam to indicate there were 0 tablets left. LVN E said the inventory sheet should be signed right after administering the medication because you never knew what could happen. She said you must have control of the medication and know when it was next due to be administered. In an interview on 1/25/23 at 2:18 p.m., the DON said controlled medications should be signed out on the inventory sheet when the medication was pulled from the blister pack. She said if the controlled sheet was not signed when administered, it could lead to a discrepancy and give a suspicion of diversion. In an interview on 1/25/23 at 2:26 p.m., the Corporate RN said the eMAR and count sheet were used to keep control of the controlled medications. He said LVN E needed to sign out the controlled drug on the inventory sheet in real time because if she left the facility there could be a discrepancy and she could explain what happened. Record review of the facility's Controlled Substances policy, dated April 2019, read in part, . The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications . Policy Interpretation and Implementation . 8. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift . 10. Upon administration: a. the nurse administering the medication is responsible for recording: 1. Name of the resident receiving the medication; 2. Name, strength, and dose of the medication; 3. Time of administration; 4. Method of administration; 5. Quantity of the medication remaining; and 6. Signature of nurse administering medication. Record review of the facility's Administering Medications policy, dated April 2019, read in part, .Medications are administered in a safe and timely manner, and as prescribed . 4. Medications are administered in accordance with prescriber orders, including any required time frame . 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified Record review of the facility's Medication and Treatment Orders policy, dated July 2016, read in part, .1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 17 of 19 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 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 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, interviews, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored securely in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for two (Nurse Medication Cart D Hall and Nurse Medication Cart A Hall) of five medication carts (Nurse Medication Cart D Hall and Nurse Medication Cart A Hall) reviewed for storage of medications. 1. -The facility failed to ensure the Nurse Medication Cart D Hall was locked when unattended. 2. -The facility failed to ensure LVN B secured medications prior to leaving the medication cart unattended. These deficient practices could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion. Findings included: 1. Observation on 01/23/2023 at 6:37 AM revealed Nurse Medication Cart D hall parked near room D6 and was unlocked and unattended by staff. LVN A was in room D6a behind the curtain with a resident. No staff, visitors or residents were in the hall. Observation on 01/23/2023 at 6:38 AM revealed LVN A returned to the medication cart. Inventory of the medication cart at this time accompanied by LVN A revealed: Left side of medication cart: Drawer #1: probiotics, vitamins, allergy medications, zinc, aspirin; Drawer #2: Resident individual medications ; Drawer #3: Resident individual medications , lidocaine topical pain patches, respiratory inhaler medications; Drawer #4: Resident medications . Right side of cart: Drawer #1: insulins, artificial tears, eye drops; Drawer #2: locked narcotic box with medications for six residents ; Drawer #3: liquid medications Maalox, Milk of Magnesia Drawer #4: medication administration supplies syringes, medication cups. In an interview on 01/23/2023 at 6:45 AM, LVN A stated she just went into the resident's room to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 18 of 19 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 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 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 check her blood pressure. The resident needed help and she took longer to provide the care to the resident. LVN A stated she normally locks locked the medication cart when she leaves left it. The medication cart should be locked when it was left unattended. The nurse on the cart was the one responsible to make sure it was locked before leaving it out of sight. The risk of the unlocked medication cart was that anyone could remove something from the cart they should not have. To prevent this again, staff make sure the cart was locked before leaving it . In an interview on 01/24/2023 at 10:04 AM with the DON, she stated her expectations were the medication carts must be locked when out of sight for management of medications. The DON stated it was the responsibility of the nurse assigned to the medication cart to ensure it was locked. The risk of an unlocked medication cart was that a resident, a family member or a visitor could get in the medication cart and remove a medication they should not have. In an Interview on 01/24/23 at 9:09 AM with the Administrator, he stated his expectations were all medication carts were to be locked when the staff leave left it. The Administrator stated the risk was a potential that someone may get into the medication cart and take a medication out they should not have. It was the responsibility of the nurse working on the cart to make sure the cart was locked when left unattended. The Administrator said the DON will would continue to educate on locking medication carts at all times when not in use. 2. Observation and interview on 01/24/2023 at 9:55 AM revealed Nurse Medication Cart A Hall was parked in the hall near room A5. There was no staff, resident or visitors was in hall. A resident's individual medication container with nine sodium chloride tablets one gram and one bottle of Senna stool softener was on top of medication cart. LVN B returned to the cart. In an interview with LVN B she stated she was in the resident room, and she could not see the medication cart from where she was. She stated she was responsible and should have locked the medications in the cart prior to leaving it. Someone could have taken them . In an interview on 01/24/2023 at 10:04 AM the DON stated the medications should not have been left on top of the medication cart they should have been locked in the cart . Record review of the facility's policy, Security of Medication Cart, revised dated April 2007, read in part Policy Statement: The medication cart shall be secured during medication passes. 1.The nurse must secure the medication cart during the medication pass to prevent unauthorized entry .4. Medication carts must be securely locked at all times when out of the nurse's view FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 19 of 19