Health inspection·August 2, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Record review of Resident CR#1's physician order summary, dated 08/02/2023, revealed the resident had an order to: -Cleanse Wound #1 (left inner ankle) and Wound#2 (left Lateral Leg) with normal saline, pat dry, apply betadine and have open to air daily every day shift for unstageable wound with a start date of 07/26/2023. Residents Affected - Few Record review of Resident #CR#1's undated care plan, revealed: Focus: [CR #1] has left inner ankle wound x2. Goal: [CR#1] will maintain or develop clean and intact skin by the review date. Interventions: Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. Provide treatment per physician order. Specialty mattress to bed. Pressure reduction mattress. Turn and reposition per facility protocol and PRN. Use a draw sheet or lifting device to move resident. In a phone interview with RP for CR#1 on 08/01/2023 at 11am, she said that facility did not notify her that CR#1 had a wound to her foot. She said she observed the wound on 07/29/2023 while visiting. In an interview with LVN A on 08/02/2023 at 12:39pm, she said she first saw CR#1 had two wounds to her left ankle on 07/24/2023. She said she worked at the facility for 3 months. She said when a new wound was identified the appearance should be documented. She said the primary doctor, wound care doctor, and family should be notified. She said the Treatment Nurse, ADON, and DON are to be notified. She said she notified Physician C on 07/24/2023. She said she did not notify the family or primary doctor after the wound was identified. She said she did not notify the ADON or DON when the wound was identified. She said she did not document the appearance of the wound observation in a progress note, skin assessment, or SBAR when the wound was assessed on 07/24/2023. She said she did not complete the tasks which caused a delay in CR#1's treatment. In an interview with DON on 08/01/2023 at 1:49pm, she said that she started at the facility on 07/26/2023. She said that when a wound is identified the nurse should document the appearance, notified the physician, wound care doctor, family, and DON. She said that if the DON is not available the ADON should be notified. She said that on 07/26/2023 the floor nurse assigned to CR#1 brought to her attention that resident had a wound to left ankle that had not been there when previously worked. She said that she instructed the floor nurse to notified primary doctor, wound care doctor, and family. She said that she reviewed progress notes completed by LVN A who identified the wound initially on 07/24/23. She said that LVN A documented that she notified the wound care doctor but not the family or DON . She said that LVN A did not notify the ADON or DON at the time that CR#1 had a wounds identified. She said that LVN A did not follow up on treatment orders after CR#1 was assessed by the wound care doctor on 07/24/2023. She said that because she did not complete the tasks CR#1's treatment was delayed. She said that LVN A did not follow the facilities protocol, and she will receive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675543 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Janisch Health Care Center 617 W Janisch St Houston, TX 77018 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 disciplinary action. Level of Harm - Minimal harm or potential for actual harm Record review of facility policy, Change in a Residents Condition or Status dated February 2021 read in part, .4. Unless otherwise instructed by the resident, a nurse will notify the residents representative when: b. there is a significant change in the resident's physical, mental, or psychosocial status; . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675543 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Janisch Health Care Center 617 W Janisch St Houston, TX 77018 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 1 of 3 residents (CR#1) reviewed for wound care. Residents Affected - Few -The facility failed to establish wound care services for CR#1 as ordered from 07/24/2023-07/25/2023. This failure could place residents at risk of not receiving adequate care in a timely manner, deterioration of skin, and decreased quality of life. Findings included: Record review of Resident CR#1's face sheet revealed a [AGE] year old female who was admitted into the facility on [DATE], readmission date on 08/06/2022, with a principal diagnosis of cerebral infarction, also known as a stroke, and secondary diagnosis of diabetes mellitus. CR#1 was discharged on 07/29/2023. Record review of CR#1's MDS, dated [DATE], revealed the resident had a BIMS score of 5 indicating residents' cognition was severely impaired in Section C. Section I revealed CR#1 was triggered for Diabetes Mellitus. Section I revealed that CR#1 was triggered for risk of developing pressure ulcers, with no current venous or arterial ulcers, and treatments in place for a pressure reduction device for the bed. Record review of weekly skin observation completed by LVN E dated 07/19/2023, revealed no new wounds to be identified. Record review of progress note completed by LVN A dated 07/24/2023 stated, Wound DR notified of PT wounds. Record review of wound care assessment completed by the Wound Care Physician dated 07/24/2023 revealed the following for CR#1: Acute Left Medial Ankle Arterial Ulcer that measured at 3cm in length and 2.5cm in width with no onset date provided. Acute Left, Medial Foot(proximal) Arterial Ulcer that measured at 1.5cm in length and 1.5cm in width with no onset date provided. Orders: Wound Dressing paint with betadine and leave open to air daily. Plan of Care discussed with facility staff. Follow up next week. Record Review of Resident CR#1's MAR dated for July of 2023, revealed that CR#1 did not receive wound care treatment on 07/24/2023 or 07/25/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675543 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Janisch Health Care Center 617 W Janisch St Houston, TX 77018 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Record review of Resident CR#1's physician order summary, dated 08/02/2023, revealed the resident had orders to: Level of Harm - Actual harm Residents Affected - Few -Cleanse Wound #1 (left inner ankle) and Wound#2 (left Lateral Leg) with normal saline, pat dry, apply betadine and have open to air daily every day shift for unstageable wound with a start date of 07/26/2023. -Portable 2 view x-ray of left lower extremity involving left inner ankle to rule out osteomyelitis(infection) with a start date of 07/26/2023. -Left Lower Extremity duplex scan with start date of 07/27/23. -Left Lower Extremity duplex scan with start date of 07/28/23. Record review radiology exam results dated 07/27/2023 of the left tibia and fibula with no evidence of infection. Record review radiology exam results dated 07/27/2023 of the doppler performed on left lower extremity with no abnormalities found. Record review radiology exam results dated 07/28/2023 of the doppler performed on left lower extremity with abnormalities found. Record review of SBAR completed by LVN A dated 07/29/2023, revealed abnormal arterial study confirmed, physician notified with recommendation to transfer to ER, and family notified. Record review of Resident #CR#1's undated care plan, revealed: Focus: [CR #1] has left inner ankle wound x2. Goal: [CR#1] will maintain or develop clean and intact skin by the review date. Interventions: Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. Provide treatment per physician order. Specialty mattress to bed. Pressure reduction mattress. Turn and reposition per facility protocol and PRN. Use a draw sheet or lifting device to move resident. Record review of CR#'1 medical records from a local hospital dated 07/29/2023 that indicated that resident presented with a nonhealing wound to the left medial ankle with no palpable pulses on the dorasalis pedis on left foot. MRI indicated, non pressure wound of left ankle, osteomyelitis, and peripheral artery disease. In a phone interview with RP for CR#1 on 08/01/2023 at 11am, she said that facility did not notify (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675543 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Janisch Health Care Center 617 W Janisch St Houston, TX 77018 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 her that CR#1 had a wound to her foot. She said that she observed the wound on 07/29/2023 while visiting, and CR#1 was sent to the hospital the same day because of the wound. Level of Harm - Actual harm Residents Affected - Few In a phone interview with LVN E on 08/01/2023 at 11:12am, she said that she started at the facility on 02/08/2023 as the wound care nurse. She said that she works Monday -Friday from 8:30am-5pm. She said that she completes all weekly skin assessments and wound care for the residents. She said that the floor nurses complete wound care when she is not in the building, and her last day at work was 07/19/2023. She said that she completed a weekly head to toe skin assessment of CR#1 on 07/19/2023, with no new wounds identified. In a phone interview with Physician C on 08/01/2023 at 4:07pm, he said that he is the wound care doctor for the facility. He said that he was notified by nursing staff on 07/24/2023 while rounding that CR#1 had a new wound identified to the left ankle. He said that he assessed the wound to be arterial with Eschar, that was warm to touch, with pulse present. He said that he gave orders to treat the wound with betadine. He said that he ordered x-ray and doppler, to confirm if there was infection or blood flow issues to leg, but the results showed no sign. He said that there was a delay in treatment as he gave verbal orders to the nurse assigned to CR#1, verbal orders for treatment. He said that it could take 1-2 weeks for the wound to progress, but could progress faster due to issues with blood flow. He said that he was notified CR#1 was sent out to the hospital after abnormal doppler results were received by primary doctor. In a phone interview with Physician B on 08/01/2023 at 12:48pm, he said that he is the primary doctor for CR#1, he said that he was not made aware that CR#1 had new wounds identified until 07/26/2023. He said that the Wound Care doctor was following CR#1 for the wound, and order x-ray and doppler on the lower extremities. He said that he was contacted with results of x-ray that had no signs of infection. He said that he was contacted on 07/29/2023 with abnormal results from the doppler. He said that gave order to send CR#1 to hospital due to concerns of Peripheral Vascular Disease. He said if he were contacted when wound was first identified he would have told staff to consult wound care doctor. In a telephone interview with Physician D on 08/02/2023 at 11:49pm, she said that she is the Medical Director for the facility. She said that she was contacted to assessed CR#1 as a part of QAPI on 07/28/2023 to address wound care. She said that there was a concern that CR#1's wound was not identified timely and reported to wound care doctor. She said that she assessed CR#1 with no concerns for infection but she had concerns with poor circulation. She said that CR#1 had x-ray and doppler that revealed no concern for infection or blood flow. She said that when she assessed CR#1 she saw some discoloration, she gave order to repeat doppler, and the results were abnormal. She said that CR#1 was sent out to the hospital on [DATE] after results were confirmed. She said that she estimated the wound to be 1 week old, and the wound could have progress faster due to circulation issues. She said that if staff identified the wound on 07/24/2023, and resident did not receive treatment until 07/26/2023 that is a concern as treatment was delayed. She said that staff should have notified the family, primary physician, and wound care doctor once the wound was identified. In an interview with LVN A on 08/02/2023 at 12:39pm, she said she has worked at the facility for 3 months. She said that she first saw that CR#1 had two wounds to her left ankle on 07/24/2023. She said that she noticed the wound while assisting the CNA F with transfer of resident for bed bath. She said that the CNA F said that the wound was not present when she gave the previous bed bath. She said that the wounds were circular, dark in color, and she held her hand up to show the size that was a little larger than a quarter. She said that she did not see any discoloration of the foot, the foot (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675543 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Janisch Health Care Center 617 W Janisch St Houston, TX 77018 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Residents Affected - Few was warm to touch, and pulse present. She said that the facility has a treatment nurse that completes wound care on all residents. She said that when the treatment nurse is out, the floor nurses must complete wound care. She said that the treatment nurse was not in the building on 07/24/2023. She said that she notified Physician C while he was in the building rounding, and he said that he would assess the resident. She said that when a new wound is identified the appearance should be documented. She said that the primary doctor, wound care doctor, and family should be notified. She said that the Treatment Nurse, ADON, and DON are to be notified. She said that Physician C assessed CR#1 on 07/24/2023 , but she did not remember if he provided orders. She said that she should have followed up with Physician C before he left the building or contacted him by phone to confirm treatment orders for CR#1. She said that she did not notify the family or primary doctor after the wound was identified. She said that she did not notify the ADON or DON when the wound was identified. She said that she did not document the appearance of the wound observation in a progress note, skin assessment, or SBAR. She said that she should have completed the tasks, she got busy, and she did not follow up or complete tasks. She said that because she did not complete the tasks CR#1's treatment was delayed. In an interview with DON on 08/02/2023 at 1:49pm, she said that she started at the facility on 07/26/2023. She said that the facility has a treatment nurse that completes wound care and weekly skin assessments on all residents Monday-Friday. She said that the Weekend supervisor completes wound care on Saturday-Sunday. She said that if the treatment nurse is out during the week the floor nurses were responsible for completing wound care and skin assessments. She said that the Treatment Nurse has been out since 07/19/2023. She said that when a wound is identified the nurse should document the appearance, notified the physician, wound care doctor, family, and DON. She said that if the DON is not available the ADON should be notified. She said that on 07/26/2023 the floor nurse assigned to CR#1 brought to her attention that resident had a wound to left ankle that had not been there when previously worked. She said that she instructed the floor nurse to notified primary doctor, wound care doctor, and family. She said that she reviewed progress note completed by LVN A, but resident did not have treatment orders in place, skin assessment, or SBAR. She said that LVN A did notify Physician C, but she did not follow up to confirm orders for CR#1 that caused delay in treatment. She said that LVN A did not notify the ADON or DON at the time that CR#1 had a wound. She said that CR#1 was sent out to the hospital on [DATE] after testing confirmed there was no blood circulation to the left leg. She said that each resident was assessed for new skin issues that may not have been identified. She said that she initiated an in-services, notified the medical director, held a QAPI, and PIP was put in place to address wound care. She said that LVN A will receive disciplinary action. In an interview with CNA F on 08/02/2023 at 4:15pm, she said that she started at the facility in 2018. She is assigned the hall where CR#1 was housed while admitted to the facility. She said that she first saw resident to have wound on 07/24/2023 when LVN A was helping her with transfer of CR#1. She said that CR#1 had wound to her ankle, but she could not remember if was located on the right or left. She said that the wound was dark in color close to the skin color of CR#1. She said that she would report a new wound to the floor nurse or wound care nurse depending on who was in the building. She said that she did not have to report the wound because the floor nurse was present, and the wound care nurse has not been at work for a few weeks. She said that the wound care doctor was in the building the same day, and the floor nurse said that she was going to have the wound care doctor look at the wound. She said that when she gave CR#1 a bed bath on 07/21/2023 she did not see the wound. Record review of facility policy, Medication and Treatment Orders dated July 2016 read in part, 7. Verbal orders must be recorded immediately in the resident's chart by the person receiving the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675543 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Janisch Health Care Center 617 W Janisch St Houston, TX 77018 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 order and must include prescribers last name, credentials, the date and the time of the order. Level of Harm - Actual harm Record review of facility policy, Pressure Ulcers/Skin Breakdown-Clinical Protocol dated July 2016 read in part, 2. In addition, the nurse shall describe and document/report the following: a. full assessment of pressure sore including location, stage, length, width and depth .d. current treatments .e. All active diagnoses Residents Affected - Few Record review of facility policy, Change in a Residents Condition or Status dated February 2021 read in part, 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR communication Form FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 8 of 8