Health inspection·August 10, 2023

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In a phone interview with the Corporate MDS Nurse on 08/10/2023 at 11:34AM, she stated if a resident did not speak English, she would expect to see the answer, Yes to the MDS question regarding the resident's need for translation services to communicate with health care staff. She stated the resident's specific language should have also be identified on the MDS. She stated the risk of not accurately assessing communication barriers was an impact on care, especially for residents who are more dependent on the staff for providing direct care. The corporate MDS Nurse stated the facility used the RAI manual for guidance on MDS assessments. In an interview with the Administrator on 08/10/2023 at 2:34PM, she stated Resident #50 was able to respond to her when miming. She stated the resident was very observant and quiet, and she had a family member who would help translate for her, and when he was not available, another family member or friend was available to help them with translation. She said the resident did need translation services for effective communication, especially when encouraging her to eat. She stated they have not been in been a situation before in which either of these family members were unavailable to translate for them over the phone and she has not thought as far as how they would communicate with her if none of them were available in the time of an emergency. Record review of the RAI Manual, dated October 2019, revealed, . Language barriers can interfere with accurate assessment . When a resident needs or wants an interpreter, the nursing home should ensure that an interpreter is available An alternate method of communication also should be made available to help to ensure that basic needs can be expressed at all times, such as a communication board with pictures on it for the resident to point to (if able) . 1. Ask the resident if he or she needs or wants an interpreter to communicate with a doctor or health care staff. 2. If the resident is unable to respond, a family member or significant other should be asked . 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 08/10/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 ensure residents received adequate care to maintain highest practical physical and psychosocial well-being for 1 of 15 residents (Resident #27) reviewed for ADL care, in that: Residents Affected - Few The facility failed to ensure Resident #27 did not have long fingernails with black grime packed underneath the nails. This failure placed residents at risk of experiencing a decreased quality of life and an increase risk of infection. Findings included: Record review of Resident #27's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with dementia, glaucoma, and hemiplegia and hemiparesis. Record review of Resident #27's comprehensive MDS assessment, dated 07/16/2023, revealed the resident had a BIMS score of 99, indicating the resident's cognition was not intact or the resident was rarely or never understood during the BIMS assessment. It also revealed the resident was dependent on staff for personal hygiene. Observation and interview with Resident #27 on 08/08/2023 at 9:52AM revealed Resident #27 lying in a geri chair. The resident stated they had been cutting her nails and shaving her but was found to have long fingernails, approximately a quarter-inch past the nail bed with black grime packed in three of her of nails on the right hand and under all of her nails on the left hand. When the surveyor pointed out the condition of the resident's nails, Resident #27 agreed and said her nails needed to be cut. In an interview with CNA J on 08/08/2023 at 9:59AM, she acknowledged the Resident #27's nails were very dirty and would not like it if her nails were to look similarly to hers. She said the residents' showers days were usually on Tuesday, Thursday and Saturday but they could clean the resident as needed. In a phone interview with CNA W on 08/10/2023 at 9:06AM, she stated she worked with Resident #27 on the 2-10 PM shift on 08/07/2023 and it was not Resident #27's bath day on Monday. She said she usually never cut residents' nails, including Resident #27's nails. She stated she only wiped resident hands down with a cloth to clean them. She stated she didn't notice the condition of Resident #27 nails and could not recall whether they were dirty or not. She stated she had never been instructed to cut any resident's nails before but believed that it was the job of a specialist to do to avoid injury. In an interview with RN A on 08/10/2023 at 9:44AM, she stated CNAs, nurses, and the wound treatment nurse all took part in nail care. She stated she worked on Tuesday, 08/08/2023, with Resident #27 and generally looked at all her residents' nails once a day. She stated grooming and nail care usually occured on their shower days. She stated she did not notice Resident #27's nails while working on (continued on next page) 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 08/10/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Tuesday. She stated nails were to be clean for infection control purposes, especially if the resident was touching their mouth and face. She said black grime under the nails are to be cleaned and CNAs are usually the first to notice them and clean them. In an interview with the DON on 08/10/2023 at 2:05PM, she stated shower days were Tuesdays, Wednesdays and Thursdays for Resident #27 and nurses, CNAs, and treatment nurses were responsible for monitoring residents' hygiene. She stated it was up to mainly the nurses and CNAs to check if the residents need nail care on at least the shower days. She said nail care was important for infection prevention, good hygiene and to prevent the residents from scratching themselves. Record review of the facility's policy on ADL, dated March 2018, revealed, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 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 08/10/2023 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 0759 Ensure medication error rates are not 5 percent or greater. 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 ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 10.26 % based on 4 errors out of 39 opportunities, which involved 2 of 6 residents (Resident #167, Resident #26) reviewed for medication errors. Residents Affected - Some 1. The facility failed to ensure Medication Aide A administered medications as ordered to Resident #167 by administering Ferrous Sulfate 325 mg instead of the ordered Ferrous Fumarate 325 mg (medication for low red blood cells). 2. Medication Aide A failed to administer medications as ordered to Resident #26 by omitting the ordered Potassium Chloride ER 8 mEq (medication for build-up of fluid in the body's tissue). 3. Medication Aide A failed to administer medications as ordered by Resident #26 by omitting the ordered Vitamin B Complex (medication for Vitamin deficiency). 4. Medication Aide A administered Vitamin D 25 mcg to Resident #26 without a physician order. These failures could place residents at risk of not receiving the desired therapeutic effect of their medications and side effects of medications that were not intended for the residents to receive. Resident #167 Record review of Resident #167's Face Sheet dated 08/09/2023 revealed, a [AGE] year-old male, that admitted to the facility on [DATE] with diagnoses which included fracture to the left hip, multiple fractures of the ribs, and pain. Record review of Resident #167's admission MDS assessment with the ARD (assessment reference date) date of 08/10/2023, revealed a BIMS score of 15 indicating intact cognition. Record review of Resident #167's Baseline Care Plan dated 08/05/2023 revealed, he was receiving antibiotic therapy and did not self-administer medications. He required one person assistance with personal hygiene, toilet use, dressing and bathing. He required two-person physical assistance with bed mobility. Record review of Resident #167's order sheet signed by the resident's Physician on 08/08/2023 at 9:44AM, revealed a telephone order dated 08/05/2023 at 2:19AM for Ferretts Oral Tablet (Ferrous Fumarate) give 325 mg by mouth two times a day for anemia with breakfast and dinner. The order was confirmed by RN B. An observation on 08/09/2023 at 8:50AM revealed, Med Aide A preparing for administration of medications to Resident #167. Med Aide A retrieved one tablet of Ferrous Sulfate 325 mg and placed into one medication cup along with four other medications. Med Aide A prepared the Miralax 17 gm powder and mixed it with 8 oz of water into a cup and entered Resident #167's room. Med Aide A administered all six medications to Resident #167. Resident #26 (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 08/10/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #26's Face Sheet dated 08/09/2023 revealed, a [AGE] year-old male, that admitted to the facility on [DATE] and initially admitted on [DATE]. His diagnoses included metabolic encephalopathy (a brain dysfunction), chronic deep vein blood clots to the lower extremity, diabetes, enlarged prostate, urinary tract infection, muscle wasting and cognitive communication deficit. Record review of Resident #26's admission MDS dated [DATE] revealed, a BIMS score of 12 out of 15 indicating he had moderate cognitive impairment. He required extensive assistance with 2 persons for bed mobility, dressing, toilet use and personal hygiene. He required total assist with 2 persons for transfers. Record review of Resident #26's Order Summary Report of active orders dated 08/09/2023 at 11:31AM revealed Potassium Chloride ER oral capsule 8 mEq, give one capsule by mouth one time a day for edema, order date 08/08/2023, Vitamin B complex oral tablet order date 07/16/2023, give one tablet by mouth in the morning for Vitamin Deficiency and Vitamin B12 oral tablet (Cyanocobalamin) give 2 tablets by mouth in the morning every Monday, Wednesday, and Friday for Vitamin Deficiency order date 07/16/2023. Further review revealed there was no order for Vitamin D 25 mcg tablets. An observation on 08/09/2023 at 9:00AM revealed Med Aide A preparing for administration of medications to Resident #26. Med Aide A retrieved one tablet of Vitamin D 25 mcg and placed into one medication cup along with Omeprazole 20 mg capsule, Allopurinol 100 mg 2 tablets, Carvedilol 25 mg tablet, Colestipol 1 gm tablet, Aspirin 81 mg tablet, Ferrous Sulfate 325 mg tablet, Furosemide 20 mg tablet, Gabapentin 300 mg two capsules, Losartan Potassium 25 mg tablet, Vitamin B-12 two tablets. Med Aide A entered Resident #26's room and administered the medications that were in the medication cup. In an interview on 08/09/2023 at 2:13PM, Medication Aide A was asked about the medications given to Resident #167 and Resident #26. Medication Aide A stated she was unable to get into the computer to view past medications administered. Medication Aide A stated, Resident #167's had a bottle of Ferrous Fumarate tablets at one time, and it was completed. Medication Aide A stated that Ferrous Sulfate 325 mg was in stock and can be given in replacement of Ferrous Fumarate. When ask who gave the instructions to give Ferrous Sulfate 325 mg, she did not reply with an answer. Medication Aide A stated she recalled giving the Potassium Chloride to Resident #26 and that she took the blister pack away before the surveyor could look at it. She stated that there was a Potassium Chloride tablet taken from the blister pack and that was the one she administered in the morning. In an interview on 08/09/2023 at 2:14PM, Medication Aide A removed the bottles of Aspirin 81 mg, Ferrous Sulfate 325 mg, vitamin D 25 mcg and Vitamin B-12 500 mcg from the top drawer of the medication cart and stated those were the floor stock medications she gave to Resident #26. When asked about why she did not administer Vitamin B Complex. Medication Aide A stated she was unable to go back into the computer to find past orders administered. When asked about why she gave Vitamin D 25 mcg to Resident #26 without an order, Medication Aide A stated she was unable to go back into the computer to find past orders administered. In an interview on 08/09/2023 at 2:15PM, LVN K stated the Iron supplement given to Resident #167 should match up with the physician order for Ferrous Fumarate 325 mg. LVN K stated, We can always call the physician to change the order to what we have in stock. LVN K stated she was not here and that it was the admitting nurse's responsibility to put orders in correctly. In an interview on 08/10/2023 at 7:50AM, the DON was asked who was authorized to make changes to the Ferrous Fumarate 325mg to Ferrous Sulfate 325mg for Resident #167, she stated the order needed to (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 08/10/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some be fixed and did not know who didn't catch the issue. She stated that Ferrous Fumarate was interchangeable with Ferrous Sulfate, and this was what the pharmacy wrote on the sheet. She stated the assumption was that the medication aides knew these two drugs were interchangeable. When asked exactly how much Ferrous Sulfate was equivalent to Ferrous Fumarate 325mg, she stated it was written on the list from the pharmacy that they were interchangeable. When asked what she expected the Medication Aide to do prior to administering the iron supplement, she stated that the order would be corrected because the two iron supplements were interchangeable. The DON stated prior to administering any medication, she expected the Medication Aide to verify the medication, verify the order and pass medications using aseptic technique. The DON stated she spoke with Medication Aide A who told her that she did not give Vitamin D to Resident #26 and pulled out the bottle of Vit B Complex when she realized she retrieved the wrong bottle. The DON stated Medication Aide A told her that she did give Resident #26 Potassium Chloride on 08/09/2023 at 9:00AM. The DON stated she had only been at the facility for 2 weeks and was still getting to know the residents. She stated she would have to follow up with the physician about the reason Resident #26 was ordered Potassium Chloride ER 8 mEq. She stated generally, the potential risk to a resident if they did not receive Potassium Chloride was cardiac issues. She stated all members of Nursing Administration would oversee to ensure the Medication Aides were following the policy for Medication Administration. Record review of the Iron Preparation list from the Pharmacy, revised on 06/2012 revealed one tablet of Ferrous Fumarate 200mg was interchangeable with 1 tablet of Ferrous Sulfate 325mg. The equivalent iron preparation for Ferrous Fumarate 325mg was 3 tablets of Ferrous Gluconate 325mg. Further review revealed there was no equivalent Ferrous Sulfate dose for Ferrous Fumarate 325mg. In an interview on 08/10/2023 at 8:00AM, the Administrator stated medication administration was not her area of expertise, but she would expect the Medication Aide would first verify the medication order to make sure it was the right medication, right route, right dose and to follow facility policy and procedures. The Administrator stated it was ultimately the facility's responsibility to clarify the physician order for the iron supplement for Resident #167. She stated she would expect the nurse to contact the physician and it would be the physician's decision whether to substitute a medication or not. She stated she would expect if the Medication Aide found a discrepancy, to stop and get clarification by notifying the charge nurse and DON who would then contact the physician. The Administrator stated the Ferrous Fumarate 325mg was not interchangeable with Ferrous Sulfate 325mg, on the list of iron supplements from the pharmacy and that we made the mistake. The Administrator stated she did not like that the Medication Aide lied about administering Vitamin D and not administering Vitamin B Complex, that there would be nothing wrong with just being honest. In a telephone interview on 08/10/2023 at 9:19AM, the Physician C stated she was not right in front of her computer but typically Ferrous Sulfate was ordered and the iron supplement for Resident #167 was not written correctly. Physician C stated the order had been corrected. Physician C stated Resident #26 was put on Lasix. She stated residents tended to lose some potassium, and that was why she added low dose Potassium Chloride. Physician C stated she was keeping an eye on his kidney function as well. Physician C stated there was no risk if Resident #26 missed a dose of Potassium d/t he was getting potassium in the foods he was eating. Physician C stated she had ordered labs for Resident #26 next week as a follow up. Physician C stated there was no risk to Resident #26 if he missed receiving Vitamin B complex d/t he was also receiving Vit B-12. Physician C stated she would have to look at Resident #26's records as she was not in front of her computer to see what the risks would be for receiving Vitamin D if he did not need it. She stated if Vitamin D was given without an order, she would expect the facility to follow facility policy and procedures. She (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 08/10/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated she expected the Medication Aides/Nurses who pass medications to check the resident's medication list to ensure they were giving the correct medication. Record review of the facility policy and procedure for Administrating Medications, revised on April 2019 read in part: Medications are administered in a safe and timely manner and as prescribed .2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions .4. Medications are administered in accordance with prescriber orders .6. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training .10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . Record review of the facility In-Service Training Report dated 07/18/2023, conducted by the ADON for Medication Aides on the topic of Medication Administration/Availability, revealed the summary of training session: Med Aides please make sure you are notifying your charge nurse for any medications that is not available. Ensure you are notifying and asking questions about any medications you are not sure about to reduce errors/omissions. Further review revealed Medication Aide A signed the training. Record review of the Med-Pass Observation Checklist for Medication Aide A, dated on 06/072023 and observed by LVN T, revealed the technique #6. Correct medication verified by visual check of medication, label and MAR was checked as met. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 8 of 8